Regina Maria França Fernandes

Propofol-induced sleep: Polysomnographic evaluation of patients with obstructive sleep apnea and controls

Objective: The localization of upper airway obstruction in patients with obstructive sleep apnea (OSA) may optimize treatment. Nasoendoscopy during propofol sedation allows such an evaluation, but the effect of this drug on respiratory patterns and muscle relaxation is unknown. The objective of the present study was to determine through polysomnography whether propofol would change sleep parameters. Study Design: Prospective study of subjects submitted to polysomnography under sedation with propofol. Setting: Tertiary referral center. Subjects and Methods: Fifteen non-obese subjects (4 controls/11 OSA patients) were submitted to two diurnal polysomnograms (90-120 minutes of sleep), with and without the use of propofol. The parameters presence of snoring, apnea-hypopnea index (AHI), oxygen desaturation, and sleep architecture were compared. Results: The use of propofol did not induce snoring in the control subjects, whereas 100 percent of the OSA patients snored. AHI and mean oxygen saturation (SaO2) did not differ significantly between examinations with and without sedation. However, minimum SaO2 differed significantly (P < 0.05) with sedation, being lower during propofol sedation. Propofol also significantly changed the sleep architecture, with a significant increase in N3 sleep (P < 0.005) and total abolishment of rapid eye movement sleep (P < 0.0005) during propofol sedation. Conclusions: These preliminary results allow us to infer that sedation with propofol changes sleep architecture but permits respiratory evaluation, because the main respiratory parameters evaluated in OSA are maintained. These preliminary results support the view that nasoendoscopy under propofol sedation is a promising examination for management of this disease.

Serial EEG during human status epilepticus Evidence for PLED as an ictal pattern

Objective: To analyze the relationship between periodic lateralized epileptiform discharges (PLED) and status epilepticus (SE), to evaluate the relationship between mortality and periodic patterns, and to determine whether a stereotypic sequence of EEG patterns exists during human SE. Methods: The authors performed a prospective clinical and electrographic study comprising 62 episodes of SE, 55 patients, and 254 ictal/postictal EEG recordings. Serial daily EEG were obtained in all cases. Results: Partial SE was the predominant clinical type. Four distinct ictal EEG patterns were identified: intermittent EEG seizures (IES), merging EEG seizures (MES), continuous ictal discharges (CID), and periodic epileptiform discharges (PED) which could be lateralized (PLED) or bilateral (PBED). IES was the most common ictal pattern. In the same record, only one combination of ictal patterns was observed corresponding to an association of PLED or PBED and MES pattern. Serial EEG demonstrated that approximately one-third of SE resolved before the second EEG, another one-third persisted and maintained the same ictal pattern throughout the entire evolution, and the final one-third showed variable ictal EEG patterns. PLED were also unequivocally associated with epileptic seizures, and in some patients were the initial ictal pattern. Conclusion: PLED can be an ictal pattern; and, in contrast to previous observations, no stereotyped sequence of ictal EEG patterns was found. PLED/PBED were not a terminal ictal pattern in every case, and outcome was more related to age and etiology than to specific ictal EEG patterns.

Calcified neurocysticercotic lesions and postsurgery seizure control in temporal lobe epilepsy

Background: Several studies suggest that neurocysticercosis is the main cause of symptomatic epilepsy in developing countries. In such areas, calcified cysticercotic lesions (CCL) are frequently found in patients with complex partial seizures associated with hippocampal sclerosis (HS). The authors studied whether there are clinical and pathologic differences between HS patients with and without CCL. Methods: The authors determined the clinical and pathologic findings of 30 patients with HS and compared them with 32 patients with HS + CCL. Hippocampi from both groups were measured for fascia dentata Timm staining and cell density in hippocampal subfields. Results: In the HS + CCL group, single or multiple CCL were found in all lobes with no lobar predominance. An initial precipitating event occurred in 83.3% of HS and in 62.5% of HS + CCL. First complex partial seizure occurred at 10.1 years in HS and at 11.9 years in HS + CCL. No significant differences were found for fascia dentata Timm staining and hippocampal cell densities. Good postsurgery outcome (Engel I classification) did not differ between groups, with this result occurring in 76.6% of patients with HS and 81.2% of patients with HS + CCL. Conclusions: The presence of CCL does not influence the clinical and pathologic profile of patients with hippocampal atrophy. Clinical histories and postsurgical outcomes were similar to those of patients with classic HS, suggesting that the CCL is probably, in this set of patients, a coincidental pathology and does not have a role in epileptogenesis.–1491

Surgical outcome in mesial temporal sclerosis correlates with prion protein gene variant.

Background: Mesial temporal lobe epilepsy related to hippocampal sclerosis (MTLE-HS) is the most common surgically remediable epileptic syndrome. Ablation of the cellular prion protein (PrPc) gene (PRNP) enhances neuronal excitability of the hippocampus in vitro and sensitivity to seizure in vivo, indicating that PrPc might be related to epilepsy. Objective: To evaluate the genetic contribution of PRNP to MTLE-HS. Methods: The PRNP coding sequence of DNA from peripheral blood cells of 100 consecutive patients with surgically treated MTLE-HS was compared to that from a group of healthy controls adjusted for sex, age, and ethnicity (n = 180). The presence of PRNP variant alleles was correlated with clinical and presurgical parameters as well as surgical outcome. Results: A variant allele at position 171 (Asn→Ser), absent in controls, was found in heterozygosis (Asn171Ser) in 23% of patients (p < 0.0001). The PRNP genotypes were not correlated with any clinical or presurgical data investigated. However, patients carrying the Asn171Ser variant had a five times higher chance of continuing to have seizures after temporal lobectomy (95% CI 1.65 to 17.33, p = 0.005) than those carrying the normal allele. At 18 months after surgery, 91.8% of patients with the normal allele at codon 171 were seizure free, in comparison to 68.2% of those carrying Asn171Ser (p = 0.005). Conclusions: The PRNP variant allele Asn171Ser is highly prevalent in patients with medically untreatable MTLE-HS and influences their surgical outcome. The results suggest that the PRNP variant allele at codon 171 (Asn171Ser) is associated with epileptogenesis in MTLE-HS.

Temporal lobe epilepsy surgery in children and adolescents: clinical characteristics and post-surgical outcome.

BACKGROUND AND PURPOSE Temporal lobe epilepsy (TLE) encompasses 10-20% of the cases of intractable epilepsy in pediatric patients. Mesial temporal sclerosis (MTS) can still be encountered in adolescent patients, but is rare in children under 5 years of age. In this paper we report on the surgical outcome of a series of TLE patients ranging in age from 1 to 18 years at the time of operation. PATIENTS AND METHODS Thirty-five patients (37 surgeries) with medically intractable TLE were operated upon between January 1996 and December 2002. The following variables were analyzed: age at surgery, age at epilepsy onset, history of an initial precipitating injury, etiology, seizure semiology, interictal and ictal EEG findings, surgical complications, and post-surgical seizure outcome. RESULTS There were 68.6% females and 31.3% males, and complex partial seizures (CPS) occurred in 86.5%. The most common etiology was MTS (40%) followed by isolated cortical developmental abnormalities (22.9%). In the age group up to 5 years, cortical development abnormalities predominated, and 71% of these children had multifocal interictal EEG. Patients older than 10 years had more frequently MTS (78.6%) and focal temporal interictal EEG abnormalities. Post-surgical seizure outcome showed that 88.5% of patients were in Engel classes I and II. CONCLUSIONS Adolescents with TLE had clinical features, electrographic findings, and seizure outcome similar to those observed in adult patients. However, younger children up to 5 years of age had distinct ictal semiology and different etiological, electrophysiological and outcome profiles, clearly suggesting that they behave as a special subgroup within the TLE.

Surgically amenable epilepsies in children and adolescents: clinical, imaging, electrophysiological, and post-surgical outcome data

Background and purposeA large number of patients with epilepsy in the pediatric population have medically intractable epilepsy. In this age group seizures are usually daily or weekly, and response to antiepileptic therapy is poor, especially for those with neurological abnormalities and symptomatic epilepsies. However, several authors have already demonstrated similarly favorable long-term post-surgical seizure control when comparing pediatric and adult populations. In this article we aim to report the experience of the Ribeirão Preto Epilepsy Surgery Program in pediatric epilepsy surgery.Patients and methodsWe analyzed 107 patients with medically intractable epilepsy operated on between July 1994 and December 2002, considering age at surgery, seizure type, pathological findings, and seizure outcome. All data were prospectively collected according to protocols previously approved by the institution ethics committee.ResultsWe analyzed a total of 115 operations performed in 107 patients. There was no difference in sex distribution. Complex partial seizures occurred in 31.4% of the patients, followed by tonic seizures (25.9%), focal motor seizures (15.4%), and infantile spasms (13.3%). The most common etiologies were cortical developmental abnormalities (25.2%), tumors (16.8%), mesial temporal sclerosis (15.9%), Rasmussen syndrome (6.5%), and tuberous sclerosis (6.5%). Overall post-surgical seizure outcome showed 67.2% of the patients within Engel classes I and II, reaching 75.0% when patients with callosotomies were excluded.ConclusionsPost-surgical seizure control in the pediatric population is similar to that in adult patients, despite the fact that epilepsies in this age group are more frequently of extratemporal origin, suggesting that surgery should be considered in children as soon as intractability is determined.

Polysomnographic evaluation of propofol-induced sleep in patients with respiratory sleep disorders and controls.

The treatment for obstructive sleep apnea syndrome (OSAS) depends on correct localization of upper airway obstruction, exception made for continuous positive airway pressure (CPAP). Drug‐induced sleep endoscopy (DISE) with propofol allows this evaluation, but the drug effects on sleep parameters are not yet well established. Our objective was to study by polysomnography (PSG) whether propofol would change sleep parameters by means of a prospective cross‐sectional clinical study in a tertiary hospital.

Cephalometric evaluation of facial pattern and hyoid bone position in children with obstructive sleep apnea syndrome.

OBJECTIVES To assess the development of face and hyoid bone in children with obstructive sleep apnea syndrome (OSAS) through lateral cephalometries. MATERIALS AND METHODS Children aged 7-10 years with mixed dentition and with no previous otorhinolaryngologic, orthodontic or speech therapy treatments were studied. Twenty nasal breathers were compared to 20 mouth breathing children diagnosed as OSAS patients. All children underwent otorhinolaryngologic evaluation and cephalometries; children with OSAS also underwent nocturnal polysomnography in a sleep laboratory. RESULTS Children with OSAS presented increase in total and lower anterior heights of the face when compared to nasal breathers. In addition, children with OSAS presented a significantly more anterior and inferior position of the hyoid bone than nasal breathers. No significant differences in upper, anterior or posterior heights of the face were observed between groups. CONCLUSION The results suggest that there are evident and early changes in facial growth and development among children with OSAS, characterized by increased total and inferior anterior heights of the face, as well as more anterior and inferior position of the hyoid bone.

Prevalence of restless legs syndrome in the rural town of Cassia dos Coqueiros in Brazil

OBJECTIVE To estimate the prevalence and evaluate the characteristics and severity of restless legs syndrome (RLS) in an urban Brazilian community. METHODS A transversal study was conducted over an 18-month period. A neurologist conducted 1155 interviews using the diagnostic criteria of the International Restless Legs Syndrome Study Group (IRLSSG). RESULTS The lifetime prevalence of RLS was found to be 6.40%. Prevalence during the last year, the last month, and the last week were found to be 5.71%, 5.36%, and 4.15%, respectively. A greater proportion of women met diagnostic criteria for RLS compared to men (OR: 2.63, CI 95%: 1.54-4.51). Furthermore, participants with low monthly family income (<

Does sudden unexpected death in children with epilepsy occur more frequently in those with high seizure frequency

1575 USD) had a lower prevalence of disease compared to those with a high monthly family income (>