Serum prolactin levels after epileptic seizures

Ischemia-modified albumin levels in children having seizure

Convulsions are one of the frequently seen problems for a neurologist in the daily routine. It is difficult to distinguish the seizure from pseudo-seizure because of lack of conclusive tests. The aim of this study is to investigate the relationship between seizure types and seizure periods by studying IMA serum levels in children having seizure. Two groups were included (patients and control) in our study. The patient group consisted of the children admitted to Pediatric Emergency Care during January 2008-January 2010 with seizure and the control group consisted of healthy children. Serum Ischemia modified albumin (IMA) level in the group having seizures was 99.7 and 83.2U/ml in the control group. In the comparison of the patient and control groups, significant differences were found between their IMA values (p=0.000). There was a significant difference between IMA values of the group having generalized tonic-clonic seizures and those of the control group (p=0.001). In comparison of the IMA values of the group having febrile convulsions and those of the control group, a significant difference was determined (p=0.011). It has been shown that if the seizure was prolonged over 5 min, IMA level increased, and there was a significant difference between the groups experiencing over 5 min of seizures and the groups experiencing less than 5 min of seizures (p=0.001). An increase in IMA levels in febrile convulsion supports the hypoxia development in the brain during the seizure. Serum IMA levels increased with the elongation of the seizure period and may be an indicator for status epilepticus.

Frontal lobe seizures

Despite the fact that clinical characteristics of frontal lobe seizures have been recently described better, differentiating seizures of frontal lobe origin from NES on clinical grounds alone is difficult. The difficulty has been compounded by the fact that both inter-ictal and ictal EEG can be normal or nonspecific, and the same is true of imaging studies. A detailed clinical history as well as video monitoring can be helpful diagnostic tools. A multidisciplinary approach is warranted and is at times essential to improve the diagnosis and care of these difficult patients.

Seizures and the pituitary gland during pregnancy

We present the anaesthetic management of a woman who, at 10 days post partum, suffered a series of convulsions in the context of two episodes of post partum haemorrhage. The probable aetiology of the convulsions is discussed.

Epilepsy and erectile dysfunction: a review

The association between epilepsy and erectile dysfunction (ED) has often been described but not clearly defined. This is a review of the literature regarding the current theories on the causes of ED in epilepsy, as well as the evaluation and treatment options available.

Interictal EEG discharges, reproductive hormones, and menstrual disorders in epilepsy

We evaluated reproductive endocrine function in women with unilateral temporolimbic epilepsy and normal control subjects to assess the effects of epilepsy, epilepsy laterality, and antiepileptic drug use on the cerebral regulation of hormonal secretion. The findings indicate that reproductive endocrine function differs between women with epilepsy and normal control subjects. Significant differences exist at all levels of the reproductive neuroendocrine axis, that is, hypothalamus, pituitary, and peripheral gland. Differences show significant relationships to the epilepsy itself as well as to medication use. Reproductive neuroendocrine changes occur in a stochastic manner such that the laterality of unilateral temporolimbic discharges is associated with predictable directional changes in hormonal secretion at all levels of the reproductive neuroendocrine axis. These directional changes are consistent with the finding that different reproductive disorders may develop in relation to left- and right-sided temporolimbic epilepsy. Hormonal changes can show close temporal relationship to the occurrence of interictal epileptiform discharges and may vary in relation to the laterality of the discharges. Antiepileptic drugs differ in their effects on reproductive hormone levels. There are notable differences between enzyme-inducing and noninducing drugs. Menstrual disorders are more common among women with interictal discharges as well as women with abnormal hormonal findings.

Effect of lactation on the expression of audiogenic seizures: association with plasma prolactin profiles

Female Wistar rats and Wistar audiogenic rats (WARs) were used to investigate the potential roles of prolactin (PRL) and progesterone in the modulation of seizure expression. Animals were screened for seizure severity in both groups. All WARs at least displayed tonic-clonic convulsions followed by clonic spasms (TC) whereas none of the Wistar rats displayed seizures (Resistant). After seizures the plasma level of PRL in nulliparous female WARs increased about 8-fold compared to their basal levels and to the levels of Resistant animals. This value was still significantly higher than basal levels 15 min later. Lactation produced a decrease in the TC proportion in seizures in WARs both with and without pups. Two sub-populations of animals could be characterized: one that had TC suppressed (low seizure severity; LSS) and one that did not (high seizure severity; HSS). In animals of the LSS subgroup, either with or without pups, seizure severity decreased gradually and lowest values were seen on the 30th day after delivery. The temporal profile of plasma PRL during a 90-min period of suckling without sound stimulation showed significantly higher levels for LSS, the HSS levels being similar to those of the Resistant group. A progressive decrease in the group means for progesterone plasma concentration between the 9th and 29th days of lactation was detected in Resistant rats (P<0.05) but not in WARs. No significant differences between groups were revealed by comparison of the overall means. Taken together these data confirm the presence of a clear-cut post-ictal PRL peak after TC with a decrease in seizure severity in female WARs with and without pups. An eventual long-term role of PRL in modulating seizure activity might be related to the multifactorial physiological conditions of both pregnancy and lactation.

Diagnosis of sudden unexplained death in epilepsy by immunohistochemical staining for prolactin in cerebral vessels

Sudden unexplained death in epilepsy occurs when epilepsy patients die suddenly and unexpectedly in the absence of recent tonic-clonic seizure activity. There is currently no known reliable indicator of acutely lethal seizure activity. Clinical studies record a relationship between recent (within 10-40 minutes) seizure activity and elevated serum prolactin levels, and postictal elevation of prolactin within peripheral vessels has proved clinically useful in determining recent seizure activity. The authors hypothesized that elevated prolactin could be detected in cerebral vessels by immunohistochemical stains, serving as a marker for sudden unexplained death in epilepsy. They conducted a retrospective study of individuals who died in their jurisdiction during the 14 years from 1986 through 1999. The study contained one group of individuals who died of sudden unexplained death in epilepsy, a group with epilepsy who died of some other cause, and a control group whose members died rapidly of a gunshot wound of the torso. Sections of hippocampus and neocortex were obtained and stained with a polyclonal prolactin antibody. No significant difference in the level of immunostaining for prolactin in cerebral vessels was found between the experimental and control groups. A review of the protocols used indicates that revision of certain aspects may provide better immunostaining and more conclusive results.

A review of diagnostic techniques in the differential diagnosis of epileptic and nonepileptic seizures

The diagnosis of psychogenic nonepileptic seizures (PNES) is complex. Long-term electroencephalogram monitoring with video recording (video EEG) is the most common method of differential diagnosis of epilepsy and PNES. However, video EEG is complex, costly, and unavailable in some areas. Thus, alternative diagnostic techniques have been studied in the search for a diagnostic method that is as accurate as video EEG, but more cost effective, convenient, and readily available. This paper reviews the literature regarding possible diagnostic alternatives and organizes findings into 7 areas of study: demographic and medical history variables, seizure semiology, provocative testing, prolactin levels, single photon emission computed tomography, psychological testing, and neuropsychological testing. For each area, the literature is summarized, and conclusions about the accuracy of the technique as a diagnostic tool are drawn. Overall, it appears unlikely that any of the reviewed alternative techniques will replace video EEG monitoring; rather they may be more successful as complementary diagnostic tools. An important focus for further investigations involves combinations of diagnostic techniques for the differential diagnosis of epilepsy and PNES.

Peripheral WBC count and serum prolactin level in various seizure types and nonepileptic events

PURPOSE

To analyze effects of different types of seizures and nonepileptic events as well as effects of seizure duration and lapse between the time of seizure and blood collection on serum prolactin level and peripheral white blood cell (WBC) count.

METHODS

We prospectively collected blood samples from all patients admitted to our Epilepsy Monitoring Unit at baseline and after an event. Blood samples were analyzed, and serum prolactin level and WBC count were determined. Statistical analyses were performed to evaluate the relation of each type of seizure, its duration, and time lapse between a seizure and collection of blood sample to the serum prolactin level and peripheral WBC count.

RESULTS

Serum prolactin level increases above twice the level at baseline after a complex partial seizure or a generalized seizure. Peripheral WBC count is elevated above the upper limit of normal in about one third of cases after a generalized seizure. In generalized seizures, the length of a seizure is positively associated, whereas the lapse time between the seizure onset and blood draw is negatively correlated with the increase in WBC count. Thus the longer the seizure and quicker the blood draw, the higher the WBC count.

CONCLUSIONS

We conclude that complex partial or generalized seizures are associated with an increase in serum prolactin level. Peripheral WBC count increases significantly after a generalized seizure and is probably transient in nature.

Seizures, hormones and sexuality

Sexual disorders (both hyposexuality and sexual dysfunction) are common in people with epilepsy, occurring in up to two-thirds of patients. However, characteristically, patients do not spontaneously report these problems. Nocturnal penile tumescence testing suggests that the erectile dysfunction has a neurophysiological component. The aetiology remains uncertain but is likely to be multifactorial, involving neurological, endocrine, iatrogenic, cognitive, psychiatric and psychosocial factors. Epilepsy-related factors include the age of onset/duration of epilepsy along with the seizure type and focus. In addition, seizure frequency might be relevant as successful epilepsy surgery can result in an improvement in sexual functioning despite remaining on anticonvulsant medication. Endocrine changes (raised sex hormone binding globulin and reduced free testosterone) have been reported in men with epilepsy, especially when treated with hepatic-enzyme inducing antiepileptic drugs. Studies have not been performed evaluating anticonvulsants that do not induce hepatic enzymes such as lamotrigine. The association between these endocrine changes and hyposexuality is not known. The relationship between seizures, hormones and anticonvulsant medication in women is explored, focusing on issues such as catamenial epilepsy, the menopause, hormone replacement therapy and the polycystic ovarian syndrome. Suggestions for future research and treatment issues are discussed.

The relationship of psychiatric illnesses and seizures

The relationship between epilepsy and behavioral disturbances has been a subject of controversy since the 19th century. Affective changes may occur prior, during, or after the ictal discharge. Depression is the most prevalent comorbidity. Anxiety, panic attacks, and pseudoseizures may resemble complex partial seizures, and their diagnosis and treatment may be confusing, even to experienced clinicians. Epilepsy-related psychosis is less common, manifesting occasionally with symptoms that are indistinguishable from schizophrenia. There is no clear evidence of a distinct "epileptoid" personality, and interictal violence is extremely rare. Pharmacologic treatment with anticonvulsants remains the cornerstone of treatment. In case of psychiatric comorbidities or refractory seizures, the diagnosis should be re-examined.

Psychogenic non-epileptic seizures: management and prognosis

AIM

To determine the outcome and identify predictive factors in children with psychogenic non-epileptic seizures (PNES).

METHOD

The biographies of 35 children with PNES, attending a tertiary paediatric neurology centre, were reviewed.

RESULTS

Thirty five children attending the department between 1987 and 1997 were evaluated at a mean follow up of 4.6 years. The age range was 6-18 years. Twenty four were girls and 11 were boys. Eleven patients had a diagnosis of epilepsy with PNES, the remainder having PNES alone. Cause fell into four categories: a history of violence, abuse, or neglect; a high level of anxiety; dysfunctional family relationships; and attention seeking or avoidance behaviour. Management in all but five cases involved assessment and follow up by a child psychologist or child psychiatrist. The outcome was encouraging, with 66% of patients becoming PNES free. A further 23% have > 50% reduction in the frequency of PNES. Only two have had no reduction. Outcome was best in the group without epilepsy.

CONCLUSION

These results suggest that the prognosis of PNES is better in children than in adults, perhaps because causes are more likely to be external to the child, more easily identified, and more amenable to prompt intervention. The importance of good assessment, good communication, and a treatment plan that includes both symptom management and addressing the precipitating and perpetuating factors is emphasised.

Prolactin levels in sudden unexpected death in epilepsy

PURPOSE

To assess serum prolactin levels in sudden unexpected death in epilepsy (SUDEP) and control groups to test the hypothesis that if seizures occur routinely as a terminal event in SUDEP, then raised prolactin levels may be an indicator of terminal seizure.

METHODS

Blood was taken for measurement of prolactin levels from subjects with SUDEP and three control groups. The control groups were those with epilepsy dying from causes other than epilepsy (e.g., ischemic heart disease or injuries), physiologically stressed individuals without epilepsy (they were admitted to the hospital after an acute illness and died after several hours to 3 days), and nonepileptic rapid deaths (these people collapsed suddenly and died at the scene). In the SUDEP group, evidence for terminal seizure was considered to be at least one of the following: body found half on, half off the bed, or urinary incontinence at the scene, or bitten lips or tongue at autopsy.

RESULTS

There was evidence for terminal seizure at the scene or at autopsy in four of the 10 SUDEP cases. Serum prolactin levels were not significantly increased in the SUDEP group compared with the controls. None of the SUDEP subjects, including those with clinical evidence of a terminal seizure, had high prolactin levels characteristic of those observed after seizures in living subjects.

CONCLUSIONS

Prolactin levels are not raised in SUDEP, even if there is evidence of terminal seizure. As prolactin takes 15-20 min to peak after a seizure in life, there may be insufficient time for a prolactin increase to occur in SUDEP. Thus prolactin levels cannot be used to determine if a deceased individual with epilepsy had a seizure or to answer the broad question whether SUDEP is always associated with a terminal seizure.

Pseudoseizures

Pseudoseizures represent the opposite end of the spectrum from seizures that mimic psychiatric disorders: they are paroxysmal changes in behavior that resemble epileptic seizures, but which are without organic cause and expected EEG changes. Accurately distinguishing pseudoseizures from epilepsy and other illnesses is difficult because of the breadth and overlap of symptoms seen in each condition and because of the frequent co-occurrence of pseudoseizures and epilepsy. This article summarizes the various neurological and psychiatric clues that help the clinician identify this form of psychiatric presentation, whether it represents, for example, a conversion disorder, a dissociative disorder, or a panic disorder.

The diagnosis of psychogenic non-epileptic seizures: a review

Diagnosing psychogenic non-epileptic seizures (PNES) is a clinical challenge. There is neither a standard in diagnosing PNES nor a comprehensive theoretical framework for this type of seizure. The diagnosis of PNES must be made by excluding epilepsy. However, epilepsy cannot always be determined and PNES and epileptic seizures may coexist. In this study, the characteristics of PNES and patients are discussed. The diagnosis of PNES and epileptic seizures was facilitated by the simultaneous recording of seizures on video tape and EEG. Seizure provoking techniques, hormonal indices, and psychological methods were also used. The benefits and limitations of these techniques are discussed and proposals are made for clinical guidelines.

Using age-appropriate prolactin levels to diagnose children with seizures in the emergency department

OBJECTIVE

To assess the utility of serum and cerebrospinal fluid (CSF) prolactin levels for identifying children who have experienced seizures.

METHODS

A prospective cohort study was performed in a pediatric ED at an urban children's hospital. A convenience sample of children underwent blood and CSF analyses in the ED over a 2-year period.

RESULTS

Thirty-five children (aged 3 months-15 years) with generalized tonic-clonic seizures and 48 ill control patients were studied. Both groups included febrile and afebrile patients. The patient characteristics in the seizure and control groups were similar with respect to age, fever, current medications, and blood, urine, and CSF cultures. When serum prolactin levels were assigned age-adjusted dichotomous values of "elevated" or "normal," the rates of elevation between the seizure and control patients were different (p < 0.001). The positive and negative predictive values of these age-adjusted levels were 68% (95% CI 47-85%) and 76% (95% CI 61-87%), respectively. The mean CSF prolactin levels of the seizure and control groups were not significantly different. In addition, there was no single threshold CSF prolactin level that could delineate seizure patients from control patients.

CONCLUSIONS

Age-adjusted serum prolactin levels are useful only as an adjunct in the prospective evaluation of the individual pediatric patient for epileptic seizure activity. CSF prolactin levels are not useful in the diagnosis of generalized seizures in children in the acute care setting.

Differential spatial patterns of Fos induction following generalized clonic and generalized tonic seizures

The expression of generalized clonic and generalized tonic seizures has been suggested to result from the activation of different and independent neuronal circuits. Using the induction of the c-fos protein (Fos) as a marker of neuronal activity, we identified brain structures that are differentially associated with the expression of electroconvulsive shock-induced generalized clonic and generalized tonic seizures. Expression of either seizure phenotype resulted in a similar bilaterally symmetrical increase in Fos immunoreactivity in many forebrain structures, including the bed nucleus of the stria terminalis, hippocampal dentate gyrus, amygdala, and piriform cortex, compared to controls. However, following tonic hindlimb extension (THE), the degree of labeling in specific thalamic, hypothalamic, and brain stem areas was significantly greater than that of either controls or animals exhibiting clonic seizures. While a greater number of neurons in the hypothalamus (e.g., ventromedial nucleus), subparafascicular thalamic nucleus, peripeduncular area, deep medial superior colliculus, dorsal and lateral central gray, and paralemniscal nuclei were robustly labeled following THE, noticeably fewer cells were immunoreactive following face and forelimb clonic seizure behaviors. These differences were also found to be independent of the stimulus magnitude. In animals stimulated with the same current intensity but expressing either of the two seizure phenotypes, the pattern of Fos induction was consistent with the seizure phenotype expressed. These results demonstrate that specific subsets of neurons are differentially activated following the expression of different generalized seizure behaviors and that activity in discrete mesencephalic and diencephalic structures is more frequently associated with the expression of generalized tonic seizures than with the expression of generalized clonic seizures.

Potential role of serum prolactin measurement in the diagnosis of late posttraumatic seizures. A case report

Posttraumatic seizures are an important medical complication after traumatic brain injury. However, the diverse clinical presentation of posttraumatic seizures, combined with the cognitive and behavior deficits frequently seen in this patient population, can make the diagnosis of posttraumatic seizures particularly challenging. Electroencephalography and imaging studies are often abnormal and nonspecific. It has been reported that serum prolactin levels frequently rise after epileptic seizures. This case report describes the use of prolactin measurement to confirm two suspected posttraumatic seizure episodes in a 42-yr-old male with severe traumatic brain injury. Each episode lasted less than 1 min and involved conspicuously altered postural tone and respiratory pattern, followed by a change in verbal and motor responsiveness. No rhythmic extremity movements were observed. Diagnostic evaluation included electroencephalography and imaging studies, which demonstrated nonspecific abnormalities. Serum prolactin levels obtained within 20 to 40 min were markedly elevated and two to three times greater than the baseline level. The use of prolactin levels in the diagnosis of posttraumatic seizures is reviewed, accompanied by discussion of pertinent aspects of normal and abnormal states of prolactin secretion and regulation.

Epilepsy and prolactin in adults: a clinical review

Serum levels of prolactin may increase as a consequence of epileptic seizures. The hormone release is caused by the propagation of epileptic activity, usually from the temporal lobe to the hypothalamic-pituitary axis. Due to the intensity of the epileptic afterdischarge, a rise is seen in approximately 60% of complex partial seizures. Prolactin usually fails to rise after psychogenic seizures, therefore, postictal prolactin levels can be used to differentiate between epileptic and psychogenic seizures. However, a subclassification of epileptic seizures by means of prolactin measurement is not possible. In repetitive seizures, prolactin may show a decrease in its postictal release. This is more common in status epilepticus, probably as a result of a diminished propagation of ictal activity during the course of status epilepticus. The influence of chronic epileptic discharges and anticonvulsant medication on prolactin release is moderate.

Audiogenic and audiogenic-like seizures: locus of induction and seizure severity determine postictal prolactin patterns

Audiogenic seizures (AS) are a model of generalized tonic-clonic seizures, evoked by high-intensity (110 dB) acoustic stimulation evaluated by means of behavioral severity indexes (SI). Postictal prolactin (PRL) is a marker of generalized seizures, both in animals and humans. Thus, in the present work we assayed postictal PRL in a) male Wistar AS susceptible (S, n = 5) and AS resistant (R, n = 13) rats made susceptible by specific midbrain lesions. b) In rats electrically stimulated in the central nucleus (CN) of the inferior colliculus (IC) (n = 20), or the cortical IC (CxIC, n = 18). In c) S rats pretreated with either bromocriptine (BRO; 4 mg/kg; SC), a PRL release inhibitor, or vehicle (V), 30 min before the electrical stimulation. Basal PRL was 2-10 ng/ml at time 0. In the S group, only animals with generalized seizures presented a postictal PRL elevation between 5 and 15 min (60-90 ng/ml; p < 0.05). R rats displayed a discrete PRL response lower than that of S animals. CxIC stimulation produced more severe seizures and greater postictal PRL enhancement than CNIC stimulation, always raising at 5-15 min (p < 0.01). BRO blocked the PRL increase even in the presence of higher seizure scores (p < 0.02). The positive correlation between seizure intensity (SI values), site of initiation (central or cortical IC nuclei), and postictal PRL patterns makes this a reliable model for studying the neurochemistry of the postictal phase and the interaction between hormones and epilepsy.

Prolactin levels in febrile and afebrile seizures

Transient hyperprolactinaemia has been reported to follow unprovoked seizures, a finding proposed to be useful in the differential diagnosis of epilepsy. There is also evidence that patients with unprovoked seizures may have high baseline prolactin levels, which could be of value in detecting those predisposed to epilepsy after a first convulsive attack. The purpose of this study was to examine whether prolactin levels are elevated: (1) postictally in febrile seizures and (2) interictally in afebrile seizures. In 17 children with simple febrile seizures, mean postictal prolactin value (370 +/- 160 mU/l, mean +/- SD) was significantly higher (approximately 0.001) than the mean baseline value of 18 seizure-free controls (202 +/- 136 mU/l). The mean baseline prolactin values were not significantly different: (1) in ten children with afebrile versus ten seizure-free controls and (2) in 18 children with febrile seizures associated with high risk for subsequent afebrile seizures versus 23 children with febrile seizures but unlikely to suffer from afebrile seizures. CONCLUSION. Postictal prolactin levels may be a useful marker of recent febrile seizures, while baseline prolactin levels do not appear to have any prognostic significance in afebrile seizures.

Plasma concentrations of prolactin, noradrenaline, vasopressin and oxytocin during and after a prolonged epileptic seizure

The time course and extent of changes in plasma prolactin, noradrenaline, vasopressin and oxytocin levels is reported following serial observations of a prolonged epileptic seizure arising in the temporal lobe, recorded by video-EEG-telemetry, in which the epileptic activity evolved from a simple partial to complex partial to secondarily generalised attack. The prolactin levels were markedly elevated during the phase of the simple partial seizure, at a time when consciousness was preserved, when motor activity was minimal and when EEG activity was highly localised. The hormonal levels continued to rise during the subsequent seizure evolution, suggesting that the duration (or intensity) of the seizure is an important, perhaps the most important, factor determining the degree of prolactin release during limbic seizures. Indeed, the prolactin elevation in this case (26 times the baseline level) is higher than any previously recorded, reflecting the unusual duration and intensity of this seizure. We did not observe the phenomenon of "exhaustion" of prolactin release and levels peaked after 49 min, and were high for over 2 h after the onset of the seizure, and after the convulsion had ceased. The concentrations of vasopressin, oxytocin and noradrenaline remained low during the aura, but rapidly increased during the phase of generalisation. The oxytocin and noradrenaline levels peaked during the phase of generalised convulsion, but the vasopressin levels peaked well into the post ictal phase, and remained high for several hours.(ABSTRACT TRUNCATED AT 250 WORDS)

Advances in the assessment of refractory epilepsy

The assessment of patients with refractory epilepsy presents both a challenge and an opportunity. The use of appropriate instruments to carefully and consistently measure a patient's seizure type and frequency, hormonal function, and medication side effects and the impact of those variables on quality of life ensures consistent, standardized assessment. A patient's epilepsy then can be classified as refractory based on any combination of factors that preclude a reasonably normal life-style by current practice standards, given the person's capabilities. Diagnostic studies and treatment strategies should address all significant adverse findings resulting from the assessment process. Accurate diagnosis of seizure type usually requires electroencephalographic (EEG) monitoring. Postictal hormonal assays and periodic measurements of estrogen and progesterone may be useful diagnostically in a selected group of patients. Awareness of a patient's compliance history, environmental stressors, and seizure triggers may reduce seizure frequency without a change in medication. For patients with medication intolerance, the usual strategy is to modify the medication regimen or treatment schedule to minimize side effects while maximizing seizure control and compliance. For most patients, monotherapy provides a greater therapeutic window than combination therapy. Devising an effective and safe therapeutic regimen is an ongoing process and can be lengthy depending on seizure type(s), frequency, and temporal pattern; anticonvulsant pharmacokinetics; drug interactions and side effects; patient's life-style; and other factors. Serial measurements of quality-of-life variables may assist in the process. Rapid strides have been recently made, and as the pace of new antiepileptic drug development quickens and surgical centers become more widely available, clinicians will need to redefine refractoriness as the expectations improve for patients with epilepsy.

Predictivity of plasma prolactin levels in differentiating epilepsy from pseudoseizures: a prospective study

The predictivity of raised plasma prolactin (PRL) concentrations in differentiating seizure from syncopal attack was prospectively assessed in all patients consecutively admitted to the Clinica Neurologica of Brescia, Italy in a 12-month period who fulfilled the criteria for either a seizure or syncopal attack. Postictal plasma prolactin concentration (P1) was assessed as soon as possible after the event. Three further assessments were performed: P2 was sampled 1 h after P1, P3, and P4 were sampled in the morning for the next 2 days. Patients who had had a seizure showed significantly increased P1 concentrations, when P1 was sampled within 60 min of the attack. In seizure patients assessed > 1 h after the event, P1 was not significantly different from either P2, P3, or P4. In patients who had had a syncopal attack, PRL concentration never increased. In patients assessed < or = 60 min after the seizure, cutoff criterion of P1 exceeding by +3 SD the mean calculated on P2, P3, and P4 yielded a positive predictive value of 89% and a negative predictive value of 61%. These findings confirm that plasma prolactin concentration is highly predictive of true epilepsy but barely predictive of pseudoseizures.

Serum prolactin concentrations and epilepsy. A study which compares healthy subjects with a group of patients in presurgical evaluation and circadian variations with those related to seizures

In 20 healthy subjects (10 female and 10 male) and 17 patients undergoing presurgical epilepsy evaluation with intracranial EEG electrodes, circadian variations of serum prolactin (PRL) were measured. A comparison between the peak values found in normals with the postictal rises in patients, led us to consider 700 microU/ml to be the threshold of diagnostic value and the observed rises above this level to be all induced by seizures. In order to assess the clinical value of this threshold, PRL was measured postictally in a further 30 patients with epilepsy and in 11 patients with psychogenic seizures. In none of the latter group did PRL rises exceed 700 microU/ml, while they did so in 39% of the complex partial seizures and in 80% of the tonic-clonic seizures. There was no significant difference with respect to sex (a rise over 700 microU/ml in 42% in male and in 55% in female patients). Based on the findings in 17 patients investigated by means of intracranial electrodes, we were not able to establish different criteria for different focus localisations: in 66% of both temporal as well as frontal lobe seizures the 700 microU/ml level was exceeded. As a trend, in the period preceding an epileptic seizure we found a slightly decreasing PRL level, whereas in healthy persons the PRL concentrations gradually increased in the 40 minutes before the maximum spontaneous peak was reached.

The effect of seizures on hormones

Serum prolactin (HPR) levels are influenced by waking and sleep states, as reflected by surges in serum concentrations during daytime naps and nocturnal sleep. Other physiological causes of hyperprolactinemia include sexual activity, pregnancy, and lactation. Drugs may stimulate or inhibit HPR secretion. Pathological causes for HPR secretion include destructive lesions of the hypothalamus, prolactin-secreting neoplasms of the pituitary gland, lesions of the spinal cord, and occasionally Parkinson's disease. The most predictable postictal changes are increased serum cortisol levels and hyperprolactinemia. Serum HPR rises after virtually all generalized tonic-clonic seizures, most complex partial seizures, and some simple partial seizures. Absence and myoclonic seizures do not affect serum HPR levels. Repeated epileptic seizures and electroconvulsive therapy treatments produce successively less marked rises in serum HPR. The postictal elevation of serum cortisol has a longer latency than for HPR and follows an earlier rise in serum ACTH. Other postictal hormonal changes are much more variable. Because of the normal diurnal variation in serum cortisol levels and the relative delay in the postictal elevation of serum cortisol, HPR is more useful as a diagnostic measure of epileptic seizures. This application of HPR requires an understanding of other factors that influence serum HPR and the use of baseline serum HPR levels for comparison. HPR data must be correlated with behavioral and electroencephalographic events.

Capillary prolactin measurement for diagnosis of seizures

Measurement of serum prolactin levels can be useful in the diagnosis of epilepsy, since prolactin levels often rise after seizures, but not after most imitators of epilepsy. Utility of the test is limited by the need to obtain blood 10 to 20 minutes after the episode. The present study documents the validity of prolactin measurements using capillary blood, which was obtained by the finger-stick method after a possible seizure and then applied to filter paper. Venous and capillary prolactin levels were determined 10 to 20 minutes after seizure-like episodes in 20 patients who were studied in an epilepsy monitoring unit. Venous and capillary prolactin values correlated, with a Pearson coefficient of 0.90. Using a criteria of any elevation above the laboratory upper limit of normal, capillary prolactin values correctly identified seizure versus pseudoseizure in 9 (100%) of 9 patients with generalized tonic-clonic seizures, in 5 (71%) of 7 patients with complex partial seizures, and 4 (100%) of 4 patients with pseudoseizures. Prolactin values were unaffected by leaving filter paper samples at room temperature for up to 1 week. This study suggests the utility of diagnostic capillary blood collection kits to assist in the diagnosis of epilepsy in outpatients.

Sexual behavior of a sample of females with epilepsy

A sample of 700 female epileptic outpatients was examined between 1985 and 1987. The incidence of psychosexual disorders was 18%. Epileptic females with psychosexual disorders were compared with epileptic females without sexual disorders and with normal female controls on selected clinical and EEG parameters. Epileptic females with sexual disorders showed: lower marriage rates, a longer duration of illness, sexually colored prodromata, predominance of partial complex seizures (83%) and a higher incidence of menstrual abnormalities. Hyposexuality and exhibitionism were the psychosexual disorders most frequently noted. Temporal lobe EEG abnormalities were significantly higher.

5-Hydroxyindoleacetic acid and homovanillic acid in cerebrospinal fluid of children with febrile convulsions

5-Hydroxyindoleacetic acid (5-HIAA) and homovanillic acid (HVA) were measured by high-performance liquid chromatography (HPLC) in lumbar cerebrospinal fluid (CSF) obtained from febrile children subdivided according to the presence or absence of convulsions. Lumbar puncture was made either early (mean time 2 h) or late (3-6 days) after the febrile convulsion. The level of 5-HIAA was significantly decreased in children early and late after the febrile convulsion as compared with the convulsion-free group, but the HVA level was reduced only early after the febrile convulsion. These results support the hypothesis that a decrease in CSF 5-HIAA may be a biologic marker of susceptibility to convulsions and indicate that the transient decrease in HVA is a secondary phenomenon related to occurrence of convulsions.

The clinical value of serum prolactin measurement in the differential diagnosis of complex partial seizures

The time course of changes in serum prolactin after complex partial seizures has been determined and compared to similar changes after other types of seizure and non-epileptic attacks. Seizures in 33 subjects were recorded on video EEG telemetry. Peak serum prolactin concentrations occurred 15-20 min after tonic-clonic seizures, 10 min after complex partial seizures, and were highest after generalised tonic-clonic seizures. Serum prolactin concentrations remained less than 1000 mU/l after absences and non-epileptic attacks. Application of Bayes' theorem showed that where serum prolactin was greater than 1000 mU/l 5-10 min post event this would identify genuine tonic-clonic or complex partial seizures. The false negative rate of this test was 9% for tonic-clonic seizures and 38% for complex partial seizures. Failure of serum prolactin to rise after an attack is of little value in distinguishing complex partial seizures from non-epileptic attacks.

A hypothesis to integrate partial seizures of temporal lobe origin and reproductive endocrine disorders

Recent demonstrations of an association between reproductive endocrine disorders and partial seizures of temporal lobe origin (TLE) have led to the following hypothesis: (1) TLE may promote the development of reproductive endocrine disorders, (2) reproductive endocrine disorders may promote the development of epileptic discharges, and (3) TLE and associated reproductive endocrine disorders may represent the parallel effects of prenatal factors which are common to the development of both the brain and the reproductive system. This article focuses on clinical and animal investigative data that form the basis of this hypothesis.

Lack of effect of naloxone on prolactin and seizures in electroconvulsive therapy

Both opiate agonist and antagonist injection have been reported to modulate prolactin secretion, alter brain excitability and produce seizures, and modify the postictal state. We studied the effects of administration of high-dose naloxone, an opiate antagonist, on postictal prolactin levels, seizure duration, and postictal behavior, using patients undergoing electroconvulsive therapy (ECT) as a seizure model. Seven patients had 8 mg naloxone injected prior to one ECT treatment and saline injected prior to another treatment, with the order of injection randomized. Before ECT and 15 min after ECT, prolactin levels were drawn, and no blunting of the expected postictal prolactin elevation by naloxone injection was observed. We found no evidence that endogenous opiates trigger prolactin secretion during seizures. Seizure duration was also similar in saline and naloxone groups, and naloxone did not reverse postictal depression, as has been reported in an animal model.

Homovanillic acid and prolactin in plasma and CSF of medicated epileptic patients

Homovanillic acid (HVA), the main dopamine metabolite, and prolactin (PRL) were estimated in plasma and cerebrospinal fluid (CSF) of 11 male epileptic patients treated with antiepileptic drugs and of 14 neurologic controls. A trend toward higher concentrations in plasma and lower concentrations in CSF in the patient group as compared with controls was observed for both parameters. The plasma to CSF ratios of HVA and PRL levels were significantly higher in the patient group. This shift may be due to an influence of the drugs on the blood-brain barrier (BBB) permeability. The PRL levels in the CSF correlated negatively to the HVA levels in CSF in the patient group only.

Prolactin in partial epilepsy: an indicator of limbic seizures

A study was performed to evaluate changes in serum prolactin levels after simple and complex partial seizures, and to identify which specific anatomical structures must be involved in seizures for postictal elevation of prolactin levels to occur. Seventy-eight seizures were studied in patients with electrodes implanted bilaterally into amygdala, hippocampus, hippocampal gyrus, and frontal sites. All 38 complex partial seizures had bilateral limbic ictal discharges, and each was followed by a significant increase in prolactin concentration (mean peak, 50.8 ng/ml; range, 16.0 to 150.0 ng/ml). Eight of 10 simple partial seizures with unilateral high-frequency regional limbic discharges were followed by prolactin elevation (mean peak, 28.2 ng/ml; range, 13.4 to 44 ng/ml). Thirty simple partial seizures with other ictal limbic discharges or without limbic discharges were not followed by an elevated prolactin level. The data indicate that serum prolactin levels always rise after complex partial seizures involving the temporal lobes, and rise after certain simple partial seizures involving limbic structures. Thus, measurement of the prolactin level can help identify which simple partial seizures involve mesial temporal lobe structures. Limbic structures serve to trigger prolactin release, which may depend upon spread of the seizure to subcortical structures.

Serum prolactin, cortisol and growth hormone concentrations after various epileptic seizures

The serial serum concentrations of prolactin (PRL), cortisol and growth hormone (GH) were measured after clinical fits of seizures in 49 epileptic patients, aged 13-77. In generalized tonic-clonic seizures, both the serum PRL and cortisol levels transiently rose and reached their maximum 30 min after the onset of clinical fits. Serum GHs were elevated in some of the patients. After complex partial seizures, significant rises were found only in serum cortisol, but no demonstrable change was observed in PRL and GH. In the other minor seizure group, no remarkable change was observed in any of the hormones. These results suggest that the postictal hormonal change is different in each type of seizure, respectively.

Effect of interictal epileptiform discharges on nocturnal plasma prolactin concentrations in epileptic patients with complex partial seizures

To investigate the effect of interictal epileptiform discharges (IEDs) on plasma prolactin (PRL) level, we studied 18 epileptic patients with complex partial seizures (CPS) who did not experience clinical or subclinical ictal events during all-night monitoring with polygraphic recording and video imaging. The density of IEDs peaked during non-REM stages and was significantly reduced during REM stage. Mean plasma PRL concentrations in epileptic patients, when sampled at 30-min intervals, showed a moderate but significant elevation during non-REM (p less than 0.001) and awake stages (p less than 0.005), but not during REM stage, when compared with 10 nonepileptic control subjects studied in a similar fashion. The data obtained in this physiologically controlled environment indicate that the cumulative effect of IEDs may modify PRL regulatory mechanisms, resulting in a modest elevation of plasma concentrations independent of ictal discharges.