Epileptic disorders : international epilepsy journal with videotape
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The cognitive outcome of the surgical removal of an epileptic focus depends on the assessment of the localisation and functional capacity of language and memory areas which need to be spared by the neurosurgeon. Traditionally, presurgical evaluation of epileptic patients has been achieved by means of the intracarotid amobarbital test assisted by neuropsychological measures. However, the advent of neuroimaging techniques has provided new ways of assessing these functions by means of non-invasive or minimally invasive methods, such as anatomical and functional magnetic resonance imaging, positron emission tomography, single-photon emission computed tomography, transcranial magnetic stimulation, functional transcranial Doppler monitoring, magnetoencephalography and near infrared spectroscopy. This paper aims at comparing and evaluating the traditional and recent preoperative approaches from a neuropsychological perspective.
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Case Reports
Unrecognized paroxysmal ventricular standstill masquerading as epilepsy: a Stokes-Adams attack.
Recognition of cardiac syncope masquerading as epilepsy may be difficult in the Emergency Department. We report a middle-aged man with recent onset convulsions who posed a diagnostic puzzle before it was found that he had paroxysmal ventricular standstill with complete atrioventricular block: he made a complete recovery after temporary pacemaker insertion. The main lessons from this case were (1) a convulsive seizure of only seconds duration and with an abrupt return of consciousness suggests syncope not epilepsy, (2) repeated, convulsive syncopes without provocation suggest cardiac syncope, (3) a 12-lead ECG should be recorded as soon as possible after such a series of episodes and should not be discontinued until an event is captured, and (4) Emergency Department clinicians should be familiar with any automatic gain on their ECG machine, lest fast, atrial activity be mistaken for narrow complex tachycardia. In summary, a good clinical history is of prime importance in differentiating convulsive syncope from epilepsy, and a simple, non-invasive cardiovascular evaluation may help to diagnose the condition as cardiac syncope.
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Multiple structural and functional imaging modalities are available to localize the epileptogenic focus. In pre-surgical evaluation of children with pharmacoresistant epilepsy, investigations with the maximum yield should be considered in order to reduce the complexity of the workup. ⋯ In paediatric epilepsy pre-surgical evaluation, the combined use of multiple functional imaging modalities for a precise localisation of the epileptogenic focus is worthwhile for both extratemporal and temporal lobe epilepsy, also when EEG and MRI alone are non-contributive, given the potential benefit of complete postoperative seizure control.
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Malformations of cortical development are frequent causes of human refractory epilepsy. The freeze-lesion model in rats shows histopathological features similar to those found in human polymicrogyria. Previous studies reported in vitro hyperexcitability in this model, but in vivo epileptogenicity has not been confirmed. ⋯ Neocortical freeze lesions induced in newborn rat pups show histological characteristics reminiscent of human cortical dysplasia. Brain slices containing neocortical freeze lesions display hyperexcitability in vitro, but the same lesion does not appear to show spontaneous epileptogenicity in vivo.
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The clinical features of seizures occurring in the pediatric intensive care unit (PICU) setting are not well characterized. Adult ICU studies reveal an incidence of seizures ranging from 0.8% to 3.3%, with vascular, metabolic abnormalities, and drug withdrawal being the most common etiologies. The objective of this study is to investigate the clinical characteristics of seizures in children admitted to the PICU at our institution. ⋯ Seizures in PICU have different clinical characteristics from those in adults. Recognizing the common seizure etiologies in PICU is likely to lead to a more prompt and effective treatment. Antiepileptic drug prophylaxis may be useful in post-craniotomy patients. A neurological consultation and EEG evaluation are of the utmost importance to help rule in or out epileptic disorders in the PICU.