Lady Diana Ladino

Epilepsy and homicide

Purpose We report the rare case of a patient with intractable epilepsy and escalating aggression, resulting in murder, who had complete resolution of her seizures and explosive behavior following a right temporal lobectomy. Patients and methods We searched the available literature from 1880 to 2013 for cases of epilepsy being used as a court defense for murder and collected information regarding the final sentencing outcomes. We selected 15 papers with a total of 50 homicides. Results We describe the case of a 47-year-old woman with drug-resistant right temporal epilepsy who developed increasing emotional lability, outbursts of anger and escalating violent behavior culminating in a violent murder. The patient was imprisoned while awaiting trial. In the interim, she underwent a successful temporal lobectomy with full resolution of seizures, interictal rage and aggressive behaviors. After the surgery, her charges were downgraded and she was transferred to a psychiatric facility. Conclusion The aggressive behavior associated with epilepsy has been described in the literature for over a century. A link between epilepsy and aggression has been disproportionally emphasized. These patients share some common characteristics: they are usually young men with a long history of epilepsy and lower than average intelligence. The violent act is postictal, sudden-onset, more likely to occur after a cluster of seizures and is usually related with alcohol abuse.

Efficacy of lacosamide in children and adolescents with drug-resistant epilepsy and refractory status epilepticus: A systematic review

PURPOSE Lacosamide, is one of the newer antiepileptic drug approved for focal drug-resistant epilepsy as an add-on treatment in patients older than 16 years. However, there is growing evidence of its use, safety and efficacy in children. We aim to evaluate efficacy and tolerability of lacosamide in focal and generalized drug-resistant epilepsy and refractory status epilepticus in the pediatric population. METHODS We conducted a systematic review on MEDLINE, EMBASE, COCHRANE, Google Scholar and Scielo from January 2008 to January 2017. The primary outcome was the efficacy of lacosamide in children with drug-resistant epilepsy and refractory status epilepticus. Efficacy and adverse events attributed to lacosamide were extracted from each publication and systematically reported. We performed no meta-analyses due to limited available data. RESULTS Of 175 abstracts identified by the search, 82 were reviewed as full-text. Twenty-six articles fulfilled eligibility criteria and described outcomes in 797 patients (57% male). The majority of studies were retrospective (69%) small series (84%). On average 51% of patients had 50% or greater seizure reduction. The mean seizure freedom rate was 24%. Adverse effects occurred in 18-59% of patients. The main events were dizziness, sedation, gastrointestinal upset, mood and behavioral changes. Half of the patients with Lennox Gastaut syndrome showed 50% or greater seizure reduction, 32% did not response to lacosamide and 17% suffered seizure aggravation. CONCLUSION Current evidence shows lacosamide as a good option in pediatric patients with focal drug-resistant epilepsy and refractory status epilepticus as an add-on therapy given its efficacy on seizure control and safety profile. The use of lacosamide in Lennox-Gastaut syndrome shows conflicting data. Large randomized controlled studies in the pediatric population are necessary to substantiate these findings.

Epidemiology of early stages of epilepsy: Risk of seizure recurrence after a first seizure

A single unprovoked seizure is a frequent phenomenon in the general population and the rate of seizure recurrence can vary widely. Individual risk prognostication is crucial in predicting patient outcomes and guiding treatment decisions. In this article, we review the most important risk factors associated with an increased likelihood of seizure recurrence after a single unprovoked seizure. In summary, the presence of focal seizure, nocturnal seizure, history of prior brain injury, family history of epilepsy, abnormal neurological exam, epileptiform discharges on electroencephalography and neuroimaging abnormalities, portend increased risk of seizure recurrence. Elucidation of these risk factors in patient assessment will augment clinical decision-making and may help determine the appropriateness of instituting anti-epilepsy treatment. We also discuss the Canadian model of single seizure clinics and the potential use to assess these patients.

Diagnostic yield of the palmomental reflex in patients with suspected frontal lesion

BACKGROUND The purpose of this study was to determine the diagnostic value of the palmomental reflex in order to identify frontal lesions in neurological outpatients. METHODS Two hundred twenty-six neurological patients with suspected intracranial lesion with an indication for magnetic resonance imaging (MRI) were included. All patients underwent the same MRI protocol. The reflex was elicited by trained and standardized nurses, and was evaluated by two neurologists. The evaluation was blind and independent. The tests accuracy was calculated. The Kappa coefficient was used to calculate the interobserver and intra-observer reliability. RESULTS The interobserver reliability between neurologists was 0.53 with 93% of agreement (p<0.001). The diagnostic accuracy measures were as follow: sensitivity of 19%, specificity of 93%, positive predictive value of 30%, negative predictive value of 88%, positive likelihood ratio of 2.7 and negative likelihood ratio of 0.87. The area under the curve was 0.56. CONCLUSION The palmomental reflex is associated with frontal structural lesions but the sensitivity is low, indicating a high percentage of frontal lesions with a negative reflex. When the test is used on its own, it is insufficient to detect frontal damage.

Meningovascular neurosyphilis with basilar artery thrombosis, a case report and literature review

Herein a case is described of a 54-years old patient, HIV negative, with cerebro-vascular disease by basilar artery thrombosis secondary to meningovascular neurosyphilis. Neurosyphilis is the impairment at any stage of the central nervous system by Treponema pallidum subspecies pallidum and includes asymptomatic and symptomatic forms of infection. The presentation can take many forms, depending on the location and extent of tissue damage. The currently recommended treatment is crystalline penicillin, 4 million units every 4 hours for 14 days.

On the Renaissance of Stereotactic EEG and Its Interpretation

Stereotactic electroencephalography (SEEG) officially celebrated its 60th birthday this past year, but it might be better said to be experiencing a renaissance. Originating with Bancaud and Talairach at Hôpital Sainte Anne in Paris, France, SEEG has since been in continuous use at a number of centres throughout the world, particularly in Europe. In Canada, chronic depth electrode recordings have been performed since the 1970s at McGill University and Université de Montréal, and in 1985 Olivier et al reported on the first 70 epilepsy patients investigated with SEEG at theMontreal Neurological Institute. Despite this long history, SEEG was confined for many decades to a minority of epilepsy centres, in large part because of the expertise needed and the requirement for a two-stage surgical procedure (stereotactic angiography and electrode implantation). However, advances in multimodal imaging that have simplified and refined the procedure (and removed the requirement for stereotactic angiography) have fostered a rebirth of SEEG in North America and around the world. In this issue of the Journal, Joswig et al describe a nearcomplete shift from subdural recordings to SEEG over the past 4 years at the London Health Sciences Centre (LHSC). The authors describe the LHSC practice change as driven by shorter mean operative times, better patient tolerability and a lower risk profile. Notwithstanding, they acknowledge a lack of high-quality evidence indicating superiority of any one technique for intracranial EEG (IEEG) monitoring, and affirm that selection of IEEG modality must currently be viewed as a state of equipoise. It is important to keep in mind that the long history of epilepsy surgery excellence at LHSC, before the shift to SEEG, comprises 30 years of fruitful IEEG monitoring using subdural electrodes. A future analysis of seizure outcomes comparing preand post-SEEG eras at LHSC will be extremely valuable to see the long-term impact of the transition in techniques on outcomes in patients receiving epilepsy surgery. Ideally, of course, other future studies will be designed to compare IEEG modalities, including randomized clinical trials. Given the current absence of class I/II evidence, an expert consensus-based recommendation was recently published on the diagnostic utility of IEEG, including the strengths, limitations and risks of the various IEEG modalities, concluding that at present “neither the position of insisting on one particular IEEG modality in all cases nor rejecting its added value altogether in any scenario lends itself to scientific scrutiny”. Subdural grid electrodes provide data from a two-dimensional cortical surface map well-suited for localizing neocortical epilepsies on the temporal, frontoparietal and occipital convexities. Large areas of cortex can be covered, however, grid electrodes have limited precision for the definition of EEG patterns arising from deep generators, such as the amygdala, hippocampus, planum temporalis, insula and mesial frontal areas. Subdural strip electrodes are flexible and can be safely passed in the subdural space without direct visualization, allowing them to be placed at either the edges of a craniotomy or separately through a small burr hole, although it is sometimes impossible to reach certain areas because of bridging veins or adhesions, and in “blind” insertions, topographic imprecision is common. In addition to seizure onset localization, grid arrays offer the option to perform cortical functional mapping to define regions of eloquence. A significant difference between subdural grid and SEEG techniques is better patient tolerance of depth electrode implantations, with minimal headache and less frequent complications such as bleeding, raised intracranial pressure or cerebrospinal fluid leakage. Another issue arising in the choice of IEEG modalities is related to the hypothesis arrived at before implantation and the expertise of the epileptologist. Because a smaller area is potentially covered with depth electrodes, a more refined hypothesis may be required in SEEG, although typically several depth electrodes are implanted and what is lost in two-dimensional cortical surface coverage may be gained in threedimensional cortical-subcortical-cortical coverage. Often forgotten in the discussions surrounding different IEEG modalities is the role of the clinical neurophysiologist interpreting the recordings. Setting aside the potential importance of analyzing broadband IEEG for infraslow activity and high-frequency oscillations, there exist uncertainties regarding IEEG interpretation in the standard clinical 0.5-70Hz band-pass range—even with respect to defining ictal onset—and evidence to suggest poor interobserver agreement. Furthermore, and particularly relevant for SEEG, basic questions surrounding the use of bipolar and referential montages and whether IEEG contacts record electrical potentials at a distance continue to be a source of debate. For example, it is often stated that IEEG electrode contacts do not “see” activity more than 5-10mm away, but large cortical fields, such as those responsible for scalp EEG visible epileptiform discharges, produce volume conducted intracranial fields that can be recorded synchronously at multiple IEEG electrodes, which may be situated centimetres away from each other. Figure 1 highlights some of the particular benefits of SEEG as well as some of the interpretative issues just described. In this patient with post-traumatic epilepsy, SEEG revealed seizure onsets within the right inferior frontal sulcus, a localization that would have been impossible to identify using subdural electrodes overlying the cortical surface. The simultaneous recording from lateral and medial structures showed the onset of leftward head

Update on Minimal Standards for Electroencephalography in Canada: A Review by the Canadian Society of Clinical Neurophysiologists

Surface electroencephalogram (EEG) recording remains the gold standard for noninvasive assessment of electrical brain activity. It is the most efficient way to diagnose and classify epilepsy syndromes as well as define the localization of the epileptogenic zone. The EEG is useful for management decisions and for establishing prognosis in some types of epilepsy. Electroencephalography is an evolving field in which new methods are being introduced. The Canadian Society of Clinical Neurophysiologists convened an expert panel to develop new national minimal guidelines. A comprehensive evidence review was conducted. This document is organized into 10 sections, including indications, recommendations for trained personnel, EEG yield, paediatric and neonatal EEGs, laboratory minimal standards, requisitions, reports, storage, safety measures, and quality assurance.

A Unique Ictal EEG Pattern in a Patient with the Coexistence of Generalized and Focal Epilepsy

The coexistence of focal and generalized epilepsy is rare. We report on a 17-year-old male with drug-resistant focal epilepsy and idiopathic generalized epilepsy (IGE). He began to experience generalized tonic-clonic seizures (GTCS) at the age of 3 years, with a good response to phenobarbital. At the age of 14 years, he began to experience complex partial seizures (CPS). Video-electroencephalography (video-EEG) telemetry showed the coexistence of right temporal spikes and bursts of generalized spike-wave (GSW). The ictal EEG showed a unique EEG pattern characterized by a 4- to 5-second burst of GSW followed by rhythmic delta activity over the right temporal region. A magnetic resonance image (MRI) showed right hippocampal sclerosis. The patient underwent a right temporal lobectomy that significantly improved his seizure control. He was rendered seizure free of the complex partial seizures and improvement of the GTCS. This case illustrates a very uncommon ictal EEG pattern, and shows that the decision for surgery in patients with focal drug-resistant epilepsy should not be affected by coexistent generalized epilepsy.