Temporal lobe neoplasm and seizures: how deep does the story go?

[March 2008-Cleveland Case Report]. There is a well-described association between the occurrence of developmental tumors and the presence of cortical dysplasia in the neighboring brain tissue. The main surgical approaches in the treatment of medically refractory epilepsy related to such developmental tumors include a lesionectomy versus a tailored cortical resection, often guided by an invasive evaluation. This case report describes the surgical management of a 26-year-old female with olfactory auras evolving into automotor seizures and convulsions, occurring in the context of a right temporo-parietal developmental lesion. It illustrates the pros and cons of various surgical approaches, and discusses some pathophysiological aspects of developmental tumors, dysplasia and epilepsy. [Published with video sequences].

Prevalence and characteristics of restless legs syndrome in patients with pulmonary hypertension.

BACKGROUND: Patients with pulmonary hypertension (PH) have an increased prevalence of risk factors for restless legs syndrome (RLS). We performed a cross-sectional study to determine the prevalence and characteristics of RLS in this population. METHODS: Patients filled out two questionnaires during a visit: (1) a diagnostic tool for RLS, based on the core clinical features; and (2) a 10-question rating scale used to assess severity. Data were obtained by medical record review with regard to demographics, characteristics of PH and known RLS risk factors. RESULTS: Restless legs syndrome was found in 43.6% (24 of 55) (mean age +/- SD: 49 +/- 14 years; 41 women, 14 men) of patients and 54% of these had moderate or severe RLS. Patients with RLS were younger but gender differences were not appreciated. Presence of RLS did not correlate with measures of PH severity; however, patients with RLS were more likely to have a better 6-minute walk distance (p = 0.015) and lower BNP level (p = 0.07) and less likely to be WHO Class IV or require oxygen during the 6-minute walk test. Patients with a history of hypothyroidism (67%; p = 0.04) and those on opioids for relief of leg pain (69%) were more likely to have RLS. CONCLUSIONS: Patients with PH had a very high prevalence of RLS and most had moderate or severe symptoms. RLS was more common in more active patients and those who were hypothyroid or on opioids for relief of leg pain. Patients with PH should be screened for RLS because good treatment options are available.

Diagnosis of sleep-related breathing disorders by visual analysis of transthoracic impedance signals in pacemakers.

BACKGROUND: Minute ventilation sensors of cardiac pacemakers measure ventilation by means of transthoracic impedance changes between the pacemaker case and the electrode tip. We investigated whether this technique might detect sleep-related breathing disorders. METHODS AND RESULTS: In 22 patients, analog waveforms of the transthoracic impedance signal measured by the pacemaker minute ventilation sensor over the course of a night were visualized, scored for apnea/hypopnea events, and compared with simultaneous polysomnography. Analysis of transthoracic impedance signals correctly identified the presence or absence of moderate to severe sleep apnea (apnea/hypopnea index, AHI >20 h(-1)) in all patients (receiver operating characteristics, ROC=1.0). The ROC for AHI scores of > or =5 h(-1) and > or =10 h(-1) showed an area under the curve of 0.95, P<0.005, and 0.97, P<0.0001, respectively. Accuracy over time assessed by comparing events per 5-minute epochs was high (Cronbach alpha reliability coefficient, 0.85; intraclass correlation, 0.73). Event-by-event comparison within +/-15 seconds revealed agreement in 81% (kappa, 0.77; P<0.001). CONCLUSIONS: Detection of apnea/hypopnea events by pacemaker minute ventilation sensors is feasible and accurate compared with laboratory polysomnography. This technique might be useful to screen and monitor sleep-related breathing disorders in pacemaker patients.

Ictal urinary urge: further evidence for lateralization to the nondominant hemisphere.

PURPOSE: To determine the lateralizing value of ictal urinary urgency. METHODS: A retrospective database search was performed for patients with ictal urinary urgency admitted to the Epilepsy Monitoring Unit at the Cleveland Clinic between 1994 and 2001. RESULTS: Six patients were identified; intracarotid amytal test demonstrated left hemispheric speech dominance in five cases. The sixth patient continued to speak during right temporal seizures. EEG and imaging data supported right temporal or frontotemporal epilepsy in all six cases. Two patients were seizure free after focal right hemispheric resection. CONCLUSIONS: Ictal urinary urge appears to be a lateralizing sign for nondominant temporal lobe epilepsy.

Sleep and Epilepsy.

Seizures and antiepileptic drugs (AEDs) affect sleep macroarchitecture and may produce excessive daytime sleepiness (EDS) in patients with epilepsy. Sleep is a potent activator of seizures and epileptiform discharges. In some patients, seizures occur exclusively or predominately in sleep. Benign focal epilepsy of childhood with centrotemporal spikes (BECTS), supplementary sensorimotor area epilepsy (SSMA) and Lennox Gastaut syndrome are a few of the more common epilepsy syndromes characterized by nocturnal seizures. Excessive daytime sleepiness is a common complaint of patients with epilepsy. Causes of EDS include seizures, AEDs, poor sleep hygiene, and coexisting sleep disorders. Pharmacologic therapy is aimed at identifying the single most effective drug for a given seizure type or epilepsy syndrome. Polytherapy is associated with a higher likelihood of adverse effects--most notably, EDS. Poor sleep hygiene leads to sleep fragmentation that can exacerbate seizures and EDS. Primary sleep disorders should be suspected in patients with EDS, particularly those treated with monotherapy at low serum drug concentrations and well controlled seizures. Treatment of sleep disorders may lead to better seizure control.

Sleep-related eating disorder in fraternal twins.

Sleep-related eating disorder (SRED) is characterized by nocturnal partial arousals associated with compulsive consumption of food and altered levels of consciousness. Reports of an increased incidence of SRED in relatives of affected individuals suggest a genetic predisposition. We report a woman with SRED whose fraternal twin sister and father are also affected.

Prediction of the final MSLT result from the results of the first three naps.

OBJECTIVES: To determine if the mean sleep latency (mSL) and the presence of significant sleep onset rapid eye movement periods (SOREMPs) can be predicted from the results of the first three naps in selected patients undergoing multiple sleep latency test (MSLT). METHODS: Retrospective analysis of a number of MSLTs to identify the tests in which the mSL category and the presence of > or =2 naps with SOREMPS can be accurately predicted from the sleep latencies (SLs) of and SOREMPs in the first three naps. RESULTS: The study included 588 consecutive MSLTs performed on 552 patients during a 3-year period. (1) The mSL was normal (> or =10 min) for all MSLTs (n=90, 15%) if either (a) the SL was normal in each of the first three naps, or (b) SL was 20 min for any two of the first three naps. (2) The mSL was low (<5 min) or borderline (> or =5 and <10 min) for 99% MSLTs with SL in the low or borderline categories, respectively. (3) The accuracy of predicting > or =2 naps with SOREMPs was 100% (normal SL), 96% (borderline SL), and 89% (low SL). (4) The mSL category (normal or low) and the presence of > or =2 naps with SOREMPs were predicted with 100% accuracy in 23% of all MSLTs. CONCLUSIONS: The category of mSL can be predicted with >99% accuracy, if SL is normal, borderline, or low in each of the first three naps, or if the patient does not sleep in any two of the first three naps. MSLT can probably be shortened to three naps in up to 23% to reduce time, labor, discomfort, and cost of the test.

Comparison of Epworth Sleepiness Scale scores by patients with obstructive sleep apnea and their bed partners.

OBJECTIVES: In some patients with obstructive sleep apnea (OSA), Epworth Sleepiness Scale scores (ESS) do not reflect the severity of disease. In many cases, bed partners (BPs) report more severe hypersomnia on the part of the patient than the patient him/herself. The purpose of this study was to assess the agreement between patients and BPs on ESS scores and to compare patients and BPs on the correlation between ESS and the severity of OSA. METHODS: ESS scores were estimated by patients and their BPs and their scores were compared. The correlation between the ESS and the apnea-hypopnea index, arousal index, minimum oxygen desaturation, and body mass index of the patient was estimated and compared between the patient and BP. RESULTS: ESS scores of the patient and BP were similar in their correlation with polysomnographic variables. BPs tended to give slightly higher ESS scores than the patient. CONCLUSIONS: ESS scores as estimated by BPs of patients with OSA did not correlate more positively with polysomnographic variables of OSA severity than scores estimated by affected patients.