In memoriam Frank Morrell: a man ahead of his time. June 4, 1926-October 22, 1996.
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Epilepsy↗
Biomedical subjects
A M Kanner
Publications and source records attributed to A M Kanner.
Postictal psychiatric events during prolonged video-electroencephalographic monitoring studies.
BACKGROUND: Postictal psychiatric events presenting as postictal psychotic events and postictal nonpsychotic events are known to occur following seizure clusters. Accordingly, patients undergoing prolonged video-electroencephalographic (EEG) monitoring studies may be at increased risk of experiencing postictal psychiatric event, as they often have flurries of seizures during these studies. OBJECTIVES: To determine the annual incidence and clinical characteristics of postictal psychotic events and postictal nonpsychotic events in video-EEG monitoring studies in patients with partial seizure disorders and to identify potential pathogenic factors. RESULTS: Thirteen patients met the criteria for a postictal psychiatric event during the 18-month study period, 10 presenting as postictal psychotic events and three as postictal nonpsychotic events. The annual incidence of postictal psychiatric events at our monitoring unit for 1988 was 7.8%, 6.4% presenting as postictal psychotic events and 1.4% as postictal nonpsychotic events. Seven patients had their first-ever postictal psychiatric event during the monitoring study. In 12 of the 13 patients, the postictal psychiatric events mimicked well-defined psychiatric entities of shorter duration (mean, 66.5 hours); they appeared 12 to 72 hours after the last seizure and remitted spontaneously or with the use of low-dose psychotropic medication. No significant differences in EEG, neuroradiologic, psychiatric, medical, or psychosocial data were found between the patients with postictal psychiatric events and a group of 13 age-matched control patients. Follow-up data of comparable duration were available in nine patients with postictal psychiatric events and nine controls. Psychiatric events were reported more frequently by patients with postictal psychiatric events than by control patients (P=.03). In three patients, postictal psychiatric events converted to interictal events. CONCLUSION: These findings suggest that monitoring studies increase the risk for postictal psychiatric events, which neurologists need to be familiar with, as they represent important morbidity associated with these studies.
Adult↗
Transient facial palsy in sphenoidal electrode placement.
PURPOSE: Sphenoidal electrode (SE) insertion can cause pain, for which local anesthesia with lidocaine or intravenous administration of fentanyl has been advocated by different epilepsy treatment centers. Transient facial palsies have been observed after SE insertion. Their frequency of occurrence, distribution, and duration have not been well characterized, however. We hypothesized that this complication is due to the effect of local anesthesia on the peripheral branches of the seventh cranial nerve. To test this hypothesis, we compared the incidence and characteristics of facial palsy during SE insertions performed with either local anesthesia or after intravenous fentanyl administration. METHODS: We performed a retrospective study in two patient groups. Group A consisted of 25 patients aged 28 +/- 8.2 years who underwent a prolonged video-EEG (VEEG) monitoring study with SE after subcutaneous infusion of 1% lidocaine in the insertion area. Group B included 25 patients aged 30.1 +/- 8.9 years whose SE were inserted after intravenous administration of 100-200 micrograms fentanyl. Blood pressure (BP) was monitored every 3-5 min throughout the procedure. RESULTS: Five patients (20%) from group A had a transient facial palsy; in 4, it was complete and in 1 it was partial; 1 patient had a bilateral facial palsy. Paresis lasted 1-7 min (mean 3.2 min). In all patients, the recovery was complete. None of the patients in group B had complications (p = 0.025, Fisher's exact test). CONCLUSIONS: Transient facial palsy is a relatively frequent complication of SE insertion when SE are placed under local anesthesia; patients should be forewarned of its possible occurrence.
Adult↗
Psychogenic seizures and the supplementary sensorimotor area.
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Diagnosis, Differential↗
Tailored anterior temporal lobectomy. Relation between extent of resection of mesial structures and postsurgical seizure outcome.
OBJECTIVE: The purpose of this study was to assess the relationship between the extent of resection of mesial temporal structures and postsurgical seizure outcome in a group of patients who had undergone a tailored anterior temporal lobectomy. METHODS: Twenty-four patients with unilateral interictal and ictal foci restricted to anterior/mesial temporal regions underwent resection of mesial and temporal lateral structures, the extent of which was tailored by intraoperative electrocorticographic findings and functional mapping of eloquent cortex. The extent of resection was determined with postoperative magnetic resonance imaging scans, using a semiquantitative method, based on a 20-compartment model of the temporal lobe. The magnetic resonance imaging scans were rated by three investigators blinded to seizure outcome. Follow-up period ranged between 18 months and 5 years. RESULTS: Amygdala and hippocampus were spared in six patients; nine patients had a partial to total resection of amygdala, eight patients had a resection of amygdala and the anterior third of the hippocampus, and one patient underwent resection of amygdala and anterior two thirds of hippocampus. Twenty-one of the 24 patients were seizure free (Engel's class I) and three had rare seizures (Engel's class II). Among these three patients, one had a resection of amygdala; one had resection of amygdala and anterior third of hippocampus; while in the third patient, mesial structures were spared. CONCLUSION: These data suggest that in patients with an anterotemporal seizure focus, the sparing or limited resection of amygdala and/or hippocampus is not necessarily associated with a poor seizure outcome, as had been previously suggested, provided that the decision not to resect is based on the absence of epileptiform activity during intraoperative electrocorticography or during recordings with depth electrodes.
Adolescent↗
Efficacy of felbamate monotherapy in patients undergoing presurgical evaluation of partial seizures.
The efficacy and safety of felbamate monotherapy were evaluated in 52 patients with refractory partial seizures with or without secondary generalization in a double-blind, randomized, placebo-controlled trial. Each patient completed a routine evaluation for epilepsy surgery and was randomized to receive either felbamate, titrated to a maximum daily dose of 3600 mg over 2 days, or placebo during the 10-day, inpatient, treatment phase. An intent-to-treat analysis was performed on the data of all 52 patients who received study medication, while a separate efficacy analysis also was performed on the data of 43 evaluable patients, which excluded protocol violators. The endpoint of the trial was completing 10 days of treatment or the occurrence of a fourth seizure. The primary efficacy variable was the average daily seizure frequency during the treatment phase for each patient. For the intent-to-treat analysis based on all 52 patients who received study medications, the mean rank of the daily seizure frequency for patients treated with felbamate was 21.6 compared to 29.6 for patients treated with placebo (P = 0.065). In the analysis based on the 43 evaluable patients, the mean rank of the daily seizure frequency for felbamate-treated patients was 17.0 compared to 25.4 for placebo-treated patients. This difference was statistically significant (P = 0.032) in favor of felbamate. Seizure frequency was decreased by 89.5% compared to baseline in nine patients who completed 10 days of felbamate therapy. This study permitted the rapid determination of the anticonvulsant activity of felbamate and demonstrated that felbamate is effective as monotherapy for the treatment of partial seizures.
Adult↗
Landau-Kleffner syndrome. Treatment with subpial intracortical transection.
Landau-Kleffner syndrome (LKS) is an acquired epileptic aphasia occurring in childhood and associated with a generally poor prognosis for recovery of speech. It is thought to be the result of an epileptogenic lesion arising in speech cortex during a critical period of development. Utilizing a new surgical technique designed to eliminate the capacity of cortical tissue to generate seizures while preserving the normal cortical physiological function, we have treated 14 children with aphasia, seizures and a severely abnormal EEG by multiple subpial transection of the epileptogenic cortex. Seven of the 14 patients (50%) have recovered age-appropriate speech, are in regular classes in school and no longer require speech therapy. Four of the 14 (29%) have shown marked improvement, are speaking and understanding verbal instruction but are still receiving speech therapy. Thus, 11 of the 14 (79%), none of whom had used language to communicate for at least 2 years, are now speaking--a rate of sustained improvement considered unusual in this disorder. This study documents the value of a treatment modality not previously used in LKS. Success depends on selection of cases having severe epileptogenic abnormality that can be demonstrated to be unilateral in origin despite a bilateral electrographic manifestation.
Adolescent↗
Seizure control after chronic pharmacotherapy in epileptic disorders beginning after 40 years of age.
Few studies have been published on the pharmacologic response to treatment of patients whose seizures begin after 40 years of age. The purpose of this study was to assess the impact of chronic pharmacotherapy on the seizure control of such patients. We retrospectively studied the seizure frequency recorded during a 12-month period in a group of 94 outpatients whose seizure disorders began after 40 years of age (median age of seizure onset 56.5 years) and who had been treated with anticonvulsant medication for a median period of 6 years (range 18 months to 12 years). We assessed the relationship between the patients' seizure frequency during the last 12 months of treatment using (a) the present and previously prescribed pharmacologic regimens, (b) anticonvulsant blood levels of present regimen, (c) etiology and duration of seizure disorder, (d) age at onset of seizures, and (e) presence of electrographic (EEG) and neuroradiologic abnormalities. We only identified side effects occurring at blood levels within or below the drug's therapeutic range. Seventy-eight patients (83%) were seizure free during the last 12 months of treatment, 11 (11%) had rare seizures, and five (6%) had more than four seizures per year. Seizure frequency was not affected by duration and etiology of seizure disorder, age at onset of seizures, seizure type, neuroradiologic or electroencephalographic abnormalities, and present or previously prescribed pharmacologic regimens. Persistent side effects were reported in seven of 76 (9%) monotherapy regimens and in two of 12 (17%) polytherapy regimens. Our data suggest that seizures beginning after the age of 40 have a favorable prognosis after chronic pharmacotherapy.
Adult↗
The utility of placing sphenoidal electrodes under the foramen ovale with fluoroscopic guidance.
Although sphenoidal electrodes are widely used to detect epileptiform activity, there is no agreement on an optimal target to which electrodes should be aimed. The purpose of this study was to determine whether fluoroscopic guidance is a reliable method for placing electrodes directly below the foramen ovale and whether such positioning enhances their capacity to detect epileptiform activity when compared to similar electrodes placed blindly into the infratemporal fossa. We examined the surface/sphenoidal EEG recordings of 17 patients with intractable partial seizures of anterotemporal origin, after fluoroscopically placed sphenoidal electrodes (FPSE) had been inserted to lie just below the foramen ovale. A criterion for eligibility was a previous prolonged video/EEG monitoring with blindly placed sphenoidal electrodes (BPSE) that failed to detect seizures with a focal onset. No blindly placed electrode, for which there was radiographic documentation, reached the foramen ovale. Fluoroscopic guidance assured accurate targeting. FPSE detected a unilateral anterotemporal interictal focus in four patients in whom BPSE had failed to record any interictal spikes and detected bitemporal independent interictal foci in one patient in whom BPSE had identified only unilateral spikes. In nine other patients, the spike count obtained with FPSE recordings increased by > 100% when compared to that obtained with BPSE recordings. FPSE recorded seizures with an anterotemporal focal onset pattern in 10 patients in whom BPSE had recorded seizures with a regional, lateralized, or nonlocalized onset pattern. In nine of these 10 patients, this was adequate to recommend surgery and avoid invasive monitoring. Fluoroscopic guidance assures accurate targeting of the foramen ovale. When compared to BPSE, FPSE resulted in better detection of interictal and ictal epileptiform activity of mesial-basal-temporal origin.
Adolescent↗
Supplementary motor seizures mimicking pseudoseizures: some clinical differences.
Supplementary motor seizures (SMS) are among the group of frontal lobe seizures that may often be misdiagnosed as pseudoseizures (PS). We designed this study to determine the value of clinical phenomena in distinguishing between the two. In a series of patients with SMS, we identified those with symptoms mimicking PS and compared the clinical phenomena with those of clinically similar PS. We found that SMS are short in duration, stereotypic, tend to occur in sleep, and often present with a tonic contraction of the upper extremities in abduction. This sign was specific for SMS, particularly when occurring at the onset. Conversely, PS are long in duration, nonstereotypic, and occur in the awake state. We conclude that clinical phenomena may be useful in distinguishing PS from SMS, although the final diagnosis must be documented by neurophysiologic means.
Diagnosis, Differential↗
Use of imipramine in children with intractable asthma and psychiatric disorders: a warning.
Imipramine is an established treatment for anxiety in adults. Some evidence also exists that it may be beneficial in children. Because of the frequent co-occurrence of anxiety and affective symptomatology in asthmatic children, a pilot study was undertaken to obtain clinical observations on the effects of imipramine on symptoms of asthma as well as those of separation anxiety and depression in children suffering from intractable asthma. The pilot trial was terminated because of medical complications after 6 patients participated.
Adolescent↗
Usefulness of unilateral interictal sharp waves of temporal lobe origin in prolonged video-EEG monitoring studies.
The value of EEG interictal epileptiform activity in predicting location of the seizure focus remains controversial. In 64 patients, scalp video-EEG monitoring studies showed one or two ipsilateral interictal foci in the temporal lobe. The site of these interictal foci correlated with location of the seizure focus recorded during prolonged video-electrocorticography (ECoG) with use of subdural grids placed under the mesiobasal temporal region and over the lateral temporal convexity. Our findings suggest that unilateral anterotemporal interictal foci can accurately predict location of seizure onset. This is also true in patients with two ipsilateral temporal interictal foci, provided that the dominant focus is localized in anterotemporal regions. We believe that in such patients invasive recordings are not warranted, but we caution against sole use of interictal epileptiform criteria for localization of the seizure focus. Correlation with clinical information, ictal EEG, neuropsychometric, and neuroimaging studies is required before performance of epilepsy surgery.
Adolescent↗