Common indications for multiphase CT
\r\n\t
",isbn:"978-1-83969-491-2",printIsbn:"978-1-83969-490-5",pdfIsbn:"978-1-83969-492-9",doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!0,hash:"49d3123cde96adbe706adadebebc5ebb",bookSignature:"Dr. Jose Carlos Jimenez-Lopez and Dr. Alfonso Clemente",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/10749.jpg",keywords:"Orphan Crops, Sustainable Agriculture, SNPs, Legume Breeding, Genetic Diversity, Functional Foods, Seed Compounds, Food Security, Food Allergy, Abiotic & Biotic Stresses, Crop Resilience, Fungal Pathogens",numberOfDownloads:null,numberOfWosCitations:0,numberOfCrossrefCitations:null,numberOfDimensionsCitations:null,numberOfTotalCitations:null,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"February 10th 2021",dateEndSecondStepPublish:"March 10th 2021",dateEndThirdStepPublish:"May 9th 2021",dateEndFourthStepPublish:"July 28th 2021",dateEndFifthStepPublish:"September 26th 2021",remainingDaysToSecondStep:"a month",secondStepPassed:!0,currentStepOfPublishingProcess:3,editedByType:null,kuFlag:!1,biosketch:"A pioneering researcher in legume seed proteins physiological and nutraceutical functions, appointed as Ramon y Cajal research fellow and tenured scientist at CSIC; AEL board member and holder of two registered patents.",coeditorOneBiosketch:"Scientist at the Spanish National Research Council, President of the Spanish Legume Association, and Author of more than 120 scientific manuscripts who has been working in legume seeds research for the last 20 years.",coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"33993",title:"Dr.",name:"Jose Carlos",middleName:null,surname:"Jimenez-Lopez",slug:"jose-carlos-jimenez-lopez",fullName:"Jose Carlos Jimenez-Lopez",profilePictureURL:"https://mts.intechopen.com/storage/users/33993/images/system/33993.jpg",biography:"Dr. Jose Carlos Jimenez-Lopez, has studied Biochemistry and Molecular Biology (1998) and obtained Bs. in Biological Sciences (2001), Ms. in Agricultural Sciences (2004), University of Granada, Spain and PhD degree in Plant Cell Biology (2008) at the Spanish National Research Council (CSIC). He was a Full-time Postdoctoral research associate at Purdue University, USA (2008-2011). Marie Curie Research Fellow (FP7-PEOPLE- 2011-IOF) (2012-2015) at the University of Western Australia and CSIC working in human health benefits of legume seed proteins, their allergy molecular aspects and cross allergenicity. He is a Senior Research Fellow (Ramon y Cajal research program - MINECO, 2016 - present), currently working in the functionality, health benefits, and allergy implications of proteins from reproductive tissues (pollen and seeds) in crop species of agro-industrial interest (mainly legumes). He is an Author of more than 60 peer-review journal articles, 25 book chapters. His work has been presented in more than 130 international congresses. He is an Active member of different Scientific Societies: Spanish and International Legume Society; Spanish and EU Microscopy societies. He is Editor of multiple books, Reviewer for more than 35 Peer-Review Journals of editorial as Elsevier, Springer, Wiley, Frontiers, etc, and international expert panels member for funding grants evaluation.",institutionString:"Spanish National Research Council (CSIC)",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"6",totalChapterViews:"0",totalEditedBooks:"6",institution:{name:"Spanish National Research Council",institutionURL:null,country:{name:"Spain"}}}],coeditorOne:{id:"149660",title:"Dr.",name:"Alfonso",middleName:null,surname:"Clemente",slug:"alfonso-clemente",fullName:"Alfonso Clemente",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRDEMQA4/Profile_Picture_1615291343716",biography:"Dr. Alfonso Clemente is a staff scientist at the Spanish National Research Council, working at the Estación Experimental del Zaidín (Granada, Spain). He has been working in legume seeds for the last 20 years, being involved in several national and international related projects. Alfonso Clemente joined different labs (Institute of Food Research, 1999–2000; John Innes Centre, 2000–2002; Sainsbury Laboratory, 2003–2004) in the UK to broaden his laboratory skills and scientific knowledge. Currently, he is the President of the Spanish Legume Association (Asociación Española de Leguminosas, www.leguminosas.es) having strong interaction with a relevant network of scientists and agricultural associations and agri-food companies in the field. He is author of more than 120 scientific manuscripts and an editorial board member of the World Journal of Gastroenterology and Frontiers in Bioscience, among others.",institutionString:"Spanish National Research Council",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"2",totalChapterViews:"0",totalEditedBooks:"0",institution:null},coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"5",title:"Agricultural and Biological Sciences",slug:"agricultural-and-biological-sciences"}],chapters:null,productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},personalPublishingAssistant:{id:"247865",firstName:"Jasna",lastName:"Bozic",middleName:null,title:"Ms.",imageUrl:"https://mts.intechopen.com/storage/users/247865/images/7225_n.jpg",email:"jasna.b@intechopen.com",biography:"As an Author Service Manager, my responsibilities include monitoring and facilitating all publishing activities for authors and editors. From chapter submission and review to approval and revision, copyediting and design, until final publication, I work closely with authors and editors to ensure a simple and easy publishing process. I maintain constant and effective communication with authors, editors and reviewers, which allows for a level of personal support that enables contributors to fully commit and concentrate on the chapters they are writing, editing, or reviewing. I assist authors in the preparation of their full chapter submissions and track important deadlines and ensure they are met. I help to coordinate internal processes such as linguistic review, and monitor the technical aspects of the process. As an ASM I am also involved in the acquisition of editors. Whether that be identifying an exceptional author and proposing an editorship collaboration, or contacting researchers who would like the opportunity to work with IntechOpen, I establish and help manage author and editor acquisition and contact."}},relatedBooks:[{type:"book",id:"6096",title:"Seed Biology",subtitle:null,isOpenForSubmission:!1,hash:"0929ebc410ef5c25efdf938e3d34b6b2",slug:"advances-in-seed-biology",bookSignature:"Jose C. Jimenez-Lopez",coverURL:"https://cdn.intechopen.com/books/images_new/6096.jpg",editedByType:"Edited by",editors:[{id:"33993",title:"Dr.",name:"Jose Carlos",surname:"Jimenez-Lopez",slug:"jose-carlos-jimenez-lopez",fullName:"Jose Carlos Jimenez-Lopez"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"1819",title:"Biochemical Testing",subtitle:null,isOpenForSubmission:!1,hash:"bab205c706b0f34b0dfcfa1196437fcf",slug:"biochemical-testing",bookSignature:"Jose C. Jimenez-Lopez",coverURL:"https://cdn.intechopen.com/books/images_new/1819.jpg",editedByType:"Edited by",editors:[{id:"33993",title:"Dr.",name:"Jose Carlos",surname:"Jimenez-Lopez",slug:"jose-carlos-jimenez-lopez",fullName:"Jose Carlos Jimenez-Lopez"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"5382",title:"Cytoskeleton",subtitle:"Structure, Dynamics, Function and Disease",isOpenForSubmission:!1,hash:"f1c57584a4107ef50eefd39ceb1c8e64",slug:"cytoskeleton-structure-dynamics-function-and-disease",bookSignature:"Jose C. Jimenez-Lopez",coverURL:"https://cdn.intechopen.com/books/images_new/5382.jpg",editedByType:"Edited by",editors:[{id:"33993",title:"Dr.",name:"Jose Carlos",surname:"Jimenez-Lopez",slug:"jose-carlos-jimenez-lopez",fullName:"Jose Carlos Jimenez-Lopez"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"8033",title:"Seed Dormancy and Germination",subtitle:null,isOpenForSubmission:!1,hash:"8dc6f520dc664e8fd07db7658931dc2d",slug:"seed-dormancy-and-germination",bookSignature:"Jose Carlos Jimenez-Lopez",coverURL:"https://cdn.intechopen.com/books/images_new/8033.jpg",editedByType:"Edited by",editors:[{id:"33993",title:"Dr.",name:"Jose Carlos",surname:"Jimenez-Lopez",slug:"jose-carlos-jimenez-lopez",fullName:"Jose Carlos Jimenez-Lopez"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"2983",title:"Current Insights in Pollen Allergens",subtitle:null,isOpenForSubmission:!1,hash:"c96b836dac36192bcd83fbe72693b972",slug:"current-insights-in-pollen-allergens",bookSignature:"Jose C. Jimenez-Lopez",coverURL:"https://cdn.intechopen.com/books/images_new/2983.jpg",editedByType:"Edited by",editors:[{id:"33993",title:"Dr.",name:"Jose Carlos",surname:"Jimenez-Lopez",slug:"jose-carlos-jimenez-lopez",fullName:"Jose Carlos Jimenez-Lopez"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"7337",title:"Legume Seed Nutraceutical Research",subtitle:null,isOpenForSubmission:!1,hash:"a01ad0ca780f39f3aefd09f00cd0b7a3",slug:"legume-seed-nutraceutical-research",bookSignature:"Jose C. Jimenez-Lopez and Alfonso Clemente",coverURL:"https://cdn.intechopen.com/books/images_new/7337.jpg",editedByType:"Edited by",editors:[{id:"33993",title:"Dr.",name:"Jose Carlos",surname:"Jimenez-Lopez",slug:"jose-carlos-jimenez-lopez",fullName:"Jose Carlos Jimenez-Lopez"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"6418",title:"Hyperspectral Imaging in Agriculture, Food and Environment",subtitle:null,isOpenForSubmission:!1,hash:"9005c36534a5dc065577a011aea13d4d",slug:"hyperspectral-imaging-in-agriculture-food-and-environment",bookSignature:"Alejandro Isabel Luna Maldonado, Humberto Rodríguez Fuentes and Juan Antonio Vidales Contreras",coverURL:"https://cdn.intechopen.com/books/images_new/6418.jpg",editedByType:"Edited by",editors:[{id:"105774",title:"Prof.",name:"Alejandro Isabel",surname:"Luna Maldonado",slug:"alejandro-isabel-luna-maldonado",fullName:"Alejandro Isabel Luna Maldonado"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"1591",title:"Infrared Spectroscopy",subtitle:"Materials Science, Engineering and Technology",isOpenForSubmission:!1,hash:"99b4b7b71a8caeb693ed762b40b017f4",slug:"infrared-spectroscopy-materials-science-engineering-and-technology",bookSignature:"Theophile Theophanides",coverURL:"https://cdn.intechopen.com/books/images_new/1591.jpg",editedByType:"Edited by",editors:[{id:"37194",title:"Dr.",name:"Theophanides",surname:"Theophile",slug:"theophanides-theophile",fullName:"Theophanides Theophile"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"3161",title:"Frontiers in Guided Wave Optics and Optoelectronics",subtitle:null,isOpenForSubmission:!1,hash:"deb44e9c99f82bbce1083abea743146c",slug:"frontiers-in-guided-wave-optics-and-optoelectronics",bookSignature:"Bishnu Pal",coverURL:"https://cdn.intechopen.com/books/images_new/3161.jpg",editedByType:"Edited by",editors:[{id:"4782",title:"Prof.",name:"Bishnu",surname:"Pal",slug:"bishnu-pal",fullName:"Bishnu Pal"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"3092",title:"Anopheles mosquitoes",subtitle:"New insights into malaria vectors",isOpenForSubmission:!1,hash:"c9e622485316d5e296288bf24d2b0d64",slug:"anopheles-mosquitoes-new-insights-into-malaria-vectors",bookSignature:"Sylvie Manguin",coverURL:"https://cdn.intechopen.com/books/images_new/3092.jpg",editedByType:"Edited by",editors:[{id:"50017",title:"Prof.",name:"Sylvie",surname:"Manguin",slug:"sylvie-manguin",fullName:"Sylvie Manguin"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}]},chapter:{item:{type:"chapter",id:"43704",title:"Computed Tomography in Abdominal Imaging: How to Gain Maximum Diagnostic Information at the Lowest Radiation Dose",doi:"10.5772/55903",slug:"computed-tomography-in-abdominal-imaging-how-to-gain-maximum-diagnostic-information-at-the-lowest-ra",body:'Computed Tomography (CT) was first introduced as a medical device in the 1970’s, and has since become a ubiquitous imaging tool. Recent technical advances including faster scan times, improved spatial resolution, and advanced multi-planar reconstruction techniques have led to the application of CT for the evaluation of numerous anatomic abnormalities and disease processes. Approximately 3 million CT scans were performed annually in the United States in 1980, but by 2008 that number had grown to 67 million and it continues to rise. [1] Over two-thirds of all medical radiation is attributable to CT, with 75% of CT scans being performed in the hospital setting. Approximately 40% of CT scans are of the head/neck/spine, 10% of the chest, 47% of the abdomen/pelvis, and the remainder of the extremities or as a procedural tool. [2, 3, 4]
Increasing awareness of medical radiation has paralleled the increase in CT usage with permeation into the popular and scientific press. This has resulted in an emphasis by several organizations on reducing overall medical radiation exposure without compromising diagnostic accuracy and usefulness. Despite this increased awareness and attention, the significance of the increased radiation exposure to the population caused by CT remains unclear. High levels of ionizing radiation exposure are known to increase cancer risk [5, 6, 7] but the data for lower doses of radiation, like those seen during medical imaging (including CT), is less clear and remains controversial. [8, 9, 10] Therefore, in the absence of clarity on this topic, the American College of Radiology (ACR), Health Physics Society (HPS) and other interested organizations have adopted the principles of
Several strategies to reduce CT-associated radiation have been attempted. One strategy is to vet CT as the appropriate diagnostic test with preferential use of other imaging modalities such as ultrasound and MRI when able, particularly in pediatrics, and to limit the CT examination to the anatomic area in question. A second strategy involves optimizing scanning parameters (such as kVp, pitch and mA) in order to reduce exposure in all patient populations. [13, 14, 15] If CT is felt to be necessary, applying optimized technical parameters and limiting the scan area can substantially reduce radiation exposure and result in dose reductions as high as 65%. [12, 15] These important techniques are described in other chapters of this book and are not our focus. Rather, we will concentrate on an important, but potentially overlooked source of unnecessary medical radiation, namely, multiphase examinations. We will discuss how multiphasic examination should be used in abdominal imaging with an emphasis on utilizing the minimum number of phases that will suffice for the clinical indication. [16]
The different phases that are possible with state-of-the-art CT scanners are myriad and include scanning before and after contrast administration, delayed imaging, venous and arterial phases, and several others (table 1). Specific patterns of contrast enhancement or evolution of findings over time can dramatically aid in diagnosis in abdominal pathology, thus justifying these additional phases in some patients. However, additional phases should only be necessary in very specific clinical indications, and should be used judiciously as each phase will result in additional radiation. If these additional phases are performed for a specific examination with the same technical parameters as the original phase, which is often the case, the radiation dose is multiplied by the number of phases making it important that the phases performed are clinically indicated and relevant.
\n\t\t\t\t | \n\t\t\t\n\t\t\t\t | \n\t\t\t\n\t\t\t\t | \n\t\t|||
\n\t\t\t\t | \n\t\t\t\n\t\t\t\tIdentify calcifications\n\t\t\t | \n\t\t\t\n\t\t\t\tN/A\n\t\t\t | \n\t\t|||
\n\t\t\t | \n\t\t | ||||
Angiography | \n\t\t\tEvaluate vascular anatomy | \n\t\t\t15-35 sec | \n\t\t|||
Arterial phase | \n\t\t\tEarly | \n\t\t\tArterial structures | \n\t\t\t15-35 sec | \n\t\t||
Late | \n\t\t\tHypervascular tumors | \n\t\t\t15-35 sec | \n\t\t|||
Portal venous phase | \n\t\t\tMajority of routine imaging is performed with this phase. Provides excellent solid organ visualization | \n\t\t\t60-90 sec | \n\t\t|||
Venous Imaging | \n\t\t\tEvaluate for venous thrombosis | \n\t\t\t180 sec | \n\t\t|||
Delayed | \n\t\t\tCholangiocarcinoma | \n\t\t\t10-15 minutes | \n\t\t|||
Adrenal adenoma | \n\t\t\t10-15 minutes | \n\t\t||||
Extravasation (i.e. active bleeding) | \n\t\t\t7-10 minutes | \n\t\t||||
Renal | \n\t\t\tCorticomedullary phase | \n\t\t\tIdentification of renal cortical abnormalities | \n\t\t\t70 sec | \n\t\t||
Nephrogenic phase | \n\t\t\tCharacterization and improved visualization of renal masses | \n\t\t\t100-200 sec | \n\t\t|||
Excretory phase | \n\t\t\tEvaluation of the renal collecting system | \n\t\t\t10 min | \n\t\t
Common indications for multiphase CT
Multiphase CT examinations are extremely useful in a certain subset of patients. The temptation in a busy practice is to perform CT with a “one size fits all” approach such that physicians will not miss the opportunity to completely characterize even the most unexpected findings. This approach usually means utilizing multiphase scans in all patients to cover multiple potential scenarios. Since most patients do not benefit from additional phases, this practice results in unnecessary radiation in the majority of patients. The dose-multiplication effect of these unnecessary phases can be dramatically reduced or eliminated with individual tailoring of CT exams to the specific clinical scenario. [16]
In an attempt to address this issue, the American College of Radiology (ACR) has developed evidence and expert opinion-based appropriateness criteria matching scanning protocols for various clinical conditions. [17] Unfortunately, the criteria often do not address the most appropriate phase for use in a specific clinical scenario, but rather allude to a “CT Abdomen and Pelvis with IV contrast”. Therefore, identification of the most appropriate phases requires a literature review to identify scenarios when additional phases can be expected to add additional useful information. Our approach is to perform single phase imaging (generally the portal venous phase) unless there is specific literature or recommendations to support additional phases. Thus, for the indications addressed by the ACR appropriateness criteria, a portal venous phase is the most likely recommendation. For each indication in the appropriateness criteria, the varying imaging modalities are ranked, but they generally do not discuss the use of different phases in CT. They define 1 as being the least appropriate study for the given indication and 9 as being the most appropriate. Similarly, the Royal College of Radiology has also developed guidelines for the same purpose and these guidelines have many similarities to, but are not identical to the ACR guidelines [18]. For the purposes of this discussion, we will attempt to describe utilization patterns for CT phases that are supported by the medical literature and while these recommendations are partially based upon the ACR guidelines, we also recommend that physicians become familiar with medical literature supporting the use of multiphasic CT.
The majority of CT imaging in the head, chest and extremities are performed with single-phase imaging and won’t be specifically addressed. However, abdominal imaging is associated with many potential uses for multiple-phase imaging and will be discussed in detail. The majority of abdominal and pelvic CT’s can be performed using a single-phase, but the evaluation of some tumor types (hepatic/pancreatic/renal), the urinary collecting system, and trauma patients among others, may be best performed with multiple phases which is described in more detail below.
In discussing the numerous phases and indications for CT, it should be noted that best patient care requires individualized CT protocols based upon each patient’s specific symptoms, pathology, and underlying co-morbidities. Although labor intensive, this provides the highest likelihood of an accurate diagnosis with the lowest necessary radiation dose. The following discussion will provide a basic outline of current best practice, but not all clinical scenarios can be accounted for. Note that the ACR appropriateness criteria can be found on the ACR website (http://www.acr.org/ac).
Non-contrast CT scans Figure 1a (left) and 1b (right) are of limited use for the differentiation of soft tissue structures. However, materials like blood, calcium (renal stones, vascular atherosclerosis), bone, and pulmonary parenchyma are highly visible and can usually be adequately assessed with non-contrast CT. For example, in the abdomen and pelvis, there are several indications for non-contrast imaging. These include: evaluation of renal calculi; assessment for gross intra-abdominal hemorrhage; and post-endostent volume measurements. In addition, non-contrast images are often obtained in conjunction with contrast enhanced images in evaluating potential renal transplant donors and in the evaluation of the pancreas (in combination with contrast phases). Of note, dual-energy CT and the development of virtual “non-contrast” images may ultimately obviate the combination scans. Additionally, CT angiography examinations performed for pathologies like aneurysms and dissection are frequently performed in conjunction with non-contrast imaging. The non-contrast images facilitate the differentiation of active extravasation or acute bleeding from vascular calcifications.
Non-contrast CT demonstrating multiple bilateral renal calculi (arrows), which can be obscured on contrast-enhanced images, particularly delayed images when there is excreted contrast in the renal collecting system; axial left, coronal reformat on right.
Contrast enhanced CT examinations can be acquired at a variety of specific time points after intravenous contrast injection (timing is dependent on the phase of contrast enhancement needed and organ system being evaluated). The timing should be chosen specifically to optimize contrast distribution within the solid organ parenchyma in question.
The most common technique is to perform portal venous phase imaging in the abdomen and pelvis (approximately 60-90 seconds after contrast administration, figure 2). This results in near optimal contrast opacification of the majority of the solid abdominal organs and it is used for a wide variety of indications: nonspecific abdominal pain; hernia; infection; masses (with a few exceptions such as hypervascular, renal, and some hepatic tumors); and in most follow-up examinations. As a general rule, this single phase is adequate unless there is a specific clinical indication that has been shown to benefit from other phases.
Contrast enhanced CT demonstrating parenchymal enhancement of the intra-abdominal organs in the portal venous phase (axial left, coronal reformat right).
CT angiography (CTA) is highly effective for evaluation of the arterial system, and has largely replaced conventional angiography due to the lower risk profile and ability to survey the entire abdomen. Images are acquired after a rapid bolus of intravenous contrast material (3-7 cc/s) during the arterial phase (15-35 seconds after injection) when the concentration of contrast material in the arterial system is high (figures 3). Images are usually acquired using narrow collimation (<1 mm) and can be retrospectively reconstructed using dedicated 3-dimensional workstations and software. CTA is commonly used in the head and chest in the evaluation of pulmonary emboli, aneurysms, vascular malformations, dissection, bleeding and ischemia. Indications for early arterial phase imaging include: evaluation of aneurysms or dissections (cerebral, aortic, etc.), hepatic, splanchnic or renal arterial anatomy, and arterial imaging in liver or kidney transplantation. Single phase arterial imaging is often used in the evaluation of trauma patients either a complete chest/abdomen/pelvis examination with arterial phase imaging of the chest and portal venous phase imaging of the abdomen/pelvis or just a portal venous phase of abdomen and pelvis depending on the mechanism and severity of the trauma. CTA is also commonly performed in the abdomen and pelvis for evaluating vascular malformations and in the evaluation of bleeding. Mesenteric ischemia can also be evaluated using CT angiography. CTA of the abdomen and pelvis is often performed in combination with a CTA for evaluating the extremity vasculature.
Axial (left) and coronal (right) CT angiography images of the abdominal aorta evaluating for aortic aneurysm.
The late arterial phase is timed to correspond to the peak concentration of contrast material in highly vascular tumors and is performed approximately 20-35 seconds after the injection of intravenous contrast. Early arterial phase imaging is predominantly utilized for angiography and will be discussed separately. Late arterial phase imaging is almost always performed in conjunction with other phases (e.g. portal venous phase) to allow more complete characterization of any identified abnormalities (figure 4). The primary indication for a late arterial phase is for the evaluation of hypervascular tumors of the liver such as hepatocellular carcinoma or hypervascular metastases (figure 4). Typical hypervascular tumors for which this would be used include: hepatocellular carcinoma; renal cell carcinoma; melanoma; carcinoid/neuroendocrine tumors; some sarcomas; choriocarcinoma; and thyroid carcinoma. Although a “hypervascular”, biphasic evaluation would generally be used for these patients, note that a single phase is often adequate for follow up imaging.
Selected images from a biphasic CT demonstrating early arterial enhancement of a posterior right hepatic lobe mass with mild wash out on delayed phase images in the setting of cirrhosis characteristic of hepatocellular carcinoma.
CT imaging specific for the venous structures is performed uncommonly. Most venous structures are partially opacified on the routine contrast enhancing images and suffice for most examinations. However, occasionally evaluation of the inferior vena cava is desired, such as prior to IVC filter placement/removal or evaluation of IVC thrombosis.
Delayed phase imaging (figure 5) encompasses scanning at a variety of different times following contrast administration, and depends on the pathology in question. Typical delayed imaging times range from a few minutes to up to 15 minutes or longer. The most common indications for delayed phase imaging are evaluation of the kidneys, collecting system (ureters and bladder) and specific kidney, liver, and adrenal tumors. [19, 20] Evaluation of the kidneys, ureters and bladder are discussed separately in the renal imaging section. Cholangiocarcinoma occurring within the extrahepatic biliary tree or intrahepatic cholangiocarcinomas are a common reason for delayed imaging. Cholangiocarcinomas are fibrotic tumors which enhance slowly, and are usually imaged following a 10-15 minute delay. Similarly, adrenal masses can be evaluated with multiphase imaging including an unenhanced CT, portal venous phase and a 10 minute delay CT which allows for evaluation and calculation of the enhancement and washout characteristics aiding in distinguishing benign adrenal adenomas from other adrenal masses.
Outside of the evaluation of masses, delayed phase images can be used in the evaluation of active vascular extravasation in trauma patients, vascular malformations, and aneurysm disruption.
Selected images form CT performed using a Cholangiocarcinoma specific protocol. 5a is a portal venous phase image demonstrating a single low attenuation mass which does not appear to enhance. 5b is a 15 minute delayed image which demonstrates delayed enhancement of the liver mass (arrow) characteristic of Cholangiocarcinoma. Several other enhancing masses (arrowheads) are also seen which were not evident on the portal venous phase images.
When evaluating hepatic masses, it can be advantageous to have both late arterial and portal venous phase images (biphasic imaging, figure 4) since some tumors enhance briskly during the arterial phase (hepatocellular carcinoma, hepatic adenoma, follicular nodular hyperplasia (FNH), and hypervascular metastasis), but may be occult or difficult to characterize on portal venous phase imaging alone (figure 6). However, it should be stressed that the addition of late arterial phase images is only indicated if one of these tumors is suspected, or if there is a need for further characterization of a hepatic mass, since the large majority of patients will not benefit from the addition of this phase. In addition, if there is a need to definitively characterize a hepatic mass, MRI is generally more sensitive and specific, with no associated radiation dose.
Selected images from a biphasic CT of Focal Nodular Hyperplasia in the left hepatic lobe (arrow). These masses have characteristic early arterial enhancement (6a) with contrast wash out on the portal venous phase images (6b) from the mass making these lesions difficult to identify on portal venous phase images alone.
Detection and characterization of renal parenchymal masses is a frequent indication for CT. An initial noncontrast CT is important for detecting calcium or fat in a lesion, and to provide baseline attenuation of any renal masses. Following noncontrast scanning, intravenous contrast is injected and a corticomedullary phase is obtained at approximately 70 seconds (figure 7a, 7b). The corticomedullary phase is characterized by enhancement of the renal cortex as well as the renal vasculature. This phase is valuable in the evaluation of benign renal variants, lymphadenopathy and vasculature, however certain medullary renal masses may not be visible during this phase due to minimal enhancement of the medulla and collecting system. The parenchymal phase is obtained approximately 100-200 seconds after the injection of contrast material (figure 7c). Parenchymal phase imaging demonstrates continued enhancement of the cortex, enhancement of the medulla, and various levels of contrast material in the collecting system. The parenchymal phase is highly important for the detection and characterization of renal masses, parenchymal abnormalities, and the renal collecting system. [21] This method of imaging does not evaluate for abnormalities of the collecting system.
Selected images from a renal mass specific protocol CT. Corticomedullary phase (axial 7a) demonstrates peripheral enhancement of the renal cortex with minimal opacification of the renal medulla. There is a large renal cell carcinoma in the right kidney which can be differentiated from the normal renal parenchyma by the heterogeneous and differential enhancement. The renal artery and vein are opacified in this phase as well. The collecting system is not opacified (coronal reformat 7b). In the parenchymal phase, the renal cortex and the medulla are enhancing. The renal cell carcinoma in the left kidney is not as well defined when compared to the corticomedullary phase images, but is actually slightly more conspicuous. There is some contrast noted within the collecting system during this phase (7c).
Common renal masses can occasionally be differentiated from each other using this imaging technique. Renal cell carcinomas and oncocytomas typically demonstrate intense heterogeneous enhancement on the parenchymal phase images and cannot be reliably differentiated from each other but can be distinguished from other renal masses. Angiomyolipomas (AML’s) also demonstrate intense contrast enhancement but characteristically contain macroscopic fat which can be detected on the noncontrast images, and can help to differentiate AML’s from renal cell carcinomas and oncocytomas. Renal lymphoma on the other hand, will often have decreased enhancement when compared to the renal parenchyma on the parenchymal phase images.
CT urography (CTU) is commonly used in the evaluation of hematuria, and specifically tailored to image the renal collecting system, ureters and bladder in addition to the renal parenchyma. Initial imaging includes a noncontrast phase to detect renal calculi as a source of hematuria. Note that dual energy CT may eventually allow the noncontrast phase to be eliminated. Contrast enhancement techniques for CTU vary from institution to institution. A common technique used at our institution and others is a double bolus, single phase imaging algorithm. This technique is a hybrid contrast injection strategy that results in opacification of the renal parenchyma (parenchymal phase, figure 8a) and the collecting system, ureters, and bladder (excretory phase, figure 8b and 8c). At our institution, a small contrast bolus is administered initially, followed 10 minutes later with a larger bolus that is imaged in the corticomedullary phase. This ensures that contrast is being excreted by the kidneys and thus the collecting system is opacified (excretory phase) from the initial injection, and that the renal parenchyma is enhancing as well from the second injection (parenchymal phase). At the conclusion of the urography protocol, we also perform a scout image in the supine and prone position to allow a global evaluation of the collecting system. Excretory phase imaging allows for not only evaluation of the ureteral lumen, but also periureteral abnormalities including external masses and lymphadenopathy. [22]
Selected images from a CT Urography protocol CT. 8a is an axial CT image from the renal parenchymal phase. There is a mildly enhancing soft tissue mass in the left renal pelvis (arrow) consistent with a transitional cell carcinoma.
Pancreatic masses are often evaluated using both an early arterial (to evaluate for vascular involvement and thus resectability, figure 9a) and a later “pancreatic” phase (which optimizes pancreatic parenchymal enhancement and thus is best at differentiating pancreatic tumors from pancreatic parenchyma, figure 9b). Pancreatic adenocarcinoma typically is hypoenhancing when compared to the surrounding parenchyma. Most other common pancreatic tumors are hypervascular with avid enhancement (such as pancreatic neuroendocrine tumors) and appear brighter than the surrounding pancreatic parenchyma after the injection of intravenous contrast material.
Selected images from a pancreatic protocol. 9a is a noncontrast CT image demonstrating subtle fullness in the region of the pancreatic neck (arrow). 9b is a CT image performed during the early arterial phase during which there is opacification of the arterial structure with subtle fullness in the pancreatic neck (arrow). The pancreas is not enhancing during this phase. 9c was performed in a late arterial/pancreatic phase demonstrating normal enhancement of the pancreas (arrowhead) with a hypoenhancing mass (arrow) in the pancreatic neck. The pancreatic mass is more visible during this phase.
CT imaging should be performed to evaluate the specific clinical question, however incidental findings are noted in approximately 5-16 % of patients scanned for an unrelated reasons. [23, 24] It is not acceptable practice to anticipate the possibility of incidental lesions given their low incidence and prospectively add additional phases to routine protocols. Unfortunately, several recent surveys demonstrated that this practice is more common than might be anticipated, and contributes to unnecessary medical radiation exposure to a large population of patients. [16] Even more egregious is the fact that many of these findings could potentially be more accurately evaluated with other non-radiation imaging modalities such as MRI or ultrasound.
Although the management of incidental findings is not the focus of this chapter, some of these findings will require complete characterization with further CT phases such as arterial phase (certain liver tumors) or delayed images (adrenal lesions). Management of incidental findings has been controversial since they are relatively common, especially in the elderly, and more CT scanning may be required for further characterization of what is frequently a benign finding. In an effort to provide guidance on which incidental findings should be appropriately further evaluated and what the appropriate imaging modality should be, the ACR published a white paper on management of incidental findings detected at CT of the abdomen in 2010. [25]
Multiphase CT examinations are very important for the detection and characterization of certain clinical conditions, but should not be generalized for every patient undergoing CT of the abdomen and pelvis. A recent survey demonstrated that many physicians are routinely performing multiphase CT for the majority of patients in an attempt to prospectively characterize potential lesions detected during the scan. However, unindicated multiphase CT examinations are an important source of medical radiation that does not contribute to the care of patients. Adherence to published standards such as the ACR Appropriateness Criteria can both decrease medical radiation and optimize imaging for the specific clinical indication.
CT (computed tomography)
kVp (Kilovoltage)
ma (Milliamperes)
CTA (Computed Tomography Angiography)
CTU (Computed Tomography Urography)
MRI (Magnetic Resonance Imaging)
ACR (American College of Radiology)
Drug-resistant epilepsy (DRE) is defined as failure of two adequate trials of appropriately chosen and administered antiepileptic drugs. Approximately about 30% of epilepsy patients are drug resistant. Accountable reasons to treatment failure including failure to recognize epilepsy syndrome, poor drug compliance, lifestyle factors etc. In modern era of medicine, DRE patient should be encouraged to have early referral to tertiary epilepsy centre for presurgical evaluation. Comprehensive neurophysiology, structural neuroimaging, neuropsychological and psychiatric assessment are regarded as essential elements. Invasive electroencephalography (EEG) monitoring in terms of subdural electrodes, depth electrodes, foramen ovale electrodes, and more advanced technique using stereo-electroencephalography (SEEG) are strong armamentarium for epilepsy surgeon. Epilepsy surgery in terms of resection, disconnection or neuro-modulation should be recommended after a multi-disciplinary agreement.
\nPatients with epilepsy whose seizures do not respond successfully to anti-epileptic drug (AED) therapy are considered to have drug-resistant epilepsy (DRE). The prior equivalent term included medically intractable epilepsy or pharma-resistant epilepsy. This group of patient have the greatest burden of epilepsy related disabilities, and also added the significantly the healthcare resources expenses.
\nIn 2010, a consensus proposal from task force of the International League Against Epilepsy (ILAE) commission on therapeutic strategies. A framework comprises two “hierarchical” levels is proposed for definition of drug-resistant epilepsy (DRE). Level 1 is categorization of outcome to a therapeutic intervention and level 2 is core definition of DRE based on how many “informative” trials of antiepileptic drugs (AEDs) resulted in a “treatment failure” outcome. The definition of DRE usually requires failure of two adequate trials of appropriately chosen and administered antiepileptic drugs (be it sequential monotherapy or combined polytherapy) [1]. It is also important to include the impact of seizure factors (frequency, severity, associated behavioural problem) on individual psychosocial wellbeing. Such impact will lead to the physicians’ decision on drug options and the urgency of considering non-medical therapies.
\nOther important areas in the clinical assessment of DRE include the following.
\nThe prevalence of epilepsy patients aged 15 years or over in Chinese communities has been estimated at about 3–5.7 per 1000 [2], and about 40,000 Hong Kong people could be expected to have active epilepsy. The cumulative probability of a second attack at 1, 2, and 3 years was 30, 37 and 42% respectively. DRE comprised about one third of all epilepsy patients. A more recent study in 2008 showed the crude prevalence of active epilepsy and seizure disorder were estimated to be 3.94/1000. So the cases that should have under tertiary care for consideration of intensive work up will be around 1000 cases annually. There existed a treatment or referral gap of 20 years in the United States for this group of patient [3, 4]. It is foreseen that the local condition will be similar and an unmet need should call for more escalated awareness.
\nProspective studies with chronic epilepsy patients suggested that 70–80% of patients retain their status as intractable versus in remission [5]. In other words, a minority, around 20% of initial intractable seizure cases will archive seizure freedom in long run and vice versa. Postulated mechanism leading to intractability includes glial proliferation and dendritic sprouting with synaptic recognition [6] in mesial temporal sclerosis. The concept of paroxysmal depolarization shift (PDS) is cellular events in which rapidly repetitive action potentials are not followed by the usual refractory period, thereby generating a prolonged membrane depolarization. Repetitive neuronal firing probably underlies the interictal and ictal unit and local field recording of high frequency oscillations (HFO).
\nAnother compelling theory is the build-up of epileptic “neuronal network” (NN), via alternation in neuronal circuitry [7, 8]. A well-defined NN example is the limbic network with sequential propagation path via hippocampus, amygdala, lateral temporal neocortex and entorhinal cortex, medial thalamus and frontal inferior lobes. The interest on neuronal network analysis in epilepsy had gained strength with the use of high resolution recording techniques. Seizures start in a well-defined brain area and spread at great speed to connected brain area recruiting specific neuronal networks into typical oscillatory behaviour. Therefore, epilepsies should be considered as resulting from disturbed network interactions that implies “multi-targeted treatments” [9, 10, 11, 12, 13].
\nIn a recent study using incident cohort of drug resistant epilepsy, which adopt ILAE DRE criteria, there are different patterns of disease progression or trajectories observed [14]. The 30% proportion of patient eventually suffered from DRE was again observed. A long delay from disease onset to failure of second AED was also found. This finding might give insights to the pathogenesis as mentioned earlier.
\nThe mortality and morbidity of DRE, is in general, believed to be higher than that of seizure free patients or patient with good seizure control [15, 16, 17]. Even in those that suffered from infrequent seizure, their daily life and subjective well-being are also jeopardized in various extents [18].
\nIt is a common practice, among epileptologist, to subdivide the refractory epilepsy cases into temporal lobe epilepsy (TLE) and non-temporal lobe epilepsy (NTLE). The former also constitute two distinct groups, namely, mesial temporal lobe epilepsy (mTLE) and neocortical temporal lobe epilepsy (NeTLE), according to the clinical and radiological manifestations. Both mTLE and NTLE shared similar pathological substrates (Table 1) apart from the mesial temporal sclerosis only found in the former. The TLE patients usually present with complex partial seizures, with or without generalized seizure, depending on the neuronal network involved. Though a minority of these TLE will became seizure free after repeated drug trials [15], most of the patients will run a clinical course of refractory seizure attack, and indeed, they form the most well-known surgically remediable epilepsy syndrome [19].
\nPathological substrate | \nMesial TLE | \nNeocortical TLE | \n
---|---|---|
Mesial temporal sclerosis | \nMost common | \nNot present | \n
\n | \n||
Neoplastic | \nHigh grade or low grade glioma | \n|
Developmental | \nFocal cortical dysplasia | \n|
Infective | \nViral encephalitis | \n|
Vascular | \nCavernous angioma | \n|
Migrational disorder | \nDNET, ganglioglioma | \n|
Trauma | \nEncephalomalacia | \n
Temporal lobe epilepsy (TLE) pathology.
For the non TLE cases, the clinical and radiological features are diverse and also depend on the underlying etiologies or pathological substrates. In general, the seizure semiology is less well defined and the MRI abnormalities are variable and they are challenging in the perspective of seizure focus localization. Usually concerted effort and multi modalities investigations (in phase 1 of presurgical evaluation) are required [20].
\nBefore considering referral to tertiary centre for work up of DRE for surgical intervention, there are certain reasons of treatment failure that should be considered:
Failure to recognize a generalized epilepsy syndromes e.g. West’s syndrome, Rasmussen’s syndrome, autosomal dominant nocturnal frontal lobe epilepsy (ADNLE), early myoclonic encephalopathy (EME) etc.
Inappropriate choice of first line anti-epileptic drug (e.g. carbamazepine) that will aggravate seizures.
Poor drug compliance and lifestyle factors contributing to seizure recurrence.
These factors are often quoted as “pseudo-resistance” [21, 22, 23].
\nThere has been a number of regional and international consensus and guidelines related to comprehensive management of epilepsy surgery. In Hong Kong, the first guideline,
Diagnosis, review, and referral
Patient education
Following a first seizure
Investigations
Classification
Principles of management
Pharmacological or AED management
Management of drug-resistant epilepsy
Side-effects of AEDs
Presurgical evaluation of drug-resistant epilepsy
Other forms of treatment
Prolonged seizures in the community
Treatment of status epilepticus
Perioperative management of seizure
Older people with epilepsy
Children and young people with epilepsy
The guidelines had the updated version in 2017–2018 and the whole guideline was divided into four sections addressing the following aspects including use of antiepileptic drugs, guideline on status epilepticus, drug resistant epilepsy, and woman and epilepsy [25].
\nThere is observation that the longer the delay between the onset of DRE and the surgery, the lower the chance of postoperative seizure freedom and improved psychosocial outcome [26]. So a timely referral is mandatory for quality care of such group of patients.
\nAnyhow, before recruiting the patient, the first step is to identify the appropriate candidate. Conceptually, the eligibility criteria will include the following:
Patient and patient’s family understand and accept the surgical treatment and the potential risk
The seizure is disabling despite adequate and appropriate drug trial
The available imaging and neurophysiological data should be consistent with the possibility of a surgical remediable epileptic syndrome.
The first objective is to identify the epileptogenic zone, EZ by various invasive and non-invasive modalities of investigations. The more sophisticated or invasive approach will also depend on the clarity of structural identifiable pathologies in neuroimaging and the link with the clinical semiology.
\nThe second objective, after screening of the potential epileptogenic zone, is to develop strategies to safeguard the lesion can be safely resected with no significant physical or cognitive sequelae.
\nThe ultimate goal in presurgical evaluation is to identify the concept of “Six cortical zones” (Figure 1).
\nSix cortical zones.
From pragmatic point of view, detailed interview of patient and patient’s family and friends who can give detailed witness history and past background is mandatory. The interview should aim for recapitulating all relevant past history and probably risk factor or etiological factors. The latter will also give insights to prognosis of the epileptic disorder with respect to surgical treatment. A good example will be a case of post encephalitic epilepsy will render surgical intervention less successful [27].
\nThere should be a multi-disciplinary team and the respective investigations should include neuroimaging, psychiatric, neuropsychological and electrophysiological assessment. A tertiary level or above epilepsy centre should have the available epilepsy surgery presurgical investigations of in two different levels:
Level 1 investigations are compulsory to all epilepsy patients for better localization of epileptogenic zone by means of: (1) improvement of detection of structural lesion on MRI, (2) mapping the source of interictal epileptiform discharges, (3) detection of focal interictal brain dysfunction, and (4) detection of ictal focal brain hyperperfusion, and for assessment of risk of postoperative deficits by means of: (1) determination of hemisphere dominant for language, (2) prediction of risk of postoperative memory decline, (3) reduction of risk of visual field deficit, and (4) reduction of risk of motor deficit.
Level 2 investigations are indicated for possible epilepsy surgery candidates with no formal conclusion about the localization or extension of epileptogenic zone. They are generally referring to those invasive monitoring tools.
The neurophysiological evaluation includes interictal and ictal EEG sampling, which can be attained by non-invasive or invasive means in a long term recording manner.
\nThe inter-ictal EEG will provide important hint to lateralization or localization of EZ. This is particularly true in cases of TLE solely unilateral anterior temporal spike is a strong predictor of post-operative seizure freedom [28]. Anyhow, it is not uncommon to have unilateral MTS with bitemporal interictal epileptiform discharges found [29]. Another interictal EEG pattern with good localizing value is short bursts of low-voltage, high frequency oscillations associated with focal cortical dysplasia [30].
\nConceptually, the video EEG recording will capture the habitual seizures and the ictal EEG discharge and the lateralization and localization of the ictal onset zone can be deduced from analysis of adequate number of captured events.
\nAfter combined analysis of ictal and interictal EEG data, the irritative and ictal onset zones can be estimated [31].
\nInvasive recording is indicated when there is a hypothesis of epileptogenic zone that is not fully supported by the non- invasive diagnostic modalities results. These difficult scenarios are especially found in the non-lesional cases [32, 33].
\nMagnetic resonance imaging (MRI) of brain constitutes the basic, yet the most important investigation of choice in presurgical evaluation. It is particularly true in some epileptic disorder like temporal lobe epilepsy, of which mesial temporal sclerosis is the pathological substrate, got its unique radiological-anatomical correlates:
\nThe MRI features of hippocampal sclerosis include (1) hippocampal atrophy on T1, (2) increased signal on T2-weighted images or fluid-attenuated inversion recovery (FLAIR) sequences, and (3) decreased signal on inversion recovery sequences [34, 35].
\nThe detection of these abnormalities should be carried out with optimized imaging techniques, which include angulated coronal sections obtained perpendicular to the long axis of the hippocampal structures.
\nFor the extratemporal substrates, MRI can also define hemimegalencephaly, schizencephaly, and focal subcortical heterotopia. Focal cortical dysplasia is the most common developmental pathology in children with extratemporal lobe seizures, and there is an international classification to define the underlying histopathology and foretell the outlook of surgical success [36].
\n3 T MRI system has better signal-to-noise ratio, spatial and tissue contrast resolution than a 1.5 T system. Studies have shown that for initially nonlesional cases scanned by 1.5 T system with standard MRI brain protocol, more than half had new findings after rescanned by 3 T MRI system with multichannel phased-array coils (Figure 2).
\nPatient was regarded to be non-lesional epilepsy initially in 1.5 T MRI (a) and found to have cortical dysplasia in left temporal stem in 3 T MRI (b). Another epilepsy patient had very subtle lesion in right subependymal region in 1.5 T MRI (c) and confirmed to be subependymal heterotopia by 3 T MRI (d).
The recommended MRI epilepsy protocol includes:
Volume acquisition T1W sequence acquired in oblique coronal orientation, orthogonal to long axis of hippocampus, covers whole brain in 0.9–1 mm partition
Oblique coronal T2WTSE an T2W FLAIR sequences, orientated perpendicular to long axis of hippocampus, 2–3 mm slice thickness
Axial T2W or T2W FLAIR sequence of 3 mm slice thickness of whole brain
Diffusion tensor imaging (DTI) and tractography can be used for fiber tracking and noninvasive structural network mapping and is an optional imaging sequence to aid preoperative planning for surgical trajectory. Recent study reported identification of significant diffusion abnormalities of tract sections in ipsilateral dorsal fornix and contralateral parahippocampal white matter bundle in patients with poor postoperative seizure control. Though more studies are warranted to make conclusion, these results may help in understanding the mechanism of postoperative persistent seizure and may act as imaging prognosticator for operation outcome.
\nHowever, there are pathological substrates that go beyond the detection of MRI analysis. As a result, multi-modality imaging of the brain will come into play [37, 38, 39].
\nThere are some functional neuroimaging modalities, namely PET, SPECT, fMRI and magnetoencephalography (MEG). Some of these scans can be co-registered with MRI to give more detailed structural-functional correlated imaging analysis. They will aid the localization of epileptogenic zone, and the sensitivity will largely depend on the epileptic syndrome. MEG helps to localize the epileptogenic zone and delineate the relationship between the suspected abnormality and the relevant regions in the brain. The placement of invasive electrodes can be guided by the MEG findings. A MEG-guided review of MRI may reveal subtle abnormalities and permit a precise surgical excision of the irritative zone. MEG is also indicated in patients with multiple intracerebral lesions, such as multiple cavernomas, in whom a sole epileptogenic lesion may be identified for lesionectomy [40, 41, 42, 43].
\nWith such information, the indication of further invasive studies will also be justified (Figure 3).
\nAlgorithm of workup of refractory epilepsy.
Conceptually, the principle of neuropsychological batteries of test lies on the functional neuroanatomy(Table 2). It is controversial to state the prediction of postoperative cognitive outcome should be based on the side that was to be resected or the side that would remain following surgery.
\n\n | Cognitive function | \nRemark | \n
---|---|---|
Temporal lobe | \nMemory and language | \nLeft side represents verbal memory Right side represents visual memory | \n
Frontal lobe | \nExecutive and behavior | \n\n |
Posterior part | \nPerception and higher sensory | \n\n |
Functional neuroanatomy.
There is always a long debate between the usage of WADA test and fMRI in determination of language dominance. In majority of cases, fMRI can clearly lateralize the language localization. However, in cases having agitation or mental compromise, or there is bilateral activations in fMRI, WADA test should be considered as a definitive test (Figure 4). Anyhow, the lower the mental reserve and the higher the functional adequacy of the resected tissue will preclude the surgical feasibility [44, 45].
\nClinical photo showing the setup for WADA test.
It is recommended that the presurgical evaluation should include a thorough psychiatric assessment [32]. There are several reasons:
The prevalence of psychiatric disorder is prevalent in epilepsy patients, and psychopathology is common in patients with TLE.
Appropriate assessment might help to anticipate acute anxiety, delusions, and the latter symptoms might be aggravated in some temporal epilepsy cases, in perioperative period
The life time history of psychiatric disorder was associated with worst post-surgical seizure outcome, though the existence of stable psychiatric disorder does not preclude epilepsy surgery.
The areas of assessment should include four domains, namely, behavioural, psychiatric, self-esteem profile and quality of life.
\nIn general, the indications to consider invasive EEG monitoring are as the followings:
To define precisely the epileptogenic zone when non-invasive data are not concordant
To conclude the divergence of non-invasive data in different regions
To map eloquent cortical and subcortical function for resective surgery planning
To further validate the epileptogenic zone or provide information of prognostic value
To perform therapeutic treatment for active regions using thermocoagulation
Traditionally, modalities of invasive EEG monitoring include subdural electrodes, intracerebral depth electrodes, epidural peg electrodes and foramen ovale electrodes. A comprehensive review on risks and benefits in using subdural and depth electrodes showed that the related complications include epidural or subdural haemorrhage, intracerebral haemorrhage or contusion, meningitis, oedema around electrode, cerebral oedema, increased intracranial pressure etc. The overall complication rate ranges from 0.4% to 6.6%.
\nStereoelectroencephalography (SEEG) is getting its popularity to enable precise recordings from deep cortical areas in bilateral and multiple lobes without subjecting the patients to have bilateral large craniotomies. The key and most important concept in considering SEEG is to test individualized
Types of invasive EEG studies: (a) subdural strips and grids, (b) intracerebral depth electrodes, (c) insular depth electrodes insertion with neuro-navigation guidance, (d) foramen ovale electrodes, and (e) stereoelectroencephalography (SEEG).
The decision of surgical intervention is usually made in a consensus agreement among the discipline which carry out the investigation in a multi-disciplinary patient management conference in each epilepsy surgery centre. Basically it is a rational estimation of the precision of the epileptogenic zone (thus the success rate of seizure cure) and the risk benefit analysis of the potential post-operative risk.
\nIn general, the outcome will be more favorable for lesional epileptic syndrome with concordance of investigation results and neuropsychological proof of “absence” of important cognitive function within the resected areas. On the contrary, the lack of concordance, the presence of important function in the pathological substrate will preclude the surgical feasibility. Besides the disease factor, there are also patient factors like seizure frequency, duration of illness, comorbidity that will govern the prognostication [50].
\nConventionally, the operative outcome will be categorized in four classes according to Engel’s classification [51] (Table 3).
\nClass I | \nFree of disabling seizures | \n
Class II | \nRare disabling seizures (“almost seizure-free”) | \n
Class III | \nWorthwhile improvement | \n
Class IV | \nNo worthwhile improvement | \n
Engel’s classification.
The rationale is to have complete resection of the epileptogenic zone. Broadly there are three types of epilepsy surgery
Curative, respective surgery in terms of resection surgery involves temporal lobe surgery and extratemporal lobe surgery. Among the different epileptic syndrome, the mesial temporal sclerosis usually has the most favorable seizure outcome: 70% of the patients have Engel’s Class I [52, 53].
Palliative surgery in terms of disconnection surgery includes corpus callosotomy, hemispherectomy (anatomical/functional), hemispherotomy, multiple subpial transections. All these procedure are often performed in pediatric group of patients and they had been shown to have seizure reduction ranged from 40 to 50% [54].
Modulatory, in terms of deep brain stimulation (DBS), vague nerve stimulation (VNS), responsive neurostimulation (RNS) and gamma knife radiosurgery [55]
Epilepsy surgery for temporal lobe epilepsy is usually recommended because of promising result. One study including 80 patients with temporal lobe epilepsy showed that the cumulative proportion of patients who were free of seizures impairing awareness was 58% in the surgical group and 8% in the medical group [56]. The Early Randomized Surgical Epilepsy Trial (ERSET) included 38 patients with mesial temporal lobe epilepsy and showed that zero of 23 participants in the medical group and 11 of 15 in the surgical group were seizure free during year 2 of follow-up [57]. Another study including more than 3000 patients from Germany concluded that the number of non-lesional patients and the need for intracranial recordings increased, and more than 50% of evaluated patients did not undergo surgery [58].
\nThere is always difficulty in identification of the epileptogenic zone in non-lesional neocortical epilepsy. Seizure free outcomes are about 55% for non-lesional temporal lobe epilepsy and 43% for non-lesional extratemporal lobe epilepsy patients. Concordance with two or more presurgical evaluations including interictal EEG, ictal EEG, FDG-PET, and ictal SPECT was significantly related to a seizure-free outcome. Another study showed that 38% of non-lesional epilepsy patients had an excellent outcome after resective epilepsy surgery after long-term intracranial EEG. In temporal lobe epilepsy with MRI negative and PET positive findings, surgery could achieve Class I surgical outcomes at postoperative 2 years in about 82% [59, 60].
\nFailure of epilepsy surgery may be caused by wrong localization of the epileptogenic zone, very widespread epileptogenic zones and very limited resection of the suspected epileptogenic zone.
\nIn patient after mesial temporal resection, seizure may arise from neocortical regions instead of from residual hippocampal structure. This may imply the existence of regional epileptogenicity. Hippocampus represents the area of cortex with the lowest threshold for seizure generation and the surrounding neocortical tissue also exhibiting epileptogenicity then becomes the site of ictal onset. About 25% of patients with seizure relapse after mesial temporal sclerosis may have seizure onset in the contralateral temporal region.
\nExtensive reevaluation of these patients is suggested for consideration of reoperation if epileptogenic focus can be localized.
\nMinimally invasive intracranial endovascular EEG monitoring by means of nanowire and catheter and stent-electrode recordings is evolving [61]. High frequency Oscillations (HFOs) are believed as a potential marker for detection of epileptogenicity and predictive factor for epilepsy surgery outcome. However, a meta-analysis was able to show the significant but small relation between removal of HFO-generating brain region and outcome [62, 63, 64].
\nThe prerequisite of seizure origin in a well circumscribed area of brain and the precision of localization of such epileptogenic zone by epilepsy work up make modern epilepsy surgery a promising treatment modality for refractory epilepsy.
\nThe pre-operative assessment, which include multiple disciplines, however, should be focused on two important conceptual facets
Data concordance: the individual seizure pattern is ascribed to the hypothetical brain lesions, as suggested by neurophysiological and radiological data.
Functional reserve: the brain pathological region, if being resected, will not leave patient with significant morbidities
The advent of wide range of diagnostic tests and available surgical techniques has widened the applicability of surgical treatment. The success rate of these surgical interventions range from 10 to 20% of seizure reduction to more than 70% seizure freedom, depend on the different scenario.
\nIn conclusion, epilepsy surgery for drug resistance epilepsy involves close collaboration and teamwork by multi-disciplinary specialties. Epilepsy surgery could be performed in different epilepsy centres. Patients should be referred early in their refractory disease course to a higher level epilepsy center for evaluation of the complex surgical options. Public education and promotion on management of refractory epilepsy by surgical treatments should be encouraged and lead by our local professional bodies and health organizations.
\nIntechOpen books are available online by accessing all published content on a chapter level.
",metaTitle:"Access policy",metaDescription:"IntechOpen books are available online by accessing all published content on a chapter level",metaKeywords:null,canonicalURL:null,contentRaw:'[{"type":"htmlEditorComponent","content":"All IntechOpen published chapters are available OPEN ACCESS can be read without the requirement for registration of any kind, immediately upon publication, without any barrier.
\\n\\nThe HTML version, as well as the PDF version of publications dated before 2012 that are accessible through a reader, are available to readers with no restriction.
\\n\\nThe full content of chapters can be read, copied and printed from the link location of the chapter and these actions are not limited or restricted in any way.
\\n\\nRegistration is requested only to download the PDF of the chapter. There are no subscription fees and there is no charge to user groups.
\\n\\nIntechOpen chapters are distributed under CC BY 3.0 licences allowing users to “copy, use, distribute, transmit and display the work publicly and to make and distribute derivative works, in any digital medium for any responsible purpose, subject to proper attribution of authorship...” and there is no non-commercial restriction.
\\n\\nAuthors may post published works to any repository or website with no delay, and Authors and Editors of IntechOpen books have direct access to the PDF of the full book.
\\n\\nAll published content can be crawled for indexing. Full text and metadata may be accessed with instructions publicly posted.
\\n\\nAll IntechOpen books are indexed in CLOCKSS and preservation of access to published content is clearly indicated.
\\n\\nPolicy last updated: 2021-02-26
\\n"}]'},components:[{type:"htmlEditorComponent",content:"All IntechOpen published chapters are available OPEN ACCESS can be read without the requirement for registration of any kind, immediately upon publication, without any barrier.
\n\nThe HTML version, as well as the PDF version of publications dated before 2012 that are accessible through a reader, are available to readers with no restriction.
\n\nThe full content of chapters can be read, copied and printed from the link location of the chapter and these actions are not limited or restricted in any way.
\n\nRegistration is requested only to download the PDF of the chapter. There are no subscription fees and there is no charge to user groups.
\n\nIntechOpen chapters are distributed under CC BY 3.0 licences allowing users to “copy, use, distribute, transmit and display the work publicly and to make and distribute derivative works, in any digital medium for any responsible purpose, subject to proper attribution of authorship...” and there is no non-commercial restriction.
\n\nAuthors may post published works to any repository or website with no delay, and Authors and Editors of IntechOpen books have direct access to the PDF of the full book.
\n\nAll published content can be crawled for indexing. Full text and metadata may be accessed with instructions publicly posted.
\n\nAll IntechOpen books are indexed in CLOCKSS and preservation of access to published content is clearly indicated.
\n\nPolicy last updated: 2021-02-26
\n"}]},successStories:{items:[]},authorsAndEditors:{filterParams:{sort:"featured,name"},profiles:[{id:"6700",title:"Dr.",name:"Abbass A.",middleName:null,surname:"Hashim",slug:"abbass-a.-hashim",fullName:"Abbass A. Hashim",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/6700/images/1864_n.jpg",biography:"Currently I am carrying out research in several areas of interest, mainly covering work on chemical and bio-sensors, semiconductor thin film device fabrication and characterisation.\nAt the moment I have very strong interest in radiation environmental pollution and bacteriology treatment. The teams of researchers are working very hard to bring novel results in this field. I am also a member of the team in charge for the supervision of Ph.D. students in the fields of development of silicon based planar waveguide sensor devices, study of inelastic electron tunnelling in planar tunnelling nanostructures for sensing applications and development of organotellurium(IV) compounds for semiconductor applications. I am a specialist in data analysis techniques and nanosurface structure. I have served as the editor for many books, been a member of the editorial board in science journals, have published many papers and hold many patents.",institutionString:null,institution:{name:"Sheffield Hallam University",country:{name:"United Kingdom"}}},{id:"54525",title:"Prof.",name:"Abdul Latif",middleName:null,surname:"Ahmad",slug:"abdul-latif-ahmad",fullName:"Abdul Latif Ahmad",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:null},{id:"20567",title:"Prof.",name:"Ado",middleName:null,surname:"Jorio",slug:"ado-jorio",fullName:"Ado Jorio",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Universidade Federal de Minas Gerais",country:{name:"Brazil"}}},{id:"47940",title:"Dr.",name:"Alberto",middleName:null,surname:"Mantovani",slug:"alberto-mantovani",fullName:"Alberto Mantovani",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:null},{id:"12392",title:"Mr.",name:"Alex",middleName:null,surname:"Lazinica",slug:"alex-lazinica",fullName:"Alex Lazinica",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/12392/images/7282_n.png",biography:"Alex Lazinica is the founder and CEO of IntechOpen. After obtaining a Master's degree in Mechanical Engineering, he continued his PhD studies in Robotics at the Vienna University of Technology. Here he worked as a robotic researcher with the university's Intelligent Manufacturing Systems Group as well as a guest researcher at various European universities, including the Swiss Federal Institute of Technology Lausanne (EPFL). During this time he published more than 20 scientific papers, gave presentations, served as a reviewer for major robotic journals and conferences and most importantly he co-founded and built the International Journal of Advanced Robotic Systems- world's first Open Access journal in the field of robotics. Starting this journal was a pivotal point in his career, since it was a pathway to founding IntechOpen - Open Access publisher focused on addressing academic researchers needs. Alex is a personification of IntechOpen key values being trusted, open and entrepreneurial. Today his focus is on defining the growth and development strategy for the company.",institutionString:null,institution:{name:"TU Wien",country:{name:"Austria"}}},{id:"19816",title:"Prof.",name:"Alexander",middleName:null,surname:"Kokorin",slug:"alexander-kokorin",fullName:"Alexander Kokorin",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/19816/images/1607_n.jpg",biography:"Alexander I. Kokorin: born: 1947, Moscow; DSc., PhD; Principal Research Fellow (Research Professor) of Department of Kinetics and Catalysis, N. Semenov Institute of Chemical Physics, Russian Academy of Sciences, Moscow.\r\nArea of research interests: physical chemistry of complex-organized molecular and nanosized systems, including polymer-metal complexes; the surface of doped oxide semiconductors. He is an expert in structural, absorptive, catalytic and photocatalytic properties, in structural organization and dynamic features of ionic liquids, in magnetic interactions between paramagnetic centers. The author or co-author of 3 books, over 200 articles and reviews in scientific journals and books. He is an actual member of the International EPR/ESR Society, European Society on Quantum Solar Energy Conversion, Moscow House of Scientists, of the Board of Moscow Physical Society.",institutionString:null,institution:{name:"Semenov Institute of Chemical Physics",country:{name:"Russia"}}},{id:"62389",title:"PhD.",name:"Ali Demir",middleName:null,surname:"Sezer",slug:"ali-demir-sezer",fullName:"Ali Demir Sezer",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/62389/images/3413_n.jpg",biography:"Dr. Ali Demir Sezer has a Ph.D. from Pharmaceutical Biotechnology at the Faculty of Pharmacy, University of Marmara (Turkey). He is the member of many Pharmaceutical Associations and acts as a reviewer of scientific journals and European projects under different research areas such as: drug delivery systems, nanotechnology and pharmaceutical biotechnology. Dr. Sezer is the author of many scientific publications in peer-reviewed journals and poster communications. Focus of his research activity is drug delivery, physico-chemical characterization and biological evaluation of biopolymers micro and nanoparticles as modified drug delivery system, and colloidal drug carriers (liposomes, nanoparticles etc.).",institutionString:null,institution:{name:"Marmara University",country:{name:"Turkey"}}},{id:"61051",title:"Prof.",name:"Andrea",middleName:null,surname:"Natale",slug:"andrea-natale",fullName:"Andrea Natale",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:null},{id:"100762",title:"Prof.",name:"Andrea",middleName:null,surname:"Natale",slug:"andrea-natale",fullName:"Andrea Natale",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"St David's Medical Center",country:{name:"United States of America"}}},{id:"107416",title:"Dr.",name:"Andrea",middleName:null,surname:"Natale",slug:"andrea-natale",fullName:"Andrea Natale",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Texas Cardiac Arrhythmia",country:{name:"United States of America"}}},{id:"64434",title:"Dr.",name:"Angkoon",middleName:null,surname:"Phinyomark",slug:"angkoon-phinyomark",fullName:"Angkoon Phinyomark",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/64434/images/2619_n.jpg",biography:"My name is Angkoon Phinyomark. I received a B.Eng. degree in Computer Engineering with First Class Honors in 2008 from Prince of Songkla University, Songkhla, Thailand, where I received a Ph.D. degree in Electrical Engineering. My research interests are primarily in the area of biomedical signal processing and classification notably EMG (electromyography signal), EOG (electrooculography signal), and EEG (electroencephalography signal), image analysis notably breast cancer analysis and optical coherence tomography, and rehabilitation engineering. I became a student member of IEEE in 2008. During October 2011-March 2012, I had worked at School of Computer Science and Electronic Engineering, University of Essex, Colchester, Essex, United Kingdom. In addition, during a B.Eng. I had been a visiting research student at Faculty of Computer Science, University of Murcia, Murcia, Spain for three months.\n\nI have published over 40 papers during 5 years in refereed journals, books, and conference proceedings in the areas of electro-physiological signals processing and classification, notably EMG and EOG signals, fractal analysis, wavelet analysis, texture analysis, feature extraction and machine learning algorithms, and assistive and rehabilitative devices. I have several computer programming language certificates, i.e. Sun Certified Programmer for the Java 2 Platform 1.4 (SCJP), Microsoft Certified Professional Developer, Web Developer (MCPD), Microsoft Certified Technology Specialist, .NET Framework 2.0 Web (MCTS). I am a Reviewer for several refereed journals and international conferences, such as IEEE Transactions on Biomedical Engineering, IEEE Transactions on Industrial Electronics, Optic Letters, Measurement Science Review, and also a member of the International Advisory Committee for 2012 IEEE Business Engineering and Industrial Applications and 2012 IEEE Symposium on Business, Engineering and Industrial Applications.",institutionString:null,institution:{name:"Joseph Fourier University",country:{name:"France"}}},{id:"55578",title:"Dr.",name:"Antonio",middleName:null,surname:"Jurado-Navas",slug:"antonio-jurado-navas",fullName:"Antonio Jurado-Navas",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/55578/images/4574_n.png",biography:"Antonio Jurado-Navas received the M.S. degree (2002) and the Ph.D. degree (2009) in Telecommunication Engineering, both from the University of Málaga (Spain). He first worked as a consultant at Vodafone-Spain. From 2004 to 2011, he was a Research Assistant with the Communications Engineering Department at the University of Málaga. In 2011, he became an Assistant Professor in the same department. From 2012 to 2015, he was with Ericsson Spain, where he was working on geo-location\ntools for third generation mobile networks. Since 2015, he is a Marie-Curie fellow at the Denmark Technical University. His current research interests include the areas of mobile communication systems and channel modeling in addition to atmospheric optical communications, adaptive optics and statistics",institutionString:null,institution:{name:"University of Malaga",country:{name:"Spain"}}}],filtersByRegion:[{group:"region",caption:"North America",value:1,count:5818},{group:"region",caption:"Middle and South America",value:2,count:5287},{group:"region",caption:"Africa",value:3,count:1757},{group:"region",caption:"Asia",value:4,count:10539},{group:"region",caption:"Australia and Oceania",value:5,count:909},{group:"region",caption:"Europe",value:6,count:15929}],offset:12,limit:12,total:119317},chapterEmbeded:{data:{}},editorApplication:{success:null,errors:{}},ofsBooks:{filterParams:{topicId:"21"},books:[{type:"book",id:"10671",title:"Connected Adolescence",subtitle:null,isOpenForSubmission:!0,hash:"f005179bb7f6cd7c531a00cd8da18eaa",slug:null,bookSignature:"Prof. Massimo Ingrassia and Prof. Loredana Benedetto",coverURL:"https://cdn.intechopen.com/books/images_new/10671.jpg",editedByType:null,editors:[{id:"193901",title:"Prof.",name:"Massimo",surname:"Ingrassia",slug:"massimo-ingrassia",fullName:"Massimo Ingrassia"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"10814",title:"Anxiety, Uncertainty, and Resilience During the Pandemic Period - Anthropological and Psychological Perspectives",subtitle:null,isOpenForSubmission:!0,hash:"2db4d2a6638d2c66f7a5741d0f8fe4ae",slug:null,bookSignature:"Prof. Fabio Gabrielli and Dr. Floriana Irtelli",coverURL:"https://cdn.intechopen.com/books/images_new/10814.jpg",editedByType:null,editors:[{id:"259407",title:"Prof.",name:"Fabio",surname:"Gabrielli",slug:"fabio-gabrielli",fullName:"Fabio Gabrielli"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"10908",title:"Decision Making",subtitle:null,isOpenForSubmission:!0,hash:"126486f7f91e18e2e3539a32c38be7b1",slug:null,bookSignature:"Prof. Fausto Pedro García Márquez",coverURL:"https://cdn.intechopen.com/books/images_new/10908.jpg",editedByType:null,editors:[{id:"22844",title:"Prof.",name:"Fausto Pedro",surname:"García Márquez",slug:"fausto-pedro-garcia-marquez",fullName:"Fausto Pedro García Márquez"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"10909",title:"Psychometrics",subtitle:null,isOpenForSubmission:!0,hash:"51388e9ab6c536936b8da4f9c226252e",slug:null,bookSignature:"",coverURL:"https://cdn.intechopen.com/books/images_new/10909.jpg",editedByType:null,editors:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"10910",title:"Learning Disabilities",subtitle:null,isOpenForSubmission:!0,hash:"8350f78c26c99f01f8130f772475504e",slug:null,bookSignature:"",coverURL:"https://cdn.intechopen.com/books/images_new/10910.jpg",editedByType:null,editors:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"10981",title:"Sport Psychology in Sports, Exercise and Physical Activity",subtitle:null,isOpenForSubmission:!0,hash:"5214c44bdc42978449de0751ca364684",slug:null,bookSignature:"Ph.D. Hilde G. Nielsen",coverURL:"https://cdn.intechopen.com/books/images_new/10981.jpg",editedByType:null,editors:[{id:"158692",title:"Ph.D.",name:"Hilde G.",surname:"Nielsen",slug:"hilde-g.-nielsen",fullName:"Hilde G. Nielsen"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}],filtersByTopic:[{group:"topic",caption:"Agricultural and Biological Sciences",value:5,count:27},{group:"topic",caption:"Biochemistry, Genetics and Molecular Biology",value:6,count:8},{group:"topic",caption:"Business, Management and Economics",value:7,count:3},{group:"topic",caption:"Chemistry",value:8,count:11},{group:"topic",caption:"Computer and Information Science",value:9,count:9},{group:"topic",caption:"Earth and Planetary Sciences",value:10,count:10},{group:"topic",caption:"Engineering",value:11,count:24},{group:"topic",caption:"Environmental Sciences",value:12,count:2},{group:"topic",caption:"Immunology and Microbiology",value:13,count:4},{group:"topic",caption:"Materials Science",value:14,count:7},{group:"topic",caption:"Mathematics",value:15,count:3},{group:"topic",caption:"Medicine",value:16,count:47},{group:"topic",caption:"Neuroscience",value:18,count:3},{group:"topic",caption:"Pharmacology, Toxicology and Pharmaceutical Science",value:19,count:3},{group:"topic",caption:"Physics",value:20,count:4},{group:"topic",caption:"Psychology",value:21,count:4},{group:"topic",caption:"Robotics",value:22,count:2},{group:"topic",caption:"Social Sciences",value:23,count:3},{group:"topic",caption:"Technology",value:24,count:1},{group:"topic",caption:"Veterinary Medicine and Science",value:25,count:2}],offset:12,limit:12,total:6},popularBooks:{featuredBooks:[{type:"book",id:"8472",title:"Bioactive Compounds in Nutraceutical and Functional Food for Good Human Health",subtitle:null,isOpenForSubmission:!1,hash:"8855452919b8495810ef8e88641feb20",slug:"bioactive-compounds-in-nutraceutical-and-functional-food-for-good-human-health",bookSignature:"Kavita Sharma, Kanchan Mishra, Kula Kamal Senapati and Corina Danciu",coverURL:"https://cdn.intechopen.com/books/images_new/8472.jpg",editors:[{id:"197731",title:"Dr.",name:"Kavita",middleName:null,surname:"Sharma",slug:"kavita-sharma",fullName:"Kavita Sharma"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"9685",title:"Agroecosystems",subtitle:"Very Complex Environmental Systems",isOpenForSubmission:!1,hash:"c44f7b43a9f9610c243dc32300d37df6",slug:"agroecosystems-very-complex-environmental-systems",bookSignature:"Marcelo L. Larramendy and Sonia Soloneski",coverURL:"https://cdn.intechopen.com/books/images_new/9685.jpg",editors:[{id:"14764",title:"Dr.",name:"Marcelo L.",middleName:null,surname:"Larramendy",slug:"marcelo-l.-larramendy",fullName:"Marcelo L. Larramendy"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"8564",title:"Cell Interaction",subtitle:"Molecular and Immunological Basis for Disease Management",isOpenForSubmission:!1,hash:"98d7f080d80524285f091e72a8e92a6d",slug:"cell-interaction-molecular-and-immunological-basis-for-disease-management",bookSignature:"Bhawana Singh",coverURL:"https://cdn.intechopen.com/books/images_new/8564.jpg",editors:[{id:"315192",title:"Dr.",name:"Bhawana",middleName:null,surname:"Singh",slug:"bhawana-singh",fullName:"Bhawana Singh"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"9629",title:"Electroencephalography",subtitle:"From Basic Research to Clinical Applications",isOpenForSubmission:!1,hash:"8147834b6c6deeeec40f407c71ad60b4",slug:"electroencephalography-from-basic-research-to-clinical-applications",bookSignature:"Hideki Nakano",coverURL:"https://cdn.intechopen.com/books/images_new/9629.jpg",editors:[{id:"196461",title:"Prof.",name:"Hideki",middleName:null,surname:"Nakano",slug:"hideki-nakano",fullName:"Hideki Nakano"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"9161",title:"Frailty in the Elderly",subtitle:"Understanding and Managing Complexity",isOpenForSubmission:!1,hash:"a4f0f2fade8fb8ba35c405f5ad31a823",slug:"frailty-in-the-elderly-understanding-and-managing-complexity",bookSignature:"Sara Palermo",coverURL:"https://cdn.intechopen.com/books/images_new/9161.jpg",editors:[{id:"233998",title:"Ph.D.",name:"Sara",middleName:null,surname:"Palermo",slug:"sara-palermo",fullName:"Sara Palermo"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"8760",title:"Structure Topology and Symplectic Geometry",subtitle:null,isOpenForSubmission:!1,hash:"8974840985ec3652492c83e20233bf02",slug:"structure-topology-and-symplectic-geometry",bookSignature:"Kamal Shah and Min Lei",coverURL:"https://cdn.intechopen.com/books/images_new/8760.jpg",editors:[{id:"231748",title:"Dr.",name:"Kamal",middleName:null,surname:"Shah",slug:"kamal-shah",fullName:"Kamal Shah"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"9385",title:"Renewable Energy",subtitle:"Technologies and Applications",isOpenForSubmission:!1,hash:"a6b446d19166f17f313008e6c056f3d8",slug:"renewable-energy-technologies-and-applications",bookSignature:"Tolga Taner, Archana Tiwari and Taha Selim Ustun",coverURL:"https://cdn.intechopen.com/books/images_new/9385.jpg",editors:[{id:"197240",title:"Associate Prof.",name:"Tolga",middleName:null,surname:"Taner",slug:"tolga-taner",fullName:"Tolga Taner"}],equalEditorOne:{id:"186791",title:"Dr.",name:"Archana",middleName:null,surname:"Tiwari",slug:"archana-tiwari",fullName:"Archana Tiwari",profilePictureURL:"https://mts.intechopen.com/storage/users/186791/images/system/186791.jpg",biography:"Dr. Archana Tiwari is Associate Professor at Amity University, India. Her research interests include renewable sources of energy from microalgae and further utilizing the residual biomass for the generation of value-added products, bioremediation through microalgae and microbial consortium, antioxidative enzymes and stress, and nutraceuticals from microalgae. She has been working on algal biotechnology for the last two decades. She has published her research in many international journals and has authored many books and chapters with renowned publishing houses. She has also delivered talks as an invited speaker at many national and international conferences. Dr. Tiwari is the recipient of several awards including Researcher of the Year and Distinguished Scientist.",institutionString:"Amity University",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"3",totalChapterViews:"0",totalEditedBooks:"1",institution:{name:"Amity University",institutionURL:null,country:{name:"India"}}},equalEditorTwo:{id:"197609",title:"Prof.",name:"Taha Selim",middleName:null,surname:"Ustun",slug:"taha-selim-ustun",fullName:"Taha Selim Ustun",profilePictureURL:"https://mts.intechopen.com/storage/users/197609/images/system/197609.jpeg",biography:"Dr. Taha Selim Ustun received a Ph.D. in Electrical Engineering from Victoria University, Melbourne, Australia. He is a researcher with the Fukushima Renewable Energy Institute, AIST (FREA), where he leads the Smart Grid Cybersecurity Laboratory. Prior to that, he was a faculty member with the School of Electrical and Computer Engineering, Carnegie Mellon University, Pittsburgh, PA, USA. His current research interests include power systems protection, communication in power networks, distributed generation, microgrids, electric vehicle integration, and cybersecurity in smart grids. He serves on the editorial boards of IEEE Access, IEEE Transactions on Industrial Informatics, Energies, Electronics, Electricity, World Electric Vehicle and Information journals. Dr. Ustun is a member of the IEEE 2004 and 2800, IEC Renewable Energy Management WG 8, and IEC TC 57 WG17. He has been invited to run specialist courses in Africa, India, and China. He has delivered talks for the Qatar Foundation, the World Energy Council, the Waterloo Global Science Initiative, and the European Union Energy Initiative (EUEI). His research has attracted funding from prestigious programs in Japan, Australia, the European Union, and North America.",institutionString:"Fukushima Renewable Energy Institute, AIST (FREA)",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"1",totalChapterViews:"0",totalEditedBooks:"0",institution:{name:"National Institute of Advanced Industrial Science and Technology",institutionURL:null,country:{name:"Japan"}}},equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"2160",title:"MATLAB",subtitle:"A Fundamental Tool for Scientific Computing and Engineering Applications - Volume 1",isOpenForSubmission:!1,hash:"dd9c658341fbd264ed4f8d9e6aa8ca29",slug:"matlab-a-fundamental-tool-for-scientific-computing-and-engineering-applications-volume-1",bookSignature:"Vasilios N. Katsikis",coverURL:"https://cdn.intechopen.com/books/images_new/2160.jpg",editors:[{id:"12289",title:"Prof.",name:"Vasilios",middleName:"N.",surname:"Katsikis",slug:"vasilios-katsikis",fullName:"Vasilios Katsikis"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"3568",title:"Recent Advances in Plant in vitro Culture",subtitle:null,isOpenForSubmission:!1,hash:"830bbb601742c85a3fb0eeafe1454c43",slug:"recent-advances-in-plant-in-vitro-culture",bookSignature:"Annarita Leva and Laura M. R. Rinaldi",coverURL:"https://cdn.intechopen.com/books/images_new/3568.jpg",editors:[{id:"142145",title:"Dr.",name:"Annarita",middleName:null,surname:"Leva",slug:"annarita-leva",fullName:"Annarita Leva"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"7031",title:"Liver Pathology",subtitle:null,isOpenForSubmission:!1,hash:"631321b0565459ed0175917f1c8c727f",slug:"liver-pathology",bookSignature:"Vijay Gayam and Omer Engin",coverURL:"https://cdn.intechopen.com/books/images_new/7031.jpg",editors:[{id:"273100",title:"Dr.",name:"Vijay",middleName:null,surname:"Gayam",slug:"vijay-gayam",fullName:"Vijay Gayam"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"3560",title:"Advances in Landscape Architecture",subtitle:null,isOpenForSubmission:!1,hash:"a20614517ec5f7e91188fe8e42832138",slug:"advances-in-landscape-architecture",bookSignature:"Murat Özyavuz",coverURL:"https://cdn.intechopen.com/books/images_new/3560.jpg",editors:[{id:"93073",title:"Dr.",name:"Murat",middleName:null,surname:"Ozyavuz",slug:"murat-ozyavuz",fullName:"Murat Ozyavuz"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"8511",title:"Cyberspace",subtitle:null,isOpenForSubmission:!1,hash:"8c1cdeb133dbe6cc1151367061c1bba6",slug:"cyberspace",bookSignature:"Evon Abu-Taieh, Abdelkrim El Mouatasim and Issam H. Al Hadid",coverURL:"https://cdn.intechopen.com/books/images_new/8511.jpg",editors:[{id:"223522",title:"Dr.",name:"Evon",middleName:"M.O.",surname:"Abu-Taieh",slug:"evon-abu-taieh",fullName:"Evon Abu-Taieh"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}}],offset:12,limit:12,total:5319},hotBookTopics:{hotBooks:[],offset:0,limit:12,total:null},publish:{},publishingProposal:{success:null,errors:{}},books:{featuredBooks:[{type:"book",id:"8472",title:"Bioactive Compounds in Nutraceutical and Functional Food for Good Human Health",subtitle:null,isOpenForSubmission:!1,hash:"8855452919b8495810ef8e88641feb20",slug:"bioactive-compounds-in-nutraceutical-and-functional-food-for-good-human-health",bookSignature:"Kavita Sharma, Kanchan Mishra, Kula Kamal Senapati and Corina Danciu",coverURL:"https://cdn.intechopen.com/books/images_new/8472.jpg",editors:[{id:"197731",title:"Dr.",name:"Kavita",middleName:null,surname:"Sharma",slug:"kavita-sharma",fullName:"Kavita Sharma"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"9685",title:"Agroecosystems",subtitle:"Very Complex Environmental Systems",isOpenForSubmission:!1,hash:"c44f7b43a9f9610c243dc32300d37df6",slug:"agroecosystems-very-complex-environmental-systems",bookSignature:"Marcelo L. Larramendy and Sonia Soloneski",coverURL:"https://cdn.intechopen.com/books/images_new/9685.jpg",editors:[{id:"14764",title:"Dr.",name:"Marcelo L.",middleName:null,surname:"Larramendy",slug:"marcelo-l.-larramendy",fullName:"Marcelo L. Larramendy"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"8564",title:"Cell Interaction",subtitle:"Molecular and Immunological Basis for Disease Management",isOpenForSubmission:!1,hash:"98d7f080d80524285f091e72a8e92a6d",slug:"cell-interaction-molecular-and-immunological-basis-for-disease-management",bookSignature:"Bhawana Singh",coverURL:"https://cdn.intechopen.com/books/images_new/8564.jpg",editors:[{id:"315192",title:"Dr.",name:"Bhawana",middleName:null,surname:"Singh",slug:"bhawana-singh",fullName:"Bhawana Singh"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"9629",title:"Electroencephalography",subtitle:"From Basic Research to Clinical Applications",isOpenForSubmission:!1,hash:"8147834b6c6deeeec40f407c71ad60b4",slug:"electroencephalography-from-basic-research-to-clinical-applications",bookSignature:"Hideki Nakano",coverURL:"https://cdn.intechopen.com/books/images_new/9629.jpg",editors:[{id:"196461",title:"Prof.",name:"Hideki",middleName:null,surname:"Nakano",slug:"hideki-nakano",fullName:"Hideki Nakano"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"8760",title:"Structure Topology and Symplectic Geometry",subtitle:null,isOpenForSubmission:!1,hash:"8974840985ec3652492c83e20233bf02",slug:"structure-topology-and-symplectic-geometry",bookSignature:"Kamal Shah and Min Lei",coverURL:"https://cdn.intechopen.com/books/images_new/8760.jpg",editors:[{id:"231748",title:"Dr.",name:"Kamal",middleName:null,surname:"Shah",slug:"kamal-shah",fullName:"Kamal Shah"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"9161",title:"Frailty in the Elderly",subtitle:"Understanding and Managing Complexity",isOpenForSubmission:!1,hash:"a4f0f2fade8fb8ba35c405f5ad31a823",slug:"frailty-in-the-elderly-understanding-and-managing-complexity",bookSignature:"Sara Palermo",coverURL:"https://cdn.intechopen.com/books/images_new/9161.jpg",editors:[{id:"233998",title:"Ph.D.",name:"Sara",middleName:null,surname:"Palermo",slug:"sara-palermo",fullName:"Sara Palermo"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"9385",title:"Renewable Energy",subtitle:"Technologies and Applications",isOpenForSubmission:!1,hash:"a6b446d19166f17f313008e6c056f3d8",slug:"renewable-energy-technologies-and-applications",bookSignature:"Tolga Taner, Archana Tiwari and Taha Selim Ustun",coverURL:"https://cdn.intechopen.com/books/images_new/9385.jpg",editors:[{id:"197240",title:"Associate Prof.",name:"Tolga",middleName:null,surname:"Taner",slug:"tolga-taner",fullName:"Tolga Taner"}],equalEditorOne:{id:"186791",title:"Dr.",name:"Archana",middleName:null,surname:"Tiwari",slug:"archana-tiwari",fullName:"Archana Tiwari",profilePictureURL:"https://mts.intechopen.com/storage/users/186791/images/system/186791.jpg",biography:"Dr. Archana Tiwari is Associate Professor at Amity University, India. Her research interests include renewable sources of energy from microalgae and further utilizing the residual biomass for the generation of value-added products, bioremediation through microalgae and microbial consortium, antioxidative enzymes and stress, and nutraceuticals from microalgae. She has been working on algal biotechnology for the last two decades. She has published her research in many international journals and has authored many books and chapters with renowned publishing houses. She has also delivered talks as an invited speaker at many national and international conferences. Dr. Tiwari is the recipient of several awards including Researcher of the Year and Distinguished Scientist.",institutionString:"Amity University",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"3",totalChapterViews:"0",totalEditedBooks:"1",institution:{name:"Amity University",institutionURL:null,country:{name:"India"}}},equalEditorTwo:{id:"197609",title:"Prof.",name:"Taha Selim",middleName:null,surname:"Ustun",slug:"taha-selim-ustun",fullName:"Taha Selim Ustun",profilePictureURL:"https://mts.intechopen.com/storage/users/197609/images/system/197609.jpeg",biography:"Dr. Taha Selim Ustun received a Ph.D. in Electrical Engineering from Victoria University, Melbourne, Australia. He is a researcher with the Fukushima Renewable Energy Institute, AIST (FREA), where he leads the Smart Grid Cybersecurity Laboratory. Prior to that, he was a faculty member with the School of Electrical and Computer Engineering, Carnegie Mellon University, Pittsburgh, PA, USA. His current research interests include power systems protection, communication in power networks, distributed generation, microgrids, electric vehicle integration, and cybersecurity in smart grids. He serves on the editorial boards of IEEE Access, IEEE Transactions on Industrial Informatics, Energies, Electronics, Electricity, World Electric Vehicle and Information journals. Dr. Ustun is a member of the IEEE 2004 and 2800, IEC Renewable Energy Management WG 8, and IEC TC 57 WG17. He has been invited to run specialist courses in Africa, India, and China. He has delivered talks for the Qatar Foundation, the World Energy Council, the Waterloo Global Science Initiative, and the European Union Energy Initiative (EUEI). His research has attracted funding from prestigious programs in Japan, Australia, the European Union, and North America.",institutionString:"Fukushima Renewable Energy Institute, AIST (FREA)",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"1",totalChapterViews:"0",totalEditedBooks:"0",institution:{name:"National Institute of Advanced Industrial Science and Technology",institutionURL:null,country:{name:"Japan"}}},equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"2160",title:"MATLAB",subtitle:"A Fundamental Tool for Scientific Computing and Engineering Applications - Volume 1",isOpenForSubmission:!1,hash:"dd9c658341fbd264ed4f8d9e6aa8ca29",slug:"matlab-a-fundamental-tool-for-scientific-computing-and-engineering-applications-volume-1",bookSignature:"Vasilios N. Katsikis",coverURL:"https://cdn.intechopen.com/books/images_new/2160.jpg",editors:[{id:"12289",title:"Prof.",name:"Vasilios",middleName:"N.",surname:"Katsikis",slug:"vasilios-katsikis",fullName:"Vasilios Katsikis"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"7031",title:"Liver Pathology",subtitle:null,isOpenForSubmission:!1,hash:"631321b0565459ed0175917f1c8c727f",slug:"liver-pathology",bookSignature:"Vijay Gayam and Omer Engin",coverURL:"https://cdn.intechopen.com/books/images_new/7031.jpg",editors:[{id:"273100",title:"Dr.",name:"Vijay",middleName:null,surname:"Gayam",slug:"vijay-gayam",fullName:"Vijay Gayam"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"3568",title:"Recent Advances in Plant in vitro Culture",subtitle:null,isOpenForSubmission:!1,hash:"830bbb601742c85a3fb0eeafe1454c43",slug:"recent-advances-in-plant-in-vitro-culture",bookSignature:"Annarita Leva and Laura M. R. Rinaldi",coverURL:"https://cdn.intechopen.com/books/images_new/3568.jpg",editors:[{id:"142145",title:"Dr.",name:"Annarita",middleName:null,surname:"Leva",slug:"annarita-leva",fullName:"Annarita Leva"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}}],latestBooks:[{type:"book",id:"9515",title:"Update in Geriatrics",subtitle:null,isOpenForSubmission:!1,hash:"913e16c0ae977474b283bbd4269564c8",slug:"update-in-geriatrics",bookSignature:"Somchai Amornyotin",coverURL:"https://cdn.intechopen.com/books/images_new/9515.jpg",editedByType:"Edited by",editors:[{id:"185484",title:"Prof.",name:"Somchai",middleName:null,surname:"Amornyotin",slug:"somchai-amornyotin",fullName:"Somchai Amornyotin"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"9021",title:"Novel Perspectives of Stem Cell Manufacturing and Therapies",subtitle:null,isOpenForSubmission:!1,hash:"522c6db871783d2a11c17b83f1fd4e18",slug:"novel-perspectives-of-stem-cell-manufacturing-and-therapies",bookSignature:"Diana Kitala and Ana Colette Maurício",coverURL:"https://cdn.intechopen.com/books/images_new/9021.jpg",editedByType:"Edited by",editors:[{id:"203598",title:"Ph.D.",name:"Diana",middleName:null,surname:"Kitala",slug:"diana-kitala",fullName:"Diana Kitala"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"7030",title:"Satellite Systems",subtitle:"Design, Modeling, Simulation and Analysis",isOpenForSubmission:!1,hash:"b9db6d2645ef248ceb1b33ea75f38e88",slug:"satellite-systems-design-modeling-simulation-and-analysis",bookSignature:"Tien Nguyen",coverURL:"https://cdn.intechopen.com/books/images_new/7030.jpg",editedByType:"Edited by",editors:[{id:"210657",title:"Dr.",name:"Tien M.",middleName:"Manh",surname:"Nguyen",slug:"tien-m.-nguyen",fullName:"Tien M. Nguyen"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"10413",title:"A Collection of Papers on Chaos Theory and Its Applications",subtitle:null,isOpenForSubmission:!1,hash:"900b71b164948830fec3d6254b7881f7",slug:"a-collection-of-papers-on-chaos-theory-and-its-applications",bookSignature:"Paul Bracken and Dimo I. Uzunov",coverURL:"https://cdn.intechopen.com/books/images_new/10413.jpg",editedByType:"Edited by",editors:[{id:"92883",title:"Prof.",name:"Paul",middleName:null,surname:"Bracken",slug:"paul-bracken",fullName:"Paul Bracken"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"9154",title:"Spinal Deformities in Adolescents, Adults and Older Adults",subtitle:null,isOpenForSubmission:!1,hash:"313f1dffa803b60a14ff1e6966e93d91",slug:"spinal-deformities-in-adolescents-adults-and-older-adults",bookSignature:"Josette Bettany-Saltikov and Gokulakannan Kandasamy",coverURL:"https://cdn.intechopen.com/books/images_new/9154.jpg",editedByType:"Edited by",editors:[{id:"94802",title:"Dr.",name:"Josette",middleName:null,surname:"Bettany-Saltikov",slug:"josette-bettany-saltikov",fullName:"Josette Bettany-Saltikov"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"8148",title:"Investment Strategies in Emerging New Trends in Finance",subtitle:null,isOpenForSubmission:!1,hash:"3b714d96a68d2acdfbd7b50aba6504ca",slug:"investment-strategies-in-emerging-new-trends-in-finance",bookSignature:"Reza Gharoie Ahangar and Asma Salman",coverURL:"https://cdn.intechopen.com/books/images_new/8148.jpg",editedByType:"Edited by",editors:[{id:"91081",title:"Dr.",name:"Reza",middleName:null,surname:"Gharoie Ahangar",slug:"reza-gharoie-ahangar",fullName:"Reza Gharoie Ahangar"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"10201",title:"Post-Transition Metals",subtitle:null,isOpenForSubmission:!1,hash:"cc7f53ff5269916e3ce29f65a51a87ae",slug:"post-transition-metals",bookSignature:"Mohammed Muzibur Rahman, Abdullah Mohammed Asiri, Anish Khan, Inamuddin and Thamer Tabbakh",coverURL:"https://cdn.intechopen.com/books/images_new/10201.jpg",editedByType:"Edited by",editors:[{id:"24438",title:"Prof.",name:"Mohammed Muzibur",middleName:null,surname:"Rahman",slug:"mohammed-muzibur-rahman",fullName:"Mohammed Muzibur Rahman"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"9959",title:"Biomedical Signal and Image Processing",subtitle:null,isOpenForSubmission:!1,hash:"22b87a09bd6df065d78c175235d367c8",slug:"biomedical-signal-and-image-processing",bookSignature:"Yongxia Zhou",coverURL:"https://cdn.intechopen.com/books/images_new/9959.jpg",editedByType:"Edited by",editors:[{id:"259308",title:"Dr.",name:"Yongxia",middleName:null,surname:"Zhou",slug:"yongxia-zhou",fullName:"Yongxia Zhou"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"8472",title:"Bioactive Compounds in Nutraceutical and Functional Food for Good Human Health",subtitle:null,isOpenForSubmission:!1,hash:"8855452919b8495810ef8e88641feb20",slug:"bioactive-compounds-in-nutraceutical-and-functional-food-for-good-human-health",bookSignature:"Kavita Sharma, Kanchan Mishra, Kula Kamal Senapati and Corina Danciu",coverURL:"https://cdn.intechopen.com/books/images_new/8472.jpg",editedByType:"Edited by",editors:[{id:"197731",title:"Dr.",name:"Kavita",middleName:null,surname:"Sharma",slug:"kavita-sharma",fullName:"Kavita Sharma"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"8760",title:"Structure Topology and Symplectic Geometry",subtitle:null,isOpenForSubmission:!1,hash:"8974840985ec3652492c83e20233bf02",slug:"structure-topology-and-symplectic-geometry",bookSignature:"Kamal Shah and Min Lei",coverURL:"https://cdn.intechopen.com/books/images_new/8760.jpg",editedByType:"Edited by",editors:[{id:"231748",title:"Dr.",name:"Kamal",middleName:null,surname:"Shah",slug:"kamal-shah",fullName:"Kamal Shah"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}]},subject:{topic:{id:"1062",title:"Psychopathology",slug:"psychopathology",parent:{title:"Mental and Behavioural Disorders and Diseases of the Nervous System",slug:"mental-and-behavioural-disorders-and-diseases-of-the-nervous-system"},numberOfBooks:2,numberOfAuthorsAndEditors:66,numberOfWosCitations:13,numberOfCrossrefCitations:27,numberOfDimensionsCitations:49,videoUrl:null,fallbackUrl:null,description:null},booksByTopicFilter:{topicSlug:"psychopathology",sort:"-publishedDate",limit:12,offset:0},booksByTopicCollection:[{type:"book",id:"5272",title:"A Multidimensional Approach to Post-Traumatic Stress Disorder",subtitle:"from Theory to Practice",isOpenForSubmission:!1,hash:"385590e5c6f7983254a16476bbf06e7e",slug:"a-multidimensional-approach-to-post-traumatic-stress-disorder-from-theory-to-practice",bookSignature:"Ghassan El-Baalbaki and Christophe Fortin",coverURL:"https://cdn.intechopen.com/books/images_new/5272.jpg",editedByType:"Edited by",editors:[{id:"157412",title:"Prof.",name:"Ghassan",middleName:null,surname:"El-Baalbaki",slug:"ghassan-el-baalbaki",fullName:"Ghassan El-Baalbaki"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"2997",title:"Psychiatric Disorders",subtitle:"New Frontiers in Affective Disorders",isOpenForSubmission:!1,hash:"330720e27a7629cb94bf484ef1e83db9",slug:"psychiatric-disorders-new-frontiers-in-affective-disorders",bookSignature:"Dieter Schoepf",coverURL:"https://cdn.intechopen.com/books/images_new/2997.jpg",editedByType:"Edited by",editors:[{id:"65393",title:"Dr.",name:"Dieter",middleName:null,surname:"Schoepf",slug:"dieter-schoepf",fullName:"Dieter Schoepf"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}],booksByTopicTotal:2,mostCitedChapters:[{id:"51986",doi:"10.5772/64476",title:"Childhood Interpersonal Trauma and its Repercussions in Adulthood: An Analysis of Psychological and Interpersonal Sequelae",slug:"childhood-interpersonal-trauma-and-its-repercussions-in-adulthood-an-analysis-of-psychological-and-i",totalDownloads:3248,totalCrossrefCites:7,totalDimensionsCites:13,book:{slug:"a-multidimensional-approach-to-post-traumatic-stress-disorder-from-theory-to-practice",title:"A Multidimensional Approach to Post-Traumatic Stress Disorder",fullTitle:"A Multidimensional Approach to Post-Traumatic Stress Disorder - from Theory to Practice"},signatures:"Caroline Dugal, Noémie Bigras, Natacha Godbout and Claude\nBélanger",authors:[{id:"57536",title:"Prof.",name:"Claude",middleName:null,surname:"Belanger",slug:"claude-belanger",fullName:"Claude Belanger"},{id:"185951",title:"Ms.",name:"Caroline",middleName:null,surname:"Dugal",slug:"caroline-dugal",fullName:"Caroline Dugal"},{id:"185952",title:"Prof.",name:"Natacha",middleName:null,surname:"Godbout",slug:"natacha-godbout",fullName:"Natacha Godbout"},{id:"185953",title:"Ms.",name:"Noémie",middleName:null,surname:"Bigras",slug:"noemie-bigras",fullName:"Noémie Bigras"}]},{id:"51478",doi:"10.5772/64224",title:"The Impact of Cognitive-Behavioral Therapies for Nightmares and Prazosin on the Reduction of Post-Traumatic Nightmares, Sleep, and PTSD Symptoms: A Systematic Review and Meta- Analysis of Randomized and Non‐Randomized Studies",slug:"the-impact-of-cognitive-behavioral-therapies-for-nightmares-and-prazosin-on-the-reduction-of-post-tr",totalDownloads:1443,totalCrossrefCites:4,totalDimensionsCites:4,book:{slug:"a-multidimensional-approach-to-post-traumatic-stress-disorder-from-theory-to-practice",title:"A Multidimensional Approach to Post-Traumatic Stress Disorder",fullTitle:"A Multidimensional Approach to Post-Traumatic Stress Disorder - from Theory to Practice"},signatures:"Katia Levrier, Carolyn Leathead, Delphine-Émilie Bourdon, Sophie\nLacerte, André Marchand and Geneviève Belleville",authors:[{id:"175626",title:"Prof.",name:"André",middleName:null,surname:"Marchand",slug:"andre-marchand",fullName:"André Marchand"},{id:"184054",title:"Dr.",name:"Katia",middleName:null,surname:"Levrier",slug:"katia-levrier",fullName:"Katia Levrier"},{id:"184055",title:"Dr.",name:"Carolyn",middleName:null,surname:"Leathead",slug:"carolyn-leathead",fullName:"Carolyn Leathead"},{id:"184056",title:"BSc.",name:"Sophie",middleName:null,surname:"Lacerte",slug:"sophie-lacerte",fullName:"Sophie Lacerte"},{id:"184057",title:"Dr.",name:"Geneviève",middleName:null,surname:"Belleville",slug:"genevieve-belleville",fullName:"Geneviève Belleville"},{id:"184058",title:"BSc.",name:"Delphine-Emilie",middleName:null,surname:"Bourdon",slug:"delphine-emilie-bourdon",fullName:"Delphine-Emilie Bourdon"}]},{id:"51883",doi:"10.5772/64842",title:"Countertransference in Trauma Clinic: A Transitional Breach in the Therapists’ Identity",slug:"countertransference-in-trauma-clinic-a-transitional-breach-in-the-therapists-identity",totalDownloads:1362,totalCrossrefCites:2,totalDimensionsCites:4,book:{slug:"a-multidimensional-approach-to-post-traumatic-stress-disorder-from-theory-to-practice",title:"A Multidimensional Approach to Post-Traumatic Stress Disorder",fullTitle:"A Multidimensional Approach to Post-Traumatic Stress Disorder - from Theory to Practice"},signatures:"Mayssa’ El Husseini, Sara Skandrani, Layla Tarazi Sahab, Elizabetta\nDozio and Marie Rose Moro",authors:[{id:"184097",title:"Dr.",name:"Layla",middleName:"Tarazi",surname:"Sahab",slug:"layla-sahab",fullName:"Layla Sahab"},{id:"184098",title:"Dr.",name:"Mayssa’",middleName:null,surname:"El Husseini",slug:"mayssa'-el-husseini",fullName:"Mayssa’ El Husseini"}]}],mostDownloadedChaptersLast30Days:[{id:"51986",title:"Childhood Interpersonal Trauma and its Repercussions in Adulthood: An Analysis of Psychological and Interpersonal Sequelae",slug:"childhood-interpersonal-trauma-and-its-repercussions-in-adulthood-an-analysis-of-psychological-and-i",totalDownloads:3248,totalCrossrefCites:7,totalDimensionsCites:13,book:{slug:"a-multidimensional-approach-to-post-traumatic-stress-disorder-from-theory-to-practice",title:"A Multidimensional Approach to Post-Traumatic Stress Disorder",fullTitle:"A Multidimensional Approach to Post-Traumatic Stress Disorder - from Theory to Practice"},signatures:"Caroline Dugal, Noémie Bigras, Natacha Godbout and Claude\nBélanger",authors:[{id:"57536",title:"Prof.",name:"Claude",middleName:null,surname:"Belanger",slug:"claude-belanger",fullName:"Claude Belanger"},{id:"185951",title:"Ms.",name:"Caroline",middleName:null,surname:"Dugal",slug:"caroline-dugal",fullName:"Caroline Dugal"},{id:"185952",title:"Prof.",name:"Natacha",middleName:null,surname:"Godbout",slug:"natacha-godbout",fullName:"Natacha Godbout"},{id:"185953",title:"Ms.",name:"Noémie",middleName:null,surname:"Bigras",slug:"noemie-bigras",fullName:"Noémie Bigras"}]},{id:"51478",title:"The Impact of Cognitive-Behavioral Therapies for Nightmares and Prazosin on the Reduction of Post-Traumatic Nightmares, Sleep, and PTSD Symptoms: A Systematic Review and Meta- Analysis of Randomized and Non‐Randomized Studies",slug:"the-impact-of-cognitive-behavioral-therapies-for-nightmares-and-prazosin-on-the-reduction-of-post-tr",totalDownloads:1442,totalCrossrefCites:4,totalDimensionsCites:4,book:{slug:"a-multidimensional-approach-to-post-traumatic-stress-disorder-from-theory-to-practice",title:"A Multidimensional Approach to Post-Traumatic Stress Disorder",fullTitle:"A Multidimensional Approach to Post-Traumatic Stress Disorder - from Theory to Practice"},signatures:"Katia Levrier, Carolyn Leathead, Delphine-Émilie Bourdon, Sophie\nLacerte, André Marchand and Geneviève Belleville",authors:[{id:"175626",title:"Prof.",name:"André",middleName:null,surname:"Marchand",slug:"andre-marchand",fullName:"André Marchand"},{id:"184054",title:"Dr.",name:"Katia",middleName:null,surname:"Levrier",slug:"katia-levrier",fullName:"Katia Levrier"},{id:"184055",title:"Dr.",name:"Carolyn",middleName:null,surname:"Leathead",slug:"carolyn-leathead",fullName:"Carolyn Leathead"},{id:"184056",title:"BSc.",name:"Sophie",middleName:null,surname:"Lacerte",slug:"sophie-lacerte",fullName:"Sophie Lacerte"},{id:"184057",title:"Dr.",name:"Geneviève",middleName:null,surname:"Belleville",slug:"genevieve-belleville",fullName:"Geneviève Belleville"},{id:"184058",title:"BSc.",name:"Delphine-Emilie",middleName:null,surname:"Bourdon",slug:"delphine-emilie-bourdon",fullName:"Delphine-Emilie Bourdon"}]},{id:"44819",title:"CBT in Affective Disorders – New Frontiers",slug:"cbt-in-affective-disorders-new-frontiers",totalDownloads:1425,totalCrossrefCites:0,totalDimensionsCites:0,book:{slug:"psychiatric-disorders-new-frontiers-in-affective-disorders",title:"Psychiatric Disorders",fullTitle:"Psychiatric Disorders - New Frontiers in Affective Disorders"},signatures:"Larissa Wolkenstein and Martin Hautzinger",authors:[{id:"151809",title:"Prof.",name:"Martin",middleName:null,surname:"Hautzinger",slug:"martin-hautzinger",fullName:"Martin Hautzinger"},{id:"164697",title:"Dr.",name:"Larissa",middleName:null,surname:"Wolkenstein",slug:"larissa-wolkenstein",fullName:"Larissa Wolkenstein"}]},{id:"51580",title:"“Growing from an Invisible Wound” A Humanistic-Existential Approach to PTSD",slug:"-growing-from-an-invisible-wound-a-humanistic-existential-approach-to-ptsd",totalDownloads:2301,totalCrossrefCites:2,totalDimensionsCites:3,book:{slug:"a-multidimensional-approach-to-post-traumatic-stress-disorder-from-theory-to-practice",title:"A Multidimensional Approach to Post-Traumatic Stress Disorder",fullTitle:"A Multidimensional Approach to Post-Traumatic Stress Disorder - from Theory to Practice"},signatures:"Mélanie Vachon, Prudence C. Bessette and Christine Goyette",authors:[{id:"184884",title:"Dr.",name:"Melanie",middleName:null,surname:"Vachon",slug:"melanie-vachon",fullName:"Melanie Vachon"},{id:"188110",title:"Dr.",name:"Prudence C.",middleName:null,surname:"Bessette",slug:"prudence-c.-bessette",fullName:"Prudence C. Bessette"},{id:"188111",title:"BSc.",name:"Christine",middleName:null,surname:"Goyette",slug:"christine-goyette",fullName:"Christine Goyette"}]},{id:"52375",title:"Childhood Traumatic Experiences and Post-Traumatic Stress Disorder in Female Adults: Which is the Role Played by Romantic Attachment?",slug:"childhood-traumatic-experiences-and-post-traumatic-stress-disorder-in-female-adults-which-is-the-rol",totalDownloads:1591,totalCrossrefCites:2,totalDimensionsCites:2,book:{slug:"a-multidimensional-approach-to-post-traumatic-stress-disorder-from-theory-to-practice",title:"A Multidimensional Approach to Post-Traumatic Stress Disorder",fullTitle:"A Multidimensional Approach to Post-Traumatic Stress Disorder - from Theory to Practice"},signatures:"Alessandra Simonelli and Chiara Sacchi",authors:[{id:"105986",title:"Prof.",name:"Alessandra",middleName:null,surname:"Simonelli",slug:"alessandra-simonelli",fullName:"Alessandra Simonelli"},{id:"183026",title:"Ph.D. Student",name:"Chiara",middleName:null,surname:"Sacchi",slug:"chiara-sacchi",fullName:"Chiara Sacchi"}]},{id:"44830",title:"Adaptation of Cognitive Behavioral Analysis System of Psychotherapy in a 29 Year Old Female Patient with Chronic Major Depression and Antecedent Dysthymic Disorder Who Switched Under Combined SSRI/CBASP Outpatient Treatment into Bipolarity: A Case Report",slug:"adaptation-of-cognitive-behavioral-analysis-system-of-psychotherapy-in-a-29-year-old-female-patient-",totalDownloads:1861,totalCrossrefCites:0,totalDimensionsCites:0,book:{slug:"psychiatric-disorders-new-frontiers-in-affective-disorders",title:"Psychiatric Disorders",fullTitle:"Psychiatric Disorders - New Frontiers in Affective Disorders"},signatures:"Viola Oertel-Knöchel and Dieter Schoepf",authors:[{id:"149741",title:"Dr.",name:"Viola",middleName:null,surname:"0ertel-Knöchel",slug:"viola-0ertel-knochel",fullName:"Viola 0ertel-Knöchel"},{id:"149742",title:"Dr.",name:"Dieter",middleName:null,surname:"Schoepf",slug:"dieter-schoepf",fullName:"Dieter Schoepf"}]},{id:"44824",title:"CBASP with Intensified Significant Other History Exercise for Chronic Major Depression with Antecedent Dysthymic Disorder in Outpatient Treatment: Rationale, Assessment and Effects on the Hypothesized Core Content of the Patient’s in-Session Interpersonal",slug:"cbasp-with-intensified-significant-other-history-exercise-for-chronic-major-depression-with-antecede",totalDownloads:7209,totalCrossrefCites:0,totalDimensionsCites:0,book:{slug:"psychiatric-disorders-new-frontiers-in-affective-disorders",title:"Psychiatric Disorders",fullTitle:"Psychiatric Disorders - New Frontiers in Affective Disorders"},signatures:"Dieter Schoepf",authors:[{id:"65393",title:"Dr.",name:"Dieter",middleName:null,surname:"Schoepf",slug:"dieter-schoepf",fullName:"Dieter Schoepf"}]},{id:"52163",title:"Disruption of Bradycardia During Vigilance: Autonomic Cardiac Dysregulation is Prelude to Disinhibition, Hyperarousal, and Attention Bias in Combat Veterans with PTSD",slug:"disruption-of-bradycardia-during-vigilance-autonomic-cardiac-dysregulation-is-prelude-to-disinhibiti",totalDownloads:1682,totalCrossrefCites:0,totalDimensionsCites:0,book:{slug:"a-multidimensional-approach-to-post-traumatic-stress-disorder-from-theory-to-practice",title:"A Multidimensional Approach to Post-Traumatic Stress Disorder",fullTitle:"A Multidimensional Approach to Post-Traumatic Stress Disorder - from Theory to Practice"},signatures:"Jay P. Ginsberg and Madan Nagpal",authors:[{id:"96444",title:"Dr.",name:"J P",middleName:null,surname:"Ginsberg",slug:"j-p-ginsberg",fullName:"J P Ginsberg"},{id:"182681",title:"Dr.",name:"Madan L.",middleName:null,surname:"Nagpal",slug:"madan-l.-nagpal",fullName:"Madan L. Nagpal"}]},{id:"44829",title:"Emotional and Motivational Processes in Bipolar Disorder: A Neural Network Perspective",slug:"emotional-and-motivational-processes-in-bipolar-disorder-a-neural-network-perspective",totalDownloads:3440,totalCrossrefCites:0,totalDimensionsCites:0,book:{slug:"psychiatric-disorders-new-frontiers-in-affective-disorders",title:"Psychiatric Disorders",fullTitle:"Psychiatric Disorders - New Frontiers in Affective Disorders"},signatures:"Michèle Wessa and Julia Linke",authors:[{id:"153148",title:"Prof.",name:"Michèle",middleName:null,surname:"Wessa",slug:"michele-wessa",fullName:"Michèle Wessa"},{id:"153195",title:"Dr.",name:"Julia",middleName:null,surname:"Linke",slug:"julia-linke",fullName:"Julia Linke"}]},{id:"51619",title:"Sleep Disturbances in PTSD",slug:"sleep-disturbances-in-ptsd",totalDownloads:1171,totalCrossrefCites:1,totalDimensionsCites:1,book:{slug:"a-multidimensional-approach-to-post-traumatic-stress-disorder-from-theory-to-practice",title:"A Multidimensional Approach to Post-Traumatic Stress Disorder",fullTitle:"A Multidimensional Approach to Post-Traumatic Stress Disorder - from Theory to Practice"},signatures:"Laurie L. Wellman, Richard J. Ross and Larry D. Sanford",authors:[{id:"58589",title:"Dr.",name:"Larry",middleName:"D",surname:"Sanford",slug:"larry-sanford",fullName:"Larry Sanford"},{id:"182930",title:"Dr.",name:"Laurie",middleName:"L",surname:"Wellman",slug:"laurie-wellman",fullName:"Laurie Wellman"},{id:"182936",title:"Dr.",name:"Richard",middleName:null,surname:"Ross",slug:"richard-ross",fullName:"Richard Ross"}]}],onlineFirstChaptersFilter:{topicSlug:"psychopathology",limit:3,offset:0},onlineFirstChaptersCollection:[],onlineFirstChaptersTotal:0},preDownload:{success:null,errors:{}},aboutIntechopen:{},privacyPolicy:{},peerReviewing:{},howOpenAccessPublishingWithIntechopenWorks:{},sponsorshipBooks:{sponsorshipBooks:[],offset:0,limit:8,total:null},route:{name:"profile.detail",path:"/profiles/83464/patricia-fox",hash:"",query:{},params:{id:"83464",slug:"patricia-fox"},fullPath:"/profiles/83464/patricia-fox",meta:{},from:{name:null,path:"/",hash:"",query:{},params:{},fullPath:"/",meta:{}}}},function(){var e;(e=document.currentScript||document.scripts[document.scripts.length-1]).parentNode.removeChild(e)}()