Seizures Provoked by Greasy Pork in a Patient With Refractory Focal Epilepsy.

Seizures have been reported to be directly triggered by certain foods in some people with epilepsy. On the other hand, eating epilepsy has been mentioned in the literature as a rare disorder characterized by clinical and EEG findings that vary from patient to patient and are interestingly prevalent in certain geographic areas. Epilepsy in these patients is either idiopathic or due to underlying brain pathology. We present a case of refractory focal epilepsy in which the patient reports seizures provoked by eating greasy pork. During the admission to the epilepsy monitoring unit (EMU), the patient did not have seizures during the first three days of the admission despite antiepileptic medication withdrawal, sleep deprivation, and photic stimulation. However, when he consumed greasy pork, he had tonic-clonic convulsions about five hours after eating. On the following day, he had another tonic-clonic seizure after eating greasy pork.

Cefepime-Induced Neurotoxicity or Nonconvulsive Status Epilepticus (NCSE): A Controversy Revisited.

Neurotoxicity is a well-known side effect of cefepime among patients commonly present with altered mental status and typical electroencephalogram (EEG) findings of generalized periodic discharges (GPDs). Some practitioners consider this pattern as encephalopathy and often treat it with the withdrawal of cefepime only, while others are at times concerned with non-convulsive status epilepticus (NCSE) and treat it with antiseizure medications (ASMs) in addition to the withdrawal of cefepime to accelerate the recovery. We present a case series of two patients who developed cefepime-induced altered mental status and EEG findings of GPDs at a rate of 2-2.5 Hz concerning for the ictal-interictal continuum (IIC). Both cases were treated as possible NCSE with ASMs in addition to the withdrawal of cefepime, resulting in different clinical outcomes. The first case showed clinical and EEG improvement shortly after the administration of parenteral benzodiazepines and ASMs. The other case showed electrographic improvement but did not show significant improvement in mentation, and the patient died eventually.

Low Serum Pyridoxine Levels Worsen Seizure Control in Adult Epilepsy Patients.

BACKGROUND: Vitamin B6 (pyridoxine) is an important cofactor in the process by which glutamic acid decarboxylase (GAD) converts the excitatory, pro-epileptogenic neurotransmitter, glutamate, into the inhibitory, anti-epileptogenic neurotransmitter, gamma-aminobutyric acid (GABA). This concept has been established in infants with pyridoxine-dependent epilepsy as well as adult patients with other epilepsy subtypes who presented with medication-resistant status epilepticus, with both patient groups experiencing cessation of seizure activity following pyridoxine administration. Given our knowledge of the role of vitamin B6 in the conversion of glutamate to GABA, its effect on seizure control in infants with specific epilepsy subtypes, reports of adult-onset seizures associated with vitamin B6 deficiency, and vitamin B6's role in terminating status epilepticus in adult patients with other types of epilepsy, we suspect that low vitamin B6 levels in adult epilepsy patients may correlate with poor seizure control across all epilepsy subtypes. This study seeks to determine whether there is a relationship between pyridoxine levels and the level of seizure control in adults with epilepsy, regardless of their seizure type. METHODS: After obtaining institutional review board approval, we prospectively enrolled 32 patients (age range: 25-57 years) with epilepsy who presented to our clinic. Patients who did not meet the study criteria or who were diagnosed with psychogenic non-epileptic seizures (PNES) were excluded from the study (n = 2). Patients were classified as well-controlled (WC) or poorly controlled (PC) based on the absence or presence of a seizure within the last three months, respectively. After classification as WC or PC, pyridoxine serum levels and anti-seizure medication (ASM) levels were drawn in that clinic visit, following patient consent. All patients were contacted regarding pyridoxine and serum ASM levels, and patients that were found to be deficient in pyridoxine were treated with appropriate supplementation. At the end of the recruitment period, we performed analyses to determine if there was a statistically significant relationship between PC status and serum pyridoxine levels. RESULTS: Of 32 patients, two patients were diagnosed with psychogenic non-epileptic events and were subsequently excluded. Of 30 patients, 10 had PC epilepsy. Median (interquartile range) serum B6 levels were 35.8 (26.8-54.2) in patients with WC epilepsy and 17.5 (10.1-41.3) in patients with PC epilepsy (P = 0.11). In the PC group, 6/10 (60%) of the patients demonstrated low serum pyridoxine compared to 3/20 (15%) in the WC group (P = 0.03). CONCLUSION: There was a statistically significant relationship between serum pyridoxine levels and seizure control. If appropriate, pyridoxine supplementation should be considered, especially in critically ill adult patients with refractory or PC seizures despite good adherence to ASMs.

Tethered Cord Syndrome Associated With Lumbar Lipomyelomeningocele: A Case Report.

The objective is to describe a rare case of lumbar lipomyelomeningocele presenting as progressive urinary incontinence. Lipomyelomeningocele is a type of closed spinal dysraphism typically presenting as a lipomatous mass contiguous with a neural defect above the gluteal crease. Tethered cord syndrome is defined as symptoms and signs caused by excessive spinal cord tension from an abnormally low conus medullaris, with an abnormally thick filum terminale attached to the lower sacral region. A 19-year-old male with no remarkable medical history presented with low back pain and urinary incontinence for the past one year. On physical exam patient had normal motor strength, sensory testing to all modalities was intact. The rectal tone was normal, and no saddle anesthesia was noted. MRI lumbar spine revealed lumbar lipomyelomeningocele with associated tethered cord syndrome. The patient underwent tethered cord release surgery with lipoma excision. Pathology of the soft tissue showed fibrovascular tissue and mature adipose tissue consistent with lipoma. The majority of cases of tethered cord syndrome are related to spinal dysraphism, a rare pediatric syndrome. It is potentially treatable if caught early, and MRI can help with an accurate diagnosis of the condition. Older adults are more likely to present with urological and neurological complaints. Surgical un-tethering is indicated in patients with progressive symptoms. In our case, the only presenting symptom was urinary incontinence, and the neurological exam was normal other than lower lumbar paraspinal tenderness.

Neuromodulation in Intractable Epilepsy Through Responsive Vagal Nerve Stimulation: A Three-Year Retrospective Study at the University of Texas Medical Branch, Galveston.

BACKGROUND: Vagus nerve stimulation (VNS) functions through neuromodulatory mechanisms to provide quality of life improvements to those with drug-resistant epilepsy. Responsive VNS (rVNS) generators are designed to further reduce seizure burden by detecting ictal tachycardia and aborting seizures soon after their onset.  Methods: Electronic medical records were accessed from January 2015 to December 2018 to identify patients with epilepsy managed with rVNS generators. Data were collected on seizure burden before and after rVNS implantation. Seizure burden was compared using t-tests, and monthly seizure reductions were gauged with the McHugh scale. Twenty-seven individuals met inclusion criteria; 10 were eliminated due to prior VNS implantation or undocumented seizure frequencies. RESULTS: The average seizure burden prior to rVNS implantation was 24.78 seizures/month. Following generator placement, the mean seizure frequencies at three months, six months, 12 months, and 18 months were 6.81, 16.57, 5.65, and 5.78 seizures/month, respectively. However, despite documented reductions in the average monthly seizure frequency, we found no statistically significant differences in seizure frequency relative to baseline. CONCLUSION: While many participants showed individual reductions in seizure burden, this study was unable to definitively conclude that rVNS therapy leads to statistically significant reduction in seizure burden.

EEG Characteristics in COVID-19 Survivors and Non-survivors With Seizures and Encephalopathy.

The objective of this study is to report EEG findings in both COVID-19 survivors and non-survivors who underwent EEG either due to seizure or encephalopathy. Out of total 1468 COVID-19-positive patients, 19 patients underwent EEG. Eight out of 19 patients had a history of seizure disorder and in the remaining 11 with no prior history of seizures, four had a clinical seizure during their hospital stay. Only one had new-onset complex focal status epilepticus on EEG. Amongst the survivors (13/19), the most common EEG findings were normal followed by mild diffuse slowing. Amongst the non-survivors (6/19), the most common EEG finding was moderate to severe slowing in 50% of the patients. It can be deduced that COVID-19 infection does not increase the propensity of epileptiform discharges on EEG. There is perhaps a trend towards increased risk of new-onset status epilepticus in patients with encephalopathy and focal lesions.

Brain-Responsive Neurostimulation for the treatment of adults with epilepsy in tuberous sclerosis complex: A case series.

OBJECTIVE: Tuberous sclerosis complex (TSC) is a genetic disorder primarily characterized by the development of multisystem benign tumors. Epilepsy is the most common neurologic manifestation, affecting 80%-90% of TSC patients. The diffuse structural brain abnormalities and the multifocal nature of epilepsy in TSC pose diagnostic challenges when evaluating patients for epilepsy surgery. METHODS: We retrospectively reviewed the safety experience and efficacy outcomes of five adult TSC patients who were treated with direct brain-responsive neurostimulation (RNS System, NeuroPace, Inc). RESULTS: The average follow-up duration was 20 months. All five patients were responders (≥50% disabling seizure reduction) at last follow-up. The median reduction in disabling seizures was 58% at 1 year and 88% at last follow-up. Three of the five patients experienced some period of seizure freedom ranging from 3 months to over 1 year. SIGNIFICANCE: In this small case series, we report the first safety experience and efficacy outcomes in patients with TSC-associated drug-resistant focal epilepsy treated with direct brain-responsive neurostimulation.

A Rare Case of Ecchordosis Physaliphora Presenting With Headache, Abducens Nerve Palsy, and Intracranial Hypertension.

We report a rare case of ecchordosis physaliphora presenting with headache, nausea, and diplopia. On neurological examination, the patient was found to have left abducens nerve palsy. CT of the head without contrast was unremarkable. Brain MRI demonstrated a non-enhancing retroclival mass with a mass effect upon the ventral pons. The mass had increased signal intensity on T2 and decreased signal intensity on T1-weighted sequences. Lumbar puncture revealed an opening pressure of 37 cm H2O. The patient underwent an endoscopic endonasal approach for retroclival mass resection three weeks later. The tissue analysis of the mass was consistent with ecchordosis physaliphora. This could have been misdiagnosed as idiopathic intracranial hypertension had the MRI of the brain not been performed.

Impact of Alzheimer's disease and related dementia diagnosis following treatment for bladder cancer.

OBJECTIVES: Our objective was to assess the incidence of Alzheimer's Disease and related dementia diagnosis following treatment for muscle-invasive bladder cancer and impact on survival outcomes. MATERIALS AND METHODS: A total of 4814 patients diagnosed with clinical stage T2-T4a, N0, M0 bladder cancer between January 1, 2002 to December 31, 2011 using the Surveillance, Epidemiology, and End Results (SEER)-Medicare database were identified. Alzheimer's disease and related dementia diagnosis was identified using International Statistical Classification of Disease-Ninth Edition outpatient and inpatient codes. Incidence of dementia following treatment were calculated and reported as dementia cases per 10,000 person-years. Cox proportional hazards models were used to assess the impact of dementia on survival outcomes. RESULTS: Of the 4814 patients, 2403 (49.9%) underwent radical cystectomy (RC) and 2411 (50.1%) underwent radiotherapy (RTX) and/or chemotherapy (CTX). Overall, 837 (17.4%) patients developed Alzheimer's disease and related dementia following bladder cancer treatment. There was no significant difference in the incidence of Alzheimer's disease and related dementia following either treatment. Patients diagnosed with Alzheimer's disease and related dementia had worse overall (Hazard Ratio (HR), 2.64; 95% Confidence Interval (CI), 2.41-2.89) and cancer-specific (HR, 2.45; 95% CI, 2.18-2.76) survival than those without a dementia diagnosis following treatment. CONCLUSION: While we observed no difference in new-onset Alzheimer's disease and related dementia diagnosis following RC or RTX and/or CTX, patients with a Alzheimer's and related dementia diagnosis was associated with worse overall and cancer-specific survival. These findings have important implications for screening and the development of targeted interventions for improving outcomes in older adults following complex cancer treatments, as observed in this bladder cancer population.

Neurocognitive sequela of burn injury in the elderly.

Elderly individuals are a fast-rising segment of the US population and are at high risk of permanent disability and premature death secondary to traumatic injuries such as burn injury. The current paper will review the extant literature to understand the prevalence of burn injury in the elderly, the neurocognitive complications unique to the aged that places this cohort at risk, and evidence-based recommendations to reduce the early and late neurocognitive effects of burn injury in the aged. The elderly are a high-risk population for burn injury and its neurological sequela. This risk, at least in part, reflects multiple factors: age-related changes in the central and peripheral nervous system; multiple pre-existing co-morbidities (such as dementia and COPD); polypharmacy; suboptimal social support; and increased susceptibility to hypothermia, burn-related infections, and electrolyte and metabolic dysregulations.