Reducing VNS stimulation parameters: Is it safe?

Introduction Vagal nerve stimulation (VNS) is an adjuvant therapy used in the treatment of patients with refractory epilepsy who are not candidates for resective surgery or who have limited results after surgical procedures. Currently, there is enough evidence to support its use in patients with various types of epilepsy. Therefore, the present study was conducted to explore the possibility of optimizing therapy by reducing the consumption of the system's battery. Methods The prospective and double-blind analysis consisted in the evaluation of 6 patients submitted to VNS implantation for 3 months, followed by adjustment of the stimulation settings and continuity of follow-up for another month. The standard protocol was replaced by another with a frequency value of 20 Hz instead of 30 Hz to increase battery life. The safety of this procedure was evaluated through the assessment of two main variables: seizures and side effects. Results The stimulation at 20 Hz showed 68% reduction in the incidence of seizures (p»0.054) as well as low incidence of side effects. Conclusion The present study suggests that the reduction of the stimulation frequency from 30 to 20 Hz is a safe procedure, and it does not compromise the effectiveness of therapy.

La experiencia de pacientes con crisis no epilépticas psicógenas: marcos interpretativos y de acción / A experiência de pacientes com crises não epiléticas psicogênicas: marcos interpretativos e de ação / The experience of patients with psychogenic non epileptic seizures: interpretative and action framework / L´expérience des patients atteints de crise psychogène non épileptique: cadres dinterprétation et daction

Resumen La perspectiva del paciente se presenta como algo importante a tener en cuenta para la comprensión del padecimiento y para lograr un tratamiento efectivo. El objetivo de la presente investigación es indagar las trayectorias terapéuticas y las experiencias durante el recorrido terapéutico de pacientes con Crisis No Epilépticas Psicógenas (CNEP) pertenecientes a un Hospital General de la Ciudad Autónoma de Buenos Aires. Se realizaron entrevistas semiestructuradas a diez pacientes diagnosticados con CNEP. Para el análisis de los datos se utilizó una metodología cualitativa basada en los principios del análisis temático. Se ha identificado una categoría central: Itinerarios terapéuticos dentro del sistema etnomédico y tres subcategorías: (1) Diagnósticos Recibidos; (2) Recursos del sistema etnomédico y (3) Evaluaciones de los recursos utilizados. La dificultad de arribar a un diagnóstico y un tratamiento que permitiera mejorar las CNEP, así como el uso de distintas medicinas, fue destacada por la totalidad de los pacientes.

Resumo A perspectiva do paciente se apresenta como algo importante a levar em conta para a compreensão do sofrimento e para se alcançar um tratamento eficaz. O objetivo desta pesquisa é investigar as trajetórias terapêuticas e as experiências durante a jornada terapêutica de pacientes com crise não epilética psicogênica (CNEP) de um Hospital Geral da Cidade Autônoma de Buenos Aires. Entrevistas semiestruturadas foram realizadas com dez pacientes com diagnóstico de CNEP. Para a análise dos dados, utilizou-se metodologia qualitativa baseada nos princípios da análise temática. Uma categoria central foi identificada: Itinerários terapêuticos dentro do sistema etnomédico; e três subcategorias: (1) Diagnósticos recebidos; (2) Recursos do sistema etnomédico; e (3) Avaliações dos recursos utilizados. A dificuldade de se chegar a um diagnóstico e a um tratamento que permitisse melhorar a CNEP, bem como o uso de diferentes medicamentos, foi destacada por todos os pacientes.

Abstract The patient's perspective is essential to understand their condition and to achieve an effective treatment. The objective of this paper is to investigate the therapeutic trajectories and experiences of patients with Psychogenic Non-Epileptic Crisis (PNES) under treatment in a General Hospital of the Autonomous City of Buenos Aires. Semi-structured interviews were conducted with ten patients diagnosed with PNES. For data analysis, a qualitative methodology based on thematic analysis was adopted. A central category has been identified: Therapeutic Itineraries within the Ethnomedical System, and three subcategories: (1) Diagnoses received; (2) Resources of the ethnomedical system; and (3) Evaluation of the resources used. The difficulty of finding a diagnosis, a treatment to improve PNES, and proper medicine were highlighted by all the patients.

Résumé Le point de vue du patient est présenté comme quelque chose d'important à prendre en compte afin de comprendre la maladie et d'obtenir un traitement efficace. L'objectif de cette recherche est d'analyser les trajectoires thérapeutiques et les expériences au cours du parcours thérapeutique des patients atteints de Crise Psychogénique Non Épileptique (CPNE) dans un hôpital général de la ville de Buenos Aires. Des entretiens semi-structurés ont été menés auprès de 10 patients diagnostiqués avec une CPNE. Pour l'analyse des données, une méthodologie qualitative basée sur les principes de l'analyse thématique a été utilisée. Une catégorie centrale a été identifiée : Les itinéraires thérapeutiques au sein du système ethno-médical et trois sous-catégories : (1) Diagnostics reçus ; (2) Ressources du système ethno-médical ; et (3) Évaluations des ressources utilisées. La difficulté d'arriver à un diagnostic et à un traitement permettant d'améliorer la CPNE, ainsi que l'utilisation de médicaments différents, a été soulignée par l'ensemble des patients.

Aneurysmal subarachnoid hemorrhage: current concepts and updates / Hemorragia subaracnoidea aneurismática: conceitos atuais

ABSTRACT Aneurysmal subarachnoid hemorrhage is a condition with a considerable incidence variation worldwide. In Brazil, the exact epidemiology of aneurysmal SAH is unknown. The most common presenting symptom is headache, usually described as the worst headache ever felt. Head computed tomography, when performed within six hours of the ictus, has a sensitivity of nearly 100%. It is important to classify the hemorrhage based on clinical and imaging features as a way to standardize communication. Classification also has prognostic value. In order to prevent rebleeding, there still is controversy regarding the ideal blood pressure levels and the use of antifibrinolytic therapy. The importance of definitely securing the aneurysm by endovascular coiling or surgical clipping cannot be overemphasized. Hydrocephalus, seizures, and intracranial pressure should also be managed. Delayed cerebral ischemia is a severe complication that should be prevented and treated aggressively. Systemic complications including cardiac and pulmonary issues, sodium abnormalities, fever, and thromboembolism frequently happen and may have na impact upon prognosis, requiring proper management.

RESUMO Hemorragia subaracnoidea aneurismática (aHSA) é uma condição com grande variação de incidência mundialmente. No Brasil, não dispomos de números epidemiológicos exatos. A apresentação clínica mais comum da HSA é a cefaleia, usualmente descrita como a pior da vida. A tomografia de crânio, quando feita nas primeiras 6 horas do ictus, tem uma sensibilidade próxima a 100%. É importante classificar a hemorragia utilizando escalas clínicas e radiológicas, como forma de padronizar a comunicação, e também predizer prognóstico. Para prevenção de ressangramento, ainda há controvérsias quanto aos níveis pressóricos ideais e uso de antifibrinolíticos. O tratamento definitivo do aneurisma, por sua vez, é fundamental, seja por meio endovascular ou cirúrgico. Hidrocefalia, crises epilépticas e a pressão intracraniana devem ser manejadas de forma apropriada. Isquemia cerebral tardia é uma complicação grave que deve ser prevenida e tratada agressivamente. Complicações sistêmicas, incluindo cardíacas, pulmonares, anormalidades de sódio, febre e tromboembolismo ocorrem frequentemente e podem ter impacto no prognóstico, necessitando de manejo adequado.

Epilepsias de origen metabólico en el neonato / Epilepsias de origen metabólico en el neonato

Las enfermedades neurometabólicas que manifiestan convulsiones y epilepsia constituyen un amplio grupo de trastornos hereditarios. Se pueden presentar a cualquier edad desde el período neonatal hasta la adolescencia. Las manifestaciones epilépticas pueden ser muy variadas y, en general, se trata de epilepsias refractarias a los fármacos antiepilépticos. La fenomenología epiléptica no contribuye al diagnóstico. Se deben conocer los errores innatos del metabolismo que responden al empleo de cofactores. En descompensaciones agudas es fundamental dar soporte nutricional, hidroelectrolítico y respiratorio. Es muy posible que en pocos años se pueda conocer el perfil metabolómico de estas enfermedades y así profundizar en el diagnóstico no invasivo y ofrecer mayores posibilidades terapéuticas para la epilepsia y especialmente para la enfermedad de base. No debemos olvidar los desórdenes metabólicos transitorios y los desequilibrios hidroelectrolíticos dentro de las causas de las convulsiones, en especial en el período neonatal, que se deben identificar y tratar precozmente para evitar daños mayores.

Neurometabolic diseases that manifest seizures and epilepsy are a large group of inherited disorders. They can present at any age from the neonatal period to adolescence. The epileptic manifestations can be very varied and, in general, they are epilepsies refractory to antiepileptic drugs. Epileptic phenomenology does not contribute to the diagnosis. The inborn errors of metabolism that respond to the use of cofactors should be known. In acute decompensation, it is essential to provide nutritional, hydroelectrolytic and respiratory support. It is possible that in a few years we can detect the metabolomic profile of these diseases, thus knowing better the diagnosis non-invasively and offering greater therapeutic possibilities for their epilepsy and especially for the underlying disease. We must not forget the transitory metabolic disorders and the electrolyte imbalances within the causes of seizures, especially in the neonatal period, and must be identified and treated early to avoid major damages.

Effects of low frequency stimulation on spontaneous inhibitory and excitatory post-synaptic currents in hippocampal CA1 pyramidal cells of kindled rats

Objective: Low-frequency stimulation [LFS] exerts suppressive effects in kindled animals. It is believed that overstimulated glutamatergic and decreased GABAergic transmission have long been associated with seizure activity. In this study, we investigated the effect of electrical LFS on different parameters of spontaneous excitatory and inhibitory post-synaptic currents [sEPSCs and sIPSCs] in hippocampal CA1 pyramidal cells in kindled animals

Materials and Methods: In this experimental study, rats were kindled by electrical stimulation of the hippocampal CA1 area in a semi-rapid manner [12 stimulations/day]. The animals were considered fully kindled when they showed stage 5 seizures on three consecutive days. One group of animals received LFS 4 times at 30 seconds, 6 hours, 18 and 24 hours following the last kindling stimulation. Each LFS consisted of 4 packages at 5 minutes intervals. Each package of LFS consisted of 200 pulses at 1 Hz and each monophasic square wave pulse duration was 0.1 millisecond. At 2-3 hours post-LFS, acute hippocampal slices were prepared and a whole cell patch clamp recording was performed in all animals to measure the different parameters of sEPSCs and sIPSCs

Results: In kindled animals, the inter-event interval [as an index of occurrence] of sEPSCs decreased, whereas sIPSC increased. In addition, the decay time constant of sIPSCs as an index of the duration of its activity decreased compared to the control group. There was no significant difference in other parameters between the kindled and control groups. Application of LFS in kindled animals prevented the observed changes. There was no significant difference between the measured parameters in kindled+LFS and control groups

Conclusion: LFS application may prevent seizure-induced increase in the occurrence of sEPSCs and seizure-induced decrease in occurrence and activity duration of sIPSCs

GC­MS Profile, Anti-Seizure and Anti-Pyretic Activities of Palm Kernel Nut Oil and its Isolate, N-Octanoic Acid from Specially Breed Palm Kernel Elaeis Guineensis

PURPOSE: Palm kernel nut oil(PKNO) from palm fruit of a rare breed of Elaeis guineensis (virescens), and one of the species belonging to the Elaeis genre of arecaceae family was subjected to Gas chromatography - Mass spectroscopic studies as well as anti-seizure and anti-pyretic studies. It is used in South-Eastern part of Nigeria as antipyretic and anti-seizure agents especially in children. The aim of this study was to evaluate the chemical contents of PKNO using GC-MS and to investigate the antiseizure and antipyretic properties of PKNO using animal model.METHOD: 1500 g Palm Kernels (PK) of the rare breed collected from Abia State were cracked open and the nuts (1000 g) poured into steel vessel and heated until oil was produced after charring the nuts. The oil (PKNO) was analyzed using GC-MS to determine its chemical composition. Yeast induced hyperthermia method was used for anti-pyretic studies while strychnine sulphate induced method was used for anti-seizure studies. PKNO and Octanoic acid (0.5 mg/kg ,1 mg/kg, 2 mg/kg) were administered intraperitoneally (IP).Paracetamol (0.15mg/kg) was used as reference standard for anti-pyretic assay while epilim and tegretol (0.14mg/kg, resp.) were used as reference standards for anti-seizure assay.RESULTS: The major component identified in the extract include: Dodecanoic acid,2,3-dihydroxypropyl ester(19.36 %),n-Hexadecanoic acid(15.49 %),Dodecanoic acid( 12.51 %),Myristic acid ( 6.47 %), Dodecanedioic acid (3.93 %),n-Acetylpyrrolidone (3.67 %) , Thiazole (0.98 %) and Octanoic acid, OA( 3.19 %).The anti-seizure results showed that doses of PKNO and OA used had Significant (p<0.02) anti-seizure activities by delaying the on-set of seizure from time of induction to time of first seizure observed. In yeast induced hyperthermia model, PKNO exhibited good level of anti-pyretic activities by direct reduction of pyrexia with the highest dose, 2.0 mg/kg. The PKNO and OA are proven to be safe till 3000 µl/kg as indicated by LD50 results.CONCLUSION: PKNO and its components mainly fatty acids, thiazole, and n- acetylpyrrolidone are potent and promising agents with anti-pyretic and antiseizure activities

People with psychogenic non-epileptic seizures: a South African perspective

Background: Psychogenic non-epileptic seizures (PNES) is a disabling disorder which has a negative effect on the quality of life of individuals with PNES. A clear understanding of the disorder is necessary; however, to date, research about PNES in South Africa is limited. Objectives: The aims of this study were to explore the demographic variables of individuals with PNES in South Africa, to review the available body of research on PNES, and to compare it with our results. Method: Twenty-two people with PNES, with confirmed video EEG, were recruited by means of convenience sampling from two hospitals. Descriptive statistics were used to describe the demographic variables of the participants. Results: Internationally comparable results revealed misdiagnoses and low treatment delivery amongst a primarily female population.Conclusion: This study provided greater insight into individuals with PNES in South Africa, highlighting the need for more information, support, effective treatment and accurate diagnosis of PNES

Psychogenic non-epileptic seizures and psychoanalytical treatment: results / Crises não epilépticas psicogênicas e tratamento psicanalítico: resultados.

Background: the occurrence of psychogenic non-epileptic seizures (PNES) is estimated to be between 2 to 33 cases in every 100,000 inhabitants. The number of patients with PNES reaches 19% of those treated as epileptics. Patients with PNES are treated as if they had intractable epilepsy, with unsatisfactory results even after medication treatment is used to its maximum. The aim of this study is to present the effects of individual psychoanalytical treatment in patients with PNES, assessing its impact in the evolution of the clinical picture and its association with sex, time of disease, social, psychological and professional harm, as well as going through with treatment. Methods: The case base was composed of 37 patients with PNES. The diagnosis was reached with video-EEG monitoring. Psychoanalytical treatment was carried out through 12 months of weekly sessions timed for around 50-minutes each, in a total of 48 individual sessions. Results: This study found a high rate of success in the treatment of PNES patients. 29.7% (n=11) of patients had cessation or cure of symptoms and 51.4% (n=19) had a decrease in the number of episodes. There is an association between cessation or decrease in the number of episodes and sex (p<0.01), religion (p<0.01) and concluding treatment (p<0.01). Conclusion: Individual psychoanalytical treatment applied to patients with PNES is considered effective and can be an essential form of assistance for the reduction or cessation of episodes. .

Introdução: estima-se que o número de casos de pacientes com crises não epilépticas psicogênicas (CNEP) seja de 2 a 33 por 100 mil habitantes. O índice de CNEP corresponde ainda a, aproximadamente, 19% dos pacientes tratados como epilépticos. Os pacientes com CNEP são tratados como portadores de epilepsia refratária, chegando ao limite máximo do tratamento medicamentoso e sem a obtenção de resultados satisfatórios. Objetivo: relatar os efeitos do tratamento psicanalítico individual em pacientes com CNEP de forma a avaliar a evolução do quadro clínico de CNEP e verificar sua associação com gênero, tempo de crise, prejuízos sociais, afetivos e profissionais, bem como término do tratamento. Métodos: a casuística foi composta por 37 pacientes com diagnóstico de CNEP feito por meio da monitoração por vídeo-EEG. Foram realizadas sessões de tratamento psicanalítico: atendimento clínico individual com frequência semanal, com duração aproximada de 50 minutos e duração total de 48 sessões em 12 meses. Resultados: este estudo constatou elevado índice de sucesso no tratamento dos pacientes com CNEP: 29,7% (n = 11) de cessação/cura dos sintomas e 51,4% (n = 19) de redução das crises convulsivas. Foi constatada associação entre cessar ou reduzir as crises e gênero (p<0,01), religião (p<0,01) e término do tratamento (p<0,01). Conclusão: este estudo apontou eficácia do tratamento psicanalítico individual realizado com pacientes com CNEP, podendo ser considerada uma forma de assistência essencial para que haja decréscimo ou cessação das crises. .

Crisis no epilépticas de origen psicógeno. Diagnóstico diferencial con la epilepsia, presentación clínica y abordaje terapéutico / [Psychogenic non-epileptic seizures. Differential diagnosis with epilepsy, clinical presentation and therapeutic approach].

The current term psychogenic non-epileptic seizures were coined by contemporary neurologists and epileptologists, since the implementation of Video electroencephalogram, considered today the gold standard diagnostic tool. Patients with psychogenic non-epileptic seizures comprise a heterogeneous group from the psychiatric point of view. The diagnosis that describes the psychogenic non-epileptic seizures is "conversion disorder", often associated with dissociative disorder. These disorders are frequently co-morbid with depression, anxiety and posttraumatic stress disorder. Furthermore, usually coexist with personality disorders, especially borderline personality disorder, although dependence personality disorder has also been described. A history of trauma is very important in the pathogenesis and development of psychogenic non-epileptic seizures. The symptoms "core" of the psychogenic non-epileptic seizures (conversion and dissociation), some co-morbidities and personality disorders are treated with psychotherapy, while psychotropic drugs are used for co-morbidities such as depression and posttraumatic stress disorder.

Efeitos do tratamento psicanalítico em pacientes com crises não epilépticas psicogênicas / Effects of psychoanalytical treatment in patients with psychogenic non-epileptic seizures

As crises não epilépticas psicogênicas (CNEP) podem ser definidas como episódios de alteração de movimentos, sensações ou experiência similar à epilepsia causada por processo psicológico e sem associação com descarga elétrica cerebral anormal. Estima-se que o número de casos de pacientes com CNEP seja de 2 a 33 por 100.000 habitantes. O índice de CNEP corresponde ainda a aproximadamente 5% dos pacientes tratados como epilépticos. Os pacientes com CNEP são tratados como possuindo epilepsia refratária, chegando ao limite máximo do tratamento medicamentoso e sem a obtenção de resultados satisfatórios. Objetivos: relatar os efeitos do tratamento psicanalítico individual em pacientes com CNEP. Método: A casuística foi composta por 37 pacientes com diagnóstico prévio de CNEP realizado por meio da monitorização por vídeo-EEG. Foram realizadas sessões individuais de tratamento psicanalítico, com frequência semanal, com duração aproximada de 50 minutos e duração total de 48 sessões em 12 meses. Resultados: Este estudo constatou elevado índice de sucesso no tratamento dos pacientes com CNEP: 29,7% (n=11) de cessação/cura dos sintomas e 51,4% (n=19) redução das crises convulsivas. Foi constatada associação entre cessar ou reduzir as crises e sexo (p < 0,01), religião (p < 0,01) e término do tratamento (p < 0,01). Conclusão: Este estudo apontou a eficácia do tratamento psicanalítico individual realizado com pacientes com CNEP, podendo ser considerada uma forma de assistência essencial para que haja decréscimo ou cessação das crises.

Psychogenic non-epileptic seizures (PNES) can be defined as episodes of alteration of movement, feeling or a similar experience to epilepsy caused by a psychological process and with no association with abnormal electrical discharges in the brain. It is estimated that the number of cases of patients with CNEP is from 2 to 33 in 100.000 inhabitants. The number of patients with PNES reaches 5% of those treated as epileptics. Patients with PNES are treated as if they had intractable epilepsy, with unsatisfactory results even after medication treatment is used to its maximum limits. Objectives: to present the effects of individual psychoanalytical treatment in patients with PNES. Methods: The case base was composed of 37 patients with PNES. The diagnosis was reached with video-EEG monitoring. . Psychoanalytical treatment was carried out through 12 months of weekly sessions of around 50-minutes each, in a total of 48 individual sessions. Results: This study found a high success rate in the treatment of PNES patients. 29,7% (n=11) of patients saw cessation or cure of symptoms and 51,4% (n=19) saw a decrease in the number of episodes. There is an association between cessation or decrease in the number of episodes and sex (p < 0,01), religion (p < 0,01) and concluding treatment (p < 0,01). Conclusions: Individual psychoanalytical treatment applied to patients with PNES is considered effective and can be considered as an essential form of assistance for the reduction of cessation of episodes. Psychogenic non-epileptic seizures, Conversion disorder, Psychoanalysis, Treatment.

Convulsões tardias após herniotomia inguinal em bebê prematuro: relato de caso / Delayed onset seizures after inguinal herniotomy in a premature infant: a case report

Relatamos um caso de recém-nascido prematuro, nascido com 34 semanas e operado com seis semanas de idade, que desenvolveu convulsões, aparentemente inexplicáveis, dez horas após o final da cirurgia sob injeção única de analgesia epidural caudal com bupivacaína e lidocaína combinadas com anestesia geral.

We report a case of a premature neonate born at 34 weeks and operated at 6 weeks of age developing unexplained seizures 10 hours after the end of surgery under single shot caudal epidural analgesia with bupivacaine and lidocaine combined with general anesthesia.

Relatamos aquí, el caso de un recién nacido prematuro, con 34 semanas, y operado con seis semanas de edad, que desarrolló convulsiones, aparentemente inexplicables, diez horas después del final de la cirugía bajo la inyección única de analgesia epidural caudal con bupivacaína y xilocaína combinadas con la anestesia general.

[Investigating the anti-epileptic and sedative effects of hydroalcoholic extract of Melissa officinalis [Lemon balm] leaf on pentylenetetrazol induced epileptiform seizures in wistar rat]

Since long lasting administration of anti-seizure drugs produces undesirable side effects, many efforts have been made during recent decades to find and replace the chemical drugs by medicinal plants. The aim of present study was to study the antiepileptic [anti-seizure] effects of hydroalcoholic extract of Melissa officinalis on experimental epileptiform seizures, induced by pentylenetetrazol [PTZ] in Wistar rat. After normalization, rats in experimental groups 1, 2 and 3 were injected [i.p] 50, 80 and 120 mg/kg hydroalcoholic extract of Melissa officinalis, respectively. Control animals were injected extract solvent as the same manner. After 30 minutes all rats were injected [i.p] 80 mg/kg PTZ and then examined for epileptiform behaviors for the next 60 minutes. The rate of mortality during the next 24 hour was also recorded. In comparison with control group, in all experimental groups the latent period of tonic-clonic generalized seizure was significantly [P < 0.05] increased. Moreover, the mortality rate was decreased from 90% in control group to 30, 50 and 60% in experimental groups 1, 2 and 3, respectively. It can be concluded that hydroalcoholic extract of Melissa officinalis has potential sedative and anticonvulsant effects and probably exerts its effects through GABAergic system

Advanced understanding in mechanisms of epilepsy and potential new treatment strategies

Over the last 25 years, neurobiologists have begun to unravel the cellular mechanisms that underlie epileptiform activity. Such investigations have two main objectives: [1] to develop new methods for treating, [curing], or preventing epilepsy; and [2] to learn more about the normal functioning of the human brain, at the cellular/molecular and neurological/psychological levels by analyzing abnormal brain functioning. The electroencephalogram [EF.G] spike is a marker for the hyperexcitable cortex and arises in or near an area with a high epileptogenic potential. The depolarizing shift [DS] that underlies the interictal discharge [ID] appears to be generated by a combination of excitatory synaptic currents and intrinsic voltage-dependent membrane currents. The hyperpolarization that follows the DS [post-DS-1 IT] hunts ID duration, determines ID frequency, and prevents ID deterioration into seizures. The disappearance of the post-DS I IP in some models is related to the onset of seizures and the spread of epileptiform activity. During the transition to seizures, the usually self-limited ID spreads in time and anatomical space. Several processes may intervene in the pathophysiolpgical dysfunction. These include enhancing GABA-mediated inhibition, dampening NMDA-mediated excitability, interfering with specific Ca[2+] currents in central neurons, and perhaps stimulating [gating] pathways

Comportamiento del estatus convulsivo en niños atendidos en la UCI-P del Hospital Fernando Vélez Paiz de enero 2008-diciembre 2009 / Convulsive status behavior in children treated at the ICU-P Fernando Velez Paiz Hospital January 2008-December 2009

El estudio realizado en niños con Estatus Convulsivo ingresados en la UCIP del HFVP de Enero 2008- Diciembre 2009 la muestra fue de 16 pacientes.En relación a la edad y el sexo, el grupo etareo más afectado fue de 1- 5 años con 58%(9), siendo 6(38%) masculino y 19%(3) femeninas, seguido del 6-10 años con el 19%, de estos13%(2) masculino y 6%(1) femenino.Al revisar los antecedentes patológicos personales el 38%(6) tenía antecedentes de convulsión febril, Epilepsia 25%(5) y el 13%(2) asfixia perinatal. La principal etiología del EC fue la Epilepsia en 44%(7), seguida de la supresión del tratamiento anticonvulsivante y la fiebre en un 25% respectivamente. En el tratamiento se utilizó la Difenilhidantoina en 15 pacientes, la dosis de impregnación fue 18-20 mg/kg en el 80%(12), el Fenobarbital se utilizó en 3 pacientes, con dosis de impregnación de 10mg/kg/d en el 60% de los pacientes que se uso. En el tratamiento de mantenimiento el fármaco más utilizado fue la Difenilhidantoina en 12 pacientes, a dosis 5mg/kg/día en el 75%, seguido del Acido Valproico en 7 pacientes a dosis de 15 mg/kg/día y Fenobarbital en 4 pacientes a dosis 5mg/kg/día .La ventilación mecánica se utilizó en 5 pacientes, de estos el 40% estuvo 4-6 días con soporte ventilatorios.Dentro de los estudios complementarios realizados en los pacientescon estatus convulsivo: al 75% se les realizó Ionograma encontrando Hipocalcemia en el 44%(7), e Hiponatremia e hipernatremia en el 13%(2) de los casos respectivamente.Se presentaron complicaciones en 7 pacientes, y la complicación que se presento con mayor frecuencia fue las alteraciones electrolíticas en el 50%(7), seguida del edema cerebral 35%(5), la hemorragia intracraneal y el infarto isquémico en el 7% respectivamente.La condición de egreso el 100% de los pacientes estudiados fue dado de alta y de estos el 88%(14) no presento ninguna secuela, solo el 13%(2) presentó secuelas dentro de ellas hemiparesias e hipotonía.

Ações neuroprotetoras da vitamina C no corpo estriado de ratos após convulsões induzidas pela pilocarpina / Neuroprotective actions of vitamin C in rat striatum after pilocarpine-induced seizures

CONTEXTO: As convulsões podem produzir danos neuronais em diversas áreas e, especialmente, nas estruturas límbicas. OBJETIVOS: O objetivo do presente trabalho foi estudar os efeitos neuroprotetores da vitamina C nas alterações histopatológicas observadas no corpo estriado de ratos convulsivos. MATERIAL E MÉTODOS: Foram utilizados ratos Wistar adultos. Os animais foram divididos em quatro grupos. O primeiro grupo foi tratado com salina 0,9 por cento (grupo controle) e o segundo, com pilocarpina (400 mg/kg, grupo P400). Já o terceiro e o quarto grupo foram tratados com vitamina C (250 mg/kg), e, 30 minutos depois, receberam P400 (grupo VIT C + P400) ou solução salina 0,9 por cento (grupo VIT C), respectivamente. Após os tratamentos, todos os grupos foram observados por 24 horas e, em seguida, sacrificados e seus cérebros removidos para as análises histopatológicas. RESULTADOS: O grupo P400 apresentou convulsões que progrediram para o estado epiléptico em 75 por cento dos animais. O pré-tratamento com vitamina C produziu uma redução de 35 por cento nesse índice. Os grupos P400 e VIT C + P400 apresentaram 80 por cento e 20 por cento de animais com lesão cerebral, respectivamente. No corpo estriado dos animais do grupo P400, houve um comprometimento de 50 por cento. Por sua vez, na região estriatal dos animais do grupo VIT C + P400 foi vista uma redução de 40 por cento nesse comprometimento. DISCUSSÃO: As convulsões induzidas pela pilocarpina são instaladas pelo sistema colinérgico e propagadas pela produção de radicais livres e pelo sistema glutamatérgico, resultado no desenvolvimento de dano cerebral. As drogas antioxidantes podem apresentar um potencial terapêutico para pacientes epilépticos na proteção contra as lesões cerebrais por meio da remoção desses radicais livres formados. Acredita-se, assim, que a vitamina C pode influenciar a epileptogênese e promover ações neuroprotetoras durante as convulsões.

BACKGROUND: Seizures may produce neuronal damage in several areas and especially in limbic structures. OBJECTIVES: This study aimed to evaluate the neuroprotective effects of vitamin C in the histopathological changes observed in rat striatum after seizures. MATERIAL AND METHODS: Healthy Wistar rats were divided into four groups. The first group was treated with 0.9 percent saline (control group) and the second one with pilocarpine (400 mg/kg, P400 group). Third and fourth groups were treated with vitamin C (250 mg/kg), 30 minutes before receiving P400 (P400 + VIT C group) or 0.9 percent saline (VIT C group), respectively. After the treatments, all groups were observed for 24 hours, sacrificed and dissected out to remove their brains for histopathological analysis. RESULTS: The group P400 presented seizures that progressed to status epilepticus in 75 percent of the animals. Pretreatment with vitamin C produced a 35 percent reduction in this index. P400 and P400 + VIT C groups revealed 80 percent and 20 percent of animals with brain injury, respectively. In P400 group, lesion severity of the striatum was 50 percent. In turn, in striatal region of animals treated with P400 + VIT C group, we detected a reduction of 40 percent in the severity degree. DISCUSSION: Pilocarpine-induced seizures are installed by the cholinergic system and propagated by free radicals and by glutamatergic system, leading to brain damage. The antioxidant drugs may have therapeutic potential for epileptic patients to protect against brain injure through removing free radicals produced, suggesting that vitamin C may influence epileptogenesis and promote neuroprotective actions during seizures.

Status epilepticus en el embarazo: un estudio en diez casos / Status epilepticus in pregnancy: study of ten cases

Evaluar la influencia del status epilepticus en la evolución del embarazo y en el recién nacido. Estudiamos las embarazadas hospitalizadas por status epilepticus, entre los años 1998 y 2004. En todas evaluamos historia de epilepsia, historia obstétrica y la salud de los recién nacidos. Maternidad “Concepción Palacios ”. Caracas. Se incluyeron diez episodios de status epilepticus en ocho embarazadas, la mayoría multigrávidas. El 50 por ciento ocurrieron en el tercer trimestre, 40 por ciento en el segundo y sólo un caso,10 por ciento, en el primero. En el 50 por ciento de los episodios el factor desencadenante fue el incumplimiento, o el abandono del tratamiento. Se practicó cesárea en el 71,5 por ciento de los nacimientos vivos, por sufrimiento fetal o causas obstétricas. Siete mujeres parieron ocho niños; uno murió en la Unidad de Cuidados Intensivos Neonatales por insuficiencia respiratoria severa. Ningún recién nacido tuvo malformaciones al nacer. Probablemente el factor desencadenante más importante del status epilepticus en el embarazo es el incumplimiento o abandono del tratamiento. El predominio en el tercer trimestre sugiere la necesidad de un control clínico más cuidadoso durante este período. Las embarazadas con status epilepticus deben ser tratadas vigorosamente para controlar las convulsiones, mientras se permite continuar el embarazo. Si se indica una cesárea ha de ser por causas fetales u obstétricas, no como medio para controlar las convulsiones.

Crises não-epilépticas: clínica e terapêutica / Nonepileptic seizures: clinical features and therapeutics

Discutir as crises ou os eventos paroxísticos que simulem crises epilépticas, enfatizando as diferenças semiológicas entre elas e as perspectivas terapêuticas. Realizamos uma revisão da literatura, selecionando artigos nas bases de dados Medline e Bireme, a partir dos unitermos: "non-epileptic seizures", "psychogenic seizures". As crises não-epilépticas (CNE) podem ser classificadas em fisiológicas (síncope, migrânea, ataque isquêmico transitório) e em psicogênicas (voluntárias ou não). O padrão-ouro para a diferenciação entre as crises epilépticas e as CNE é o videoeletroencefalograma, mas vários dados semiológicos podem auxiliar esse processo. O tratamento das CNE baseia-se em psicoterapia e em farmacoterapia direcionadas aos transtornos psiquiátricos comórbidos. Apesar de a alta prevalência das CNE e de sua elevada morbidade, são escassos os estudos na literatura nacional. São muitos os desafios diagnósticos e terapêuticos. Assim, o psiquiatra atentar-se à sua ocorrência, evitando iatrogenia, como o uso desnecessário de drogas antiepilépticas.

To discuss paroxysmal events that mimic epileptic seizures with emphasis on their semiologic differences and therapeutic perspectives. We did a narrative review of the literature based on selected papers in Medline and Bireme after searching for the uniterms "non-epileptic seizures" and "psychogenic seizures". Nonepileptic seizures (NES) can be classified in physiological (syncope, migraine, transitory ischemic attack) and psychogenic (voluntary or involuntary). The gold-standard in the differentiation of epileptic and nonepileptic seizures is the video-electroencefalogram, but many semiologic features can contribute to this process. The treatment of NES is based mainly on psychotherapy and pharmacotherapy directed to comorbid psychiatric disorders. Despite the high prevalence and elevated morbidity of the NES, there are just few studies on this subject in the Brazilian literature. There are many diagnostic and therapeutic challenges related to NES. Hence, psychiatrists should be aware of the occurrence of NES, avoiding iatrogenic interventions such as the unnecessary administration of anti-epileptic drugs.

O advento do tratamento psiquiátrico moderno: a terapia convulsiva de László Meduna / Lessons from an early account of convulsive therapy

A terapia convulsiva (TC) constitui uma das principais contribuições européias ao tratamento psiquiátrico moderno e à psiquiatria biológica. A TC foi introduzida na psiquiatria em 1934 por László Meduna, neuropsiquiatra húngaro. As publicações subseqüentes sobre o primeiro paciente tratado com TC, Zoltán L (ZL), baseiam-se nos artigos e na autobiografia de Meduna. De acordo com essas referências, após quatro anos de estupor catatônico, ZL recebeu TC induzida por cânfora que resultou em plena remissão dos sintomas esquizofrênicos, culminando com alta da instituição. Este artigo reconstrói a história do caso de ZL a partir da recente recuperação de anotações - algumas escritas pelo próprio Meduna - dos Arquivos do Instituto Nacional de Psiquiatria e Neurologia (Hungria). Essas anotações mostram que ZL recebeu repetidas sessões de TC entre 1934 e 1937, primeiramente induzidas por cânfora e depois por cardiazol. A primeira série de TC resultou na suspensão do estupor catatônico e na remissão parcial da psicose. Entretanto, a remissão foi breve e, a despeito de repetidas sessões de TC, ZL nunca esteve inteiramente livre de sintomas, nunca teve alta hospitalar e veio a falecer no Instituto em 1945. Na discussão do caso de ZL, tentamos explicar as possíveis razões das discrepâncias entre o relato de Meduna e as notas originais do prontuário médico.

Convulsive therapy (COT) is a major European contribution to the psychiatric armamentarium and biological psychiatry. COT was introduced in psychiatry by László Meduna, a Hungarian neuropsychiatrist. All subsequent publications about the first patient treated with COT, Zoltán L (ZL), were based on Meduna's papers and autobiography. After 4 years of catatonic stupor, ZL received camphor-induced COT which resulted in full remission and discharge from the institution. The aim of this paper is to reconstruct ZL's case history from the original case notes-partly written by Meduna himself-which were recovered from the archives of the National Institute of Psychiatry and Neurology. The case notes show that ZL repeatedly received COT between 1934 and 1937, first with camphor and then with cardiazol induction. After the first course of COT the catatonic stupor was resolved and the psychotic symptoms subsided. However, the remission lasted for only a few months and was followed by a relapse. Despite repeated courses of COT, ZL never became symptom free again, was never discharged and died in the Institute in 1945. This historical case is discussed from both the diagnostic and therapeutic points of view, and an attempt is made to explain the possible reasons for the discrepancies found between Meduna's account and ZL's case notes.

Optimización de la provisión y uso racional de anticonvulsivantes en pacientes del INPRO (Instituto Nacional de Protección a Personas Excepcionales) / Optimization of the supply and rational utilization of anticonvulsionants in INPRO patients

Objetivo: Optimizar la provisión y uso racional de anticonvulsivantes en pacientes de 20 a 40 años de edad que concurren al Instituto Nacional de Protección a Personas Excepcionales en el primer semestre del año 2007. Estudio descriptivo de corte transversal realizado a 139 pacientes de ambos sexos que padecen de convulsiones y que consumen anticonvulsivantes. De acuerdo al número total de pacientes estudiados el 59% de la población utiliza como fármacos anticonvulsivantes la carbamazepina, el 22% fenobarbital y 19% fenitoina. Teniendo en cuenta el factor sexo, el 73% corresponde al masculino y el 66% al femenino. A través de la investigación se detectó que se carece de varios puntos importantes a tener en cuenta para el manejo de anticonvulsivantes en la población en estudio, como: la información del paciente, plan de tratamiento de la convulsión, entre otros. Debido a estas carencias se recomienda informatización del sistema y el mejoramiento de cada paciente con la finalidad de que el médico como el paciente se sientan seguros del tratamiento indicado.