Gelastic seizures associated with hypothalamic hamartomas. An update in the clinical presentation, diagnosis and treatment

Temporal lobe malacia as a rare cause of gelastic seizure: A case report

BACKGROUND

Gelastic seizure (GS) is a rare type of epilepsy that most commonly appears in patients with hypothalamic hamartoma. It is rarely associated with other types of brain damage. This particular type of epilepsy is relatively rare and has few links to other brain lesions. Temporal lobe malacia is mostly caused by cerebral infarction or cerebral hemorrhage, which can lead to seizures. We report a case of GS in a woman with temporal lobe malacia which was reported for the first time in the literature.

CASE SUMMARY

A 73-year-old female, diagnosed case of GS, presented with repetitive stereotyped laughter a month prior to presentation, happening multiple times daily and with each time lasting for 5-15s. Electroencephalogram displayed a focal seizure seen in the right temporal region. Magnetic resonance imaging head with contrast showed a right temporal lobe malacia. The patient was started on levetiracetam daily. The patient indicated that they had fully recovered and were not experiencing any recurrent or stereotyped laughter during their daily routines. These results remained consistent even after a one-year follow-up period.

CONCLUSION

GS can be caused by temporal lobe malacia, which is an uncommon but potentially grave condition. The outcome of this present case exhibited the importance of the temporal lobe in the genesis of GS.

Laughter isn't always the best medicine, sometimes it's one of the symptoms

Gelastic seizure is a rare type of seizure characterized by bouts of uncontrolled, stereotyped laughter and often associated with hypothalamic hamartomas. In this case study we review a patient with a low grade ganglioglioma in the temporal lobe, a rare type of brain tumor that commonly causes seizures. The 8-year-old ambidextrous patient presented with seizures starting four days prior to presentation, happening multiple times daily and with each seizure lasting for 5-15 s. The patient's neurological examination was normal between episodes, and VEEG recorded ictal laughing events originating focally from the anterior temporal and/or inferior frontal region. Seizures were stopped with Levetiracetam, however given MRI findings surgical intervention was additionally deemed necessary. MRI head with contrast showed 8 mm nodular enhancing lesion located in the anteroventral portion of the right temporal pole with surrounding edema that extended to the anterior margin of the fusiform gyrus. The patient recovered well from surgery with no neurological deficits, is no longer on any antiseizure medications and remains seizure free at 3-year follow-up.

A clinical evaluation of gelastic and dacrystic seizures: a multicenter study

BACKGROUND

Gelastic seizures are extremely rare, short-lasting, unprovoked, and uncontrollable laughing attacks. We conducted this retrospective evaluation to determine whether these symptoms, manifesting in different forms, such as cheerful laughter, laughing, smiling, and sobbing had any value in terms of etiology or localization.

METHODS

A total of 31 patients who exhibited bouts of laughing or crying and who were under follow-up between 2000 and 2019 at tertiary epilepsy centers were included in the study. Laughing seizures were divided into three groups in terms of semiology (i.e., laughter with mirth, laughter without mirth, and smile). Dacrystic seizures were accompanied by some gelastic seizures and were divided into two groups in terms of semiology (i.e., weeping loudly [motor and voice-sobbing] and crying).

RESULTS

Of the 27 patients with laughing seizures, 12 had seizures that manifested with smiling, 7 had seizures that manifested with laughing and mirth, and 8 had seizures that manifested with laughter without mirth. Dacrystic-gelastic seizures were observed in four patients, among whom 2 patients had crying and laughter without mirth and 2 patients had weeping loudly and laughter without mirth episodes.

CONCLUSION

Gelastic and dacrystic seizures often suggest hypothalamic hamartomas, in the literature. This rare ictal behavior can originate from different cortical locations and lesions of a different nature. However, we found that gelastic seizures with smiling were a more homogenous group with regard to location in the temporal lobe, which we aimed to show by evaluating the patients included in this study.

A myriad spectrum of seizures on magnetic resonance imaging - A pictorial essay

Patients with seizures represent a challenging clinical population both in pediatrics and adults. Accurate diagnosis of the cause of a seizure is important in choosing an effective treatment modality, surgical planning, predicting a prognosis, and follow-up. Magnetic resonance (MR) imaging using a dedicated epilepsy protocol plays a key role in the workup of these patients. Additional MR techniques such as T2 relaxometry and MR spectroscopy show a promising role to arrive at a final diagnosis. The spectrum of epileptogenic causes is broad. Radiologists and physicians need to be updated and require a patterned approach in light of clinical history and electroencephalogram findings to arrive at a reasonable differential diagnosis. This pictorial essay aims to review a few of the common and uncommon causes of seizures and their imaging features.

MR imaging of hypothalamic hamartoma in a patient with gelastic seizures

Hypothalamic hamartomas (HHs) are non-neoplastic malformations that occur in the region of the hypothalamus. HH is the leading cause of gelastic seizures in children and adolescents, where laughing is characteristically manifested. However, these patients can also experience different forms of complex or generalized tonic-clonic seizures that can obscure the diagnosis of HHs. We present a case of a 10 year-old boy that experienced several seizure types, but was subsequently diagnosed with HH after MR imaging was performed. This case highlights the complementary role of MR imaging in ascertaining seizure etiololgy when the clinical history and EEG findings are non-specific. The importance of early diagnosis with MR imaging is further underscored by the fact that patients diagnosed with HH usually develop drug resistance towards antiepileptic drugs, mandating neurosurgical assessment and intervention.

Glutamic acid decarboxylase 65-positive autoimmune encephalitis presenting with gelastic seizure, responsive to steroid: A case report

BACKGROUND

Anti-glutamic acid decarboxylase (GAD) antibody is known to cause several autoimmune-related situations. The most known relationship is that it may cause type I diabetes. In addition, it was also reported to result in several neurologic syndromes including stiff person syndrome, cerebellar ataxia, and autoimmune encephalitis. Decades ago, isolated epilepsy associated with anti-GAD antibody was first reported. Recently, the association between temporal lobe epilepsy and anti-GAD antibody has been discussed. Currently, with improvements in examination technique, many more autoimmune-related disorders can be diagnosed and treated easier than in the past.

CASE SUMMARY

A 44-year-old female Asian with a history of end-stage renal disease (without diabetes mellitus) under hemodialysis presented with diffuse abdominal pain. The initial diagnosis was peritonitis complicated with sepsis and paralytic ileus. Her peritonitis was treated and she recovered well, but seizure attack was noticed during hospitalization. The clinical impression was gelastic seizure with the presentation of frequent smiling, head turned to the right side, and eyes staring without focus; the duration was about 5–10 s. Temporal lobe epilepsy was recorded through electroencephalogram, and she was later diagnosed with anti-GAD65 antibody positive autoimmune encephalitis. Her seizure was treated initially with several anticonvulsants but with poor response. However, she showed excellent response to intravenous methylprednisolone pulse therapy. Her consciousness returned to normal, and no more seizures were recorded after 5 d of intravenous methylprednisolone treatment.

CONCLUSION

In any case presenting with new-onset epilepsy, in addition to performing routine brain imaging to exclude structural lesion and cerebrospinal fluid studies to exclude common etiologies of infection and inflammation, checking the autoimmune profile has to be considered. In the practice of modern medicine, autoimmune-related disorders are relatively treatable and should not be missed.

A systematic review of stereotactic radiofrequency ablation for hypothalamic hamartomas

BACKGROUND

The seizure activity associated with hypothalamic hamartomas (HHs) is refractory to medical management and surgical intervention is often required. Stereotactic Radiofrequency Ablation (SRFA) is a minimally invasive technique offering targeted lesion ablation with a reduced risk of complications.

OBJECTIVE

Here, we review the current literature on the use of SRFA for HHs.

METHODS

This study was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for systematic literature review. A database search of PubMed, Cochrane, Embase, and Web of Science was conducted in July 2020.

RESULTS

A total of 12 articles were included in this review, showing outcomes for 185 unique patients. Of these patients, 142 (76.8%) experienced some extent of therapeutic benefit in alleviating seizures following SRFA, with 128 (69.2%) patients achieving complete freedom from seizures. Common transient complications included hyponatremia (52 patients, 28.1%), hyperphagia (48 patients, 25.9%), hyperthermia (47 patients, 25.4%), Horner's syndrome (103 patients, 55.7%), and weight gain (75 patients, 40.5%).

CONCLUSIONS

SRFA is a potential therapy for patients with HHs, especially when resection confers significant risk to surrounding structures. Multiple rounds of SRFA treatment may be needed in approximately a quarter of patients to improve gelastic seizure outcomes but may not affect non-gelastic seizures. There is limited data on the use of SRFA for HHs and further case series and clinical trials are needed to establish the use of SRFA for HHs.

Successful Endoscopic Disconnection for Hypothalamic Hamartomas in a Child with Gelastic Seizures: An Unusual Case in a Resource-Scare Setting

Although the endoscopic disconnection surgery for the hamartomas was previously shown as a safe and effective treatment strategy in eliminating gelastic epilepsy, to date, there was no convincing evidence with this procedure in the resource-scare settings. We discuss an unusual case of a 7-year-old child who suffered from pharmacoresistant gelastic seizures was surgically treated with the endoscopic disconnection of the hypothalamic hamartomas. The patient underwent endoscopic surgery through the left ventricle approach to disconnect the lesion of the hypothalamus. Immediately after surgery, the patient’s clinical laughter was eliminated with no complications. From the initial experience at our center, successful outcome of this case contributes to supporting the solid evidence in choosing the right treatment approach for the hypothalamus in subsequent cases, towards not only Vietnam but also the countries having similar resource-scare conditions.

The spectrum of involuntary vocalizations in humans: A video atlas

In clinical practice, involuntary vocalizing behaviors are typically associated with Tourette syndrome and other tic disorders. However, they may also be encountered throughout the entire tenor of neuropsychiatry, movement disorders, and neurodevelopmental syndromes. Importantly, involuntary vocalizing behaviors may often constitute a predominant clinical sign, and, therefore, their early recognition and appropriate classification are necessary to guide diagnosis and treatment. Clinical literature and video-documented cases on the topic are surprisingly scarce. Here, we pooled data from 5 expert centers of movement disorders, with instructive video material to cover the entire range of involuntary vocalizations in humans. Medical literature was also reviewed to document the range of possible etiologies associated with the different types of vocalizing behaviors and to explore treatment options. We propose a phenomenological classification of involuntary vocalizations within different categorical domains, including (1) tics and tic-like vocalizations, (2) vocalizations as part of stereotypies, (3) vocalizations as part of dystonia or chorea, (4) continuous vocalizing behaviors such as groaning or grunting, (5) pathological laughter and crying, (6) vocalizations resembling physiological reflexes, and (7) other vocalizations, for example, those associated with exaggerated startle responses, as part of epilepsy and sleep-related phenomena. We provide comprehensive lists of their associated etiologies, including neurodevelopmental, neurodegenerative, neuroimmunological, and structural causes and clinical clues. We then expand on the pathophysiology of the different vocalizing behaviors and comment on available treatment options. Finally, we present an algorithmic approach that covers the wide range of involuntary vocalizations in humans, with the ultimate goal of improving diagnostic accuracy and guiding appropriate treatment. © 2019 The Authors. Movement Disorders published by Wiley Periodicals, Inc. on behalf of International Parkinson and Movement Disorder Society.

Inappropriate Laughter and Behaviours: How, What, and Why? Case of an Adult with Undiagnosed Gelastic Seizure with Hypothalamic Hamartoma

Gelastic seizures (GS) are a rare form of epilepsy characterized by inappropriate, uncontrolled laughter. They are highly associated with abnormal cognitive development and behavioral problems in patients. Research has shown that GS can originate from hypothalamic hamartomas (HH), non- neoplastic masses consisting of gray matter with large and small neurons interspersed with glial nuclei. GS have also been observed in patients with frontal and temporal lobe lesions. The patient in this case report is a 40-year-old man with a past medical history significant for brain tumor, diabetes mellitus, and schizophrenia who presented with a long standing history of sudden, involuntary laughter occurring 2-3 times a week since 8 years old. Since the onset of these laughing spells the patient has displayed gradual cognitive impairment and increasing behavioral problems. Subsequent EEG (21-channel electroencephalogram) showed focal epileptiform activity in the right frontotemporal region and MRI studies revealed a mass arising from the hypothalamus suggestive of a HH. Other conditions should be considered in the differential diagnosis for laughing spells and distinguishing different causes can be challenging. As demonstrated by this case report, in patients with behavioral issues, especially those with inappropriate uncontrolled laughter, gelastic seizures need to be included in the differential diagnosis. Thus, a thorough workup should include neuroimaging with attention to the suprasellar region and EEG. Accurate, early diagnosis and patient education are critical in avoiding excessive and unnecessary treatments. This condition may be pharmacoresistant and is often associated with progressive cognitive and behavioral issues. Studies have shown a surgical treatment approach may be effective.

Open resection of hypothalamic hamartomas for intractable epilepsy revisited, using intraoperative MRI

INTRODUCTION

Hypothalamic hamartomas (HHs) are rare non-neoplastic lesions which cause drug-resistant epilepsy with associated behavioural, psychiatric and endocrine issues. With the development of new minimally invasive techniques for the treatment of HH, there is a need to reappraise the effectiveness and safety of each approach. We review the outcomes of HH patients treated surgically, utilizing intraoperative magnetic resonance imaging (IOMRI), by a team of Alder Hey NHS Foundation Trust tumour and epilepsy neurosurgeons since 2011.

METHODS

Patient records of all HH cases operated on since 2011 were reviewed to confirm history of presentation and clinical outcomes.

RESULTS

Ten patients have undergone surgery for HH under the dual care of Alder Hey tumour and epilepsy neurosurgeons during this period. Eight cases had a midline transcallosal, interforniceal approach with the remaining 2 having a transcallosal, transforaminal approach. All patients had an IOMRI scan, with 40% needing further tumour resection post-IOMRI. Forty percent had a total resection, 3 patients had near-total resection and 3 patients had subtotal resection (~ 30% tumour residual on post-operative MRI). No new neurological complications developed post-operatively. Hypothalamic axis derangements were seen in 3 cases, including 1 diabetes insipidus with hypocortisolaemia, 1 hypodipsia and 1 transient hyperphagia. Eighty percent are seizure free; the remaining two patients have had significant improvements in seizure frequency.

CONCLUSIONS

IOMR was used to tailor the ideal tumour resection volume safely based on anatomy of the lesion, which combined with the open transcallosal, interforniceal route performed by surgeons experienced in the approach resulted in excellent, safe and effective seizure control.

Ictal laughter and crying: Should they be classified as automatisms?

Gelastic seizures (GS) describe ictal laughter and are associated with hypothalamic lesions, as well as other cortical areas. Dacrystic seizures (DS), characterized by ictal crying, also have been reported in hypothalamic lesions and focal epilepsy. We describe a young girl with drug resistant focal dyscognitive seizures associated with gelastic and dacrystic features. However, neither laughter nor crying was correlated with a stereotyped electroencephalographic (EEG) pattern or involvement of a particular brain region. Additionally, based on the variety of epileptogenic foci associated with GS and DS in the literature, laughter and crying appear to represent ictal or peri-ictal automatisms.

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Case report of focal dyscognitive seizures with gelastic and dacrystic features

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Patient seizure free after resection of parietal and insular cortical dysplasia

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She underwent scalp (sEEG) and intracranial (icEEG) video-EEG monitoring.

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Gelastic/dacrystic features not linked to specific EEG pattern or cortical area

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Gelastic/dacrystic symptoms represent automatisms without localizing significance.

Memory outcome one year after stereotactic interstitial radiosurgery in patients with epilepsy due to hypothalamic hamartomas

Epileptic seizures caused by hypothalamic hamartomas (HHs) are highly pharmacoresistant. Resective surgical approaches have shown some efficacy in controlling seizures; however, they bear a significant risk of postoperative mnemonic deterioration due to the close anatomical proximity of the HHs to structures essential for memory functions. We report on cognitive outcome in 26 patients with structural epilepsy due to HHs one year after interstitial radiosurgery. Individually, deteriorations occurred more frequently in declarative memory functions (in 20 to 50% of the patients), whereas more than 80% of the patients revealed stable or even improved performance in attentional functions. Preoperative better memory functions were associated with higher risk of postoperative performance decline. After radiosurgery, half of the patients showed more than 50%, and some up to 90%, of seizure reduction. Hypothalamic hamartoma volumes were significantly reduced at follow-up. Transient radiogenic edema found in 10/26 patients was not associated with further cognitive decline after radiosurgery. These results are highly relevant for therapeutic decisions and patient consultation on timing and choice of nonmedical treatment options for HHs.

Child with temporal lobe hamartoma: A to Z images and a case report

Gelastic seizure was first described by Trousseau in 1877 and comes from the Greek word gelos (laughs), as laughter is the main feature [1]. Normal laughter is a reactive emotional behaviour and motor action that involves the limbic system, hypothalamus, temporal cortex, and several regions of the brainstem. A female patient, six years old, left-handed, with gelastic seizures, uncontrolled despite being treated with two antiepileptic drugs at high doses, was treated. A simple axial tomography was done, where a hypodense lesion that shapes the inner table of the skull temporal level was observed; later, magnetic resonance imaging was requested, better characterising an intraxial lesion in the right second temporal gyrus cystic appearance.

Gelastic epilepsy in combination with hypothalamic hamartoma and partial agenesis of the corpus callosum: A case report and review of the literature

Gelastic epilepsy has been reported to originate from various conditions, particularly from hypothalamic hamartoma (HH). In the present study, we report a patient with gelastic seizures (GSs), followed by complex partial and tonic-clonic seizures. Magnetic resonance imaging (MRI) revealed a rare combination of HH and partial agenesis of the corpus callosum (ACC). Following resectioning of the HH, the seizures were reduced, but not fully controlled, with medication by the one year follow-up. HH and partial ACC patients may experience seizures; the seizures in the case presented in this study may have originated from HH, partial ACC or both. Considering the fact that seizure frequency reduced following surgery, they may have mainly occurred from HH. Additionally it was considered to be likely that the seizures following surgery were due to secondary epileptogenesis, partial ACC, or both.

Prenatal corticosteroids modify glutamatergic and GABAergic synapse genomic fabric: insights from a novel animal model of infantile spasms

Prenatal exposure to corticosteroids has long-term postnatal somatic and neurodevelopmental consequences. Animal studies indicate that corticosteroid exposure-associated alterations in the nervous system include hypothalamic function. Infants with infantile spasms, a devastating epileptic syndrome of infancy with characteristic spastic seizures, chaotic irregular waves on interictal electroencephalogram (hypsarhythmia) and mental deterioration, have decreased concentrations of adrenocorticotrophic hormone (ACTH) and cortisol in cerebrospinal fluid, strongly suggesting hypothalamic dysfunction. We have exploited this feature to develop a model of human infantile spasms by using repeated prenatal exposure to betamethasone and a postnatal trigger of developmentally relevant spasms with NMDA. The spasms triggered in prenatally primed rats are more severe compared to prenatally saline-injected ones and respond to ACTH, a treatment of choice for infantile spasms in humans. Using autoradiography and immunohistochemistry, we have identified a link between the spasms in our model and the hypothalamus, especially the arcuate nucleus. Transcriptomic analysis of the arcuate nucleus after prenatal priming with betamethasone but before trigger of spasms indicates that prenatal betamethasone exposure down-regulates genes encoding several important proteins participating in glutamatergic and GABAergic transmission. Interestingly, there were significant sex-specific alterations after prenatal betamethasone in synapse-related gene expression but no such sex differences were found in prenatally saline-injected controls. A pairwise relevance analysis revealed that, although the synapse gene expression in controls was independent of sex, these genes form topologically distinct gene fabrics in males and females and these fabrics are altered by betamethasone in a sex-specific manner. These findings may explain the sex differences with respect to both normal behaviour and the occurrence and severity of infantile spasms. Changes in transcript expression and their coordination may contribute to a molecular substrate of permanent neurodevelopmental changes (including infantile spasms) found after prenatal exposure to corticosteroids.

Pathological laughter associated with paroxysmal kinesigenic dyskinesia: A rare presentation of acute disseminated encephalomyelitis

A 13-year-old boy presented with recurrent episodes of sudden brief posturing of the right upper and lower limbs accompanied by transient inability to speak and a tendency to smile which would sometimes break into laughter. Awareness was retained during the attack, and there was no associated emotional abnormality. The events were precipitated by walking and occurred several times in a day. The laughter was pathological in nature, and the abnormal posturing was akin to ‘paroxysmal kinesigenic dyskinesia’ (PKD). ‘Pathological laughter or crying’ is defined as an involuntary, inappropriate, unmotivated laughter, crying or both, without any associated mood change. It can occur as a result of cerebral lesions like tumors, trauma, vascular insults, multiple sclerosis and/or degenerative disorders. It can also be a component of gelastic epilepsy which is characterized by stereotyped recurrences, presence of interictal and ictal epileptiform discharges and absence of external precipitants. In our patient, however, there was no ictal or interictal EEG correlate. Paroxysmal kinesigenic dyskinesia is characterized by intermittent, involuntary movements triggered by kinesigenic stimuli and is usually familial but can also be secondary to metabolic and structural brain disorders. Magnetic Resonance Imaging (MRI), in our case, revealed multiple T2 and FLAIR hyperintense, non-enhancing lesions in the periaqueductal gray matter, pontine and midbrain tegmentum, bilateral thalami and left lentiform nucleus suggesting a diagnosis of ‘acute disseminated encephalomyelitis’, in which this unique combination of pathological laughter and PKD has not been described so far. Magnetic Resonance Spectroscopy (MRS) confirmed a demyelinating pathology, and the patient responded well to steroids.

Gelastic seizures due to hypothalamic hamartoma: rapid resolution after endoscopic tumor disconnection

Gelastic epilepsy are focal seizures manifesting as recurrent brief seizures starting as laughter or grimaces. They are most commonly associated with other types of seizures and can be secondary to infectious, malformative, metabolic, or neoplastic processes involving the central nervous system. We report on an 18-month-old girl who presented since the age of 2 months with multiple, recurrent, unprovoked episodes of stereotypical laughter. Brain magnetic resonance study revealed an hypothalamic hamartoma. Endoscopic tumor disconnection of the hamartoma resulted in rapid resolution of neurological symptomatology.

Seizure semiology: its value and limitations in localizing the epileptogenic zone

Epilepsy surgery has become an important treatment option in patients with medically refractory epilepsy. The ability to precisely localize the epileptogenic zone is crucial for surgical success. The tools available for localization of the epileptogenic zone are limited. Seizure semiology is a simple and cost effective tool that allows localization of the symptomatogenic zone which either overlaps or is in close proximity of the epileptogenic zone. This becomes particularly important in cases of MRI negative focal epilepsy. The ability to video record seizures made it possible to discover new localizing signs and quantify the sensitivity and specificity of others. Ideally the signs used for localization should fulfill these criteria; 1) Easy to identify and have a high inter-rater reliability, 2) It has to be the first or one of the earlier components of the seizure in order to have localizing value. Later symptoms or signs are more likely to be due to ictal spread and may have only a lateralizing value. 3) The symptomatogenic zone corresponding to the recorded ictal symptom has to be clearly defined and well documented. Reproducibility of the initial ictal symptoms with cortical stimulation identifies the corresponding symptomatogenic zone. Unfortunately, however, not all ictal symptoms can be reproduced by focal cortical stimulation. Therefore, the problem the clinician faces is trying to deduce the epileptogenic zone from the seizure semiology. The semiological classification system is particularly useful in this regard. We present the known localizing and lateralizing signs based on this system.

The gelastic seizures-hypothalamic hamartoma syndrome: facts, hypotheses, and perspectives

Hypothalamic hamartoma (HH) can be associated with a wide spectrum of epileptic conditions, ranging from a mild form with seizures characterized by urge to laugh and no cognitive involvement up to a catastrophic encephalopathy with early onset gelastic seizures (GS), precocious puberty, and mental retardation. Moreover, a refractory, either focal or generalized, epilepsy develops during the clinical course in nearly all the cases. Neurophysiologic and neuroimaging studies have demonstrated that HH itself generates GS and starts a process of secondary epileptogenesis responsible for refractory focal or generalized epilepsy. The intrinsic epileptogenicity of HH may be explained by the neurophysiological properties of small GABAergic, spontaneously firing HH neurons. Surgical ablation of HH can reverse epilepsy and encephalopathy. Gamma-knife radiosurgery and image-guided robotic radiosurgery seem to be useful and safe approaches for treatment, in particular of small HH. Here, we review this topic, based on literature reports and our personal observations. In addition, we discuss pathogenetic hypotheses and suggest new approaches to this intriguing issue.

Gonadotropin-dependent precocious puberty: neoplastic causes and endocrine considerations

Premature activation of the hypothalamic-pituitary-gonadal (HPG) axis manifests as gonadotropin-dependent precocious puberty. The mechanisms behind HPG activation are complex and a clear etiology for early activation is often not elucidated. Though collectively uncommon, the neoplastic and developmental causes of gonadotropin-dependent precocious puberty are very important to consider, as a delay in diagnosis may lead to adverse patient outcomes. The intent of the current paper is to review the neoplastic and developmental causes of gonadotropin-dependent precocious puberty. We discuss the common CNS lesions and human chorionic gonadotropin-secreting tumors that cause sexual precocity, review the relationship between therapeutic radiation and gonadotropin-dependent precocious puberty, and finally, provide an overview of the therapies available for height preservation in this unique patient population.

Case report. Gelastic seizures in a patient with right gyrus cinguli astrocytoma

OBJECTIVE AND IMPORTANCE

Gelastic seizure (GS) also known as "gelastic epilepsy" is a rare type of seizure associated with several different conditions such as tumors--hypothalamic hamartromas, tuberous sclerosis, hemangiomas, post infectious foci, cortical temporal dysplasia. We report one case of this rare condition generated by a right gyrus cinguli gr. II astrocytoma.

CLINICAL PRESENTATION

A 27 year-old male, right handed, was admitted for a 2 years history of very frequent gelastic seizures accompanied sometimes by simple motor partial seizures in both arms, more often being involved his left arm, without impairment of his consciousness state. His neurological examination was normal. Diagnosis was made on native CT scan: minimal hypodense frontal right paramedian lesion, cerebral MRI showed a small well delimited right, parenchymal, homogeneous lesion (16/22/15 mm), involving gyrus cinguli, without perilesional edema and mass effect, hyperintense both on T1 and T2 MR sequences, non-enhancing after Gadolinium. The cerebral lesion was also documented on EEG and video-EEG recordings. Using an interhemispheric microsurgical approach, above the corpus callosum and the right pericallosal artery, at the level of gyrus cinguli, a yellow-gray, infiltrative tumor, having a moderate vascularisation, has been identified and totally removed. The anatomopathological analysis revealed a grade II astrocytoma. The patient recovered very well, without deficits, no gelastic seizures or epileptic manifestations; three months after operation he is still free of seizures.

CONCLUSION

A case of gelastic seizures accompanied by simple motor partial seizures in both arms, without the impairment of his consciousness state induced by a grade II right gyrus cinguli astrocytoma is described and documented by radiological and electrophysiological studies. Using microsurgical resection, the tumor was totally removed, the patient clinical condition improved. Without an affective connotation as in temporal or hypothalamus topography, gelastic seizures are not patognomonic for hypothalamic hamartomas and in the case of frontal localization of the lesion; they can be associated with motor involvement of the limbs as in our case.

Autoimmune thyroiditis and diabetes mellitus type 1 after long-term gonadotropin-releasing hormone agonist treatment for central precocious puberty: evolution or coincidence?

Very few abnormalities in endocrine function have been reported during long term gonadotropin-releasing hormone agonist (GnRHa) treatment in girls. Most authors agree that this therapy is safe and effective. We present an unusual outcome of long term GnRHa therapy in two girls with central precocious puberty(CPP) of idiopathic or organic origin. They have received monthly depot injections of triptorelin acetate for a time period of 8 years. Thyroid function was examined by measuring serum levels of thyrotropin (TSH), thyroxine (T4), thyroid antibodies, and ultrasound of the thyroid gland. One of the girls was at the age of 8.5 years, having elevated thyroid antibodies, mild goitier and an abnormal ultrasound of the thyroid gland, suggesting autoimmune thyroiditis. Another girl with a hypothalamic hamartoma developed diabetes mellitus at the age of 9 years. Both of these girls were early diagnosed for CPP, at 6 months and 8 months respectively, and given GnRHa treatment. So far, it is not known whether these autoimmune diseases are related to the GnRHa treatment or are simply a coincidence. However, we suggest a closer monitoring of girls with CPP who have had a long period of treatment.