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A 33-year-old man with complex partial seizures developed de novo hypertension after the initiation of carbamazepine, which resolved on discontinuation. Although rare, a variety of cardiovascular effects including hypertension have been reported with carbamazepine. Numerous mechanisms may be responsible; however, shared pharmacologic properties with the tricyclic antidepressants are suspect. Hypertension is a rare side effect of carbamazepine.
The question of whether the influence of the cerebral hemispheres on cardiovascular activity exhibits left/right differences is important for the understanding of the psychophysiology of the autonomous nervous system. Experimental results have been contradictory. One experimental procedure used is the intracarotid amobarbital test (Wada test: short anesthesia of one cerebral hemisphere). Even with this test contradictory results have been obtained in various studies, although all involved relatively small of numbers of patients. Some authors have described increases in heart rate following anesthesia of the left hemisphere, while others found little or no effect at all. We therefore searched for evidence of lateralization in a larger number of patients (36) with complex partial seizures. These patients underwent the Wada test as part of the preoperative diagnostic evaluation. In this study, inactivation of the left or right hemisphere did not lead to significantly different effects on heart rate, or on systolic or diastolic blood pressure.
A 42-year-old man with human immunodeficiency virus (HIV) infection and a history of complex partial seizures developed severe anemia after the addition of valproic acid to his stable antiretroviral regimen of zidovudine, lamivudine, and abacavir. The inhibition of zidovudine glucuronidation by valproic acid and the resultant zidovudine hematologic toxicity is the proposed mechanism of the interaction.
16 right-handed men and 19 women were asked to feel various sized wooden cubes with the dominant hand for 2 sec. (without visual feedback) and then to select this cube from a random visual arrangement of cubes (tactile-visual matching) after a brief delay. The accuracy for men and women for this task did not differ significantly; however, the accuracy was significantly correlated (rho = 0.61) with a history of complex partial epileptic-like signs for the women but not for the men. The results support the hypothesis that elevated scores for complex partial epileptic-like signs in right-handed women enhance their capacity to associate different perceptual domains of the same stimuli because there is elevated activity within the (multimodal) hippocampal-amygdaloid system (sensory-limbic hyperconnectionism) and the correlative enhanced intercalation between the right and left temporoparietal lobes.
In placebo-controlled trials, the overall incidence of nonconvulsive status epilepticus was no higher in the tiagabine-treated group than in the placebo-group. Case reports of nonconvulsive status epilepticus under tiagabine suggested a specific role of dose levels, since in these patients symptoms occurred mostly at 40 mg/day or higher. We report a case of complex partial status epilepticus in a patient receiving a low dose of tiagabine and review all 11 case reports of nonconvulsive status epilepticus in patients on tiagabine, with regard to daily doses. Our analysis suggests an individual risk threshold of unknown aetiology.
We report a patient with band heterotopia whose electroencephalogram (EEG) showed typical morphological features of intermittent rhythmic delta activity (IRDA). This 18-year-old woman had complex partial seizures. Neuropsychometry revealed mental dysfunction. Magnetic resonance imaging (MRI) showed bilaterally symmetrical layer of heterotopic gray matter in deep white matter over the frontal, parietal and occipital regions. This case is the first report of IRDA detected in band heterotopia.
In this study, we determined whether childhood seizures were associated with hippocampal neuron loss and mossy fibre synaptic reorganization and if hippocampal sclerosis evolved from longer seizure histories. Children undergoing surgical treatment for catastrophic epilepsy were grouped into the following pathology categories: (i) those with generalized seizures and extra-hippocampal congenital pathologies (i.e. prenatal cortical dysplasia; n = 17); (ii) cases of generalized seizures and extra-hippocampal acquired lesions. (i.e. postnatal ischaemic injuries and encephalitis; n = 7); (iii) children with complex partial hippocampal epilepsy (n = 4). Further, to determine whether the epileptogenic location influenced hippocampal pathology, the seizure focus was classified as (i) hippocampal, (ii) temporal (n = 13) or (iii) extra-temporal (n = 11). Surgical and autopsy (n = 23) hippocampi were studied for (i) fascia-dentata (FD) and Ammon's horn (AH) neuron densities; (ii) thickness; height or length of the FD molecular layer, stratum granulosum (SG) and stratum pyramidale; and (iii) grey value (GV) densities of supragranular neo-Timm's staining. Statistically significant results (P < 0.05) showed the following. (i) Autopsy hippocampal neuron densities for the hilus (H), AH and prosubiculum (Pro) decreased logarithmically at the same time as the thickness of the stratum pyramidale and Pro increased. By contrast, autopsy granule cell densities and thickness did not significantly change with age; however, the SG lengthened-expanding around the enlarging H. Further, the supragranular molecular layer height increased logarithmically, and took longer than the increase in stratum pyramidale thickness. (ii) Compared with age-matched autopsies, young children with a history of hippocampal seizures showed decreased granule cell, hilar and regio superior neuron densities similar to adults with hippocampal sclerosis (average loss 70%). By contrast, children with extra-hippocampal congenital or acquired pathologies showed only decreased granule cell densities, along with a thinner and shorter SG. Compared with extra-temporal locations, those with temporal lobe lesions showed decreased hilar and AH neuron densities, but averaged 20-30% less than autopsies and not in the pattern typical of hippocampal sclerosis. (iii) The neo-Timm's GV densities, when compared with autopsies, showed supragranular mossy fibre sprouting in children with congenital pathologies and temporal lobe lesions; however, the greatest GVs were in children with hippocampal seizures. (iv) Of the children with extra-hippocampal congenital or acquired pathologies there were no statistical correlations between longer duration of seizures with changes in neuron densities, hippocampal heights, or mossy fibre sprouting. These results indicate the following. (i) In the human there is anatomical evidence for postnatal maturation of the hippocampus and our results are consistent with the notion that AH pyramids are a stable population; however, there are probably increases in granule cell numbers. Further, compared with the AH, dendritic maturation of the FD granule cells appears to take longer. (ii) Extra-hippocampal childhood seizures whether from prenatal or postnatal aetiologies are associated with moderate FD and minimal AH neuron losses and signs of aberrant mossy fibre sprouting. (iii) By contrast, young children with the syndrome of mesial temporal epilepsy show patterns of neuron loss and mossy fibre sprouting, typical of hippocampal sclerosis. (iv) Repeated extra-hippocampal childhood seizures are not associated with progressive evolution of hippocampal damage or mossy fibre sprouting. These findings support the hypothesis that childhood seizures can damage or alter the postnatally developing granule cells of the human hippocampus, and that early neuron loss and aberrant axon circuits may contribute to chronic hippocampal seizures. However, repeated childhood generalized seiz
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.
PURPOSE: To assess the comparative therapeutic value of valproate (VPA), lamotrigine (LTG), and their combination in patients with complex partial seizures resistant to other established antiepileptic drugs (AEDs). METHODS: After a 3-month prospective baseline, 20 adults with refractory complex partial seizures not exposed previously to VPA and LTG were scheduled to receive three consecutive add-on treatments with VPA, LTG, or their combination, according to an open, response-conditional, crossover design. Each period consisted of a 6- to 12-week dose optimization followed by 3-month evaluation at stabilized serum drug levels. Only patients not responding to one phase proceeded to the next. RESULTS: A >50% reduction in seizure frequency was observed in three of 20 patients given VPA and in four of 17 patients given LTG. Of the remaining 13 patients, four became seizure free, and an additional four experienced seizure reductions of 62-78% when VPA and LTG were given in combination. Mild tremor was observed in three patients receiving VPA and in all patients taking the VPA--LTG combination. In patients responding to combination therapy, optimized dosages and peak serum levels of both VPA and LTG were lower than those during separate administration. CONCLUSIONS: A considerable proportion of patients who failed to respond to VPA and LTG separately improved when the two drugs were combined, although serum levels of both agents were lower during combination therapy. Despite methodologic limitations in the nonrandomized treatment sequence, these findings suggest that VPA and LTG exhibit a favorable pharmacodynamic interaction in patients with refractory partial epilepsy. The dosage of both drugs, however, may need to be reduced to minimize the risk of intolerable side effects.
MRI showed a cortically-based partially cystic and markedly enhancing mass in the uncus of the right temporal lobe in a patient with long standing refractory partial complex seizures. Histopathological examination revealed a pleomorphic xanthoastrocytoma, a rare, usually benign tumour thought to originate from subpial astrocytes.
Using alpha- and beta- tubulin cDNA Probes and Northern blot hybridization technique, we analyzed the effect of intraperitoneally injected Qingyangshen (QYS), a traditional Chinese medicine with antiepileptic property, and diphenylhydrantoin sodium (DPH) on hippocampal alpha- and beta-tubulin gene expression during kainic acid (KA) induced chronic seizures. It was found that: 1) thirty days after intraperitoneal injection of KA, alpha- and beta-tubulin mRNAs in animals showing chronic seizures increased 3.02 +/- 1.05 and 4.07 +/- 1.32 times respectively compared with control; 2) neither QYS (15 mg/kg, q.o.d. x 6) nor DPH (50 mg/kg, q.o.d. x 6), when used separately, could inhibit the above mentioned effect of KA; 3) when QYS (15 mg/kg, q.o.d. x 6) and DPH (50 mg/kg, q.o.d. x 6) were given in combination, the long-term increase in tubulin gene expression induced by KA was significantly reduced, with alpha- and beta-tubulin mRNAs being decreased to 0.44 +/- 0.08 and 0.50 x 0.10 times of corresponding values in animals treated with KA alone. The results indicate that the mechanism of antiepileptic effect of QYS is at least partially related to the inhibition of tubulin synthesis and subsequent reduction in mossy fiber sprouting and neosynaptogenesis.
Magnetic resonance imaging (MRI) was performed on an infant with typical complex partial seizures. Visual analysis revealed MRI signs of left hippocampal sclerosis (HS) at an age of 9 months. Morphometric data including volumetry and relaxometry confirming the diagnosis are shown. This is the first report of an infant younger than 2 years with typical MRI findings including morphometric data on HS.
Complex partial status epilepticus (SE) has been reported rarely in children. We describe the clinical case of a 14 year-old girl with complex partial seizures (CPS) since age 10 who developed a complex partial SE probably because she was not adherent to treatment. The neurologic examination and computed tomography scan were normal. During the SE she received diazepam and phenytoin and became free of the seizures after 5 minutes. The ictal EEG showed spikes and slow waves over the right temporal region.
Clinical and electrographic features were retrospectively studied in 57 patients with midline (Fz, Cz, Pz) spikes as the only epileptiform activity in their EEG to determine possible predictors of outcome. Our study confirmed previous reports of early age of onset, activation by sleep, and Cz as the most frequent spike location. In contrast to previous studies with smaller numbers of patients, midline spikes were more common in males and most often associated with partial complex seizures and were not activated by sleep at an older age. Of the 29 patients who were followed for 6 months to 9 years, only 15 (52%) achieved good seizure control. Although a tendency toward a poor outcome was noted with several independent variables (positive family history of epilepsy, later age of seizure onset, abnormal EEG background activities, abnormal neuroimaging, abnormal neurologic examination), none was of statistical significance. This study suggests that epilepsy with midline spikes is not necessarily benign and that future studies with larger patient groups may be necessary to identify factors that influence prognosis.
Machado de Assis (1839-1908) is considered the most important Brazilian writer and a great universal literary figure. Little is know about his medical, personal and family history. He hid his "disease" as much as possible. Machado referred to "strange things" having happened to him in his childhood. He described seizures as "nervous phenomena", "absenses", "my illness". Laet observed a seizure and described it as: "... when Machado approached us and spoke to me in disconnected words. I looked at him in surprise and found his features altered. Knowing that from time to time he had nervous problems, ... and only permitted Machado take the Laranjeiras Street car, when I saw that he was completely well". A photographically documented seizure is shown. Alencar wrote, "The preoccupation with health was frequent: either he was having the consequences of a fit or was foreboding one". It is clear that Machado presented localized symptomatic epilepsy with complex partial seizures secondarily generalized of unknown etiology. The seizures which began in infancy or childhood had remission in adolescence and then recurred in his thirties and became more frequent in his later years. His depression got markedly worse with age. In our opinion, the greatest consequence of Machado's epilepsy, was his psychological suffering due to the prejudice of the times. Despite this Machado showed all his genius, which is still actual and universal.
3-Hydroxy-3-methylglutaryl coenzyme A lyase deficiency, an inborn error of ketone body synthesis and leucine degradation, is a rare disorder. There are few reports demonstrating clinical and neuroradiologic findings of this condition. This report describes a 3.5-year-old previously healthy male who was admitted with complex partial seizures and was diagnosed as having 3-hydroxy-3-methylglutaryl coenzyme A lyase deficiency. The patient's previous medical history was unremarkable. His development and neurologic examination were normal. Cranial magnetic resonance imaging indicated prominent corticospinal tract and pontine involvement with focal cerebral white matter changes which have not been described in the literature before.
A previously healthy woman had a prolonged amnestic state caused by complex partial status epilepticus with bilateral mesiotemporal lobe involvement confirmed by EEG with nasopharyngeal electrodes. A magnetic resonance imaging (MRI) scan obtained shortly after recovery from the amnesia showed reversible focal abnormalities consisting of increased signal intensity on T2-weighted scan in the mesiotemporal lobe.
The authors report postictal language evaluation in patients monitored with bitemporal depth electrodes. Patients whose seizures began in the nondominant temporal lobe and propagated to the contralateral temporal lobe had a prolonged postictal language delay (PILD) with paraphasic errors compared with seizures that did not spread. Shorter propagation time was also associated with a longer PILD. Our study suggests that ictal involvement of the dominant temporal lobe is important in postictal language behavior.