Differences in factors associated with insomnia symptoms between patients with epilepsy with and without depressive symptoms.

OBJECTIVE: To determine if insomnia-related factors differ depending on the presence of depression in patients with epilepsy. METHODS: This cross-sectional multicenter study collected data on depressive symptoms, insomnia symptoms, and excessive daytime sleepiness, which were defined as a Patient Health Questionnaire-9 (PHQ-9) score of ≥ 10, an Insomnia Severity Index (ISI) score of ≥ 15, and an Epworth Sleepiness Scale (ESS) of ≥ 11, respectively. Further, uncontrolled seizures were defined as one or more seizures per month during antiseizure medications treatment. A stepwise logistic regression analysis was conducted, with a logistic regression with interaction terms performed to identify differences in insomnia-related factors depending on depressive symptoms. RESULTS: Of 282 adults with epilepsy (men, 58 %; mean age, 40.4 ± 13.9 years), a PHQ-9 score ≥ 10, an ISI score ≥ 15, an ESS score ≥ 11 were noted in 23.4 % (n = 66), 20.2 % (n = 57), and 12.8 % (n = 36), respectively. More patients with depressive symptoms had an ISI score ≥ 15 (56.1 % vs. 9.3 %; p < 0.001) than those without. In multiple logistic regression, uncontrolled seizures (odds ratio [OR], 4.896; p < 0.01), daytime sleepiness (OR, 5.369; p < 0.05), and a history of psychiatric disorders (OR, 3.971; p < 0.05) were identified as significant factors that were more likely to be associated with an ISI score ≥ 15; however, this was only true in patients without depressive symptoms. In contrast, use of perampanel (OR, 0.282; p < 0.05) was less likely associated, while female sex (OR, 3.178; p < 0.05) was more likely associated with an ISI score ≥ 15 only in patients with depressive symptoms. CONCLUSIONS: Insomnia-related factors in patients with epilepsy may differ between patients with and without depression. Our findings of different insomnia-related factors based on the presence of depression may facilitate the management of patients with epilepsy.

Aggression is more strongly associated with suicidality, independent of depression, than emotional instability and impulsivity in people with epilepsy.

PURPOSE: We evaluated the relative contributions of emotional instability, impulsivity, and aggression to the presence of suicide risk in people with epilepsy after adjusting for depressive symptoms. METHODS: This was a cross-sectional study that used the short form of the Affective Lability Scale (ALS-18), the Barratt Impulsiveness Scale Version 11 (BIS-11), the Brief Aggression Questionnaire (BAQ), and the Patient Health Questionnaire-9 (PHQ-9). Suicidality was assessed using the Mini International Neuropsychiatric Interview (MINI), and the presence of suicide risk was defined as a MINI suicidality score ≥1. Stepwise logistic regression and mediation analyses using a two-stage regression method were performed. RESULTS: Of the 171 subjects (63.2% men) included, suicide risk was present in 38 subjects (22.2%). The stepwise logistic regression analysis identified four variables that were independently associated with suicide risk: higher PHQ-9 score, higher BAQ score, longer duration of epilepsy, and unemployment. The univariate analysis showed that ALS-18 and BIS-11 scores were significantly associated with suicide risk; however, they were backward eliminated from the logistic model according to the criterion of p > 0.1. The mediating effects of ALS-18 and BIS-11 scores on suicide risk via PHQ-9 scores (but not BAQ scores) were significant, with the proportion mediated 61.5% and 54.0% of the total effect, respectively. CONCLUSIONS: Alongside depressive symptoms, aggression may be a more useful concept than emotional instability and impulsivity for identifying suicidal risk in people with epilepsy.

Effectiveness of Calcitonin Gene-Related Peptide Receptor Antagonists for Migraine Treatment: A Meta-Analysis.

INTRODUCTION: The pathophysiology of migraine has been researched incessantly, and it has been suggested that calcitonin gene-related peptide (CGRP) is associated with migraine attacks. CGRP receptor blockers are attracting attention as potential agents for migraine prevention and treatment of acute episodes. This meta-analysis aimed to assess the effects of available CGRP receptor antagonists, focusing on their therapeutic doses for acute migraine treatment. METHODS: We systematically searched MEDLINE and Embase from inception to March 27, 2021, for English-language publications using the keywords "migraine" and "calcitonin gene-related peptide"; the searches were limited to human studies. RESULTS: Five studies that focused on examining the effects of CGRP receptor antagonists on acute migraine treatment met the eligibility criteria for this meta-analysis. A pooled analysis demonstrated that CGRP receptor antagonists significantly increased freedom from pain (odds ratio [OR] = 2.066, 95% confidence interval [CI] 1.766-2.418, I2 = 0%) and from bothersome symptoms in general (OR = 1.606, 95% CI = 1.408-1.830, I2 = 0%); reduced the intensity of pain (OR = 1.791, 95% CI = 1.598-2.008, I2 = 0%); and increased freedom from nausea (OR = 1.361, 95% CI = 1.196-1.548, I2 = 0%) compared to a placebo. CONCLUSIONS: CGRP receptor antagonists are effective for acute migraine treatment and are expected to be used clinically as emerging therapeutic agents.

Comparisons of clinical characteristics, brain MRI findings, and responses to epidural blood patch between spontaneous intracranial hypotension and post-dural puncture headache: retrospective study.

BACKGROUND: Spontaneous intracranial hypotension and post-dural puncture headache are both caused by a loss of cerebrospinal fluid but present with different pathogeneses. We compared these two conditions concerning their clinical characteristics, brain imaging findings, and responses to epidural blood patch treatment. METHODS: We retrospectively reviewed the records of patients with intracranial hypotension admitted to the Neurology ward of the Pusan National University Hospital between January 1, 2011, and December 31, 2019, and collected information regarding age, sex, disease duration, hospital course, headache intensity, time to the appearance of a headache after sitting, associated phenomena (nausea, vomiting, auditory symptoms, dizziness), number of epidural blood patch treatments, and prognosis. The brain MRI signs of intracranial hypotension were recorded, including three qualitative signs (diffuse pachymeningeal enhancement, venous distention of the lateral sinus, subdural fluid collection), and six quantitative signs (pituitary height, suprasellar cistern, prepontine cistern, mamillopontine distance, the midbrain-pons angle, and the angle between the vein of Galen and the straight sinus). RESULTS: A total of 105 patients (61 spontaneous intracranial hypotension patients and 44 post-dural puncture headache patients) who met the inclusion criteria were reviewed. More patients with spontaneous intracranial hypotension required epidural blood patch treatment than those with post-dural puncture headache (70.5% (43/61) vs. 45.5% (20/44); p = 0.01) and the spontaneous intracranial hypotension group included a higher proportion of patients who underwent epidural blood patch treatment more than once (37.7% (23/61) vs. 13.6% (6/44); p = 0.007). Brain MRI showed signs of intracranial hypotension in both groups, although the angle between the vein of Galen and the straight sinus was greater in the post-dural puncture headache group (median [95% Confidence Interval]: 85° [68°-79°] vs. 74° [76°-96°], p = 0.02). CONCLUSIONS: Patients with spontaneous intracranial hypotension received more epidural blood patch treatments and more often needed multiple epidural blood patch treatments. Although both groups showed similar brain MRI findings, the angle between the vein of Galen and the straight sinus differed significantly between the groups.

Insomnia moderates the association between recurrent seizures and emotional instability in persons with epilepsy.

PURPOSE: We investigated the moderating effect of sleep disturbance on the association between seizure recurrence and emotional instability in patients with epilepsy, independent of psychological distress. METHODS: This was a cross-sectional study. Patients completed the short form of the Affective Lability Scale (ALS-18), Insomnia Severity Index (ISI), Patient Health Questionnaire-9 (PHQ-9), and Generalized Anxiety Disorder-7 (GAD-7). A stepwise linear regression analysis and an analysis of covariance with an interaction term were performed. RESULTS: A total of 171 subjects (63.2% men) were included. The mean ALS-18 score was 15.6 ±â€¯11.3. An ISI ≥ 15, PHQ-9 ≥ 10, and GAD-7 ≥ 7 were noted in 20.5%, 18.1%, and 23.4% of subjects, respectively. A stepwise linear regression analysis found that recurrent seizures in the last year, an ISI ≥ 15, a GAD-7 ≥ 7, and use of levetiracetam were significant and independent factors that were positively associated with higher ALS-18 scores. The coefficient of determination for the model was 0.331. The interaction between recurrent seizures and an ISI ≥ 15 had a significant effect on the ALS-18 scores (F = 6.812, p = 0.010, partial eta2 = 0.040). An ISI ≥ 15 was associated with ALS-18 scores in patients without seizure recurrence (p < 0.001). This association almost reached significance (p = 0.084) in those with recurrent seizures. In contrast, the presence of recurrent seizures was associated with ALS-18 scores in patients with an ISI < 15 (p < 0.001), but not in those with an ISI ≥ 15 (p = 0.360). CONCLUSIONS: The significant interaction between insomnia and seizure status may have an effect on emotional instability. These findings have clinical implications in the development of potential interventions for emotional instability in patients with epilepsy.

Sex differences in seizure effects on social anxiety in persons with epilepsy.

PURPOSE: We investigated sex differences in the effect of seizures on social anxiety in persons with epilepsy. METHOD: In this cross-sectional multicenter study, social anxiety was measured using the short forms of the Social Phobia Scale (SPS-6) and Social Interaction Anxiety Scale (SIAS-6). SPS-6 scores ≥ 9 and SIAS-6 scores ≥ 12 were considered to indicate social phobia and social interaction anxiety, respectively. The Patient Health Questionnaire-9, Stigma Scale-Revised, and Family Adaptation-Partnership-Growth-Affection-Resolve scale were also completed. A logistic regression analysis with an interaction term was used to analyze the data. RESULTS: Out of 285 participants, a SPS-6 score ≥ 9 and a SIAS-6 score ≥ 12 were noted in 62 (21.8%) and 36 (12.6%) of participants, respectively. There was no difference in the prevalence of social anxiety between men and women. Intractable seizures and lack of seizure freedom were associated with a SPS-6 score ≥ 9 and a SIAS-6 score ≥ 12, but statistical significance was lost in the adjusted models. However, intractable seizures and lack of seizure freedom significantly interacted with sex for a SPS-6 score ≥ 9 (p = 0.018) and a SIAS-6 score ≥ 12 (p = 0.048) in both the separate and adjusted models. Specifically, intractable seizures tended to be positively associated with SPS-6 scores ≥ 9 than non-intractable seizures in men only (odds ratio = 2.602, p = 0.068), whereas lack of seizure freedom tended to be negatively associated with SIAS-6 scores ≥ 12 than seizure freedom in women only (odds ratio = 4.804, p = 0.053). CONCLUSION: We found significant sex differences in seizure effects on social anxiety. Intractable seizures were associated with social phobia in men, whereas lack of seizure freedom in the last year was associated with social interaction anxiety in women.

Factors associated with obsessive-compulsive symptoms in people with epilepsy.

PURPOSE: Obsessive-compulsive disorder (OCD) is a common but underrecognized psychiatric condition comorbid with epilepsy. We thus investigated clinical factors associated with obsessive-compulsive symptoms (OCS) in adults with epilepsy. METHODS: This was a cross-sectional multicenter study in Republic of Korea. Obsessive-compulsive symptoms were assessed using the Obsessive-Compulsive Inventory-Revised (OCI-R). Clinical factors that were assessed included age, sex, seizure-related variables, and the number and use of antiepileptic drugs (AEDs) prescribed. Data were analyzed by stepwise linear regression and adjusted according to anxiety and depressive symptoms as assessed by Hospital Anxiety Depression Scale (HADS). RESULTS: The study population comprised 221 adults with epilepsy (42.1% male, 39.7 ±â€¯11.9 years of age). The mean OCI-R score was 18.0 (standard deviation, 12.7), and an OCI-R score of ≥21 was obtained for 40.3% of the study sample. On a stepwise linear regression analysis, epilepsy severity, temporal lobe seizures, the use of topiramate, and the use of lamotrigine were identified as independent factors associated with OCI-R score after adjusting for anxiety according to the HADS. All factors except topiramate usage were positively associated with OCS. The total explained variance was 37.3%. CONCLUSIONS: Obsessive-compulsive symptoms are common in persons with epilepsy and are associated with severe epilepsy, temporal lobe seizures, and the use of topiramate and lamotrigine. Specifically, the use of lamotrigine may aggravate OCS, whereas the use of topiramate may have beneficial effects on OCS.

Factors associated with stigma and depressive symptoms in family members of patients with epilepsy.

PURPOSE: Literature regarding family stigma related to epilepsy is scarce. This study investigated the prevalence of family stigma and depressive symptoms and the associated factors among the family members of patients with epilepsy. METHODS: In a cross-sectional study, Stigma Scale-Revised score ≥ 4 and Patient Health Questionnaire-9 score ≥ 10 were considered indicative of moderate-to-severe stigma and depressive symptoms, respectively. Stepwise logistic regression analyses were performed. RESULTS: Of the 482 family members, a mean age was 47.1 ±â€¯9.4 years, and 73.4% were female. Of the patients, a mean age was 25.5 ±â€¯16.7 years, and 45.0% were female. Idiopathic generalized epilepsy and focal epilepsy were noted in 22.4% and 65.6% of patients, respectively. Family stigma and depressive symptoms were noted in 10.0% and 11.2% of family members, respectively. Family stigma was significantly associated with high seizure frequency and being a sibling or offspring of a patient independent of their depressive symptoms. By contrast, depressive symptoms in family members were significantly associated with polytherapy, being parents of a patient, and neurological comorbidities independent of family stigma. In a subset of patients and their family, patients had higher proportion of stigma and depressive symptoms than their family. Depressive symptoms and stigma among patients were significantly correlated with those among parents, but not spouse. CONCLUSION: Family stigma is common in families with epilepsy and is closely related to depressive symptoms. Frequent seizures, polytherapy, neurological comorbidities, and the relationship to a patient may be factors that are independently associated with family stigma and depressive symptoms in family members.

Does the new Korean term for epilepsy reduce the stigma for Korean adults with epilepsy?

PURPOSE: The purpose of this study was to evaluate differences in stigma, disclosure management of epilepsy, and knowledge about epilepsy between patients with epilepsy who recognized and did not recognize the new Korean term for epilepsy. METHODS: This was a cross-sectional, multicenter study. The Stigma Scale-Revised, the Disclosure Management Scale, the Patient Health Questionnaire-9, and a questionnaire assessing knowledge about epilepsy were used. The set of questionnaires had two versions, using either the old or new name for epilepsy. Multivariate logistic regression analyses were used. RESULTS: A total of 341 patients with epilepsy and 509 family members were recruited. Approximately 62% of patients felt some degree of epilepsy-related stigma. Mild stigma, severe concealment of epilepsy diagnosis, and increased knowledge about epilepsy were independently identified as factors associated with recognition of the new term in patients. Recognition of the new term was more prevalent in patients and family members with higher education, female family members, and family members having patients with younger age at seizure onset and shorter duration of epilepsy. There were no significant differences between the two types of questionnaires. About 81% of patients and 93% of family members had a positive attitude about renaming epilepsy. CONCLUSION: The use of the new Korean term for epilepsy (cerebroelectric disorder) increased knowledge about epilepsy but did not reduce stigma and concealment of epilepsy diagnosis in Korean adults with epilepsy. Higher education may be an important factor for knowing the new term in patients and family members.

Factors associated with social anxiety in South Korean adults with epilepsy.

PURPOSE: The aim of this study was to examine social anxiety in South Korean adults with epilepsy and to identify associated factors. METHOD: This was a cross-sectional, multicenter study in South Korea. Social anxiety was assessed using short forms of the Social Phobia Scale (SPS-6) and Social Interaction Anxiety Scale (SIAS-6). The SPS-6 scores ≥9 and SIAS-6 scores ≥12 were considered indicative of social phobia and social interaction anxiety, respectively. The Patient Health Questionnaire-9 (PHQ-9); Stigma Scale-Revised (SS-R); Disclosure Management Scale; Family Adaptation, Partnership, Growth, Affection, Resolve (F-APGAR) scale; and a questionnaire assessing knowledge about epilepsy were also used. RESULTS: Of a total of 219 patients with epilepsy, 21% and 11% had SPS-6 scores ≥9 and SIAS-6 scores ≥12, respectively. In logistic regression analysis, SPS-6 scores ≥9 were independently associated with SS-R scores of 4-9 (odds ratio [OR]: 8.626, 95% confidence interval [CI]: 2.515-29.587, p = .001), SS-R scores 1-3 (OR: 5.496, 95% CI: 1.757-17.197, p = .003), and PHQ-9 scores ≥10 (OR: 4.092, 95% CI: 1.823-9.185, p = .001). In contrast, SIAS-6 scores ≥12 were related only to PHQ-9 scores ≥10 (OR: 8.740, 95% CI: 3.237-23.599, p < .001). Belonging to a dysfunctional family and lack of knowledge about epilepsy tended to be associated with social phobia (p = .071) and social interaction anxiety (p = .090), respectively. Epilepsy-related variables were not related to social anxiety. CONCLUSION: Social anxiety is not rare in patients with epilepsy. In this study, social phobia was associated with perceived stigma and depressive symptoms, whereas social interaction anxiety was related only to depressive symptoms in patients with epilepsy.

Associations between religiosity and anxiety, depressive symptoms, and well-being in Korean adults living with epilepsy.

PURPOSE: Religiosity can be important in the everyday life of persons with epilepsy (PWE). How PWE live with religiosity can be influenced by their cultural background. We determined whether religiosity is associated with anxiety, depressive symptoms, and well-being in Korean adults with epilepsy. METHODS: This multicenter cross-sectional study was conducted in the outpatient clinics of five university hospitals in Korea. Religiosity was assessed using the five-item Duke University Religion Index (DUREL). The WHO-Five Well-Being Index (WHO-5) and Hospital Anxiety Depression Scale were used. The participants were categorized into three subgroups bounded by the 33rd and 66th percentiles of their DUREL scores. RESULTS: Of a total of 226 participants, 61.1% declared that they had religious affiliation. The median DUREL score was 11 (interquartile ranges 6, 18). All three subscales of the DUREL were significantly related to WHO-5 (p<0.01). Non-organizational religious activities such as prayer and meditation were also inversely related to anxiety (p<0.05) and depressive symptoms (p<0.01). After controlling for confounding variables, anxiety and depressive symptoms were more extensive in the low religiosity subgroup than in the high or no religiosity subgroup (p<0.01) and well-being was higher in the high or low religiosity subgroup than in the no religiosity subgroup (p<0.05). CONCLUSIONS: Religiosity is significantly associated with anxiety, depressive symptoms, and well-being in Korean adults with epilepsy.

Factors contributing to the development of perceived stigma in people with newly diagnosed epilepsy: A one-year longitudinal study.

PURPOSE: We evaluated the course of perceived stigma and the factors associated with perceived stigma over the first year in newly diagnosed people with epilepsy (PWE). METHODS: We recruited newly diagnosed PWE from 12 tertiary hospitals in Korea. The perceived stigma of epilepsy was assessed using the Stigma Scale at baseline and one year later. At the time of diagnosis, demographic, clinical seizure-related, and psychological data were collected. The predictive factors for perceived stigma over one year were analyzed using logistic regression analyses. RESULTS: Two hundred eighteen newly diagnosed PWE were included at baseline, and 153 completed the study. The percentage of participants who felt stigmatized decreased from 30.7% at the time of diagnosis to 17.6% at the end of follow-up. Introverted personality and a high level of anxiety were independent factors contributing to stigma at the time of epilepsy diagnosis. At the one-year follow-up, introverted personality and lower economic status were predictive of the development of perceived stigma. CONCLUSION: Introverted personality was an important factor contributing to the development of perceived stigma at the time of diagnosis and at one year after diagnosis. In addition, a high level of anxiety and a low economic status were independently related to feelings of stigma at baseline and at one year after diagnosis, respectively. There may be a decrease in the perception of stigma over one year in newly diagnosed PWE.

Quantitative EMG criteria for diagnosing idiopathic REM sleep behavior disorder.

PURPOSE: The purpose of this study is to determine the diagnostic cutoff for the proportion of rapid eye movement (REM) sleep with tonic and phasic activities of the submentalis muscle activity that can be used to diagnose REM sleep behavior disorder (RBD). METHODS: Seventeen patients clinically diagnosed as idiopathic RBD and 15 age- and gender-matched controls were studied. Surface electromyography was recorded from the submentalis muscle, and two sleep technologists manually identified epochs with tonic and phasic activities during REM sleep. Receiver operating characteristic (ROC) curves were constructed to find the optimal cutoff values for diagnosing RBD using the proportion of REM sleep with tonic and phasic activities of the submentalis muscle. Cohen's kappa coefficient was calculated to evaluate interrater reliability. RESULTS: The cutoff value with the optimal sensitivity and specificity was 6.5% for the proportion of REM sleep with tonic activity (sensitivity, 94.1%; specificity, 93.3%; area under the ROC curve, 0.976) and 9.5% for the proportion of REM sleep with phasic activity (sensitivity, 94.1%; specificity, 93.3%; area under the ROC curve, 0.992). The cutoff value required to achieve a specificity of 100% was 8.9% for tonic activity and 11.1% for phasic activity. Cohen's kappa coefficient between two scorers was 0.96 (95% confidence interval, 0.95-0.97) and 0.95 (95% confidence interval, 0.94-0.95) for tonic and phasic activities, respectively (both p < 0.001). CONCLUSIONS: Identifying periods of tonic and phasic activities of the submentalis muscle during REM sleep is useful to discriminate patients with idiopathic RBD from controls.

Gender differences in the effect of comorbid insomnia symptom on depression, anxiety, fatigue, and daytime sleepiness in patients with obstructive sleep apnea.

PURPOSE: This study investigated gender differences in the effect of comorbid insomnia symptom on depression, anxiety, fatigue, daytime sleepiness, and quality of life in patients with obstructive sleep apnea. There are gender differences in the presentation of obstructive sleep apnea. However, the influence of gender on the presentation of comorbid insomnia symptom and obstructive sleep apnea is not known. METHODS: Allparticipantsperformed overnightpolysomnography and completed a battery of questionnaires including Beck Depression Inventory, State-Trait Anxiety Inventory, Multidimensional Fatigue Inventory, Epworth Sleepiness Scale, and Short Form-36 Health Survey. Insomnia symptom was defined as present if a patient had any insomnia complaints longer than 1 month and at least one time per week. RESULTS: Six hundred fifty-five adult patients with obstructive sleep apnea were enrolled; 233 (35.5 %) reported comorbid insomnia symptom with obstructive sleep apnea. The severity of obstructive sleep apnea was not related to comorbid insomnia symptom. Based on linear regression, women had higher depression, fatigue, and daytime sleepiness and lower health-related quality of life than men (all, p<0.05). The presence of insomnia symptom had negative effects on fatigue (p=0.005) and quality of life only (p=0.015) in men but not in women when taking gender-by-insomnia interaction into consideration. There were significant differences in polysomnography-based sleep architecture between the obstructive sleep apnea-only and obstructive sleep apnea-insomnia groups, but only in the subgroup of men. CONCLUSIONS: Men are more prone to the negative impact of comorbid insomnia symptom and obstructive sleep apnea on their level of fatigue and quality of life than women.

Assessing the performance of ChatGPT's responses to questions related to epilepsy: A cross-sectional study on natural language processing and medical information retrieval.

BACKGROUND: Epilepsy is a neurological condition marked by frequent seizures and various cognitive and psychological effects. Reliable information is essential for effective treatment. Natural language processing models like ChatGPT are increasingly used in healthcare for information access and data analysis, making it crucial to assess their accuracy. OBJECTIVE: This study aimed to investigate the accuracy of ChatGPT in providing educational information related to epilepsy. METHODS: We compared the answers from ChatGPT-4 and ChatGPT-3.5 to 57 common epilepsy questions based on the Korean Epilepsy Society's "Epilepsy Patient and Caregiver Guide." Two epileptologists reviewed the responses, with a third serving as an arbiter in cases of disagreement. RESULTS: Out of 57 questions, 40 responses from ChatGPT-4 had "sufficient educational value," 16 were "correct but inadequate," and one was "mixed with correct and incorrect" information. No answers were entirely incorrect. GPT-4 generally outperformed GPT-3.5 and was often on par with or better than the official guide. CONCLUSIONS: ChatGPT-4 shows promise as a tool for delivering reliable epilepsy-related information and could help alleviate the educational burden on healthcare professionals. Further research is needed to explore the benefits and limitations of using such models in medical contexts.

Case report: Neuronal intranuclear inclusion disease initially mimicking reversible cerebral vasoconstriction syndrome: serial neuroimaging findings during an 11-year follow-up.

Neuronal intranuclear inclusion disease (NIID) is a rare, progressive neurodegenerative disorder known for its diverse clinical manifestations. Although episodic neurogenic events can be associated with NIID, no reported cases have demonstrated concurrent clinical features or MRI findings resembling reversible cerebral vasoconstriction syndrome (RCVS). Here, we present the inaugural case of an adult-onset NIID patient who initially displayed symptoms reminiscent of RCVS. The 59-year-old male patient's initial presentation included a thunderclap headache, right visual field deficit, and confusion. Although his brain MRI appeared normal, MR angiography unveiled left posterior cerebral artery occlusion, subsequently followed by recanalization, culminating in an RCVS diagnosis. Over an 11-year period, the patient encountered 10 additional episodes, each escalating in duration and intensity, accompanied by seizures. Simultaneously, cognitive impairment progressed. Genetic testing for NIID revealed an abnormal expansion of GGC repeats in NOTCH2NLC, with a count of 115 (normal range, <60), and this patient was diagnosed with NIID. Our report highlights that NIID can clinically and radiologically mimic RCVS. Therefore, in the differential diagnosis of RCVS, particularly in cases with atypical features or recurrent episodes, consideration of NIID is warranted. Additionally, the longitudinal neuroimaging findings provided the course of NIID over an 11-year follow-up period.

Comparison of three actigraphic algorithms used to evaluate sleep in patients with obstructive sleep apnea.

PURPOSE: Actigraphy is a non-invasive and valid method to detect sleep/wake status. However, the technique lacks reliability in patients with sleep-disordered breathing and its results may depend on the algorithm employed. METHODS: We compared three currently used algorithms (the Cole-Kripke, Sadeh, and University of California San Diego [UCSD]) and determined which is the most reliable in patients with obstructive sleep apnea (OSA) assessing total sleep time. After identification of the most reliable algorithm, we compared total sleep time with the severity of obstructive sleep apnea. RESULTS: The mean total sleep time was not significantly different from that yielded by polysomnography when the UCSD algorithm was employed (p = 0.798) and UCSD algorithm was associated with the smallest bias. The correlation levels (with polysomnographic data) were mild-to-modest when the results yielded by all algorithms were evaluated, but were highest when the UCSD algorithm was employed (UCSD, r = 0.498, p < 0.001; Cole-Kripke, r = 0.389, p < 0.01; Sadeh, r = 0.272, p = 0.057). Actigraphic measures of mean total sleep time underestimated sleep in patients with severe obstructive sleep apnea (apnea-hypopnea index [AHI] ≥30), and the correlation was low (r = 0.317, p = 0.116), but overestimated sleep, with high correlations, in patients with mild (5 ≤ AHI < 15) and moderate OSA (15 ≤ AHI < 30; r = 0.859, p < 0.001; r = 0.842, p < 0.001, respectively). CONCLUSIONS: Among the three actigraphic algorithms tested in this study, sleep duration estimated by the UCSD algorithm was the most correlated with polysomnography data in an OSA population. However, none of them was reliable enough for estimating sleep time in patients with sleep-disordered breathing, especially in patients with severe OSA.

Comparisons of impulsivity among patients with different subtypes of epilepsy.

PURPOSE: This study assessed whether patients with epilepsy have a higher level of impulsivity than healthy controls, and compared impulsivity among patients with different subtypes of epilepsy. METHODS: The multicenter study included 108 subjects with epilepsy and 56 healthy volunteers. Subjects were evaluated by the Barratt Impulsiveness Scale-11 (BIS-11) and Patient Health Questionnaire-9, with BIS-11 scores analyzed as both dichotomized and continuous variables. High impulsivity was defined as a total BIS-11 score ≥ 67. RESULTS: Of the 108 subjects with epilepsy, 36 had idiopathic generalized epilepsy (IGE), 47 had temporal lobe epilepsy (TLE), and 25 had frontal lobe epilepsy (FLE). A significantly higher percentage of subjects with epilepsy (22.2%) than controls (1.8%) had BIS-11 scores ≥ 67 (p = 0.001), although mean BIS-11 scores were similar in subjects with epilepsy (59.5 ± 10.0) and controls (58.8 ± 4.6). Higher percentages of subjects with IGE and FLE had BIS-11 scores ≥ 67 than subjects with TLE and controls. Mean total BIS-11 scores did not differ between controls and subjects with IGE and FLE, but were lower in subjects with TLE than in controls. Differences in impulsivity among controls and subjects with epilepsy subtypes varied depending on BIS-11 subscale. CONCLUSIONS: Patients with epilepsy, particularly IGE and FLE, were more likely to have high impulsivity scores, defined by a certain cutoff on the BIS-11, than controls and subjects with TLE. However, mean impulsivity scores did not differ among controls and subjects with IGE and FLE. Dichotomizing BIS-11 scores may be necessary to avoid false negative results in subjects with epilepsy.

Clinical significance of Epstein-Barr virus in the cerebrospinal fluid of immunocompetent patients.

INTRODUCTION: Polymerase chain reaction (PCR)-based testing of cerebrospinal fluid (CSF) samples has greatly facilitated the diagnosis of central nervous system (CNS) infections. However, the clinical significance of Epstein-Barr virus (EBV) DNA in CSF of individuals with suspected CNS infection remains unclear. We wanted to gain a better understanding of EBV as an infectious agent in immunocompetent patients with CNS disorders. METHODS: We identified cases of EBV-associated CNS infections and reviewed their clinical and laboratory characteristics. The study population was drawn from patients with EBV PCR positivity in CSF who visited Pusan National University Hospital between 2010 and 2019. RESULTS: Of the 780 CSF samples examined during the 10-year study period, 42 (5.4 %) were positive for EBV DNA; 9 of the patients (21.4 %) were diagnosed with non-CNS infectious diseases, such as optic neuritis, Guillain-Barré syndrome, and idiopathic intracranial hypotension, and the other 33 cases were classified as CNS infections (22 as encephalitis and 11 as meningitis). Intensive care unit admission (13/33 patients, 39.3 %) and presence of severe neurological sequelae at discharge (8/33 patients, 24.2 %) were relatively frequent. In 10 patients (30.3 %), the following pathogens were detected in CSF in addition to EBV: varicella-zoster virus (n = 3), cytomegalovirus (n = 2), herpes simplex virus 1 (n = 1), herpes simplex virus 2 (n = 1), Streptococcus pneumomiae (n = 2), and Enterococcus faecalis (n = 1). The EBV-only group (n = 23) and the co-infection group (n = 10) did not differ in age, gender, laboratory data, results of brain imaging studies, clinical manifestations, or prognosis; however, the co-infected patients had higher CSF protein levels. CONCLUSION: EBV DNA in CSF is occasionally found in the immunocompetent population; the virus was commonly associated with encephalitis and poor prognosis, and frequently found together with other microbes in CSF.

Herpes simplex viruses (1 and 2) and varicella-zoster virus infections in an adult population with aseptic meningitis or encephalitis: A nine-year retrospective clinical study.

ABSTRACT: Three α-herpesviruses are known to be associated with central nervous system (CNS) infection; however, there are limited data on the incidence and clinical characteristics of α-herpesviruses CNS infections. This study aimed to assess the clinical manifestations, laboratory findings, and outcomes in patients with human herpes simplex virus 1 (HSV-1), human herpes simplex virus 2 (HSV-2), and varicella-zoster virus (VZV) CNS infections.We identified cases of HSV-1, HSV-2, and VZV CNS infections and reviewed their clinical and laboratory characteristics. The study population was drawn from patients with HSV-1, HSV-2, and VZV polymerase chain reaction positivity in cerebrospinal fluid (CSF) who visited Pusan National University Hospital between 2010 and 2018.During the 9-year study period, a total of 727 CSF samples were examined, with 72.2% (525/727) patients identified as having a CNS infection. Of 471 patients with aseptic meningitis and encephalitis, the causative virus was identified in 145 patients, and no virus was detected in 337 patients. A total of 15.2% (80/525) were diagnosed with one of the 3 herpesviruses as causative agents, 59 patients had meningitis, and 21 patients had encephalitis. Eleven patients with HSV-1, 27 patients with HSV-2, and 42 patients with VZV CNS infections were included. The distribution of cases by age showed different patterns depending on the type of herpesvirus infection. Compared with the HSV-1 group, the median age in the HSV-2 group was younger (HSV-1: 58 years; HSV-2: 38 years; P = .004), and patients with VZV infections showed a bimodal age distribution. Encephalitis was more common in the HSV-1 group, and HSV-1 infection was associated with a poor prognosis at discharge. CSF white blood cell counts were significantly lower in patients infected with HSV-1 (117 × 106 cells/L) than in patients infected with VZV (301 × 106 cells/L) (P = .008).These 3 herpesviruses are important causes of CNS infections regardless of immunologic status. HSV-1 infection was commonly associated with encephalitis and poor prognosis; HSV-2 and VZV CNS infections were associated with a low risk of mortality and neurological sequelae.