Showing papers in "Epilepsia in 1991"

Prevalence of epilepsy in Rochester, Minnesota: 1940-1980.

Abstract: Summary: : The prevalence of epilepsy in Rochester, Minnesota has been determined for a specific date in each of 5 decennial census years. Individuals with a diagnosis of epilepsy (recurrent unprovoked seizures) who were known to have experienced a seizure or who had received antiepileptic medication in the preceding 5 years were considered active prevalence cases. By this definition, the age-adjusted prevalence per 1,000 population, increased steadily from 2.7 in 1940 to 6.8 in 1980. At each of five prevalence dates, for all prevalence cases, 60% had epilepsy manifest by partial seizures, and 75% had no known etiology. Prevalence was higher for males than females for all except the last prevalence day. After 1950, prevalence tended to increase with advancing age and was highest in the oldest age groups. On the average, the 1980 prevalence cases had epilepsy 50% had their first diagnosis in the first 20 years of life. RESUME La prevalence de ľ epilepsie dans le Comtede Rochester, dans le Minnesota, a eteevaluee pour une date precise de chacune des 5 annees du recensement decennal. Les individus pour lesquels le diagnostic ďepilepsie avait ete pose (crises spontanees recurrentes) et qui avaient presente une crise ou recevaient un traitement antiepileptiques dans les 5 annees precedentes, ont ete consideres comme des cas de prevalence active. Selon cette definition, la prevalence ajustee pour Page pour 1000 habitants a agumente constamment de 2.7 en 1940 a 6.8 en 1980. A chacune des 5 dates de prevalence, pour tous les cas, 60% ont presente une epilepsie se manifestant par des crises partielles, et 75% n'avaient pas ďetiologie connue. La prevalence teAait plus elevee chez les hommes que chez les femmes, sauf lors du dernier jour de prevalence. Apres 1950, la prevalence tendait a augmenter avec ľâge, elle etait la plus forte dans les groupes ďâge eleve En moyenne, les cas de 1980 avaient une epilepsie evoluant depuis moins de 10 ans et plus de 50% avaient une epilepsie diagnos-tiquee au cours des 20 premieres annees de vie. RESUMEN Se ha determinado la prevalencia de epilepsyia en Rochester, Minnesota, para una fecha especifica en cada uno de los 5 dece-nios del censo. Individuos con diagnostico de epilepsia “ataques recurrentes sin provocacion” que habian tenido un ataque o recibido medicateon antiepileptica en los 5 anos precedentes, fueron considerados como casos activos de prevalencia. Segun esta definition la prevalencia ajustada a la edad por 1.000 habitantes se incremento continuadamente de 2.7 en 1940 a 6.8 en 1980. En cada una de las 5 fechas de prevalencia para todos los casos prevalentes, el 60% tenia epilepsyia manifestada por ataques parciales y el 75% de etiologia desconocida. La prevalencia fue mas elevada en varones que en hembras en todos los dias de prevalencia excepto el ultimo. Despues de 1950 la prevalencia mostro una tendencia al aumento con incremento de la edad y fue mas elevada en los grupos de mayor edad. Como promedio, los casos de prevalencia en 1980 habian padecido epilepsyia durante menos de 10 anos y mas del 50% tuvieron el primer diagnostico en los primeros 20 anos de su vida. ZUSAMMENFASSUNG Die Praevalenz der Epilepsie in Rochester, Minnesota wurde an einem bestimmten Datum in funf aufeinanderfolgenden Cen-sus-Decenien bestimmt. Personen mit der Diagnose Epilepsie (wiederholte nicht provozierte Anfalle), die einene Anfall erlitten hatten oder Antiepileptika eingenommen hatten wurden als ak-tive Praevalenz-Falle betrachtet. Demnach stieg die altersberei-nigte Praevalenz fur 1000 Einwohner kontinuierlich von 2,7 1940 auf 6,8 1980 an. Zu jedem der funf Praevalenz-Daten aller Praevalenz-Falle manifestierte sich die Epilepsie in 60% durch Partialanfalle, davon 75% ohne bekannte Atiologie. Die Praevalenz war fur Manner hoher als fur Frauen wahrend aller Stichtage, ausgenommen des letzten. Nach 1950 stieg die Praevalenz mit zunehmendem Alter leicht an und erreichte ihren hochsten Wert in der altesten Altersgruppe. Im Durchschnitt hatten 1980 die Praevalen-Falle eine Epilepsie fur weniger als 10 Jahre. Bei mehr als 50% wurde die Erstdiagnose Epilepsie in den ersten 20 Le-bensjahren gestellt.

Long-term effects of pilocarpine in rats: structural damage of the brain triggers kindling and spontaneous recurrent seizures.

Abstract: Structural damage of the human brain (perinatal damage, cerebral trauma, head injury, cerebrovascular and degenerative diseases, intracranial tumor, metabolic diseases, toxins, drug-induced seizures) may lead to chronic epilepsy in survivors. Epidemiologic analyses show that a considerable time-delay occurs between the exposure of the brain to injury and the appearance of seizures. Such seizures are usually partial or mixed, may develop at any age, and are difficult to treat. In rats subjected to structural damage of the brain induced by sustained convulsions triggered by systemic administration of the cholinergic agent pilocarpine, spontaneous seizures may develop after a mean latency of 14-15 days. The mean frequency of spontaneous recurrent convulsions remains constant for several months. Evolution of these convulsions proceeds through several electrographic and behavioral stages resembling kindling. Kindling may be otherwise induced in rodents by repeated systemic administration of convulsants or by repeated electrical stimulation of sensitive brain regions. These observations demonstrate that structural damage of the brain may lead to spontaneously recurrent convulsions (chronic epilepsy) in rats and that kindling may be involved in the evolution of such a condition. This finding suggests that kindling mechanisms underlie the development of epileptic foci from structural brain lesions. Such mechanisms may be involved in the etiology of some forms of epilepsy in humans.

Intractable epilepsy and structural lesions of the brain: mapping, resection strategies, and seizure outcome.

Abstract: Forty-seven patients with structural brain lesions on neuroimaging studies and partial epilepsy intractable to medical therapy were studied. Prolonged noninvasive interictal and ictal EEG recording was performed, followed by more focused mapping using chronically implanted subdural electrode plates. Surgical procedures included lesion biopsy, maximal lesion excision, and/or resection of zones of epileptogenesis depending on accessibility and involvement of speech or other functional areas. The epileptogenic zone involved exclusively the region adjacent to the structural lesion in 11 patients. It extended beyond the lesion in 18 patients. Eighteen other patients had remote noncontiguous zones of epileptogenesis. Postoperative control of epilepsy was accomplished in 17 of 18 patients (94%) with complete lesion excision regardless of extent of seizure focus excision. Postoperative control of epilepsy was accomplished in 5 of 6 patients (83%) with incomplete lesion excision but complete seizure focus excision and in 12 of 23 patients (52%) with incomplete lesion excision and incomplete focus excision. The extent of lesion resection was strongly associated with surgical outcome either in itself (p less than 0.003), or in combination with focus excision. Focus resection was marginally associated with surgical outcome as a dichotomous variable (p = 0.048) and showed a trend toward significance (p = 0.07) only as a three-level outcome variable. We conclude that structural lesions are associated with zones of epileptogenesis in neighboring and remote areas of the brain. Maximum resection of the lesion offers the best chance at controlling intractable epilepsy; however, seizure control is achieved in many patients by carefully planned subtotal resection of lesions or foci.(ABSTRACT TRUNCATED AT 250 WORDS)

Role of the frontal lobes in the propagation of mesial temporal lobe seizures.

Abstract: Summary: The depth ictal electroencephalographic (EEG) propagation sequence accompanying 78 complex partial seizures of mesial temporal origin was reviewed in 24 patients (15 from the University of Pittsburgh Epilepsy Center and 9 from UCLA). All patients were monitored with bilateral mesial frontal and mesial temporal depth electrodes and later received anterior temporal lobectomy. Ictal EEG records were categorized according to sequence of spread from the temporal focus to the other regions. Although propagation patterns varied both within and between patients, certain features were notable: (a) It was very common for seizure activity to spread initially to the ipsilateral frontal lobe (observed in 22 of 24 patients), (b) The most common mode of spread (15 of 24 patients) was initiating temporal lobe ipsilateral frontal lobe, *contralateral frontal lobe* contralateral temporal lobe, (c) Occasionally, seizure discharges invaded the frontal lobes but failed to invade the contralateral temporal lobe (2 of 24 patients), (d) Seizure activity occasionally invaded the contralateral temporal lobe prior to invading the frontal lobes (2 of 24 patients). Other notable features included (i) a clear tendency for mesial temporal seizure discharges initially to invade orbitofrontal (as opposed to anterior cingulate) cortex and (ii) the emergence of a period of clear asymmetry in the frontal lobes during which high-amplitude, rapid discharges were present on the side ipsilateral to the initiating temporal lobe. These results suggest that the prefrontal region, especially the orbitofrontal cortex, is strongly influenced by mesial temporal ictal activity. This region appears to be frequently involved in the propagation of seizures initiated in the mesial temporal lobe and may play a role in the interhemispheric propagation of mesial temporal seizures. RESUME La sequence de propagation critique sur

Double‐Blind Study of Gabapentin in the Treatment of Partial Seizures

Abstract: Forty-three patients completed a double-blind, placebo-controlled study of Gabapentin (GBP) as add-on therapy in partial and secondarily generalized seizures. All patients were followed for an initial 3-month baseline period, after which they were randomly allocated to receive either a placebo or 900 or 1,200 mg/day GBP for 3 months. A statistically significant difference in seizure frequency from the baseline to the treatment phase was noted between patients receiving placebo and GBP 1,200 mg, in whom seizure frequency decreased 57%. The GBP dosage of 900 mg appeared to be ineffective. A close relationship was observed between the serum GBP concentrations and the GBP dosage based on the seizure frequency. Serum GBP concentrations greater than 2 micrograms/ml resulted in a lower frequency of seizures. The adverse effects were minor and consisted mainly of transient drowsiness. GBP appears to be effective in the treatment of partial epileptic seizures in a dosage-related manner.

Postnatal Epilepsy After EEG-Confirmed Neonatal Seizures

Abstract: SUMMARY: We examined infants whose neonatal seizures were confirmed by randomly recorded ictal EEG tracings to determine the types and frequency of postnatal epilepsy (PNE)—unprovoked, recurring postnatal seizures. Perinatal and postnatal clinical and EEG variables were also examined for their relevance to PNE. Forty infants with EEG-documented neonatal seizures of diverse etiologies were studied. The 27 survivors were followed for a mean of 31 months. PNE developed in 56% (15 of 27) of the cohort. The first seizure appeared at a mean-corrected age of 12.7 months and occurred despite ongoing antiepileptic medication in 60% (9 of 15) of the group. Seizures were classified as infantile spasms or minor motor (7 patients), complex partial (4 patients), or generalized tonic-clonic (4 patients). Perinatal variables that significantly correlated with PNE included the presence of coma but not the age at seizure onset, the estimated gestational age, or Apgar scores. PNE occurred in 68% (13 of 19) of patients with moderately or markedly abnormal EEG backgrounds but in only 25% (2 of 8) without (p = 0.035). There was a strong trend for PNE to develop in patients with > 10 electrographic seizures per hour but in only 45% (9 of 20) of infants with fewer seizures (p = 0.058). Several postnatal variables were significantly related to PNE—the presence of cerebral palsy (CP), mental retardation (MR), CP with MR, and follow-up EEGs. PNE occurred in only 27% (3 of 11) of patients without spikes or sharp waves on postnatal EEGs performed at age 3 months but in 100% (3 of 3) of patients with spikes or sharp waves (p = 0.022). We conclude that in infants whose clinical neonatal seizures are confirmed by ictal EEG tracings obtained randomly, PNE (often in the form of serious seizure syndromes such as infantile spasms) occurs far more frequently than previously reported and often despite ongoing treatment. Infants comatose during the neonatal period who had serious background EEG abnormalities and who later developed CP/MR and displayed spikes/sharp waves on postnatal follow-up EEGs were at greatest risk to develop PNE. RESUME Les auteurs ont examine des nourrissons chez lesquels des crises neonatales avaient ete confirmees par des EEG critiques, afin de determiner le type et la frequence de l'epilepsie postnatale (EPN) definies commes des crises postnatales recurrentes non provoquees. Les variables cliniques et EEG peri- et postnatales ont ete correlees a l'EPN. Quarante nourrissons ayant presente des crises neonatales d'etiologies diverses, documentees par l'EEG, ont eteetudies. Les 27 survivants ont ete suivis pendant une periode moyenne de 21 mois. Une EPN est survenue chez 56% (15/27) des nourrissons de ce groupe. La premiere crise est apparue a un âge moyen (corrige) de 12,7 mois, elle est survenue malgre la poursuite d'un traitement antiepileptique chez 60% des patients (9/15). Les crises ont ete classees comme spasmes infantiles ou crises motrices mineures (7 cas), crises partielles complexes (4 cas), et crises generalisees tonicocloniques (4 cas). La presence d'un coma est significativement correlee a l'EPN, il n'en etait pas de meme pour les autres variables perinatales, comme l'âge de debut des crises, l'âge gestationnel, ou le score d'Apgar. L'EPN est survenu chez 68% (13/19) des patients avec activite de fond EEG legerement ou profondement alteree, mais chez seulement 25% (2/8) avec activite de fond EEG normale (p = 0.035). II y avait une forte tendance vers un developpement d'une EPN chez des patients ayant presente des crises neonatales plus frequentes: chez 86% (6/7) de patients presentant plus de 10 crises EEG par heure, mais chez seulement 45% (9/20) des nourrissons avec moins de 10 crises par heure (p = 0.058). Plusieurs variables postnatales ont ete significativement correlees a l'EPN: la presence d'une IMC, d'un retard mental, d'une IMC et d'un retard mental associes, les EEG effectues pendant le suivi. L'EPN est survenu chez seulement 27% (3/11) des patients ne presentant pas de pointes ou elements angulaires sur les EEG postnataux effectues a l'âge de 3 mois, mais chez 100% (3/3) des patients presentant des anomalies paroxystiques (p = 0.022). Les auteurs concluent que chez les nourrissons ayant presente des crises neonatales confirmees par des enregistrements EEG critiques obtenus au hasard, l'EPN (souvent a type de syndrome severe, comme les spasmes infantiles) survient beaucoup plus frequemment qu'il n'a ete signale plus tot, souvent malgre la poursuite d'un traitement anticonvulsivant. Les nourrissons qui etaient comateux pendant la periode neonatale, qui presentaient des anomalies nettes de l'activite de fond EEG et qui ont presente plus tard un retard mental ou une IMC et chez lesquels l'EEG met en evidence des elements paroxystiques lors du suivi postnatal, presentaient le risque le plus important d'EPN.

Postictal psychosis after partial complex seizures: a multiple case study.

Abstract: Bouts of unusually frequent partial complex seizures originating in the temporal lobe, that sometimes became secondarily generalized, induced psychotic episodes in 9 patients. In 7, the increase in seizures occurred at a time when antiepileptic drugs (AEDs) were being reduced during intensive EEG monitoring with a view to surgical treatment of intractable epilepsy. According to DSM-III-R criteria, the postictal psychosis resembled an organic delusional syndrome which was paranoid in 7 and schizophreniform in 1 and an organic mood syndrome in 1. A high incidence of ictal fear, of bilateral independent epileptogenic discharge, and of small foreign tissue lesion were unexpected findings and appeared to represent risk factors, especially in patients otherwise handicapped by an epileptic personality disorder. Recognition of postictal psychosis in this setting and in others is important both prognostically and therapeutically. Postictal psychosis does not constitute a contraindication to surgical treatment of epilepsy.

Reproductive endocrine considerations and hormonal therapy for men with epilepsy.

Abstract: Androgen deficiency is unusually common among men with epilepsy. It may contribute to reproductive and sexual dysfunction and possibly exacerbate seizure frequency. The most important androgen is testosterone. it exists in the serum in a free form or bound to albumin or sex hormone-binding globulin (SHBG). Free testosterone levels have correlated significantly with measures of potency and sexual interest. The possibility that measures of non-SHBG-bound testosterone may provide a more sensitive assessment of biologically and perhaps clinically significant androgen levels is raised for consideration. Androgen deficiency may result from increased catabolism and binding induced by antiepileptic drugs (AEDs). It is a feature of the reproductive endocrine disorders that are often associated with epilepsy: hypogonadotropic hypogonadism, hypergonadotropic hypogonadism, and functional hyperprolactinemia. It may be a consequence of medication-induced elevations in serum estradiol. Estradiol exerts a potent inhibitory influence on luteinizing hormone secretion and may contribute to premature aging of the reproductive system, both at the level of the testes and the hypothalamus. Testosterone therapy may moderately benefit reproductive and sexual function. Despite its antiseizure effects in animal experiments, however, it has not been reported to improve seizures clinically. One possible explanation is that AEDs that induce enzyme synthesis may enhance the conversion of testosterone to estradiol by aromatase. This possibility is supported by the improved seizure control achieved with the adjunctive use of the aromatase inhibitor testolactone or the antiestrogen clomiphene.

Intracranial, Intraaxial, Space‐Occupying Lesions in Patients with Intractable Partial Seizures: An Anatomoclinical, Neuropsychological, and Surgical Correlation

Abstract: Summary: : Fifty of ˜250 patients evaluated for intractable partial seizures were shown to have a space-occupying lesion detected with radiographs and/or neuroimaging. Twenty-eight males and 22 females had a mean age at seizure onset of 13 years and a mean duration of seizures of 11 years. All patients had closed-circuit television with EEG monitoring and complete neurologic and neuropsychological assessment. Findings were correlated with lesion location and surgical data. Twenty-seven lesions (54%) were located in the temporal lobe. Thirty-five lesions (70%) were neoplastic. All patients with temporal lobe lesions had complex partial seizures, as did 74% of patients with extratemporal lesions. A good correlation between clinical seizure characteristics and lesion localization was found with the temporal, occipital, and frontal lesions but not with the parietal lesions. Sixty-six percent of patients had focal interictal EEG findings. Lateralization corresponded to the side of the lesion in 64% and was localized to the region of the lesion in 30%. Lateralized ictal EEGs occurred in 58% of patients, corresponding with the side of the lesion in all but one patient. Abnormal findings on neuropsychological testing were congruent with lesion lateralization in 56% of patients and were localized to the region in 26%. Thirty-nine of 47 patients who underwent a subtotal lobectomy to include the lesion are seizure-free after ≫1 year of follow-up, and five others are markedly improved. RESUME Chez 50 patients sur 250 evalues pour des crises partielles rebelles, les auteurs ont detecte par la neuro-imagerie une lesion occupant ľespace. Chez 28 sujets masculins et 22 sujets feminins ľepilepsie avait commence en moyenne a 13 ans, et presentaient des crises depuis en moyenne 11 ans. tous les patients beneficiaient ďune surveillance EEG video et ďune evaluation neu-rologique et neuropsychologique complete. Les constatations Etaient correlees avec la localisation de la lesion et les donnees chirurgicales. 27 lesions (54%) se trouvaient au niveau des lobes temporaux. 35 lesions (70%) etaient neoplasiques. Tous les patients presentant des lesions du lobe temporal avaient des crises partielles complexes, comme 74% des patients presentant des lAesions extra-temporales. Les auteurs ont constate une bonne correlation entre les caracteristiques cliniques des crises et la localisation de la lesion dans les cas ou la lesion etait temporale, occipitale ou frontale, mais pas dans les cas ou la lesion etait parietale. 66% des patients presentaient des anomalies intercri-tiques focales sur ľEEG. La lateralisation correspondait a celle de la lesion chez 64%, elle etait localisee a la region de la lesion chez 30%. Des EEG critiques lateralises ont ete constates chez 58% des patients, correspondant au cote de la lesion chez tous les patients sauf 1. Les anomalies constatees aux tests neuropsy-chologiques ont ete coherentes avec la lateralisation de la leasion chez 56% des cas, elles etaient meme localieses a la region de la lesion chez 26%. 39 des 47 patients qui ont beneficie ďune lobec-tomie sub-totale incluant la lesion n'ont plus de crises apres un suivi ďau moins un an, 5 patients supplementaires presentent une amelioration importante. RESUMEN En 50 de aproximadamente 250 pacientes estudiados por padecer ataques parciales resistentes a la terapia se encontro una lesion ocupante de espacio mediante estudios de rayos-x y/o neuroimagen. La edad media fue de 13 anos en 28 varones y 22 hembras y la duracion media de los ataques fue de 11 a4nTos. Todos los pacientes fueron sometidos a monitorizacion del EEG y de televiseon en circuito cerrado a la vez que a un estudio complete neurologico y neuropsicoldgico. Los hallazgos se cor-relacionaron con la localizacion de la lesion y la informacion quinirgica. Se encontro una localization en el lobulo temporal en 27 lesiones (54%) y 25 de ellas (70%) fueron neoplasias. Todos los pacientes con lesiones de lobulo temporal tenian ataques parciales complejos asi como 74% de los pacientes con lesiones extratemporales. Se encontro una correlation buena entre las characteristicas clinicas de los ataques y la localizacion de la lesion en el lobulo temporal, occipital y frontal pero no conlesiones del lobulo parietal. El 66% de los enfermos tenian hallazgos focales en el EEG interictal. La lateralizacion correspondid al lado de la lesion en 64% de los casos y se localizo la region de la lesion en el 30%. Se registro un EEG con lateralizacion ictal en el 58% de los pacientes que correspondia al lado de la lesion en todos ellos menos un caso. Los hallazgos anormales en los estudios neuropsicologicos fueron congruentes con la lateralizacion de la lesion en el 56% de los casos y con la localizacion exacta de la region en el 26%. En 39 enfermos de los 47 pacientes que fueron sometidos a una lobectomia subtotal, que incluia la lesion, se consiguid un pen'odo libre de ataques de un ano o mas y ana marcada mejoria en 5 anos adicionales. ZUSAMMENFASSUNG Bei 50 von etwa 250 Patienten, die wegen therapieresistenter Partialanfalle mit bildgebenden Verfahren untersucht wurden, fand sich eine Raumforderung. 28 Manner und 22 Frauei erkrankten im Mittel im 13. Lebensjahr an Anfallen mit einet Dauer von durchschnittlich 11 Jahren. Bei alien Patienten wurden Doppelbildaufzeichnungen, EEG, neurologischer und neu-ropsychologischer Befund dokumentiert. Die Ergebnisse wurden mit der Lokalisation der L%aUsion und den neurochirurgischen Daten verglichen. 27 Raumforderungen lagen im Temporallap-pen (54%). Bei 35 Fallen handelt es sich urn Neoplasien (79%). Alle Patienten mit Temporallappenbefunden boten komplexe Partialanfalle; demgegenuber nur 74% bei extratemporaler Lasion. Eine gute (Correlation zwischen klinischen Anfallssymp-tomen und Lokalisation der Lasion fand sich bei temporalem, occipitalem und frontalem Sitz, jedoch nicht bei parietalem. 66% der Patienten boten interiktual fokale EEG-Befunde. In 64% korrespondierte der Seitenhinweis im EEG mit der Lasion, in 30% mit der eigentlichen Hirnlokalisation. Lateralisierte iktuale EEG-Befunde zeigten 58% der Patienten, die bei allen, auser einem, der pathologischen Seite entsprachen. Pathologische Be-funde und neuropsychologische Testungen waren in 56% deck-ungsgleich mit der Seitenlokalisation aber nur in 26% mit der Hirnregion. 39 von 47 Patienten mit subtotaler Lobektomie waren 1 Jahr und langer anfallsfrei und weitere 5 waren deutlich gebessert.

Neurochemical and behavioral aspects of lamotrigine.

Abstract: Lamotrigine (LTG), a new anticonvulsant, chemically unrelated to current antiepileptic drugs (AEDs), resembles phenytoin (PHT) and carbamazepine (CBZ) in ability to block hindlimb extension in both the maximal electroshock test and leptazol-induced seizures. Results indicate that LTG may be of value in both partial and generalized seizures. In in vitro studies, LTG has been shown to inhibit veratrine-evoked release of glutamate when a threshold depolarizing concentration (4 micrograms/ml) is used, and also inhibits aspartate release when a larger stimulus is given (10 micrograms/ml). However, LTG does not block potassium-evoked transmitter release. LTG is a less potent inhibitor of the release of gamma-aminobutyric acid (GABA), acetylcholine, noradrenaline, and dopamine. LTG blocks the neurotoxicity of kainic acid in vivo, supporting the in vitro findings, and suggests that the anticonvulsant effect of LTG may be due to inhibition of glutamate release. In a test of working memory and phencyclidine (PCP) discrimination studies, LTG had no effect, indicating no sharing of the same PCP-like side effects associated with NMDA receptor blockade. In the gerbil model of global ischemia, high doses of LTG provided protection against damage to the CA1 region of the hippocampus. Analogues of LTG of higher potency to block the release of glutamate may be necessary to ensure protection against ischemic brain damage.

Juvenile myoclonic epilepsy: factors of error involved in the diagnosis and treatment.

Abstract: Juvenile myoclonic epilepsy (JME), a common form of idiopathic generalized epilepsy, has a distinct clinical and electroencephalographic profile. Often JME is not recognized, with serious consequences on the sufferers. We examined factors contributing to the missed diagnosis even in an epilepsy clinic. Of 70 JME patients, 66 (91.4%) were not diagnosed on referral and 22 (33%) were not initially recognized in the epilepsy clinic. The correct diagnosis was established after a mean of 8.3 +/- 5.5 years from disease onset and an interval of 17.7 +/- 10.4 months from first evaluation in the epilepsy clinic. Myoclonic jerks, the hallmark of the disease, were not usually reported by patients. Similarly, relevant questioning may not be included in the history. Absence seizures antedating jerks by many years, myoclonic jerks reported as unilateral, generalized tonic-clonic seizures occurring during sleep and focal EEG abnormalities are other factors contributing to not recognizing JME. Our study reemphasizes the need to have not only a correct seizure diagnosis but also a correct epilepsy-disease diagnosis.

Felbamate: a clinical trial for complex partial seizures.

Abstract: Summary: We performed a randomized, double-blind, three-period cross-over study of felbamate (FBM, 2-phenyl-l,3-propanediol dicarbamate: Carter-Wallace 554) in patients with complex partial seizures. Patients continued carbamazepine (CBZ) throughout the study and were observed in the hospital for the entire trial period. The entry criteria required at least six seizures in a 3-week baseline period (and no more than 1 week with a single seizure) with CBZ alone. Thirty subjects were randomized. Two left the study after randomization, 1 owing to seizure exacerbation, and 1 owing to hyponatremia, which may have been related to CBZ therapy. The daily dosage of 50 mg/kg (maximum 3,000 mg) FBM per day was well tolerated by all 28 patients who completed the study. Only mild adverse experiences were observed during the trial. FBM reduced CBZ level (p < 0.0001; 95% confidence interval -28%, -20%). There was no significant difference in seizure frequency between placebo and FBM periods (one-sided p = 0.172), but when a correction was made for the lower CBZ level noted during FBM periods, the data suggested a strong antiseizure effect of FBM. RESUME Les auteurs ont realise une etude du Felbamate (FBM, 2-phenyl-1, 3-propanediol dicarbamate: Carter-Wallace 554) chez des patients presentant des crises partielles complexes, suivant un protocole randomise, en double-aveugle, avec croisement sur trois periodes. Les patients ont maintenu un traitement par carbamazepine (CBZ) tout au long de l'etude, et ont ete conserves et observes en milieu hospitalier pendant toute la periode de l'etude. Les criteres d'entree comprenaient un minimum de 6 crises pendant la periode de base de 3 semaines (avec moins d'une semaine avec une seule crise) sous monotherapie sous CBZ. Trente sujets ont ete randomises dans cette etude. Deux ont quitte l'etude apres randomisation, l'un en raison d'une exacerbation des crises, l'autre en raison d'une hyponatremie, qui pouvait etre due au traitement par CBZ. La dose quotidienne de FBM a 50 mg/kg (maximum 3,000 mg) a ete bien toleree par les 28 patients quo ont poursuivi l'etude jusqu'a la fin. 11 n'y a eu que des effets secondaires mineurs. Le FBM a diminue les taux de CBZ (p < 0.0001; intervalle de confiance a 95% -28%, -20%). il n'y avait pas de difference significative dans la frequence des crises entre le placebo et les periodes FBM (p = 0.172). Cependant, apres correction tenant compte de l'abaissement des taux sanguins de CBZ pendant les periodes sous FBM, les resultats sont en faveur d'un effet antiepileptique puissant du FBM. RESUMEN En enfermos con epilepsia parcial compleja se ha realizado, de modo randomizado, un estudio doble ciego con 3 periodos de cruce con felbamato (FBM, 2-fenil-l, 3-propanediol dicarba-mato: Carter-Wallace 554). Los pacientes continuaron tomanddo carbamacepina (CBZ) a lo large del estudio y se observaron en el hospital durante todo el periodo de ensayo. Los criterios de inclusion requirieron al menos haber tenido 6 ataques en un periodo basal de 3 semanas (no mas de una semana sin un ataques) tomando solo CBZ. Los 30 sujetos fueron randomizados. Dos abandonaron el estudio despues de la randomizacion, 1 debido a una exacerbacion de los ataques y otro a una hiponatremia que pudo estar relacionada con la terapia con CBZ. La dosis diaria de 50 mg/kg (maximo 3,000 mg) de FBM al dia, se tolero bien en los 28 enfermos que terminaron el estudio. Solamente se encon-traron minimos sintomas colaterales durante el ensayo. El FBM reduce los niveles de CBZ (p < 0.0001; 95% de intervalo de confianza -28%, -20%). No se encontraron diferencias significa-tivas en la frecuencia de ataquesentre los periodos placebo o con FBM (p = 0.172). Sin embargo, cuando se realizo una correccion para los niveles mas bajos de CBZ encontrados durante los periodos de tratamiento con FBM, la informacion sugiere un potente efecto antiataque del FBM. ZUSAMMENFASSUNG Wir fuhrten eine randomisierte, Doppelblindstudie durch mit drei Cross-over-Perioden mit Felbamat (FBM), (2-phenyl-l, 3-propanediol dicarbamat: Carter-Wallace 554) bei Patienten mit komplexen Partialanfallen. Wahrend der Untersuchung nahmen die Patienten CBZ weiter ein und wurden stationar im Kranken-haus beobachtet. Als Aufnahmekriterium galten wenigstens 6 Anfalle in den vorangegangenen drei Wochen und nicht mehr als eine Woche mit nur einem Anfall unter CBZ-Monotherapie. 30 Patienten wurden randomisiert. 2 verlieβen die Studie nach der Randomisierung wegen vermehrter Anfalle und wegen Hypona-triamie, moglicherweise im Gefolge der CBZ-Therapie. Die Tag-esdosis von 50 mg/kg KG (max 0.3 g) FBM wurde von alien 28 Patienten gut vertragen. Nur leichte Nebenwirkungen wurden wahrend des Versuchs festgestellt. FBM verminderte die Car-bamazepinspiegel (p = 0.0001). Es erbag sich keine signifinkante Anderung der Anfallsfrequenz wahrend Placebo und FBM-GAbe (p = 0.172). Wurden jedoch die verminderten CBZ-Spiegel ko-rrigiert, so fand sich wahrend der FBM-Periode ein deutlich an-tiepileptischer Effekt von FBM.

Epilepsy in children with mental retardation: a cohort study.

Abstract: Summary: The cumulative risk of seizures and epilepsy was investigated in a prospectively identified cohort of 221 children with mental retardation (MR) born between 1951 and 1955 in Aberdeen, Scotland. By age 22 years, 33 (15%) had epilepsy. An additional 16 (7%) had had at least one seizure, but did not meet the criteria for epilepsy. The cumulative risk of epilepsy was 9, 11, 13, and 15% at 5, 10, 15, and 22 years, respectively. In children with MR and no associated disabilities, the cumulative risk of epilepsy was only 2.6, 3.2, 3.9, and 5.2% at 5, 10, 15, and 22 years. In children with MR and cerebral palsy (CP), the cumulative risk was 28, 31, and 38% at 5, 10, and 22 years. Children with a postnatal injury associated with MR had a cumulative risk of epilepsy of 53, 66, and 66% at 5, 10, and 15 years after the injury. By age 22 years, 39% had achieved 5-year seizure-free remission, including 56% of children with MR without associated disability, 47% of children with MR and CP, and 11% of children with a postnatal injury. We conclude that, in the absence of associated disability or postnatal injury, the risk of epilepsy in the retarded population is low. Epilepsy in this population also will frequently enter remission in later life.

Clinical pharmacology of lamotrigine.

Abstract: The pharmacokinetics and pharmacodynamics of lamotrigine (LTG), a new antiepileptic drug (AED), were studied in healthy volunteers. In an open dose-escalating study, LTG 240 mg produced peak plasma concentrations of around 3 micrograms/mg with no significant adverse events. Subsequent pharmacokinetic studies revealed complete oral absorption, first-order kinetics with a mean half-life of approximately 1 day, and elimination mainly as a glucuronide in the urine. Early studies in patients with epilepsy revealed more rapid metabolism when given with enzyme-inducing AEDs and delayed metabolism by valproate. A placebo-controlled, double-blind study compared LTG 120 and 240 mg with phenytoin (PHT) 500 and 1,000 mg, and diazepam (DZP) 10 mg. Visual analogue scales showed sedation after PHT 1,000 mg and DZP 10 mg, but not after LTG. Smooth pursuit eye movements and adaptive tracking were impaired by DZP and PHT 1,000 mg. LTG did not affect these variables. A comparison of LTG 150 and 300 mg and carbamazepine (CBZ) 200, 400, and 600 mg demonstrated impairment of smooth pursuit and saccadic eye movements by CBZ 600 and 400 mg, but not by LTG. Additionally, CBZ 600 mg impaired adaptive tracking and increased body sway and heart rate. These studies have shown LTG to have desirable and predictable pharmacokinetic properties for an AED. Pharmacodynamic effects were absent, suggesting a high therapeutic index.

Temporal Lobectomy and Independent Bitemporal Interictal Activity: What Degree of Lateralization Is Sufficient?

Abstract: Summary: We attempted to determine whether the degree of lateralization of independent bitemporal interictal spikes and sharp waves (ISSW) is correlated with good results after temporal lobectomy. Three observers independently counted ISSW in the scalp EEGs of 59 candidates for temporal lobectomy to determine the degree of lateralization of ISSW. Interobserver correlation in percentage of lateralization was excellent (r= 0.92). Thirty-one candidates were also evaluated with depth EEG (DEEG). Operative success was graded by the number of seizures reported in the second postoperative year. There was a significant progressive decrease in the number of good operative results as the degree of lateralization of ISSW lessened (p = 0.0142). Ninety-two percent of patients with >90% lateralization had a good surgical outcome, whereas only 50% with 90% lateralization appeared to have better outcomes than patients with 90% lateralization of temporal ISSW is associated with good surgical outcome, and DEEG may not be necessary in these patients. Less than 90% lateralization is associated with poor surgical outcome and the additional information provided by DEEG may be especially useful in such patients. RESUME Les auteurs ont essaye de savoir si le degre de lateralisation de pointes et d'elements angulaires intercritiques bitemporaux in-dependants (PIBI) est corrElE avec de bons rEsultats apres lobec-tomie temporale. Trois observateurs independants ont compte les PIBI sur les EEG de surface chez 39 candidats a une lobec-tomie temporale, afin de preciser le degre de lateralisation des PIBI. La correlation inter-observateurs dans le pourcentages de lateralisation s'est revelee excellente (r = 0.92). Trente et un candidats ont egalement beneficie d'une evaluation par EEG in-tra-cerebral (EEGIC). Le succes de l'acte chirurgical a ete cote en fonction du nombre de crises signalees pendant la seconde annee postoperatoire. Les auteurs ont constate une diminution progressive significative du nombre de bons resultats chirurgi-caux lorsque le degre de lateralisation des PIBI diminuait (p = 0.0142). 92% des patients presentant une lateralisation superieure a 90% avaient une evolution postchirurgicale satisfaisante, contre seule 50% des patients avec une lateralisation inferieure a 90%. Meme lorsque toutes les crises enregistrees par EEGIC prenaient Ieur origine du cote de la lobectomie, les patients presentant une lateralisation superieure a 90% avaient une evolution meilleure que les patients presentant une lateralisation inferieure a 90%. Les auteurs concluent qu'une lateralisation superieure a 90% des PIBI est corrElEe a une bonne Evolution postchirurgicale, et que l'enregistrement par electrodes pro-fondes peut etre superflu chez ces patients. Une lateralisation inferieure a 90% est correlee avec une evolution postchirurgicale peu satisfaisante, et l'information supplementaire apportee par l'EEGIC peut etre particulierement utile chez de la tels patients. RESUMEN Hemos intentado determinar si el grado de lateralizacion de puntas interictales bitemporales independientes y ondas agudas (ISSW) se correlacionan con resultados buenos depues de una lobectomia temporal. Las ISSW fueron contadas en EEGs con electrodos en cuero cabelludo por 3 observdores independientes en 50 candidates para lobectomia temporal y determinar el grado de Iateralizacion de las ISSW. La correlateon interobservador con repecto al procentaje de Iateralizacion fue excelente (r = 0.92). Treinta y un candidatos fueron tambiEn evaluados con EEGs registrados con electrodos profundos (DEEG). El Exito quinirgico se graduo con el niimero de ataques que aparecieron en el 2o ano postoperatorio. Se observes una reducvcion progre-siva y significativa con respecto al numero de buenos resultados a medida que el grado de Iateralizacion de las ISSW disminuyo (p = 0.142). El 92% de Ios enfermos con una lateralizacion mayor que el 90% presentaron un resultado quinirgico bueno mientras que solo el 50% con menos del 90% de lateralization alcanzaron este resultado. Incluso cuando todos los ataques registrados me-diante DEEG se originaban en el lado de la lobectomia, los pa-cientes con un porcentaje de lateralization mayor que 90 mos-traron unos resultados mejores que los enfermos con menos del 90% de lateralizacion. Hemos concluido que la lateralizacion mayor del 90% de las ISSW temporales se asocian con buenos resultados quirurgicos y que no es necesario practicar un DEEG en estos enfermos. Una Iateralizacion menor del 90% se asocian con resultados quirurgicos pobres y la informacion adicional que puede proporcionar el DEEG puede ser especialmente util en estos casos.

Localization of lesions by neuropsychological testing.

Abstract: Neuropsychological evaluation differs from other methods used to localize cerebral lesions in that it analyzes cognitive function. Tests sample widely among cognitive abilities, contrasting language proficiency with visuospatial skills. A thorough assessment of memory is crucial in the investigation because of the prominence of the temporal lobes in epileptogenesis and their importance in memory. Different aspects of learning and memory are tested, and measures sensitive to hippocampal function should be included. Patients who will undergo elective surgery may also undergo intracarotid sodium amobarbital tests, which provide additional information about the integrity of each hippocampal region. Appraisal of frontal-lobe function is another important part of neuropsychological evaluation. A growing number and variety of neuropsychological tests have proven to be sensitive to lesions in this large and complex cortical area. Frontal-lobe function could be expected to vary according to the function of subregions within the frontal lobes, and some tests appear to be sensitive to specific regions.

Epilepsy with continuous spike-waves during slow sleep and its treatment.

Abstract: SUMMARY: Five children with epilepsy with “continuous spike-waves during slow sleep” (CSWS) are reported. The main clinical features of CSWS include (a) onset between 5 and 7 years of age, (b) the occurrence of several types of seizure (i.e., partial motor, generalized motor, and atypical absence), and (c) the presence of language disturbances and abnormal behavior based on emotional impairment. The EEG findings were characterized by sleep tracings showing almost continuous (>95%), diffuse slow spike and wave activity. After treatment with valproate (VPA) (or ethosuximide, ESM) and clonazepam (CZP), the spike and wave complex status disappeared. Symptoms and signs of the CSWS also decreased. We suggest that combined treatment is an appropriate treatment for CSWS. RESUME Cinq enfants presentant une epilepsie avec pointes ondes continues pendant le sommeil lent (POCS) ont eteetudies par les auteurs. Les principales caracteristiques cliniques du syndrome des POCS comprennent: (1) installation entre l'âge de 5 et 7 ans, (2) survenue de plusieurs types de crises (partielles motrices, generalisees motrices et absences atypiques), (3) presence de perturbations du langage et d'anomalies comportementales fondees sur des deficits emotionnels. Les constations EEG ont ete caracterisees par l'existence sur les traces de sommeil de pointes ondes continues diffuses (+ de 95%). Un traitement associant valproate (ou ethosuximide) et clonazepam a permis d'obtenir une disparition de l'etat de mal infraclinique. Les symptomes du syndrome des POCS ont diminue Les auteurs suggerent qu'un traitement associe est justifie dans le syndrome des POCS. RESUMEN Se presentan cinco ninos con epilepsia con “complejos puntaonda continuos durante la fase de sueno lento” (CSWS). Los hallazgos clinicos mas importantes de los CSWS incluyen: 1-comienzo entre los 5 y los 7 anos de edad, 2-aparicion de varios tipos de ataques (motores parciales, motores generalizados y ausencias atipicas) y 3- presencia de trastornos del lenguaje y comportamiento anormal basados en alteraciones emocionales. Los hallazgos en el EEG se caracterizaron por registros, durante el sueno, que mostraban actividad difusa de punta-onda casi continua (mas de 95%). Despues de un tratamiento con Valproato (o etosuximida) y Clonazepam, el status de complejos punta-onda desaparecieron. Tambien disminuyeron los sintomas y signosde los CSWS. Sugerimos que un tratamiento combinado es apropiado para control de los CSWS. ZUSAMMENFASSUNG Uber 5 Kinder mit einer Epilepsie mit kontinuierlichen spikewaves wahrend des langsamen Schlafs (CSWS) wird berichtet. Klinische Hauptmerkmale sind: 1. Beginn zwischen 5. und 7. Lebensjahr 2. Auftreten von verschiedenen Anfallen, z.B. fokale und generalisierte motorische Anfalle sowie atypische Absencen. 3. Auftreten von Sprachstorungen und Verhaltensauffalligkeiten aufgrund emotionaler Verschlechterung Das EEG zeigt in den Schlafableitungen fast kontinuierliche diffuse slow-spike-wave-Aktivitat (bei fast 95%). Nach einer Kombinationstherapie mit Valproat (Suximid) und Clonazepam verschwand der SW-Status, ebenso verringerten sich die klinischen Auffalligkeiten. Aufgrund dieser Erfahrungen halten wir diese Komedikation fur die angemessene Behandlung des CSWS.

A retrospective study of spontaneous remission and long-term outcome in patients with infantile spasms.

Abstract: The spontaneous remission rate and long-term outcome in 44 patients with infantile spasms not treated with hormonal drugs were studied. The cumulative spontaneous remission rate during the first 12 months after onset of infantile spasms, as determined by retrospective analysis, was as follows: 1 month, 2%; 2 months, 2%; 3 months, 5%; 4 months, 7%; 5 months, 9%; 6 months, 11%; 7 months, 11%; 8 months, 14%; 9 months, 16%; 10 months, 18%; 11 months, 25%; 12 months, 25%. The average age at follow-up was 80 months. Nine percent of patients had normal development or only mild impairment. The remainder showed various degrees of retardation. These data should be useful in the design and interpretation of therapeutic drug trials in patients with infantile spasms.

Effect of Valproate on Human Cerebral Glucose Metabolism

Abstract: We studied the effects of valproate (VPA) on local cerebral glucose metabolism (LCMRglc) in eight patients with partial seizure disorders and two with primary generalized epilepsy. Each patient had two positron-emission tomography (PET) scans with 18F-2-deoxyglucose (FDG), with, and without, VPA (mean level 52 mg/dl, range 30-127 mg/dl). Patients continued carbamazepine (CBZ) for both scans: serum concentrations were not significantly changed by VPA (CBZ range 5.4-12 mg/dl). Seven patients had the "without-VPA" scan first. Mean interval between PET scans was 75 days. Global CMRglc was decreased by 22% by addition of VPA (7.2 +/- 1.8 mg/100 g/min without VPA, 5.6 +/- 1.1 g/min with VPA, p less than 0.05, corrected). Thirteen regions of interest (ROIs) were analyzed in each hemisphere in each PET scan. Metabolic rates were significantly lower in 15 of 26 ROIs with VPA (p less than 0.05, corrected). VPA depresses cerebral metabolism to a greater degree than do CBZ and phenytoin (PHT) but less than does phenobarbital (PB). The metabolic effect may be related to the mechanism of action and have neuropsychological implications.

Pregnancy and epilepsy.

Abstract: Women with epilepsy account for approximately 0.5% of all pregnancies. Their pregnancies are high risk because of an increased frequency of maternal seizures, complications of pregnancy, and adverse pregnancy outcomes. The increase in seizure frequency is associated with a progressive decline in antiepileptic drug (AED) levels during pregnancy even with constant dosing. Fetal deaths after a generalized seizure, although rare, have been reported, and a marked decline in fetal heart rate has been demonstrated after such seizures during delivery. AEDs have been implicated in causing a twofold increase in the rate of congenital malformations, a variety of minor physical anomalies, mostly involving the midface, and a neonatal hemorrhagic disorder. The clinician caring for a pregnant woman with epilepsy is therefore faced with a dilemma and must carefully chart a middle ground providing effective seizure control while minimizing fetal exposure to AEDs.

Surgical Versus Medical Treatment for Epilepsy. I. Outcome Related to Survival, Seizures, and Neurologic Deficit

Abstract: Summary: We conducted a retrospective parallel longitudinal cohort study comparing surgical and medical treatment for epilepsy. The surgical group contained 201 patients treated with resective surgery for epilepsy in Norway since the first operation in 1949 until January 1988. The 185 control group patients treated medically only were closely matched for year of treatment, age at treatment, sex, seizure type, and neurologic deficit before treatment. There was no significant difference in survival between the two groups. The total monthly seizure frequency in the first and second year after operation and last year of registration (median 9 years) was significantly lower in the surgical group than in the control group (Mann-Whitney U test, two-tailed p < 0.0001). The patterns were similar, with significant differences for subgroups with similar pretreatment status, such as seizure frequency, age, etiology and EEG-focality. Twenty-three and four-tenths percent (n = 40) of the surgically treated, and 2.9% of the controls had contracted neurologic deficits within 2 years after treatment. The difference was significant (chi square = 32.89, p < 0.0001). Psychosis or permanent psychotic symptoms were reported in 6.7% (n = 11) of the surgically treated patients, and we suspect a higher proportion of psychotic development in the surgical group than in the control group. We conclude that surgical treatment for partial epilepsy is more successful than medical treatment in producing seizure reduction, provided the indications for operation exist. Surgical treatment produces more neurologic deficits than medical treatment (and possibly more psychiatric morbidity), and this factor must be weighed against the reduction in seizure frequency. The two treatments are equal for long-term survival. RESUME Une etude retrospective longitudinale de cohortes paralleles a ete menee pour comparer le traitement medical et chirurgical de ľepilepsie. Le groupe chirurgical etait constitue par 201 patients ay ant beneficieďune chirurgie de resection en Norvege depuis la premiegre operation en 1949 jusqu'en Janvier 1988. Le groupe controle, avec traitement medical seul, etait constitue de 185 sujets apparies pour la duree du traitement, ľâge au moment du traitement, le sexe, le type de crises, et ľexistence ďun deficit neurologique avant traitement. II n'y a pas eu de difference significative dans la survie entre les deux groupes. La frequence mensuelle des crises dans la premiere et seconde annee apres ľintervention et pendant la derniere annee de suivi (mediane: 9 ans) etait significativement plus basse dans le groupe chirurgical que dans le groupe controle (Test-Mann-Whitney U, p < 0.0001). La comparaison donne des resultats similaires, avec des differences significatives dans les sous-groupes presentant un status pre-thearapeutique semblable, comme la frequence des crises, ľâge, ľetiologie et la focalisation sur ľEEG. 23.4% (n = 40) des patients traites chirurgicalement, et 2.9% des sujets controles ont vu s'installer des deficits neurologiques dans les deux annees qui ont suivi le traitement. La difference est significative x2= 32.89, p < 0.0001). Une psychose ou des symptooCmes psychotiques permanents ont ete signales chez 6.7% (n = 11) des patients traites par chirurgie, et les auteurs pensent qu'il y a une proportion plus e1evee ďevolution vers la psychose dans le groupe chirurgical que dans le groupe controle. Les auteurs concluent que le traitement chirurgical ďune epilepsie partielle est plus efficace que le traitement medical dans ľobtention ďune reduction des crises, dans la mesure ouľindication de la chirurgie peut Stre retenue. Le traitement chirurgical produit plus de deficits neurologiques que le traitement medical, et peut-etre plus de morbidite psychiatrique, ceci doit etre pris en consideration lorsque ľon parle de reduction de la frequence des crises. Les deux traitements sont egaux pour la survie a long terme. RESUMEN Se ha completado un estudio retrospectivo de cohortes, longitudinal y paralelo, comparando el tratamiento quirurgico y medico para la epilepsyia. El grupo quirurgico consistia en todos los 201 enfermos tratados en Noruega con reseccion quirurgical para epilepsyia desde la primera operacion realizada en 1949 hasta 1988. Los 185 controles trados medicamente eran comparables en lo que respecta al comienzo des tratamiento, la duration del mismo, el sexo, el tipo de ataques y el deficit neurologico anterior al tratamiento. No se encontraron diferencias significativas en la supervivencia entre los dos grupos. La frecuencia mensual total de los ataques en el primero y en el segundo al despues de la operacion y en el ultimo de la inclusion en el registro (media de 9 anos), fue significativamente mas baja en el grupo quirurgico que en el control (Mann-Whitney U-Test de dos ramas p < 0.0001). Los patrones fueron similares con diferencias significatives para subgrupos con semejante situation pre-tratamiento tales como frecuencia de ataques, edad, etiologia y focalidad en el EEG. El 23.4% (n = 40) de los tratados quirurgicamente y el 2.9% de los controles presentaron deficits neurologicos contraidos durante los dos anmacr;os que siguieron al tratamiento. Esta diferencia es significativa (x2= 32.89, p < 0.0001). Se observaron psicosis o sintomas psicoticos permanentes en el 6.7% (n = 11) de los tratados quirurgicamente y se sopecha una proporcion mas elevada de desarrollo psicotico entre el grupo tratado quirurgicamente que en el group control. Se concluye que el tratamiento quirurgico para la epilepsyia parcial conduce a un exito mayor que el tratamiento medico en lo que se refiere a reduction de los ataques, siempre que existan las indicaciones para la cirugia. El tratamiento quirurgico produce mas deficits neurologicos que el tratamiento medico y posiblemente una morbilidad psiquidtrica mayor. Estos datos deben ser tenido en cuenta en relacion con la reduccion de la frecuencia de los ataques. Los dos tratamientos producen las mimsas prolongadas expectativas de vida. Los criterios fundamentals para realizar cirugia como tratamiento de la epilepsyia son: (1) fracaso de un intenso intento de medicateon antiepileptica que ofrezca el suficiente control de los ataques, (2) la demostracion de un origen focal de los ataques en un area del cerebro que puedo ser extirpada sin producir defectos neurologicos significativos y (3) la realizacion por parte del paciente de una alteration significativa a nivel personal o social causda por los ataques incontrolados. ZUSAMMENFASSUNG Es handelt sich um eine retrospektive parallele Kohortenuntersuchung zum Vergleich von chirurgischer und konservativer Epilepsie-Behandlung. Die chirurgische Gruppe umfasst alle 201 Patienten mit Resektion wegen einer Epilepsie seit der ersten Operation 1949 in Norwegen bis Januar 1988. Die 185 konservativ behandelten Patienten der Kontrollgruppe wurden passend nach Behandlungsjahr, Alter bei Behandlung, Geschlecht, Anfallstyp und neurologischen Defiziten vor der Behandlung ausgewahlt. Die beiden Gruppen unterschieden sich nicht in der Uberlebenszeit. Die gesamte monatliche Anfallsfre-quenz im ersten und zweiten Jahr nch der Operation und im letzten Jahr der Aufzeichnung (Median 9 Jahre) war bei der operierten Gruppe signifikant geringer als bei der konservativ behandelten Gruppe (Mann-Whitney-U-Test, sweiteilig, p < 0.0001). Die Muster sind ahnlich mit signifikanten Unterschieden in den Untergruppen mit vergleichbarem Status vor Behandlung, wie Anfallsfrequenz., Alter, Atiologie und EEG-Fokalitat. 23.4% (n = 40) der Operierten und 2.9% der Kontrollen zeigten neurologische Defizite Innerhalb von 2 Jahren nach der Behandlung. Dieser Unterschied ist signifikant (x2= 32.89, p < 0.0001). Eine Psychose oder permanente psychotische Symptome wurden bei 6.7% (n = 11) der chirurgisch behandelten Patienten berichtet. Wir vermuten bei der chirurgischen Gruppe einen hoheren Anteil psychotischer Entwicklungen als bei der Kontrollgruppe. Wir schliesen, das eine chirurgische Behandlung bei Partialepilepsie-Patienten erfolgreicher zur Anfallsreduktion als eine konservative Behandlung ist, vorausgestzt, eine Operationsindikation liegt vor. Die operative Behandlung fuhrt zu mehr neurologischen Defiziten als die konservative Behandling und moglicherweise auch haufiger qu einer psychiatrischen Erkrankung. Dies mus gegenuber der Reduktion der Anfallsfrequenz abgewogen werden. Die beiden Behandlungs-modalitaten sind hinsichtlich der Langzeituberlebenschancen gleichwertig.

Human safety of lamotrigine.

Abstract: Summary: The clinical safety of lamotrigine (LTG), assessed in four completed randomized, double-blind, placebo-controlled crossover trials and an interim analysis of 27 12-month open studies, is discussed. LTG was added to existing anti-epileptic drugs (AEDs) of adult patients with refractory epilepsy, using a twice-daily regimen. In the pooled data from the four double-blind studies (n= 92), the incidence of adverse experiences with LTG and placebo did not differ significantly. Two patients were withdrawn on LTG due to adverse experiences (one rash, one nausea and vomiting). In the open studies (pooled data; n= 572) the most commonly reported adverse experiences were dizziness, diplopia, somnolence, headache, ataxia, and asthenia (10–14% incidence). Forty-nine patients (8.6%) were withdrawn with adverse events, most commonly for rash (2.3%). No patients were withdrawn from any of the studies with physical, neurological, or ECG abnormalities thought attributable to LTG treatment. Laboratory measures, vital signs, and weight did not show any consistent changes of clinical significance, and no significant changes in plasma concentrations of concomitant AEDs after the addition of LTG were observed.

Analysis of Foramen Ovale Electrode‐Recorded Seizures and Correlation with Outcome Following Amygdalohippocampectomy

Abstract: We report a detailed electroclinical analysis of 320 seizures recorded by foramen ovale electrodes in 77 potential candidates for selective temporal lobe surgery because of antiepileptic drug-resistant seizures. The exact localization of the origin of seizure discharges, the electroencephalographic (EEG) seizure onset patterns, transhemispheric propagation, propagation time, duration of discharge, laterality of discharge termination, postictal focal slowing, correspondence between foramen ovale recordings and the scalp EEG, and the influence of antiepileptic drug modifications were studied and correlated with the clinical seizure semiology and with postoperative outcome following selective amygdalohippocampectomy. In general, the foramen ovale electrode technique provided good neurophysiological information in candidates for selective amygdalohippocampectomy. The following ictal signs predicted a good surgical outcome: (a) unilateral and anterior mediobasal temporal lobe seizure onset, (b) short seizure duration, (c) no or infrequent contralateral seizure discharge propagation, and (d) if propagation to the contralateral mediobasal temporal lobe occurred, the postoperative outcome was better the later the contralateral mediobasal temporal lobe was affected. Postoperative outcome was also better the less frequently contralateral interictal spikes occurred. No direct predictive value could be attributed to the presence of an initial arrest reaction.

Impact of the Children's Epilepsy Program on parents.

Abstract: Summary: A randomized controlled trial was conducted in Santiago, Chile to test the efficacy of the Children's Epilepsy Program, a child-centered, family-focused intervention developed and pilot tested in Los Angeles, CA, U.S.A., using a counseling model for parents of children with seizure disorders to help them (a) deal with their anger, resentment, and grief related to the loss of a normal child; (b) increase their knowledge about caring for their child; (c) reduce anxieties related to having a child with a seizure disorder; and (d) improve their decisionmaking skills. All parents were pretested and then retested 5 months after the educational interventions. Parents in the experimental group (n = 185) and their children separately attended four 1 A-h sessions and then met together at the end of each session to share learning experiences. Comparison group parents (n = 180) and their children jointly attended three 2-h lecture sessions followed by question-and-answer periods. Although parents' overall knowledge of epilepsy was relatively high initially, it improved considerably in both comparison and experimental groups. With regard to anxiety, at the 5-month evaluation, experimental group parents and mothers in particular were more likely than control parents to state that they were less anxious (p < 0.001), and their anxiety, as measured by the Taylor Manifest Anxiety scale, was significantly reduced (p < 0.01). RESUME Une etude randomisee et controlee a ete menee a Santiago (Chili), afin ďevaluer ľefficaciteďun programme ďeducation pour ľepilepsie de ľenfant: il s'agit ďune intervention centree sur ľenfant, en milieu familial, qui a ete mise au point et testee a Los Angeles (U.S.A.) selon un modele de conseils aux parents ďenfants epleptiques. Ce programme avait pour but: (1) de traiterles sentiments de colere, ressentiment, et tristesse lies a la perte ďun enfant normal; (2) augmenter les connaissances surles soins a apporter aľenfant; (3) reduire ľanxiete liee aľepilepsie de leur enfant; (4) ameliorer leur formation et leur conduite. Tous les parents ont ete evalues de facon preliminaire puis re-evalues 5 mois apres les interventions educatives. Les parents du groupe experimental (n = 185) et leurs enfants ont assiste separement a 4 sessions ď1 heure 1/2, puis se rencontraient a la fin de chaque session pour partager leur experience ďapprentissage. Un groupe controle de parents (n = 180) et leurs enfants ont assiste ensemble a 3 sessions comprenant des cours de 2 heures suivis par des sessions de questions et reponses. Bien que la connaissance globale de ľepilepsie chez les parents ait ete relativement importante des le depart, elle a ete considerablement amealioree dans le groupe experimental comme dans le groupe controle. En ce qui concerne ľanxiete, ľevaluation a 5 mois a montre que les parents du groupe experimental, en particulier les meres, signalaient plus souvent que les parents du groupe controle qu'ils etaient moins anxieux (p < 0.001); leur anxiete, mesuree par ľechelle ďAnxiete Manifeste de Taylor, etait significativement moindre (p < 0.01). ZUSAMMENFASSUNG Eine randomisierte, kontrollierte Studie wurde in Santiago, Chile durchgefuhrt, um die Wirkung eines Kinder-Epilepsie-Programms zu testen: dabei handelt es sich um ein in Los Angeles, Kalifornien entwickeltes und pilotgetestetes Modell zur kind und familiengerechten Intervention, entsprechend einem Beratungsmodell fur Eltern von Kindern mit Anfallen. Ziel war es, den Eltern zu helfen: (1) im Umgang mit ihren Angsten, Resentiments und Kummer durch den Verlust eines normalen Kindes (2) ihr Wissen uber die Betreuung ihres Kindes zu vergrosern (3) ihre Angst zu verringern, ein Kind mit einem Anfallsleiden zu haben (4) ihre Entscheidungsfahigkeit zu verstarken. Samtliche Eltern wurden vorgetestet und 5 Monate spater, nach der Unterweisung nachgetestet. In der Testgruppe (n = 185) besuchten die Eltern und ihre Kinder getrennt 4 1 1/2 Stunden Seminare, um sich nach jeder Sitzung noch gemeinsam zur Vertiefung des Gelernten zu treffen. In einer Vergleichgruppe (n = 180) besuchten Eltern und Kinder 3 2-Stunden-Vorlesungen, gefolgt von einer Frage- und Antwortstunde. Obwohl bei alien Eltern das Wissen ziemlich gut war, verbesserte es sich jedoch betrachtlich in beiden Gruppen. Bezuglich der Angst waren nach 5 Monaten die Eltern, besonders die Mutter der Testgruppe in der Lage zu sagen, sie seien weniger angstlich als die der Kontrollgruppe (p = 0.001); gemessen an der Taylor-Angst-Skala war ihre Angst signifikant verringert (p = 0.01).

Surgical versus medical treatment for epilepsy. II. Outcome related to social areas.

Abstract: Summary: We conducted a retrospective parallel cohort study comparing surgical and medical treatment for epilepsy. The surgical group contained all 201 patients treated with resective surgery for epilepsy in Norway since the first operation in 1949 until January 1988. The 185 patients in the control group, medically treated only, were closely matched for year of treatment, age at treatment, sex, seizure type, and neurologic deficit before treatment. Between 75 and 95% of the survivors (median 17 years after treatment) completed two questionnaires on their social situation. Although surgical treatment improved the seizure situation (about one-fourth had some neurologic deficit), a considerably smaller long-range influence on different social aspects was observed. There were no significant differences between the two groups in educational status, social pensions, social status, marital status, fertility, dependency in residential situation, the need for aid in daily activities of living (ADL), or the need for being looked after, when we controlled for pretreat-ment status. In all, 25.3% of the surgically treated patients and 8.5% of the controls were not receiving anti-epileptic drugs (AEDs) at the time of investigation (Mann-Whitney U test, two-tailed p = 0.0011). A considerably higher proportion of the surgically treated (53.2%) than control patients (24.2%) claimed that the treatment had improved their “working ability” (Mann-Whitney [/test, two-tailed p < 0.0001), but this resulted in significant improvements in the actual working situation only for those in regular education or work before treatment (x2= 6.514, p = 0.038). RESUME Les auteurs ont mene une enquete retrospective de cohortes paralleles afin de comparer le traitement chirurgical et medical de ľepilepsie. Le groupe chirurgical comprend tous les 201 patients qui ont MneTicie' ďune chirurgie resective pour epilepsie en Norvege depuis la premiere operation de 1949 jusqu'en Janvier 1988. Un groupe controle de 185 patients traites uniquement par medicaments a ete apparie de facon stricte pour ľannee de traitement, ľâge au debut du traitement, le sexe, le type des crises et ľexistence ďun deficit neurologique avant traitement. Entre 75 et 95% des survivants (en moyenne 17 ans apres le dbeAut du traitement) ont rempli deux questionnaires portant sur leur situation sociale. Alors que la chirurgie a ameliore la situation sur le plan des crises (avec environ 1/4 des patients ayant acquis un deficit neurologique apres chirurgie) les auteurs ont observe une influence bien inferieure a long terme sur les differents aspects de la situation sociale des patients. II n'y avait pas de differences significatives entre les deux groupes pour le statut educatif, les pensions sociales, le statut social, le statut marital, la dependance au point de vue du logement, le besoin ďune aide dans les activite A quotidiennes, ou le besoin ďune tierce per-sonne, lorsque les sujets etaient controles en fonction du statut avant traiteme nt. 25.3% des patients operes et 8.5% des sujets controle s elaient sans traitement antiepileptique au moment de ľenquete (Mann-Whitney test-U, p = 0.0011). Une proportion nettement plus elevee des patients operas (53.2% contre 24.2% des controles) ont signale que le traitement avait ameliore leurs capacityes de travail (Mann-Whitney u-test p < 0.0001); cepen-dant, une amelioration significative de la situation reelle du travail n'a ete observee que chez les sujets qui etaient inseres normalement au point du vue scolaire ou dans leur travail le traitement (χ2= 6.514, p = 0.038). RESUMEN Se ha realizado un estudio de cohorte retrospectivo y paralelo comparando los tratamientos medicos y quirurgicos para la epilepsia. El grupo quirurgico incluia todos los 201 enfermos tratados en Noruega con resecciones quirurgicas para la epilepsia desde la primera operacion en 1949 hasta Enero de 1988. Los 185 controles tratados medicamente se ajustaban bien en lo que se refiere a ano de comienzo y duracion de tratamiento, sexo, tipo de ataques y deficits neurologicos anteriores al tratamiento. Entre el 75% y el 95% de los supervivientes (media de 17 anos despues del tratamiento) completaron dos cuestionarios que hacian referenda a su situacion social. Mientras el tratamiento quirurgico mejoraba la situacion de los ataques (con el desarrollo de algun deficit neurologico en 1/4 de los casos) se observo una mucho menor influencia a largo plazo en diferentes aspectos de la situacion social. No se observaron diferencias significativas entre los dos grupos con respecto al nivel educacional, las pensiones sociales, el nivel social, el estado matrimonial, la fertilidad, la necesidad de ayuda para actividades de la vida diaria o la necesidad de supervision segun su situacion pre tratamiento. El 25.3% de los tratados quirurgicamente y el 8.5% de los casos control permanecian sin medicacion antiepileptica durante el momento de la investigacion (Mann-Whitney U-test, dos ramas, p = 0.0011). Una proporcion considerablemente mas elevada de casos tratados (53.2%) que los casos control (24.2%), afirmaban que el tratamiento habia mejorado su capacidad de trabajo (Mann-Whitney U-test, dos ramas, p < 0.0001) pero esto condujo a una mejoria significativa de su real situacion de trabajo solo en aquellos que tenian una educacion regular o trabajaban antes del tratamiento (X2= 6.5214, p = 0.038). ZUSAMMENFASSUNG Es handelt sich um eine retrospektive parallele Kohortenuntersuchung zum Vergleich von chirurgischer und konservativer Epilepsie-Behandlung. Die chirurgische Gruppe umfasst alle 201 Patienten mit Resektion wegen einer Epilepsie seit der ersten Operation 1949 in Norwegen bis Januar 1988. Die 185 konservativ behandelten Patienten der Kontrollgruppe wurden passend nach Behandlungsjahr, Alter bei Behandlung, Geschlecht, Anfallstyp und neurologischen Defiziten vor der Behandlung ausgewahlt. Zwischen 75% und 95% der noch Lebenden (Median 17 Jahre nach Behandlung) fullten zwei Fragebogen zu ihrer sozialen Situation aus. Wahrend die Operation die Anfallssituation verbesserte (bei 1/4 mit neurologischen Defiziten), hatte sie einen deutlich geringeren Langzeiteffekt auf verschiedene soziale Aspekte. Es gab keinen signifikanten Unterschied zwischen den beiden Gruppen bezuglich des Ausbildungsstatus, der sozialen Absicherung, des sozialen Status, des Partnerstatus, der Fruchtbarkeit, der Abhangigkeit innerhalb der Wohnumgebung, der Notwendigkeit von Unterstutzung bei den taglichen Verrichtungen, bzw. der Notwendigkeit uberwacht zu werden im Vergleich zur Situation vor der Behandlung. 25.3% der operierten Patienten und 8.5% der Kontrollen waren zum Zeitpunkt der Untersuchung ohne Medikation (Mann-Whitney-U-Test, zweiteilig, p = 0.0011). Ein deutlich hohrerer Prozentsatz der operierten Patienten (53.2%) im Vergleich zu 24.2% der Kontrollen gab an, das die Behandlung ihre Arbeitsfahigkeit verbessert hatte (Mann-Whitney-U-Test, zweiteilig, p = 0.0001). Dies hatte jedoch einen signifikanten Effekt zur Besserung der Arbeitssituation nur bei Patienten mit normaler Ausbildung oder einer Arbeit bereits vor der Behandlung (X2= 6.514, p = 0.038).

Anticonvulsant actions of anticholinergic drugs in soman poisoning.

Abstract: The acute effects of the organophosphorus cholinesterase inhibitor soman include hypersecretions, convulsions, and death. The purpose of this study was to evaluate the anticholinergic compounds aprophen, atropine sulfate, azaprophen, benactyzine, benztropine, biperiden, scopolamine HBr, and trihexyphenidyl for their efficacy in preventing soman-induced hypersecretions and convulsions. Male rats were injected with the oxime HI-6 (125 mg/kg, i.p.), to increase survival time, along with various intramuscular doses of the anticholinergics 30 min prior to a dose of soman (180 micrograms/kg, s.c.; equivalent to 1.6 x the median lethal dose) that produced 100% convulsions. Signs of intoxication as well as the time-to-onset of convulsions were observed. The calculated anticonvulsant median effective dose values were 0.18, 0.33, 0.36, 0.55, 2.17, 2.30, 2.45, and 31.09 mumol/kg for scopolamine HBr, biperiden, trihexyphenidyl, benactyzine, benztropine, azaprophen, aprophen, and atropine sulfate, respectively. The same rank order of potency for inhibition of hypersecretions among these compounds was observed. Parallel studies with quaternary analogs of atropine sulfate and scopolamine HBr demonstrated, however, that these charged compounds afford no protection against soman-induced hypersecretions and convulsions. The results indicate that tertiary anticholinergic compounds afford protection against soman-induced convulsions and hypersecretions and that the beneficial anticonvulsant effects are mediated through the central cholinergic system. Excitatory amino acid neurotransmitter systems may be involved in the effectiveness of these compounds.

Nonepileptic events in childhood.

Abstract: The medical records of 27 children admitted to the MINCEP Epilepsy Program for evaluation of intractable epilepsy but later shown to have nonepileptic events by EEG with simultaneous video monitoring were reviewed. Four groups were identified: pure psychogenic events (5 patients), psychogenic events plus epileptic seizures (3 patients), pure nonepileptic physiologic events (5 patients), and nonepileptic physiologic events plus seizures (14 patients). Historical data, physical examinations, and neurodiagnostic evaluations (including previous EEGs, neuroradiologic evaluations, and neuropsychologic testing) were reviewed. Children in all groups, except for those with pure psychogenic seizures, had a history of multiple seizure types identified by parents or caretakers. A history of status epilepticus was obtained in 64% (of 22 patients), including 11 of 14 patients with physiologic events plus seizures. Abnormal findings on neurologic examination were common, especially in children with nonepileptic physiologic events. All but two patients had a history of interictal epileptiform abnormalities on previous routine EEGs. Based on identification of nonepileptic events, antiepileptic drugs (AEDs) were discontinued completely in eight patients (30%) and the total number of AEDs was reduced in nine others (33%). A diagnosis of nonepileptic events should be considered in all children with refractory seizures or multiple seizure types. Abnormal findings on routine (interictal) EEG may actually confound the diagnosis. Intensive neurodiagnostic EEG-video recording is the preferred method for distinguishing nonepileptic from epileptic seizures.

Intracarotid amobarbital procedure: II. Lateralizing value in evaluation for temporal lobectomy.

Abstract: Summary: The intracarotid amobarbital procedure (IAP) was assessed for lateralizing value in 37 patients who later had temporal lobectomy for intractable epilepsy. Among patients who failed IAP memory testing on one side (defined as a retention score for test items at least 20% lower on one side than the other), significantly more patients failed the injection contralateral (16 of 20, 80%) than ip-silateral (4 of 20, 20%) to the side of later resection (p = 0.008). In addition, preoperative EEG evidence of bilateral temporal epileptogenicity was significantly more frequent among patients who failed the ipsilateral IAP injection (2 of 4, 50%) than among patients who passed the ipsilateral IAP injection (2 of 33, 6%) (p = 0.050). Finally, failure of the contralateral IAP injection involved significantly more severe amnesia for test items (median retention score 25%) than did failure of the ipsilateral injection (median retention score 59%) (p = 0.047). Profoundly low retention scores <33% occurred only with contralateral injection. These findings suggest that the IAP has some adjunctive lateralizing value for the epileptogenic hemisphere in patients with temporal lobe epilepsy, especially when the retention score with one injection is profoundly low. RESUME Le test aľamobarbital intracarotidien (AIC) a eteevalue pour sa valeur lateralisatrice chez 37 patients qui ont beneficie ensuite d'une lobectomie temporale pour epilepsie intraitable. Parmi les patients qui ont echoue au test de memorisation sous AIC (avec comme definition un score de retention inferieur de 20% d'un cote par rapport aľautre), il y a eu un nombre significativement plus eleve de patients ayant echoue apres injection controlaterale (16/20, 80%) qu'apres injection ipsilaterale (4/20, 20%) par rapport au cote de la resection ulterieure (p = 0.008). De plus, la mise en evidence pre-operatoire aľEEG d'anomalies epileptiques temporales bilaterales, etait significativement plus frequente chez les patients qui ont echoue apres injection ipsilaterale (2/4, 50%) que chez les patients qui n'ont pas echoue apres ľinjection ipsilaterale (2/33, 6%) (p = 0.050). Finalement, ľechec de ľinjection controlaterale a produit une amnesie significativement plus severe pour les items du test (score de retention moyen: 25%) que ľechec apres injection ipsilaterale (score de retention moyen: 59%) (p = 4.047). Des scores de retention profondement abaisses, inferieurs a 33%, n'ont ete constates qu'apres injection controlaterale. Ces constatations suggerent que ľAIC a une valeur de lateralisation supplemental pour ľhemisphere epileptogene chez les patients presentant une epilepsie du lobe temporal, en particulier quand le score retention est particulierement bas, apres une injection. RESUMEN La capacidad de lateralizacion de la inyeccion intracarotidea de amobarbital (IAP) ha sido estudiada en 37 pacientes que, mas tarde, fueron sometidos a una lobectomia temporal para epilepsia incontrolable. Entre los pacientes que fallaron los tests de memoria en la IAP o unilateral (definida como resultados de retencion para los items contenidos en el test de al menos un 20% mas bajos en un lado que en el otro) un numero mas elevado de pacientes fallaron de modo significativo en la inyeccion contralateral (16/20, 80%) que en la ipsilateral (4/20, 20%) correspondiente al lado de la reseccion quirurgica posterior (p = 0.008). Ademas la evidencia preoperatoria en el EEG de epileptogenesis bilateral temporal fue significativamente mas frecuente en los enfermos que fallaron en la IAP ipsilateral (2/4, 50%) que en pacientes que pasaron la IAP ipsilateral (3/33, 6%) (p = 0.050). Finalmente, el fallo de la IAP contralateral produjo amnesia significativamente mas severa para los items del test (promedio de retencion: 25%) que la obtenida tras el fallo de la inyeccion ipsilateral (retencion media: 59%) (p = 0.047). Resultados profundamente mas reducidos (menos del 33%) ocurrieron solamente en la inyeccion contralateral. Estos resultados sugieren que la IAP posee un valor de lateralizacion anadido para el hemisferio epileptogenico en pacientes con epilepsia del lobulo temporal, especialmente cuando el numero de retenciones con una inyeccion es profundamente bajo. ZUSAMMENFASSUNG Die intraarterielle Karotis-Amobarbital-Untersuchung (IAP) wurde zur Seitenbestimmung bei 37 Patienten durchefuhrt, die spater einer temporalen Lobektomie bei therapieresistenter Epilepsie unterzogen wurden. Unter den Patienten mit verschlechtertem IAP Gedachtnis-Test auf einer Seite (definiert als Speicherwert fur die Testitems, der wenigstens 20% niedriger auf einer Seite als auf der anderen ist) befand sich signifikant mehr mit Verschlechterung bei kontralateraler Injektion (16/20; 80%) als bei ipsilateraler Injektion (4/20; 20%), in Bezug auf die zu resezierende Seite. Zusatzlich zeigte das praeoperative EEG bi-lateral-temporale Epileptogenitat signifikant haufiger bei Patienten mit Verschlechterung bei der ipsilateralen IAP-Injektion (2/4; 50%), als bei Patienten mit normaler IAP (2/33; 6%) (p = 0.050). Schlieslich ging die Verschlechterung bei kontrolateraler IAP mit signifikant schwerer Amnesie fur die Testitems einher (Median-Speicher-Wert = 25%) als bei Verschlechterung nach ipsilateraler IAP (Median-Speicher-Wert = 59%) (p = 0.047). Extrem niedrige Speicherwerte von weniger als 33% traten nur bei kontralateraler IAP auf. Diese Ergebnisse lassen vermuten, das die IAP einen zusatzlichen Seitenhinweis gibt fur die epileptogene Hemisphare bei temporaler Epilepsie, besonders dann, wenn die Speicherwerte extrem niedrig sind.

Hyperglycemia presenting with occipital seizures.

Abstract: Seizures are common in hyperglycemia and are often the first manifestation, particularly in nonketotic hyperglycemia (NKH). Published reports emphasize partial motor seizures almost exclusively. In a 3-year period, we observed three patients in whom occipital seizures, documented by ictal EEG recording, were the initial symptom of hyperglycemia. One patient was mildly ketotic at first. Seizures were visual in two patients and visual and adversive in the third. Seizures regressed with correction of abnormal glucose levels and did not recur during follow-up of less than or equal to 1 year despite discontinuation of antiepileptic drugs (AEDs) in two. Computed tomography (CT) scans did not show correlative abnormalities. Although published reports suggest that frontal lobe structures are particularly susceptible to the epileptogenic effects of NKH, our experience indicates that in NKH epileptic foci may originate in other cortical areas, such as occipital.

Phenytoin-induced elevation of serum estradiol and reproductive dysfunction in men with epilepsy.

Abstract: Summary: Reproductive and sexual dysfunction in men with epilepsy has been attributed to androgen deficiency Low serum free testosterone (FT) levels occur in both hypogonadotropic and hypergonadotropic hypogonadism Antiepileptic drugs (AEDs) have been implicated Proposed mechanisms include induction of increased sex hormone binding globulin (SHBG) resulting in decreased FT, as well as dysfunction or premature aging of the hypothalamopituitary-gonadal axis In an investigation comparing serum reproductive steroid levels among 20 men receiving phenytoin (PHT) monotherapy for complex partial seizures, 21 untreated men with complex partial seizures, and 20 age-matched normal controls, total estradiol levels were significantly higher in the PHT group (563 ± 294 pg/ml, mean ± SD) than in the untreated (324 ± 274 pg/ml, p < 001) and normal control (343 ± 127 pg/ml, p < 005) groups The physiologically active non-SHBG-bound serum estradiol levels were also significantly higher in the medicated group (451 ± 217 pg/ml) than in the untreated (299 ± 172 pg/ml, p < 001) and normal control (311 ± 114 pg/ml, p = 005) groups These findings suggest that PHT may lower FT by induction of aromatase, enhancing FT conversion to estradiol, as well as SHBG synthetase Estradiol exerts a potent inhibitory influence on luteinizing hormone secretion and has been suggested to play a major role in negative feedback in men as well as women Suppression of LH secretion results in hypogonadotropic hypogonadism Chronically low FT leads to testicular failure and hypergonadotropic hypogonadism Finally, estradiol has been shown to produce premature aging of the hypothalamic arcuate nucleus, which secretes go-nadotropin-releasing hormone RESUME La dysfonction reproductive et sexuelle des hommes epileptiques est attribuee a un deficit androgenique Un abaissement des taux seriques de testosterone libre (TL) survient dans le cadre ďun hypogonadisme hypogonadotrope ou hypergonadotrope Les medications antiepileptiques ont ete impliquees dans ce phenomene Les mecanismes proposes incluent une induction ďune augmentation de la sex-binding-globulin (SBG) aboutissant a une diminution de la TL, ainsi qu'une dysfonction ou un vieillissement premature de ľaxe hypothalamo-hypophysogonadique Dans une eatude comparant les taux de steroides sexuels chez 20 hommes traites par phenytoine en monotheiapie pour des crises partielles complexes, 21 sujets non traites presentant des crises partielles complexes, et 20 sujets-controles apparies pour ľâge, les auteurs ont constate que les taux ďestra-diol total ont ete significativement augmentes dans le groupe PHT (563 ± 294 pg/ml, m ± SD) par rapport au groupe non traite (324 ± 254 pg/ml, p < 001) et au groupe controle (343 ± 127 pg/ml, p < 005) ľEstradiol physiologiquement actif, non liea la SBG, etait a des taux egalement significativement eleves dans le groupe traite (451 ± 217 pg/ml) par rapport au groupe non traite (299 ± 172 pg/ml, p < 001) et dans le groupe controle (311 ± 114 pg/ml, p = 005) Ces constatations suggerent que la PHT diminue la TL par ľinduction de ľaromatase, avec augmentation de la conversion de TL en estradiol, mais aussi par une augmentation de synthese de la SBG ľestradiol a une influence inhibitrice puissante sur la secretion de LH, et on a suggere que ľestradiol joue un role important dans le feedback negatif chez ľhomme comme chez la femme Une suppression de la secretion de LH entraine un hypogonadisme hypogonadotrophique Un abaissement chronique de la TL peut conduire a un deficit testiculaire avec hypogonadisme hypergonadotrophique Enfin ľestradiol a pu etre rendu responsable ďun viellissement premature du noyau arque de ľhypothalamus, qui est aľorigine de la secretion de LHRH RESUMEN Las disfunciones reproductivas y sexuales en hombres con epilepsia han sido atribuidas a un deficit de androgenos En el seno de un hipogonadismo hipogonadotropico o hipergonado-tropico se encuentran niveles sericos bajos de testosterona libre (FT) Se piensa que las medicaciones antiepilepticas contribuyen a esta alteration y los mecanismos propuestos incluyen la induction de un incremento de la globulina a la que se acopla la hor-mano sexual (SHBG) Este incremento conduce a una reduction de la FT asi como a una disfuncion o envejecimiento prematuro del eje hipotalamopituitario-gonadal En una investigateon en la que se han comparado los niveles sericos del esteroide reproductive en 20 hombres que recibian fenitoina (PHT), como monoterapia para crisis parciales complejas, con las de 21 varones no tratados con epilepsia parcial compleja y con los de 20 controles normales con edades comparables Se ha encon-trado que los niveles de estradiol total eran significativamente mas elevados en el grupo que recibia PHT (563 ± 294 pg/ml; promedio ± SD) que en los no tratados (324 ± 274 pg/ml; p < 001) y los controles normales (343 ± 127 pg/ml; p < 005) Los niveles sericos del estradiol fisiologicamente activo pero no acoplado a la SHBG, fueron tambien significativamente mas elevados en el grupo que recibia la medication (451 ± 217 pg/ml) que en los sujetos no tratados (299 ± 172 pg/ml; p < 001) y en los sujetos normales (311 ± 114 pg/ml; p = 005) Estos hal-lazgos sugieren que la PHT puede reducir la FT mediante la induction de aromatasa, que incrementa la conversion de FT a estradiol, asi como de la SHBG-sintetasa El estradiol ejerce una influencia inhibitoria potente sobre la secretion de hormona luteinizante y se ha sugerido que juega un papel importante en la retroalimentacion negativa tanto en hombres como en mujeres La supresion de la secrecyon de LH conduce a un hipogonadismo hipogonadotropico Los niveles conicamente bajos de FT conducen a un fallo testicular y a un hipogonadismo hipergonadrotropico Finalmente, se ha demostrado que el estradiol produce an envejecimiento prematuro del nucleo arcuato hipotalamico que segrega hormona liberadora de gonadotropina ZUSAMMENFASSUNG Bei Mannern mit Epilepsie werden reproduktive und sexuelle Dysfunktionen einem Androgen-Mangel zugeordnet Es kommt sowohl bei hypogonadotropem als auch bei hypergonadotropem Hypogonadismus zu niedrigem freiem Serum Testosteron (FT) Die antiepileptische Medikation ist dabei involviert Mogliche Mechanismen schliesen die Induktion eines erhohten Sexualhor-mon- bindenden Globulins (SHBG) mit ein, die zu einem er-niedrigten FT fuhren, aber auch eine Dysfunktion oder ein vorzeitiges Altern der hypothalamopituitar-gonadalen Achse Bei 20 Mannern mit komplex-partiellen Anfallen unter Phenytoin-Monotherapie sowie bei 21 unbehandelten Mannern mit komplex-partiellen Anfallen und 20 nach Alter passend ausgewahlten normalen Kontrollen wurden im Serum die Spiegel der re-produktiven Steroide untersucht Der totale Ostradiolspiegel war bei der PHT-Gruppe erhoht (563 ± 294 pg/ml; Mittelwert ± Standardabweichung) im Vergleich zu der unbehandelten (324 ± 274 pg/ml; p < 001) und normalen Kontrollgruppe (343 ± 127 pg/ml; p < 005) Die physiologisch aktiven, nicht SHBG gebundenen Serum-Ostradiol-Spiegel waren ebenfalls bei der be-handelten Gruppe (451 ± 217 pg/ml) im Vergleich zu der unbehandelten (299 ± 172 pg/ml; p < 001) und normalen Kontrollgruppe (311 ± 114 pg/ml; p = 005) signifikant erhoht Die Ergebnisse legen nahe, das PHT das FT durch eine Induktion von Aromatase erniedrigt, welches die FT-Umwandlung zu Ostradiol verstarkt, sowie durch Induktion einer SHBG-Synthetase Ostradiol hat eine starke inhibitorische Wirkung auf die Sekretion von LH und spielt vermutlich sowohl bei Mannern als auch bei Frauen eine wichtige Rolle im negativen Feedback Die Unterdruckung der LH-Sekretion resultiert in einem hypo-gonadotropen Hypogonadismus Ein chronisch niedriges FT fuhrt zu einem testikularen Ausfall und einem hypergonado-tropen Hypogonadismus Schlieslich wurde gezigt, dasOstradiol zu einem vorzeitigem Altern des hypothalamischen Nucleus ar-cuatus fuhrt, welcher Gonadotropin Releasing Hormone produziert)