Bilateral Posterior Fracture-Dislocation of the Shoulders Secondary to Uremic Encephalopathy.

Bilateral posterior fracture-dislocation of the shoulder is an uncommon injury pattern usually caused by epileptic seizures. The cause of the seizure activity remains unknown in most cases, although the injury has been associated with several conditions. A 59-year-old man with uncontrolled hypertension presented with new-onset generalized tonic-clonic seizures. He was diagnosed with uremic encephalopathy and bilateral posterior fracture-dislocation of his shoulders. His medical condition required stabilization leading to a delay in definitive surgery and a subsequent poor outcome. This case highlights the previously unknown association between bilateral fracture-dislocation of the shoulders and seizures caused by uremic encephalopathy. In these complex situations with competing clinical priorities, it is important to initiate prompt treatment of the cause in any new-onset seizures, to facilitate expedient surgical management of the orthopaedic injury.

Bilateral fracture of the shoulders following epileptic seizures: a case report / Fratura bilateral de ombros após convulsões epilépticas: relato de caso

Convulsive seizures caused by hyponatremia occur when this condition is severe and develops quickly, resulting in a brain's adaptive inability to contain brain swelling. Seizures are rarely the cause of shoulder fractures. This is a case report of bilateral humerus fracture following a single epileptic seizure caused by drug hyponatremia, an unconventional event in medical practice. A 69-year-old woman was admitted to the emergency room after a single tonic-clonic seizure with spontaneously ceased sphincter relaxation, showing Glasgow 6. No falls or restraint were reported by observers. When alert, the patient reported pain and difficulty moving both arms. During examination, the movement was li- mited to the right and left. Anteroposterior radiographs revealed bilateral fracture at the neck of humerus. To complement inves- tigation for further lesions, a computed tomography confirmed bilateral fracture-dislocation with impaction of the humeral head with the glenoid. Atraumatic bilateral fracture-dislocation of the humerus after epileptic seizure is a very rare event. It is believed that some of these diagnoses have been neglected due to the difficulty of characterizing the patient's pain in a postictal state. The importance of a detailed physical examination shall be emphasized in risk groups such as the polymedicated elderly.

Convulsive seizures caused by hyponatremia occur when this condition is severe and develops quickly, resulting in a brain's adaptive inability to contain brain swelling. Seizures are rarely the cause of shoulder fractures. This is a case report of bilateral humerus fracture following a single epileptic seizure caused by drug hyponatremia, an unconventional event in medical practice. A 69-year-old woman was admitted to the emergency room after a single tonic-clonic seizure with spontaneously ceased sphincter relaxation, showing Glasgow 6. No falls or restraint were reported by observers. When alert, the patient reported pain and difficulty moving both arms. During examination, the movement was li- mited to the right and left. Anteroposterior radiographs revealed bilateral fracture at the neck of humerus. To complement inves- tigation for further lesions, a computed tomography confirmed bilateral fracture-dislocation with impaction of the humeral head with the glenoid. Atraumatic bilateral fracture-dislocation of the humerus after epileptic seizure is a very rare event. It is believed that some of these diagnoses have been neglected due to the difficulty of characterizing the patient's pain in a postictal state. The importance of a detailed physical examination shall be emphasized in risk groups such as the polymedicated elderly.

Treatments for the prevention of Sudden Unexpected Death in Epilepsy (SUDEP).

BACKGROUND: This is an updated version of the original Cochrane Review, published in 2016, Issue 7. Sudden Unexpected Death in Epilepsy (SUDEP) is defined as sudden, unexpected, witnessed or unwitnessed, non-traumatic or non-drowning death of people with epilepsy, with or without evidence of a seizure, excluding documented status epilepticus and in whom postmortem examination does not reveal a structural or toxicological cause for death. SUDEP has a reported incidence of 1 to 2 per 1000 patient-years and represents the most common epilepsy-related cause of death. The presence and frequency of generalised tonic-clonic seizures (GTCS), male sex, early age of seizure onset, duration of epilepsy, and polytherapy are all predictors of risk of SUDEP. The exact pathophysiology of SUDEP is currently unknown, although GTCS-induced cardiac, respiratory, and brainstem dysfunction appears likely. Appropriately chosen antiepileptic drug treatment can render around 70% of patients free of all seizures. However, around one-third will remain drug-resistant despite polytherapy. Continuing seizures place patients at risk of SUDEP, depression, and reduced quality of life. Preventative strategies for SUDEP include reducing the occurrence of GTCS by timely referral for presurgical evaluation in people with lesional epilepsy and advice on lifestyle measures; detecting cardiorespiratory distress through clinical observation and seizure, respiratory, and heart rate monitoring devices; preventing airway obstruction through nocturnal supervision and safety pillows; reducing central hypoventilation through physical stimulation and enhancing serotonergic mechanisms of respiratory regulation using selective serotonin reuptake inhibitors (SSRIs); and reducing adenosine and endogenous opioid-induced brain and brainstem depression. OBJECTIVES: To assess the effectiveness of interventions in preventing SUDEP in people with epilepsy by synthesising evidence from randomised controlled trials of interventions and cohort and case-control non-randomised studies. SEARCH METHODS: For the latest update we searched the following databases without language restrictions: Cochrane Register of Studies (CRS Web, 4 February 2019); MEDLINE (Ovid, 1946 to 1 February 2019); SCOPUS (1823 to 4 February 2019); PsycINFO (EBSCOhost, 1887 to 4 January 2019); CINAHL Plus (EBSCOhost, 1937 to 4 February 2019); ClinicalTrials.gov (5 February 2019); and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP, 5 February 2019). We checked the reference lists of retrieved studies for additional reports of relevant studies and contacted lead study authors for any relevant unpublished material. We identified any grey literature studies published in the last five years by searching: Zetoc database; ISI Proceedings; International Bureau for Epilepsy (IBE) congress proceedings database; International League Against Epilepsy (ILAE) congress proceedings database; abstract books of symposia and congresses, meeting abstracts, and research reports. SELECTION CRITERIA: We aimed to include randomised controlled trials (RCTs), quasi-RCTs, and cluster-RCTs; prospective non-randomised cohort controlled and uncontrolled studies; and case-control studies of adults and children with epilepsy receiving an intervention for the prevention of SUDEP. Types of interventions included: early versus delayed pre-surgical evaluation for lesional epilepsy; educational programmes; seizure-monitoring devices; safety pillows; nocturnal supervision; selective serotonin reuptake inhibitors (SSRIs); opiate antagonists; and adenosine antagonists. DATA COLLECTION AND ANALYSIS: We aimed to collect data on study design factors and participant demographics for included studies. The primary outcome of interest was the number of deaths from SUDEP. Secondary outcomes included: number of other deaths (unrelated to SUDEP); change in mean depression and anxiety scores (as defined within the study); clinically important change in quality of life, that is any change in quality of life score (average and endpoint) according to validated quality of life scales; and number of hospital attendances for seizures. MAIN RESULTS: We identified 1277 records from the databases and search strategies. We found 10 further records by searching other resources (handsearching). We removed 469 duplicate records and screened 818 records (title and abstract) for inclusion in the review. We excluded 785 records based on the title and abstract and assessed 33 full-text articles. We excluded 29 studies: eight studies did not assess interventions to prevent SUDEP; eight studies were review articles, not clinical studies; five studies measured sensitivity of devices to detect GTCS but did not directly measure SUDEP; six studies assessed risk factors for SUDEP but not interventions for preventing SUDEP; and two studies did not have a control group. We included one cohort study and three case-control studies of serious to critical risk of bias. The 6-month prospective cohort study observed no significant effect of providing patients with SUDEP information on drug compliance and quality of life, anxiety and depression levels. The study was too short and with no deaths observed in either group to determine a protective effect. Two case control studies reported a protective effect for nocturnal supervision against SUDEP. However due to significant heterogeneity, the results could not be combined in meta-analysis. One study of 154 SUDEP cases and 616 controls reported an unadjusted odds ratio (OR) of 0.34 (95% CI 0.22 to 0.53; P < 0.0001). The same study demonstrated the protective effect was independent of seizure control, suggesting that nocturnal supervision is not just a surrogate marker of seizure control. The second case-control study of 48 SUDEP cases and 220 controls reported an unadjusted OR of 0.08 (95% CI 0.02 to 0.27; P < 0.0001). The third case-control study of residential care centre patients who were already receiving physical checks more than 15 minutes apart throughout the night did not report any protective effect for additional nocturnal supervision (physical checks < 15 minutes apart; use of listening devices; dormitory setting; and use of bed sensors). However the same study did ascertain a difference between centres: the residential centre with the lowest level of supervision had the highest incidence of SUDEP. The case-control studies did not report on quality of life or depression and anxiety scores. AUTHORS' CONCLUSIONS: We found limited, very low-certainty evidence that supervision at night reduces the incidence of SUDEP. Further research is required to identify the effectiveness of other current interventions - for example seizure detection devices, safety pillows, SSRIs, early surgical evaluation, educational programmes, and opiate and adenosine antagonists - in preventing SUDEP in people with epilepsy.

Clinical Features of Patients with Diffuse Alveolar Hemorrhage due to Negative-Pressure Pulmonary Edema.

PURPOSE: Diffuse alveolar hemorrhage (DAH) with negative-pressure pulmonary edema (NPPE) is an uncommon yet life-threatening condition. We aimed at describing the circumstances, clinical, radiological, and bronchoscopic features, as well as the outcome of patients with NPPE-related DAH. METHODS: We performed a retrospective, observational cohort study, using data prospectively collected over 35 years in an intensive care unit (ICU). RESULTS: Of the 149 patients admitted for DAH, we identified 18 NPPE episodes in 15 patients, one admitted four times for recurrent NPPE-related DAH. The patients were primarily young, male, and athletic. The NPPE setting was postoperative (n = 12/18, 67%) or following generalized tonic-clonic seizures (n = 6/18, 33%). Hemoptysis was almost constant (n = 17/18, 94%), yet rarely massive (>200 cc, n = 1/18, 6%), with anemia observed in 10 (56%) episodes. The DAH triad (hemoptysis, anemia, and pulmonary infiltrates) was observed in 50% of episodes (n = 9/18), and acute respiratory failure in 94% (n = 17/18). Chest computed tomography revealed diffuse bilateral ground glass opacities (n = 10/10, 100%), while bronchoscopy detected bilateral hemorrhage (n = 12/12, 100%) and macroscopically bloody bronchoalveolar lavage, with siderophage absence in most (n = 7/8, 88%), indicating acute DAH. While one episode proved fatal, the other 17 recovered rapidly, with a mean ICU stay lasting 4.6 (2-15) days. Typically, the evolution was rapidly favorable under supportive care. CONCLUSION: NPPE-related DAH is a rare life-threatening condition occurring primarily after tonic-clonic generalized seizure or generalized anesthesia. Clinical circumstances are a key to its diagnosis. Early diagnosis and recognition likely allow for successful management of this potentially serious complication, whereas ictal-DAH appears ominous in epileptic patients.

Long-term outcome characteristics in mesial temporal lobe epilepsy with and without associated cortical dysplasia.

OBJECT: The intention of our study was to identify predictive characteristics for long-term seizure control and running down phenomenon after surgical treatment of pharmacoresistant mesiotemporal lobe epilepsy (mTLE) with and without associated cortical dysplasia. MATERIALS AND METHODS: Our study comprises a consecutive series of 458 patients who underwent surgical treatment for intractable mTLE at the Epilepsy Center Freiburg. Data evaluated included semiology, duration and frequency of seizures, results of presurgical diagnostics including video-EEG monitoring, MRI, PET and SPECT as well as postoperative seizure outcome. Results were evaluated forming two groups: Group A consisted of isolated mesiotemporal lesions. Group B comprised patients with mTLE and additional focal cortical dysplasia (FCD). Statistical evaluation was based on the Kaplan Meier survival analysis, using log-rank-tests and a multivariate regression model. Postoperative running down phenomenon was defined as seizure freedom after a period of gradual reduction of postoperative seizure frequency. This was compared to patients with ongoing epilepsy. RESULTS: Complete seizure freedom was achieved in 65.0% of investigated patients at 1year and in 56.5% at long-term follow-up of ≥5 years after surgery. Corresponding results were 64.2% and 56.8% at 1 and ≥5 years, respectively in group A and 66.4% and 56.0%, respectively in group B. Predictive for favorable postoperative outcome in the total group were younger age at surgery, shorter duration of epilepsy, absence of secondarily generalized tonic-clonic seizures (SGTCS), presence of strictly ipsilateral temporal interictal epileptiform discharges (IEDs), complete resection of the lesion as well as absence of postoperative epileptiform activity and of early postoperative seizures. In subgroup analyses, patients of group A demonstrated longer postoperative seizure-free intervals with adolescent age at surgery, short duration of epilepsy before surgery and absence of SGTCS, whereas in patients of group B ipsilateral temporal seizure onset and strictly unilateral IEDs in EEG as well as complete resection were predictors for favorable seizure outcome. Furthermore, absence of early postoperative seizures and of spikes in EEG were predictive factors for long-term seizure-freedom in both subgroups. The running down phenomenon was found in 33 (7.2%) patients. None of the parameters evaluated demonstrated significant predictive power. Only late seizure onset and neoplastic lesions showed a trend for postoperative gradual seizure reduction in multivariate analyses. CONCLUSION: Depending on the presence or absence of focal cortical dysplasia in addition to mesiotemporal structural alterations, predictors of long-term seizure control differed regarding the relevant clinical and electrophysiological features. This is important for specific patient counseling in respective groups.

Treatments for the prevention of Sudden Unexpected Death in Epilepsy (SUDEP).

BACKGROUND: Sudden Unexpected Death in Epilepsy (SUDEP) is defined as sudden, unexpected, witnessed or unwitnessed, non-traumatic or non-drowning death of people with epilepsy, with or without evidence of a seizure, excluding documented status epilepticus and in whom postmortem examination does not reveal a structural or toxicological cause for death. SUDEP has a reported incidence of 1 to 2 per 1000 patient years and represents the most common epilepsy-related cause of death. The presence and frequency of generalised tonic-clonic seizures (GTCS), male sex, early age of seizure onset, duration of epilepsy, and polytherapy are all predictors of risk of SUDEP. The exact pathophysiology of SUDEP is currently unknown, although GTCS-induced cardiac, respiratory, and brainstem dysfunction appears likely. Appropriately chosen antiepileptic drug treatment can render around 70% of patients free of all seizures. However, around one-third will remain drug refractory despite polytherapy. Continuing seizures place patients at risk of SUDEP, depression, and reduced quality of life. Preventative strategies for SUDEP include reducing the occurrence of GTCS by timely referral for presurgical evaluation in people with lesional epilepsy and advice on lifestyle measures; detecting cardiorespiratory distress through clinical observation and seizure, respiratory, and heart rate monitoring devices; preventing airway obstruction through nocturnal supervision and safety pillows; reducing central hypoventilation through physical stimulation and enhancing serotonergic mechanisms of respiratory regulation using selective serotonin reuptake inhibitors (SSRIs); reducing adenosine and endogenous opioid-induced brain and brainstem depression. OBJECTIVES: To assess the effectiveness of interventions in preventing SUDEP in people with epilepsy by synthesising evidence from randomised controlled trials of interventions and cohort and case-control non-randomised studies. SEARCH METHODS: We searched the following databases: Cochrane Epilepsy Group Specialized Register; Cochrane Central Register of Controlled Trials (CENTRAL, Issue 11, 2015) via the Cochrane Register of Studies Online (CRSO); MEDLINE (Ovid, 1946 onwards); SCOPUS (1823 onwards); PsycINFO (EBSCOhost, 1887 onwards); CINAHL Plus (EBSCOhost, 1937 onwards); ClinicalTrials.gov; and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP). We used no language restrictions. The date of the last search was 12 November 2015. We checked the reference lists of retrieved studies for additional reports of relevant studies and contacted lead study authors for any relevant unpublished material. We identified duplicate studies by screening reports according to title, authors' names, location, and medical institute, omitting any duplicated studies. We identified any grey literature studies published in the last five years by searching: Zetoc database; ISI Proceedings; International Bureau for Epilepsy (IBE) congress proceedings database; International League Against Epilepsy (ILAE) congress proceedings database; abstract books of symposia and congresses, meeting abstracts, and research reports. SELECTION CRITERIA: We aimed to include randomised controlled trials (RCTs), quasi-RCTs, and cluster-RCTs; prospective non-randomised cohort controlled and uncontrolled studies; and case-control studies of adults and children with epilepsy receiving an intervention for the prevention of SUDEP. Types of interventions included: early versus delayed pre-surgical evaluation for lesional epilepsy; educational programmes; seizure-monitoring devices; safety pillows; nocturnal supervision; selective serotonin reuptake inhibitors (SSRIs); opiate antagonists; and adenosine antagonists. DATA COLLECTION AND ANALYSIS: We aimed to collect data on study design factors and participant demographics for included studies. The primary outcome of interest was the number of deaths from SUDEP. Secondary outcomes included: number of other deaths (unrelated to SUDEP); change in mean depression and anxiety scores (as defined within the study); clinically important change in quality of life, that is any change in quality of life score (average and endpoint) according to validated quality of life scales; and number of hospital attendances for seizures. MAIN RESULTS: We identified 582 records from the databases and search strategies. We found 10 further records by searching other resources (handsearching). We removed 211 duplicate records and screened 381 records (title and abstract) for inclusion in the review. We excluded 364 records based on the title and abstract and assessed 17 full-text articles. We excluded 15 studies: eight studies did not assess interventions to prevent SUDEP; five studies measured sensitivity of devices to detect GTCS but did not directly measure SUDEP; and two studies assessed risk factors for SUDEP but not interventions for preventing SUDEP. One listed study is awaiting classification.We included one case-control study at serious risk of bias within a qualitative analysis in this review. This study of 154 cases of SUDEP and 616 controls ascertained a protective effect for the presence of nocturnal supervision (unadjusted odds ratio (OR) 0.34, 95% confidence interval (CI) 0.22 to 0.53) and when a supervising person shared the same bedroom or when special precautions, for example a listening device, were used (unadjusted OR 0.41, 95% CI 0.20 to 0.82). This effect was independent of seizure control. Non-SUDEP deaths; changes to anxiety, depression, and quality of life; and number of hospital attendances were not reported. AUTHORS' CONCLUSIONS: We found very low-quality evidence of a preventative effect for nocturnal supervision against SUDEP. Further research is required to identify the effectiveness of other current interventions, for example seizure detection devices, safety pillows, SSRIs, early surgical evaluation, educational programmes, and opiate and adenosine antagonists in preventing SUDEP in people with epilepsy.

Infección por VIH/SIDA y múltiples enfermedades oportunistas simultáneas / HIV/AIDS Infection and multiple simultaneous opportunistic diseases

La infección por Virus de Inmunodeficiencia Humana y el Síndrome de Inmunodeficiencia Adquirida en fase avanzada de la infección, propician condiciones de vulnerabilidad para las infecciones oportunistas. Caso Clínico: Paciente femenina de 21 años, sin antecedentes conocidos, se presentó a emergencia con historia de convulsión tónico-clónica de dos minutos de duración, acompañada de oculogiros, sin relajación de esfínteres; pérdida ponderal de ocho meses de evolución, acompañada de astenia, adinamia, hiporexia y tos seca. En el examen físico de tórax: a la inspección de piel se observó costra serohematica impetiginizada en hemitórax izquierdo, sin cruzar la línea media, acompañado de dolor y seguía el trayecto dermatomérico; a la auscultación, crépitos escasos en lóbulo medio de pulmón derecho. Durante la evaluación de ingreso presentó dos episodios convulsivos similares. Se practicó radiografía de tórax posteroanterior, se observó masa circular en lóbulo medio de pulmón derecho; hematología demostró falla renal aguda, anemia normocitica-normocromica y sospecha de inmunosupresión. Se diagnosticó Infección por Virus de Inmunodeficiencia Humana/Síndrome Inmunodeficiencia Adquirida mediante serología y conteo de linfocitos CD4, histoplasmosis sistémica, herpes zóster y tuberculosis pulmonar; se instauró tratamiento. Al finalizar terapia y la evolución clínica se decide su egreso, para control ambulatorio. Conclusión: la intervención temprana y la terapia adecuada son esenciales para la evolución y desenlace clínico; la paciente tuvo evolución satisfactoria posterior al inicio de una terapia antifimica profiláctica, se egresó y se dio control en consulta externa de Infectología del Hospital Escuela Universitario...(AU)

Factors associated with tonic-clonic seizures in patients with drug-resistant mesial temporal epilepsy.

PURPOSE: Among different seizure types, tonic-clonic seizures are more significant because they are more often associated with morbidity. No prior study has been done to investigate risk factors associated with tonic-clonic seizures in patients with mesial temporal epilepsy. METHODS: In this retrospective study, all drug-resistant mesial temporal epilepsy patients in the database of patients who underwent epilepsy surgery at Jefferson comprehensive epilepsy center were recruited. These patients were prospectively registered in a database from 1986 till 2014. Patients' age, gender, epilepsy risk factors, age at seizure onset, and preoperative seizure type(s) were registered routinely. Potential risk factors associated with experiencing preoperative tonic-clonic seizures were investigated. RESULTS: Two hundred seventy-five patients (132 males and 143 females) were studied. Aura type was associated with experiencing perioperative tonic-clonic seizures. Patients with epigastric auras less frequently reported having tonic-clonic seizures compared with those who had other types of auras (odds ratio: 0.37 and 95% confidence interval: 0.19-0.70; p=0.001) and those who did not have any auras (odds ratio: 0.35 and 95% confidence interval: 0.16-0.77; p=0.008). CONCLUSION: Epigastric auras may indicate that a specific anatomic location is involved in epileptogenesis from which generalization is harder because of that location's poor connections with other brain regions.

Bilateral, locked, recurrent anterior shoulder dislocation: case report.

Bilateral anterior dislocation of the shoulder is a rare condition. Most of the cases are seen as posterior dislocations which generally occur during diffuse tonic-clonic contractions of epileptic seizures or after being exposed to strong electric shock. In this article, we report a 21-year-old epileptic patient who had severe bilateral shoulder pain and joint restriction. Diagnoses of bilateral, locked, anterior shoulder dislocation and Hill-Sachs lesions were made with shoulder X-rays and computed tomography. Arthroscopic Bankart repair and remplissage technique were applied in surgical treatment of both shoulders. Posterior dislocations of shoulder usually occur during epileptic seizures but anterior dislocations are rare in the literature. This may lead to delay in diagnosis. Computed tomography scan may be helpful in making diagnosis in uncertain patients. It should not be forgotten that recurrent anterior dislocations may be seen in epileptic patients. Such dislocations should be followed up regularly and instability must be treated to prevent excessive damage to the shoulder.

Atlanto axial rotatory dislocation in adults: a rare complication of an epileptic seizure--case report.

Atlanto Axial Rotatory Dislocations (AARDs) are a heterogeneous group of post-traumatic pathologies typical of the pediatric age, and rare in adults. We describe the case of a 34-year-old woman, developing Atlanto Axial Rotatory Fixation (AARF) after a generalized tonic-clonic epileptic seizure, an extremely rare traumatic cause never described in literature. AARF was detected only 1 month after the accident and nonsurgical treatment was attempted at the beginning. The patient underwent surgery only 2 months after the accident. The best treatment should be conservative reduction within 1 month; when it is not possible, it is advisable to perform surgery as soon as possible. C1-C2 fixation with Harm's technique is the gold standard for fixed luxations. Delay of treatment makes intraoperative reduction more difficult and increase the establishment of the chronic permanent change of neck muscles and ligaments.

Seizure outcomes after corpus callosotomy for drop attacks.

BACKGROUND: Medically intractable epilepsy involving drop attacks can be difficult to manage and negatively affect quality of life. Most studies investigating the effect of corpus callosotomy (CC) on seizures have been limited, focusing on the pediatric population or drop seizures alone, with little attention to other factors influencing seizure outcome. OBJECTIVE: To assess seizure outcomes after CC in adults and children. METHODS: Retrospective analysis was performed on all patients who underwent CC (anterior two thirds, 1- or 2-stage complete) at our institution between 1990 and 2011. Change in frequency after CC was assessed for drop seizures and other seizure types. Multiple factors were evaluated for impact on seizure outcome. RESULTS: Fifty patients met inclusion criteria. The median age was 1.5 years at seizure onset and 17 years at time of surgery. Anterior two-thirds CC was performed in 28 patients, 1-stage complete in 17, and 2-stage complete in 5. All 3 groups experienced a significant decrease in drop seizures (P < .001, P < .001, and P = .020, respectively), with 40% experiencing complete resolution, and 64% dropping at least 1 frequency category. Other seizure types significantly decreased in anterior two-thirds CC and 1-stage complete (P = .0035, P = .001, respectively). Younger age at surgery correlated with better seizure outcomes (P = .043). CONCLUSION: CC for medically refractory generalizing epilepsy is effective for both drop seizures and other seizure types. CC should be considered soon after a patient has been deemed medically refractory because earlier age at surgery results in lower risk and better outcome.

The spectrum of acute heart failure after venlafaxine overdose.

OBJECTIVE: Venlafaxine is a bicyclic antidepressant that may be associated with severe cardiotoxicity following large overdose. The purpose of this short case series is to present different patterns of venlafaxine-related cardiotoxicity and to discuss the potential mechanisms. CASE SERIES: Between January 2010 and July 2011, four patients were admitted to an ICU with acute left ventricular failure following large venlafaxine overdoses. The age of the four female patients ranged from 35 to 65 years. None of them had no history of cardiovascular disease. The amount of venlafaxine ingested by history ranged from 3150 to 13500 mg (extended-release preparation in two cases). The peak serum venlafaxine concentration was between 2153.3 and 9950 ng/ml. Three patients died and one recovered rapidly. The initial ECG revealed only mild abnormalities in two cases. In two patients, at least one ECG recording demonstrated a widening of QRS interval. In three patients, echocardiography disclosed a left ejection fraction of 15%-18%. Two patients presented a severe serotonin syndrome, with major rhabdomyolysis. Seizures were noted in two cases, including one patient with status epilepticus. Three patients were mechanically ventilated. The causes of death were refractory hypoxemia, malignant arrhythmias, and cardiogenic shock, respectively. DISCUSSION: Severe and diffuse left ventricular dysfunction may be observed after large venlafaxine overdoses and this is not always associated with severe cardiac conduction function abnormalities. The mechanisms underlying venlafaxine-related cardiac failure with preserved normal cardiac conduction are discussed. A possible explanation may be a catecholamine-induced myocardial damage in relationship with the inhibition of norepinephrine (and dopamine) reuptake.

Sindrome de sandifer: a propósito de la enfermedad por reflujo gastroesofágico en niños / Sandifer syndrome and gastroesophageal reflux in childre

El Síndrome de Sandifer es un trastorno neuroconductual con movimientos de hiperextensión de cuello, cabeza y tronco, con rotación de cabeza, que generalmente se presentan durante o inmediatamente después de la ingesta de alimentos y cesa durante el sueño, secundario a enfermedad por reflujo gastroesofágico. Se caracteriza por esofagitis, anemia por deficiencia de hierro y son confundidos con frecuencia como crisis de origen epiléptico. Lactante masculino de 5 meses referido por movimientos de tónico-clónicos generalizados, de segundos de duración, con una frecuencia de 30 episodios al día, que no ceden con el uso de 3 anticonvulsivantes. Disfagia a alimentos pastosos. Hospitalización al mes de vida por episodio de amenazante de la vida. Estudios neurológicos normales. Paraclínica: anemia microcítica e hipocrómica. Videodeglutoscopia: Disfagia de fase oral leve, disfagia fase esofágica a estudiar (Regurgitación), reflujo faringolaringeo según escala de Belafsky y Larigomalacia grado I; pHmetría de 24 horas con impedancia, puntación de Boix-Ochoa de 26%, durante la colocación de la sonda se observo posición anómala de la cabeza e hiperextensión del dorso. Estudio contrastado de esófago, estómago y duodeno sin anormalidad anatómica. Endoscopia digestiva superior: Esofagitis no erosiva, Hernia hiatal. El Síndrome de Sandifer es una de las presentaciones atípicas de RGE en lactantes. Amerita la evaluación de un equipo multidisciplinario para establecer el diagnóstico. El manejo medico incluyó medidas antireflujo, esomeprazol y técnica de alimentación adecuada con evolución satisfactoria. La diversidad de enfermedades relacionadas con RGE exige el uso de variadas técnicas para lograr diagnósticos más asertivos

Sandifer's syndrome is a neurobehavioral disorder with hyperextension movements of neck, head and trunk, head rotation, which usually occur during or immediately after food intake and ceases during sleep, secondary to gastroesophageal reflux disease. It is characterized by esophagitis, anemia and iron deficiency are often confused as a crisis of epileptic origin. A male infant of 5 months reported by tonic-clonic movements of widespread, lasting seconds, with a frequency of 30 episodes per day, which do not yield with the use of 3 anticonvulsants. Pasty food dysphagia. Hospitalization month of life-threatening episode of life. Normal neurological studies. Paraclinical: hypochromic microcytic anemia. Videodeglutoscopia: mild oral phase dysphagia, esophageal dysphagia to study phase (regurgitation), pharyngolaryngeal reflux as Belafsky and Larigomalacia scale grade I, ph-metry of 24 hours with impedance, Boix-Ochoa score of 26% during the placement of probe was observed abnormal head position and hyperextension of the back. Contrast study of esophagus, stomach and duodenum without anatomical abnormality. Upper gastrointestinal endoscopy: nonerosive esophagitis, hiatal hernia. Sandifer Syndrome is one of the atypical presentations of GER in infants. Warrants evaluation by a multidisciplinary team to establish the diagnosis. The medical management included antireflux measures, esomeprazole and proper feeding technique with satisfactory outcome. The diversity of diseases associated with GER requires the use of various diagnostic techniques to get more assertive

Awake craniotomy, electrophysiologic mapping, and tumor resection with high-field intraoperative MRI.

BACKGROUND: Awake craniotomy and electrophysiologic mapping (EPM) is an established technique to facilitate the resection of near eloquent cortex. Intraoperative magnetic resonance imaging (iMRI) is increasingly used to aid in the resection of intracranial lesions. Standard draping protocols in high-field iMRI units make awake craniotomies challenging, and only two groups have previously reported combined EPM and high-field iMRI. METHODS: We present an illustrative case describing a simple technique for combining awake craniotomy and EPM with high-field iMRI. A movable platter is used to transfer the patient from the operating table to a transport trolley and into the adjacent MRI and still maintaining the patient's surgical position. This system allows excess drapes to be removed, facilitating awake craniotomy. RESULTS: A 57-year-old right-handed man presented with new onset seizures. Magnetic resonance imaging demonstrated a large left temporal mass. The patient underwent an awake, left frontotemporal craniotomy. The EPM demonstrated a single critical area for speech in his inferior frontal gyrus. After an initial tumor debulking, the scalp flap was loosely approximated, the wound was covered with additional drapes, and the excess surrounding drapes were trimmed. An iMRI was obtained. The image-guidance system was re-registered and the patient was redraped. Additional resection was performed, allowing extensive removal of what proved to be an anaplastic astrocytoma. The patient tolerated this well without any new neurological deficits. CONCLUSIONS: Standard protocols for positioning and draping in high-field iMRI units make awake craniotomies problematic. This straightforward technique for combined awake EPM and iMRI may facilitate safe removal of large lesions in eloquent cortex.

A diagnostic dilemma of intracranial pathology: coincidence or the result of cranial trauma?

A 21-year-old man presented to the accident and emergency department at St Peter's Hospital, London, in September 2008. Following consumption of alcohol, the patient had been assaulted and had experienced facial trauma. Later, the patient had a witnessed generalised tonic-clonic seizure and the next day noted weakness of the right leg. A CT scan of the brain revealed a solitary lesion in the left presylvian region close to the vertex, involving the leg area of the primary motor cortex. A subsequent MRI scan showed the lesion to be a cavernous haemangioma. The patient had no history of epilepsy. This raised the question as to whether the assault caused the lesion to haemorrhage, resulting in the seizure and spastic monoparesis, or did the formerly asymptomatic cavernoma bleed spontaneously with the assault being coincidental?

Simultaneous bilateral femoral neck fractures secondary to epileptic seizures: treatment by bilateral total hip arthroplasty.

Simultaneous bilateral femoral neck fracture following an epileptic seizure attack are rare. Open reduction and internal fixation remains the most used therapeutic option. Arthroplasty, carrying a high risk of dislocation is less often recommended. We report the favourable evolution of a 49-year-old man who benefited from a single stage bilateral total hip arthroplasty operation for his simultaneous bilateral, femoral neck fractures secondary to a generalized seizure. This nonconsensual choice, in this case, was justified on multiple grounds: surgical care delay longer than 48 hours, substantial bone displacement, borderline bone quality, adequate antiepileptic treatment efficacy and tolerance. A ceramic-on-ceramic bearing surfaces couple, a large-diameter head and a cementless implantation design together should be able to provide an acceptable longevity in a young and active patient.