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Erdemir G, Pestana-Knight E, Honomichl R, Thompson NR, Lachhwani D, Kotagal P, Wyllie E, Gupta A, Bingaman WE, Moosa ANV. Surgical candidates in children with epileptic spasms can be selected without invasive monitoring: A report of 70 cases. Epilepsy Res 2021; 176:106731. [PMID: 34339941 DOI: 10.1016/j.eplepsyres.2021.106731] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 07/14/2021] [Accepted: 07/23/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Prior surgical series in children with drug-resistant epileptic spasms have reported use of intracranial EEG monitoring in up to two-third of patients. We report outcome after epilepsy surgery for drug-resistant epileptic spasms in a cohort of children without the use of intracranial EEG monitoring in any of the patients. METHODS Medical records of all consecutive children aged 5 years or under who had epilepsy surgery for epileptic spasms at Cleveland Clinic between 2000 and 2018 were reviewed. Post-operative seizure outcome and predictors of prognosis of seizure outcome were analyzed. RESULTS Seventy children with active epileptic spasms underwent surgical resections during the study period. Mean age at seizure onset was 6.8 (+9.31) months and median age at surgery was 18.5 months. An epileptogenic lesion was identified on brain MRI in all patients; 17 (24%) had bilateral abnormalities. Etiologies included malformations of cortical development (58%), perinatal infarct/encephalomalacia (39%), and tumor (3%). None of the patients had intracranial EEG. Surgical procedures included hemispherectomy (44%), lobectomy/ lesionectomy (33%), and multilobar resections (23%). Twelve children needed repeat surgery; six (50%) became seizure free after the second surgery. At six months follow-up, 73% (51/70) were seizure-free since surgery. At a mean follow-up of 4.7 years, 60% (42/70) had Engel 1 outcome. In those with seizure recurrence, 17 (60%) reported improvement. Shorter epilepsy duration (p = 0.05) and lobar or sub-lobar epileptogenic lesions (p = 0.02) predicted favorable seizure outcome at 6 months after surgery. For long term outcome, patients with bilateral abnormalities on MRI (p = 0.001), and multilobar extent on MRI (p = 0.02) were at higher risk for recurrence. SIGNIFICANCE Children with drug-resistant epileptic spasms secondary to an epileptogenic lesion detected on MRI could be selected for epilepsy surgery without undergoing intracranial EEG monitoring. A surgical selection paradigm without intracranial monitoring may allow early surgery without the risks of invasive monitoring.
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Affiliation(s)
- Gozde Erdemir
- Epilepsy Center, Cleveland Clinic, Cleveland, OH, 44195, United States; Division of Pediatric Neurology, University of Maryland, Baltimore, MD, United States
| | | | - Ryan Honomichl
- Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Nicolas R Thompson
- Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Deepak Lachhwani
- Epilepsy Center, Cleveland Clinic, Cleveland, OH, 44195, United States
| | - Prakash Kotagal
- Epilepsy Center, Cleveland Clinic, Cleveland, OH, 44195, United States
| | - Elaine Wyllie
- Epilepsy Center, Cleveland Clinic, Cleveland, OH, 44195, United States
| | - Ajay Gupta
- Epilepsy Center, Cleveland Clinic, Cleveland, OH, 44195, United States
| | | | - Ahsan N V Moosa
- Epilepsy Center, Cleveland Clinic, Cleveland, OH, 44195, United States.
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Steriade C, Jehi L, Krishnan B, Morita-Sherman M, Moosa ANV, Hantus S, Chauvel P. Perisylvian vulnerability to postencephalitic epilepsy. Clin Neurophysiol 2020; 131:1702-1710. [PMID: 32504929 PMCID: PMC7879563 DOI: 10.1016/j.clinph.2020.04.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 03/31/2020] [Accepted: 04/01/2020] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Postencephalitic epilepsy is often resistant to antiseizure medications, leading to evaluation for epilepsy surgery. Characterizing its localization carries implications for optimal surgical approach. We aimed to determine whether a prior history of encephalitis is associated with specific epileptogenic networks among patients with drug resistant epilepsy undergoing stereotactic EEG (SEEG). METHODS We conducted a retrospective cohort study of drug resistant epilepsy, with and without a prior history of encephalitis. We analyzed SEEG recordings to identify patterns of seizure onset and organization. Seventeen patients with a history of encephalitis (of infectious etiology in two subjects) were identified from a database of patients undergoing SEEG and were compared to seventeen drug-resistant epilepsy controls without a history of encephalitis matched for confounding variables including pre-implantation hypotheses, epilepsy duration, age, and sex. RESULTS Independent bilateral seizures were noted in 65% of the postencephalitic epilepsy cohort. We identified four SEEG-ictal patterns in patients with a prior history of encephalitis: (1) anteromesial temporal onset (24%), (2) anteromesial temporal onset with early spread to the perisylvian region (29%), (3) perisylvian (59%) and (4) synchronized anteromesial temporal and perisylvian (29%) onsets. Patterns 3 and 4, with perisylvian involvement at onset, were unique to the encephalitis group (p = 0.0003 and 0.04 respectively) and exhibited a "patchwork" organization. None of the encephalitis patients vs 5/7 matched controls had Engel I outcome (p = 0.0048). CONCLUSIONS Postencephalitic epilepsies involve anteromesial temporal and perisylvian networks, often in a bilateral independent manner. Unique ictal patterns involving the perisylvian regions was identified in the encephalitis group, but not in the matched control group. SIGNIFICANCE These findings may reflect a selective vulnerability of the perisylvian regions to epilepsy resulting from encephalitis, significantly mitigating the chances of success with SEEG-guided temporal resections.
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Affiliation(s)
- Claude Steriade
- Epilepsy Center, Cleveland Clinic Foundation, Cleveland, OH, USA; New York University Langone Comprehensive Epilepsy Center, New York University, New York, NY, USA.
| | - Lara Jehi
- Epilepsy Center, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Balu Krishnan
- Epilepsy Center, Cleveland Clinic Foundation, Cleveland, OH, USA
| | | | - Ahsan N V Moosa
- Epilepsy Center, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Stephen Hantus
- Epilepsy Center, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Patrick Chauvel
- Epilepsy Center, Cleveland Clinic Foundation, Cleveland, OH, USA
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Morsi A, Maldonado A, Lal D, Moosa ANV, Pestana-Knight E, Bingaman W. Vasospasm Following Hemispherectomy: A Case Report of a Novel Complication. World Neurosurg 2020; 137:357-361. [PMID: 32059966 DOI: 10.1016/j.wneu.2020.02.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2019] [Revised: 02/01/2020] [Accepted: 02/03/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Hemispherectomy has been shown to be successful in treating medically intractable epilepsy, with favorable seizure-free outcomes. However, the procedure is technically challenging with high rates of in-hospital complications. We present a unique case of functional hemispherectomy complicated by diffuse cerebral vasospasm and subsequent death in a patient with COL4A1 gene mutation. CASE DESCRIPTION A 17-year-old boy presented with right hemispheric epilepsy and a previously diagnosed autosomal dominant heterozygous COL4A1 gene mutation (c.4380T>G;p.Cys1460Trp). Functional hemispherectomy was performed without complications. On postoperative day 8, he developed an acute decline in neurologic status requiring urgent intubation for airway protection. Magnetic resonance imaging revealed areas of restricted diffusion throughout bilateral hemispheres that was explained by severe vasospasm and minimal cerebral blood flow seen on cerebral angiography. Intra-arterial calcium channel blocker infusion and balloon angioplasty were attempted without improvement in perfusion. With a worsening clinical picture, he was transitioned to comfort care and died. CONCLUSIONS This is the first report in the literature describing global vasospasm and delayed cerebral ischemia following hemispherectomy in a patient carrying COL4A1 gene mutation. We postulate that his COL4A1 gene mutation might have resulted in this exaggerated vasospasm despite minimal residual postoperative subarachnoid hemorrhage burden. This hypothesis needs to be studied in animal models of this genetic disorder.
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Affiliation(s)
- Amr Morsi
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA.
| | - Andres Maldonado
- Department of Neurosurgery, University of Illinois College of Medicine Peoria, Peoria, Illinois, USA
| | - Dennis Lal
- Genomic Medicine Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Ahsan N V Moosa
- Department of Neurology, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | | | - William Bingaman
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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Abstract
PURPOSE OF REVIEW The treatment of epilepsy in children is highly individualized at each and every major step in the management. This review examines various factors that modify the treatment from the point of initiation of therapy to the decision to stop an antiepileptic drug (AED). RECENT FINDINGS AED therapy leads to seizure freedom in about 70% of all children with epilepsy. AED initiation could be delayed until a second seizure in most children and may be avoided altogether in many children with self-limited childhood focal epilepsies. Three key factors influence the choice of AED: seizure type(s), efficacy of the drug for the seizure type, and the side effect profile of the drug(s). For epileptic spasms, steroids and vigabatrin are the most effective treatment options. For absence seizures, ethosuximide and valproic acid are superior to lamotrigine. For focal seizures, many newer AEDs have favorable side effect profiles with efficacy comparable to older-generation drugs. For generalized epilepsies, valproic acid remains the most effective drug for a broad range of seizure types. Genetic and metabolic etiologies may guide unique treatment choices in some children. After 2 years or more of seizure freedom, if the recurrence risk after AED withdrawal is acceptable, slow weaning of AEDs should be done over the span of 6 weeks or longer. After discontinuation, about 70% of patients remain seizure free, and of those with recurrence, the majority achieve seizure control with restarting an AED. When treatment with two or more AEDs fails, other treatment opportunities for drug-resistant epilepsy, including epilepsy surgery, vagal nerve stimulation, and dietary therapies should be considered. SUMMARY Carefully selected medical therapy guided by seizure type and AED characteristics is effective in more than two-thirds of children with epilepsy.
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McGovern RA, N V Moosa A, Jehi L, Busch R, Ferguson L, Gupta A, Gonzalez-Martinez J, Wyllie E, Najm I, Bingaman WE. Hemispherectomy in adults and adolescents: Seizure and functional outcomes in 47 patients. Epilepsia 2019; 60:2416-2427. [PMID: 31677151 DOI: 10.1111/epi.16378] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 10/09/2019] [Accepted: 10/10/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To examine longitudinal seizure and functional outcomes after hemispherectomy in adults and adolescents. METHODS We reviewed 47 consecutive patients older than 16 years who underwent hemispherectomy between 1996 and 2016 at our center. Clinical, electroencephalographic (EEG), imaging, neuropsychological, surgical, and functional status data were analyzed. RESULTS Thirty-six patients were 18 years or older at surgery; 11 were aged between 16 and 18 years. Brain injury leading to hemispheric epilepsy occurred before 10 years of age in 41 (87%) patients. At a mean follow-up of 5.3 postoperative years (median = 2.9 years), 36 (77%) had Engel class I outcome. Longitudinal outcome analysis showed 84% seizure freedom (Engel IA) at 6 months, 76% at 2 years, and 76% at 5 years and beyond, with stable longitudinal outcomes up to 12 years from surgery. Multivariate analysis demonstrated that acute postoperative seizures and contralateral interictal spikes at 6-month follow-up EEG were associated with seizure recurrence. Patients who could walk unaided preoperatively and had no cerebral peduncle atrophy on brain magnetic resonance imaging were more likely to experience worsening of motor function postoperatively. Otherwise, postoperative ambulatory status and hand function were unchanged. Of the 19 patients who completed neuropsychological testing, 17 demonstrated stable or improved postoperative outcomes. SIGNIFICANCE Hemispherectomy in adults is a safe and effective procedure, with seizure freedom rates and functional outcome similar to those observed in children.
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Affiliation(s)
- Robert A McGovern
- Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota
| | | | - Lara Jehi
- Epilepsy Center, Cleveland Clinic, Cleveland, Ohio
| | - Robyn Busch
- Epilepsy Center, Cleveland Clinic, Cleveland, Ohio
| | | | - Ajay Gupta
- Epilepsy Center, Cleveland Clinic, Cleveland, Ohio
| | | | | | - Imad Najm
- Epilepsy Center, Cleveland Clinic, Cleveland, Ohio
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Wang W, Lin Y, Wang S, Jones S, Prayson R, Moosa ANV, McBride A, Gonzalez-Martinez J, Bingaman W, Najm I, Alexopoulos A, Wang ZI. Voxel-based morphometric magnetic resonance imaging postprocessing in non-lesional pediatric epilepsy patients using pediatric normal databases. Eur J Neurol 2019; 26:969-e71. [PMID: 30685877 DOI: 10.1111/ene.13916] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 01/21/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND PURPOSE Pre-surgical evaluation of pediatric patients with drug-resistant focal epilepsy and negative (non-lesional) magnetic resonance imaging (MRI) is particularly challenging. Focal cortical dysplasia (FCD), a frequent pathological substrate in such setting, may be subtle on MRI and evade detection. The aim of this study was to use voxel-based MRI postprocessing to improve the detection of subtle FCD in pediatric surgical candidates. METHODS A consecutive cohort of pediatric patients undergoing pre-surgical evaluation with a negative MRI by visual analysis was included. MRI postprocessing was performed using a voxel-based morphometric analysis program (MAP) on T1-weighted volumetric MRI, with comparison to an age-specific normal pediatric database. The pertinence of MAP-positive areas was confirmed by surgical outcome and pathology. RESULTS A total of 78 patients were included. Forty-four patients (56%) had positive MAP regions. Complete resection of the MAP-positive regions was positively associated with seizure-free outcome compared with the no/partial resection group (P < 0.001). Patients with no/partial resection of the MAP-positive regions had worse seizure outcomes than the MAP-negative group (P = 0.002). The MAP-positive rate was 100%, 77%, 63% and 40% in the 3-5, 5-10, 10-15 and 15-21 year age groups, respectively. MAP-positive rates were 45% in patients with temporal resection and 63% in patients with extratemporal resection. Complete resection of the MAP-positive regions was positively associated with seizure-free outcome in the extratemporal group (P = 0.001) but not in the temporal group (P = 0.070). CONCLUSION Our data suggest the importance of using MRI postprocessing in the pre-surgical evaluation process of pediatric epilepsy patients with apparently normal MRI.
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Affiliation(s)
- W Wang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China.,Epilepsy Center, Cleveland Clinic Foundation (CCF), Cleveland, OH, USA
| | - Y Lin
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China.,Epilepsy Center, Cleveland Clinic Foundation (CCF), Cleveland, OH, USA
| | - S Wang
- Epilepsy Center, Cleveland Clinic Foundation (CCF), Cleveland, OH, USA.,Epilepsy Center, Second Affiliated Hospital of Zhejiang University, Hangzhou, China
| | - S Jones
- Imaging Institute, CCF, Cleveland, OH, USA
| | - R Prayson
- Department of Anatomic Pathology, CCF, Cleveland, OH, USA
| | - A N V Moosa
- Epilepsy Center, Cleveland Clinic Foundation (CCF), Cleveland, OH, USA
| | - A McBride
- Cleveland Clinic Lerner College of Medicine, CCF, Cleveland, OH, USA
| | | | - W Bingaman
- Department of Neurosurgery, CCF, Cleveland, OH, USA
| | - I Najm
- Epilepsy Center, Cleveland Clinic Foundation (CCF), Cleveland, OH, USA
| | - A Alexopoulos
- Epilepsy Center, Cleveland Clinic Foundation (CCF), Cleveland, OH, USA
| | | | - Z I Wang
- Epilepsy Center, Cleveland Clinic Foundation (CCF), Cleveland, OH, USA
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McGovern RA, Knight EP, Gupta A, Moosa ANV, Wyllie E, Bingaman WE, Gonzalez-Martinez J. Robot-assisted stereoelectroencephalography in children. J Neurosurg Pediatr 2018; 23:288-296. [PMID: 30544342 DOI: 10.3171/2018.7.peds18305] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Accepted: 07/11/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVEThe goal in the study was to describe the clinical outcomes associated with robot-assisted stereoelectroencephalography (SEEG) in children.METHODSThe authors performed a retrospective, single-center study in consecutive children with medically refractory epilepsy who were undergoing robot-assisted SEEG. Kaplan-Meier survival analysis was used to calculate the probability of seizure freedom. Both univariate and multivariate methods were used to analyze the preoperative and operative factors associated with seizure freedom.RESULTSFifty-seven children underwent a total of 64 robot-assisted procedures. The patients' mean age was 12 years, an average of 6.4 antiepileptic drugs (AEDs) per patient had failed prior to implantation, and in 56% of the patients the disease was considered nonlesional. On average, children had 12.4 electrodes placed per implantation, with an implantation time of 9.6 minutes per electrode and a 10-day postoperative stay. SEEG analysis yielded a definable epileptogenic zone in 51 (89%) patients; 42 (74%) patients underwent surgery, half of whom were seizure free at last follow-up, 19.6 months from resection. In a multivariate generalized linear model, resective surgery, older age, and shorter SEEG-related hospital length of stay were associated with seizure freedom. In a Cox proportional hazards model including only the children who underwent resective surgery, older age was the only significant factor associated with seizure freedom. Complications related to bleeding were the major contributors to morbidity. One patient (1.5%) had a symptomatic hemorrhage resulting in a permanent neurological deficit.CONCLUSIONSThe authors report one of the largest pediatric-specific SEEG series demonstrating that the modern surgical management of medically refractory epilepsy in children can lead to seizure freedom in many patients, while also highlighting the challenges posed by this difficult patient population.
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Lin Y, Fang YHD, Wu G, Jones SE, Prayson RA, Moosa ANV, Overmyer M, Bena J, Larvie M, Bingaman W, Gonzalez-Martinez JA, Najm IM, Alexopoulos AV, Wang ZI. Quantitative positron emission tomography-guided magnetic resonance imaging postprocessing in magnetic resonance imaging-negative epilepsies. Epilepsia 2018; 59:1583-1594. [PMID: 29953586 DOI: 10.1111/epi.14474] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/30/2018] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Detection of focal cortical dysplasia (FCD) is of paramount importance in epilepsy presurgical evaluation. Our study aims at utilizing quantitative positron emission tomography (QPET) analysis to complement magnetic resonance imaging (MRI) postprocessing by a morphometric analysis program (MAP) to facilitate automated identification of subtle FCD. METHODS We retrospectively included a consecutive cohort of surgical patients who had a negative preoperative MRI by radiology report. MAP was performed on T1-weighted volumetric sequence and QPET was performed on PET/computed tomographic data, both with comparison to scanner-specific normal databases. Concordance between MAP and QPET was assessed at a lobar level, and the significance of concordant QPET-MAP+ abnormalities was confirmed by postresective seizure outcome and histopathology. QPET thresholds of standard deviations (SDs) of -1, -2, -3, and -4 were evaluated to identify the optimal threshold for QPET-MAP analysis. RESULTS A total of 104 patients were included. When QPET thresholds of SD = -1, -2, and -3 were used, complete resection of the QPET-MAP+ region was significantly associated with seizure-free outcome when compared with the partial resection group (P = 0.023, P < 0.001, P = 0.006) or the no resection group (P = 0.002, P < 0.001, P = 0.001). The SD threshold of -2 showed the best combination of positive rate (55%), sensitivity (0.68), specificity (0.88), positive predictive value (0.88), and negative predictive value (0.69). Surgical pathology of the resected QPET-MAP+ areas revealed mainly FCD type I. Multiple QPET-MAP+ regions were present in 12% of the patients at SD = -2. SIGNIFICANCE Our study demonstrates a practical and effective approach to combine quantitative analyses of functional (QPET) and structural (MAP) imaging data to improve identification of subtle epileptic abnormalities. This approach can be readily adopted by epilepsy centers to improve postresective seizure outcomes for patients without apparent lesions on MRI.
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Affiliation(s)
- Yicong Lin
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China.,Epilepsy Center, Cleveland Clinic, Cleveland, OH, USA
| | - Yu-Hua Dean Fang
- Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan
| | - Guiyun Wu
- Department of Nuclear Medicine, Cleveland Clinic, Cleveland, OH, USA
| | | | | | | | - Margit Overmyer
- Department of Pediatric Neurology, Helsinki University Hospital, Helsinki, Finland
| | - James Bena
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Mykol Larvie
- Department of Nuclear Medicine, Cleveland Clinic, Cleveland, OH, USA.,Imaging Institute, Cleveland Clinic, Cleveland, OH, USA
| | - William Bingaman
- Department of Neurosurgery, Cleveland Clinic, Cleveland, OH, USA
| | | | - Imad M Najm
- Epilepsy Center, Cleveland Clinic, Cleveland, OH, USA
| | | | - Z Irene Wang
- Epilepsy Center, Cleveland Clinic, Cleveland, OH, USA
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Steriade C, Moosa ANV, Hantus S, Prayson RA, Alexopoulos A, Rae-Grant A. Electroclinical features of seizures associated with autoimmune encephalitis. Seizure 2018; 60:198-204. [PMID: 30031297 DOI: 10.1016/j.seizure.2018.06.021] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 06/22/2018] [Accepted: 06/24/2018] [Indexed: 11/18/2022] Open
Abstract
PURPOSE We sought to characterize the electroclinical features of seizures associated with autoimmune encephalitis and their relevance to outcome. METHODS 19 patients with seizures and autoimmune encephalitis were identified from a database of 100 patients (2008-2017) with autoimmune neurological disorders. Clinical and electroclinical characteristics were collected. Persistent seizures at last follow-up were then correlated with electroclinical features. RESULTS Status epilepticus (53%) and early intractability to AEDs (median time to second AED 9.5 days) marked the onset of refractory seizures (median number of AEDs 3). Seizure semiology (abdominal (16%), psychic (42%), olfactory (6%) auras), interictal temporal epileptiform discharges (42%), and ictal onset in the temporal region (63%) mirrored radiologic involvement of the medial temporal regions (on MRI in 74% and/or FDG-PET in 75%). In addition, multimodal auras, with somatosensory (26%), autonomic (26%), gustatory (11%), and visual (16%), features were seen in 82% of patients with focal aware seizures, invoking broader involvement of the perisylvian regions. A change in seizure semiology and EEG findings was often seen. Electroclinical features were similar regardless of antibody type, with the exception of the association of faciobrachial dystonic seizures with LGI1 antibodies. Eight patients had medically intractable seizures at last follow-up and were more likely than patients with seizure remission to have generalized tonic-clonic seizures and temporal lobe involvement on the basis of semiological features, interictal EEG and MRI changes. CONCLUSIONS Seizures associated with autoimmune encephalitis exhibit common electroclinical features which show dynamic evolution over time. We propose a role for the temporo-perisylvian regions in their generation.
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Affiliation(s)
- Claude Steriade
- Epilepsy Center, Cleveland Clinic Foundation, Cleveland, OH, USA.
| | - Ahsan N V Moosa
- Epilepsy Center, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Stephen Hantus
- Epilepsy Center, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Richard A Prayson
- Department of Anatomic Pathology, Cleveland Clinic Foundation, Cleveland, OH, USA
| | | | - Alexander Rae-Grant
- Mellen Center for Multiple Sclerosis, Cleveland Clinic Foundation, Cleveland, OH, USA
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10
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Ristić AJ, Jovanović O, Popadić D, Pađen V, Moosa ANV, Krivokapić A, Parojčić A, Berisavac I, Ilanković A, Baščarević V, Vojvodić N, Sokić D. Does facial attractiveness influence perception of epilepsy diagnosis? An insight into stigma in epilepsy. Epilepsy Behav 2017; 77:1-7. [PMID: 29065282 DOI: 10.1016/j.yebeh.2017.09.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2017] [Revised: 09/16/2017] [Accepted: 09/18/2017] [Indexed: 11/25/2022]
Abstract
BACKGROUND Using a group of young healthy individuals and patients with multiple sclerosis (pMS), we aimed to investigate whether the physical attractiveness judgment affects perception of epilepsy. We tested hypothesis that subjects, in the absence of relevant clues, would catch upon the facial attractiveness when asked to speculate which person suffers epilepsy and select less attractive choices. METHOD Two photo-arrays (7 photos for each gender) selected from the Chicago Face Database (180 neutral faces of Caucasian volunteers with unknown medical status) were shown to study participants. Photos were evenly distributed along a continuum of attractiveness that was estimated by independent raters in prestudy stage. In each photo-array, three photos had rating 1-3 (unattractive), one photo had rating 4 (neutral), and three photos had rating 5-7 (attractive). High-quality printed photo-arrays were presented to test subjects, and they were asked to select one person from each photo-array "who has epilepsy". Finally, all subjects were asked to complete questionnaire of self-esteem and 19-item Scale of stereotypes toward people with epilepsy. RESULTS In total, 71 students of psychology, anthropology, or andragogy (mean age: 21.6±1.7years; female: 85.9%) and 70 pMS (mean age: 37.9±8years; female: 71.4%) were tested. Majority of students or pMS had no previous personal experience with individuals with epilepsy (63.4%; 47.1%, p=0.052). Male photo was selected as epileptic in the following proportions: students - 84.5% unattractive, 8.5% neutral, and 7% attractive; pMS - 62.9% unattractive, 8.6% neutral, and 28.6% attractive (p=0.003). Female photo was selected as epileptic in the following proportions: students - 38% unattractive, 52.1% neutral, and 9.9% attractive; pMS - 32.9% unattractive, 34.3% neutral, and 32.9% attractive (0.003). Both groups showed very low potential for stigmatization: significantly lower in pMS in 10 items. Patients with multiple sclerosis showed significantly higher self-esteem than students (p=0.007). CONCLUSION Facial attractiveness influences the perception of diagnosis of epilepsy. Both students and pMS were less willing to attribute epilepsy to attractive person of both genders.
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Affiliation(s)
- Aleksandar J Ristić
- Center for Epilepsy and Sleep Disorders, Neurology Clinic, Medical School, University of Belgrade, Serbia.
| | - Olja Jovanović
- Department of Psychology, Faculty of Philosophy, University of Belgrade, Serbia
| | - Dragan Popadić
- Department of Psychology, Faculty of Philosophy, University of Belgrade, Serbia
| | - Višnja Pađen
- Center for Epilepsy and Sleep Disorders, Neurology Clinic, Medical School, University of Belgrade, Serbia
| | | | | | - Aleksandra Parojčić
- Center for Epilepsy and Sleep Disorders, Neurology Clinic, Medical School, University of Belgrade, Serbia
| | - Ivana Berisavac
- Center for Epilepsy and Sleep Disorders, Neurology Clinic, Medical School, University of Belgrade, Serbia
| | - Andrej Ilanković
- Clinic for Psychiatry, Medical School, University of Belgrade, Serbia
| | | | - Nikola Vojvodić
- Center for Epilepsy and Sleep Disorders, Neurology Clinic, Medical School, University of Belgrade, Serbia
| | - Dragoslav Sokić
- Center for Epilepsy and Sleep Disorders, Neurology Clinic, Medical School, University of Belgrade, Serbia
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Abstract
Cognitive dysfunction in children with epilepsy is primarily contributed by etiology, seizures, frequency of interictal epileptiform discharges, and adverse effects of antiepileptic drugs. The direct effect of epilepsy surgery on cognitive outcome depends on two key factors: the function that is present in the epileptogenic zone to be removed, and the dysfunction outside the epileptogenic zone caused by epilepsy. Studies on cognitive outcome in children after various types of epilepsy surgery estimate "no significant change" in about 70% of children, improvement in cognition in 10%-15%, and decline in 10%-15%. In young children with epileptic encephalopathy, the reversible dysfunction outside the epileptogenic zone is larger and hence carry better chances of improved outcome after successful surgery. If the epileptogenic zone harbors significant cognitive function (memory, language, or other function), then a decline in function may occur with its resection. Understanding the pathophysiological basis for the cognitive changes after epilepsy surgery assists in counseling patients and families before surgery.
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Affiliation(s)
- Ahsan N V Moosa
- Department of Neurology, Epilepsy Center, Neurological Institute, Cleveland Clinic, Cleveland, OH,.
| | - Elaine Wyllie
- Department of Neurology, Epilepsy Center, Neurological Institute, Cleveland Clinic, Cleveland, OH
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Cho SM, Zeft A, Knight EP, Kotagal P, Wyllie E, Moosa ANV. Refractory status epilepticus secondary to atypical Rasmussen encephalitis successfully managed with aggressive immunotherapy. Neurol Clin Pract 2017; 7:e5-e8. [PMID: 29849226 DOI: 10.1212/cpj.0000000000000261] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Sung-Min Cho
- Epilepsy Center (S-MC, EPK, PK, EW, ANVM), Cleveland Clinic Neurological Institute; and Center for Pediatric Rheumatology and Immunology (AZ), Cleveland Clinic, OH
| | - Andrew Zeft
- Epilepsy Center (S-MC, EPK, PK, EW, ANVM), Cleveland Clinic Neurological Institute; and Center for Pediatric Rheumatology and Immunology (AZ), Cleveland Clinic, OH
| | - Elia Pestana Knight
- Epilepsy Center (S-MC, EPK, PK, EW, ANVM), Cleveland Clinic Neurological Institute; and Center for Pediatric Rheumatology and Immunology (AZ), Cleveland Clinic, OH
| | - Prakash Kotagal
- Epilepsy Center (S-MC, EPK, PK, EW, ANVM), Cleveland Clinic Neurological Institute; and Center for Pediatric Rheumatology and Immunology (AZ), Cleveland Clinic, OH
| | - Elaine Wyllie
- Epilepsy Center (S-MC, EPK, PK, EW, ANVM), Cleveland Clinic Neurological Institute; and Center for Pediatric Rheumatology and Immunology (AZ), Cleveland Clinic, OH
| | - Ahsan N V Moosa
- Epilepsy Center (S-MC, EPK, PK, EW, ANVM), Cleveland Clinic Neurological Institute; and Center for Pediatric Rheumatology and Immunology (AZ), Cleveland Clinic, OH
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13
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Wang ZI, Krishnan B, Shattuck DW, Leahy RM, Moosa ANV, Wyllie E, Burgess RC, Al-Sharif NB, Joshi AA, Alexopoulos AV, Mosher JC, Udayasankar U, Jones SE. Automated MRI Volumetric Analysis in Patients with Rasmussen Syndrome. AJNR Am J Neuroradiol 2016; 37:2348-2355. [PMID: 27609620 DOI: 10.3174/ajnr.a4914] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Accepted: 07/04/2016] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Rasmussen syndrome, also known as Rasmussen encephalitis, is typically associated with volume loss of the affected hemisphere of the brain. Our aim was to apply automated quantitative volumetric MR imaging analyses to patients diagnosed with Rasmussen encephalitis, to determine the predictive value of lobar volumetric measures and to assess regional atrophy differences as well as monitor disease progression by using these measures. MATERIALS AND METHODS Nineteen patients (42 scans) with diagnosed Rasmussen encephalitis were studied. We used 2 control groups: one with 42 age- and sex-matched healthy subjects and the other with 42 epileptic patients without Rasmussen encephalitis with the same disease duration as patients with Rasmussen encephalitis. Volumetric analysis was performed on T1-weighted images by using BrainSuite. Ratios of volumes from the affected hemisphere divided by those from the unaffected hemisphere were used as input to a logistic regression classifier, which was trained to discriminate patients from controls. Using the classifier, we compared the predictive accuracy of all the volumetric measures. These ratios were used to further assess regional atrophy differences and correlate with epilepsy duration. RESULTS Interhemispheric and frontal lobe ratios had the best prediction accuracy for separating patients with Rasmussen encephalitis from healthy controls and patient controls without Rasmussen encephalitis. The insula showed significantly more atrophy compared with all the other cortical regions. Patients with longitudinal scans showed progressive volume loss in the affected hemisphere. Atrophy of the frontal lobe and insula correlated significantly with epilepsy duration. CONCLUSIONS Automated quantitative volumetric analysis provides accurate separation of patients with Rasmussen encephalitis from healthy controls and epileptic patients without Rasmussen encephalitis, and thus may assist the diagnosis of Rasmussen encephalitis. Volumetric analysis could also be included as part of follow-up for patients with Rasmussen encephalitis to assess disease progression.
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Affiliation(s)
- Z I Wang
- From the Epilepsy Center (Z.I.W., B.K., A.N.V.M., E.W., R.C.B., A.V.A., J.C.M.)
| | - B Krishnan
- From the Epilepsy Center (Z.I.W., B.K., A.N.V.M., E.W., R.C.B., A.V.A., J.C.M.)
| | - D W Shattuck
- Ahmanson-Lovelace Brain Mapping Center (D.W.S., N.B.A.-S.), Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - R M Leahy
- Signal and Image Processing Institute (A.A.J., R.M.L.), University of Southern California, Los Angeles, California
| | - A N V Moosa
- From the Epilepsy Center (Z.I.W., B.K., A.N.V.M., E.W., R.C.B., A.V.A., J.C.M.)
| | - E Wyllie
- From the Epilepsy Center (Z.I.W., B.K., A.N.V.M., E.W., R.C.B., A.V.A., J.C.M.)
| | - R C Burgess
- From the Epilepsy Center (Z.I.W., B.K., A.N.V.M., E.W., R.C.B., A.V.A., J.C.M.)
| | - N B Al-Sharif
- Ahmanson-Lovelace Brain Mapping Center (D.W.S., N.B.A.-S.), Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - A A Joshi
- Signal and Image Processing Institute (A.A.J., R.M.L.), University of Southern California, Los Angeles, California
| | - A V Alexopoulos
- From the Epilepsy Center (Z.I.W., B.K., A.N.V.M., E.W., R.C.B., A.V.A., J.C.M.)
| | - J C Mosher
- From the Epilepsy Center (Z.I.W., B.K., A.N.V.M., E.W., R.C.B., A.V.A., J.C.M.)
| | - U Udayasankar
- Department of Radiology (U.U.), University of Arizona College of Medicine, Tucson, Arizona
| | | | - S E Jones
- Imaging Institute (S.E.J.), Cleveland Clinic, Cleveland, Ohio
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Thome U, Klima P, Moosa ANV, Gupta A, Parikh S, Pestana Knight EM. Electrographic status epilepticus in sleep in an adult with cerebral folate deficiency. Neurol Clin Pract 2016; 6:e4-e7. [PMID: 26918205 DOI: 10.1212/cpj.0000000000000199] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Ursula Thome
- Epilepsy Center (UT, PK, ANVM, AG, EMPK) and Pediatric Neurology Section (PS), Cleveland Clinic, Cleveland, OH
| | - Paula Klima
- Epilepsy Center (UT, PK, ANVM, AG, EMPK) and Pediatric Neurology Section (PS), Cleveland Clinic, Cleveland, OH
| | - Ahsan N V Moosa
- Epilepsy Center (UT, PK, ANVM, AG, EMPK) and Pediatric Neurology Section (PS), Cleveland Clinic, Cleveland, OH
| | - Ajay Gupta
- Epilepsy Center (UT, PK, ANVM, AG, EMPK) and Pediatric Neurology Section (PS), Cleveland Clinic, Cleveland, OH
| | - Sumit Parikh
- Epilepsy Center (UT, PK, ANVM, AG, EMPK) and Pediatric Neurology Section (PS), Cleveland Clinic, Cleveland, OH
| | - Elia M Pestana Knight
- Epilepsy Center (UT, PK, ANVM, AG, EMPK) and Pediatric Neurology Section (PS), Cleveland Clinic, Cleveland, OH
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Abstract
BACKGROUND AND PURPOSE Epilepsy surgery for medically refractory epilepsy secondary to cortical dysplasia in children poses special challenges. We aim to review the current available literature on the outcome after epilepsy surgery for cortical dysplasia in children and critically evaluate the prognostic predictors of outcome. METHODS A comprehensive review of the literature was performed focusing on the outcome after epilepsy surgery for cortical dysplasia in children. Two large recent meta-analyses that included children and adults and several pediatric series of cortical dysplasia in children were reviewed. RESULTS AND CONCLUSIONS The overall seizure freedom rates range from 40 to 73 %, at about 2 years after surgery; most studies report 50-55% success rate. Complete resection of the epileptogenic lesion/zone remains the most important variable predictive of postoperative seizure freedom. Features unique to cortical dysplasia that limits our ability to ensure complete resection of the epileptogenic zone are reviewed.
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Affiliation(s)
- Ahsan N V Moosa
- Section of Pediatric Epilepsy, Epilepsy Center, Department of Neurology, Neurological Institute, Cleveland Clinic, 9500 Euclid Avenue, Desk S-51, Cleveland, OH, 44195, USA,
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Moosa ANV, Jehi L, Marashly A, Cosmo G, Lachhwani D, Wyllie E, Kotagal P, Bingaman W, Gupta A. Long-term functional outcomes and their predictors after hemispherectomy in 115 children. Epilepsia 2013; 54:1771-9. [PMID: 23980759 DOI: 10.1111/epi.12342] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/12/2013] [Indexed: 11/26/2022]
Affiliation(s)
- Ahsan N. V. Moosa
- Department of Neurology; Section of Pediatric Epilepsy; Epilepsy Center; Neurological Institute; Cleveland Clinic; Cleveland; Ohio; U.S.A
| | - Lara Jehi
- Department of Neurology; Section of Pediatric Epilepsy; Epilepsy Center; Neurological Institute; Cleveland Clinic; Cleveland; Ohio; U.S.A
| | - Ahmad Marashly
- Department of Neurology; Section of Pediatric Epilepsy; Epilepsy Center; Neurological Institute; Cleveland Clinic; Cleveland; Ohio; U.S.A
| | - Gary Cosmo
- Department of Neurology; Section of Pediatric Epilepsy; Epilepsy Center; Neurological Institute; Cleveland Clinic; Cleveland; Ohio; U.S.A
| | - Deepak Lachhwani
- Department of Neurology; Section of Pediatric Epilepsy; Epilepsy Center; Neurological Institute; Cleveland Clinic; Cleveland; Ohio; U.S.A
| | - Elaine Wyllie
- Department of Neurology; Section of Pediatric Epilepsy; Epilepsy Center; Neurological Institute; Cleveland Clinic; Cleveland; Ohio; U.S.A
| | - Prakash Kotagal
- Department of Neurology; Section of Pediatric Epilepsy; Epilepsy Center; Neurological Institute; Cleveland Clinic; Cleveland; Ohio; U.S.A
| | - William Bingaman
- Department of Neurosurgery; Section of Pediatric Epilepsy; Epilepsy Center; Neurological Institute; Cleveland Clinic; Cleveland; Ohio; U.S.A
| | - Ajay Gupta
- Department of Neurology; Section of Pediatric Epilepsy; Epilepsy Center; Neurological Institute; Cleveland Clinic; Cleveland; Ohio; U.S.A
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Abstract
Mutations in the smooth muscle-specific isoform of α-actin (ACTA2) cause vascular smooth muscle dysfunction leading to aortic aneurysm and moyamoya syndrome. A unique R179H mutation in ACTA2 has been reported to result in widespread smooth muscle dysfunction affecting vascular and extravascular smooth muscles. We report a 7-year-old girl with an ACTA2 R179H mutation manifesting with neonatal seizures due to multifocal infarcts, asymmetric motor deficits, global developmental delay, spasticity, congenital bilateral mydriasis, and a large patent ductus arteriosus. Serial magnetic resonance imaging (MRI) of the brain over 7 years showed diffuse supratentorial white matter abnormalities consistent with a progressive leukoencephalopathy. Magnetic resonance angiography of the cerebral vessels showed stenosis in the terminal portion of the bilateral internal carotid arteries with fusiform dilation of the proximal segment. Neonatal onset of neurologic symptoms in ACTA2 mutations has not been previously reported. R179H mutation in ACTA2 represents the severe end of the disease spectrum.
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Affiliation(s)
- Ahsan N V Moosa
- Center for Pediatric Neurology, Neurological Institute, Cleveland Clinic, Cleveland, OH 44195, USA
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Abstract
The spectrum of focal epileptogenic lesions and their clinical manifestations in children differ substantially from those seen in adults. In adults, mesial temporal sclerosis is the common lesion in surgical series; but in children, MTS is uncommon, and when it does occur, it exists frequently as dual pathology. The most common lesions in pediatric epilepsy surgery candidates are malformations of cortical development, developmental tumors, or encephalomalacia from infarction, hypoxia, trauma, or infection. Careful analysis of the lesion characteristics on brain MRI is sufficiently predictive of pathology in most cases. Histopathological evaluation remains the gold standard for diagnosis of mass lesions. The electroclinical phenotype of epilepsy in adults is largely determined by the anatomical location of the lesion and its connectivity. In children, in addition to the location of the lesion, the age at onset of the lesion and the age at onset of epilepsy have a major impact on the electroclinical phenotype. Children with congenital or early acquired lesions may manifest with generalized features on EEG and seizure semiology. Experience from various centers has demonstrated that a subset of these children benefit from epilepsy surgery despite a generalized epilepsy phenotype. All children with medically refractory epilepsy and a focal lesion should undergo evaluation for potential epilepsy surgery irrespective of the EEG findings and seizure semiology.
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Affiliation(s)
- Ahsan N V Moosa
- Neurological Institute, Cleveland Clinic, Cleveland, OH, USA.
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Abstract
The authors report an 8-year-old girl with refractory status epilepticus due to hypertensive encephalopathy, secondary to end-stage renal disease. Brain magnetic resonance imaging (MRI) in the acute phase showed striking hyperintensities in the brain stem and medial thalamus along with subtle cortical lesions. After successful control of hypertensive crisis and status epilepticus, the patient recovered to her baseline. Near total resolution of the lesions was noted on follow-up imaging performed 9 days later. Predominant brainstem involvement as a feature of posterior reversible encephalopathy syndrome due to hypertensive crisis is extremely rare in children and has not been well documented.
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Affiliation(s)
- Ahsan N V Moosa
- Center for Pediatric Neurology, Cleveland Clinic, Cleveland, OH 44120, USA.
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Affiliation(s)
- Ahsan N V Moosa
- Child Neurology, Department of Neurology, Cleveland Clinic, 9500 Euclid Avenue, Cleveland OH 44195, USA.
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