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Zhang J, Ling L, Xiang L, Li W, Bao P, Yue W. Clinical features of neuronal intranuclear inclusion disease with seizures: a systematic literature review. Front Neurol 2024; 15:1387399. [PMID: 38707999 PMCID: PMC11069311 DOI: 10.3389/fneur.2024.1387399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Accepted: 04/08/2024] [Indexed: 05/07/2024] Open
Abstract
Background Infant, junior, and adult patients with neuronal intranuclear inclusion disease (NIID) present with various types of seizures. We aimed to conduct a systematic literature review on the clinical characteristics of NIID with seizures to provide novel insight for early diagnosis and treatment and to improve prognosis of these patients. Methods We used keywords to screen articles related to NIID and seizures, and data concerning the clinical characteristics of patients, including demographic features, disease characteristics of the seizures, treatment responses, imaging examinations, and other auxiliary examination results were extracted. Results The included studies comprised 21 patients with NIID with seizures. The most common clinical phenotypes were cognitive impairment (76.20%) and impaired consciousness (57.14%), and generalized onset motor seizures (46.15%) represented the most common type. Compared with infantile and juvenile cases, the use of antiepileptic drugs in adults led to significant seizure control and symptom improvement, in addition to providing a better prognosis. The number of GGC sequence repeats in the NOTCH2NLC gene in six NIID patients with seizures who underwent genetic testing ranged 72-134. Conclusion The most common clinical phenotypes in patients with NIID with seizures were cognitive impairment and consciousness disorders. Patients with NIID presented with various types of seizures, with the most common being generalized onset motor seizures. Adult patients had a better prognosis and were relatively stable. The early diagnosis of NIID with seizures is of great significance for treatment and to improve prognosis.
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Affiliation(s)
- Jinwei Zhang
- Clinical College of Neurology, Neurosurgery and Neurorehabilitation, Tianjin Medical University, Tianjin, China
| | - Ling Ling
- Department of Neurology, Tianjin Huanhu Hospital, Tianjin, China
| | - Lei Xiang
- Department of Neurology, Tianjin Huanhu Hospital, Tianjin, China
| | - Wenxia Li
- Clinical College of Neurology, Neurosurgery and Neurorehabilitation, Tianjin Medical University, Tianjin, China
| | - Pengnan Bao
- Clinical College of Neurology, Neurosurgery and Neurorehabilitation, Tianjin Medical University, Tianjin, China
| | - Wei Yue
- Clinical College of Neurology, Neurosurgery and Neurorehabilitation, Tianjin Medical University, Tianjin, China
- Department of Neurology, Tianjin Huanhu Hospital, Tianjin, China
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Orlandi N, Giovannini G, Cioclu MC, Biagioli N, Madrassi L, Vaudano AE, Pugnaghi M, Lattanzi S, Meletti S. Remote seizures and drug-resistant epilepsy after a first status epilepticus in adults. Eur J Neurol 2024; 31:e16177. [PMID: 38258477 DOI: 10.1111/ene.16177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Revised: 11/21/2023] [Accepted: 11/23/2023] [Indexed: 01/24/2024]
Abstract
BACKGROUND AND PURPOSE Long-term consequences after status epilepticus (SE) represent an unsettled issue. We investigated the incidence of remote unprovoked seizures (RS) and drug-resistant epilepsy (DRE) in a cohort of first-ever SE survivors. METHODS A retrospective, observational, and monocentric study was conducted on adult patients (age ≥ 14 years) with first SE who were consecutively admitted to the Modena Academic Hospital, Italy (September 2013-March 2022). Kaplan-Meier survival analyses were used to calculate the probability of seizure freedom following the index event, whereas Cox proportional hazard regression models were used to identify outcome predictors. RESULTS A total of 279 patients were included, 57 of whom (20.4%) developed RS (mean follow-up = 32.4 months). Cumulative probability of seizure freedom was 85%, 78%, and 68% respectively at 12 months, 2 years, and 5 years. In 45 of 57 patients (81%), the first relapse occurred within 2 years after SE. The risk of RS was higher in the case of structural brain damage (hazard ratio [HR] = 2.1, 95% confidence interval [CI] = 1.06-4.01), progressive symptomatic etiology (HR = 2.7, 95% CI = 1.44-5.16), and occurrence of nonconvulsive evolution in the semiological sequence of SE (HR = 2.9, 95% CI = 1.37-6.37). Eighteen of 57 patients (32%) developed DRE; the risk was higher in the case of super-refractory (p = 0.006) and non-convulsive SE evolution (p = 0.008). CONCLUSIONS The overall risk of RS was moderate, temporally confined within 2 years after the index event, and driven by specific etiologies and SE semiology. Treatment super-refractoriness and non-convulsive SE evolution were associated with DRE development.
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Affiliation(s)
- Niccolò Orlandi
- Neurology Unit, Ospedale Civile, Azienda Ospedaliera-Universitaria di Modena, Modena, Italy
- Department of Biomedical, Metabolic, and Neural Science, Center for Neuroscience and Neurotechnology, University of Modena and Reggio Emilia, Modena, Italy
| | - Giada Giovannini
- Neurology Unit, Ospedale Civile, Azienda Ospedaliera-Universitaria di Modena, Modena, Italy
| | - Maria Cristina Cioclu
- Department of Biomedical, Metabolic, and Neural Science, Center for Neuroscience and Neurotechnology, University of Modena and Reggio Emilia, Modena, Italy
| | - Niccolò Biagioli
- Neurology Unit, Ospedale Civile, Azienda Ospedaliera-Universitaria di Modena, Modena, Italy
- Department of Biomedical, Metabolic, and Neural Science, Center for Neuroscience and Neurotechnology, University of Modena and Reggio Emilia, Modena, Italy
| | - Laura Madrassi
- Neurology Unit, Ospedale Civile, Azienda Ospedaliera-Universitaria di Modena, Modena, Italy
- Department of Biomedical, Metabolic, and Neural Science, Center for Neuroscience and Neurotechnology, University of Modena and Reggio Emilia, Modena, Italy
| | - Anna Elisabetta Vaudano
- Neurology Unit, Ospedale Civile, Azienda Ospedaliera-Universitaria di Modena, Modena, Italy
- Department of Biomedical, Metabolic, and Neural Science, Center for Neuroscience and Neurotechnology, University of Modena and Reggio Emilia, Modena, Italy
| | - Matteo Pugnaghi
- Neurology Unit, Ospedale Civile, Azienda Ospedaliera-Universitaria di Modena, Modena, Italy
| | - Simona Lattanzi
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Stefano Meletti
- Neurology Unit, Ospedale Civile, Azienda Ospedaliera-Universitaria di Modena, Modena, Italy
- Department of Biomedical, Metabolic, and Neural Science, Center for Neuroscience and Neurotechnology, University of Modena and Reggio Emilia, Modena, Italy
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Lattanzi S, Orlandi N, Giovannini G, Brigo F, Trinka E, Meletti S. The risk of unprovoked seizure occurrence after status epilepticus in adults. Epilepsia 2024; 65:1006-1016. [PMID: 38339985 DOI: 10.1111/epi.17912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Revised: 01/25/2024] [Accepted: 01/25/2024] [Indexed: 02/12/2024]
Abstract
OBJECTIVE Status epilepticus (SE) may lead to long-term consequences. This study evaluated the risk and predictors of seizure occurrence after SE, with a focus on SE due to acute symptomatic etiologies. METHODS Prospectively collected data about adults surviving a first non-hypoxic SE were reviewed. The outcome was the occurrence of unprovoked seizures during the follow-up. Kaplan-Meier survival curve analysis and log-rank test were used to analyze the time to seizure occurrence and determine the statistical significance between etiological groups. Three subcategories within acute etiology were considered according to the presence of the following: (1) structural lesion (acute-primary); (2) brain involvement during systemic disorders (acute-secondary); and (3) drug or alcohol intoxication/withdrawal (acute-toxic). Cox proportional hazards model was adopted to estimate hazard ratios (HRs) with the 95% confidence intervals (CIs). RESULTS Two hundreds fifty-seven individuals were included. Fifty-four subjects (21.0%) developed seizures after a median of 9.9 (interquartile range 4.3-21.7) months after SE. The estimated 1-, 2-, and 5-year rates of seizure occurrence according to acute SE etiologies were 19.4%, 23.4%, and 30.1%, respectively, for acute-primary central nervous system (CNS) pathology; 2.2%, 2.2%, and 8.7%, respectively, for acute-secondary CNS pathology; and 0%, 9.1%, and 9.1%, respectively, for acute-toxic causes. Five-year rates of seizure occurrence for non-acute SE causes were 33.9% for remote, 65.7% for progressive, and 25.9% for unknown etiologies. In multivariate Cox regression model, progressive etiology (adjusted HR [adjHR] 2.27, 95% CI 1.12-4.58), SE with prominent motor phenomena evolving in non-convulsive SE (adjHR 3.17, 95% CI 1.38-7.25), and non-convulsive SE (adjHR 2.38, 95% CI 1.16-4.90) were independently associated with higher hazards of unprovoked seizures. Older people (adjHR .98, 95% CI .96-.99) and people with SE due to acute-secondary CNS pathology (adjHR .18, 95% CI .04-.82) were at decreased risk of seizure occurrence. SIGNIFICANCE SE carries a risk of subsequent seizures. Both the underlying cause and epileptogenic effects of SE are likely to contribute.
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Affiliation(s)
- Simona Lattanzi
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Niccolò Orlandi
- Neurology Unit, OCB Hospital, AOU Modena, Modena, Italy
- Department of Biomedical, Metabolic and Neural Science, Center for Neuroscience and Neurotechnology, University of Modena and Reggio Emilia, Modena, Italy
| | - Giada Giovannini
- Neurology Unit, OCB Hospital, AOU Modena, Modena, Italy
- PhD Program in Clinical and Experimental Medicine, University of Modena and Reggio Emilia, Modena, Italy
| | - Francesco Brigo
- Department of Neuroscience, Biomedicine and Movement Science, University of Verona, Verona, Italy
- Division of Neurology, "Franz Tappeiner" Hospital, Merano, Italy
| | - Eugen Trinka
- Department of Neurology, Neurointensive Care, and Neurorehabilitation, Christian Doppler University Hospital, Paracelsus Medical University, Member of EpiCARE, Salzburg, Austria
- Neuroscience Institute, Center for Cognitive Neuroscience, Christian Doppler University Hospital Salzburg, Salzburg, Austria
- Public Health, Health Services Research and HTA, University for Health Sciences, Medical Informatics and Technology, Hall i.T, Austria
| | - Stefano Meletti
- Neurology Unit, OCB Hospital, AOU Modena, Modena, Italy
- Department of Biomedical, Metabolic and Neural Science, Center for Neuroscience and Neurotechnology, University of Modena and Reggio Emilia, Modena, Italy
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Bosque Varela P, Tabaee Damavandi P, Machegger L, Prüwasser T, Zimmermann G, Oellerer A, Steinbacher J, McCoy M, Pfaff J, Trinka E, Kuchukhidze G. Magnetic resonance imaging fingerprints of status epilepticus: A case-control study. Epilepsia 2024. [PMID: 38507291 DOI: 10.1111/epi.17949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 02/29/2024] [Accepted: 03/01/2024] [Indexed: 03/22/2024]
Abstract
OBJECTIVE Status epilepticus (SE) is frequently associated with peri-ictal magnetic resonance imaging (MRI) abnormalities (PMA). However, the anatomical distribution of these alterations has not been systematically studied. The aim of this study was to assess the localization patterns of PMA in patients with SE. METHODS In this prospective case-control study, we compared the distribution and combinations of diffusion-restricted PMA to diffusion-restricted lesions caused by other neurological conditions. All patients of the SE group and the control group underwent MRI including a diffusion-weighted imaging sequence. Patients with SE were imaged within 48 h after its onset. RESULTS We enrolled 201 patients (51 with SE and 150 controls). The most frequent locations of PMA in SE were cortex (25/51, 49%), followed by hippocampus (20/51, 39%) and pulvinar of thalamus (10/51, 20%). In the control group, the cortex was involved in 80 of 150 (53%), white matter in 53 of 150 (35%), and basal ganglia in 33 of 150 (22%). In the control group, the pulvinar of thalamus was never affected and hippocampal structures were rarely involved (7/150, 5%). Involvement of the pulvinar of thalamus and the hippocampus had high specificity for SE at 100% (95% confidence interval [CI] = 98-100) and 95% (95% CI = 91-98), respectively. The sensitivity, however, was low for both locations (pulvinar of thalamus: 20%, 95% CI = 10-33; hippocampus: 39%, 95% CI = 26-54). SIGNIFICANCE Diffusion-restricted MRI lesions observed in the pulvinar of thalamus and hippocampus are strongly associated with SE. These changes may help physicians in diagnosing SE-related changes on MRI in an acute setting, especially in cases of equivocal clinical and electroencephalographic manifestations of SE.
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Affiliation(s)
- Pilar Bosque Varela
- Department of Neurology, Christian Doppler University Hospital, member of the European Reference Network EpiCARE, Center for Cognitive Neuroscience, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Payam Tabaee Damavandi
- Department of Neurology, Christian Doppler University Hospital, member of the European Reference Network EpiCARE, Center for Cognitive Neuroscience, Paracelsus Medical University of Salzburg, Salzburg, Austria
- Department of Neurology, Fondazione IRCCS San Gerardo dei Tintori, School of Medicine and Surgery, Milan Center for Neuroscience, University of Milano-Bicocca, Monza, Italy
| | - Lukas Machegger
- Department of Neuroradiology, Christian Doppler University Hospital, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Tanja Prüwasser
- Department of Neurology, Christian Doppler University Hospital, member of the European Reference Network EpiCARE, Center for Cognitive Neuroscience, Paracelsus Medical University of Salzburg, Salzburg, Austria
- Department of Mathematics, Paris-Lodron University, Salzburg, Austria
| | - Georg Zimmermann
- Department of Mathematics, Paris-Lodron University, Salzburg, Austria
- Team Biostatistics and Big Medical Data, IDA Lab Salzburg, Paracelsus Medical University, Salzburg, Austria
- Research and Innovation Management, Paracelsus Medical University, Salzburg, Austria
| | - Andreas Oellerer
- Department of Neuroradiology, Christian Doppler University Hospital, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Jürgen Steinbacher
- Department of Neuroradiology, Christian Doppler University Hospital, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Mark McCoy
- Department of Neurology, Christian Doppler University Hospital, member of the European Reference Network EpiCARE, Center for Cognitive Neuroscience, Paracelsus Medical University of Salzburg, Salzburg, Austria
- Neuroscience Institute, Christian Doppler University Hospital, Salzburg, Austria
| | - Johannes Pfaff
- Department of Neuroradiology, Christian Doppler University Hospital, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Eugen Trinka
- Department of Neurology, Christian Doppler University Hospital, member of the European Reference Network EpiCARE, Center for Cognitive Neuroscience, Paracelsus Medical University of Salzburg, Salzburg, Austria
- Neuroscience Institute, Christian Doppler University Hospital, Salzburg, Austria
- Karl Landsteiner Institute for Neurorehabilitation and Space Neurology, Salzburg, Austria
| | - Giorgi Kuchukhidze
- Department of Neurology, Christian Doppler University Hospital, member of the European Reference Network EpiCARE, Center for Cognitive Neuroscience, Paracelsus Medical University of Salzburg, Salzburg, Austria
- Neuroscience Institute, Christian Doppler University Hospital, Salzburg, Austria
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Bonduelle T, Ollivier M, Gradel A, Aupy J. Brain MRI in status epilepticus: Relevance of findings. Rev Neurol (Paris) 2024:S0035-3787(24)00423-5. [PMID: 38472033 DOI: 10.1016/j.neurol.2023.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 12/21/2023] [Accepted: 12/27/2023] [Indexed: 03/14/2024]
Abstract
Status epilepticus (SE) represents one of the most common neurological emergencies, associated with high mortality and an important risk of functional sequelae in survivors. Magnetic resonance imaging (MRI) offers the possibility of early and noninvasive observation of seizure-induced parenchymal disturbances secondary to the epileptic process. In the present review, we propose a descriptive and comprehensive understanding of current knowledge concerning seizure-induced MRI abnormalities in SE, also called peri-ictal MRI abnormalities (PMAs). We then discuss how PMAs, as a noninvasive biomarker, could be helpful to optimize patient prognostication in SE management. Finally, we discuss alternative promising MRI approaches, including arterial spin labeling (ASL), susceptibility-weighted imaging (SWI), dynamic contrast-enhanced (DCE) MRI and dynamic susceptibility contrast (DSC) MRI that could refine our understanding of SE, particularly in non-convulsive form.
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Affiliation(s)
- T Bonduelle
- Department of Clinical Neurosciences, Epilepsy Unit, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France.
| | - M Ollivier
- Department of Neuroimaging, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - A Gradel
- Department of Clinical Neurosciences, Epilepsy Unit, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - J Aupy
- Department of Clinical Neurosciences, Epilepsy Unit, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France; CNRS, IMN, UMR 5293, Université de Bordeaux, Bordeaux, France
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6
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Musto E, Gambardella ML, Perulli M, Quintiliani M, Veredice C, Verdolotti T, Berté G, Leoni C, Onesimo R, Pulitanò SM, Tartaglia M, Zampino G, Contaldo I, Battaglia DI. Status epilepticus in BRAF-related cardio-facio-cutaneous syndrome: Focus on neuroimaging clues to physiopathology. Epilepsia Open 2024; 9:258-267. [PMID: 37943120 PMCID: PMC10839340 DOI: 10.1002/epi4.12864] [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] [Received: 02/05/2023] [Accepted: 11/06/2023] [Indexed: 11/10/2023] Open
Abstract
OBJECTIVE Cardio-facio-cutaneous syndrome (CFC) is a genetic disorder due to variants affecting genes coding key proteins of the Ras/MAPK signaling pathway. Among the different features of CFC, neurological involvement, including cerebral malformations and epilepsy, represents a common and clinically relevant aspect. Status epilepticus (SE) is a recurrent feature, especially in a specific subgroup of CFC patients with developmental and epileptic encephalopathy (DEE) and history of severe pharmacoresistant epilepsy. Here we dissect the features of SE in CFC patients with a particular focus on longitudinal magnetic resonance imaging (MRI) findings to identify clinical-radiological patterns and discuss the underlying physiopathology. METHODS We retrospectively analyzed clinical, electroencephalogram (EEG), and MRI data collected in a single center from a cohort of 23 patients with CFC carrying pathogenic BRAF variants who experienced SE during a 5-year period. RESULTS Seven episodes of SE were documented in 5 CFC patients who underwent EEG and MRI at baseline. MRI was performed during SE/within 72 hours from SE termination in 5/7 events. Acute/early post-ictal MRI findings showed heterogenous abnormalities: restricted diffusion in 2/7, focal area of pcASL perfusion change in 2/7, focal cortical T2/FLAIR hyperintensity in 2/7. Follow-up images were available for 4/7 SE. No acute changes were detected in 2/7 (MRI performed 4 days after SE termination). SIGNIFICANCE Acute focal neuroimaging changes concomitant with ictal EEG focus were present in 5/7 episodes, though with different findings. The heterogeneous patterns suggest different contributing factors, possibly including the presence of focal cortical malformations and autoinflammation. When cytotoxic edema is revealed by MRI, it can be followed by permanent structural damage, as already observed in other genetic conditions. A better understanding of the physiopathology will provide access to targeted treatments allowing to prevent long-term adverse neurological outcome. PLAIN LANGUAGE SUMMARY Cardio-facio-cutaneous syndrome is a genetic disorder that often causes prolonged seizures known as status epilepticus. This study has a focus on electroclinical and neuroimaging patterns in patients with cardio-facio-cutaneous syndrome. During these status epilepticus episodes, we found different abnormal brain imaging patterns in patients, indicating various causes like brain malformations and inflammation. Understanding these patterns could help doctors find specific treatments, protecting cardio-facio-cutaneous syndrome patients from long-term brain damage.
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Affiliation(s)
- Elisa Musto
- Department of Life Sciences and Public HealthUniversità Cattolica del Sacro CuoreRomeItaly
- Neurology, Epilepsy and Movement Disorders, Full member of European Reference Network EpiCAREBambino Gesù Children's Hospital, IRCCSRomeItaly
| | - Maria Luigia Gambardella
- Child Neurology and Psychiatric Unit, Fondazione Policlinico Universitario Agostino GemelliIRCCSRomeItaly
| | - Marco Perulli
- Department of Life Sciences and Public HealthUniversità Cattolica del Sacro CuoreRomeItaly
- Child Neurology and Psychiatric Unit, Fondazione Policlinico Universitario Agostino GemelliIRCCSRomeItaly
| | - Michela Quintiliani
- Child Neurology and Psychiatric Unit, Fondazione Policlinico Universitario Agostino GemelliIRCCSRomeItaly
| | - Chiara Veredice
- Child Neurology and Psychiatric Unit, Fondazione Policlinico Universitario Agostino GemelliIRCCSRomeItaly
| | - Tommaso Verdolotti
- Radiology and Neuroradiology Unit, Fondazione Policlinico Universitario Agostino GemelliIRCCSRomeItaly
| | - Giovanna Berté
- Radiology and Neuroradiology Unit, Fondazione Policlinico Universitario Agostino GemelliIRCCSRomeItaly
| | - Chiara Leoni
- Center for Rare Disease and Congenital Defects, Fondazione Policlinico Universitario Agostino GemelliIRCCSRomeItaly
| | - Roberta Onesimo
- Center for Rare Disease and Congenital Defects, Fondazione Policlinico Universitario Agostino GemelliIRCCSRomeItaly
| | - Silvia Maria Pulitanò
- Pediatric Intensive Care Unit Trauma Center Pediatric, Fondazione Policlinico Universitario Agostino GemelliIRCCSRomeItaly
| | - Marco Tartaglia
- Molecular Genetics and Functional Genomics, Ospedale Pediatrico Bambino GesùIRCCSRomeItaly
| | - Giuseppe Zampino
- Department of Life Sciences and Public HealthUniversità Cattolica del Sacro CuoreRomeItaly
- Center for Rare Disease and Congenital Defects, Fondazione Policlinico Universitario Agostino GemelliIRCCSRomeItaly
| | - Ilaria Contaldo
- Child Neurology and Psychiatric Unit, Fondazione Policlinico Universitario Agostino GemelliIRCCSRomeItaly
| | - Domenica Immacolata Battaglia
- Department of Life Sciences and Public HealthUniversità Cattolica del Sacro CuoreRomeItaly
- Child Neurology and Psychiatric Unit, Fondazione Policlinico Universitario Agostino GemelliIRCCSRomeItaly
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Lee DA, Sohn G, Park KM, Kim SE. Neuroimaging correlation with EEG in status epilepticus. Seizure 2024; 114:106-110. [PMID: 38118284 DOI: 10.1016/j.seizure.2023.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 12/04/2023] [Accepted: 12/12/2023] [Indexed: 12/22/2023] Open
Abstract
PURPOSE This study was to correlate EEG patterns with peri‑ictal perfusion CT abnormality (PCA) or peri‑ictal MR abnormality (PMA) in patients with status epilepticus (SE). METHODS This is a retrospective study done with SE patients from January 2016 to December 2021. We defined the PCA as single or multi-territorial cortical and/or thalamic hyper-perfusion. The PMA was defined as increased signal intensity in multiple brain regions including the cortex and subcortical regions. EEG patterns were categorized into electrographic seizure (ESz)/electroclinical seizure (ECSz), ictal-interictal continuum (IIC), and lateralized periodic discharges (LPDs) per the American Clinical Neurophysiology Society's guideline. We analyzed the association between the patterns of EEG and the presence of PCA or PMA. RESULTS Among 73 patients, 26 % (19/73) showed PCA and 25 % (18/73) demonstrated PMA. The patterns of EEG were as follows; ESz/ECSz in 25 % (18/73), IIC in 34 % (25/73), and LPD in 12 % (9/73). There was a significant correlation between the patterns of EEG and the presence of PMA, but not PCA. 48 % (12/25) had both PMA and PCA whereas 52 % (13/25) showed either PMA (6/25) or PCA (7/25). CONCLUSION Although PCA did not reveal an electro-radiographical correlation, PMA was strongly linked to ESz, ECSz, IIC, and LPD.
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Affiliation(s)
- Dong Ah Lee
- Department of Neurology, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - GyeongMo Sohn
- Department of Neurology, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - Kang Min Park
- Department of Neurology, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - Sung Eun Kim
- Department of Neurology, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea.
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Gaspard N. Magnetic Resonance Imaging in Status Epilepticus: Useful Scrying Board or Expensive Stopwatch? Epilepsy Curr 2023. [DOI: 10.1177/15357597231160608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023] Open
Abstract
[Box: see text]
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9
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Kalamatianos T, Mavrovounis G, Skouras P, Pandis D, Fountas K, Stranjalis G. Medial Pulvinar Stimulation in Temporal Lobe Epilepsy: A Literature Review and a Hypothesis Based on Neuroanatomical Findings. Cureus 2023; 15:e35772. [PMID: 37025746 PMCID: PMC10071339 DOI: 10.7759/cureus.35772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/05/2023] [Indexed: 03/07/2023] Open
Abstract
While bilateral stimulation of the anterior thalamic nuclei remains the only approved deep brain stimulation (DBS) option for focal epilepsy, two additional thalamic targets have been proposed. Earlier work indicated the potential of centromedian thalamic nucleus stimulation with recent findings highlighting the medial pulvinar nucleus. The latter has been shown to exhibit electrophysiological and imaging alterations in patients with partial status epilepticus and temporal lobe epilepsy. On this basis, recent studies have begun assessing the feasibility and efficacy of pulvinar stimulation, with encouraging results on the reduction of seizure frequency and severity. Building on existing neuroanatomical knowledge, indicating that the medial pulvinar is connected to the temporal lobe via the temporopulvinar bundle of Arnold, we hypothesize that this is one of the routes through which medial pulvinar stimulation affects temporal lobe structures. We suggest that further anatomic, imaging, and electrophysiologic studies are warranted to deepen our understanding of the subject and guide future clinical applications.
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Bonduelle T, Ollivier M, Trin K, Thomas B, Daubigney A, Michel V, De Montaudouin M, Marchal C, Aupy J. Association of Peri-ictal MRI Abnormalities With Mortality, Antiseizure Medication Refractoriness, and Morbidity in Status Epilepticus. Neurology 2023; 100:e943-e953. [PMID: 36443013 PMCID: PMC9990431 DOI: 10.1212/wnl.0000000000201599] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 10/06/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Status epilepticus (SE) is a life-threatening emergency requiring a prompt assessment of patient prognosis to guide management. MRI allows the identification of peri-ictal MRI abnormalities (PMAs) and provides insight into brain structural modifications induced by SE. However, little is known about the significance of PMA in SE prognosis. The aim of this study was to determine whether PMAs are associated with an increased mortality in SE and to establish the association between PMA and refractoriness to antiseizure medications, complications encountered, and induced morbidity. METHODS We conducted a retrospective observational cohort study including all eligible consecutive patients over 15 years old and hospitalized with SE at Bordeaux University Hospital (France) between January 2015 and December 2019. The primary end point was in-hospital mortality. A dedicated neuroradiologic reassessment was performed, together with a comprehensive medical review assessing baseline characteristics, in-hospital death, SE characterization, drug refractoriness, and following outcome in survivors. RESULTS Of 307 patients included, 79 (26%) showed PMA related to SE. Demographic, functional status at baseline and median delay between SE onset and MRI examination were similar in the PMA-positive and PMA-negative groups. In-hospital death occurred in 15% (45/307) patients and was significantly higher in the PMA-positive group (27%, 21/79 vs 11%, 24/228; p < 0.001). In multivariate analysis, the presence of PMA (odds ratio [OR] 2.86, 95% CI 1.02-8.18; p = 0.045), together with SE duration (OR 1.01, 95% CI 1.01-1.02; p = 0.007), older age at SE onset (OR 1.05, 95% CI 1.01-1.09; p = 0.013), preexisting ultimately fatal comorbidity (OR 4.01, 95% CI 1.56-10.6; p = 0.004), and acute lesional SE etiology (OR 3.74, 95% CI 1.45-10.2; p = 0.007) were independent predictors associated with in-hospital death. Patients with PMA had a higher risk of refractory SE (71 vs 33%, p < 0.001). Among survivors, delayed-onset epilepsy (40% vs 21%, p = 0.009) occurred more frequently in the PMA-positive group. DISCUSSION PMA-positive cases had a higher mortality rate in the largest cohort so far to assess the prognosis value of PMA in SE. As a noninvasive and easily available tool, PMA represents a promising structural biomarker for developing a personalized approach to prognostication in patients with SE receiving MRI.
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Affiliation(s)
- Thomas Bonduelle
- From the Department of Clinical Neurosciences (T.B., B.T., A.D., V.M., M.D.M., C.M., J.A.), Department of Neuroimaging (M.O.), and Department of Medical Information (K.T.), Centre Hospitalier Universitaire de Bordeaux; and CNRS (J.A.), IMN, UMR 5293, Univ. Bordeaux, France.
| | - Morgan Ollivier
- From the Department of Clinical Neurosciences (T.B., B.T., A.D., V.M., M.D.M., C.M., J.A.), Department of Neuroimaging (M.O.), and Department of Medical Information (K.T.), Centre Hospitalier Universitaire de Bordeaux; and CNRS (J.A.), IMN, UMR 5293, Univ. Bordeaux, France
| | - Kilian Trin
- From the Department of Clinical Neurosciences (T.B., B.T., A.D., V.M., M.D.M., C.M., J.A.), Department of Neuroimaging (M.O.), and Department of Medical Information (K.T.), Centre Hospitalier Universitaire de Bordeaux; and CNRS (J.A.), IMN, UMR 5293, Univ. Bordeaux, France
| | - Benjamin Thomas
- From the Department of Clinical Neurosciences (T.B., B.T., A.D., V.M., M.D.M., C.M., J.A.), Department of Neuroimaging (M.O.), and Department of Medical Information (K.T.), Centre Hospitalier Universitaire de Bordeaux; and CNRS (J.A.), IMN, UMR 5293, Univ. Bordeaux, France.
| | - Antoine Daubigney
- From the Department of Clinical Neurosciences (T.B., B.T., A.D., V.M., M.D.M., C.M., J.A.), Department of Neuroimaging (M.O.), and Department of Medical Information (K.T.), Centre Hospitalier Universitaire de Bordeaux; and CNRS (J.A.), IMN, UMR 5293, Univ. Bordeaux, France
| | - Veronique Michel
- From the Department of Clinical Neurosciences (T.B., B.T., A.D., V.M., M.D.M., C.M., J.A.), Department of Neuroimaging (M.O.), and Department of Medical Information (K.T.), Centre Hospitalier Universitaire de Bordeaux; and CNRS (J.A.), IMN, UMR 5293, Univ. Bordeaux, France
| | - Marie De Montaudouin
- From the Department of Clinical Neurosciences (T.B., B.T., A.D., V.M., M.D.M., C.M., J.A.), Department of Neuroimaging (M.O.), and Department of Medical Information (K.T.), Centre Hospitalier Universitaire de Bordeaux; and CNRS (J.A.), IMN, UMR 5293, Univ. Bordeaux, France
| | - Cécile Marchal
- From the Department of Clinical Neurosciences (T.B., B.T., A.D., V.M., M.D.M., C.M., J.A.), Department of Neuroimaging (M.O.), and Department of Medical Information (K.T.), Centre Hospitalier Universitaire de Bordeaux; and CNRS (J.A.), IMN, UMR 5293, Univ. Bordeaux, France
| | - Jérôme Aupy
- From the Department of Clinical Neurosciences (T.B., B.T., A.D., V.M., M.D.M., C.M., J.A.), Department of Neuroimaging (M.O.), and Department of Medical Information (K.T.), Centre Hospitalier Universitaire de Bordeaux; and CNRS (J.A.), IMN, UMR 5293, Univ. Bordeaux, France
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11
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Bosque Varela P, Machegger L, Oellerer A, Steinbacher J, McCoy M, Pfaff J, Trinka E, Kuchukhidze G. Imaging of status epilepticus: Making the invisible visible. A prospective study on 206 patients. Epilepsy Behav 2023; 141:109130. [PMID: 36803874 DOI: 10.1016/j.yebeh.2023.109130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 01/29/2023] [Accepted: 01/30/2023] [Indexed: 02/20/2023]
Abstract
BACKGROUND Peri-ictal MRI abnormalities (PMA) frequently affect the cerebral cortex, hippocampus, pulvinar of the thalamus, corpus callosum, and cerebellum. In this prospective study, we aimed to characterize the spectrum of PMA in a large cohort of patients with status epilepticus. METHODS We prospectively recruited 206 patients with SE and an acute MRI. The MRI protocol included diffusion weighted imaging (DWI), fluid-attenuated inversion recovery (FLAIR), arterial spin labeling (ASL), and T1-weighted imaging pre-and post-contrast application. Peri-ictal MRI abnormalities were stratified as either neocortical or non-neocortical. Amygdala, hippocampus, cerebellum, and corpus callosum were regarded as non-neocortical structures. RESULTS Peri-ictal MRI abnormalities were observed in 93/206 (45%) of patients in at least one MRI sequence. Diffusion restriction was observed in 56/206 (27%) of patients, which was mainly unilateral in 42/56 (75%) affecting neocortical structures in 25/56 (45%), non-neocortical structures in 20/56 (36%) and both areas in 11/56 (19%) of patients. Cortical DWI lesions were located mostly in frontal lobes 15/25 (60%); non-neocortical diffusion restriction affected either the pulvinar of the thalamus or hippocampus 29/31 (95%). Alterations in FLAIR were observed in 37/203 (18%) of patients. They were mainly unilateral 24/37 (65%); neocortical 18/37 (49%), non-neocortical 16/37 (43%), or affecting both neocortical and non-neocortical structures 3/37 (8%). In ASL, 51/140 (37%) of patients had ictal hyperperfusion. Hyperperfused areas were located mainly in the neocortex 45/51 (88%) and were unilateral 43/51 (84%). In 39/66 (59%) of patients, PMA were reversible in one week. In 27/66 (41%), the PMA persisted and a second follow-up MRI was performed three weeks later in 24/27 (89%) patients. In 19/24 (79%) PMA were resolved. CONCLUSIONS Almost half of the patients with SE had peri-ictal MRI abnormalities. The most prevalent PMA was ictal hyperperfusion followed by diffusion restriction and FLAIR abnormalities. Neocortex was most frequently affected especially the frontal lobes. The majority of PMAs were unilateral. This paper was presented at the 8th London-Innsbruck Colloquium on Status Epilepticus and Acute Seizures held in September 2022.
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Affiliation(s)
- Pilar Bosque Varela
- Department of Neurology, Christian Doppler University Hospital, Member of the European Reference Network EpiCARE, and Centre for Cognitive Neuroscience, Paracelsus Medical University of Salzburg, Austria
| | - Lukas Machegger
- Department of Neuroradiology, Christian Doppler University Hospital, Paracelsus Medical University of Salzburg, Austria
| | - Andreas Oellerer
- Department of Neuroradiology, Christian Doppler University Hospital, Paracelsus Medical University of Salzburg, Austria
| | - Jürgen Steinbacher
- Department of Neuroradiology, Christian Doppler University Hospital, Paracelsus Medical University of Salzburg, Austria
| | - Mark McCoy
- Department of Neurology, Christian Doppler University Hospital, Member of the European Reference Network EpiCARE, and Centre for Cognitive Neuroscience, Paracelsus Medical University of Salzburg, Austria; Neuroscience Institute, Christian Doppler University Hospital, Salzburg, Austria
| | - Johannes Pfaff
- Department of Neuroradiology, Christian Doppler University Hospital, Paracelsus Medical University of Salzburg, Austria
| | - Eugen Trinka
- Department of Neurology, Christian Doppler University Hospital, Member of the European Reference Network EpiCARE, and Centre for Cognitive Neuroscience, Paracelsus Medical University of Salzburg, Austria; Neuroscience Institute, Christian Doppler University Hospital, Salzburg, Austria; Karl Landsteiner Institute for Neurorehabilitation and Space Neurology, Salzburg, Austria
| | - Giorgi Kuchukhidze
- Department of Neurology, Christian Doppler University Hospital, Member of the European Reference Network EpiCARE, and Centre for Cognitive Neuroscience, Paracelsus Medical University of Salzburg, Austria; Neuroscience Institute, Christian Doppler University Hospital, Salzburg, Austria.
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12
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Cornwall CD, Dahl SM, Nguyen N, Roberg LE, Monsson O, Krøigård T, Beier CP. Association of ictal imaging changes in status epilepticus and neurological deterioration. Epilepsia 2022; 63:2970-2980. [PMID: 36054260 PMCID: PMC9826342 DOI: 10.1111/epi.17404] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 08/10/2022] [Accepted: 08/29/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVE In patients with status epilepticus (SE), the clinical significance of ictal changes on magnetic resonance imaging (MRI) is insufficiently understood. We here studied whether the presence of ictal MRI changes was associated with neurological deterioration at discharge. METHODS The retrospective cohort comprised all identifiable patients treated at Odense University Hospital in the period 2008-2017. All amenable MRIs were systemically screened for ictal changes. Patient demographics, electroencephalography, seizure characteristics, treatment, and SE duration were assessed. Neurological status was estimated before and after SE. The predefined endpoint was the association of neurological deterioration and ictal MRI changes. RESULTS Of 261 eligible patients, 101 received at least one MRI during SE or within 7 days after cessation; 43.6% (44/101) had SE due to non- or less brain-damaging etiologies. Patients who received MRI had a longer duration of SE, less frequently had a history of epilepsy, and were more likely to have SE due to unknown causes. Basic characteristics (including electroencephalographic features defined by the Salzburg criteria) did not differ between patients with (n = 20) and without (n = 81) ictal MRI changes. Timing of MRI was important; postictal changes were rare within the first 24 h and hardly seen >5 days after cessation of SE. Ictal MRI changes were associated with a higher risk of neurological deterioration at discharge irrespective of etiology. Furthermore, they were associated with a longer duration of SE and higher long-term mortality that reached statistical significance in patients with non- or less brain-damaging etiologies. SIGNIFICANCE In this retrospective cohort, ictal changes on MRI were associated with a higher risk of neurological deterioration at discharge and, possibly, with a longer duration of SE and poorer survival.
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Affiliation(s)
| | | | - Nina Nguyen
- Department of RadiologyOdense University HospitalOdenseDenmark
| | | | - Olav Monsson
- Department of NeurologyOdense University HospitalOdenseDenmark
| | - Thomas Krøigård
- Department of NeurologyOdense University HospitalOdenseDenmark,Department of Clinical ResearchUniversity of Southern DenmarkOdenseDenmark
| | - Christoph Patrick Beier
- Department of NeurologyOdense University HospitalOdenseDenmark,Department of Clinical ResearchUniversity of Southern DenmarkOdenseDenmark,Open Patient Data Explorative NetworkOdense University HospitalOdenseDenmark
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13
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Piffer S, Nannoni S, Maulucci F, Beaud V, Rouaud O, Cereda CW, Maeder P, Michel P. Acute neurological disease as a trigger or co-occurrence of transient global amnesia: a case series and systematic review. Neurol Sci 2022; 43:5959-5967. [PMID: 35838848 DOI: 10.1007/s10072-022-06259-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Accepted: 07/05/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Transient global amnesia (TGA) represents a benign neurological syndrome of unknown pathophysiology, often accompanied by vanishing hippocampal punctate lesions on diffusion-weighted imaging (hippocampal punctate diffusion lesion, HPDL). The recent literature suggests that TGA may be triggered by acute neurological conditions. OBJECTIVE To study patients with TGA triggered by an acute neurological disease. METHODS We retrospectively reviewed patients from two neurology centres with TGA (with or without HPDL) in whom an acute neurological condition could be identified as trigger. We also performed a systematic review of the literature of this situation using predefined search terms. RESULTS We identified 38 patients (median age 62 years, 55.3% female): 6 from our centres and 32 from the literature. Acute neurovascular diseases that preceded or were associated with TGA included ischemic and haemorrhagic strokes, convexity subarachnoid haemorrhage, and reversible cerebral vasoconstriction syndrome. As non-vascular acute neurological diseases, we identified migraine and peripheral-origin vertigo. The clinical manifestation of the neurological trigger showed a variable temporal relation with TGA onset; in some cases preceding and in others co-occurring with TGA manifestation. In some cases, presumed neurological triggers were asymptomatic and diagnosed from the neuroimaging done for the TGA. CONCLUSIONS Acute vascular and non-vascular neurological events may trigger TGAs or may occur simultaneously. In the first case, such an acute neurological disease may activate direct pathways within the nervous systems leading to TGA, or alternatively elicit a bodily sympathetic overactivity cascade. In the second case, both neurological events may be the result of a common external stressor.
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Affiliation(s)
- Silvio Piffer
- Stroke Centre and Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.
- Neurology Unit, Department of Emergency, Santa Chiara Hospital, Trento, Italy.
| | - Stefania Nannoni
- Stroke Centre and Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Francesco Maulucci
- Stroke Centre EOC, Neurology Department, Neurocentre of Southern Switzerland (NSI), Ospedale Civico, Lugano, Switzerland
| | - Valérie Beaud
- Neuropsychology and Neurorehabilitation Service, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Olivier Rouaud
- Leenaards Memory Centre, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Carlo W Cereda
- Stroke Centre EOC, Neurology Department, Neurocentre of Southern Switzerland (NSI), Ospedale Civico, Lugano, Switzerland
| | - Philippe Maeder
- Department of Radiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Patrik Michel
- Stroke Centre and Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
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14
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Monsson OS, Roberg LE, Gesche J, Beier CP, Krøigård T. Salzburg consensus criteria are associated with long-term outcome after non-convulsive status epilepticus. Seizure 2022; 99:28-35. [DOI: 10.1016/j.seizure.2022.05.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 05/08/2022] [Accepted: 05/09/2022] [Indexed: 12/12/2022] Open
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15
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Ng YS, Lax NZ, Blain AP, Erskine D, Baker MR, Polvikoski T, Thomas RH, Morris CM, Lai M, Whittaker RG, Gebbels A, Winder A, Hall J, Feeney C, Farrugia ME, Hirst C, Roberts M, Lawthom C, Chrysostomou A, Murphy K, Baird T, Maddison P, Duncan C, Poulton J, Nesbitt V, Hanna MG, Pitceathly RDS, Taylor RW, Blakely EL, Schaefer AM, Turnbull DM, McFarland R, Gorman GS. Forecasting stroke-like episodes and outcomes in mitochondrial disease. Brain 2022; 145:542-554. [PMID: 34927673 PMCID: PMC9014738 DOI: 10.1093/brain/awab353] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 07/16/2021] [Accepted: 08/06/2021] [Indexed: 12/03/2022] Open
Abstract
In this retrospective, multicentre, observational cohort study, we sought to determine the clinical, radiological, EEG, genetics and neuropathological characteristics of mitochondrial stroke-like episodes and to identify associated risk predictors. Between January 1998 and June 2018, we identified 111 patients with genetically determined mitochondrial disease who developed stroke-like episodes. Post-mortem cases of mitochondrial disease (n = 26) were identified from Newcastle Brain Tissue Resource. The primary outcome was to interrogate the clinico-radiopathological correlates and prognostic indicators of stroke-like episode in patients with mitochondrial encephalomyopathy, lactic acidosis and stroke-like episodes syndrome (MELAS). The secondary objective was to develop a multivariable prediction model to forecast stroke-like episode risk. The most common genetic cause of stroke-like episodes was the m.3243A>G variant in MT-TL1 (n = 66), followed by recessive pathogenic POLG variants (n = 22), and 11 other rarer pathogenic mitochondrial DNA variants (n = 23). The age of first stroke-like episode was available for 105 patients [mean (SD) age: 31.8 (16.1)]; a total of 35 patients (32%) presented with their first stroke-like episode ≥40 years of age. The median interval (interquartile range) between first and second stroke-like episodes was 1.33 (2.86) years; 43% of patients developed recurrent stroke-like episodes within 12 months. Clinico-radiological, electrophysiological and neuropathological findings of stroke-like episodes were consistent with the hallmarks of medically refractory epilepsy. Patients with POLG-related stroke-like episodes demonstrated more fulminant disease trajectories than cases of m.3243A>G and other mitochondrial DNA pathogenic variants, in terms of the frequency of refractory status epilepticus, rapidity of progression and overall mortality. In multivariate analysis, baseline factors of body mass index, age-adjusted blood m.3243A>G heteroplasmy, sensorineural hearing loss and serum lactate were significantly associated with risk of stroke-like episodes in patients with the m.3243A>G variant. These factors informed the development of a prediction model to assess the risk of developing stroke-like episodes that demonstrated good overall discrimination (area under the curve = 0.87, 95% CI 0.82-0.93; c-statistic = 0.89). Significant radiological and pathological features of neurodegeneration were more evident in patients harbouring pathogenic mtDNA variants compared with POLG: brain atrophy on cranial MRI (90% versus 44%, P < 0.001) and reduced mean brain weight (SD) [1044 g (148) versus 1304 g (142), P = 0.005]. Our findings highlight the often idiosyncratic clinical, radiological and EEG characteristics of mitochondrial stroke-like episodes. Early recognition of seizures and aggressive instigation of treatment may help circumvent or slow neuronal loss and abate increasing disease burden. The risk-prediction model for the m.3243A>G variant can help inform more tailored genetic counselling and prognostication in routine clinical practice.
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Affiliation(s)
- Yi Shiau Ng
- Wellcome Centre for Mitochondrial Research, Translational and Clinical Research Institute; NIHR Newcastle Biomedical Research Centre and Campus for Ageing and Vitality, Newcastle University, Newcastle upon Tyne NE2 4HH, UK
- Directorate of Neurosciences, Royal Victoria Infirmary, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne NE1 4LP, UK
- Department of Neurosciences, NHS Highly Specialised Service for Rare Mitochondrial Disorders, Newcastle upon Tyne NE2 4HH, UK
| | - Nichola Z Lax
- Wellcome Centre for Mitochondrial Research, Translational and Clinical Research Institute; NIHR Newcastle Biomedical Research Centre and Campus for Ageing and Vitality, Newcastle University, Newcastle upon Tyne NE2 4HH, UK
| | - Alasdair P Blain
- Wellcome Centre for Mitochondrial Research, Translational and Clinical Research Institute; NIHR Newcastle Biomedical Research Centre and Campus for Ageing and Vitality, Newcastle University, Newcastle upon Tyne NE2 4HH, UK
| | - Daniel Erskine
- Wellcome Centre for Mitochondrial Research, Translational and Clinical Research Institute; NIHR Newcastle Biomedical Research Centre and Campus for Ageing and Vitality, Newcastle University, Newcastle upon Tyne NE2 4HH, UK
| | - Mark R Baker
- Directorate of Neurosciences, Royal Victoria Infirmary, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne NE1 4LP, UK
- Campus for Ageing and Vitality, Newcastle Brain Tissue Resource, Newcastle University, Edwardson Building, Newcastle upon Tyne NE4 5PL, UK
| | - Tuomo Polvikoski
- Campus for Ageing and Vitality, Newcastle Brain Tissue Resource, Newcastle University, Edwardson Building, Newcastle upon Tyne NE4 5PL, UK
| | - Rhys H Thomas
- Wellcome Centre for Mitochondrial Research, Translational and Clinical Research Institute; NIHR Newcastle Biomedical Research Centre and Campus for Ageing and Vitality, Newcastle University, Newcastle upon Tyne NE2 4HH, UK
- Directorate of Neurosciences, Royal Victoria Infirmary, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne NE1 4LP, UK
- Department of Neurosciences, NHS Highly Specialised Service for Rare Mitochondrial Disorders, Newcastle upon Tyne NE2 4HH, UK
| | - Christopher M Morris
- Campus for Ageing and Vitality, Newcastle Brain Tissue Resource, Newcastle University, Edwardson Building, Newcastle upon Tyne NE4 5PL, UK
| | - Ming Lai
- Directorate of Neurosciences, Royal Victoria Infirmary, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne NE1 4LP, UK
| | - Roger G Whittaker
- Directorate of Neurosciences, Royal Victoria Infirmary, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne NE1 4LP, UK
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne NE2 4HH, UK
| | - Alasdair Gebbels
- Directorate of Neurosciences, Royal Victoria Infirmary, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne NE1 4LP, UK
| | - Amy Winder
- Directorate of Neurosciences, Royal Victoria Infirmary, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne NE1 4LP, UK
| | - Julie Hall
- Directorate of Neurosciences, Royal Victoria Infirmary, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne NE1 4LP, UK
| | - Catherine Feeney
- Wellcome Centre for Mitochondrial Research, Translational and Clinical Research Institute; NIHR Newcastle Biomedical Research Centre and Campus for Ageing and Vitality, Newcastle University, Newcastle upon Tyne NE2 4HH, UK
- Directorate of Neurosciences, Royal Victoria Infirmary, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne NE1 4LP, UK
- Department of Neurosciences, NHS Highly Specialised Service for Rare Mitochondrial Disorders, Newcastle upon Tyne NE2 4HH, UK
| | - Maria Elena Farrugia
- Institute of Neurological Sciences, Queen Elizabeth University Hospital, Glasgow G51 4TF, UK
| | - Claire Hirst
- Trust Headquarters, One Talbot Gateway, Baglan Energy Park, Baglan, Port Talbot SA12 7BR, UK
| | - Mark Roberts
- Greater Manchester Neuroscience Centre, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Salford M6 8HD, UK
| | - Charlotte Lawthom
- Aneurin Bevan Epilepsy Specialist Team, Aneurin Bevan University Health Board, Newport, NP20 2UB, UK
| | - Alexia Chrysostomou
- Wellcome Centre for Mitochondrial Research, Translational and Clinical Research Institute; NIHR Newcastle Biomedical Research Centre and Campus for Ageing and Vitality, Newcastle University, Newcastle upon Tyne NE2 4HH, UK
| | - Kevin Murphy
- Department of Neurology, Sligo University Hospital, Sligo F91 H684, Ireland
| | - Tracey Baird
- Institute of Neurological Sciences, Queen Elizabeth University Hospital, Glasgow G51 4TF, UK
| | - Paul Maddison
- Department of Neurology, Queen’s Medical Centre, Nottingham NG7 2UH, UK
| | - Callum Duncan
- Department of Neurology, Aberdeen Royal Infirmary, NHS Grampian, Aberdeen AB25 2ZN, UK
| | - Joanna Poulton
- Nuffield Department of Women’s and Reproductive Health, University of Oxford, Oxford OX3 9DU, UK
| | - Victoria Nesbitt
- Department of Paediatrics, Medical Sciences Division, Oxford University, Oxford OX3 9DU, UK
- Department of Paediatrics, The Children's Hospital, Oxford, OX3 9DU, UK
| | - Michael G Hanna
- Department of Neuromuscular Diseases, University College London Queen Square Institute of Neurology and The National Hospital for Neurology and Neurosurgery, London WC1N 3BG, UK
| | - Robert D S Pitceathly
- Department of Neuromuscular Diseases, University College London Queen Square Institute of Neurology and The National Hospital for Neurology and Neurosurgery, London WC1N 3BG, UK
| | - Robert W Taylor
- Wellcome Centre for Mitochondrial Research, Translational and Clinical Research Institute; NIHR Newcastle Biomedical Research Centre and Campus for Ageing and Vitality, Newcastle University, Newcastle upon Tyne NE2 4HH, UK
- Department of Neurosciences, NHS Highly Specialised Service for Rare Mitochondrial Disorders, Newcastle upon Tyne NE2 4HH, UK
| | - Emma L Blakely
- Wellcome Centre for Mitochondrial Research, Translational and Clinical Research Institute; NIHR Newcastle Biomedical Research Centre and Campus for Ageing and Vitality, Newcastle University, Newcastle upon Tyne NE2 4HH, UK
- Department of Neurosciences, NHS Highly Specialised Service for Rare Mitochondrial Disorders, Newcastle upon Tyne NE2 4HH, UK
| | - Andrew M Schaefer
- Wellcome Centre for Mitochondrial Research, Translational and Clinical Research Institute; NIHR Newcastle Biomedical Research Centre and Campus for Ageing and Vitality, Newcastle University, Newcastle upon Tyne NE2 4HH, UK
- Directorate of Neurosciences, Royal Victoria Infirmary, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne NE1 4LP, UK
- Department of Neurosciences, NHS Highly Specialised Service for Rare Mitochondrial Disorders, Newcastle upon Tyne NE2 4HH, UK
| | - Doug M Turnbull
- Wellcome Centre for Mitochondrial Research, Translational and Clinical Research Institute; NIHR Newcastle Biomedical Research Centre and Campus for Ageing and Vitality, Newcastle University, Newcastle upon Tyne NE2 4HH, UK
- Department of Neurosciences, NHS Highly Specialised Service for Rare Mitochondrial Disorders, Newcastle upon Tyne NE2 4HH, UK
| | - Robert McFarland
- Wellcome Centre for Mitochondrial Research, Translational and Clinical Research Institute; NIHR Newcastle Biomedical Research Centre and Campus for Ageing and Vitality, Newcastle University, Newcastle upon Tyne NE2 4HH, UK
- Department of Neurosciences, NHS Highly Specialised Service for Rare Mitochondrial Disorders, Newcastle upon Tyne NE2 4HH, UK
| | - Gráinne S Gorman
- Wellcome Centre for Mitochondrial Research, Translational and Clinical Research Institute; NIHR Newcastle Biomedical Research Centre and Campus for Ageing and Vitality, Newcastle University, Newcastle upon Tyne NE2 4HH, UK
- Directorate of Neurosciences, Royal Victoria Infirmary, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne NE1 4LP, UK
- Department of Neurosciences, NHS Highly Specialised Service for Rare Mitochondrial Disorders, Newcastle upon Tyne NE2 4HH, UK
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Dericioglu N, Volkan B, Gocmen R, Arat A. Lateralized Periodic Discharges in a Patient With Dural Arteriovenous Fistula: SPECT and DWI Studies Suggest They are Ictal. Clin EEG Neurosci 2022; 53:138-142. [PMID: 33900142 DOI: 10.1177/15500594211012352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Lateralized periodic discharges (LPDs) are unilateral electroencephalography (EEG) waveforms, recurring at regular intervals. There has been a long-lasting debate about whether they represent ictal or interictal phenomena. Very few patients in the literature have been investigated with multimodal functional imaging techniques. Here, we present a 58-year-old male patient with symptomatic epilepsy who had cerebral venous sinus thrombosis in the right temporo-parietal area and dural arteriovenous fistula (dAVF) over the left fronto-parietal region. He developed acute speech disturbances and altered mental status after a generalized tonic-clonic seizure. Video-EEG monitoring (VEEGM) demonstrated LPDs over the left fronto-central area, overlapping in part with the dAVF. Diffusion-weighted imaging (DWI) and apparent diffusion coefficient (ADC) sequences revealed restricted diffusion compatible with cytotoxic edema, whereas single-photon emission computed tomography (SPECT) indicated hyperperfusion in the same region, leading to the conclusion that he was having possible nonconvulsive status epilepticus (NCSE). An increase in antiseizure medications led to gradual improvement in clinical status and the disappearance of LPDs.
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Affiliation(s)
- Nese Dericioglu
- 64005Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Bilge Volkan
- 64005Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Rahsan Gocmen
- 64005Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Anil Arat
- 64005Hacettepe University Faculty of Medicine, Ankara, Turkey
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17
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Orlandi N, Giovannini G, Mirandola L, Monti G, Marudi A, Mosca F, Lalla A, d'Orsi G, Francavilla M, Meletti S. An ultra-long new onset refractory status epilepticus: Winning the battle but losing the war? Epilepsy Behav Rep 2022; 18:100537. [PMID: 35445189 PMCID: PMC9014360 DOI: 10.1016/j.ebr.2022.100537] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 03/20/2022] [Accepted: 03/21/2022] [Indexed: 11/29/2022] Open
Abstract
Enduring epileptic seizures can lead to a wide array of neuroradiological and EEG alterations. Even in case of resolution, ultra-long NORSE has severe and disabling consequences. NORSE of unknown etiology is a therapeutic challenge. This case points out the need for disease modifying treatments in NORSE.
New onset refractory status epilepticus (NORSE), is a rare and challenging condition occurring in previously healthy people. The etiology often remains undiscovered and is frequently associated with an unfavorable outcome. We report the electroclinical and neuroradiological evolution of an ultra-long case of NORSE of unknown etiology. A 38-year-old woman with a prodrome of fever, vomiting and diarrhea was admitted to our Intensive Care Unit for refractory convulsive status epilepticus (SE). Her past medical history was unremarkable. Extensive examinations were negative for potential viral, autoimmune and metabolic etiologies. Despite multiple therapeutical attempts with antiseizures medications, anesthetics and immunotherapy, seizures persisted. After nearly 6 months of enduring seizures, SE finally ceased and the patient gradually recovered to a minimum state of awareness. She was then able to communicate through one-word utterances and to understand simple tasks. At a three-years follow-up, she developed multifocal drug-resistant epilepsy, subcortical myoclonus and severe spastic quadraparesis, becoming completely dependent for activities of daily living. To our knowledge, this represents one of the longest cases of NORSE with final status resolution at this time. However, ultra-long SE in this case led to severe and disabling neurological sequelae. Future studies focused on disease modifying treatments for refractory SE are needed.
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Affiliation(s)
- Niccolò Orlandi
- Neurology Unit, OCB Hospital, Azienda Ospedaliera-Universitaria, Modena, Italy
- Department of Biomedical, Metabolic and Neural Science, University of Modena and Reggio Emilia, Modena, Italy
| | - Giada Giovannini
- Neurology Unit, OCB Hospital, Azienda Ospedaliera-Universitaria, Modena, Italy
- PhD Program in Clinical and Experimental Medicine, University of Modena and Reggio Emilia, Modena, Italy
| | - Laura Mirandola
- Department of Biomedical, Metabolic and Neural Science, University of Modena and Reggio Emilia, Modena, Italy
- Neurology Unit, San Giovanni Bosco Hospital, Turin, Italy
| | - Giulia Monti
- Neurology Unit, Ospedale Ramazzini di Carpi, AUSL Modena, Italy
| | - Andrea Marudi
- Intensive Care Unit, OCB Hospital, Azienda Ospedaliera-Universitaria, Modena, Italy
| | - Francesco Mosca
- Intensive Care Unit, OCB Hospital, Azienda Ospedaliera-Universitaria, Modena, Italy
| | - Alessandra Lalla
- Epilepsy Centre – S.C. Neurologia Universitaria, Policlinico Riuniti, Foggia, Italy
| | - Giuseppe d'Orsi
- Neurology Unit, IRCCS Casa Sollievo della Sofferenza, Foggia, Italy
| | | | - Stefano Meletti
- Neurology Unit, OCB Hospital, Azienda Ospedaliera-Universitaria, Modena, Italy
- Department of Biomedical, Metabolic and Neural Science, University of Modena and Reggio Emilia, Modena, Italy
- Corresponding author at: Department of Biomedical, Metabolic, and Neural Sciences, Center for Neurosciences and Neurotechnology, University of Modena and Reggio Emilia, Via Giardini, 1355 – Ospedale Civile S. Agostino Estense, Modena 41126, Italy.
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18
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Maeso C, Sánchez-Masian D, Ródenas S, Font C, Morales C, Domínguez E, Puig J, Arévalo-Serrano J, Montoliu P. Prevalence, distribution, and clinical associations of suspected postictal changes on brain magnetic resonance imaging in epileptic dogs. J Am Vet Med Assoc 2022; 260:71-81. [PMID: 34793322 DOI: 10.2460/javma.21.02.0088] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To determine the prevalence of presumed postictal changes (PC) on brain MRI in epileptic dogs, describe their distribution, and recognize possible correlations with different epilepsy features. ANIMALS 540 client-owned dogs with epilepsy and a complete medical record that underwent brain MRI at 4 veterinary referral hospitals between 2016 and 2019. PROCEDURES Data were collected regarding signalment, seizure type, seizure severity, time between last seizure and MRI, and etiological classification of epilepsy. Postictal changes were considered when solitary or multiple intraparenchymal hyperintense lesions were observed on T2-weighted and fluid-attenuated inversion recovery images and were hypointense or isointense on T1-weighted sequences, which were not confined to a vascular territory and showed no to mild mass effect and no to mild contrast enhancement. RESULTS Sixty-seven dogs (12.4%) showed MRI features consistent with PC. The most common brain sites affected were the piriform lobe, hippocampus, temporal neocortex, and cingulate gyrus. Dogs having suffered cluster seizures or status epilepticus were associated with a higher probability of occurrence of PC, compared to dogs with self-limiting seizures (OR 2.39; 95% confidence interval, 1.33 to 4.30). Suspected PC were detected both in dogs with idiopathic epilepsy and in those with structural epilepsy. Dogs with unknown-origin epilepsy were more likely to have presumed PC than were dogs with structural (OR 0.15; 95% confidence interval, 0.06 to 0.33) or idiopathic epilepsy (OR 0.42; 95% confidence interval, 0.20 to 0.87). Time between last seizure and MRI was significantly shorter in dogs with PC. CLINICAL RELEVANCE MRI lesions consistent with PC were common in epileptic dogs, and the brain distribution of these lesions varied. Occurrence of cluster seizures or status epilepticus, diagnosis of unknown origin epilepsy, and lower time from last seizure to MRI are predictors of suspected PC.
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Affiliation(s)
| | | | | | | | | | | | - Jordi Puig
- Anicura Ars Veterinaria, Barcelona, Spain
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19
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Bartolini E, Valenti R, Sander JW. Hyperosmolar hyperglycaemic state causing atypical status epilepticus with hippocampal involvement. Pract Neurol 2021; 22:117-119. [PMID: 34903674 DOI: 10.1136/practneurol-2021-003222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2021] [Indexed: 11/03/2022]
Abstract
Diabetes mellitus may arise abruptly and decompensate suddenly, leading to a hyperglycaemic hyperosmolar state. Coma often ensues, although this usually reverses after the metabolic abnormalities have resolved. Acute symptomatic seizures can also occur in patients who are conscious, although these usually resolve after osmolarity and glycaemia have normalised. We describe an elderly woman who failed to regain vigilance despite prompt treatment; the cause was an unusual non-convulsive status epilepticus arising from the mesial temporal lobe and promoting a progressive and selective hippocampal involvement. During follow-up, her seizures recurred after stopping antiseizure medication and she developed hippocampal sclerosis, although she subsequently became seizure-free with antiseizure medications. Patients who are unresponsive in a hyperglycaemic hyperosmolar state may be having subclinical epileptiform discharges and risk developing permanent brain damage and long-term epilepsy.
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Affiliation(s)
- Emanuele Bartolini
- Neurology Unit, Nuovo Ospedale Santo Stefano, USL Tuscany Center, Prato, Italy
| | - Raffaella Valenti
- Neurology Unit, Nuovo Ospedale Santo Stefano, USL Tuscany Center, Prato, Italy
| | - Josemir W Sander
- Chalfont Centre for Epilepsy, London, UK.,UCL Queen Square Institute of Neurology, NIHR University College London Hospitals Biomedical Research Centre, London, UK
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20
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Wenner AM, Weitz L, Ostertag K, Hubmer S, Springer E, Stoiser B, Baumgartner C, Riederer F. Human Herpesvirus 6 in the CSF of a Woman With New-Onset Seizures: Encephalitis or Genomic Integration? Neurol Clin Pract 2021; 11:e753-e756. [PMID: 34840899 DOI: 10.1212/cpj.0000000000001024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 10/21/2020] [Indexed: 11/15/2022]
Affiliation(s)
- Allyson M Wenner
- Medical University of Vienna (AMW, LW); Department of Neurology (KO, SH, CB, FR), Hietzing Hospital with Neurological Center Rosenhuegel and Karl Landsteiner Institute for Clinical Epilepsy Research and Cognitive Neurology (KO, SH, CB, FR); Institute of Radiology (ES), and Department of Microbiology (BS), Hietzing Hospital with Neurological Center Rosenhuegel; Medical Faculty (CB), Sigmund Freund Private University, Vienna, Austria; and Department of Neurology (FR), University Hospital Zurich, University of Zurich, Switzerland
| | - Lisa Weitz
- Medical University of Vienna (AMW, LW); Department of Neurology (KO, SH, CB, FR), Hietzing Hospital with Neurological Center Rosenhuegel and Karl Landsteiner Institute for Clinical Epilepsy Research and Cognitive Neurology (KO, SH, CB, FR); Institute of Radiology (ES), and Department of Microbiology (BS), Hietzing Hospital with Neurological Center Rosenhuegel; Medical Faculty (CB), Sigmund Freund Private University, Vienna, Austria; and Department of Neurology (FR), University Hospital Zurich, University of Zurich, Switzerland
| | - Karoline Ostertag
- Medical University of Vienna (AMW, LW); Department of Neurology (KO, SH, CB, FR), Hietzing Hospital with Neurological Center Rosenhuegel and Karl Landsteiner Institute for Clinical Epilepsy Research and Cognitive Neurology (KO, SH, CB, FR); Institute of Radiology (ES), and Department of Microbiology (BS), Hietzing Hospital with Neurological Center Rosenhuegel; Medical Faculty (CB), Sigmund Freund Private University, Vienna, Austria; and Department of Neurology (FR), University Hospital Zurich, University of Zurich, Switzerland
| | - Stefan Hubmer
- Medical University of Vienna (AMW, LW); Department of Neurology (KO, SH, CB, FR), Hietzing Hospital with Neurological Center Rosenhuegel and Karl Landsteiner Institute for Clinical Epilepsy Research and Cognitive Neurology (KO, SH, CB, FR); Institute of Radiology (ES), and Department of Microbiology (BS), Hietzing Hospital with Neurological Center Rosenhuegel; Medical Faculty (CB), Sigmund Freund Private University, Vienna, Austria; and Department of Neurology (FR), University Hospital Zurich, University of Zurich, Switzerland
| | - Elisabeth Springer
- Medical University of Vienna (AMW, LW); Department of Neurology (KO, SH, CB, FR), Hietzing Hospital with Neurological Center Rosenhuegel and Karl Landsteiner Institute for Clinical Epilepsy Research and Cognitive Neurology (KO, SH, CB, FR); Institute of Radiology (ES), and Department of Microbiology (BS), Hietzing Hospital with Neurological Center Rosenhuegel; Medical Faculty (CB), Sigmund Freund Private University, Vienna, Austria; and Department of Neurology (FR), University Hospital Zurich, University of Zurich, Switzerland
| | - Brigitte Stoiser
- Medical University of Vienna (AMW, LW); Department of Neurology (KO, SH, CB, FR), Hietzing Hospital with Neurological Center Rosenhuegel and Karl Landsteiner Institute for Clinical Epilepsy Research and Cognitive Neurology (KO, SH, CB, FR); Institute of Radiology (ES), and Department of Microbiology (BS), Hietzing Hospital with Neurological Center Rosenhuegel; Medical Faculty (CB), Sigmund Freund Private University, Vienna, Austria; and Department of Neurology (FR), University Hospital Zurich, University of Zurich, Switzerland
| | - Christoph Baumgartner
- Medical University of Vienna (AMW, LW); Department of Neurology (KO, SH, CB, FR), Hietzing Hospital with Neurological Center Rosenhuegel and Karl Landsteiner Institute for Clinical Epilepsy Research and Cognitive Neurology (KO, SH, CB, FR); Institute of Radiology (ES), and Department of Microbiology (BS), Hietzing Hospital with Neurological Center Rosenhuegel; Medical Faculty (CB), Sigmund Freund Private University, Vienna, Austria; and Department of Neurology (FR), University Hospital Zurich, University of Zurich, Switzerland
| | - Franz Riederer
- Medical University of Vienna (AMW, LW); Department of Neurology (KO, SH, CB, FR), Hietzing Hospital with Neurological Center Rosenhuegel and Karl Landsteiner Institute for Clinical Epilepsy Research and Cognitive Neurology (KO, SH, CB, FR); Institute of Radiology (ES), and Department of Microbiology (BS), Hietzing Hospital with Neurological Center Rosenhuegel; Medical Faculty (CB), Sigmund Freund Private University, Vienna, Austria; and Department of Neurology (FR), University Hospital Zurich, University of Zurich, Switzerland
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21
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Mangiardi M, Anticoli S, Bertaccini L, Cozzolino V, Pezzella FR. Acute Onset Focal Epilepsy Mimicking Stroke. Cureus 2021; 13:e18600. [PMID: 34786219 PMCID: PMC8577821 DOI: 10.7759/cureus.18600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/08/2021] [Indexed: 11/17/2022] Open
Abstract
A wide range of acute neurological disorders may present with symptoms similar to a stroke, so-called 'stroke mimics'. Migraine aura and seizures account for the most extensive stroke mimics population. A large number of patients with a definite stroke mimics diagnosis (most commonly those with psychiatric disorders or seizures) had been treated with IV alteplase without adverse related events. We report a case of a man aged 70 years admitted to the emergency room because of acute onset of delirium and a loss of strength in the left arm (National Institutes of Health Stroke Scale {NIHSS}: 10), severe hyponatremia (127 mEq/L), and no evidence of intracranial arterial occlusion at CT scan. He was eligible for intravenous thrombolysis and, after treatment, neurological symptoms improved (NIHSS: 2). The subsequent appearance of “clonus” in the left lower limb, the persistence of hyponatremia, and the presence of electroencephalogram (EEG) abnormalities led to the clinical suspicion of focal motor-onset seizure with impaired awareness. The patient was treated successfully with anti-seizure medications (ASMs): lacosamide 200 mg IV during the acute setting care, followed by oral lacosamide 200 mg bis in die (BID). Since two other focal seizures occurred, brivaracetam 25 mg BID has been added in therapy with subsequent clinical discontinuance and EEG normalization. Two consecutive magnetic resonance imaging (MRI) examinations showed several cortical lesions restricted in high signal in diffusion‐weighted imaging (DWI) which corresponding to T2‐weighted and fluid‐attenuated inversion recovery (FLAIR) hyperintensities, but without lesions evidence in apparent diffusion coefficient (ADC) map. These radiological changes disappeared at a follow-up MRI performed 20 days after the symptoms’ onset. The patient fully recovered was discharged home without developing pharmacological adverse events. In this case, MRI provided an opportunity for early identification of seizure-related alterations. Hence, we discuss how prospective MRI studies during seizures and interictal period would contribute to defining the relationship between the electroclinical characteristics and MRI alteration patterns, and therefore, the potential role of MRI in the differential diagnosis between seizures and stroke mimic.
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Affiliation(s)
| | - Sabrina Anticoli
- Stroke Unit, Azienda Ospedaliera San Camillo Forlanini, Rome, ITA
| | - Luca Bertaccini
- Neuroradiology, Azienda Ospedaliera San Camillo Forlanini, Rome, ITA
| | - Valeria Cozzolino
- Neuroradiology, Azienda Ospedaliera San Camillo Forlanini, Rome, ITA
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22
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Sarria-Estrada S, Santamarina E, Quintana M, Pareto D, Sueiras M, Auger C, Toledo M, Rovira A. Magnetic resonance imaging findings in focal-onset status epilepticus. Eur J Neurol 2021; 29:3-11. [PMID: 34390102 DOI: 10.1111/ene.15065] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 06/08/2021] [Accepted: 08/10/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND AND PURPOSE Magnetic resonance imaging (MRI) is commonly used in the diagnostic work-up for status epilepticus (SE). The purpose of this study was to characterize MRI features in SE patients and determine their association with clinical and electroencephalography (EEG) findings. The mid-term consequences of baseline MRI features were also analysed. METHODS This is a prospective study including consecutive patients with SE who underwent brain MRI within 240 h after SE onset. The MRI protocol included T1-weighted (T1WI), T2-weighted (T2W), fluid-attenuated inversion recovery (FLAIR) and diffusion-weighted imaging (DWI) sequences. Follow-up MRI was performed after SE resolution in some patients. RESULTS Sixty patients (56.7% men, mean age 58.3 years) were included. SE-related MRI abnormalities were seen in 31 (51.7%), manifesting as hyperintensities on T2W/FLAIR imaging (58.1%) and DWI (74.2%) sequences. Hippocampal and pulvinar involvement was seen in 58.0% and 25.8% of patients, respectively. MRI abnormalities were associated with a longer SE duration (p = 0.013) and the presence of lateralized periodic discharges (LPDs) on EEG (p < 0.001). Amongst the 33 follow-up MRIs, nine (27.3%) showed mesial temporal sclerosis (MTS), which was associated with severe clinical status (p = 0.031), hippocampal oedema (p = 0.001) and LPDs (p = 0.001) at baseline. A poorer clinical outcome was associated with baseline T2W/FLAIR imaging hyperintensities (p = 0.003). CONCLUSION MRI showed abnormalities in more than half of SE patients. A longer SE duration and LPDs on EEG were associated with SE-related MRI abnormalities and the development of MTS.
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Affiliation(s)
- Silvana Sarria-Estrada
- Neuroradiology Section, Radiology Department, Vall d'Hebron Hospital, Barcelona, Spain.,Vall d'Hebron Research Institute, Neuroradiology Research, Barcelona, Spain.,Department of Medicine, Autonomous University of Barcelona (UAB), Barcelona, Spain
| | - Estevo Santamarina
- Department of Medicine, Autonomous University of Barcelona (UAB), Barcelona, Spain.,Epilepsy Unit, Neurology Department, Vall d'Hebron Hospital, Barcelona, Spain
| | - Manuel Quintana
- Department of Medicine, Autonomous University of Barcelona (UAB), Barcelona, Spain.,Epilepsy Unit, Neurology Department, Vall d'Hebron Hospital, Barcelona, Spain
| | - Deborah Pareto
- Neuroradiology Section, Radiology Department, Vall d'Hebron Hospital, Barcelona, Spain.,Vall d'Hebron Research Institute, Neuroradiology Research, Barcelona, Spain
| | - Maria Sueiras
- EEG Unit, Neurophysiology Department, Vall d'Hebron Hospital, Barcelona, Spain
| | - Cristina Auger
- Neuroradiology Section, Radiology Department, Vall d'Hebron Hospital, Barcelona, Spain
| | - Manuel Toledo
- Epilepsy Unit, Neurology Department, Vall d'Hebron Hospital, Barcelona, Spain
| | - Alex Rovira
- Neuroradiology Section, Radiology Department, Vall d'Hebron Hospital, Barcelona, Spain.,Vall d'Hebron Research Institute, Neuroradiology Research, Barcelona, Spain
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23
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Mariajoseph FP, Muthusamy S, Amukotuwa S, Seneviratne U. Seizure-induced reversible MRI abnormalities in patients with single seizures: a systematic review. Epileptic Disord 2021; 23:552-562. [PMID: 34240708 DOI: 10.1684/epd.2021.1300] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Accepted: 02/24/2021] [Indexed: 11/17/2022]
Abstract
Differentiating seizure-induced reversible MRI abnormalities from MRI changes secondary to underlying cerebral pathologies can be challenging for clinicians in the investigation of seizures. The aim of this study was to delineate the characteristic features of reversible seizure-induced MRI abnormalities. A systematic search of the databases Medline (1946-2020), PubMed (1996-2020), and Embase (1947-2020) was performed in keeping with the Preferred Items Reporting for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. All publications in English, including case reports, of single unprovoked seizure patients with seizure-induced MRI abnormalities demonstrating complete resolution, were included. Two authors extracted data using a predefined template and evaluated the quality of the included studies. MRI data were additionally reviewed by a neuroradiologist. All data were synthesised qualitatively. There were 11 publications altogether, yielding a total of 27 cases that were pertinent to our research question. Abnormalities were most commonly observed on T2-weighted sequences. The most commonly observed constellations of MRI features ("composite pattern") included the following: cortical or subcortical signal change with or without leptomeningeal enhancement, signal abnormality in the splenium of the corpus callosum, and hippocampal signal abnormality. Seizure-induced reversible MRI abnormalities were observed as early as six hours from seizure onset and resolved completely as early as five days from seizure onset. A key limitation of this systematic review was the variability and incomplete reporting of clinical data, especially with regards to seizure semiology and MRI sequences performed, which may have limited our ability to make more definitive conclusions. Seizure-induced reversible MRI changes may appear within hours of seizure onset and resolve within a variable time frame, ranging from days to weeks. Bilateral seizure-induced reversible MRI abnormalities tend to be associated with generalised seizures while unilateral seizure-induced reversible MRI abnormalities may be associated with focal seizures, usually ipsilateral to the seizure focus.
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Affiliation(s)
- Frederick P Mariajoseph
- School of Clinical Sciences at Monash Health, Department of Medicine, Monash University, Melbourne, Victoria, Australia
| | | | | | - Udaya Seneviratne
- School of Clinical Sciences at Monash Health, Department of Medicine, Monash University, Melbourne, Victoria, Australia, Department of Neurology, Monash Medical Centre, Clayton, Melbourne, Australia, Department of Medicine, St. Vincent's Hospital, University of Melbourne, Melbourne, Australia
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24
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Unterberger I, Trinka E, Ransmayr G, Scherfler C, Bauer G. Epileptic aphasia - A critical appraisal. Epilepsy Behav 2021; 121:108064. [PMID: 34052636 DOI: 10.1016/j.yebeh.2021.108064] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 04/30/2021] [Accepted: 05/10/2021] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Aphasic and other language disturbances occur in patients with epilepsy during and after epileptic seizures. Moreover, the interictal language profile in these patients is heterogeneous, varying from normal language profile to impairment in different language functions. The aim of this paper was to critically review the terms and concepts of ictal language alterations. MATERIAL AND METHOD For this review we performed an extensive literature search on the term "epileptic aphasia" and analyzed the semiology and terminology indicating language-associated seizure symptoms. In addition, we give an overview on EEG, etiology, and brain imaging findings and ictal language disorders. RESULTS In the literature, a plethora of terms indicates language-associated seizure symptoms. Simultaneous Video-EEG monitoring represents the gold standard to correctly classify ictal versus postictal language disturbances and to differentiate aphasic symptoms from speech automatisms. Different rhythmic and periodic EEG patterns associated with ictal language disturbances are recognized. Cerebral magnetic resonance imaging (cMRI) is essential in the diagnosis of seizures and epilepsy. Brain tumors and acute or remote cerebrovascular lesions are the most frequently reported structural etiologies underlying ictal language alterations. However, it has to be recognized that brain imaging may show alterations being the consequence of seizures itself rather than its cause. Functional brain imaging might be informative in patients with inconclusive EEG and MRI findings. Overall, seizure-associated aphasia is reported to have good lateralizing significance. CONCLUSION Various language disturbances are caused by different types of seizures, epilepsies and underlying etiologies. In the clinical context, simultaneous Video-EEG monitoring facilitates precise classification of ictal versus postictal language alterations and differentiation of aphasic symptoms from speech automatisms.
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Affiliation(s)
- Iris Unterberger
- Department of Neurology, Innsbruck Medical University, Innsbruck, Austria.
| | - Eugen Trinka
- Department of Neurology, Christian-Doppler-Klinik, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Gerhard Ransmayr
- Department of Neurology 2, Kepler University Hospital, Linz, Austria
| | | | - Gerhard Bauer
- Department of Neurology, Innsbruck Medical University, Innsbruck, Austria
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25
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El-Wahsh S, Dunkerton S, Ang T, Winters HS, Delcourt C. Current perspectives on neuroimaging techniques used to identify stroke mimics in clinical practice. Expert Rev Neurother 2021; 21:517-531. [PMID: 33787426 DOI: 10.1080/14737175.2021.1911650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Urgent clinical assessment and brain imaging are essential for differentiating stroke mimics from stroke and to avoid unnecessary initiation of reperfusion and other therapies in stroke mimic patients. AREAS COVERED In this article, the authors will review acute stroke imaging and then the imaging patterns of the most common stroke mimics. The authors have focused our review on brain CT scan, and more specifically CT perfusion, as this is the most commonly available and emerging tool in emergency settings. The authors also provide information on acute brain MRI and MR perfusion. EXPERT OPINION Imaging can contribute to the detection and diagnosis of acute stroke mimics. Knowledge of imaging findings in different stroke mimics can help distinguish these from patients with stroke who require timely reperfusion therapy. CT and MRI perfusion and diffusion-weighted imaging (DWI) MRI are useful imaging modalities for the assessment of acute stroke patients as they provide more accurate information than plain CT scan. Some of these modalities should be available in the emergency setting. The authors recommended CT perfusion as a useful tool for stroke management and differentiation with stroke mimics.
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Affiliation(s)
- Shadi El-Wahsh
- Neurology Department, Royal Prince Alfred Hospital, the University of Sydney, Sydney, New South Wales, Australia.,South Western Sydney Clinical School, University of New South Wales, Sydney, Australia
| | - Sophie Dunkerton
- Neurology Department, Royal Prince Alfred Hospital, the University of Sydney, Sydney, New South Wales, Australia
| | - Timothy Ang
- Neurology Department, Royal Prince Alfred Hospital, the University of Sydney, Sydney, New South Wales, Australia
| | - Hugh Stephen Winters
- Neurology Department, Royal Prince Alfred Hospital, the University of Sydney, Sydney, New South Wales, Australia
| | - Candice Delcourt
- The George Institute for Global Health, The University of New South Wales, Sydney, Australia.,Department of Clinical Medicine, Faculty of Medicine, Health and Human Sciences, Macquarie University, Macquarie Park, New South Wales, Australia
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26
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Lee JJ, Park JM, Kang K, Kwon O, Lee WW, Kim BK. Three Cases of Aphasic Status Epilepticus: Clinical and Electrographic Characteristics. CLINICAL MEDICINE INSIGHTS-CASE REPORTS 2021; 14:11795476211009241. [PMID: 33953631 PMCID: PMC8042546 DOI: 10.1177/11795476211009241] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 03/20/2021] [Indexed: 11/23/2022]
Abstract
Aphasic status epilepticus (ASE) is unusual and has clinical characteristics similar to those of other disorders. Herein, we report 3 cases of ASE. A left-handed man (patient 1) showed continuous aphasia after the administration of flumazenil. He had underlying alcoholic liver cirrhosis and traumatic brain lesions in the right hemisphere. Electroencephalography (EEG) revealed periodic epileptiform discharges in the right frontotemporal area, which were intervened by rhythmic activity with spatiotemporal evolutions. A right-handed woman (patient 2) showed recurrent aphasia. Blood tests revealed a high blood glucose level (546 mg/dL) and high serum osmolality (309 mMol/L). Her EEG showed rhythmic activity in the left frontotemporal area with spatiotemporal evolutions on a normal background rhythm. She became seizure-free after the administration of an antiepileptic drug and strict glucose regulation. A right-handed woman (patient 3) developed subacute aphasia a week before hospital admission. She had a gradual decline of cognition 1 year before. Her EEG showed intermittent quasi-rhythmic fast activity in the frontotemporal area bilaterally, with fluctuating frequency and amplitude. The patient became seizure-free after the administration of an antiepileptic drug. Brain single-photon emission tomography performed after seizure control showed decreased perfusion in the left frontotemporal area. After discharge, her cognitive function gradually declined to a severe state of dementia. ASE can be caused by diverse etiologies; it is usually caused by cerebral lesions and less frequently by non-lesional etiologies or degenerative disorders. Adequate treatment of underlying disorders and seizures is critical for curing the symptoms of ASE.
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Affiliation(s)
- Jung-Ju Lee
- Department of Neurology, Nowon Eulji Medical Center, Eulji University, Seoul, Korea
| | - Jong-Moo Park
- Department of Neurology, Uijeongbu Eulji Medical Center, Eulji University, Kyeongkido, Korea
| | - Kyusik Kang
- Department of Neurology, Nowon Eulji Medical Center, Eulji University, Seoul, Korea
| | - Ohyun Kwon
- Department of Neurology, Uijeongbu Eulji Medical Center, Eulji University, Kyeongkido, Korea
| | - Woong-Woo Lee
- Department of Neurology, Nowon Eulji Medical Center, Eulji University, Seoul, Korea
| | - Byung-Kun Kim
- Department of Neurology, Nowon Eulji Medical Center, Eulji University, Seoul, Korea
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[S2k guidelines: status epilepticus in adulthood : Guidelines of the German Society for Neurology]. DER NERVENARZT 2021; 92:1002-1030. [PMID: 33751150 PMCID: PMC8484257 DOI: 10.1007/s00115-020-01036-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Accepted: 11/17/2020] [Indexed: 01/16/2023]
Abstract
This S2k guideline on diagnosis and treatment of status epilepticus (SE) in adults is based on the last published version from 2021. New definitions and evidence were included in the guideline and the clinical pathway. A seizures lasting longer than 5 minutes (or ≥ 2 seizures over more than 5 mins without intermittend recovery to the preictal neurological state. Initial diagnosis should include a cCT or, if possible, an MRI. The EEG is highly relevant for diagnosis and treatment-monitoring of non-convulsive SE and for the exclusion or diagnosis of psychogenic non-epileptic seizures. As the increasing evidence supports the relevance of inflammatory comorbidities (e.g. pneumonia) related clinical chemistry should be obtained and repeated over the course of a SE treatment, and antibiotic therapy initiated if indicated.Treatment is applied on four levels: 1. Initial SE: An adequate dose of benzodiazepine is given i.v., i.m., or i.n.; 2. Benzodiazepine-refractory SE: I.v. drugs of 1st choice are levetiracetam or valproate; 3. Refractory SE (RSE) or 4. Super-refractory SE (SRSE): I.v. propofol or midazolam alone or in combination or thiopental in anaesthetic doses are given. In focal non-convulsive RSE the induction of a therapeutic coma depends on the circumstances and is not mandatory. In SRSE the ketogenic diet should be given. I.v. ketamine or inhalative isoflorane can be considered. In selected cased electroconvulsive therapy or, if a resectable epileptogenic zone can be defined epilepsy surgery can be applied. I.v. allopregnanolone or systemic hypothermia should not be used.
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Ohtomo S, Otsubo H, Arai H, Shimoda Y, Homma Y, Tominaga T. Hyperperfusion in the thalamus on arterial spin labelling indicates non-convulsive status epilepticus. Brain Commun 2020; 3:fcaa223. [PMID: 33501426 PMCID: PMC7811763 DOI: 10.1093/braincomms/fcaa223] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 11/04/2020] [Accepted: 11/24/2020] [Indexed: 12/15/2022] Open
Abstract
Non-convulsive status epilepticus describes the syndrome of unexplained impaired consciousness in critically ill patients. Non-convulsive status epilepticus is very likely to lead to delayed diagnosis and poor outcomes because of the absence of convulsive symptoms. EEG is essential for the diagnosis of non-convulsive status epilepticus to establish the association between periodic discharges and rhythmic delta activity in addition to ictal epileptiform discharges according to the Salzburg criteria. Arterial spin labelling, a type of perfusion MRI, has been applied for rapid and non-invasive evaluation of the ictal state. Ictal cerebral cortical hyperperfusion is the most common finding to demonstrate focal onset seizures. Hyperperfusion of the thalamus on single photon emission computed tomography was found in patients with impaired awareness seizures. We hypothesized that thalamocortical hyperperfusion on arterial spin labelling identifies non-convulsive status epilepticus and such thalamic hyperperfusion specifically associates with periodic/rhythmic discharges producing impaired consciousness without convulsion. We identified 27 patients (17 females; age, 39-91 years) who underwent both arterial spin labelling and EEG within 24 h of suspected non-convulsive status epilepticus. We analysed 28 episodes of suspected non-convulsive status epilepticus and compared hyperperfusion on arterial spin labelling with periodic/rhythmic discharges. We evaluated 21 episodes as a positive diagnosis of non-convulsive status epilepticus according to the Salzburg criteria. We identified periodic discharges in 15 (12 lateralized and 3 bilateral independent) episodes and rhythmic delta activity in 13 (10 lateralized, 1 bilateral independent and 2 generalized) episodes. Arterial spin labelling showed thalamic hyperperfusion in 16 (11 unilateral and 5 bilateral) episodes and cerebral cortical hyperperfusion in 24 (20 unilateral and 4 bilateral) episodes. Thalamic hyperperfusion was significantly associated with non-convulsive status epilepticus (P = 0.0007; sensitivity, 76.2%; specificity, 100%), periodic discharges (P < 0.0001; 93.3%; 84.6%), and rhythmic delta activity (P = 0.0006; 92.3%; 73.3%). Cerebral cortical hyperperfusion was significantly associated with non-convulsive status epilepticus (P = 0.0017; 100%; 57.1%) and periodic discharges (P = 0.0349; 100%; 30.8%), but not with rhythmic delta activity. Thalamocortical hyperperfusion could be a new biomarker of non-convulsive status epilepticus according to the Salzburg criteria in critically ill patients. Specific thalamic hyperexcitability might modulate the periodic discharges and rhythmic delta activity associated with non-convulsive status epilepticus. Impaired consciousness without convulsions could be caused by predominant thalamic hyperperfusion together with cortical hyperperfusion but without ictal epileptiform discharges.
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Affiliation(s)
- Satoru Ohtomo
- Department of Neurosurgery, South Miyagi Medical Center, Shibata-gun, Miyagi, Japan
| | - Hiroshi Otsubo
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Hiroaki Arai
- Department of Neurosurgery, South Miyagi Medical Center, Shibata-gun, Miyagi, Japan
| | - Yoshiteru Shimoda
- Department of Neurosurgery, South Miyagi Medical Center, Shibata-gun, Miyagi, Japan
| | - Yoichiro Homma
- Department of General Internal Medicine, Seirei-Hamamatsu General Hospital, Hamamatsu, Shizuoka, Japan
| | - Teiji Tominaga
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
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Successful treatment of drug-resistant status epilepticus in an adult patient with Mowat-Wilson syndrome: A case report. Epilepsy Behav Rep 2020; 14:100410. [PMID: 33344924 PMCID: PMC7736901 DOI: 10.1016/j.ebr.2020.100410] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 11/11/2020] [Accepted: 11/11/2020] [Indexed: 01/10/2023] Open
Abstract
Some epilepsy associated with Mowat-Wilson syndrome (MWS) is resistant to anti-seizure drugs. Occasionally, determining the best combination of therapeutic anti-seizure drugs for the management of MWS is challenging. In the management of MWS, keeping the patient seizure-free warrants close monitoring. Adult MWS patients may be prone to develop recurrent intractable status epilepticus.
Mowat-Wilson syndrome (MWS) is a rare genetic disorder characterized by intellectual disability, distinctive facial features, epilepsy, and multiple anomalies caused by heterozygous loss-of-function mutations in the zinc finger E-box-binding homeobox-2 gene (ZEB2). Treatment choice is very important as patients with MWS because patients sometimes develop drug-resistant epilepsy. Here, we report the case of a 45-year-old male patient with MWS who developed drug-resistant status epilepticus after a 26-years seizure-free period while taking multiple anti-seizure medications. He showed a characteristic magnetic resonance imaging finding with a focal lesion in his left thalamic pulvinar nucleus, a finding not previously reported in status epilepticus with MWS. We succeeded in controlling seizures in the patient after trying multiple new antiseizure drug combinations. These findings indicate that patients with MWS may develop drug-resistant status epilepticus with age, even after a long-term seizure-free period, which can be managed with anti-seizure medication. Therefore, careful monitoring of seizures is important for the treatment of people with MWS, even in patients who have not experienced seizures for a long time.
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Gao R, Zhang X, Bhekharee AK, Zhang Y. Solitary juxtacortical lesion associated with anti-N-methyl-D-aspartate receptor encephalitis: a case report. BMC Neurol 2020; 20:421. [PMID: 33218312 PMCID: PMC7678186 DOI: 10.1186/s12883-020-01997-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 11/09/2020] [Indexed: 12/02/2022] Open
Abstract
Background Anti-N-methyl-D-aspartate (NMDA) receptor encephalitis is a severe autoimmune encephalitis mediated by anti-NMDA receptor antibodies. Brain MRI manifestations vary and are non-specific. If there are any lesions, they tend to be diffusely or multifocally distributed. Solitary lesion is relatively rare. Case presentation We report a 16-year-old girl who initially presented with focal seizures but developed severe psychiatric and extrapyramidal symptoms later on. Brain MRI revealed a solitary juxtacortical demyelinating lesion in the left frontal lobe. No enhancement was noted. Electroencephalogram captured epileptiform discharges in the same region. NMDAR IgGs were tested positive in the serum and cerebrospinal fluid. Corticosteroid and intravenous IgG were administered and the patient completely recovered. Brain MRI revealed a fainter lesion in the left frontal lobe. Conclusion In very rare instances, anti-NMDA receptor encephalitis can present with a solitary brain lesion. A full panel of antibodies for autoimmune encephalitis is the key leading to the diagnosis.
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Affiliation(s)
- Rupan Gao
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xiang Zhang
- Department of Neurology, Huashan Hospital, Fudan University, No. 12 Mid Urumqi Road, Jin'an District, Shanghai, 200040, China
| | | | - Yue Zhang
- Department of Neurology, Huashan Hospital, Fudan University, No. 12 Mid Urumqi Road, Jin'an District, Shanghai, 200040, China.
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Alkhachroum A, Der-Nigoghossian CA, Rubinos C, Claassen J. Markers in Status Epilepticus Prognosis. J Clin Neurophysiol 2020; 37:422-428. [PMID: 32890064 PMCID: PMC7864547 DOI: 10.1097/wnp.0000000000000761] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Status epilepticus (SE) is a neurologic emergency with high morbidity and mortality. The assessment of a patient's prognosis is crucial in making treatment decisions. In this review, we discuss various markers that have been used to prognosticate SE in terms of recurrence, mortality, and functional outcome. These markers include demographic, clinical, electrophysiological, biochemical, and structural data. The heterogeneity of SE etiology and semiology renders development of prognostic markers challenging. Currently, prognostication in SE is limited to a few clinical scores. Future research should integrate clinical, genetic and epigenetic, metabolic, inflammatory, and structural biomarkers into prognostication models to approach "personalized medicine" in prognostication of outcomes after SE.
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Affiliation(s)
- Ayham Alkhachroum
- Department of Neurology, Columbia University, New York, NY, USA
- Department of Neurology, University of Miami, Miami, FL, USA
| | | | - Clio Rubinos
- Department of Neurology, Columbia University, New York, NY, USA
| | - Jan Claassen
- Department of Neurology, Columbia University, New York, NY, USA
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Kim HJ, Lee SA, Kim HW, Kim SJ, Jeon SB, Koo YS. The timelines of MRI findings related to outcomes in adult patients with new-onset refractory status epilepticus. Epilepsia 2020; 61:1735-1748. [PMID: 32715470 DOI: 10.1111/epi.16620] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 06/25/2020] [Accepted: 06/25/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To identify the timelines of magnetic resonance imaging (MRI) abnormalities and their relationships with the clinical outcomes of patients with new-onset refractory status epilepticus (NORSE). METHODS This retrospective observational study enrolled patients with NORSE who were admitted from March 2008 to July 2018. MRI abnormalities were analyzed visually with the readers blinded to the clinical characteristics of the patients. Poor functional outcome was defined as a Glasgow Outcome Scale score ≤ 3 at discharge. Subsequent pharmacoresistant epilepsy was defined as seizures not controlled by two or more anti-seizure medications 6 months after discharge. RESULTS Among 39 patients with NORSE, 32 (82.1%) exhibited an MRI abnormality. The most common abnormalities were persisting mesial temporal lobe signal abnormality (51.3%); initial diffuse leptomeningeal enhancement within 16 days from seizure onset (15/35, 42.9%); and hippocampal atrophy, which started to appear 26 days after seizure onset (15/26, 57.7%). Only three patients had claustrum abnormalities. Patients with insular involvement had longer treatment delay than those without (24.0 vs 5.5 hours, respectively, P = .02). Duration of status epilepticus (SE) tended to have a linear association with hippocampal atrophy (P = .055). Patients with diffuse leptomeningeal enhancement were more likely to have a poor functional outcome and to develop subsequent pharmacoresistant epilepsy than those without this finding (93.3% vs 15.0%, P < .001; 75.0% vs 22.2%, P = .004, respectively); the results were significant even after adjusting for age, sex, and duration of SE. Hippocampal atrophy and diffuse cortical atrophy were also significantly associated with poor functional outcomes (P = .001 and P = .002, respectively), and patients with these conditions were more likely to develop subsequent pharmacoresistant epilepsy than those without these conditions, after adjusting for age and sex (P = .035 and P = .048, respectively), but not after adjusting for duration of SE. SIGNIFICANCE Initial diffuse leptomeningeal enhancement and later hippocampal atrophy were associated with a poor functional outcome and subsequent pharmacoresistant epilepsy.
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Affiliation(s)
- Hyo Jae Kim
- Department of Neurology, Asan Medical Center, Seoul, South Korea
| | - Sang-Ahm Lee
- Department of Neurology, Asan Medical Center, Seoul, South Korea
| | - Hyun-Woo Kim
- Department of Neurology, Pusan National University Yangsan Hospital, Yangsan, South Korea
| | - Soo Jeong Kim
- Department of Neurology, Asan Medical Center, Seoul, South Korea
| | - Sang-Beom Jeon
- Department of Neurology, Asan Medical Center, Seoul, South Korea
| | - Yong Seo Koo
- Department of Neurology, Asan Medical Center, Seoul, South Korea
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Yang Y, Zhang S, Duan J, Zhang X, Tang Y. Acute visual impairment as a main presenting symptom of non-convulsive status epilepticus: a case report. BMC Neurol 2020; 20:51. [PMID: 32046682 PMCID: PMC7014744 DOI: 10.1186/s12883-020-1630-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 01/29/2020] [Indexed: 11/26/2022] Open
Abstract
Background Nonconvulsive status epilepticus (NCSE) is a state of ongoing seizure activity without convulsions. The heterogeneous and subtle clinical features of NCSE make diagnosis and treatment challenging. Here, we report a patient with NCSE who showed a main presenting symptom of acute visual impairment, which is a rare and atypical clinical symptom of NCSE. Case presentation A 62-year-old man was admitted to the neurology department after complaining of an inability to see in the right eye for 2 days and progressive headache. He had a history of poststroke epilepsy and vascular dementia. Physical examination revealed right visual field hemianopia, visual neglect and cognitive impairment. T2 and diffusion-weighted magnetic resonance imaging showed high signal intensity in the left temporal, parietal and occipital lobes. Electroencephalography monitoring was performed, which found continuous sharp wave discharges, especially in the regions of the left temporal, parietal and occipital lobes. These findings were most consistent with the diagnosis of NCSE. Thus, a treatment of intravenous pumping of diazepam and an oral antiepileptic drug was added immediately. After that, the visual loss in the patient recovered quickly, and electroencephalography did not find epileptiform waves. On day 11, a follow-up MRI was performed, which showed that the abnormal signals of the left temporal, parietal and occipital lobes were markedly attenuated, and the patient returned to his premorbid state with a modified Rankin Scale score of 3. Conclusions Acute visual impairment can be seen in NCSE, and it can be reversed by administering effective antiepileptic treatment. Meanwhile, transient peri-ictal MRI abnormalities can be observed in NCSE.
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Affiliation(s)
- Yi Yang
- Department of Neurology, Mianyang Central Hospital, Changjia Alley 12#, Fucheng district, Mianyang City, 621000, Sichuan, China
| | - Shunyuan Zhang
- Department of Radiology, Mianyang Central Hospital, Mianyang City, China
| | - Jinfeng Duan
- Department of Neurology, Mianyang Central Hospital, Changjia Alley 12#, Fucheng district, Mianyang City, 621000, Sichuan, China
| | - Xianwen Zhang
- Department of Neurology, Mianyang Central Hospital, Changjia Alley 12#, Fucheng district, Mianyang City, 621000, Sichuan, China
| | - Yufeng Tang
- Department of Neurology, Mianyang Central Hospital, Changjia Alley 12#, Fucheng district, Mianyang City, 621000, Sichuan, China.
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Nicholson P, Abdulla S, Alshafai L, Mandell DM, Krings T. Decreased Subcortical T2 FLAIR Signal Associated with Seizures. AJNR Am J Neuroradiol 2019; 41:111-114. [PMID: 31806597 DOI: 10.3174/ajnr.a6328] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 10/02/2019] [Indexed: 11/07/2022]
Abstract
Abnormally decreased T2/T2 FLAIR signal can be seen on brain imaging of patients who are experiencing clinical or subclinical seizures and can be associated with various intracranial pathologies. We identified 29 such patients. The abnormal signal was unilateral in 75.9% of patients. It affected various lobes of the brain, but only in the anterior circulation. In 28 patients (96.6%), there was corresponding decreased signal on DWI. The ADC was normal in all cases. In 26 patients (89.7%), there was corresponding low signal on SWI/gradient recalled-echo; 44.8% of patients underwent contrast-enhanced scans, and there was no abnormal enhancement. Twenty-two (75.9%) patients had documented clinical seizures on the day of imaging. The most frequent concomitant pathology was a subdural hematoma. Electroencephalograms obtained within 24 hours of imaging were available in 65.5%. Findings of all of these electroencephalograms were abnormal, and these electroencephalogram changes were either localized to the area of the abnormal MR imaging signal (where the signal was unilateral) or were bilateral (where the MR imaging changes were bilateral). In summary, decreased white matter T2/T2 FLAIR signal changes can be seen in patients with remarkably similar clinical findings (particularly seizures). These changes are often correlated with abnormal electroencephalogram activity localized to the involved lobes.
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Affiliation(s)
- P Nicholson
- From the Division of Neuroradiology, Joint Department of Medical Imaging, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada.
| | - S Abdulla
- From the Division of Neuroradiology, Joint Department of Medical Imaging, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - L Alshafai
- From the Division of Neuroradiology, Joint Department of Medical Imaging, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - D M Mandell
- From the Division of Neuroradiology, Joint Department of Medical Imaging, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - T Krings
- From the Division of Neuroradiology, Joint Department of Medical Imaging, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
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Erbguth F. [Management of refractory and super-refractory status epilepticus]. Med Klin Intensivmed Notfmed 2019; 114:628-634. [PMID: 31463678 DOI: 10.1007/s00063-019-00610-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 07/30/2019] [Accepted: 07/30/2019] [Indexed: 11/30/2022]
Abstract
If status epilepticus continues despite the use of intravenous antiepileptic drugs or narcotics, it is called "refractory" or "super-refractory" status epilepticus (RSE, SRSE). Prolonged seizure activity is associated with neuronal damage, systemic complications and mortality rates of up to 50%, especially in generalized tonic clonic seizure types. In order to terminate the status, several rescue interventions with drugs and other measures are available. However, their evidence base is low because the effectiveness of the measures was almost exclusively derived from case reports and case series. In individual cases, a good outcome is possible even after several months of ongoing SRSE.
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Affiliation(s)
- Frank Erbguth
- Klinik für Neurologie, Klinikum Nürnberg, Paracelsus Medizinische Privatuniversität, Breslauer Str. 201, 90471, Nürnberg, Deutschland.
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Yamanaka H, Hashimoto S, Suenaga T. [Neuronal intranuclear inclusion disease with prolonged impaired consciousness and status epilepticus: a case report]. Rinsho Shinkeigaku 2019; 59:425-430. [PMID: 31243248 DOI: 10.5692/clinicalneurol.cn-001264] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Neuronal intranuclear inclusion disease (NIID) is a neurodegenerative disease presenting with various manifestations including dementia, weakness, transient impaired consciousness, encephalitis-like episodes and also epileptic seizures. However, the nature of epileptic seizures, focal or generalized onset, remains unclear. A man at age 76 was admitted to a local hospital due to febrile impaired consciousness lasting several days. During the hospital stay, a generalized convulsion occurred, and afterward he remained obtunded. He was transferred to our hospital for further treatment. One additional seizure occurred while on an ambulance to our hospital and two additional seizures shortly after the arrival, which indicated convulsive status epilepticus (SE). The ictal EEG showed low amplitude fast activity arising from the left centro-parietal area with an evolutionary pattern. The clinical concomitant was the contralateral versive seizure evolving to a bilateral convulsion. Inter-ictal epileptiform abnormalities seen on the tracings taken on later days consisted of brief potentially ictal rhythmic discharges (B(I)RDs) and frequent sharp waves recorded from both frontal areas. These findings along with the ictal discharges would indicate a multifocal epileptic disorder in this patient. Diffusion weighted images (DWIs) of this patient showed hyperintensity signals in the cortico-medullary junctions in the bilateral frontal and the left parietal regions. Skin biopsy revealed characteristic intranuclear inclusions, and hence the diagnosis of NIID was made. The regions of epileptic foci on EEG corresponded well to the hyperintensity areas in DWIs, which suggests the cerebral cortices near the DWI hyperintensity could be more hyperactive than other regions. This case report suggests that some of the prolonged impaired consciousness and the encephalitis-like episodes in NIID could be related to epileptic seizures and even non-convulsive SE or a post-ictal twilight state after an unwitnessed convulsion. This issue should be further studied for the appropriate treatment of episodic encephalopathy and epileptic seizures in NIID.
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Meletti S, Monti G, Mirandola L, Vaudano AE, Giovannini G. Neuroimaging of status epilepticus. Epilepsia 2018; 59 Suppl 2:113-119. [PMID: 30160066 DOI: 10.1111/epi.14499] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/12/2017] [Indexed: 12/28/2022]
Abstract
In the past 2 decades we have observed an extensive use of different neuroimaging techniques to evaluate patients with status epilepticus. Magnetic resonance imaging (MRI) in particular may show a broad spectrum of abnormalities that are either the causes or the consequences of sustained epileptic activity. Neuroimaging techniques can offer a contribution both in the clinical management of individual patients, identifying hemodynamic patterns that support the diagnosis, and also in the recognition of periictal reversible or irreversible alterations. For the future it is necessary to develop larger and prospective studies in which imaging techniques and electroencephalography (EEG) recordings are acquired closely to understand which EEG patterns are related to imaging biomarkers of neuronal damage.
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Affiliation(s)
- Stefano Meletti
- Department of Biomedical, Metabolic and Neural Sciences, Center for Neuroscience and Neurotechnology, University of Modena and Reggio Emilia, Modena, Italy.,Department of Neurosciences, OCSAE Hospital, AOU Modena, Modena, Italy
| | - Giulia Monti
- Department of Neurosciences, OCSAE Hospital, AOU Modena, Modena, Italy
| | - Laura Mirandola
- Department of Biomedical, Metabolic and Neural Sciences, Center for Neuroscience and Neurotechnology, University of Modena and Reggio Emilia, Modena, Italy.,Department of Neurosciences, OCSAE Hospital, AOU Modena, Modena, Italy
| | - Anna Elisabetta Vaudano
- Department of Neurosciences, OCSAE Hospital, AOU Modena, Modena, Italy.,Department of Medicine and Surgery, Sleep Medicine Center, University of Parma, Parma, Italy
| | - Giada Giovannini
- Department of Neurosciences, OCSAE Hospital, AOU Modena, Modena, Italy
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