A. James Fessler

Anti-NMDA receptor encephalitis causing prolonged nonconvulsive status epilepticus

Anti-NMDA receptor encephalitis is characterized by dyskinesias, psychosis, and seizures1 secondary to antibodies to the NR1-NR2B heteromer of the NMDA receptor.2 This syndrome, more common in women, is often related to an ovarian tumor1; the prognosis is better if the tumor is identified within 3 months of onset. Our case had nonconvulsive status epilepticus lasting 6 months, with marked improvement following removal of the ovarian tumor. ### Case report. A 35-year-old woman, previously healthy and without history of psychosis, had a 3-week history of progressive headaches, short-term memory loss, and irritability. On admission, she was psychotic, requiring physical and chemical restraints. She was unable to follow commands, had echolalia, and had occasional dystonic posturing of her limbs. One week later, she became unresponsive to external stimuli. An EEG demonstrated persistent nonconvulsive status epilepticus (NCSE). Initial CSF studies were remarkable for a lymphocytic pleocytosis with 386 leukocytes. Brain MRI showed diffusion-weighted imaging hyperintensity in the right medial temporal lobe transitioning to fluid-attenuated inversion recovery hyperintensity on repeat imaging (figure 1A). Tests for multiple viral and bacterial pathogens, including herpes simplex virus, were negative. A paraneoplastic …

The Effects of Remifentanil on Epileptiform Discharges during Intraoperative Electrocorticography in Patients Undergoing Epilepsy Surgery

Summary:  Purpose: High‐dose i.v. opioids (e.g., alfentanil, 50 μg/kg bolus) are known to increase the intraoperative reading of epileptiform activity during epilepsy surgery (ES), thereby facilitating localization of the epileptogenic zone (i.e., the site of ictal onset and initial seizure propagation). However, this phenomenon has not been studied with remifentanil (i.e., a novel ultra‐short acting opioid). The purpose of the present study was to evaluate the effect of remifentanil on electrocorticography (ECoG) during ES.

Correlation of Severity of FDG-PET Hypometabolism and Interictal Regional Delta Slowing in Temporal Lobe Epilepsy

Summary:  Purpose: We investigated the association of severity of hypometabolism detected by positron emission tomography (PET) with [18F]fluorodeoxyglucose (FDG) and persistence of interictal EEG focal slowing in patients with refractory temporal lobe epilepsy.

Levetiracetam Reduces Spike–Wave Density and Duration during Continuous EEG Monitoring in Patients with Idiopathic Generalized Epilepsy

Levetiracetam reduces spike-wave density and duration during continuous EEG monitoring in patients with idiopathic generalized epilepsy.

Self‐reported Seizure Frequency and Time to First Event in the Seizure Monitoring Unit

Summary:  Purpose: To compare seizure frequency reported in the clinic with time to first diagnostic event during video‐EEG monitoring. The effect of the artificial environment of the monitoring unit on self‐reported seizure frequency was explored.

Epilepsy and aggression: Proceed with caution

The relationship between aggressive or violent behavior and epilepsy has been extensively debated. A longstanding belief that patients with epilepsy exhibit increased aggression and are prone to violence was proposed by a number of early studies including studies noting an increased incidence of epilepsy in prisoner populations.1 The description of bizarre though stereotyped behaviors during some seizures, particularly of frontal lobe origin2 and the not infrequent use of epilepsy as a courtroom defense strategy for violent crime,3 continue to perpetuate this belief. While the association between epilepsy and aggression remains in question, it continues to contribute to public perception and amplifies the stigma associated with the disease. While it is unclear that patients with epilepsy exhibit increased aggression, aggressive acts have been seen in association with seizures themselves. Most commonly, aggression may occur in the postictal state and can be seen even hours to days after initial periods of confusion.4 In particular, directed, postictal violent behavior may be seen in association with postictal psychosis.5 Rarely violent behavior may be part of the seizure itself, and when aggressive behavior occurs, typical characteristics of seizures must also be present including abrupt …

Reliability of Seizure Semiology in Patients With 2 Seizure Foci

OBJECTIVE To determine whether seizure semiology is reliable in localizing and distinguishing seizures at 2 independent brain foci in the same patient. DESIGN Two masked reviewers localized seizures from 2 foci by their clinical semiology and intracranial electroencephalograms (EEGs). SETTING Epilepsy monitoring unit of referral comprehensive epilepsy program. PATIENTS Seventeen consecutive patients (51 seizures) with sufficient video and intracranial EEG data were identified by reviewing medical records of 366 patients older than 10 years. MAIN OUTCOME MEASURES The primary outcome measures were interobserver agreement between the 2 masked reviewers; the proportion of seizures localized by semiology; the proportion of localized seizures concordant with intracranial EEG localization; and comparison between concordant and nonconcordant seizures in latency of intracranial EEG seizure spread. RESULTS Interobserver agreement was 41% (κ score, 0.16). Only 30 of 51 seizures (59%) were localized by seizure semiology. The focus localized by semiology was concordant with the location of intracranial EEG seizure onset in 16 of 30 seizures (53%). No significant difference was observed between concordant and nonconcordant seizures in relation to the speed with which the EEG discharge spread from the location of seizure onset to another lobar region (P = .09, Wilcoxon rank sum test). CONCLUSION Clinical seizure semiology is not as useful as intracranial EEG in localizing seizure onset in patients with dual seizure foci.

Evaluation of phenytoin serum levels following a loading dose in the acute hospital setting

PURPOSE Due to the complex pharmacokinetic profiles of phenytoin (PHT) and fosphenytoin (FOS), achieving sustained, targeted serum PHT levels in the first day of use is challenging. METHODS A population based approach was used to analyze total serum PHT (tPHT) level within 2-24h of PHT/FOS loading with or without supplementary maintenance or additional loading doses among PHT-naïve patients in the acute hospital setting. Adequate tPHT serum level was defined as ≥20μg/mL. RESULTS Among 494 patients with 545 tPHT serum levels obtained in the first 2-24h after the loading dose (LD), tPHT serum levels of either <or≥20μg/mL were observed along wide and overlapping cumulative dose ranges. Among those receiving 15-20mg/kg and 20-55mg/kg weight-based loading dose, 63% and 51% respectively did not attain tPHT serum level of ≥20μg/mL even within the first 6h of treatment. For the 393 available concomitant free and total serum PHT levels, correlation was weak, r=0.36. CONCLUSION Close laboratory surveillance and PHT/FOS dose adjustments are recommended to ensure adequate and sustained tPHT serum levels early in treatment. Free serum PHT level is the preferred method of drug monitoring.