Diagnosis of epilepsy.

Essential in the diagnosis of epilepsy are repeated seizures due to discharge of electrical activity in the brain neurons, occurring without massive provocation. It is important to differentiate between epileptic seizures from syncopal reactions, cardiac dysrhythmias, vascular causes, metabolic disturbances, and psychogenic seizures. The type of seizure should always be established. It is of utmost importance to find the primary etiology of the seizure and to clarify the role of predisposing factors and the risk for seizure recurrence. Numerous important technical advances in the last few years have been of great benefit in the examination of patients with suspected epilepsy. It is worth keeping in mind, however, that the diagnosis of epilepsy is a clinical diagnosis, and it is not proper to speak of epilepsy until the patient has had two or more epileptic seizures within a relatively short interval and without massive provocation.

A double-blind study comparing oxcarbazepine and carbamazepine in patients with newly diagnosed, previously untreated epilepsy.

Two hundred and thirty-five patients suffering from newly diagnosed epilepsy were randomly allocated to treatment with either oxcarbazepine or carbamazepine in a double-blind multi-centre study. After a titration phase (between 4 and 8 weeks), the optimal individual dose of trial medication was determined and treatment with that dose was continued for another 48 weeks. The criteria for assessment were: efficacy--seizure frequency, EEG tracings, global evaluation; tolerability--side effects observed by the patient or the investigator, laboratory tests; other assessments--blood pressure and heart rate, carbamazepine and 10,11-dihydro-10-hydroxycarbamazepine trough serum levels. The results of the study showed the following: no significant difference in seizure frequency between oxcarbazepine and carbamazepine; no correlation between the therapeutic effect and the EEG findings in either treatment group; oxcarbazepine caused significantly fewer (P = 0.04) 'severe' side effects than carbamazepine; global evaluation of tolerability demonstrated a trend towards the better tolerability of oxcarbazepine; no correlation was observed between either efficacy or tolerability and the actual serum trough levels of antiepileptic drugs; clinically relevant abnormal laboratory test findings were observed in 2 patients, both on carbamazepine. The authors consider oxcarbazepine to be a valuable alternative to carbamazepine, particularly in patients who develop side effects which prevent optimal seizure control.

Chronic subdural hematoma in adults. Influence of patient's age on symptoms, signs, and thickness of hematoma.

The relationship of age to clinical and pathological findings was analyzed in 109 adult patients operated on because of chronic subdural hematoma. A well-formed membrane on the inner and outer surface of the hematoma was used as the criterion for chronicity of the hematoma. Younger patients had more evidence of increased intracranial pressure; older patients had more evidence of mental deterioration and pyramidal tract lesions. The interval from trauma to operation was shorter in the young patients. The thickness of the hematoma as measured from angiograms increased with the age of the patient. The cause of this difference is discussed.

Epilepsy after stroke.

A retrospective follow-up of 200 consecutive stroke patients [ischemic brain infarction (IBI) 157, intracerebral hemorrhage (ICH) 20, subarachnoid hemorrhage (SAH) 23] who were in need of ambulatory rehabilitation was conducted for a mean period of 40 months after stroke. Epilepsy developed in 33 (17%) patients. The occurrence of epilepsy was 14% in IBI, 15% in ICH, and 35% in SAH. Significantly more patients developed epilepsy in the SAH group than in the IBI group (8 of 23 vs. 22 of 157, p less than 0.05). Of the 33 patients, 15% had their first seizures within the first 2 weeks after stroke, and 55% developed epilepsy in 6 months. Forty-eight percent of the patients had generalized seizures. Antiepileptic drug (AED) treatment was started in 28 of 33 patients, of whom 17 still had seizures during follow-up. Epilepsy was an important consequence of stroke among patients who needed rehabilitation, especially in SAH patients. In most, this was due to arterial spasm leading to IBI.

Epidemiology of chronic subdural haematoma.

During the seven year period 1967-1973 a total of 64 residents of the City of Helsinki were diangosed as having chronic subdural haematomas. Forty of the patients were diagnosed during life at the Departments of Neurology and Neurosurgery, University of Helsinki, and treated surgically. Twenty four were diagnosed at autopsy at the Department of Forensic Medicine, University of Helsinki, at which the autopsies in virtually all cases of subdural haematoma in Helsinki are performed. The total of 64 cases gives an incidence of 1.72/100,000/year in the average population, the incidence increasing steeply with advancing age up to 7.35/100,000/year in the age groups 70-79 years.

Prognosis of patients with middle cerebral artery occlusion.

The long-term prognosis of 78 stroke patients with occlusion of the middle cerebral artery (MCA) or its branches is described. The mean age of the patients was 44 years. The mortality rate in the acute phase was 5%. The acute and total mortality rates of men were higher than those of women (p less than 0.05). Life-table analysis gave 94% probability for one year's survival, 84% for three years' survival, and 78% for five years' survival. Subsequent strokes were twice as common as cardiovascular events as the cause of death. Seventy-two percent of the survivors became fully independent in activities of daily living (ADL) , 27% required assistance, 1% was totally disabled, and 43% returned to work. Left-sided occlusion was overrepresented in those who died (p less than 0.00(1) and those who returned to work (p less than 0.05), and right-sided occlusion was overrepresented in those who required assistance in ADL (p less than 0.05).

Bilateral internal carotid artery thrombosis. Prognosis and risk factors.

Fourteen patients with bilateral internal carotid artery thrombosis were analysed with respect to long-term prognosis and the prevalence of risk factors of cerebrovascular disease. The patients comprised seven per cent of all patients with internal carotid thrombosis treated in 1966-73 at the Department of Neurology, University of Helsinki. During the follow-up period of 3 to 86 months (median 50 months) five patients died, three during the first, and two during the second year of follow-up. Of the surviving patients: two needed institutionalization; three were able to take care of themselves; and four who were virtually symptom-free, were able to work. The risk factors of cerebrovascular disease were analysed: 91 per cent were cigarette smokers; 70 per cent had serum triglycerides of 140 mg/100ml or higher; and 62 per cent had cholesterol values of 280 mg/100 ml or higher. Fasting glucose values higher than 95 mg/100 ml, and ECG abnormalities were encountered in every third, and obesity and hypertension in every fourth patient. Cigarette smoking and high triglycerides were more prevalent than in the general population. No association between the number of risk factors in the individual patients and the prognosis could be found.

Aortic dissection and paraparesis.

3 cases of dissecting aneurysm of the aorta and paraparesis are presented. 1 patient had an ascending dissection of acute onset with paraplegia but without pain. He was treated conservatively but the patient died. At autopsy a large coronary infarction was also found in the area of the right coronary artery, which was compressed at the starting point of the dissection. The second patient had momentary intensive chest pain and reversible paraparesis, and a descending dissection was seen in aortic angiography. He received hypotensive treatment and was symptomless when last seen 9 months after onset. The third patient had momentary intensive chest and back pain without any other symptoms. A descending dissection was found in aortic angiography and an operation was performed. During the operation the aorta was occluded for 57 min, which was too long for the medullary circulation and permanent paraplegia was the result. Modern diagnostic and therapeutic possibilities are discussed.

Chronic bilateral subdural haematoma in adults.

Twenty-nine patients with chronic bilateral subdural haematomas were surgically treated during 1966 to 1977. Twenty-four of them (83%) had a history of head injury, which caused unconsciousness in eight cases. The mean interval from trauma to operation was eleven weeks. The mean age of the patients was 60 years. The prevalence of the most commonly encountered symptoms and signs was: headache 72%, mental symptoms 48%, papilloedema 41%, vertigo 31%, nausea 28%, reduced consciousness 28%, walking difficulties 24%, hemiparesis 24%, and paraparesis 14%. The aggregate thickness of haematomas was 34 mm, 36 mm, and 40 mm in age groups of 20--39, 40--59, and over 60 years, respectively. All patients were operated on, four of them only unilaterally. Three patients in the whole series died. Two of them had been operated upon only on one side in the first session, the haematoma of the other side being evacuated 8 1/2 hours and four days later, respectively. Unilateral operation is likely to cause severe distortion of the midline structures and the brain stem and thus aggravates the cerebral situation. Therefore the necessity of simultaneous evacuation of the haematomas on both sides is stressed. The reason for the death of the third patient was delay in diagnosis. All three patients who died belonged to the group of eight patients with a reduced level of consciousness before surgery. Twenty-three of the survivors were fully independent in their daily lives, and three needed some help after operative treatment.