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Aboseif A, Maly EF, Syed FH, Punia V, Kunchok A, Abbatemarco JR. Episodic aphasia following a motor vehicle collision. Pract Neurol 2024:pn-2024-004181. [PMID: 38871448 DOI: 10.1136/pn-2024-004181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/16/2024] [Indexed: 06/15/2024]
Affiliation(s)
- Albert Aboseif
- Department of Neurology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Emily F Maly
- Department of Neurology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Faez H Syed
- Department of Neurology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Vineet Punia
- Epilepsy Center, Department of Neurology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Amy Kunchok
- Mellen Center for Multiple Sclerosis Treatment and Research, Cleveland Clinic, Cleveland, Ohio, USA
| | - Justin R Abbatemarco
- Mellen Center for Multiple Sclerosis Treatment and Research, Cleveland Clinic, Cleveland, Ohio, USA
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Merli E, Romoli M, Galluzzo S, Bevacqua L, Cece ES, Ricci G, Testoni S, Zaniboni A, Viola MM, Simonetti L, Bisulli F, Contardi S, Tinuper P, Zini A. Pragmatic computerised perfusion diagnostics for non-convulsive status epilepticus: a prospective observational study. J Neurol Neurosurg Psychiatry 2024; 95:471-476. [PMID: 38041670 DOI: 10.1136/jnnp-2023-332152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 11/01/2023] [Indexed: 12/03/2023]
Abstract
BACKGROUND Non-convulsive status epilepticus (NCSE) is a time-dependent neurological disorder often misdiagnosed in the emergency setting. Electroencephalography (EEG) is often not available on a 24/7 basis, and Salzburg criteria may at times miss the diagnosis. Here, we tested the accuracy of hyperperfusion on CT perfusion imaging (CTP) in the identification of NCSE against Salzburg criteria, to define its potential role in a pragmatic diagnostic workflow. METHODS We enrolled consecutive patients with suspected acute seizure or seizure disorder undergoing brain imaging with CTP and EEG from January 2021 to March 2023. EEG recordings, Salzburg criteria and CTP hyperperfusion were rated and adjudicated by two independent experts blinded to patient status. A reference standard including all clinical, lab, imaging, EEG and therapeutic data was used to adjudicate NCSE diagnosis. Sensitivity, specificity, diagnostic accuracy, positive and negative predictive values (NPV) were calculated for CTP hyperperfusion and Salzburg criteria versus NCSE adjudicated according to reference standard. RESULTS Seventy-seven patients were enrolled. Among 21 NCSE cases, 17 were adjudicated according to Salzburg criteria (81%) and 4 received NCSE diagnosis according to reference standard. Agreement between EEG and CTP emerged in 16/21 NCSE cases, reaching sublobar level in 37.5% of cases. Receiver operator curve analysis suggested good accuracy for CTP hyperperfusion for the diagnosis of NCSE (AUROC 0.79, 95% CI 0.69 to 0.89). CTP hyperperfusion had a high NPV for NCSE (NPV 0.97, 95% CI 0.86 to 1). CONCLUSION CTP hyperperfusion may be implemented in the emergency fast-track to rule out NCSE, given very high NPV. Further validation studies are needed to evaluate CTP application in real-world setting for NCSE codes.
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Affiliation(s)
- Elena Merli
- IRCCS Istituto Delle Scienze Neurologiche di Bologna, Neurologia e Rete Stroke Metropolitana, Ospedale Maggiore, Bologna, Italy
| | - Michele Romoli
- Neurology and Stroke Unit, Maurizio Bufalini Hospital, Cesena, Italy
| | - Simone Galluzzo
- IRCSS Istituto delle Scienze Neurologiche di Bologna, Neuroradiologia, Ospedale Maggiore, Bologna, Italy
| | - Lorenzo Bevacqua
- IRCCS Istituto Delle Scienze Neurologiche di Bologna, Neurologia e Rete Stroke Metropolitana, Ospedale Maggiore, Bologna, Italy
| | - Emanuele Saverio Cece
- IRCCS Istituto Delle Scienze Neurologiche di Bologna, Neurologia e Rete Stroke Metropolitana, Ospedale Maggiore, Bologna, Italy
| | - Gabriele Ricci
- IRCCS Istituto Delle Scienze Neurologiche di Bologna, Neurologia e Rete Stroke Metropolitana, Ospedale Maggiore, Bologna, Italy
| | - Stefania Testoni
- IRCCS Istituto Delle Scienze Neurologiche di Bologna, Neurologia e Rete Stroke Metropolitana, Ospedale Maggiore, Bologna, Italy
| | - Anna Zaniboni
- IRCCS Istituto Delle Scienze Neurologiche di Bologna, Neurologia e Rete Stroke Metropolitana, Ospedale Maggiore, Bologna, Italy
| | - Maria Maddalena Viola
- IRCCS Istituto Delle Scienze Neurologiche di Bologna, Neurologia e Rete Stroke Metropolitana, Ospedale Maggiore, Bologna, Italy
| | - Luigi Simonetti
- IRCSS Istituto delle Scienze Neurologiche di Bologna, Neuroradiologia, Ospedale Maggiore, Bologna, Italy
| | - Francesca Bisulli
- IRCSS Istituto delle Scienze Neurologiche di Bologna, Department of Neurological Sciences, University of Bologna, Bologna, Italy
- Dipartimento di Scienze Biomediche e Neuromotorie, University of Bologna, Bologna, Italy
| | - Sara Contardi
- IRCCS Istituto Delle Scienze Neurologiche di Bologna, Neurologia e Rete Stroke Metropolitana, Ospedale Maggiore, Bologna, Italy
| | - Paolo Tinuper
- IRCSS Istituto delle Scienze Neurologiche di Bologna, Department of Neurological Sciences, University of Bologna, Bologna, Italy
- Dipartimento di Scienze Biomediche e Neuromotorie, University of Bologna, Bologna, Italy
| | - Andrea Zini
- IRCCS Istituto Delle Scienze Neurologiche di Bologna, Neurologia e Rete Stroke Metropolitana, Ospedale Maggiore, Bologna, Italy
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Orlandi N, Giovannini G, Cioclu MC, Biagioli N, Madrassi L, Vaudano AE, Pugnaghi M, Lattanzi S, Meletti S. Remote seizures and drug-resistant epilepsy after a first status epilepticus in adults. Eur J Neurol 2024; 31:e16177. [PMID: 38258477 PMCID: PMC11235869 DOI: 10.1111/ene.16177] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Revised: 11/21/2023] [Accepted: 11/23/2023] [Indexed: 01/24/2024]
Abstract
BACKGROUND AND PURPOSE Long-term consequences after status epilepticus (SE) represent an unsettled issue. We investigated the incidence of remote unprovoked seizures (RS) and drug-resistant epilepsy (DRE) in a cohort of first-ever SE survivors. METHODS A retrospective, observational, and monocentric study was conducted on adult patients (age ≥ 14 years) with first SE who were consecutively admitted to the Modena Academic Hospital, Italy (September 2013-March 2022). Kaplan-Meier survival analyses were used to calculate the probability of seizure freedom following the index event, whereas Cox proportional hazard regression models were used to identify outcome predictors. RESULTS A total of 279 patients were included, 57 of whom (20.4%) developed RS (mean follow-up = 32.4 months). Cumulative probability of seizure freedom was 85%, 78%, and 68% respectively at 12 months, 2 years, and 5 years. In 45 of 57 patients (81%), the first relapse occurred within 2 years after SE. The risk of RS was higher in the case of structural brain damage (hazard ratio [HR] = 2.1, 95% confidence interval [CI] = 1.06-4.01), progressive symptomatic etiology (HR = 2.7, 95% CI = 1.44-5.16), and occurrence of nonconvulsive evolution in the semiological sequence of SE (HR = 2.9, 95% CI = 1.37-6.37). Eighteen of 57 patients (32%) developed DRE; the risk was higher in the case of super-refractory (p = 0.006) and non-convulsive SE evolution (p = 0.008). CONCLUSIONS The overall risk of RS was moderate, temporally confined within 2 years after the index event, and driven by specific etiologies and SE semiology. Treatment super-refractoriness and non-convulsive SE evolution were associated with DRE development.
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Affiliation(s)
- Niccolò Orlandi
- Neurology UnitOspedale CivileAzienda Ospedaliera–Universitaria di ModenaModenaItaly
- Department of BiomedicalMetabolic, and Neural ScienceCenter for Neuroscience and NeurotechnologyUniversity of Modena and Reggio EmiliaModenaItaly
| | - Giada Giovannini
- Neurology UnitOspedale CivileAzienda Ospedaliera–Universitaria di ModenaModenaItaly
| | - Maria Cristina Cioclu
- Department of BiomedicalMetabolic, and Neural ScienceCenter for Neuroscience and NeurotechnologyUniversity of Modena and Reggio EmiliaModenaItaly
| | - Niccolò Biagioli
- Neurology UnitOspedale CivileAzienda Ospedaliera–Universitaria di ModenaModenaItaly
- Department of BiomedicalMetabolic, and Neural ScienceCenter for Neuroscience and NeurotechnologyUniversity of Modena and Reggio EmiliaModenaItaly
| | - Laura Madrassi
- Neurology UnitOspedale CivileAzienda Ospedaliera–Universitaria di ModenaModenaItaly
- Department of BiomedicalMetabolic, and Neural ScienceCenter for Neuroscience and NeurotechnologyUniversity of Modena and Reggio EmiliaModenaItaly
| | - Anna Elisabetta Vaudano
- Neurology UnitOspedale CivileAzienda Ospedaliera–Universitaria di ModenaModenaItaly
- Department of BiomedicalMetabolic, and Neural ScienceCenter for Neuroscience and NeurotechnologyUniversity of Modena and Reggio EmiliaModenaItaly
| | - Matteo Pugnaghi
- Neurology UnitOspedale CivileAzienda Ospedaliera–Universitaria di ModenaModenaItaly
| | - Simona Lattanzi
- Neurological ClinicDepartment of Experimental and Clinical MedicineMarche Polytechnic UniversityAnconaItaly
| | - Stefano Meletti
- Neurology UnitOspedale CivileAzienda Ospedaliera–Universitaria di ModenaModenaItaly
- Department of BiomedicalMetabolic, and Neural ScienceCenter for Neuroscience and NeurotechnologyUniversity of Modena and Reggio EmiliaModenaItaly
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4
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Lattanzi S, Orlandi N, Giovannini G, Brigo F, Trinka E, Meletti S. The risk of unprovoked seizure occurrence after status epilepticus in adults. Epilepsia 2024; 65:1006-1016. [PMID: 38339985 DOI: 10.1111/epi.17912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Revised: 01/25/2024] [Accepted: 01/25/2024] [Indexed: 02/12/2024]
Abstract
OBJECTIVE Status epilepticus (SE) may lead to long-term consequences. This study evaluated the risk and predictors of seizure occurrence after SE, with a focus on SE due to acute symptomatic etiologies. METHODS Prospectively collected data about adults surviving a first non-hypoxic SE were reviewed. The outcome was the occurrence of unprovoked seizures during the follow-up. Kaplan-Meier survival curve analysis and log-rank test were used to analyze the time to seizure occurrence and determine the statistical significance between etiological groups. Three subcategories within acute etiology were considered according to the presence of the following: (1) structural lesion (acute-primary); (2) brain involvement during systemic disorders (acute-secondary); and (3) drug or alcohol intoxication/withdrawal (acute-toxic). Cox proportional hazards model was adopted to estimate hazard ratios (HRs) with the 95% confidence intervals (CIs). RESULTS Two hundreds fifty-seven individuals were included. Fifty-four subjects (21.0%) developed seizures after a median of 9.9 (interquartile range 4.3-21.7) months after SE. The estimated 1-, 2-, and 5-year rates of seizure occurrence according to acute SE etiologies were 19.4%, 23.4%, and 30.1%, respectively, for acute-primary central nervous system (CNS) pathology; 2.2%, 2.2%, and 8.7%, respectively, for acute-secondary CNS pathology; and 0%, 9.1%, and 9.1%, respectively, for acute-toxic causes. Five-year rates of seizure occurrence for non-acute SE causes were 33.9% for remote, 65.7% for progressive, and 25.9% for unknown etiologies. In multivariate Cox regression model, progressive etiology (adjusted HR [adjHR] 2.27, 95% CI 1.12-4.58), SE with prominent motor phenomena evolving in non-convulsive SE (adjHR 3.17, 95% CI 1.38-7.25), and non-convulsive SE (adjHR 2.38, 95% CI 1.16-4.90) were independently associated with higher hazards of unprovoked seizures. Older people (adjHR .98, 95% CI .96-.99) and people with SE due to acute-secondary CNS pathology (adjHR .18, 95% CI .04-.82) were at decreased risk of seizure occurrence. SIGNIFICANCE SE carries a risk of subsequent seizures. Both the underlying cause and epileptogenic effects of SE are likely to contribute.
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Affiliation(s)
- Simona Lattanzi
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Niccolò Orlandi
- Neurology Unit, OCB Hospital, AOU Modena, Modena, Italy
- Department of Biomedical, Metabolic and Neural Science, Center for Neuroscience and Neurotechnology, University of Modena and Reggio Emilia, Modena, Italy
| | - Giada Giovannini
- Neurology Unit, OCB Hospital, AOU Modena, Modena, Italy
- PhD Program in Clinical and Experimental Medicine, University of Modena and Reggio Emilia, Modena, Italy
| | - Francesco Brigo
- Department of Neuroscience, Biomedicine and Movement Science, University of Verona, Verona, Italy
- Division of Neurology, "Franz Tappeiner" Hospital, Merano, Italy
| | - Eugen Trinka
- Department of Neurology, Neurointensive Care, and Neurorehabilitation, Christian Doppler University Hospital, Paracelsus Medical University, Member of EpiCARE, Salzburg, Austria
- Neuroscience Institute, Center for Cognitive Neuroscience, Christian Doppler University Hospital Salzburg, Salzburg, Austria
- Public Health, Health Services Research and HTA, University for Health Sciences, Medical Informatics and Technology, Hall i.T, Austria
| | - Stefano Meletti
- Neurology Unit, OCB Hospital, AOU Modena, Modena, Italy
- Department of Biomedical, Metabolic and Neural Science, Center for Neuroscience and Neurotechnology, University of Modena and Reggio Emilia, Modena, Italy
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Bonduelle T, Ollivier M, Gradel A, Aupy J. Brain MRI in status epilepticus: Relevance of findings. Rev Neurol (Paris) 2024:S0035-3787(24)00423-5. [PMID: 38472033 DOI: 10.1016/j.neurol.2023.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 12/21/2023] [Accepted: 12/27/2023] [Indexed: 03/14/2024]
Abstract
Status epilepticus (SE) represents one of the most common neurological emergencies, associated with high mortality and an important risk of functional sequelae in survivors. Magnetic resonance imaging (MRI) offers the possibility of early and noninvasive observation of seizure-induced parenchymal disturbances secondary to the epileptic process. In the present review, we propose a descriptive and comprehensive understanding of current knowledge concerning seizure-induced MRI abnormalities in SE, also called peri-ictal MRI abnormalities (PMAs). We then discuss how PMAs, as a noninvasive biomarker, could be helpful to optimize patient prognostication in SE management. Finally, we discuss alternative promising MRI approaches, including arterial spin labeling (ASL), susceptibility-weighted imaging (SWI), dynamic contrast-enhanced (DCE) MRI and dynamic susceptibility contrast (DSC) MRI that could refine our understanding of SE, particularly in non-convulsive form.
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Affiliation(s)
- T Bonduelle
- Department of Clinical Neurosciences, Epilepsy Unit, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France.
| | - M Ollivier
- Department of Neuroimaging, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - A Gradel
- Department of Clinical Neurosciences, Epilepsy Unit, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - J Aupy
- Department of Clinical Neurosciences, Epilepsy Unit, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France; CNRS, IMN, UMR 5293, Université de Bordeaux, Bordeaux, France
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Musto E, Gambardella ML, Perulli M, Quintiliani M, Veredice C, Verdolotti T, Berté G, Leoni C, Onesimo R, Pulitanò SM, Tartaglia M, Zampino G, Contaldo I, Battaglia DI. Status epilepticus in BRAF-related cardio-facio-cutaneous syndrome: Focus on neuroimaging clues to physiopathology. Epilepsia Open 2024; 9:258-267. [PMID: 37943120 PMCID: PMC10839340 DOI: 10.1002/epi4.12864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Accepted: 11/06/2023] [Indexed: 11/10/2023] Open
Abstract
OBJECTIVE Cardio-facio-cutaneous syndrome (CFC) is a genetic disorder due to variants affecting genes coding key proteins of the Ras/MAPK signaling pathway. Among the different features of CFC, neurological involvement, including cerebral malformations and epilepsy, represents a common and clinically relevant aspect. Status epilepticus (SE) is a recurrent feature, especially in a specific subgroup of CFC patients with developmental and epileptic encephalopathy (DEE) and history of severe pharmacoresistant epilepsy. Here we dissect the features of SE in CFC patients with a particular focus on longitudinal magnetic resonance imaging (MRI) findings to identify clinical-radiological patterns and discuss the underlying physiopathology. METHODS We retrospectively analyzed clinical, electroencephalogram (EEG), and MRI data collected in a single center from a cohort of 23 patients with CFC carrying pathogenic BRAF variants who experienced SE during a 5-year period. RESULTS Seven episodes of SE were documented in 5 CFC patients who underwent EEG and MRI at baseline. MRI was performed during SE/within 72 hours from SE termination in 5/7 events. Acute/early post-ictal MRI findings showed heterogenous abnormalities: restricted diffusion in 2/7, focal area of pcASL perfusion change in 2/7, focal cortical T2/FLAIR hyperintensity in 2/7. Follow-up images were available for 4/7 SE. No acute changes were detected in 2/7 (MRI performed 4 days after SE termination). SIGNIFICANCE Acute focal neuroimaging changes concomitant with ictal EEG focus were present in 5/7 episodes, though with different findings. The heterogeneous patterns suggest different contributing factors, possibly including the presence of focal cortical malformations and autoinflammation. When cytotoxic edema is revealed by MRI, it can be followed by permanent structural damage, as already observed in other genetic conditions. A better understanding of the physiopathology will provide access to targeted treatments allowing to prevent long-term adverse neurological outcome. PLAIN LANGUAGE SUMMARY Cardio-facio-cutaneous syndrome is a genetic disorder that often causes prolonged seizures known as status epilepticus. This study has a focus on electroclinical and neuroimaging patterns in patients with cardio-facio-cutaneous syndrome. During these status epilepticus episodes, we found different abnormal brain imaging patterns in patients, indicating various causes like brain malformations and inflammation. Understanding these patterns could help doctors find specific treatments, protecting cardio-facio-cutaneous syndrome patients from long-term brain damage.
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Affiliation(s)
- Elisa Musto
- Department of Life Sciences and Public HealthUniversità Cattolica del Sacro CuoreRomeItaly
- Neurology, Epilepsy and Movement Disorders, Full member of European Reference Network EpiCAREBambino Gesù Children's Hospital, IRCCSRomeItaly
| | - Maria Luigia Gambardella
- Child Neurology and Psychiatric Unit, Fondazione Policlinico Universitario Agostino GemelliIRCCSRomeItaly
| | - Marco Perulli
- Department of Life Sciences and Public HealthUniversità Cattolica del Sacro CuoreRomeItaly
- Child Neurology and Psychiatric Unit, Fondazione Policlinico Universitario Agostino GemelliIRCCSRomeItaly
| | - Michela Quintiliani
- Child Neurology and Psychiatric Unit, Fondazione Policlinico Universitario Agostino GemelliIRCCSRomeItaly
| | - Chiara Veredice
- Child Neurology and Psychiatric Unit, Fondazione Policlinico Universitario Agostino GemelliIRCCSRomeItaly
| | - Tommaso Verdolotti
- Radiology and Neuroradiology Unit, Fondazione Policlinico Universitario Agostino GemelliIRCCSRomeItaly
| | - Giovanna Berté
- Radiology and Neuroradiology Unit, Fondazione Policlinico Universitario Agostino GemelliIRCCSRomeItaly
| | - Chiara Leoni
- Center for Rare Disease and Congenital Defects, Fondazione Policlinico Universitario Agostino GemelliIRCCSRomeItaly
| | - Roberta Onesimo
- Center for Rare Disease and Congenital Defects, Fondazione Policlinico Universitario Agostino GemelliIRCCSRomeItaly
| | - Silvia Maria Pulitanò
- Pediatric Intensive Care Unit Trauma Center Pediatric, Fondazione Policlinico Universitario Agostino GemelliIRCCSRomeItaly
| | - Marco Tartaglia
- Molecular Genetics and Functional Genomics, Ospedale Pediatrico Bambino GesùIRCCSRomeItaly
| | - Giuseppe Zampino
- Department of Life Sciences and Public HealthUniversità Cattolica del Sacro CuoreRomeItaly
- Center for Rare Disease and Congenital Defects, Fondazione Policlinico Universitario Agostino GemelliIRCCSRomeItaly
| | - Ilaria Contaldo
- Child Neurology and Psychiatric Unit, Fondazione Policlinico Universitario Agostino GemelliIRCCSRomeItaly
| | - Domenica Immacolata Battaglia
- Department of Life Sciences and Public HealthUniversità Cattolica del Sacro CuoreRomeItaly
- Child Neurology and Psychiatric Unit, Fondazione Policlinico Universitario Agostino GemelliIRCCSRomeItaly
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Lee DA, Sohn G, Park KM, Kim SE. Neuroimaging correlation with EEG in status epilepticus. Seizure 2024; 114:106-110. [PMID: 38118284 DOI: 10.1016/j.seizure.2023.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 12/04/2023] [Accepted: 12/12/2023] [Indexed: 12/22/2023] Open
Abstract
PURPOSE This study was to correlate EEG patterns with peri‑ictal perfusion CT abnormality (PCA) or peri‑ictal MR abnormality (PMA) in patients with status epilepticus (SE). METHODS This is a retrospective study done with SE patients from January 2016 to December 2021. We defined the PCA as single or multi-territorial cortical and/or thalamic hyper-perfusion. The PMA was defined as increased signal intensity in multiple brain regions including the cortex and subcortical regions. EEG patterns were categorized into electrographic seizure (ESz)/electroclinical seizure (ECSz), ictal-interictal continuum (IIC), and lateralized periodic discharges (LPDs) per the American Clinical Neurophysiology Society's guideline. We analyzed the association between the patterns of EEG and the presence of PCA or PMA. RESULTS Among 73 patients, 26 % (19/73) showed PCA and 25 % (18/73) demonstrated PMA. The patterns of EEG were as follows; ESz/ECSz in 25 % (18/73), IIC in 34 % (25/73), and LPD in 12 % (9/73). There was a significant correlation between the patterns of EEG and the presence of PMA, but not PCA. 48 % (12/25) had both PMA and PCA whereas 52 % (13/25) showed either PMA (6/25) or PCA (7/25). CONCLUSION Although PCA did not reveal an electro-radiographical correlation, PMA was strongly linked to ESz, ECSz, IIC, and LPD.
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Affiliation(s)
- Dong Ah Lee
- Department of Neurology, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - GyeongMo Sohn
- Department of Neurology, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - Kang Min Park
- Department of Neurology, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - Sung Eun Kim
- Department of Neurology, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea.
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Dedeoglu Ö, Akça H, Emeksiz S, Kartal A, Kurt NÇ. Management of Status Epilepticus by Different Pediatric Departments: Neurology, Intensive Care, and Emergency Medicine. Eur Neurol 2023; 86:315-324. [PMID: 37647871 PMCID: PMC10623395 DOI: 10.1159/000533191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 07/15/2023] [Indexed: 09/01/2023]
Abstract
INTRODUCTION The aim of this study was to explore the differences in status epilepticus (SE) management among pediatric neurology, emergency medicine, and intensive care specialists in Turkey. METHODS A 22-item questionnaire regarding first-, second-, and third-line management strategies of SE including demographic characteristics and common etiologies according to the specialty of participants was mailed to 370 specialists working in Turkey. RESULTS A total of 334 participants (response rate 90%) comprising 136 pediatric neurologists, 102 pediatric emergency medicine specialists, and 96 pediatric intensive care specialists completed the survey. While intensive care specialists frequently managed SE due to metabolic and autoimmune reasons, the most common etiologies encountered by emergency medicine specialists were epilepsy and infections. More than half of the intensive care specialists (64.6%) reported using non-BZD antiseizure medications in the 5th minute of the seizure. Most of the neurologists (76.4%) preferred to administer intravenous (IV) levetiracetam infusion as a second-line agent. About half of intensive care specialists and neurologists tried immunomodulatory therapies in super-refractory SE. Intensive care and emergency medicine specialists were less likely to favor ketogenic diet and pyridoxine therapy for the treatment of super-refractory SE. The rate of requesting EEG monitoring to recognize nonconvulsive SE (NCSE) was found to be very low except for neurologists. CONCLUSION There was no consensus among neurologists, intensive care specialists, and emergency medicine specialists in the management of SE in Turkey. Familiarity with particular antiseizure medications and the etiologies they manage seem to be the most important factors influencing the attitudes.
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Affiliation(s)
- Özge Dedeoglu
- Department of Pediatric Neurology, Ankara City Hospital, Ankara, Turkey
| | - Halise Akça
- Department of Pediatric Emergency Medicine, Ankara City Hospital, Ankara, Turkey
| | - Serhat Emeksiz
- Department of Pediatric Intensive Care, Ankara City Hospital, Ankara, Turkey
| | - Ayşe Kartal
- Department of Pediatric Neurology, Ankara City Hospital, Ankara, Turkey
| | - Neşe Çıtak Kurt
- Department of Pediatric Neurology, Ankara City Hospital, Ankara, Turkey
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Becker LL, Gratopp A, Prager C, Elger CE, Kaindl AM. Treatment of pediatric convulsive status epilepticus. Front Neurol 2023; 14:1175370. [PMID: 37456627 PMCID: PMC10343462 DOI: 10.3389/fneur.2023.1175370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 06/12/2023] [Indexed: 07/18/2023] Open
Abstract
Status epilepticus is one of the most common life-threatening neurological emergencies in childhood with the highest incidence in the first 5 years of life and high mortality and morbidity rates. Although it is known that a delayed treatment and a prolonged seizure can cause permanent brain damage, there is evidence that current treatments may be delayed and the medication doses administered are insufficient. Here, we summarize current knowledge on treatment of convulsive status epilepticus in childhood and propose a treatment algorithm. We performed a structured literature search via PubMed and ClinicalTrails.org and identified 35 prospective and retrospective studies on children <18 years comparing two and more treatment options for status epilepticus. The studies were divided into the commonly used treatment phases. As a first-line treatment, benzodiazepines buccal/rectal/intramuscular/intravenous are recommended. For status epilepticus treated with benzodiazepine refractory, no superiority of fosphenytoin, levetirazetam, or phenobarbital was identified. There is limited data on third-line treatments for refractory status epilepticus lasting >30 min. Our proposed treatment algorithm, especially for children with SE, is for in and out-of-hospital onset aids to promote the establishment and distribution of guidelines to address the treatment delay aggressively and to reduce putative permanent neuronal damage. Further studies are needed to evaluate if these algorithms decrease long-term damage and how to treat refractory status epilepticus lasting >30 min.
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Affiliation(s)
- Lena-Luise Becker
- Department of Pediatric Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Center for Chronically Sick Children, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Institute of Cell Biology and Neurobiology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Alexander Gratopp
- Department of Pediatric Pneumonology, Immunology and Intensive Care, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Christine Prager
- Department of Pediatric Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Center for Chronically Sick Children, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Christian E. Elger
- Department of Pediatric Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Center for Chronically Sick Children, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Beta Clinic, Bonn, Germany
| | - Angela M. Kaindl
- Department of Pediatric Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Center for Chronically Sick Children, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Institute of Cell Biology and Neurobiology, Charité-Universitätsmedizin Berlin, Berlin, Germany
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10
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Bonduelle T, Ollivier M, Trin K, Thomas B, Daubigney A, Michel V, De Montaudouin M, Marchal C, Aupy J. Association of Peri-ictal MRI Abnormalities With Mortality, Antiseizure Medication Refractoriness, and Morbidity in Status Epilepticus. Neurology 2023; 100:e943-e953. [PMID: 36443013 PMCID: PMC9990431 DOI: 10.1212/wnl.0000000000201599] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 10/06/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Status epilepticus (SE) is a life-threatening emergency requiring a prompt assessment of patient prognosis to guide management. MRI allows the identification of peri-ictal MRI abnormalities (PMAs) and provides insight into brain structural modifications induced by SE. However, little is known about the significance of PMA in SE prognosis. The aim of this study was to determine whether PMAs are associated with an increased mortality in SE and to establish the association between PMA and refractoriness to antiseizure medications, complications encountered, and induced morbidity. METHODS We conducted a retrospective observational cohort study including all eligible consecutive patients over 15 years old and hospitalized with SE at Bordeaux University Hospital (France) between January 2015 and December 2019. The primary end point was in-hospital mortality. A dedicated neuroradiologic reassessment was performed, together with a comprehensive medical review assessing baseline characteristics, in-hospital death, SE characterization, drug refractoriness, and following outcome in survivors. RESULTS Of 307 patients included, 79 (26%) showed PMA related to SE. Demographic, functional status at baseline and median delay between SE onset and MRI examination were similar in the PMA-positive and PMA-negative groups. In-hospital death occurred in 15% (45/307) patients and was significantly higher in the PMA-positive group (27%, 21/79 vs 11%, 24/228; p < 0.001). In multivariate analysis, the presence of PMA (odds ratio [OR] 2.86, 95% CI 1.02-8.18; p = 0.045), together with SE duration (OR 1.01, 95% CI 1.01-1.02; p = 0.007), older age at SE onset (OR 1.05, 95% CI 1.01-1.09; p = 0.013), preexisting ultimately fatal comorbidity (OR 4.01, 95% CI 1.56-10.6; p = 0.004), and acute lesional SE etiology (OR 3.74, 95% CI 1.45-10.2; p = 0.007) were independent predictors associated with in-hospital death. Patients with PMA had a higher risk of refractory SE (71 vs 33%, p < 0.001). Among survivors, delayed-onset epilepsy (40% vs 21%, p = 0.009) occurred more frequently in the PMA-positive group. DISCUSSION PMA-positive cases had a higher mortality rate in the largest cohort so far to assess the prognosis value of PMA in SE. As a noninvasive and easily available tool, PMA represents a promising structural biomarker for developing a personalized approach to prognostication in patients with SE receiving MRI.
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Affiliation(s)
- Thomas Bonduelle
- From the Department of Clinical Neurosciences (T.B., B.T., A.D., V.M., M.D.M., C.M., J.A.), Department of Neuroimaging (M.O.), and Department of Medical Information (K.T.), Centre Hospitalier Universitaire de Bordeaux; and CNRS (J.A.), IMN, UMR 5293, Univ. Bordeaux, France.
| | - Morgan Ollivier
- From the Department of Clinical Neurosciences (T.B., B.T., A.D., V.M., M.D.M., C.M., J.A.), Department of Neuroimaging (M.O.), and Department of Medical Information (K.T.), Centre Hospitalier Universitaire de Bordeaux; and CNRS (J.A.), IMN, UMR 5293, Univ. Bordeaux, France
| | - Kilian Trin
- From the Department of Clinical Neurosciences (T.B., B.T., A.D., V.M., M.D.M., C.M., J.A.), Department of Neuroimaging (M.O.), and Department of Medical Information (K.T.), Centre Hospitalier Universitaire de Bordeaux; and CNRS (J.A.), IMN, UMR 5293, Univ. Bordeaux, France
| | - Benjamin Thomas
- From the Department of Clinical Neurosciences (T.B., B.T., A.D., V.M., M.D.M., C.M., J.A.), Department of Neuroimaging (M.O.), and Department of Medical Information (K.T.), Centre Hospitalier Universitaire de Bordeaux; and CNRS (J.A.), IMN, UMR 5293, Univ. Bordeaux, France.
| | - Antoine Daubigney
- From the Department of Clinical Neurosciences (T.B., B.T., A.D., V.M., M.D.M., C.M., J.A.), Department of Neuroimaging (M.O.), and Department of Medical Information (K.T.), Centre Hospitalier Universitaire de Bordeaux; and CNRS (J.A.), IMN, UMR 5293, Univ. Bordeaux, France
| | - Veronique Michel
- From the Department of Clinical Neurosciences (T.B., B.T., A.D., V.M., M.D.M., C.M., J.A.), Department of Neuroimaging (M.O.), and Department of Medical Information (K.T.), Centre Hospitalier Universitaire de Bordeaux; and CNRS (J.A.), IMN, UMR 5293, Univ. Bordeaux, France
| | - Marie De Montaudouin
- From the Department of Clinical Neurosciences (T.B., B.T., A.D., V.M., M.D.M., C.M., J.A.), Department of Neuroimaging (M.O.), and Department of Medical Information (K.T.), Centre Hospitalier Universitaire de Bordeaux; and CNRS (J.A.), IMN, UMR 5293, Univ. Bordeaux, France
| | - Cécile Marchal
- From the Department of Clinical Neurosciences (T.B., B.T., A.D., V.M., M.D.M., C.M., J.A.), Department of Neuroimaging (M.O.), and Department of Medical Information (K.T.), Centre Hospitalier Universitaire de Bordeaux; and CNRS (J.A.), IMN, UMR 5293, Univ. Bordeaux, France
| | - Jérôme Aupy
- From the Department of Clinical Neurosciences (T.B., B.T., A.D., V.M., M.D.M., C.M., J.A.), Department of Neuroimaging (M.O.), and Department of Medical Information (K.T.), Centre Hospitalier Universitaire de Bordeaux; and CNRS (J.A.), IMN, UMR 5293, Univ. Bordeaux, France
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11
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Bosque Varela P, Machegger L, Oellerer A, Steinbacher J, McCoy M, Pfaff J, Trinka E, Kuchukhidze G. Imaging of status epilepticus: Making the invisible visible. A prospective study on 206 patients. Epilepsy Behav 2023; 141:109130. [PMID: 36803874 DOI: 10.1016/j.yebeh.2023.109130] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 01/29/2023] [Accepted: 01/30/2023] [Indexed: 02/20/2023]
Abstract
BACKGROUND Peri-ictal MRI abnormalities (PMA) frequently affect the cerebral cortex, hippocampus, pulvinar of the thalamus, corpus callosum, and cerebellum. In this prospective study, we aimed to characterize the spectrum of PMA in a large cohort of patients with status epilepticus. METHODS We prospectively recruited 206 patients with SE and an acute MRI. The MRI protocol included diffusion weighted imaging (DWI), fluid-attenuated inversion recovery (FLAIR), arterial spin labeling (ASL), and T1-weighted imaging pre-and post-contrast application. Peri-ictal MRI abnormalities were stratified as either neocortical or non-neocortical. Amygdala, hippocampus, cerebellum, and corpus callosum were regarded as non-neocortical structures. RESULTS Peri-ictal MRI abnormalities were observed in 93/206 (45%) of patients in at least one MRI sequence. Diffusion restriction was observed in 56/206 (27%) of patients, which was mainly unilateral in 42/56 (75%) affecting neocortical structures in 25/56 (45%), non-neocortical structures in 20/56 (36%) and both areas in 11/56 (19%) of patients. Cortical DWI lesions were located mostly in frontal lobes 15/25 (60%); non-neocortical diffusion restriction affected either the pulvinar of the thalamus or hippocampus 29/31 (95%). Alterations in FLAIR were observed in 37/203 (18%) of patients. They were mainly unilateral 24/37 (65%); neocortical 18/37 (49%), non-neocortical 16/37 (43%), or affecting both neocortical and non-neocortical structures 3/37 (8%). In ASL, 51/140 (37%) of patients had ictal hyperperfusion. Hyperperfused areas were located mainly in the neocortex 45/51 (88%) and were unilateral 43/51 (84%). In 39/66 (59%) of patients, PMA were reversible in one week. In 27/66 (41%), the PMA persisted and a second follow-up MRI was performed three weeks later in 24/27 (89%) patients. In 19/24 (79%) PMA were resolved. CONCLUSIONS Almost half of the patients with SE had peri-ictal MRI abnormalities. The most prevalent PMA was ictal hyperperfusion followed by diffusion restriction and FLAIR abnormalities. Neocortex was most frequently affected especially the frontal lobes. The majority of PMAs were unilateral. This paper was presented at the 8th London-Innsbruck Colloquium on Status Epilepticus and Acute Seizures held in September 2022.
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Affiliation(s)
- Pilar Bosque Varela
- Department of Neurology, Christian Doppler University Hospital, Member of the European Reference Network EpiCARE, and Centre for Cognitive Neuroscience, Paracelsus Medical University of Salzburg, Austria
| | - Lukas Machegger
- Department of Neuroradiology, Christian Doppler University Hospital, Paracelsus Medical University of Salzburg, Austria
| | - Andreas Oellerer
- Department of Neuroradiology, Christian Doppler University Hospital, Paracelsus Medical University of Salzburg, Austria
| | - Jürgen Steinbacher
- Department of Neuroradiology, Christian Doppler University Hospital, Paracelsus Medical University of Salzburg, Austria
| | - Mark McCoy
- Department of Neurology, Christian Doppler University Hospital, Member of the European Reference Network EpiCARE, and Centre for Cognitive Neuroscience, Paracelsus Medical University of Salzburg, Austria; Neuroscience Institute, Christian Doppler University Hospital, Salzburg, Austria
| | - Johannes Pfaff
- Department of Neuroradiology, Christian Doppler University Hospital, Paracelsus Medical University of Salzburg, Austria
| | - Eugen Trinka
- Department of Neurology, Christian Doppler University Hospital, Member of the European Reference Network EpiCARE, and Centre for Cognitive Neuroscience, Paracelsus Medical University of Salzburg, Austria; Neuroscience Institute, Christian Doppler University Hospital, Salzburg, Austria; Karl Landsteiner Institute for Neurorehabilitation and Space Neurology, Salzburg, Austria
| | - Giorgi Kuchukhidze
- Department of Neurology, Christian Doppler University Hospital, Member of the European Reference Network EpiCARE, and Centre for Cognitive Neuroscience, Paracelsus Medical University of Salzburg, Austria; Neuroscience Institute, Christian Doppler University Hospital, Salzburg, Austria.
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12
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Reindl C, Madžar D, Hamer HM. [Status epilepticus-Detection and treatment in the intensive care unit]. DER NERVENARZT 2023; 94:120-128. [PMID: 36534176 DOI: 10.1007/s00115-022-01418-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/08/2022] [Indexed: 12/24/2022]
Abstract
Status epilepticus is characterized by persistent or repetitive seizures which, without successful treatment, can lead to neuronal damage, neurological deficits and death of the patient.While status epilepticus with motor symptoms can usually be clinically diagnosed, nonconvulsive status epilepticus is often clinically overlooked due to its ambiguous semiology, so that electroencephalography (EEG) recording is necessary. The treatment of status epilepticus is performed in four treatment steps, whereby a difficult to treat status epilepticus is present from the third step at the latest and intensive medical care of the patient is necessary. Timely initiation of treatment and sufficient dosage of anticonvulsive medication are decisive for the success of treatment. There is little evidence for the "late" stages of treatment. Intensive medical measures pose the risk of complications that worsen the prognosis. Especially in nonconvulsive status epilepticus, the use of anesthetics must be weighed against possible complications of mechanical ventilation.
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Affiliation(s)
- Caroline Reindl
- Neurologische Klinik, Epilepsiezentrum, Universitätsklinikum Erlangen, Schwabachanlage 6, 91054, Erlangen, Deutschland.
| | - Dominik Madžar
- Neurologische Klinik, Universitätsklinikum Erlangen, Schwabachanlage 6, 91054, Erlangen, Deutschland
| | - Hajo M Hamer
- Neurologische Klinik, Epilepsiezentrum, Universitätsklinikum Erlangen, Schwabachanlage 6, 91054, Erlangen, Deutschland
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13
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Liang C, Chu E, Kuoy E, Soun JE. Autoimmune-mediated encephalitis and mimics: A neuroimaging review. J Neuroimaging 2023; 33:19-34. [PMID: 36217010 DOI: 10.1111/jon.13060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 09/10/2022] [Accepted: 09/20/2022] [Indexed: 02/01/2023] Open
Abstract
Autoimmune encephalitis is a category of autoantibody-mediated neurological disorders that often presents a diagnostic challenge due to its variable clinical and imaging findings. The purpose of this image-based review is to provide an overview of the major subtypes of autoimmune encephalitis and their associated autoantibodies, discuss their characteristic clinical and imaging features, and highlight several disease processes that may mimic imaging findings of autoimmune encephalitis. A literature search on autoimmune encephalitis was performed and publications from neuroradiology, neurology, and nuclear medicine literature were included. Cases from our institutional database that best exemplify major imaging features were presented.
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Affiliation(s)
- Conan Liang
- Department of Radiological Sciences, University of California, Irvine Medical Center, Orange, California, USA
| | - Eleanor Chu
- Department of Radiological Sciences, University of California, Irvine Medical Center, Orange, California, USA
| | - Edward Kuoy
- Department of Radiological Sciences, University of California, Irvine Medical Center, Orange, California, USA
| | - Jennifer E Soun
- Department of Radiological Sciences, University of California, Irvine Medical Center, Orange, California, USA
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14
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Romoli M, Merli E, Galluzzo S, Muccioli L, Testoni S, Zaniboni A, Contardi S, Simonetti L, Tinuper P, Zini A. Hyperperfusion Tmax mapping for nonconvulsive status epilepticus in the acute setting: A pilot case-control study. Epilepsia 2022; 63:2534-2542. [PMID: 35793391 PMCID: PMC9796764 DOI: 10.1111/epi.17359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 07/02/2022] [Accepted: 07/05/2022] [Indexed: 01/07/2023]
Abstract
OBJECTIVE Nonconvulsive status epilepticus (NCSE) is misdiagnosed in >50% of cases in the emergency department. Computed tomographic perfusion (CTP) has been implemented in the hyperacute setting to detect seizure-induced hyperperfusion. However, the diagnostic value of CTP is limited by the lack of thresholds for hyperperfusion and high interrater variability. This pilot case-control study aims at identifying the diagnostic value of reverse Tmax (rTmax) in differentiating NCSE from acute ischemic stroke in the hyperacute setting. METHODS We enrolled patients with NCSE (Salzburg criteria-based diagnosis) and stroke cases 1:1 matched for clinical features and time of presentation. CTP standard maps (mean transit time [MTT]-cerebral blood volume-cerebral blood flow [CBF]) and rTmax maps were elaborated and rated by two experts in CTP blinded to the final diagnosis. Hyperperfusion was adjudicated for standard CTP maps as an increase in CBF and a decrease in MTT, and for rTmax as the presence of a black area on 3-, 2-, and 1-s threshold maps. Cronbach alpha was used for interrater agreement; receiver operating curve analysis was run to measure accuracy with area under the curve. RESULTS Overall, 34 patients were included (17 NCSE, 17 stroke; time from onset to imaging = 2 h for both groups). People with NCSE were older and more frequently had a history of epilepsy. NCSE patients had hyperperfusion on rTmax maps in 11 of 17 cases versus zero of 17 in stroke. Intra- and interrater reliability was higher for rTmax than for standard CTP maps (κ = 1 vs. κ = .6). rTmax was 82% (95%CI = 67-97%) accurate in predicting NCSE versus stroke in the hyperacute setting. Agreement between neuroimaging and electroencephalography (EEG) was limited at a hemispheric level for standard CTP maps, whereas rTMax had agreement with EEG largely reaching the sublobar level. SIGNIFICANCE rTmax mapping might represent a reliable tool to spot NCSE-induced hyperperfusion with a threshold-based reproducible approach. Further studies are needed for validation and implementation in the differential diagnosis of focal neurological deficit in the hyperacute setting.
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Affiliation(s)
| | - Elena Merli
- IRCCS Istituto delle ScienzeNeurologiche di BolognaNeurologia e Rete Stroke Metropolitana, OspedaleMaggioreBolognaItaly
| | - Simone Galluzzo
- IRCCS Istituto delle ScienzeNeurologiche di BolognaNeuroradiologia, Ospedale MaggioreBolognaItaly
| | - Lorenzo Muccioli
- Department of Biomedical and Neuromotor SciencesUniversity of BolognaBolognaItaly
| | - Stefania Testoni
- IRCCS Istituto delle ScienzeNeurologiche di BolognaNeurologia e Rete Stroke Metropolitana, OspedaleMaggioreBolognaItaly
| | - Anna Zaniboni
- IRCCS Istituto delle ScienzeNeurologiche di BolognaNeurologia e Rete Stroke Metropolitana, OspedaleMaggioreBolognaItaly
| | - Sara Contardi
- IRCCS Istituto delle ScienzeNeurologiche di BolognaNeurologia e Rete Stroke Metropolitana, OspedaleMaggioreBolognaItaly
| | - Luigi Simonetti
- IRCCS Istituto delle ScienzeNeurologiche di BolognaNeuroradiologia, Ospedale MaggioreBolognaItaly
| | - Paolo Tinuper
- Department of Biomedical and Neuromotor SciencesUniversity of BolognaBolognaItaly,IRCCS Istituto delle ScienzeNeurologiche di BolognaFull Member of the ERN EpiCAREBolognaItaly
| | - Andrea Zini
- IRCCS Istituto delle ScienzeNeurologiche di BolognaNeurologia e Rete Stroke Metropolitana, OspedaleMaggioreBolognaItaly
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15
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Manganotti P, Furlanis G, Cova MA, Olivo S, Dore F, Sartori A, Naccarato M. Isolated aphasic status epilepticus: CT perfusion, SPECT and EEG reveal neurovascular coupling and support the differential diagnosis. Epileptic Disord 2022; 24:549-554. [PMID: 35653085 DOI: 10.1684/epd.2022.1421] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 02/03/2022] [Indexed: 11/08/2023]
Abstract
Objective Among the clinical manifestations of stroke mimics, isolated aphasia is one of the most challenging due to its aetiopathogenic diagnosis. This short communication describes a specific perfusion and brain oscillatory pattern in a challenging case of prolonged isolated aphasia caused by status epilepticus, jointly investigated by computed tomography (CT) perfusion, single-photon emission computerized tomography (SPECT)/CT and EEG qualitative and quantitative analysis. Methods We discuss the different patterns of perfusion neuroimaging and EEG between SE and ischaemic stroke or postictal (Todd's)-related isolated aphasia, and propose these differences as a basis to support the differential diagnosis. Results The pattern associated with SE was characterized by focal hyperperfusion on CT perfusion maps (the left mean transit time was shorter with >10% asymmetry, and left cerebral blood volume and cerebral blood flow increased or slightly altered, relative to the contralateral side) and SPECT (focal left temporal hyperperfusion), without any early ischaemic signs on non-enhanced CT, while the EEG showed a predominant left hemispheric slow delta power. The aforementioned perfusion pattern contrasts with postictal epileptic Todd's phenomenon, which is characterized by hypoperfusion on CT perfusion (the mean transit time is prolonged and cerebral blood volume and cerebral blood flow are reduced, compared to the contralateral hemisphere) and SPECT (focal hypoperfusion), not restricted to the specific vascular territories. Significance CT perfusion patterns may add valuable information to support the differential diagnosis of status epilepticus, rather than acute ischaemic stroke or postictal Todd's phenomenon, in cases with challenging symptoms of prolonged isolated aphasia.
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16
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Lillis KP. Putting the Neuro in Neurovascular Coupling. Epilepsy Curr 2022; 22:184-186. [PMID: 36474829 PMCID: PMC9684592 DOI: 10.1177/15357597221084810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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17
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Doniselli FM, Deleo F, Criscuolo S, Stabile A, Pastori C, Di Giacomo R, Didato G, Chiapparini L, Villani F. MRI in Late-Onset Rasmussen Encephalitis: A Long-Term Follow-Up Study. Diagnostics (Basel) 2022; 12:diagnostics12020502. [PMID: 35204592 PMCID: PMC8871246 DOI: 10.3390/diagnostics12020502] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 02/09/2022] [Accepted: 02/11/2022] [Indexed: 11/23/2022] Open
Abstract
Late-onset Rasmussen encephalitis (LoRE) is a rare unihemispheric progressive inflammatory disorder causing neurological deficits and epilepsy. The long-term radiological evolution has never been fully described. We retrospectively analyzed the MR images of 13 LoRE patients from a total of 136 studies, and searched for focal areas of volume loss or signal intensity abnormality in grey matter or white matter. Each subject had a median of nine MRI studies (IQR 7–13). Frontal and temporal lobes were the most affected regions (13/13 and 8/13, respectively) and showed the greatest worsening over time in terms of atrophic changes (9/13 and 5/8, respectively). A milder cortical atrophy was found in the insular and parietal lobes. The caudate nucleus was affected in seven patients. Hyperintensities of grey matter and white matter on T2-WI and FLAIR images were observed in all patients, and transiently in eight patients. In two cases out of the latter patients, these transient alterations evolved into atrophy of the same region. Disease duration was significantly associated with signal abnormalities in the grey matter at last follow-up. LoRE MRI alterations are milder, and their progression is markedly slower compared to radiological findings described in the childhood form.
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Affiliation(s)
- Fabio Martino Doniselli
- Neuroradiology Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Celoria 11, 20133 Milan, Italy; (F.M.D.); (L.C.)
- Department of Biomedical Sciences for Health, University of Milan, Via Mangiagalli 31, 20122 Milan, Italy
| | - Francesco Deleo
- Epilepsy Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Celoria 11, 20133 Milan, Italy; (A.S.); (C.P.); (R.D.G.); (G.D.)
- Correspondence: ; Tel.: +39-02-23942242
| | - Stefania Criscuolo
- Postgraduational School of Radiodiagnostics, University of Milan, Via Festa del Perdono 7, 20122 Milan, Italy;
| | - Andrea Stabile
- Epilepsy Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Celoria 11, 20133 Milan, Italy; (A.S.); (C.P.); (R.D.G.); (G.D.)
| | - Chiara Pastori
- Epilepsy Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Celoria 11, 20133 Milan, Italy; (A.S.); (C.P.); (R.D.G.); (G.D.)
| | - Roberta Di Giacomo
- Epilepsy Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Celoria 11, 20133 Milan, Italy; (A.S.); (C.P.); (R.D.G.); (G.D.)
| | - Giuseppe Didato
- Epilepsy Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Celoria 11, 20133 Milan, Italy; (A.S.); (C.P.); (R.D.G.); (G.D.)
| | - Luisa Chiapparini
- Neuroradiology Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Celoria 11, 20133 Milan, Italy; (F.M.D.); (L.C.)
| | - Flavio Villani
- Division of Clinical Neurophysiology and Epilepsy Center, IRCCS Ospedale Policlinico San Martino, Largo R. Benzi 10, 16132 Genoa, Italy;
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Lee DA, Lee J, Kim HC, Park KM, Kim SE. Hippocampal injury in patients with status epilepticus: Quantitative analysis of hippocampal volume and structural co-variance network. Seizure 2022; 95:84-89. [PMID: 35030375 DOI: 10.1016/j.seizure.2022.01.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 12/16/2021] [Accepted: 01/05/2022] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVE This study aimed to evaluate the differences in hippocampal structural volumes and intra-hippocampal networks between patients with status epilepticus (SE) and healthy controls. METHODS We enrolled 45 patients with SE and 35 age- and sex-matched healthy controls. We excluded patients with active structural lesions, which could be a direct cause of SE, but included patients with co-existing lesions. Co-existing lesions were defined as any lesions possibly related to the occurrence of SE, including encephalomalacia, cavernous malformation, dural arteriovenous fistula, and normal pressure hydrocephalus, etc. We divided 45 patients into those with co-existing lesions (n = 21) and those without co-existing lesions (n = 24). We conducted a volumetric analysis using FreeSurfer (version 7), and the intra-hippocampal structural co-variance network was analyzed with a graph theoretical analysis based on the structural volumes of the hippocampal subfields. RESULTS The structural volumes and intra-hippocampal structural co-variance networks were not different between patients with and without co-existing lesions. However, both structural volumes and intra-hippocampal structural co-variance networks were significantly different in patients with SE compared to healthy controls, and the ratio of the volume difference: [(volume of controls-volume of patients)/volume of controls] was highest in the left hippocampus (0.195), left amygdala (0.143), left thalamus (0.126), and right cortex (0.084). In addition, the global connectivity measurements including radius, diameter, eccentricity, and assortativity were significantly increased, and the small-worldness index was significantly decreased in patients with SE. Notably, structural volumes were negatively related to age but not to the duration of SE. SIGNIFICANCE Our study revealed significant alterations in structural volumes and intra-hippocampal structural co-variance networks in patients with SE compared to healthy controls, even though hippocampal atrophy was not evident on visual analysis; this is likely due to the direct effect of SE itself.
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Affiliation(s)
- Dong Ah Lee
- Department of Neurology, Haeundae Paik Hospital, Inje University College of Medicine, Busan, South Korea
| | - Joonwon Lee
- Department of Neurology, Haeundae Paik Hospital, Inje University College of Medicine, Busan, South Korea
| | - Hyung Chan Kim
- Department of Neurology, Haeundae Paik Hospital, Inje University College of Medicine, Busan, South Korea
| | - Kang Min Park
- Department of Neurology, Haeundae Paik Hospital, Inje University College of Medicine, Busan, South Korea
| | - Sung Eun Kim
- Department of Neurology, Haeundae Paik Hospital, Inje University College of Medicine, Busan, South Korea.
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Orlandi N, Giovannini G, Mirandola L, Monti G, Marudi A, Mosca F, Lalla A, d'Orsi G, Francavilla M, Meletti S. An ultra-long new onset refractory status epilepticus: Winning the battle but losing the war? Epilepsy Behav Rep 2022; 18:100537. [PMID: 35445189 PMCID: PMC9014360 DOI: 10.1016/j.ebr.2022.100537] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 03/20/2022] [Accepted: 03/21/2022] [Indexed: 11/29/2022] Open
Abstract
Enduring epileptic seizures can lead to a wide array of neuroradiological and EEG alterations. Even in case of resolution, ultra-long NORSE has severe and disabling consequences. NORSE of unknown etiology is a therapeutic challenge. This case points out the need for disease modifying treatments in NORSE.
New onset refractory status epilepticus (NORSE), is a rare and challenging condition occurring in previously healthy people. The etiology often remains undiscovered and is frequently associated with an unfavorable outcome. We report the electroclinical and neuroradiological evolution of an ultra-long case of NORSE of unknown etiology. A 38-year-old woman with a prodrome of fever, vomiting and diarrhea was admitted to our Intensive Care Unit for refractory convulsive status epilepticus (SE). Her past medical history was unremarkable. Extensive examinations were negative for potential viral, autoimmune and metabolic etiologies. Despite multiple therapeutical attempts with antiseizures medications, anesthetics and immunotherapy, seizures persisted. After nearly 6 months of enduring seizures, SE finally ceased and the patient gradually recovered to a minimum state of awareness. She was then able to communicate through one-word utterances and to understand simple tasks. At a three-years follow-up, she developed multifocal drug-resistant epilepsy, subcortical myoclonus and severe spastic quadraparesis, becoming completely dependent for activities of daily living. To our knowledge, this represents one of the longest cases of NORSE with final status resolution at this time. However, ultra-long SE in this case led to severe and disabling neurological sequelae. Future studies focused on disease modifying treatments for refractory SE are needed.
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Affiliation(s)
- Niccolò Orlandi
- Neurology Unit, OCB Hospital, Azienda Ospedaliera-Universitaria, Modena, Italy
- Department of Biomedical, Metabolic and Neural Science, University of Modena and Reggio Emilia, Modena, Italy
| | - Giada Giovannini
- Neurology Unit, OCB Hospital, Azienda Ospedaliera-Universitaria, Modena, Italy
- PhD Program in Clinical and Experimental Medicine, University of Modena and Reggio Emilia, Modena, Italy
| | - Laura Mirandola
- Department of Biomedical, Metabolic and Neural Science, University of Modena and Reggio Emilia, Modena, Italy
- Neurology Unit, San Giovanni Bosco Hospital, Turin, Italy
| | - Giulia Monti
- Neurology Unit, Ospedale Ramazzini di Carpi, AUSL Modena, Italy
| | - Andrea Marudi
- Intensive Care Unit, OCB Hospital, Azienda Ospedaliera-Universitaria, Modena, Italy
| | - Francesco Mosca
- Intensive Care Unit, OCB Hospital, Azienda Ospedaliera-Universitaria, Modena, Italy
| | - Alessandra Lalla
- Epilepsy Centre – S.C. Neurologia Universitaria, Policlinico Riuniti, Foggia, Italy
| | - Giuseppe d'Orsi
- Neurology Unit, IRCCS Casa Sollievo della Sofferenza, Foggia, Italy
| | | | - Stefano Meletti
- Neurology Unit, OCB Hospital, Azienda Ospedaliera-Universitaria, Modena, Italy
- Department of Biomedical, Metabolic and Neural Science, University of Modena and Reggio Emilia, Modena, Italy
- Corresponding author at: Department of Biomedical, Metabolic, and Neural Sciences, Center for Neurosciences and Neurotechnology, University of Modena and Reggio Emilia, Via Giardini, 1355 – Ospedale Civile S. Agostino Estense, Modena 41126, Italy.
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Kim TJ, Choi JW, Han M, Kim BG, Park SA, Huh K, Choi JY. Usefulness of arterial spin labeling perfusion as an initial evaluation of status epilepticus. Sci Rep 2021; 11:24218. [PMID: 34930959 PMCID: PMC8688435 DOI: 10.1038/s41598-021-03698-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 12/06/2021] [Indexed: 11/09/2022] Open
Abstract
This study aimed to evaluate the sensitivity and prognostic value of arterial spin labeling (ASL) in a large group of status epilepticus (SE) patients and compare them with those of other magnetic resonance (MR) sequences, including dynamic susceptibility contrast (DSC) perfusion imaging. We retrospectively collected data of patients with SE in a tertiary center between September 2016 and March 2020. MR images were visually assessed, and the sensitivity for the detection of SE and prognostication was compared among multi-delay ASL, DSC, fluid-attenuated inversion recovery (FLAIR), and diffusion-weighted imaging (DWI). We included 51 SE patients and 46 patients with self-limiting seizures for comparison. Relevant changes in ASL were observed in 90.2% (46/51) of SE patients, a percentage higher than those for DSC, FLAIR, and DWI. ASL was the most sensitive method for initial differentiation between SE and self-limiting seizures. The sensitivity of ASL for detecting refractory SE (89.5%) or estimating poor outcomes (100%) was higher than those of other MR protocols or electroencephalography and comparable to those of clinical prognostic scores, although the specificity of ASL was very low as 9.4% and 15.6%, respectively. ASL showed a better ability to detect SE and predict the prognosis than other MR sequences, therefore it can be valuable for the initial evaluation of patients with SE.
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Affiliation(s)
- Tae-Joon Kim
- Department of Neurology, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Jin Wook Choi
- Department of Radiology, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Miran Han
- Department of Radiology, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Byung Gon Kim
- Department of Neurology, Ajou University School of Medicine, Suwon, Republic of Korea.,Departments of Brain Science and Neurology, Ajou University School of Medicine, 164, World cup-ro, Yeongtong-gu, Suwon, Gyeonggi-do, 16499, Republic of Korea
| | - Sun Ah Park
- Department of Neurology, Ajou University School of Medicine, Suwon, Republic of Korea.,Department of Anatomy, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Kyoon Huh
- Department of Neurology, Ajou University School of Medicine, Suwon, Republic of Korea.,Department of Medical Humanities & Social Medicine, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Jun Young Choi
- Department of Neurology, Ajou University School of Medicine, Suwon, Republic of Korea. .,Departments of Brain Science and Neurology, Ajou University School of Medicine, 164, World cup-ro, Yeongtong-gu, Suwon, Gyeonggi-do, 16499, Republic of Korea.
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21
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Ahmed QS, Sadighi ZS, Lucas JT, Khan RB. Stroke-Like Migraine after Radiation Treatment Syndrome in Children with Cancer. JOURNAL OF PEDIATRIC NEUROLOGY 2021. [DOI: 10.1055/s-0041-1740364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
AbstractStroke-like migraine attacks after radiation therapy (SMART) syndrome is a symptom complex of transient neurological deficits, headache, and abnormal cortical contrast enhancement on brain MRI. Pathophysiology is unclear, but exposure to cranial radiation (RT) is a sine qua non. We report five children with SMART syndrome treated with RT therapy for medulloblastoma (n = 3), atypical teratoid rhabdoid tumor (n = 1), and pleomorphic xanthoastrocytoma (n = 1). Median age at tumor diagnosis was 9.4 years (range 5.1–14.7). Median follow-up from cancer diagnosis was 3.1 years (range 1.4–12.9). All patients had 54 Gy focal RT treatment and medulloblastoma children had additional 36 Gy craniospinal irradiation. Median time from the end of RT to first transient neurological deficit was 1 year (range 0.7–12.1). The median follow-up since first SMART episode was 0.6 years (range 0.3–2.6). Presenting symptoms included the gradual development of unilateral weakness (n = 4), non-fluent dysphasia (n = 1), somnolence (n = 1), and headaches (n = 3). Neurological deficits resolved within 30 minutes to 10 days. Transient cortical enhancement on magnetic resonance imaging (MRI) was confirmed in two children and was absent in the other three. Two children had a single and three had multiple episodes over the next few months. Two children with protracted symptoms responded to 3 days treatment with high dose intravenous methylprednisolone. Symptoms ultimately resolved in all patients. SMART syndrome is a rare disorder characterized by slow evolution of neurological deficits with variable abnormal cortical contrast enhancement. The use of steroids may improve symptoms and speed resolution.
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Affiliation(s)
- Qurratulain S. Ahmed
- Department of Medicine, Bay State Medical Center, Springfield, Massachusetts, United States
| | - Zsila S. Sadighi
- Division of Neurology, St. Jude Children's Research Hospital, Memphis, Tennessee, United States
| | - John T. Lucas
- Department of Radiation Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee, United States
| | - Raja B. Khan
- Division of Neurology, St. Jude Children's Research Hospital, Memphis, Tennessee, United States
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22
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Status Epilepticus and Neurosyphilis: A Case Report and a Narrative Review. NEUROSCI 2021. [DOI: 10.3390/neurosci2040031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Neurosyphilis is a rare but life-threatening complication of syphilis that can develop even decades after the primary infection and can be unrecognized. Seizures and status epilepticus (SE) may represent the first manifestation in a previously undiagnosed syphilitic patient. We present an exemplification case of a new onset refractory status epilepticus caused by neurosyphilis and we reviewed the existing literature. We selected all studies reporting cases of SE in the context both of patients with a known diagnosis of syphilis and as the first manifestation of neurosyphilis. We identified 50 patients, mostly composed of immunocompetent, middle-aged males. Thirty-nine patients (83%) presented a new onset SE. A history of subtle and rapidly progressive mood and/or cognitive impairment suggesting a limbic encephalitis-like presentation was frequently observed. Focal frontal or temporal SE was reported in 26. Brain MRI frequently showed T2/FLAIR hyperintensities widely involving the medial temporal structures and the frontal lobes. This review should increase the clinician’s awareness of neurosyphilis as a possible etiology of a new onset SE of unknown etiology, especially in the context of a “limbic encephalitis”-like clinical presentation. Prompt recognition and treatment for neurosyphilis partially or completely reverse neurologic sequelae, changing the natural history of the disease.
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Bascuñana P, Wolf BJ, Jahreis I, Brackhan M, García-García L, Ross TL, Bengel FM, Bankstahl M, Bankstahl JP. 99mTc-HMPAO SPECT imaging reveals brain hypoperfusion during status epilepticus. Metab Brain Dis 2021; 36:2597-2602. [PMID: 34570340 PMCID: PMC8580894 DOI: 10.1007/s11011-021-00843-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 09/14/2021] [Indexed: 11/09/2022]
Abstract
Status epilepticus (SE) is a clinical emergency with high mortality. SE can trigger neuronal death or injury and alteration of neuronal networks resulting in long-term cognitive decline or epilepsy. Among the multiple factors contributing to this damage, imbalance between oxygen and glucose requirements and brain perfusion during SE has been proposed. Herein, we aimed to quantify by neuroimaging the spatiotemporal course of brain perfusion during and after lithium-pilocarpine-induced SE in rats. To this purpose, animals underwent 99mTc-HMPAO SPECT imaging at different time points during and after SE using a small animal SPECT/CT system. 99mTc-HMPAO regional uptake was normalized to the injected dose. In addition, voxel-based statistical parametric mapping was performed. SPECT imaging showed an increase of cortical perfusion before clinical seizure activity onset followed by regional hypo-perfusion starting with the first convulsive seizure and during SE. Twenty-four hours after SE, brain 99mTc-HMPAO uptake was widely decreased. Finally, chronic epileptic animals showed regionally decreased perfusion affecting hippocampus and cortical sub-regions. Despite elevated energy and oxygen requirements, brain hypo-perfusion is present during SE. Our results suggest that insufficient compensation of required blood flow might contribute to neuronal damage and neuroinflammation, and ultimately to chronic epilepsy generated by SE.
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Affiliation(s)
- Pablo Bascuñana
- Department of Nuclear Medicine, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
- Department of Neuropathology, University of Oslo and Oslo University Hospital, Oslo, Norway.
| | - Bettina J Wolf
- Department of Nuclear Medicine, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
- Department of Pharmacology, Toxicology and Pharmacy, University of Veterinary Medicine, Hannover, Germany
| | - Ina Jahreis
- Department of Nuclear Medicine, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
- Department of Pharmacology, Toxicology and Pharmacy, University of Veterinary Medicine, Hannover, Germany
| | - Mirjam Brackhan
- Department of Nuclear Medicine, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
- Department of Neuropathology, University of Oslo and Oslo University Hospital, Oslo, Norway
- Department of Pharmacology, Toxicology and Pharmacy, University of Veterinary Medicine, Hannover, Germany
| | - Luis García-García
- Unidad de Cartografía Cerebral, Instituto Pluridisciplinar, Universidad Complutense de Madrid, Paseo Juan XXIII, 1, 28040, Madrid, Spain
- Departamento de Farmacología, Farmacognosia y Botánica, Facultad de Farmacia, Universidad Complutense de Madrid, Plaza Ramón y Cajal s/n, 28040, Madrid, Spain
| | - Tobias L Ross
- Department of Nuclear Medicine, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Frank M Bengel
- Department of Nuclear Medicine, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Marion Bankstahl
- Department of Pharmacology, Toxicology and Pharmacy, University of Veterinary Medicine, Hannover, Germany
- Hannover Medical School, Institute for Laboratory Animal Science, Hannover, Germany
| | - Jens P Bankstahl
- Department of Nuclear Medicine, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
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24
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Giovannini G, Malagoli M, Turchi G, Miani A, Orlandi N, Vaudano AE, Meletti S. Cortical and thalamic hyper-perfusion in non-convulsive status epilepticus. Relationship between perfusion CT patterns and Salzburg EEG criteria. Seizure 2021; 92:10-17. [PMID: 34391029 DOI: 10.1016/j.seizure.2021.08.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 08/01/2021] [Accepted: 08/03/2021] [Indexed: 12/01/2022] Open
Abstract
INTRODUCTION Status epilepticus (SE) is a neurological emergency and in particular nonconvulsive SE (NCSE) represents a diagnostic challenge. To improve clinical decision-making, cerebral perfusion-computed tomography (PCT) has been shown as a helpful tool to support the diagnosis of focal NCSE. MATERIALS AND METHODS This is a monocentric retrospective study. Among the 602 cases of SE observed between September 2013 and April 2020 we included 21 patients that were studied with PCT. The perfusion maps were first visually analysed then a quantitative analysis (by regions of interest, ROI) was obtained. For each patient, the diagnostic EEG was reviewed and classified in accordance to the Salzburg Criteria for NCSE (SCC) as definite (D-NCSE) and possible (P-NCSE). Finally, we analysed the relationship between PCT and EEG patterns. RESULTS Hyper-perfusion was observed in 18 patients (86%), while in the remaining 3 (14%) a normo-perfused pattern was present. Hyper-perfusion was observed in 14 of the D-NCSE group (88%) and in the two patients with a P-NCSE (100%). No one among the patients with a P-NCSE had a thalamic hyper-perfusion, while among the 6 patients with continuous sustained epileptiform discharges > 2.5 Hz (pattern 1 of SCC), 4 (67%) showed cortical plus thalamic hyper-perfusion. CONCLUSIONS PCT could facilitate the differential diagnosis and speed-up the diagnostic process of NCSE in emergency situations. Finding cortical multi-lobar hyper-perfusion, especially if present together with homolateral thalamic hyper-perfusion in a patient with an acute-onset of motor/sensory/language deficits is highly suggestive for the presence of NCSE and is particularly related to continuous/sustained ictal patterns.
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Affiliation(s)
- Giada Giovannini
- Department of Biomedical, Metabolic, and Neural Science, Center for Neuroscience and Neurotechnology, University of Modena and Reggio Emilia, Modena, Italy; Neurology Unit, OCB Hospital, Azienda Ospedaliera Universitaria di Modena, Italy; PhD Program in Clinical and Experimental Medicine, University of Modena and Reggio Emilia, Modena, Italy
| | - Marcella Malagoli
- Neuroradiology Unit, OCB Hospital, Azienda Ospedaliera Universitaria di Modena, Italy
| | - Giulia Turchi
- Neurology Unit, OCB Hospital, Azienda Ospedaliera Universitaria di Modena, Italy
| | - Alice Miani
- Department of Biomedical, Metabolic, and Neural Science, Center for Neuroscience and Neurotechnology, University of Modena and Reggio Emilia, Modena, Italy
| | - Niccolò Orlandi
- Department of Biomedical, Metabolic, and Neural Science, Center for Neuroscience and Neurotechnology, University of Modena and Reggio Emilia, Modena, Italy; Neurology Unit, OCB Hospital, Azienda Ospedaliera Universitaria di Modena, Italy
| | | | - Stefano Meletti
- Department of Biomedical, Metabolic, and Neural Science, Center for Neuroscience and Neurotechnology, University of Modena and Reggio Emilia, Modena, Italy; Neurology Unit, OCB Hospital, Azienda Ospedaliera Universitaria di Modena, Italy.
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25
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Mariajoseph FP, Muthusamy S, Amukotuwa S, Seneviratne U. Seizure-induced reversible MRI abnormalities in patients with single seizures: a systematic review. Epileptic Disord 2021; 23:552-562. [PMID: 34240708 DOI: 10.1684/epd.2021.1300] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Accepted: 02/24/2021] [Indexed: 11/17/2022]
Abstract
Differentiating seizure-induced reversible MRI abnormalities from MRI changes secondary to underlying cerebral pathologies can be challenging for clinicians in the investigation of seizures. The aim of this study was to delineate the characteristic features of reversible seizure-induced MRI abnormalities. A systematic search of the databases Medline (1946-2020), PubMed (1996-2020), and Embase (1947-2020) was performed in keeping with the Preferred Items Reporting for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. All publications in English, including case reports, of single unprovoked seizure patients with seizure-induced MRI abnormalities demonstrating complete resolution, were included. Two authors extracted data using a predefined template and evaluated the quality of the included studies. MRI data were additionally reviewed by a neuroradiologist. All data were synthesised qualitatively. There were 11 publications altogether, yielding a total of 27 cases that were pertinent to our research question. Abnormalities were most commonly observed on T2-weighted sequences. The most commonly observed constellations of MRI features ("composite pattern") included the following: cortical or subcortical signal change with or without leptomeningeal enhancement, signal abnormality in the splenium of the corpus callosum, and hippocampal signal abnormality. Seizure-induced reversible MRI abnormalities were observed as early as six hours from seizure onset and resolved completely as early as five days from seizure onset. A key limitation of this systematic review was the variability and incomplete reporting of clinical data, especially with regards to seizure semiology and MRI sequences performed, which may have limited our ability to make more definitive conclusions. Seizure-induced reversible MRI changes may appear within hours of seizure onset and resolve within a variable time frame, ranging from days to weeks. Bilateral seizure-induced reversible MRI abnormalities tend to be associated with generalised seizures while unilateral seizure-induced reversible MRI abnormalities may be associated with focal seizures, usually ipsilateral to the seizure focus.
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Affiliation(s)
- Frederick P Mariajoseph
- School of Clinical Sciences at Monash Health, Department of Medicine, Monash University, Melbourne, Victoria, Australia
| | | | | | - Udaya Seneviratne
- School of Clinical Sciences at Monash Health, Department of Medicine, Monash University, Melbourne, Victoria, Australia, Department of Neurology, Monash Medical Centre, Clayton, Melbourne, Australia, Department of Medicine, St. Vincent's Hospital, University of Melbourne, Melbourne, Australia
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26
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Saitov G, Müller A, Bastian B, Michalski D. [Pharmacotherapy and intensive care aspects of status epilepticus: update 2020/2021]. Anaesthesist 2021; 70:874-887. [PMID: 34212230 PMCID: PMC8492596 DOI: 10.1007/s00101-021-01000-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/21/2021] [Indexed: 11/30/2022]
Abstract
Die gezielte Therapie epileptischer Ereignisse und im Speziellen des Status epilepticus (SE) setzt das sichere Erkennen der Krankheitsbilder voraus, wofür gerade bei Formen mit vorwiegend nichtmotorischen Symptomen klinische und elektroenzephalographische Expertise notwendig ist. Die im Jahr 2020 erfolgte Fortschreibung der deutschen Leitlinie zur Behandlung des SE hält an der streng stufengerechten Therapie fest, die eskalierend die Anwendung von Benzodiazepinen, spezifischen Antiepileptika und Anästhetika vorsieht. Bisher ist die Eingrenzung eines in den allermeisten Fällen wirksamen sowie zugleich sicheren und interaktionsfreien Antiepileptikums nicht gelungen. Individuelle Vorerkrankungen und aktuelle Begleitumstände gehen daher genauso wie Erfahrungen des Behandlerteams in die differenzierte Behandlung des SE ein. Insbesondere bei therapierefraktären Formen des SE erweist sich die Therapie als durchaus kompliziert und hat regelhaft intensivmedizinische Implikationen. Mithin ergeben sich im Zuge der modernen SE-Behandlung zahlreiche interdisziplinäre Schnittstellen. Zukünftige wissenschaftliche Fragstellungen werden sich u. a. mit der optimalen Therapie des nonkonvulsiven SE und hier v. a. dem Ausmaß und dem Zeitpunkt von adäquaten Therapieschritten sowie mit assoziierten ethischen Fragen einer Therapieeskalation beschäftigen.
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Affiliation(s)
- Gabrielė Saitov
- Klinik und Poliklinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Leipzig, Liebigstr. 20, 04103, Leipzig, Deutschland.
| | - Annekatrin Müller
- Klinik und Poliklinik für Neurologie, Universitätsklinikum Leipzig, Liebigstr. 20, 04103, Leipzig, Deutschland
| | - Börge Bastian
- Klinik und Poliklinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Leipzig, Liebigstr. 20, 04103, Leipzig, Deutschland
| | - Dominik Michalski
- Klinik und Poliklinik für Neurologie, Universitätsklinikum Leipzig, Liebigstr. 20, 04103, Leipzig, Deutschland.
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El-Wahsh S, Dunkerton S, Ang T, Winters HS, Delcourt C. Current perspectives on neuroimaging techniques used to identify stroke mimics in clinical practice. Expert Rev Neurother 2021; 21:517-531. [PMID: 33787426 DOI: 10.1080/14737175.2021.1911650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Urgent clinical assessment and brain imaging are essential for differentiating stroke mimics from stroke and to avoid unnecessary initiation of reperfusion and other therapies in stroke mimic patients. AREAS COVERED In this article, the authors will review acute stroke imaging and then the imaging patterns of the most common stroke mimics. The authors have focused our review on brain CT scan, and more specifically CT perfusion, as this is the most commonly available and emerging tool in emergency settings. The authors also provide information on acute brain MRI and MR perfusion. EXPERT OPINION Imaging can contribute to the detection and diagnosis of acute stroke mimics. Knowledge of imaging findings in different stroke mimics can help distinguish these from patients with stroke who require timely reperfusion therapy. CT and MRI perfusion and diffusion-weighted imaging (DWI) MRI are useful imaging modalities for the assessment of acute stroke patients as they provide more accurate information than plain CT scan. Some of these modalities should be available in the emergency setting. The authors recommended CT perfusion as a useful tool for stroke management and differentiation with stroke mimics.
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Affiliation(s)
- Shadi El-Wahsh
- Neurology Department, Royal Prince Alfred Hospital, the University of Sydney, Sydney, New South Wales, Australia.,South Western Sydney Clinical School, University of New South Wales, Sydney, Australia
| | - Sophie Dunkerton
- Neurology Department, Royal Prince Alfred Hospital, the University of Sydney, Sydney, New South Wales, Australia
| | - Timothy Ang
- Neurology Department, Royal Prince Alfred Hospital, the University of Sydney, Sydney, New South Wales, Australia
| | - Hugh Stephen Winters
- Neurology Department, Royal Prince Alfred Hospital, the University of Sydney, Sydney, New South Wales, Australia
| | - Candice Delcourt
- The George Institute for Global Health, The University of New South Wales, Sydney, Australia.,Department of Clinical Medicine, Faculty of Medicine, Health and Human Sciences, Macquarie University, Macquarie Park, New South Wales, Australia
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28
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[S2k guidelines: status epilepticus in adulthood : Guidelines of the German Society for Neurology]. DER NERVENARZT 2021; 92:1002-1030. [PMID: 33751150 PMCID: PMC8484257 DOI: 10.1007/s00115-020-01036-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Accepted: 11/17/2020] [Indexed: 01/16/2023]
Abstract
This S2k guideline on diagnosis and treatment of status epilepticus (SE) in adults is based on the last published version from 2021. New definitions and evidence were included in the guideline and the clinical pathway. A seizures lasting longer than 5 minutes (or ≥ 2 seizures over more than 5 mins without intermittend recovery to the preictal neurological state. Initial diagnosis should include a cCT or, if possible, an MRI. The EEG is highly relevant for diagnosis and treatment-monitoring of non-convulsive SE and for the exclusion or diagnosis of psychogenic non-epileptic seizures. As the increasing evidence supports the relevance of inflammatory comorbidities (e.g. pneumonia) related clinical chemistry should be obtained and repeated over the course of a SE treatment, and antibiotic therapy initiated if indicated.Treatment is applied on four levels: 1. Initial SE: An adequate dose of benzodiazepine is given i.v., i.m., or i.n.; 2. Benzodiazepine-refractory SE: I.v. drugs of 1st choice are levetiracetam or valproate; 3. Refractory SE (RSE) or 4. Super-refractory SE (SRSE): I.v. propofol or midazolam alone or in combination or thiopental in anaesthetic doses are given. In focal non-convulsive RSE the induction of a therapeutic coma depends on the circumstances and is not mandatory. In SRSE the ketogenic diet should be given. I.v. ketamine or inhalative isoflorane can be considered. In selected cased electroconvulsive therapy or, if a resectable epileptogenic zone can be defined epilepsy surgery can be applied. I.v. allopregnanolone or systemic hypothermia should not be used.
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Kim HJ, Lee SA, Kim HW, Kim SJ, Jeon SB, Koo YS. The timelines of MRI findings related to outcomes in adult patients with new-onset refractory status epilepticus. Epilepsia 2020; 61:1735-1748. [PMID: 32715470 DOI: 10.1111/epi.16620] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 06/25/2020] [Accepted: 06/25/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To identify the timelines of magnetic resonance imaging (MRI) abnormalities and their relationships with the clinical outcomes of patients with new-onset refractory status epilepticus (NORSE). METHODS This retrospective observational study enrolled patients with NORSE who were admitted from March 2008 to July 2018. MRI abnormalities were analyzed visually with the readers blinded to the clinical characteristics of the patients. Poor functional outcome was defined as a Glasgow Outcome Scale score ≤ 3 at discharge. Subsequent pharmacoresistant epilepsy was defined as seizures not controlled by two or more anti-seizure medications 6 months after discharge. RESULTS Among 39 patients with NORSE, 32 (82.1%) exhibited an MRI abnormality. The most common abnormalities were persisting mesial temporal lobe signal abnormality (51.3%); initial diffuse leptomeningeal enhancement within 16 days from seizure onset (15/35, 42.9%); and hippocampal atrophy, which started to appear 26 days after seizure onset (15/26, 57.7%). Only three patients had claustrum abnormalities. Patients with insular involvement had longer treatment delay than those without (24.0 vs 5.5 hours, respectively, P = .02). Duration of status epilepticus (SE) tended to have a linear association with hippocampal atrophy (P = .055). Patients with diffuse leptomeningeal enhancement were more likely to have a poor functional outcome and to develop subsequent pharmacoresistant epilepsy than those without this finding (93.3% vs 15.0%, P < .001; 75.0% vs 22.2%, P = .004, respectively); the results were significant even after adjusting for age, sex, and duration of SE. Hippocampal atrophy and diffuse cortical atrophy were also significantly associated with poor functional outcomes (P = .001 and P = .002, respectively), and patients with these conditions were more likely to develop subsequent pharmacoresistant epilepsy than those without these conditions, after adjusting for age and sex (P = .035 and P = .048, respectively), but not after adjusting for duration of SE. SIGNIFICANCE Initial diffuse leptomeningeal enhancement and later hippocampal atrophy were associated with a poor functional outcome and subsequent pharmacoresistant epilepsy.
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Affiliation(s)
- Hyo Jae Kim
- Department of Neurology, Asan Medical Center, Seoul, South Korea
| | - Sang-Ahm Lee
- Department of Neurology, Asan Medical Center, Seoul, South Korea
| | - Hyun-Woo Kim
- Department of Neurology, Pusan National University Yangsan Hospital, Yangsan, South Korea
| | - Soo Jeong Kim
- Department of Neurology, Asan Medical Center, Seoul, South Korea
| | - Sang-Beom Jeon
- Department of Neurology, Asan Medical Center, Seoul, South Korea
| | - Yong Seo Koo
- Department of Neurology, Asan Medical Center, Seoul, South Korea
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30
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Pottkämper JCM, Hofmeijer J, van Waarde JA, van Putten MJAM. The postictal state - What do we know? Epilepsia 2020; 61:1045-1061. [PMID: 32396219 PMCID: PMC7317965 DOI: 10.1111/epi.16519] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 04/05/2020] [Accepted: 04/08/2020] [Indexed: 02/06/2023]
Abstract
This narrative review provides a broad and comprehensive overview of the most important discoveries on the postictal state over the past decades as well as recent developments. After a description and definition of the postictal state, we discuss postictal sypmtoms, their clinical manifestations, and related findings. Moreover, pathophysiological advances are reviewed, followed by current treatment options.
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Affiliation(s)
- Julia C M Pottkämper
- Clinical Neurophysiology, Technical Medical Centre, Faculty of Science and Technology, University of Twente, Enschede, The Netherlands.,Department of Psychiatry, Rijnstate Hospital, Arnhem, The Netherlands.,Department of Neurology, Rijnstate Hospital, Arnhem, The Netherlands
| | - Jeannette Hofmeijer
- Clinical Neurophysiology, Technical Medical Centre, Faculty of Science and Technology, University of Twente, Enschede, The Netherlands.,Department of Neurology, Rijnstate Hospital, Arnhem, The Netherlands
| | | | - Michel J A M van Putten
- Clinical Neurophysiology, Technical Medical Centre, Faculty of Science and Technology, University of Twente, Enschede, The Netherlands
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31
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Bargalló N, Conde Blanco E. How to interpret images in epileptic seizures: correlation between clinical and functional MRI findings. RADIOLOGIA 2020. [DOI: 10.1016/j.rxeng.2020.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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How to interpret images in epileptic seizures: correlation between clinical and functional MRI findings. RADIOLOGIA 2019; 62:102-111. [PMID: 31787322 DOI: 10.1016/j.rx.2019.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2018] [Revised: 09/15/2019] [Accepted: 09/23/2019] [Indexed: 11/23/2022]
Abstract
Neuroimaging studies are essential in patients with epilepsy, both for diagnosis and surgical management. This article focuses on adult epileptic patients, reviewing the updated clinical criteria published by the International League Against Epilepsy for the definitions of seizures, epilepsy, and status epilepticus. It also describes the different types of epilepsy, the different presentations, the signs, the radiologic approach to managing seizures, and the differences between generalized and focal seizures. Finally, it discusses the relations between possible functional cerebral deficits secondary to potentially epileptogenic lesions and epilepsy surgery, underlining the importance of functional magnetic resonance imaging studies.
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Status Epilepticus. Clin Neuroradiol 2019. [DOI: 10.1007/978-3-319-61423-6_54-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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34
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Status Epilepticus. Clin Neuroradiol 2019. [DOI: 10.1007/978-3-319-68536-6_54] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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