Usefulness of ictal and interictal 99mTc ethyl cysteinate dimer single photon emission computed tomography in patients with refractory partial epilepsy

OBJECTIVE: The aim was to investigate the feasibility of recording the electrical auditory brain stem response (EABR) evoked by electrical stimulation at the promontory (Prom-EABR) as a tool to assist selection of the ear for cochlear implantation in young children. STUDY DESIGN: The study group consisted of young children for whom the decision to proceed with implantation with the Nucleus mini 22-channel cochlear implant (Cochlear (UK) Ltd., London, UK) had already been made. SETTING: The Prom-EABR was recorded after the children had been anesthetised, but before the start of surgery. PATIENTS: A group of 25 children (11 boys and 14 girls), whose age at implantation ranged from 2 years 11 months to 6 years 8 months (mean age, 4 years 5 months), were investigated. INTERVENTION: Recordings of the Prom-EABR were used to determine which ear would receive the cochlear implant, providing there were no preexisting contraindications regarding selection of the ear. MAIN OUTCOME MEASURE: It has been suggested from earlier studies that the characteristics of the amplitude input/output (I/O) function of the EABR are related to neuronal survival. If the ear with the "better" I/O function is chosen for implantation, it might be expected that these children will perform better on average than those in whom the ear has been selected at random. RESULTS: Reliable recordings of the Prom-EABR were achieved in 40 ears (80%) of the 50 ears in the study. In 20 of the 25 children the technique was actively employed for selection of the ear for implantation. CONCLUSIONS: Recording of the Prom-EABR in the operating theater is a viable technique. Future analysis of long-term outcome measures of performance with the implant will confirm or dispute the benefit of ear selection using the Prom-EABR.     

Stability of cortical self-regulation in epilepsy patients

Biofeedback-supported self-regulation of slow cortical potentials (SCP) is increasingly being used for treatment of intractable epilepsy. However, it is unknown whether the acquired ability to regulate one's own cortical potentials remains stable over time. In this study, 18 patients with drug-resistant partial epilepsy performed 35 training sessions in which they learned to generate slow cortical potential shifts in either positive or negative direction. At the end of training, they differentiated significantly between required cortical positivity and required cortical negativity. Six months after this point, they still demonstrated an unchanged between-condition differentiation. The performance in the booster session was particularly good in trials without continuous SCP feedback. The ability to generate positive SCP shifts was related to decrease of seizure frequency during the 6 months follow-up period compared with the 3 month baseline period. This data indicate that the acquired ability of humans to regulate their cortical potentials did not decrease over a 6 month period but rather, tended to consolidate.     

Usefulness of transdermal hormone substitution in high risk postmenopausal patients

The authors studied whether hormone replacement therapy can be performed in postmenopausal patients with high risk factors among anamnestic data such as thromboembolia, diabetes mellitus, hypertension, epilepsy. 50 mg 17 beta estradiol patch (twice weekly) and 10 mg medroxyprogesteron (in the last 12 days of the cycle) were prescribed. Data of 102 patients with the above conditions were analyzed at the beginning and at the 3,6, and 12 month follow-up visits. The frequency of exacerbation of anamnestic disease, biased and unbiased complaints, efficacy and side effects of the therapy were studied. In the authors opinion hormone replacement therapy can be safely performed in patients with high risk factors among anamnestic data, in addition it may be useful to prevent them.     

Usefulness of pulsatile bidirectional cavopulmonary shunt in high-risk Fontan patients

BACKGROUND: A bidirectional cavopulmonary shunt has been performed for the high-risk Fontan patient. It is well known that in the presence of the bidirectional cavopulmonary shunt alone to secure pulmonary blood flow, the central pulmonary artery size decreases over time. We have performed pulsatile bidirectional cavopulmonary shunt (PBCPS), keeping pulmonary blood flow from the ventricle through the stenotic pulmonary valve, or a Blalock-Taussig shunt in patients who do not meet the criteria for the Fontan operation. METHODS: Eleven patients who underwent PBCPS between 1989 and 1993 were reviewed. We compared the results of cardiac catheterization immediately before PBCPS and during the postoperative observation period (310 +/- 257 days). RESULTS: Pulmonary blood flow and arterial oxygen saturation increased significantly after PBCPS (p = 0.01). Pulmonary artery area index showed a tendency to increase (p = 0.11). The mean number of risk factors for the Fontan procedure decreased significantly for 1.8 +/- 1.1 to 0.7 +/- 0.8 after PBCPS (p < 0.05). Overall, 5 of the 11 patients (45.5%) met the criteria for the Fontan procedure, and a fenestrated Fontan procedure was carried out in 4 of them. CONCLUSIONS: The PBCPS is useful for high-risk Fontan patients not only in the staged Fontan operation, but also as definitive palliation.     

Usefulness of transesophageal echocardiography in the treatment of critically ill patients

To evaluate the usefulness of transesophageal echocardiography (TEE) in the treatment of critically ill patients, 80 patients (51 male and 29 female; mean age, 53 years) undergoing both transthoracic echocardiography (TTE) and TEE were studied in a 2-year period. Of these, 48 patients were studied in the ICU, while the other 32 patients were directly referred from the emergency departments. Indications for the study included suspected aortic dissection (34 patients), hemodynamic instability (22 patients), suspected cardiac source of embolism (11 patients), evaluation of the severity of mitral regurgitation (7 patients), and suspected infective endocarditis (6 patients). The probe was passed successfully in 78 of 80 attempts (98 percent). No significant complications were recorded during the transesophageal echocardiographic study. Transesophageal echocardiography provided critical information that was not obtained by TTE in 39 of 78 studies (50 percent, p < 0.005). Cardiac surgery was prompted by TEE findings in 14 patients (18 percent) and these findings were all confirmed at operation. Transesophageal echocardiography was a safe, well-tolerated, and valuable diagnostic approach for the rapid detection of specific cardiac abnormalities in patients with critical illness; TEE should be considered in the treatment of critically ill patients especially when TTE provided inadequate information.     

Auditory middle latency responses in patients with epilepsy

Middle latency auditory responses (MLRs) were studied in 55 normal subjects and 49 epileptic patients. We evaluated the function of the auditory system and of the temporal lobe in epileptic patients using MLRs. (1) The patients with epilepsy had significantly prolonged Pa and Nb latencies and the significantly increased amplitude of Pa-Nb component. (2) The prolongation and the increase of MLR components in latency and amplitude were more obvious in patients with intractable epilepsy than patients without intractable epilepsy. (3) The difference between left and right sides was larger in epileptic patients than normal subjects. (4) Epileptic patients with polypharmacy had reduced amplitude of Pa-Nb component and prolonged latency of Pa component than patients with monotherapy. Antiepileptic drugs (AEDs) appeared to decrease the amplitude of Pa-Nb component. It was supposed that the enhancement of amplitude of Pa-Nb component represented the abnormality of central nerve system in epileptic patients, in part.     

Prolonged polysomnography in a case with recurrent hypersomnia

A 49-y-old male, who had travelled in Central Africa, was admitted to hospital with oedema of the right forearm. He was diagnosed as having thrombosis of the ulnar veins. Subsequently eosinophilia and positive serology for filariae established the aetiologic agent as Loa loa. The patient received antithrombotic and antiparasitic therapy. This is, to our knowledge, the first reported case of thrombosis of the ulnar veins associated with Loa loa.     

Surgical management of intractable epilepsy in patients with ganglioglioma

Long-standing intractable seizures are common manifestation of cerebral gangliogliomas. There is much controversy regarding the most appropriate surgical treatment (lesionectomy vs resection of the epileptogenic cortex with the lesion) for patients with intractable epilepsy associated with gangliogliomas. We reported 2 cases, in which the favorable seizure outcome was obtained following lesionectomy alone. (Case 1) Nine-year-old female developed attack of abnormal sensation in her left upper limb followed by motor seizure in her left limbs since 5 years old. MRI revealed hyperintense tumor in the right medial frontal lobe. Chronic invasive subdural recording showed that ictal onset zone was located in the hand motor area. Following lesionectomy alone, she became free from seizures. (Case 2) Eight-year-old girl had intractable generalized seizure since 6 years old. MRI revealed a cystic tumor in the right parietal lobe. She had multiple spike foci on electroencephalography and magnetoencephalography, and intraoperative electrocorticography failed to reveal the paroxysm. Following lesionectomy, she had good relief with less than one minor seizure per 1-3 months. Thus, lesionectomy, even without resection of the epileptogenic cortex, may improve seizure outcome in patients with ganglioglioma-associated epilepsy.     

Autoantibodies to brain tissue antigens in epilepsy patients

Dynamics of neuroepithelial cells reaction was studied in different areas of brain obtained from mouse embryos affected by X-rays irradiation on 10th, 12th and 13th days of pregnancy. It was shown that as differentiation starts after the irradiation regeneration processes arise along with cell death. This develops in all brain areas due to total mitotic division of unchanged neuroepithelial cells. Forming of rosettes on proliferative centers is mainly characteristic for the forebrain. After the irradiation of mice at 1-2 days pregnancy rosettes form only in rostral part of anterior encephalic vesicle. In irradiation on 13th pregnancy day a significant number forms in rostral, lateral and dorsal parts of the embryonic forebrain. Irradiation on the 14th day causes the forming of the rosettes in the forebrain ventral part.     

Symptoms of depression and anxiety in pediatric epilepsy patients

The XPF and ERCC1 proteins form a tight complex and function as an endonuclease to incise on the 5'-side of pyrimidine dimers in DNA. Levels of both proteins are extremely low in group F xeroderma pigmentosum (XP-F) cells. We transfected XP-F cells with the plasmids expressing XPF or ERCC1 and examined levels of both proteins in the cells. Although XP-F cells are sensitive to UV and mitomycin C (MMC), cells overexpressing XPF expressed ERCC1 as well and resistance to UV and MMC was restored to the normal level. In contrast, cells overexpressing ERCC1 did not express XPF and were still sensitive to UV and MMC. These results indicate that both the XPF and ERCC1 proteins are required to repair UV- and MMC-induced DNA damage. Even though a high level of ERCC1, which has been presumed to be a catalytic subunit of the endonuclease, is stably present in XP-F cells, ERCC1 protein alone cannot carry out excision repair completely.     

Sex differences in patients with mesial temporal lobe epilepsy

Possible sex differences in the pattern of interictal hypometabolism were investigated, and also seizure spread in patients with mesial temporal lobe epilepsy (n=48) and hippocampal sclerosis (MTLE). Male patients (n=21) more often had a frontal lobe hypometabolism ipsilateral to the seizure onset (p<0.0001) and a spread of epileptiform activity to this region (p=0.001). By contrast, female patients more often exhibited hypometabolism (p=0.0052) and an ictal spread to the contralateral temporal lobe (p=0.0097). These findings suggest sex differences in spatial distribution of brain dysfunction in MTLE, perhaps reflecting sexual dimorphism in regional cerebral connectivity.     

Using topiramate in patients with epilepsy: practical aspects

Clinical trials are important in determining the relative efficacy and safety of a new antiepileptic drug (AED); however, experience acquired in clinical practice will eventually determine its position in the antiepileptic armamentarium. Topiramate (TPM), a new AED has been available in the United Kingdom since mid-1995 and a considerable number of patients have being treated. As a result of this experience, a number of changes have being made in the way TPM is used, particularly in the starting doses and titration rates. This seems to have improved patients' tolerability of treatment, an important consideration if a drug is to be used to its optimum level. In this article, practical tips for the use of TPM are given and these include starting doses, titration rates, options for managing side effects occurring early in treatment, advice concerning the withdrawal of concomitant AEDs and indications for discontinuation of TPM. The need for adequate patient counseling regarding potential side effects and expectations of treatment is also reviewed.     

Usefulness of Doppler ultrasound in the evaluation of patients with active Crohn's disease

OBJECTIVES: To assess the usefulness of Doppler ultrasound in the evaluation of the vascular changes in the splanchnic circulation and bowel wall described in patients with active Crohn's disease (ACD). DESIGN: We analyzed prospectively with Doppler ultrasound the mean velocity of portal flow, the resistive index (RI) of the superior mesentery artery (SMA) and we looked for vessels within the bowel wall. PATIENTS: 50 patients with ACD and 30 normal individuals. RESULTS: In comparison with normal individuals, patients with ACD showed a statistically significant difference (p < 0.001) in the mean velocity of the portal flow and in the RI of the SMA. In all patients with ACD, vessels could be seen within the bowel wall using the color Doppler ultrasound. CONCLUSION: Doppler ultrasound can be used as a non-invasive method to evaluate the vascular changes which develop in the splanchnic circulation and bowel wall of patients with ACD.     

Learning and memory skills in patients with cryptogenic epilepsy

The purpose of this investigation was to determine the nature of memory deficits in patients with cryptogenic epilepsy and partial seizures. Sixty-two patients were compared to forty-four controls on several verbal and visual memory tests (short-term memory, learning, long-term recall, and recognition). Performance in the patients group was significantly impaired only on the test of verbal delayed recall.     

Usefulness of blood and plasma viscosity measurements in the evaluation of arteriopathic patients

Blood viscosity represents the internal friction of the blood, in other terms, its resistance to be deformed and to flow under a tangential force. This function is conditioned by the intrinsic characteristics of blood and the geometry of the system in which flow occurs. Thus, any in vitro (or ex vivo) system of measurement of blood viscosity represents a relatively approximate evaluation of the ratio between intertial forces and viscous resistance. However, the possibility of measuring blood viscosity in a reproducible way provided the opportunity of identifying some clinical conditions associated with a worsening in rheologic parameters. Thus, "primary" and "secondary" hyperviscosity syndromes have been defined, on the basis of the pathogenetic responsibility of rheologic or hemodynamic factors, respectively. The possibility of performing in vitro measurement of blood viscosity provided the opportunity of planning several clinical pharmacology studies with theoretically active drugs. On such a basis, the rationale has arisen for a "rheologic therapy" of circulatory disturbances. Moreover, the evaluation of rheologic parameters is extremely useful since epidemiological studies have shown that viscosity may represent a marker and a prognostic factor for the progression of ischemic diseases as well as an independent risk factor, thus suggesting the opportunity of performing controlled clinical studies to evaluate the impact of hemorheological changes in the prevention of cardiovascular events.     

Technology fuels hope for patients with epilepsy

Technological advances are making surgery a viable option for people with medically intractable epilepsy. More temporal lobectomies are being performed on young adults, fueled by recognition that many consequences of growing up with epilepsy can be avoided with early surgery.     

Usefulness of aspiration surgery for elderly patients with hypertensive cerebellar hemorrhage

Synthesis of 1-[11C]methylpiperidin-4-yl propionate ([11C]PMP), an in vivo substrate for acetylcholinesterase, is reported. An improved preparation of 4-piperidinyl propionate (PHP), the immediate precursor for radiolabeling, was accomplished in three steps from 4-hydroxypiperidine by (a) protection of the amine as the benzyl carbamate, (b) acylation with propionyl chloride, and (c) deprotection of the carbamate by catalytic hydrogenation. The final product was obtained in an overall 82% yield. Reaction of the free base form of PHP with [11C]methyl trifluoromethanesulfonate at room temperature in N,N-dimethylformamide, followed by high performance liquid chromatography (HPLC) purification, provided [11C]PMP in 57% radiochemical yield, > 99% radiochemical purity, and > 1500 Ci/mmol at the end of synthesis. The total synthesis time from end-of-bombardment was 35 min. [11C]PMP can thus be reliably prepared for routine clinical studies of acetylcholinesterase in human brain using positron emission tomography.     

Population analysis of the pharmacokinetics of tiagabine in patients with epilepsy

PURPOSE: In two open-label long-term safety studies, we determined tiagabine (TGB) pharmacokinetics in patients with epilepsy. METHODS: In all, 2,147 plasma samples from 511 patients who participated in the studies were available. The total daily dose ranged from 2 mg administered once daily to 80 mg administered in four doses. A one-compartment model with first-order absorption and elimination was used to fit the TGB plasma concentration-time data, with a population pharmacokinetic approach. RESULTS: The patients' average (+/-SD) weight and age were 73.8+/-20.7 kg and 32.1+/-12.3 years. The most significantly factor affecting TGB pharmacokinetics was concomitant administration of other antiepileptic drugs (AEDs). The central clearance value in patients receiving AEDs known to induce hepatic drug metabolism was 21.4 L/h, a value 67% higher than the central clearance estimate obtained for the patients receiving AEDs not known to affect hepatic drug metabolism (12.8 L/h). There was no evidence of any dose or time effect, indicating that TGB pharmacokinetics are linear. TGB pharmacokinetics were not different in white, black, or Hispanic patients, although our ability to explore racial effects was limited since 90% of the patients were white. No other demographic variables (including age and smoking) or any clinical chemistry measurements (including bilirubin, SGOT, and SGPT) were important in explaining the variability in the clearance estimates. CONCLUSIONS: TGB pharmacokinetics are linear, influenced by enzyme-inducing AEDs, and largely unaffected by other demographic variables.