Cerebral dominance in an unusual case of Landau-Kleffner syndrome

Landau-Kleffner syndrome (LKS) is described by the International Classification of Epileptic Syndromes since 1985 as a constellation of clinical and electrographic signs, including acquired aphasia, regression of language milestones and seizures, along with sleep-activated paroxysms on electroencephalogram which can progress to electrographic status epilepticus of sleep. In this case, a 7-year-old boy presented with an atypical history of new-onset aphasia and regression of language milestones with rare seizures. However, there was an electrographic mismatch in the form of right-sided epileptiform activity and continuous spike and wave of sleep pattern. Detailed speech analysis and perusal of the history revealed a possibly ambidextrous child with right hemispheric language dominance, and he was diagnosed with LKS and treated. This report illustrates the many pitfalls in the diagnosis and treatment of this rare epileptic syndrome.

Current practices in epilepsy monitoring units (EMU) in India

AIM

As an initial step to develop guidelines for epilepsy monitoring units (EMUs) appropriate for developing countries, we inquired the existing practices in EMUs in India.

METHODS

After checking for the content and face validity as well for clarity, we sent a 52-item online non-anonymized questionnaire to all the 52 EMUs in India.

RESULTS

The questionnaire was completed by 51 of the 52 EMUs (98% response rate). The majority of the EMUs are located in major cities and 51% are located in non-governmental corporate hospitals. There are total of 122 prolonged video-EEG monitoring (PVEM) beds in India and 70% EMUs have ≤2 beds. Approximately two-thirds of the EMUs have defined protocols for pre-procedure consent and risk assessment, management of seizure clusters and status epilepticus, continuous observation of patients, and peri‑ictal testing. Only one-third of the EMUs have protocols for management of post-ictal psychosis, anti-suffocation pillows, and protected environment within bathrooms. The waiting period for PVEM is more (49.9 ± 101 vs. 4.9 ± 10.9 days; p = 0.04) and mean cost for 3-day PVEM is less (INR 8311 ± 9021 vs. 30,371 ± 17,563; p <0.0001) in public as compared to private hospitals. There was a negative correlation between cost of PVEM and the waiting period (r=-0.386; p = 0.01). Safety practices are similar in public and private hospitals.

CONCLUSIONS

Although practices in EMUs in India vary widely, they are comparable to those in developed countries. India has severe shortage of EMUs and long waiting lists for affordable PVEM.

Treatment outcomes in drug resistant juvenile myoclonic epilepsy: Valproate resistance may not be the end of the road

OBJECTIVE

To determine treatment responses to various antiseizure medicines (ASMs) in patients with drug resistant juvenile myoclonic epilepsy (DRJME) METHODS: We reviewed records of all JME patients attending epilepsy clinics at 5 centers during a 5-year period. We used International Consensus Criteria to diagnose JME and International League Against Epilepsy Criteria to define drug resistance and sustained seizure freedom. We only used broad spectrum medicines which included valproate, lamotrigine, topiramate, levetiracetam, clobazam, phenobarbitone, clonazepam, and zonisamide. We considered an ASM successful if patient achieved seizure freedom within 3 months of attaining maintenance dose.

RESULTS

We studied 116 patients (61 males) with DRJME. At terminal followup, 82 (70.7%) patients had achieved sustained seizure freedom with a mean followup of 3.2 ± 1.3 years after last dose change. In patients where valproate failed as first- or second-line ASM (n=70; 60.3%), 49(70%) became seizure-free. In this group, 33(67%) patients became seizure-free after addition of lamotrigine. Success rate of lamotrigine and valproate combination was 69% as compared to 9% with all other combinations (p = 0.001). In patients who were not exposed to valproate as initial therapy (n=46), 33 (71.7%) became seizure-free, 30 (91%) after adding valproate. At last follow-up, 75 (90%) seizure-free patients were receiving valproate including 45 (55%) patients with a combination of valproate and lamotrigine. Only one of 24 patients became seizure-free after failing valproate and lamotrigine combination.

CONCLUSION

Seizure freedom can be achieved in two-thirds of patients with DRJME. A combination of valproate and lamotrigine is the most effective duotherapy.

Pathophysiological Mechanisms and Neurological Manifestations in COVID-19

With increasing knowledge of the coronavirus disease-2019 (COVID-19), we now understand that COVID-19 presents with various extrapulmonary manifestations with multi-organ involvement. Involvement of the central nervous system (CNS) occurs probably via transsynaptic spread or transfer across the blood-brain barrier. Hypoxia, immune-mediated injury, and vascular damage are the potential mechanisms for the CNS manifestations. Headache, dizziness, chemosensory disturbances, such as loss of smell, taste, encephalopathy, stroke, etc., are among the commonly encountered neurological presentations. Headache is identified as one of the red flag symptoms for COVID-19. Sudden onset of loss of smell and/or taste in the absence of nasal congestion can help in COVID-19 case identification and testing prioritization. Both hemorrhagic and ischemic brain injury is common in patients developing stroke. Besides these, COVID-19-associated CNS involvement demands more careful attention toward patients with existing neurological disorders especially that are managed with immunosuppressant agents. In all, neurological involvement in COVID-19 is not uncommon and may precede, occur concomitantly or after the respiratory involvement. It may also be the sole presentation in some of the patients necessitating high vigilance for COVID-19. In this review, we briefly discussed the pathogenesis of CNS involvement and some important neurological manifestations in COVID-19. How to cite this article: Zirpe KG, Dixit S, Kulkarni AP, Sapra H, Kakkar G, Gupta R, et al. Pathophysiological Mechanisms and Neurological Manifestations in COVID-19. Indian J Crit Care Med 2020;24(10):975-980.

Eating Epilepsy in North India: Case Series and Its Management

Eating epilepsy is a rare form of reflex epilepsy where seizures are triggered by eating. We describe a case series of 12 such patients presenting to our epilepsy clinic based in North India. Eating epilepsy was noted to have male predominance with focal seizures with impaired awareness. Most of these patients had either temporal or perisylvian localization. Clobazam taken half an hour before meal was found to be an effective add-on therapy in its management.

An Unusual Cause of Posterior Reversible Encephalopathy Syndrome

Posterior reversible encephalopathy syndrome (PRES) is a clinical radiographic diagnosis of heterogeneous etiologies. The pathogenesis of PRES remains unclear, but may be related to impaired cerebral autoregulation and endothelial dysfunction. We present a case of intravascular nonionic contrast-induced PRES observed after cerebral angiography. The index patient was a follow-up case of large vertebrobasilar artery-dissecting aneurysm for which endovascular coiling was done 6 months back. She improved completely within a week. Contrast-induced PRES is a reversible benign condition, knowledge of which is crucial for appropriate management.

Combining carotid endarterectomy with off-pump coronary artery bypass graft surgery is safe and effective

Background:

We, as neurologists, are frequently consulted to give neurological clearance for surgery in patients who are undergoing coronary artery bypass graft (CABG) surgery and have suffered from stroke or transient ischemic attack (TIA) in past. Similarly clearance is also sought in another group of patients who, though have not suffered from stroke or TIA, but found to have significant carotid stenosis on routine screening prior to surgery. Cardiac surgeons and anesthetists want to know the risk of perioperative stroke in such patients and should carotid endarterectomy (CEA) be done along with CABG. In absence of any clear-cut guideline, neurologists often fail to give any specific recommendation.

Aim:

To find out safety and efficacy of synchronous CEA in patients undergoing CABG.

Design:

Retrospective study.

Materials and Methods:

Out of 3,700 patients who underwent CABG, 150 were found to have severe carotid stenosis of >70%. Out of this, 46 patients with >80% stenosis (three symptomatic and 43 asymptomatic) and one patient with >70% symptomatic carotid stenosis (TIA within last 2 weeks) were taken for simultaneous CEA along with CABG. These three symptomatic carotid patients had suffered from stroke within last 6 months.

Results:

One patient with asymptomatic near total occlusion of carotid artery suffered from hyperperfusion syndrome. None suffered from ischemic stroke, myocardial infarction (MI), or death during perioperative period.

Conclusion:

Combining CEA along with CABG is a safe and effective procedure.

Comparative evaluation of conservative management versus early surgical intervention in appendicular mass--a clinical study

The management of appendicular mass seems to be taking turn with the availability of better antibiotics, care and anaesthesia. Quite a few workers turned to the other extreme of traditional conservative approach and reported acceptable results with immediate intervention during phlegmonous stage. But practically, surgeons still continue to adopt the same old regime. To alleviate this fear and circumvent the disadvantages of immediate intervention a midpath regime called early appendicectomy has been clinically evaluated. With this new approach in the present study preventing misdiagnosis (15%), no chance of recurrence as also of missing in the follow-up and shorter overall hospital stay with economy are some strong reasons to adopt this regime.