Cortico-cortical evoked potential and language mapping: A meta-analysis.

PURPOSE: The purpose of this meta-analysis was to determine the best available evidence for the use of cortico-cortical evoked potential (CCEP) for language mapping. METHODS: PubMed/Medline/Google Scholar/Cochrane and Scopus electronic databases were searched for articles using CCEP for language mapping. CCEP data was obtained including the area of the cortex generating CCEP, resection data, and post-resection language outcomes. Inclusion criteria were clinical articles reporting the use of CCEP in language regions of the brain, reporting language outcomes and whether there was final resection of the cortex, studies with more than five patients, and studies in either English or Spanish. Review articles, systematic reviews, meta-analyses, or case series with less than five patients were excluded. RESULTS: Seven studies with a total of 59 patients were included in this meta-analysis. The presence of CCEPs from stimulation of Broca's area or posterior perisylvian region in the resection predicts language deficits after surgery. The diagnostic odds ratio shows values greater than 0 perioperatively (0.69-5.82) and after six months (1.38-11), supporting a high likelihood of a language deficit if the presence of CCEPs from stimulation of Broca's area or posterior perisylvian region are included in the resection and vice versa. The True Positive rate varied between 0.38 and 0.87. This effect decreases after six months to 0.61 (0.30-0.86). However, the True Negative rate increased from 0.53 (0.32-0.79) to 0.71 (0.55-0.88). CONCLUSION: This meta-analysis supports the utility of CCEP to predict the probability of having long-term language deficits after surgery. .

US Generic Antiseizure Medication Supply Chain: Observations from Analysis of US Government Databases.

BACKGROUND: Generic drug manufacturing has shifted away from the U.S. in the last few decades. The medication supply chain, from manufacturers to resellers, has become increasingly globalized and complex. This has led to bottlenecks in their manufacture resulting in medication shortages. Review of this process as it pertains to antiseizure medications (ASM) shows gaps in our comprehension of its complexities. Understanding these processes will be essential for preventing medication shortages. OBJECTIVES: The aim of this research is to examine the generic ASM supply with an emphasis on production, labeling, and repackaging. METHODS: Data from the United States Food and Drug Administration (FDA) and the National Library of Medicine (NLM) website DailyMed was used to evaluate supply chain details to gather information on antiseizure medication formulations, manufacturing locations, and labeling. RESULTS: Out of 3142 ASM-related active National Drug Code (NDC-9) codes, 2663 NDC-9 codes with Abbreviated New Drug Application (ANDA) status were included in the analysis. Most (94.8 %) were enteral, with only 5.2 % being parenteral (intravenous and intramuscular route). We identified the manufacturing country for 82 % of these codes, corresponding to 306 unique ANDA numbers. 119 manufacturing sites in 12 countries produce generic ASM Finished Dosage Forms (FDF): 103 for enteral and 21 for parenteral. India is the main producer of enteral ASM FDFs with 49 sites, followed by the US with 36. Regarding parenteral formulation, five countries had 21 unique manufacturing locations. 42 % of the 103 enteral ASM FDFs manufacturing sites produced multiple ASM FDFs, with one facility making eight distinct ASMs. 34.4 % of facilities were associated with over 3 ANDAs, and 15.1 % with more than 5. 22.7 % of ANDAs lacked a manufacturing facility identifier. Repackaged ASM FDFs constituted 48 % of NDC-9 s. Gabapentin and pregabalin were the most common oral ASMs. CONCLUSIONS: India is the major source for generic ASM FDFs manufacturing, leading to concerns about overall supply dependency on that country. There is a paucity of facilities for the global supply of parenteral ASM FDFs. There is missing data for many NDC-9 codes emphasizing urgency for transparency in the supply chain.

Neural representations of self-perception of voice: An intracortical evoked potential analysis based on an adolescent with right temporal lobe epilepsy.

INTRODUCTION: The neural bases for language perception have been studied elsewhere using Transcranial Magnetic Stimulation, functional Magnetic Resonance Imaging and Direct Cortical Stimulation. However, to our knowledge, there is no previous report about a patient identifying the change in his voice tone, speed, and prosody because of right temporal cortical stimulation. Nor has there been a cortico-cortical evoked potential (CCEP) assessment of the network underlying this process. CASE REPORT: We present CCEP from a patient with right focal refractory temporal lobe epilepsy of tumoral etiology who reported changes in the perception of his own speech prosody during stimulation. This report will serve as a complement to the understanding of the neural networks of language and prosody. CONCLUSION: The present report shows that right superior temporal gyrus, transverse temporal gyrus, right amygdala, hippocampus, and fusiform gyrus (FG) are part of the neural network subjacent to own human voice perception.

Disrupted functional connectivity patterns of the left inferior frontal gyrus subregions in benign childhood epilepsy with centrotemporal spikes.

Background: Benign epilepsy with centrotemporal spikes (BECTS) is one of the most common pediatric epileptic syndromes. Recent studies have shown that BECTS can lead to significant language dysfunction. Although research supports the role of the left inferior frontal gyrus (LIFG) in BECTS, it is unclear whether the subregions of the LIFG show different change patterns in patients with this syndrome. Methods: Using resting-state functional magnetic resonance imaging (fMRI) data in a group of 49 BECTS patients and 49 healthy controls, we investigated whether the BECTS patients show abnormal connectivity patterns of the LIFG subregions. Results: Compared with healthy controls, the BECTS patients exhibited higher connectivity between the following: the inferior frontal sulcus (IFS) and the right anterior cingulate cortex (ACC), and the ventral area 44 (A44v) region and the left hippocampus/parahippocampus. Also, a decreased connectivity was found between the IFS and the left inferior temporal gyrus (ITG). No other significant differences in functional connectivity were found in the other 4 functional subregions of the LIFG in the BECTS. Conclusions: These findings provide evidence for BECTS-related functional connectivity patterns of the LIFG subregions and suggest that different subregions may be involved in different neural circuits associated with language function in the BECTS.

Recognition of interictal and ictal discharges on EEG. Focal vs generalized epilepsy.

INTRODUCTION: The differentiation between focal and generalized epilepsies based on clinical and electroencephalographic features is difficult and sometimes confusing. OBJECTIVE: To review the EEG findings in patients with focal epilepsy. METHODS: An extensive literature review was done. We used the following Pubmed and Medline descriptors alone and in different combinations for database searching: focal, partial, epilepsy, electroencephalographic findings, and EEG. Additional filters included review, original articles, and language limited to Spanish and English. Using the above criteria, a total of 69 articles showed the interictal and ictal EEG findings in focal epilepsy. DEVELOPMENT: Focal epileptiform discharges and persistence of focal abnormalities, characterize the interictal EEG findings in focal epilepsies. To distinguish SBS from primary generalized spike waves are required to note: (a) a lead-in time of at least 2 s, (b) the morphology of the focal triggering spikes clearly differ from that of the bisynchronous epileptiform paroxysms, and (c) the morphology of triggering spikes resemble that of other focal spikes from the same region. Focal and Generalized Epilepsy can coexist. Delayed Lateralization on EEG with inconclusive onset and bizarre semiology confusing semiology should not be confused with generalized onset seizures with focal evolution. CONCLUSIONS: A close attention to localization and morphology of epileptiform discharges, the correct interpretation of secondary bilateral synchrony, and provocative maneuvers help to correctly identify the EEG findings leading to diagnose focal epilepsies. The presence of generalized epileptiform activity does not rule out the existence of a focal epilepsy.

Periictal sign of the cross or Signum Crucis as a lateralizing sign in focal epilepsies: Not only a right temporal lobe epilepsy feature.

INTRODUCTION: The sign of the cross (SC) is a catholic ritual that has been described as an automatism during the ictal phase in patients with right temporal lobe epilepsy. OBJECTIVE: The study aimed to describe the prevalence of the SC and analyze the characteristics of patients who presented this phenomenon during the video-electroencephalography (VEEG) admission in our Epilepsy department. METHODS: This is a retrospective analysis of 1308 recorded seizures; 14 patients presented the SC during the admission. Seizure semiology, electroencephalography (EEG), etiology, neuroimaging, and surgical findings were analyzed. RESULTS: A prevalence of 1.1% was found, and the sign was not only an ictal finding (21% was postictal) but also exclusive of patients with temporal lobe epilepsy (15% were extratemporal) in contrast to what has been reported so far. The localizing and lateralizing value of the ictal SC was low (sensitivity 75%, specificity 33.3%, positive predictive value 60%, negative predictive value 50% for a right temporal epileptogenic zone (EZ)) compared with other previously described signs. Regardless of the lateralization of the EZ, the sign was always performed with the right hand supporting the hypothesis of a possible learned behavioral automatism. CONCLUSION: The SC is a rare ictal or postictal manifestation that occurs in patients with temporal and extratemporal epilepsies without clear localizing and lateralizing value compared with previously described signs.

Temporal plus epilepsy: Anatomo-electroclinical subtypes.

BACKGROUND: Mesial temporal lobe epilepsy (TLE) is a remediable epileptic syndrome. About 40% of patients continue to have seizures after standard temporal lobectomy. It has been suggested that some of these patients could actually suffer from a more complex epileptogenic network. Because a few papers have been dedicated to this topic, we decided to write an article updating this theme. METHODS: We performed a literature search using the following terminology: "temporal plus epilepsy and networks," "temporal plus epilepsy," "orbito-temporal epilepsy," "temporo-insular epilepsy," "temporo-parieto-occipital (TPO) epilepsy," "parieto-temporal epilepsy," "intracortical evoked potential and temporal plus epilepsy," "temporal lobe connectivity and epilepsy," "intracortical evoked potential and epilepsy surgery," "role of extratemporal structures in TLE," "surgical failure after temporal lobectomy," "Diffusion tensor imaging (DTI) and temporal epilepsy," and "positron emission tomography (PET) in temporal plus lobe epilepsy" in the existing PubMed databases. We searched only English and Spanish literature. Only papers that fit with the above-mentioned descriptors were included as part of the evidence. Other articles were used to reference some aspects of the temporal plus epilepsy. RESULTS: A total of 48 papers from 2334 were revised. The most frequently reported auras in these groups of patients are gustatory hallucinations, vestibular illusions, laryngeal and throat constriction, atypical distribution of somatosensory symptoms (perioral and hands, bilaterally hands paresthesias, trunk and other). The most common signs are tonic posturing, hemifacial twist, and frequent bilateral clonic movements. Interictal electroencephalographic (EEG) patterns exhibit regional and frequently bilateral spikes and/or slow waves. The first ictal electrographic change is mostly regional. It is important to note that the evidence is supported by case series or case reports. Thus, most of the data presented could represent the features on these cases and not actually the totality of the iceberg. CONCLUSION: Temporal plus epilepsy is a diagnosis that can be done only after the invasive recordings have been analyzed but an adequate suspicion may arise based on clinical, EEG and imaging data.

Memoria autobiográfica en pacientes con epilepsia del lóbulo temporal por esclerosis hipocampal / Autobiographical memory in patients with temporal lobe epilepsy by hippocampal sclerosis

Introducción: la epilepsia del lóbulo temporal (ELT) suele cursar con trastornos en el funcionamiento mnésico. Es probable que el paciente con epilepsia tenga dificultades en la memoria autobiográfica, principalmente en los casos donde la etiología es la esclerosis hipocampal (EH). Objetivo: determinar las posibles alteraciones de la memoria autobiográfica en los pacientes con epilepsia del lóbulo temporal por esclerosis hipocampal, en comparación con personas sanas. Material y métodos: la muestra estuvo conformada por 25 pacientes con diagnóstico electroclínico e imagenalógico de ELT por EH y fue contrastada con 15 controles sanos. A los pacientes que previamente habían sido valorados por neurología y neuropsicología, se les suministró la Entrevista de Memoria Autobiográfica para valorar el desempeño en memoria personal semántica e incidentes autobiográficos. Para la comparación de los pacientes frente a los controles en memoria autobiográfica, se utilizó la prueba U de Mann Whitney y se calculó el tamaño del efecto no paramétrico. Resultados: los pacientes presentaron dificultades en el recuerdo de la información personal semántica de los últimos cinco años y marcadas alteraciones en el recuerdo de incidentes autobiográficos relacionados con la niñez, la adultez y la vida reciente. Conclusión: los resultados confirman las dificultades que los pacientes con ELT por EH presentan en la activación de rastros de memoria en el hipocampo para la evocación y re-experimentación detallada de los incidentes autobiográficos de toda su historia personal.

Introduction: The temporal lobe epilepsy (TLE) is usually associated with memory disorders. Patients with epilepsy probably will have difficulties in the autobiographical memory, mainly in cases where the etiology is for hippocampal sclerosis (HS) Objective: Determine the possible impairments of autobiographical memory in patients with temporal lobe epilepsy by hippocampal sclerosis compared to healthy subjects. Materials and methods: The sample was composed by 25 patients diagnosed with TLE by HS using neuroimaging, and where contrasted with a control group composed by 15 healthy subjects. Patients who previously were evaluated by neurology and neuropsychology, performed the autobiographical memory interview to test the semantic personal memory performance and autobiographical incidents. In order to compare autobiographical memory in both groups, the U test from Mann Whitney was used and the size of the no parametric effect was calculated. Results: he patients presented difficulties remembering personal semantic information in the last 5 years and had relevant alterations remembering autobiographical incidents related to childhood, adulthood, and recent life. Conclusion: The results confirmed the difficulties of patients with TLE by HS to activate memories from the hippocampus for evoking and experimenting again detailed autobiographical incidents from their personal history.

Mortality in patients with refractory temporal lobe epilepsy at a tertiary center in Cuba.

OBJECTIVES: We aimed to investigate the prevalence and risk of mortality in patients with refractory temporal lobe epilepsy. METHODS: Eligible patients included all adults referred to the National Institute of Neurology (NIN) in Havana, Cuba. All patients were followed up for 9 years. All analyses were made with the data available at the last follow-up. The frequency of death related to refractory TLE was analyzed taking into account the total number of patients included in the study. We analyzed the causes of death for each case. Multivariate analysis was made to determine the specific variables related to the death. All values were statistically significant if p<0.05. RESULTS: Six out of 117 patients died during follow-up. Fifty percent of patients died because of suicide. Only the presence of aura, specifically experiential psychic auras, and prodromal depressive disorders were associated significantly with the deaths (p<0.05). Patients who died had a higher concern about their seizures than patients who were still alive at last follow-up (p<0.01); they also had a poor perception of the overall QOL (p<0.01); and they were more concerned about the possible medication side effects than patients who did not die (p<0.05). Logistic regression provided only one variable related to the deaths in our cohort in multivariate analysis: presence of prodromal depressive disorder. CONCLUSION: The causes of death in patients with refractory temporal lobe epilepsy were similar to those documented in the general population of patients with epilepsy.

Efficacy and tolerability of add-on Lacosamide treatment in adults with Lennox-Gastaut syndrome: An observational study.

PURPOSE: To evaluate the efficacy, safety, and tolerability of lacosamide in adults with LGS in the clinical setting. METHOD: The present report is a retrospective, open-label treatment study carried out from June 2013 to December 2014 at the National Institute of Colombia. Lacosamide was introduced as add-on therapy. All caregivers were instructed to initiate lacosamide at low doses (25-50 mg) and gradually increasing it every 2 weeks. The efficacy was evaluated based on the reduction in the rate of each countable type of seizure. We also evaluated the retention rate for lacosamide as the number of days with lacosamide during follow-up. The tolerability was evaluated base on account the adverse events. RESULTS: We found that lacosamide only improves the seizure rate in three out of 19 patients with LGS, in two of them by more than 50%. The highest seizure reduction rate was observed in the focal and tonic-clonic seizures. The most commonly reported adverse events were worsening of seizures, aggressiveness and irritability. Nine patients (47.4%) showed worsening of their behavior during the treatment with lacosamide. CONCLUSION: Lacosamide can exacerbate both, the tonic and astatic seizures, and the encephalopathy associated with this epileptic syndrome. However, it is interesting to consider the likelihood of suppression of generalized tonic-clonic and focal seizures. That is why; lacosamide could be an option after carefully balancing risks and benefits in each individual case.

Suicidal risk, affective dysphoric disorders, and quality-of-life perception in patients with focal refractory epilepsy.

OBJECTIVES: We aim to study the frequency of (suicidal ideation) in patients with focal refractory epilepsy and its possible association with factors such as perceived QOL (quality of life) and ASDD (affective somatoform dysphoric disorder) using the 2007 ILAE proposal to classify affective disorders of epilepsy. METHODS: A total sample of 82 patients was divided into two groups depending on the presence of suicidal risk: (A) study group - with suicidal risk and (B) control group - without suicidal risk. Questionnaires, scales, interviews, and clinical charts were evaluated by professionals with expertise in neurology and epileptology (RAM and AGA), psychiatry (AGE), and neuropsychology (FGR). Suicidal risk was evaluated with the M.I.N.I. (Mini-International Neuropsychiatric Interview) suicidal module that specifies the current suicidal risk based on scores. Quality of life was evaluated with the Quality of Life in Epilepsy Inventory - 31 (QOLIE-31) survey. Logistic regression was conducted to ascertain if ASDD and QOL significantly predicted suicidal risk. The results were considered statistically significant when the p-value was <0.05. RESULTS: Suicidal risk was present in 33 (40.3%) patients. It was classified as severe in 31.7% of the patients, and it was only present in cases with temporal lobe epilepsy (p=0.002). More than half (52%) of patients with ASDD had risk of suicide (p=0.006). The presence of ASDD was found to be a risk factor for suicidal risk (OR=3.86; IC=1.3-12.2). Patients with suicidal risk had a lower QOL score compared with patients without suicidal risk (57.8±16.9 vs. 46.0±18.2; p<0.05), and an affected QOL significantly increased suicidal risk (OR=2.9; CI=1.3-7.8). Multivariate analysis demonstrated that an impaired QOL (OR=2.2) and the presence of ASDD (OR=4.1) significantly increased the probability of having suicidal risk (x(2)=13.6; OR=5.2; p=0.009). SIGNIFICANCE: Affective somatoform dysphoric disorder and low QOL perception increase, independently, the risk of suicide.

Parasitosis intestinales en pacientes con epilepsia de origen desconocido / Intestinal parasitosis found in patients with epilepsy of unknown etiology

Introducción: la epilepsia es una alteración del sistema nervioso central que afecta a un estimado de 50 millones de personas en el mundo, de los cuales 85 porciento vive en países en desarrollo. Alrededor de 20 porciento de las epilepsias son de difícil control o refractarias. En Cuba no existen antecedentes de estudios acerca del comportamiento de las parasitosis intestinales en estos pacientes, por lo cual se decidió realizar la presente investigación en un grupo de pacientes con epilepsia de origen desconocido del Instituto de Neurología y Neurocirugía de La Habana. Objetivos: determinar la prevalencia y las manifestaciones clínicas de las parasitosis intestinales, y relacionar estas infecciones con la existencia de epilepsia refractaria a los fármacos antiepilépticos. Métodos: se aplicó un cuestionario y se recogió una muestra de heces por cada paciente, se realizaron técnicas de diagnóstico coproparasitológico, como son el examen directo, el método de concentración de Willis y el procedimiento cuantitativo de Kato Katz(AU)

Introduction: the epilepsy is an alteration of the central nervous system (CNS) which roughly affects 50 millions of persons worldwide; almost 85 percent of them live in developing countries. Approximately 20 percent of epilepsies are difficult to control or they are called refractory epilepsies. Taking into account the lack of Cuban reports about the behavior of intestinal parasitic infections in these patients, it was decided to carry out this research study in a group of epileptic patients with unknown etiology, from the Institute of Neurology and Neurosurgery in Havana. Objectives: to determine the prevalence and the clinical manifestations of intestinal parasitic infections, and the possible association of these infections with epilepsy refractory to the antiepileptic drugs. Methods: a questionnaire was applied and one fecal sample was taken per patient. Various parasitological techniques were implemented, including direct wet mount, Willis concentration technique, and Kato Katz quantitative procedure(AU)

Parasitosis intestinales en pacientes con epilepsia de origen desconocido / Intestinal parasitosis found in patients with epilepsy of unknown etiology

Introducción: la epilepsia es una alteración del sistema nervioso central que afecta a un estimado de 50 millones de personas en el mundo, de los cuales 85 porciento vive en países en desarrollo. Alrededor de 20 porciento de las epilepsias son de difícil control o refractarias. En Cuba no existen antecedentes de estudios acerca del comportamiento de las parasitosis intestinales en estos pacientes, por lo cual se decidió realizar la presente investigación en un grupo de pacientes con epilepsia de origen desconocido del Instituto de Neurología y Neurocirugía de La Habana. Objetivos: determinar la prevalencia y las manifestaciones clínicas de las parasitosis intestinales, y relacionar estas infecciones con la existencia de epilepsia refractaria a los fármacos antiepilépticos. Métodos: se aplicó un cuestionario y se recogió una muestra de heces por cada paciente, se realizaron técnicas de diagnóstico coproparasitológico, como son el examen directo, el método de concentración de Willis y el procedimiento cuantitativo de Kato Katz

Introduction: the epilepsy is an alteration of the central nervous system (CNS) which roughly affects 50 millions of persons worldwide; almost 85 percent of them live in developing countries. Approximately 20 percent of epilepsies are difficult to control or they are called refractory epilepsies. Taking into account the lack of Cuban reports about the behavior of intestinal parasitic infections in these patients, it was decided to carry out this research study in a group of epileptic patients with unknown etiology, from the Institute of Neurology and Neurosurgery in Havana. Objectives: to determine the prevalence and the clinical manifestations of intestinal parasitic infections, and the possible association of these infections with epilepsy refractory to the antiepileptic drugs. Methods: a questionnaire was applied and one fecal sample was taken per patient. Various parasitological techniques were implemented, including direct wet mount, Willis concentration technique, and Kato Katz quantitative procedure

Lacosamide in Lennox-Gastaut syndrome: case report.

INTRODUCTION: Lennox Gastaut syndrome (LGS) is an epileptic encephalopathy characterized by tonic, atonic, and atypical absence seizures usually refractory to pharmacological treatment. Patients generally continue with seizures despite treatment with the commercially available antiepileptic drugs (AEDs). Lacosamide (LCM) is a new AED recently approved for treatment of partial onset seizures with or without secondary generalization. Lacosamide has a novel mechanism of action that seems to be different in relation to other conventional AEDs. OBJECTIVE: To report LCM-caused worsening of tonic seizures and electroencephalographic pattern in a patient with Lennox-Gastaut syndrome. CASE REPORT: We report the evolution of a patient with LGS resistant to several AEDs with a cryptogenic hepatopathy in whom LCM caused worsening of tonic seizures and electroencephalographic pattern. Once LCM was discontinued, the patient returned to his clinical and electrical baseline. CONCLUSION: Lennox Gastaut syndrome may exacerbate tonic seizures and electrical pattern of patients with LGS.

Wisconsin Card Sorting Test performance and impulsivity in patients with temporal lobe epilepsy: suicidal risk and suicide attempts.

OBJECTIVE: The goal of the study described here was to determine if executive dysfunction and impulsivity are related to risk for suicide and suicide attempts in patients with temporal lobe epilepsy. METHOD: Forty-two patients with temporal lobe epilepsy were recruited. A detailed medical history, neurological examination, serial EEGs, Mini-International Neuropsychiatric Interview, executive function, and MRI were assessed. Multiple regression analysis was carried out to examine predictive associations between clinical variables and Wisconsin Card Sorting Test measures. RESULTS: Patients' scores on the Risk for Suicide Scale (n=24) were greater than 7, which means they had the highest relative risk for suicide attempts. Family history of psychiatric disease, current major depressive episode, left temporal lobe epilepsy, and perseverative responses and total errors on the Wisconsin Card Sorting Test increased by 6.3 and 7.5 suicide risk and suicide attempts, respectively. Executive dysfunction (specifically perseverative responses and more total errors) contributed greatly to suicide risk. CONCLUSION: Executive performance has a major impact on suicide risk and suicide attempts in patients with temporal lobe epilepsy.

Neuropatías por vasculitis en la infancia / Neuropathies due to vasculitis in infancy

Las vasculitis se caracterizan por el infiltrado inflamatorio, predominantemente de células mononucleares, de la pared de los vasos sanguíneos, que pueden llevar a la oclusión con necresis y el consiguiente infarto del tejido afectado(AU)

Meningoencefalitis eosinofilica en Villa Clara, Cuba / eosinophilic meningoencephalitis in Villa Clara, Cuba

La meningoencefalitis eosinofilica ha sido reportada en Cuba desde 1981; es una enfermedad del sistema nervioso central en la cual las meninges se hallan predominantemente afectadas, produciéndose un cuadro de cefalea aguda interna, fiebre ligera, vómitos, parestesias y rigidez de nuca y espalda. Con el objetivo de analizar los princiaples elementos socio epidemiológico, el comportamieto clínico, de laboratotio, económico y la evolución de los pacientes notificados con ese diagnóstico