Etiology of a short-term mortality in the group of 750 patients with 920 episodes of status epilepticus within a period of 10 years (1988-1997).

PURPOSE: To determine the etiology of short-term mortality in patients with status epilepticus (SE). METHODS: 920 episodes of SE were recorded among 750 patients in a 10-year period. According to the clinical assessment, sequence of events that led to death in a particular case showed two major causes of death: (1) underlying disease, and (2) complications caused by convulsions, therapy or coma. RESULTS: Among 920 episodes of SE, 120 (13%) patients passed away. 79 patients (65.8%) died due to the underlying disease and 27 patients (22.5%) died of the combination caused by complications of underlying disease, convulsions, therapy, and/or coma. Among remaining 14 patients (11.7%), underlying disease was not the cause of death. Those 14 patients suffered complications caused by convulsions, therapy, and coma which caused death in four; therapy and coma in three; therapy in three; coma in two; and convulsions and coma in two patients, in the order already mentioned. CONCLUSIONS: Among approximately 9 out of 10 patients with SE, death was the result of underlying disease. Although with very few patients, additional factors could provoke fatal complications of SE. In case of 1 among 10 patients complications caused by coma, therapy, and/or convulsions were the immediate cause of death. In case of such patients timely and adequate treatment could prevent death.

[Efficacy of therapy, recurrence of seizures and respiratory complications in the treatment of status epilepticus by intravenous administration of diazepam or midazolam]. / Efikasnost terapije, recidivi napada i respiracione komplikacije u lecenju epileptickog statusa intravenskom primenom diazepama ili midazolama.

During a nine-month period we have treated 46 patients with status epilepticus with intravenous application of diazepam or midazolam. The initial doze od diazepam was 10 mg (rate: 2-5 mg/min) and of midazolam 15 mg (rate: 5 mg/min). Diazepam was effective in 26 and ineffective in 15 patients. Midazolam stopped status in 4 out of 7 patients. Both drugs were more effective when they were administered at the beginning of status. After the initial termination of status and recovering of consciousness, seizures returned in 10 patients (22%). In the group treated with diazepam, 4 patients had sudden apnea and 6 respiratory depression (totally 10 out of 41). In the group treated with midazolam, 3 had apnea and 2 respiratory depression (totally 5 out of 7). All patients with apnea or respiratory depression received higher doses of both drugs at the higher rates than the others. We conclude that the efficacy of the therapy is moderate while the frequency of serious complications is high. In status epilepticus, where the life of patient is in danger, drugs with such activity are of limited value.

[Intravenous loading doses of sodium phenobarbitone in the treatment of status epilepticus]. / Fenobarbiton-natrium u intravenskoj dozi opterecenja u lecenju epileptickog statusa.

Over a period of nine months 14 adult patients with status epilecticus were treated with intravenous loading dose of phenobarbital-sodium. The initial dose was 9 to 12 mg/kg of body weight; it was increased to 36 mg/kg when seizures were stopped. The rate of infusion was 100 mg/min. In 11 of 14 patients (79%) this treatment was effective. The dose ranged from 9 to 14 mg/kg in ten patients and 36 mg/kg in the remaining one. Seizures stopped during the first minute of infusion in nine patients. This treatment was unsuccessful in 3 patients. The rate of infusion was faster in the group where the therapy was successful. In this group higher plasma levels of phenobarbital were obtained with smaller loading doses than in the other patients. Side-effects were mild and transient; they comprised prolonged postical depression of consciousness. No respiratory or cardio-vascular side-effect were observed. There was no potentiation of side-effect with subsequent application of intravenous diazepam. We conclude that intravenous phenobarbital-sodium is highly effective and safe in the treatment of status epilecticus.

[Treatment of status epilepticus with intravenous lidocaine (Xylocaine)]. / Lecenje epilepticnog statusa intravenskim likokainom (Xylocain).

A case history of a 19-year old epileptic woman with diffuse encephalopathy of unknown aetiology and frequent attacks of status, epilepticus, whose last episode of the status epilepticus was successfully treated with intravenous lidocaine, after several first-line antiepileptic drugs failed to control, it, is presented. Although highly effective in treating refractory status epilepticus this treatment received little attention in clinical practice. We observed no un desired side effects of such treatment. The authors shortly reviewed current knowledge about several widely used treatment protocols. Some specific pharmacokinetic and pharmacodynamic properties of lidocaine during convulsions were also mentioned. A warning was drawn to toxic fide effects of lidocaine which were precipitated by increasing brain-blood pH gradient during convulsions, which in high doses included seizures caused by lidocaine per se. The effects of high dose lidocaine on the latencies and the amplitudes of the BAER and possible ways for mechanism of drug action were also reviewed.

[Dr. John Hughlings Jackson]. / Dr Dzon Hjulings Dzekson.

The great English neurologist, Dr. John Hughlings Jackson was born in Providence Green, Yorkshire, north England, in 1835. He spent his apprenticeship in the city of York, continued his medical education at St. Bartholomew's hospital in London, and qualified in medicine in 1856. After working in the city of York, he studied in London and in 1860 graduated at St. Andrews university in Scotland. He died in London in 1911, famous and celebrated by his colleagues as the "father of British neurology". Jackson was a prolific writer, witty and ingenious person, but also solitary and absent minded, with a lat of "tiny peculiarities of a genius". At first he was committed to become a philosopher but was persuaded by Jonathan Hutchinson, one of his rare friends, to enter medicine. His "Selected Writings" were first published in 1931 and reprinted recently, in 1996, by Arts & Boeve. Jackson, unlike William Richard Gowers, wrote his articles in a style which was not palatable to his contemporary colleagues. This could be the reason that his medical work was not widely known and would have remained in shadow had it not been rediscovered mostly by German neurologists, who preceded their English colleagues and collected the fame. Jackson gave the first classification of epileptic seizures acceptable, to a degree, even today. It was twofold: the first, taxonomic, which corresponds to contemporary classification of seizures, he compared to the attitude of a gardener who classifies flowers according to their beauty, height or color, and was aware of its purely phenotypic, descriptive and utilitarian character; the second was scientific, physiologic and it would correspond nowadays to the current concept of syndromic classification. Jackson was aware that this 'scientific classification' was to await for the future time, when the knowledge of the real nature of epilepsy became fundamentally broadened. On the other hand, he thought that all the epilepsies were partial becoming generalized only secondarily. Partial epilepsies were the starting point in his work. He realized that epileptic attacks are not different types of epilepsies with different pathophysiological mechanisms, but that they differ in respect to the focus of origin; he stressed their gray matter (cortical) arigin with the cause located as the rule "on the side of the brain, opposite to the body convulsed". Jackson's ideas on epileptogenesis and the localization of epileptogenic processes represent his fundamental contribution to the understanding of their pathophysiology. His most philosophical contribution to neurology was the concept of the evolution and dissolution of the nervous system, which was the consequence of his ideas on its organization. Symptoms observed after the lesion of a certain part of the brain are not the consequence of its function; they are the result of the function of the remaining non-lesioned regions which are in a certain way freed from the adjacent or a higher control. This concept of interpretation af the symptoms of the nervous diseases remains applicable even today. Jackson was the first to stress the importance of ophthalmoscopy in neurology in all cases of neurologic disease, especially in cases of optic neuritis (papilloedema) which may be present even if the patient did not notice the minimized visual acuity. The way of thinking that Jackson introduced in medicine and neurology may be his most precious legacy to the generations that followed.

[The intrathecal manometric lumbar infusion test (Katzman Test) in the diagnosis of normotensive hydrocephalus]. / Intratekalni manometrijski lumbalni infuzioni test (Kacmonov Test) u dijagnostici normotenzivnog hidrocefalusa.

Over 12-months 17 patients were admitted to the hospital for the presumed diagnosis of normal pressure hydrocephalus (NPH). Four patients had cardinal signs of the syndrome: gait disturbance, dementia and urinary incontinence. Six patients had gait disturbance and dementia. Five patients had gait disturbance and ventricular enlargement on CT scans of the brain, while the last two patients had only urinary incontinence and dementia. All patients underwent neurological examination and CT scans. Clinical and radiological results of these patients were compared with the results of the Katzman's test. Katzman's test was performed in all patients. Physiologic solution of 0.9% NaCl was infused in the lumbal subarachnoid space. The rate of infusion was 1 ml/min during 60 minutes. Cerebrospinal fluid (CSF) pressure was recorded simultaneously using metal aneroid. The test was considered positive if either CSF pressure over 300 mm H2 or undulating waves were recorded at any time of the test. Katzman's test was positive in 12 patients (9 of them with NPH). The undulating waves were recorded in 6 patients (5 with NPH). Four of them experienced tachycardia, hyperventilation, cephalea and mild confusion during the test. The test was positive in all 9 patients with NPH but also in 3 patients with different but pathophysiologically similar disorders. The test was positive in all 4 patients with the characteristic clinical triad of the syndrome and also in all 4 patients with periventricular hypodensity on their CT scans. No patient without gait disturbance had positive test. All except one patient with focal signs or pronounced cortical atrophy, besides with dramatic clinical improvement.(ABSTRACT TRUNCATED AT 250 WORDS)

[Epilepsy, eponyms and patron saints (history of Western civilization)]. / Epilepsija, eponimi i pokrovitelji (istorijat zapadnih civilizacija).

From a historic point of view, epilepsy and its eponyms were in an ontogenetic symbiosis throughout their history. Epilepsy is a disease with a history of eponyms presenting the frame of mind of both streetwise as well as skilled "authors" about its origin and nature. From ancient times the names for epilepsy, archetypal Hippocratic disease, just as rich in number as varied in their implication, reflected the local folkways of thinking. In this article we briefly presented more than 50 eponyms and patrons of epilepsy. As the source of information we used both the apocryphal, canonical and hagiographic as well as heretic literature, legends and iconography from the Middle Ages of domestic and foreign origin. Pre- and post-Hippocratic era, apart from stemming from the oldest written medical sources, point to the position that the disease had organic origin located in the brain. The period of Rome adopted the attitudes set by Galen which remained en vogue throughout the emerging Middle Ages and Renaissance. These eras generated new eponyms which reflected a downfall in the manor, stating that the disease is the consequence of supernatural forces. In the "Age of darkness" eponyms for epilepsy reflected more the relation of men to the Nature than to the disease or a sick man; this is evidenced through the generation of number of patrons for the disease. The most famous patron of patients with epilepsy was St. Valentine (after conversion from pagandom he died in Rome as a martyr, c. 270). He was allotted a patronage either due to the phonic resemblance of his name with the (past participle of the) verb "fallen"-as Martin Luther claimed, or due to a cure of epilepsy of the son of a Roman rhetor who built for him a chapel in which he continued to cure the sick. The emergence of a flamboyant personality of Paracelsus on the historic scene of the XVI century represents a less successful attempt to revoke the way of thinking set by the old Greek doctors; however, it brought about the precipitous decay of attitudes that started with Romans and inaugurated the way of thinking characteristic of Renaissance and the ages thereafter. Serbian literature of the Middle Age was strongly impacted by influences that fanned from Italy (Salerno) and south France (Montpellier), reflecting the attitudes of medical schools and universities prevailing at that time Europe. The name [symbol: see text] from Hilandar Medical Codex No 517 (XV-XVI century) is obviously taken from Byzantine medicine, which was founded on the works of Hippocrates, Galen and Dioscurides. It came down to us through the Serbian folk Byzantine codices named "latrosophia of Hilandar", preserved mostly from the author Michail Pselos (XI century). On the other hand, the name [symbol: see text] or morbus magnus, reflects its Roman origin. The name [symbol: see text] meaning fainting, loss of consciousness or syncope, stems from the same source. The name [symbol: see text] designated epileptic disease in Serbian monks, monasteries probably being the only niche where epileptics could find refuge. Children's epilepsy or convulsions are expressed as [symbol: see text] No mention is found of epileptic status except for the notion [symbol: see text] meaning "to be without consciousness for a longer period of time'; it does not, however, refer directly to epilepsy or convulsions. It is worthy noting that already in the XIV century Serbs had their medical literature translated to their own language, and were the only one of all Slavic peoples that did so. Nevertheless, both apocryphal and canonical, as well as consecrated medicine were based on magic, astrology and occultism. The magic formulas used in Middle Age Serbia for the cure of epileptics as well as sick in general, were basically irrational; still, as a trace of its descension they contained unintelligible words of the eastern origin (Greek, Persian or Jewish). (ABSTRACT TRUNCATED)

[Eponyms and epilepsy (history of Eastern civilizations)]. / Eponimi i epilepsija (istorijat istocnih civilizacija).

The history of eponyms for epilepsy in the lands of the Eastern globe present the portrait of the attitudes of both the laymen and skilled people towards the disease and patient, as well as to the Nature itself. As opposed to the West which during the Middle ages changed its concepts of epilepsy as the organic brain disease for the sublime 'alchemic' position, the people of the East were more prone to consider from the beginning of their civilization till the XIX century that epilepsy is the consequence of the evanescent spiritual and extracorporal forces which by themselves were out of their reach. As compared to the western civilization, the historical resources are, often as a consequence of a linguistic barriers, more scarce-as consequently is the number of eponyms, but are nevertheless picturesque. The medical science from Babylonian period presumed that epileptic manifestations are the consequence of the demonic or ill spiritual actions. There existed an attitude that at the beginning of an epileptic attack the patient was possessed by a demon (the Akkadic, i.e., Babylonian verb "sibtu" denoting epilepsy, had the meaning "to seize" or "to be obsessed"); at the end of the clonic phase the demon departed from the body. Different demons were responsible for different forms of epilepsy such as nocturnal and children epilepsy, absence epilepsy and pure convulsions, simple and complex automatisms, and gelastic epilepsy. Thus, the doctors from the period of Babylon aside from making primordial classification of epilepsies, knew about their clinical picture (prodromal symptoms and aura, Jackson's epilepsy. Todd's paralysis), postictal phenomena and intericatl emotional instability; provocative factors were also known (sleep deprivation, emotions, as well as alcohol, albeit in a negative sense-as a cure for epilepsy). There is no doubt than in the period of Babylon the clinical picture of serial fits and its progress to status epilepticus were clearly recognized and considered as life threatening events. Persian history of epilepsy, except from the 6th century Zoroastrian "Avesta" document, lacks the written or spoken medical heritage untill the 7th century A.D. and the Arabic conquest of the entire Moslem world. On the other hand, Islamic medicine should be freed from the simple prejudice that the Moslem authors were only the translators of Greek medicine; contrary to such a view, their work contains a high degree of individuality. Although Mohammed introduced a lot of novelty into medicine, Khoran and the Sayings do not explicitly refer to epilepsy. Of importance is to notice that Moslem medicine did not have demons in the "repertoire" of direct causes of epilepsy. The causes and the cures of epilepsy were more magic-mystical and occult in nature, which is reminiscent of the European, as well as Serbian Middle age attitudes. Avicenna recognized difference between children and adult epilepsy. He considered insomnia and afternoon siesta as well as intensive sounds and light to be a provocative factors, whereby we see that at least empirically he knew of sleep (deprivation), startle and reflex epilepsy. The XIII century invasion of Mongols brought about the recession in Moslem Medicine; it recovered only in the XVIII century under the strong influence of European medicine handed over to us through Jewish doctors of various nationalities. The story of the China history of epilepsy has its debut approximately in the 8th century B. C. Medical texts from this period name epilepsy "Dian" and "Xian" which meant "the falling sickness" and "convulsions", respectively. Chinese medical terminology often interchangeably used the words "mania", "madness" and "psychosis" for "epilepsy" which, aside from a prominent language barrier, brings additional confusion. Although Chinese documents gave the first description of the grand mal epileptic attack already in the 8th century B. C. (ABSTRACT TRUNCATED)

Seizures in multiple sclerosis.

PURPOSE: In patients with multiple sclerosis (MS), epileptic seizures occur more frequently than in the general population. The aim of this study was to analyze clinical characteristics of epilepsy in patients with MS, potential correlation between the semiology of seizures, EEG and magnetic resonance imaging (MRI) findings in these patients, as well as to examine the response to anticonvulsant therapy. METHODS: In a series of 268 consecutive patients with definite MS hospitalized at the Institute of Neurology, Belgrade, we identified 20 (7.5%) patients with seizures or epilepsy. All patients with seizures or epilepsy were submitted to standard EEG and brain MRI with gadopentetate dimeglumine. RESULTS: In four patients, epilepsy occurred 1-5 years before other clinical manifestations of MS. Eight patients had seizures only during MS relapses (provoked seizures). In two of them, seizures were the only manifestations of relapse. In 12 patients, seizures occurred regardless of the phase of MS (chronic epilepsy). In the majority of patients, seizures were partial with secondary generalization. Five patients experienced episodes of status epilepticus, and they all had dementia. Abnormal EEG pattern was found in 11 patients. Brain MRI disclosed cortical-subcortical lesions in nine patients and focal cortical atrophy in one, whereas in the remaining patients, findings were inconclusive. Probable EEG-MRI-seizure type correlation existed in 10 patients. CONCLUSIONS: Our data suggest that epilepsy may represent an initial symptom of MS and a single clinical manifestation of a relapse, and further support the assumption of the existing correlation between the presence of cortical-subcortical lesions and epileptic seizures or epilepsy in patients with MS.