Robert J. Wilkus

Carbamazepine--a double-blind comparison with phenytoin.

In a double-blind crossover study, carbamazepine and phenytoin were compared as single anticonvulsants in 47 patients with focal and major generalized seizures. Each drug provided superior seizure control in about half the patients, but significantly fewer patients had objective side effects while taking carbamazepine. Neuropsychologic testing showed improved performance in cognitive function and emotional status of patients while on carbamazepine. No hematotoxic complications arose, but vigilant follow-up is advised. Mean serum level of carbamazepine was 9.3 μg per milliliter with a suggested therapeutic range of 8 to 12 μg per milliliter, reached by eventual doses of 16 to 20 mg per kilogram. Carbamazepine offers an independent choice of improved seizure control with a possibility of fewer side effects.

Factors Affecting the Outcome of MMPI and Neuropsychological Assessments of Psychogenic and Epileptic Seizure Patients

Summary: The literature reveals conflicting information regarding the extent to which psychogenic seizure patients have emotional disorders and neuropsychological deficits as compared with patients with epileptic seizures. Among groups matched for numbers of subjects, age, sex, and years of education, we observed that patients who had solely psychogenic seizures with either a major component of affectual expression or relatively minor motor activity were more disturbed emotionally than epileptic patients with partial seizures. In contrast, the personality characteristics of psychogenic seizure patients whose attacks had either little affectual display or prominent motor expression could not be distinguished from those of epileptic patients with convulsive generalized seizures. Closely matched groups of patients with solely psychogenic seizures, partial seizures, or generalized seizures did not differ in neuropsychological performance. However, psychogenic seizure patients performed much better on neuropsychological measures than a less‐well‐educated, but otherwise matched group of patients with generalized epileptic seizures.

Multiple Subpial Transections for Partial Seizures in Sensorimotor Cortex

We report six patients with complex partial seizures arising from the primary sensorimotor cortex who underwent invasive long-term ictal electroencephalogram/video monitoring and brain mapping and then multiple subpial transections. Although four patients demonstrated no abnormalities on magnetic resonance imaging, each patient showed moderate to marked gliosis in cortex biopsied from the site of ictal onset. Extensive preoperative and postoperative neuropsychological tests demonstrated no functional deficits resulting from surgery. Only one patient failed to derive significant postoperative seizure improvement, and he subsequently underwent additional subpial sectioning without further significant improvement. We propose a modification for this surgical technique and hypothesize that these patients may represent a syndrome of central cortical epilepsy.

Cataplexy and monoamine oxidase deficiency in Norrie disease

Norrie disease (ND) is an X-linked recessive disorder causing ocular atrophy, mental retardation, deafness, and dysmorphic features. Virtually absent monoamine oxidase (MAO) type-A and -B activity has been found in some boys with chromosome deletions. We report the coexistence of cataplexy and abnormal REM sleep organization with ND. Three related boys, referred for treatment of medically refractory atonic spells and apneas, underwent extended EEG-video-polysomnographic monitoring. They demonstrated attacks of cataplexy and inappropriate periods of REM sleep during which they were unarousable. One boy also had generalized tonic-clonic seizures. Previous testing revealed that all three have complete ND gene deletions. In all subjects, platelet MAO-B activity was absent, serum serotonin levels were markedly increased, and plasma catecholamine levels were normal. Data from the canine narcolepsy syndrome model implicate abnormal catecholaminergic and cholinergic activities in the pathogenesis of cataplexy. Our findings suggest that abnormal MA0 activity or an imbalance between serotonin and other neurotransmitter levels may be involved in the pathogenesis of human cataplexy.

Relationships between intelligence and electroencephalographic epileptiform activity in adult epileptics

Intellectual correlates of electroencephalographic epileptiform activity were examined by administering the Wechsler Adult Intelligence Scale to epileptic patients divided into groups on the basis of presence or absence, average rate, and topographic distribution of discharges. The results showed that lower intelligence levels were associated with the presence of discharges, especially when they were generalized rather than focal and when they occurred at an average rate of more than one per minute. An examination of patients having discharges ipsilateral and contralateral to their handedness showed few findings, as did an analysis based on an assessment of strengths and weaknesses within individuals. The results suggest that electroencephalographic epileptiform activity is significantly related to the intellectual functioning of epileptics.

Comparison of EEG derived from sphenoidal, infrazygomatic, anterior temporal, and midtemporal electrodes during complex partial seizures

A prospective study was performed to determine whether complex partial seizures are better, or differently, recorded by sphenoidal (SP) or infrazygomatic (IZ) electrodes. Two seizures in each of 20 patients were recorded from radiographically documented SP and IZ, as well as anterior temporal (AT) and mid-temporal (MT) electrodes. Initial ictal bipolar EEG changes appeared at means of 0.57 s (SP) and 0.16 s (IZ) before, and 0.06 s (AT) and 2.36 s (MT) after, the onset of clinical signs. Mean first lateralized ictal bipolar EEG discharges appeared 0.11 s (SP), 0.88 s (IZ), 2.98 s (AT), and 3.94 s (MT) after behavioral seizure onsets. These changes occurred earlier (statistically significant) at SP than at other electrodes. Referentially, mean first ictal EEG changes occurred 0.28 s (SP) before to 0.20 s (MT) after, and ictal lateralization appeared 0.68 s (IZ) to 1.19 s (MT) after, the appearance of clinical seizure onsets. Ictal EEG amplitudes were largest (statistically significant) at SP and progressively smaller at IZ, AT, and MT electrodes. Overall, however, SP electrodes closer to the foramen ovale did not consistently reveal earlier ictal features or higher EEG amplitudes than SP electrodes farther from this landmark. For clinical purposes, SP and IZ electrodes were virtually equivalent.

Preoperative EEG correlates of seizure outcome from epilepsy surgery in children

Abstract To identify criteria for selecting pediatric candidates for cortical resection, we compared preoperative standard EEGs, extracranial or intracranial (subdural strip or grid) electrode EEG-video monitoring and imaging studies, and surgical pathology findings with long-term (mean = 6.1 years) seizure outcome. Of 47 children, 83% were either seizure-free or substantially improved. Children with a predominant single interictal focus in standard EEGs over time or with seizures that were mostly well localized (even with equal numbers of bilaterally independent spikes) during monitoring had significantly better outcomes than those who had mostly diffuse or bilaterally independent interictal and ictal discharges. Factors not associated with poor outcomes were some seizures unaccompanied by ictal EEG patterns, spikes in postresection electrocorticograms, extratemporal resection, younger age at surgery, and older age of seizure onset. Significantly more patients with than without tumors were seizure-free. Significantly more preteenagers than teenagers had poorly localized interictal and ictal discharges.

Alpha coma with sedative overdose

alpha coma after sedative drug intoxication is rather underestimated. I do not entirely sham their opinion, especiauy considering alpha coma after drug intoxication not associated with cardioreapiratory arrest. A retmpctive analysis performed in our hospital during the last 2 yeara revealed 26 patients admitted with sedative drug intoxication not associated with reapiratory or cardiopulmonary arrest. In this group of patienta we observed only four patients (15%) who presented an alphapattern coma. The majority of theae patients had taken a mixture of tranquilizers. A brief literature survey of alpha coma after drug intoxication without cardiorespiratory failure yielded five more caaea (table). From our observations and these literature findings we would conclude that alpha coma related to sedative drug overdose is not as common as suggested by the authors.