Kerstin Anneken

Frequency of seizures and epilepsy in neurological HIV-infected patients

BACKGROUND Infection with the human immunodeficiency virus (HIV) is associated both with infections of the central nervous system and with neurological deficits due to direct effects of the neurotropic virus. Seizures and epilepsy are not rare among HIV-infected patients. We investigated the frequency of acute seizures and epilepsy of patients in different stages of HIV infection. In addition, we compared the characteristics of patients who experienced provoked seizures only with those of patients who developed epilepsy. METHODS The database of the Department of Neurology, University of Münster, was searched for patients with HIV infection admitted between 1992 and 2004. Their charts were reviewed regarding all available sociodemographic, clinical, neurophysiological, imaging and laboratory data, therapy and outcome. Stage of infection according to the CDC classification and the epileptogenic zone were determined. RESULTS Of 831 HIV-infected patients treated in our department, 51 (6.1%) had seizures or epilepsy. Three of the 51 patients (6%) were diagnosed with epilepsy before the onset of the HIV infection. Fourteen patients (27%) only had single or few provoked seizures in the setting of acute cerebral disorders (eight patients), drug withdrawal or sleep withdrawal (two patients), or of unknown cause (four patients). Thirty-four patients (67%) developed epilepsy in the course of their HIV infection. Toxoplasmosis (seven patients), progressive multifocal leukencephalopathy (seven patients) and other acute or subacute cerebral infections (five patients) were the most frequent causes of seizures. EEG data of 38 patients were available. EEG showed generalized and diffuse slowing only in 9 patients, regional slowing in 14 patients and regional slowing and epileptiform discharges in 1 patient. Only 14 of the patients had normal EEG. At the last contact, the majority of the patients (46 patients=90%) were on highly active antiretroviral therapy (HAART). Twenty-seven patients (53%) were on anticonvulsant therapy (gabapentin: 14 patients, carbamazepine: 9 patients, valproate: 2 patients, phenytoin: 1 patient, lamotrigine: 1 patient). Patients with only provoked seizures had no epilepsy risk factors except HIV infection, and were less likely to be infected via intravenous drug abuse. CONCLUSIONS Seizures are a relevant neurological symptom during the course of HIV infection. Although in some patients seizures only occur provoked by acute disease processes, the majority of patients with new onset seizures eventually develops epilepsy and require anticonvulsant therapy. Intravenous drug abuse and the presence of non-HIV-associated risk factors for epilepsy seem to be associated with the development of chronic seizures in this patient group.

Transient lesion in the splenium related to antiepileptic drug: Case report and new pathophysiological insights

Transient focal lesions in the splenium of the corpus callosum (SCC) have been associated with antiepileptic drug (AED) treatment. However, the aetiology is widely unknown. We describe a transient SCC lesion in an epilepsy patient after abrupt AED reduction. Whole head high-field diffusion tensor imaging (DTI) including fully automated quantitative fractional anisotropy (FA) analysis was used to get insight into the pathophysiology of transient SCC lesions. Our results demonstrate that a reversible loss of directional fibre organisation in the splenium, likely due to intramyelinic oedema, is the morphological correlate of transient SCC lesions. We conclude that DTI provides a highly sensitive and quantitative tool to detect subtle and transient loss of fibre integrity associated with AED treatment.

An unusual case of musicogenic epilepsy in a patient with a left fronto-temporal tumour.

Sirs: Musicogenic (or music-induced) epilepsy is a rare condition of reflex epilepsy precipitated by complex stimuli. Although the first known reference to musicogenic epilepsy goes back to the 16th century the pathophysiology still remains unclear [2]. An important role is attributed to the emotional aspect of music [1]. Musicogenic epilepsy has a strong correlation with the temporal lobe with a right-sided preponderance. In most cases, however, no structural brain lesion can be found [2]. The usual type of seizure is partial complex or generalized tonic-clonic. Precipitating factors are quite specific, reaching from a simple sound to an individual kind of music. Musical training may predispose to musicogenic epilepsy. We report a 48 year old right handed woman with epileptic auras triggered by listening to songs with sorrowful lyrics and predominant instrumental background. Our patient was a non musician. Seven years prviously she had presented for the first time with a generalized tonic-clonic seizure at our epilepsy clinic. An MRI scan of the brain showed a left fronto-temporal lesion (see Fig 1). Stereotactic biopsy revealed an astrocytoma (WHO grade II) which was not operable. The interictal EEG revealed intermittent theta activity and sharp wave like transients in the left fronto-temporal region (see Fig 2). An IMT-SPECT showed left temporal hyperactivity, a thallium SPECT showed normal activity. The patient had left hemispheric language dominance as measured by functional transcranial dopplersonography (fTCD). During the next years the patient suffered from recurrent spontaneous complex partial seizures of her right arm introduced by an epigastric or olfactory aura and occasionally followed by generalized tonicclonic seizures. Treatment with carbamazepine (1200 mg daily, higher doses were not tolerated) reduced the frequency to one seizure every other month. Other drugs like oxcarbazepine were not tolerated. However, two years after her first epileptic seizure the patient developed musicogenic seizures. The seizures had a stereotyped course. Listening to songs with sorrowful lyrics and predominant instrumental background triggered psychogenic (deja vu) and epigastric auras in the patient. The music induced always the same familiar thought in her mind, but the patient was not able to remember it. The thought was usually followed by a rising epigastric discomfort. The auras lasted for a total of two minutes and started always two minutes after music onset. Further, the patient reported that the music evoked strong negative emotions in her. Neither alteration of consciousness nor motor symptoms occurred. Under the maximum dose of 1200 mg carbamazepine daily the frequency of musicogenic auras decreased only moderately. Avoidance of music was a sure help. We describe a case of musicogenic epilepsy with psychogenic and epigastric auras in a patient with temporal lobe epilepsy based on a tumour. In concordance with other studies, the seizures were triggered by a specific kind of music that evoked strong emotions in the patient. The occasional spontaneous seizures in our patient are a Fig. 1 MRI scan of the brain: a: T1 weighted MRI with contrast medium. b: T2 weighted MRI without contrast medium. The MRI images show a left fronto-temporal tumour which was classified as an astrocytoma WHO grade II by stereotactic biopsy. LETTER TO THE EDITORS J Neurol (2006) 253 : 1502–1504 DOI 10.1007/s00415-006-0257-1