Polymorphism of glucocorticoid receptor gene (rs41423247) in functional seizures (psychogenic nonepileptic seizures/attacks)

OBJECTIVE

We investigated the association between the glucocorticoid receptor (GR) gene, also known as the nuclear receptor subfamily 3, group C, member 1 (NR3C1), rs41423247 polymorphism, and functional seizures (psychogenic nonepileptic seizures/attacks) in a case-control study. We hypothesized that the tested polymorphism has significant associations with functional seizures (psychogenic nonepileptic seizures/attacks) independent from comorbid depression.

METHODS

Seventy patients with functional seizures (psychogenic nonepileptic seizures/attacks), 70 with major depressive disorder (MDD), and 70 healthy controls (HCs) were studied. Their DNAs were analyzed for NR3C1 rs41423247 polymorphism.

RESULTS

Genotype and allele frequencies of rs41423247 were different between the three groups. G allele carriers were more frequent in patients with functional seizures (psychogenic nonepileptic seizures/attacks) and those with MDD compared to HCs (p = 0.0001). However no significant difference was observed with respect to allele distributions between functional seizures (psychogenic nonepileptic seizures/attacks) and MDD groups (p = 0.391). CC genotype was less often associated with functional seizures (psychogenic nonepileptic seizures/attacks) versus HC: Codominant model; p = 0.001, OR = 0.11, 95% CI = 0.05-0.24, and -2loglilkelihood = 231.7. In comparison between functional seizures (psychogenic nonepileptic seizures/attacks) group and other (MDD + HC) groups, we observed a significant association between CG genotype and functional seizures (psychogenic nonepileptic seizures/attacks) (Codominant model; p = 0.001, OR = 5.63, 95% CI = 2.60-12.40 and -2loglikelihood = 245.99).

SIGNIFICANCE

Patients with functional seizures (psychogenic nonepileptic seizures/attacks) and those with MDD were significantly more often G allele carriers in rs41423247 compared with HCs. We observed a significant association between CG genotype and functional seizures (psychogenic nonepileptic seizures/attacks). However, we could not exclude the possibility of confounding effects of depression. Future genetic studies of patients with functional seizures (psychogenic nonepileptic seizures/attacks) should include a comparison group with depression in addition to a comparison group of HCs.

Potential role of FKBP5 single-nucleotide polymorphisms in functional seizures

OBJECTIVE

We investigated the associations between FKBP5 single-nucleotide polymorphisms (SNPs) and functional seizures (FS).

METHODS

Seventy patients with FS, 140 with major depressive disorder (MDD), and 140 healthy controls were studied. Their DNAs were analyzed for the rs1360780 in the 3' region and rs9470080 in the 5' region of the FKBP5. Childhood trauma questionnaire and hospital anxiety and depression scale were used.

RESULTS

Patients with FS and those with MDD had less GG and more AA genotypes in both rs9470080 and rs1360780 SNPs compared with those in healthy controls. Similar results were observed for allelic frequencies. There were no significant differences between FS and MDD groups in terms of genotype and allelic frequencies for both SNPs. The results of multinomial logistic regression analysis showed that FKBP5 polymorphisms were not associated with the diagnosis.

SIGNIFICANCE

Patients with FS and those with MDD had significantly different genotypes in both rs9470080 and rs1360780 SNPs compared with those in healthy controls. However, it seems that FKBP5 polymorphisms were not associated with FS in the absence of depression. Further genetic investigations of patients with FS may increase our understanding of the neurobiological underpinnings of this condition, but such studies should be large enough and very well designed; they should include a comparison group with depression in addition to a healthy control group.

A case of multiple sclerosis with protracted course of COVID-19

BACKGROUND

We reported a case of multiple sclerosis (MS) with persistent symptomatic COVID-19 which was complicated by new-appearing severe pneumonia 40 days after disease onset.

CASE PRESENTATION

A 38-year-old man with history of multiple sclerosis referred to our hospital with fever, shaking chills, cough and dyspnea. In his history, the patient had developed mild COVID-19 from 40 days ago. After 7 days of disease onset, the COVID symptoms had been subsided partially but fatigue, myalgia, intermittent fever and loss of taste and smell had been continued. In physical examinations, his oral temperature was 39.4 °C. He had respiratory distress and his blood oxygen saturation on the room air was 90%. The spiral chest CT scan was performed which revealed bilateral ground glass and alveolar opacities in favor of COVID-19 pneumonia. The result of RT-PCR test for SARS-COV-2 was reported positive, subsequently. His current MS medication was rituximab and he had received the last dose of rituximab, two months before developing COVID-19. The patient was admitted to COVID ward and put on Remdesivir, subcutaneous interferon-beta1b and dexamethasone. He improved gradually and was discharged from the hospital with favorable condition after 10 days. This patient had a rare protracted disease course. We presumed that prolong high degree fever (above 38 °C) in our patient is beyond the diagnosis of post-COVID-19 syndrome and is more compatible with persistent infection.

CONCLUSION

Although, most immunocompromised patients effectively clear SARS-CoV-2 infection, but this case report highlights the risk of persistent infection associated with recurrence of disease.

Volumetric Assessment of Extratemporal Structures in Patients With Temporal Lobe Epilepsy

Background: We assessed the presence of brain volume loss in the extratemporal structures in patients with temporal lobe epilepsy (TLE). The associations between brain volume loss in these structures and epilepsy duration, magnetic resonance imaging (MRI) findings, and occurrence of focal to bilateral tonic-clonic seizures (TCS) were assessed. Methods: In this cross-sectional study, all adult patients with drug-resistant TLE, who were admitted to the epilepsy monitoring unit at Loghman-Hakim Hospital, Tehran, Iran, during 2016-2020, were included. For all the participants, brain MRI was performed and patients with TLE were divided into two subgroups of those with hippocampal sclerosis (TLE-HS) and patients with normal-appearing brain MRI findings (TLE-no). Independent sample t test was applied to compare quantitative variables in the study groups. Pearson correlation test examined the correlation between the clinical and volumetric features. Results: 203 participants (81 patients with TLE and 122 healthy controls) were studied. Compared with healthy controls, patients with TLE showed a decrease in their midbrain (P=0.02) and thalamus (P=0.01) volume. The degree of thalamic atrophy was more significant in TLE-HS (P=0.03). Moreover, the degree of midbrain volume loss was more significant (P=0.07) in patients who had TCS in the past two years (N=31) compared with those who did not (N=50). The volume of the thalamus (r: -0.252, P=0.02) and pallidum (r: -0.255, P=0.02) had inverse correlations with the epilepsy duration. Conclusion: Patients with TLE have lower midbrain and thalamus volume compared with the healthy controls, which may be attributed to the seizure-induced injury. Midbrain atrophy may theoretically increase the risk of sudden unexpected death in epilepsy (SUDEP) because of the enhanced autonomic dysfunction.

Factors predisposing patients with temporal lobe epilepsy to seizure cluster

Background: We aimed to identify the potential risk factors associated with seizure clusters in patients with temporal lobe epilepsy (TLE). Methods: This retrospective cross-sectional study was performed on all the consecutive patients with TLE, who were admitted to the Epilepsy Monitoring Unit (EMU), Loghman-Hakim Hospital, Tehran, Iran. Seizure cluster was defined as three or more habitual seizures occurring within 24 hours, in over 50% of ictal events, with inter-seizure interval of less than 8 hours. The patients' demographic data, epilepsy duration, seizure frequency, frequency of interictal epileptiform discharges (IEDs), and brain magnetic resonance imaging (MRI) findings were collected. Results: Among a total number of 124 patients with TLE, 62 (50.0%) patients reported seizure clusters. In addition, 44 (37.9%), 42 (36.2%), and 30 (25.9%) patients had normal-appearing brain MRI, mesial temporal sclerosis (MTS), and other brain pathologies, respectively. In terms of IEDs frequency, 35 (29.4%), 43 (36.1%), 17 (14.3%), and 24 (20.2%) patients had respectively frequent, occasional, rare, and no spikes in one-hour of interictal scalp electroencephalography (EEG) recording. In our study, seizure clusters were not associated with the epilepsy duration (P = 0.100), the amount of IEDs (P = 0.764), or MRI findings (P = 0.112). Conclusion: In patients with TLE, seizure clustering had no correlation with the epilepsy duration, the amount of IEDs, or brain MRI findings.

Complementary and alternative medicine in epilepsy: A global survey of physicians' opinions

PURPOSE

To investigate the opinions of physicians on the use of complementary and alternative medicine (CAM) in patients with epilepsy (PWE) worldwide.

METHODS

Online survey addressed to neurologists and psychiatrists from different countries.

RESULTS

Totally, 1112 physicians from 25 countries (different world region: Europe, North America, South America, Middle-East, Africa, Former Soviet Union Republics) participated; 804 (72.3%) believed that CAM might be helpful in PWE. The most commonly endorsed CAM included meditation (41%) and yoga (39%). Female sex, psychiatry specialization, and working in North and South America were associated with the belief that CAM is helpful in PWE. Two-hundred and forty five out of 1098 participants (22.3%) used/prescribed CAM to PWE; among them, 174 (71%) people perceived CAM to be less effective and 114 (46.5%) people found CAM to be safer than conventional antiseizure medications (ASMs). The most common reasons to prescribe CAM for PWE were: to satisfy the patient (49.9%), dissatisfaction with the efficacy (35.6%), and dissatisfaction with the adverse effects (31.2%) of conventional therapies.

CONCLUSION

Although the evidence supporting the use of CAM for the treatment of epilepsy is extremely sparse, most physicians worldwide believe that it could be integrated with the use of conventional ASMs, at least in some patients. High-quality controlled trials are warranted to provide robust evidence on the usefulness of CAM options in PWE.

Neurochemicals of limbic system and thalamofrontal cortical network: Are they different between patients with idiopathic generalized epilepsy and psychogenic nonepileptic seizure?

OBJECTIVE

Thalamofrontal cortical network and limbic system are proposed to be involved in psychogenic nonepileptic seizure (PNES) and idiopathic generalized epilepsy (IGE). This study aimed to investigate neurochemical changes in prefrontal cortex, thalamus, and limbic circuits in patients with PNES and IGE. We also analyzed the interaction between cognitive functions and neurochemical changes in both groups.

METHODS

Hydrogen proton magnetic resonance spectroscopy (1H-MRS) was used to measure N-acetyl aspartate (NAA), choline (Cho), creatine (Cr), glutamate-glutamine (Glx), and myo-inositol (MI). The voxels were placed on the bilateral dorsolateral prefrontal cortex (DLPFC), dorsomedial prefrontal cortex (DMPFC), anterior cingulate cortex (ACC), and thalamus. Attention and inhibitory control, as well as general intelligence status, were investigated using the Integrated Visual and Auditory Continuous Performance Test (IVA-CPT) and the Wechsler Adult Intelligence Scale (WAIS), respectively, in patients with PNES and IGE, as well as healthy volunteers.

RESULTS

The 1H-MRS showed a decreased ratio of NAA/Cr in the right and left thalamus, right DMPFC, and right ACC in patients with IGE and PNES. Furthermore, a decrease of the NAA/Cr ratio in the left DMPFC and an increase of NAA/Cr ratio in the right DLPFC were observed in patients with PNES compared with the controls. The patient groups had a decreased ratio of Cho/Cr in right ACC compared with the healthy subjects. Moreover, the NAA/Cr ratio in the left thalamus and left DMPFC was correlated with seizure frequency in patient groups. Reduced NAA/Cr ratio in the right ACC and left DLPFC were also correlated with poor IVA-CPT scores.

CONCLUSION

This study highlighted the dysfunction in prefrontal-thalamic-limbic circuits and impairment in neurocognition in patients with PNES and IGE.

The Significance of Interictal Spike Frequency in Temporal Lobe Epilepsy

Purpose. In this study, the frequency of interictal epileptiform discharges (IEDs) in patients with drug-resistant temporal lobe epilepsy (TLE) was measured to determine its correlation with epilepsy duration, seizure frequency, brain magnetic resonance imaging (MRI) findings, and recent occurrence of focal to bilateral tonic clonic seizures (FBTCS). Methods. Our study was performed on TLE patients, who admitted to epilepsy monitoring unit of Loghman-Hakim hospital, Tehran, from 2016 to 2018. The patients' IEDs frequency were measured from their scalp EEG recording during no-rapid eye movement (NREM) sleep. The IEDs frequency was classified into 3 groups of rare, occasional, and frequent. Results. A total of 142 patients, with the mean age of 33.95 ± 12.73 years, were included in the study. The patients' mean epilepsy duration was 17.27 ± 12.19 years and the mean seizure frequency was 10.56 ± 12.95 attacks per month. The mean IEDs frequency was 123.48 ± 513.01 per hour. Thirty-five (24.6%) patients had history of FBTCS in the past year. Our findings revealed no significant association between IEDs frequency with epilepsy duration (P = .22), the recent occurrence of FBTCS (P = .42), and the type of MRI abnormalities (P = .66). There was only a weak positive correlation between seizure frequency and interictal spike density (r = 0.2, P = .007). Conclusions. In patients with TLE, standard EEG recording may not be a reliable method to predict the probability of occurring future seizures.

Attention and inhibitory control deficits in patients with genetic generalized epilepsy and psychogenic nonepileptic seizure

This study aimed to evaluate the attention and inhibitory control functions in patients with genetic generalized epilepsy (GGE) and psychogenic nonepileptic seizure (PNES) and compare the results with the healthy control subjects. A total of 30 patients with GGE, 30 patients with PNES, and 32 healthy control subjects were included in the study. The severity of attention and inhibitory control deficit, general intelligence status, and psychopathology screening in all subjects were respectively investigated with the Integrated Visual and Auditory Continuous Performance Test (IVA-CPT), the Wechsler Adult Intelligence Scale (WAIS), and the Symptoms Checklist 90-revised (SCL-90-R). Patients with PNES had severe impairments in all performed tasks compared with the control group and the group with GGE (p < 0.01), whereas patients with GGE had significantly lower attention quotient versus healthy subjects (p < 0.01). The full-scale attention quotient (FSAQ) and full-scale response control quotient (FSRCQ) in patients with PNES were significantly lower in comparison with GGE (47.83 ± 32.68, 60.18 ± 35.35, p < 0.01), respectively. Multiple regression analysis did not demonstrate any significant effect of seizure frequency or epilepsy duration on attention and inhibitory control deficits, but patient's intelligence quotient (IQ) showed a significant effect on FSAQ and FSRCQ (β: 0.997, p < 0.001; β: 0.933, p < 0.001, respectively). Attention and inhibitory control are significantly impaired in patients with GGE and PNES. The cognitive deficits in patients with GGE and PNES have potentially important clinical implications in planning their neuropsychological rehabilitation.

Seizure in Alzheimer's Disease: An Underestimated Phenomenon

Alzheimer's disease (AD) is considered as a potential risk factor for the development of seizure due to neurodegeneration and imbalance between stimulatory and inhibitory circuits in the brain. Seizure could occur in any point during the course of AD, and its presentation varies from fluctuation in cognitive domains to more typical seizures. The clinical diagnosis of seizure in patients with dementia may be challenging due to difficulty in history taking and clinical assessment. No paraclinic methods other than electroencephalogram (EEG) could provide arguments for the diagnosis of AD-related seizures (neither imaging modalities nor cerebrospinal fluid biomarkers). Standard 30-minute EEG may not be sufficiently sensitive to detect epileptiform discharges. In the present study, we aim to review different aspects of seizure in AD, including seizure prevalence, risk factors, underlying mechanisms, electroencephalographic findings, clinical presentations, impact of seizures on AD, and treatment options.

The diagnostic value of serum UCHL-1 and S100-B levels in differentiate epileptic seizures from psychogenic attacks

OBJECTIVE

To assess the value of postictal serum Ubiquitin C-terminal hydrolase (UCHL-1), a neuronal biomarker, and S100-B, a glial biomarker, levels, in differentiate epileptic seizures (ES) form psychogenic attacks.

METHODS

In this analytical cross-sectional study, serum UCHL-1 and S100-B levels were measured within six hours of occurring seizure, in 43 patients with ES, 20 patients with psychogenic non-epileptic seizures (PNES) and 19 healthy individuals by electrochemiluminescence immunoassay.

RESULTS

Both serum UCHL-1 and S100-B levels were significantly higher in patients with ES than PNES (P < 0.05) and controls (P < 0.01). PNES patients had significantly higher serum S100-B levels compared to controls (P < 0.01). There was a significant correlation between the serum UCHL-1 and S100-B levels in patients with ES (r = 0.46, P = 0.002).

CONCLUSIONS

Our study showed that serum UCHL-1 level could be potentially used in differentiate ES from PNES (sensitivity 72%, specificity 59%). Serum S100-B level had lower value compared to UCHL-1 (AUC 0.68 for UCHL-1 v/s 0.59 for S100B). Post-seizure serum UCHL-1 and S100-B levels could be used in future studies to better understand the underlying mechanism of seizures and may offer as an adjunctive diagnostic test in differentiate ES from PNES.

Serum GFAP level: A novel adjunctive diagnostic test in differentiate epileptic seizures from psychogenic attacks

PURPOSE

There has been increasing interest in the use of different biomarkers to help distinguish psychogenic from epileptic seizures, in patients presenting acutely with seizure-like events. In the present study, we measured serum glial fibrillary astrocytic protein (GFAP) levels in patients presenting with such events who were subsequently diagnosed as epileptic seizures (ESs) or psychogenic non-epileptic seizures (PNESs) and compared GFAP levels obtained with those found in healthy subjects.

METHODS

Sixty-three patients with seizures (43 with ES and 20 with PNES), and 19 healthy subjects participated in the study. Venous blood samples were obtained within the first 6 h after seizures and serum GFAP levels were measured by protein quantification (ELIZA kit) with an electrochemical luminescence immunoassay.

RESULTS

Serum GFAP levels were significantly higher in patients with ES compared to PNES or healthy controls. A cut-off point of 2.71 ng/ml was found optimally to differentiate ES from PNES (sensitivity 72%, specificity 59%).

CONCLUSION

Our study suggests that post-seizure serum GFAP levels could be used in future studies better to understand the underlying mechanism of seizures and may offer as an adjunctive diagnostic test in differentiating ES from PNES.

Interictal electrocardiographic alternations in patients with drug-resistant epilepsy

PURPOSE

Previous studies suggested the possible role of autonomic dysfunction in sudden unexpected death in epilepsy (SUDEP). The aim of this study is to assess the interictal ECG alternations especially heart rate variability (HRV), as a marker of autonomic dysfunction, in patients with drug-resistant epilepsy and determine the effect of epilepsy type and duration, seizure frequency and anti-epileptic drugs (AEDs) on ECG findings.

METHODS

In this comparative cross-sectional study, the interictal ECG parameters of 64 consecutive patients with drug-resistant epilepsy and the same number of age and sex-matched controls were analyzed. Epilepsy type and duration, seizure frequency, MRI findings and patients' anti-convulsive medications were determined.

RESULTS

Our study showed significant longer mean PR interval, shorter mean QRS duration, shorter mean QTc interval and longer corrected QT interval dispersion (QTcd) in patients with epilepsy compared to healthy subjects. The analysis of RR intervals revealed reduced RR standard deviation (SDNN), which is a marker of reduced HRV. A positive linear correlation was found between QRS duration and epilepsy duration. No significant correlation was found between taking a certain kind of AED, and ECG alternations, except for mild QTcd prolongation in patients taking valproate.

CONCLUSION

Our study showed clinically important alternations in interictal ECG parameters in patients with drug-resistant epilepsy which could result in sudden cardiac death.

The efficacy comparison of citalopram, fluoxetine, and placebo on motor recovery after ischemic stroke: a double-blind placebo-controlled randomized controlled trial

Objective:

The present study aimed to assess the effectiveness of oral citalopram, compared with fluoxetine and a placebo, in patients with post-stroke motor disabilities.

Design:

A randomized double-blind placebo-controlled clinical trial was conducted between January 2015 and January 2016.

Setting:

The neurology department of a university-affiliated urban hospital in Tehran, Iran.

Subjects:

Ninety adult patients with acute ischemic stroke, hemiplegia, or hemiparesis and a Fugl-Meyer Motor Scale score of below 55 were included.

Interventions:

Participants were randomly allocated to one of three groups: Group A received 20 mg PO of fluoxetine daily, Group B received 20 mg PO of citalopram daily, and Group C received a placebo PO The duration of the therapy was 90 days. In addition to the medications, all of the participants received physiotherapy.

Main measures:

Functional status at 90 days, which was measured by the Fugl-Meyer Motor Scale score.

Results:

The initial mean (SD) Fugl-Meyer Motor Scale scores for the placebo, fluoxetine, and citalopram groups were 18.2 (11.42), 20.08 (14.53), and 17.07 (14.92), respectively. After 90 days, the scores were 27.96 (18.71) for the placebo group, 52.42 (26.24) for the fluoxetine group, and 50.89 (27.17) for the citalopram group. Compared with the placebo group, the mean Fugl-Meyer Motor Scale scores showed significant increases in the fluoxetine and citalopram groups ( P = 0.001).

Conclusion:

There was no significant difference between citalopram and fluoxetine in facilitating post-stroke motor recovery in ischemic stroke patients. However, compared with a placebo, both drugs improved post-stroke motor function.

Efficacy of Intralipid infusion in reducing amphotericin-B-associated nephrotoxicity in head and neck invasive fungal infection: A randomized, controlled trial

Amphotericin B deoxycholate (ABD) is the best therapeutic agent available for the treatment of most systemic fungal infections. However, some untoward adverse effects such as nephrotoxicity may limit its appropriate therapeutic use. We conducted a randomized, controlled trial ofthe infusion of fat emulsion (Intralipid) shortly after the infusion of ABD to evaluate its effects on reducing ABD-associated nephrotoxicity. Our patient population was made up of 31 patients who were randomized into two groups: an intervention group (n = 16) and a control group (15 patients). There were no statistically significant differences between the two groups in demographic or clinical variables. All patients received 1mg/kg/day of ABD in dextrose 5%. In addition, the patients in the intervention arm received Intralipid 10%, which was started as soon as possible within 1 hour after the infusion of ABD. ABD-associated nephrotoxicity was defined as a minimum 50% increase in baseline serum creatinine to a minimum of 2mg/dl. We also measured daily serum creatinine changes during the first 2 weeks of treatment, and we compared some other relevant indices of renal function, as well as ABD-related hypokalemia. We found no statistically significant differences between the two treatments in terms of ABD-associated nephrotoxicity or any of the other indices. We conclude that the administration of Intralipid 10% early after infusion of ABD in dextrose 5% does not have any effect in decreasing ABD-associated nephrotoxicity or hypokalemia.

AR2, a novel automatic muscle artifact reduction software method for ictal EEG interpretation: Validation and comparison of performance with commercially available software

Objective: To develop a novel software method (AR2) for reducing muscle contamination of ictal scalp electroencephalogram (EEG), and validate this method on the basis of its performance in comparison to a commercially available software method (AR1) to accurately depict seizure-onset location. Methods: A blinded investigation used 23 EEG recordings of seizures from 8 patients. Each recording was uninterpretable with digital filtering because of muscle artifact and processed using AR1 and AR2 and reviewed by 26 EEG specialists. EEG readers assessed seizure-onset time, lateralization, and region, and specified confidence for each determination. The two methods were validated on the basis of the number of readers able to render assignments, confidence, the intra-class correlation (ICC), and agreement with other clinical findings. Results: Among the 23 seizures, two-thirds of the readers were able to delineate seizure-onset time in 10 of 23 using AR1, and 15 of 23 using AR2 (p<0.01). Fewer readers could lateralize seizure-onset (p<0.05). The confidence measures of the assignments were low (probable-unlikely), but increased using AR2 (p<0.05). The ICC for identifying the time of seizure-onset was 0.15 (95% confidence interval (CI), 0.11-0.18) using AR1 and 0.26 (95% CI 0.21-0.30) using AR2.  The EEG interpretations were often consistent with behavioral, neurophysiological, and neuro-radiological findings, with left sided assignments correct in 95.9% (CI 85.7-98.9%, n=4) of cases using AR2, and 91.9% (77.0-97.5%) (n=4) of cases using AR1. Conclusions: EEG artifact reduction methods for localizing seizure-onset does not result in high rates of interpretability, reader confidence, and inter-reader agreement. However, the assignments by groups of readers are often congruent with other clinical data. Utilization of the AR2 software method may improve the validity of ictal EEG artifact reduction.

Post-epilepsy surgery psychogenic nonepileptic seizures

OBJECTIVES

We investigated the prevalence of post-epilepsy surgery psychogenic nonepileptic seizures (PNES) in patients with drug-resistant epilepsy and the possible influence of risk factors on these seizures.

METHODS

In this retrospective study, we examined data from all patients with a clinical diagnosis of drug-resistant epilepsy who underwent epilepsy surgery at Graduate Hospital and the Jefferson Comprehensive Epilepsy Center between 1986 and 2016. Postsurgical outcome was identified for up to 15 years after surgery. Diagnosis of PNES was verified in the epilepsy monitoring unit with video-electroencephalography (EEG) ictal recording. Potential associated factors were assessed by comparing patients with or without postoperative PNES.

RESULTS

A total of 1,105 patients were studied; 697 patients had postoperative seizures, and, of these, 27 patients (3.9%) had documented PNES after surgery. A full-scale intelligence quotient (IQ) <80 was significantly associated with post-epilepsy surgery PNES (odds ratio [OR] 2.89, p = 0.007, 95% confidence interval [CI] 1.33-6.29). A history of a preoperative psychiatric diagnosis was also significantly associated with post-epilepsy surgery PNES (OR 4.67, p = 0.0001, 95% CI 2.01-10.82). Other factors were not significantly associated with post-epilepsy surgery PNES.

SIGNIFICANCE

Post-epilepsy surgery PNES should be considered when patients report recurrent seizures after epilepsy surgery. Although these seizures probably occur relatively infrequently, attention to factors such as appearance of new ictal behaviors, a preoperative history of a psychiatric disorder, and a low full-scale IQ should raise suspicion and lead to appropriate diagnostic measures.

Ictal pain: occurrence, clinical features, and underlying etiologies

PURPOSE

We analyzed a series of patients with ictal pain to estimate its occurrence and characterize the underlying etiologies.

METHODS

We retrospectively reviewed all the long-term video-EEG reports from Jefferson Comprehensive Epilepsy Center over a 12-year period (2004-2015) for the occurrence of the term "pain" in the text body. All the extracted reports were reviewed, and patients with at least one documented episode of ictal pain in the epilepsy monitoring unit (EMU) were included in the study.

RESULTS

During the study period, 5133 patients were investigated in our EMU. Forty-six patients (0.9%) had at least one documented episode of ictal pain. Twenty-four patients (0.5%) had psychogenic nonepileptic seizures (PNES), 10 patients (0.2%) had epilepsy, 11 patients (0.2%) had migraine, and one woman had a cardiac problem. Pain location was in the upper or lower extremities (with or without other locations) in 80% of the patients with epilepsy, 33% of the patients with PNES (p=0.01), and none of the patients with migraine.

CONCLUSION

Ictal pain is a rare finding among patients evaluated in EMUs. Psychogenic nonepileptic seizures are the most common cause, but ictal pain is not specific for this diagnosis. Location of the ictal pain in a limb may help differentiate an epileptic cause from others.

Prevalence, main determinants, and early outcome of patients with atrial fibrillation hospitalized with ischemic stroke: evaluation of the value of risk assessment scores for predicting risk of stroke or major bleeding following anticoagulation therapy

BACKGROUND

Despite controllable nature of atrial fibrillation in most patients, it increases the risk of atrial thrombosis leading to ischemic stroke. The researchers assessed the underlying risk factors for brain stroke and also major bleeding in patients with ischemic stroke and atrial fibrillation.

METHODS

Among 900 patients hospitalized with the diagnosis of ischemic brain stroke between 2013 and 2014, 100 patients had atrial fibrillation that included into this cross-sectional study. The risk of stroke and major bleeding was assessed using CHA2DS2-VASc and HAS-BLED risk scores, respectively; but new stroke was not considered.

RESULTS

Of 900 patients with evidences of ischemic stroke, 100 had atrial fibrillation with an overall prevalence of 11.1%. Mean CHA2DS2-VASc score was 4.35 ± 1.76 that the total score was ≥ 2 points in 93% of subjects showing necessity to anticoagulation therapy in 93% of the patients before recent stroke. Mean HAS-BLED score was 2.83 ± 1.30 that was ≥ 3 in 61% indicating risk of bleeding in 61% of all patients. 31% of the patients had previous history of atrial fibrillation, but only less than half of them (51%) were under treatment with warfarin, and also the measured INR was lower than the therapeutic range in 95.5% of individuals on warfarin therapy. In-hospital mortality was reported in 9% of all study subjects. The main determinants of early mortality included history of stroke, renal failure, presence of coronary artery disease, acetylsalicylic acid use, and Clopidogrel use. The analysis using the ROC curve showed that both CHA2DS2-VASc score (AUC = 0.788) and HAS-BLED score (AUC = 0.960) could strongly predict in-hospital mortality.

CONCLUSION

The patients with atrial fibrillation hospitalized with ischemic stroke showed an important absolute risk of further stroke and early mortality. Despite substantiated advantages of warfarin prophylaxis, its limited application is still very common.

The effects of different doses of atorvastatin on serum lipid profile, glycemic control, and liver enzymes in patients with ischemic cerebrovascular accident

BACKGROUND

Despite established effects of atorvastatin on level of serum lipid profile in patients with different underlying clinical conditions, the effects of this drug on other serum biomarkers remain uncertain. We examined the effects of atorvastatin therapy on lipid profile, glycemic control, and liver enzymes in patients with ischemic cerebrovascular accident without any history or clinical evidences of diabetes, heart failure, renal failure, or hepatic disease.

METHODS

In a randomized double-blinded controlled trial, 140 hospitalized patients with an ischemic cerebrovascular accident were included and randomly assigned to receive either atorvastatin 40 mg (n = 70) or atorvastatin 20 mg daily (n = 70) for 3 months. The levels of biomarkers were measured at the time of administrating drugs as well as at the time of completing the treatment.

RESULTS

A significant reduction was revealed in serum triglyceride, total cholesterol, low-density lipoprotein, non-high-density lipoprotein (HDL) cholesterol, and also aspartate aminotransferase levels as well as a significant increase in serum HDL level following administration of atorvastatin in both case and control groups who received the atorvastatin 40 mg/day and 20 mg/day, respectively (all P < 0.050). Although a significant increase in fasting blood sugar and hemoglobin A1c was observed in the case group received atorvastatin 40 mg/day (both P < 0.001), but this elevation was not occurred in another group treated with lower dose of the drug (both P > 0.050).

CONCLUSION

Daily administration of 20 mg and 40 mg doses of atorvastatin for 3 months provides improvement in serum lipid profiles; however, because of interfering effect of high-dose atorvastatin on glycemic control status, the use of the former dose may be preferred. This is very important in these patients because the positive effects of high-dose atorvastatin in stroke patients are not confirmed.

Clinical features of laryngeal tuberculosis in Iran

Tuberculosis is a major health problem in Iran and its laryngeal involvement is not uncommon. Laryngeal tuberculosis is so infectious and delay in diagnosis and treatment could result spread of disease and causes divesting complications. We reviewed clinical and para-clinical characteristics of patients with laryngeal tuberculosis in Iran. In a cross sectional study, patients with laryngeal tuberculosis were studied and followed. All patients admitted from May 2000 to Dec 2011 in Amir-Alam hospital, a referral center for laryngeal diseases in Tehran. We studied 19 cases of laryngeal tuberculosis with typical histopathology (chronic granulomatous inflammation with caseous necrosis and langhans-type giant cells) and 6 cases of laryngeal tuberculosis with atypical histopathology (chronic granulomatous inflammation or chronic inflammation without necrosis). They had laryngeal symptoms and signs from 2 to 12 months before definitive diagnosis. Macroscopic appearances of laryngeal lesions were exophytic in 11 cases and ulcerative in 14 cases. True vocal cords were involved in 22 cases. The primary clinical diagnosis was malignancy in 17 cases, tuberculosis in 5 cases, and nonspecific inflammation in 3 cases. The chest x-ray findings were compatible with tuberculosis in 14 patients. The response to anti-tuberculosis therapy was desirable in all patients. In endemic area, tuberculosis should be considered as an important diagnosis in patients with laryngeal lesions even when histopathology of laryngeal lesions is not typical. Association with pulmonary tuberculosis helps for diagnosis.

Determination of the accuracy and optimal cut-off point for ELISA test in diagnosis of human brucellosis in Iran

In endemic area the most challenging problem for brucellosis is to find a reliable diagnostic method. In this case-control study, we investigated the accuracy of ELISA test for diagnosis of human brucellosis and determined the optimal cut-off value for ELISA results in Iran. The laboratory diagnosis of brucellosis was performed by blood isolation of Brucella organism with a BACTEC 9240 system and/or detection of Brucella antibodies by standard agglutination test (titer ≥ 1:160). Serum level of ELISA IgG and ELISA IgM from 56 confirmed cases of brucellosis and 126 controls were compared with each other by Box plot graph and Receiver Operating Characteristic (ROC) curve. Box plot graphs showed the high degree of dispersion for IgG and IgM data in patients compared with all controls. We observed partially overlapping for IgM data (not for IgG) between cases and controls in graphs. The area under ROC curve for distinguishing between cases and controls was larger for IgG compared to IgM. Based on results of this study, ELISA IgG test was more reliable than ELISA IgM test in diagnosis of human brucellosis in Iran. Using a cut-off of 10 IU/ml and 50 IU/ml had most sensitivity (92.9%) and most specificity (100%) for ELISA IgG test, respectively.

Experience of cyclone Gonu in the Islamic Republic of Iran: lessons learned

Gonu, the second tropical cyclone of the 2007 northern Indian ocean cyclone season, affected Oman, Pakistan, the United Arab Emirates and the Islamic Republic of Iran. This report examines the effects of cyclone Gonu in the Islamic Republic of Iran where it approached on its path on 6 June 2007 and reviews the actions taken before, during and after the cyclone. The incident highlighted the need for a special protocol to be prepared for all types of natural disasters. Responsible organizations should train their personnel according to the prepared protocols and service packages. Among the important lessons learned were the need for early warning, proper community involvement, access to essential data for risk analysis, special attention to safety of infrastructures, coordination and command integrity.

Barking seizure: acute episodes of barking in a 75-year-old previously healthy man

A 75-year-old right-handed man was admitted to our emergency department complaining of recurrent episodes of involuntary 'barking' within the past 12h. The episodes had occurred after an initial two-minute attack from sleep involving tonic contraction of the upper extremities and jaw locking. By the time of admission, the patient had had a total of at least 7-10 'barking' episodes, each lasting 30-45 s. Seven months prior to his current admission, the patient had had a minor ischemic stroke causing mild left paresis, which had resolved completely. His awake EEG revealed a normal background pattern interrupted by runs of two per second slow waves mixed with low-voltage spikes in the left temporal lobe with a left mid-temporal emphasis. The patient was diagnosed with recurrent simple partial seizures, and treatment with intravenous valproic acid was initiated. He was discharged four days later without having experienced any further barking episodes. Atypical presentations of the epileptic seizures have been described in the literature, but ictal barking is very rare manifestation of epilepsy.

A rare presentation of medulloblastoma in adults as primary leptomeningeal involvement

Medulloblastoma is one of the most common primary tumors of the central nervous system of children but it is uncommon in adult age. We report a case of young male presented with a history of generalized headache that was found to have medulloblastoma with diffuse leptomeningeal involvement without prominent mass lesion. To our knowledge, our patient is the second reported case of medulloblastoma in adults identified with primary leptomeningeal involvement without a prominent mass lesion. The clinical, radiological and pathologic features of this entity are described.

A rare case of facioscapulohumeral muscular dystrophy and myasthenia gravis

Facioscapulohumeral muscular dystrophy (FSHD) is a common inherited muscular dystrophy presented clinically with slowly progressive weakness and wasting of facial and limb muscles and rare bulbar muscle involvement. We present herein a 70-year-old man who was a known case of FSHD with complaint of 15-day history of progressive difficulty in chewing and dysarthria and was found to have myasthenia gravis. Related literatures have been also reviewed.

Anxiety, depression and health-related quality of life in those injured by landmines, Ilam, Islamic Republic of Iran

We assessed depression, anxiety and health-related quality of life (HRQOL) in 137 cases of landmine injury in Ilam province, using the Hospital Anxiety & Depression Scale (HADS) and the Short Form Health Survey (SF36) questionnaires. We also compared their scores with an uninjured control group (n = 360). Most of the injured were male (93.4%) and illiterate (54.7%) with some irreversible sequelae (86.9%). Overall, 69.3% of the injured participants scored high for both anxiety and depression. The level of anxiety and depression was significantly higher in older cases, those not completely recovered compared with recovered cases and those with amputation compared with those without amputation. The injured also had significantly lower mean scores in all HRQOL components than the control group. Landmine injured should be monitored for early identification and treatment of depression and anxiety.

Risk factors associated with injury attributable to falling among elderly population with history of stroke

BACKGROUND AND PURPOSE

Stroke survivors are at high risk for falling. Identifying physical, clinical, and social factors that predispose stroke patients to falls may reduce further disability and life-threatening complications, and improve overall quality of life.

METHODS

We used 5 biennial waves (1998-2006) from the Health and Retirement Study to assess risk factors associated with falling accidents and fall-related injuries among stroke survivors. We abstracted demographic data, living status, self-evaluated general health, and comorbid conditions. We analyzed the rate ratio (RR) of falling and the OR of injury within 2 follow-up years using a multivariate random effects model.

RESULTS

We identified 1174 stroke survivors (mean age+/-SD, 74.4+/-7.2 years; 53% female). The 2-year risks of falling, subsequent injury, and broken hip attributable to fall were 46%, 15%, and 2.1% among the subjects, respectively. Factors associated with an increased frequency of falling were living with spouse as compared to living alone (RR, 1.4), poor general health (RR, 1.1), time from first stroke (RR, 1.2), psychiatric problems (RR, 1.7), urinary incontinence (RR, 1.4), pain (RR, 1.4), motor impairment (RR, 1.2), and past frequency of > or = 3 falls (RR, 1.3). Risk factors associated with fall-related injury were female gender (OR, 1.5), poor general health (OR, 1.2), past injury from fall (OR, 3.2), past frequency of > or = 3 falls (OR, 3.1), psychiatric problems (OR, 1.4), urinary incontinence (OR, 1.4), impaired hearing (OR, 1.6), pain (OR, 1.8), motor impairment (OR, 1.3), and presence of multiple strokes (OR, 3.2).

CONCLUSIONS

This study demonstrates the high prevalence of falls and fall-related injuries in stroke survivors, and identifies factors that increase the risk. Modifying these factors may prevent falls, which could lead to improved quality of life and less caregiver burden and cost in this population.

Outcomes and recurrence rates in chronic subdural haematoma

The object of this study was to determine the relationship between outcome (assessed by Glasgow Outcome Scale) and recurrence in chronic subdural haematoma (CSDH). Eighty-two consecutive patients who underwent surgery for CSDH were included in this study. The relationship between the following variables and CSDH recurrence was studied: sex; age; history of trauma; Glasgow Coma Scale (GCS) at the time of admission (stage 1: GCS>12, stage 2: GCS: 8 - 12, stage 3: GCS<8); interval between head injury (when a history of trauma was present) and surgery; presence of a midline shift on CT scans; presence of intracranial air 7 days after surgery; haematoma density; haematoma width; presence of brain atrophy; and Glasgow Outcome Scale (GOS, both quantitative and non-quantitative) at the time of discharge. Throughout the analysis, p<0.05 was considered statistically significant. The results showed lower GCS (p<0.001), higher GOS (p<0.001), presence of intracranial air 7 days after surgery (p=0.002), and a high density haematoma (p<0.001) were significantly associated with recurrence of CSDH. It was concluded that GOS is related with recurrence in CSDH.

THE ROLE OF POSTOPERATIVE PATIENT POSTURE IN THE RECURRENCE OF TRAUMATIC CHRONIC SUBDURAL HEMATOMA AFTER BURR-HOLE SURGERY

OBJECTIVE

Chronic subdural hematoma (CSDH) is one of the most common types of intracranial hemorrhage, especially in the elderly, with a significant recurrence rate ranging from 9.2 to 26.5%. The role of postoperative patient posture in the recurrence of CSDH has not been studied sufficiently.

METHODS

A total of 84 consecutive patients with unilateral traumatic CSDH without known risk factors of CSDH recurrence were prospectively enrolled in this study. All patients underwent burr-hole surgery with closed system drainage and were then allocated randomly to either of two groups: Group A (n = 42) patients were kept in a supine position for 3 days after the operation, whereas Group B (n = 42) patients assumed a sitting position in bed, with the head of the bed elevated to 30 to 40 degrees, for the same duration as Group A. After 3 days, there was no restriction in patients' activities in both groups. All patients were followed-up for at least 3 months after surgery.

RESULTS

The groups were not significantly different in age, sex, presence of brain atrophy or hydrocephalus, preoperative hematoma width, and postsurgery subdural space width. The recurrence rate in Groups A and B were 2.3 and 19.0% (necessitating repeat surgery in one patient), respectively (P = 0.02). Other complications in Groups A and B, respectively, were atelectasis (10 versus seven; P = 0.41), pneumonia (five versus four; P = 0.72), decubitus ulcer (three versus two; P = 0.64), and deep vein thrombosis (zero versus one; P = 0.31).

CONCLUSION

Assuming an upright posture soon after burr-hole surgery was associated with a significantly increased incidence of CSDH recurrence but not with a significant change in other position-related postsurgical complications. According to this result, it is not recommended that elderly patients assume an upright posture soon after burr-hole surgery to prevent postoperative atelectasis and dementia, as these might significantly increase the risk of CSDH recurrence.