A case of auditory auras: application of general principles to define and localize the epileptogenic zone

An illustrative case of auditory aura and complex partial seizures is presented to highlight challenges in the accurate localization of the epileptogenic zone. Application and interpretation of various diagnostic tools is discussed in this case using the North American approach to the localization of the epileptogenic zone. Whenever possible, the differences and similarities between the North American and the French/Italian approach for the localization of the epileptogenic zone are discussed.

Thought disorder: A developmental disability in pediatric epilepsy

This study compared thought disorder (i.e., impaired use of language to formulate and organize thoughts) in 93 children with complex partial seizures (CPSs) and 56 children with primary generalized epilepsy with absence (PGE) and its relationship to age, seizure, cognitive, and linguistic variables. By the use of psychopathology, social competence, academic achievement, and school problem measures, the functional implications of thought disorder in these two groups were compared. When demographic variables were controlled for, there were no significant differences in thought disorder scores between the CPS and PGE groups. However, the profile of age, gender, seizure, and cognitive variables related to thought disorder differed in the CPS and PGE groups. Within each group, different aspects of thought disorder were associated with different seizure variables. Thought disorder was related to psychopathology, school problems, decreased academic achievement, and poor peer interaction in the CPS group, but with school problems in the PGE group. These findings suggest that CPS and PGE affect the normal maturation of children's discourse skills, albeit through different mechanisms. The relationship of thought disorder to behavioral, academic, and social problems implies that these discourse deficits are one component of the developmental disabilities or comorbidities associated with pediatric CPS and PGE.

Linear scleroderma en coup de sabre with associated neurologic abnormalities

Linear scleroderma represents a unique form of localized scleroderma that primarily affects the pediatric population, with 67% of patients diagnosed before 18 years of age. When linear scleroderma occurs on the head, it is referred to as linear scleroderma en coup de sabre, given the resemblance of the skin lesions to the stroke of a sabre. Here we describe 3 pediatric patients with linear scleroderma en coup de sabre who presented with neurologic abnormalities before or concurrent with the diagnosis of their skin disease. Our patients' cases highlight the underrecognized relationship between neurologic complications and linear scleroderma en coup de sabre and illustrate the importance of a thorough skin examination in patients with unexplained neurologic disease.

Unidirectional whole body turning: a new lateralising sign in complex partial seizures

BACKGROUND

The lateralising significance of unidirectional whole body turning in patients with complex partial seizures (CPS) arising from the temporal lobe was evaluated.

METHODS

A total of 330 patients undergoing long term video-EEG study were included. "Unidirectional whole body turning" was defined as rotation of the trunk, head, and limbs by >90 degrees and lasting >10 s. EEG correlates, MRI, and SPECT findings were compared and outcome after surgery was noted for patients with follow up data for >1 year.

RESULTS

Unidirectional whole body turning was observed in 13 patients with a mean age of 18+/-8 years. Concordance of the side of whole body turning with the EEG focus and MRI findings was observed in 11 of the 13 patients (84.7%) and in 26 of 28 seizures (92.8%). The six patients who underwent temporal lobectomy or resection of lesion, opposite to the direction of body turning, had good seizure outcome.

CONCLUSION

Unidirectional whole body turning is a new lateralising sign in temporal lobe CPS with good predictive value for epileptogenic focus contralateral to the direction of turning.

Type 1 diabetes mellitus and drug-resistant epilepsy: presence of high titer of anti-glutamic acid decarboxylase autoantibodies in serum and cerebrospinal fluid

A 55-year-old man who was diagnosed as having type 1 diabetes mellitus (DM) at the age of 50 years was started on insulin therapy. At 54 years old of age, he suddenly developed complex partial seizures, which frequently occurred despite intensive anti-epileptic drug therapy. Neurological examination on admission revealed hyporeflexia in bilateral upper and lower extremities without any muscle rigidity, painful spasm or cerebellar ataxia. Laboratory examination showed poor glycemic control with increased glycated hemoglobin levels. Positive anti-thyroglobulin antibodies and anti-thyroid peroxidase (TPO) antibodies and slight elevation of TSH levels are consistent with subclinical hypothyroidism due to Hashimoto's thyroiditis. A high titer of anti-glutamic acid decarboxylase (GAD) antibodies was detected in the patient's serum and cerebrospinal fluid (CSF). Electroencephalography showed temporal spikes, consistent with complex partial seizure. This is a very rare case presenting with concomitant type 1 diabetes and drug-resistant epilepsy associated with high titers of circulating and CSF anti-GAD antibodies.

Prolonged postictal stupor: nonconvulsive status epilepticus, medication effect, or postictal state?

We describe a patient who entered a stuporous state after receiving benzodiazepine treatment for generalized tonic-clonic status epilepticus. A diagnosis of generalized NCSE with tonic seizures was made on the basis of the clinical picture and response to barbiturate anaesthetic, although the EEG pattern was not typical of the changes previously described in tonic seizures-tonic status epilepticus. This report discusses the differential diagnosis of postictal stupor, nonconvulsive status epilepticus with tonic seizures and sedation caused by the emergency treatment of status epilepticus, and summarizes the literature on tonic seizures and tonic status epilepticus.

Recurrent postictal depression with Cotard delusion

Depression is a common occurrence among epileptic patients and constitutes, along with anxiety disorders, the most frequent psychiatric condition in these patients. However, little work is done in the area of post-ictal depression especially in children with epilepsy. Here, the authors report an adolescent boy who developed recurrent depression associated with Cotard's delusion following complex partial seizure at the age of 7 years. Trial of antidepressant drug and lithium worsened the clinical picture but ultimately he responded well to carbamazepine. This case is unique in its presentation due to recurrent depression itself is rare at this age and secondly rarity of onset of Cotard delusion in prepubertal phase. This case also showed that post-ictal depression is biological process rather than psychological and social reaction. Prompt identification and management of underlying cause would definitely prevent further complication and would also prevent the child from exposing unnecessary with various pharmacological treatments.

[Postoperative complete atrioventricular block induced by carbamazepine in a patient with congenital heart disease]

We report here a boy with epilepsy and congenital heart defect, complicated postoperatively by complete atrioventricular (A-V) block caused by an adverse effect of carbamazepine (CBZ). He had been taking CBZ for 7 years to treat complex partial seizures. He also had endocardial cushion defect and first-degree A-V block, and underwent cardiac surgery at the age of 17 years. The postoperative course was unremarkable except transient complete left bundle branch block occuring one day after the surgery. Oral CBZ (400 mg per day) was continued. Five days after the surgery, bradycardia (20 beats per minute) suddenly developed, and electrocardiography (ECG) showed complete A-V block. Pervenous pacing was begun, and the heart rate gradually recovered. CBZ was discontinued on the suspicion that it caused the arrhythmia, although its serum level was estimated to be within the therapeutic range (4 to 5 microg/ml). He underwent pervenous pacing for 12 days. He was discharged 27 days after the surgery, when ECG returned to first-degree A-V block. In this case, the cardiac conduction system was affected by an adverse effect of CBZ, in combination with the preoperative first-degree A-V block and the effects of cardiac surgery, resulting in complete A-V block. Although reports of similar cases are scarce, caution should be made in prescribing CBZ to patients who either have cardiac conduction abnormalities or undergo cardiac surgery.

[Transient lesion in the splenium of the corpus callosum in epileptic child with cerebral low grade glioma]

We report on a seven years-old boy with complex partial seizures and the presence of low grade glioma in left fronto-parietal region. The magnetic resonance imaging showed focal non-hemorrhagic lesion in the splenium of the corpus callosum. The description of the transient lesion in the splenium of the corpus callosum was related in three previous studies, in patients with epilepsy. Thus, the observed transient focal lesion in the splenium of the corpus callosum of this child, probably, has correlation with to prolonged focal partial seizures and not to the presence of glioma low grade.

Transient unilateral hearing loss induced by electrocortical stimulation

A 32-year-old patient with seizures experienced decreased right-ear hearing during electrocortical stimulation mapping of the left lateral superior temporal gyrus. Audiometric testing under headphones confirmed a reversible, moderate unilateral hearing loss. Under binaural listening conditions, auditory comprehension was impaired at the same site, whereas word repetition, environmental sound recognition, naming, and spontaneous speech remained intact.

Severe anemia secondary to a probable drug interaction between zidovudine and valproic acid

A 42-year-old man with human immunodeficiency virus (HIV) infection and a history of complex partial seizures developed severe anemia after the addition of valproic acid to his stable antiretroviral regimen of zidovudine, lamivudine, and abacavir. The inhibition of zidovudine glucuronidation by valproic acid and the resultant zidovudine hematologic toxicity is the proposed mechanism of the interaction.

Reversible language regression as an adverse effect of topiramate treatment in children

Profound language regression developed in three children with epilepsy 4 to 28 weeks after beginning topiramate (TPM). TPM was administered as an adjunctive antiepileptic drug at doses of 2.5 to 6.0 mg/kg/day. Language functions recovered while TPM was being reduced in dose or stopped.

Complex partial seizures and depression

A long-recognized association exists between epilepsy and affective disturbance, especially depression. People with complex partial seizures that result from temporal lobe seizure foci are highly vulnerable to psychiatric disorders. Accurate diagnosis of such disorders is an important key to treatment. Interictal depression or dysphoria is the most clinically significant problem of this type. Pharmacotherapeutic treatments that have positive effects in other types of depressive illness are also effective for depression associated with epilepsy. Electroconvulsive therapy is helpful to some patients with depression that is refractory to drug treatment or psychotherapy. Surgical resection of seizure foci may lead to psychiatric improvement for some individuals, but can also have psychiatric complications.

Transient Kluver-Bucy syndrome following complex partial status epilepticus

The characteristic features of Kluver-Bucy syndrome include hypersexuality, hyperorality, placidity, hypermetamorphosis, visual agnosia, changes in dietary habits, and memory impairment. Human cases have been reported with herpes simplex encephalitis, head injury, Pick's disease, transtentorial herniation, adrenoleukodystrophy, and Reye's syndrome, all involving bilateral temporal lobe pathology. We present the case of a patient with no evidence of a structural lesion in the temporal lobes and behavioral changes consistent with Kluver-Bucy syndrome following complex partial status epilepticus.

Level and contents of consciousness in connection with partial epileptic seizures

The present study introduces concepts and methods that can be used in the systematic psychological study of a seizure, to gain more insight into the seizure as it is experienced by the patient and the significant other. Fourteen patients reported 40 descriptions of their subjective experiences during complex partial seizures. We analyzed the descriptions with respect to the temporal progression of the seizure and the level and contents of consciousness. There were three main findings: (1). We identified an impairment of the voluntary control of attention ("forced attention") that seems to characterize the early stages of the seizure in all patients. (2). Although most patients reported the total absence of consciousness, we identified a subgroup of patients with a fluctuating level of consciousness during the seizure. (3). The patients who reported some contents of consciousness during the seizure were found to usually experience internal mental images rather than other contents of consciousness (e.g., sensations or perceptions). We propose that use of a qualitative methodology for the psychological assessment of seizures could lead to a better understanding of seizures as experienced from the patient's perspective and thereby to improvements in the treatment of seizures.

Attentional disorders in patients with complex partial epilepsy

A study of concentrated attention patterns in epileptic patients was conducted with the objectives: characterization of the patients' epileptic condition; assessment of the concentrated attention levels in epileptic and nonepileptic individuals; comparison of the attention levels of the two groups. An evaluation was performed of 50 adult outpatients with complex partial seizures and 20 non-epileptic individuals (comparative group) at the Neuroepilepsy Ambulatory Unit, State University of Campinas SP, Brazil.

METHOD

characterization of seizure types, frequency and duration; concentrated attention assessment (Concentrated Attention Test - Toulouse-Pi ron); comparison of the epileptic with non-epileptic individuals.

RESULTS

A statistically significant difference was observed between the groups with regard to Correct Response, Wrong Response and No Response. A difference was observed in relation to Time, but it was statistically insignificant. The epileptic patients presented inferior cognitive performance in relation to concentrated attention when compared with the non-epileptic individuals, findings compatible with the clinical complaints.

VNS in patients with previous unsuccessful resective epilepsy surgery: antiepileptic and psychotropic effects

OBJECTIVES

To assess the efficacy of vagus nerve stimulation (VNS) in patients with medically and surgically intractable complex partial seizures (CPS).

PATIENTS AND METHODS

Sixteen patients with previous temporal [15] and frontal [one] resections were treated with VNS between 1994 and 1999 at King's College Hospital, London, UK. Post-operative video-electroencephalogram telemetry had shown that CPS started from the operated side in 12 patients, contralaterally in three and bilaterally independently in one.

RESULTS

Three patients (18.75%) had 50% or more reduction in seizure frequency, but one showed severe worsening of epilepsy, which remitted upon VNS discontinuation. The antiepileptic effect of VNS was not different with respect to the type of operation (anterior temporal lobectomy vs amygdalohippocampectomy), the side of operation, or the side of seizure onset. We observed psychotropic effects in two patients with post-ictal psychosis, in two others with depression, and in a child with severe behavioral disorder.

CONCLUSIONS

VNS may have a rather limited antiepileptic role to play in patients with persistent seizures following epilepsy surgery, but may independently possess useful antipsychotic and mood-stabilizing properties.

[Myokymia of the obliquus superior muscle and cryptogenetic epilepsy]

BACKGROUND

Myokymia of the obliquus superior muscle is a rare episodic microtremor caused by uncontrolled activities of the trochlearis nerve fibres. Epilepsy is also caused by spontaneous discharges of neurons. In our report we present an associated epilepsy which to the best of our knowledge is described for the first time.

PATIENT

An 61-year old man with twitches of the right eye for 6 weeks and a subjective feeling of eye movement was investigated at our hospital. His history was void of any ophthalmologic diseases. However, he suffered from cryptogenetic epilepsy known since childhood. The morphological and orthoptical findings of his eyes were normal. During the slit-lamp investigation a unilateral rotating microtremor of the right eye induced by looking downward was seen. The neurologic investigation, magnetic resonance imaging and assessment of the thyreoid function did not show further pathological results. The patient underwent treatment with carbamazepine. Under this therapy he did not show any symptoms of myokymia during follow-up.

SUMMARY

To the best of our knowledge this is the first case of myokymia of the obliquus superior muscle associated to epilepsy. To our opinion, any case of this syndrome should be investigated for epilepsy. A causal relation is unlikely since the most probable etiologies are either spontaneous discharges of trochlear nucleus neurons or a close contact between vessel and nerve analogously to trigeminal neuralgia.