Kette D. Valente

Repetitive transcranial magnetic stimulation is as effective as fluoxetine in the treatment of depression in patients with Parkinson’s disease

Objective: To study the efficacy of 15 Hz repetitive transcranial magnetic stimulation (rTMS) in treating depression in patients with Parkinson’s disease. Methods: 42 patients were enrolled into two groups: group 1, active rTMS (15 Hz rTMS for 10 days) and placebo drug treatment; group 2, sham rTMS and fluoxetine 20 mg/day. A specially designed sham coil was used for sham stimulation. The unified Parkinson’s disease rating scale (UPDRS), activities of daily living (ADL), Hamilton rating scale for depression (HRSD), Beck depression inventory (BDI), and mini-mental state examination (MMSE) were assessed by a rater blinded to treatment arm. Results: HRSD and BDI were improved to the same extent in both groups after two weeks of treatment (38% and 32% for group 1, 41% and 33% for group 2, respectively). At week 8 there was a tendency for worse motor UPDRS scores in group 2 (NS). ADL showed improvement at week 8 only in group 1. MMSE improved in both groups after treatment, but faster in group 1 than in group 2. There were fewer adverse effects in group 1 than in group 2. Conclusions: rTMS has the same antidepressant efficacy as fluoxetine and may have the additional advantage of some motor improvement and earlier cognitive improvement, with fewer adverse effects.

A Controlled Clinical Trial of Cathodal DC Polarization in Patients with Refractory Epilepsy

Summary:  Purpose: To study the effects of cathodal DC polarization in patients with refractory epilepsy and malformations of cortical development (MCDs) as indexed by seizure frequency and epileptiform EEG discharges.

A randomized clinical trial of repetitive transcranial magnetic stimulation in patients with refractory epilepsy.

To study the antiepileptic effects of rTMS in patients with refractory epilepsy and malformations of cortical development in a randomized, double‐blind, sham‐controlled trial.

Which factors may play a pivotal role on determining the type of psychiatric disorder in children and adolescents with epilepsy

Physicians have become aware of the high prevalence of psychiatric disorders (PDs) in children and adolescents with epilepsy; however, there are many controversies as to which factors may have an important role in the different types of PD. This study was designed to assess the main PD; verify the age of onset compared with the age of diagnosis of the PD; and determine which factors may be correlated with the type of PD described. For this purpose, a multidisciplinary team evaluated children and adolescents (4-18 years) with epilepsy and analyzed patient-related factors such as age (grouped according to Piagets cognitive scale: <6 years, 7-13 years, >13 years), sex, family history of PDs, and cognitive status. With respect to epilepsy features, we considered age of onset, duration, seizure control at the time of psychiatric evaluation, refractoriness, antiepileptic drugs (mono- vs polytherapy), seizure type (generalized vs focal), and epilepsy type (idiopathic vs symptomatic/probably symptomatic). Depression occurred in 36.4% and attention-deficit hyperactivity disorder (ADHD) in 29.1%, these being the most frequent PDs in this series. Focal epilepsy was significantly more frequent in children and adolescents with PDs. As to the type of PD, age was an important factor, with a predominance of ADHD in children and depression in adolescents (P<0.0001). Family history was contributory for depression, but not for others PDs (P<0.0001). Depression remained underdiagnosed and untreated for a longer period. Impact of early diagnosis and treatment remains unknown.

Antiepileptic effects of repetitive transcranial magnetic stimulation in patients with cortical malformations: an EEG and clinical study.

Objective: To study the effects of repetitive transcranial magnetic stimulation (rTMS) on epileptic EEG discharges in patients with refractory epilepsy and malformations of cortical development (MCDs). Methods: Eight patients with MCD and refractory epilepsy underwent 1 session of low-frequency rTMS (0.5 Hz, 600 pulses) focally targeting the MCD. The number of epileptiform discharges (EDs) in the EEG and seizures were measured before (baseline), immediately after as well as 15 and 30 days after rTMS treatment. Results: Stimulation significantly decreased the number of EDs 15 and 30 days after rTMS treatment (mean reduction of 46.4%, 95% CI 12.7–80.2%, and mean reduction of 42.1%, 95% CI 8.2–75.7%, respectively). This was associated with a significant reduction in the number of seizures reported as compared with the 4-week period preceding rTMS (mean reduction of 57.3%, 95% CI 33.1–80.3%, and mean reduction of 51.2%, 95% CI 27.9–74.9%, respectively). Conclusion: This open study shows a significant antiepileptic effect of rTMS based on clinical and electrophysiological criteria and supports the therapeutic utility of rTMS for patients with well-localized epileptogenic cortical malformations.

Sertraline and fluoxetine: Safe treatments for children and adolescents with epilepsy and depression

OBJECTIVE Depression is frequent, underdiagnosed, and untreated in people with epilepsy. The lack of treatment is partially explained by the concerns over the proconvulsive effects of psychoactive drugs. There are few studies on the effects of selective serotonin reuptake inhibitors (SSRIs) in adults with epilepsy and none in children. The main purpose of the present study was to analyze the impact of SSRIs on the severity and frequency of seizures in children and adolescents with epilepsy and major depressive disorders. In addition, we also evaluated the efficacy of SSRIs in the treatment of depressive symptoms and side effects other than seizure aggravation. METHODS Monthly frequency of seizures was recorded in the 3-6 months preceding the introduction of SSRIs. According to the criteria proposed by A.M. Kanner, A.M. Kozak and M. Frey (Epilepsy Behav 2000;1:100-5), a positive correlation between introduction of SSRIs and seizure worsening should be considered in the following circumstances: (1) occurrence of de novo generalized tonic-clonic (GTC) seizures; (2) recurrence of GTC seizures following a period of at least 1 year without such episodes; and (3) increase in monthly seizure frequency compared with that reported before introduction of SSRIs. Seizure worsening was considered as probably caused by an SSRI when the increase in monthly frequency occurred in a period up to 3 months after the beginning of SSRI use. RESULTS Thirty-six children with epilepsy had a depressive disorder. Seizures worsened in two patients. Among this group of patients with depression, all had an improvement in their depressive symptoms. One patient taking fluoxetine had a facial rash and one patient taking sertraline had gastrointestinal disorders. These conditions improved, with total remission, when fluoxetine was replaced with sertraline and vice versa. CONCLUSION In this sample of children and adolescents with epilepsy and depressive disorders, we observed that SSRIs are a good therapeutic option, considering their efficacy in remission of depressive symptoms, their few adverse effects, and their maintenance of satisfactory seizure control. Treatment of depression should be considered relevant in the treatment of patients with epilepsy.

Risk factors for psychogenic nonepileptic seizures in children and adolescents with epilepsy

There is evidence that psychogenic nonepileptic seizures (PNES) remain underdiagnosed, especially in children and adolescents. Diagnosis of such events is even more difficult in patients that do have epilepsy, leading to delayed diagnosis and treatment and, consequently, iatrogenic complications. This study aimed to evaluate possible risk factors in children with epilepsy who had PNES. Seizures and epileptic syndromes were classified according to International League Against Epilepsy guidelines. Patients were evaluated with a structured psychiatric anamnesis and classified according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition; Classification of Mental and Behavioral Disorders: Diagnostic Criteria for Research; and Schedule for Affective Disorders and Schizophrenia for School-Age Children--Epidemiological Version. Risk factors such as head trauma, physical, sexual and psychological abuse, and psychiatric diagnoses, among others, were investigated. Family history of epilepsy and psychiatric illness were detected by review of medical records and/or follow-up interviews. Gender was not a predictive factor, and although older children had a higher risk for PNES, younger children also presented truly psychogenic events mimicking epileptic seizures. The most common associated psychiatric diagnosis was depression. Family histories for epilepsy and psychiatric illness were a frequent finding. An inadequate family environment was more common than sexual or physical abuse. Current knowledge obtained from adults with PNES has been used to understand children with PNES. However, this study of children with epilepsy revealed some similarities and many differences. These features may help to identify predictive factors in a population in need of adequate diagnosis of and therapy for this long-lasting pathology.

Effects of antidepressant treatment with rTMS and fluoxetine on brain perfusion in PD

Background: Although depression is highly prevalent in Parkinson disease (PD), little is known about the neural correlates associated with depression and antidepressant treatment in PD. Objective: To examine the effects of fluoxetine and repetitive transcranial magnetic stimulation (rTMS) on regional cerebral blood flow (rCBF) using SPECT in patients with PD and depression. Methods: Twenty-six patients were enrolled into two groups: One received active rTMS and placebo medication and the other sham rTMS and fluoxetine 20 mg/day. Brain SPECT was performed at baseline and after 2 and 8 weeks. Changes in rCBF were compared across timepoints and correlated with clinical scores. In addition, baseline rCBF of these patients was compared with that of 29 healthy, age-matched subjects. Results: At baseline, patients with PD and depression showed significantly lower rCBF in the left prefrontal cortex, posterior cingulate gyrus, left insula, and right parietal cortex when compared with healthy controls. Both treatments induced significant clinical improvement and increases in rCBF in the posterior cingulate gyrus and decreases in rCBF in the right medial frontal gyrus. These changes were significantly correlated to the clinical outcome. Furthermore, the comparison between these two treatments revealed that whereas rTMS treatment was associated with an increased perfusion in the right and left prefrontal cortex, fluoxetine treatment was associated with a relative rCBF increase in the occipital lobe. Conclusion: Depression in patients with Parkinson disease is correlated with a dysfunction of the frontal–limbic network that can be modulated by two different antidepressant therapies.

Temporal Lobe Epilepsy in Childhood: Comprehensive Neuropsychological Assessment

The neuropsychological features of children with temporal lobe epilepsy are not yet well defined. The aim of this study was to identify the neuropsychological deficits in children with temporal lobe epilepsy. We evaluated 25 patients and compared them with 25 normal children. All children underwent a comprehensive neuropsychological assessment. We found a significant difference in favor of the control group in the following measures: IQ; forward digit; Trail Making Test for Children B; Wisconsin Card Sorting Test; block design; Boston naming test, verbal fluency; and Wide Range Assessment of Memory and Learning verbal learning, visual learning, verbal memory, visual memory, delayed recall of verbal learning, delayed recall of stories, and recognition of stories. Our findings show that children with temporal lobe epilepsy present with several neuropsychological deficits, despite normal IQ. These findings point to a dysfunction of cerebral areas other than temporal lobe, particularly the frontal lobes.

Angelman Syndrome: Difficulties in EEG Pattern Recognition and Possible Misinterpretations

Summary:  Purpose: This study aimed to evaluate the sensitivity of the EEG in Angelman syndrome (AS), to verify the age at onset of suggestive EEGs and to study EEG patterns, analyzing variations and comparing our findings with nomenclature previously used.