Katia Lin

Predictors of quality of life in patients with refractory mesial temporal lobe epilepsy

PURPOSE The identification of variables associated with health-related quality of life (HRQoL) in patients with mesial temporal lobe epilepsy related to hippocampal sclerosis (MTLE-HS) would improve surgical decision-making and post-operatory follow-up in this group of patients. METHODS We analyzed the independent association between the Quality of Life in Epilepsy Inventory-31 (QOLIE-31) of 81 consecutive patients with refractory MTLE-HS. The clinical, demographic, radiological and electrophysiological variables were analyzed by multiple linear regression analysis. KEY FINDINGS Approximately 36% (adjusted R(2)=0.36; R coefficient=0.66) of the QOLIE-31 overall score variance was explained by the history of initial precipitant injury, family history of epilepsy, disease duration, age of epilepsy onset, seizure frequency and presence of psychiatric axis-II diagnosis. The variance of QOLIE-31 sub-scales was: seizure worry=7%; overall QOL=11%; emotional well-being=32%; energy/fatigue=38%; cognitive function=13%; medication effects=7%; social function=13% (R coefficient between 0.30 and 0.65). SIGNIFICANCE The pre-surgical variables studied had relatively low prediction capacity for the overall QOLIE-31 score and its sub-scales in this set of Brazilian patients with refractory MTLE-HS.

CLIPPERS-like MRI findings in a patient with multiple sclerosis

Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) has been described as a clinically and radiologically distinct pontine-predominant encephalomyelitis with a favorable response to high dose corticosteroids and usually requiring chronic immunosuppresive therapy. Brain magnetic resonance imaging (MRI) reveals a characteristic pattern of punctate and curvilinear enhancement lesions in the pons extending variably to surrounding areas. We herein describe such imaging findings in a patient with a definite diagnosis of relapsing-remitting multiple sclerosis (MS).

Validation of diagnostic tests for depressive disorder in drug-resistant mesial temporal lobe epilepsy

PURPOSE This study aimed to evaluate the diagnostic accuracy of the Hamilton Rating Scale for Depression (HRSD), the Beck Depression Inventory (BDI), the Hospital Anxiety and Depression Scale (HADS), and the Hospital Anxiety and Depression Scale-Depression subscale (HADS-D) as diagnostic tests for depressive disorder in drug-resistant mesial temporal lobe epilepsy with hippocampal sclerosis (MTLE-HS). METHODS One hundred three patients with drug-resistant MTLE-HS were enrolled. All patients underwent a neurological examination, interictal and ictal video-electroencephalogram (V-EEG) analyses, and magnetic resonance imaging (MRI). Psychiatric interviews were based on DSM-IV-TR criteria and ILAE Commission of Psychobiology classification as a gold standard; HRSD, BDI, HADS, and HADS-D were used as psychometric diagnostic tests, and receiver operating characteristic (ROC) curves were used to determine the optimal threshold scores. RESULTS For all the scales, the areas under the curve (AUCs) were approximately 0.8, and they were able to identify depression in this sample. A threshold of ≥9 on the HRSD and a threshold of ≥8 on the HADS-D showed a sensitivity of 70% and specificity of 80%. A threshold of ≥19 on the BDI and HADS-D total showed a sensitivity of 55% and a specificity of approximately 90%. The instruments showed a negative predictive value of approximately 87% and a positive predictive value of approximately 65% for the BDI and HADS total and approximately 60% for the HRSD and HADS-D. CONCLUSIONS HRSD≥9 and HADS-D≥8 had the best balance between sensitivity (approximately 70%) and specificity (approximately 80%). However, with these thresholds, these diagnostic tests do not appear useful in identifying depressive disorder in this population with epilepsy, and their specificity (approximately 80%) and PPV (approximately 55%) were lower than those of the other scales. We believe that the BDI and HADS total are valid diagnostic tests for depressive disorder in patients with MTLE-HS, as both scales showed acceptable (though not high) specificity and PPV for this type of study.

Hippocampal sclerosis and ipsilateral headache among mesial temporal lobe epilepsy patients

PURPOSE To investigate the frequency and patterns of headache in a well-defined and homogeneous group of mesial temporal lobe epilepsy with hippocampal sclerosis (MTLE-HS) patients. METHODS One hundred consecutive MTLE-HS patients under comprehensive presurgical evaluation were evaluated from May 2009 to April 2010. A standardized questionnaire was applied according to the criteria of the International Headache Society (IHS). Headache diagnosis was based on the second edition of the International Classification of Headache Disorders (ICHD-II). RESULTS Ninety-two patients (92%) had at least one headache episode during the previous 12 months. Migraine occurred in 51.9% of patients and tension-type headache (TTH) in 39.1%. Patients with migraine presented higher frequency (p=0.002) and severity of episodes (p<0.001), as well as lateralized pain (p=0.001) than individuals with TTH. MTLE-HS patients with unilateral HS and predominantly unilateral headache (irrespective of the type), presented pain ipsilateral to the HS (OR 8.5; CI 95%=2.1-35.1; p=0.003). CONCLUSIONS Headache is a frequent clinical symptom of lateralizing value, which may share common pathophysiology with epileptogenesis among MTLE-HS patients.

Seizure precipitants and inhibiting factors in mesial temporal lobe epilepsy

Epileptic seizures may be triggered by both nonspecific facilitating factors and specific reflex epileptic mechanisms. These consist of sensory or cognitive inputs activating neural networks that, due to some functional instability, may respond with an epileptic discharge. The aim of this study was to determine the prevalence and nature of self-perceived seizure-inducing and -inhibiting factors in patients with mesial temporal lobe epilepsy (MTLE) followed from March 3rd to December 8th, 2009 at the Centro de Epilepsia de Santa Catarina Outpatient Clinic of the Hospital Governador Celso Ramos in Florianópolis, Brazil and their relation to demographics, epilepsy-related variables and anxiety level. Of the 71 patients, 60 (84.5%) patients identified at least one seizure trigger, and 36 (50.7%) patients identified inhibiting factors. In order of frequency, the most freely recalled precipitants were nervousness (58.8%), worrying (21.6%) and menstruation (19.6%), while the precipitants that were most frequently identified from a list were worrying (73.2%), anxiety (66.2%) and anger (53.5%). Knowledge of precipitant factors may have implications on the treatment and seizure control of patients.

Glucose-dependent insulinotropic peptide receptor expression in the hippocampus and neocortex of mesial temporal lobe epilepsy patients and rats undergoing pilocarpine induced status epilepticus.

The glucose-dependent insulinotropic peptide receptor (GIPR) has been implicated with neuroplasticity and may be related to epilepsy. GIPR expression was analyzed by immunohistochemistry in the hippocampus (HIP) and neocortex (Cx) of rats undergoing pilocarpine induced status epilepticus (Pilo-SE), and in three young male patients with left mesial temporal lobe epilepsy related to hippocampal sclerosis (MTLE-HS) treated surgically. A combined GIPR immunohistochemistry and Fluoro-Jade staining was carried out to investigate the association between the GIPR expression and neuronal degeneration induced by Pilo-SE. GIPR was expressed in the cytoplasm of neurons from the HIP CA subfields, dentate gyrus (DG) and Cx of animals and human samples. The GIPR expression after the Pilo-SE induction increases significantly in the HIP after 1h and 5 days, but not after 12h or 50 days. In the Cx, the GIPR expression increases after 1h, 12h and 5 days, but not 50 days after the Pilo-SE. The expression of GIPR 12h after Pilo-SE was inversely proportional to the Fluoro-Jade staining intensity. In the human tissue, GIPR expression patterns were similar to those observed in chronic Pilo-SE animals. No Fluoro-Jade stained cells were observed in the human sample. GIPR is expressed in human HIP and Cx. There was a time and region dependent increase of GIPR expression in the HIP and Cx after Pilo-SE that was inversely associated to neuronal degeneration.

Neurological complications following bariatric surgery

OBJECTIVE It was to report on Brazilian cases of neurological complications from bariatric surgery. The literature on the subject is scarce. METHOD Cases attended by neurologists in eight different Brazilian cities were collected and described in the present study. RESULTS Twenty-six cases were collected in this study. Axonal polyneuropathy was the most frequent neurological complication, but cases of central demyelination, Wernicke syndrome, optical neuritis, radiculits, meralgia paresthetica and compressive neuropathies were also identified. Twenty-one patients (80%) had partial or no recovery from the neurological signs and symptoms. CONCLUSION Bariatric surgery, a procedure that is continuously increasing in popularity, is not free of potential neurological complications that should be clearly presented to the individual undergoing this type of surgery. Although a clear cause-effect relation cannot be established for the present cases, the cumulative literature on the subject makes it important to warn the patient of the potential risks of this procedure.

Predictors of meaningful improvement in quality of life after temporal lobe epilepsy surgery: A prospective study

To investigate prospectively the independent predictors of a minimum clinically important change (MCIC) in quality of life (QOL) after anterior temporal lobectomy (ATL) for drug‐resistant mesial temporal lobe epilepsy related to hippocampal sclerosis (MTLE‐HS) in Brazilian patients.

Socio-demographic and Clinical Characteristics of Brazilian Patients with Epilepsy Who Drive and Their Association with Traffic Accidents

PURPOSE To identify variables associated with driving in patients with epilepsy and their association with traffic accidents. METHODS Binary logistic regression analysis was performed to determine the independent association between demographic and clinical variables and driving in 144 outpatients with epilepsy. Traffic accidents caused by seizures were also analyzed. RESULTS Sixty-eight patients (47.2%) drove after the diagnosis of epilepsy. Among these patients, 67.6% drove in the last 12 months, 89% of whom did so in spite of uncontrolled seizures. Driving was independently associated with male sex, higher income, occurrence of simple partial seizures, age at epilepsy onset over 18 years and monotherapy treatment. Seventeen patients (only male) had accidents due to seizures, which were independently associated with lower education and age at epilepsy onset over 18 years. CONCLUSIONS Identification of variables associated with driving and traffic accidents may help to minimize risks and improve the quality of life of patients with epilepsy.

A single high dose of dexamethasone affects the phosphorylation state of glutamate AMPA receptors in the human limbic system

Glucocorticoids (GC) released during stress response exert feedforward effects in the whole brain, but particularly in the limbic circuits that modulates cognition, emotion and behavior. GC are the most commonly prescribed anti-inflammatory and immunosuppressant medication worldwide and pharmacological GC treatment has been paralleled by the high incidence of acute and chronic neuropsychiatric side effects, which reinforces the brain sensitivity for GC. Synapses can be bi-directionally modifiable via potentiation (long-term potentiation, LTP) or depotentiation (long-term depression, LTD) of synaptic transmission efficacy, and the phosphorylation state of Ser831 and Ser845 sites, in the GluA1 subunit of the glutamate AMPA receptors, are a critical event for these synaptic neuroplasticity events. Through a quasi-randomized controlled study, we show that a single high dexamethasone dose significantly reduces in a dose-dependent manner the levels of GluA1-Ser831 phosphorylation in the amygdala resected during surgery for temporal lobe epilepsy. This is the first report demonstrating GC effects on key markers of synaptic neuroplasticity in the human limbic system. The results contribute to understanding how GC affects the human brain under physiologic and pharmacologic conditions.