Outcomes of posterior component separation with transversus abdominis release for repair of abdominally based breast reconstruction donor site hernias

PURPOSE

Abdominally based autologous breast reconstruction (ABABR) is common after mastectomy, but carries a risk of complex abdominal wall hernias. We report experience with posterior component separation (PCS) and transversus abdominis release (TAR) with permanent synthetic mesh repair of ABABR-related hernias.

METHODS

Patients at Cleveland Clinic Foundation and Penn State Health were identified retrospectively. Outcomes included postoperative complications, hernia recurrence, and patient-reported outcomes (PROs): Hernia Recurrence Inventory, HerQLes Summary Score, Patient-Reported Outcome Measurement Information System (PROMIS) Pain Intensity 3a Survey, and the Decision Regret Scale (DRS).

RESULTS

Forty patients underwent PCS/TAR repair of hernias resulting from pedicled (35%), free (5%), muscle-sparing TRAMs (15%), and DIEPs (28%) from August 2014 to March 2021. Following PCS, 30-day complications included superficial surgical site infection (13%), seroma (8%), and superficial wound breakdown (5%). Five patients (20%) developed clinical hernia recurrence. At a minimum of 1 year, 17 (63%) reported a bulge, 12 (44%) reported pain, median HerQLes Quality Of Life Scores improved from 33 to 63/100 (p value < 0.01), PROMIS 3a Pain Intensity Scores improved from 52 to 38 (p value < 0.05), and DRS scores were consistent with low regret (20/100).

CONCLUSION

ABABR-related hernias are complex and technically challenging due to missing abdominal wall components and denervation injury. After repair with PCS/TAR, patients had high rates of recurrence and bulge, but reported improved quality of life and pain and low regret. Surgeons should set realistic expectations regarding postoperative bulge and risk of hernia recurrence.

Achievement of Target Gain Larger than Unity in an Inertial Fusion Experiment

On December 5, 2022, an indirect drive fusion implosion on the National Ignition Facility (NIF) achieved a target gain G_{target} of 1.5. This is the first laboratory demonstration of exceeding "scientific breakeven" (or G_{target}>1) where 2.05 MJ of 351 nm laser light produced 3.1 MJ of total fusion yield, a result which significantly exceeds the Lawson criterion for fusion ignition as reported in a previous NIF implosion [H. Abu-Shawareb et al. (Indirect Drive ICF Collaboration), Phys. Rev. Lett. 129, 075001 (2022)PRLTAO0031-900710.1103/PhysRevLett.129.075001]. This achievement is the culmination of more than five decades of research and gives proof that laboratory fusion, based on fundamental physics principles, is possible. This Letter reports on the target, laser, design, and experimental advancements that led to this result.

Development of an Immediate-Release Prototype Tablet Formulation of Hydroxychloroquine Sulfate with an Interwoven Taste-Masking System

Hydroxychloroquine sulfate (HCQS) was granted US-FDA approval in 1955 for the prevention and treatment of malaria. Since then, its uses have expanded to treat systemic lupus erythematosus and rheumatoid arthritis.  For each indication, HCQS is a crucial option for the treatment of pediatric, juvenile, adult, and elderly populations. Existing currently on the market are only 200-mg strength tablets exclusively for adult administration. To facilitate weight-based administration for pediatric and juvenile patients, an HCQS suspension is made by compounding a 200-mg HCQS tablet and suspending the crushed granules into water and Ora-Plus®. The Ora-Plus® suspension does not alter the extreme bitterness of HCQS such that it facilitates oral administration. Additional research has been executed to affirm that a slightly buffered, ion-pairing system, reduces the bitterness of HCQS. The buffered, ion-pairing system can be interwoven into an immediate-release tablet formulation likely without compromising tablet performance. With the taste-masking system embedded, the tablet could be more easily be compounded and suspended in water to generate a palatable oral suspension. Such a novel HCQS 200-mg tablet would be tailored for adult usages wherein the interwoven task-masking system could be utilized to facilitate weight-based administration for pediatric and juvenile patients. The dual quality target product profile of the tablet and the tablet compounded for suspension in water would make the tablet formulation applicable to a wide patient population ranging from pediatric to elder adults to facilitate in improving compliance and overall health outcomes.

Lawson Criterion for Ignition Exceeded in an Inertial Fusion Experiment

For more than half a century, researchers around the world have been engaged in attempts to achieve fusion ignition as a proof of principle of various fusion concepts. Following the Lawson criterion, an ignited plasma is one where the fusion heating power is high enough to overcome all the physical processes that cool the fusion plasma, creating a positive thermodynamic feedback loop with rapidly increasing temperature. In inertially confined fusion, ignition is a state where the fusion plasma can begin "burn propagation" into surrounding cold fuel, enabling the possibility of high energy gain. While "scientific breakeven" (i.e., unity target gain) has not yet been achieved (here target gain is 0.72, 1.37 MJ of fusion for 1.92 MJ of laser energy), this Letter reports the first controlled fusion experiment, using laser indirect drive, on the National Ignition Facility to produce capsule gain (here 5.8) and reach ignition by nine different formulations of the Lawson criterion.

Combined counter-maneuvers accelerate recovery from orthostatic hypotension in familial dysautonomia

BACKGROUND

In patients with familial dysautonomia (FD), prominent orthostatic hypotension (OH) endangers cerebral perfusion. Supine repositioning or abdominal compression improves systolic and diastolic blood pressure (BPsys and BPdia).

OBJECTIVE

To determine whether OH recovers faster with combined supine repositioning and abdominal compression than with supine repositioning alone.

METHODS

In 9 patients with FD (17.8 ± 3.9 years) and 10 healthy controls (18.8 ± 5 years), we assessed 2-min averages of BPsys, BPdia, and heart rate (HR) during supine rest, standing, supine repositioning, another supine rest, second standing, and supine repositioning with abdominal compression by leg elevation and flexion. We determined BPsys- and BPdia-recovery-times as intervals from return to supine until BP reached values equivalent to each participant's 2-min average at supine rest minus two standard deviations. Differences in signal values and BP-recovery-times between groups and positions were assessed by ANOVA and post hoc testing (significance: P < 0.05).

RESULTS

Patients with FD had pronounced OH that improved with supine repositioning. However, BP only reached supine rest values with additional abdominal compression. In controls, BP was stable during positional changes. Without abdominal compression, BP-recovery-times were longer in patients with FD than those in controls, but similar to control values with compression (BPsys: 83.7 ± 64.1 vs 36.6 ± 49.5 s; P = 0.013; BPdia: 84.6 ± 65.2 vs 35.3 ± 48.9 s; P = 0.009).

CONCLUSION

Combining supine repositioning with abdominal compression significantly accelerates recovery from OH and thus lowers the risk of hypotension-induced cerebral hypoperfusion.

Phenomenology of hallucinations, illusions, and delusions as part of seizure semiology

In partial epilepsy, a localized hypersynchronous neuronal discharge evolving into a partial seizure affecting a particular cortical region or cerebral subsystem can give rise to subjective symptoms, which are perceived by the affected person only, that is, ictal hallucinations, illusions, or delusions. When forming the beginning of a symptom sequence leading to impairment of consciousness and/or a classic generalized seizure, these phenomena are referred to as an epileptic aura, but they also occur in isolation. They often manifest in the fully awake state, as part of simple partial seizures, but they also can be associated to different degrees of disturbed consciousness. Initial ictal symptoms often are closely related to the physiological functions of the cortical circuit involved and, therefore, can provide localizing information. When brain regions related to sensory integration are involved, the seizure discharge can cause specific kinds of hallucinations, for example, visual, auditory, gustatory, olfactory, and cutaneous sensory sensations. In addition to these elementary sensory perceptions, quite complex hallucinations related to a partial seizure can arise, for example, perception of visual scenes or hearing music. By involving psychic and emotional spheres of human perception, many seizures also give rise to hallucinatory emotional states (e.g., fear or happiness) or even more complex hallucinations (e.g., visuospatial phenomena), illusions (e.g., déjà vu, out-of-body experience), or delusional beliefs (e.g., identity change) that often are not easily recognized as epileptic. Here we suggest a classification into elementary sensory, complex sensory, and complex integratory seizure symptoms. Epileptic hallucinations, illusions, and delusions shine interesting light on the physiology and functional anatomy of brain regions involved and their functions in the human being. This article, in which 10 cases are described, introduces the fascinating phenomenology of subjective seizure symptoms.

Ictal delusion of sexual transformation

Psychic and psychotic symptoms can be part of seizure-related symptoms, especially within the postictal phase in partial epilepsies. Among the classic examples are dysmnestic phenomena, visual and acoustic hallucinations, and more rarely delusional syndromes. Here we report about the unique seizure symptom of transformation towards the opposite gender in a patient with a right amygdalar tumor, which we classify as ictal delusional misidentification syndrome.

Clinical prediction of postoperative seizure control: structural, functional findings and disease histories

OBJECTIVE

Mesial temporal lobe epilepsy (MTLE) constitutes a heterogenic entity with different clinical histories, pathomorphological hippocampal findings and varying postoperative outcome.

METHOD

64 patients with MTLE, scheduled for hippocampal resection, were included. Initial precipitating injuries (IPI), structural and functional findings and neuropathological classification of hippocampal specimens were related to prediction of surgical outcome.

RESULTS

Patients with severe hippocampal sclerosis (mesial temporal sclerosis (MTS) type 1b) became completely seizure free (80% Engel Ia) significantly more often compared with approximately 40% of seizure freedom in other types of MTS or in patients without hippocampal cell loss (non-MTS), irrespective of the extent of hippocampal resection. Age at IPI was found to be related to MTS variants (p<0.01) and significantly correlated with cell loss in the CA1 sector and the dentate gyrus (p<0.05). Presurgical MRI discriminated between MTS and non-MTS, but did not discriminate between different MTS subtypes. The most reliable predictors of MTS type 1b were the Wada memory scores combined with interictal and ictal EEG.

CONCLUSIONS

A particular cohort of MTLE patients benefit most from surgical treatment. These patients are clinically best recognised as presenting with (1) very early IPI; (2) a silent period of about 5 years; (3) unequivocal unilateral EEG localisation; (4) MRI signs of MTS; and (5) Wada Test indicates contralateral memory compensation and ipsilateral reduced memory capacity. MTS type 1b, characterised by severe cell loss in all hippocampal subfields including the dentate gyrus, and associated with optimal postoperative seizure control, was preoperatively clinically best differentiated from other MTS types by the Wada Memory Test.

The Wada test in Austrian, Dutch, German, and Swiss epilepsy centers from 2000 to 2005: a review of 1421 procedures

Twenty-six Austrian, Dutch, German, and Swiss epilepsy centers were asked to report on use of the Wada test (intracarotid amobarbital procedure, IAP) from 2000 to 2005 and to give their opinion regarding its role in the presurgical diagnosis of epilepsy. Sixteen of the 23 centers providing information had performed 1421 Wada tests, predominantly the classic bilateral procedure (73%). A slight nonsignificant decrease over time in Wada test frequency, despite slightly increasing numbers of resective procedures, could be observed. Complication rates were relatively low (1.09%; 0.36% with permanent deficit). Test protocols were similar even though no universal standard protocol exists. Clinicians rated the Wada test as having good reliability and validity for language determination, whereas they questioned its reliability and validity for memory lateralization. Several noninvasive functional imaging techniques are already in use. However, clinicians currently do not want to rely solely on noninvasive functional imaging in all patients.

Deficient memory acquisition in temporal lobe epilepsy is predicted by hippocampal granule cell loss

BACKGROUND

The hippocampal formation is essentially involved in the formation of conscious memories for facts and events and neurologic diseases affecting the hippocampus associate with severe memory deficits, i.e., temporal lobe epilepsies.

METHODS

We studied the degree of declarative memory dysfunction in 24 human subjects with unilateral mesial temporal lobe epilepsy, using the unique possibility to access memory performance of each isolated hippocampus by intracarotid amobarbital anesthesia. Subsequently, hippocampal specimens from the same patients were available for neuropathologic analysis following surgical treatment of intractable seizures.

RESULTS

Neuronal cell loss in the dentate gyrus and all hippocampal subfields correlated with memory performance with the exception of CA2. Moreover, multiple regression and partial correlation analyses identified neuronal cell loss within the internal limb of the dentate gyrus, a developmentally distinct subregion of the hippocampal formation known to generate new neurons throughout life, as highly significant predictor for the patient's ability to learn and recall memories.

CONCLUSIONS

In accordance with animal studies, the dentate gyrus may play a critical role in the neuronal network associated with memory formation.

The RAGE pathway in inflammatory myopathies and limb girdle muscular dystrophy

Oxidative stress and nuclear factor-kappaB (NF-kappaB) activation are linked to the pathogenesis of many metabolic, degenerative, and chronic inflammatory diseases. Activation of the receptor for advanced glycation end products (RAGE) by its specific ligand N(epsilon)-carboxymethyllysine (CML) results in the activation of NF-kappaB and the production of proinflammatory cytokines. To determine whether engagement of RAGE contributes to the pathogenesis of inflammatory myopathies, we performed immunohistochemical studies on the presence of CML-modified proteins, RAGE and activated NF-kappaB in muscle biopsies of patients with polymyositis (PM, n=10), dermatomyositis (DM, n=10), limb girdle muscular dystrophy (LGMD, n=10) and in 10 controls with normal muscle biopsy results. In inflammatory myopathies CML, RAGE and NF-kappaB were detected in mononuclear cells and in regenerating muscle fibers. CML, NF-kappaB and, to a lesser extent, RAGE were also found in degenerating muscle fibers, but colocalization of CML, RAGE and NF-kappaB was only seen in infiltrating mononuclear cells and regenerating muscle fibers. Immunofluorescence double labeling demonstrated an expression of CML, RAGE and NF-kappaB in CD4-, CD8-, CD22- and CD68-positive mononuclear cells. Western blot analysis showed an increased immunoreactivity for CML-modified proteins in PM and DM. In LGMD, CML, RAGE and NF-kappaB were found in regenerating muscle fibers and less frequently in degenerating muscle fibers, and with lower staining intensities than in inflammatory myopathies. Our data suggests that the CML-RAGE-NF-kappaB pathway is an evident proinflammatory pathomechanism in mononuclear effector cells in PM and DM. RAGE-mediated NF-kappaB activation may be involved in muscle fiber regeneration in inflammatory myopathies and LGMD.

Short TE single-voxel 1H-MR spectroscopy of hippocampal structures in healthy adults at 1.5 Tesla--how reproducible are the results?

The purpose of our study was to evaluate inter- and intra-subject variability and scan-rescan reproducibility of single-voxel 1H-MR spectroscopy (1H-MRS) in hippocampal structures at 1.5 T field strength. Thirty healthy adults were studied bilaterally by optimized, standardized short echo time single-voxel 1H-MRS (PRESS, TE=30 ms, TR=3000 ms, oblique voxel orientation, voxel size 2 cm3). Spectral analysis and absolute metabolite quantitation of N-acetylaspartate+N-acetylaspartyl-glutamate (tNAA), choline (Cho), creatine (Cr), total glutamate plus glutamine (Glu+Gln) and myo-inositol (Ins) were carried out by LCModel. Inter- and intra-individual reproducibility of these metabolite values were investigated by calculation of mean, standard deviation, coefficient of variation (CV), and by analysis of variance for repeated measurements. The smallest CV in intersubject variability was obtained for tNAA, followed by Cr, Cho, Ins and Glu+Gln. The results of the analysis of variance for repeated measures in inter-subject variability showed a marginal effect of scan repetition for Cr (p=0.063) and Glu+Gln (p=0.082); the rescan of both metabolites showed slightly higher concentrations. No statistical significant effect of scan repetition was seen for tNAA (p=0.913), Cho (p=0.857), and Ins (p=0.826). Rescan led to the same results and gave proof of good reproducibility. Scan-rescan testing in one subject showed comparable results: tNAA (CV=4.8%), followed by Cr, Ins, Glu+Gln and Cho (all CV above 10%).

[Morbidity of dilatation and evacuation in the second trimester: an analysis]

OBJECTIVE

To compare the rates of complications of dilatation and evacuation (D&E) in the second trimester of pregnancy.

STUDY DESIGN

Retrospective analysis of early complications after D&E in the second trimester (group A: 1988-1994) in comparison with D&E in the first trimester (group B: 1997) and with the induction of abortion by extra-amniotic application of prostaglandins in the second trimester of pregnancy (literature).

RESULTS

The overall complication rate of D&E was statistically significantly higher in the second than in the first trimester (p < 0.0001). The most frequent complication in both groups was a blood loss > 500 ml (p < 0.009). As with blood loss, there was a statistically significant increase in the incidence of postoperative bleeding (p < 0.001) and fever > 38 degrees C (p = 0.042) with rising gestational age, too. We registered similar rates for incomplete abortion, infection, cervical injury, uterine perforation and thrombosis.

CONCLUSION

Second-trimester pregnancy termination with D&E is associated with higher morbidity rates than in the first trimester. Overall, the rates of complications of D&E in our study were acceptable and comparable with the results of previous studies. Compared with the induction of abortion by extra-amniotic prostaglandins, D&E shows lower morbidity rates. In particular, the advantages of D&E are in the early second trimester.

A new approach in anti-epileptic drug evaluation

Presurgical trials with video-electroencephalogram (EEG) monitoring for a couple of days provide the possibility to objectively and quantitatively analyze seizure activity during different drug treatments. Patients are provided with the optimal medical care and safety precautions when hospitalized. Hereby a method used in the antiepileptic drug (AED) trials called therapeutic intensive seizure analysis (TISA) has been recently introduced, by which AED efficacy on seizure activity can be objectively quantified by using continuous video-EEG monitoring. This could be used not only as a supplement to the traditional evaluation of AEDs' efficacy by treatment failure designs in large groups, but also can provide early individual information on the changes of seizure activity of each patient during the therapy. Data from TISA studies suggest that secondarily generalized tonic-clonic seizures (SGTCs) mostly occur in patients with a SGTC history after withdrawal of AED. The first 3 days of titration of a newly introduced AED was important for efficacy assessment; with a low risk of SGTCs. By using the TISA method an early recognition of first effects of a new AED on seizure activity and neuropsychological changes is possible, which can be correlated to serum concentration levels in a small sample size. The essentials of the proposed modification to the conventional presurgical trial are: (1) a complete withdrawal of AEDs should be avoided, if possible and (2) a titration phase limited to 3 days is suggested, using a condensed evaluation setting including the TISA method, serum concentration and neuropsychological monitoring. In addition long-term effects can be evaluated by repeated video-EEG monitoring.

Subclinical Late Cardiomyopathy After Doxorubicin Therapy for Lymphoma in Adults

Purpose

To assess the cardiac status of the long-term survivors and to estimate the incidence and the features of subclinical cardiotoxicity induced after conventional treatment with doxorubicin for non-Hodgkin's lymphoma or Hodgkin's lymphoma.

Patients and Methods

We analyzed a group of patients who previously received doxorubicin-based chemotherapy for lymphoma. Echocardiograms were performed at least 5 years after therapy with anthracyclines. Clinical cardiomyopathy was defined by the presence of clinical signs of congestive heart failure (CHF). Subclinical cardiomyopathy was defined by decrease of left ventricular fractional shortening (FS) without clinical signs of CHF. Cumulative dose of doxorubicin, male sex, older age, relapse, radiotherapy (mediastinal or total-body irradiation), autologous stem-cell transplantation, high-dose cyclophosphamide, and cardiovascular risk factors (hypertension, diabetes, hypercholesterolemia, familial history of cardiac disease, being overweight, and smoking history) were evaluated as potential risk factors for the development of cardiac dysfunction.

Results

Of 141 assessable patients (median age, 54 years; median cumulative dose of doxorubicin, 300 mg/m2), only one developed CHF. Criteria of subclinical cardiomyopathy were found in 39 patients. In multivariate analysis, factors that contributed to decreased FS were male sex (P < .01), older age (P < .01), higher cumulative dose of doxorubicin or association with another anthracycline (P = .04), radiotherapy (P = .04), and being overweight (P = .04).

Conclusion

Cardiac abnormalities can occur in patients treated with doxorubicin for lymphoma in the absence of CHF, even in patients who received moderate anthracycline doses. Male sex, older age, higher dose of doxorubicin, radiotherapy, and being overweight were risk factors for the development of cardiomyopathy.

1H-MR spectroscopy: a promising method in distinguishing subgroups in temporal lobe epilepsy?

Proton MR spectroscopy offers an additional noninvasive method of supporting focus lateralization in patients with intractable temporal lobe epilepsy. In this study involving 57 patients, the ability of multivoxel 1H-MRS to differentiate between mesial and lateral TLE was investigated in addition to its ability to lateralize the epileptogenic focus. Temporal lobe epilepsy (TLE) was classified into mesiobasal or lateral temporal lobe epilepsy according to the results of preoperative diagnostics including neurological and neuropsychological examinations, video-EEG monitoring and high resolution MRI. 1H-MR-spectroscopy (1H-MRS) showed that pathological changes in the mesial temporal lobes indicate a predominance in different parts of the ipsilateral temporal lobe (hippocampal and parahippocampal areas) correlating to the clinically defined groups. In addition, mesiobasal TLE tends to have higher concomitant contralateral abnormalities. Our results reveal that 1H-MRS is able to distinguish between mesiobasal and lateral pathologies in patients with TLE and represents a useful tool for noninvasive TLE classification.

Fractionated stereotactically guided radiotherapy of pharmacoresistant temporal lobe epilepsy

PURPOSE

This prospective study evaluated the efficacy of fractionated stereotactically guided radiotherapy (SRT) as a treatment of pharmacoresistant temporal lobe epilepsy.

PATIENTS AND METHODS

Inclusion criteria were patients aged between 17 and 65 years with unilateral temporal focus, without sufficient epilepsy control by antiepileptic drugs or neurosurgery. Two groups of 6 patients each were treated with 21 Gy (7 times 3 Gy) and 30 Gy (15 times 2 Gy). Study end points were change in seizure frequency, intensity, seizure length and neuropsychological parameters.

RESULTS

All patients experienced a marked reduction in seizure frequency. The mean reduction of seizures was 37% (range 9-77%, i.e. seizures reduced from a monthly mean number of 11.75 to 7.52) at 18 months following radiation treatment and 46% (23-94%, i.e. 0.2-23 seizures per month) during the whole follow-up time. Seizure length was reduced in 5 out of 11 patients and intensity of seizures in 7 out of 11 patients.

CONCLUSION

Radiotherapy was identified as a safe and effective treatment for pharmacoresistant epilepsy since a good reduction of seizure frequency during longer follow-up was observed. SRT means an appropriate alternative for patients with contraindication against neurosurgery or insufficient seizure reduction after neurosurgery.

Progressive cognitive decline in epilepsy: an indication of ongoing plasticity

In addition to the identification of epileptic syndromes associated with cognitive decline, the influence of suppression of secondarily generalized seizures on IQ is reviewed. Our own data concerning cognitive function in temporal lobe epilepsy show a decrease of IQ and verbal memory with long duration of epilepsy and frequent tonic-clonic seizures, but not with simple or complex partial seizures. The use of a 'nucleus shell structure model' may be helpful to visualize the dynamic changes ('running up') in seizure structures in the long-term course of epilepsies. In addition to the localization and extent of structural changes, functional monitoring of cognition and pathology of MR spectroscopy is now available for long-term studies in progressive epileptic disorders. Concepts for memory storage and consolidation and mechanisms of plasticity concerning epileptic activity as well as modification of long-term potentiation for plasticity with regard to memory functions are also discussed.

Sex differences and lateral asymmetry in heart rate modulation in patients with temporal lobe epilepsy

This study was designed to study the influence of gender and lateral hemispheric asymmetry on heart rate modulation during temporal lobe seizures. Heart rate was recorded during complex partial seizures in 10 female and 11 male patients (12 with a right temporal lobe focus, nine with a left focus), with simultaneous video monitoring and bilateral subdural electrode placement. Heart rate changes were analysed during the seizure, at a time when the epileptic activity was restricted to one hemisphere. In this analysed interval, the heart rate of patients with a right temporal lobe focus showed a significant increase, from 73.5 to 91.0 beats/min (F = 10.7, df = 2.3/27, p < 0.001), while the heart rate of patients with a left sided focus only increased slightly, from 77.0 to 82.5 beats/min (NS). An effect of sex was demonstrated, in that the influence of focus laterality could only be shown in male patients (F = 14.24, df = 2.58/27, p < 0.001). These results confirm the right hemispheric lateralisation of sympathetic cardiac control in male patients.

Autonomic auras: left hemispheric predominance of epileptic generators of cold shivers and goose bumps?

PURPOSE

Autonomic seizures in temporal lobe epilepsies associated with "cold shivers and goose bumps" as a principal ictal sign or aura have only rarely been studied.

METHODS

Sixteen patients with autonomic auras [cold shivers or cold sweats (n=11), goose bumps (n=4), one patient showed both ictal signs] were analyzed.

RESULTS

Lesions were detected in 12 patients. The etiology was heterogeneous [cryptogenic, arteriovenous (AV)-malformation cyst, trauma, hippocampal sclerosis]. Eight patients underwent epilepsy surgery. The localization and lateralization of the focal epileptic activity in the temporal lobes was determined either by magnetic resonance imaging lesions, EEG, ictal signs, or single-photon emission computed tomography imaging.

CONCLUSIONS

The patients with temporal lobe epilepsies associated with "cold shivers and/or goose bumps" showed a left hemispheric predominance of the focal abnormality in the temporal lobe.

Therapeutic intensive seizure analysis (TISA) in presurgical evaluation of Losigamone

OBJECTIVE

The new method TISA was used to evaluate Losigamone efficacy.

METHODS

Sixteen patients with pharmacoresistant partial seizures undergoing presurgical evaluation were randomized in this double-blind, placebo-controlled, parallel-group Losigamone monotherapy study under continuous video-EEG monitoring. Duration (in s, of each seizure and each ictal sign), intensity (grade zero to three), N/24h (number of seizures and ictal signs per 24 h), D/24h (seconds per 24 h covered by seizures and ictal signs) and seizure free intervals were recorded.

RESULTS

A total of 246 seizures were intensively analyzed. The duration and intensity of all seizures improved more in the active treatment group than in the placebo group. There was a statistically significant superiority in the duration of the seizure free interval in the Losigamone group. Ictal signs such as oro-alimentary automatisms and fumbling were improved during Losigamone treatment.

CONCLUSION

Losigamone has a preferred inhibitory effect on propagated epileptic activity. TISA is a sensitive method for evaluation of the selective effects of AEDs.

Topiramate on ictal seizure semiology: a quantitative, randomized, low and medium dose-controlled study

OBJECTIVE

Intensive and quantitative evaluation of the severity and frequency of seizures and ictal signs during topiramate (TPM) treatment.

METHODS

Twenty patients with refractory partial seizures undergoing presurgical evaluation were randomized into a low dosage (100 mg daily) and a parallel medium dosage (200 mg daily) group of TPM add-on medication. Study phases included a 3-day baseline video-EEG phase, a 10-day TPM titration phase without video-EEG and a 3-day TPM dose maintenance phase with video-EEG. During the baseline and the dose maintenance phase seizures were recorded using video-EEG monitoring and the following parameters were measured: duration (lasting seconds of each seizure and ictal sign), intensity (on a 0-3 scale), N/24 h (numbers of attacks per 24 h), D/24 h (duration per 24 h) of both seizures and defined ictal signs.

RESULTS

A total of 399 seizures during the baseline phase and the dose maintenance phase were intensively analyzed. Intergroup comparison suggested that duration, N/24 h and D/24 h of all seizures decreased more in the medium dosage group computing the reduction from baseline to the dose maintenance phase (P<0.05). There were statistically more significant reductions in the duration, intensity and N/24 h of ictal signs like hypermotoric movements, fumbling and vocalization in the medium dosage group (P<0.05).

CONCLUSION

Topiramate has an early dose-dependent effect on ictal seizures.

SHORT COMMUNICATION

The present study intensively analyzed the duration, intensity, N/24 h and D/24 h of ictal seizure manifestations. The quantitative data suggested that topiramate had an early effect on ictal phenomena like ictal hypermotoric movements, fumbling and vocalization (P<0.05); effects were more prominent in the medium dosage group (200 mg daily) than the low dosage group (100 mg daily).

Patients with rheumatoid arthritis adapt differently to repetitive painful stimuli compared to healthy controls

The aim of the study was to investigate whether there are changes of the nociceptive system in patients with chronic inflammatory joint pain. A pain model was used which is based on the recording of cortical chemo-somatosensory event-related potentials (CSSERP) after nociceptive stimulation of the nasal mucosa with gaseous carbon dioxide (CO(2)). Twenty-five patients with rheumatoid arthritis (RA) were compared to healthy controls matched for age and gender. Responses to both different intensities of painful stimuli and constant intensities of series of 4 stimuli were analysed. When testing increasing CO(2) concentrations ratings and CSSERP amplitudes increased for both patients and controls. However, when repetitive stimulation was performed with an interval of 2s CSSERP amplitudes N1 were significantly greater in RA patients. It is hypothesized that chronic inflammatory joint pain changes nociceptive processing in terms of generalized changes of the nociceptive system which may amplify chronic pain.

Ictal fear in temporal lobe epilepsy: surgical outcome and focal hippocampal changes revealed by proton magnetic resonance spectroscopy imaging

BACKGROUND

Ictal fear (IF) is most frequently associated with epileptic discharges from mesial temporal areas.

OBJECTIVES

To determine whether patients with IF were more likely to become seizure free after anteromesial temporal lobe resection compared with those without IF and whether they show more anteriorly pronounced metabolic changes assessed by means of multivoxel magnetic resonance spectroscopy (MRS) along the hippocampal axis.

METHODS

Surgical outcome was assessed in 33 consecutive patients with temporal lobe epilepsy after a mean follow-up of 25 months (range, 12-38 months). Proton multivoxel MRS of the hippocampal formation was applied to detect regional differences along the axis of the hippocampus in patients with and without IF. Magnetic resonance tomography showed typical features of hippocampal sclerosis in all patients.

RESULTS

Twelve (36%) of the 33 patients reported fear at the beginning of their habitual seizures. Eleven of these patients were seizure free postoperatively. In contrast, only 11 of 21 patients without IF had a favorable outcome. Results of MRS revealed significantly higher pathologic N-acetylaspartate-choline ratios in the anterior portion of the hippocampal formation in patients with than in those without IF, indicating focal metabolic and/or morphologic changes in the head of the hippocampus.

CONCLUSIONS

These results indicate the importance of diagnosing auras with IF to provide a more detailed prognosis of the surgical outcome. In addition, our data emphasize that multivoxel MRS is a valuable tool in the presurgical evaluation, as it may reveal different topographical patterns of hippocampal sclerosis.

Qualitative and quantitative olfactometric evaluation of different concentrations of ethanol peppermint oil solutions

Selection of an adequate placebo is a major problem in clinical trials of Euminz(R) (10% peppermint oil/ethanol) which is used topically for the treatment of tension-type headache. This randomized, controlled, double-blind, cross-over study was performed to investigate whether there are qualitative differences between 10%, 1%, 0.5%, 0.1%, and 0% peppermint oil. Forty-one healthy subjects participated (age range 21-28 years); they rated both intensity, and hedonic tone of the stimuli. Verbal descriptions were combined to multiple response sets (MRS). In addition, the trigeminal impact of odorants was determined. Intensity ratings and MRS "menthol like" and "alcohol/solvent" changed with stimulus concentration. However, intensity had no significant effect on hedonics, trigeminal impact, or the number of descriptive items used. When MRS "menthol like" and "alcohol/solvent" were analysed after being weighted with intensity ratings, changes in relation to stimulus concentration were lost. Thus, the differences between the five concentrations of peppermint oil were--to their largest part--due to changes in stimulus intensity. Considering the large day-to-day variability of olfactory sensitivity the present data support the hypothesis that the odour quality of 10% peppermint oil cannot be discriminated from the odour of 0.1%, 0.5%, or 1% peppermint oil when tested on separate days.

[Diagnostic imaging in refractory temporal lobe epilepsy. A comparison of MR volumetry and multivoxel-MR-spectroscopy for assessment of postoperative prognosis]

While the importance of magnetic resonance (MR) spectroscopy, volumetry, and T2-relaxometry for preoperative localization has already been verified, the question arises as to what extent the individual techniques are useful for assessing postoperative prognosis with respect to seizures and neuropsychological outcome. In a prospective comparative study, 26 patients were examined preoperatively with a 1.5 T whole-body scanner. The MR spectroscopy was taken by high resolution 1 H proton spectroscopy, the volumetry with MP rage technique. The postoperative outcome was laid down using Engel's classification. Our results show that the metabolic changes can be divided into three groups using MR spectroscopy: unilateral, slightly bilateral, and severely bilateral to contralateral. In case of bilateral changes, the severity of metabolic changes in the nonoperated, contralateral side was decisive for postoperative outcome. The results from volumetry did not correlate with postoperative outcome.

Magnetic resonance spectroscopy and histopathological findings in temporal lobe epilepsy

PURPOSE

In some patients with temporal lobe epilepsy, histopathological evaluation of resected brain tissue after surgical treatment may reveal several features indicative of discrete cortical malformations. We sought to determine whether these histopathological features were accompanied by hippocampal changes detectable preoperatively by proton magnetic resonance (MR) spectroscopy and to evaluate their relationship with postoperative outcome.

METHODS

In 25 consecutive temporal lobe epilepsy patients who were scheduled for surgical treatment, MR spectroscopy was performed, and resected brain tissue was analyzed histopathologically for the presence of discrete cortical malformations (e.g., microdysgenesis). Outcome was assessed in all patients with an average postoperative period of 26 months.

RESULTS

In 13 patients, we found subtle, histopathologically detectable signs of cortical malformation: 6 of them with concomitant hippocampal sclerosis (dual pathology) and 7 without. The latter subgroup had a worse surgical outcome and showed enhanced bilateral and/or contralateral pathological changes in the hippocampal formation when investigated by MR spectroscopy.

CONCLUSIONS

These data suggest that by showing contralaterally or bilaterally abnormal spectra, MR spectroscopy might be able to indicate pathological changes in subtle developmental disorders that are possibly more widespread over the brain. This observation may improve noninvasive diagnosis in presurgical evaluation and the neurobiological understanding of cortical malformations in pharmacoresistant temporal lobe epilepsy.

The significance of bilateral CSI changes for the postoperative outcome in temporal lobe epilepsy

PURPOSE

In a prospective study, we evaluated the significance of preoperative bilateral chemical shift spectroscopy imaging (CSI) changes for the prognosis of postoperative seizure outcome in the surgical treatment of patients with temporal lobe epilepsy (TLE).

METHOD

CSI using multivoxel spectroscopy was performed. Twenty-six consecutive TLE patients scheduled for epilepsy surgery were included. To evaluate the value of the CSI with respect to postoperative seizure outcome, discriminant analysis with ipsilateral and contralateral CSI was performed.

RESULTS

The discriminant analysis showed that the contralateral metabolic changes alone are able to predict seizure outcome whereby 92.3% of cases were correctly classified. Upon comparison of the two groups of seizure-free and non-seizure-free patients with respect to contralateral metabolic changes, the difference proved to be highly significant (paired t test: t = -6.3, df = 24, p < 0.001).

CONCLUSION

Bilateral metabolic CSI changes have a predictive value for the postoperative outcome in patients with TLE. In patients with severe bilateral metabolic changes, poor seizure outcome is a likely result.

Multicenter investigation of 1,036 subjects using a standardized method for the assessment of olfactory function combining tests of odor identification, odor discrimination, and olfactory thresholds

"Sniffin' Sticks" is a test of nasal chemosensory performance that is based on penlike odor-dispensing devices. It is comprised of three tests of olfactory function: tests for odor threshold, discrimination and identification. Previous work has already established its test-retest reliability and validity in comparison to established measures of olfactory sensitivity. The results of this test are presented as a composite TDI score--i.e., the sum of results obtained for threshold, discrimination and identification measures. The present multicenter investigation aimed at providing normative values in relation to different age groups. To this end, 966 patients were investigated in 11 centers. An additional study tried to establish values for the identification of anosmic patients, with 70 anosmics investigated in five specialized centers where the presence of anosmia was confirmed by means of olfactory evoked potentials. For healthy subjects, the TDI score at the 10th percentile was 24.5 in subjects younger than 15 years, 30.3 for ages from 16 to 35 years, 28.8 for ages from 36 to 55 years and 27.5 for subjects older than 55 years. While these data can be used to estimate individual olfactory abilities in relation to a subject's age, hyposmia was defined as the 10th percentile score of 16- to 35-year-old subjects. Our latter study revealed that none of 70 anosmics reached a TDI score higher than 15. This score of 15 is regarded as the cut-off value for functional anosmia. These results provide the basis for the routine clinical evaluation of patients with olfactory disorders using "Sniffin' Sticks."

Maculo-papillary branch retinal artery occlusions following the Wada test

BACKGROUND

The Wada test induces short-term anesthesia of one hemisphere by injection of sodium amytal into an internal carotid artery. It is an important presurgical diagnostic tool in epileptic patients.

PATIENT

A 22-year-old man with idiopathic epilepsy noticed a shadow in the central visual field of his right eye immediately following a Wada test of the right hemisphere.

RESULTS

The patient presented with an occlusion of two small branch retinal arteries and corresponding defects in his visual field. Fluorescence angiography revealed small dense hyperfluorescent spots within the occluded retinal vessels.

CONCLUSION

Branch retinal artery occlusions are a possible complication of the Wada test, possibly induced by undissolved contrast medium or sodium amytal.

[Temporal lobe epilepsy: effect of focus side on the autonomic regulation of heart rate?]

Epileptic activity can modulate reactions of the autonomic nervous system. Although there is some evidence of a differential left/right hemispheric influence on the cardiovascular system, diverse investigations have shown controversial results. In our study, complex partial seizures of patients with temporal lobe epilepsy were recorded using subdural electrodes, thus providing reliable information on the focus side. We analyzed the preictal and ictal heart rates of 27 patients, 16 revealing right and 11 revealing left temporal foci. During the seizures, both groups showed a significant increase in heart rate. Preictal tachycardia was only significant in the right focus group, whereas no significant change in heart rates could be detected in the left focus group. Our results confirm a right hemispheric lateralization of sympathetic cardiac control.