A single-center observational study on long-term neurodevelopmental outcomes in children with tuberous sclerosis complex

BACKGROUND

Tuberous sclerosis complex (TSC) is a rare multisystem disorder caused by mutations in the TSC1 or TSC2 gene. More than 90% of patients with TSC develop neurological and/or neuropsychiatric manifestations. The aim of the present study was to determine the developmental and cognitive long-term outcomes of pediatric TSC patients.

METHODS

This cross-sectional, monocenter study included pediatric TSC patients who received multidisciplinary long-term care with a last visit between 2005 and 2019. Neurological manifestations and cognitive development (BSID, K-ABC) were analyzed in relation to age and type of mutation.

RESULTS

Thirty-five patients aged 13.5 ± 7.8 years were included in the study. Diagnosis was confirmed genetically in 65.7% of patients (TSC1, 26.1%; TSC2, 65.2%; NMI, 8.7%). Mean age at diagnosis was 1.3 ± 3.5 years; 74.3% of the patients had been diagnosed within the first year of life due to seizures (62.9%) or/and cardiac rhabdomyomas (28.6%). The most common TSC manifestations included structural brain lesions (cortical tubers, 91.4%; subependymal nodules, 82.9%), epilepsy (85.7%), and cardiac rhabdomyomas (62.9%). Mean age at seizure onset was 1.5 ± 2.3 years, with onset in 80.0% of patients within the first two years of life. Infantile spasms, which were the first seizure type in 23.3% of the patients, developed earlier (0.6 ± 0.4 years) than focal seizures (1.8 ± 2.5 years). Refractory epilepsy was present in 21 (70.0%) patients, mild or severe intellectual impairment in 66.6%, and autism spectrum disorders in 11.4%. Severe cognitive impairment (33.3%) was significantly associated with epilepsy type and age at seizure onset (p < 0.05).

CONCLUSIONS

The results emphasized the phenotypic variability of pediatric-onset TSC and the high rate of neurological and neuropsychiatric morbidity. Early-onset refractory epilepsy was associated with impaired cognitive development. Children of all ages with TSC require multidisciplinary long-term care and individual early-intervention programs.

Alterations of intracerebral connectivity in epilepsy patients with secondary bilateral synchrony

INTRODUCTION

The aim of our study was to evaluate intracerebral network changes in epilepsy patients demonstrating secondary bilateral synchrony (SBS) in EEG by applying a new Diffusion Tensor Imaging (DTI) method using an energy-based global tracking algorithm.

MATERIALS AND METHODS

10 MRI negative epilepsy patients demonstrating SBS in 10-20 surface EEG were included. EEG findings were analyzed for irritative zones characterized by focal interictal epileptiform discharges (IEDs) triggering SBS. In addition, DTI including an energy-based global tracking algorithm was applied to analyze fiber tract alterations in irritative zones. To measure the deviation of a certain cortical connection in comparison to healthy controls, normalized differences of fiber tract streamline counts (SC) and their p-values were evaluated in comparison to corresponding fibers of the control group.

RESULTS

In 6 patients the irritative zone initiating SBS was located in the frontal lobe, in 3 patients in the temporal lobe and in 1 patient in the region surrounding the right central sulcus. All patients demonstrated significantly altered SC in brain lobes where the irritative zone triggering SBS was located (p ≤ 0.05). Seven out of 10 patients demonstrated SC alterations in tracts connecting brain lobes between the ipsilateral and the contralateral hemisphere (p ≤ 0.05).

CONCLUSION

Our data demonstrate that alterations in fiber tracts in irritative zones triggering SBS are not necessarily associated with intracerebral lesions visible in high resolution MRI. Our study gives evidence that diffusion tensor imaging is a promising non-invasive additive tool for intracerebral network analyses even in MRI-negative epilepsy patients.

Behavioural changes in patients with intellectual disability treated with brivaracetam

OBJECTIVE

The purpose of this study was to evaluate the tolerability and efficacy of brivaracetam (BRV) in residential patients at our epilepsy centre.

PATIENTS AND METHODS

We assessed retrospectively 33 patients (14 females; mean age 38.2 years, with range 17-63 years) with intellectual disability (ID) and drug-resistant epilepsy using an industry-independent, non-interventional study design based on standardized daily seizure records. Mean seizure frequency was compared between the 3-month baseline period and subsequent 3-month treatment period. Evaluation, including calculation of retention rate, was carried out for the intervals 3-6 and 9-12 months after brivaracetam initiation. Responders were defined as having a 50% reduction in seizure frequency. The Clinical Global Impression scale (CGI) was applied to allow assessment of qualitative changes in seizure severity, and the Aggressive Behaviour Scale (ABS) gave further insights into challenging behaviour.

RESULTS

The responder rate was 19%, and one non-responder attained an improvement in CGI score. The retention rate after 12 months was 37%. Brivaracetam treatment was stopped because of adverse events (n = 3), lack of efficacy (n = 8) or both (n = 6). Thirteen patients experienced behavioural changes, with aggressive behaviour being the commonest effect. We also observed ataxia (n = 2), gastrointestinal disorder (n = 3) and sedation (n = 2). The ABS showed deterioration, or new occurrence, of aggressive behaviour in 13 patients.

CONCLUSIONS

Brivaracetam seems to be effective in a small number of patients suffering from difficult-to-treat epilepsy and intellectual disability. Challenging behaviour was documented in a relevant number of patients, with psychiatric illness being a risk factor for this.

Behavioural changes in patients with intellectual disability treated with perampanel

OBJECTIVES

The aim of this cross-sectional retrospective study was to assess the tolerability and efficacy of perampanel in patients with drug-resistant epilepsy who also suffered from intellectual disability (ID).

PATIENTS AND METHODS

We used an industry-independent, non-interventional retrospective evaluation based on standardized, daily seizure records. Twenty-seven patients with ID and drug-resistant epilepsy were started on perampanel between September 2012 and November 2015 after a 3-month observation period without perampanel treatment. Perampanel was given at a maximum dosage of 4-12 mg daily. Evaluation was carried out after 6, 12 and 24 months, including calculation of the retention rate. Mean seizure frequency was compared between the 3-month baseline period and subsequent 3-month treatment periods. The Clinical Global Impression scale was applied to assess qualitative changes in seizure severity, and the Aggressive Behaviour Scale (ABS) gave further insights into challenging behaviour.

RESULTS

Perampanel was efficacious and well tolerated in five of 25 patients. In 18 patients, perampanel treatment was stopped, mainly because of adverse events (n=6), lack of efficacy (n=3) or both (n=9). Behavioural changes were documented in 15 of 27 patients, with aggressive behaviour being the commonest effect; we observed ataxia (n=6) and sedation (n=8) in further patients. The ABS showed worsening of aggressive behaviour in six patients.

CONCLUSIONS

Perampanel was well tolerated and efficacious in one-fifth of our patients. We observed challenging behaviour, ataxia and sedation in a relevant number of patients with ID under perampanel treatment. Further studies are warranted to explore the tolerability of perampanel in patients with ID.

Predicting return to work following treatment of chronic pain disorder

BACKGROUND

The care of injured workers with chronic pain remains an important public health issue given its increasing prevalence. The consequences often include loss of self-esteem and stress in family relationships.

AIMS

To report our interdisciplinary approach to the care of chronic pain disorder (CPD) and describe the predictors associated with a successful return to work (RTW).

METHODS

Relevant covariates, including demographic data, time from injury, and functional scores were recorded for clients injured at work in Ontario, Canada. Our primary outcome, RTW, was assessed at 3 months post-discharge. Descriptive statistics and logistic regression were used to identify those factors predicting a successful RTW.

RESULTS

Of the injured workers who participated in the interdisciplinary CPD treatment programme, 1002 clients met our inclusion criteria and were included in the study. Fifty-five per cent were male with a mean age of 46 years. Median time from injury to treatment was 720 days. At 3 months post-treatment, 136 (14%) of the participants were working. Multivariable logistic regression revealed that earlier time since injury (OR = 0.71, 95% CI 0.55-0.92) and presence of an RTW coordinator (RTWC) (OR = 3.42, 95% CI 2.08-5.63) were significant predictors of successful RTW. There was also a significant interaction between RTWC involvement and time since injury. The latter did not appear to influence the likelihood of RTW when an RTWC was present.

CONCLUSIONS

Workers compensation boards should refer injured workers with CPD to treatment programmes as early as possible to achieve a successful RTW. Additionally, RTWCs play an important role in improving work outcomes.

Acute Cerebrovascular Disease in the Young

Background and Purpose—

Strokes have especially devastating implications if they occur early in life; however, only limited information exists on the characteristics of acute cerebrovascular disease in young adults. Although risk factors and manifestation of atherosclerosis are commonly associated with stroke in the elderly, recent data suggests different causes for stroke in the young. We initiated the prospective, multinational European study Stroke in Young Fabry Patients (sifap) to characterize a cohort of young stroke patients.

Methods—

Overall, 5023 patients aged 18 to 55 years with the diagnosis of ischemic stroke (3396), hemorrhagic stroke (271), transient ischemic attack (1071) were enrolled in 15 European countries and 47 centers between April 2007 and January 2010 undergoing a detailed, standardized, clinical, laboratory, and radiological protocol.

Results—

Median age in the overall cohort was 46 years. Definite Fabry disease was diagnosed in 0.5% (95% confidence interval, 0.4%–0.8%; n=27) of all patients; and probable Fabry disease in additional 18 patients. Males dominated the study population (2962/59%) whereas females outnumbered men (65.3%) among the youngest patients (18–24 years). About 80.5% of the patients had a first stroke. Silent infarcts on magnetic resonance imaging were seen in 20% of patients with a first-ever stroke, and in 11.4% of patients with transient ischemic attack and no history of a previous cerebrovascular event. The most common causes of ischemic stroke were large artery atherosclerosis (18.6%) and dissection (9.9%).

Conclusions—

Definite Fabry disease occurs in 0.5% and probable Fabry disease in further 0.4% of young stroke patients. Silent infarcts, white matter intensities, and classical risk factors were highly prevalent, emphasizing the need for new early preventive strategies.

Clinical Trial Registration Information—

URL: http://www.clinicaltrials.gov .Unique identifier: NCT00414583

Vorschlag für eine neue patientenorientierte Epilepsieklassifikation

The recent proposal by the ILAE Task Force for Epilepsy Classification is a multiaxial, syndrome-oriented approach. Epilepsy syndromes--at least as defined by the ILAE Task Force--group patients according to multiple, usually poorly defined parameters. As a result, these syndromes frequently show significant overlap and may change with patient age. We propose a five-dimensional and patient-oriented approach to epilepsy classification. This approach shifts away from syndrome orientation, using independent criteria in each of the five dimensions similarly to the diagnostic process in general neurology. The main dimensions of this new classification consist of (1) localizing the epileptogenic zone, (2) semiology of the seizure, (3) etiology, (4) seizure frequency, and (5) related medical conditions. These dimensions characterize all information necessary for patient management, are independent parameters, and include information more pertinent than the ILAE axes with regard to patient management. All cases can be classified according to this five-dimensional system, even at initial encounter when no detailed test results are available. Information from clinical tests such as MRI and EEG are translated into the best possible working hypothesis at the time of classification, allowing increased precision of the classification as additional information becomes available.

Mechanical prophylaxis of deep-vein thrombosis after total hip replacement a randomised clinical trial

Routine prophylaxis for venous thromboembolic disease after total hip replacement (THR) is recommended. Pneumatic compression with foot pumps seems to provide an alternative to chemical agents. However, the overall number of patients investigated in randomised clinical trials has been too small to draw evidence-based conclusions. This randomised clinical trial was carried out to compare the effectiveness and safety of mechanical versus chemical prophylaxis of DVT in patients after THR. Inclusion criteria were osteoarthritis of the hip and age less than 80 years. Exclusion criteria included a history of thromboembolic disease, heart disease, and bleeding diatheses. There were 216 consecutive patients considered for inclusion in the trial who were randomised either for management with the A-V Impulse System foot pump. We excluded 16 patients who did not tolerate continuous use of the foot pump or with low-molecular-weight heparin (LMWH). Patients were monitored for DVT using serial duplex sonography at 3, 10 and 45 days after surgery. DVT was detected in three of 100 patients in the foot-pump group and with six of 100 patients in the LMWH group (p < 0.05). The mean post-operative drainage was 259 ml in the foot-pump group and 328 ml in the LMWH group (p < 0.05). Patients in the foot-pump group had less swelling of the thigh (10 mm compared with 15 mm; p < 0.05). One patient developed heparin-induced thrombocytopenia. This study confirms the effectiveness and safety of mechanical prophylaxis of DVT in THR. Some patients cannot tolerate the foot pump.

[Mechanical versus drug prevention of thrombosis after total hip endoprosthesis implantation. A randomized, controlled clinical study]

Pharmacological prophylaxis is routinely applied after total hip replacement. Although it effectively reduces deep-vein thrombosis, side effects (bleeding, haematoma, swelling, thrombocytopenia) are not infrequent. Since in Germany use of foot pumps as only means of prophylaxis is unpopular, we investigated their efficacy and safety in a randomized study. 106 patients used either low molecular weight heparin (Fraxiparin, Sanofi-Synthelabo, Germany) or the foot-pump (A-V Impulse System, Orthofix, Mühltal, Germany), and were monitored for deep-vein thrombosis using serial duplex sonography on postoperative days 4, 12 and 45. Clinical observations included daily measurements of thigh circumference, recording of postoperative drainage amounts, and monitoring of wound healing. None of the 50 patients treated with the foot-pump developed deep-vein thrombosis, while 4 of the 50 patients (8 per cent) on pharmacological prophylaxis did so. Six patients stopped using the foot-pump during the study. One patient developed heparin-induced thrombocytopenia. Patients on mechanical prophylaxis had smaller amounts of drainage (mean 247 ml vs. 272 ml, p = 0.485) and significantly less swelling of the thigh (10 mm compared with 15 mm, p or = < 0.001), The good results in terms of prevention of thromboembolic complications and soft tissue swelling favour the general use of foot pumps as mechanical prophylaxis.

[Hemodynamics of the lower extremity with pneumatic foot compression. Effect on leg position]

External pneumatic compression of the foot is being used more and more to increase the venous blood flow in the lower limbs and thus reduce the risk of postoperative deep venous thrombosis. We have investigated the efficacy of the foot pump pneumatic compression device (A-V Impulse, Novamedix, Andover, England) in 10 healthy subjects and in 10 patients undergoing total hip arthroplasty. The velocity of venous blood flow in the common femoral artery was measured in the horizontal, Trendelenburg (head-down, foot-up) and reverse Trendelenburg (head-up and foot-down) positions using a duplex ultrasound unit (Sonoline Elegra, Siemens, Erlangen, Germany) with a 5 MHz linear array probe. Application of the foot pump produced an increase in venous blood flow velocity in all healthy subjects and in all patients. In healthy subjects the mean increase in the horizontal position was 31.18% (SD = 15.86%), and in the Trendelenburg position 20.72 (SD = 15.69%) (right limb). In the reverse Trendelenburg position, the foot pump produced a mean increase of 94.08% (SD = 55.00%). The difference is statistically significant (p < 0.005). In patients with a total hip arthroplasty, the mean increase in the horizontal position was 28.67% (SD = 9.95%), and in the Trendelenburg position 20.34% (SD = 17.85%) (operated limb). In the reverse Trendelenburg, the foot pump produced a mean increase of 91.55% (SD = 42.38%). The difference is statistically significant (p < 0.005). There was no noteworthy difference in results between the controls and patients. Pneumatic compression devices designed to reduce venous stasis are effective in decreasing the rate of deep venous thrombosis after surgery on the lower limb. The results of the present study show that the efficiency of the foot pump in increasing venous return is improved by adopting the reverse Trendelenburg position. This may increase its thromboprophylactic effect.

The clinical relevance of embolic events detected by transesophageal echocardiography during cemented total hip arthroplasty: a randomized clinical trial

The first aim of this prospective clinical study was to characterize the relationship between embolic events observed during cemented total hip arthroplasty using transesophageal echocardiography (TEE), and changes in cardiopulmonary function. The second aim was to assess the efficiency of a modified cementing technique that was developed to reduce the risk of embolism. The modification consists in a vacuum drainage placed in the proximal femur to reduce the increase of intramedullary pressure during insertion of the prosthesis. One hundred twenty patients were randomized into two groups. Group 1 received a total hip arthroplasty cemented conventionally, whereas Group 2 was cemented with the modified technique. Continuous TEE, hemodynamic monitoring, and blood gas analysis were done during the perioperative period. Severe embolic events were imaged during the insertion of the femoral component and the reduction of the hip joint. Embolism occurred in 93.3% of patients operated on with the conventional cementing technique, compared with 13.3% of patients operated on with the modified technique (P < 0.05). Intraoperative shunt values during insertion of the femoral component increased from 8.2% to 10.3% (P < 0.05) in Group 1 patients, whereas there was no significant change in Group 2 patients. We observed no clinical signs of fat embolism syndrome in any study patient. The results of the study indicate that embolic events observed using TEE can cause increased pulmonary shunt values during hip arthroplasty, especially in patients with systemic disease (ASA physical status III). The modified surgical technique effectively reduced the incidence of embolization during cemented hip arthroplasty.

IMPLICATIONS

Use of conventional cementing techniques is associated with echocardiographic evidence of embolism in 93% of patients and with a significant increase in pulmonary shunting. The incidence of embolism and change in shunting are reduced with a modified cementing technique that limits increases in intramedullary pressure.

A new epileptic seizure classification based exclusively on ictal semiology

Historically, seizure semiology was the main feature in the differential diagnosis of epileptic syndromes. With the development of clinical EEG, the definition of electroclinical complexes became an essential tool to define epileptic syndromes, particularly focal epileptic syndromes. Modern advances in diagnostic technology, particularly in neuroimaging and molecular biology, now permit better definitions of epileptic syndromes. At the same time detailed studies showed that there does not necessarily exist a one-to-one relationship between epileptic seizures or electroclinical complexes and epileptic syndromes. These developments call for the reintroduction of an epileptic seizure classification based exclusively on clinical semiology, similar to the seizure classifications which were used by neurologists before the introduction of the modern diagnostic methods. This classification of epileptic seizures should always be complemented by an epileptic syndrome classification based on all the available clinical information (clinical history, neurological exam, ictal semiology, EEG, anatomical and functional neuroimaging, etc.). Such an approach is more consistent with mainstream clinical neurology and would avoid the current confusion between the classification of epileptic seizures (which in the International Seizure Classification is actually a classification of electroclinical complexes) and the classification of epileptic syndromes.

Staring spells in children: descriptive features distinguishing epileptic and nonepileptic events

OBJECTIVE

To identify questions sensitive and specific for staring spells of epileptic (absence seizures [AS]) or nonepileptic etiology to increase the yield of history taking.

STUDY DESIGN

A questionnaire was completed by parents of 40 children who presented with staring spells. Results from 17 children with AS and 23 with nonepileptic staring (NES) were compared.

RESULTS

Features with moderate sensitivity (43% to 56%) but high specificity (87% to 88%) for NES included preserved responsiveness to touch, lack of interruption of playing, and initial identification by a teacher or health professional. These features were more frequent in NES than in AS (P = .013, .016, .030). Body rocking occurred only in NES, but sensitivity was low (13%). Features with high specificity (91% to 100%) for AS included limb twitches, upward eye movements, and urinary incontinence; but sensitivities were low (13% to 35%).

CONCLUSION

In children with normal interictal electroencephalography findings and without neurologic disease, staring spells are most likely nonepileptic when parents report preserved responsiveness to touch, body rocking, or initial identification by a teacher or health professional without limb twitches, upward eye movements, interruption of play, or urinary incontinence. In these cases a diagnosis of NES may be confidently applied, with confirmation based on long-term follow-up.

Semiological seizure classification

We propose an epileptic seizure classification based exclusively on ictal semiology. In this semiological seizure classification (SSC), seizures are classified as follows: a. Auras are ictal manifestations having sensory, psychosensory, and experiential symptoms. b. Autonomic seizures are seizures in which the main ictal manifestations are objectively documented autonomic alterations. c. "Dialeptic" seizures have as their main ictal manifestations an alteration of consciousness that is independent of ictal EEG manifestations. The new term "dialeptic" seizure has been coined to differentiate this concept from absence seizures (dialeptic seizures with a generalized ictal EEG) and complex partial seizures (dialeptic seizures with a focal ictal EEG). d. Motor seizures are characterized mainly by motor symptoms and are subclassified as simple or complex. Simple motor seizures are characterized by simple, unnatural movements that can be elicited by electrical stimulation of the primary and supplementary motor area (myoclonic, tonic, clonic and tonic-clonic, versive). Complex motor seizures are characterized by complex motor movements that resemble natural movements but that occur in an inappropriate setting ("automatisms"). e. Special seizures include seizures characterized by "negative" features (atonic, astatic, hypomotor, akinetic, and aphasic seizures). The SSC identifies in detail the somatotopic distribution of the ictal semiology as well as the seizure evolution. The advantages of a pure SSC, as opposed to the current classification of the International League Against Epilepsy (ILAE), which is actually a classification of electroclinical syndromes, are discussed.

[Semiologic classification of epileptic seizures]

Recent advances in epileptology and epilepsy surgery require revision of the currently used International Classification of Epileptic Seizures, which was published 1981. We present a classification of epileptic seizures which is based purely on the clinical seizure semiology. The advantages of a semiological seizure classification are stressed.

Symptomatic and asymptomatic high-grade unilateral internal carotid artery stenosis: scalp topography of event-related potentials (P300) and psychometric testing

Unilateral internal carotid artery (ICA) stenosis may be accompanied by widespread atherosclerosis of extra- and intracranial vessels leading to subtle cognitive disorders. We applied multichannel recording of P300 in 28 patients (68.3 +/- 8.1 years; 15 asymptomatic, 13 with a history of transient ischemic attack (TIA)) and compared them with an age- and sex-matched control group. All underwent a visual "odd-ball paradigm" as well as a psychometric test, the Cognitive Performance Test (CPT), testing mainly visual attention and memory. The potentials were derived from 16 electrodes according to the 10/20 system against linked mastoids. The latencies and amplitudes of N250 and P300 were measured and their amplitudes additionally mapped. Furthermore, the early sensory exogenous potentials, P1 and N1, within the P300 potentials as well as conventional pattern reversal visual evoked potentials (PVEPs) were evaluated. (1) Both the early exogenous potentials and the conventional PVEPs showed no significant differences among all groups. (2) There were no significant differences between asymptomatic patients and those with a TIA history in all parameters of the P300 complex so that one total patient group was constructed and compared to the controls. (3) Patients' P300 amplitudes showed significant reductions over hemispheres ipsilateral (P < or = 0.014) and contralateral (P < or = 0.044) to the stenosis. (4) The N250 amplitudes were reduced only in the central leads (P < or = 0.05). (5) The latencies of N250 potentials were significantly prolonged at many electrodes, not only ipsi-(P < or = 0.0007) but also contralateral (P < or = 0.022) to the stenosis. (6) The patients' P300 latencies showed significant lengthening only at occipital sites (P < or = 0.05) compared to controls. (7) In all measured parameters, within the patient group, the differences between hemispheres ipsilateral versus contralateral to the ICA stenoses did not reach statistical significance. (8) The CPT values detected slight cognitive disorders for both patient groups and they correlated significantly with the latencies in many leads. (9) The highest test sensitivity to classify patients versus controls (z score > 2) was reached in P300 maps of TIA patients (77%). An altered P300 indicates electrophysiologically, and CPT behaviorally, subclinical cognitive deficits even in asymptomatic patients with unilateral tight ICA stenoses. Interestingly, no differences between asymptomatic and TIA patients with a high-grade unilateral ICA stenosis could be found.

Application of pattern reversal visual evoked potentials (PVEPS) in transient monocular blindness (resp. amaurosis fugax)

We investigated 11 patients (63.1 +/- 10.9 y) after recovery (median: 3 days) from amaurosis fugax of 12.1 +/- 12.0 min duration with the method of pattern reversal visual evoked potentials (PVEPs) derived from Oz to Fz (Cz ground) after randomized monocular stimulation.

SELECTION CRITERIA

clear-cut cases with no hemispheric symptomatology, normal vision and normal cranial CT. The parameters were measured without knowing the affected eye and compared with age matched controls (n = 32). N80 latencies of the affected eyes were significantly prolonged (3.2 +/- 1.9 ms; p < .025) in comparison with the not affected eyes. The controls did not show such interocular difference. P100 latency behaved similarly but less prominently so (2.0 +/- 2.3 ms; p < .05; controls: p > .05). N80/P100 amplitude was reduced in 82% after stimulation of the affected side without reaching statistical significance. The 5 patients showing angiographically ipsilateral very tight stenosis of carotid artery (> 95%) behaved more prominently so in all 3 parameters. The findings indicate a damage of nerval tissue responsible for visual perception or a hemodynamic insufficiency under stimulus condition in affected eyes outlasting the clinical symptomatology for a certain period of time.

Parenchymal "damage" in transient ischemic attacks (TIAs) and prolonged reversible ischemic neurologic deficits (PRINDs):--the role of cranial CT and EEG

Over a period of 6 years (1985-1990) we reviewed records of patients with one or more TIAs or PRINDs (196 TIAs, 63 PRINDs). 111 patients (42.9%) suffered from TIAs/PRINDs of the anterior circulation. In all cranial CT scanning (CCT) was performed, whereas only in 79 EEG was recorded after recovery from the symptoms. 25 patients (22.5%) out of the 111 showed low density areas of recent onset in CCT made responsible for the attack. Among the EEGs of the 79 patients 35 (44.3%) revealed corresponding electrical abnormalities. Out of the 79 patients investigated by both methods in 14 (17.7%) a lesion was demonstrated in CCT and focal abnormality in EEG. In 11 (13.9%) EEG was normal despite a lesion manifested in CCT. Vice versa 21 patients (26.6%) showed normal CCTs but focal abnormalities in EEG. By far most cases (43%) had normal CCTs and EEGs. These results may contribute to a redefinition of TIA and PRIND as clinically defined syndromes in prae-CT-area.

Pattern reversal visual evoked potentials (PVEPs) in transient ischemic attacks (TIAs) and prolonged reversible ischemic neurological deficits (PRINDs) of anterior circulation with normal EEGs and normal cranial CTs

Out of 75 patients with TIA or PRIND we selected 9 TIAs and 6 PRINDs with normal EEGs and CCTs, full recovery of neurological function, no history of amaurosis fugax and no findings of visual impairments. PVEPs were derived from 01-02 to Fz and Cz as ground following binocular pattern reversal visual stimuli of 1.9 Hz. Interhemispheric differences of the latencies of P60, N80, P100 and of the amplitudes N80/P100 and P100/N140 were compared with the corresponding parameters of 22 age matched controls. In contrary to the latency differences the interhemispheric difference of the amplitude N80/P100 was highly significantly larger (33.5 +/- 16.0%) in patients than in the control group (12.8 +/- 9.8%) (p < or = .0005). The amplitude P100/N140 behaved the same way (p < or = .025); the amplitude of the affected side being smaller. There were no statistical differences between TIAs and PRINDs and a tendency was seen for normalization of the differences with increasing time distances between the onset of the ischemic attack and the point of time of the recordings.