Treatment of posttraumatic epilepsy with new generation antiepileptic drugs (AEDs) - our experience.

Aim To investigate influence of therapy with new generation antiepileptic drugs (AEDs) in fastening of posttraumatic epilepsy (PTE) remission comparing to therapy with standard AEDs, as well as the time to remission in the presence of psychiatric comorbidities. Methods The study was conducted during the 1988-2008 period and included 113 patients (47 females and 67 males) with PTE and 113 patients (93 females and 20 males) suffering from complex partial seizures (CPS) of temporal lobe origin. In both patient groups, epileptic seizure phenotype, brain magnetic resonance imaging (1.5 T and 3.0 T) and electroencephalogram were analyzed within 24 hours of epileptic seizure and after 5 years of treatment. Psychological testing was administered prior to therapy initiation. Results The patients treated with standard AEDs achieved remission in 82 (73%) cases as compared with 87 (77%) patients administered with a new generation AEDs; in the latter group, remission was achieved faster (1.85 vs. 1.6 months). In both patient groups, psychiatric comorbidity prolonged time to remission by 3.4 months. Conclusion Therapy with new generation AEDs enables achieving faster and complete remission in PTE patients.

Attention and executive functions in a rat model of chronic epilepsy.

OBJECTIVE: Temporal lobe epilepsy is a relatively frequent, invalidating, and often refractory neurologic disorder. It is associated with cognitive impairments that affect memory and executive functions. In the rat lithium-pilocarpine temporal lobe epilepsy model, memory impairment and anxiety disorder are classically reported. Here we evaluated sustained visual attention in this model of epilepsy, a function not frequently explored. METHODS: Thirty-five Sprague-Dawley rats were subjected to lithium-pilocarpine status epilepticus. Twenty of them received a carisbamate treatment for 7 days, starting 1 h after status epilepticus onset. Twelve controls received lithium and saline. Five months later, attention was assessed in the five-choice serial reaction time task, a task that tests visual attention and inhibitory control (impulsivity/compulsivity). Neuronal counting was performed in brain regions of interest to the functions studied (hippocampus, prefrontal cortex, nucleus basalis magnocellularis, and pedunculopontine tegmental nucleus). RESULTS: Lithium-pilocarpine rats developed motor seizures. When they were able to learn the task, they exhibited attention impairment and a tendency toward impulsivity and compulsivity. These disturbances occurred in the absence of neuronal loss in structures classically related to attentional performance, although they seemed to better correlate with neuronal loss in hippocampus. Globally, rats that received carisbamate and developed motor seizures were as impaired as untreated rats, whereas those that did not develop overt motor seizures performed like controls, despite evidence for hippocampal damage. SIGNIFICANCE: This study shows that attention deficits reported by patients with temporal lobe epilepsy can be observed in the lithium-pilocarpine model. Carisbamate prevents the occurrence of motor seizures, attention impairment, impulsivity, and compulsivity in a subpopulation of neuroprotected rats.

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Pre- and postictal, not ictal, heart rate distinguishes complex partial and psychogenic nonepileptic seizures.

Psychogenic nonepileptic seizures (PNES) remain poorly understood neurobiologically. Previously reported work suggests that adjunct ictal heart rates (HRs) may differentiate PNES from complex partial seizures (CPS). We retrospectively reviewed and compared preictal, ictal, and postictal HR differences in patients with PNES (n=42) and CPS controls (n=46) electively admitted for video/EEG monitoring to further characterize PNES autonomic patterns. Statistically significant preictal HR increases (P=0.006) and postictal (P=0.015) HR reductions normalized to baseline were identified in subjects with PNES compared with CPS controls. Ictal HRs were not found to differentiate between PNES and CPS events. This pattern of pre-event HR increases and postevent HR decreases in patients with PNES compared with those with CPS suggests frontolimbic neural circuit dysfunction and merits further exploration.

Emergence of complex partial epilepsy-like experiences following closed head injuries: personality variables and neuropsychological profiles.

To pursue Richard Roberts' epileptic spectrum disorder (ESD) and the emergence of complex partial epilepsy-like experiences, items and total scores for the ESD Inventory were examined for 185 patients who had sustained mechanical impacts (and were diagnosed with or without neuropsychological impairment) and a reference group (n=68) of university students. Results from neuropsychological, personality, neurological screening, and interview data supported the role of temporal lobe origins for these experiences. The incidences of these experiences were sufficient to adversely affect adaptation and to produce psychiatric profiles. Although only 70% of the patients who were impaired versus not impaired could be differentiated by items from the ESD Inventory, >95% of the patients with scores >100 on the ESD Inventory displayed abnormal scores on more than four Minnesota Multiphasic Personality Inventory scales. These results support Roberts' ESD concept and strongly suggest that persistent, subclinical occurrence of these experiences could be the cause or major correlate of neuropsychological impairment for these patients.

Cognitive and behavioral functioning in Coffin-Siris syndrome and epilepsy: a case presentation.

The authors characterized the cognitive, adaptive, and behavioral sequelae of Coffin-Siris (CS) syndrome and epilepsy in a 7.5-year-old child. Little is known about the early neurobehavioral presentation of CS. Clinical features consistent with this genetic anomaly include underdeveloped tips and nails of the fifth fingers, extended infranasal depression, and craniofacial abnormalities. MRI findings often reveal callosal agenesis. The authors conducted a neuropsychological evaluation and obtained parental ratings of behavioral and adaptive functioning. Attentional abilities were limited. As assessed by the Mullen Scales of Early Learning, receptive language abilities (age equivalent [AE]: 3-3) were relatively stronger than expressive skills (AE: 1-4). Adaptive functioning was low across all domains (Vineland Adaptive Behavior Composite AE: 1-9). On the Behavior Assessment for Children (BASC-2), social skills dysfunction, stereotyped and self-stimulatory behaviors, restricted interests, ritualistic play, and inappropriate object usage were noted. No significant mood disturbances were endorsed. Study findings indicate a diffuse pattern of neurobehavioral deficits in a child with CS and epilepsy. Further clinical assessment and research should include multidimensional assessment techniques, including evaluation of adaptive behavior, in an effort to capture the full range developmental sequelae in children with CS.

Lamotrigine treatment of a patient affected by epilepsy and anxiety disorder.

Epilepsy often occurs in comorbidity with mental diseases and disorders. Early detection and/or treatment of such disorders in patients affected by epilepsy, as well as their socialisation are crucially important since epileptic patients tend to suffer more due to lack of social support than to frequent epileptic seizures. Prevalence of psychiatric disorders is higher in patients with epilepsy than in general population, the most frequent being: anxiety, depression, panic attacks, behavioural disorders as well as psychotic states with paranoid elements. The efficacy of AE treatment of patients affected by epilepsy and mood disorders has also directed clinicians to investigate possible AE benefits in treating other mental disorders such as anxiety states, depression and bipolar disorder. The examined case displays complex partial epilepsy and comorbid mental disorder. The use of lamotrigine, a fourth-generation antiepileptic, which is also a mood stabilizer, has assured a favourable remission of symptoms related to both epilepsy and mood disorders. Side-effects caused by lamotrigine were only temporary and dose reduction was sufficient to eliminate their symptoms.

Absence seizures in the first 3 years of life: an electroclinical study of 46 cases.

PURPOSE: Early onset absence seizures have been considered a rare heterogeneous group with a poor prognosis. Only few patients may be categorized into well-known syndromes. We have evaluated electroclinical features, evolution, and the nosologic boundaries of early onset absence seizures. METHODS: Forty-six neurologically normal patients with absence seizures associated with bilateral, synchronic, or asynchronic, and symmetric or asymmetric spike-and-wave paroxysms with onset in the first 3 years of life were included. Patients with abnormal neurologic examination and brain imaging were excluded from the study. KEY FINDINGS: In our study, 39 patients met the clinical and electroencephalography (EEG) criteria of well-defined epileptic syndromes. Childhood absence epilepsy was found in 11 patients, benign myoclonic epilepsy in infancy in 18 patients, eyelid myoclonic epilepsy in 4, and epilepsy with myoclonic absences in 6. We did not find clinical and EEG criteria of well-recognized epileptic syndromes in seven children. Nine of 11 patients with simple absence seizures became seizure free. All these patients had normal neurologic and neuropsychological evaluations. Of the 35 patients who had absence seizures associated with myoclonic seizures, 20 became seizure free. Fifteen of 35 children continue having seizures. At the last visit, 20 of these 35 patients had normal neurologic and neuropsychological evaluations, 11 presented with mild mental retardation, and 4 with severe mental retardation. SIGNIFICANCE: Epilepsies with absence seizures of early onset are relatively uncommon. Most of the patients had well-defined epileptic syndromes with a variable evolution. The evolution depended on the epileptic syndromes.

Lessons learned from a comparison of language localisation using fMRI and electrocortical mapping: case studies of neocortical epilepsy patients.

Electrocortical mapping (ECM) is recognised as an established method for localisation of eloquent cortex in patients undergoing resective surgery for epilepsy management. Functional MRI (fMRI) has been utilised for language and other cortical function localisation. We describe language localisation in two patients using both ECM and fMRI. Co-registration of fMRI and ECM revealed that although two fMRI tasks localised multiple language areas, the verb generation task had an advantage over the semantic decision/tone decision task in that there was a clear overlap between the language areas identified by the verb generation task and ECM. In addition to the language areas detected by ECM, fMRI showed other language-related areas that may be important for post-operative language outcome. Therefore, fMRI may provide additional and complementary information to ECM in presurgical evaluation of patients with epilepsy. The correlation between fMRI and ECM may depend on the language testing methods utilised during the procedures.

Dissociation between neurovegetative signs and subjective symptoms in a case of idiopathic pilomotor seizures.

OBJECTIVE: Pilomotor seizure (PS) is a rare subtype of simple and complex partial seizures, often related to temporal lobe epilepsy and occasionally linked to alterations of amygdala. The physiologic role played by this latter region in the coordination of autonomic responses to fear-induced emotional changes raises the question as to whether the involvement of amygdala in PS might elicit a disconnection between subjective symptoms and neurovegetative signs. METHODS: We report a case of idiopathic bilateral PS studied with video electroencephalogram, polygraphic 24-hour Holter electroencephalogram, and magnetic resonance imaging, plus spectral functional magnetic resonance imaging, in which the seizures were associated with abrupt tachycardia occurring in a state of emotional neutrality, without either clouding or loss of consciousness. RESULTS: Electroencephalogram documented PS episodes occurring during waking, rapid eyes movements, and nonrapid eye movement sleep stages. Although no morphologic alteration was detected, spectral magnetic resonance imaging visualized alterations of the metabolic ratios of N-acetylaspartate and creatine-phosphocreatine in hippocampus and amygdala, whereas no apparent involvement of the temporal lobe was found. CONCLUSIONS: These findings suggest that the limited involvement of amygdala and hippocampus in PS triggers the repertoire of fear-related sympathetic responses uncoupled from alterations in emotional status. This phenomenon supports the possibility that autonomic responses involved in fear or extreme alertness follow a kind of "ethological" modularity.

Clinical use of an herbal-derived compound (Huperzine A) to treat putative complex partial seizures in a dog.

A Bernese mountain dog was diagnosed with complex partial seizures that were supported by electroencephalographic findings. Clinical signs of the problem included "star gazing," fly snapping, licking, vacuous chewing, and ongoing anxiety. Treatment with Huperzine A, a compound isolated from Chinese club moss with NMDA receptor blocking activity, anticholinesterase activity, and anticonvulsant properties, produced useful suppression of the abnormal behavior for more than months. A relapse occurred when the dog was treated with tramadol for joint pain and the improvement that had been made was not recaptured with Huperzine A. At this stage, phenobarbital therapy was instituted and the dog improved greatly. The role of Huperzine A in controlling seizures is discussed.

Assessment of the attention impairment in absence epilepsy: comparison of visual and auditory P300.

We report an investigation of P300 measures of information processing in patients with generalized epilepsy of the absence type and those with complex partial epilepsy. Studies have demonstrated that absence patients perform more poorly than complex partial patients on behavioral tests of sustained attention (the Continuous Performance Test, or CPT). Duncan [Duncan, C.C., 1988. Application of event-related brain potentials to the analysis of interictal attention in absence epilepsy. In: Myslobodsky, M.S., Mirsky, A.F. (Eds.), Elements of Petit Mal Epilepsy. Peter Lang, New York, pp. 341-364] reported that P300 was significantly reduced in a group of absence patients as compared with healthy controls. The present investigation was undertaken to compare the attention deficit in absence patients to that in complex partial seizure patients. Thus, ERPs were recorded while participants with absence seizure disorder, complex partial seizure disorder, and healthy controls performed auditory and visual versions of the CPT. A significant reduction in the amplitude of P300 on the visual CPT was observed in both groups of seizure patients as compared to controls. In contrast, P300 on the auditory CPT was reduced only in the group with absence seizures. These ERP data support and amplify previous behavioral findings of the impaired capacity of absence patients to mobilize and sustain attentional resources. Auditory sustained attention seems to be more affected by the pathophysiology of absence epilepsy than visual attention. Two possible factors may be involved: (a) There are separate visual and auditory attention systems in the brain, and the latter is more vulnerable than the former [Duncan, C.C., Kosmidis, M.H., Mirsky, A.F., 2005. Closed head injury-related information processing deficits: An event-related potential analysis. Int. J. Psychophysiol. 58, 133-157]; and (b) Auditory processing depends on intact mechanisms in the brainstem, which are dysfunctional in patients with absence seizures.

Theories of impaired consciousness in epilepsy.

Although the precise mechanisms for control of consciousness are not fully understood, emerging data show that conscious information processing depends on the activation of certain networks in the brain and that the impairment of consciousness is related to abnormal activity in these systems. Epilepsy can lead to transient impairment of consciousness, providing a window into the mechanisms necessary for normal consciousness. Thus, despite differences in behavioral manifestations, cause, and electrophysiology, generalized tonic-clonic, absence, and partial seizures engage similar anatomical structures and pathways. We review prior concepts of impaired consciousness in epilepsy, focusing especially on temporal lobe complex partial seizures, which are a common and debilitating form of epileptic unconsciousness. We discuss a "network inhibition hypothesis" in which focal temporal lobe seizure activity disrupts normal cortical-subcortical interactions, leading to depressed neocortical function and impaired consciousness. This review of the major prior theories of impaired consciousness in epilepsy allows us to put more recent data into context and to reach a better understanding of the mechanisms important for normal consciousness.

Symptomatic complex partial status epilepticus manifesting as utilization behavior of a mobile phone.

Utilization behavior (UB) consists of reaching out and using objects in the environment in an automatic manner and out of context. This behavior has been correlated to frontal lobe dysfunction, especially of the right hemisphere. We describe a 60-year-old woman, affected by a glioblastoma located in the right frontal region, who presented with intermittent UB of the mobile phone as the main clinical manifestation of partial complex status epilepticus. Video/EEG studies showed a striking correlation between mobile phone utilization and ictal epileptic activity. Clinical and EEG findings were markedly reduced after the introduction of antiepileptic drugs. This case study suggests that UB may be added to the symptoms described for partial seizures originating from frontal areas.

Behavioral status of children with cryptogenic localization-related epilepsy.

Using the Child Behavior Checklist, behavior of 51 children with cryptogenic localization-related epilepsy was studied. According to parent report, children with cryptogenic localization-related epilepsy scored in the clinical range on the subscales "internalizing behavior," ''total behavior,'' and "attentional problems.'' No relation between the epilepsy factors seizure frequency, age at onset, duration of epilepsy or the number of antiepileptic drugs, and the subscales of the Child Behavior Checklist was found. Only for seizure type a relationship was found. Although in the normal range, the more severe the seizure type, the more delinquent, aggressive, and externalizing behavioral problems. Other studies have demonstrated that in children with epilepsy, internalizing problems are more common than externalizing problems, and that attentional, social, and thought problems are relatively specific. Therefore, we can conclude that the behavioral problems we found in our cohort are not very different from behavioral problems described in other epilepsy types.

Patient awareness of seizures as documented in the epilepsy monitoring unit.

Treatment for epilepsy depends largely on seizure frequency reported by patients through their seizure diaries. However, patients may be unaware of some of their seizures, which may lead to incomplete diary data, impacting on appropriate treatment plans. The purpose of this study was to quantify awareness of seizures in patients admitted to an epilepsy monitoring unit through post event assessments by registered nurses. Results indicated that only 44.5% of complex partial and secondarily generalized tonic-clonic seizures were recognized by patients with epilepsy. Incomplete data in seizure diaries are likely a widespread problem, which may have an important impact on treatment and, thereby, on the safety and quality of life of individuals with epilepsy.

Evaluation of mediators of change in the treatment of epilepsy with acceptance and commitment therapy.

The present study examined the mediators of change accounting for outcomes of a previously published study on acceptance and commitment therapy for the self-management of epilepsy and its life restricting impact. Conducted with 27 poor South Africans, a 9-h ACT protocol that included seizure management methods was shown to greatly reduce epileptic seizures and to increase quality of life over the next year as compared to an attention placebo control. A series of bootstrapped non-parametric multiple mediator tests showed that pre to follow-up changes in: seizures, quality of life, and well-being outcomes were mediated to a degree by ACT process measures of epilepsy-related acceptance or defusion, values attainment, persistence in the face of barriers, or their combination. The results of this study contribute to the understanding of the contextual conditioning mechanisms at work for those suffering from epilepsy and may show that helping people live vital lives may also help to reduce seizures.

Consultants' conflicts: a case discussion of differences and their resolution.

Conflicts among consultants are frequent in general hospitals. Unfortunately, such disputes are rarely resolved to the satisfaction of all concerned. The authors discuss the conflicts that may arise among consultants and review techniques that can lead to more effective collaboration. Authors review the literature on consultants' conflicts and discuss strategies for their resolution. They present the case of a man with neuropsychiatric symptoms and discuss how practitioners of psychiatry and neurology often approach differential diagnosis, work-up, and treatment of challenging cases. The consultants were able to find several points of agreement and generated a workable plan that led to improvement in the patient's symptoms. Conflict among medical consultants is poorly described in the literature. However, an understanding of conflict and strategies for its resolution can lead to improved patient care. Conflict is a common and virtually unavoidable aspect of multidisciplinary care. However, effective tools exist that can help physicians embrace, rather than avoid, conflict, and lead to more effective collaboration. Effective management of interdisciplinary conflict improves communication, assists in medical decision-making, and, most importantly, improves the delivery of patient care.