H-coil repetitive transcranial magnetic stimulation for treatment of temporal lobe epilepsy: A case report.

Low frequency repetitive TMS (rTMS) of a cortical seizure focus is emerging as an antiepileptic treatment. While conventional rTMS stimulators activate only superficial cortical areas, reaching deep epileptic foci, for example in temporal lobe epilepsy (TLE), is possible using specially designed H-coils. We report the results of rTMS in a young adult with pharmacoresistant bilateral TLE who underwent three courses (of 10, 15, and 30 daily sessions) of unilateral rTMS over the hemisphere from which seizures originated most often. Seizure frequency was assessed before and after each block of rTMS sessions, as was the tolerability of the procedure. Seizure frequency declined significantly, by 50 to 70% following each rTMS course. All sessions were well-tolerated.

Rufinamide for the treatment of epileptic spasms.

OBJECTIVE: The purpose of this study was to determine the safety and efficacy of rufinamide for treatment of epileptic spasms. METHODS: We retrospectively reviewed patients treated with rufinamide for epileptic spasms from January 2009 to March 2010. Age, presence of hypsarrhythmia, change in seizure frequency following rufinamide initiation, and side effects were assessed. Patients who had a ≥ 50% reduction in spasm frequency were considered responders. RESULTS: Of all 107 children treated with rufinamide during the study period, 38 (36%) had epileptic spasms. Median patient age was 7 years (range: 17 months to 23). One patient had hypsarrhythmia at the time of treatment with rufinamide, and 9 other patients had a history of hypsarrhythmia. Median starting dose of rufinamide was 9 mg/kg/day (range: 2-18) and median final treatment dose was 39 mg/kg/day (range: 8-92). All patients were receiving concurrent antiepileptic drug therapy, with the median number of antiepileptic drugs being 3 (range: 2-6). Median duration of follow-up since starting rufinamide was 171 days (range: 10-408). Responder rate was 53%. Median reduction in spasm frequency was 50% (interquartile range=-56 to 85%, P<0.05). Two patients (5%) achieved a >99% reduction in spasms. Rufinamide was discontinued in 7 of 38 patients (18%) because of lack of efficacy, worsening seizures, or other side effects. Minor side effects were reported in 14 of 38 patients (37%). CONCLUSIONS: Rufinamide appears to be a well-tolerated and efficacious adjunctive therapeutic option for children with epileptic spasms. A prospective study is warranted to validate our observations.

Do antiepileptic drugs differ in suppressing interictal epileptiform activity in children?

Antiepileptic drugs may suppress interictal epileptiform activity in addition to suppressing seizures, although the comparative rates of suppression of interictal epileptiform activity for phenobarbital (PHB), carbamazepine (CBZ), and valproate (VPA) in children are unknown. Electroencephalogram (EEG) pairs were identified in which the first tracing illustrated interictal epileptiform activity before antiepileptic drug treatment; the rate of clearance of such activity in the subsequent tracing was assessed according to the drug introduced. EEG pairs (n = 213) were identified for CBZ, PHB, and VPA. Overall suppression rates of epileptiform activity in the second EEG were 12/55 (22%) for PHB, 27/81 (33%) for CBZ, and 35/77 (46%) for VPA (P = 0.005 for VPA vs PHB). When suppression rates were assessed comparing sleep-state pairs, suppression rates were 24/80 (30%) for PHB, 51/129 (40%) for CBZ, and 60/120 (50%) for VPA (P = 0.005 for PHB vs VPA). A subanalysis for focal discharges yielded suppression rates of 10/43 (23%) for PHB, 19/60 (32%) for CBZ, and 8/19 (42%) for VPA; for generalized discharges, 2/12 (17%) for PHB, 8/21 (38%) for CBZ, and 27/58 (47%) for VPA. VPA, and to a lesser extent CBZ, appeared superior to PHB in suppressing interictal epileptiform activity, including both focal and generalized epileptiform activity.

Clinical correlations of occipital epileptiform discharges in children.

OBJECTIVES: To determine the frequency of different causes of occipital epileptiform discharges (OEDs) in children and to analyze the EEG features that help predict epilepsy type and prognosis. METHODS: We identified children with OEDs in the absence of other focal discharges using an EEG database at our center; the presence of generalized spike-wave discharges (GSW) or slowing was not an exclusion criterion. Diagnosis, neurologic status, seizure semiology, and seizure remission status were recorded. RESULTS: Of 90 patients with OEDs, 50 (56%) had symptomatic seizures (18 with cerebral palsy, 11 with cerebral dysgenesis, 8 with genetic abnormalities); 31 (34%) had idiopathic seizures, including 6 with benign childhood epilepsy with occipital paroxysms (BCEOP), 8 (9%) had no seizures; and 1 (1%) had febrile seizures. Only two reported ictal visual symptoms. Eighty-seven percent with background slowing had symptomatic seizures, and 87% with normal backgrounds had idiopathic seizures (p < 0.001). Of 72 children with seizures and adequate follow-up, 28 of 45 (62%) with a normal background experienced seizure remission compared with 10 of 27 (37%) with background slowing (p = 0.04). Twenty of 81 patients with epilepsy had GSW. Twelve (60%) of the 20 GSW-positive patients had idiopathic epilepsy compared with 19 of 61 (31%) without GSW (p = 0.02). CONCLUSIONS: Most epilepsy in referred children with OEDs is symptomatic; syndromes such as BCEOP are rare. Visual ictal symptoms are rare. The presence of GSW or a normal background rhythm correlates with idiopathic seizures and a better prognosis.

Acetazolamide and furosemide for posthemorrhagic hydrocephalus of the newborn.

The authors evaluated the efficacy of acetazolamide (ACZ) and furosemide (FUR) in avoiding ventricular shunting procedures in preterm infants with posthemorrhagic hydrocephalus (PHH) and increased intracranial pressure (ICP). Preterm infants were screened for PHH (defined as ventriculomegaly [VM] and increased ICP measured with the Ladd fiberoptic monitor). PHH infants were randomized to ACZ and FUR treatment or serial lumbar puncture (LP) and monitored until not receiving medications or having undergone shunting. Of 69 infants with IVH screened for the study, 39 never developed VM, 14 developed VM, without increased ICP, and 16 developed PHH. Ten PHH infants were randomized to ACZ and FUR treatment and six to serial LP. Nine (90%) of the 10 infants assigned to the ACZ and FUR group avoided shunting. Nephrocalcinosis developed in a significant proportion of treated infants. Three (50%) of the six LP group infants did not require shunting procedures (P = 0.118). The authors conclude that ACZ and FUR therapy is useful in the treatment of preterm infants with PHH. Because a significant number of infants treated with both ACZ and FUR developed nephrocalcinosis, close monitoring for increased calcium excretion in the urine, or use of ACZ without FUR, is advised.

Tonic "seizures" in a patient with brainstem demyelination: MRI study of brain and spinal cord.

Tonic seizures are a poorly understood manifestation of demyelinating disease, first reported in 4 patients with multiple sclerosis. We describe a patient with tonic extension of the left limbs caused by a right-sided brainstem lesion as the first manifestation of demyelinating disease. A 19-year-old man was referred with a 4-month history of spontaneous attacks of mild paresthesias of the left arm and leg, followed by 15-45 s of rigid extension of the left limbs, occurring up to 25 times per day. Two months after onset, an MRI scan revealed areas of T2 abnormality in the lateral right cerebral peduncle and deep frontal white matter. The EEG was normal, including during hyperventilation which induced a typical episode. All attacks were successfully suppressed by carbamazepine, phenytoin, and valproate monotherapy. Serologic testing for toxoplasmosis, cytomegalovirus, Epstein-Barr virus, Lyme disease, and HIV was negative. Cerebrospinal fluid oligoclonal bands were absent but cerebrospinal fluid immunoglobulin G was mildly elevated (4.2 mg/dl). Over the next 30 months, serial MRIs revealed a normal spinal cord and persistence of the midbrain lesion, with resolution of some of the white matter lesions but reappearance of others. At 46 months, the midbrain lesion resolved on MRI, and the spasms no longer occurred spontaneously, nor could they be elicited by hyperventilation. While two previous reports have shown internal capsule lesions to underlie the tonic spasms in demyelinating disease, this is the first report in which a brainstem lesion has been causative.

Hemimegalencephaly: a longitudinal MR study.

An infant with hemimegalencephaly was studied with MR at 5 days and again at 10 months of age. The initial scan showed an abnormally large left cerebral hemisphere. At the age of 10 months, the left cerebral hemisphere was smaller than the right--an apparent left-sided micrencephaly caused by normal growth of the right hemisphere and arrested growth of the left. The age of imaging of a patient with hemimegalencephaly can be important if the correct diagnosis is to be made.

A simple mathematical method revealing the early stage of acute leukemia in patients with cytopenias.

On the basis of findings in examinations made in 50 patients (25 with hypoplastic anaemia and 15 in the hypoplastic stage of acute leukemia) a simple mathematical method was developed for the differential diagnosis of these two diseases. The following laboratory findings were used for calculating a formula: cellularity of the bone-marrow, percentage of blast cells in the myelogram, percentage of blast cells in leukocyte concentrate, morphology of erythrocytes, presence of normoblastosis, percentage of monocytes and absolute number of neutrophils in the peripheral blood. This method allows the correct diagnosis to be made in 91% of cases with hypoplastic anaemia and in 100% of cases with acute leukemia. By using 7 laboratory findings to be obtained easily this method will enable a correct diagnosis to be made even in those situations where hitherto it was very difficult to make a differential diagnosis or where it was impossible at all.