Abstract Rationale Hypermotor seizures are most often reported from the frontal lobe but may also have temporal, parietal, or insular origin. We noted a higher proportion of patients with temporal ...lobe epilepsy in our surgical cohort who had hypermotor seizures. We evaluated the anatomic localization and surgical outcome in patient with refractory hypermotor seizures who had epilepsy surgery in our center. Methods We identified twenty three patients with refractory hypermotor seizures from our epilepsy surgery database. We analyzed demographics, presurgical evaluation including semiology, MRI, PET scan, interictal/ictal scalp video-EEG, intracranial recording, and surgical outcomes. We evaluated preoperative variables as predictors of outcome. Results Most patients (65%) had normal brain MRI. Intracranial EEG was required in 20 patients (86.9%). Based on the presurgical evaluation, the resection was anterior temporal in fourteen patients, orbitofrontal in four patients, cingulate in four patients, and temporoparietal in one patient. The median duration of follow-up after surgery was 76.4 months. Fourteen patients (60%) had been seizure free at the last follow up while 3 patients had rare disabling seizures. Conclusions Hypermotor seizures often originated from the temporal lobe in this series of patients who had epilepsy surgery. This large proportion of temporal lobe epilepsy may be the result of a selection bias, due to easier localization and expected better outcome in temporal lobe epilepsy. With extensive presurgical evaluation, including intracranial EEG when needed, seizure freedom can be expected in the majority of patients.
Abstract Psychogenic pseudosyncope (PPS) is the appearance of transient loss of consciousness (TLOC) in the absence of true loss of consciousness. Psychiatrically, most cases are classified as ...conversion disorder, which is hypothesized to represent the physical manifestation of internal stressors. The incidence of PPS is likely under-recognized and the disorder is under investigated in the unexplained syncope population, yet it can be diagnosed accurately with a focused history and confirmed with investigations including head-up tilt testing (HUTT), electroencephalogram (EEG; sometimes combined with video) or, in some centers, transcranial Doppler (TCD). Patients are more likely to be young females with an increased number of episodes over the past 6 months. They frequently experience symptoms prior to their episodes including light-headedness, shortness of breath and tingling. Conversion disorder is associated with symptomatic chronicity, increased psychiatric and physical impairment, and diminished quality of life. Understanding the epidemiology, biological underpinnings and approach to diagnosis of PPS is important to improve the recognition of this disorder so that patients may be managed appropriately. The general treatment approach involves limiting unnecessary interventions, providing the patient with needed structure, and encouraging functionality. While there are no treatment data available for patients with PPS, studies in related conversion disorder populations support the utility of psychotherapy. Psychotropic medications should be considered in patients with comorbid psychiatric disorders.
Temporal lobe encephaloceles are characterized by protrusion of brain parenchyma through a structural defect in the floor of the middle fossa. They have been reported to cause cerebrospinal fluid ...(CSF) leaks, conductive hearing loss, meningitis, and seizures. The association between temporal encephaloceles and epileptiform activity is particularly rare.
All patients who presented to a single tertiary referral center between 2011 and 2014 with intractable seizures and radiographic evidence of a middle cranial fossa encephalocele were evaluated. Five patients from this subset who underwent surgical repair of their encephalocele are presented.
Middle cranial fossa approach for encephalocele repair.
Postoperative epileptiform activity.
Five patients underwent a craniotomy for resection of a temporal lobe encephalocele with repair of a middle fossa floor defect. After surgery, CSF rhinorrhea resolved, when present, and all patients remained seizure-free through their last available follow-up. Range of follow-up time was 3.5 months to 4 years. Average follow-up time was 19.7 months.
Temporal lobe encephaloceles are an infrequent cause of seizures. Given that these lesions can be missed with standard imaging modalities, they are likely underdiagnosed upon initial medical evaluation. This diagnosis should be considered in patients with intractable seizures. If an encephalocele is found, focused resection of epileptogenic tissue associated with herniation and repair of the temporal floor defect can provide definitive treatment.
Wicket spikes (WS) are a benign EEG variant classically defined to be bilateral independent temporal in localization. The authors observed that the majority of WS are exclusively unilateral temporal. ...The aim was to identify the laterality and clinical significance of the WS.
Epilepsy monitoring unit reports of adult patients were searched for keywords "wicket" or "wickets" and examined for WS lateralization dividing it into three groups: bilateral, left, and right temporal. The age, sex, hand dominance, admission duration, epilepsy risk factors, cerebral microvascular disease, and final diagnosis were also collected.
Wicket spikes were present in 133 studies and were significantly more prevalent in the left temporal region (69%, P < 0.05). Cerebral microvascular disease was more prevalent in patients with left temporal WS (64%, P < 0.05). There were no differences in the remaining studied variables among the three groups. Wicket spikes were not associated with epilepsy.
The authors' findings demonstrate that the majority of WS are strictly left temporal. Despite their predominant unilaterality, WS are not associated with epilepsy but may be associated with cerebral microvascular disease. The authors propose redefining the WS lateralization to be mostly unilateral rather than bilateral. This may prevent misinterpretation of this challenging yet benign EEG variant.
The incidence of new-onset epilepsy is high among elderly patients. Seizures can present differently to and with more subtle semiology than those in younger adults. This difference in presentation ...frequently poses a diagnostic challenge. Elderly patients also often have comorbidities, are usually on multiple medications that can interact, have altered medication pharmacokinetics, and tend to be particularly sensitive to adverse effects of medication. Seizures in the elderly tend, however, to respond better to antiepileptic drugs than those in younger individuals, and can often be appropriately controlled with monotherapy. After the diagnosis of epilepsy is confirmed, treatment should be started with a single medication at a low dose, with subsequent gradual upward titration until seizures are controlled. First-generation antiepileptic drugs should be avoided in the elderly in view of poor tolerability. A large trial has shown that lamotrigine and gabapentin are better tolerated than carbamazepine. In elderly patients whose seizures remain uncontrolled on antiepileptic medications, surgery can be considered if excellent results are predicted and the risks are low.
Summary
In 2011, the American Academy of Neurology (AAN) established eight epilepsy quality measures (EQMs) for chronic epilepsy treatment to address deficits in quality of care. This study assesses ...the relationship between adherence to these EQMs and epilepsy‐related adverse hospitalizations (ERAHs). A retrospective chart review of 475 new epilepsy clinic patients with an ICD‐9 code 345.1‐9 between 2010 and 2012 was conducted. Patient demographics, adherence to AAN guidelines, and annual number of ERAHs were assessed. Fisher's exact test was used to assess the relationship between adherence to guidelines (as well as socioeconomic variables) and the presence of one or more ERAH per year. Of the eight measures, only documentation of seizure frequency, but not seizure type, correlated with ERAH (relative risk RR 0.343, 95% confidence interval CI 0.176–0.673, p = 0.010). Among patients in the intellectually disabled population (n = 70), only review/request of neuroimaging correlated with ERAH (RR 0.128, 95% CI 0.016–1.009, p = 0.004). ERAHs were more likely in African American patients (RR 2.451, 95% CI 1.377–4.348, p = 0.008), Hispanic/Latino patients (RR 4.016, 95% CI 1.721–9.346, p = 0.016), Medicaid patients (RR 2.217, 95% CI 1.258–3.712, p = 0.009), and uninsured patients (RR 2.667, 95% CI 1.332–5.348, p = 0.013). In this retrospective series, adherence to the eight AAN quality measures did not strongly correlate with annual ERAH.
Pregabalin is a new antiepileptic medication that works by binding to alpha 2 delta subunit of the voltage-dependent calcium channels present in presynaptic neurons. Its pharmacokinetic advantages ...include rapid and almost complete absorption, lack of protein binding, linear kinetics, absence of enzyme induction, and absence of interactions with other drugs. Pregabalin was found effective as adjunctive therapy for refractory partial-onset seizures, with up to 51% responder at a dose of 600 mg/day. The lowest effective dose was 150 mg/day. Pregabalin is also approved for treatment of painful diabetic polyneuropathy, postherpetic neuralgia and pain with fibromyalgia. Studies also suggest a beneficial effect on sleep and generalized anxiety disorders. Its main adverse effects in randomized adjunctive trials in adults have been mild to moderate. Most common side effects were dizziness, ataxia, somnolence and diplopia. Weight gain was not prominent in pivotal pregabalin trials, but was more problematic in long-term postmarketing analyses in epilepsy patients. Pregabalin, with its potent antiseizure effect, favorable pharmacokinetic profile, and effectiveness in common co-morbidities is an important addition to the treatment of epilepsy.
Abstract Psychogenic nonepileptic seizures (PNES) are very common, but limited outcome data are available. The purpose of this study was to evaluate the predictors of seizure remission after the ...diagnosis of PNES is made with video/EEG monitoring in an epilepsy referral center. The subjects for this analysis were 48 consecutive patients who returned for follow-up after diagnosis of PNES. We evaluated demographic, psychosocial, educational, and clinical features as predictors of outcome, using logistic regression analysis outcome. At follow-up, only 35% of patients had achieved seizure remission, and only 50% of these were employed. Educational status and being accompanied to the first clinic visit were favorable predictors of outcome. Type of spell was also a predictor: motionless spells had a more favorable outcome. Other variables were not predictors of outcome. These data may help with counseling and resource allocation for patients with PNES.
Summary
Purpose: To describe five patients with ictal aphasia and one patient with ictal amnesia, who had focal positron emission tomography (PET) hypermetabolism but no clear ictal activity on ...electroencephalography (EEG).
Methods: 18F‐Fluorodeoxyglucose (FDG)–PET scans with concomitant EEG were obtained in five patients with suspected ictal aphasia or ictal amnesia without ictal activity on EEG. We reviewed medical history, EEG, imaging data, and treatment outcome.
Results: Brain magnetic resonance imaging (MRI) showed no structural abnormalities in any of the patients. EEG showed left temporal irregular delta activity in three patients, with aphasia and nonspecific abnormalities in two other patients, all without clear ictal pattern. All patients demonstrated focal hypermetabolism on PET scan. The hypermetabolism was in the left frontotemporal region in patients with ictal aphasia and in the bilateral hippocampal region in the patient with amnesia. Three patients who received intravenous benzodiazepines during their episodes had transient clinical improvement. With antiepileptic drug (AED) treatment, symptoms gradually resolved in all patients. Concomitant resolution of PET hypermetabolism was documented in three patients who had follow up scans. One patient with ictal aphasia later developed recurrent episodes, each with recurrent PET hypermetabolism. This patient and one other patient required immune‐modulating therapy in addition to AEDs.
Discussion: FDG‐PET imaging should be considered as a diagnostic tool in patients with suspected ictal aphasia or amnesia, who fail to show clear evidence of ictal activity on EEG.
Abstract Objective Psychogenic nonepileptic seizures (PNES) are common paroxysmal events that mimic and can often be misdiagnosed as epileptic seizures. PNES account for 10 to 40% of patients ...referred to epilepsy centers. Patients with uncontrolled PNES are at times subjected to vagus nerve stimulator (VNS) implantation. We report a series of such referred patients studied with video/EEG monitoring at our institution. Methods We evaluated patients who were implanted with a VNS by their primary neurologist for refractory seizures and who were referred to the Vanderbilt University epilepsy monitoring unit for a second opinion. The presumed diagnosis of epilepsy was based on abnormal routine EEG studies obtained by their primary neurologist. We evaluated these patients and recorded their typical spells between 2005 and 2009. We describe the results of 13 patients with VNS who were found to have PNES. The total number of patients with a VNS studied during this time was 60. Results None of the patients had undergone prior long-term video/EEG monitoring to document the nature of their events. A total of 13 patients with an implanted VNS had exclusive PNES, 9 women and 4 men with a mean age of 38.2 ± 10.4 years. Mean age at seizure onset was 28.5 ± 15.4 years. Patients were taking two to four antiepileptic medications in addition to VNS at the time of video/EEG monitoring. The average latency from the time of VNS implantation to the confirmatory diagnosis was 2.8 years. One to ten (median = 3) of these patients’ typical seizures were recorded during video/EEG monitoring. All patients were subsequently discharged off antiepileptic medications, and five of these patients were discharged home with the VNS turned off. Conclusion A VNS may be implanted inappropriately in patients with PNES. As video/EEG monitoring may help in excluding the diagnosis of PNES and preventing unnecessary VNS implants, it should be a requirement before VNS implantation.
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