Ictal Cotard delusion as a manifestation of nonconvulsive status epilepticus: A case report and commentary.

Psychosis of epileptic origin can present a wide range of cognitive and affective symptoms and is often underrecognized. Usually occurring in the inter- and postictal phase, epileptic psychosis is mostly related to temporal lobe epilepsy. Here, we describe the clinical presentation and diagnostic workup including routine EEG recording and brain MRI of a 63-year-old woman expressing isolated nihilistic delusions comprising belief of being dead and denial of self-existence. EEG showed an ictal pattern fulfilling the Salzburg criteria of nonconvulsive status epilepticus and brain MRI revealed extensive peri-ictal hyperperfusion. Delusional symptoms and EEG abnormalities subsided after acute antiseizure treatment. Our case illustrates how nihilistic delusions can occur as a direct clinical correlate of seizure activity, thereby expanding the spectrum of ictal neuropsychiatric phenomena in temporal lobe epilepsy and highlighting the need to consider an epileptic origin in patients presenting with psychotic symptoms.

Comprehensive Evaluation of Cerebral Hemodynamics and Oxygen Metabolism in Revascularization of Asymptomatic High-Grade Carotid Stenosis.

INTRODUCTION: Revascularization procedures in carotid artery stenosis have shown a positive effect in the restoration of cerebral oxygen metabolism as assessed by T2' (T2 prime) imaging as well as capillary homeostasis by measurement of capillary transit time heterogeneity (CTH); however, data in patients with asymptomatic carotid stenosis without manifest brain lesions are scarce. PATIENTS AND METHODS: The effect of revascularization on the hemodynamic profile and capillary homeostasis was evaluated in 13 patients with asymptomatic high-grade carotid stenosis without ischemic brain lesions using dynamic susceptibility contrast perfusion imaging and oxygenation-sensitive T2' mapping before and 6-8 weeks after revascularization by endarterectomy or stenting. The cognitive performance at both timepoints was further assessed. RESULTS: Perfusion impairment at baseline was accompanied by an increased CTH (p = 0.008) in areas with a time to peak delay ≥ 2 s in the affected hemisphere compared to contralateral regions. Carotid intervention improved the overall moderate hemodynamic impairment at baseline by leading to an increase in normalized cerebral blood flow (p = 0.017) and a decrease in mean transit time (p = 0.027), oxygen extraction capacity (OEC) (p = 0.033) and CTH (p = 0.048). The T2' values remained unchanged. CONCLUSION: This study presents novel evidence of a state of altered microvascular function in patients with high-grade carotid artery stenosis in the absence of ischemic brain lesions, which shows sustained normalization after revascularization procedures.

Etiologic Evaluation of Ischemic Stroke in Young Adults: A Comparative Study between Two European Centers.

INTRODUCTION: Identifying the cause of ischemic stroke in young adults is often difficult. Our objective was to compare the etiologic diagnostic strategy for ischemic stroke in young adults between 2 European centers and investigate the influence of workup variations in the diagnosed etiologies. PATIENTS AND METHODS: We included patients aged 18-55 years admitted for ischemic stroke or transient ischemic attack to the stroke units of Santa Maria Hospital in Lisbon, Portugal, and Innsbruck University Hospital in Innsbruck, Austria, between 2014 and 2016. Etiology and diagnostic procedures were compared between centers. RESULTS: We included 156 patients from Innsbruck University Hospital and 110 patients from Santa Maria Hospital. Search for intracranial large-vessel disease was performed mainly by computed tomography/magnetic resonance angiography in Innsbruck (83.9% versus 52.7%; P < .01) and by transcranial Doppler in Lisbon (91.8% versus 43.2%; P < .01). Transoesophageal echocardiography was preferred in Innsbruck for detecting paradoxical embolism (80.0% versus 68.2%; P < .05), whereas in Lisbon contrast transcranial Doppler was preferred (80.9% versus 3.9%; P < .01). For investigation of other causes, Lisbon patients were more commonly screened for thrombophilia (100.0% versus 92.3%; P < .05) and autoimmune disorders (91.7% versus 44.5%; P < .01) while in Innsbruck consultation by other specialists was more frequent (51.6% versus 10.0%; P < .01). No significant differences were found in etiologies between centers. CONCLUSION: The differences in diagnostic workup did not influence etiologic diagnosis. Extensive laboratory testing does not seem to influence diagnosis of stroke of other determined cause, emphasizing the importance of a clinically-oriented approach for the etiologic diagnosis of stroke in young adults.