Transient perivascular inflammation of the carotid artery-A transient but potentially recurrent disease.

Transient perivascular inflammation of the carotid artery (TIPIC syndrome) is a rare, unclassified vascular syndrome that usually affects the distal part of the common carotid artery and has a favorable prognosis. The disease is often misdiagnosed even by neurologists due to the moderate intensity of clinical symptoms and their transient character. We present a case of a 52-year-old man who experienced two episodes of transient neck pain and moderate local tenderness one and a half years apart. Different imaging modalities, such as ultrasound, CT angiography, and high-resolution 3T MR, were applied to better visualize the perivascular inflammation of the common carotid arteries. Based on the clinical-radiological characteristics of our case and applying the diagnostic criteria, we established the diagnosis of TIPIC syndrome. The patient was treated with nonsteroidal anti-inflammatory drugs for few weeks, and reduction in perivascular changes was observed in both episodes. The case raises questions about the phases of the disease, its duration and the intervals between follow-ups. Our article also increases the awareness of this rare clinical-radiological entity and presents recent data from the literature.

Atypical clinical and radiologic findings in a patient with brain metastatic lesions.

We report the case of a 47-year-old man who was admitted to our clinic with an intractable headache, nausea, and sporadic vomiting, as well as speech difficulties and a 'floating' sensation. This man had no prior medical history. MRI of the brain showed evidence of over 20 supra- and infratentorial capsulated ring-enhancing lesions. All other paraclinical investigations done in our clinic were unremarkable and we excluded our first assumption of neurocysticercosis, as well as other parasitic infections. The patient was then referred to the Oral and Maxillofacial Surgery Clinic for an excisional biopsy of a submandibular formation, which was later verified to represent a lymph node metastasis from a poorly differentiated adenocarcinoma. A chest X-ray failed to demonstrate any significant pathology and the immunohistochemical constellation of the lymph node metastasis excluded the possibility of the primary tumor originating in the lung or the prostate. Due to the unresolved diagnostic query, a whole-body PET/CT was performed demonstrating a formation with malignant characteristics in the basal segment of the left lung, reaching the pleura and the left hilum, as well as solitary enlarged mesenteric and mediastinal lymph nodes. Following clinical consultations, it was determined that the patient was inoperable and chemotherapy and palliative CNS irradiation were recommended.

Effect of levetiracetam on nocturnal sleep in patients with epilepsy.

AIM OF THE STUDY: The purpose of our study was the evaluation of the effect of 2,000 mg levetiracetam monotherapy over a 3-month period on nocturnal sleep in patients with epilepsy. CLINICAL RATIONALE: Levetiracetam (LEV) is a novel antiepileptic drug with a unique anticonvulsive mechanism of action. It has been commonly reported to cause sleep disruption and daytime sleepiness in epilepsy patients. Its advantages (its broad antiepileptic spectrum, optimal pharmacokinetics, good safety and tolerability) have led to its frequent use in clinical practice, although little is yet known about LEV's effect on nocturnal sleep architecture. MATERIAL AND METHODS: The effect of LEV on nocturnal sleep was assessed through a full-night lab polysomnography (PSG), followed by a four-nap multiple sleep latency test. Both procedures were performed at baseline and after three months of LEV treatment. The dynamics of seven main PSG variables was evaluated prior to, and three months after, LEV therapy. RESULTS: Twenty five patients with newly diagnosed or untreated epilepsy completed the study. We found no statistically significant difference at baseline and after LEV therapy in the following sleep parameters: total sleep time, sleep onset, wake after sleep onset, N1 stage and rapid eye movement (REM) sleep (minutes and percentages), and latency of all sleep stages including REM sleep. However, we found a statistically significant increase in the number of awakenings and arousals, an increase in N2 and a decrease in N3 stages (minutes and percentages) after therapy. We also observed an increase in N1 stage and a trend toward a reduction in REM sleep (in both minutes and percentages), but they did not reach statistical significance. CONCLUSIONS: Levetiracetam 2,000 mg/day does not affect sleep continuity and may be considered a sleep-friendly antiepileptic drug.

Levetiracetam effectiveness as add-on therapy in Bulgarian patients with drug-resistant epilepsy.

INTRODUCTION: There are no reliable prospective studies on the effectiveness of LEV in Bulgarian adult patients with drug-resistant epilepsy. AIM: The study aimed at conducting an open, prospective study on various aspects of levetiracetam (LEV) effectiveness in Bulgarian patients with drug-resistant epilepsy. MATERIALS AND METHODS: The study was performed with patients with epilepsy recruited from those attending the Department of Neurology at the University Hospital in Plovdiv, Bulgaria. The patients completed diaries about seizure frequency, severity, and adverse events. There were regular documented visits at 3 or 6 months during the first year of treatment with LEV and at 6 months afterwards, with dynamic assessment of seizure frequency, severity, adverse events, and EEG recordings. RESULTS: LEV was applied as an add-on therapy in 135 patients (86 males, mean age 35 years). There was a relatively mild and persisting dynamic improvement of seizure severity, a satisfactory seizure frequency reduction in 49.6% of participants, a persisting mean seizure frequency reduction (48-58%) from 6 to 36 months of treatment and a high responder rate (53-60%) during the same period. New seizure types (focal with impaired awareness with /without evolution to bilateral tonic-clonic seizures) occurred in 4 patients. There were adverse events (dizziness, memory impairment, aggressiveness, numbness, non-epileptic seizures, depression, anxiety, speech disturbances, visual hallucinations, sleepiness, pelvic muscles weakness, confusion, sleep disturbances, loss of appetite, unstable gait, hair loss, acne, generalized rash) in 13.33% of patients. CONCLUSIONS: LEV treatment is associated with: low and persisting improvement of seizure severity, a good and persisting improvement of seizure frequency, a possible worsening of seizure control, a possible appearance of new seizure types, a good safety and tolerability.

Various Aspects of Tiagabine Effectiveness as Add-on Therapy in Patients with Refractory Epilepsy.

The aim of the present study was to investigate various aspects of tiagabine (TGB) effectiveness in Bulgarian patients with drug-resistant epilepsy. This open, prospective study recruited the patients with epilepsy attending the Clinic of Neurology at the University Hospital of Plovdiv, Bulgaria. The patients completed diaries about the seizure frequency, severity, and adverse events. There were regular documented visits at 3 or 6 months during the first year of treatment with TGB and at 6 months or 1 year afterwards, with dynamic assessment of seizure frequency, severity, adverse events, and EEG recordings. TGB was applied as an add-on treatment in 43 patients (24 males, mean age 39 years). There was relatively mild and transient dynamic improvement of seizure severity, satisfactory seizure frequency reduction in 32.6% of participants, stable mean seizure frequency reduction (40-50%) from month 6 to month 24 and a stable response rate (52.3-50%) during the same period. New seizure types (myoclonic, myoclonic-atonic) occurred in 2 patients. The final clinical efficacy was higher in patients with initial monotherapy. There were adverse events (dizziness/vertigo, sedation, memory impairment, loss of appetite and weight, confusion, psychosis, insomnia, transient diplopia, lymphadenomegaly, rash, nausea, depression, anxiety, tremor of hands, unstable gait, legs edema, thrombocytopenia, cervical muscles tightening) in 26.19% of patients. In conclusion, TGB treatment is associated with low and transient improvement of seizure severity, good and stable improvement of seizure frequency, possible worsening of seizure control, possible appearance of new seizure types, and acceptable safety and tolerability.

Topiramate Effectiveness as Add-on Therapy in Bulgarian Patients with Drug-resistant Epilepsy.

INTRODUCTION: There are no reliable prospective studies on the effectiveness of topiramate in Bulgarian adult patients with drug-resistant epilepsy. AIM: The aim of the study was to conduct an open, prospective study on various aspects of topiramate (TPM) effectiveness in Bulgarian patients with drug-resistant epilepsy. PATIENTS AND METHODS: The study included patients with epilepsy who attended the Clinic of Neurology at the University Hospital in Plovdiv, Bulgaria. Patients completed diaries for seizure frequency, seizure severity, and adverse events. There were regular documented visits at 3 or 6 months during the first year of TPM treatment and at 6 months afterwards, with a dynamic assessment of seizure fre-quency, severity, adverse events, and EEG recordings. RESULTS: TPM was used as an add-on treatment in 120 patients (69 males, mean age 37 years). There was a relatively mild and stable dynamic improvement of seizure severity, a satisfactory seizure frequency reduction in 37% of participants, a stable mean seizure fre-quency reduction (47%) from month 6 to month 24 of treatment and a stable responder rate (48-51%) during the same period. New seizure types (focal with impaired awareness with/without evolution to bilateral tonic-clonic seizures) occurred in 5 patients. There were adverse events (dizziness/vertigo, irritability, speech disturbances, memory impairment, concentration problems, tremor, loss of appe-tite and weight, weakness, numbness, bradypsychia, confusion, visual hallucinations, sleepiness, insomnia, headache, itching, unstable gait, nausea, and vomiting) in 20% of patients. CONCLUSIONS: TPM treatment is associated with low and stable improvement of seizure severity, good and stable improvement of sei-zure frequency, possible worsening of seizure control and appearance of new seizure types, good safety and tolerability.

Neuromyelitis Optica and Systemic Lupus Erythematosus Association ­ the Chicken or the Egg Dilemma: a Case Repor.

We present a case report of a 32-year-old woman diagnosed with opticomyelitis of Devic (OMD) and systemic lupus erythematosus (SLE). The onset of neurological symptoms was with optic neuritis. Five months later the neurological deficit progressed within a few days to lower paraplegia and upper paraparesis, retention of urine and faeces, impaired somatic and deep sensation below the level of Th1 dermatome. The results from laboratory investigations confirmed anaemic syndrome, increased urea and creatinine, hypoproteinemia and severe proteinuria. The results from CSF investigations demonstrated hyperproteinorachia with extremely high Ig fractions. Serum and CSF oligoclonal bands and positive serum Aquaporin IgG 32 times higher than the upper referent limit were found. The association with SLE was confirmed by the increased levels of total ANA and anti-ds-DNA ANA. MRT visualized the spinal cord as non-homogenously hypointense on T1 and extremely hyperintense on FLAIR sequences through its whole length up to the bulbar-pontine region. The MRT findings and the serum Aquaporin IgG confirmed the diagnosis OMD. The patient was treated with intravenous immunomodulating agents. We consider the presented case of special interest because of the comorbidity of an aggressive autoimmune systemic and an organ-specific disease of the central nervous system.

Comparative effectiveness of add-on therapy with newer-generation antiepileptic drugs in Bulgarian patients with refractory epilepsy.

OBJECTIVES: The objective of this study is to perform an open, prospective study on various aspects of comparative effectiveness of newer-generation antiepileptic drugs as add-on therapy in Bulgarian patients with drug-resistant epilepsy. METHODS: The study was performed with the participation of 1259 patients with epilepsy who attended the Clinic of Neurology at the University Hospital in Plovdiv, Bulgaria for regular visits and completed diaries about seizure frequency, severity, and adverse events. RESULTS: Oxcarbazepine was used in 82 patients, topiramate in 120 patients, lamotrigine in 73 patients, levetiracetam in 135 patients, pregabalin in 47 patients, tiagabine in 43 patients, gabapentin in 18 patients, lacosamide in 12 patients, and retigabine in 6 patients. During the first 24 months of study, improvement of seizure severity and frequency was most frequent in patients on treatment with pregabalin and levetiracetam and rarest in those on treatment with oxcarbazepine. The retention rate of patients on pregabalin and tiagabine was significantly lower compared to the retention rate of patients on most of the other antiepileptic drugs. The frequency of adverse events was higher in patients on treatment with tiagabine and pregabalin. CONCLUSION: Despite some similar characteristics of newer-generation antiepileptic drugs' effectiveness, levetiracetam stands out with better dynamic improvement of seizure severity and frequency and satisfactory tolerability; typical for pregabalin is a very good dynamic improvement of seizure severity and frequency mainly in patients with focal seizures, but a lower tolerability, and the main advantage of oxcarbazepine is a good tolerability, efficacy, however, is less satisfactory.

Relation of Perceived Stigma to Adverse Events of Medications in Patients with Epilepsy.

Purpose. We aimed to assess the influence of adverse events (AEs) of antiepileptic drugs (AEDs) on perceived stigma of Bulgarian patients with epilepsy. Methods. Our study was based on questionnaires (Liverpool Adverse Events Profile (LAEP) and stigma scale), information from medical documentation, and an interview on clinical factors of 153 consecutive patients with epilepsy. Results. Perceived stigma was observed in 64.71% of the study participants. There was a significant association between perceived stigma and the total LAEP score (p < 0.05, F = 13.71). Patients who reported AEs had an increased risk of perceiving stigma compared to those who did not experience AEs. A significant correlation between perceived stigma and the presence of neurological and psychiatric AEs (p < 0.001, r = +0.60) and a mild correlation between perceived stigma and the presence of nonneurological AEs (p < 0.01, r = +0.20) were verified. In a multivariate regression analysis the only predictors of perceived stigma were AED polytherapy and the presence of neurological and psychiatric AEs. Conclusions. AEs of AEDs in patients with epilepsy significantly correlate with perceived stigma. Our study results will be useful in the campaign to overcome stigma predictors.

Seizure frequency and severity: How really important are they for the quality of life of patients with refractory epilepsy.

INTRODUCTION: The data in the scientific literature about the significance of seizure severity and frequency for the quality of life (QOL) of patients with refractory epilepsy (RE) are contradictory. OBJECTIVE: Our objective was to assess the impact of the seizure severity and frequency on the QOL of Bulgarian patients with RE. MATERIALS AND METHODS: A total of 70 patients with RE were studied by examining the medical documentation and seizure diaries. All study participants completed quality of life epilepsy inventory (QOLIE-89). Seizure severity of only 59 patients who had a seizure in the last month was assessed by the Liverpool seizure severity scale. RESULTS: A limited negative impact of the seizure severity and frequency on some aspects of the physical health, epilepsy, all aspects of the social health and epilepsy and the overall QOL has been demonstrated. A weak to moderate reverse correlation between the specified factors and the respective QOLIE-89 subscales has been found. CONCLUSION: The clinical factors seizure severity and seizure frequency have a limited negative impact mostly on the social aspects of QOL. The study results support the multidisciplinary approach to persons with epilepsy.

Validation of the Bulgarian version of the quality of life in epilepsy inventory (QOLIE-89).

INTRODUCTION: The quality of life in epilepsy inventory (QOLIE-89) is the most comprehensive and widely used instrument for assessment of the quality of life of patients with epilepsy. AIM: To prove that the Bulgarian version of QOLIE-89 shows good reliability and validity. PATIENTS AND METHODS: The study included 35 patients with refractory epilepsy: 20 women (57.14%) and 15 men (42.86%) at the mean age of 43.11 +/- 2.38 years and mean duration of epilepsy 22.46 +/- 2.05 years. All respondents completed QOLIE-89 twice at an interval of one to three weeks; they also completed QOLIE-31 once. RESULTS: Cronbach's alpha was between 0.90 and 0.92 for all subscales, the mean assessment score was 0.91. These results, the high Spearman-Brown coefficient (0.90) and the low mean inter-item correlation (0.33) suggest that the Bulgarian version of QOLIE-98 shows excellent internal consistency and high reliability. This is supported by the high coefficient of correlation (0.83-0.98) between the subscales scores and the overall assessment of the quality of life in the two completions of the questionnaire. The questionnaire proved to be valid based on the strong correlation we found between the overall assessment score (0.91) of QOLIE-31 and QOLIE-89 and the subscales of seizure worry, overall quality of life, energy/fatigue and overall scores--all in the range of 0.95-1.00. The correlations of coefficients for the other subscales were between 0.69-0.86. CONCLUSIONS: The psychometric properties of the Bulgarian version of QOLIE-98 are good; they are similar to those of the original American version and the validated Norwegian and Chinese versions. It shows high reliability and validity and can be used to assess the quality of life of elderly people with epilepsy.

Pseudoresistance in patients with epilepsy--characteristics and determining factors.

INTRODUCTION: In pseudorefractory epilepsy (20% of the cases diagnosed with refractory epilepsy) the factors responsible for triggering the seizures are extraneous to epilepsy and the seizures can be controlled after diagnostic and therapeutic re-evaluation. AIM: To determine the factors causing development of pseudoresistance in patients with epilepsy. PATIENTS AND METHODS: Detailed case histories of 191 patients with a diagnosis of drug-resistant epilepsy were collected; the medical records were analyzed retrospectively. Thirty-nine patient (20.42%) were found to be with pseudorefractory epilepsy. The patients were classified by demographic criteria and specific clinical signs, and by laboratory findings. RESULTS: The patients (age range 18 to 72 years, mean duration of disease 27 years) presented with partial (56.41%), generalized (43.59%) and polymorphic seizures (17.95%) with a higher relative percentage of the patients with symptomatic (41.03%) and cryptogenic (35.9%) epilepsy. The main groups of factors that determined pseudoresistance were diagnostic (46.15%) and therapeutic errors (69.23%), poor compliance (33.33%), external factors (5.12%), as well as a combination of these (53.84%). We found that compliance correlated weakly with age and education, but showed high and moderate correlation with duration of epilepsy less than 20 years and male gender. Therapy adjustment had a beneficial effect in 16 of 24 patients (66.67%) in our study. CONCLUSION: The detailed analysis of the causes for pseudoresistance focuses on some pitfalls of the diagnostic and therapeutic process, compliance of the patient and influence of external factors aiming at reduction of the number of cases with pseudorefractory epilepsy and achieving more favourable clinical effect of treatment.

Depressivity, anxiety and quality of life in patients with refractory epilepsy.

INTRODUCTION: Depressive and anxiety disorders are very often comorbid with refractory epilepsy. AIM: To determine the impact of depressivity and anxiety on some aspects of the quality of life of patients with refractory epilepsy. PATIENTS AND METHODS: The present open prospective study included 94 patients (67 women) with refractory epilepsy (mean age 42 years) who were categorised according to their medical history, individual clinical parameters and results of paraclinical studies. Beside these, the patients completed the questionnaires for depression (BDI-II), anxiety (HAS) and quality of life (QOLIE-89). RESULTS: We found different degrees of depressivity in 59 patients (63.44%). Only three of the participants (3.19%) were found to have no depressivity or anxiety. In the remaining 91 patients (96.81%) we diagnosed anxiety in a different degree. The QOLIE-89 showed a low overall assessment of the quality of life in 54 patients (57.45%). We found: 1. A strong correlation between depressivity and the low overall assessment of quality of life as well as the assessment in the subscales for limitations due to physical problems, emotional wellbeing, attention/concentration, and memory. 2. A strong correlation between the increase of severity of depressivity and decrease of the overall assessment of quality of life. 3. A weak correlation between anxiety and the low overall assessment of QOL as well as the assessment in all subscales. CONCLUSIONS: Depressivity is a factor which worsens significantly all aspects of quality of life of patients with refractory epilepsy. This makes the timely diagnosis and treatment of the disease absolute necessity.