Isolation and characterization of vasoformative endothelial cells from the rat aorta

INTRODUCTION: Psychosis is the most severe psychiatric complication after epilepsy surgery. PATIENTS AND METHODS: We evaluated postoperatively at 1 year the psychoses of a series of 57 adult patients with intractable epilepsy who underwent temporal lobe surgery. RESULTS: Five patients (8.8%) developed postoperative psychosis. Two (3.5%) of these 5 revealed postictal psychotic episodes in connection with persisting seizures, both of them had had similar episodes even preoperatively. Two patients (3.5%) exhibited a definite and one patient (1.8%) a probable de novo schizophrenia. CONCLUSION: Our findings clearly emphasize the need for careful postoperative psychiatric follow-up for patients with temporal lobectomy.     

A prospective study of the early postsurgical psychiatric associations of epilepsy surgery

OBJECTIVES: To examine prospectively the frequency and nature of psychiatric symptoms seen in patients during the first three months after temporal lobe surgery for chronic intractable epilepsy and in addition to study the relation between presurgical mental state, laterality of surgery, and postsurgical seizure and psychiatric course. METHOD: A consecutive series of 60 patients being assessed for temporal lobe surgery for intractable epilepsy were studied. They were interviewed before surgery and at six weeks and again at three months after operation. RESULTS: At six weeks after surgery half of those with no psychopathology preoperatively had developed symptoms of anxiety or depression and 45% of all patients were noted to have increased emotional lability. By three months after surgery emotional lability and anxiety symptoms had diminished whereas depressive states tended to persist. Patients with a left hemispheric focus were more likely to experience persisting anxiety. CONCLUSION: The early months after surgery for epilepsy are characterised by the relatively common presence of psychiatric symptoms. It is proposed that presurgical and early postsurgical neuropsychiatric involvement in programmes of surgery for epilepsy will help to improve the quality of the treatment package offered to patients.     

New-onset psychogenic seizures after surgery for epilepsy

BACKGROUND: The emergence of psychogenic seizures after surgery for epilepsy is not well recognized. OBJECTIVES: To identify the frequency of psychogenic seizures in an 11-year surgical experience and to characterize the patients with this complication. METHODS: Ninety-six patients underwent surgery for epilepsy between 1985 and 1996. The surgical database was reviewed and all patients who experienced postoperative psychogenic seizures were identified. Patients were characterized by sex, age, psychopathologic conditions, full-scale IQ, duration of epilepsy, surgical procedure, and operative complications. Patients were compared with the surgical group as a whole for these variables. SETTING: A comprehensive epilepsy center. RESULTS: Five patients were identified: 3 men and 2 women. Mean full-scale IQ was 73 (range, 66-82). Mean age was 29.8 years (range, 22-36 years). Three patients were diagnosed as having psychosis, 1 with borderline personality disorder and 1 with generalized anxiety. Operations included 4 anterior temporal lobectomies and 1 occipital lobectomy. Two patients experienced operative complications. Compared with the surgical cohort, patients had a higher frequency of preoperative psychopathologic conditions, lower mean full-scale IQ, and a greater occurrence of operative complications. CONCLUSIONS: (1) Patients can develop new-onset psychogenic seizures after surgery for epilepsy. (2) Low full-scale IQ, serious preoperative psychopathologic conditions, and major surgical complications may be risk factors. (3) Atypical postoperative seizures should be evaluated with video electroencephalographic monitoring before concluding that they are epileptic.     

Involvement of insulin-like growth factors-I and -II and their receptors in medroxyprogesterone acetate-induced growth of mouse mammary adenocarcinomas

Data about psychiatric disorders associated with epilepsy as well as their risk factors are heterogeneous. The overall prevalence of psychiatric disturbances in epileptic patients can be estimated between 20 and 30 per cent. It is the highest in pharmocoresistant cases seen in specialized centers. Psychotic disorders, depression, and suicide are the three most common among interictal disturbances. Psychoses affect 2 to 9 per cent of patients and are more frequent in cases with aura or altered consciousness, such as in complex partial seizures and absences. They correlate positively with the multiplicity of seizures but often inversely with their frequency. Temporal lobe epilepsy is associated with schizo phrenic-like and paranoid types of psychosis, but frontal lobe epilepsy is also common. A putative association with predominant left or bilateral EEG abnormalities in cases with partial epilepsy remains to be confirmed, as well as the frequency of underlying structural lesions. Depressive disorders affect 20 to 60 per cent of patients. While their occurrence with partial complex seizures and left hemisphere foci is common, the role of temporal lobe involvement still appears controversial. Depression prevails in cases with seizures that occasionally, albeit rarely, secondarily generalize and correlates with the duration of the disease, intractable seizures, and polypharmacy. A genetic factor is likely to play a role. Suicides rates are increased, encountered in 0.2-0.5 per cent of patients and causing deaths in 3-7 per cent of them. The overall risk might be the highest during the first years after diagnosis of epilepsy, as well as in patients with temporal lobe foci, depression, or psychosis. Great variability and discordance in results show the major difficulties encountered in epidemiologic studies. Most of these problems relate to the classification of epileptic disorders as well as that of psychiatric disorders, the variability in the methods and measures which are used, and frequent bias in the selection of patients. We review here data about the frequency of major psychiatric disorders in epileptic patients or the frequency of epileptic disorders in psychiatric patients, and also possible risk factors related to the epileptic disease and its evolution.     

Elevated blood lead levels in children are associated with lower erythropoietin concentrations

PURPOSE: We investigated the incidence of well-directed violent behavior and suicide attempts in patients with temporal lobe epilepsy, with special attention to postictal psychosis. METHODS: We compared 57 episodes of postictal psychosis with 62 episodes of acute interictal (or alternative) psychosis and with 134 complex partial seizures. All patients were matched for age and for age at onset of seizures. RESULTS: The incidence of well-directed violent behavior against human beings was significantly higher (23%) during postictal psychotic episodes than during acute interictal episodes (5%) and postictal confusion (1%). Suicide attempts were also more frequent during postictal psychosis (7%) than during either acute interictal psychosis (2%) or postictal confusion (0%). CONCLUSIONS: Our study showed that well-directed violent and self-destructive behavior was not a feature of epileptic psychosis in general but a specific hallmark of postictal psychosis.     

Spectral EEG during short-term discontinuation of antiepileptic medication in partial epilepsy

The effect of short-term discontinuation of antiepileptic drugs (AEDs) on spectral analysis of EEG background activity (spectral EEG) was studied in patients undergoing preoperative evaluation for epilepsy surgery. We also wished to clarify whether AED discontinuation would provide lateralizing evidence in spectral EEGs of patients with temporal lobe epilepsy (TLE). Spectral EEGs were performed in 15 patients receiving their regular medication regimen and again after a 1-week period during AED withdrawal. A subgroup of 9 patients who had previously undergone temporal lobectomies (TLE group) was studied separately. In this group, we evaluated the effect of preceding seizures on spectral EEG derived from temporal neocortical areas. In all patients, spectral EEG changes were detected even after a short-term AED withdrawal. The total amount of absolute delta activity was reduced and occipital peak frequency and relative alpha activity were increased as compared with baseline values. In TLE patients with habitual seizures occurring < 20 h before the spectral EEG recording, lateralization was correctly identified by the greater amount of absolute delta activity ipsilateral to the epileptogenic focus. Epileptic seizures are accompanied by subtle focal slowing in spectral EEG for a much longer period than has been assumed. In addition, postictal spectral EEG over the temporal lobes may have lateralizing value. Further studies in larger numbers of patients are needed to evaluate the role of spectral EEG in the preoperative evaluation of patients for temporal lobe surgery.     

Clinical evaluation and noninvasive electroencephalography. Preoperative evaluation

Epilepsy surgery has been shown to be a safe and effective alternative to antiepileptic drug therapy for many patients with medical refractory partial seizure disorders. Surgical treatment should be considered when the patients experience and impairment in the quality of life related to the seizures, medical therapy, or both. Surgically remediable epileptic syndromes include medical temporal lobe epilepsy and lesional epilepsy. A comprehensive presurgical evaluation is performed to identify appropriate candidates for epilepsy surgery.     

Primary therapy with OKT3 for biopsy-proven acute renal allograft rejection

Our patient underwent right anteromesial temporal resection at 17 years of age for intractable complex partial seizures due to hippocampal sclerosis, and then developed juvenile myoclonic epilepsy after a change in medication. Postoperative seizures ceased after a change to valproate monotherapy. Our patient reminds us to remain aware that generalized and focal epilepsy may coexist as an unusual cause for surgical failure. We feel that these patients may still be favorable candidates for epileptic surgery, as long as the focal epileptogenic zone is amenable to resection and the generalized epilepsy appears to be readily controllable.     

Outcome and life prospects after surgical management of medically intractable epilepsy in patients under 18 years of age

A retrospective analysis of seizure outcome and quality of life assessment was done in 64 patients under 18 years of age with medically refractory epilepsy who underwent 64 primary and 16 repeat operative procedures in an attempt to control their epilepsy. At least 2 years' follow-up data were available for each patient. Operative procedures were 44 temporal lobe resections; 16 extratemporal resections; and 4 hemispherectomies. Effective control of previously intractable seizures was obtained in most patients: 55%, 11%, and 17% achieved Engel class I, II, and III status, respectively. Successful seizure control was thus obtained in 83%, while 17% (Engel class IV) failed to improve significantly after operation. Quality-of-life measures parallelled the improvements in seizures control, being highest in Engel I, outcome group and lowest in Engel IV outcome group. In appropriately selected pediatric and adolescent patients with medical refractory epilepsy, surgical management can offer a safe and effective adjunct to medication.     

Medical causes of seizures

Seizures are commonly encountered in patients who do not have epilepsy. Factors that may provoke such seizures include organ failure, electrolyte imbalance, medication and medication withdrawal, and hypersensitive encephalopathy. There is usually one underlying cause, which may be reversible in some patients. A full assessment should be done to rule out primary neurological disease. Treatment of seizures in medically ill patients is aimed at correction of the underlying cause with appropriate short-term anticonvulsant medication. Phenytoin is ineffective in the management of seizures secondary to alcohol withdrawal, and in those due to theophylline or isoniazid toxicity. Control of blood pressure is important in patients with renal failure and seizures. Non-convulsive status epilepticus should be considered in any patient with confusion or coma of unclear cause, and electroencephalography should be done at the earliest opportunity. Most ill patients with secondary seizures do not have epilepsy, and this should be explained to patients and their families. Only those patients with recurrent seizures and uncorrectable predisposing factors need long-term treatment with anticonvulsant medication.     

Histological change of keratinocyte in full-thickness skin autograft and its effect on hyperpigmentation of the graft

OBJECTIVES: To investigate the frequency of ECG abnormalities suggestive of myocardial ischaemia in patients with severe drug resistant epilepsy and without any indication of previous cardiac disease, assuming that these changes may be of significance for the group of epileptic patients with sudden unexpected death. MATERIAL AND METHODS: Twelve patients with medically intractable epilepsy were investigated with simultaneous long ECG and EEG recordings while attending either epilepsy surgery investigational procedures or the investigational programme for diagnostic purposes, and one while having an episode of status epilepticus. RESULTS: The ECG recording failed in 1 patient. This patient had chest pain and minor yet morphologically conspicuous changes in the ECG, suggestive of myocardial infarction. He died in heart arrest. Eight epilepsy patients had episodes of ST segment depression in the ECG, many of which coincided with video- and EEG documented epileptic seizures. Two patients experiencing simple partial seizures and 1 patient experiencing absence seizures had no ST segment depressions in the ECG. One patient had an episode of status epilepticus secondary to brain damage and no ST segment deviation was seen during the ECG recording which continued until 3 h before the patient died. CONCLUSION: Patients with severe drug resistant epilepsy have episodes of ST segment changes, some of which are closely related to epileptic seizures. Further studies are needed to confirm the present results and to investigate the nature of these changes and document the effect of prophylactic treatment with cardioactive drugs to reduce the risk of sudden death.     

Memory and epilepsy

INTRODUCTION: The neuropsychological literature has shown the presence of memory deficits in patients with epilepsy. These alterations in memory are due to several factors, such as the aetiology of the epilepsy, age at onset of the seizures, the duration of the disorder, and the frequency and type of the epileptic seizures. DEVELOPMENT: These memory defects reflect the structural and functional damage caused by the repeated epileptic seizures and/or the anti-epileptic drugs. Apart from this, neuro-surgical treatment of temporal lobe epilepsy may also lead to memory defects. These will depend on the site and side of the epileptic focus, the level of memory prior to surgery, the age of onset of the epileptic seizures, the chronological age at the time of operation and the reduction in the number of seizures after surgery. In spite of the evidence that memory is affected in patients with epilepsy, this does not mean that all people with epilepsy have these changes. CONCLUSIONS: Neuropsychological examination is of fundamental clinical importance since it allows the evaluation of cognitive function in each patient, and thus permits optimization of both the pharmacological treatment and intellectual and physical performance.     

Modulation of the chemotactic peptide- and immunoglobulin G-triggered respiratory burst in human neutrophils by exogenous and endogenous adenosine

BACKGROUND: Premenstrual dysphoria has shown a significant relationship to epilepsy, and its symptoms correspond to those of the interictal dysphoric disorder. The established treatment for interictal dysphoric disorder is explored as an effective treatment for premenstrual dysphoria. METHODS: Women with premenstrual dysphoria (the majority with epilepsy) were evaluated and treated systematically. RESULTS: Premenstrual disorder responded well to the combination of antidepressant and antiepileptic medication. CONCLUSION: Concordance of symptomatology between interictal and premenstrual dysphoric disorder may extend to treatment. LIMITATIONS: The treatment needs to be evaluated in a large series of women without epilepsy. CLINICAL RELEVANCE: A novel understanding and treatment of premenstrual dysphoria is suggested.     

Context-processing deficits in schizophrenia: Diagnostic specificity, 4-week course, and relationships to clinical symptoms.

Previous research on schizophrenia suggests that context-processing disturbances are one of the core cognitive deficits present in schizophrenia. However, it is not clear whether such deficits are specific to schizophrenia as compared with other psychotic disorders. To address this question, the authors administered a version of the AX Continuous Performance Test designed to assess context processing in a sample of healthy controls, patients with schizophrenia, and patients with other psychotic disorders. Participants were tested at index (when medication naive and experiencing their first contact with psychiatric services) and 4 weeks later, following medication treatment. At index, patients with schizophrenia and the psychotic comparison group demonstrated similar impairments in context processing. However, context-processing deficits improved in the psychotic comparison group at 4 weeks but did not improve in patients with schizophrenia. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Bilateral reductions in hippocampal volume in adults with epilepsy and a history of febrile seizures

OBJECTIVES: To examine the degree and frequency of reductions in hippocampal volume in patients with temporal lobe epilepsy with and without a history of febrile seizures. METHODS: In vivo measures of hippocampal volume were computed from three dimensional gradient echo (FLASH) images in 44 patients undergoing comprehensive evaluations for epilepsy surgery. Twenty one patients (48%) reported a history of febrile seizures. The volumes from these patients were compared with those from 23 patients without a history of febrile seizures and 34 healthy controls. RESULTS: The febrile seizure group had significant reductions in volume, both ipsilateral (30% decrease) and contralateral (15% decrease), to the EEG seizure focus. Twelve of 18 patients with febrile seizures exhibited clinically significant ipsilateral volume reductions, defined as volumes falling 2 SD below the mean obtained from the control sample. Only four of 19 patients without febrile seizures exhibited this degree of reduction. No significant correlations were found between seizure variables (for example, duration of epilepsy, seizure frequency) and ipsilateral reductions in volume. However, a significant inverse correlation (r=-0.45, P<0.05) between seizure frequency and the volume of the hippocampus contralateral to the seizure focus was found in the febrile seizure group. CONCLUSION: These results suggest that a history of febrile seizures is associated with the finding of a smaller hippocampus on the side ipsilateral to the subsequent temporal lobe focus whereas chronic factors seem to be be related to pathology contralateral to the seizure focus.     

Release of nontransmembrane full-length Alzheimer''s amyloid precursor protein from the lumenar surface of chromaffin granule membranes

OBJECTIVE: To evaluate the effectiveness and safety of a single-dose treatment for acute repetitive seizure (ARS) episodes (e.g., clusters) administered in a nonmedical setting by caregivers. BACKGROUND: Patients with epilepsy may experience ARS episodes despite optimal anticonvulsant treatment. Such episodes require rapid treatment as medical emergencies. Typically, the patient is treated in an emergency medical setting with i.v. medication by trained medical personnel. METHODS: The authors undertook a multicenter, randomized, parallel, double-blind study of a single administration of Diastat (diazepam rectal gel) for treating episodes of ARS. ARS episodes and treatment criteria were defined for each patient at the start of the study. Caregivers were taught to determine ARS episode onset, administer a predetermined dose of study medication, monitor outcome, count respirations, and record seizures and adverse events. RESULTS: A total of 29 centers enrolled 158 patients, of whom 114 patients had a treated ARS episode (Diastat, n = 56; placebo, n = 58). Diastat treatment reduced median seizure frequency (p = 0.029). More Diastat patients were seizure free post-treatment (Diastat, 55%; placebo, 34%; p = 0.031). Kaplan-Meier analysis of the time to the next seizure favored Diastat treatment (p < 0.007). The most common adverse event was somnolence. CONCLUSION: Administration of a single rectal dose of Diastat was significantly more effective than placebo in reducing the number of seizures following an episode of ARS. Caregivers could administer treatment safely and effectively in a nonmedical setting.     

Continuous source imaging of scalp ictal rhythms in temporal lobe epilepsy

PURPOSE: We wished to determine whether continuous EEG source imaging can predict the location of seizure onset with sublobar accuracy in temporal lobe epilepsy (TLE). METHODS: We retrospectively analyzed the earliest scalp ictal rhythms, recorded with 23- to 27-channel EEG, in 40 patients with intractable TLE. A continuous source analysis technique with multiple fixed dipoles (Focus 1.1) decomposed the EEG into source components representing the activity of major cortical sublobar surfaces. For the temporal lobe, these were basal, anterior tip, anterolateral, and posterolateral cortex. Ictal EEG onset was categorized according to its most prominent and leading source component. All patients underwent intracranial EEG studies before epilepsy surgery, and all had a successful surgical outcome (follow-up >1 year). RESULTS: Most patients with ictal rhythms having a predominant basal source component had hippocampal-onset seizures, whereas those with seizures with prominent lateral source activity had predominantly temporal neocortical seizure origins. Seizures with a prominent anterior temporal tip source component mostly had onset in entorhinal cortex. Seizures in some patients had several equally large and nearly synchronous source components. These seizures, which could be modeled equally well by a single oblique dipole, had onset predominantly in either entorhinal or lateral temporal cortex. CONCLUSIONS: Multiple fixed dipole analysis of scalp EEG can provide information about the origin of temporal lobe seizures that is useful in presurgical planning. In particular, it can reliably distinguish seizures of mesial temporal origin from those of lateral temporal origin.     

Influence of head trauma on outcome following anterior temporal lobectomy

BACKGROUND: There is controversy in the literature regarding the importance of risk factors in developing epilepsy and seizure outcome following anterior temporal lobectomy. Some of the existing studies may be biased because of patient selection and limitations in determining predisposition. OBJECTIVE: To investigate the role of risk factors for epilepsy in determining outcome following anterior temporal lobectomy. PATIENTS AND METHODS: We identified 102 patients in a consecutive surgery series for epilepsy from a tertiary center with a minimum of 1-year postoperative follow-up. Risk factors for epilepsy were determined prospectively on at least 3 occasions before anterior temporal lobectomy. Risk factors investigated were a history of febrile convulsions, family history of epilepsy, significant head trauma, history of meningitis, history of encephalitis, or significant perinatal insult. Foreign tissue lesions on magnetic resonance imaging was also included if an anterior temporal lobectomy was performed for presumed dual pathologic findings (hippocampus and lesion). Outcome was determined using Engel's classification. For statistical analysis we used successive logistic regression analysis, chi(2) test, Fisher exact test, and t test. RESULTS: Of the 102 patients, 13 had no identified risk factor for epilepsy, 49 had 1 identified risk factor, and 40 had more than 1. Frequencies were 39 febrile convulsions (15 complex febrile convulsions), 29 head trauma, 22 with lesions seen on magnetic resonance imaging, 12 history of meningitis, 2 history of encephalitis, 19 family history of epilepsy, and 4 perinatal insult. Seventy-one (70%) were classified as Engel's class I, with 56 patients continuously free of seizures at follow-up. Those without risk factor were as likely to be rendered free of seizures following anterior temporal lobectomy as those with a risk factor (P = .27). No risk factor alone or in combination was correlated with complete freedom from seizures following anterior temporal lobectomy, but the presence of head trauma, alone or in combination, was correlated with continued seizures following anterior temporal lobectomy (P = .03; odds ratio, 2.6). Better outcomes were not seen in those with head trauma before the age of 5 years (P = .57). These findings did not change if all those with lesions on magnetic resonance imaging were excluded in the analysis. Those with a history of head trauma were as likely to have pathologic evidence of mesial temporal sclerosis as others (P = .82). CONCLUSIONS: Patients with a history of significant head trauma are less likely to become free of seizures following anterior temporal lobectomy. No other risk factor correlated with a statistically significant greater or lesser chance of freedom from seizures. This information may be used in preoperative counseling of patients.     

Primary intracerebral small lymphocytic non-Hodgkin''s lymphoma with plasmacytoid differentiation, associated with prominent extracellular proteinaceous deposits

Surgical treatment is increasingly used for patients with medically re fractory seizures. Valproate (VPA) is an effective, widely used anticonvulsant in this patient population, but believed by some researchers to increase surgical bleeding because of quantitative thrombocytopenia and functional defects in platelet aggregation. Because we have observed no clinical evidence that perioperative administration of VPA increases blood loss or complications related to postoperative bleeding in patients undergoing temporal lobectomy at our institution, we sought to test this hypothesis. We made a retrospective review of the medical records of all patients who underwent epilepsy surgery at the University of California, San Francisco Medical Center, from September 1986 through January 1993. Patients who had a temporal lobectomy and whose medical records documented preoperative platelet counts and pre- and postoperative hematocrit and hemoglobin values were included. We excluded patients who had cranial surgery before temporal lobectomy and those with intracranial neoplasms or vascular malformations. Patients were divided into two groups: those who received VPA in the immediate preoperative period and those who had not received VPA recently. We compared the estimated surgical blood loss and the estimated change in red blood cell (RBC) volume between groups by unpaired t tests. The charts of 87 consecutive patients qualified for inclusion in the study. Patients in the VPA group had relative (but not absolute) thrombocytopenia preoperatively (235 +/- 64 vs. 277 +/- 69 k in the No-VPA group). There were no differences in the estimated blood loss, RBC volume, or in the incidence of postoperative transfusion. VPA apparently does not increase complications of hemostasis during therapeutic surgical resections for epilepsy. Therefore, we do not recommend routinely discontinuing VPA before craniotomy.