Unblinded, randomized multicenter trial comparing lamotrigine and valproate combination with controlled-release carbamazepine monotherapy as initial drug regimen in untreated epilepsy.

PURPOSE: To compare controlled-release carbamazepine monotherapy (CBZ-CR) with lamotrigine and valproate combination therapy (LTG + VPA) in equivalent total drug load, as initial drug regimen in untreated patients with partial and/or generalized tonic-clonic seizures (GTCS). METHODS: This unblinded, randomized, 60-week superiority trial recruited patients having two or more unprovoked seizures with at least one seizure during previous three months. After randomization into CBZ-CR or LTG + VPA, patients entered into eight-week titration phase (TP), followed by 52-week maintenance phase (MP). Median doses of CBZ-CR and LTG + VPA were 600 mg/day and 75 mg/day + 500 mg/day, respectively. Primary outcome measure was completion rate (CR), a proportion of patients who have completed the 60-week study as planned. Secondary efficacy measures included seizure-free rate (SFR) for 52-week of MP and time to first seizure (TTFS) during MP. RESULTS: Among 207 randomized patients, 202 underwent outcome analysis (104 in CBZ-CR, 98 in LTG + VPA). CR was 62.5% in CBZ-CR and 65.3% in LTG + VPA (p = 0.678). SFR during MP was higher in LTG + VPA (64.1%) than CBZ-CR (47.8%) (P = 0.034). TTFS was shorter with CBZ-CR (p = 0.041). Incidence of adverse effects (AEs) were 57.7% in CBZ-CR and 60.2% in LTG + VPA and premature drug withdrawal rates due to AEs were 12.5% and 7.1%, respectively, which were not significantly different. CONCLUSION: CR was comparable between LTG + VPA and CBZ-CR, however, both SFR for 52-week MP and TTFS during MP were in favor of LTG + VPA than CBZ-CR. The study suggested that LTG + VPA can be an option as initial drug regimen for untreated patients with partial seizures and/or GTCS except for women of reproductive age.

Age-related differences in the brain areas outside the classical language areas among adults using category decision task.

Older adults perform much like younger adults on language. This similar level of performance, however, may come about through different underlying brain processes. In the present study, we evaluated age-related differences in the brain areas outside the typical language areas among adults using a category decision task. Our results showed that similar activation patterns were found in classical language processing areas across the three age groups although regional lateralization indices in Broca's and Wernicke's areas decreased with age. The greatest differences, however, among the three groups were found primarily in the brain areas not associated with core language functioning including the hippocampus, middle frontal gyrus, ventromedial frontal cortex, medial superior parietal cortex and posterior cingulate cortex. Therefore, the non-classical language areas may exhibit an age-related difference between three age groups while the subjects show a similar activation pattern in the core, primary language processing during a semantic decision task.

Frontal lobe epilepsy may present as myoclonic seizures.

We describe a patient with seizures arising from right anterior-inferior frontal lobe presenting as myoclonic epilepsy. A 19-year-old man had experienced frequent paroxysmal bilateral myoclonic jerks involving his upper arms, shoulders, neck, and upper trunk since the age of 10. His baseline EEG showed intermittent right frontal spikes, and his ictal EEG showed rhythmic sharp theta discharges in the same area. MRI revealed cortical dysplasia in the right inferior frontal gyrus, and ictal-interictal SPECT analysis by SPM showed increased signal abnormality in this region. Diffusion tensor imaging (DTI) showed defects in fasciculi in the same area. These findings suggest that frontal lobe epilepsy should be considered in some patients with myoclonic seizures.

Incidence of atypical handedness in epilepsy and its association with clinical factors.

The incidence of atypical handedness (left-handedness and ambidexterity) in patients with epilepsy, particularly its association with major clinical factors, is not well established. We evaluated a full range of clinical variables in 478 patients with epilepsy from the United States and Korea. With the Edinburgh Handedness Inventory, handedness was established as both a categorical variable (right-handed, left-handed, ambidextrous) and a continuous variable. Seizures were classified as complex or simple partial, primary generalized, or generalized tonic-clonic. The relationship between handedness and a range of clinical findings was explored. The overall incidence of atypical handedness in our patients was higher than in the general population (13.6%) and significantly higher in the U.S. patient group (17.6%) than in the Korean patients (8.8%). Handedness was not associated with sex; age; seizure type; age at onset; type, side, or site of EEG or brain imaging abnormalities; family history of seizures; refractory epilepsy; or history of epilepsy surgery.

Autosomal dominant nocturnal frontal lobe epilepsy and mild memory impairment associated with CHRNB2 mutation I312M in the neuronal nicotinic acetylcholine receptor.

Certain paroxysmal nocturnal behaviors have been established as features of nocturnal frontal lobe epilepsy (NFLE). Despite insight into its genetics, the majority of patients with NFLE are not linked to a known mutation and clinical diagnosis remains a challenge. We describe a family presenting with stereotyped nocturnal arousals from non-rapid eye movement sleep, bilateral hand posturing, and pelvic thrusting in the mother, but subtle motor activity in the daughter, and minimal or no epileptiform EEG discharges. Despite normal IQ, there were moderate and severe verbal memory deficits in the mother and daughter, respectively. Genetic testing revealed the CHRNB2 mutation I312M in transmembrane region 3 (M3) of the neuronal nicotinic acetylcholine receptor. Phenotypic similarities in unrelated families suggest the determining role of this mutation in NFLE, whereas different inter- and intrafamilial cognitive profiles point to other factors. The absence of clear motor features of NFLE in the daughter emphasizes the shortcomings of current clinical criteria and the potential for genetic testing to further guide clinical diagnostic criteria.

Inhibitory effects of glucosamine on lipopolysaccharide-induced activation in microglial cells.

The aim of the present study was to investigate the effects of glucosamine on lipopolysaccharide (LPS)-induced cellular activation in microglia and to evaluate the inhibitory mechanisms involved. Lipopolysaccharide (100 ng/mL) was used for the activation of primary cultured rat microglial or BV2 microglial cells. Changes in intracellular Ca2+ levels and outward K+ currents were measured using fura-2/AM and whole-cell patch-clamp methods, respectively. Lipopolysaccharide-induced expression of tumour necrosis factor (TNF)-alpha mRNA was analysed by reverse transcription-polymerase chain reaction. Lipopolysaccharide transformed cell morphology into an amoeboid shape in vitro and induced microglial activation in vivo, as measured by immunohistochemical staining, but glucosamine inhibited this activation. Glucosamine also inhibited LPS-induced Ca2+ influx, outward K+ currents and TNF-alpha mRNA expression, which are typically representative of microglial activation. 4. The results suggest that the inhibitory mechanisms of glucosamine on LPS-induced microglial activation include inhibition of Ca2+ influx and outward K+ currents, as well as downregulation of the microglial activator gene TNF-alpha.

A Korean kindred with autosomal dominant nocturnal frontal lobe epilepsy and mental retardation.

BACKGROUND: A Korean family had distinctive clinical and neuroimaging features and carried the same genetic mutation that was found in a previously described Japanese kindred with autosomal dominant nocturnal frontal lobe epilepsy. OBJECTIVE: To describe the first Korean family with autosomal dominant nocturnal frontal lobe epilepsy. METHODS: Members of a large family, including 9 affected individuals from 3 generations, underwent a comprehensive genetic, clinical, electroencephalographic, neuropsychological, and neuroimaging evaluation. Affected members were tested for possible mutations in transmembrane regions 1 through 3 of the neuronal nicotinic acetylcholine receptor alpha4 subunit (CHRNA4) by direct sequencing and subsequent restriction analysis. RESULTS: Seizures began in childhood, presenting as nocturnal episodes of staring, confusion, shouting, perioral movements, unintelligible speech, and hand waving. Some patients had ictal or interictal epileptiform activity in the temporal and/or frontocentral areas. Neurological examination and brain magnetic resonance imaging results showed no abnormalities, except that all patients available for testing had mild to moderate mental retardation. Fluorodeoxyglucose F 18 with positron emission tomography showed mild decreased glucose uptake in the superior and middle frontal regions, more so on the left than on the right. Patient response to carbamazepine was poor. All affected members were heterozygous for the CHRNA4 Ser252Leu mutation. CONCLUSIONS: Disorders associated with mutations in the transmembrane region 2 of CHRNA4 are genetically and phenotypically heterogeneous. Distinctive features of this kindred include (1) mental retardation in all affected members available for testing, (2) abnormal brain findings on fluorodeoxyglucose F 18 with positron emission tomography, (3) poor response to carbamazepine, and (4) full penetrance.

Hearing symptoms in migrainous infarction.

BACKGROUND: In case reports, migraine headaches have been associated with fluctuating low-frequency hearing loss and sudden, unilateral hearing loss. Auditory symptoms associated with migrainous infarction have not previously been emphasized. OBJECTIVE: To describe migrainous infarction presenting with acute auditory symptoms. DESIGN: Case reports. SETTING: Tertiary care hospitals. PATIENTS: A 40-year-old man with a history of migraine suddenly developed bilateral hearing loss associated with severe, throbbing, occipital headache, tinnitus, vertigo, speech disturbance, and right hemiparesis. An early audiogram showed profound, down-sloping, sensorineural-type hearing loss bilaterally. Sixteen days later, a follow-up pure tone audiogram documented marked improvement in both sides to a pure tone average of 30 dB. Right hemiparesis and dysarthria also improved steadily for 2 months. A 25-year-old woman with a history of migraine with aura suddenly developed hyperacusis, unilateral hearing loss, and migraine headache early in migrainous infarction. Magnetic resonance imaging documented infarcts in the pons and cerebellum. CONCLUSIONS: In these patients, acute auditory symptoms are a part of the prodrome of migrainous infarction. We speculate that these symptoms may have resulted from migraine-associated vasospasm. Migrainous infarction should be considered in the differential diagnosis of acute auditory symptoms, including sudden, bilateral hearing loss.

Sudden deafness and anterior inferior cerebellar artery infarction.

BACKGROUND AND PURPOSE: Acute ischemic stroke in the distribution of the anterior inferior cerebellar artery (AICA) is known to be associated with vertigo, nystagmus, facial weakness, and gait ataxia. Few reports have carefully examined the deafness associated with the AICA infarction. Furthermore, previous neurological reports have not emphasized the inner ear as a localization of sudden deafness. The aim of this study was to investigate the incidence of deafness associated with the AICA infarction and the sites predominantly involved in deafness. METHODS: Over 2 years, we prospectively identified 12 consecutive patients with unilateral AICA infarction diagnosed by brain MRI. Pure-tone audiogram, speech discrimination testing, stapedial reflex testing, and auditory brainstem response were performed to localize the site of lesion in the auditory pathways. Electronystagmography was also performed to evaluate the function of the vestibular system. RESULTS: The most common affected site on brain MRI was the middle cerebellar peduncle (n=11). Four patients had vertigo and/or acute auditory symptoms such as hearing loss or tinnitus as an isolated manifestation from 1 day to 2 months before infarction. Audiological testings confirmed sensorineural hearing loss in 11 patients (92%), predominantly cochlear in 6 patients, retrocochlear in 1 patient, and combined on the affected side cochlear and retrocochlear in 4 patients. Electronystagmography demonstrated no response to caloric stimulation in 10 patients (83%). CONCLUSIONS: In our series, sudden deafness was an important sign for the diagnosis of AICA infarction. Audiological examinations suggest that sudden deafness in AICA infarction is usually due to dysfunction of the cochlea resulting from ischemia to the inner ear.

Migraine and isolated recurrent vertigo of unknown cause.

Chronic recurrent attacks of vertigo, not associated with any auditory or neurological symptoms, are a common reason for referral to our neurotology clinic. Even after an extensive neurotological evaluation, some cases remain undiagnosed. We prospectively evaluated 72 consecutive patients who presented to the clinic with isolated recurrent vertigo of unknown cause. All patients underwent diagnostic evaluation to exclude identifiable causes of isolated recurrent vertigo. We compared the prevalence of migraine, according to the International Headache Society (IHS) criteria, in the isolated recurrent vertigo group, with a sex- and age-matched control group of orthopedic patients. The prevalence of migraine according to IHS criteria was higher in the isolated recurrent vertigo group (61.1%) than in the control group (10%; p < 0.01). Only 16.7% of patients had an abnormal vestibular function test. The most common abnormal finding was a unilateral vestibular weakness to caloric stimulation. Our results suggest that migraine should be considered in the differential diagnosis of isolated recurrent vertigo of unknown cause.