[Adult patients treated for focal epilepsy with antiepileptic drugs (AEDs) in combination in France: description according to the 2009 ILAE definition of AED resistance (ESPERA study)]. / Patients adultes traités par une association d'antiépileptiques pour une épilepsie focale en France: description et mode de prise en charge selon les nouveaux critères de définition de la pharmacorésistance (étude ESPERA).

AIMS: To describe the adult population treated with antiepileptic drugs (AEDs) in combination for focal epilepsy according to the definition of AED resistance proposed by the International League Against Epilepsy (ILAE) in 2009 and to evaluate its implementation in current practice. METHODS: ESPERA was a multicenter, observational, cross-sectional study with a clinical data collection covering the past 12 months conducted by neurologists. Classifications according to AED responsiveness established by investigators for each enrolled patient were revised by two experts. RESULTS: Seventy-one neurologists enrolled 405 patients. Their mean age was 42.7 years (sex-ratioM/F 0.98). According to the investigators, 60% of epilepsies were drug-resistant, 37% drug-responsive and 3% had an undefined drug-responsiveness. After revision of experts, 71% of epilepsies were classified as drug resistant, 22% as responsive and 7% as undefined. Among the participating neurologists, 76% have made at least one error in classifying their patients according to the 2009 ILAE definition of AED resistance. Because of epilepsy, 24% of patients (age≤65) were inactive and 42% could not drive (respectively 29 and 49% of patients with AED resistant epilepsy). Half of patients had at least one other chronic condition. Number of prescribed drugs in combination and health care resource utilisation were significantly higher in patients with drug-resistant epilepsies than in patients with drug responsive epilepsies. CONCLUSION: ESPERA study shows that the use of new definition of drug-resistance in everyday practice seems difficult without any additional training and that the social and professional disability is frequent in adults with focal epilepsies treated with polytherapy.

Drug-resistant temporal lobe epilepsy is associated with postural control abnormalities.

Epilepsy is responsible for falls that are not systematically associated with seizures and that therefore suggest postural impairment. There are very few studies of postural control in patients with epilepsy and none of them focus on temporal lobe epilepsy (TLE), although part of the vestibular cortex is located in the temporal cortex. The aim of this study was to evaluate the characteristics of postural control in a homogeneous population of patients with complex partial TLE. Twenty-six patients with epilepsy and 26 age-matched healthy controls underwent a sensory organization test combining six conditions, with and without sensory conflicting situations. Patients with epilepsy displayed poorer postural control, especially in situations where vestibular information is necessary to control balance. In addition to potential antiepileptic drug side effects, vestibular dysfunction could be related to the temporal pathology. Our study allows for a better understanding of the mechanism underlying falls in this population of patients.

Psychogenic nonepileptic seizures: characterization of two distinct patient profiles on the basis of trauma history.

This prospective study investigated and compared psychiatric features of 25 consecutive patients with psychogenic nonepileptic seizures (PNES) on the basis of presence of reported trauma. The "trauma" group comprised 19 patients (76%) and the "no-trauma" group comprised 6 patients (34%). We compared history of PNES, psychiatric comorbidity, alexithymia, and symptoms of dissociation. The study clearly characterized two distinct profiles of patients with PNES on the basis of trauma history. Patients with trauma had at least one psychiatric comorbidity or antecedent (vs 0% in the no-trauma group NT, P<0.001) and a higher median score of dissociation (P<0.001). Patients without trauma had more frequent "frustration situations" as a factor triggering PNES and subsequent sick leaves as perpetuating factors (P=0.001). Trauma antecedents correlated with a high rate of psychiatric comorbidity and a strong dissociative mechanism. Patients without trauma had no psychiatric comorbidity and a weaker dissociative mechanism.

Pre-existing arterial stiffness can predict hypotension during induction of anaesthesia in the elderly.

BACKGROUND: The aim of the present study was to establish whether elevated carotid-femoral pulse wave velocity (c-fPWV), an indicator of aortic stiffness, assessed before surgery, is correlated with variations in arterial pressure (AP) during induction of anaesthesia in elderly patients undergoing non-cardiovascular surgery. METHODS: c-fPWV was measured with the PulsePen(®) device during pre-surgical anaesthetic evaluation. Monitoring included electrocardiography, pulse oximetry, non-invasive AP, heart rate, bispectral index (BIS), and oxygen concentration during induction of anaesthesia with propofol and remifentanil. Anaesthesia was induced so as to maintain BIS values between 40 and 50. RESULTS: Forty-five patients, aged [mean (sd)] 71.1 (5.8) yr, were studied. The mean value of c-fPWV was 12.1 (3.9) m s⁻¹. There was no correlation between hypotension during anaesthesia induction and total dosage or rate of administration of propofol or remifentanil. In univariate analysis, only age and PWV significantly correlated with the decreases in AP, and the association between c-fPWV and a decrease in AP was also seen in multivariate analysis (r = 0.36, P< 0.05). Patients classified as having 'high stiffness' (c-fPWV ≥ 12.9 m s⁻¹) had 25% further decrease in systolic AP during anaesthesia induction than those with lower PWV [75.2 (5.7) vs 60.2 (4.2) mm Hg, P < 0.05]. CONCLUSIONS: Increased aortic stiffness, as assessed by PWV measured during preoperative anaesthetic evaluation, is associated with more pronounced hypotension during induction of anaesthesia. Measurement of aortic stiffness in the elderly may thus represent a valid indicator of the risk of hypotension during anaesthesia induction.

Automated cortical projection of EEG sensors: anatomical correlation via the international 10-10 system.

Several studies have described cranio-cerebral correlations in accordance with the 10-20 electrode placement system. These studies have made a significant contribution to human brain imaging techniques, such as near-infrared spectroscopy and trans-magnetic stimulation. With the recent development of high resolution EEG, an extension of the 10-20 system has been proposed. This new configuration, namely the 10-10 system, allows the placement of a high number (64-256) of EEG electrodes. Here, we describe the cranio-cerebral correlations with the 10-10 system. Thanks to the development of a new EEG-MRI sensor and an automated algorithm which enables the projection of electrode positions onto the cortical surface, we studied the cortical projections in 16 healthy subjects using the Talairach stereotactic system and estimated the variability of cortical projections in a statistical way. We found that the cortical projections of the 10-10 system could be estimated with a grand standard deviation of 4.6 mm in x, 7.1 mm in y and 7.8 mm in z. We demonstrated that the variability of projections is greatest in the central region and parietal lobe and least in the frontal and temporal lobes. Knowledge of cranio-cerebral correlations with the 10-10 system should enable to increase the precision of surface brain imaging and should help electrophysiological analyses, such as localization of superficial focal cortical generators.

[Risk of epilepsy after a first epileptic seizure in adults: Can we predict the future?]. / Prise en charge d'une première crise épileptique de l'adulte : peut-on prévoir l'avenir ?

The new definition of epilepsy recently proposed by an international panel of experts relies on the association of a first clinically certain seizure and of an enduring predisposition of the brain increasing the likelihood of future seizures. In the first part of this review, we will expose and organize into a hierarchical order the risk factors of subsequent recurrence. The major factors are: seizure(s) prior to presentation, paroxysmal abnormalities on early EEG, a remote symptomatic etiology. In the second part of this review, we will address the issue of clinical uncertainty when assessing the epileptic origin of a first clinical paroxysmal event, the reasons of uncertainty and the means to minimize it. We will analyze successively: the accuracy of eyewitness observations of transient loss of consciousness, the reliability and predictive validity of clinical criteria used for seizure assessment, the issue of overlapping clinical features between seizure and other non epileptic paroxysmal events (such as psychogenic non epileptic seizures), and finally the reliability and diagnostic value of early EEG for seizure assessment. To conclude, seizure assessment and diagnosis of epilepsy cannot be dissociated from syndrome and etiology diagnosis, which should be periodically reassessed towards a greater accuracy during the course of the disease.

[Specificity of epileptic seizures in the elderly: A proposed electro-clinical scale]. / Spécificités des crises d'épilepsie chez le sujet âgé : proposition d'un score électro-radioclinique d'orientation.

Diagnosis of epileptic seizure may be difficult in older patients because seizure manifestations are often unusual: confusion, paresis... and because there are multiple differential diagnoses (syncope, transient ischemic attack, transient global amnesia...). To promote and facilitate the diagnosis of seizures in the elderly, neurologists and gerontologists must work together and focus their strategy on two points: firstly, the knowledge of the specific presentation of seizures in elderly patients, and secondly, the adoption of a reasoning based on seizures and not epileptic syndromes. A multidisciplinary group worked on epilepsy of the elderly to elaborate an electro-clinical score which aims to help establish the diagnosis of epilepsy in elderly patients in different clinical settings. This electro-clinical score is based on a systematic review of scientific literature and the recommendations are explicitly linked to supporting evidence. Further, clinical validation of the electro-clinical score is required.

Multiple sclerosis with a progressive course from onset in Lorraine-Eastern France.

To investigate the patient characteristics, disease progression, and associated risk factors in patients with multiple sclerosis (MS) with a progressive onset, we conducted a longitudinal population-based study of 359 patients (252 with primary progressive MS (PPMS) and 107 with progressive relapsing MS (PRMS)) in Lorraine, France. As outcome measures, we assessed the time from MS onset to reaching disability status scale (DSS) scores of 4, 6 and 7 and the time from assignment of DSS score of 6 to assignment of DSS score of 7. We studied the influence on these outcomes of sex, age of onset and symptoms of onset. We also studied the influence of the time from MS onset to assignment of DSS 6 on the time from MS onset to assignment of DSS 7. There were no significant differences in the demographic data (gender and age at onset of MS) and clinical data (median time to DSS scores of 4, 6 and 7) between the patients with PPMS and PRMS suggesting such a distinction may be unnecessary. The male/female ratio in all 359 patients with MS with a progressive onset was 1/1.36. The median age at onset was 42.7 years (25% Q1 = 34.7; 75% Q3 = 50.0), was lower for male (40.5 years) than for female patients (44.2 years; p = 0.002). The median time to DSS scores of 4, 6 and 7 were (in years) 3.0 (95% CI = 2.8 to 3.7), 9.9 (95% CI = 9.0 to 10.6), and 17.0 (95% CI = 14.9 to 19.0). A cane was required in 25% of patients 5 years after onset and in 75% 15 years after onset. We did not find any significant unfluence of sex, age at onset, or symptoms at onset on the time from MS onset to assignment of scores 6 or 7 or on the time from the assignment of a score of 6 to the assignment of a score of 7.

Cerebral venous thrombosis caused by spontaneous intracranial hypotension: two cases.

The association of spontaneous intracranial hypotension (SIH) with cerebral venous thrombosis (CVT) is rare. We are reporting two new cases. In one case, CVT is extensive concerning three sinuses and bilateral parietal cortical veins and, in the other case, only a cortical vein is involved. Both the patients presented had no thrombosis risk factors. There is certainly a link between these two pathologies. SIH should be considered as a risk factor of CVT. Modification of symptoms of SIH leading to CVT must be known to start early treatment.

Spatial localization of EEG electrodes.

AIM OF THE STUDY: An important goal for EEG-based functional brain studies is to estimate the location of brain sources that produce the scalp-recorded signals. Such source localization requires locating precisely the position of the EEG sensors. This review describes and compares different methods that are used for localizing EEG sensors. RESULTS: Five different methods have been described in literature. Manual methods consist in manual measurements to calculate the 3D coordinates of the sensors. Electromagnetic and ultrasound digitization permit localization by using trade devices. The photogrammetry system consists in taking pictures of the patient's head with the sensors. The last method consists in directly localizing the EEG sensors in the MRI volume. DISCUSSION AND CONCLUSIONS: The spatial localization of EEG sensors is an important step in performing source localization. This method should be accurate, fast, reproducible, and cheap. Currently, electromagnetic digitization is the most currently used method but MRI localization could be an interesting way because no additional method or device needs to be used to locate the EEG sensors.

Fatigue in multiple sclerosis is related to disability, depression and quality of life.

Fatigue in multiple sclerosis is a frequent and disabling symptom that can interfere in daily functioning. The aim of this study is to demonstrate the relationship between fatigue and disability, disease course, depression and quality of life. We administered French valid versions of the Fatigue Impact Scale (EMIF-SEP), the short form of the Beck depression inventory (13 items) and the SF-36 to 237 out of 312 patients with clinically definite multiple sclerosis with EDSS

Determinants of arterial stiffness in an apparently healthy population over 60 years.

Arterial stiffness assessed by the pulse wave velocity (PWV), a non-invasive and reproducible method, predicts cardiovascular morbidity and mortality. The main determinants of arterial stiffness are well established in younger and middle-aged populations, but much less in the elderly. The aim of this study was to describe the determinants of arterial stiffness in elderly apparently healthy subjects. The study included 221 voluntary subjects born before 1944 (mean age 67.4+/-5.0 years), who had a standard health check-up at the 'Centre de Médecine Préventive' of Nancy. Arterial stiffness was evaluated by measuring the carotid-femoral PWV with the PulsePen automatic device. Clinical and biological parameters were evaluated at the same day. Measurements were valid and analysed in 207 subjects (94 women). Mean PWV was 9.39+/-2.64 m/s. Men showed higher PWV values than women (9.99+/-2.56 vs 8.66+/-2.56, P<0.001). In univariate analysis, PWV was correlated with age (r=0.26, P<0.001) and mean arterial pressure (MAP) (r=0.40, P<0.001), and these relationships were similar in men and women. Subjects with hypertension (P<0.001), diabetes mellitus (P<0.001) and obesity (P<0.01) had higher values of PWV. In multiple regression analysis, PWV correlated positively and independently with age, male gender, MAP and diabetes mellitus. In conclusion, in an apparently healthy elderly population, the main determinants of arterial stiffness are the age, MAP, diabetes and gender. Our study also shows that the gender-related differences in arterial stiffness observed in middle-aged subjects are maintained in the elderly.

[MRI findings in a case of prolonged status epilepticus]. / Suivi iconographique d'un etat de mal epileptique prolonge.

We report the MR imaging findings in a 20 year old woman with status epilepticus of more than 3 months duration following an episode of lymphocytic meningitis. Repeated MR examinations showed progressive symmetrical cortical lesions, followed by subcortical and basal ganglia lesions which evolved to cortical laminar necrosis and hemorrhagic necrosis with eventual subcortical cerebral atrophy. This case has similarities with animal status epilepticus models. Biological investigations were all negative. This suggests that the brain lesions may be related to the prolonged status epilepticus.

Lafora disease is not linked to the Unverricht-Lundborg locus.

Lafora disease and Unverricht-Lundborg disease are two forms of progressive myoclonus epilepsies (PME). Recently the gene for Unverricht-Lundborg disease (EPM1) was mapped to chromosome 21q22.3. Using three highly polymorphic DNA markers (D21S212, PFKL, and D21S171) which flank the EPM1 locus, we performed linkage analysis to investigate whether or not the EPM1 gene is also implicated in Lafora disease. Linkage was excluded in three North-African pedigrees each comprising at least two affected individuals. This result suggests that differential diagnosis of Lafora disease and Unverricht-Lundborg disease may be facilitated by molecular genetic analysis.

Brain death and transcranial Doppler: experience in 130 cases of brain dead patients.

BACKGROUND AND PURPOSE: Diagnosis of brain death requires confirmation of the clinical diagnosis by appropriate tests, generally electroencephalography (EEG) and angiography. The diagnostic limitations or logistical problems inherent to these tests indicate the need to develop other more appropriate methods. The results obtained with transcranial Doppler (TCD) led us to conduct this prospective study of TCD recordings in brain dead patients. METHODS: 130 patients, aged 2-88 years were diagnosed as brain dead between July 1987 and June 1993. Clinical criteria were confirmed in all cases by EEG (n=88) and or angiography (n=64). Intracranial anterior circulation was insonated via temporal windows or, when impossible, via a transorbital approach. The posterior circulation was studied only in more recent patients. Examinations were made as soon as possible after brain death diagnosis and repeated for about 30 min. Vital parameters and treatments were taken into account. RESULTS: There was only one false negative result, in a patient with an extended skull defect, who retained TCD and angiographic intracranial circulation despite confirmed irreversible brain death. All other patients displayed typical ultrasonic patterns of cerebral circulation arrest: an oscillating signal (n= 190, 73%), a systolic spike (n=62, 24%) or a unilateral absence of signal (n=5). Despite a total correlation for positive diagnosis, TCD and angiography may differ as to the level of circulation arrest. TCD is useful for patients under sedative drugs. No false positive result was encountered but we were unable to insonate any intracranial artery in 5 patients. CONCLUSION: Data from previous studies and the results of this study indicate that TCD is a very sensitive and safe method for diagnosing cerebral circulatory arrest. TCD may be used as a confirmatory test alongside EEG and angiography. TCD is more widely applicable than EEG and may be earlier and safer than angiography.

Are prescribed medications effective in the treatment of insomnia complaints?

Although frequently investigated in the general population, the epidemiology of insomnia complaints and their treatment have received little attention in general practice. This study recruited patients > or =15 years of age, consecutively, from 127 general practitioners in France. The physicians collected data from 11,810 of their patients, of whom 55.5% were women. Insomnia complaints were reported by 26.2% (25.4% to 27%) of the sample and use of sleep-promoting medication by 10.1% (9.7% to 10.7%). About 47% of the prescribed drugs used were anxiolytics and 45% hypnotics. Most consumers took sleep-enhancing drugs on a daily and long-term basis and most reported that the medication improved their quality of sleep. However, few distinctions emerged between elderly drug-taking insomniacs and elderly nontreated insomniacs with respect to the various dimensions of sleep. Results underscore the persistent general tendency among French general practitioners to overprescribe anxiolytics for the treatment of insomnia complaints and that they do so on a long-term basis, despite the findings of numerous studies showing that benzodiazepines are ineffective in the treatment of sleep complaints over the long term.

[Indications for emergency EEG in disease, a brief loss of consciousness in generalized epileptic seizures in the adult]. / Les indications urgentes de l'EEG face à un malaise, une perte de connaissance brève, une crise épileptique généralisée chez l'adulte.

EEG provides essential information for the management of patients in whom a first epileptic seizure is suspected because of transient alteration of consciousness. Postictal or interictal EEG abnormalities are useful to the clinician even when the diagnosis of epileptic seizure appears clinically evident. EEG is especially useful when recordings are performed immediately after the episode, in the absence of benzodiazepine therapy, and repeated later. After a transient loss or alteration of consciousness, the EEG should be considered as part of the emergency management, and thus rapidly obtained, whenever the evolution and/or the clinical signs of the episode are consistent with a focal epileptic seizure, especially if gestual or oro-facial automatisms, or bizarre deambulatory behavior have preceded the episode. EEG should also be considered as an emergency examination when a tonic-clonic seizure is suspected clinically, eg, when loss of consciousness is prolonged and inconsistent with a syncopal attack; when it is accompanied by clonic movements or spasms and followed by postictal confusion or stertor; when it entails a head injury or a tongue biting, or when it is preceded by premonitory signs or symptoms consistent with epilepsy. In the absence of such clinical suspicion, an EEG is not justified.

[Therapeutic education and information]. / Education thérapeutique et information.

The authors show that therapeutic education of the epileptic patient and his proxies is necessary but not yet organized for drug-resistant epilepsy; the objectives of this education are detailed after looking at the current status and the needs. The authors insist on the necessity of a global consideration of the patient: subjective and organic as well, taking into account the psychological and social dimensions and the experiences of the patient. The need of a specific formation for the physician and other health workers is emphasized, awaiting a status for therapeutic education. The authors propose a project of therapeutic education of the patient suffering from drug-resistant epilepsy.

[Five years after a first epileptic seizure appearing late in life]. / Cinq ans après une première crise épileptique apparue tardivement.

A first epileptic seizure in adulthood leads to fear a brain tumor and other important features of late epilepsies have received little attention. We have analyzed the etiologies in a group of 392 patients consecutively seen from 1977 to 1980. Our data are in keeping with previously reported data. One hundred and eighty patients were followed for five years or more. Fifty eight had only a single seizure (only 23 were treated, and 20 stopped therapy). Seizures recurred in 122 patients (97 untreated). The characteristics of recurrence have been analyzed. Some predictive factors appear significant. Socio-professional results have been considered. By and large, the prognosis was good for 75 p. 100 of patients.

[Neurological manifestations of alveolar echinococcosis]. / Manifestations neurologiques de l'échinococcose alvéolaire.

Among 78 cases of alveolar echinococcosis reported in Lorraine, France, 5 had neurologic complications which in 3 cases revealed the disease. Results of parasitic tests are discussed and emphasis is placed on differences between this disease and hydatidosis. Encephalic localizations (3 cases) were multiple making neurosurgery impossible. The outcome was fatal in 2 cases: 1 month after the initial neurologic signs in the absence of treatment (case 1) and 4 months after treatment with flubendazole (case 2). This drug was however effective in the 3rd case (hepatic, pulmonary and cerebral form) with follow-up now at 4 years. Epidemiologic, histopathologic, clinical, diagnostic characteristics and course of these encephalic localizations are reviewed. Spinal localizations (2 cases) presented with a picture of spinal cord compression. After laminectomy and flubendazole, the course was marked by relapse with death in one case and a satisfactory neurologic course with a 4 year follow-up in the other one.