Efeitos do enriquecimento ambiental sobre padrões de comportamento e ansiedade no Status Epilepticus / Effects of environmental enrichment on behavioral and anxiety no Status Epilepticus

Introdução: O Enriquecimento ambiental (EA) tem sido estudado em reabilitação para diversas patologias. Objetivo: investigar os efeitos do EA em ratos wistar jovens submetidos ao status epilepticus, sobre os padrões de comportamento e ansiedade. Métodos: Estudo longitudinal com 40 ratos, submetidos às crises no 15º dia e enriquecimento ambiental e, posteriormente, aos testes labirinto em cruz elevado e campo aberto. Utilizou-se o teste ANOVA two-way, considerando como significante valor de p<0,05. Resultados: No teste do labirinto houve relação entre levantar em duas patas (p<0,01), comportamento de risco (p<0,01) tempo nos braços abertos (p<0,01), número de entradas nos braços fechados (p<0,01), tempo nos braços fechados (p<0,01) e o número de cruzamentos no campo aberto (p=0,01) com status epilepticus. Não houve relação entre os testes e o EA. Conclusão: O EA não reverteu os padrões de ansiedade e comportamento afetados pelo status epilepticus. (AU)

Background: Environmental Enrichment (EE) has been studied in rehabilitation for several pathologies. Objective: to investigate the effects of EE on young wistar rats submitted to status epilepticus, on behavior and anxiety patterns. Methods: Longitudinal study with 40 rats, submitted to seizures on the 15th day and environmental enrichment, and later to the labyrinth tests in high cross and open field. The two-way ANOVA test was used, considering a significant value of p <0.05. Results: In the labyrinth test, there was a relationship between two paws (p <0.01), risk behavior (p <0.01) in open arms (p <0.01), number of entries in closed arms (p <0.01), time in the closed arms (p <0.01) and the number of crosses in the open field (p = 0.01) with status epilepticus. There was no relationship between the tests and the EE. Conclusion: The EE did not reverse the behavior and anxiety patterns affected by the status epilepticus. (AU)

Effect of music on the recovery of a patient with refractory nonconvulsive status epilepticus.

The effect of music in epilepsy has been reported as beneficial but mainly in the interictal condition. There are no reports of the effect of music in an acute condition such as status epilepticus. Herein, we report a remarkable response to music in a patient with medically refractory nonconvulsive status epilepticus.

Predictors and prognosis of refractory status epilepticus treated in a neurological intensive care unit.

OBJECTIVE: To assess risk factors and prognosis in patients with refractory status epilepticus (RSE). METHODS: We retrospectively analysed all episodes of status epilepticus (SE) treated between 1993 and 2002 on the neurological intensive care unit (NICU) of the Charite-Universitatsmedizin Berlin. The predictive and prognostic features of RSE were compared with non-RSE (NRSE). All patients with "de novo" SE were followed up to identify the possible development of post-SE symptomatic epilepsy. RESULTS: A total of 83 episodes fulfilled our criteria of SE. Of these 43% were refractory to first line anticonvulsants. The mean age of patients with SE was 53.3 (SD 19) years, with only two patients younger than 18 years. Encephalitis was significantly more often the primary cause in RSE (p<0.05), whereas low levels of antiepileptic drugs were significantly more often associated with NRSE (p<0.001). Hyponatraemia within the first 24 hours after onset of status activity was significantly more often associated with RSE (p<0.05). In RSE, compared with NRSE, significantly longer duration of seizure activity (p<0.001), more frequent recurrence of epileptic activity within the first 24 hours after the end of seizure activity (p<0.001), longer stay in the NICU and in hospital (p<0.001 and p<0.01, respectively), and more frequent development of symptomatic epilepsy (p<0.05) were seen. CONCLUSIONS: SE treated in the NICU is frequently refractory to first line anticonvulsant drugs. Encephalitis is a predictor for RSE, which is associated with markedly poor outcome, in particular, the development of post-SE symptomatic epilepsy. Thus prevention of this most severe form of SE should be the primary target of treatment of SE.

[Status epilepticus as a cause of hospitalization]. / Stan padaczkowy jako przyczyna hospitalizacji.

OBJECTIVES: Status epilepticus (SE) in children as the most severe, life-threatening condition requires rapid, correct, standard and efficient treatment. The results depend on the properly coordinated management at patient's home, emergency, intensive care units and pediatric neurology departments. THE AIM: The aim of this research was to recognise type of diagnostic and therapeutic problems in children hospitalized with SE. Differences between two groups of children: I group with SE as the first manifestation of epilepsy and group II with epilepsy treated before occurrence of SE were studied as well. MATERIALS AND METHODS: In this retrospective study, 33 hospitalizations of 24 children (14 boys and 10 girls) aged 5 months to 15 years (mean 7 years) were analysed. Patients with SE hospitalized in the Intensive Care Unit and Emergency Department, Collegium Medicum Jagiellonian University in Cracow between 1.01.2002 and 31.12.2004 were included. The group I consisted of 13 children (54%) and the group II consisted of 11 children. In both groups the age and gender of patients, duration of hospitalisation, necessity of assisted ventilation and thiopental coma were analysed. Causes of epilepsy and SE were studied as well. RESULTS: Duration of SE before hospitalization, similar in both groups ranged between 30 minutes and 2 hours, counting to its termination in the hospital. The cause of epilepsy was established in 15/24 children. Out of 33 SE, 10 were provoked by hyperthermia in children of both groups. The probable risk factor of SE was the association with mental retardation. The mean age of SE occurrence was in I group 4 years, while in the II group 10 years (with epilepsy duration since 1,5 year of age). The mean duration of hospitalisation was similar in both groups (21:22 days), however children of the I group were hospitalized in the Intensive Care Unit shorter, almost twice (2,5:4,5 days) as compared to the II group; intubation was necessary less often (3:6) and assisted ventilation shorter (1,5:3 days), respectively. None of the children died due to SE during 3 years. CONCLUSIONS: The better outcome of intensive care in children of group I may be a result of later occurrence of epilepsy. In the management of SE in children of group II, especially with recurrent SE, the early employment of intensive care procedures should be considered. The effective management of SE in the emergency department may help to prevent of death caused by SE in children.

[Status epilepticus in hospitalized children]. / Wystepowanie stanu padaczkowego u dzieci w czasie hospitalizacji.

OBJECTIVES: Status epilepticus (SE), as it was established in several analyses, occurs in at least 6% of patients with epilepsy. The prognosis, in the high degree, depends on the type and duration of SE, being worse in the case of symptomatic epilepsy, metabolic disease, neuroinfection and hypoxic injury of the brain. Results of therapy are dependent on the proper treatment and rapidity of its initiation as well. THE AIM: The aim of this research was to establish frequency and type of SE, time of duration and efficacy of treatment of SE in hospitalised children. MATERIALS: 1505 children with epilepsy, aged 1 month to 18 years were hospitalised between 1996 and 2004 in the Department of Pediatric Neurology in Cracow. SE was diagnosed in 21 children of all groups, what makes 1.4%. The group consisted of 9 girls and 12 boys. SE appeared most frequently in children diagnosed with epilepsy during the first two years of life (76.2%). In majority of patients (66.66%) SE occurred in the first year, since falling ill with epilepsy (between 1 month and 12 years). RESULTS: In 6 children SE was shorter than 1 hour, in 11 children shorter than 3 hours and in 4 children longer than 3 hours. 14/21 children became seizure free in the Department of Pediatric Neurology, however in the remaining 7 children continuation of treatment in the Intensive Care Unit was necessary and all children survived. Discontinuation of treatment was not a reason of SE in any of cases. In 18 children with SE (85.7%) symptomatic epilepsy was diagnosed and in another 3 children probable symptomatic. Symptomatic epilepsy was caused by birth trauma in 4 children, in 2 other children was associated with encephalitis, in 6 children with progressive encephalopathy, in the next 3 children with cortical developmental abnormalities and with cerebral palsy in another 3 children. Specific background of epilepsy was not established in 3 children. Drugs were used in the treatment of SE in recommended doses, most frequently Klonazepam (17), Diazepam (8), Gardenal (7), Midazolam (6) and Epanutin (3). In 5 children rectal Chloralhydrat was effective in the therapy of SE. 7/21 children experienced improved seizure control in the Intensive Care Unit due to thiopental coma. Additional antiedematous treatment was provided in 17 children. CONCLUSIONS: The majority of cases of SE in hospitalised patients were related to epilepsy in children during first two years of life and to first year duration of the illness. The low frequency of SE can be related to continuos access to pediatric neurologists and experienced nurse teams.

Outcome at adulthood of the continuous spike-waves during slow sleep and Landau-Kleffner syndromes.

PURPOSE: The aim of this study was to determine the clinical, social, and/or professional and cognitive outcomes in adulthood of the continuous spike-waves during slow sleep (CSWS) and Landau-Kleffner syndromes, which are two rare epileptic syndromes occurring in children. METHODS: We enrolled seven young adults, five who had a CSWS syndrome, and two, a Landau-Kleffner syndrome in childhood. We evaluated their intellectual level as well as their oral and written language and executive functions. RESULTS: This study confirmed that the epilepsy associated with these syndromes has a good prognosis. Only one patient still had active epilepsy. However, the neuropsychological disorders particular to each syndrome persisted. Only two patients had followed a normal pathway in school. Three of the five patients with a CSWS syndrome during childhood remained globally and nonselectively mentally deficient. We found no evidence of the persistence of a dysexecutive syndrome in this study group. The intellectual functions of the two patients with Landau-Kleffner syndrome were normal; however, their everyday lives were disrupted by severe, disabling language disturbances. We discuss the role of some prognostic factors such as the location of the interictal electric focus and the age at onset of CSWS. CONCLUSIONS: These two epileptic syndromes of childhood are very similar in many respects, but their clinical outcomes in adulthood are different.

Beneficial effects of enriched environment following status epilepticus in immature rats.

BACKGROUND: There is increasing evidence that enriching the environment can improve cognitive and motor deficits following a variety of brain injuries. Whether environmental enrichment can improve cognitive impairment following status epilepticus (SE) is not known. OBJECTIVE: To determine whether the environment in which animals are raised influences cognitive function in normal rats and rats subjected to SE. METHODS: Rats (n = 100) underwent lithium-pilocarpine-induced SE at postnatal (P) day 20 and were then placed in either an enriched environment consisting of a large play area with toys, climbing objects, and music, or in standard vivarium cages for 30 days. Control rats (n = 32) were handled similarly to the SE rats but received saline injections instead of lithium-pilocarpine. Rats were then tested in the water maze, a measure of visual-spatial memory. A subset of the rats were killed during exposure to the enriched or nonenriched environment and the brains examined for dentate granule cell neurogenesis using bromodeoxyuridine (BrdU) and phosphorylated cyclic AMP response element binding protein (pCREB) immunostaining, a brain transcription factor important in long-term memory. RESULTS: Both control and SE rats exposed to the enriched environment performed significantly better than the nonenriched group in the water maze. There was a significant increase in neurogenesis and pCREB immunostaining in the dentate gyrus in both control and SE animals exposed to the enriched environment compared to the nonenriched groups. Environmental enrichment resulted in no change in SE-induced histologic damage. CONCLUSIONS: Exposure to an enriched environment in weanling rats significantly improves visual-spatial learning. Even following SE, an enriched environment enhances cognitive function. An increase in neurogenesis and activation of transcription factors may contribute to this enhanced visual-spatial memory.

Status epilepticus arising de novo in hospitalized patients: an analysis of 41 patients.

Most of the information on predisposing factors and mortality in status epilepticus (SE) arises from data obtained from patients presenting to the casualty department. However, another population which is frequently seen by consultative neurologists are medically ill patients who develop SE while in hospital. These patients are often notoriously difficult to treat once SE arises. We sought to characterize patients at risk for SE arising when they are hospitalized for other reasons. By doing this, risk factors for developing SE and prognostic indicators might be determined. We retrospectively reviewed records from three urban hospitals in the United States to identify hospitalized patients developing SE over a 1 year period. SE was defined as a clinical seizure lasting 30 minutes or longer, or repeated seizures without recovery. Patients who were admitted in SE or for an epilepsy-related problem, or who were less than 1 year old were excluded from the study. Forty-one patients with in-hospital SE were identified. There were 28 males and 13 females with an age range from 1 to 91 years (mean: 60 years, median: 65 years). The mean interval from hospital admission to the onset of status epilepticus was 26 days. Nineteen (46%) patients had a prior history of either epilepsy or symptomatic seizures, and of these, 10 were inadequately treated as judged by serum anticonvulsant levels at the time SE developed. Focal brain abnormality was present in 26 (63%) patients, the most common of which was stroke (17 patients ). Major metabolic derangements including hypoxia, electrolyte imbalance, hepatic encephalopathy, and sepsis were present in 23 (56%) patients. Eleven (27%) patients were being treated with theophylline preparations at the time SE developed. Mortality in this group of patients with in-hospital SE was 61% (25 deaths), with about one-third dying while in status, and two-thirds dying subsequently in hospital. In this retrospective study, there was no clear relationship between mortality and the duration of SE in this group of patients. In-hospital development of SE is usually related to underlying focal brain abnormality, especially stroke, in combination with systemic metabolic derangement. Prognosis is poor, and appears to be more related to underlying conditions rather than to status duration. More accurate prospective studies are warranted.

Use of a comprehensive programme of external cueing to enhance procedural memory in a patient with dense amnesia.

This case study describes rehabilitation efforts with a 24-year-old woman who exhibited dense amnesia secondary to status epilepticus following a motor vehicle accident. She was 20 months post-injury upon entry into our day treatment programme. The functional severity of her amnesia was reflected in numerous ways, including no recall of what she wore from day to day and an inability to find the toilet after 2 weeks in the programme. A multidisciplinary comprehensive programme of external cueing was established to exploit her preserved procedural memory. Objective measures of functional compliance were gathered over time and contrasted with both standard neuropsychological test scores and early levels of functioning in rehabilitation. Results demonstrated enhanced functioning via utilization of procedural memory. In addition, the patient actually demonstrated increased independent generalization of strategies and techniques over time. Practical treatment implications are reviewed and discussed.

A missed diagnosis. A missed opportunity for community integration.

The quality of life of people with learning disability and epilepsy, in the community, can be improved by regular review and appropriate use of anti-convulsants. This paper reports two successful outcomes using a newer anti-convulsant, lamotrigine.

Movement disorders after status epilepticus and other brain injuries.

A retrospective medical record review was conducted of 173 consecutive children hospitalized for acquired brain injuries on a specialized pediatric rehabilitation service. The chart review identified children who developed movement disorders with acquired brain injuries: 8 with status epilepticus, 2 with trauma, and 1 with anoxia. Movement disorders were observed more frequently following status epilepticus (8 of 12) than following other causes of acquired brain injury (3 of 161; P = .0001). Four additional children had severe neurologic deficits following status epilepticus but did not develop movement disorders. The 11 patients who developed movement disorders had choreiform movements predominantly. Even though status epilepticus is a clinical phenomenon resulting from a variety of etiologies, the features of movement disorders in these children were strikingly similar. The pathophysiology of this complication is unknown.