[Depression in epilepsy: symptom or syndrome?]

An occurrence of depression or depressive symptomatology has been reported in 30% of patients with epilepsy. Depression has been reported peri- and interictally. To make a differentiation may be difficult in patients with frequent seizures. However, complex partial seizures, particularly if are located on temporal lobe, appear to be etiologic factors, especially in men with left-sided epileptic foci. Depression is also more frequent in patients treated with polytherapy, particularly with phenobarbital and vigabatrin. The depression appears to be endogenous and has also been described in patients with temporal lobectomy. Underlying risk factors (genetic, metabolic, etc) and some psychosocial condition also play a part and may explain the increased rates of depression in patients with epilepsy. Treatment approaches include psychotherapy, rationalization of antiepileptic drug medication and antidepressant treatment. The use of antidepressant treatment, in these patients, still raises uncertainties because of the widespread persuasion that this drugs exacerbated seizures. This adverse event is relatively uncommon at therapeutic dosages, and its incidence with some of most frequently used antidepressant drugs is close to that of spontaneous seizures calculated for the general population, but the incidence may rise up to 30-40% after overdosage. On the basis of the data reported in literature, it appears fair to say that maprotiline and amoxapine show the greatest seizure risk, whereas trazodone, fluoxetine and fluvoxamine show the least. The data also showed that antidepressant drugs may display both convulsant and anticonvulsant effect and it is likely that the most important factor to assess the effect of a given antidepressant drug in terms of inhibition-excitation is drug dosage. Nevertheless, further studies are needed in this field, both to clarify the complex modulating effects of antidepressants on seizure threshold and to identify clearer and safer guidelines to manage the treatment of patients with epilepsy and concomitant depression.

Language dysfunction in epileptic conditions

Epilepsy may disrupt brain functions necessary for language development by its associated intellectual disabilities or directly as a consequence of the seizure disorder. Additionally, in recent years, there has been increasing recognition of the association of epileptiform electroencephalogram (EEG) abnormalities with language disorders and autism spectrum disorders. Any process that impairs language function has long-term consequences for academic, social, and occupational adjustments in children and adolescents with epilepsy. Furthermore, impairments in specific language abilities can impact memory and learning abilities. This article reviews interictal language function in children and adults with epilepsy; epilepsy surgery and language outcome; and language disorders associated with abnormal EEGs. The relationship between epilepsy and language function is complicated as the neuroanatomic circuits common to both overlap. We demonstrate how magnetoencephalography (MEG) offers the ability to analyze the relationship of language, EEG abnormalities, and epilepsy.

Interictal schizophrenia-like psychosis in a patient with double cortex syndrome

The authors report a female patient with sporadic double cortex syndrome who manifested recurrent interictal schizophrenia-like psychoses. She had no mutations in the doublecortin gene but a pericentric inversion of chromosome 9. Neurodevelopmental disturbances and seizures may be associated with her mental dysfunction.

The lateralizing significance of version of head and dystonic limb posturing in epileptic seizures

Several clinical signs have been described for lateralization and localization of seizure focus in complex partial seizures; however, the specificity of each of these has been widely debated upon. The present study was done to evaluate 'dystonic unilateral limb posturing' and 'versive head movements' for lateralization and localization of epileptic foci in patients with intractable partial complex seizures, being investigated with long term Video-EEG monitoring. Fifteen patients with 46 seizures, studied with long term Video EEG, had either one or both of these signs. The video recordings of the clinical behaviour were noted and later compared with the corresponding EEG. Unilateral dystonic limb posturing and versive head movements had good lateralising value in complex partial seizures, suggestive of temporal lobe origin, contralateral to the seizure focus, with a specificity of 87.5% and 86% respectively. In addition, turning of the whole body to one side was associated with a contralateral seizure focus in 100% cases. Appendicular automatisms were found to be of no lateralising significance, as they occurred on either side with equal frequency. These motor phenomena should, therefore, be enquired about in detail, during history taking for lateralization or localization of seizure focus.

Unusual eye movements in a patient with complex partial seizure disorder

BACKGROUND

A complex partial seizure can cause a variety of visual system signs and symptoms, including visual hallucinations, dilated pupils, and changes in vision. Little information is known about the influence of this disorder on the visual system during nonseizure moments. This case report examines the unusual eye movements-during these nonseizure times-of a patient diagnosed with complex partial seizure disorder.

CASE REPORT

An 8-year-old boy was referred to the clinic by his pediatric neurologist for a comprehensive examination to rule out a visual cause for the abnormal eye movements observed by the patient's mother. Ocular examination revealed periodic, spontaneous, versional eye movements to the left and right, accompanied by a small widening of the fissures and turning of the head. No vergence or accommodative problems were detected, but Developmental Eye Movement (DEM) and Visagraph testing showed mild dysfunction. Ocular health was unremarkable, while radiology studies and neurological evaluation yielded no observable pathology.

CONCLUSION

Complex partial seizure disorder can affect the visual system in a wide variety of ways. The precise role, if any, that complex partial seizure disorder plays in ocular motility control during nonseizure moments is unknown. The most-plausible etiology of the observed ocular movements in this patient is the presence of a tic disorder. Patients with unknown eye movement disorders deserve a thorough evaluation, including a search for systemic causes.

Cerebral arteriovenous malformation mimicking acute coronary syndrome

We report a case of cerebral arteriovenous malformation in a 34 year-old male patient presenting with chest pain. Electrocardiographic findings showed ST elevations in the precordial leads. However, a coronary angiogram showed no coronary lesions. Laboratory tests suggested that troponin and cardiac enzymes were within normal limits. Further investigation led to the diagnosis of a cerebral arterio-venous malformation occupying the left temporal and parietal lobes. The chest pain may be explained by the occurrence of a complex partial seizure.

[A case with frontal lobe epilepsy presenting with absence seizures as cardinal manifestation: ictal EEG findings]

We report here a 9-year-old boy presenting with absence and complex partial seizures. Absence seizures occurred several times a day, with sudden arrest of speech and gesture, alteration of consciousness, myoclonus of unilateral or bilateral angles of the mouth, occasional simple automatism and brisk recovery of consciousness. Complex partial seizures occurred once to three times a month with loss of consciousness, salivation, deviation of the head and eyes toward the left, elevation of upper limbs and tonic convulsion of the left upper and lower limbs. Interictal EEG showed right frontal pole-dominant high-voltage slow waves or spike-and-waves. Ictal simultaneous video-EEG recordings of absence seizures revealed a frontal dominant 3-3.5 Hz spike-wave burst lasting several seconds. A partial seizure never preceded the absence seizure. Transverse topographical analysis revealed that the first spike component of the spike-wave burst of absence seizure always showed phase reversal on the right anterior temporal electrode. The following ones, however, showed phase reversal on the left anterior temporal electrode. Ictal EEG of the complex partial seizure could not be detected because it rarely occurred. There was no abnormal finding on brain MRI. Interictal single photon emission tomography (SPECT) indicated hypoperfusion of the dorsal and medial cortex of the right middle frontal lobe. Interictal positron emission tomography (PET) also indicated hypometabolic areas in the dorsal and medial cortex of the right frontal lobe, together with those in the right temporal and parietal cortex. EEG evolution and neuroimaging studies suggested that the epileptic focus of the absence seizure might have originated at the dorsal cortex of the right middle frontal lobe and immediately spread to the medial cortex. Both the seizures were well controlled by the combination of phenytoin and high dose sodium valproate.

[Difficulties in the treatment of psychosis in young patients with epilepsy]

Diagnostic considerations and treatment strategies in adolescents with partial complex epilepsy and emerging psychosis are discussed. We will argue for considering clozapine early in treatment if other antipsychotics have failed based on two cases; these patients both developed epilepsy in early childhood and schizophrenia in mid adolescence. Their partial complex epilepsy were unsuccessfully treated with different antiepileptic drugs. Clozapine was tried with a distinct improvement in psychotic symptoms and functional level. In both cases there was an early unexpected improvement in seizure control on clozapine. It appears that a reduction of psychotic activity improved seizure control. Later on, there appeared to be a trade off between clozapines effect on psychotic symptoms and recurrence of seizure activity.

CONCLUSION

A schizophrenic development must be taken into consideration if psychiatric symptoms emerge in adolescents with a partial complex epileptic disorder. Clozapine treatment can be considered if other antipsychotic drugs are ineffective or cause motor side effects.

[A pediatric case of intractable complex partial seizures associated with mesial temporal lobe astrocytoma: usefulness of interictal epileptiform discharges in the present case]

The patient was a 10-year-old male with normal developmental milestones. He had medically intractable complex partial seizures since the age of 7 years. At the age of 10 years, he had focal motor seizures of the right face, and a head CT scan showed a calcified lesion in the left mesial temporal region. The tumor exhibited low intensity on T 1-weighted and high intensity on T 2-weighted MR images, and was not enhanced by gadolinium-diethylenetriamine pentaacetic acid. Interictal SPECT showed hypoperfusion in the left temporal region. One-day video/EEG monitoring revealed very frequent epileptiform discharges which occurred only during sleep period exclusively in the left anterior-to-middle temporal region. The patient underwent lesionectomy with the guidance of electrocorticography. The histological study of the resected tissue showed astrocytoma. After surgery he has had no seizures for 10 months. It was concluded that very frequent interictal epileptiform discharges strictly localized to the temporal lobe at which MRI-identified tumor was present could be predictive of epileptogenic zone in the present patient in whom clinical symptoms and the results of other studies were also concordant.

Complex partial seizure mimicking psychotic reaction in an adolescent

A previously healthy 15-year-old boy initially diagnosed to have acute psychotic reaction had a history of a single generalized seizure and prolonged amnestic states of varying intensity and duration. An ictal electroencephalogram (EEG) showed bitemporal ictal discharges starting from the left side. Carbamazepine was started. A magnetic resonance imaging (MRI) obtained on the 10th day of the antiepileptic therapy showed increased signal intensity on the T2 weighted images. The patient's memory function markedly improved during 10 months' follow-up with antiepileptic treatment, although he described brief attacks of dizziness. A repeat MRI examination showed normal findings. The amnesticstates were thought to be due to frequent complex partial seizures, and transient MRI changes to hippocampal edema. This case illustrates the importance of epileptic disorders in the differential diagnosis of psychiatric conditions.

[Ictal automatisms during partial complex seizures in 36 children]

Partial complex seizures are relatively frequent type of epileptic seizures. These attacks are having aura in 60% of cases, that can be vegetative, motor, sensor or psychological one. Important is aura in the form of uncinatus seizures (unpleasant odor), because we must exclude tumor of temporal region in these patients. Altered consciousness comes after aura, patient has opened eyes, face can be pale or red, and automatism appear, in the form of different movements. These automatisms are often considered insignificant by parents or eyewitnesses. There is often misdiagnosis of this type of seizures, because only about 20% of standard EEG recordings find specific epileptic grapho-elements. Therapy of these seizures is difficult, with the success in only 50% of cases. Ictal automatisms were tested in the group of 36 children with partial complex seizures aged 4 to 17 years. Duration of epilepsy was 1 to 5 years. All patients had proved diagnosis of partial complex seizures, clinically and on electroencephalography, CT scan and MRI in medically intractable seizures. Eleven patients were videotaped during the attack. All patients had questionnaire filled by parents, about automatisms. Thirty-four patients (94.4%) had ictal automatisms, and 2 with epileptic focus in frontal region did not. Some patients had different types of automatisms. Most frequent ones were mimicking (15.19%), sitting-standing up (10.76%), swinging (8.23%), swallowing (7.59%) etc. It can be concluded that automatisms are almost obligatory part of partial complex seizure, and their registration is essential for correct diagnosis and treatment of these seizures.

No, some types of nonconvulsive status epilepticus cause little permanent neurologic sequelae (or: "the cure may be worse than the disease")

Nonconvulsive status epilepticus (NCSE) is characterized by a cognitive or behavioral change which lasts for at least 30 minutes, with EEG evidence of seizures. Although there is little argument that generalized nonconvulsive status epilepticus (GNSE) does not cause lasting deficits, there is still debate regarding the morbidity of complex partial status epilepticus (CPSE). Because the EEG is used for diagnosis, a strong argument can be made that NCSE is significantly under-recognized and diagnosed. Furthermore, since the documented cases of permanent neurologic sequelae are few, the potential permanent morbidity from CPSE may be significantly exaggerated. The literature indicates that comatose patients have a poor prognosis largely as a result of comorbid conditions and coma, whereas lightly obtunded or slightly confused patients with NCSE have little or no sequelae. Patients with NCSE may suffer (hypotension and respiratory suppression) from iatrogenic 'aggressive' treatment with intravenous anti-epileptic drugs (IV-AEDs), and the findings in the literature indicate that subjects treated with benzodiazepines may have a worse prognosis. The clinician must balance the potential but rare neurologic morbidity associated with NCSE against the not infrequent morbidity caused by IV-AEDs. Better stratification of the level of consciousness and comorbid conditions is needed when evaluating outcomes so as to clearly distinguish among the deficits due to: comorbid conditions; the effects of treatment and the effects of status epilepticus (SE) proper.

[Longitudinal study of cognitive function in two patients with focal cortical dysplasia]

To clarify the relationship between epileptic attacks and cognitive dysfunction, we examined the serial findings of 123I-IMP single photon emission computed tomography (SPECT) in relation to the intelligence quotient (IQ), assessed by Wechsler Intelligence Scale of Children-Revised, in two female patients with focal cortical dysplasia (FCD) over a 10-year period. The age of patient 1 at the initial assessment was 2 years, and the age of patient 2 was 9 months. They developed complex partial epilepsy in infancy, and were treated with antiepileptic drugs, which remained effective until 11 years of age, when their epileptic attacks recurred. Patient 1, a 14-year-old girl with FCD of the left parietal lobe suffered from dyscalculia, right-left disorientation, and finger agnosia even when she was free of epileptic attacks. Following the recurrence of seizures which occurred every night, she became unable to understand what was said to her. A hypoperfusion area detected by 123I-IMP SPECT was restricted to the left parietal lobe during the seizure-free period, but spread to the temporo-parietal lobes following the recurrence. Her verbal IQ declined from 94 (at 9 years of age) to 63 (at 11 years and 8 months). After her seizures were controlled again (at 14 years and 4 months), the 123I-IMP SPECT findings improved. Patient 2, a 12-year-old girl with FCD of the left frontal lobe, showed cognitive dysfunction. Her verbal IQ declined from 91 (at 7 years and 5 months) to 76 (at 11 years and 8 months) following a recurrence of epileptic attacks. 123I-IMP SPECT showed hypoperfusion in the left frontal lobe, where the accumulation count ratio (left/right ratio) declined from 0.86 (at 3 years) to 0.64 (at 11 years). These findings suggest that epileptic attacks are related to cognitive dysfunction in FCD patients. This cognitive dysfunction appears to correlate with the appearance of hypoperfusion areas, as detected by 123I-IMP SPECT.

[Status epilepticus with confusional symptomatology]

Non-convulsive confusional status epilepticus (NCSE) is classically separated into two forms on the basis of the ictal EEG, i.e., absence status (AS) and complex partial status epilepticus (CPSE). The diagnosis is difficult on the basis of clinical semiology alone, and requires emergency EEG investigation. Absence status, or 'petit mal' status, is a polymorphic condition that can complicate many epileptic syndromes, and is the most frequently encountered form of NCSE. It is characterized by confusion of varying intensity, associated in 50% of cases with bilateral periocular myoclonias. The EEG shows ictal generalized paroximal activity; normalization is obtained after benzodiazepine injection. In AS, there is a significant nosographic heterogeneity. Four groups can be distinguished: i) typical AS occurs in the context of a generalized idiopathic epilepsy; ii) atypical AS occurs in patients with symptomatic or cryptogenic generalized epilepsies; iii) 'de novo' AS (of late onset) is characterized by toxic or metabolic precipitating factors in middle-aged subjects with no previous history of epilepsy; iv) AS with focal characteristics occurs in subjects with a pre-existing or newly diagnosed partial epilepsy, mostly of extra-temporal origin. The majority of cases are in fact transitional forms between these four groups. CPSE is characterized by continuous or rapidly recurring complex partial seizures which may involve temporal and/or extratemporal regions. Cyclic disturbance of consciousness is characteristic of CPSE of temporal lobe origin, which requires vigorous treatment to prevent recurrence or cognitive sequelae. CPSE of frontal lobe origin is a diagnostic challenge: it is rare, the symptoms are unusual, and the patients should be documented extensively. A focal frontal lesion is revealed in one-third of cases.

Venous angiomas and epilepsy

The purpose of this study was to evaluate the frequency and characteristics of epilepsy associated with cerebral venous angiomas (VA). We examined epileptic patients in which magnetic resonance imaging (MRI) showed VA. The characteristics of epilepsy and its relationships to VA were studied. Out of 1020 epileptic patients submitted to MRI in a 10-year period, 4 presented with VA. All had partial seizures, most frequently complex partial, with secondary generalizations in 3. Drug resistance was observed in 2. One patient had a small area of cortical dysplasia near the VA; another had a cutaneous angioma. In 2 patients, there was no topographic concordance between the VA and the focus on electroencephalography. Our study reveals that VA are rarely found in epileptic patients, differently from other vascular malformations, in particular cavernomas. Topographic and/or etiological relationships between VA and epilepsy are still undefined.

Temporal lobe epilepsy, temporal lobectomy, and major depression

Sixty-two patients with medically intractable complex partial seizures who had either surgical or no surgical intervention were followed up at a mean of 10.9 years after surgery or initial evaluation. Of the 49 surgical patients, 45% had a life-time history of depression, versus 15% of the 13 patients in the nonsurgical comparison group. In the surgical group, 77% had prior history of depression; of these, 47% experienced no further episodes after surgery. Depression occurred de novo after lobectomy in 5 surgical patients (approximately 10%), 4 developing depression within 1 year. Presurgical presence of depressive episodes predicted continued postoperative depressive episodes. The significantly higher depression rate in patients with temporal lobe seizure foci suggests limbic system dysfunction in the increased risk for depression. Postsurgical resolution of episodes in almost 50% of these patients supports the tenet that depression per se is not a contraindication for surgery in patients with intractable seizures.

Neuropsychological and behavioral status of children with complex partial seizures

Neuropsychological and behavioral status were examined in 57 children aged 7 to 16 years with complex partial seizures (CPS) and compared with 27 sibling control children of the same age. Epilepsy had a significant effect on both cognitive and behavioral adjustment measures. Children with CPS had significant impairment across all seven cognitive domains assessed, reflective of a profile of relatively diffuse and generalized cognitive dysfunction. Age at onset of recurrent seizures was the strongest and most consistent predictor of adequacy of cognitive functioning; earlier age at onset was associated with poorer cognitive status. Children with CPS also had more problems compared with sibling control children on measures of social and school competence and internalizing behavior problems, but not externalizing behaviors. Further, frequency of seizure activity in the past year, rather than age at seizure onset, emerged as the strongest predictor of these behavioral difficulties. These findings are discussed in the context of understanding the impact of CPS on cognition and behavioral adjustment, and identifying the contribution of various aspects of the neurodevelopmental course of CPS to these issues.

[Memory disorders in epileptic patients]

The author studied the mnemonic activity from epileptic patients with complex partial seizures (CPS), with the aims: 1) to identify memory disorders; and 2) to compare the patients' with the controls' results. Fifty adult patients and 20 subjects without neuropsychiatric disorders were studied. The methods consisted in: 1) investigation of the mnemonic activity through the Wechsler Memory Test (subtests: Storage and Recall, Recent Memory, and Immediate Memory); 2) comparison among the results of both groups; association from mnemonic activity with brain SPECT. In the three subtests, the patients showed cognitive performance significantly lower than the controls (p < 0.05). It was found association from reduced blood flow, mainly in left temporal region, with memory impairment of the three subtetsts. The conclusion was that the CPS are associated to memory impairment.

Benign epileptic discharges in patients with lesional partial epilepsies

Case reports of four patients with therapy-resistant lesional partial epilepsies and additional foci of benign epileptic discharges of childhood, in addition to the usual electroencephalogram (EEG) changes, are presented. A family history of epileptic or febrile seizures in childhood was reported in all four patients. A distant relative of one patient, not manifesting seizures, demonstrated rolandic spikes on EEG. An abnormal pregnancy (polyhydramnion, premature pains, induced labor because of an abnormal CTG , placenta insufficiency) was reported in one patient, risk factors during birth (birth 14 days after term, placenta insufficiency) were reported in one, and bacterial meningitis at 4 weeks of age was reported in one. All patients manifested a retarded, partly severe, unfavorable infantile psychomotor development. An early seizure onset was observed in all patients (in three patients during the first year of life and in one patient during the second year). A hemifacial seizure symptomatology was seen, in addition to other symptoms, in two patients, possibly indicating the seizure pattern indicative of benign partial seizures; seizures occurred exclusively in sleep in one patient. The benign focus was never located in the lesional area. It was recorded over the same hemisphere in two patients and over the other hemisphere in the other two.

Epilepsy surgery in children with pervasive developmental disorder

Pervasive developmental disorder (PDD) is occasionally associated with medically intractable complex partial seizures. The outcome of PDD was explored in three males and two females who underwent epilepsy surgery at 32 months to 8 years of age (mean = 4 years) after onset of epilepsy at 1 week to 21 months of age (mean = 11 months). Four children had temporal lobe resections (three right, one left; two for focal cortical dysplasia, and two for tumors), and one had a right temporoparieto-occipital resection (for focal cortical dysplasia). Each child underwent repeated evaluations by a pediatric neuropsychologist and psychiatrist. Fourteen to 47 months (mean = 23 months) after operation, one child with persistent seizures had moderate developmental and behavioral improvement, three children (two seizure free, one with rare staring spells) had mild developmental and behavioral improvement, and the remaining child (seizure free) experienced a worsening of her PDD. The four children with mild-to-moderate improvement in postoperative cognitive and behavioral development still demonstrated persistent delay. Cognitive gains were confirmed by neuropsychologic testing in the oldest patient but were not reflected in test results from the three younger children, who had more modest improvement. The child with worsening of her PDD had cognitive and emotional deterioration to babbling, echolalia, aggressiveness, decreased social interaction, and increased mouthing of objects beginning several months postoperatively. These results suggest that families should be counseled that PDD symptoms in children with focal epileptogenic lesions may or may not improve after epilepsy surgery, even if the surgery is successful with respect to seizure control.

Successful treatment with gabapentin in the presence of hypersensitivity syndrome to phenytoin and carbamazepine: a report of three cases

We report three consecutive patients with hypersensitivity syndrome (HSS) due to phenytoin and carbamazepine and successful treatment with gabapentin. HSS is a rare but potentially fatal reaction to multiple drugs including several anticonvulsants. Cross-reactivity among drugs may occur. Immediate withdrawal of the offending drug is the most important step in treatment. Benzodiazepines acutely and, after resolution of the hepatitis, valproic acid have been successfully used for seizure control in patients with HSS. Our cases indicate that gabapentin is also a safe anticonvulsant in HSS.