Incidence and localizing value of vertigo and dizziness in patients with epilepsy: Video-EEG monitoring study

Vertigo and dizziness are common neurological complaints that have long been associated with epilepsy. However, studies of patients with epileptic vertigo or dizziness with concurrent EEG monitoring are scarce. We performed the present study to investigate the incidence and localizing value of vertigo and dizziness in patients with epilepsy who had confirmation of EEG changes via video-EEG monitoring. Data of aura and clinical seizure episodes of 831 consecutive patients who underwent video-EEG monitoring were analyzed retrospectively. Out of 831 patients, 40 patients (4.8%) experienced vertigo or dizziness as aura (mean age, 32.8±11.8years), all of whom had partial seizures. Eight had mesial temporal, 20 had lateral temporal, four had frontal, one had parietal, and seven had occipital lobe onset seizures. An intracranial EEG with cortical stimulation study was performed in seven patients, and the area of stimulation-induced vertigo or dizziness coincided with the ictal onset area in only one patient. Our study showed that vertigo or dizziness is a common aura in patients with epilepsy, and that the temporal lobe is the most frequent ictal onset area in these patients. However, it can be suggested that the symptomatogenic area in patients with epileptic vertigo and dizziness may not coincide with the ictal onset area.

[Unusual Migraine Manifestations]

Migraine is a complex neurologic disorder by which several systems of the central nervous system (autonomous system, affective, cognitive, sensoric and motoric system) may be affected on different levels. Around a fourth of the patients have migraine aura. The most common aura is the visual aura, followed by sensoric aura. But motoric deficits as well as deficits of higher cortical centers (disorders of thinking, orientation, coherence or concentration) may occur as well. In analogy with a headache calendar, an aura calendar can deliver important help in the diagnostic process of rare migraine manifestations and prevent underdiagnosis of unusual migraine manifestations. Complex migraine manifestations are diagnoses of exlusion, and a broad diagnostic work-up is warranted in order to exclude dangerous neurologic pathologies. There are no specific therapeutic recommendations, as there is a lack of randomized controlled studies.

Rapid chain generation of interpostsynaptic functional LINKs can trigger seizure generation: Evidence for potential interconnections from pathology to behavior

The experimental finding that a paroxysmal depolarizing shift (PDS), an electrophysiological correlate of seizure activity, is a giant excitatory postsynaptic potential (EPSP) necessitates a mechanism for spatially summating several EPSPs at the level of the postsynaptic terminals (dendritic spines). In this context, we will examine reversible interpostsynaptic functional LINKs (IPLs), a proposed mechanism for inducing first-person virtual internal sensations of higher brain functions concurrent with triggering behavioral motor activity for possible pathological changes that may contribute to seizures. Pathological conditions can trigger a rapid chain generation and propagation of different forms of IPLs leading to seizure generation. A large number of observations made at different levels during both ictal and interictal periods are explained by this mechanism, including the tonic and clonic motor activity, different types of hallucinations, loss of consciousness, gradual worsening of cognitive abilities, a relationship with kindling (which uses an augmented stimulation protocol than that used for inducing long-term potentiation (LTP), which is an electrophysiological correlate of behavioral makers of internal sensation of memory), effect of a ketogenic diet on seizure prevention, dendritic spine loss in seizure disorders, neurodegenerative changes, and associated behavioral changes. The interconnectable nature of these findings is explained as loss of function states of a proposed normal functioning of the nervous system.

Auras in patients with temporal lobe epilepsy and mesial temporal sclerosis

We investigated auras in patients with drug-resistant temporal lobe epilepsy (TLE) and mesial temporal sclerosis (MTS). We also investigated the clinical differences between patients with MTS and abdominal auras and those with MTS and non-mesial temporal auras. All patients with drug-resistant TLE and unilateral MTS who underwent epilepsy surgery at Jefferson Comprehensive Epilepsy Center from 1986 through 2014 were evaluated. Patients with good postoperative seizure outcome were investigated. One hundred forty-nine patients (71 males and 78 females) were studied. Thirty-one patients (20.8%) reported no auras, while 29 patients (19.5%) reported abdominal aura, and 30 patients (20.1%) reported non-mesial temporal auras; 16 patients (10.7%) had sensory auras, 11 patients (7.4%) had auditory auras, and five patients (3.4%) reported visual auras. A history of preoperative tonic-clonic seizures was strongly associated with non-mesial temporal auras (odds ratio 3.8; 95% CI: 1.15-12.98; p=0.02). About one-fifth of patients who had MTS in their MRI and responded well to surgery reported auras that are historically associated with non-mesial temporal structures. However, the presence of presumed non-mesial temporal auras in a patient with MTS may herald a more widespread epileptogenic zone.

Identifying clinical correlates for suicide among epilepsy patients in South Korea: A case-control study

OBJECTIVE

Suicide is a major cause of premature mortality in patients with epilepsy. We aimed to identify the clinical correlates of suicide in these patients.

METHODS

We conducted a matched, case-control study based on a clinical case registry of epilepsy patients (n = 35,638) treated between January 1994 and December 2011 at an academic tertiary medical center in Seoul, Korea. Each epilepsy patient in the suicide group (n = 74) was matched with three epilepsy patients in the nonsuicide group (n = 222) by age, gender, and approximate time at first treatment. The clinical characteristics of the patients in both groups were then compared.

RESULTS

In a univariate analysis, seizure frequency during the year before suicide, use of antiepileptic drug polytherapy, lack of aura before seizure, diagnosis of temporal lobe epilepsy, use of levetiracetam, psychiatric comorbidity, and use of antidepressants were all significantly higher in the suicide group than in the nonsuicide group. Multivariate analysis revealed that a high seizure frequency (odds ratio [OR] 3.3, 95% confidence interval [CI] 1.04-10.2), a lack of aura before seizure (OR 4.0, 95% CI 1.7-9.3), temporal lobe epilepsy (OR 3.7, 95% CI 1.6-8.6), and use of levetiracetam (OR 7.6, 95% CI 1.1-53.7) and antidepressants (OR 7.2, 95% CI 1.5-34.1) were all associated with a higher probability of suicide.

SIGNIFICANCE

Patients with temporal lobe epilepsy who experience seizures weekly or more frequently, experience a lack of aura, use levetiracetam, or take antidepressants are all at a higher risk of suicide and should be monitored closely.

Comparison of temporal lobe epilepsy with hippocampal sclerosis and temporal lobe epilepsies due to other etiologies

BACKGROUND

This study compares the clinical characteristics of patients with mesial temporal lobe epilepsy with hippocampal sclerosis (mTLE-HS) with those who have temporal lobe epilepsy (TLE) due to other etiologies.

METHODS

In this retrospective study all patients with a clinical diagnosis of TLE were recruited in a referral outpatient epilepsy clinic at Shiraz University of Medical Sciences from September 2008 to May 2013. We classified the patients with TLE as having mesial temporal sclerosis if they had clear signs of mesial temporal sclerosis and/or atrophy in their MRI and others who had any other MRI abnormality.

RESULTS

A total of 174 patients were studied (including 105 patients with mTLE-HS and 69 patients with TLE due to other etiologies). Frequency of seizure types was not significantly different between these two groups. Earlier age at epilepsy onset (p= 0.005), a past history of febrile seizures (p= 0.010) and presence of affective auras (p= 0.008) were commonly seen in patients with mTLEHS, while auditory auras (p= 0.020) were more frequent in those with TLE due to other etiologies.

CONCLUSION

The mainstay for making a correct diagnosis, when evaluating a patient with seizure, is having a standardized approach, particularly with regard to taking a detailed clinical history. One may find important clues in the clinical history (e.g., age at disease onset, detailed seizure description and past history) to make a correct diagnosis.

Type of preoperative aura may predict postsurgical outcome in patients with temporal lobe epilepsy and mesial temporal sclerosis

PURPOSE

As the initial symptoms of epileptic seizures, many types of auras have significant localizing or lateralizing value. In this study, we hypothesized that the type of aura may predict postsurgical outcome in patients with medically refractory temporal lobe epilepsy (TLE) and mesial temporal sclerosis (MTS).

METHODS

In this retrospective study, all patients with a clinical diagnosis of medically refractory TLE due to unilateral mesial temporal sclerosis who underwent epilepsy surgery at the Jefferson Comprehensive Epilepsy Center were recruited. Patients were prospectively registered in a database from 1986 through 2014. Postsurgical outcome was classified into two groups: seizure freedom or relapse. Outcome was compared between seven groups of patients according to their preoperative auras.

RESULTS

Two hundred thirty-seven patients were studied. The chance of becoming free of seizures after surgery in patients with abdominal aura was 65.1%, while in other patients, this was 43.3% (P=0.01). In two-by-two comparisons, no other significant differences were observed.

CONCLUSION

Patients with medically refractory TLE-MTS who reported abdominal auras preceding their seizures fared better postoperatively with regard to seizure control compared with those who did not report auras, which may indicate bitemporal dysfunction, and to patients with other auras, which may indicate a widespread epileptogenic zone in the latter group of patients.

Pediatric Headaches

Pediatric headaches are common, and many may never require intervention by a health care provider. However, migraines can become more difficult to treat, especially if they become chronic daily headaches. Pediatric headache is a subjective and unique experience that requires attention to both psychological and physiologic components in diagnosis and treatment. A biopsychosocial, multidisciplinary approach, including both medication management and psychological treatment, is considered essential for effective management.

The Alice in Wonderland Syndrome: A Case of Aura Accompanying Cluster Headache

BACKGROUND

Cluster headache (CH) is a primary headache which has highly specific and sensitive criteria, and notpresence of an aura. It has been recently reported that CH may not presence with aura more than ever and this condition will be identified by headache specialists as a new form of CH.

CASE REPORT

As there is no report to our knowledge on Alice in Wonderland syndrome (AIWS) manifested as CH aura in the literature, we present a case of a 35-year-old man having AIWS as CH aura.

CONCLUSION

Clinically, AIWS is not uncommon and is likely to be underestimated as a diagnostic entity. Valproate may be preferred for treatment in CH patients with AIWS aura.

[Unusual consequences of foam sclerotherapy]

Neurological disorders are rare complications of foam sclerotherapy. Visual disturbances and headache are the most commonly reported events and are thought to be equivalent to migraine with aura. Exceptionally, strokes have been reported. Papillary fibroelastoma is a rare cardiac tumor, which may embolize in cerebral arteries. We report the case of a patient in whom neurological disorders occurred during a session of foam sclerotherapy, and led to the discovery of a cardiac fibroelastoma.

An Investigation of the Relationship between the eNOS Gene Polymorphism and Diagnosed Migraine

We investigated the phenotype-genotype association of the following endothelial nitric oxide synthase (eNOS) gene polymorphisms, rs743506, rs2070744, rs1799983, rs180079, rs3918226, rs207468799 and rs148554851, in patients suffering from migraine living in Edirne, Turkey. A total of 175 individuals, who had been diagnosed with migraine between April 2013 and December 2013, at the Neurology Department, Trakya University Medical Faculty, Edirne, Turkey, and 125 healthy controls were recruited. The above gene polymorphisms were analyzed from genomic DNA in both patient and control groups, using the pyro-sequencing method. The eNOS rs1799983 TT genotype frequency in migraine patients who had a headache duration of longer than 24 hours was statistically significantly higher than in patients who had migraine attacks that lasted under 24 hours (p = 0.047). In terms of the AGGTGGA haplotype, the severity of headache was statistically significant, and was found to be severe in 61.0% (p = 0.0001). Also in terms of the AGGTGGA haplotype, the duration of headache was statistically significant, and was >24 hours in 56.0% of patients (p = 0.008). In our study, there was no significant genotypephenotype relationship between eNOS rs743506, rs2070744, rs1799983, rs180079, rs3918226, rs207468799 and rs148554851 gene polymorphisms and migraine patients with and without aura living in Edirne, Turkey. The AGGTGGA haplotype constitutes a risk in terms of the severity and the duration of headaches in patients with migraine. This risk is significantly higher in patients with migraine with aura than patients with migraine without aura.

Hiccups as a migraine aura

OBJECTIVE

To report a case series of hiccup as a migraine aura.

BACKGROUND

Hiccup is a syndrome of inappropriate muscle contraction. To our knowledge, hiccup as a migraine aura has not been reported.

CASE SERIES

We describe series of patients who presented with hiccups as their migraine aura symptom.

CONCLUSION

Hiccups can present as a primary aura symptom in patients with migraine.

Acetylsalicylic Acid in migraine with aura prevention - a retrospective study

In a retrospective study we evaluated the efficacy and tolerability of Acetylsalicylic Acid (ASA), an antiplatelet drug, in the prophylactic treatment of migraine with aura (MA). We reviewed the charts of 203 patients suffering from MA according to the ICHD II criteria, attending to Turin University Headache Centre. 95 subjects (46.8%) were treated with ASA at low dose, 108 (53.2%) with other prophylactic therapies normally used for migraine for a period that ranged from at least 4 months to 194 months. Eighty-four patients (88.4%) treated with ASA referred positive results, while only 64 patients (59.3%) who underwent other prophylactic treatments did (p < 0.001). The attacks' frequency of patients treated with ASA decreased significantly from 3.83±1.57 pre-treatment to 1.38±0.87 after treatment (p<0.001). Aura duration was markedly reduced from 36.21±19.80 pre-treatment to 22.0±15.5 after treatment (p<0.001). ASA was well-tolerated. ASA is a safe drug with minor possible side effects that can be routinely used when prophylactic treatment of MA is required.

Epigone migraine vertigo (EMV): a late migraine equivalent

Migrainous headache is determined by pathogenetic mechanisms that are also able to affect the peripheral and/or central vestibular system, so that vestibular symptoms may substitute and/or present with headache. We are convinced that there can be many different manifestations of vestibular disorders in migrainous patients, representing true different clinical entities due to their different characteristics and temporal relashionship with headache. Based on such considerations, we proposed a classification of vertigo and other vestibular disorders related to migraine, and believe that a particular variant of migraine-related vertigo should be introduced, namely "epigone migraine vertigo" (EMV): this could be a kind of late migraine equivalent, i.e. a kind of vertigo, migrainous in origin, starting late in the lifetime that substitutes, as an equivalent, pre-existing migraine headache. To clarify this particular clinical picture, we report three illustrative clinical cases among 28 patients collected during an observation period of 13 years (November 1991 - November 2004). For all patients, we collected complete personal clinical history. All patients underwent standard neurotological examination, looking for spontaneous-positional, gaze-evoked and caloric induced nystagmus, using an infrared video camera. We also performed a head shaking test (HST) and an head thrust test (HTT). Ocular motility was tested looking at saccades and smooth pursuit. To exclude other significant neurological pathologies, a brain magnetic resonance imaging (MRI) with gadolinium was performed. During the three months after the first visit, patients were invited to keep a diary noting frequency, intensity and duration of vertigo attacks. After that period, we suggested that they use prophylactic treatment with flunarizine (5 mg per day) and/or acetylsalicylic acid (100 mg per day), or propranolol (40 mg twice a day). All patients were again recommended to note in their diary the frequency and intensity of both headache and vertigo while taking prophylactic therapy. Control visits were programmed after 4, 12 and 24 months of therapy. All patients considerably improved symptoms with therapy: 19 subjects (68%) reported complete disappearance of vestibular symptoms, while 9 (32%) considered symptoms very improved. The subjective judgement was corroborated by data from patients diaries. We conclude that EMV is a clinical variant of typical migraine-related vertigo: a migraineassociated vertigo, headache spell independent, following a headache period, during the lifetime of a patient.

An unusual case report on the possible role of Warfarin in migraine prophylaxis

BACKGROUND

Migraine is a complex disease whose physiopathological mechanisms are still not completely revealed.

FINDINGS

We describe an unusual case, not yet described in literature, of a patient who reported migraine remission, but still presented aura attacks, since starting a therapy with Warfarin.

CONCLUSIONS

This case report brings out new questions on the role of the coagulation, especially the blood coagulation pathway, in migraine with aura pathogenesis, and on the possibility to use vitamin K synthesis inhibitors, Warfarin or new generation drugs, as possible therapy to use in migraine prophylaxis.

Cardiovascular risk factors and migraine without aura: A case-control study

BACKGROUND

Migraine with aura (MA) has been identified as a risk factor for cardiovascular disease. Previous observation has also found higher prevalence of cardiovascular risk factors in migraineurs without aura (MO), but the results have been conflicting. The present study was conducted to assess the association between cardiovascular risk factors and migraine without aura among Iranians.

METHODS

In our study the prevalence of cardiovascular risk factors, including hypertension, hyperglycemia, dyslipidemia, obesity, cigarette smoking, and family history of early coronary artery disease, were studied in 347 migraineurs without aura and 267 non-migraineurs. The odds ratio (ORs) with 95% confidence interval (95% CI) was used to assess the strength of the association.

RESULTS

Patients with migraine without aura were at an increased risk of developing hypertension (ORadj = 1.9; P = 0.029), but there was no difference in other cardiovascular risk profiles, including hyperglycemia, dyslipidemia, obesity, cigarette smoking, and family history of early coronary artery disease.

CONCLUSION

Our study revealed that the prevalence of hypertension was higher in migraineurs without aura in comparison with non-migraineurs. Therefore, physicians are supposed to be more vigilant in examining these patients and take care not to prescribe medications that may provoke hypertension.

Links between headaches and epilepsy: current knowledge and terminology

INTRODUCTION AND OBJECTIVES

Headaches (including migraines) and epilepsy have a high level of comorbidity and may be confused during diagnosis. Although physicians have known for centuries that these two conditions are somehow linked, their relationship remains poorly understood. Herein we describe the known associations between them, their underlying physiopathologic and genetic mechanisms, and the treatments recommended for them.

METHOD

We have reviewed the most relevant publication of headache/migraine and epilepsy by using the PubMed data base.

DESCRIPTION

An individual can suffer both from headaches (either migraine and/or other type of headache) and epilepsy, either by chance or because of a common underlying pathology. In these cases, the headache usually occurs at a different moment than the seizure ("interictal headache"). However, headaches sometimes occur simultaneously with, or very close in time to, the seizure: one that occurs at the same time as an epileptic seizure is known as an "ictal epileptic headache" or as "hemicrania epileptica"; one that precedes a seizure is known as a "pre-ictal headache"; and one that follows a seizure is known as a "post-ictal headache". There is a particular type of pre-ictal headache, known as "migralepsy", which occurs during or just after a migraine aura.

CONCLUSIONS

The terminology and concepts employed to describe possible associations between headaches (mainly migraines) and epilepsy have evolved over time with increasing clinical and physiopathogenic knowledge. Some researchers have suggested eliminating the term migralepsy and using the terms ictal epileptic headache and hemicrania epileptica exclusively and uniformly in all classification systems.

Simple Partial Status of Forced Thinking Originated in the Mesial Temporal Region: Intracranial Foramen Ovale Electrode Recording and Ictal PET

Forced thinking (FT) is a rare epileptic phenomenon which is usually seen in patients with frontal lobe epilepsy. We report a rare case of mesial temporal lobe epilepsy presenting FT as simple partial status epilepticus. A 50-year-old woman with left hippocampal sclerosis developed a prolonged episode of continuous FT for five days after she experienced a clustering of complex partial seizures during the period of preoperative video-electroencephalography (EEG) monitoring. The EEG demonstrated continuous focal ictal discharges in the left foramen ovale electrodes. Positron emission tomography showed focal glucose hypermetabolism in the left mesial temporal region. This case indicates that the anatomical substrate for the development of FT is located in the mesial temporal region as well as the frontal lobe, and prolonged FT can occur as a seizure manifestation.

Coexistence of acute myocardial infarction with normal coronary arteries and migraine with aura in a female patient

Acute myocardial infarction with normal coronary arteries is a well known condition, which is typically diagnosed in young patients. Coronary vasospasm, inherited, acquired or malignancy-induced hypercoagulable state, collagen vascular disease and coronary arterial embolism have been considered as underlying etiologic factors. An association between migraine with aura and increased risk of ischemic stroke, angina and myocardial infarction has been demonstrated in studies. Patients with migraine and especially with aura should be followed closely against cardiovascular events even if they are young and do not have traditional risk factors.

Migraine with prolonged aura: correlation of clinical and EEG features

Migraine with prolonged aura has rarely been examined with regard to the sequence of the neurological symptoms and the associated EEG changes. This report describes five patients who underwent clinical assessment and EEG recordings during attacks of migraine with prolonged aura. CT scan of the brain was obtained in four of them. Follow-up EEG was also obtained. The aura symptoms either preceded the headache or were coincident with it. The aura symptoms evolved in a manner consistent with posterior-to-anterior dysfunction of the cerebral cortex. The EEG abnormalities were non-epileptiform and consisted of focal delta slow waves or theta slow waves. The EEG abnormalities showed good correlation with the patients' aura symptoms and resolved when the patients became symptom free. The posterior-to-anterior sequence of the aura symptoms is in accord with the findings during cerebral blood flow studies in patients having migraine with aura. Also the symptoms and EEG changes in our patients indicate dysfunction of the cerebral cortex, consistent with the notion that spreading cortical depression may be the underlying pathophysiological event in migraine with aura.