Ana Rita Peralta

Antiepileptic drugs management and long-term seizure outcome in post surgical mesial temporal lobe epilepsy with hippocampal sclerosis.

Surgery is the treatment of choice for refractory temporal lobe epilepsies, but unexpected seizure recurrences occur and the AEDs management strategy may be an implicated factor. We evaluated the AEDs managements role in the outcome of post surgical epilepsy patients with hippocampal sclerosis (HS). Epileptic patients submitted to amigdalohippocampectomy due to HS in Engel class IA 12 months after surgery were selected. The following variables were studied: age, gender, time of post-surgical follow-up, present Engel class, number of antiepileptic AEDs before surgery and at the time of the interview, AED changes after surgery (stopped, increased, decreased, maintained), timing for AED changes after surgery and seizure recurrences. Sixty-seven consecutive patients were studied (mean time of follow-up of 4.9 ± 2.8 years). Among these, 46.3% were tapering AEDs, 38.8% had not changed and 14.9% had increased AEDs. The global recurrence rate was 32.8%. Recurrence rates for patients tapering and not tapering AEDs were similar (34.2% and 31%, respectively). Fifteen patients tapered AEDs before 2 years and 20 at or 2 years after surgery, with similar recurrence rates (33% and 30%, respectively). All patients who recurred due to AED tapering and 66.7% of the patients who recurred with no AED reduction resumed the Engel class I. This study suggests that in HS patients submitted to AHE who are seizure free during the first postsurgical year, AEDs tapering is achieved in a substantial percentage of patients. Tapering AEDs, independently of its timing, will induce seizure recurrence in about a third of patients. However, patients relapsing after tapering AEDs regain control after resuming therapy.

Hypothyroidism and cerebral vein thrombosis – a possible association

BackgroundThere are many systemic illnesses that constitute risk factors for cerebral vein thrombosis (CVT). Hypothyroidism was never associated with CVT, despite growing evidence supporting a possible etiopathogenic link. We report two patients with CVT in whom hypothyroidism was concomitantly diagnosed.Clinical casesCases were women 21 and 52 years old. They both presented with intracranial hypertension syndrome and symptomatic focal epilepsy. CVT was diagnosed with MRI and MR venography. Hypothyroidism was diagnosed in the acute phase of CVT. Both had an autoimmune thyroiditis. None of the patients had diffuse goitre. Other risk factors for CVT were oral contraceptives and elevated homocysteine in one and hormonal replacement therapy in the other. Both were treated with anticoagulation, anti-epileptic drugs and thyroid replacement therapy, with good clinical outcome.ConclusionsThe association found between untreated hypothyroidism and CVT in these patients may result from chance. However, several haemostatic and fibrinolytic parameters have been demonstrated to be disturbed in hypothyroidism suggesting a possible role of this disease in CVT pathogenesis. In addition, indirect evidence also supports possible endothelial dysfunction and venous stasis in hypothyroidism, further emphasizing the physiopathological link between the two conditions. More research is needed to determine a possible causal role of hypothyroidism on CVT. We suggest that thyroid function should be included in the usual workup of CVT patients.

Epileptic manifestations in stroke patients treated with intravenous alteplase

Intravenous alteplase (rtPA) may be associated with seizures and epileptic activity in the electroencephalogram (EEG). The aim of this work was to compare the frequency of seizures and EEG abnormalities between stroke patients treated and not treated with rtPA.

Amygdalohippocampotomy: surgical technique and clinical results.

OBJECT The removal of mesial temporal structures, namely amygdalohippocampectomy, is the most efficient surgical procedure for the treatment of epilepsy. However, disconnection of the epileptogenic zones, as in temporal lobotomy or, for different purposes, hemispherotomy, have shown equivalent results with less morbidity. Thus, authors of the present study began performing selective amygdalohippocampotomy in cases of refractory mesial temporal lobe epilepsy (TLE) to treat mesial temporal lobe sclerosis (MTLS). METHOD The authors conducted a retrospective analysis of all cases of amygdalohippocampotomy collected in a database between November 2007 and March 2011. RESULTS Since 2007, 21 patients (14 males and 7 females), ages 20-58 years (mean 41 years), all with TLE due to MTLS, were treated with selective ablation of the lateral amygdala plus perihippocampal disconnection (anterior one-half to two-thirds in dominant hemisphere), the left side in 11 cases and the right in 10. In 20 patients the follow-up was 2 or more years (range 24-44 months, average 32 months). Clinical outcome for epilepsy 2 years after surgery (20 patients) was good/very good in 19 patients (95%) with an Engel Class I (15 patients [75%]) or II outcome (4 patients [20%]) and bad in 1 patient (5%) with an Engel Class IV outcome (extratemporal focus and later reoperation). Surgical morbidity included hemiparesis (capsular hypertensive hemorrhage 24 hours after surgery, 1 patient), verbal memory worsening (2 patients), and quadrantanopia (permanent in 2 patients, transient in 1). Late psychiatric depression developed in 3 cases. Operative time was reduced by about 30 minutes (15%) on average with this technique. CONCLUSIONS Amygdalohippocampotomy is as effective as amygdalohippocampectomy to treat MTLS and is a potentially safer, time-saving procedure.

Epilepsia partialis continua after an anterior circulation ischaemic stroke

Although cerebrovascular disorders are the main cause of epilepsia partialis continua (EPC) in adulthood, the frequency of EPC after stroke is unknown. The aim was to prospectively ascertain its frequency 1 year after an ischaemic stroke.

Seizures, electroencephalographic abnormalities, and outcome of ischemic stroke patients

Seizures and electroencephalographic (EEG) abnormalities have been associated with unfavorable stroke functional outcome. However, this association may depend on clinical and imaging stroke severity. We set out to analyze whether epileptic seizures and early EEG abnormalities are predictors of stroke outcome after adjustment for age and clinical/imaging infarct severity.

Early EEG predicts poststroke epilepsy

Electroencephalography (EEG) can identify biomarkers of epileptogenesis and ictogenesis. However, few studies have used EEG in the prediction of poststroke seizures. Our primary aim was to evaluate whether early EEG abnormalities can predict poststroke epilepsy.

Usefulness of EEG for the differential diagnosis of possible transient ischemic attack

Highlights • FSWA was the commonest EEG abnormality in patients with possible TIA.• FSWA in the early EEG did not distinguish TIA from epileptic seizure patients.• The majority of epileptic seizure patients did not have EA in the early or late EEG.• In patients with seizures, FSWA in the early EEG was more common than EA.• FSWA in late EEG was more likely in patients with an epileptic seizure than with a TIA.

Sleepiness and Motor Vehicle Crashes in a Representative Sample of Portuguese Drivers: The Importance of Epidemiological Representative Surveys

Objective: Sleepiness is considered to be a leading cause of crashes. Despite the huge amount of information collected in questionnaire studies, only some are based on representative samples of the population. Specifics of the populations studied hinder the generalization of these previous findings. For the Portuguese population, data from sleep-related car crashes/near misses and sleepiness while driving are missing. The objective of this study is to determine the prevalence of near-miss and nonfatal motor vehicle crashes related to sleepiness in a representative sample of Portuguese drivers. Methods: Structured phone interviews regarding sleepiness and sleep-related crashes and near misses, driving habits, demographic data, and sleep quality were conducted using the Pittsburgh Sleep Quality Index and sleep apnea risk using the Berlin questionnaire. A multivariate regression analysis was used to determine the associations with sleepy driving (feeling sleepy or falling asleep while driving) and sleep-related near misses and crashes. Results: Nine hundred subjects, representing the Portuguese population of drivers, were included; 3.1% acknowledged falling asleep while driving during the previous year and 0.67% recalled sleepiness-related crashes. Higher education, driving more than 15,000 km/year, driving more frequently between 12:00 a.m. and 6 a.m., fewer years of having a drivers license, less total sleep time per night, and higher scores on the Epworth Sleepiness Scale (ESS) were all independently associated with sleepy driving. Sleepiness-related crashes and near misses were associated only with falling asleep at the wheel in the previous year. Sleep-related crashes occurred more frequently in drivers who had also had sleep-related near misses. Conclusion: Portugal has lower self-reported sleepiness at the wheel and sleep-related near misses than most other countries where epidemiological data are available. Different population characteristics and cultural, social, and road safety specificities may be involved in these discrepancies. Despite this, Portuguese drivers report sleep-related crashes in frequencies similar to those of drivers in other countries.

The urge to move and breathe – the impact of obstructive sleep apnea syndrome treatment in patients with previously diagnosed, clinically significant restless legs syndrome

OBJECTIVE The association between restless legs syndrome (RLS) and obstructive sleep apnea syndrome (OSAS) has seldom been reported. There is one study reporting improvement of RLS symptoms severity in patients naive of treatment after initiation of continuous positive airway pressure (CPAP) for OSAS. The aim of this study was to evaluate the impact of the OSAS treatment in patients with previously diagnosed, clinically significant RLS in a usual clinical setting. METHODS This was a retrospective study of RLS patients from a sleep clinic with a concomitant or subsequent diagnosis of OSAS. All patients who started treatment for OSAS and had a follow-up of ≥3 months were selected. Exclusion criteria included noncompliance, absence of sufficient information on clinical records, and RLS improvement following treatment of secondary causes. The primary outcome variable was clinical status of RLS symptoms following OSA treatment. Other variables included demographics, RLS treatment and outcome, OSA diagnosis, treatment, compliance, outcome, and PSG characteristics. RESULTS From a database of 97 RLS patients, 56 patients had both OSA and RLS. Of these patients, 28 met the criteria for the study. In all, 17 patients (60.9%) were female, with a mean age 60 years. A total of 16 patients (57.1%) were diagnosed with idiopathic RLS. OSAS was diagnosed, on average, 21 months after the RLS diagnosis. A total of 19 (70.4%) patients were overweight or obese, 26 (92.9%) reported snoring, and 10 (35.7%) witnessed apneas. A total of 16 patients (57.1%) had excessive daytime sleepiness and 23 (84.1%) had insomnia. The mean apnea-hypopnea index was 19. Patients were mostly treated with dopamine agonists (19 patients, 67.9%) for the RLS, and nine patients were treated with more than two drugs for RLS. A total of 20 patients (71.4%) had improvement of symptoms of RLS after therapy for OSAS, of whom nine stopped drug therapy and eight reduced the dose. CONCLUSIONS In patients with clinically significant RLS, treatment of concomitant OSAS significantly improved RLS symptoms, enabling drug therapy reduction in more than half of the patients. These data reinforce the need to actively diagnose OSAS in RLS patients.