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Ghannam M, Beran A, Ghazaleh D, Lyerla R, Al-Assadi R, Ferderer T, Elahian B, Henry T, Patel S, Berry B. Insulinoma as a Potential Insidious Presenter in Medical Refractory Epilepsy. Neuro Endocrinol Lett 2020; 41:46-52. [PMID: 32338852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Accepted: 12/12/2019] [Indexed: 06/11/2023]
Abstract
BACKGROUND Insulinoma as a cause of epileptic seizure has been thoroughly described but often not considered in differentials for previously established diagnoses of seizure disorder. Hypoglycemic symptoms can mimic neurological disorders such as epilepsy. CASE PRESENTATION A 52-year-old woman presented with a history of epilepsy on anti-epileptic drugs (AEDs) developed repeated episodes consisting of seizures and neuropsychiatric symptoms with no predisposing factors for epilepsy at age 52. She had received full AED treatment before the possibility of hypoglycemia was considered. Following a clinical diagnosis of insulinoma, distal pancreatectomy was performed, and her seizures did not occur again. CONCLUSION The early diagnosis of insulinoma requires vigilance, not only for hypoglycemia in patients with neuropsychiatric symptoms, but also for the possible masking effects of a history of epilepsy and preceding AED usage.
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Affiliation(s)
- Malik Ghannam
- Department of Neurology, University of Minnesota, Minneapolis, MN, USA
| | - Azizullah Beran
- Department of Internal Medicine, the University of Toledo, Toledo, OH, USA
| | - Dana Ghazaleh
- Department of Internal Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Ryan Lyerla
- Department of Endocrinology, University of Minnesota, Minneapolis MN, USA
| | - Rami Al-Assadi
- Department of Neurology, University of Minnesota, Minneapolis, MN, USA
| | - Tanner Ferderer
- Department of Neurology, University of Minnesota, Minneapolis, MN, USA
| | - Bahareh Elahian
- Department of Biomedical Engineering, University of Minnesota, Minneapolis, MN, USA
| | - Thomas Henry
- Department of Neurology, University of Minnesota Health/MINCEP Epilepsy Care, 5775 Wayzata Blvd, Minneapolis, MN 55416, USA
| | - Sima Patel
- Department of Neurology, University of Minnesota Health/MINCEP Epilepsy Care, 5775 Wayzata Blvd, Minneapolis, MN 55416, USA
| | - Brent Berry
- Department of Neurology, University of Minnesota, Minneapolis, MN, USA
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Waldman ZJ, Camarillo-Rodriguez L, Chervenova I, Berry B, Shimamoto S, Elahian B, Kucewicz M, Ganne C, He XS, Davis LA, Stein J, Das S, Gorniak R, Sharan AD, Gross R, Inman CS, Lega BC, Zaghloul K, Jobst BC, Davis KA, Wanda P, Khadjevand M, Tracy J, Rizzuto DS, Worrell G, Sperling M, Weiss SA. Ripple oscillations in the left temporal neocortex are associated with impaired verbal episodic memory encoding. Epilepsy Behav 2018; 88:33-40. [PMID: 30216929 PMCID: PMC6240385 DOI: 10.1016/j.yebeh.2018.08.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 08/14/2018] [Accepted: 08/15/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND We sought to determine if ripple oscillations (80-120 Hz), detected in intracranial electroencephalogram (iEEG) recordings of patients with epilepsy, correlate with an enhancement or disruption of verbal episodic memory encoding. METHODS We defined ripple and spike events in depth iEEG recordings during list learning in 107 patients with focal epilepsy. We used logistic regression models (LRMs) to investigate the relationship between the occurrence of ripple and spike events during word presentation and the odds of successful word recall following a distractor epoch and included the seizure onset zone (SOZ) as a covariate in the LRMs. RESULTS We detected events during 58,312 word presentation trials from 7630 unique electrode sites. The probability of ripple on spike (RonS) events was increased in the SOZ (p < 0.04). In the left temporal neocortex, RonS events during word presentation corresponded with a decrease in the odds ratio (OR) of successful recall, however, this effect only met significance in the SOZ (OR of word recall: 0.71, 95% confidence interval (CI): 0.59-0.85, n = 158 events, adaptive Hochberg, p < 0.01). Ripple on oscillation (RonO) events that occurred in the left temporal neocortex non-SOZ also correlated with decreased odds of successful recall (OR: 0.52, 95% CI: 0.34-0.80, n = 140, adaptive Hochberg, p < 0.01). Spikes and RonS that occurred during word presentation in the left middle temporal gyrus (MTG) correlated with the most significant decrease in the odds of successful recall, irrespective of the location of the SOZ (adaptive Hochberg, p < 0.01). CONCLUSION Ripples and spikes generated in the left temporal neocortex are associated with impaired verbal episodic memory encoding. Although physiological and pathological ripple oscillations were not distinguished during cognitive tasks, our results show an association of undifferentiated ripples with impaired encoding. The effect was sometimes specific to regions outside the SOZ, suggesting that widespread effects of epilepsy outside the SOZ may contribute to cognitive impairment.
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Affiliation(s)
- Zachary J. Waldman
- Dept. of Neurology and Neuroscience, Thomas Jefferson University, Philadelphia, PA USA 19107
| | | | - Inna Chervenova
- Dept. of Pharmacology & Experimental Therapeutics, Thomas Jefferson University, Philadelphia, PA USA 19107
| | - Brent Berry
- Dept. of Neurology, Mayo Systems Electrophysiology Laboratory (MSEL).,Dept. of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN USA 55905
| | - Shoichi Shimamoto
- Dept. of Neurology and Neuroscience, Thomas Jefferson University, Philadelphia, PA USA 19107
| | - Bahareh Elahian
- Dept. of Neurology and Neuroscience, Thomas Jefferson University, Philadelphia, PA USA 19107
| | - Michal Kucewicz
- Dept. of Neurology, Mayo Systems Electrophysiology Laboratory (MSEL).,Dept. of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN USA 55905
| | - Chaitanya Ganne
- Dept. of Neurology, Thomas Jefferson University, Philadelphia, PA USA 19107
| | - Xiao-Song He
- Dept. of Neurology, Thomas Jefferson University, Philadelphia, PA USA 19107
| | - Leon A. Davis
- Dept. of Psychology, Mayo Clinic, Rochester, MN USA 55905
| | - Joel Stein
- Department of Radiology, Mayo Clinic, Rochester, MN USA 55905
| | - Sandhitsu Das
- Penn Image Computing and Science Laboratory, Department of Radiology, Mayo Clinic, Rochester, MN USA 55905.,Penn Memory Center, Department of Neurology, Mayo Clinic, Rochester, MN USA 55905
| | - Richard Gorniak
- Dept. of Radiology, Thomas Jefferson University, Philadelphia, PA USA 19107
| | - Ashwini D. Sharan
- Dept. of Neurosurgery, Thomas Jefferson University, Philadelphia, PA USA 19107
| | - Robert Gross
- Emory University, Dept. of Neurosurgery, Atlanta, GA USA 30322
| | - Cory S. Inman
- Emory University, Dept. of Neurosurgery, Atlanta, GA USA 30322
| | - Bradley C. Lega
- University of Texas Southwestern Medical Center, Dept. of Neurosurgery, Dallas, TX USA 75390
| | - Kareem Zaghloul
- Surgical Neurology Branch, NINDS, NIH, Bethesda, MD USA 20892
| | - Barbara C. Jobst
- Dartmouth-Hitchcock Medical Center, Dept. of Neurology, Lebanon, NH USA 03756
| | - Katheryn A. Davis
- Dept. of Neurology, University of Pennsylvania, Philadelphia, PA USA 19104
| | - Paul Wanda
- Dept. of Psychology, Mayo Clinic, Rochester, MN USA 55905
| | - Mehraneh Khadjevand
- Dept. of Neurology, Mayo Systems Electrophysiology Laboratory (MSEL).,Dept. of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN USA 55905
| | - Joseph Tracy
- Dept. of Neurology, Thomas Jefferson University, Philadelphia, PA USA 19107
| | | | - Gregory Worrell
- Dept. of Neurology, Mayo Systems Electrophysiology Laboratory (MSEL).,Dept. of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN USA 55905
| | - Michael Sperling
- Dept. of Neurology, Thomas Jefferson University, Philadelphia, PA USA 19107
| | - Shennan A. Weiss
- Dept. of Neurology and Neuroscience, Thomas Jefferson University, Philadelphia, PA USA 19107
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Elahian B, Lado NE, Mankin E, Vangala S, Misra A, Moxon K, Fried I, Sharan A, Yeasin M, Staba R, Bragin A, Avoli M, Sperling MR, Engel J, Weiss SA. Low-voltage fast seizures in humans begin with increased interneuron firing. Ann Neurol 2018; 84:588-600. [PMID: 30179277 DOI: 10.1002/ana.25325] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 08/29/2018] [Accepted: 08/29/2018] [Indexed: 12/17/2022]
Abstract
OBJECTIVE Intracellular recordings from cells in entorhinal cortex tissue slices show that low-voltage fast (LVF) onset seizures are generated by inhibitory events. Here, we determined whether increased firing of interneurons occurs at the onset of spontaneous mesial-temporal LVF seizures recorded in patients. METHODS The seizure onset zone (SOZ) was identified using visual inspection of the intracranial electroencephalogram. We used wavelet clustering and temporal autocorrelations to characterize changes in single-unit activity during the onset of LVF seizures recorded from microelectrodes in mesial-temporal structures. Action potentials generated by principal neurons and interneurons (ie, putative excitatory and inhibitory neurons) were distinguished using waveform morphology and K-means clustering. RESULTS From a total of 200 implanted microelectrodes in 9 patients during 13 seizures, we isolated 202 single units; 140 (69.3%) of these units were located in the SOZ, and 40 (28.57%) of them were classified as inhibitory. The waveforms of both excitatory and inhibitory units remained stable during the LVF epoch (p > > 0.05). In the mesial-temporal SOZ, inhibitory interneurons increased their firing rate during LVF seizure onset (p < 0.01). Excitatory neuron firing rates peaked 10 seconds after the inhibitory neurons (p < 0.01). During LVF spread to the contralateral mesial temporal lobe, an increase in inhibitory neuron firing rate was also observed (p < 0.01). INTERPRETATION Our results suggest that seizure generation and spread during spontaneous mesial-temporal LVF onset events in humans may result from increased inhibitory neuron firing that spawns a subsequent increase in excitatory neuron firing and seizure evolution. Ann Neurol 2018;84:588-600.
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Affiliation(s)
- Bahareh Elahian
- Department of Neuroscience, Thomas Jefferson University, Philadelphia, PA.,Department of Neurology, Thomas Jefferson University, Philadelphia, PA.,Department of Electrical and Computer Engineering, University of Memphis, Memphis, TN
| | - Nathan E Lado
- Department of Neuroscience, Thomas Jefferson University, Philadelphia, PA.,Department of Neurology, Thomas Jefferson University, Philadelphia, PA
| | - Emily Mankin
- Department of Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Sitaram Vangala
- Department of Medicine, Statistics Core, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Amrit Misra
- Department of Neurology, Massachusetts General Hospital, Boston, MA
| | - Karen Moxon
- Department of Biomedical Engineering, Science, and Health Systems, Drexel University, Philadelphia, PA
| | - Itzhak Fried
- Department of Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Ashwini Sharan
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA
| | - Mohammed Yeasin
- Department of Electrical and Computer Engineering, University of Memphis, Memphis, TN
| | - Richard Staba
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Anatol Bragin
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Massimo Avoli
- Department of Neurology and Neurosurgery, McGill University, Montreal, Quebec, Canada.,Department of Physiology, McGill University, Montreal, Quebec, Canada.,Montreal Neurological Institute, McGill University, Montreal, Quebec, Canada
| | | | - Jerome Engel
- Department of Neurobiology, David Geffen School of Medicine at UCLA, Los Angeles, CA.,Department of Psychiatry and Biobehavioral Sciences, Brain Research Institute, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Shennan A Weiss
- Department of Neuroscience, Thomas Jefferson University, Philadelphia, PA.,Department of Neurology, Thomas Jefferson University, Philadelphia, PA
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