[Hypothalamic involvement in multiple sclerosis]. / Atteintes hypothalamiques dans la sclérose en plaques.

Hypothalamic involvement is a rare condition in patients with multiple sclerosis (MS). We report two patients with a long history of MS who presented with severe acute hypothermia with associated thrombocytopenia and elevated transaminase levels. Several cases of hypothermia or hyperthermia in patients with MS have been reported in the literature. They could be linked with hypothalamic lesions, in particular in the pre-optic area. However, other anatomical locations seem to be involved in thermoregulation and can be affected by MS. Besides, some cases of syndrome of inappropriate antidiuretic hormone secretion have been reported in patients with MS. Finally, some sleep disorders, particularly hypersomnia or narcolepsy, could be related to hypothalamic lesions, through the fall in hypocretin-1 in the cerebrospinal fluid. Hypocretin-1 is a neuropeptide that is secreted by some hypothalamic cells. It plays a role in the sleep-awake rhythm. We report one patient with narcolepsy and cataplexy before the first symptoms of MS appeared. Hypothalamic signs are rare in MS. However, several series of autopsies have shown a high frequency of demyelinating lesions in the hypothalamic area. Among these lesions, the proportion of active lesions seems elevated. Yet only few of them have a clinical or biological translation such as thermoregulation dysfunction, sleep disorders or natremia abnormalities. Thus, it seems unlikely that inflammatory hypothalamic lesions alone, even when bilateral, could be the explanation of these signs. A sufficient number of inflammatory demyelinating lesions, which we can observe in patients with a long history of MS and an already severe disability, is probably necessary to develop such a rare symptomatology. Hypothalamic signs might be a factor of poor prognosis for the disease course and progression of the disability.

[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.

Comparison of twice- and three times daily tiagabine for the adjunctive treatment of partial seizures in refractory patients with epilepsy: an open label, randomised, parallel-group study.

UNLABELLED: A multicentre, open label, randomised, parallel group study compared the efficacy, tolerability and safety of two dosing regimens, t.i.d. and b.i.d., of tiagabine as an adjunctive therapy for the treatment of refractory patients with partial seizures. A total of 347 patients were randomised and treated (175 t.i.d. and 172 b.i.d.). Each group was administered the same daily dose of tiagabine incremented stepwise during a 12-week fixed-schedule titration period to a target dose of 40 mg/day. The patients were followed for a further 12-week flexible continuation phase. A significantly greater number of patients in the t.i.d. group completed the fixed schedule titration period (81.4% versus 73.1%; 95% CI of odds ratio = 0.331, 0.970; p = 0.038). The proportion of responders (patients showing at least a 50% decrease in all-seizure frequency from baseline) was similar for both groups (42.3% for b.i.d. and 47.1% for t.i.d.) during the last 8 weeks of the flexible phase and seven (4.0%) patients in the b.i.d. group were seizure-free compared to 14 (8.1%) patients in the t.i.d. group. Adverse events were of similar incidence in both groups, and mainly occurred during the fixed schedule titration period; they were mainly mild and CNS-related with somnolence being the most frequently reported. CONCLUSION: Tiagabine was effective as add-on treatment of refractory partial seizures. Although both regimens appear to offer a similar efficacy and safety profile, significantly more patients completed the study in the t.i.d. group compared to b.i.d., probably as a consequence of a lesser tolerability when high doses are given undivided. These results confirm that a slow titration and appropriate adjustment of dosing are essential conditions to ensure optimal use of tiagabine.

[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.

The feasibility of home polysomnographic recordings prescribed for sleep-related neurological disorders: a prospective observational study.

OBJECTIVE: Home polysomnography is being increasingly developed for sleep studies, with various grades of quality. This study aimed to determine the feasibility of affordable, high quality home polysomnographic recordings prescribed for suspected sleep-related neurological disorders. PATIENTS AND METHODS: We prospectively screened all patients referred to the specialist sleep disorders clinic in Nancy University Hospital between May 2011 and August 2011. Patients were eligible for inclusion if they required polysomnography for the diagnosis of a sleep-related neurological disorder. One-night, polysomnography was performed in each patient's home by a trained sleep technician. Financial cost was determined prior to inclusion. A recording was considered as satisfactory if all the following criteria were present: at least, one EEG channel with continuous signal allowing determination of sleep stages and wake during more than 66% of sleep time; at least, one usable respiratory channel (airflow or either band) during more than 66% of sleep time; and usable oximetry during more than 66% of sleep time. RESULTS: Forty-eight of the 139 screened patients were included. Among the 48 home polysomnography recordings, 35 (72.9%) were satisfactory. Thirteen (27.1%) tracings displayed an unsatisfactory loss of EEG data, including seven (14.6%) tracings with an unsatisfactory loss of respiratory data. CONCLUSION: Home polysomnography prescribed for suspected sleep-related neurological disorders is feasible, with affordable costs, whilst maintaining high quality recording. Further studies are needed to measure the real medico-economic impact of promoting outpatient domiciliary explorations for sleep-related neurological disorders.

[Perioperative anaesthetic management of an epileptic patient treated with a vagus nerve stimulation]. / Gestion périopératoire d'un patient épileptique porteur d'une neurostimulation du nerf vague.

The vagal nerve stimulation is approved for medically refractory epilepsy and major depression. We report the perioperative management of an epileptic patient with this indwelling device. This observation summarizes the physiologic implications and the specific anaesthetic considerations for procedures with this pre-existing device.