"Caterpillar sign" in corpus callosum associated with curvilinear pericallosal lipoma in MRI: A case report

Lipoma of the corpus callosum, also known as pericallosal lipoma, is a rare congenital brain abnormality associated with corpus callosum dysgenesis or agenesis. Two morphological types are described: tubulonodular and curvilinear, with the latter being mostly asymptomatic. We present the case of a 30-year-old woman with epilepsy, whose magnetic resonance imaging revealed a "caterpillar sign" in the corpus callosum associated with a curvilinear pericallosal lipoma. The "caterpillar sign" in the corpus callosum showed low signal intensity on magnetization prepared rapid acquisition with gradient echo, high signal on fluid-attenuated inversion recovery, and low on susceptibility-weighted imaging, possibly indicating abnormal blood vessels penetrating from the ventricle to the posterior callosal vein. We need to be conscious of this unusual finding, particularly when considering surgical intervention in the corpus callosum in cases of pericallosal lipoma, to avoid vascular complications.

Ongoing EEG artifact correction using blind source separation

OBJECTIVE

Analysis of the electroencephalogram (EEG) for epileptic spike and seizure detection or brain-computer interfaces can be severely hampered by the presence of artifacts. The aim of this study is to describe and evaluate a fast automatic algorithm for ongoing correction of artifacts in continuous EEG recordings, which can be applied offline and online.

METHODS

The automatic algorithm for ongoing correction of artifacts is based on fast blind source separation. It uses a sliding window technique with overlapping epochs and features in the spatial, temporal and frequency domain to detect and correct ocular, cardiac, muscle and powerline artifacts.

RESULTS

The approach was validated in an independent evaluation study on publicly available continuous EEG data with 2035 marked artifacts. Validation confirmed that 88% of the artifacts could be removed successfully (ocular: 81%, cardiac: 84%, muscle: 98%, powerline: 100%). It outperformed state-of-the-art algorithms both in terms of artifact reduction rates and computation time.

CONCLUSIONS

Fast ongoing artifact correction successfully removed a good proportion of artifacts, while preserving most of the EEG signals.

SIGNIFICANCE

The presented algorithm may be useful for ongoing correction of artifacts, e.g., in online systems for epileptic spike and seizure detection or brain-computer interfaces.

Referral odyssey plot to visualize causes of surgical delay in mesial temporal lobe epilepsy with hippocampal sclerosis

The "odyssey plot" was used to visualize referral delays in epilepsy surgery. Participants were 36 patients (19 males; 13-67 years, median 27 years) with mesial temporal lobe epilepsy with hippocampal sclerosis (HS) who underwent resection surgery. The "referral odyssey plot" included five clinical episodes: seizure onset (T1), first visits to a non-epileptologist (T2) and to an epileptologist (T3), first admission to our epilepsy monitoring unit (EMU) (T4), and resection surgery (T5). For each patient, we identified the first seizure type: the physician who first diagnosed focal aware seizure (FAS), focal impaired awareness seizure (FIAS), focal to bilateral tonic-clonic seizure (FBTCS), and radiologically suspected HS. Within the overall delay (T1-T5, median 18 years; interquartile range [IQR] 14), non-epileptologist's delay (T2-T3, 11.5 years; IQR 12.25) was far (p < 0.0001) longer than patient's (T1-T2, 0 year; IQR 2.25), epileptologist's (T3-T4, 1 year; IQR 4), or after-EMU delay (T4-T5, 1 year; IQR 1). FAS onset cases had significantly longer T1-T2 (N = 5, median 7 years; IQR 6) than FIAS (N = 22, 0 year; IQR 1, p < 0.005) or FBTCS onset cases (N = 9, 0 year; IQR 0, p < 0.001). FAS was correctly diagnosed first by non-epileptologists in 17.9%, by out-patient epileptologists in 35.7%, and at the EMU in 46.4%. FIAS was correctly diagnosed first by non-epileptologists in 94.4% and by out-patient epileptologists in 5.6%. Non-epileptologists diagnosed FBTCS in all cases. HS was diagnosed by non-epileptologists in 13.9%, by out-patient epileptologists in 47.2%, and at the EMU in 38.9%. Early referral to epileptologists is most critical for early surgery. Early utilization of the EMU is highly recommended because FAS is often overlooked by outpatient epileptologists. The odyssey plot will be useful to improve the healthcare system for other types of epilepsy.

Exploring the efficacy of an educational approach of case-writing for remote learners: insights from a novice writer

empty.

Case study of a migraine patient with multiple extracephalic symptoms including melena due to telangiectasia of the sigmoid colon : a possible new migraine-associated symptom

Migraine is a chronic neurological disorder characterized by headaches and extracephalic symptoms. We report a 73-year-old male patient with a history of migraines as well as several other chronic conditions including abdominal pain accompanied by nausea and vomiting, pain and ecchymosis of the limbs, dysmetropsia, syncope, and melena due to telangiectasia of the sigmoid colon. After a thorough evaluation of the migraine condition, we hypothesized that the patient's melena due to telangiectasia of the sigmoid colon might in fact be a migraine-related phenomenon. In this report, we discuss a possible mechanism for melena due to telangiectasia in migraine patients, as well as "tips" for identifying subtle and/or unreported clinical features of migraine conditions. J. Med. Invest. 70 : 298-300, February, 2023.

Ictal chest discomfort in a patient with temporal lobe seizures and amygdala enlargement

Chest discomfort is the representative symptom of dangerous coronary artery disease (CAD), but rarely occurs in patients with seizures. We treated a 74-year-old man with right mesial temporal lobe epilepsy and amygdala enlargement, who was initially suspected of CAD and underwent repeated cardiac angiography because of recurrent episodes of paroxysmal chest discomfort starting from 68 years old. He visited an epileptologist and underwent long-term video electroencephalography monitoring (LTVEM), which confirmed right temporal seizure onset during a habitual episodes of "chest discomfort," stereotyped movement of chest rubbing with the right hand, followed by impaired conscousness. Brain magnetic resonance imaging revealed right amygdala enlargement. The present case emphasizes the importance of the wide range of symptoms, such as chest discomfort, which may associated with epielpsy and result in a delayed diagnosis. LTVEM is useful for diagnosis of epilepsy with unusual seizure semiology by recording ictal EEG changes during chest discomfort.

Distribution of postictal slowing has an additional yield to interictal epileptiform discharge in predicting surgical outcomes in temporal lobe epilepsy

OBJECTIVE

To investigate whether the slowing of bilateral postictal scalp electroencephalography (EEG) after focal impaired awareness seizures is associated with poor seizure outcomes after temporal lobe epilepsy (TLE) surgery.

METHODS

This retrospective cohort study was conducted in the Department of Epileptology, Tohoku University Hospital from 2010 to 2020. The study included 42 patients with TLE who underwent a detailed presurgical evaluation and sequential resective surgery for the unilateral probable epileptogenic temporal lobe with 1 year or more of follow-up. We reviewed the interictal epileptiform distribution and those of the ictal and postictal epochs of the first focal impaired awareness seizure recorded in presurgical scalp EEG. We classified patients either with postoperative seizure-free status (Engel I) as group A or those with seizure persistence (Engel II-IV) as group B.

RESULTS

Of 42 patients, 29 (69%) were classified into group A. Compared with group B, group A had a lower number of bilateral postictal polymorphic delta activity (PPDA) (10.3%: 61.5%) and bilateral interictal epileptiform discharges (IEDs) (13.8%: 69.2%) (P = 0.003, P = 0.001, respectively). A combined analysis of bilateral PPDA and IEDs per individual patient showed significantly more frequent seizure persistence after surgery (P < 0.0001) than a single analysis of bilateral IEDs or PPDA alone (P = 0.001). The regression analysis revealed that bilaterally distributed PPDA or IEDs had 13.50 or 13.72 times higher odds of persisting seizures within 1 year of surgery (95% confidence interval: 1.90-95.88; 2.12-88.87, respectively) (P = 0.009, 0.006).

SIGNIFICANCE

The results of this study revealed that the bilateral distribution of PPDA was associated with poor postoperative seizure outcomes in patients with TLE, as well as bilateral IEDs. Additionally, the concomitant bilateral distribution of interictal and postictal changes is a strong indicator of poor surgical outcomes.

Development and validation of the Japanese version of the Epilepsy Stigma Scale in adults with epilepsy

BACKGROUND

Self-stigma is considered to have immensely negative influences on the living and psychological states in patients with epilepsy. Understanding the stigma experienced by patients with epilepsy is essential considering its negative impact on their treatment and quality of life (QOL). However, few sufficiently validated self-report instruments are available to evaluate self-stigma in patients with epilepsy. The Epilepsy Stigma Scale (ESS) is one of the most commonly used self-reported questionnaires available to evaluate self-stigma in patients with epilepsy. The present study translated the ESS into Japanese to validate the Japanese version of the ESS (ESS-J) in Japanese adults with epilepsy.

METHODS

The study included 338 patients with epilepsy (166 men, aged 18-75 years) who underwent comprehensive assessment including long-term video-electroencephalography monitoring, neuroimaging studies, and neuropsychological and psychosocial assessments in the Tohoku University Hospital Epilepsy Monitoring Unit. This study consisted of two phases: (1) translation of the ESS into Japanese using the back-translation technique; and (2) statistical analysis of the ESS-J to evaluate the factor structure, reliability, and validity.

RESULTS

The 2-factor model achieved acceptable fit to the data: χ² = 161.27, df = 34, p < 0.01, comparative fit index = 0.929, root mean square error of approximation = 0.105, standardized root mean squared residual = 0.047, Akaike's information criterion = 203.27 and, Bayesian information criterion = 283.56. These two subscales were named enacted stigma and felt stigma based on the theoretical model of self-stigma. We found the ESS-J to have acceptable internal consistency as follows: enacted (7 items; α = 0.88) and felt stigma subscale (3 items; α = 0.82). The concurrent validity was confirmed by adequate correlation with other related instruments. Both enacted and felt stigma had positive and moderate correlations with depression as measured by the Neurological Disorders Depression Inventory for Epilepsy (r = 0.44, p < 0.01; r = 0.41, p < 0.01, respectively) and with anxiety as measured by the Generalized Anxiety Disorder -7 (r = 0.48, p < 0.01; r = 0.38, p < 0.01, respectively).

CONCLUSION

The ESS-J demonstrated acceptable validity and reliability. The present study provided preliminary evidence about the psychometric properties of the ESS-J, indicating the reliable factorial structure, adequate internal consistency, and satisfactory construct and concurrent validity. Measurement of the two types of self-stigma may offer a useful tool for clinical interpretation of patients' psychological state throughout epilepsy care, and as one of the patient-reported outcomes in QOL research.

Educational Approaches That Enhance Online Clinical Clerkship during the COVID-19 Pandemic

Objective This cross-sectional national study determined which educational approaches are associated with the effectiveness of online clerkship for medical students. Method A survey was conducted for medical students at 78 medical schools in Japan from May 29 to June 14, 2020. It comprised the following aspects: (a) participants' profiles, (b) number of opportunities to learn from each educational approach (lecture, medical quiz, assignment, oral presentation, observation of a physician's practice, clinical skill practice, participation in interprofessional meetings, and interactive discussions with physicians) in online clerkship, (c) frequency of technical problems, and (d) educational outcome measurement (satisfaction, motivation, knowledge acquisition, skill acquisition, change in self-study time, and understanding of the importance of medical care team). Results Of the 2,640 respondents, 2,594 (98.3%) agreed to cooperate. Ultimately, 1,711 matched our inclusion criteria. All educational approaches but assignments were positively associated with satisfaction and motivation. All educational approaches excluding assignment submission and interprofessional meeting were positively associated with knowledge acquisition. Observation, practice, and interprofessional meeting were positively associated with skill acquisition. Only assignment submission was positively associated with the change in self-study time. Educational approaches excluding medical quizzes were positively associated with understanding the importance of the medical care team. Technical problems were negatively associated with motivation, knowledge acquisition, and skill acquisition. Conclusions Educators should implement various educational approaches, especially observation and practice, even in online clinical clerkship. They also need to minimize the technical problems associated with the Internet, as they reduce the effectiveness of online clerkship.

Age-Related Recovery of Daily Living Activity After 1-Stage Complete Corpus Callosotomy: A Retrospective Analysis of 41 Cases

BACKGROUND

Recovery time after corpus callosotomy (CC) is known to be longer in elderly than in younger patients.

OBJECTIVE

To evaluate the relationship between patient age and recovery time of activities of daily living (ADL) after 1-stage complete CC.

METHODS

This study included 41 patients (22 women; aged 13 months-34 years, median 7 years) who underwent 1-stage complete CC for medically intractable seizures with drop attacks, infantile spasms, and/or bilaterally synchronized electroencephalographic discharges between August 2009 and April 2019. The timing of restart of competence in 5 ADL categories and surgical outcomes were recorded.

RESULTS

Patients (1) restarted speech at 2.2 ± 1.3 (mean ± 2 standard deviations; range 1-5) days, (2) restarted replying with their own name on request at 5.5 ± 8.6 (2-33) days, (3) restarted oral intake at 1.6 ± 1.7 (1-11) days, (5) discontinued intravenous feeding at 6.0 ± 3.0 (2-16) days, and (5) restarted ambulation or wheelchair movement at 5.8 ± 3.4 (2-10) days. Younger patients showed significantly (P < .0223) earlier recovery of ambulation or wheelchair movement, but no age difference was found in the other 4 ADL categories. Overall seizure freedom was achieved in 5 patients, excellent (>80%) seizure reduction in 11, good (50%-80%) seizure reduction in 5, and poor (<50%) seizure reduction in 20.

CONCLUSION

Early ADL recovery after 1-stage complete CC is favorable in both young and adult patients. These findings, with good surgical outcomes, will encourage more positive consideration of 1-stage complete CC in both pediatric and adult patients.

Acceptance of disability predicts quality of life in patients with epilepsy

BACKGROUND

Acceptance of disability (AOD) is a key concept in rehabilitation psychology that enhances psychosocial adjustment of individuals with disability. However, the impact of AOD on well-being has never been examined for patients with epilepsy. The present study investigated whether AOD affects quality of life (QOL) in patients with epilepsy in the presence of other multiple aspects of epilepsy based on the biopsychosocial model.

METHODS

We retrospectively reviewed 151 consecutive patients with epilepsy (77 men, aged 18-74 years) who underwent comprehensive assessment including long-term video-EEG monitoring, neuroimaging studies, and neuropsychological and psychosocial assessment in our epilepsy monitoring unit. Data were obtained from medical records and self-reported questionnaires. The outcome variable was QOL. Predictive variables included demographic characteristics, seizure-related variables (i.e., duration of epilepsy, seizure frequency, and number of antiepileptic drugs), psychological factors (i.e., AOD, depression, and self-stigma), and social factors (i.e., social support and education level). Acceptance of disability was measured by the Adaptation of Disability Scale-Revised (ADS-R), which we translated into Japanese with the original author's approval, and examined its internal consistency reliability. Data were analyzed using four hierarchical multiple regression analysis models.

RESULTS

The mean ADS-R score was 80 (range 45-115). The predictors accounted for 42% of the variance in QOL (R² = 0.45, ΔR² = 0.42, F[8, 141] = 14.47, p = 0.00). Higher AOD (p < 0.01), higher social support (p < 0.01), and lower depression scores (p = 0.02) were found to contribute significantly to higher overall QOL.

CONCLUSION

The present study revealed AOD as an important psychological concept, in addition to social support and depression as previously reported, to improve the QOL of patients with epilepsy. Acceptance of disability should be incorporated in the intervention to increase QOL of patients with epilepsy.

Magnetoencephalography to confirm epileptiform discharges mimicking small sharp spikes in temporal lobe epilepsy

OBJECTIVE

To determine whether magnetoencephalography (MEG) can identify epileptiform discharges mimicking small sharp spikes (SSSs) on scalp electroencephalography (EEG) in patients with temporal lobe epilepsy (TLE).

METHODS

We retrospectively reviewed simultaneous scalp EEG and MEG recordings of 83 consecutive patients with TLE and 49 with extra-TLE (ETLE).

RESULTS

SSSs in scalp EEG were detected in 15 (18.1%) of 83 TLE patients compared to only two (4.1%) of 49 ETLE patients (p = 0.029). Five of the 15 TLE patients had MEG spikes with concurrent SSSs in EEG, but neither of the 2 ETLE patients. Three of these 5 TLE patients had additional interictal epileptiform discharges (IEDs) in EEG and MEG. Equivalent current dipoles (ECDs) of MEG spikes with concurrent SSSs and IEDs showed no difference in temporal lobe localization and horizontal orientation, whereas ECD moments were smaller in MEG spikes with concurrent SSSs than those with IEDs.

CONCLUSIONS

SSSs were more common in TLE than in ETLE. At least some morphologically diagnosed SSSs are true but low-amplitude epileptiform discharges in TLE which can be identified with simultaneous MEG.

SIGNIFICANCE

Simultaneous MEG is useful to identify epileptiform discharges mimicking SSSs in patients with TLE.

Initial delta and delayed theta/alpha pattern in the temporal region on ictal EEG suggests purely hippocampal epileptogenicity in patients with mesial temporal lobe epilepsy

OBJECTIVE

To determine whether the ictal scalp EEG findings suggest purely hippocampal epileptogenicity in patients with mesial temporal lobe epilepsy (mTLE) associated with hippocampal sclerosis (HS).

METHODS

Twenty-three patients with mTLE with pathologically confirmed HS were divided into 12 with epileptogenicity only in the hippocampus (HS only group) and 11 with epileptogenicity in both the hippocampus and temporal neocortex or other locations (HS plus group), based on the combination of surgical procedures, postoperative outcome, and pathological findings. Sixteen underwent selective amygdalohippocampectomy (SelAH) and 7 received anterior temporal lobectomy. Ictal scalp EEG findings of 79 focal impaired awareness seizures were compared between the HS only and HS plus groups. We focused on the 1-4 Hz rhythmic delta activity at ictal onset followed by 5-9 Hz rhythmic theta/alpha activity 10-30 s after the onset in the temporal region.

RESULTS

The initial delta and delayed theta/alpha (ID-DT) pattern was observed in 8 of 12 patients in the HS only group, but in none of 11 patients in the HS plus group (p < 0.01).

CONCLUSIONS

ID-DT pattern on ictal EEG suggests purely hippocampal epileptogenicity in mTLE with HS.

SIGNIFICANCE

Patients with the ID-DT pattern are likely to become seizure-free after SelAH.

Normal Variants in Magnetoencephalography

Normal variants, although not occurring frequently, may appear similar to epileptic activity. Misinterpretation may lead to false diagnoses. In the context of presurgical evaluation, normal variants may lead to mislocalizations with severe impact on the viability and success of surgical therapy. While the different variants are well known in EEG, little has been published in regard to their appearance in magnetoencephalography. Furthermore, there are some magnetoencephalography normal variants that have no counterparts in EEG. This article reviews benign epileptiform variants and provides examples in EEG and magnetoencephalography. In addition, the potential of oscillatory configurations in different frequency bands to appear as epileptic activity is discussed.

Diagnostic yield of seizure recordings and neuroimaging in patients with focal epilepsy without interictal epileptiform discharges

OBJECTIVE

Repeated routine electroencephalography (EEG) or even long-term video-EEG monitoring (VEM) does not always record interictal epileptiform discharges (IEDs) in some patients with epilepsy. The present study investigated whether focal seizures detected by VEM and focal abnormalities on neuroimaging are useful for the diagnosis of patients with focal epilepsy without IEDs.

METHODS

We retrospectively reviewed 409 consecutive patients with focal epilepsy (207 men, aged 9 to 76 years) who underwent 4- or 5-day VEM, magnetic resonance imaging (MRI), and fluorine-18-fluorodeoxyglucose positron emission tomography (FDG-PET) for diagnosis to identify patients without IEDs. The occurrence of focal seizures during VEM and the presence of focal abnormalities on neuroimaging were investigated in those patients. The occurrence rate of seizures during VEM was investigated in patients with daily, weekly, monthly, and yearly seizure frequency based on history-taking.

RESULTS

Ninety-five (23.2%) of 409 patients with focal epilepsy did not have IEDs. Fifty-five (57.9%) of the 95 patients had focal seizures during VEM. Fifty-four patients (56.8%) showed focal abnormalities compatible with seizure semiology on neuroimaging investigations. Neither seizure recordings nor neuroimaging abnormalities were seen in 16 (16.8%) of the 95 patients. The occurrence rate of seizures during VEM depended on the seizure frequency at history-taking. However, 28 (45.9%) of 61 patients with monthly and yearly seizure frequency had focal seizures during 4- or 5-day VEM with seizure induction.

CONCLUSIONS

Video-EEG monitoring can detect focal seizures in patients with focal epilepsy but no IEDs. Comprehensive assessment including VEM and neuroimaging study is important for the diagnosis.

Assessment of the Utility of Ictal Magnetoencephalography in the Localization of the Epileptic Seizure Onset Zone

Importance

Literature on ictal magnetoencephalography (MEG) in clinical practice and the relationship to other modalities is limited because of the brevity of routine studies.

Objective

To investigate the utility and reliability of ictal MEG in the localization of the epileptogenic zone.

Design, Setting, and Participants

A retrospective medical record review and prospective analysis of a novel ictal rhythm analysis method was conducted at a tertiary epilepsy center with a wide base of referrals for epilepsy surgery evaluation and included consecutive cases of patients who experienced epileptic seizures during routine MEG studies from March 2008 to February 2012. A total of 377 studies screened. Data were analyzed from November 2011 to October 2015.

Main Outcomes and Measures

Presurgical workup and interictal and ictal MEG data were reviewed. The localizing value of using extended-source localization of a narrow band identified visually at onset was analyzed.

Results

Of the 44 included patients, the mean (SD) age at the time of recording was 19.3 (14.9) years, and 25 (57%) were male. The mean duration of recording was 51.2 minutes. Seizures were provoked by known triggers in 3 patients and were spontaneous otherwise. Twenty-five patients (57%) had 1 seizure, 6 (14%) had 2, and 13 (30%) had 3 or more. Magnetoencephalography single equivalent current dipole analysis was possible in 29 patients (66%), of whom 8 (28%) had no clear interictal discharges. Sublobar concordance between ictal and interictal dipoles was seen in 18 of 21 patients (86%). Three patients (7%) showed clear ictal MEG patterns without electroencephalography changes. Ictal MEG dipoles correlated with the lobe of onset in 7 of 8 patients (88%) who underwent intracranial electroencephalography evaluations. Reasons for failure to identify ictal dipoles included diffuse or poor dipolar ictal patterns, no MEG changes, and movement artifact. Resection of areas containing a minimum-norm estimate of a narrow band at onset, not single equivalent current dipole, was associated with sustained seizure freedom.

Conclusions and Significance

Ictal MEG data can provide reliable localization, including in cases that are difficult to localize by other modalities. These findings support the use of extended-source localization for seizures recorded during MEG.

Two males with sick sinus syndrome in a family with 0.6 kb deletions involving major domains in MECP2

Mutations in methyl-CpG-binding protein 2 (MECP2) in males can lead to various phenotypes, ranging from neonatal encephalopathy to intellectual disability. In this study, using Nord's method of next-generation sequencing in three siblings, we identified a 0.6 kb deletion involving the transcriptional repression domain (TRD). Two males and one female had intellectual disability and apnea, but none met the criteria of Rett syndrome. Both males had sick sinus syndrome and severe tracheomalacia that resulted in early death. The mother, with skewed X-inactivation, had no symptoms. Therefore, this mutation is pathological for both males and females, resulting in sick sinus syndrome and severe tracheomalacia with strong reproducibility in males. Deletions involving major domains in MECP2 can result in a severe phenotype, and deletion of the TRD domain can cause severe autonomic nervous system dysregulation in males in these cases.

Levetiracetam improves symptoms of multiple chemical sensitivity: Case report

Multiple chemical sensitivity (MCS) is a disorder of unknown etiology with no effective treatment. Many clinicians accept that a diagnosis of somatic symptoms disorder (SSD) is an appropriate diagnostic category for MCS. We found that administration of levetiracetam improved recurrent symptoms of MCS in a patient. A 23-year-old female presented with recurrent multiple symptoms of musculoskeletal, airway or mucous membrane, heart/chest-related, gastrointestinal, cognitive, affective, neuromuscular, head-related, and skin-related induced by exposure to diesel or gas engine exhaust, tobacco smoke, insecticide, gasoline, paint or paint thinner, cleaning products, fragrances, tar or asphalt, nail polish or hairspray, and new furnishings. Gastrointestinal, cognitive, and skin-related symptoms were precipitated by some food additives. She suffered partial seizures from the age of 17 years, and was diagnosed with right parietal lobe epilepsy. Administration of levetiracetam (250 mg/day) eliminated her MCS symptoms. Levetiracetam reduces the release of presynaptic neurotransmitter including glutamate by binding to presynaptic vesicle protein. A recent study established the presence of glutamatergic overactivation in somatization disorder, a form of SSD. Our case may indicate that a subset of patients with SSD have glutamatergic overactivation, which levetiracetam can normalize. J. Med. Invest. 64: 296-298, August, 2017.

Teleconference-based education of epileptic seizure semiology

BACKGROUND

To evaluate whether a teleconference-based lecture provides similar understanding of seizure semiology to a face-to-face lecture for physicians.

METHODS

Subjects were 66 physicians consisting of adult and pediatric neurologists, neurosurgeons, psychiatrists, and general practitioners. All attended the 30-minute lecture to introduce various types of seizure semiology using video-clips by one of the authors (Yo.K.) and then joined the comprehensive case conference which discussed three cases in 1.5 h. Group A received the lecture and conference using a teleconference system (N = 43) and Group B attended in person (N = 23) for geographical reasons. After the conference, 32 subjects (23 in Group A and nine in Group B) scored their own post-lecture understanding of seizure semiology using the four-point Likert scale from 1 (not at all) to 4 (very well) as well as the estimated pre-lecture score. Data was analyzed to assess whether their understanding was improved after the lecture.

RESULTS

No significant difference was found in improvement of understanding after the lecture between Group A (43%) and Group B (22%; p = 0.42). Pre-lecture score of subjects with improved understanding was significantly lower (2.3 +/- 0.2) than those without improvement (3.7 +/- 0.1) (p < 0.05).

SIGNIFICANCE

Teleconference-based lectures can be a useful tool to educate seizure semiology for physicians, especially at the inexperienced level, by overcoming geographical limitations.

Predictive factors of higher drug load for seizure freedom in idiopathic generalized epilepsy: Comparison between juvenile myoclonic epilepsy and other types

PURPOSE

Predictive factors of higher drug load for seizure freedom were investigated in idiopathic generalized epilepsy (IGE), focusing on the difference between juvenile myoclonic epilepsy (JME) and other types of IGE (non-JME IGE).

METHODS

Twelve patients with JME and 12 patients with non-JME IGE, who achieved seizure freedom for 1 year or longer with appropriate antiepileptic drugs (AEDs) after video electroencephalography monitoring, were reviewed retrospectively. The sum of prescribed daily dose/defined daily dose ratio of all prescribed AEDs at the final visit was defined as total AED load. Patients requiring total AED load >1 were classified into the higher AED load group. Clinical background and the presence of interictal focal epileptiform abnormalities (FEAs) were compared between the higher and lower AED load groups.

RESULTS

Higher AED load group of patients with JME had interictal FEAs and family history of epilepsy more frequently than the lower AED load group (p = 0.03 and p = 0.03). Similar comparison of patients with non-JME IGE showed no significant differences.

CONCLUSIONS

The presence of interictal FEAs and a family history of epilepsy are significantly associated variables for higher AED load for seizure freedom in patients with JME, but not in patients with non-JME IGE.

A novel mutation in the proteolytic domain of LONP1 causes atypical CODAS syndrome

Cerebral, ocular, dental, auricular, skeletal (CODAS) syndrome is a rare autosomal recessive multisystem disorder caused by mutations in LONP1. It is characterized by intellectual disability, cataracts, delayed tooth eruption, malformed auricles and skeletal abnormalities. We performed whole-exome sequencing on a 12-year-old Japanese male with severe intellectual disability, congenital bilateral cataracts, spasticity, hypotonia with motor regression and progressive cerebellar atrophy with hyperintensity of the cerebellar cortex on T2-weighted images. We detected compound heterozygous mutation in LONP1. One allele contained a paternally inherited frameshift mutation (p.Ser100Glnfs*46). The other allele contained a maternally inherited missense mutation (p.Arg786Trp), which was predicted to be pathogenic by web-based prediction tools. The two mutations were not found in Exome Variant Server or our 575 in-house control exomes. Some features were not consistent with CODAS syndrome but overlapped with Marinesco-Sjögren syndrome, a multisystem disorder caused by a mutation in SIL1. An atypical mutation site may result in atypical presentation of the LONP1 mutation.

[Ictal Speech Manifesting as Sleep Talking: A Case Report]

We present a 28-year-old female patient whose epilepsy started at the age of 19. MRI showed right perisylvian polymicrogyria. She exhibited various seizure symptoms, such as somatosensory aura involving the left leg, dyscognitive seizures, and amnesic seizures. Her mother indicated that the patient sometimes had "sleep talking", which was associated with presence of epileptic seizures of the next day. Long-term video electroencephalography (EEG) revealed that her episodes of "sleep talking" were epileptic events, specifically ictal speech, originating in the right hemisphere. The present case demonstrates the importance of considering "sleep talk" as an epileptic symptom. Careful history taking is fundamental to carry patients with possibly pathological "sleep talk" to the long-term video EEG, which will contribute correct diagnosis and treatment. (Received August 16, 2016; Accepted September 9, 2016; Published February 1, 2017).

Writing Case Reports: Teaching and Tuition Techniques, and the Improvement of Clinical Diagnostic Reasoning

NA

Structured Didactic Education Program for Writing Case Reports Can Motivate Medical Students

NA

Differences in sleep architecture between left and right temporal lobe epilepsy

To investigate whether seizure lateralization affects sleep macrostructure in patients with left and right temporal lobe epilepsy (TLE), as rapid eye movement (REM) sleep is shorter in patients with right hemispheric cerebral infarction than with left. We retrospectively analyzed data from 16 patients with TLE (6 men and 10 women aged 34.9 ± 11.4 years) who underwent polysomnography as well as long-term video electroencephalography. Ten patients were diagnosed with left TLE and six patients with right TLE. Sleep stages and respiratory events were scored based on the American Academy of Sleep Medicine criteria. Sleep and respiratory parameters were compared between the patient groups. Percentage of REM stage sleep was significantly (p < 0.05) lower in patients with left TLE (median 8.8 %, interquartile range 5.5-13.8 %) than in patients with right TLE (median 17.0 %, interquartile range 14.1-18.3 %). The other parameters showed no significant differences. Shorter REM sleep in patients with left TLE sharply contrasts with the previous report of shorter REM sleep in patients with right cerebral infarction. Laterality of the irritative epileptic focus versus destructive lesion may have different effects on the sleep macrostructures.

Fantastic confabulation in right frontal lobe epilepsy

Background

Interictal behavioral symptoms in frontal lobe epilepsy (FLE) are variable and often difficult to discriminate from other localization-related epilepsies.

Methods and results

We report two female patients with right FLE who exhibited fantastic confabulations. One of the patients had a 14-year history of hypermotor seizures, and the other had a 10-year history of dyscognitive seizures with automatism. Their fantastic confabulations arose in the context of moderate-to-severe cognitive impairment and of a variety of behavioral abnormalities, including emotional withdrawal and compulsive behaviors.

Conclusion

Fantastic confabulations are rare but may be a relatively specific behavioral marker for FLE-associated psychosis.

Acute encephalitis with refractory, repetitive partial seizures: Pathological findings and a new therapeutic approach using tacrolimus

Acute encephalitis with refractory, repetitive partial seizures (AERRPS) is characterized by prolonged severe seizures and a high-grade fever. We experienced a boy with severe AERRPS with frequent partial seizures that exhibited right-side predominance. The patient required the continuous intravenous administration of many antiepileptic drugs and respirator management for several months. Methylprednisolone pulse therapy and intravenous immunoglobulin administration were only temporarily effective. The MRI and EEG showed the abnormality in the left occipital lobe. Although occipital lobectomy was performed, his seizures continued. His cerebrospinal fluid exhibited elevated protein and proinflammatory cytokine levels, and was positive for anti-glutamate receptor ε2 antibodies. Pathological examination showed infiltration of many neutrophilic leukocytes, T cells, and microglia in the area exhibiting severe spongiosis. We thought that the exaggerated microglia and T-cell responses were related to the pathogenesis of the patient's seizures, and we therefore initiated treatment with tacrolimus. As a result, many of the daily seizure clusters were ameliorated, and the patient was discharged. We attempted to discontinue the tacrolimus twice, but the patient's seizure clusters recurred each time. This is the first case report of the pathological findings of AERRPS and showing an effective therapeutic approach using tacrolimus. Tacrolimus may be an effective immunosuppressant, especially for patients with severe AERRPS.

A case of 3p deletion syndrome associated with cerebellar hemangioblastoma

We described clinical course of a 24-year-old woman with 3p deletion syndrome associated with cerebellar hemangioblastoma at the age of 16 years old. She presented dysmorphic facial features, growth retardation and severe psychomotor retardation associated with 3p deletion syndrome. We identified de novo 3p deletion encompassing p25 by using array-based comparative genomic hybridization, where causative gene of von Hippel-Lindau (VHL) disease located. Surgical therapy for cerebellar hemangioblastoma was performed, and histological examination was consistent in cerebellar hemangioblastoma. She showed no other tumors associated VHL disease till 24 years old. This is the first case report of a patient with 3p deletion syndrome whose cerebellar hemangioblastoma may be associated with VHL disease. Repeat imaging studies were recommended for the patients with 3p deletion syndrome.

Clinical features and long-term outcome of a group of Japanese children with inflammatory central nervous system disorders and seropositivity to myelin-oligodendrocyte glycoprotein antibodies

BACKGROUND

Myelin-oligodendrocyte glycoprotein and aquaporin-4 have been extensively analyzed as targets for humoral immune reactions in central nervous system (CNS) demyelinating diseases, and the results indicated a possible role of these antibodies in the pathogenesis of various demyelinating diseases.

OBJECTIVE

To investigate the antibody titer levels against myelin-oligodendrocyte glycoprotein and aquaporin-4 in pediatric patients with inflammatory CNS disorders, and to evaluate clinical significance to study anti-myelin-oligodendrocyte glycoprotein antibodies.

METHODS

Sera at onset from patients with acute disseminated encephalomyelitis (ADEM) in 7, optic neuritis (ON) in 5, pediatric MS in 4 and neuromyelitis optica in one were tested for myelin-oligodendrocyte glycoprotein and aquaporin-4 antibodies using cell-based assays with live transfected cells. The duration of the observation periods ranged from 1 to 21 years (median, 10 years). We also described clinical course of patients with positive anti-myelin-oligodendrocyte glycoprotein antibodies.

RESULTS

Among 17 patients diagnosed with inflammatory CNS demyelinating diseases nine (52%) were positive to anti-myelin-oligodendrocyte glycoprotein antibodies. Of note, all cases with positive anti-myelin-oligodendrocyte glycoprotein antibodies showed seronegativity against anti-aquaporin-4 antibodies and had a favorable prognosis.

CONCLUSIONS

This preliminary report showed that anti-myelin-oligodendrocyte glycoprotein antibodies testing at onset could be a useful tool predicting clinical outcome of children with ADEM, ON, and MS.

Obsessive-compulsive behavior induced by levetiracetam

A novel antiepileptic drug, levetiracetam, has been reported to cause several psychiatric adverse effects in spite of its effectiveness on epilepsy. However, a possible relationship between levetiracetam and obsessive-compulsive behavior has only been reported in a few studies with adult epilepsy patients. We treated a pediatric patient with epilepsy without past or family history of psychiatric disorder. Levetiracetam was started to control generalized tonic-clonic seizure. Two months after initiation of levetiracetam with favorable seizure control, she started to show an obsessive-compulsive behavior such as repetitive checking of her back, pants, and chair. Based on the course of its appearance, levetiracetam administration was identified as a possible cause. After termination of levetiracetam, her obsessive-compulsive behavior completely disappeared with reappearance of seizures. This case provides clear evidence that levetiracetam may cause obsessive-compulsive behavior even in a pediatric epilepsy patient without psychiatric background, possibly mediated by modulation of the glutamate system by levetiracetam.

[A case of focal epilepsy manifesting multiple psychiatric auras]

We present a case of epilepsy with multiple types of focal seizures that were misdiagnosed as psychiatric disorders. A 20-year-old female patient presented with a variety of episodes, including loss of consciousness, deja vu, fear, delusion of possession, violent movements, and generalized convulsions. Each of these symptoms appeared in a stereotypic manner. She was initially diagnosed with a psychiatric disorder and treated with psychoactive medications, which had no effect. Long-term video electroencephalography revealed that her episodes of violent movement with impaired consciousness and secondarily generalized seizure were epileptic events originating in the right hemisphere. High-field brain magnetic resonance imaging for detecting subtle lesions revealed bilateral lesions from periventricular nodular heterotopia. Her final diagnosis was right hemispheric focal epilepsy. Carbamazepine administration was started, which successfully controlled all seizures. The present case demonstrates the pitfall of diagnosing focal epilepsy when it presents with multiple types of psychiatric aura. Epilepsy should thus be included in differential diagnoses, considering the stereotypic nature of symptoms, to avoid misdiagnosis.

Earlier tachycardia onset in right than left mesial temporal lobe seizures

OBJECTIVE

To clarify whether the presence and timing of peri-ictal heart rate (HR) change is a seizure lateralizing sign in patients with mesial temporal lobe epilepsy (mTLE).

METHODS

Long-term video EEGs were retrospectively reviewed in 21 patients, 7 men and 14 women aged 13 to 67 years, diagnosed as mTLE with MRI lesions in the mesial temporal structures (hippocampal sclerosis in 20 cases, amygdala hypertrophy in 1 case). Seventy-seven partial seizures without secondary generalization were extracted. Peri-ictal HR change was compared between 29 right seizures (9 patients) and 48 left seizures (12 patients).

RESULTS

HR abruptly increased in all 29 right seizures and 42 of 48 left seizures. Onset time of HR increase in relation to ictal EEG onset was significantly earlier in right seizures than in left seizures (mean ± SD, -11.5 ± 14.8 vs 9.2 ± 21.7 seconds; p < 0.0001). Time of maximum HR was also significantly earlier in right seizures than in left seizures (36.0 ± 18.1 vs 58.0 ± 28.7 seconds; p < 0.0001). Maximum HR changes from baseline showed no significant difference between right and left seizures (47.5 ± 19.1 vs 40.8 ± 20.0/min).

CONCLUSIONS

Significantly earlier tachycardia in right than left mTLE seizures supports previous hypotheses that the right cerebral hemisphere is dominant in the sympathetic network. No HR change, or delayed tachycardia possibly due to seizure propagation to the right hemisphere, may be a useful lateralizing sign of left mTLE seizures.

Pediatric-onset extracephalic stabbing pain

Idiopathic stabbing headache is a primary headache defined as "transient stabs of pain in the head that occur spontaneously in the absence of underlying organic disease." Although its variant form, stabbing pain with extracephalic distribution, has been reported in rare adult cases, pediatric presentation is extremely rare. We report an 8-year-old boy suffering from severe stabbing pain in the left side of the chest, right side of the abdomen, and right knee lasting 2 to 3 minutes with increasing frequency. He was completely normal between attacks. The attack was not accompanied with headache initially. Investigation showed no abnormality. A diagnosis of extracephalic stabbing pain was made. The patient's symptoms were ameliorated by administration of valproic acid. This report illustrates that extracephalic stabbing pain can occur in pediatric patients. It is important to be aware of this peculiar condition because the pain is so severe, and it can be treatable with medication.