Crisis otolítica de Tumarkin: revisión de la literatura / Tumarkin's otolithic crisis: a review

Las crisis de Tumarkin consisten en caídas bruscas al suelo sin pródromos previos ni pérdida de conciencia y de segundos de duración que pueden ocurrir con frecuencia relativa en pacientes con enfermedad de Ménière. Si bien pueden presentarse de manera aislada durante la evolución de la enfermedad, existen casos con crisis recurrentes que comprometen significativamente la calidad de vida de los pacientes. Se postula que las crisis se producen por una alteración de la función del órgano otolítico, específicamente del sáculo. El tratamiento puede ser desde el manejo expectante hasta el uso de laberintectomía química o quirúrgica.

Tumarkin´s otolithic crisis is a sudden fall that comes with no loss of consciousness, and without warning or prodrome. It has a short duration and can occur with relative frequency in patients with Meniere disease. When it is present, it significantly compromises life quality of patients. There is no certainty about its mechanism, but it is assumed that the crises are caused by an otolithic organ disfunction, specifically a collapse of the saccule. Treatment can range from observation to chemical or surgical labyrinthectomy.

Resultados de callosotomía en adultos con diagnóstico de epilepsia refractaria y drop-attack / Callosotomy results in adults with diagnosis of refractory epilepsy and drop-attack

Introduction: For patients with refractory epilepsy patients, the sub-group characterized for seizures involving falls or drop-attack, the technique of callosotomy, as a palliative measure has been validated and used to control this type of seizures. Method: Group of 16 patients operated during period of four years, evaluated by protocol, which was performed as a palliative callosotomy crisis management technique was evaluated. Results: The observed group, 10 were males and 6 females, mean age 30 years, range between 19-46 years. Average evolution of epilepsy in 20.8 years, 14 cases crisis was starting before age 14. Major crises were TCG (generalized tonic clonic) and a tonic seizures were being 62.5 percent daily and 37.5 percent monthly, 100 percent had a history of TEC (brain trauma) and 56 percent history of status epilepticus. Was performed anterior callosotomy two thirds in 8 patients (mean follow-up 23.8 months), 6 patients complete callosotomy (average follow-up 15.5 months), and in 2 cases, two anterior thirds and then total callosotomy (1 case 22 months, and another 1 month follow-up). Seizures management fall > 50 percent in 75 percent of patients (3 cases without seizures of fall with anterior callosotomy two thirds), and for complete callosotomy, 100 percent control crisis in > 80 percent of patients (3 cases without seizures of fall was found in this group). Conclusion: The technique callosotomy as a palliative measure in the context of drop-attack or crises involving falls, in our experience with adult patients, has been a good tool in controlling this type of seizures.

Introducción: Dentro del grupo de pacientes refractarios en epilepsia, el sub-grupo caracterizado por crisis que involucran caídas o drop-attack, la técnica de callosotomía, como medida paliativa, ha sido validada y utilizada para el control de este tipo de crisis. Método: Se evaluó grupo de 16 pacientes adultos operados durante período de 4 años, evaluados por protocolo, donde se realizó callosotomía como técnica paliativa de control de crisis. Resultados: Del grupo observado, 10 fueron varones, 6 mujeres, promedio de edad 30 años, rango entre 19 a 46 años. Promedio de evolución de epilepsia de 20,8 años. En 14 casos el inicio de crisis fue antes de los 14 años. Principales crisis fueron TCG (tónico clónico generalizada) y atónicas, siendo en el 62,5 por ceinto diarias y en el 37,5 por ciento mensuales, el 100 por ceinto tenía antecedente de TEC (trauma encéfalo craneano) y en el 56 por ciento antecedente de status epiléptico. Se realizó callosotomía dos tercios anterior en 8 pacientes (seguimiento 23,8 meses promedio), 6 pacientes callosotomía total (seguimiento 15,5 meses promedio), y en 2 casos, dos tercios anterior y luego callosotomía total (1 caso 22 meses, y otro, 1 mes de seguimiento). Se encontró control de crisis de caídas > 50 por ciento en el 75 por ciento (3 casos sin crisis) de casos con callosotomía dos tercios anterior, para callosotomía completa, 100 por ciento control de crisis en > 80 por ciento (3 casos sin crisis) de este grupo. Conclusión: La técnica de callosotomía como medida paliativa en el contexto de drop-attack o crisis que involucren caídas, en nuestra experiencia en pacientes adultos, ha sido una herramienta útil en el control de este tipo de crisis.

A Case of Tumarkin Otolithic Crisis: Failed to Treat with Intratympanic Gentamicin Injection / 대한평형의학회지

Tumarkin otolithic crisis is an unusual manifestation of Meniere's disease that shows sudden falling without loss of consciousness. As a kind of life-threatening otologic emergency due to high risk of injury, the surgical ablation therapy rather than the medical one is preferred. Intratympanic injection of gentamicin (ITIG) is being introduced as a treatment by chemical ablation of vestibular function. The authors report a case of life-threatening Tumarkin otolithic crisis in 76-year-old female, after onset of Meniere's disease, failed to treat with multiple application of ITIG, and successfully eradicated the symptom with total labyrinthectomy after then. Also we introduce her clinical feature of Tumarkin otolithic crisis. A 76-year-old female visited clinic suffering from recurrent rotatory vertigo accompanied with fluctuating hearing loss and tinnitus on her left ear, and diagnosis of Meniere's disease was made. Four months after medical treatment, the patient experienced sudden drop attack during walking on the street without any prodromes, and her right wrist and skull base were fractured as a result. She denied to got surgery and ITIG was applied. During 1 year after initial drop attack, she experienced 7 times of severe drop attack and 4 times of ITIG, and finally she accepted to get surgery. The patient no longer suffered from drop attack after total labyrinthectomy later. Tumarkin otolithic crisis is an otologic emergency, may cause life-threatening falling. Our experience from this case is that vestibular ablation by surgical method is needed for safety and quality of life of patients.

A Case of Suspicious Focal Atonic Seizure Characterized by Drop Attack / 대한소아신경학회지

Atonic seizures exhibits loss of postural tone, resulting in head drops or falling. When this event is extremely brief, It has been known as a drop attack. Atonic seizure are firmly placed under the category of generalized seizures. However, a various phenomena satisfying the above description has been recognized in patients with partial seizures. A 13-year-old girl had brief episodes of drop attacks. She complained of weakness of both legs in the absence of consciousness loss. These episodes occurred at a frequency of 4 or 5 time per day for 1 year. Her developmental and physical examinations were normal. Also, the brain MRI was normal. However, her Interictal EEG showed the repetitive spike and wave complexes on C(z) electrode. She was controlled completedly by antiepileptic drungs. We report a patient who suffered from focal atonic seizures characterized by drop attack.

The Outcome of Corpus Callosotomy for Intractable Epilepsy: 10 Years Experience of Corpus Callosotomy

OBJECTIVE: The purpose of this study is to evaluate the effect of the corpus callosotomy and to elucidate possible prognostic factors. METHODS: The cases of 39 patients who underwent corpus callosotomy were reviewed retrospectively. Clinical outcomes were analyzed using Engel's classification, with consideration of various presurgical conditions and the extent of the callosal resection during follow-up more than one year. RESULTS: Satisfactory outcome (Engel's class I, II) was obtained in 20 patients (51%) of 39 patients. In 36 cases with drop attack seizures, the class I, II outcomes were 22 patients (61%). When the patients were grouped according to the extent of callosal resection, the class I, II outcomes were 50% of the patients with anterior 1/2 or 2/3, 50% of those with anterior 4/5 callosotomy, and 57% of those with total callosotomy, respectively. The mean follow-up period was 34 months (24 to 58 months). CONCLUSION: Although it is not statistically significant, the patients who had underwent total callosotomy show better outcomes than those with partial callosotomy. Corpus callosotomy is efficacious in controlling medically intractable epilepsy in appropriately selected patients.

The Results of One stage Total Callosotomy in Pediatric Epilepsy / 대한간질학회지

PURPOSE: In the pediatric patients who have medically intractable epilepsy the callosotomy is useful to prevent the propagation of seizure from one hemisphere to the other. The indications of callosotomy are drop attack, life threatening primarily or secondarily generalized seizure, medically refractory mixed seizure types such as Lennox-Gastaut syndrome. In addition, the retarded children are not contraindicated. The anterior callosotomy is used to perform to control medically intractable epilepsy which is believed to have some advantages to total callosotomy. But, we propose that the anterior callosotomy does not seem to be superior to total callosotomy for the prevention of the propagation of seizure or complication. We describe a series of 21 patients with medically intractable epilepsy who underwent total callosotomy in one stage. METHODS: The diagnoses in these patients included Lennox-Gastaut syndrome, atonic seizure, infantile hemiplegia, and no obvious solitary seizure focus on chronic video/EEG monitoring to characterize seizures, electrographic activity, and postictal behaviors. Preoperatively 16 patients suffered from disabling drop attacks or intense head drop seizures which caused frequent physical injuries. Other types of seizures are 12 generalized tonic-clonic seizures, 7 complex partial seizures, 1 absence seizure, and 7 myoclonic seizures. Male:Female=14:7, Age: 2-22 years (Mean: 9.4 years). The follow-up period ranged from 0.8 to 3.8 years (median 2.4 years). Seizure outcome, parental assessment of daily function, and parental satisfaction with outcome were assessed postoperatively. RESULTS: Drop attacks disappeared completely during the entire follow-up period in 13 patients and decreased to less than 10% of baseline in five. The corpus callosum of the one patient were not completely sectioned in Diffusion Tensor Image, tractography. Other types of seizures resolved completely in 14 patients and decreased in 7. 2 patients experienced a transient disconnection syndrome, but completely resolved within four weeks. Overall daily function improved and parents were satisfied with the surgical outcome in all patients except three who experienced recurrent of drop attacks after operation. There was no sign of significant and persistent neurological deficits in any case. CONCLUSION: Results of total callosotomy in patients with medically intractable epilepsy with diffuse epileptic foci were favorable in most cases. The procedure was particularly effective against drop attacks causing physical injuries and impaired quality of life in these patients.

Otologic Causes of Drop Attacks in Elderly Patients

BACKGROUND AND OBJECTIVES: Many neurologists are unaware of the drop attack that may occur from an inner ear dysfunction especially in elderly. We performed this study to investigate the clinical features and results of quantitative audiovestibular tests in six elderly patients (> or =65 years of age) who presented with drop attacks attributable to an inner ear pathology. MATERIALS AND METHOD:Group was divided into Meniere's syndrome (4) or non-Meniere peripheral vestibulopathy (2). Standard dizziness questionnaire and quantitative audiovestibular function testing were performed. RESULTS:Episodes were described as a sudden push to the ground in four or a violent illusionary movement of environment leading to a fall in two. All cases gave a history of prior vertiginous episodes and vestibular testing revealed unilateral caloric paresis. Ipsilateral hearing loss was documented in four cases. CONCLUSIONS:Our results suggest that otologic causes should be considered in the differential diagnosis of the drop attack in elderly, even if the symptoms and signs were not consistent with Meniere's syndrome.

The Surgical Effect of Callosotomy in the Treatment of Intractable Seizure

We evaluated the surgical effects of the callosotomy, particularly with respect to the effect of callosotomy in some seizure types and the extent of surgery. Twenty-one patients with a minimum follow-up of two year were enrolled. The most significant effect of callosotomy was the complete suppression of the generalized seizures associated with drop attack in 12 of 21 patients and seizure reduction of more than 75% in 6 of 21 patients. The surgical effect on the partial seizures was very variable. Transient disconnection syndrome appeared in 4 patients after anterior callosotomy. Total callosotomy by staged operation significantly suppressed generalized seizures associated with drop attack without any disconnection syndrome. Our data show that callosotomy is quite a good approach to the surgical treatment of drop attacks accompanied by disabling generalized seizures.

Tumarkin's Otolithic Crisis

Tumarkin's otolithic crisis refers to drop attacks of vestibular origins. It usually occurs without warning in patients with late or end-stage endolymphatic hydrops. However, drop attacks of vestibular origins may occur in patients without otologic deficit. We report a patient with Tumarkin's otolithic crisis from delayed endolymphatic hydrops. The careful delineation of drop attacks in patients with vertigo can provide appropriate therapeutic options for patients with this potentially dangerous condition.

Outcome of Callosotomy in Treatment of Intractable Epilepsy

The purpose of the present study was to verify the effect of callosotomy on generalized seizures, to check the effect on other seizure types and to search for possible prognostic factors. Twenty-one patients with a minimum follow-up of one year were available for our analysis. Mean follow up duration was 3.1years(1 to 7years). In four of them the total callosotomy was performed in two stages(total: 25 surgical procedures). Age ranged from 7 to 37years(mean 19.4years). Different aetiologies were known in 10 patients. Duration of epilepsy ranged from 2 to 23years(mean 8years). The frequency of seizures ranged between 5 and 300 per month. The most significant effect of surgery was the complete suppression of the generalized seizures associated with falling in 12/21 and their reduction of more than 75% in 6/21 patients. Sixteen(84.2%) of 19 patients with generalized tonic-clonic seizure had a significant reduction in automatisms: this reduction consisted of simplification of automatic movements and shorter duration of seizures. The surgical effect on the partial seizures was variable. The role of age, aetiology, duration of the disease, single or more seizure types and mental impairment remains uncertain. Mild disconnection syndrome appeard in 4 patients although the splenium was spared. Second opeartion, total callosotomy, could signigicantly suppress the generalized seizures associated with falling without disconnection syndrome. The present findings confirm that the main indication for callosotomy is generalized seizures with fall. Surgery can be initially limited to the anterior 2/3 of the corpus callosum; further posterior section of the corpus, excluding the splenium, should be regarded as a second step, when necessary.