Temporal lobe epilepsy. / Temporallappsepilepsi.

The temporal lobes are the part of the brain most likely to give rise to epileptic seizures. Seizures originating in the temporal lobes vary greatly in character; some may be so unusual that they are not even recognised as epileptic. For patients who have been diagnosed with hippocampal sclerosis and whose seizures cannot be controlled with drugs, epilepsy surgery may be a good treatment option. In this brief clinical review, we summarise the key features of epilepsy and highlight the importance of accurate and early diagnosis for achieving good clinical outcomes.

The Value of Macular Optical Coherence Tomography in Watchful Waiting of Suprasellar Masses: A 2-Year Observational Study.

BACKGROUND: A possible benefit of optical coherence tomography (OCT) in the approach to tumors involving the optic chiasm may be the ability to foresee visual deterioration. This study investigated the value of OCT in watchful waiting for compressive optic neuropathy as the primary management of suprasellar masses. METHODS: The research was conducted as a 2-year observational study of a patient cohort with conservatively managed mass lesions involving the optic chiasm on MRI. Threshold perimetry and macular OCT were performed at baseline and each follow-up examination. Univariate Cox regression was used to determine the effect of baseline and longitudinal covariates upon development of visual field (VF) loss compatible with chiasmal dysfunction. RESULTS: Nineteen eyes of 19 patients were included. The optic chiasm-tumor relationship on baseline MRI was abutment in 6 cases and compression in 13 cases. Seven eyes developed VF loss. None of the baseline covariates were predictors of VF loss. The longitudinal decrease in mean macular ganglion cell complex (mGCC) thickness on OCT was 2.5 µm/yr for eyes that developed VF loss and 0.2 µm/yr for eyes that did not develop VF loss (P = 0.02). The hazard ratio for VF loss per 1-µm/yr decrease in mGCC thickness was 1.30 (95% confidence interval [CI] 1.04-1.62; P = 0.02) for the inferior nasal quadrant and 1.45 (95% CI 1.02-2.07; P = 0.04) for the inferior temporal quadrant. CONCLUSIONS: OCT offers a valuable complement to perimetry in monitoring for compressive optic neuropathy. Longitudinal mGCC thinning can anticipate VF loss.

A man in his fifties with variable weakness and difficulty in walking. / En mann i 50-årene med varierende kraftsvikt og gangvansker.

BACKGROUND: An active man in his fifties was treated for atrial fibrillation with ablation. One week later he noticed variable weakness in his lower extremities. In the days that followed, his symptoms improved but could vary from day to day. CASE PRESENTATION: On admission 3 months after the initial symptoms, he had spasticity and weakness in both lower extremities, with hyperreflexia and positive Babinski. Spinal fluid contained slightly elevated protein levels. Spinal MRI showed cord oedema and gadolinium enhancement over multiple spinal levels. Autoimmune myelitis was suspected, and he was treated with high dose steroids and rituximab. Due to lack of effect, repeated examinations were initiated. Information from his patient history regarding symptom exacerbation by walking or bending forward was emphasised. Repeated MRI showed unchanged spinal oedema and dilated peri- and intramedullary vessels. MRA and spinal digital DSA revealed a dural fistula at third lumbar level, with the left L3 radiculomedullary artery as the feed artery. The fistula was successfully ligated by the neurosurgeon. INTERPRETATION: Spinal vascular lesions are rare and the diagnosis may be challenging due to atypical presentation. The case shows that detailed information from the patient history and thorough clinical investigation is of paramount importance to disclose this probably underreported condition.

Color Doppler ultrasound-guided transducer compression of post biopsy bleeding of kidney transplants.

BACKGROUND: Color Doppler ultrasound (CDUS) has a potential of early detection of post biopsy bleeding. We describe CDUS guidance in planning, acquisition, and, in the case of bleeding, compression of the needle tract in biopsy procedures of kidney transplants. METHODS: Eighty-three kidney transplant biopsy procedures performed on clinical indication were performed in 71 adult patients, 25 women, mean age 51 years, using CDUS and 18-G biopsy needles. Bleeding needle tracts were compressed using CDUS guidance. RESULTS: CDUS immediately detected blood leakage and facilitated compression of the bleeding needle tract in 34 (41%) of the 83 procedures, including 53 (25%) of 215 needle passes. In 34 bleeding procedures, the mean duration of the longest bleeding time after a needle pass was 124 seconds (median, 20 seconds; range, 3-1440 seconds). In 12 of these procedures (35%), the bleeding time was 30 seconds or more. In six procedures (18%), a bleeding of 120 seconds or more was observed. Complications included seven small hematomas. Five hematomas developed in procedures where the longest duration CD bleeding was 120 seconds or more. CONCLUSIONS: CDUS detects bleeding and facilitates direct transducer compression of the needle tract in a substantial portion of biopsy procedures of kidney transplants. Only minor hematomas occurred.

Vaccine Induced Immune Thrombotic Thrombocytopenia Causing a Severe Form of Cerebral Venous Thrombosis With High Fatality Rate: A Case Series.

During a 2-week period, we have encountered five cases presenting with the combination of cerebral venous thrombosis (CVT), intracerebral hemorrhage and thrombocytopenia. A clinical hallmark was the rapid and severe progression of disease in spite of maximum treatment efforts, resulting in fatal outcome in for 4 out of 5 patients. All cases had received ChAdOx1 nCov-19 vaccine 1-2 weeks earlier and developed a characteristic syndrome thereafter. The rapid progressive clinical course and high fatality rate of CVT in combination with thrombocytopenia in such a cluster and in otherwise healthy adults is a recent phenomenon. Cerebral autopsy findings were those of venous hemorrhagic infarctions and thrombi in dural venous sinuses, including thrombus material apparently rich in thrombocytes, leukocytes and fibrin. Vessel walls were free of inflammation. Extra-cerebral manifestations included leech-like thrombi in large veins, fibrin clots in small venules and scattered hemorrhages on skin and membranes. CVT with thrombocytopenia after adenovirus vectored COVID-19 vaccination is a new clinical syndrome that needs to be recognized by clinicians, is challenging to treat and seems associated with a high mortality rate.

Loss of horizontal macular ganglion cell complex asymmetry: an optical coherence tomography indicator of chiasmal compression.

OBJECTIVE: To estimate the macular ganglion cell complex (GCC) asymmetry in patients with suprasellar tumours, to compare its diagnostic performance to the nasal GCC thickness and visual field (VF) and to investigate how the parameters correlate with magnetic resonance imaging (MRI) findings. METHODS AND ANALYSIS: Cross-sectional study of patients with suprasellar tumours affecting the optic chiasm. Macular optical coherence tomography (OCT) scans were evaluated for nasal GCC sector thinning and loss of normal GCC asymmetry between corresponding nasal-temporal sectors. Equivalently, VFs were analysed for defects compatible with chiasm dysfunction. The relationship between optic chiasm and tumour was measured on MRI. RESULTS: Thirty-three eyes of 33 patients were included. There were OCT findings in 14 eyes. Nasal GCC thinning was found in 9 eyes and loss of GCC asymmetry in 12 eyes; the two parameters were not significantly different with respect to number of positive findings (p=0.45). Loss of GCC asymmetry, however, occurred in 5 eyes among 24 without GCC thinning (proportion 0.21; 95% confidence interval 0.071 to 0.42). In 8 eyes, VF indicated pathology; of these, 7 had concurring OCT findings. The prevalence of OCT and VF findings increased significantly with suprasellar tumour extension on MRI. CONCLUSION: The diagnostic capabilities of nasal GCC thinning and loss of GCC asymmetry were comparable, whilst their complementary performances increased the proportion of eyes in which OCT suggested compression. The prevalence of both OCT and VF findings grew with suprasellar tumour extension. In several cases, however, structural findings on OCT preceded detectable VF deficits.

Pressure-derived versus pressure wave amplitude-derived indices of cerebrovascular pressure reactivity in relation to early clinical state and 12-month outcome following aneurysmal subarachnoid hemorrhage.

OBJECT: Indices of cerebrovascular pressure reactivity (CPR) represent surrogate markers of cerebral autoregulation. Given that intracranial pressure (ICP) wave amplitude-guided management, as compared with static ICP-guided management, improves outcome following aneurysmal subarachnoid hemorrhage (SAH), indices of CPR derived from pressure wave amplitudes should be further explored. This study was undertaken to investigate the value of CPR indices derived from static ICP-arterial blood pressure (ABP) values (pressure reactivity index [PRx]) versus ICP-ABP wave amplitudes (ICP-ABP wave amplitude correlation [IAAC]) in relation to the early clinical state and 12-month outcome in patients with aneurysmal SAH. METHODS: The authors conducted a single-center clinical trial enrolling patients with aneurysmal SAH. The CPR indices of PRx and IAAC of Week 1 after hemorrhage were related to the early clinical state (Glasgow Coma Scale [GCS] score) and 12-month outcome (modified Rankin Scale score). RESULTS: Ninety-four patients were included in the study. The IAAC, but not the PRx, increased with decreasing GCS score; that is, the higher the IAAC, the worse the clinical state. The PRx could differentiate between survivors and nonsurvivors only, whereas the IAAC clearly distinguished the groups "independent," "dependent," and "dead." In patients with an average IAAC ≥ 0.2, mortality was approximately 3-fold higher than in those with an IAAC < 0.2. CONCLUSIONS: The IAAC, which is based on single ICP-ABP wave identification, relates significantly to the early clinical state and 12-month outcome following aneurysmal SAH. Impaired cerebrovascular pressure regulation during the 1st week after a bleed relates to a worse outcome. CLINICAL TRIAL REGISTRATION NO.: NCT00248690.

A randomized and blinded single-center trial comparing the effect of intracranial pressure and intracranial pressure wave amplitude-guided intensive care management on early clinical state and 12-month outcome in patients with aneurysmal subarachnoid hemorrhage.

BACKGROUND: In patients with aneurysmal subarachnoid hemorrhage (SAH), preliminary results indicate that the amplitude of the single intracranial pressure (ICP) wave is a better predictor of the early clinical state and 6-month outcome than the mean ICP. OBJECTIVE: To perform a randomized and blinded single-center trial comparing the effect of mean ICP vs mean ICP wave amplitude (MWA)-guided intensive care management on early clinical state and outcome in patients with aneurysmal SAH. METHODS: Patients were randomized to 2 different types of ICP management: maintenance of mean ICP less than 20 mm Hg and MWA less than 5 mm Hg. Early clinical state was assessed daily using the Glasgow Coma Scale. The primary efficacy variable was 12-month outcome in terms of the Rankin Stroke Score. RESULTS: Ninety-seven patients were included in the study. There were no significant differences in treatment between the 2 groups apart from a larger volume of cerebrospinal fluid drained during week 1 in the MWA group. There was a tendency toward higher Glasgow Coma Scale scores in the MWA group during weeks 1 (P = .08) and 2 (P = .07). Outcome in terms of Rankin Stroke Score at 12 months was significantly better in the MWA group (P < .05). CONCLUSION: This randomized and blinded trial disclosed a significant better primary efficacy variable (Rankin Stroke Score after 12 months) in the MWA patient group. We suggest that proactive intensive care management with MWA-tailored cerebrospinal fluid drainage during the first week improves aneurysmal SAH outcome.