Evaluation of Seizure Etiology From Routine Testing to Genetic Evaluation

Immunopsychiatry: An Update on Autoimmune Encephalitis for Neuropsychiatrists

INTRODUCTION

Autoimmune encephalitis (AIE) is a group of immune-mediated inflammatory processes of the brain with marked psychiatric features. Although relatively rare, they might offer difficult differential diagnosis with psychiatric conditions, especially catatonia and psychotic syndromes. Anti-N-methyl-d-aspartate receptor (NMDAR) encephalitis is the most common AIE, presenting with psychiatric syndromes in 90% of cases. The associated psychopathology is complex, pleomorphic and best characterized when there is involvement of a psychiatrist in the assessment.

AREAS COVERED

This text will review the main aspects of AIE to psychiatrists and/or neuropsychiatrists.

EXPERT OPINION

Immune system dysfunction has been implicated in the pathophysiology of psychiatric symptoms and disorders. The use of diagnostic criteria of possible AIE, especially when specific antibodies of AIE are not available, allows early diagnosis and prompt treatment which are associated with better clinical outcomes. The study of the psychiatric aspects of AIE can broaden our knowledge of the underlying mechanisms of various psychiatric manifestations.

Perioperative routine EEG can reliably predict de novo seizures after supratentorial craniotomy

BACKGROUND

The contributing risk factors in development of seizure after supratentorial craniotomy, the optimal duration of prophylactic antiepileptic therapy, the high-risk patient to treat, and the drug of choice are subjects of debate as is the gold standard diagnostic tool for patient screening. Combining routine electroencephalography (EEG) with clinical data to identify high-risk patients and determine the ideal time of recording after surgery was the goal of this study.

METHODS

In this prospective cohort, 59 patients were evaluated with three EEG recordings after different intervals of supratentorial craniotomy due to different etiologies and were followed for 9 months for development of seizures. Demographic and disease-related variables as well as EEG results were analyzed to determine the contributing risk factors for development of seizures.

RESULTS

Neoplastic etiology and abnormal perioperative EEG (performed before surgery or in the first postoperative week) were the only independent variables associated with development of de novo seizure.

CONCLUSION

Routine EEG in the perioperative period and neoplastic etiology are two independent powerful predictors of developing seizure after supratentorial craniotomy and may help deciding whether to continue prophylactic antiepileptic medications for an extended period or not.

Cryptococcal Meningitis Presenting as New-Onset Seizures in an Immunocompetent Patient

This report describes a 30-year-old immunocompetent male with new-onset seizures, later found on imaging to have 2 enhancing lesions in the brain. The patient underwent a left parietal craniectomy with resection of one of the masses, which demonstrated focal areas of necrosis and many small cystic structures positive for periodic acid-Schiff and Gomori's methenamine silver special stain. Numerous laboratory examinations, including HIV test, rapid plasma reagin, toxoplasma immunoglobulin G and immunoglobulin M, Lyme, cytomegalovirus, tuberculosis, cysticercosis, and Echinococcus serology, were all negative. Despite negative cerebrospinal fluid (CSF) culture and several negative CSF antigen tests, continued investigation, and follow-up, CSF antigen testing ultimately revealed Cryptococcus as the causative agent. In light of the mysterious and unusual presentation, the authors discuss potential infectious differential diagnoses in patients with atypical clinical presentation, laboratory tests, and surgical pathology.