Zeki Gökçil

Time-dependent changes in the serum levels of prolactin, nesfatin-1 and ghrelin as a marker of epileptic attacks young male patients

A relationship between hormones and seizures has been reported in animals and humans. Therefore, the purpose of this study was to investigate the association between serum levels of prolactin, nesfatin-1 and ghrelin measured different times after a seizure or non-epileptic event and compared with controls. The study included a total of 70 subjects, and of whom 18 patients had secondary generalized epilepsy (SGE), 16 patients had primary generalized epilepsy (PGE), 16 patients exhibited paroxysmal event (psychogenic) and 20 healthy males were control subjects. The first sample was taken within 5min of a seizure, with further samples taken after 1, 24, and 48h so long as the patient did not exhibit further clinically observable seizures; blood samples were taken once from control subjects. Prolactin was measured immediately using TOSOH Bioscience hormone assays. Nesfatin-1 and ghrelin peptides were measured using a commercial immunoassay kit. Patients suffering from focal epilepsy with secondary generalization and primary generalized epilepsy presented with significantly higher levels of serum prolactin and nesfatin-1 and lower ghrelin levels 5min, 1 and 24h after a seizure than patients presenting with paroxysmal events (psychogenic) and control subjects; the data were similar but not statistically significant after 48h. The present study suggests that increased serum prolactin and nesfatin-1 concentrations, decreased ghrelin concentrations could be used as markers to identify patients that have suffered a recent epileptic seizure or other paroxysmal event (psychogenic).

The value of MRI in a case of Tolosa-Hunt syndrome

We report a case of Tolosa-Hunt syndrome (THS) in which the lesion has been demonstrated by magnetic resonance imaging (MRI), computed tomography (CT), and angiography. A healthy 23-year-old man developed an acute painful ophthalmoplegia on the right side. CT and MRI scans revealed asymmetric enlargement of the right cavernous sinus with contrast enhancement extending down to the region of trigeminal ganglion. MRI further delineated the detailed anatomical structures of the region and excluded any infiltration of the surrounding tissues by a mass lesion. Cerebral angiography showed a significant decrease in the calibration of petrous segment and a mild decrease in the calibration of cavernous segment of the ipsilateral internal carotid artery. The patient was treated with oral prednisone, 100 mg daily. Neurological findings totally subsided after 2 weeks on corticosteroid and MRI showed resolution of the lesion in the cavernous sinus. The patient was symptom-free for 6 months after discharge. Our findings have suggested that MRI is the most valuable imaging technique for demonstration and follow-up of lesions in the cavernous sinus that are directly responsible for the symptoms of THS and the lesions can be more extensive than was currently believed.

Antiepileptic activity of melatonin in guinea pigs with pentylenetetrazol-induced seizures

Abstract Background: Antiepileptic and neuroprotective effects of melatonin (N-acetyl-5-methoxytryptamine) have been shown at higher doses (50–160 mg/kg). We aimed to investigate the antiepileptic effects of low-dose melatonin (10 mg/kg) on pentylenetetrazol (PTZ)-induced experimental epilepsy model. Materials and Methods: Twelve male albino guinea pigs weighing 500–800 g were used in our work. Initially, latent period, seizure intensity and mortality parameters were evaluated during the epileptic seizure induced by PTZ. After a recovery period of 7 days, effects of the neuroprotective agent, melatonin (which is dissolved in 2.5% ethanol–saline solution), on epileptic seizures induced by PTZ were evaluated. Effects of 2.5% ethanol, which is an anticonvulsant agent when administered acutely in high concentrations, on PTZ-induced seizures were also evaluated. Results: Data obtained from the study groups (PTZ, PTZ + melatonin and PTZ + ethanol) were evaluated by paired t-test, and p<0.005 was considered statistically significant. The differences of latent periods between the PTZ and PTZ + melatonin groups were found to be statistically significant (p<0.001). Conclusion: Although melatonin does not have a primary anticonvulsant effect at low doses (10 mg/kg), it lowers the mortality rates and attenuates seizure severity while increasing the latent period.

α-interferon and isoprinosine in adult-onset subacute sclerosing panencephalitis

We report eight patients with adult-onset subacute sclerosing panencephalitis (SSPE), of which, four were treated with oral isoprinosine and four with intraventricular α-interferon plus oral isoprinosine. One of the four patients treated with oral isoprinosine died within two months, and the disease progressed in three patients. Of the four patients treated with oral isoprinosine plus intraventricular α-interferon, one showed mild progression, one remission, and the remaining two showed stabilization. The group of patients is relatively small, but our results suggest that treatment with oral isoprinosine plus α-interferon is effective for SSPE.

Effect of pramipexole on cutaneous-silent-period parameters in patients with restless legs syndrome

OBJECTIVE The aim of this study was to investigate cutaneous-silent-period (CSP) parameters in patients with restless legs syndrome (RLS) and examine the effects of treatment on CSP which, to our knowledge, have not been investigated till date. METHODS A total of 25 patients with RLS and 25 healthy volunteers were studied. CSP latency and duration in the upper and lower extremities were examined in the two groups. In RLS patients, the variables were examined before and after pramipexole treatment. RESULTS Lower-extremity CSP latency was longer (106.22±11.69 ms vs. 91.67±8.53 ms; p<0.001) and CSP duration was shorter (35.50±10.91 ms vs. 49.47±6.43 ms; p<0.001) in patients, compared with controls. In the patient group, CSP durations in the upper (40.88±7.95 ms vs. 46.84±10.22 ms; p=0.006) and lower extremities (35.50±10.91 ms vs. 44.91±6.43 ms; p=0.005) were prolonged after treatment, compared with pre-treatment values. CONCLUSIONS Small-fibre neuropathy may exist in RLS. In addition, we suggest that pramipexole may regulate cortical and spinal inhibitory mechanisms. SIGNIFICANCE The use of CSP may aid in the diagnosis of RLS and may be used as a measure of treatment effectiveness.

Long-term follow-up of patients with adult-onset subacute sclerosing panencephalitis

Subacute sclerosing panencephalitis (SSPE) is a rare infectious central nervous system disease with a poor prognosis. Nineteen patients, 18 males and one female, ranging in age from 18 to 22, mean 19.6+/-1.5 years with SSPE were evaluated. We treated 9 patients with oral isoprinosine and 10 patients with alpha-interferon plus oral isoprinosine and followed up for 16 to 160 months. Of the 9 patients treated with oral isoprinosine, 7 (77.7%) died, one stabilized, and one showed progression. Seven (70%) of 10 patients treated with alpha-interferon plus oral isoprinosine died, one showed progression, and stabilization was observed in two patients. Thus, we suggest that isoprinosine alone or in combination with intraventricular interferon did not change the prognosis in long-term follow-up periods.

Is asymmetric dimethylarginine responsible for the vascular events in patients under antiepileptic drug treatment

Some recent studies indicated that administration of antiepileptic drugs (AEDs) is associated with occlusive vascular diseases. Asymmetric dimethylarginine (ADMA) is an endogenous nitric oxide (NO) synthase inhibitor and increased plasma ADMA levels are associated with cardiovascular morbidity. We hypothesized that elevated plasma ADMA concentrations exist in patients receiving AEDs and administration of AEDs may result in an increased risk of occlusive vascular disease. Thirty five newly diagnosed epilepsy patients participated, patients were classified into two groups according to their antiepileptic drug regimen. In the first group patients were treated with valproic acid (VPA, n=17) (500-1500 mg/day), and in the second group with carbamazepine (CBZ, n=18) (400-1200 mg/day). ADMA levels significantly increased after treatment in both VPA (p=0.002) and CBZ (p=0.024) groups. Homocysteine levels increased in both groups, but the difference was significant only in VPA group (p=0.005). Serum folate levels did not differ in VPA group, but significantly decreased in CBZ group (p=0.006). Vitamin B(12) levels significantly increased in VPA group (p=0.001) but did not differ in CBZ group. Correlation analysis showed that the increases in ADMA and homocysteine levels in the VPA group were higher however the differences between the groups were insignificant. The correlations of the changes between ADMA and other parameters were all insignificant in both VPA and CBZ groups. In conclusion our data suggest that elevated ADMA levels may be responsible for the increased cardiovascular risk in patients with epilepsy under AED therapy.

Essential palatal myoclonus in monozygotic male twins

Sirs: Palatal myoclonus (PM) is an uncommon movement disorder characterized by vertical oscillation of the soft palate at 1 to 3 Hz and usually bilateral. Occasionally some other brainstem-innervated muscles may be involved. Some authors call it a palatal tremor [10, 12]. We report monozygotic male twins with essential palatal myoclonus. To our knowledge this is the first report in which essential PM can be genetically linked. 39 year old twin brothers were admitted to hospital for treatment of involuntary movements of the soft palate and clicking in both ears. In their medical history it was learned that symptoms developed at the age of 14–15 years in one of them and at the age of 37 years in the other. The patients’ parents were healthy and unrelated. The patients’ general and neurological examination was unremarkable except easily audible clicking in time with the visible rhythmical movements of the soft palate. It was not associated with synchronized movements of eyes, tongue, larynx, diagram, intercostal muscles, extremity or trunk. The patient’s whose soft palate frequency had developed at the age of 14–15 years was 2Hz. symptoms, and was higher than his brother’s whose frequency was 1,5Hz. Chronic treatment with clonazepam, piracetam, valproic acid, amitriptiline and carbamazepine failed to improve PM in the first patient and clonazepam, carbamazepine, valproic acid were administered with no effect in the second. Because the different drugs did not improve the PM, five units of botulinum toxin (Botox®/Allergan) in 0.2 ml. saline solution were injected into each side of tensor veli palatini through a special needle under EMG guidance. The first patient reported some initial difficulty with swallowing, in the second patient there was no severe side effect. Three days after the injections PM and clicking began to diminish and had completely disappeared after 6 days in both of them. They remained free of the PM and clicking at the every three months followup visit for one year in the first patient and six months in the second. The investigations including routine blood chemistry, computed tomography (CT), magnetic resonance imaging (MRI), electroencephalography (EEG), somatosensory evoked potentials (SEP) and brainstem auditory evoked potentials (BAEP) were all normal. There are two forms of palatal myoclonus. Essential palatal myoclonus is characterized by a vertical oscillation of the soft palate at 1 to 3 Hz. unaltered by voluntary actions, and an annoying ear click. There are no other neurological signs or symptoms, and the pathophysiology of essential palatal myoclonus is unknown. Symptomatic palatal myoclonus is nearly always associated with syncronous movements of the eyes, larynx, pharynx, face, diaphragm, cervical and axial muscles. Some authors, however, point to difficulties in classifying their patients with palatal myoclonus as either the essential or the symptomatic type [1, 8, 9, 13]. Symptomatic palatal myoclonus produced by a lesion involving the pathway connecting dendate, red and inferior oliver nuclei. Olivary enlargement can be visible on MRI in some symptomatic cases [4, 5, 9, 13]. The patients may complain only of annoying ear click, the origin of which is uncertain, although many believe it arises from muscles contracting around the eustachian tube. The potential role of heredity in the etiology of essential palatal myoclonus is unknown. These monozygotic twin brothers with essential palatal myoclonus in which symptoms developed at the age of 14–15 years in one of them and at the age of 37 years in the other are of interest for suggesting the hereditary etiology of essential palatal myoclonus. In our monozygotic male twins the first symptoms of palatal myoclonus were noted 22 years later than in the other one. These findings indicate that there is a role of inheritance in the pathogenesis of essential palatal myoclonus but also that some other factors contribute to the clinical presentation of palatal myoclonus. Similar findings have been described in monozygotic twins with idiopathic dystonia and Huntington’s disease [3, 6, 11]. As the relationship between the disease and its genetic linkage could be confirmed in our patients, it might also be thought that the pathology may not be inherited. Successful treatment of essential palatal myoclonus by botulinum toxin has been reported several times [2, 7]. In our monozygotic male twins, five units botulinum toxin in 0.2 ml. saline solution were injected into each side of tensor veli palatini and both cases were rendered free of their myoclonus a few days after injection until 11 months in the first patient and 6 months in the second one. In conclusion, the essential LETTER TO THE EDITORS

Hot water epilepsy: seizure type, water temperature, EEG findings and treatment.

OBJECTIVES Hot water epilepsy (HWE) or bathing epilepsy is one of the reflex epilepsies induced by hot water pouring over the head, face, neck, or trunk during bathing. The aim of this study was to demonstrate the clinical and electroencephalographic features and the management alternatives of the patients with HWE. METHODS The age of seizure onset, duration of seizure, family history, interictal and postictal electroencephalography findings, triggering temperature of water, type of seizure, medication, and follow-up results were evaluated for each patient. RESULTS The mean age at seizure onset was 10.5 years. The mean duration of seizures was 10 years. Interictal EEG recordings showed focal abnormalities in 4 patients and generalized abnormalities in 3 patients. Only one patient had normal interictal EEG findings. Among the 8 patients with HWE, 6 had seizures only during hot bathing, whereas 2 had additional seizures. Seven patients had generalized tonic-clonic seizures and 1 patient had complex partial seizure during their hot bathings. The mean triggering temperature of water was calculated as 41.4 degrees C. The mean duration of follow-up period was 23 months. Five patients became seizure-free during the follow-up period and seizures persisted in 3 patients. Antiepileptic drugs were given (800 mg/d carbamazepine for 2 patients and 600 mg/d phenytoin for 1 patient) to these 3 patients and they also became seizure-free during the follow-up period. CONCLUSIONS Hot water epilepsy is a benign reflex epilepsy. Lowering water temperature must be the first step for the treatment. If needed, antiepileptic drugs should be considered as an additive treatment.Objectives:Hot water epilepsy (HWE) or bathing epilepsy is one of the reflex epilepsies induced by hot water pouring over the head, face, neck, or trunk during bathing. The aim of this study was to demonstrate the clinical and electroencephalographic features and the management alternatives of the patients with HWE. Methods:The age of seizure onset, duration of seizure, family history, interictal and postictal electroencephalography findings, triggering temperature of water, type of seizure, medication, and follow-up results were evaluated for each patient. Results:The mean age at seizure onset was 10.5 years. The mean duration of seizures was 10 years. Interictal EEG recordings showed focal abnormalities in 4 patients and generalized abnormalities in 3 patients. Only one patient had normal interictal EEG findings. Among the 8 patients with HWE, 6 had seizures only during hot bathing, whereas 2 had additional seizures. Seven patients had generalized tonic-clonic seizures and 1 patient had complex partial seizure during their hot bathings. The mean triggering temperature of water was calculated as 41.4°C. The mean duration of follow-up period was 23 months. Five patients became seizure-free during the follow-up period and seizures persisted in 3 patients. Antiepileptic drugs were given (800 mg/d carbamazepine for 2 patients and 600 mg/d phenytoin for 1 patient) to these 3 patients and they also became seizure-free during the follow-up period. Conclusions:Hot water epilepsy is a benign reflex epilepsy. Lowering water temperature must be the first step for the treatment. If needed, antiepileptic drugs should be considered as an additive treatment.

Foot drop due to cranial gunshot wound.

OBJECTIVE We present a case of foot drop from hemorrhagic contusion after cranial gunshot, which has never been reported. METHODS A 21-year-old man was admitted with inability of dorsiflexion 1 day after a tangential gunshot wound of the scalp. The scalp skin was cut by the rifle bullet. He had foot drop and his neurological examination was normal except for weakness at dorsiflexion of the right foot. Pathological reflexes and sensation failure were not detected. T1- and T2-weighted magnetic resonance images showed hyperintense contusion at the right superior frontal gyrus and mild subdural hemorrhage. Peripheral nervous system examination was electrophysiologically normal. Motor-evoked potentials showed the location of the lesion at the motor cortex because no electrical record was obtained from the right anterior tibial and extensor digitorum brevis muscles, and there was a normal record on the left. Six months later, the patients neurological examination was uneventful. CONCLUSION When a cranial gunshot wound injury victim presents with foot drop, the central causes should be included in the differential diagnosis list.