RESUMO
Determination of side of seizure onset is critical for a successful outcome following epilepsy surgery. Little is known about the significance of lateralized seizure termination. Sustained seizure activity contralateral to side of seizure onset, following termination of ictal activity ipsilateral to side of onset, may suggest the presence of an independent focus. Such activity, if present, should predict a poor outcome. We studied side of seizure termination in 13 patients undergoing monitoring with bitemporal depth electrodes and correlated this to outcome following anterior temporal lobectomy (ATL). Side of seizure onset was determined for all seizures during that evaluation. Based on side of final cessation of ictal activity, patients were classified as having ipsilateral final termination or simultaneous termination (Group 1; N=6) or contra-lateral or mixed final termination (Group 2; N=7). The Duke outcome classification system was used. At the end of 2 years follow-up, 6/6 patients in Group 1 and 3/7 patients in Group 2 were seizure free. We conclude that lateralized seizure termination during evaluation with depth electrodes may be useful in predicting outcome following ATL. Continued seizure activity contralateral to side of seizure onset (following termination of ictal activity ipsilateral to side of onset) predicts a poor outcome. This may indicate the presence of an independent seizure focus opposite to the side of surgery.
Assuntos
Lateralidade Funcional , Convulsões/cirurgia , Lobo Temporal/cirurgia , Adolescente , Adulto , Criança , Eletroencefalografia , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Monitorização Intraoperatória , Convulsões/fisiopatologia , Lobo Temporal/fisiopatologia , Resultado do TratamentoRESUMO
Objective: The purpose of this study was to correlate changes in PSG parameters between the diagnostic polysomnogram (dPSG) and the first night of treatment with continuous positive airway pressure (CPAP) (cpapPSG) to subjective improvement in sleep quality.Background: In patients with obstructive sleep apnea syndrome (OSAS), therapy with CPAP results in reduction of sleep latency, stage 1 sleep, arousal index (Al) and respiratory disturbance index (RDI), and increase in stage 2 sleep, REM sleep and REM density. No data exists on the differences in polysomnographic (PSG) parameters in patients who have subjective improvement in sleep quality and those who do not.Methods: We retrospectively reviewed PSG studies of 44 patients with OSAS who presented to the Sleep Disorders Center at Duke University Medical Center. Patient's qualitative assessment of sleep was noted using a Likert-type scale administered the morning after the dPSG and cpapPSG. PSG indices of patients noting subjective improvement were compared to those with no improvement.Results: Patients noting a subjective improvement in sleep quality showed a decrease in the percentages of stage 1 sleep (P<0.001) and an increase in percentages of stages 3 and 4 sleep (slow wave sleep rebound; P<0.007) and stage REM sleep (REM rebound; P<0.008).
RESUMO
Juvenile myoclonic epilepsy (JME) is often exquisitely responsive to treatment with valproic acid (VPA). However, a subset of patients does not respond to this medication and often has intractable seizures. We wanted to identify differences between these two subsets of JME patients. Charts of all JME patients followed at the Duke Epilepsy Center were reviewed. Clinical parameters, electroencephalogram (EEG) findings and magnetic resonance imaging (MRI) data were reviewed. These features were compared between patients with VPA sensitive and VPA resistant JME. Thirty-three patients with JME were identified: 23 (70%) were VPA sensitive (13 females, 10 males; mean age of onset 15.9 years) and 10 (30%) were VPA resistant (5 females, 5 males; mean age of onset 14.1 years). The VPA resistant group had a higher frequency of EEG asymmetries (40% vs. 10%); atypical seizure characteristics including auras and post-ictal confusion (30% vs. 4%); and intellectual deficiency (20% vs. 0%). Clinical characteristics combined with EEG data may help in predicting which JME patients will respond favorably to VPA. This study also raises the issue whether VPA resistant JME is in fact a localization-related epilepsy.
Assuntos
Anticonvulsivantes/uso terapêutico , Epilepsia Mioclônica Juvenil/tratamento farmacológico , Ácido Valproico/uso terapêutico , Adolescente , Resistência a Medicamentos , Eletroencefalografia , Feminino , Humanos , Imageamento por Ressonância Magnética , Masculino , Epilepsia Mioclônica Juvenil/diagnósticoRESUMO
Changes in EEGs during cardiac arrest have been described in detail by many authors; however, mortality because of an EEG has never been reported. The authors report the case of a patient who developed cardiac arrest causally related to administration of succinylcholine for reduction of excessive amounts of myogenic artifact during an EEG. This case indicates the need for caution when doing an EEG study in an intensive care unit setting.
Assuntos
Eletroencefalografia , Parada Cardíaca/etiologia , Hiperpotassemia/induzido quimicamente , Hiperpotassemia/complicações , Fármacos Neuromusculares Despolarizantes/efeitos adversos , Succinilcolina/efeitos adversos , Evolução Fatal , Parada Cardíaca/diagnóstico , Humanos , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-IdadeRESUMO
The association between gray matter heterotopias and seizures is well established; whether seizures originate from these lesions is not known. We evaluated three patients with intractable complex partial seizures and periventricular nodular heterotopias (PNHs) with video-EEG monitoring with multiple depth electrodes, including placement in the PNH, to determine whether seizures originate from the PNH. In two of the three patients, all seizures arose from the PNH as low-voltage beta activity. In the third patient, 80% arose from the hippocampi and 20% from the heterotopia. PNHs may serve as an epileptogenic focus in patients with intractable epilepsy.
Assuntos
Encefalopatias/diagnóstico , Ventrículos Cerebrais , Coristoma/diagnóstico , Epilepsia Parcial Complexa/diagnóstico , Adulto , Encefalopatias/complicações , Coristoma/complicações , Eletrodos , Eletroencefalografia , Epilepsia Parcial Complexa/etiologia , Feminino , Hipocampo/fisiopatologia , Humanos , Imageamento por Ressonância Magnética , MasculinoRESUMO
We report a case of relapsing polychondritis with focal sensorimotor seizures, aseptic meningitis, and migratory leptomeningeal enhancement on contrast MRI. These abnormalities on imaging studies correlated accurately with laterality of the patient's seizures, facilitating early aggressive management of his neurologic symptoms.
Assuntos
Epilepsias Parciais/diagnóstico , Meningite/diagnóstico , Policondrite Recidivante/diagnóstico , Idoso , Epilepsias Parciais/complicações , Lateralidade Funcional , Humanos , Aumento da Imagem , Imageamento por Ressonância Magnética , Masculino , Meningite/complicações , Policondrite Recidivante/complicaçõesRESUMO
Magnetic resonance imaging (MRI) was performed after complex febrile convulsions (CFCs) in 27 infants. Definite MRI abnormalities were seen in 6 of the 15 infants with focal or lateralized CFCs and in none of the 12 infants with generalized CFCs. In 2 of the 6 infants with lateralized CFCs and abnormal MRIs, the MR images showed preexisting bilateral hippocampal atrophy consistent with the history of perinatal insults in these infants. However, the remaining 4 infants with MRI abnormalities and lateralized CFCs had significantly longer seizures than other infants and had MRI changes suggesting acute edema with increased hippocampal T2-weighted signal intensity and increased volume predominantly in the hippocampus in the hemisphere of seizure origin. Of those with acute edema, 1 had electrographical seizure activity recorded in the temporal region and another had a choroid fissure cyst displacing the affected hippocampus; both infants had follow-up MRIs showing that hippocampal atrophy had developed. These patients demonstrate that prolonged and focal CFCs can occasionally produce acute hippocampal injury that evolves to hippocampal atrophy. Finally, evidence of preexisting hippocampal abnormalities in several infants and electrographical temporal lobe seizure activity in 1 suggests the possibility that CFCs actually originated in the temporal lobes in some patients.
Assuntos
Encéfalo/patologia , Febre/patologia , Hipocampo/patologia , Convulsões/patologia , Temperatura Corporal , Encéfalo/fisiopatologia , Pré-Escolar , Eletroencefalografia , Feminino , Febre/complicações , Febre/fisiopatologia , Lateralidade Funcional , Hipocampo/fisiopatologia , Humanos , Lactente , Imageamento por Ressonância Magnética/métodos , Masculino , Convulsões/complicações , Convulsões/fisiopatologiaRESUMO
We present the clinical and neuroradiologic findings of a 31-year-old man with Kearns-Sayre syndrome- related dilated cardiomyopathy who experienced a left middle cerebral artery territory stroke, thought to be due to cardiogenic embolism. The rate of clinically apparent cardiomyopathy in Kearns-Sayre patients can be expected to increase as their survival is prolonged by the use of cardiac pacemaker devices. Under these circumstances, stroke caused by cardiogenic embolism, which is presently rare, may become more common.
Assuntos
Cardiomiopatia Dilatada/complicações , Infarto Cerebral/complicações , Síndrome de Kearns-Sayre/complicações , Adulto , Cardiomiopatia Dilatada/diagnóstico , Infarto Cerebral/diagnóstico por imagem , Doenças em Gêmeos , Eletrocardiografia , Humanos , Masculino , Tomografia Computadorizada por Raios XRESUMO
To assess the value of magnetic resonance imaging (MRI)-measured hippocampal volume in the detection of hippocampal sclerosis, we studied 28 patients undergoing anterior temporal lobectomy for medically intractable mesial temporal lobe epilepsy. Hippocampal volumetry and visual analysis of T2 signal change were performed using fast spin-echo T2-weighed MRI. Quantitative neuronal density measurements were performed in the resected hippocampal specimens. There was a significant correlation between MRI-measured absolute hippocampal volume (AHV) and neuronal density in CA1, CA2, and CA3 subfields (p < 0.0001, p < 0.01, and p < 0.05, respectively). Differential hippocampal volume (side-to-side volume difference) failed to detect bilateral atrophy in three patients, but the bilateral hippocampal atrophy was recognized by considering AHV in these patients. This study suggests that MRI-measured AHV can be of value in elevating patients with mesial temporal lobe epilepsy, especially when there is no side-to-side difference in hippocampal volumetry.
Assuntos
Epilepsia do Lobo Temporal/cirurgia , Hipocampo , Imageamento por Ressonância Magnética , Neurônios/citologia , Lobo Temporal/cirurgia , Adolescente , Adulto , Encefalopatias/diagnóstico , Contagem de Células , Interpretação Estatística de Dados , Feminino , Hipocampo/anatomia & histologia , Hipocampo/citologia , Humanos , Imageamento por Ressonância Magnética/métodos , Masculino , Pessoa de Meia-Idade , Esclerose/diagnósticoRESUMO
In prior work, we developed a model of self-sustaining limbic status epilepticus (SSLSE) induced by continuous hippocampal stimulation (CHS). Previous electrographic studies showed that SSLSE was synchronized between the cerebral hemispheres. On the basis of this initial work, we postulated that hippocampal commissures were critical for the initiation and maintenance of SSLSE. In the current experiments, we tested this hypothesis by applying CHS in animals with (CMX) or without (-CMX) hippocampal commissurotomies. In the -CMX group, electrographic SSLSE was synchronized between the stimulated and contralateral sides. In the CMX group, SSLSE developed only on the stimulated sides. Regional cerebral glucose utilization (RCGU) was also studied acutely (1 hour) after CHS using 2-deoxyglucose autoradiography. In the -CMX group, there was symmetrically increased RCGU in the hippocampus, retrohippocampal structures, and associated limbic and subcortical nonlimbic regions. In the CMX group, a similar pattern was found, but confined to the side of stimulation. CMX alone did not change RCGU values from those in control (-CMX, nonstimulated) brain in any of the regions studied. Areas of bilateral neocortical hypometabolism were found in both (CMX and -CMX) SSLSE groups. These results lead to rejection of the hypothesis that hippocampal commissures play an essential role in the initiation and maintenance of SSLSE. Instead, a feedback circuit involving the hippocampus and its adjacent structures seems to be the critical anatomic substrate for SSLSE. The presence of neocortical hypometabolism after CMX indicates that the structures other than the hippocampal commissure (eg, the thalamus or other forebrain commissures) mediate this effect.
Assuntos
Hipocampo/fisiopatologia , Sistema Límbico/fisiopatologia , Estado Epiléptico/fisiopatologia , Animais , Autorradiografia , Desoxiglucose , Estimulação Elétrica , Eletroencefalografia , Sistema Límbico/metabolismo , Masculino , Ratos , Ratos Endogâmicos , Estado Epiléptico/metabolismoRESUMO
Regional cerebral glucose utilization (RCGU) increases during seizures whereas hypometabolism occurs in postictal and interictal states. Recently, we developed a model of nonconvulsive, self-sustaining limbic status epilepticus (SSLSE) in which electrographic seizures persist 12 to 24 hours after 90 minutes of continuous hippocampal stimulation. The present studies define the functional anatomy of SSLSE and the states thereafter. RCGU was studied by 2-deoxyglucose autoradiography in (1) a group of rats acutely (1 hour after induction) during SSLSE, and (2) two groups of rats chronically (1 week or 1 month) after SSLSE. RCGU measurements in these groups were compared with those obtained in naive and electrode-implanted control rats. In the acute group, there were bilateral increases in RCGU in the hippocampus, retrohippocampal structures, and associated limbic and subcortical nonlimbic regions; hypometabolism was found in several neocortical structures. Chronically, RCGU was elevated in certain limbic areas at 7 days but returned to control values at 30 days. On the basis of our findings, we postulate a feedback network involving the hippocampus and neighboring parahippocampal structures (the hippocampal-parahippocampal "loop") as a critical substrate for establishing limbic system status epilepticus. In addition, the results indicate that metabolic responses can persist long after the cessation of status epilepticus and that both increases and decreases in RCGU can be seen in acute limbic status epilepticus.
Assuntos
Encéfalo/metabolismo , Sistema Límbico/metabolismo , Estado Epiléptico/metabolismo , Doença Aguda , Análise de Variância , Animais , Autorradiografia , Córtex Cerebral/metabolismo , Doença Crônica , Desoxiglucose , Estimulação Elétrica , Eletroencefalografia , Sistema Límbico/fisiologia , Masculino , Ratos , Ratos Endogâmicos , Estado Epiléptico/fisiopatologiaRESUMO
Controversy has arisen about the effectiveness of phenytoin against kindled seizures. It has been suggested that the reports of ineffectiveness could be accounted for by phenytoin being given by an intraperitoneal (i.p.) route in those experiments so that adequate serum concentrations were not achieved. Another possibility for the different results was dissimilar stimulus protocols employed in the various studies. The present study examined these issues. Doses of i.p. phenytoin were studied for their actions against kindled responses elicited with short (1 s) and long (10 s) stimulus trains through hippocampal electrodes. Serial application of the stimuli determined time-action relationships. Dose-dependent effects were demonstrated for all time points examined. There was a consistently greater suppression of kindled motor seizures than limbic behavioral seizures or electrographic seizures. Phenytoin either totally blocked or did not affect the duration of afterdischarges. Actions of phenytoin against responses by short duration stimuli were greater than against long duration stimuli. Additional pharmacokinetic studies compared i.p. versus intravenous (i.v.) phenytoin. After i.p. phenytoin, serum levels peaked later than after i.v. delivery, but were maintained in the 'therapeutic' range longer. The present experiments provide additional support for the idea that kindled seizures are a useful model for complex partial seizures in humans. In addition, they show that major actions of phenytoin are to decrease seizure spread and to elevate afterdischarge thresholds and that the i.p. route is appropriate for assaying the effect of phenytoin against kindled seizures in rats.
Assuntos
Epilepsia/fisiopatologia , Excitação Neurológica/efeitos dos fármacos , Fenitoína/administração & dosagem , Animais , Comportamento Animal/efeitos dos fármacos , Relação Dose-Resposta a Droga , Estimulação Elétrica , Epilepsia/tratamento farmacológico , Injeções Intraperitoneais , Injeções Intravenosas , Masculino , Fenitoína/farmacologia , Ratos , Ratos EndogâmicosRESUMO
Acyclovir sodium is the drug of choice for the treatment of herpes simplex encephalitis. We treated an immunocompetent patient with a ten-day course of intravenous acyclovir sodium at the recommended dosage of 10 mg/kg every eight hours for clinically apparent herpes simplex encephalitis. After marked improvement, his condition deteriorated four days after completing acyclovir therapy. A subsequent brain biopsy specimen disclosed acyclovir-sensitive herpes simplex virus type 1. A longer duration of acyclovir therapy (14 to 21 days) should be considered for treating herpes simplex encephalitis.