Olli Waltimo

Epilepsy after stroke

Summary: A retrospective follow‐up of 200 consecutive stroke patients [ischemic brain infarction (IBI) 157, intracerebral hemorrhage (ICH) 20, subarachnoid hemorrhage (SAH) 231 who were in need of ambulatory rehabilitation was conducted for a mean period of 40 months after stroke. Epilepsy developed in 33 (17%) patients. The occurrence of epilepsy was 14% in IBI, 15% in ICH, and 35% in SAH. Significantly more patients developed epilepsy in the SAH group than in the IBI group (8 of 23 vs. 22 of 157, p < 0.05). Of the 33 patients, 15% had their first seizures within the first 2 weeks after stroke, and 55% developed epilepsy in 6 months. Forty‐eight percent of the patients had generalized seizures. Antiepileptic drug (AED) treatment was started in 28 of 33 patients, of whom 17 still had seizures during follow‐up. Epilepsy was an important consequence of stroke among patients who needed rehabilitation, especially in SAH patients. In most, this was due to arterial spasm leading to IBI.

Seizures Associated with Propofol Anesthesia

Propofol is a new, fast‐acting intravenous (i.v.) anesthetic. Involuntary movements or epileptic sei zures have occurred during or after propofol‐induced an esthesia in ∼50 reported cases; a third of the patients have had epilepsy. We report 5 patients with seizures in association with propofol anesthesia. A female epileptic patient developed severe status epilepticus; the other patients with short‐lasting seizures had no previous epi lepsy. Although propofol has been used in treatment of patients of status epilepticus, the risk of precipitation of epileptic seizures warrants consideration especially when planning anesthesia for epileptic patients.

Thyroid Status of Patients Receiving Long‐Term Anticonvulsant Therapy Assessed by Peripheral Parameters: A Placebo‐Controlled Thyroxine Therapy Trial

Summary: Thyroid hormone concentrations and measures reflecting thyroid function were studied in sera from 35 patients receiving long‐term phenytoin (PHT) or carbamazepine (CBZ) therapy. The mean concentrations of T4 FT4 FT3 and rT3 but not T3 of these patients were significantly lower than those of 19 controls of similar age and sex distribution. The mean serum thyrotropin (TSH) concentration was slightly but significantly higher in patients than in controls, but the serum TSH response to TRH was not significantly increased. In patients, the higher mean clinical diagnostic index of hypothyroidism (CDI‐HT: ‐20.3 ±‐19.1 vs.‐33.7 ± 8.5, p < 0.05) and higher ratio of preejection period to left ventricular ejection time (PEP/LVET: 0.343 5 0.065 vs. 0.334 2 0.030, p < 0.05) than in controls were compatible with tissue hypothyroidism. However, comparison of the mean levels of alanine aminotransferase (ALAT), creatine kinase (CK), creatinine, triglycerides, cholesterol, high‐density lipoprotein (HDL) cholesterol, osteocalcin, procollagen type III aminoterminal propeptide, and somatomedin‐C showed no significant differences between patients and controls. The increased mean angiotensin convertase and sex hormone‐binding globulin (SHBG) levels, typical of hyperthyroidism, were probably caused by drug effects. Fourteen patients with a subnormal FT4 concentration in serum participated in a doubleblind thyroxine treatment cross‐over study. Neither the mean CDI‐HT score, nor the systolic time intervals were significantly different between the thyroxine and placebo periods. Five patients benefited subjectively from the treatment. On the basis of all data from the cross‐sectional and thyroxine treatment studies, we conclude that patients receiving anticonvulsant drugs chronically are eumetabolic and do not need thyroxine supplementation.

Bilateral internal carotid artery thrombosis. Prognosis and risk factors.

Fourteen patients with bilateral internal carotid artery thrombosis were analysed with respect to long‐term prognosis and the prevalence of risk factors of cerebrovascular disease. The patients comprised seven per cent of all patients with internal carotid thrombosis treated in 1966–73 at the Department of Neurology, University of Helsinki. During the follow‐up period of 3 to 86 months (median 50 months) five patients died, three during the first, and two during the second year of follow‐up. Of the surviving patients: two needed institutionalization; three were able to take care of themselves; and four who were virtually symptom‐free, were able to work. The risk factors of cerebrovascular disease were analysed: 91 per cent were cigarette smokers; 70 per cent had serum triglycerides of 140 mg/100 ml or higher; and 62 per cent had cholesterol values of 280 mg/100 ml or higher. Fasting glucose values higher than 95 mg/100 ml, and ECG abnormalities were encountered in every third, and obesity and hypertension in every fourth patient. Cigarette smoking and high triglycerides were more prevalent than in the general population. No association between the number of risk factors in the individual patients and the prognosis could be found.

BRAIN SCANNING IN DETECTION OF INTRACRANIAL ARTERIOVENOUS MALFORMATIONS

Routine brain scanning, using a scintillation camera and Tc99m pertechnetate, was performed on 42 patients with an intracranial arteriovenous malformation. Thirty‐two (76 %) of them had a positive brain scan, and the location of increased uptake correlated well with the localisation of the malformation found in carotid angiography. Large malformations were detected significantly better than small malformations. The largest malformations with negative brain scanning were located in the posterior fossa and temporobasally. In 18 cases (43 %) one or several “tails” of increased activity on the scan were seen sprouting from the local uptake. These tails corresponds to the afferent and efferent vessels of the malformation seen in carotid angiography. Such tails of increased activity are highly suggestive of intracranial arteriovenous malformation.

Zu den neurologischen Manifestationen des Xeroderma pigmentosum

SummaryXeroderma pigmentosum is described in four patients including two sisters aged 12 and 26 years, and in two sporadic cases of two females aged 19 and 37 years. In addition to the common cutaneous changes there was a decrease in head circumference, mental retardation, a number of neurological symptoms like pyramidal, extrapyramidal and cerebellar disturbances, dwarfism and gonadal hypoplasia in one case. Other endocrine and metabolic laboratory findings were normal. The pneumencephalography and autopsies, respectively, disclosed cortical and central supratentorial atrophy and in addition cerebellar atrophies in two other patients. One of the two sisters showed a chromosomal anomaly: There were 45 chromosomes due to translocation in group D. Her parents as well as her sister displayed normal chromosome numbers. Among relatives of the two sisters there has been no evidence of xeroderma pigmentosum for the last three generations. The inheritance and the occurrence of xeroderma pigmentosum, its neurological manifestations and theories on its pathogenesis are considered.ZusammenfassungEs werden 4 Patienten, 2 Schwestern von 12 und 26 Jahren und 2 sporadische Fälle, Frauen im Alter von 19 und 37 Jahren, mit Xeroderma pigmentosum beschrieben. Neben den typischen Hautveränderungen fanden sich ein verminderter Kopfumfang, geistige Entwicklungsstörungen, eine Reihe neurologischer Symptome wie pyramidale, extrapyramidale und cerebelläre Störungen, Zwergwuchs und in einem Fall auch eine Gonadenhypoplasie. Andere endokrinologische und metabolische Laboruntersuchungen hatten normale Resultate. PEG-Untersuchungen bzw. Autopsien deckten eine corticale und zentrale supratentoriale Atrophie und bei zwei Patientinnen zusätzlich noch cerebelläre Atrophien auf. Eine der 2 Schwestern zeigte eine chromosomale Anomalie: 45 Chromosomen durch Translokation in der Gruppe D. Ihre Eltern und die Schwester hatten einen normalen Chromosomensatz. Bei den Verwandten der Geschwister hatte man keine Spur der Xp in den letzten drei Generationen gefunden. Auf Vererbung und Vorkommen der Xp, die neurologischen Manifestationen und auf die Theorien über die Pathogenese wird eingegangen.

Diagnosis of epilepsy.

ABSTRACT Essential in the diagnosis of epilepsy are repeated seizures due to discharge of electrical activity in the brain neurons, occurring without massive provocation. It is important to differentiate between epileptic seizures from syncopal reactions, cardiac dysrhythmias, vascular causes, metabolic disturbances, and psychogenic seizures. The type of seizure should always be established. It is of utmost importance to find the primary etiology of the seizure and to clarify the role of predisposing factors and the risk for seizure recurrence.

A controlled study with taltrimide and sodium valproate: valproate effective in partial epilepsy

Taltrimide was compared with valproate and placebo in 17 patients with intractable epilepsy being on carbamazepine monotherapy. Taltrimide (400 mg/day), valproate (1000 mg/day) or placebo were added to the treatment for periods of 3 months using a randomized cross‐over design. Serum carbamazepine concentrations remained within the therapeutic range throughout the trial. Thirteen patients completed the study. In partial epilepsy of 7 the seizure frequency was reduced by 27% during valproate (p < 0.05), compared with placebo, while no improvement was found during taltrimide. In 6 with primary generalized epilepsy, the number oif seizures was reduced by 49% during taltrimide and by 38% during valproate, but neither effect was significant, compared with placebo. Headache was reported by 3 patients while on taltrimide. One with hypersensitivity history developed petecchiae and nasal bleeding during taltrimide and, therefore, the treatment was stopped. The three other interruptions were independent of taltrimide. Thus, the only statistically significant effect in this study was that of valproate in partial epilepsy.

THE ELECTROENCEPHOLOGRAM AS AN AID IN REVEALING INTRACRANIAL ARTERIOVENOUS MALFORMATIONS

Routine electroencephalography was performed on 58 patients with an intracranial arteriovenous malformation. Local abnormal EEG findings were observed in 23 (40 %) of them, 15 (26 %) had a general abnormality, and in 20 (34 %) the EEG was normal. In two patients with a local abnormality the abnormality was contralateral to the AVM. There was no relation between EEG abnormality and age of patients or duration of the symptoms. The size and radiological density of the AVM were not related with the frequency of EEG abnormality, nor were any differences seen in the distribution of findings between the non‐haemorrhagic, subarachnoid haemorrhage and intracerebral haemorrhage groups. In patients with a history of epileptic seizures abnormality of the EEG was more frequent (p < 0.05) than in those with no epileptic seizures. Parietal and temporal AVMs combined had a higher frequency (p < 0.001) of local EEG abnormalities than in those patients in whom the AVM was occipital, central or in the posterior fossa. EEG as a screening method for intracranial AVM is noted to reveal only 62% of those AVMs found by brain scanning. On the other hand, half of the patients in whom scanning failed (due to small size or temporal location of the AVM) the EEG showed a local abnormality.