Cases reported "Epilepsy"

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1/14. Can early postnatal closed head injury induce cortical dysplasia.

    PURPOSE: Increased availability of surgically resected epileptogenic tissues reveals often unsuspected cortical dysplasia (CD). There is some controversy about the ontogenic stages in which these occur. Although most take place during neuroblast proliferation and migration, there is some evidence for some CD occurring during postmigrational intrinsic cortical organization. It has been shown that various kinds of focal cortical manipulations in rats, if performed within 3-4 postnatal days, lead to the genesis of various cortical malformations including a four-layered microgyrus or an unlayered CD. It is not known whether such events also might occur in the human brain. methods: Two children sustained minor head trauma within 4 postnatal days and later developed intractable epilepsy, which was relieved by surgery. Neuropathologic analysis of the resected tissues revealed an unsuspected microdysplastic cortex immediately adjacent to a focal, modest meningeal fibrosis, presumably secondary to the old closed head trauma. RESULTS: The main histologic features were a disorganized, unlayered cortex; abnormal clusters of neurons, often with complex, randomly oriented proximal dendritic patterns with absent apical orientation; the presence of a number of heterotopic small and large neurons in the white matter; absence of inflammatory infiltrates, of hemosiderine, of reactive gliosis, or of an excessive number of blood vessels. The morphologic features in these surgical specimens suggest that these focal malformations occur because of a regional disorder of postmigrational intrinsic cortical remodeling. CONCLUSIONS: The clinical histories and the pathologic findings lend some support to the hypothesis that minor morbid events occuring in the immediate postnatal period may lead to microdysplasia in the human similar to those induced in rat pups. The animal model could be helpful to clarify the genesis of some cases of CD and of the epileptogenicity often manifesting later in life.
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2/14. Is epilepsy a progressive disease? The neurobiological consequences of epilepsy.

    While primary, or idiopathic, epilepsies may exist, in the vast majority of cases epilepsy is a symptom of an underlying brain disease or injury. In these cases, it is difficult if not impossible to dissociate the consequences of epilepsy from the consequences of the underlying disease, the treatment of either the disease or the epilepsy, or the actual seizures themselves. Several cases of apparent complications of epilepsy are presented to illustrate the range of consequences encountered in clinical practice and the difficulty in assigning blame for progressive symptomatology in individual cases. Because of the difficulty in interpreting clinical material, many investigators have turned to epilepsy models in order to address the potential progressive consequences of recurrent seizures. The authors review experimental data, mainly from animal models, that illustrate short-, medium-, and long-term morphological and biochemical changes in the brain occurring after seizures, and attempt to relate these observations to the human condition.
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3/14. Antiepileptic effect of high-frequency stimulation of the subthalamic nucleus (corpus luysi) in a case of medically intractable epilepsy caused by focal dysplasia: a 30-month follow-up: technical case report.

    OBJECTIVE AND IMPORTANCE: Currently, some forms of epilepsy are resistant to both pharmacological and surgical interventions. As a result, there is a need for new therapeutic strategies. Because the nigral system modulates neuronal excitability in animal models of epilepsy, we considered therapeutic high-frequency stimulation of the subthalamic nucleus (STN). We were encouraged by the known relationship between the STN and the nigral system, as well as by our experience with high-frequency stimulation of the STN in Parkinsonian patients. CLINICAL PRESENTATION: A 5-year-old girl with pharmacologically resistant, inoperable epilepsy caused by focal centroparietal dysplasia underwent implantation with a permanent electrode in the left STN and was chronically stimulated. To date, we have followed up this patient for 30 months postoperatively. TECHNIQUE: High-frequency stimulation of the STN induced a significant voltage-dependent reduction (by 80%) in the number and severity of seizures. In addition, consistent improvement in both motor and cognitive functions was noted as a result of reduced postictal states. The effect was more prominent for seizures occurring in clusters (89% reduction) and during the day (88% reduction) than for those that occurred during sleep (53% reduction). CONCLUSION: This is the first report of epilepsy control using chronic high-frequency stimulation of the STN. Preliminary observations in three other operated patients (at 2, 12, and 18 mo) confirm these data. We think that high-frequency stimulation of the STN may hold significant future potential as a treatment for epilepsy, similar to its established role in the treatment of Parkinson's disease. This finding opens completely new experimental and therapeutic avenues for the treatment of surgically and medically intractable epilepsy.
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4/14. Epileptiform activity in chronically isolated cerebral cortex in humans.

    The ability of neuronally isolated human cerebral cortex to sustain epileptiform rhythms over long time intervals is unknown. We report here two patients after functional hemispherectomy for infantile hemiplegia and infantile meningoencephalitis. Both patients had intractable seizures. EEG performed early and up to 3 years after surgery showed persistent epileptiform activity in the isolated frontal cortex in both cases. This indicates that human isolated cortex retains its epileptogenic potential for years, independently of subcortical influences. Previous related animal and human studies are briefly reviewed.
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5/14. Laminar analysis of human neocortical interictal spike generation and propagation: current source density and multiunit analysis in vivo.

    Multicontact microelectrodes were chronically implanted in epilepsy patients undergoing subdural grid implantation for seizure localization. Current source density and multiple unit activity of interictal spikes (IISs) were sampled every approximately 150 microm in a line traversing all layers of a cortical column. Our data suggest that interictal epileptiform events in humans are initiated by large postsynaptic depolarizations, consistent with the hypothesis that human IISs correspond to animal paroxysmal depolarization shifts. Furthermore, the cortical layer where the initial depolarization occurs may differ according to whether the IIS is locally generated or propagated from a distant location, and among the propagated IISs, whether the IIS is in the direct path of propagation or on the periphery of that path.
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6/14. Deep EEG recordings of the mammillary body in epilepsy patients.

    PURPOSE: To our knowledge, the epileptic and nonepileptic electroencephalographic (EEG) discharges recorded within the human mammillary body (MB) and mammillothalamic tract (MTT) areas have never been published. Herein, we present the EEG recordings from these structures in patients with refractory epilepsy (RE). methods: Three men (ages 41-43 years) were enrolled in a clinical trial for deep brain stimulation (DBS) of MB-MTT in RE. Previous evaluations had demonstrated a low likelihood of successful response to medication or resective surgery. DBS macroelectrodes were bilaterally implanted within the MB-MTT under general anesthesia and their location checked by magnetic resonance imaging (MRI). We obtained a surface-depth EEG for a 2- to 4-day period, including monitoring of the cardiorespiratory and mnemonic functions. RESULTS: The background pattern of EEG recorded from MB-MTT was low-amplitude (usually <25 microv for MB and <20 microv for MTT) waves with a variable combination of theta-beta rhythms. In two patients, pseudoperiodic slow spikes were unilaterally recorded with or without clinical signs. For one patient, several focal ictal discharges were recorded in the right MB without scalp EEG changes. CONCLUSIONS: The analysis of our depth EEG revealed that the theta-beta pattern represents the predominant physiologic profile of MB. Paroxysmal epileptiform discharges can be observed in human MB. These data supplement those available from animal observations.
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7/14. epilepsy care in zambia: a study of traditional healers.

    PURPOSE: Most people with epilepsy (PWE) reside in developing countries with limited access to medical care. In sub-Saharan africa (SSA), traditional healers (THs) play a prominent role in caring for PWE, yet little is known about epilepsy care by THs. We conducted a multimethod, qualitative study to better understand the epilepsy care delivered by THs in zambia. methods: We conducted focus-group discussions with THs, in-depth semistructured interviews with a well-recognized TH at his place of work, and multiple informal interviews with healthcare providers in rural zambia. RESULTS: THs recognize the same symptoms that a neurologist elicits to characterize seizure onset (e.g., olfactory hallucinations, jacksonian march, automatisms). Although THs acknowledge a familial propensity for some seizures and endorse causes of symptomatic epilepsy, they believe witchcraft plays a central, provocative role in most seizures. Treatment is initiated after the first seizure and usually incorporates certain plant and animal products. patients who do not experience further seizures are considered cured. Those who do not respond to therapy may be referred to other healers. Signs of concomitant systemic illness are the most common reason for referral to a hospital. As a consequence of this work, our local epilepsy Care Team has developed a more collaborative relationship with THs in the region. CONCLUSIONS: THs obtain detailed event histories, are treatment focused, and may refer patients who have refractory seizures to therapy to other healers. Under some circumstances, they recognize a role for modern health care and refer patients to the hospital. Given their predominance as care providers for PWE, further understanding of their approach to care is important. Collaborative relationships between physicians and THs are needed if we hope to bridge the treatment gap in SSA.
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8/14. Landmark article Sept 17, 1938: sodium diphenyl hydantoinate in the treatment of convulsive disorders. By H. Houston Merritt and Tracy J. Putnam.

    In a previous study it has been shown that sodium diphenyl hydantoinate is effective in preventing electrically induced convulsive seizures in cats. The drug is relatively nontoxic and well tolerated by the usual laboratory animals. A clinical trial of sodium diphenyl hydantoinate was made in 200 patients with frequent convulsive seizures which had not been relieved by the previous modes of therapy. In 142 such patients who have received the treatment for periods varying from two to eleven months, grand mal attacks were relieved in 58 per cent and greatly decreased in frequency in an additional 27 per cent; petit mal attacks were relieved in 35 per cent and greatly decreased in frequency in an additional 49 per cent, and psychic equivalent attacks were relieved in 67 per cent and greatly decreased in frequency in 33 per cent. There were no fatalities. A toxic dermatitis occurred in ten patients (5 per cent), nonthrombocytopenic purpura in one patient and minor (in many instances, transient) toxic reactions, tremors, ataxia, dizziness and the like in approximately 15 per cent.
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9/14. More intense focal seizure types after callosal section: the role of inhibition.

    corpus callosum section reduces the incidence of generalized seizures associated with loss of consciousness. Minimal data are available, however, regarding the types of seizures that may be present following surgery. Five of 17 patients in our clinic who underwent partial or complete corpus callosum section developed more intense and sometimes newly patterned (but not necessarily more frequent) focal seizures postoperatively. These patients were not predictably different from the other 12 in terms of age at onset of seizures or at surgery, cause of seizures, extent of callosum sectioned, radiographically demonstrable structural lesions, or the types of preoperative seizures. All 5 patients, however, had bilateral independent frontal electroencephalographic foci. No patients without these electroencephalographic findings developed more intense focal seizures after surgery. The findings are consistent with the results of experimental animal studies and argue for a suppressive influence of the contralateral hemisphere on some types of seizures.
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10/14. seizures in thyrotoxicosis.

    Over a period of 2 years we have observed 3 thyrotoxic patients who presented with a convulsive encephalopathy. These patients had no history of seizures before and experienced no further seizures after subsidence of the thyroid dysfunction. During the convulsive period, electroencephalograms of 2 patients showed evidence of cerebral hyperexcitability, but in both cases it returned to normal once the thyroid disorder was corrected. We believe that thyrotoxic seizures are not rare. These seizures can be focal as well as generalized and can constitute the presenting symptoms of the disease. Absence of other laboratory abnormalities such as serum electrolytes, or osmolality changes, or hypoglycemia in all patients who reportedly suffered from thyrotoxic seizures, and the data obtained from animal studies, suggest that human thyrotoxic seizures result mainly from the direct effect of thyroid hormones over the cerebral tissue.
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