Systematic prolonged video-electroencephalograms identify electrographic seizures in 5% of acute stroke patients with aphasia.

In stroke units, diagnosing seizures may be difficult, especially in aphasic patients. We discuss herein our systematic 4-hour video EEG monitoring of 61 patients with aphasia within the first 72hours after the onset of ischaemic stroke. Five electrographic seizures were identified in 3 patients, with no clinical signs apparent on the video and no symptoms reported by patients. We did not record status epilepticus nor generalized seizure. Comparative analyses disclosed a higher risk of early seizures in patients with haemorrhagic transformation. Video EEG monitoring detected electrographic seizures in 5% of stroke patients with aphasia. This monitoring could be useful for selected patients, especially those with haemorrhagic transformation.

Epilepsy after stroke: Definitions, problems and a practical approach for clinicians.

Stroke, whether ischemic or hemorrhagic, is the main etiology of epilepsy in the elderly. However, incidences and outcomes differ according to stroke subtype and delay of onset following the stroke. While the medical literature is extensive, it is not always consistent, and many questions still remain regarding risk factors and management of vascular epilepsy. Thus, the present report here is an overview of the clinical aspects of vascular epilepsy using a practical approach that integrates data from meta-analyses and the more recently published expert recommendations.

Ictal speech and language dysfunction in adult epilepsy: Clinical study of 95 seizures.

PURPOSE: To analyze the semiological characteristics of the language and speech disorders arising during epileptic seizures, and to describe the patterns of language and speech disorders that can predict laterality of the epileptic focus. METHOD: This study retrospectively analyzed 95 consecutive videos of seizures with language and/or speech disorders in 44 patients admitted for diagnostic video-EEG monitoring. Laterality of the epileptic focus was defined according to electro-clinical correlation studies and structural and functional neuroimaging findings. Language and speech disorders were analyzed by a neurologist and a speech therapist blinded to these data. RESULTS: Language and/or speech disorders were subdivided into eight dynamic patterns: pure anterior aphasia; anterior aphasia and vocal; anterior aphasia and "arthria"; pure posterior aphasia; posterior aphasia and vocal; pure vocal; vocal and arthria; and pure arthria. The epileptic focus was in the left hemisphere in more than 4/5 of seizures presenting with pure anterior aphasia or pure posterior aphasia patterns, while discharges originated in the right hemisphere in almost 2/3 of seizures presenting with a pure vocal pattern. No laterality value was found for the other patterns. CONCLUSION: Classification of the language and speech disorders arising during epileptic seizures into dynamic patterns may be useful for the optimal analysis of anatomo-electro-clinical correlations. In addition, our research has led to the development of standardized tests for analyses of language and speech disorders arising during seizures that can be conducted during video-EEG sessions.

Diffusion tensor changes in epileptogenic hippocampus of TLE patients.

PURPOSE: Diffusion tensor imaging (DTI) can provide quantitative information of brain abnormalities in patients with temporal lobe epilepsy (TLE) that are not detectable with conventional magnetic resonance imaging (MRI). METHODS: Seventeen patients with medically TLE were selected for the study. The patients and ten healthy subjects underwent 25 directions DTI acquisition. The patients were separated into two groups based on the MRI findings: eight TLE MRI-negative patients with no signal abnormalities on conventional MRI and nine TLE patients with hippocampal sclerosis (HS). Fractional anisotropy (FA), mean diffusivity (MD), and the three diffusivities (lambda(1), lambda(2) and lambda(3)) were measured in bilateral hippocampi of controls, MRI-negative, and HS patients. Comparisons between the three groups were performed for hippocampi ipsi- and contralateral to epileptogenic zone. RESULTS: The ipsilateral hippocampus of MRI-negative patients presented statistical increased anisotropy and no significant difference in diffusivities versus controls. Significant differences in anisotropy and diffusivities were detected between the ipsilateral hippocampus of HS when compared with controls. CONCLUSION: DTI depicted hippocampal abnormalities in TLE patients with a normal conventional MRI different from those found in patients with HS. Diffusivity and anisotropy indices provide significant differences inside hippocampus and should be jointly considered to improve the DTI measurements specificity in TLE patients.

[Epilepsy surgery in France]. / La chirurgie de l'épilepsie en France Evaluation de l'activité

We report here the results of the first survey on epilepsy surgery activity in France. Data from a questionnaire sent to 17 centers practicing epilepsy surgery were analyzed. All centers responded; however, all items were not completely documented. Over 50 years, more than 5000 patients have been operated on for drug-resistant epilepsy and more than 3000 patients underwent some invasive monitoring, most often SEEG. Currently, nearly 400 patients (including more than 100 children) are operated on yearly for epilepsy in France. Over a study period varying among centers (from two to 20 years; mean, 9.5 years), results from more than 2000 patients including one-third children were analyzed. Important differences between adults and children, respectively, were observed in terms of location (temporal: 72% versus 4.3%; frontal: 12% versus 28%; central: 2% versus 11%), etiology (hippocampal sclerosis: 41% versus 2%; tumors 20% versus 61%); and procedures (cortectomy: 50% versus 23%; lesionectomy: 8% versus 59%), although overall results were identical (seizure-free rates following temporal lobe surgery: 80.6% versus 79%; following extratemporal surgery: 65.9% versus 65%). In adults, the best results were observed following temporomesial (TM) resection associated with hippocampal sclerosis or other lesions (class I: 83% and 79%, respectively), temporal neocortical (TNC) lesional (82%), while resections for cryptogenic temporal resections were followed by 69% (TM) and 63% (TNC) class I outcome. Extratemporal lesional resections were associated with 71% class I outcome and cryptogenic 43%. In children, the best results were obtained in tumor-associated epilepsy regardless of location (class I: 80%). A surgical complication occurred in 8% after resective surgery - with only 2.5% permanent morbidity - and 4.3% after invasive monitoring (mostly hemorrhagic). Overall results obtained by epilepsy surgery centers were in the higher range of those reported in the literature, along with a low rate of major surgical complications. Growing interest for epilepsy surgery is clearly demonstrated in this survey and supports further development to better satisfy the population's needs, particularly children. Activity should be further evaluated, while existing epilepsy surgery centers as well as healthcare networks should be expanded.

[Healthcare networks in epilepsy: situation in the greater Paris region]. / Réseaux de santé et épilepsie: état des lieux en Ile-de-France.

The goal of healthcare networks is to provide global care for patients and to coordinate the actions of the different healthcare professionals to provide the most appropriate treatment based on patient needs. Such networks have been created in Ile-de-France for some neurological diseases but not epilepsy. However, the needs of the population are significant, with 55,000 to 70,000 epilepsy patients in the geographic area. Contacts between the three main adult epilepsy centers, although not formal, form the basis of a dedicated epilepsy network so that the quality of care can be improved and surgical treatment made easier if indicated.

Evaluation of brivaracetam, a novel SV2A ligand, in the photosensitivity model.

OBJECTIVE: To assess the activity of brivaracetam, a novel SV2A ligand, in the photosensitivity model as a proof-of-principle of efficacy in patients with epilepsy. METHODS: A subject-blind placebo-controlled study in patients with photosensitive epilepsy was performed to investigate the effect of single-dose brivaracetam (10, 20, 40, or 80 mg) on photosensitive responses. Each patient was exposed to intermittent photic stimulation that evoked a generalized photoparoxysmal EEG response. Individual standard photosensitivity ranges (SPRs) were recorded post-placebo (day -1) and post-brivaracetam until return to baseline (day 1 to 3). Plasma concentrations of brivaracetam and any concomitant antiepileptic drugs were determined. RESULTS: Of the 18 evaluable patients, none achieved SPR abolishment post-placebo, whereas 14 (78%) achieved complete abolishment post-brivaracetam. Decrease in SPR was seen in 8 patients (44%) post-placebo compared to 17 (94%) post-brivaracetam. Duration of response was twice as long post-brivaracetam 80 mg (59.5 hours) compared with lower doses, although the overall effect was not dose-dependent. Time to maximal photosensitive response was dose-related with the shortest time interval observed at the highest dose (0.5 hours post-brivaracetam 80 mg). The area under the effect curve (SPR change from pre-dose vs time) appeared linearly correlated with the area under the plasma concentration curve. Brivaracetam was well tolerated. The most common adverse events were dizziness and somnolence. CONCLUSIONS: Our findings show that brivaracetam clearly suppresses generalized photoparoxysmal EEG response. As such, investigations of the antiepileptic properties and tolerability of brivaracetam are warranted in further clinical studies of patients with epilepsy.

[Pregnancy and epilepsy]. / Grossesse et épilepsie.

Pregnant women with epilepsy risk complications. Perinatal mortality and congenital malformations are more frequent than in the general population. Offspring of parents with epilepsy have a higher risk for seizure later in life. Identification of factors associated with complications may lead to improved pregnancy outcome. Recommendations about neurological, obstetric and pediatric care of pregnant women with epilepsy are proposed.

[Epilepsy and videogame: which physiopathological mechanisms to expect?]. / Epilepsie et jeux vidéo: quelles approches physiopathologiques envisager?

Video games may induce epileptic seizures in some subjects. Most of them have photosensitive epilepsy. The triggering factors are multiple: characteristics of the softwares, effects of the electronic screen and interactivity. The wide diffusion of the video games explain the large number of descriptions of videogame induced seizures. Historical aspects and an analysis of the underlying mechanisms of videogame induced seizures are presented.

Epilepsies and video games: results of a multicentric study.

OBJECTIVES: The purpose of this study was to research whether or not video games may induce paroxysmal discharges (PD) in different groups of patients. METHODS: One hundred and fifteen subjects from 5 different French laboratories were studied: 33 had seizures exclusively under visual stimuli, 42 had both photogenic seizures and spontaneous seizures occuring independently, and 40 had non-photogenic seizures. The same protocol which included one TV sequence, 3 sequences of video games selected on particular criteria (pattern, luminosity and nature of the scene), were presented at different distances from the TV screen at 50 and 100 Hz. RESULTS: Among the factors provoking paroxysmal discharges (PD) some seem crucial: the frequency of the TV screen (the 100 Hz screen was significantly safer than 50 Hz), the distance from the screen (1 m safer than 50 cm), and, particularly for the 50 Hz screen, the specific pattern of the images and the act of playing. CONCLUSIONS: Video games are ineffective for subjects known as having a non-photosensitive epilepsy, but may induce PD on subjects known as photosensitive even when intermittent light stimulation (ILS) is not effective. These results based on a different approach than in other publications confirm data which were suggested by the literature, and suggest that 100 Hz TV screens should be recommended to patients with TV-induced attacks.

MRI in chronic progressive radiation myelopathy.

OBJECTIVE: Our goal was to assess medullary lesions in patients suffering from chronic progressive radiation myelopathy (CPRM) using MRI. MATERIALS AND METHODS: In a group of 10 patients suffering from CPRM, MRI findings (11 examinations), radiation protocols, and patient prognoses were reviewed. RESULTS: A cord enlargement was demonstrated in five cases, whereas four cases presented with medullary atrophy. As demonstrated by MRI, radiation-induced medullary lesions progressed toward cord atrophy in one patient. When MRI and/or comparison myelogram were performed within 8 months following the onset of the myelopathy, a cord enlargement was usually encountered. When the patient was evaluated > 8 months after the first neurological symptoms, a cord atrophy was always demonstrated. Medullary lesions extended beyond the boundaries of the radiation field in 67% of the cases. However, with the exception of one case, the main focus of the cord damage was included within an irradiated cord segment. An enlarged cord was often associated with a neurologic deterioration and a fatal outcome. In patients with cord atrophy, the neurologic deficit was often static and survival rates were better. CONCLUSION: These results suggest a revision of classic criteria used for the diagnosis of CPRM. By demonstrating cord lesions, MRI helps to establish disease prognosis.

Gadolinium-enhanced MRI in central nervous system Behçet's disease.

Two cases of central nervous system Behçet's disease, studied by gadolinium-enhanced MRI, are presented. In one patient, whose clinical picture was dominated by a brain syndrome, the gadolinium enhancement resolved with clinical improvement, although the hyperintense areas in the mesencephalon on T2-weighted images persisted. In the second, who had a pseudobulbar palsy and a mild right hemiparesis, there were many abnormal areas, but an enhancing focus in the posterior limb of the left internal capsule was probably the lesion responsible for the hemiparesis.

[Postural hypotension with myoclonia in multisystemic atrophy]. / Hypotension posturale avec myoclonies dans une atrophie multisystémique.

Each time he stood up a 60-year old man experienced myoclonic jerks, quickly followed by a syncope due to major postural hypotension. Progressive autonomic failure was associated with pyramidal, extrapyramidal and cerebellar features in a pattern characteristic of Shy-Drager disease. Myoclonic jerks suggested seizures, but no electroencephalographic epileptiform activity was found. This case together with data from the literature suggest, that such involuntary movements may result from cerebral anoxia.

[Neurologic complication of lymphography. Apropos of a case]. / Complication neurologique de la lymphographie. A propos d'un cas.

A lymphography was performed as a diagnostic procedure in a 69-year-old female patient hospitalized for protracted fever. Akinetic mutism with left hemiparesis occurred 10 minutes after the injection of ultrafluid lipiodol. The patient died 13 days later. Neurologic complications of lymphography are extremely rare but may be life-threatening. Speculations as to the mechanisms which may be responsible for these complications, through a modification of the usual distribution of the contrast media, include lymphovenous shunts, lymphatic vessel compression or obstruction, pulmonary arteriovenous shunts and right-to-left intracardiac shunts. These mechanisms may facilitate cerebral embolization of the contrast media. Indications of lymphography must be restricted in patients with patent lymphatic obstruction.