Comparison of Cognitive Effects of Lamotrigine and Oxcarbazepine in Epilepsy Patients

BACKGROUND AND PURPOSE: This study compared the cognitive effects of 1 year of treatment with lamotrigine (LTG) and oxcarbazepine (OXC) in epilepsy patients. METHODS: This retrospective study investigated 60 epilepsy patients undergoing neuropsychological tests who were either newly diagnosed or untreated in the preceding 6 months. The cognitive function in 30 patients receiving LTG monotherapy and 30 age-matched patients receiving OXC monotherapy was compared after 1 year. The neuropsychological scores at baseline and all of the epilepsy-relevant variables except seizure type did not differ between the groups. The mean daily dosages of LTG and OXC at 1 year were 93 mg and 825 mg, respectively. RESULTS: The posttreatment list-learning performance was better in the LTG group than in the OXC group (p<0.05). The incidence of cognitive complaints did not differ between the two groups. The list-learning performance and Trail Making Test scores were better in each group after treatment. CONCLUSIONS: LTG and OXC monotherapies have similar, slightly beneficial effects on cognitive function, and are probably not harmful.

Cognitive Profiles of Lamotrigine in Epilepsy Patients : A Comparative Study with Valproate / 대한간질학회지

PURPOSE: To identify cognitive effects of lamotrigine (LTG) compared with valproate (VPA) in epilepsy patients after 1 year of treatment. METHODS: Cognitive tests and subjective complaints of 22 patients with LTG monotherapy (50-200 mg/day) were retrospectively compared with those of 22 patients with VPA monotherapy (500-1300 mg/day) at 1 year of medication. RESULTS: LTG group did not show any significant difference in the performance of cognitive tests compared with VPA group. The incidence of cognitive complaints between two drugs were also not different. Both groups showed a better performance of list learning and Trail Making Test type A after antiepileptic drug medication. CONCLUSION: The impact of LTG and VPA monotherapy on cognitive functioning is similar. Both drugs may not be harmful or rather slightly beneficial for cognitive functions.

Cognitive Effects of Low-dose Topiramate Compared with Oxcarbazepine in Epilepsy Patients

BACKGROUND AND PURPOSE: Low-dose topiramate (TPM) monotherapy has recently been found effective for seizure control in newly diagnosed epilepsy. In higher dosages, TPM has been associated with relatively high rates of adverse cognitive effects; similar side effects have been seen after rapid titration or polytherapy. However, its cognitive effects during low-dose monotherapy have not been established. We evaluated the cognitive effects of low-dose TPM compared with oxcarbazepine (OXC), a drug that does not appear to affect cognitive function. METHODS: Cognitive tests and subjective complaints of 30 patients with low-dose TPM monotherapy (50-200 mg/day) were retrospectively compared with those of 30 patients with OXC monotherapy at 1 year of medication. The two groups did not differ with respect to epilepsy-relevant variables, nor on baseline neuropsychological tests. RESULTS: The TPM group showed a significant difference in the performance of delayed word recall (P<0.05), backward digit span (P<0.01), and verbal fluency (P<0.05) compared with the OXC group. The TPM group showed worse performances of digit span and verbal fluency. The OXC group showed better performances of delayed word recall. The incidence of cognitive complaints was higher in the TPM group (50%) than in the OXC group (20%) (P<0.05). These cognitive effects shown in the TPM group were dose-related. The cognitive dysfunction was trivial with patients taking 50 mg/day TPM. CONCLUSIONS: Even at low-dose, TPM has a negative effect on working memory and verbal fluency compared with OXC. It can be demonstrated at 1 year of treatment.

Hemichoreoballism with Anterior Cerebral Artery Territory Infarction

Various movement disorders associated with cerebral infarction have been introduced. However patients with anterior cerebral artery territory infarction presenting with hemichoreoballism have never been reported. We present a 64-year-old man with hemichoreoballism and frontal alien hand syndrome on his right hand. Diffusion weighted brain MRI revealed hyperintensities in anterior two third of corpus callosum and superior frontal gyrus. Hemichoreoballism was improved after one day treated by clonazepam. We report the case with hemichoreoballism after anterior cerebral artery territory infarction.

Clinical Features and Brain MRI Findings in Liver Cirrhosis-related Acute Metabolic Encephalopathy

BACKGROUND: Chronic liver disease is a common cause of metabolic neurologic deterioration. We analyzed the clinical features and MRI findings of patients with liver cirrhosis who showed rapidly progressing cerebral dysfunction. METHODS: From August 2001 to July 2003, we had 9 liver cirrhosis patients hospitalized due to acutely developed and rapidly progressed neurologic symptoms that were caused not by other metabolic disturbances. Blood tests and liver ultrasonography were performed to assess the severity of liver cirrhosis. A brain MRI study was done in all patients. RESULTS: The causes of liver cirrhosis were viral hepatitis (n=6), chronic alcoholism (n=2), and autoimmune disease (n=1). Serum ammonia and electrolyte levels were within the normal range. Truncal or limbs ataxia and dysarthria were the most common symptoms. The corpus callosum and dentate nucleus of the cerebellum were commonly involved on diffusion- and T2-weighted MRI. In spite of intensive investigation and treatment, all patients had a rapidly deteriorating course with the appearance of uncontrolled abnormal movements and a decreased consciousness level. Their deaths occured within 1 month of the onset of symptoms. CONCLUSIONS: We present nine liver cirrhosis patients with characteristic clinical features and diffusion- and T2-weighted MRI findings for the first time. It is assumed that some neurologic circuit plays a role in pathogenesis.

Topiramate Related Cognitive Dysfunction during Migraine Prevention

BACKGROUND: Topiramate (TPM), a broad-spectrum antiepileptic drug, has recently been demonstrated to be effective as a monotherapeutic device for migraine prevention. We investigated the impact of TPM on cognition during migraine prevention. METHODS: Twenty-eight migraineurs were evaluated. They were instructed to take 25 mg of TPM per day, with 25 mg weekly increments to a maximum of 100 mg per day according to the therapeutic responsiveness. We assessed cognitive dysfunctions by spontaneous patient reports and several neuropsychological tests comparing the baseline and at 3 months during on-treatment. We also compared these tests to age, sex, education, clinical features of migraine, TPM dose, and global effectiveness. RESULTS: After 3 months of therapy, 21 patients undertook a follow-up neuropsychological test. Even though headache frequency, severity, and disability were significantly decreased in a follow-up period, there was a significant impairment in backward digit span (P=.006) and verbal fluency (P=.023). Thirteen patients (62%) showed an impaired backward digit span, and 11 patients (52%) exhibited an impaired verbal fluency. Five patients (24%) complained of symptoms associated with these impairments. Cognitive impairments were well correlated to the frequency of migraine attack, higher daily TPM dose, and global effectiveness. In six patients who showed the impairment of both items, TPM was withdrawn and their cognition was retested after 2 weeks. There was a significant improvement in these cognitive functions. CONCLUSIONS: TPM appears to exert a dose-related, strong negative influence on working memory and verbal fluency during migraine prevention. It can be related to drug tolerability.

A Case of Recurrent Hypersomnia

Recurrent hypersomnia is a disorder characterized by recurrent episodes of hypersomnia that typically occur weeks or months apart. We describe a 60-year-old woman with a four-year history of recurrent hypersomnia. Physical examinations, laboratory tests, and brain MRI showed no significant abnormality in the patient. Nocturnal polysomnographic study showed high sleep efficiency, absent sleep stage 3 and 4, and reduced sleep latency. The multiple sleep latency tests showed short sleep latency and five episodes of sleep-onset REM periods. This is the oldest known case of recurrent hypersomnia.

Effects of Divalproex sodium for Visual Cortex Excitability in Migraine: A Study Using Transcranial Magnetic Stimulation

BACKGROUND: The pathophysiology of migraine has not been fully understood. One of the hypotheses is cortical hyperexcitability. Transcranial magnetic stimulation (TMS) is a noninvasive electrophysiologic tool for the investigation of cortical excitability. Divalproex sodium may prevent migraine attacks by increasing the GABA-ergic tone. We examined the phosphene generation using TMS in migraine patients in order to investigate the cortical excitability and its response by valproate prophylaxis. METHODS: We applied TMS to 27 migraineurs and 27 control subjects. TMS was performed by a Magstim Rapid Stimulator connected to a 70 mm figure-of-eight coil to examine the phosphene threshold between migraineurs and controls on primary (V1) and bilateral secondary (V5) visual cortices. Twelve migraine patients completed a one month administration of divalproex sodium 500 mg/day. We compared the phosphene threshold between pre- and post-treatment with devalproex sodium in these patients. RESULTS: The prevalence of the phosphene generation was significantly higher in migraineurs compared with controls in V1 and V5. The phosphene average thresholds were significantly lower in migraineurs compared with controls in V1 and V5. The phosphene average thresholds in the same areas were significantly higher in post-treatment compared with pre-treatment in migraineurs. CONCLUSIONS: The differences of the phosphene threshold in the visual cortex between migraineurs and controls comply with the theory of cortical hyperexcitability for the pathophysiology of migraine. Valproate might play a significant role in the prophylaxis of migraine by decreasing cortical hyperexcitability.

Psychomotor Variant in a Case of Juvenile Absence Epilepsy: An Evidence of Misnomer by Gibbs / 대한간질학회지

The psychomotor variant is a rare EEG pattern as a rhythmical activity at about 6 Hz that may occur in brief or longer runs, independently in the temporal areas during drowsy mental state. It was originally named by Gibbs and Gibbs because of its existence during the ictal or interictal period in patients with psychomotor seizures. We report a 14-year-old girl with juvenile absence epilepsy who showed the long runs of psychomotor variant followed by generalized ictal discharges.

The Bone Mineral Densities in Patients with Hemiplegic Stroke

OBJECTIVE: Stroke patient are prone to fall and, therefore, frequently get fractures, especially at the hip joint of the hemiplegic side, which is often osteoporotic. So osteoporosis in hemiplegic stroke patients is an important clinical problem. The aim of this study was to investigate the mode of the development of osteoporosis in hemiplegic stroke patients and define the relationship between functional status and bone mineral densities (BMDs). METHOD: The subjects were 21 hemiplegic stroke patients, 11 men, 10 women, age 60.3 +/- 8.4 years and 21 age and sex matched controls. We measured BMDs in patients, and compared BMDs of the affected and unaffected sides, and compared BMDs of each affected and unaffected sides with controls, and evaluate the relationship between BMDs with functional parameters. RESULTS: Stroke patients have high prevalence of osteoporosis and osteopenia, and affected side BMDs of patients were lower in upper and lower limbs compared with the controls. BMDs of the affected side were lower for the upper and lower limbs compared with the unaffected side. CONCLUSION: Stroke patients have high prevalence of osteoporosis. Therefore early rehabilitative care, including weight- bearing and outdoor ambulation, is essential for hemiplegic stroke patients in order to prevent possible complications, especially osteoporotic fractures.

Cerebrovascular Reserve Measured by Acetazolamide-challenged Tc-99m ECD Brain Perfusion SPECT in Symptomatic Internal Carotid Artery and Middle Cerebral Artery Disease

BACKGROUND: Hemodynamic evaluation of the brain may be helpful for the identification of a risk of stroke in patients with middle cerebral artery (MCA) or internal carotid artery (ICA) steno-occlusive disease. The aim of this study was to evaluate the hemodynamic state in patients with steno-occlusive disease of ICA or MCA on the base of MRI/MRA and acetazolamide (ACZ)-challenged Tc-99m ECD brain perfusion SPECT findings. METHODS: An analysis of 68 patients who underwent MRI/MRA and ACZ-challenged Tc-99m ECD brain perfusion SPECT was performed. We divided these patients into two groups - MCA and ICA steno-occlusions. RESULTS: The cerebrovascular reserve (CVR) was impaired in 18 of 32 (56.3%) MCA disease patients (20 stenosis and 12 occlusions), and in 19 of 36 (52.8%) ICA disease patients (20 stenosis and 16 occlusion). The CVR was impaired in 22 of 28 (78.6%) occlusive patient, whereas in 15 of 40 (37.5%) stenotic patient (p< 0.01). The insular lesion was more commonly involved in the occlusion group (54%) than in the stenosis group (15%) (p< 0.01). CONCLUSIONS: There was no difference in CVR between MCA and ICA steno-occlusion groups. Incidence of impaired CVR was higher in occlusion group than stenosis group.

Cerebrovascular Reserve Measured by Acetazolamide-challenged Tc-99m ECD Brain Perfusion SPECT in Symptomatic Internal Carotid Artery and Middle Cerebral Artery Disease

BACKGROUND: Hemodynamic evaluation of the brain may be helpful for the identification of a risk of stroke in patients with middle cerebral artery (MCA) or internal carotid artery (ICA) steno-occlusive disease. The aim of this study was to evaluate the hemodynamic state in patients with steno-occlusive disease of ICA or MCA on the base of MRI/MRA and acetazolamide (ACZ)-challenged Tc-99m ECD brain perfusion SPECT findings. METHODS: An analysis of 68 patients who underwent MRI/MRA and ACZ-challenged Tc-99m ECD brain perfusion SPECT was performed. We divided these patients into two groups - MCA and ICA steno-occlusions. RESULTS: The cerebrovascular reserve (CVR) was impaired in 18 of 32 (56.3%) MCA disease patients (20 stenosis and 12 occlusions), and in 19 of 36 (52.8%) ICA disease patients (20 stenosis and 16 occlusion). The CVR was impaired in 22 of 28 (78.6%) occlusive patient, whereas in 15 of 40 (37.5%) stenotic patient (p< 0.01). The insular lesion was more commonly involved in the occlusion group (54%) than in the stenosis group (15%) (p< 0.01). CONCLUSIONS: There was no difference in CVR between MCA and ICA steno-occlusion groups. Incidence of impaired CVR was higher in occlusion group than stenosis group.

Episodic Central Neurogenic Hyperventilation in an Awake Patient with Unilateral Pontine Infarction

Central neurogenic hyperventilation (CNH) is characterized by sustained tachypnea inspite of an elevated arterial PaO2, pH and a low arterial PaCO2. CNH is common in patients with brainstem injury accompanied by a decreased level of consciousness but this also has been described in some alert patients with an invasive brainstem tumor. We report one case with CNH resulting from a unilateral pontine infarction. His consciousness was clear, and CNH spontaneously disappeared without any medication.

Sudden Deafness and Anterior Inferior Cerebellar Artery Infarction

BACKGROUND AND OBJECTIVES : Acute ischemic stroke in the distribution of the anterior inferior cerebellar artery (AICA) is known to be associated with vertigo, nystagmus, facial weakness, and gait ataxia. There have been few reports on deafness associated with the AICA infarction. Furthermore, previous neurological reports have not emphasized the inner ear as a localization of sudden deafness. The aim of this study was to investigate the incidence of deafness associated with the AICA infarction and the sites predominantly involved in deafness. MATERIALS AND METHOD : During two years we prospectively identified 12 consecutive patients with unilateral AICA infarction diagnosed by brain MRI. Pure tone audiogram, speech discrimination testing, stapedial reflex testing, and auditory brainstem responses were performed to localize the site of lesion in the auditory pathways. Electronystagmography was also performed to evaluate the function of the vestibular system. RESULTS :The most common affected site on brain MRI was the middle cerebellar peduncle (11). Four patients had vertigo and/or acute auditory symptoms such as hearing loss or tinnitus as an isolated manifestation from 1day to 2 months prior to infarction. Audiological testings confirmed sensorineural hearing loss in 11 (92%) patients, predominantly involved the cochlea in 6 and retrocochlear in 1. The other 4 patients had a severe to profound hearing loss most likely of cochlear origin. Electronystagmography demonstrated no response to caloric stimulation in 10 (83%) patients. CONCLUSIONS : In our series, sudden deafness was an important sign for the diagnosis of the AICA infarction. Audiological examinations suggest that sudden deafness in AICA infarction is usually due to dysfunction of the cochlea, resulting from ischemia to the inner ear.

Three Cases of Anticonvulsant Hypersensitivity Syndrome Associated with Lamotrigine

Among the various side effects of anticonvulsant medication, the anticonvulsant hypersensitivity syndrome (AHS) is underrecognized. This condition developed frequently with aromatic anticonvulsants, but with new antiepileptic drugs as well. We experienced three lamotrigine-induced AHS cases with symptoms such as fever, rash, leukopenia, eosinophilia and lymphadenopathy, which subsided after withdrawal of lamotrigine.

Subdural Strip Electrode Studies in Temporal Lobe Epilepsy: Relation between Interhemispheric Propagation Time and Surgical Outcome

BACKGROUND: We evaluated whether the time required for a seizure to spread contralaterally, interhemispheric propagation time (IHSPT) could be related to post-surgical outcome in temporal lobectomy. METHODS: We performed a retrospective study of 28 patients. All patients had previously undergone a phase I presurgical evaluation including MRI and video-EEG monitoring with scalp and sphenoidal electrodes, which strongly suggested the diagnosis of mesial temporal lobe epilepsy, but proved inadequate to lateralize the epileptogenic zone. All patients performed the video-EEG monitoring with bilateral subdural strip electrodes on their basal and mesial temporal area and unilateral temporal lobectomy with a minimum of 1-year follow up postoperatively. IHSPT was divided into two categories, 0~5.0 seconds, 5.1 seconds or longer. RESULTS: Sixteen patients (57.1%) were seizure free and 12 suffered persistent seizures. A prolonged IHSPT (> 5.0sec) significantly correlated with a favorable surgical outcome (P = 0.05). Hippocampal atrophy on MRI significantly correlated with prolonged IHSPT (P<0.05). CONCLUSIONS: Our result suggests that hippocampal atrophy on MRI and IHSPT can predict the surgical outcome and may be used as the selection criteria of temporal lobectomy for patients with intractable temporal lobe epilepsy.

A Case of Recurrent Bickerstaff's Brainstem Encephalitis with an Overlap of Guillain-Barre Syndrome

Bickerstaff 's brainstem encephalitis (BBE) is characterized by acute ophthalmoplegia and ataxia. Some patients with BBE show mental changes, pyramidal signs and sensory disturbance. A forty-three year old woman was diagnosed as BBE in 1996. In 2000, she admitted again with complaints of ataxia and ophthalmoplegia. She was diagnosed as recurrent BBE and an overlap of Guillain-Barre syndrome (GBS). This is the first case of an overlap of BBE and GBS, as well as BBE in Korea.