Morphological Description of Frontal EEG Interictal and Ictal Discharges in an Adult Cohort of 175 Patients.

Clinical and electroencephalogram (EEG) features in frontal lobe epilepsy (FLE) vary considerably among patients, making the diagnosis a challenge. The objective of this study was to describe interictal and ictal EEG activity, identifying variables that could help to differentiate and diagnose frontal lobe epilepsy cases. A prospective cross-sectional study from patients with frontal interictal epileptiform discharges (IED) referred to the Vall d'Hebron University Hospital (Barcelona, Spain) after a clinical event compatible with epileptic seizures was designed. The interictal and ictal activity were analyzed to provide a detailed EEG description of the cases, using different statistical analyses. The morphological seizure pattern at the ictal onset remained globally unchanged over time in seizures arising from the frontal lobe for each patient. Isolated sharp waves were the most frequent waveforms in the expression of IED. Frontal lobe seizures are frequently short and sometimes appear grouped in clusters within the same recording. Often the ictal expression of the electrical activity in frontal lobe seizure is subtle and challenging to interpret. A description of the main findings is summarized to identify seizures arising from the frontal lobe and avoid false negatives findings in EEG interpretations.

Levetiracetam and Valproate Retention Rate in Juvenile Myoclonic Epilepsy.

BACKGROUND: Valproic acid (VPA) is an effective treatment in juvenile myoclonic epilepsy (JME), but concerns on its use during pregnancy are remarkable. Levetiracetam (LEV) is approved as second-line therapy, and used as monotherapy in clinical practice. Our objective was to analyze the outcome of LEV and VPA in JME. MATERIALS AND METHODS: We analyzed patients with JME attending our epilepsy unit between 2010 and 2014, including all patients treated with LEV and/or VPA at some point of the disease course. The primary end point was drug retention rate in monotherapy after the final analysis. RESULTS: We identified 58 patients (62% women). All had myoclonic seizures, 86% had generalized tonic-clonic seizures (GTCS) before the diagnosis, and 9% also had absences. All had generalized spike and wave on the interictal electroencephalogram, and 86% of them also had generalized polyspike and wave discharges. In total, LEV monotherapy was maintained in 15 (65%) of 23 patients, and VPA was maintained in 37 (74%) of 50 patients (P = 0.062). In women younger than 35 years, LEV had a similar retention rate with VPA (P = 0.939). More VPA patients achieved seizure freedom during follow-up (P < 0.01), whereas LEV patients showed a trend toward higher myoclonic freedom (0.085). CONCLUSIONS: Levetiracetam showed lower retention rate than VPA, primarily due to poorer seizure control during long-term follow-up. More LEV patients achieved myoclonic seizure freedom than VPA patients. In women younger than 35 years, LEV and VPA had comparable retention rate; therefore, LEV could be a good option for women with JME with prominent myoclonic seizures.

Epilepsia partialis continua: aetiology, semiology and prognosis in a Spanish adult cohort.

To describe the semiological features in patients suffering with Epilepsia Partialis Continua (EPC), also referred as Kozhevnikov syndrome and their relationship with aetiology, duration, and prognosis, as well as recurrence during follow-up. We analysed consecutive EPC patients diagnosed and followed in our centre over a seven-and-a half year period. We collected demographic and clinical data, along with neuroimaging and EEG recordings. All patients were followed for more than six months. Patients were categorised with single body area or multiple body area involvement according to the body parts affected. Recurrence was defined as a second EPC episode after one week. We collected data from 27 adult patients; 70.4% were men, the mean age was 65.2 years old (range: 17-89 years), and 40.7% had previous epilepsy. EPC causes were structural in 85.1% (stroke being the most frequent; 44.4%), metabolic in 11.1%, and of unknown origin in 7.4%. A cortical lesion on neuroimaging was shown in 70.4%. Involvement of multiple body areas was reported in 55.6% of patients. The optimal cut-off period to predict death was nine days (with a sensitivity of 62.5% and specificity of 75%; p=0.039), and this group of patients exhibited more multiple body area involvement (88.9% vs 38.9%; p=0.04). During follow-up, patients with cortical lesions had more EPC relapses (p=0.037). The most frequent aetiology of EPC in our patients was stroke. Multiple body area involvement and duration were associated with mortality. Patients with cortical lesions had more EPC relapses during follow-up.

[Visual epileptic seizures. Signs and symptoms, and clinical implications]. / Crisis epilepticas visuales. Semiologia e implicaciones clinicas.

INTRODUCTION: Visual phenomena can be symptoms of epileptic seizures, although with an uncertain clinical meaning and relationship with the epileptogenic focus. AIMS: To describe the clinical implications of visual epileptic seizures according to their signs and symptoms in adults. PATIENTS AND METHODS: Data were collected consecutively over a period of one year from patients who reported visual signs and symptoms as the main manifestation of their seizures, and the visual symptoms are classified according to the characteristics of the description. RESULTS: The sample consisted of 78 patients, with a mean age of 43.5 years. Focal epilepsy accounted for 97% of the cases. Of the 63% that were symptomatic epilepsies, 57% were vascular. The visual seizures were, in 81.9% of cases, the aura prior to the seizure, and 17.9% were isolated visual seizures. The coexistence of visual seizures and other types of seizure was associated to pharmacoresistance (p = 0.021). The visual symptoms reported were as follows: simple hallucinations (55.1%), illusions (23.1%), complex hallucinations (15.4%) and loss of vision (6.4%). The lobar localisation of the lesions was occipital (24.4%), temporoparietooccipital (21.8%), temporal (9%), parietal (3.8%) and frontal (1.3%). Occipital lesions were associated with simple visual hallucinations (p < 0.001), and visual illusions and complex visual hallucinations, with lesions affecting the temporoparietooccipital junction (p < 0.05). Of the 55.1% of patients with a unilateral lesion in the magnetic resonance scan, 33% reported symptoms in the contralateral visual hemifield. CONCLUSIONS: Visual seizures mainly present as epileptic auras. Simple hallucinations are related with an occipital origin, whereas complex hallucinations are associated with more anterior regions of the brain. The appearance of lateralised visual phenomena suggests an origin located in the contralateral hemisphere.

TITLE: Crisis epilepticas visuales. Semiologia e implicaciones clinicas.Introduccion. Los fenomenos visuales pueden ser sintomas de crisis epilepticas, aunque con un significado clinico y una relacion con el foco epileptogeno incierto. Objetivo. Describir las implicaciones clinicas de las crisis epilepticas visuales segun su semiologia en adultos. Pacientes y metodos. Durante un año se recoge consecutivamente a pacientes que describian semiologia visual como manifestacion principal de sus crisis y se clasifican los sintomas visuales segun las caracteristicas de la descripcion. Resultados. Se incluye a 78 pacientes con una edad media de 43,5 años. El 97% de los casos eran epilepsias focales. Entre el 63% de las epilepsias sintomaticas, el 57% eran vasculares. Las crisis visuales eran, en un 81,9%, el aura previa a la crisis, y en un 17,9%, crisis visuales aisladas. La coexistencia de crisis visuales y otro tipo de crisis se asocio a farmacorresistencia (p = 0,021). Los sintomas visuales fueron: alucinaciones simples (55,1%), ilusiones (23,1%), alucinaciones complejas (15,4%) y perdida de vision (6,4%). La localizacion lobar de las lesiones era occipital (24,4%), temporoparietooccipital (21,8%), temporal (9%), parietal (3,8%) y frontal (1,3%). Las lesiones occipitales se asociaron con alucinaciones visuales simples (p < 0,001), y las ilusiones visuales y alucinaciones visuales complejas, con lesiones de la encrucijada temporoparietooccipital (p < 0,05). Del 55,1% de los pacientes con lesion unilateral en la resonancia magnetica, el 33% referia los sintomas en el hemicampo visual contralateral. Conclusiones. Las crisis visuales se presentan, principalmente, como auras epilepticas. Las alucinaciones simples se relacionan con el origen occipital, mientras que las alucinaciones complejas se asocian con regiones cerebrales mas anteriores. La aparicion de fenomenos visuales lateralizados nos orienta a un origen en el hemisferio contralateral.

[Malformations of cortical development in adult patients with epilepsy: a series of 79 cases]. / Malformaciones del desarrollo cortical en pacientes adultos con epilepsia: serie de 79 casos.

INTRODUCTION: Malformations of cortical development (MCD) are an important cause of epilepsy, delayed psychomotor development or neurological deficits. AIM. To report on the long-term clinical course and differential characteristics of several groups of MCD in adults with epilepsy. PATIENTS AND METHODS: Our sample consisted of patients over 16 years of age with MCD confirmed by magnetic resonance imaging, and epilepsy. The characteristics of the epilepsy, presence of neurological deficits, intellectual disability, history of perinatal pathology and electroencephalogram recordings were analysed. The patients were classified into three groups (G) in accordance with the Barkovich classification. RESULTS: A total of 85 patients with MCD were identified from 2630 patients with epilepsy and 79 of them were finally included in the sample. Mean age: 37 years, 57% were females. Mean age at onset of the crises: 17.8 years, and 59.5% were medication resistant. The distribution of the cases according to the Barkovich classification was: G1 (alterations affecting neuronal proliferation): 59.5%; G2 (alterations affecting migration): 25.3%; and G3 (alterations affecting cortical organisation): 15.2%. Focal neurological deficit was observed in 19% and 34.2% had an intelligence quotient < 80. On analysing by groups, G3 was found to display a higher percentage of focal neurological and intelligence quotient deficits than G1 and G2 (p < 0.05). CONCLUSIONS: Patients with MCD in G3 are more likely to have neurological deficit, intellectual disability and better control over their crises than patients from G1 and G2, most of whom present refractory epilepsy.

TITLE: Malformaciones del desarrollo cortical en pacientes adultos con epilepsia: serie de 79 casos.Introduccion. Las malformaciones del desarrollo cortical (MDC) son una causa importante de epilepsia, retraso del desarrollo psicomotor o deficits neurologicos. Objetivo. Describir la evolucion clinica a largo plazo y las caracteristicas diferenciales de los distintos grupos de MDC en adultos con epilepsia. Pacientes y metodos. Pacientes mayores de 16 años con MDC confirmada por resonancia magnetica y epilepsia. Se analizaron las caracteristicas de la epilepsia, la presencia de deficits neurologicos, la discapacidad intelectual, los antecedentes de patologia perinatal y el electroencefalograma. Los pacientes se clasificaron en tres grupos (G) segun la clasificacion de Barkovich. Resultados. Se identificaron 85 pacientes con MDC de 2.630 pacientes con epilepsia, y se incluyeron 79 pacientes. Edad media: 37 años, el 57% mujeres. Edad media al inicio de las crisis: 17,8 años. El 59,5% era farmacorresistente. La distribucion de los casos segun la clasificacion de Barkovich fue: G1 (alteraciones de la proliferacion neuronal): 59,5%; G2 (alteraciones de la migracion): 25,3%; y G3 (alteraciones de la organizacion cortical): 15,2%. El 19% presentaba un deficit neurologico focal y el 34,2% tenia un cociente intelectual < 80. Al analizar por grupos, el G3 mostraba un mayor porcentaje de deficits neurologicos focales y discapacidad intelectual que el G1 y el G2 (p < 0,05). Conclusion. Los pacientes con MDC del G3 tienen mayor probabilidad de tener deficit neurologico, discapacidad intelectual y mejor control de las crisis que los pacientes del G1 y G2, que se manifiestan, predominantemente, con epilepsia farmacorresistente.

[Aetiology and treatment of epilepsy in a series of 1,557 patients]. / Etiologia y tratamiento de la epilepsia en una serie de 1.557 pacientes.

INTRODUCTION: The aetiology of epilepsy is an important decisive factor in its treatment and prognosis. Diagnostic and therapeutic advances suggest that the causal distribution, treatment and prognosis of the population with epilepsy may have undergone some modification. AIM: To describe the distribution of syndromes, aetiology and pharmacological treatment in patients with epilepsy. PATIENTS AND METHODS: We conducted a cross-sectional descriptive study of patients with epilepsy who were treated consecutively in our epilepsy department. Demographic data were collected, together with information about syndromes, aetiology and pharmacological treatment at the time of eligibility. The data were analysed jointly and by age groups. RESULTS: Altogether 1,557 patients were included, 54% of them males. Seventy-three per cent of the sample had focal epilepsy, which was secondary to a structural lesion in 56% of patients. Generalised epilepsies accounted for 20%. Five per cent were unclassifiable. By ages, vascular causation predominated in practically all the groups and its prevalence increased with age. The most commonly used antiepileptic drugs were valproic acid (29%), levetiracetam (27%) and carbamazepine (20%). Seventy per cent of the generalised epilepsies and 57% of the focal ones were on monotherapy treatment. CONCLUSIONS: The prevalence by age groups was similar to that reported in developed countries, although a lower prevalence of cryptogenic epilepsies was observed. More than 60% of patients followed monotherapy and valproic acid was the most widely used.

TITLE: Etiologia y tratamiento de la epilepsia en una serie de 1.557 pacientes.Introduccion. La etiologia de la epilepsia es un determinante importante del tratamiento y el pronostico. Los avances diagnosticos y terapeuticos hacen pensar que la distribucion causal, el tratamiento y el pronostico de la poblacion con epilepsia se hayan podido ver modificados. Objetivo. Describir la distribucion sindromica, etiologica y el tratamiento farmacologico en los pacientes con epilepsia. Pacientes y metodos. Estudio descriptivo transversal de pacientes con epilepsia atendidos de manera consecutiva en la consulta de nuestra unidad de epilepsia. Se recogieron datos demograficos, de sindrome, etiologia y tratamiento farmacologico en el momento de la inclusion. Se analizaron los datos de modo conjunto y por grupos de edad. Resultados. Se incluyeron 1.557 pacientes, el 54% varones. El 73% de la muestra tenia una epilepsia focal, que era secundaria a una lesion estructural en el 56%. Las epilepsias generalizadas representaron el 20%. El 5% fue inclasificable. Por edad, la etiologia vascular predominaba en practicamente todos los grupos y su prevalencia aumentaba en relacion con la edad. Los farmacos antiepilepticos mas utilizados fueron acido valproico (29%), levetiracetam (27%) y carbamacepina (20%). El 70% de las epilepsias generalizadas y el 57% de las focales seguian tratamiento en monoterapia. Conclusiones. La prevalencia por grupos de edad fue similar a la descrita en paises desarrollados aunque se observo una menor prevalencia de epilepsias criptogenicas. Mas del 60% de los pacientes seguia monoterapia y el acido valproico fue el mas utilizado.

[Non-convulsive status epilepticus secondary to subarachnoid haemorrhage as the presenting symptom of a cerebral amyloid angiopathy]. / Estado de mal epiléptico no convulsivo secundario a hemorragia subaracnoidea como forma de presentación de una angiopatía amiloide cerebral.

INTRODUCTION: Cerebral amyloid angiopathy is a frequent cause of haemorrhagic cerebrovascular disease in persons over the age of 65 and, sometimes, the initial symptoms can be epilepsy-like. CASE REPORT: A 62-year-old female with no relevant past history who was admitted to hospital due to non-convulsive status epilepticus, auditory hallucinations and ideomotor apraxia; an electroencephalogram performed on the patient revealed periodic lateralised epileptiform discharges in the right parietooccipital region. Susceptibility-weighted magnetic resonance imaging showed a sub-acute focal subarachnoid haemorrhage in the right parietotemporal region and cortico-subcortical microbleeding in different stages of the progression of the disease that were compatible with cerebral amyloid angiopathy. A critical simple single-photon emission tomography scan was performed and findings revealed an area of hyperperfusion in the same region. Antiepileptic treatment was established with clinical, neurophysiological and scintigraphic resolution. CONCLUSIONS: The article reports a case with non-convulsive status epilepticus as the initial symptom of cerebral amyloid angiopathy. It also highlights the usefulness of sequences of susceptibility-weighted magnetic resonance imaging and the physiopathogenesis of periodic lateralised epileptiform discharges as an element of epileptic activity is discussed.