Encephalopathy in a Patient with Pancreatitis: Pancreatic Encephalopathy

Pancreatic encephalopathy is a rare complication of acute pancreatitis. We report a 80-year-old woman who, after an acute episode of pancreatitis, developed a fluctuating confusion and clouded consciousness. She experienced two relapses with alternating encephalopathic features. Serum amylase was highly increased and symptoms were relieved in accord with normalized amylase value. We suggest that this encephalopathic features may be related with pancreatitis.

Usefulness of Sphenoidal Electrodes for Localization of Temporal Lobe Seizure Focus : Ictal EEG / 대한간질학회지

PURPOSE: Usefulness of sphenoidal electrodes for detecting mesial temporal seizure foci remains controversial. Our aim is to determine whether sphenoidal electrodes are superior to surface electrodes for EEG localization in patients with mesial temporal lobe epilepsy (TLE). METHODS: We retrospectively reviewed ictal EEGs recorded simultaneously with standard International 10-20 System, subtemporal and sphenoidal electrodes in 92 patients who underwent temporal lobectomy. Patients were divided into mesial (n=67) and neocortical (n=25) TLE. Ictal EEGs were reviewed in a blinded fashion in both longitudinal bipolar and Pz referential montages. RESULTS: Thirty four (13.1%) of 259 mesial temporal seizures were exclusively isolated to sphenoidal electrode at least 3 seconds before involvement of subtemporal electrodes or were localized to temporal lobe on sphenoidal electrode when scalp electrode failed to localize seizure onset, whereas only 2 (2.6%) of 75 neocortical temporal seizures were (p<0.05). The usefulness of sphenoidal electrode was related to the distribution but not the frequency of ictal onset on scalp EEG. CONCLUSIONS: Although isolated or localized sphenoidal seizure onset in patients with mesial TLE are not frequent, sphenoidal electrodes are superior to scalp electrodes for the localization of mesial temporal seizure foci.

Combined Bilateral Depth and Subdural Electrode Investigation in Temporal Lobe Epilepsy

BACKGROUND: Depth and subdural electroencephalographic (EEG) recordings are often required to identify an area of the brain for epileptic surgery. We simultaneously compared bilaterally placed depth and subdural electrode EEGs to determine the site of seizure origins from the temporal lobes. METHODS: We included nine consecutive patients with medically refractory temporal lobe epilepsy, whose noninvasive evaluations such as magnetic resonance imaging, scalp and sphenoidal EEG, and other tests had not proved consistent lateralization. All patients had bilateral temporal depth electrodes, anterior and lateral temporal subdural strip electrodes. Thirty-eight clinical seizures and 3 subclinical seizures were evaluated. RESULTS: Seven out of 9 patients (78%) had unitemporal seizures, one patient had bilateral seizures, and the other had lateral temporal seizures in an invasive study. Ictal onset was localized by depth electrodes in 8 patients, and subdural strip electrodes in one. In ictal recordings, the ictal rhythms never spread to the contralateral neocortex before the ipsilateral neocortex. Most of the ictal rhythms began focally with periodic spikes or fast activities in the depth electrode, then spread to the ipsilateral strip electrode after 14 to 90 seconds (mean : 35.2 seconds). If ictal rhythms propagated to the contralateral side, it took 14 to 140 seconds (mean : 64.2 seconds). Subdural strip electrodes were less sensitive than depth electrodes in the detection of seizure onset and subclinical seizures, but were accurate when lateralized. CONCLUSIONS: We conclude that EEG recordings with depth and subdural strip electrodes correctly identify and lateralize temporal lobe seizures more often than subdural electrodes alone.

Differentiation of Temporal Lobe Epilepsy by Scalp Ictal EEG and Its Correlation with Surgical Outcome / 대한간질학회지

PURPOSE: Ebersole and Pacia recently introduced a classification of scalp ictal EEG in temporal lobe epilepsy (TLE). So we investigated whether scalp ictal EEG without sphenoidal electrode can differentiate mesial TLE from neocortical TLE and can be predictive of surgical outcome after temporal lobectomy. METHODS: A consecutive 77 patients (male 43, female 34) with TLE were included who had temporal lobectomy after the comprehensive presurgical evaluation. The patients with mesial TLE were 59 and those with neocortical TLE 18. The total 358 seizures were analyzed using bipolar and monopolar montage without sphenoidal electrodes. Scalp ictal EEGs were categorized into 3 types based on Ebersole and Pacia's classification and then were evaluated with regard to the differentiation of TLE and its correlation with surgical outcome. RESULTS: 1) Out of the total 77 patients, type 1 pattern was observed in 23 (30%), type 2 in 51 (65%), and type 3 in 3 (5%). The number of patients with mesial TLE were 17 (74%) out of 23 with type 1, 41 (80%) out of 51 with type 2, 1 out of 3 with type 3. Type 1 pattern was relatively specific (74%) but not sensitive (30%) for mesial TLE. Also the lesion location of neocortical TLE with type 1 onset was not limited to medial temporal area. 2) Scalp ictal EEG patterns were significantly correlated with surgical outcome only in the subgroup of mesial TLE (p=0.006) but not in neocortical TLE. Type 1 onset pattern in mesial TLE was associated with favorable outcome comparing to type 2 onset. CONCLUSIONS: Scalp ictal EEG onset pattern cannot accurately differentiate mesial TLE from neocortical TLE. However, its onset pattern can be predictive of surgical outcome.

The Pharmacokinetic Interaction and Therapeutic Plasma Concentration of Oxcarvazepine / 대한간질학회지

PURPOSE: Oxcarbazepine (OXC) is chemically related to carbamazepine (CBZ). OZC exerts less liver enzyme induction than CBZ and is completely metabolized by reduction to the active metabolite, 10, 11-dihydro-10-hydroxy-5H-dibenzo (b,f) azepine-5-carboxamide (MHD). It was known that OXC had no significant pharmacokinetic interactions with other antiepileptic drugs. But it is not thoroughly studied yet because of short duration of clinical application. We investigated whether the plasma concentration of OXC metabolite (MHD) is changed by valproic acid compared with OXC monotherapy and studied the correlation of the dose of OXC with the plasma concentration of its active metabolite (MHD). METHODS: The patient with OXC monotherapy (19 cases) and patients with OXC and valproic acid(16 cases) were incluses. We analyzed the level of its metabolites MHD by HPLC RESULTS: The plasma concerntration of MHD in OXC monotherapy is 15.5+/-3.2 microgram/ml and that of the MHD in polytherapy with valproic acid is 16.4+/-3.4 microgram/ml at the same dose of OXC. The plasma concentration of MHD is ranged from 7.4 microgram/ml at 600 mg/day of OXC to 27.0 microgram/ml at 1800 mg/day of OXC and highly correlated with OXC dose per body weight (r=0.72-84). CONCLUSION: There is no significant change or difference of MHD plasma concentraion between OXC monotherapy and polytherapy with valproic acid at the same dose of OXC. THe plasma concentration of MHD is highly correlated with OXC dose per body weight.

Cortical Dysplasia and Mesial Temporal Sclerosis in Temporal Lobe Epilepsy Pre-operative Clinical Feature and Surgical Outcome between Patients with Dual Pathology and Patients with Mesial Temporal Sclerosis

BACKGROUND: Mesial temporal sclerosis (MTS) is a well-known cause of temporal lobe epilepsy. Coexistence with cortical dysplasia (CD) has been reported, but its role is not well recognized. This study aims to determine whether there is any difference about clinical feature and surgical outcome between patients with MTS and coexistent CD (group 1) and patients with isolated MTS (group 2). METHODS: Retrospectively, surgical series of 45 patients (male:22, female:23) diagnosed as temporal lobe epilepsy were reviewed. We excluded patients who had another pathology (e. g., tumor, vascular malformation) except MTS or CD. The pathology, case histories, interictal EEG, and surgical outcome were compared. RESULTS: There was a tendency for group 1 patients to have earlier seizure onset age (10.9+/-6.35 versus 14.5+/-6.03, p=0.06) There was no statistically significant difference in the history of febrile convulsions (68.4% versus 53.8%, p>0.16) No statistically significant difference between groups were also found in disease duration, the head trauma/mental retardation history, seizure frequency, interictal EEG, and surgical outcome. CONCLUSIONS: CD in MTS appears to have an influence on seizure onset. The relationships among CD, febrile convulsion, and mesial temporal sclerosis must be more investigated.

Cortical Dysplasia and Mesial Temporal Sclerosis in Temporal Lobe Epilepsy Pre-operative Clinical Feature and Surgical Outcome between Patients with Dual Pathology and Patients with Mesial Temporal Sclerosis

BACKGROUND: Mesial temporal sclerosis (MTS) is a well-known cause of temporal lobe epilepsy. Coexistence with cortical dysplasia (CD) has been reported, but its role is not well recognized. This study aims to determine whether there is any difference about clinical feature and surgical outcome between patients with MTS and coexistent CD (group 1) and patients with isolated MTS (group 2). METHODS: Retrospectively, surgical series of 45 patients (male:22, female:23) diagnosed as temporal lobe epilepsy were reviewed. We excluded patients who had another pathology (e. g., tumor, vascular malformation) except MTS or CD. The pathology, case histories, interictal EEG, and surgical outcome were compared. RESULTS: There was a tendency for group 1 patients to have earlier seizure onset age (10.9+/-6.35 versus 14.5+/-6.03, p=0.06) There was no statistically significant difference in the history of febrile convulsions (68.4% versus 53.8%, p>0.16) No statistically significant difference between groups were also found in disease duration, the head trauma/mental retardation history, seizure frequency, interictal EEG, and surgical outcome. CONCLUSIONS: CD in MTS appears to have an influence on seizure onset. The relationships among CD, febrile convulsion, and mesial temporal sclerosis must be more investigated.

Comparison of factors related to persistent aura in TLE patients after temporal lobectomy

BACKGROUND: Persistent auras after temporal lobectomy may be bothersome to the patients even though they are seizure free. But most authors specifically are concerned about the seizure outcome itself. The aim of the present study was to investigate which factors are related to persistent auras in patients with temporal lobe epilepsy(TLE) after temporal lobectomy. METHODS: We have retrospectively analysed many factors in 38 TLE patients with aura. All patients underwent anterior temporal lobectomy with amygdalo-hippocampectomy. Twenty three patients were seizure and aura free (completely seizure-free) and 15 patients had persistent auras(persistent auras) in spite of seizure-free. Characteristics of auras, past medical history, presence of secondary GTC, seizure frequency, age of surgery, age of onset, duration of habitual seizure, ictal EEG pattern, and pre- and postoperative MRI findings were compared between group with completely seizure-free and group with persistent aura. RESULTS: Characteristics of aura, past medical history, presence of secondary GTC, seizure frequency, ictal EEG pattern, age of onset, and age of surgery had no statistical differences between both groups. Seizure duration of group with persistent aura seemed to be longer than that of group with completely seizure-free(13.6 years vs 17.0 years, median test, p=0.10) and remained hippocampus in postsurgical MRI seemed to be related to persistent auras(Fisher's exact test, p=0.06). CONCLUSIONS: We found that there were suggestive differences in seizure duration and remained hippocampus between the two groups.

A Case of Porphyria with reversible MRI findings

The porphyrias are inherited or acquired disorders of specific enzymes in the heme biosynthetic pathway. Porphyrias have diverse neurologic manifestations with unknown mechanism. Some authors have proposed ischemic vasculopathy as a cause of neurologic deficits, which was supported by reversible MRI lesions in porphyrias. We report a rare case with reversible MRI findings in porphyria. A 27-year-old woman was presented with seizures and hallucinations. MRI revealed multiple lesions of both hemispheres. After treatment, MRI lesions showed marked resolution of signal abnormalities.