Johannes Rösche

Treatment and course of different subtypes of status epilepticus.

Since randomized controlled trials are difficult to perform for ethical reasons in a potentially deadly condition like status epilepticus (SE), a retrospective database analysis may be welcome to broaden the evidence for the treatment of SE. In this retrospective study we evaluated every SE treatment at the neurological department of the University of Rostock from January 2000 to December 2009 in order to determine the efficacy of different antiepileptic drugs (AEDs) in terminating different kinds of SE. We analyzed the frequency of refractory courses in different types of SE, at which time which AED was administered and at which time which AED was effective to terminate the different epileptic conditions. A second aim of this study was to evaluate the course and the outcome of different kinds of SE. Statistical comparisons were performed with the χ(2)-test. 167 episodes of SE in 118 patients could be evaluated. The efficacy rates of AEDs differed significantly, mainly due to the superior efficacy of clonazepam (CZP). CZP seemed to be more effective than DZP, LEV, MDM and VPA in terminating generalized convulsive status epilepticus (GCSE), whereas there was no significant difference in the efficacy for terminating nonconvulsive status epilepticus (NCSE) and epilepsia partialis continua (EPC) between the used AEDs. Anaesthesia and CZP both terminated GCSE more effectively than NCSE and EPC. Concerning the course of the different kinds of SE the following results were obtained: 13 patients died during hospital treatment. Treatment in NCSE and EPC started significantly later than in GCSE. There was no significant difference in mortality between the types of SE. However the frequency of refractory courses differed between the types of SE. At the time of SE termination without the administration of anaesthesia a combination therapy using 2 or more AEDs was established in most episodes.

Possible effect of perampanel on focal status epilepticus after generalized tonic–clonic status epilepticus

Since in refractory status epilepticus (SE), additional glutamate receptors such as alpha-amino-3-hydroxy-5-methyl4-isoxazolepropionic acid (AMPA) and N-methyl-Daspartate (NMDA) receptors are built up in the synaptic membrane [1], perampanel, a novel noncompetitive AMPA-receptor antagonist, may be effective in this condition. During the treatment of refractory SE, usually a combination therapy of several antiepileptic drugs (AEDs) is established. Therefore, the drug, which has terminated the SE, cannot easily be identified. A possible effect of an AED on the termination of a SE may be supposed, when the termination of a SE is associated with the introduction of an AED in the therapy or an increased dose of an AED in combination with other changes in the antiepileptic medication at the same time [2]. Here we present a case where perampanel was the last AED introduced in the treatment of a focal SE before its termination 24 h later.

Recurrent aphasic status epilepticus after prolonged generalized tonic–clonic seizures versus a special feature of Todd's paralysis

Postictal aphasia may be a feature of Todds paralysis or the presentation of aphasic nonconvulsive status epilepticus (NCSE). We describe a 74-year-old woman with three episodes of aphasic status epilepticus after prolonged generalized tonic-clonic seizures. In the first episode, the NCSE was not definitively diagnosed, but an increase in the epileptic medication led to resolution of the epileptic activity within 2 weeks. During the second episode, NCSE was terminated within 7 days under intensified antiepileptic treatment. In the third episode, phenytoin treatment led to intoxication and resulted in further treatment on an intensive care unit. The patient required several months to recover from this episode. NCSE in the elderly is difficult to recognize, especially when it presents as a prolonged postictal deficit like aphasia. Once diagnosed it has to be treated carefully, because in the elderly, aggressive treatment strategies may be associated with a high risk of adverse events.

Magnetic resonance-transcranial ultrasound fusion imaging: A novel tool for brain electrode location

A combination of preoperative magnetic resonance imaging (MRI) with real‐time transcranial ultrasound, known as fusion imaging, may improve postoperative control of deep brain stimulation (DBS) electrode location. Fusion imaging, however, employs a weak magnetic field for tracking the position of the ultrasound transducer and the patients head. Here we assessed its feasibility, safety, and clinical relevance in patients with DBS.

Comparison of the effectiveness of four antiepileptic drugs in the treatment of status epilepticus according to four different efficacy criteria

The preliminary data presented here shall give an impression on how different criteria for the identification of an antiepileptic drug (AED) with a possible or certain treatment effect can have an influence on the results of retrospective case series. We present a data subset from a large retrospective study which, when completed, will cover all treatment episodes of status epilepticus (SE) at the neurological department of the Universitätsmedizin Rostock from January 2010 to June 2013. We compare and contrast the results of four different efficacy criteria for the effectiveness of phenytoin (PHT), valproate (VPA), levetiracetam (LEV), and lacosamide (LCM): criterion 1 = the last AED administered before SE termination; criterion 2 = the last drug introduced into the antiepileptic therapy within 72 h before SE termination and without changes in the comedication; criterion 3 = the last drug introduced into the antiepileptic therapy or increased in dose within 24h before SE termination without changes in the comedication; and criterion 4 = the last drug introduced into the antiepileptic therapy within 72 h before SE termination, even allowing changes in the comedication. Thirty-seven treatment episodes in 32 patients (13 male and 19 female, mean age at first episode: 68 years, SD: 17) could be analyzed. In 31 episodes, at least one AED was given intravenously. Efficacy rates in the whole case series according to all four criteria were not significantly different between the four AEDs, but there was a considerable difference in the efficacy rates of each AED when evaluating them with the different efficacy criteria. Our data show that statistically significant results concerning the efficacy of different AEDs in different subtypes of SE may depend on the outcome criteria. Therefore, efficacy criteria for the effectiveness of AEDs in the treatment of SE should be standardized. This article is part of a Special Issue entitled Status Epilepticus.

Neuropsychological deficits after a first unprovoked seizure and depressive symptoms in the week before

This prospective study was performed to investigate whether verbal memory deficits are present in patients with a first unprovoked seizure irrespective of significant lesions in the brain and whether symptoms of depression were experienced by those patients in the week before the seizure. After having given informed consent, patients who presented with a first unprovoked seizure were investigated with a psychometric battery consisting of a verbal memory test, a figural memory test, a test following the Stroop paradigm, and a self-rating scale for depression in addition to the routine diagnostic work-up with EEG and MRI. The data of 53 patients aged 45years on average (33 males and 20 females) were available. Verbal memory deficits were present in 60% of the patients, and 21% of the patients delivered a self-rating that was suggestive of at least minor depression in the week before the seizure. Neither verbal memory deficits nor symptoms of depression were associated with a significant lesion of the brain. There was a significant negative correlation between immediate recall in the verbal memory test and the score in the self-rating scale for depression. Our data suggest that even at the time of the first unprovoked seizure, there is an epileptic condition of the brain, which facilitates the occurrence of verbal memory deficits and depression in the presence of an epileptogenic focus irrespective of its localization.

The efficacy of different kinds of intravenously applied antiepileptic drugs in the treatment of status epilepticus. How can it be determined

We explored the influence of four different efficacy criteria on the results of observational studies concerning the treatment of status epilepticus (SE) and its subtypes. We compared and contrasted the results of four different efficacy criteria for the effectiveness of phenytoin, valproate, levetiracetam, and lacosamide. Criterion 1=the last antiepileptic drug (AED) administered before SE termination. Criterion 2=the last drug introduced into the antiepileptic therapy within 72h before the cessation of SE and without changes in dosage or number of the co-medication. Criterion 3=the last drug introduced into the antiepileptic therapy or increased in dose within 24h before termination of the SE without changes in the co-medication. Criterion 4=the last drug introduced into the antiepileptic therapy within 72h before the cessation of SE even allowing changes in the co-medication. We used two-tailed χ2-tests with the Yates adjustment for small samples to evaluate statistical differences between efficacy rates of different AEDs in the entire group and in subgroups of SE according to the second level of subdivisions in axis 1 and according to axis 2 of the new ILAE classification. A total of 145 treatment episodes in 124 patients (47 male, 77 female) were evaluated. There were 23 significant differences in efficacy according to the different criteria. Only criteria 1 and 3 led to significant results in our analysis. When incorporating theoretical considerations and the results of this study, criterion 3 seems to be the most appropriate measure for the evaluation of efficacy of an AED in the treatment of SE, because it seems to be more reasonable than criterion 1.

Creutzfeldt-Jakob–Like Syndrome due to Hypercalcemic Encephalopathy

Hypercalcemia can cause a subacute syndrome of progressive dementia and marked changes in the electroencephalogram (EEG). We report a case of iatrogenic hypercalcemia with a close correlation between the clinical course and the EEG changes. A 73-year-old woman presented with a subacute syndrome of progressive dementia and bursts of 1.5 to 2 Hz intermittent rhythmic delta activity superimposed on a low-voltage background activity in the EEG. Clinical and EEG abnormalities rapidly resolved after normalization of serum calcium levels. As part of the diagnostic workup of a subacute progressive dementia, a serum calcium level and an EEG should be obtained to detect a Creutzfeldt-Jakob like syndrome in hypercalcemia. Unlike in Creutzfeldt-Jakob disease, and Creutzfeldt-Jakob–like syndrome induced by lithium intoxication, there are rarely myoclonic jerks and periodic discharges in hypercalcemic encephalopathy.

Case report: absence-status as late reexacerbation of genetic epilepsy of adolescence

Recently the Task Force of the International League against Epilepsy (ILAE) on Classification of Status Epilepticus (SE) proposed a new classification system of SE [1]. Case reports and studies using this new classification system may contribute to the development of specific treatment strategies for different subgroups of SE. Here we describe the treatment of an absence status epilepticus (ASE) in an elderly patient with genetic epilepsy of adolescence, who had previously been seizure free for more than 40 years. He had suffered about three generalized tonic–clonic seizures in his adolescence and was treated with a medication, which he did not remember. Absences had not been observed. According to the new classification system his recent SE has to be classified on axis 1 as B.2.a.a., ‘‘typical absence status’’, and on axis 4 as 5 de novo (or relapsing) absence status in later life. The impact of this case is that it suggests that in this condition levetiracetam (LEV) is not as efficient as valproic acid (VPA).

Disappearance of Breach Rhythm Heralding Recurrent Tumor Progression in a Patient With Astrocytoma

The breach rhythm is sometimes considered the consequence of reduced resistance between the cortex and the scalp electrode in the region of a skull defect. On the other hand, the electroencephalographic (EEG) changes after craniotomy were attributed to an activation of EEG activity by meningocortical adhesions with admixed gliosis. We report changes of the breach rhythm in a patient with astrocytoma, which give further evidence that the breach rhythm is not merely the result of physical changes in the area of a skull defect. In our patient, the breach rhythm was no longer detectable before a new tumor progression took place, showed up again, and at the end changed into localized slowing before the deterioration of the patient’s general medical condition. This case suggests that in patients with brain tumors, the loss or attenuation in frequency of an established breach rhythm might be considered as an indication of a new tumor progression.