Midline spikes.

Midline spikes are characterized by spike foci recorded at Cz, Fz, or Pz with amplitude ranging from 20 to 350 microvolts. Out of 7,929 EEGs performed at the Neurodiagnostics Laboratory, Kaiser Permanente Medical Center, Anaheim, California, between 1996 and 2006, 17 EEGs (0.21%) were identified as having interictal midline spikes with or without other epileptiform discharges. Eight EEGs showed midline spikes at Cz, 2 at Fz, 2 at Cz and Fz, 1 at Cz and C3, 1 at Cz, C3, and P3, 1 at Cz and F8, 1 at Cz and T4, and 1 at Cz with 2 Hz generalized spike and slow wave complex. Midline spikes were recorded in 10 males and 7 females. The age ranged from 4 days to 38-years-old with a mean age of 10.8 years. Twelve patients (70.6%) were children. Twelve patients (70.6%) had generalized tonic-clonic seizures and 5 had partial motor seizures. Of the 17 patients, 14 had no known causes, 1 had an agenesis of corpus callosum, 1 had a left frontal arteriovenous malformation, and 1 had a left frontal area stroke. We postulate that the mechanism for the genesis of midline spikes may be heterogeneous. Midline spikes may be triggered by thalamocortical network in a generalized tonic-clonic seizure, or may originate in the parasagittal cortex in a partial motor seizure.

Measures of psychopathology in children with complex partial seizures and primary generalized epilepsy with absence.

OBJECTIVE: This investigation examined psychopathology in 48 children with complex partial seizures (CPS), 39 children with primary generalized epilepsy with absence (PGE), and 59 nonepileptic children, aged 5 to 16 years, by comparing the Child Behavior Checklist (CBCL) and the Schedule for Affective Disorders and Schizophrenia for School-Age Children (K-SADS). METHOD: The CBCL was completed by parents and the K-SADS was administered to both parent and child. RESULTS: The CBCL identified psychopathology in 26% and the K-SADS in 51% of the CPS and PGE patients (kappa = 0.32). The CPS and PGE groups had significantly higher mean CBCL scores, as well as higher rates of psychiatric diagnoses and symptoms of psychopathology, compared with the nonepileptic group. However, the CPS and PGE groups did not differ in these measures. Within each patient group, Full Scale IQ, but not seizure control, was associated with these measures of psychopathology. CONCLUSION: These findings suggest that the K-SADS identifies more children with psychopathology than the CBCL in children with CPS and PGE.

Conversational repair in pediatric epilepsy.

This study examined if children with complex partial seizures disorder (CPS) and primary generalized epilepsy with absence (PGE) were impaired in the use of self-initiated repair during a conversation compared to normal children. Transcriptions of speech samples of 92 CPS, 51 PGE, and 65 normal children, ages 5-16 years, were coded for self-initiated repair according to Evans (1985). The WISC-R, a structured psychiatric interview, and seizure-related information were obtained for each child. We found impaired use of repair in both the CPS and PGE groups compared to the normal subjects. The CPS patients, particularly those with a temporal lobe focus, overused self-initiated corrections of referents and syntax compared to the PGE and normal subjects. The CPS and PGE patients with frontal lobe involvement underused fillers compared to the normal children. These findings provide additional evidence that both CPS and PGE impact the ongoing development of children's communication skills.

An unusual case of multiple cranial nerve palsies in Wegener's granulomatosis.

We describe an unusual case of Wegener's granulomatosis, which initially caused fulminant palsies affecting cranial nerves II, V, VI, VII, and VIII during a brief episode of the disease. The patient was successfully treated with immunosuppressive therapy. Wegener's granulomatosis should be suspected when multiple cranial nerves are initially affected.

Correlation of electroencephalography and the active and inactive forms of neurocysticercosis.

We studied the interictal EEG of 50 epileptic patients (28 males, 22 females) who had parenchymal neurocysticercosis, diagnosed by CAT/MRI of the brain, positive immunological reaction for cysticercosis in cerebral spinal fluid or both. Age ranged from 5 to 61 years old; the mean age of onset was 24.2 +/- 12.2 years. Thirty-six patients had generalized seizures, 13 partial seizures with secondarily generalized seizures, and 1 had complex partial seizures. Twenty-two patients had parenchymal calcifications (inactive form); 21 had parenchymal cysts (active form) and 7 had both. EEG was abnormal in 14 patients (28%): 8 had focal slowing, 3 had focal sharp or spike activity, and 3 had both. The EEG was normal in patients with inactive forms of neurocysticercosis. The EEG was abnormal in 50% of patients with active and mixed forms of neurocystercosis and in 48% of patients with active form only. We conclude that the active forms of neurocysticercosis should be suspected when the EEG is found to be abnormal. In additional, EEG abnormality does not depend on the number of lesions, but rather on location and viability of the cysts, and on host response.

Psychopathology in pediatric complex partial and primary generalized epilepsy.

Structured psychiatric interviews were administered to 60 children with complex partial seizure disorder (CPS), 40 children with primary generalized epilepsy with absences (PGE), and 48 control children, aged 5 to 16 years. Significantly more patients with epilepsy had psychiatric diagnoses compared with the control children. There were no statistically significant differences, however, in the number of patients with CPS and PGE with psychiatric diagnoses. Other than a schizophrenia-like psychosis found only in the patients with CPS, the two groups of patients had similar psychiatric diagnoses. The presence of psychopathology was related to significantly lower IQ scores and socioeconomic status, but not to seizure-related factors. These findings suggest that the psychopathology of children with CPS and PGE reflects different subtle neuropsychological deficits.

Formal thought disorder and psychopathology in pediatric primary generalized and complex partial epilepsy.

OBJECTIVE: To examine whether formal thought disorder and psychopathology occurred in children with complex partial seizures (CPS) rather than children with primary generalized epilepsy with absences (PGE) or nonepileptic children. METHOD: Formal thought disorder was coded in 30 children with CPS, 24 children with PGE, and 61 nonepileptic children, and structured interview-based psychiatric diagnoses were obtained for the epileptic subjects. RESULTS: The CPS subjects had significantly more illogical thinking than the PGE and nonepileptic children. The severity of their illogical thinking was related to global cognitive dysfunction and a schizophrenia-like psychosis. Age of onset and seizure control, however, were significantly associated with the severity of illogical thinking in the PGE group. One or more psychiatric diagnoses were found in 63% of the CPS and 54% of the PGE patients, particularly if they had global cognitive deficits. CONCLUSION: Illogical thinking, associated with cognitive dysfunction or schizophrenia-like symptoms, might be a feature of pediatric CPS. Psychopathology might be related to global cognitive dysfunction in pediatric CPS and PGE.

Recording of brainstem evoked potentials and their association with gentamicin in neonates.

Brainstem auditory evoked potential (BAEP) recording was used to screen presymptomatically the hearing of 200 neonates treated with ampicillin (100 mg/kg daily) and gentamicin sulfate (5 mg/kg daily). The study included 130 male and 70 female neonates; post-conceptional age ranged from 34 to 57 weeks (mean 42.36 weeks). We divided neonates into 2 groups according to duration of antibiotic treatment; group 1 consisted of 179 patients who were treated with antibiotic agents for < or = 7 days. Although 15 (8.4%) in this group initially manifested abnormal BAEP recordings, only 8 of these brain-damaged neonates (4.5%) (6 with peripheral and 2 with central dysfunction) later manifested abnormal recordings. Group 2 consisted of 21 neonates who were treated for 10 to 30 days; BAEP recordings were abnormal in 7 patients (33.3%) (4 with peripheral and 3 with central dysfunction). We conclude that BAEP is indicated only for neonates treated with gentamicin sulfate for > 10 days. In this group, infants so treated usually have underlying disease or severe infection, including birth asphyxia, hypoxia, sepsis, and meningoencephalitis, all of which are clinically significant indicators of high risk for auditory pathway dysfunction.

Somatosensory evoked potentials in acute migraine with sensory aura.

One current view of migraine pathophysiology suggests that vasospasm causes cerebral ischemia and focal symptoms during an aura and that reactive hyperemia accompanies the headaches. Eight patients with acute migraine with sensory aura were studied with somatosensory evoked potential (SEP) to examine the vascular theory of acute migraine headache. All patients had sudden onset of hemiparesthesia as an aura followed by throbbing headaches. SEPs were obtained from the median nerve stimulation in two patients during the aura phase and six during the headache phase. SEPs were abnormal in both cases during the aura phase. The abnormality consisted of attenuation of amplitude and prolongation of N19 in the sensory cortex, resulting in prolongation of central conduction time, which gradually returned to normal during the headache phase. SEPs of six other patients obtained during the headache phase were also normal. The study concludes that: (1) there is a different pathophysiology between aura and headache phase; (2) the changes of SEPs during the aura may result from cerebral ischemia; and (3) normal SEPs during the headache phase suggest that reactive hyperemia may not alter SEP wave forms.

Felbamate monotherapy for partial-onset seizures: an active-control trial.

We evaluated felbamate (FBM) monotherapy in 111 patients with uncontrolled partial-onset seizures in a multicenter, double-blind, parallel-group trial. During the 56-day baseline period, patients had at least eight partial-onset seizures and received one standard antiepileptic drug (AED) at a therapeutic level; a second AED was allowed if at a subtherapeutic level. Patients received either FBM 3,600 mg/d or valproate (VPA) 15 mg/kg/d. The baseline AED at therapeutic levels was discontinued by one-third decrements on study days 1, 14, and 28 and the sub-therapeutic AED, if any, was discontinued completely on study day 1. Study endpoints were completion of 112 study days or fulfilling one or more escape criteria. Criteria for escape relative to baseline were (1) twofold increase in monthly seizure frequency, (2) twofold increase in highest 2-day seizure frequency, (3) single generalized tonic-clonic seizure (GTC) if none occurred during baseline, or (4) significant prolongation of GTCs. The primary efficacy variable was the number of patients in each treatment group who met escape criteria. Thirty-seven patients on VPA and 18 on FBM met escape criteria (p < 0.001). Even when we considered FBM dropouts to have fulfilled escape criteria and VPA dropouts to have completed the 112-day trial, the treatment difference remained statistically significant (p = 0.039) in favor of FBM. Adverse experiences with FBM were all mild or moderate in severity. The frequency of adverse experiences was much lower during monotherapy. FBM monotherapy was effective in the treatment of partial-onset seizures with or without secondarily generalized seizures and demonstrated a favorable safety profile.

The usefulness of one to two hour video EEG monitoring in patients with refractory seizures.

Video EEG monitoring for 1-2 hours was performed on 100 outpatients (57 females and 43 males) with refractory seizures or frequent paroxysmal events. Patients' ages ranged from 8 days to 67 years (mean age 21). At least one clinical seizure or paroxysmal event was observed in 66 patients; 24 of these patients had subtle seizures that would be difficult to observe without videotape monitoring. The combination of videotape and EEG monitoring was able to confirm the diagnosis in 80 cases. The referral diagnosis was changed in 37 patients; they included changes in seizure types in 17 epileptic patients; 10 patients were found to have pseudoseizures and 10 patients had nonepileptic neurological disorders. The yield of EEG seizure activity differed significantly between video EEG monitoring and routine EEG recording (p < 0.001). EEG seizure activity was reported in 77 patients with video EEG monitoring compared to 49 patients with routine EEG recording. We conclude that outpatient video EEG monitoring yields more information on the presence or absence of seizures and their types, improving patient management, and averting the need for prolonged inpatient intensive monitoring.

Sepulveda Epilepsy Education: the efficacy of a psychoeducational treatment program in treating medical and psychosocial aspects of epilepsy.

The present study evaluated the efficacy of the Sepulveda Epilepsy Education program (SEE), using a controlled outcome design. SEE is a 2-day psychoeducational treatment program designed to provide medical education and psychosocial therapy. Thirty-eight outpatients, matched according to seizure type and frequency, were randomly assigned to treatment (n = 20) or waiting-list control (n = 18) groups. The major outcome measures used were a 50-item true-false test specifically designed to evaluate the SEE program, the Washington Psychosocial Seizure Inventory, the Beck Depression Inventory, Lubin's Depression Adjective Checklist, the State-Trait Anxiety Inventory, the Acceptance of Disability Scale, and Sherer's Self-Efficacy Scale. Significant differences between the two groups were found on the three major subscales of the 50-item true-false test. The treatment group demonstrated a significant increase in overall understanding of epilepsy, a significant decrease in fear of seizures, and a significant decrease in hazardous medical self-management practices. In addition, an objective measure of blood levels of antiepileptic drugs (AEDs) showed the treatment group to have a significant increase in medication compliance.

Dose-response effects of chronic methylphenidate administration on late event-related potentials in attention deficit disorder.

Stimulants, such as methylphenidate, are extensively used in the treatment of attention deficit disorder. In the present study, we used a double-blind placebo-controlled, prospective protocol to evaluate the effects of methylphenidate (MP) (dose 0.1 and 0.33 mg/kg three times daily) on the late event-related potentials, some of which are considered biological attention correlates. Sixteen patients, 6-15 years old, were tested, using an auditory target selection paradigm. The latencies of N200 and amplitudes of P150 increased with MP (p less than 0.01). These effects are in the direction of normal maturational change. The latencies of P300 tended to be shorter in adolescents than in children, and with high MP dose the P300 latencies became even shorter in adolescents but were prolonged in children (p less than 0.05). This pattern of change supports the view that pharmacological interactions with various cerebral phenomena including cognition may be age-specific.

Primary lymphoma of the central nervous system: a diagnostic problem.

Primary lymphoma of the central nervous system (CNS) is difficult to diagnose because of the difficulty in differentiating it from multiple sclerosis, sarcoidosis, metastatic disease, chronic granulomatous disease, and cerebral cysticercosis. With the patient presented in this report, no abnormalities were found after performing laboratory tests, using radiographic modalities, and taking biopsies. Dexamethasone treatment was initiated, and patient's symptoms improved.Primary CNS lymphoma was not diagnosed until a year after presentation, due to lack of tissue diagnosis. CNS must be suspected when a diagnosed tumor treated with steroid is not found at surgery. It is suggested that a computerized tomographic scan be requested before the start of steroid therapy, as the lesion can disappear with steroid treatment.

The pharmacodynamic properties of lorazepam and methylphenidate drugs on event-related potentials and power spectral analysis in normal subjects.

The effect of lorazepam and methylphenidate on the ERPs and power spectral analysis was studied. Lorazepam caused prolonged latency and decreased amplitude of N200 and P300. This result suggests that lorazepam affects the neural processing of cognitive function. The drowsiness induced by lorazepam correlated inversely with alpha frequency power, but had no direct correlation with fast activity. On the contrary, when methylphenidate was given, there was no change in ERPs. There was an increase in percent alpha frequency correlated with the alertness of the subjects. An analysis of variance involving the factors of drug and time of rating showed that subjects showed a significant (p less than 0.0001) decrease in alertness over time while receiving lorazepam, and a significant (p less than 0.05) increase in alertness over time while receiving methylphenidate.

Event-related potential in Alzheimer disease.

Auditory event - related potentials were studied in 20 patients with SDAT and 20 age and sex matched normal controls. Patients with SDAT showed prolonged latencies of N200 and P300 components. The mean amplitudes of N200 and P300 were lower in the SDAT group. This reflects the impairment of the speed of neural processing in patients with SDAT. There were no significant correlations of the progression of P300 latencies from mild to severe dementia according to global dementia scales.

Grand mal discharge.

Two hundred nineteen grand mal discharges were reviewed in 50 epileptic patients. It was commonly seen in patients with prenatal and perinatal causes, mental deficiency with neurological deficits, and multiple types of seizures. Eighty-eight percent of the discharges were bilaterally synchronous with 49 percent of bifrontal predominance. Fifty-eight percent were associated with drowsiness or sleep, and 64 percent were associated with clinical accompaniments. The most common clinical signs were tonic movement of arms, legs or neck, eye opening, eye fluttering, head drop, etc. The increased frequency of clinical seizures usually observed during the occurrence of this pattern may provide some clues that the antiepileptic medication should be reassessed to control the oncoming seizure attacks.

Familial syndrome of deafness, myoclonus, and cerebellar ataxia.

We report a case of identical twins with progressive sensorineural hearing loss, myoclonus, intention tremor, and ataxia. The involved member of the family may suggest of autosomal dominant transmission with variable penetrance.