Gena R. Ghearing

The ictal bradycardia syndrome : Localization and lateralization

Summary:  Purpose: Previous studies have established the importance of the insular cortex and temporal lobe in cardiovascular autonomic modulation. Some investigators, based on the results of cortical stimulation response, functional imaging, EEG recordings of seizures, and lesional studies, have suggested that cardiac sympathetic and parasympathetic function may be lateralized, with sympathetic representation lateralized to the right insula, and parasympathetic, to the left. These studies have suggested that ictal bradycardia is most commonly a manifestation of activation of the left temporal and insular cortex. However, the evidence for this is inconsistent. We sought to assess critically the predictable value of ictal bradycardia for seizure localization and lateralization.

Panic attack symptoms differentiate patients with epilepsy from those with psychogenic nonepileptic spells (PNES)

Psychogenic nonepileptic spells (PNES) are frequently challenging to differentiate from epileptic seizures. The experience of panic attack symptoms during an event may assist in distinguishing PNES from seizures secondary to epilepsy. A retrospective analysis of 354 patients diagnosed with PNES (N=224) or with epilepsy (N=130) investigated the thirteen Diagnostic and Statistical Manual-IV-Text Revision panic attack criteria endorsed by the two groups. We found a statistically higher mean number of symptoms reported by patients with PNES compared with those with epilepsy. In addition, the majority of the panic attack symptoms including heart palpitations, sweating, shortness of breath, choking feeling, chest discomfort, dizziness/unsteadiness, derealization or depersonalization, fear of dying, paresthesias, and chills or hot flashes were significantly more frequent in those with PNES. As patients with PNES frequently have poor clinical outcomes, treatment addressing the anxiety symptomatology may be beneficial.

The treatment of ictal asystole with cardiac pacing

Ictal asystole may contribute to seizure‐related injury and mortality. The purpose of this study was to evaluate the effect of cardiac pacing on seizure‐related injury rates in ictal asystole patients. A survey was conducted to determine seizure‐related fall rate and other morbidity in all seven patients with ictal asystole who underwent cardiac pacing at our institution between 1990 and 2004. The rate of seizure‐related falls and other morbidities before and after pacing were compared using the Wilcoxon rank‐sum test. The mean fall rate was 3.28 falls/month pre‐pacemaker implantation. Following pacemaker implantation, this was reduced to 0.005 falls/month (p = 0.001). Seizure‐related fractures and motor vehicle accidents were also reduced following cardiac pacing. These findings may have implications in mitigating the potential morbidity associated with ictal asystole.

Medical comorbidities in patients with psychogenic nonepileptic spells (PNES) referred for video-EEG monitoring

Differentiating between psychogenic nonepileptic spells (PNES) and epileptic seizures without video-EEG monitoring is difficult. The presence of specific medical comorbidities may discriminate the two, helping physicians suspect PNES over epilepsy earlier. A retrospective analysis comparing the medical comorbidities of patients with PNES with those of patients with epilepsy was performed in 280 patients diagnosed with either PNES (N = 158, 74.7% females) or epilepsy (N = 122, 46.7% females) in the Epilepsy Monitoring Unit (EMU) of the University of Pittsburgh Medical Center over a two-year period. Patients with PNES, compared to those with epilepsy, were mostly female, significantly more likely to have a history of abuse, had more functional somatic syndromes (fibromyalgia, chronic fatigue syndrome, chronic pain syndrome, tension headaches, and irritable bowel syndrome), and had more medical illnesses that are chronic with intermittent attacks (migraines, asthma, and GERD). The presence of at least of one these disorders may lead physicians to suspect PNES over epilepsy and expedite appropriate referral for video-EEG monitoring for diagnosis.

Thoughts, emotions, and dissociative features differentiate patients with epilepsy from patients with psychogenic nonepileptic spells (PNESs)

Psychogenic nonepileptic spells (PNESs) are often very difficult to treat, which may be, in part, related to the limited information known about what a person experiences while having PNESs. For this retrospective study, thoughts, emotions, and dissociative features during a spell were evaluated in 351 patients diagnosed with PNESs (N=223) or epilepsy (N=128). We found that a statistically higher number of thoughts, emotions, and dissociative symptoms were endorsed by patients with PNESs versus patients with epilepsy. Patients with PNESs reported significantly more anxiety and frustration, but not depression, compared with those with epilepsy. Emotions and dissociations, but not thoughts, and a history of any type of abuse were endorsed significantly more often by patients with PNESs. Patients with PNESs are prone to having poor outcomes, and interventions focusing on their actual experiences may be helpful for treatment planning.

Early seizure termination in ictal asystole

To evaluate the association between cerebral hypoperfusion and seizure termination, we compared seizure duration in seven patients with syncopal ictal asystole (IA), seven with non-syncopal ictal bradycardia, and ten with non-bradycardic seizures. Mean seizure duration was 34.4±13 s in IA, 67±28.9 s in ictal bradycardia, and 82.1±31.1 in non-bradycardic seizures. These were significantly different (ANOVA, p<0.02). This suggests cerebral hypoxia-ischemia favors seizure termination.

Carpal tunnel syndrome after ciprofloxacin-induced tendinitis.

To the Editor: Different types of antibiotics can affect the peripheral nervous system and cause neuropathies, myopathies, and neuromuscular junction disorders by direct or indirect mechanisms.1 Fluoroquinolones may also cause seizures or encephalopathy, and a few cases of tendinitis have been reported as well.2-4 Tendinitis may occur as early as 2 hours after the first dose, and 50% of patients develop symptoms within 6 days of starting medication. Tenosynovitis has also been reported in association with recurrent carpal tunnel syndrome.5 We report a case of ciprofloxacin-related tendinitis leading to carpal tunnel syndrome A 77-year-old right-handed woman developed a urinary tract infection and was empirically treated with oral ciprofloxacin. Three days later, she developed bilateral hand pain and swelling, which improved after the medication was stopped and with a brief course of oral steroids and antihistamines. Symptoms were consistent with flexor tendinitis with focal tenderness and swelling. There was no history of diabetes, gout, rheumatoid arthritis, or of other autoimmune diseases. Because severe pain persisted waking her up, she was referred to a neurologist. At that time, 4 weeks after the onset and swelling resolved, the pain still involved the first three fingers, more severely on the left. She performed her daily activities independently, but pain got worse when these fingers were touched. She denied any neck or upper arm discomfort. On examination, she had slight atrophy and weakness of left thenar muscles (Medical Research Council 5-/5) with decreased sensation over distal aspects of the first three fingers on the left and left thenar allodynia. The remainder of the examination was normal. Electrodiagnostic testing was performed at 6 weeks after the onset and confirmed the diagnosis of bilateral distal median nerve entrapments (carpal tunnel syndrome) (Table 1), more severe on the left. Needle examination showed only few fibrillation potentials in the left abductor pollicis brevis muscle. The use of a wrist splint did not alleviate the symptoms. Repeat study 3 months later did not show significant improvement. Because symptoms persisted, she underwent bilateral sequential carpal tunnel releases resulting in resolution of her symptoms. Flexor tendinitis and inflammatory arthritis can precipitate median nerve entrapment in a confined space of carpal tunnel. Increased incidence of tendonitis has been described in elderly (older than 60 years of age) and with renal dysfunction or corticosteroid treatment.2-4 Most commonly, Achilles and patellar tendons are affected, but few cases of shoulder and hand tendinitis were reported. 2,3 Tendon rupture was reported in 5% of patients with quinolone-related tendinitis.2 Timely discontinuation of ciprofloxacin in our patient probably prevented tendon rupture and more significant nerve injury. Asymmetry of median nerve entrapments with more severe findings on the left in our case may be attributable to asymmetric tendinitis or possible pre-existing nerve entrapment aggravated by inflammation. Therefore, we should consider drug-induced tendinitis as a potential cause of musculoskeletal pain after institution of fluoroquinolone therapy. A recent report indicates that fluoroquinolones may also precipitate painful small fiber neuropathy expanding the spectrum of their toxicity.6 Early recognition of possible toxicity is crucial to stop the offending agent, avoid exercise, and hopefully reduce morbidity of fluoroquinolone-induced tendinitis.

Short-term neurocognitive outcomes following anterior temporal lobectomy

Changes in cognitive function are a well established risk of anterior temporal lobectomy (ATL). Deficits in verbal memory are a common postoperative finding, though a small proportion of patients may improve. Postoperative evaluation typically occurs after six to 12months. Patients may benefit from earlier evaluation to identify potential needs; however, the results of a formal neuropsychological assessment at an early postoperative stage are not described in the literature. We compared pre- and postoperative cognitive function for 28 right ATL and 23 left ATL patients using repeated measures ANOVA. Changes in cognitive function were compared to ILAE seizure outcome. The mean time to postoperative neuropsychological testing was 11.1weeks (SD=6.7weeks). There was a side×surgery interaction for the verbal tasks: immediate memory recall (F(1,33)=20.68, p<0.001), short delay recall (F(1,29)=4.99, p=0.03), long delay recall (F(1,33)=10.36, p=0.003), recognition (F(1,33)=5.69, p=0.02), and naming (F(1,37)=15.86, p<0.001). This indicated that the left ATL group had a significant decrement in verbal memory following surgery, while the right ATL group experienced a small but significant improvement. For the right ATL group, there was a positive correlation between ILAE outcome and improvement in immediate recall (r=-0.62, p=0.02) and long delay recall (r=-0.57, p=0.03). There was no similar finding for the left ATL group. This study demonstrates that short-interval follow-up is effective in elucidating postoperative cognitive changes. Right ATL was associated with improvement in verbal memory, while left ATL resulted in a decrement in performance. Improvement in the right ATL group was related to improved seizure outcome. Short-interval follow-up may lend itself to the identification of patients who could benefit from early intervention.

Fast 3D rosette spectroscopic imaging of neocortical abnormalities at 3 T: Assessment of spectral quality

To use a fast 3D rosette spectroscopic imaging acquisition to quantitatively evaluate how spectral quality influences detection of the endogenous variation of gray and white matter metabolite differences in controls, and demonstrate how rosette spectroscopic imaging can detect metabolic dysfunction in patients with neocortical abnormalities.

Features of Simultaneous Scalp and Intracranial EEG That Predict Localization of Ictal Onset Zone

Objective. To assess the utility of simultaneous scalp EEG in patients with focal epilepsy undergoing intracranial EEG evaluation after a detailed presurgical testing, including an inpatient scalp video EEG evaluation. Methods. Patients who underwent simultaneous scalp and intracranial EEG (SSIEEG) monitoring were classified into group 1 or 2 depending on whether the seizure onset zone was delineated or not. Seizures were analyzed using the following 3 EEG features at the onset of seizures latency, location, and pattern. Results. The criteria showed at least one of the following features when comparing SSIEEG: prolonged latency, absence of anatomical congruence, lack of concordance of EEG pattern in 11.11% (1/9) of the patients in group 1 and 75 % (3/4) of the patients in group 2. These 3 features were not present in any of the 5 patients who had Engel class I outcome compared with 1 of the 2 patients (50%) who had seizure recurrence after resective surgery. The mean latency of seizure onset in scalp EEG compared with intracranial EEG of patients in group 1 was 17.48 seconds (SD = 16.07) compared with 4.33 seconds (SD = 11.24) in group 2 (P = .03). None of the seizures recorded in patients in group 1 had a discordant EEG pattern in SSIEEG. Conclusion. Concordance in EEG features like latency, location, and EEG pattern, at the onset of seizures in SSIEEG is associated with a favorable outcome after epilepsy surgery in patients with intractable focal epilepsy. Significance. Simultaneous scalp EEG complements intracranial EEG evaluation even after a detailed inpatient scalp video EEG evaluation and could be part of standard intracranial EEG studies in patients with intractable focal epilepsy.