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Levy M. Immune-Mediated Myelopathies. Continuum (Minneap Minn) 2024; 30:180-198. [PMID: 38330478 PMCID: PMC10868882 DOI: 10.1212/con.0000000000001382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2024]
Abstract
OBJECTIVE Immune-mediated myelopathies are conditions in which the immune system attacks the spinal cord. This article describes the distinguishing characteristics of immune-mediated myelopathies and treatment strategies for patients affected by these disorders. LATEST DEVELOPMENTS New biomarkers, such as aquaporin 4 and myelin oligodendrocyte glycoprotein antibodies, in the blood and spinal fluid have led to the identification of antigen-specific immune-mediated myelopathies and approved therapies to prevent disease progression. ESSENTIAL POINTS The first step in the diagnosis of an immune-mediated myelopathy is confirming that the immune system is the cause of the attack by excluding non-immune-mediated causes. The second step is to narrow the differential diagnosis based on objective biomarkers such as serology and MRI patterns. The third step is to treat the specific immune-mediated myelopathy by using evidence-based medicine.
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Olie SE, van Zeggeren IE, ter Horst L, Citroen J, van Geel BM, Heckenberg SGB, Jellema K, Kester MI, Killestein J, Mook BB, Titulaer MJ, van Veen KEB, Verschuur CVM, van de Beek D, Brouwer MC. Seizures in adults with suspected central nervous system infection. BMC Neurol 2022; 22:426. [PMID: 36376810 PMCID: PMC9661800 DOI: 10.1186/s12883-022-02927-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 10/21/2022] [Indexed: 11/16/2022] Open
Abstract
Background Seizures can be part of the clinical presentation of central nervous system (CNS) infections. We describe patients suspected of a neurological infection who present with a seizure and study diagnostic accuracy of clinical and laboratory features predictive of CNS infection in this population. Methods We analyzed all consecutive patients presenting with a seizure from two prospective Dutch cohort studies, in which patients were included who underwent cerebrospinal fluid (CSF) examination because of the suspicion of a CNS infection. Results Of 900 episodes of suspected CNS infection, 124 (14%) presented with a seizure. The median age in these 124 episodes was 60 years (IQR 45–71) and 53% of patients was female. CSF examination showed a leukocyte count ≥ 5/mm3 in 41% of episodes. A CNS infection was diagnosed in 27 of 124 episodes (22%), a CNS inflammatory disorder in 8 (6%) episodes, a systemic infection in 10 (8%), other neurological disease in 77 (62%) and in 2 (2%) episodes another systemic disease was diagnosed. Diagnostic accuracy of clinical and laboratory characteristics for the diagnosis of CNS infection in this population was low. CSF leukocyte count was the best predictor for CNS infection in patients with suspected CNS infection presenting with a seizure (area under the curve 0.94, [95% CI 0.88 – 1.00]). Conclusions Clinical and laboratory features fail to distinguish CNS infections from other causes of seizures in patients with a suspected CNS infection. CSF leukocyte count is the best predictor for the diagnosis of CNS infection in this population.
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Fan JM, Singhal NS, Guterman EL. Management of Status Epilepticus and Indications for Inpatient Electroencephalography Monitoring. Neurol Clin 2022; 40:1-16. [PMID: 34798964 DOI: 10.1016/j.ncl.2021.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Status epilepticus (SE) is a neurologic emergency requiring immediate time-sensitive treatment to minimize neuronal injury and systemic complications. Minimizing time to administration of first- and second-line therapy is necessary to optimize the chances of successful seizure termination in generalized convulsive SE (GCSE). The approach to refractory and superrefractory GCSE is less well defined. Multiple agents with differing complementary actions that facilitate seizure termination are recommended. Nonconvulsive SE (NCSE) has a wide range of presentations and approaches to treatment. Continuous electroencephalography is critical to the management of both GCSE and NCSE, while its use for patients without seizure continues to expand.
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Affiliation(s)
- Joline M Fan
- Department of Neurology, University of California, San Francisco, 505 Parnassus Avenue, M798 Box 0114, San Francisco, CA 94143, USA; Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA 94143, USA.
| | - Neel S Singhal
- Department of Neurology, University of California, San Francisco, 505 Parnassus Avenue, M798 Box 0114, San Francisco, CA 94143, USA; Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA 94143, USA
| | - Elan L Guterman
- Department of Neurology, University of California, San Francisco, 505 Parnassus Avenue, M798 Box 0114, San Francisco, CA 94143, USA; Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA 94143, USA
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Süße M, Gag K, Hamann L, Hannich MJ, von Podewils F. Time dependency of CSF cell count, lactate and blood-CSF barrier dysfunction after epileptic seizures and status epilepticus. Seizure 2021; 95:11-16. [PMID: 34954628 DOI: 10.1016/j.seizure.2021.12.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 12/15/2021] [Accepted: 12/17/2021] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND This retrospective observational study was conducted to examine the temporal relationship between increased cell count, lactate concentration in cerebrospinal fluid (CSF) and blood-CSF barrier dysfunction and the onset of a seizure event. METHODS Patients with a seizure event who underwent lumbar puncture for CSF analysis during diagnostic work-up (interindividual analysis) and those with at least one follow-up CSF analysis (intraindividual analysis) were studied. Pathologically altered parameters, such as cell count, lactate concentration, and blood-CSF barrier dysfunction as indicated by the albumin quotient (QAlb=CSF albumin/serum albumin), were examined with regard to the changes over time after seizure onset. RESULTS An increased CSF cell count (>4/µl) was shown in 3% of our patients, whereas pathological lactate concentrations were found in 24% after single seizures and 28% after status epilepticus (SE)/recurring seizures. However, lactate levels showed a marked decrease with increasing time after an isolated seizure (p<0.0001) but not after SE/recurring seizures. Lactate levels were most frequently and significantly elevated within the first six hours after a single seizure (p<0.0001). Blood-CSF barrier dysfunction was detected in 34% after isolated seizures and in 47% after SE/recurrent seizures. Blood-CSF barrier dysfunction showed no association with latency between seizure onset and time of CSF collection. CONCLUSIONS Changes in lactate and CSF protein concentrations are common after epileptic seizures. In contrast, CSF pleocytosis is uncommon and should prompt careful investigation for the presence of intrathecal infection or autoimmune CNS disease. Elevated lactate levels more than 6 h after the seizure event may indicate ongoing epileptic activity.
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Affiliation(s)
- M Süße
- Department of Neurology, University Medicine Greifswald, Greifswald.
| | - K Gag
- Department of Neurology, University Medicine Greifswald, Greifswald
| | - L Hamann
- Department of Neurology, University Medicine Greifswald, Greifswald
| | - M J Hannich
- Institute for Clinical Chemistry and Laboratory Medicine, University Medicine Greifswald, Greifswald
| | - F von Podewils
- Department of Neurology, University Medicine Greifswald, Greifswald
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Langenbruch L, Wiendl H, Groß C, Kovac S. Diagnostic utility of cerebrospinal fluid (CSF) findings in seizures and epilepsy with and without autoimmune-associated disease. Seizure 2021; 91:233-243. [PMID: 34233238 DOI: 10.1016/j.seizure.2021.06.030] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 06/12/2021] [Accepted: 06/17/2021] [Indexed: 01/17/2023] Open
Abstract
Patients with seizures and epilepsy routinely undergo multiple diagnostic tests, which may include cerebrospinal fluid (CSF) analysis. This review aims to outline different CSF parameters and their alterations in seizures or epilepsy. We then discuss the utility of CSF analysis in seizure patients in different clinical settings in depth. Some routine CSF parameters are frequently altered after seizures, but are not specific such as CSF protein and lactate. Pleocytosis and CSF specific oligoclonal bands are rare and should be considered as signs of infectious or immune mediated seizures and epilepsy. Markers of neuronal damage show conflicting results, and are as yet not established in clinical practice. Parameters of neuronal degeneration and more specific immune parameters are less well studied, and are areas of further research. CSF analysis in new-onset seizures or status epilepticus serves well in the differential diagnosis of seizure etiology. Here, considerations should include autoimmune-associated seizures. CSF findings in these disorders are a special focus of this review and are summarized in a comprehensive overview. Until now, CSF analysis has not yielded clinically helpful biomarkers for refractory epilepsy or for assessment of neuronal damage which is a subject of further studies.
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Affiliation(s)
- Lisa Langenbruch
- Department of Neurology with Institute of Translational Neurology, University of Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149 Münster, Germany; Department of Neurology, Klinikum Osnabrück, Am Finkenhügel 1, 49076 Osnabrück, Germany.
| | - Heinz Wiendl
- Department of Neurology with Institute of Translational Neurology, University of Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149 Münster, Germany.
| | - Catharina Groß
- Department of Neurology with Institute of Translational Neurology, University of Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149 Münster, Germany.
| | - Stjepana Kovac
- Department of Neurology with Institute of Translational Neurology, University of Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149 Münster, Germany.
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Cerebrospinal Fluid Pleocytosis Not Attributable to Status Epilepticus in First 24 Hours. Can J Neurol Sci 2021; 49:210-217. [PMID: 33902768 DOI: 10.1017/cjn.2021.83] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Status epilepticus (SE) has traditionally been thought to cause cerebrospinal fluid (CSF) pleocytosis. However, attributing CSF pleocytosis solely to SE without addressing the underlying etiology may lead to poor outcomes. Leukocyte recruitment to CSF has been shown to peak around 24 hours after prolonged seizures in animal studies, suggesting that CSF pleocytosis within the first 24 hours of SE onset may be due to underlying causes. The goal of this study is to assess if SE is associated with CSF pleocytosis, independent of other causes within the first 24 hours of onset. METHODS We completed a historical cohort study of adult patients with SE admitted to the intensive care unit of Vancouver General Hospital between March 2010 and May 2019. RESULTS Of the 441 patients admitted with SE during the study period, 107 met our inclusion criteria leading to 111 lumbar punctures (LPs), with 4 patients receiving two LPs. CSF pleocytosis was seen in 12 of 72 patients who underwent an LP within the first 24 hours of SE onset. In all 12 patients, a secondary etiology for the pleocytosis was observed aside from SE. Of the six CSF samples collected after 24 hours of onset that demonstrated pleocytosis, four had no cause for pleocytosis other than SE. CONCLUSIONS In all 12 patients with CSF pleocytosis in the first 24 hours of onset of SE, an underlying etiology was identified. Therefore, any pleocytosis noticed within the first 24 hours of onset of refractory SE should not be attributed solely to SE.
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Spera KM, Doughty CT, Prasad S. Clinical Reasoning: A 53-year-old woman with headache and altered mental status. Neurology 2018; 90:e1267-e1270. [DOI: 10.1212/wnl.0000000000005260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Cerebrospinal fluid findings in non-infectious status epilepticus. Epilepsy Res 2017; 140:61-65. [PMID: 29276970 DOI: 10.1016/j.eplepsyres.2017.12.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 12/01/2017] [Accepted: 12/08/2017] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Ictal activity itself can cause pathological cerebrospinal fluid (CSF) findings. However, data regarding pathological CSF findings caused by SE itself to date remain scarce. We here evaluated the frequency and specificity of pathological CSF findings in non-infectious SE. METHODS We performed a retrospective analysis of CSF samples in adult patients with episodes of non-infectious SE, who had been admitted to the Department of Neurology, University Hospital of Cologne. The following parameters were assessed: cell count, protein, and lactate content, CSF/serum glucose quotient (QGlc), disturbances of blood-brain-barrier function assessed by CSF/serum albumin quotient (QAlb), and qualitative intrathecal IgG synthesis assessed by unmatched oligoclonal bands in CSF. RESULTS We analysed 54 episodes of non-infectious SE in which CSF had been obtained. CSF pleocytosis was infrequent (6%). Elevated CSF protein content was present in 44% of all cases, whereas elevated CSF lactate content was found in 23% of the cases. A decreased QGlc was present in 9%. Dysfunction of blood-brain-barrier (BBBD) was the most frequent pathological finding, amounting to 55%. Unmatched oligoclonal bands in CSF were seen in 10% of non-infectious SE. Further analysis revealed that elevated CSF protein content was found predominantly in recfractory SE (p = 0.04). Elevated CSF lactate content was associated with shorter latency between onset of SE and CSF retrieval (p = 0.004), positive history of epilepsy (p = 0.02) and an acute symptomatic etiology (p = 0.04). BBBD was also present more often in acute symptomatic SE (p = 0.001) and was the sole pathological CSF parameter associated with clinical outcome: presence of BBBD was associated with a less favorable outcome (p = 0.02). SIGNIFICANCE Non-infectious SE itself does not commonly cause CSF pleocytosis. Data suggest that the detection of CSF pleocytosis should prompt further diagnostics for an underlying infectious or neoplastic etiology. In contrast, elevation of CSF protein content and BBBD were found frequently in non-infectious SE.
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Abstract
Preview Dr Morgenlander provides answers to some of the questions primary care physicians may have about lumbar puncture and cerebrospinal fluid (CSF) examination: What can be done to prevent post-lumbar puncture headache and how should it be treated? Does CSF pleocytosis in a patient who has had a seizure necessarily signify an underlying infectious or inflammatory process? Should every patient with dementia undergo CSF examination?
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Abstract
OBJECTIVES To assess the etiology of cerebrospinal fluid (CSF) pleocytosis in critical care patients with seizure(s) or status epilepticus (SE). Many previous studies, some performed decades ago, concluded that CSF pleocytosis may be entirely attributable to seizure activity. METHODS We undertook a retrospective chart review of adult patients with an admitting or acquired diagnosis of seizure(s) or SE in critical care units at the Winnipeg Health Sciences Centre between 2009 and 2012. Patients were identified through a critical care information database at a tertiary care center. We limited our study to patients who had lumbar punctures at our center within 5 days of seizure(s) or SE. RESULTS Of 426 patients with seizures in critical care units, 51 met the inclusion criteria. Seizure subtypes included focal seizures (5 or 10%), generalized seizures (14 or 27%), and SE (32 or 63%). Twelve (seven with SE) of the 51 (24%) were found to have CSF pleocytosis. A probable etiological cause for the CSF pleocytosis was identified in all 12 cases. CONCLUSIONS We conclude that seizures do not directly induce a CSF pleocytosis. Instead, the CSF pleocytosis more likely reflects the underlying acute or chronic brain process responsible for the seizure(s). This was not readily apparent in early studies without magnetic resonance imaging (MRI) of the brain and currently available laboratory investigations. An etiological cause of CSF pleocytosis must always be sought when patients present with seizures and it should never be assumed that seizures are the cause.
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Abstract
Although the majority of seizures are brief and cause no long-term consequences, a subset is sufficiently prolonged that long-term consequences can result. These very prolonged seizures are termed "status epilepticus" (SE) and are considered a neurological emergency. The clinical presentation of SE can be diverse. SE can occur at any age but most commonly occurs in the very young and the very old. There are numerous studies on SE in animals in which the pathophysiology, medication responses, and pathology can be rigorously studied in a controlled fashion. Human data are consistent with the animal data. In particular, febrile status epilepticus (FSE), a form of SE common in young children, is associated with injury to the hippocampus and subsequent temporal lobe epilepsy (TLE) in both animals and humans.
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Affiliation(s)
- Syndi Seinfeld
- Virginia Commonwealth University, Richmond, Virginia 23298-0211
| | | | - Shlomo Shinnar
- Comprehensive Epilepsy Management Center, Montefiore Medical Center, Albert Einstein College of Medicine, New York, New York 10467
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Alvarez V, Westover MB, Drislane FW, Dworetzky BA, Curley D, Lee JW, Rossetti AO. Evaluation of a clinical tool for early etiology identification in status epilepticus. Epilepsia 2014; 55:2059-2068. [PMID: 25385281 DOI: 10.1111/epi.12852] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/25/2014] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Because early etiologic identification is critical to select appropriate specific status epilepticus (SE) management, we aim to validate a clinical tool we developed that uses history and readily available investigations to guide prompt etiologic assessment. METHODS This prospective multicenter study included all adult patients treated for SE of all but anoxic causes from four academic centers. The proposed tool is designed as a checklist covering frequent precipitating factors for SE. The study team completed the checklist at the time the patient was identified by electroencephalography (EEG) request. Only information available in the emergency department or at the time of in-hospital SE identification was used. Concordance between the etiology indicated by the tool and the determined etiology at hospital discharge was analyzed, together with interrater agreement. RESULTS Two hundred twelve patients were included. Concordance between the etiology hypothesis generated using the tool and the finally determined etiology was 88.7% (95% confidence interval (CI) 86.4-89.8) (κ = 0.88). Interrater agreement was 83.3% (95% CI 80.4-96) (κ = 0.81). SIGNIFICANCE This tool is valid and reliable for identification early the etiology of an SE. Physicians managing patients in SE may benefit from using it to identify promptly the underlying etiology, thus facilitating selection of the appropriate treatment.
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Affiliation(s)
- Vincent Alvarez
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A.,Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A.,Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, U.S.A.,Neurology Service, Internal Medicine department,, Hôpital du Valais, 19501, Sion, Switzerland
| | - M Brandon Westover
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Frank W Drislane
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Barbara A Dworetzky
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - David Curley
- Emergency Department, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Jong Woo Lee
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Andrea O Rossetti
- Department of Clinical Neurosciences, CHUV and Lausanne University, Lausanne, Switzerland
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Hugo TB, Heading KL, Labuc RH. Canine cerebrospinal fluid total nucleated cell counts and cytology associations with the prevalence of magnetic resonance imaging abnormalities. VETERINARY MEDICINE-RESEARCH AND REPORTS 2014; 5:75-84. [PMID: 32670848 PMCID: PMC7337202 DOI: 10.2147/vmrr.s63805] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Accepted: 04/23/2014] [Indexed: 11/23/2022]
Abstract
Introduction The combination of cerebrospinal fluid (CSF) analysis and magnetic resonance imaging (MRI) are often used to investigate intracranial disease in dogs. The aim of this retrospective study was to determine if the total nucleated cell count (TNCC) or cytology findings in abnormal CSF are associated with the prevalence of MRI abnormalities. Materials and methods For each case, the TNCC was categorized into one of three groups: A (<25×106/L); B (25-100×106/L); and C (>100×106/L). Cytology findings were categorized by the predominant cell type as lymphocytic, monocytoid, neutrophilic, or eosinopilic. MRI descriptions were classified as either normal or abnormal, and abnormal studies were further evaluated for the presence of specific characteristics (multifocal or diffuse disease versus focal disease, positive T2-weighted hyperintensity, positive FLAIR hyperintensity, contrast enhancement, mass effect, and the presence of poorly or well-defined lesion margins). Results Forty-five dogs met the inclusion criteria and MRI abnormalities were found in 29/45 (64%) dogs. TNCCs were not associated with the prevalence of MRI abnormalities or specific characteristics. Cytology categories were significantly associated with the prevalence of MRI abnormalities (P<0.001). Specifically, monocytoid cytology was 22.8 times more likely to have an abnormal MRI than lymphocytic cytology. CSF cytology was not significantly associated with specific abnormal MRI characteristics. Conclusion There are minimal associations between CSF abnormalities and the prevalence of MRI abnormalities. These results support the continued importance of utilizing both tests when investigating intracranial disease. When CSF analysis must be performed initially, this study has demonstrated that an abnormal CSF with a monocytoid cytology supports the value of performing a brain MRI in dogs with evidence of intracranial neurological disease.
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Affiliation(s)
- Timothy B Hugo
- Melbourne Veterinary Specialist Centre, Glen Waverley, Vic, Australia
| | - Kathryn L Heading
- Melbourne Veterinary Specialist Centre, Glen Waverley, Vic, Australia
| | - Robert H Labuc
- Melbourne Veterinary Specialist Centre, Glen Waverley, Vic, Australia
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Puoti G, Elefante A, Saracino D, Capasso A, Cotrufo R, Anello CB. New-onset refractory status epilepticus mimicking herpes virus encephalitis. Case Rep Neurol 2013; 5:162-7. [PMID: 24163672 PMCID: PMC3806676 DOI: 10.1159/000355273] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
New-onset refractory status epilepticus (NORSE) is a recently defined clinical entity that describes patients who present with status epilepticus of unclear etiology that is highly refractory to therapy. Magnetic resonance imaging (MRI) of NORSE usually discloses no specific abnormalities except for an occasional mild T2/FLAIR hyperintense signal of the mesial temporal lobe. Here, we report a peculiar case of NORSE in which brain MRI showed massive alteration of both temporal lobes, with features strongly supporting the diagnosis of herpes virus encephalitis, but lacking any laboratory evidence of viral infection in the blood and cerebrospinal fluid. It showed also striking signal alterations in the thalamus, which got worse in the course of the disease. This report emphasizes the possibility that seizure activity alone plays a critical role in both determining the disease and whether it will be self-sustaining.
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Affiliation(s)
- Gianfranco Puoti
- I Division of Neurology, Department of Clinical and Experimental Medicine, Naples, Italy
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Li J, Saldivar C, Maganti RK. Plasma exchange in cryptogenic new onset refractory status epilepticus. Seizure 2013; 22:70-3. [DOI: 10.1016/j.seizure.2012.09.011] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2012] [Revised: 09/14/2012] [Accepted: 09/17/2012] [Indexed: 10/27/2022] Open
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Abstract
Status epilepticus is among the most dramatic of clinical presentations encountered by emergency room physicians, neurologists, neurosurgeons and intensivists. While progress in its management has been aided significantly with an increasing number of effective treatment options, improved diagnostic methods and more effective monitoring, poor outcomes and diagnostic failures are still frequently encountered. Refractory cases still carry significant morbidity and mortality rates, including poor cognitive outcomes. This review discusses basic pathophysiology and management of status epilepticus, neuroimaging findings, the role of continuous electroencephalogram monitoring and nonconvulsive status epilepticusas well as recent developments in treatment options for refractory cases.
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Shah AM, Vashi A, Jagoda A. Review article: Convulsive and non-convulsive status epilepticus: an emergency medicine perspective. Emerg Med Australas 2011; 21:352-66. [PMID: 19840084 DOI: 10.1111/j.1742-6723.2009.01212.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Status epilepticus (SE) is divided into convulsive and non-convulsive types; both are associated with significant morbidity and mortality. Although convulsive SE is easily recognized, non-convulsive SE remains an elusive diagnosis as physical signs are varied and subtle. Successful management depends on a comprehensive approach that involves diagnostic testing and pharmacological interventions while ensuring cerebral oxygenation and perfusion at all times. There are a limited number of well-designed studies to support the development of evidence-based recommendations for the management of SE, especially for the management of non-convulsive status. Benzodiazepines, specifically lorazepam, continue to be the most commonly recommended first-line therapy; best treatment for refractory status cases depends on resources available and must be tailored to the individual institution. In order to facilitate care, it is recommended that each institution develop a management protocol for these patients.
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Affiliation(s)
- Amish M Shah
- Department of Emergency Medicine, Mount Sinai School of Medicine, ne Gustave Levy Place Box1490, New York, NY 10128, USA.
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Abstract
Status epilepticus (SE) is one of the most commonly occurring neurologic emergencies. About 40% of SE cases occur in people with epilepsy. Convulsive SE is easily recognized, but nonconvulsive SE is not and requires both a high index of suspicion and EEG confirmation. SE has a high mortality risk and requires rapid effective treatment for optimal response to therapy and outcome. The goal of treatment is to stop all clinical and electrographic seizures while maintaining vital functions. If seizures continue after initial treatment with a benzodiazepine, additional antiepileptic therapy should be administered. When SE is refractory to these treatments, continuous IV infusion with midazolam, propofol, or a barbiturate suppresses seizure activity. Standard treatment protocols are useful in promoting rapid intervention with appropriate medications.
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Sahaya K, Lardizabal D. Catatonia in encephalitis and nonconvulsive seizures: a case report and review of the literature. Epilepsy Behav 2010; 17:420-5. [PMID: 20153983 DOI: 10.1016/j.yebeh.2010.01.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2009] [Revised: 12/17/2009] [Accepted: 01/08/2010] [Indexed: 11/26/2022]
Abstract
A 20-year-old woman was admitted for psychosis. On further investigation, she was found to be have viral encephalitis and generalized nonconvulsive seizures. After the seizures were controlled, she remained in a prolonged catatonic state. Repeated intravenous benzodiazepine administration, improved her cognition dramatically. This case emphasizes that catatonia may occur after encephalitis and nonconvulsive seizures.
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Affiliation(s)
- Kinshuk Sahaya
- Department of Neurology, University of Missouri-Columbia, Columbia, MO 65212, USA.
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Mishra SK, Newton CRJC. Diagnosis and management of the neurological complications of falciparum malaria. Nat Rev Neurol 2009; 5:189-98. [PMID: 19347024 PMCID: PMC2859240 DOI: 10.1038/nrneurol.2009.23] [Citation(s) in RCA: 108] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Malaria is a major public health problem in the developing world owing to its high rates of morbidity and mortality. Of all the malarial parasites that infect humans, Plasmodium falciparum is most commonly associated with neurological complications, which manifest as agitation, psychosis, seizures, impaired consciousness and coma (cerebral malaria). Cerebral malaria is the most severe neurological complication; the condition is associated with mortality of 15-20%, and a substantial proportion of individuals with this condition develop neurocognitive sequelae. In this Review, we describe the various neurological complications encountered in malaria, discuss the underlying pathogenesis, and outline current management strategies for these complications. Furthermore, we discuss the role of adjunctive therapies in improving outcome.
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Cryptogenic New Onset Refractory Status Epilepticus (NORSE) in adults—Infectious or not? J Neurol Sci 2009; 277:26-31. [DOI: 10.1016/j.jns.2008.10.007] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2008] [Revised: 09/27/2008] [Accepted: 10/02/2008] [Indexed: 11/23/2022]
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Dietzel J, Krebs A, Lüdemann J, Roser M, Dressel A. Neutrophils in cerebrospinal fluid without pleocytosis. Eur J Neurol 2008; 15:634-6. [PMID: 18474079 DOI: 10.1111/j.1468-1331.2008.02139.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Neutrophils in cerebrospinal fluid (CSF) samples are commonly considered a pathological feature; however, there is little information on the frequency and significance of these cells in CSF samples without pleocytosis. Therefore, the frequency and possible clinical significance of neutrophils in CSF was investigated. In a retrospective study comprising 1556 consecutive CSF samples, cytologies and patient records were reviewed. Five hundred thirty-eight CSF samples without pleocytosis were identified. Neutrophils were detected in 35.5% of these samples. The presence of neutrophils was associated with sepsis (P < 0.01), recent epileptic seizure (P < 0.0001), and blood contamination (P < 0.01). Amongst patients without CSF pleocytosis, CNS infections were not more frequent if neutrophils were present. Neutrophils are frequently observed in CSF with normal leukocyte counts. As sepsis but not CNS infection occurred more frequently in these patients, we conclude that in the absence of CSF pleocytosis, neutrophils are not indicative of CNS infections.
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Affiliation(s)
- J Dietzel
- Department of Neurology, Ernst-Moritz-Arndt-University Greifswald, Ferdinand-Sauerbruch-Strasse, Germany
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23
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Updates in the Management of Seizures and Status Epilepticus in Critically Ill Patients. Neurol Clin 2008; 26:385-408, viii. [DOI: 10.1016/j.ncl.2008.03.017] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Abstract
This chapter discusses the anatomy, functions, and biochemistry of cerebrospinal fluid (CSF). CSF has four major functions: physical support of neural structures, excretion and “sink” action, intracerebral transport, and control of the chemical environment of the central nervous system. CSF provides a “water jacket” of physical support and buoyancy. The CSF is protective because its volume changes reciprocally with changes in the volume of intracranial contents, particularly blood. Thus, the CSF protects the brain from changes in arterial and central venous pressure associated with posture, respiration, and exertion. Acute or chronic pathological changes in intracranial contents can be accommodated, to a point, by changes in the CSF volume. The direct transfer of brain metabolites into the CSF provides excretory function. This capacity is important because the brain lacks a lymphatic system. The lymphatic function of the CSF is also manifested in the removal of large proteins and cells, such as bacteria or blood cells, by bulk CSF absorption. The “sink” action of the CSF arises from the restricted access of water-soluble substances to the CSF and the low concentration of these solutes in the CSF.
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Abou Khaled KJ, Hirsch LJ. Advances in the management of seizures and status epilepticus in critically ill patients. Crit Care Clin 2007; 22:637-59; abstract viii. [PMID: 17239748 DOI: 10.1016/j.ccc.2006.06.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Seizures and status epilepticus are common in critically ill patients. They can be difficult to recognize because most are non-convulsive and require electroencephalogram monitoring to detect; hence, they are currently underdiagnosed. Early recognition and treatment are essential to obtain maximal response to first-line treatment and to prevent neurologic and systemic sequelae. Anti-seizure medication should be combined with management of the underlying cause and reversal of factors that can lower the seizure threshold, including many medications, fever, hypoxia, and metabolic imbalances. This article discusses specific treatments and specific situations, such as hepatic and renal failure patients and organ transplant patients.
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Affiliation(s)
- Karine J Abou Khaled
- Comprehensive Epilepsy Center, Department of Neurology, Columbia University Neurological Institute, New York, NY 10032, USA
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26
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Bösebeck F, Möddel G, Anneken K, Fischera M, Evers S, Ringelstein EB, Kellinghaus C. [Refractory status epilepticus: diagnosis, therapy, course, and prognosis]. DER NERVENARZT 2006; 77:1159-60, 1162-4, 1166-75. [PMID: 16924462 DOI: 10.1007/s00115-006-2125-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Status epilepticus (SE) is a frequent neurological emergency with an annual incidence of 10-20/100,000 individuals. The overall mortality is about 10-20%. Patients present with long-lasting fits or series of epileptic seizures or extended stupor and coma. Furthermore, patients with SE can suffer from a number of systemic complications possibly also due to side effects of the medical treatment. In the beginning, standardized treatment algorithms can successfully stop most SE. A minority of SE cases prove however to be refractory against the initial treatment and require intensified pharmacologic intervention with nonsedating anticonvulsive drugs or anesthetics. In some partial SE, nonpharmacological approaches (e.g., epilepsy surgery) have been used successfully. This paper reviews scientific evidence of the diagnostic approach, therapeutic options, and course of refractory SE, including nonpharmacological treatment.
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Affiliation(s)
- F Bösebeck
- Klinik und Poliklinik für Neurologie, Universitätsklinikum Münster, Albert-Schweitzer-Strasse 33, 48129, Münster.
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27
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Kim JM, Kim YM, Kwon SH. Clinical significance of cerebrospinal fluid pleocytosis in pediatric refractory status epilepticus. KOREAN JOURNAL OF PEDIATRICS 2006. [DOI: 10.3345/kjp.2006.49.10.1086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Jung Mi Kim
- Department of Pediatrics, College of Medicine, Kyungpook National University,Daegu,Korea
| | - Young Mi Kim
- Department of Pediatrics, College of Medicine, Kyungpook National University,Daegu,Korea
| | - Soon Hak Kwon
- Department of Pediatrics, College of Medicine, Kyungpook National University,Daegu,Korea
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Abstract
Status epilepticus (SE) is a life-threatening emergency that requires prompt treatment, including basic neuroresuscitation principles (the ABCs), antiepileptic drugs to stop the seizure, and identification of etiology. Symptomatic SE is more common in younger children. Treating the precipitating cause may prevent ongoing neurologic injury and facilitates seizure control. A systematic treatment regimen, planned in advance, is needed, including one for refractory status epilepticus (RSE). Here we emphasize definitions, clinical and electroencephalography stages, early treatment, special circumstances that may require immediate seizure control, and treatment of RSE. Because much clinical research in SE has been done in adults, we indicate the patient population studied.
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Affiliation(s)
- James J Riviello
- Division of Epilepsy and Clinical Neurophysiology, Critical Care Neurology Service, Department of Neurology, Children's Hospital, Harvard Medical School, Boston, MA, USA
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29
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Bush WW, Barr CS, Darrin EW, Shofer FS, Vite CH, Steinberg SA. Results of cerebrospinal fluid analysis, neurologic examination findings, and age at the onset of seizures as predictors for results of magnetic resonance imaging of the brain in dogs examined because of seizures: 115 cases (1992-2000). J Am Vet Med Assoc 2002; 220:781-4. [PMID: 11918271 DOI: 10.2460/javma.2002.220.781] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To determine whether neurologic examination findings, results of CSF analysis, or age at the onset of seizures could be used to predict whether results of magnetic resonance imaging (MRI) would be normal or abnormal in dogs with seizures. DESIGN Retrospective study. ANIMALS 115 dogs. PROCEDURE Information on results of neurologic examination, results of CSF analysis, age at the onset of seizures, and results of MRI was obtained from the medical records. RESULTS Results of MRI were abnormal in 61 dogs and normal in 54. Sensitivity and specificity of neurologic examination alone were 77 (47/61) and 91% (49/54), respectively. Sensitivity and specificity of CSF analysis alone were 79 (48/61) and 69% (37/54), respectively. Results of MRI were abnormal for 12 of 28 (43%) dogs with abnormal CSF analysis results and normal neurologic examination results but for only 2 of 35 (6%) dogs with normal CSF analysis and normal neurologic examination results. Similarly, results of MRI were abnormal for 36 of 37 (97%) dogs with abnormal CSF analysis and abnormal neurologic examination results but for only 11 of 15 (73%) dogs with normal CSF analysis results and abnormal neurologic examination results. Age at the onset of seizures (< 6 vs > or = 6 years old) was not significantly associated with results of MRI. CONCLUSIONS AND CLINICAL RELEVANCE Results suggest that neurologic examination findings and results of CSF analysis are useful in predicting whether results of MRI will be abnormal in dogs examined because of seizures, but age at the onset of seizures is not.
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Affiliation(s)
- William W Bush
- Department of Neurology, Veterinary Hospital of the University of Pennsylvania, Philadelphia 19104, USA
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Peltola J, Laaksonen J, Haapala AM, Hurme M, Rainesalo S, Keränen T. Indicators of inflammation after recent tonic-clonic epileptic seizures correlate with plasma interleukin-6 levels. Seizure 2002; 11:44-6. [PMID: 11888259 DOI: 10.1053/seiz.2001.0575] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Cerebrospinal fluid (CSF) and peripheral blood pleocytosis have been observed after epileptic seizures without any evidence of infections, but no systematic studies on the acute phase reaction in such patients have been performed. We have previously reported increased levels of interleukin-6 (IL-6) in patients with recent tonic--clonic seizures. Because IL-6 is a major inducer of the systemic acute phase reaction, we decided to study various indicators of inflammation in the blood as well as their correlation with plasma and CSF IL-6 levels. CSF and blood samples were studied from 37 patients with previously undiagnosed and untreated tonic-clonic seizures without any clinical evidence of systemic or central nervous system infections as well as from 40 controls. The mean peripheral blood and CSF-leukocyte counts were significantly higher in patients compared with controls ( 7.9 x 10(9)vs. 6.1 x 10(9), P= 0.002 and 1.9 x 10(6)vs. 1.1 x 10(6), P= 0.032, respectively). There was some indication of increased concentration of C-reactive protein (CRP) and no difference in haptoglobin levels. There was a significant correlation between plasma but not CSF IL-6 concentration and those of both B-leukocyte count ( r= 0.051, P= 0.009) and CRP ( r= 0.42, P= 0.009). Epileptic seizures provoke a production of cytokines such as IL-6 that may in turn cause an activation of the acute phase reaction. Thus, CSF pleocytosis and increase in some indicators of inflammation should not automatically be attributed to systemic or CNS infections in patients with acute seizures.
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Affiliation(s)
- J Peltola
- Department of Neurology, Tampere University Hospital, Finland.
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Abstract
OBJECTIVES To determine the frequency and characteristics of seizure-induced cerebrospinal fluid (CSF) abnormalities in children and to identify potential alternative causes of these findings. METHODS Consecutive patients (n = 80) who underwent lumbar puncture within 24 hours after a seizure were studied retrospectively. The presence of CSF abnormalities in total leukocytes, polymorphonuclear cells, and protein was determined by using age-specific reference values. Coexisting conditions that could affect CSF findings, such as traumatic lumbar puncture, concurrent neurologic disease, and undiagnosed meningitis, were identified. RESULTS Eighteen of the 80 patients were excluded from the final study group because of the presence of another condition that could alter the CSF. More than 50% of the excluded patients had an abnormal CSF leukocyte count or protein level, including 2 patients with initially undiagnosed meningitis, which was subsequently detected by post-hoc polymerase chain reaction testing. In the remaining 62 patients, postictal pleocytosis was detected in only 3 (5%), and increased protein was detected in only 6 (10%). The maximal postictal pleocytosis and protein level were 8 x 10(6) leukocytes/L (8 leukocytes/mm(3)) and 0.52 g/L (52 mg/dL), respectively. CONCLUSIONS Seizure-induced CSF abnormalities are rare in children, and alternative, often unidentified, disease processes may account for many observed postictal abnormalities. All patients with abnormal CSF after a seizure should be thoroughly evaluated for other causes of the abnormality.
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Affiliation(s)
- M Wong
- Department of Neurology, Washington University School of Medicine, St Louis, Missouri, USA
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32
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Bradford JC, Kyriakedes CG. Evaluation of the patient with seizures: an evidence based approach. Emerg Med Clin North Am 1999; 17:203-20, ix-x. [PMID: 10101347 DOI: 10.1016/s0733-8627(05)70053-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Statistics tell us that as many as 1 in 20 members of the population will suffer a seizure at some point in their lifetime, a figure which becomes even more likely if one lives to the age of 80. Thus, a careful evidence based approach to the patient with seizure is immensely useful to the emergency physician. The authors evaluate current studies on the subject, discuss seizures as they relate to specific patient groups, and, ultimately, make recommendations on this important subject.
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Affiliation(s)
- J C Bradford
- Department of Emergency Medicine, Northeastern Ohio Universities College of Medicine, Rootstown, USA
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Prösch S, Schielke E, Reip A, Meisel H, Volk HD, Einhäupl KM, Krüger DH. Human cytomegalovirus (HCMV) encephalitis in an immunocompetent young person and diagnostic reliability of HCMV DNA PCR using cerebrospinal fluid of nonimmunosuppressed patients. J Clin Microbiol 1998; 36:3636-40. [PMID: 9817887 PMCID: PMC105254 DOI: 10.1128/jcm.36.12.3636-3640.1998] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Human cytomegalovirus (HCMV) encephalitis in adult nonimmunosuppressed patients has rarely been reported. We have diagnosed HCMV encephalitis in an anti-HCMV immunoglobulin G-negative, nonimmunosuppressed young woman by HCMV DNA PCR and virus isolation from cerebrospinal fluid (CSF). At the same time, HCMV antigen and HCMV DNA could be demonstrated in peripheral blood leukocytes, and the virus was isolated in fibroblast cultures. After 22 days of acute illness, the virus disappeared from the CSF. Remarkably, the patient did not generate detectable anti-HCMV antibodies within 5 months after the beginning of illness. To investigate the significance of HCMV DNA detection in CSF, samples of CSF, blood cells, and serum from 35 nonimmunosuppressed patients with various neurological disorders (but no herpes simplex virus central nervous system [CNS] disease) were tested for HCMV DNA, antigen, and antibodies. Eleven of these patients were found to be positive for virus DNA and/or antigen in peripheral blood leukocytes. Additionally, HCMV DNA was detected in the CSF of two patients with noninflammatory CNS diseases. A causative role of HCMV in the CNS diseases of these two patients was not evident. In summary, HCMV DNA amplification from CSF samples is a very suitable method to verify HCMV-associated encephalitis, but it should be taken into consideration that there are few cases of positive PCR with DNA from CSF without any known clinical correlative.
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Affiliation(s)
- S Prösch
- Departments of Medical Virology, Charité Medical School, Humboldt University, D-10098 Berlin, Germany
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34
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Batista MS, Silva DF, Ferraz HB, de Andrade LA. Complex partial seizures and aphasia as initial manifestations of non-ketotic hyperglycemia. Case report. ARQUIVOS DE NEURO-PSIQUIATRIA 1998; 56:296-9. [PMID: 9698744 DOI: 10.1590/s0004-282x1998000200022] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
We describe a case of non-ketotic hyperglycemia (NKH), heralded by complex partial seizures and aphasia of epileptic origin, besides versive and partial motor seizures. This clinical picture was accompanied by left fronto-temporal spikes in the EEG. The seizures were controlled by carbamazepine only after the control of the diabetes. A month later, carbamazepine was discontinued. The patient remained without seizures, with normal language, using only glybenclamide. Complex partial seizures, opposed to simple partial seizures, are rarely described in association to NKH. Epileptic activity localized over language regions can manifest as aphasia.
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Affiliation(s)
- M S Batista
- Escola Paulista de Medicina (EPM)/Universidade Federal de São Paulo (UNIFESP), Brasil
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35
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Ford-Jones EL, MacGregor D, Richardson S, Jamieson F, Blaser S, Artsob H. Acute childhood encephalitis and meningoencephalitis: Diagnosis and management. Paediatr Child Health 1998; 3:33-40. [PMID: 20401194 PMCID: PMC2851260 DOI: 10.1093/pch/3.1.33] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
This paper seeks to discuss the differential diagnosis of childhood encephalitis and to review the course of investigation in a child presenting with encephalopathy, encephalitis and meningoencephalitis. The paper also reviews the current understanding of acute demyelinating encephalomyelitis (ADEM) and presents the crucial therapeutic alternatives in the management of childhood encephalitis, including ADEM and infectious diseases.
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Affiliation(s)
- E Lee Ford-Jones
- Departments of Microbiology, Neurology and Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario and Zoonotic Diseases, National Laboratory for Special Pathogens, Ottawa, Ontario
| | - Daune MacGregor
- Departments of Microbiology, Neurology and Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario and Zoonotic Diseases, National Laboratory for Special Pathogens, Ottawa, Ontario
| | - Susan Richardson
- Departments of Microbiology, Neurology and Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario and Zoonotic Diseases, National Laboratory for Special Pathogens, Ottawa, Ontario
| | - Fran Jamieson
- Departments of Microbiology, Neurology and Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario and Zoonotic Diseases, National Laboratory for Special Pathogens, Ottawa, Ontario
| | - Susan Blaser
- Departments of Microbiology, Neurology and Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario and Zoonotic Diseases, National Laboratory for Special Pathogens, Ottawa, Ontario
| | - Harvey Artsob
- Departments of Microbiology, Neurology and Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario and Zoonotic Diseases, National Laboratory for Special Pathogens, Ottawa, Ontario
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36
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Millichap JG. Pleocytosis after Status Epilepticus. Pediatr Neurol Briefs 1994. [DOI: 10.15844/pedneurbriefs-8-3-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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