Seizures in the Emergency Department: clinical and diagnostic data from a series of 153 patients.

INTRODUCTION: Seizures are a frequent reason for admission to emergency departments and require early, precise diagnosis and treatment. The objective of this study was to describe the clinical and prognostic characteristics of a series of patients with seizures attended at our hospital's emergency department. METHODS: We performed a retrospective, observational study of all patients with seizures who were admitted to our hospital's emergency department and attended by the on-call neurology service between February and August 2017. RESULTS: We included 153 patients, representing 9.9% of all neurological emergency department admissions. The median age was 58 years, 52.3% of patients were women, and 51% had history of epilepsy. Onset was focal in 82.4% of cases, and the most frequent aetiology was cerebrovascular disease (24.2%). Twelve patients (7.8%) developed status epilepticus, which was associated with higher scores on the ADAN scale (P < .001) and with history of refractory epilepsy (P = .002). The in-hospital mortality rate was 3.7%, and in-hospital mortality was associated with older age (P = .049) and status epilepticus (P = .018). Eighty percent of patients with no history of epilepsy were diagnosed with epilepsy at the emergency department; all started treatment. The kappa coefficient for epilepsy diagnosis in the emergency department compared to diagnosis after one year of follow-up by the epilepsy unit was 0.45 (diagnosis was modified in 20% of patients). CONCLUSIONS: Seizures are a frequent neurological emergency with potential complications and considerable morbidity and mortality rates. In patients with no known history of epilepsy, the condition may be diagnosed in the emergency department, but follow-up at specialised epilepsy units is recommended.

Stereoelectroencephalography in the preoperative assessment of patients with refractory focal epilepsy: experience at an epilepsy centre.

OBJECTIVE: Stereoelectroencephalography (SEEG) is a technique for preoperative evaluation of patients with difficult-to-localise refractory focal epilepsy (DLRFE), enabling the study of deep cortical structures. The procedure, which is increasingly used in international epilepsy centres, has not been fully developed in Spain. We describe our experience with SEEG in the preoperative evaluation of DLRFE. MATERIAL AND METHODS: In the last 8 years, 71 patients with DLRFE were evaluated with SEEG in our epilepsy centre. We prospectively analysed our results in terms of localisation of the epileptogenic zone (EZ), surgical outcomes, and complications associated with the procedure. RESULTS: The median age of the sample was 30 years (range, 4-59 years); 27 patients (38%) were women. Forty-five patients (63.4%) showed no abnormalities on brain MR images. A total of 627 electrodes were implanted (median, 9 electrodes per patient; range, 1-17), and 50% of implantations were multilobar. The EZ was identified in 64 patients (90.1%), and was extratemporal or temporal plus in 66% of the cases. Follow-up was over one year in 55 of the 61 patients undergoing surgery: in the last year of follow-up, 58.2% were seizure-free (Engel Epilepsy Surgery Outcome Scale class I) and 76.4% had good outcomes (Engel I-II). Three patients (4.2%) presented brain haemorrhages. CONCLUSION: SEEG enables localisation of the EZ in patients in whom this was previously impossible, offering better surgical outcomes than other invasive techniques while having a relatively low rate of complications.

The importance of timing in epilepsia partialis continua.

INTRODUCTION: Timing is one of the most important modifiable prognostic factors in the management of status epilepticus. Epilepsia partialis continua (EPC) is a status epilepticus subtype of highly variable, occasionally prolonged, duration. The aim of this study was to analyse the relationship between EPC duration and outcomes. METHODS: We performed an observational prospective study of all patients with EPC admitted to our tertiary hospital between 1 September 2017 and 1 September 2018. RESULTS: The sample included 10 patients, of whom 9 were women; median age was 74 years. The most frequent aetiology was cerebrovascular disease (n = 6). EPC onset occurred outside the hospital in 5 patients, with a median time to hospital admission of 4 hours. The median time to treatment onset (TT) for all patients was 12.3 hours. The median time from treatment onset to EPC control (TC) was 30 hours; TC showed a strong positive correlation with TT (Spearman's rho = 0.88). Six patients presented hyperglycaemia at onset; this was positively correlated with TC (rho = 0.71). All 6 patients with hyperglycaemia presented a brain injury explaining the EPC episode. CONCLUSIONS: Delays were observed in different phases of EPC management, which was related to longer duration of the episode. Glycaemia was also related to episode duration, probably acting as a triggering factor rather than as the aetiology.

Status epilepticus without impairment of consciousness: Long-term outcomes according to duration.

OBJECTIVE: The point after which non-convulsive status epilepticus (NCSE) can cause permanent damage remains to be elucidated. The aim of this study was to analyze the association between time to resolution and long-term outcomes in NCSE. METHODS: We performed a retrospective study of all patients with focal NCSE without consciousness impairment at two tertiary care hospitals in Spain. All the data were registered prospectively and the study period was December 2014-May 2018. We collected information on demographics, SE etiology, time to administration of different lines of treatment, time to NCSE resolution, and outcomes at discharge, 1 year, and 4 years. Clinical outcome was prospectively categorized as good (return to baseline function) or poor (new disability and death). RESULTS: Seventy-four patients with a mean (±SD) age of 63.4 ±â€¯17.5 years and a mean follow-up time of 2.4 ±â€¯2.2 years were studied. A poor outcome at discharge was associated with a potentially fatal etiology (p < 0.001), EMSE score (Epidemiology-based Mortality Score in Status Epilepticus) (p = 0.012), lateral periodic discharges on EEG (p = 0.034), and occurrence of major complications during hospitalization (p = 0.007). An SE duration of >100 h was clearly associated with a worse outcome (p < 0.001). In the multiple regression analysis, the only independent predictors of a poor outcome at discharge were an SE duration of >+100 hours (p = 0.001), a potentially fatal etiology (p = 0.001), and complications during hospitalization (p = 0.010). An SE duration of >100 hours retained its value as the optimal cutoff point for predicting poor outcomes at both 1 year (p = 0.037) and 4 years (p = 0.05). Other predictors of poor long-term outcomes were a potentially fatal etiology (p < 0.001) and EMSE score (p = 0.034) at 1 year, and progressive symptomatic etiology at 4 years (p = 0.025). SIGNIFICANCE: In patients with focal NCSE without consciousness impairment, a potentially fatal etiology and an SE duration of >100 h were associated with poor short-term and long-term outcomes.

Identifying areas for improvement in epilepsy management in developing countries: An experience of neurocooperation in Cameroon. / Identificando puntos de mejoría en el manejo de la epilepsia en países en vías de desarrollo: experiencia de neurocooperación en Camerún.

INTRODUCTION: Epilepsy is especially prevalent in developing countries: incidence and prevalence rates are at least twice as high as in our setting. Epilepsy is also highly stigmatised, and few resources are available for its management. MATERIAL AND METHODS: We performed a descriptive observational study in December 2016, distributing a questionnaire on epilepsy management to healthcare professionals from 3 different hospitals in Cameroon. Data are presented as means or percentages. RESULTS: Thirty-eight healthcare providers participated in the survey; 42.1% were female and mean age was 40.1 years (range, 22-62). Regarding the causes of epilepsy, 68.4% considered it a psychiatric condition, 34.2% a degenerative disease, 28.9% a hereditary condition, and 21.1% secondary to infection. In terms of management, 23.7% considered that thorough clinical history is sufficient to establish a diagnosis. Only 60.5% considered the clinical interview to be important for diagnosis, 52.6% considered EEG to be necessary, and 28.9% considered laboratory analyses to be important. Only 13.2% mentioned neuroimaging. In the treatment of pregnant women, 36.8% recommended folic acid supplementation, 65.8% believed antiepileptic treatment should be maintained, and only 39.5% recommended breastfeeding. Concerning treatment, the participants knew a mean of 2 antiepileptic drugs: phenobarbital was the best known (81.6%), followed by carbamazepine (55.3%) and valproic acid (28.9%). CONCLUSIONS: There is a need among healthcare professionals for education and information on the disease, its diagnosis, and management options, in order to optimise management and consequently improve patients' quality of life.

Seizures in the Emergency Department: Clinical and diagnostic data from a series of 153 patients. / Crisis epilépticas en urgencias: aspectos clínicos y diagnósticos de una serie de 153 pacientes.

INTRODUCTION: Seizures are a frequent reason for admission to emergency departments and require early, precise diagnosis and treatment. The objective of this study was to describe the clinical and prognostic characteristics of a series of patients with seizures attended at our hospital's emergency department. METHODS: We performed a retrospective, observational study of all patients with seizures who were admitted to our hospital's emergency department and attended by the on-call neurology service between February and August 2017. RESULTS: We included 153 patients, representing 9.9% of all neurological emergency department admissions. The median age was 58 years, 52.3% of patients were women, and 51% had history of epilepsy. Onset was focal in 82.4% of cases, and the most frequent aetiology was cerebrovascular disease (24.2%). Twelve patients (7.8%) developed status epilepticus, which was associated with higher scores on the ADAN scale (P<.001) and with history of refractory epilepsy (P=.002). The in-hospital mortality rate was 3.7%, and in-hospital mortality was associated with older age (P=.049) and status epilepticus (P=.018). Eighty percent of patients with no history of epilepsy were diagnosed with epilepsy at the emergency department; all started treatment. The kappa coefficient for epilepsy diagnosis in the emergency department compared to diagnosis after one year of follow-up by the epilepsy unit was .45 (diagnosis was modified in 20% of patients). CONCLUSIONS: Seizures are a frequent neurological emergency with potential complications and considerable morbidity and mortality rates. In patients with no known history of epilepsy, the condition may be diagnosed in the emergency department, but follow-up at specialised epilepsy units is recommended.

Management of neurological care during the COVID-19 pandemic. / La gestión de la asistencia neurológica en tiempos de la pandemia de Covid-19.

INTRODUCTION: The COVID-19 epidemic has led to the need for unprecedented decisions to be made to maintain the provision of neurological care. This article addresses operational decision-making during the epidemic. DEVELOPMENT: We report the measures taken, including the preparation of a functional reorganisation plan, strategies for hospitalisation and emergency management, the use of telephone consultations to maintain neurological care, provision of care at a unit outside the hospital for priority patients, decisions about complementary testing and periodic in-hospital treatments, and the use of a specific telephone service to prioritise patients with epileptic seizures. CONCLUSION: Despite the situation of confinement, neurology departments must continue to provide patient care through different means of operation. Like all elements of management, these must be evaluated.

Stereoelectroencephalography in the preoperative assessment of patients with refractory focal epilepsy: Experience at an epilepsy centre. / Estereoelectroencefalografía en la evaluación prequirúrgica de epilepsias focales refractarias: experiencia de un centro de epilepsia.

OBJECTIVE: Stereoelectroencephalography (SEEG) is a technique for preoperative evaluation of patients with difficult-to-localise refractory focal epilepsy (DLRFE), enabling the study of deep cortical structures. The procedure, which is increasingly used in international epilepsy centres, has not been fully developed in Spain. We describe our experience with SEEG in the preoperative evaluation of DLRFE. MATERIAL AND METHODS: In the last 8 years, 71 patients with DLRFE were evaluated with SEEG in our epilepsy centre. We prospectively analysed our results in terms of localisation of the epileptogenic zone (EZ), surgical outcomes, and complications associated with the procedure. RESULTS: The median age of the sample was 30 years (range, 4-59 years); 27 patients (38%) were women. Forty-five patients (63.4%) showed no abnormalities on brain MR images. A total of 627 electrodes were implanted (median, 9 electrodes per patient; range, 1-17), and 50% of implantations were multilobar. The EZ was identified in 64 patients (90.1%), and was extratemporal or temporal plus in 66% of the cases. Follow-up was over one year in 55 of the 61 patients undergoing surgery: in the last year of follow-up, 58.2% were seizure-free (Engel Epilepsy Surgery Outcome Scale class I) and 76.4% had good outcomes (Engel I-II). Three patients (4.2%) presented brain haemorrhages. CONCLUSION: SEEG enables localisation of the EZ in patients in whom this was previously impossible, offering better surgical outcomes than other invasive techniques while having a relatively low rate of complications.

The importance of timing in epilepsia partialis continua. / La relevancia del tiempo en la epilepsia parcial continua.

INTRODUCTION: Timing is one of the most important modifiable prognostic factors in the management of status epilepticus. Epilepsia partialis continua (EPC) is a status epilepticus subtype of highly variable, occasionally prolonged, duration. The aim of this study was to analyze the relationship between EPC duration and outcomes. METHODS: We performed an observational prospective study of all patients with EPC admitted to our tertiary hospital between 1 September 2017 and 1 September 2018. RESULTS: The sample included 10 patients, of whom 9 were women; median age was 74 years. The most frequent aetiology was cerebrovascular disease (n=6). EPC onset occurred outside the hospital in 5 patients, with a median time to hospital admission of 4hours. The median time to treatment onset for all patients was 12.3hours. The median time from treatment onset to EPC control was 30hours; time from treatment onset to EPC control showed a strong positive correlation with TT (Spearman's rho=0.88). Six patients presented hyperglycaemia at onset; this was positively correlated with time from treatment onset to EPC control (rho=0.71). All 6 patients with hyperglycaemia presented a brain injury explaining the EPC episode. CONCLUSIONS: Delays were observed in different phases of EPC management, which was related to longer duration of the episode. Glycaemia was also related to episode duration, probably acting as a triggering factor rather than as the aetiology.

Specificity of electroclinical features in the diagnosis of ring chromosome 20.

BACKGROUND: Ring chromosome 20 (R20) syndrome is a chromosomal disorder characterized mainly by drug-resistant frontal lobe seizures, recurrent nonconvulsive status epilepticus (NCSE), and typical EEG features. The aim of this study was to investigate if this triad is common and specific to all patients with R20. METHODS: In this cross-sectional study (from 2000 to 2011), we selected patients who fulfilled at least two out of three criteria: drug-resistant frontal lobe seizures, recurrent NCSE, and characteristic electroencephalography (EEG) features. In all patients, diagnosis was based on karyotype analysis of at least 100 metaphases. RESULTS: We identified 36 patients who met at least two of the selected criteria: six patients (16.7%) with R20 and 30 (83.3%) without R20 (non-R20). All patients with R20 met all three criteria. Eleven (36.7%) patients without R20, however, also displayed the full triad. In 19 patients without R20 (63.3%), one of the three clinical features was missing: frontal lobe seizures were not resistant to antiepileptic drugs (AED) in four (13.3%), recurrent NCSE was missing in six (20%), and nine (30%) patients did not have typical EEG features. Based on this data, specificity was 63.3%, positive predictive value was 35.3%, and sensitivity and negative predictive values were 100%. Additionally, a review of all publications describing the R20 phenotype revealed that 81.98% of patients with R20 display the full electroclinical triad. CONCLUSIONS: In our study, all patients with R20 displayed the three electroclinical characteristics. This is in line with previous reports (presenting high sensitivity and negative predictive value). However, these features can also be observed in other epilepsies and are not specific to R20. Our findings suggest that in the presence of the full triad of symptoms, karyotype analysis focused on chromosome 20 should be conducted.

Global vision system in laparoscopy. / Sistema de visión global en laparoscopia.

OBJECTIVE: The main difficulty in laparoscopic or robot-assisted surgery is the narrow visual field, restricted by the endoscope's access port. This restriction is coupled with the difficulty of handling the instruments, which is due not only to the access port but also to the loss of depth of field and perspective due to the lack of natural lighting. In this article, we describe a global vision system and report on our initial experience in a porcine model. MATERIAL AND METHODS: The global vision system consists of a series of intraabdominal devices, which increase the visual field and help recover perspective through the simulation of natural shadows. These devices are a series of high-definition cameras and LED lights, which are inserted and fixed to the wall using magnets. The system's efficacy was assessed in a varicocelectomy and nephrectomy. RESULTS: The various intraabdominal cameras offer a greater number of intuitive points of view of the surgical field compared with the conventional telescope and appear to provide a similar view as that in open surgery. Areas previously inaccessible to the standard telescope can now be reached. The additional light sources create shadows that increase the perspective of the surgical field. CONCLUSION: This system appears to increase the possibilities for laparoscopic or robot-assisted surgery because it offers an instant view of almost the entire abdomen, enabling more complex procedures, which currently require an open pathway.

Validity of the clinical and content scales of the Multiphasic Personality Inventory Minnesota 2 for the diagnosis of psychogenic non-epileptic seizures.

INTRODUCTION: The use of the Multiphasic Personality Inventory Minnesota 2 (MMPI-2) for the diagnosis of psychogenic non-epileptic seizures (PNES) is controversial. This study examines the validity of the clinical scales and, unlike previous works, the content scales. METHODS: Cross-sectional study of 209 patients treated in the epilepsy unit. We performed a logistic regression analysis, taking video-electroencephalography as the reference test, and as predictor variables age, sex, IQ and clinical (model A) or content scales (model B) of the MMPI-2. The models were selected according to the Aikake index and compared using the DeLong test. RESULTS: We analyzed 37 patients with PNES alone, or combined with seizures, and 172 patients with seizures only. The model consisting of sex, Hs (hypochondriasis) and Pa (paranoia) showed a sensitivity of 77.1%, a specificity of 76.8%, a percentage of correct classification of 76.8%, and an area under the curve (AUC) of 0.836 for diagnosing CNEP. Model B, consisting of sex, HEA (health concerns) and FRS (fears), showed a sensitivity of 65.7%, a specificity of 78.0%, a percentage of correct classification of 75.9% and an AUC of 0.840. DeLong's test did not detect significant differences. CONCLUSIONS: The MMPI-2 has a moderate validity for the diagnosis of PNES in patients referred to an epilepsy unit. Using content scales does not significantly improve results from the clinical scales.

A minimally invasive surgery robotic assistant for HALS-SILS techniques.

This paper is focused in the design and implementation of a robotic surgical motion controller. The proposed control scheme addresses the issues related to the application of a robot assistant in novel surgical scenario, which combines hand assisted laparoscopic surgery (HALS) with the single incision laparoscopic surgery (SILS) techniques. It is designed for collaborating with the surgeon in a natural way, by performing autonomous movements, in order to assist the surgeon during a surgical maneuver. In this way, it is implemented a hierarchical architecture which includes an upper auto-guide velocity planner connected to a low-level force feedback controller. The first one, based on a behavior approach, computes a collision free trajectory of the surgical instrument tip, held by the robot, for reaching a goal location inside of the abdominal cavity. On the other hand, the force feedback controller uses this trajectory for performing the instrument displacement by taking into account the holonomic movement constraints introduced by the fulcrum point. The aim of this controller is positioning the surgical instrument by minimizing the forces exerted over the abdominal wall due to the fulcrum location uncertainty. The overall system has been integrated in the control architecture of the surgical assistant CISOBOT, designed and developed at the University of Malaga. The whole architecture performance has been tested by means of in vitro trials.

Validation of a short useful questionnaire in Spanish for the epidemiological screening of epilepsy in Spain. EPIBERIA Questionnaire.

INTRODUCTION: There is a major gap in knowledge about the epidemiology of epilepsy in Mediterranean countries. The EPIBERIA group was formed with the aim of promoting the conducting of epidemiological studies in this region in order to improve this situation. This paper deals with the validation of a brief questionnaire for screening patients with epilepsy in the general population. METHODS: We selected an English-language questionnaire previously validated by the Ottman group. It was translated, modified to suit the characteristics of the Spanish population, and administered to a sample of 200 patients (93 epileptics and 107 non-epileptic patient controls) sampled consecutively from 5 epilepsy units in different cities in Spain. Both groups were homogeneous in demographic variables and the control group was representative of the general population. RESULTS: We obtained a sensitivity of 100% and a specificity of 74.77% for the least rigorous correction model for the questionnaire, with a sensitivity of 94.62% and a specificity of 99.07% for the most stringent correction model. The PPV ranged from 7.48% for the first case to 69.49% in the second, assuming an epilepsy prevalence of 2%. CONCLUSIONS: The questionnaire EPIBERIA is a valid Spanish tool for epilepsy screening in the general population in Spain.

[Photodynamic therapy for acne: use of the pulsed dye laser and methylaminolevulinate]. / Estudio del empleo de láser de colorante pulsado y metilaminolevulinato en la terapia fotodinámica del acné.

Recent decades have seen the inclusion of acne vulgaris as a potential new indication for photodynamic therapy. Photodynamic therapy and light sources can be considered to be additional tools for primary or adjunctive therapy in patients with recurrent acne or those in whom it is not possible to use other treatments. We investigated the use of pulsed dye laser plus methylaminolevulinate for photodynamic therapy and have performed a comparative study of the use of this laser alone and as an element in photodynamic therapy.

[Experimental models in epilepsy]. / Modelos experimentales en epilepsia.

INTRODUCTION: epilepsy is one of the neurological pathologies with the highest rate of incidence and with a significant number of negatives consequences. Current pharmacological treatments have an antiepileptic effect, allowing control over 70% of the patients, but they are not able to prevent the development of epileptogenesis from occurring. METHOD: ee have reviewed the most relevant publications of experimental animal models with epilepsy by using the PubMed data base. RESULTS: we found a large number of publications related to different kinds of experimental models, both genetic (transgenic, genetically determined) and lesional which appeared to resemble the different types of human epilepsy. CONCLUSIONS: even though many important improvements have been accomplished in the area of epilepsy in the last decades, there are still many aspects to be clarified. In this regard, experimental models might become a very useful means for a better understanding of pathophysiological mechanisms and in the search for more efficient treatments.

Biomagnetic profiles of verbal memory success in patients with mesial temporal lobe epilepsy.

The risk of cognitive decline after mesial temporal lobe (MTL) resection in the dominant hemisphere for treatment of epilepsy has been assessed with the intracarotid amytal procedure and functional neuroimaging. In this study we used magnetoencephalography (MEG) to analyze memory profiles in patients with left hippocampal sclerosis (HS). Biomagnetic brain activity related to successful memory was compared in nine patients with left HS and nine age-matched controls. Patients manifested a higher number of activity sources over the right inferior parietal lobe in the late portion of the time window, and higher activity in the right than in the left MTL between 400 and 800 ms. This was reinforced by a -0.46 MTL laterality index, which indicates right MTL dominance. Controls showed a higher number of dipoles in the left anterior ventral prefrontal region, between 400 and 600 ms, and in the left MTL across the whole time window. Three patients who underwent a left temporal lobectomy, were seizure free, and who did not exhibit memory impairment after left temporal lobectomy, showed no activity in the left MTL presurgically. These results could support the ability of MEG to describe the time-modulated brain activity related to memory success in patients with epilepsy with left HS.

Pulsed dye laser vs. photodynamic therapy in the treatment of refractory nail psoriasis: a comparative pilot study.

BACKGROUND: Nail psoriasis is often refractory to traditional treatments, and patients with nail psoriasis usually demand a therapeutic option. Both photodynamic therapy (PDT) and pulse dye laser (PDL) have proved effective for plaque-type psoriasis, but they have not been evaluated in nail psoriasis. On the other hand, delta-aminolaevulinic acic has been shown to penetrate into the nail matrix and nail bed occluded with bioadhesive patches. OBJECTIVES: To compare the efficacy of PDT and PDL in the treatment of nail psoriasis. METHODS: We studied 61 nails treated with PDT and 60 nails treated with PDL in a group of 14 patients. The PDT used PDL as the light source. Sessions were applied monthly treating one hand with PDT and the other with PDL. The hand treated with PDT was occluded with methyl-aminolaevulinic acic (MAL, Metvix) for 3 h using a bioadhesive patch. The nails treated were evaluated at baseline, and after 3 and 6 months according to the Nail Psoriasis Severity Index (NAPSI) score. RESULTS: A decrease in NAPSI score was observed with both treatments and in both nail matrix and nail bed involvement. No statistical differences were found between PDT and PDL (P = 0.632, P = 0.084, P = 0.535, at baseline, and 3 and 6 months, respectively), and between nail matrix and nail bed NAPSI scores (P = 0.423 and P = 0.853, respectively). The subjective impression of the patients was good, especially regarding the decrease in the pain. CONCLUSIONS: PDL seems to be effective in the treatment of nail psoriasis and improves nail matrix and nail bed involvement. MAL does not seem to play role in the clinical response.