Low-frequency stimulation of a fiber tract in bilateral temporal lobe epilepsy.

OBJECTIVE: Pharmacoresistant bilateral mesial temporal lobe epilepsy often implies poor resective surgical candidacy. Low-frequency stimulation of a fiber tract connected to bilateral hippocampi, the fornicodorsocommissural tract, has been shown to be safe and efficacious in reducing seizures in a previous short-term study. Here, we report a single-blinded, within-subject control, long-term deep-brain stimulation trial of low-frequency stimulation of the fornicodorsocommissural tract in bilateral mesial temporal lobe epilepsy. Outcomes of interest included safety with respect to verbal memory scores and reduction of seizure frequency. METHODS: Our enrollment goal was 16 adult subjects to be randomized to 2-Hz or 5-Hz low-frequency stimulation of the fornicodorsocommissural tract starting at 2 mA. The study design consisted of four two-month blocks of stimulation with a 50%-duty cycle, alternating with two-month blocks of no stimulation. RESULTS: We terminated the study after enrollment of five subjects due to slow accrual. Fornicodorsocommissural tract stimulation elicited bilateral hippocampal evoked responses in all subjects. Three subjects underwent implantation of pulse generators and long-term low-frequency stimulation with mean monthly seizures of 3.14 ±â€¯2.67 (median 3.0 [IQR 1-4.0]) during stimulation-off blocks, compared with 0.96 ±â€¯1.23 (median 1.0 [IQR 0-1.0]) during stimulation-on blocks (p = 0.0005) during the blinded phase. Generalized Estimating Equations showed that low-frequency stimulation reduced monthly seizure-frequency by 0.71 per mA (p < 0.001). Verbal memory scores were stable with no psychiatric complications or other adverse events. SIGNIFICANCE: The results demonstrate feasibility of stimulating both hippocampi using a single deep-brain stimulation electrode in the fornicodorsocommissural tract, efficacy of low-frequency stimulation in reducing seizures, and safety as regards verbal memory.

Rapid response EEG with needle electrodes in an intensive care unit with limited resources.

Objective: Continuous EEG (cEEG) is the gold standard for detecting seizures and rhythmic and periodic patterns (RPPs) in critically ill patients but is often not available in health systems with limited resources. The current study aims to determine the feasibility and utility of low-cost, practical, limited montage, sub-dermal needle electrode EEG in a setting where otherwise no EEG would be available. Methods: The study included all adult patients admitted to the intensive care unit of a single center over a 24-month period. Members of the existing ICU care team, mostly nurses, were trained to place 8 sub-dermal needle EEG electrodes to achieve rapid, limited montage-EEG recording. Clinical outcomes were recorded, including any reported major complications; and the EEG findings documented, including background characterization, RPPs, and seizures. Results: One hundred twenty-three patients, mean age 68 years, underwent an average of 15.6 min of EEG recording. There were no complications of electrode placement. Overall, 13.0% had seizures (8.1% qualifying as status epilepticus [SE]), 18.7 % had generalized periodic discharges (GPDs), 4.9% had lateralized periodic discharges (LPDs), and 11.4 % sporadic epileptiform discharges (sEDs). Greater mortality was observed in patients with worse background EEGs, seizures, LPDs, or sEDs. Conclusions: Rapid, limited montage EEG could be achieved safely and inexpensively in a broad population of critically ill patients following minimal training of existing care teams. Significance: For resource poor centers or centers outside of major metropolitan areas who otherwise have no access to EEG, this may prove a useful method for screening for non-convulsive seizures and status epilepticus.

Ophthalmoplegia in a Her2+ and ß-hCG+ Patient With Leptomeningeal Carcinomatosis Secondary to Gastric Adenocarcinoma.

Leptomeningeal carcinomatosis (LMC) is an uncommon and devastating late complication of metastatic malignancy that carries a poor prognosis, typically faring worse when secondary to solid tumors. Diagnosis of LMC can be challenging, especially if the underlying cancer is undiagnosed, as presenting symptoms can be nonspecific or involve focal deficits such as cranial nerve palsies. Typically, LMC can be recognized due to new central neurological findings with concomitant peripheral nerve involvement, but there has not been a case of LMC with isolated peripheral nerve findings to our knowledge. In this report, we present a case of LMC secondary to metastatic gastric adenocarcinoma in a patient whose only manifestation was cranial nerve palsies, and whose cancer was also found to be Her2+ and ß-hCG positive, two markers not widely recognized in gastric cancer.

Multifocal myoclonus as a presentation of levetiracetam toxicity.

BACKGROUND: Levetiracetam (LEV) is widely used for treatment of focal and myoclonic seizures, but reports of LEV toxicity are scarce. Here, we report a rare case of multifocal myoclonus due to LEV toxicity in a patient with chronic renal insufficiency. CASE PRESENTATION: A 52-year-old woman with history of chronic kidney disease was admitted to the ICU for sedation and intubation after a cardiac arrest. She developed nonconvulsive status epilepticus that resolved after administration of propofol while receiving LEV 1500 mg twice a day. After holding the propofol infusion, the patient started having multifocal myoclonic jerks, documented on video-EEG recordings with a supratherapeutic level of LEV. After discontinuation of LEV, the myoclonus resolved. CONCLUSION: This is a unique manifestation of LEV toxicity, which has been scarce in the literature. It suggests an inverted U-shaped dose-response of the antimyoclonic effect of LEV.