Cognitive dysfunction after generalized tonic-clonic status epilepticus in adults.

OBJECTIVES: Generalized tonic-clonic status epilepticus (GTC-SE) is considered a risk for cognitive impairment. Research with standardized tools is scarce and non-conclusive. We systematically assessed short-term and long-term cognitive function after GTC-SE. MATERIALS AND METHODS: Thirty-three patients were tested after the clinical post-ictal phase of GTC-SE (timepoint 1) and again after 1 year (timepoint 2). Twenty controls were examined with the same tests. Tests from Cambridge Neuropsychological Test Automated Battery were used. Motor screening test (MOT) assessed motor speed, delayed matching to sample (DMS) and paired associates learning (PAL) assessed memory, and Stockings of Cambridge (SOC) assessed executive function. Estimated premorbid IQ and radiologically visible brain lesions were controlled for in adjusted results. Outcome measures were z-scores, the number of standard deviations a score deviates from the mean of a norm population. RESULTS: At timepoint 1, unadjusted patient results were significantly below both norm and control group performances on all subtests. Patient mean was 1.9 z-scores below controls (P < .001) on PAL total errors. Results remained significant for PAL and DMS after adjustments. Patient results improved at timepoint 2, but memory tests remained lower than norms and for controls. An executive dysfunction emerged on the most complex SOC stage (z-score difference -0.83; P = .008, adjusted difference -0.94; P = .02). CONCLUSIONS: Memory and learning impairment in the early phase after SE and late developing executive dysfunction remained significant after adjusting for estimated premorbid IQ and pre-SE brain lesions. Results suggest that GTC-SE poses a risk for cognitive impairment.

Identifying patients at risk of acute symptomatic seizure after ischemic stroke.

BACKGROUND: Contributors to post-stroke seizure research have advocated the need for prospective studies of acute symptomatic seizures after stroke. Identification of the patient at risk of seizure and the impact of the event on outcome is a prerequisite for this kind of research. The aim of this study was to identify risk factors, make an outline for a risk score, and look at consequences of seizure on short-time clinical outcomes. METHODS: This registry-based study included patients with ischemic stroke admitted between 2007 and 2013. We identified variables associated with the presence of acute symptomatic seizures and made a risk score. Clinical outcome measures were modified Rankin scale, National Institute of Health Stroke Scale (NIHSS), and death at discharge or at day seven. RESULTS: A total of 2598 ischemic stroke patients were included, 66 experiencing seizure within seven days of stroke. We found diabetes mellitus, NIHSS on admission, and cortical lesion to be associated with the risk of seizure. The risk score had a sensitivity of 58%, specificity of 85%, and a positive predictive value of 9% with a three-point cutoff. We found a negative effect of seizure on survival in mild-to-moderate strokes after adjusting for infections and stroke severity. CONCLUSIONS: Because of low incidence and the lack of specific risk factors, acute symptomatic seizure after ischemic stroke is hard to predict. The negative effect of seizure on stroke outcome is uncertain, and more thorough studies are needed because of possible subtle or non-overt seizures.

EFNS guideline on the management of status epilepticus in adults.

The objective of the current article was to review the literature and discuss the degree of evidence for various treatment strategies for status epilepticus (SE) in adults. We searched MEDLINE and EMBASE for relevant literature from 1966 to January 2005 and in the current updated version all pertinent publications from January 2005 to January 2009. Furthermore, the Cochrane Central Register of Controlled Trials (CENTRAL) was sought. Recommendations are based on this literature and on our judgement of the relevance of the references to the subject. Recommendations were reached by informative consensus approach. Where there was a lack of evidence but consensus was clear, we have stated our opinion as good practice points. The preferred treatment pathway for generalised convulsive status epilepticus (GCSE) is intravenous (i.v.) administration of 4-8 mg lorazepam or 10 mg diazepam directly followed by 18 mg/kg phenytoin. If seizures continue more than 10 min after first injection, another 4 mg lorazepam or 10 mg diazepam is recommended. Refractory GCSE is treated by anaesthetic doses of barbiturates, midazolam or propofol; the anaesthetics are titrated against an electroencephalogram burst suppression pattern for at least 24 h. The initial therapy of non-convulsive SE depends on type and cause. Complex partial SE is initially treated in the same manner as GCSE. However, if it turns out to be refractory, further non-anaesthetising i.v. substances such levetiracetam, phenobarbital or valproic acid should be given instead of anaesthetics. In subtle SE, in most patients, i.v. anaesthesia is required.

EFNS guideline on the management of status epilepticus.

The objective of the current paper was to review the literature and discuss the degree of evidence for various treatment strategies for status epilepticus (SE) in adults. We searched MEDLINE and EMBASE for relevant literature from 1966 to January 2005. Furthermore, the Cochrane Central Register of Controlled Trials (CENTRAL) was sought. Recommendations are based on this literature and on our judgement of the relevance of the references to the subject. Recommendations were reached by informative consensus approach. Where there was a lack of evidence but consensus was clear we have stated our opinion as good practice points. The preferred treatment pathway for generalised convulsive status epilepticus (GCSE) is intravenous (i.v.) administration of 4 mg of lorazepam or 10 mg of diazepam directly followed by 15-18 mg/kg of phenytoin or equivalent fosphenytoin. If seizures continue for more than 10 min after first injection another 4 mg of lorazepam or 10 mg of diazepam is recommended. Refractory GCSE is treated by anaesthetic doses of midazolam, propofol or barbiturates; the anaesthetics are titrated against an electroencephalogram burst suppression pattern for at least 24 h. The initial therapy of non-convulsive SE depends on the type and the cause. In most cases of absence SE, a small i.v. dose of lorazepam or diazepam will terminate the attack. Complex partial SE is initially treated such as GCSE, however, when refractory further non-anaesthetising substances should be given instead of anaesthetics. In subtle SE i.v. anaesthesia is required.

Autosomal recessive mitochondrial ataxic syndrome due to mitochondrial polymerase gamma mutations.

OBJECTIVE: To investigate three families and one sporadic case with a recessively inherited ataxic syndrome. METHODS: Clinical and genetic studies were performed in six individuals. Southern blotting and real time PCR were used to detect deletions of mtDNA and mutations in the POLG gene were identified using a combination of DHPLC and direct DNA sequencing. RESULTS: The patients have a distinctive, progressive disorder that starts with episodic symptoms such as migraine-like headache or epilepsy. Ataxia, which is a combination of central and peripheral disease, develops later as does ophthalmoplegia. The commonest form of epilepsy was focal and involved the occipital lobes. Myoclonus was common and patients have a high risk of status epilepticus. MRI typically shows signal changes in the central cerebellum, olivary nuclei, occipital cortex, and thalami. COX negative muscle fibers were found in four of six; in one patient these were rare and in another absent. Multiple mtDNA deletions were identified in all patients, although in two these were not apparent on Southern blotting and real time PCR was required to demonstrate the defect. Two families were homozygous for a previously described POLG mutation, G1399A (A467T). One family and the sporadic case had the same two new mutations, a G to C at position 1491 (Q497H) and a G to C at 2243 (W748S). CONCLUSIONS: Mutations in POLG cause a recessively inherited syndrome with episodic features and progressive ataxia. Characteristic changes on MRI are seen and although skeletal muscle may appear morphologically normal, multiple mtDNA deletions can be detected using real-time PCR.

Social influences in the development of anorexia nervosa. A case study.

This paper is an overview of theory and research findings on social influences on the development of eating disorders. Included are feminist theories of socialisation, theories of autonomy and modelling within the family context self-esteem, perfectionism, and temperament as well as the displacement hypothesis. This overview is followed by a case study. An 18-year-old female patient and her history are described from various angles of incidence to determine how far components of these findings may have contributed to her development of anorexia nervosa (AN). Vulnerability, precipitating, and perpetuating factors are discussed. It is shown that the patient demonstrated relatively high levels of risk factors known to play a part in the etiology of AN.

Different brain areas activated during imagery of painful and non-painful 'finger movements' in a subject with an amputated arm.

The purpose of the present study was to investigate differences in brain activation with functional magnetic resonance imaging (fMRI) during imagery of painful and non-painful 'finger movements' and 'hand positioning' in a subject with an amputated arm. The subject was a right-handed man in his mid-thirties who lost his right arm just above the elbow in a car-train accident. MRI was performed with a 1.5 T Siemens Vision Plus scanner. The basic design involved four conditions: imagining 'painful finger movements', 'non-painful finger movements', 'painful hand positioning', 'non-painful hand positioning'. Imagery of finger movements uniquely activated the contralateral primary motor cortex which contains the classic 'hand area'. The lateral part of the anterior cerebellar lobe was also activated during imagery of finger movements. Imagery of pain uniquely activated the somatosensory area, and areas in the left insula and bilaterally in the ventral posterior lateral nucleus of the thalamus. It is suggested that the insula and thalamus may involve neuronal pathways that are critical for mental processing of pain-related experiences, which may relate to a better understanding of the neurobiology of phantom limb pain.

The impact of affectivity dispositions, self-efficacy and locus of control on psychosocial adjustment in patients with epilepsy.

The main hypothesis of this study was that negative and positive affectivity, self-efficacy and health-related locus of control are important for psychosocial adjustment in patients with epilepsy. These dimensions are rarely examined directly in relation to the psychosocial adjustment in these patients. Correlations between measures of these constructs and measures of psychosocial adjustment in epilepsy were investigated. One hundred and one patients answered the Washington psychosocial seizure inventory (WPSI), the positive and negative affect schedule (PANAS-X), the multidimensional health locus of control scales (MHLC), the generalized self-efficacy scale and a scale measuring self-efficacy in epilepsy. Reliability analyses, correlational analyses and multiple stepwise regression analyses were performed. Negative affectivity (NA), positive affectivity (PA) and generalized self-efficacy showed high correlations with the WPSI scales emotional adjustment, overall psychosocial adjustment and quality of life. The epilepsy self-efficacy measures showed high, but lower correlations with the same WPSI scales. The MHLC scales showed low correlations with the WPSI scales. Multiple regression analyses showed that PA, NA and measures of self-efficacy explained more than 50% of the variances on emotional adjustment, overall psychosocial functioning and quality of life. In conclusion, positive and negative affectivity and self-efficacy are important predictors of perceived emotional adjustment, psychosocial adjustment and quality of life in patients with epilepsy. NA is the best predictor, but PA and self-efficacy measures give unique predictions independent of NA.

A comparison of three questionnaires (EAT-12, EDI, and EDE-Q) for assessment of eating problems in healthy female adolescents.

On the basis of the restraint theory and the continuum hypothesis of eating disorders, the objective of this paper was twofold. First, subjects who, on the basis of items from the Eating Disorder Examination Questionnaire (EDE-Q) which are generated from DSM-III-R diagnostic criteria, fulfilled the diagnostic criteria for anorexia nervosa (AN) and bulimia nervosa (BN) were identified. Second, differences in scale scores between a case group and a non-case group were tested, and case group distribution of the two self-report questionnaires Eating Attitudes Test (EAT-12) and Eating Disorder Inventory (EDI) was compared as a means for investigating the sensitivity of the instruments in detecting eating disorder cases. In a classroom setting 224 8th-grade female students from 5 schools in western Norway completed the questionnaires. The responses to the questionnaires were analysed by case group and instrument/subscales by using the t test, Cohen's d-values, eta squared statistic, point biserial correlation, and two-way ANOVA. No BN cases and 10 AN cases were identified. AN cases scored significantly higher on all measures of eating problems than normal subjects and differed most from non-cases on the "dieting" dimension. Clinical implications are discussed in the light of screening.

Prevalence and dimensionality in adolescent eating problems.

Prevalence of three eating problem dimensions (body concerns, dieting, and loss of control over eating) was studied in a Norwegian sample consisting of 4129 normal adolescents aged 12-16. The existence of eating problem dimensionality had been demonstrated in an earlier study of the same sample, and is in line with the reasoning presented in both restraint theory and the continuum hypothesis for eating disorders. Body concern was the most dominant dimension in both genders in the present study, whereas loss of control over eating was the least dominant for girls. For boys, both the dieting and the loss of control over eating dimension showed a low dominance. Older girls reported significantly more eating problems than younger girls, but this difference was not found for boys. The results are discussed and taken to support restraint theory and the continuum hypothesis. It is concluded that the study gives support to the view of the relationship between the three dimensions as cumulative and developmental, and that longitudinal research should be conducted to examine how these eating problems are related to later eating disorders.

[Non-convulsive status epilepticus--confusion and cognitive failure during seizures]. / Ikke-konvulsiv status epilepticus--anfallsvis konfusjon og kognitiv svikt.

BACKGROUND: Non-convulsive status epilepticus is characterized by confusion and impaired consciousness, lasting at least half an hour. Seizure activity in the EEG confirms the diagnosis, but ictal discharges can be heterogeneous and difficult to classify. There is controversy regarding evidence of morbidity in humans. MATERIAL AND METHODS: We report three patients with non-convulsive status epilepticus. RESULTS: In two patients, the clinical findings during seizures were subtle cognitive impairment. One patient was confused during seizures. Localisation of seizure activity in the EEG was mainly frontal in two patients, and generalised with focal predominance in one. There were no sign of neurologic sequelae after the seizures were terminated. INTERPRETATION: Complex partial status epilepticus of frontal origin is common, but differentiation between complex partial and generalised non-convulsive status can be difficult. The clinical symptoms may overlap, and generalised EEG seizure activity does not exclude initial focal ictal discharges. Presumably the reported sequelae after this condition are in most cases a consequence of underlying cerebral illness. Treatment response to diazepam can be variable, with high recurrence risk. Effective prophylactic treatment is most important.

Multidimensionality in adolescent eating problems. A two-phase measurement study.

The aims of this study were, firstly, to examine the factor structure of single items from several self-report methods used to measure eating disorder symptoms, and secondly, in search for a short assessment instrument to reduce the number of items within each factor. Factor analyses were employed to identify and confirm the constructs measured by a total of sixty items drawn from these assessment methods. In phase one, 508 secondary school pupils were recruited as subjects, and principal factor analysis identified three factors; body concern, dieting, and loss of control over eating. Twenty-nine items were retained, and in phase two subjected to a second data collection among 4129 secondary school pupils. Confirmatory factor analysis was employed to cross-validate the factor structure from phase one. The three-factor structure was confirmed satisfactorily for boys, but not for girls aged 12-14 years. For girls aged 14-16 years, it was confirmed when a number of items were omitted. The findings are discussed in relation to restraint theory and the continuum hypothesis.

The dimensionality of the 12-item version of the Eating Attitudes Test. Confirmatory factor analyses.

The assumed three-dimensional structure of the 12-item version of the Eating Attitudes Test was examined by confirmatory factor analysis in a non-clinical sample of 224 female and 261 male adolescents in grade 8 aged 14-15 years. Alternative models were examined. Data did neither support a three-dimensional structure, nor a one-dimensional structure using twelve items. Three dimensions were supported when one and three items were omitted from the girls' and boys' analyses, respectively. A second order factor structure was supported in both genders. Conceptual and psychometric issues are discussed. A discussion of the measurement domain of the eating problem construct in non-clinicals is warranted.

A generalizability study of the Eating Attitudes Test (EAT-12) in non-clinical adolescents.

One of the most frequently used measures of eating and weight problems is the Eating Attitudes Test (EAT). The paper discusses conceptual heterogeneity in the EAT in the light of eating disorder continuum theory. Psychometric qualities of the Norwegian 12-item version of the EAT was based on a sample of 224 female and 261 male adolescents aged 14-15 years. Generalizability theory enabled us to study the impact of multiple sources of measurement errors of the EAT-12. The analyses suggest that acceptable generalizability is achieved by the present design on applying 4 items within 3 categories of the EAT. Alternative designs are suggested, and the utility of G-theory is discussed. The results also provide evidence of a gender difference in the structure of the universe score variance. Non-clinical adolescents' ways of organizing information about food and eating are discussed in the light of gender differences.

Juvenile myoclonic epilepsy: clinical characteristics, treatment and prognosis in a Norwegian population of patients.

Forty-three patients with juvenile myoclonic epilepsy (JME) is presented. The female to male ratio was 2.9:1. The patients answered a standardized questionnaire pertaining to social situation, medical history, onset of epilepsy, types and frequency of seizures, treatment, experienced control over seizures and consequences of having epilepsy. Myoclonic jerks, which are the hallmark of the condition, are often forgotten by the patients or not considered as epileptic seizures. This could be one reason why JME still seems underdiagnosed. JME may comprise absence, myoclonic and generalized tonic-clonic seizures (GTCS), proposed to occur in age-related sequence. We found that absence seizures may start after onset of other seizures. Our results confirm the need for medication since, during the last year, only 7% were seizure free without medication. Of patients on antiepileptic drugs (AEDs), 79.5% had no GTCS and 41% were seizure free during the last year, which confirms a relatively good response to appropriate treatment. Although most patients used AED daily and many still had one or more types of epileptic seizure, the epilepsy in general had very little impact on their lives.

Differential effect of carbamazepine and valproate monotherapy on plasma levels of oestrone sulphate and dehydroepiandrosterone sulphate in male epileptic patients.

Steroid sulphates such as oestrone sulphate (OE1S) and dehydroepiandrosterone sulphate (DHEAS) have been suggested to be of biological importance in different disease states such as breast cancer and atherosclerosis. Previous studies have shown that drugs such as aminoglutethimide and rifampicin that induce P450-dependent mixed-function oxygenases selectively suppress plasma OE1S levels. The aim of this study was to evaluate the influence of treatment with carbamazepine, an antiepileptic drug known to stimulate mixed-function oxygenases, on plasma levels of OE1S and DHEAS. We measured plasma OE1S and DHEAS together with other plasma oestrogens and androgens in male epileptic patients before and during carbamazepine monotherapy. Patients treated with valproate monotherapy acted as a control group. Treatment with carbamazepine decreased plasma OE1S levels from a mean value of 810.8 to 411.6 pmol/l (mean suppression to 50.7% of pretreatment levels, P < 0.001). Similarly, the ratio of OE1S to OE1 fell to 59.9% of pretreatment levels (P < 0.001)). DHEAS decreased from a mean level of 4.9 mumol/l before treatment to 3.0 mumol/l during carbamazepine therapy (mean reduction to 62.7% of pretreatment levels (P < 0.001), while the ratio of DHEAS to DHEA fell to 63.0% of pretreatment values (P < 0.01). No significant change in plasma levels of the other oestrogens or androgens measured was observed. Treatment with valproate caused a slight decrease in FSH levels (P < 0.05), but no change in any of the other hormones measured was observed. Studies are warranted to evaluate the possible effects of long-term treatment with carbamazepine on the risk of developing endocrine-sensitive tumours and cardiovascular disease and also the possible effects of alterations in plasma DHEAS on epileptic activity.

Epileptic seizures in patients with multiple sclerosis. Is the prognosis of epilepsy underestimated?

The exact prevalence of epileptic seizures in patients with multiple sclerosis (MS) is still a matter of some controversy. In a population-based, unselected group of 423 patients with MS we identified 17 (4.02%) with epileptic seizures. The mean age at onset of MS was 25.2 years and at onset of epilepsy 32.6 years. A prevalence of 'active epilepsy', i.e. seizures within the last 5 years, was estimated to 3.2%. The prevalence of epilepsy in our MS population is much higher than should be expected when compared to lifetime prevalence of epilepsy in corresponding age groups. The occurrence of convulsive status epilepticus is also higher than expected, and suggests a rather serious prognosis. Thus, drug treatment should be considered after the first epileptic seizure.

Unilateral frontal decortication changes cerebral blood flow distribution during hyperbaric oxygen exposure in rats.

Distribution of rCBF was measured with 10.7 +/- 0.5 microns differently radiolabelled microspheres (MS) during control at 1 bar air, and after 5 and 35 min at 5 bar (0.5 MPa) 95% O2 on awake, habituated rats 10 d after right-sided frontal decortication. A decreased tolerance to hyperbaric O2 was found compared to normal rats of the same strain. The systolic arterial pressure increased during O2 exposure (11%, p < 0.05), the mean arterial pressure remained unchanged, but the cardiac output and heart rate fell by 29 and 14% (p < 0.01), respectively. The arterial acid-base balance remained normal during O2 exposure, although a small reduction of CO2 (24%) and HCO3 (11%) was observed (p < 0.01 and p < 0.05), possibly due to increased alveolar ventilation caused by an elevated respiratory rate of 24% (p < 0.05). The arterial O2 content at 5 bar increased by about 30% (p < 0.01). During control, blood flow in 16 regions of each hemisphere was found to be lower, more scattered, and differently distributed on the lesioned side. After 5 min at 5 bar, the blood flow fell in nearly all regions of the brain (up to 40%), similarly in the two brain halves. During the 35 min exposure, the blood flow increased, so that 60% of the examined areas on the lesioned side had blood flow levels of control or above, in contrast to the undisturbed side where blood flow remained below control values. The O2 supply to different regions varied similarly.(ABSTRACT TRUNCATED AT 250 WORDS)