Richard Torkelson

Increased cerebrospinal fluid 5-hydroxytryptamine and 5-hydroxyindoleacetic acid in kleine-levin syndrome

A 17-year-old man with the Kleine-Levin syndrome died unexpectedly of cardiopulmonary arrest during a period of autonomic instability that followed an episode of megaphagia. At autopsy, the only pertinent finding was mild depigmentation of the locus ceruleus and sub-stantia nigra. Premortem CSF levels of 5-hydroxytryptamine (5-HT) and 5-hydroxyindoleacetic acid (5-HIAA) levels were elevated. These findings I indicate that many symptoms of the Kleine-Levin syndrome are a result of a neurotransmitter imbalance in the serotonergic pathway of the brainstem.

Surgical treatment of intractable seizures with multilobar or bihemispheric seizure foci (MLBHSF)

BACKGROUND Patients with multilobar or bihemispheric seizure foci (MLBHSF) are generally not considered candidates for major resective surgery because of the high risk of complications. A combination of relatively less invasive surgical procedures were used to treat 19 patients with intractable seizures with MLBHSF. METHODS Epileptogenic areas were identified via standard techniques. Locations of the seizure foci were in two lobes of a hemisphere in 11 patients, three lobes of a hemisphere in four patients, four lobes of a hemisphere in one patient, and both hemispheres in three patients. All 19 patients had multiple subpial transections; in addition, seven patients had small topectomies and nine patients had amygdala hippocampotomies. RESULTS The longest follow-up is 54 months and the median for follow-up is 33 months. Nine patients (47%) are either free of seizures or have only rare seizures; eight patients (41%) have greater than 90% reduction in seizure frequency; one patient (6%) has complete cessation of myoclonic seizures and secondary generalization, and greater than 50% reduction in partial complex seizures; and one patient (6%) has greater than 50% reduction in seizure frequency. There were no permanent operative complications. CONCLUSION Though the follow-up is relatively short and the number of patients is small, these results are encouraging, because the majority of patients in this group were poor surgical candidates.

Minimally Invasive Surgical Approach for Intractable Seizures

Minimally invasive procedures (multiple subpial transection, topectomy and amygdalahippocampotomy) were used to treat 24 patients with intractable seizures. The seizure foci were in both hemispheres i

Isolation of Dominant Seizure Foci by Multiple Subpial Transections

Dominant seizure foci (DSF) are seizure foci that do not respond to multiple subpial transections (MST). DSF were isolated in 15/31 patients who underwent MST in the past 6 years. These patients had MST over both hemispheres (6 patients) or over multiple lobes of one hemisphere (9 patients). DSF measured 0.5-1 cm in diameter and numbered 1-4 (in each patient). Their excision resulted in dramatic improvement in EEG over wide areas of the cortex. The longest postoperative follow-up is 67 months, with a median of 21 months. Nine of 15 patients are free of seizures, 3/15 have rare seizures, 2/15 have > 90% reduction in seizure frequency, and 1/15 has > 70% reduction in seizure frequency with improvement in motor and speech functions. In summary, DSF are resistant to MST and influence the electrical activity of the surrounding cortex. MST combined with excision of DSF resulted in good seizure control in this series, which included patients with multilobar and bihemispheric seizure foci.

Book Review: Textbook of Child Neurology, ed 3, by John H. Menkes. Published in 1985 by Lea & Febiger, Philadelphia, 827 pages,

diseases in infants and young children; Tom Caskey provides a fast-paced and up-to-date survey of antenatal diagnostic techniques; Tom Zion provides a readable and discerning overview of anticonvulsant therapy. The authors achieve their goals often enough for this work to be recommended for students, pediatric and family practice housestaff, and primary practitioners. Virtually all topics of interest to the general practitioner are covered, and much neurologic esoterica is omitted. Overall, readability is good; there is a laudable paucity of jargon and abbreviations. The table of contents and index give the reader easy access to specific topics. All of the authors are from Houston except for Darryl DeVivo and Arthur Hays (Neuromuscular Disease, Reye Syndrome) and Paul Rosman (Acute Head Injuries, Increased Intracranial Pressure). As with most multipleauthored books, the pleasure of reading an insightful chapter by a thoughtful expert is offset by aggravating drawbacks. The disadvantages include repetition of material (Duchenne muscular dystrophy is covered twice), occasional contradictions among authors (IVH as a cause of seizures in premature infants vs uncertainty over whether IVH is cause or effect), and variation between chapters in the amount of detail. Even so, most chapters have enough similarities that the reader can view the book as a coherent