In vivo mapping of the deep and superficial white matter connectivity in the chimpanzee brain.

Mapping the chimpanzee brain connectome and comparing it to that of humans is key to our understanding of similarities and differences in primate evolution that occurred after the split from their common ancestor around 6 million years ago. In contrast to studies on macaque species' brains, fewer studies have specifically addressed the structural connectivity of the chimpanzee brain and its comparison with the human brain. Most comparative studies in the literature focus on the anatomy of the cortex and deep nuclei to evaluate how their morphology and asymmetry differ from that of the human brain, and some studies have emerged concerning the study of brain connectivity among humans, monkeys, and apes. In this work, we established a new white matter atlas of the deep and superficial white matter structural connectivity in chimpanzees. In vivo anatomical and diffusion-weighted magnetic resonance imaging (MRI) data were collected on a 3-Tesla MRI system from 39 chimpanzees. These datasets were subsequently processed using a novel fiber clustering pipeline adapted to the chimpanzee brain, enabling us to create two novel deep and superficial white matter connectivity atlases representative of the chimpanzee brain. These atlases provide the scientific community with an important and novel set of reference data for understanding the commonalities and differences in structural connectivity between the human and chimpanzee brains. We believe this study to be innovative both in its novel approach and in mapping the superficial white matter bundles in the chimpanzee brain, which will contribute to a better understanding of hominin brain evolution.

Cognitive effect of antiseizure medications in medial temporal lobe epilepsy.

BACKGROUND AND PURPOSE: The specific effects of antiseizure medications (ASMs) on cognition are a rich field of study, with many ongoing questions. The aim of this study was to evaluate these effects in a homogeneous group of patients with epilepsy to guide clinicians to choose the most appropriate medications. METHODS: We retrospectively identified 287 refractory patients with medial temporal lobe epilepsy associated with hippocampal sclerosis. Scores measuring general cognition (global, verbal and performance IQ), working memory, episodic memory, executive functions, and language abilities were correlated with ASM type, number, dosage and generation (old vs. new). We also assessed non-modifiable factors affecting cognition, such as demographics and epilepsy-related factors. RESULTS: Key parameters were total number of ASMs and specific medications, especially topiramate (TPM) and sodium valproate (VPA). Four cognitive profiles of the ASMs were identified: (i) drugs with an overall detrimental effect on cognition (TPM, VPA); (ii) drugs with negative effects on specific areas: verbal memory and language skills (carbamazepine), and language functions (zonisamide); (iii) drugs affecting a single function in a specific and limited area: visual denomination (oxcarbazepine, lacosamide); and (iv) drugs without documented cognitive side effects. Non-modifiable factors such as age at testing, age at seizure onset, and history of febrile seizures also influenced cognition and were notably influenced by total number of ASMs. CONCLUSION: We conclude that ASMs significantly impact cognition. Key parameters were total number of ASMs and specific medications, especially TPM and VPA. These results should lead to a reduction in the number of drugs received and the avoidance of medications with unfavorable cognitive profiles.

Late but not early seizures impact negatively early post stroke recovery: A case-control study.

BACKGROUND: Seizures are a frequent complication of strokes. The initial severity of the stroke is a risk factor for both seizure occurrence and poor functional recovery. AIM: To determine whether epilepsy has a negative impact on functional recovery or is just a proxy for the initial severity of the stroke. PATIENTS AND METHODS: We conducted a monocentric retrospective case-control study in 408 consecutive patients hospitalized in the neurological rehabilitation department of the Pitié-Salpêtrière Hospital for rehabilitation of a recent stroke between 1999 and 2019. We matched 1:1 stroke patients with and without seizures according to numerous variables that may influence the outcome: type of stroke (ischemic vs hemorrhagic (ICH)), type of endovascular treatment performed (thrombolysis, thrombectomy), exact location of the stroke (arterial territory for ischemic strokes, lobar territory for ICH), extent of the stroke, side of the stroke, and age at the time of stroke. Two criteria were used to judge the impact on neurological recovery: the change in modified Rankin score between entry and the discharge from the rehabilitation department, and the length of stay. Seizures were divided into early (within 7 days of stroke) and late (after 7 days) seizures. RESULTS: We accurately matched 110 stroke patients with and without seizures. Compared to seizure-free matched stroke patients, stroke patients with late seizures had a poorer neurological functional recovery in terms of Rankin score evolution (p = 0.011*) and length of stay (p = 0.004*). The occurrence of early seizures had no significant impact on functional recovery criteria. CONCLUSION: Late seizures, that is, stroke-related epilepsy, have a negative impact on early rehabilitation, whereas early symptomatic seizures do not negatively impact functional recovery. These results reinforce the recommendation not to treat early seizures.

Early identification of seizure freedom with medical treatment in patients with mesial temporal lobe epilepsy and hippocampal sclerosis.

BACKGROUND: Mesial temporal lobe epilepsy with hippocampal sclerosis (MTLE-HS) is usually associated with a poor response to antiseizure medications. We focused on MTLE-HS patients who were seizure free on medication to: (1) determine the clinical factors associated with seizure freedom and (2) develop a machine-learning classifier to better earlier identify those patients. METHODS: We performed a retrospective, multicentric study comparing 64 medically treated seizure-free MTLE-HS patients with 200 surgically treated drug-resistant MTLE-HS patients. First, we collected medical history and seizure semiology data. Then, we developed a machine-learning classifier based on clinical data. RESULTS: Medically treated seizure-free MTLE-HS patients were seizure-free for at least 2 years, and for a median time of 7 years at last follow-up. Compared to drug-resistant MTLE-HS patients, they exhibited: an older age at epilepsy onset (22.5 vs 8.0 years, p < 0.001), a lesser rate of: febrile seizures (39.0% vs 57.5%, p = 0.035), focal aware seizures (previously referred to as aura)(56.7% vs 90.0%, p < 0.001), autonomic focal aware seizures in presence of focal aware seizure (17.6% vs 59.4%, p < 0.001), dystonic posturing of the limbs (9.8% vs 47.0%, p < 0.001), gestural (27.4% vs 94.0%, p < 0.001), oro-alimentary (32.3% vs 75.5%, p < 0.001) or verbal automatisms (12.9% vs 36.0%, p = 0.001). The classifier had a positive predictive value of 0.889, a sensitivity of 0.727, a specificity of 0.962, a negative predictive value of 0.893. CONCLUSIONS: Medically treated seizure-free MTLE-HS patients exhibit a distinct clinical profile. A classifier built with readily available clinical data can identify them accurately with excellent positive predictive value. This may help to individualize the management of MTLE-HS patients according to their expected pharmacosensitivity.

A novel male Japanese quail structural connectivity atlas using ultra-high field diffusion MRI at 11.7 T.

The structural connectivity of animal brains can be revealed using post-mortem diffusion-weighted magnetic resonance imaging (MRI). Despite the existence of several structural atlases of avian brains, few of them address the bird's structural connectivity. In this study, a novel atlas of the structural connectivity is proposed for the male Japanese quail (Coturnix japonica), aiming at investigating two lines divergent on their emotionality trait: the short tonic immobility (STI) and the long tonic immobility (LTI) lines. The STI line presents a low emotionality trait, while the LTI line expresses a high emotionality trait. 21 male Japanese quail brains from both lines were scanned post-mortem for this study, using a preclinical Bruker 11.7 T MRI scanner. Diffusion-weighted MRI was performed using a 3D segmented echo planar imaging (EPI) pulsed gradient spin-echo (PGSE) sequence with a 200 [Formula: see text]m isotropic resolution, 75 diffusion-encoding directions and a b-value fixed at 4500 s/mm2. Anatomical MRI was likewise performed using a 2D anatomical T2-weighted spin-echo (SE) sequence with a 150 [Formula: see text]m isotropic resolution. This very first anatomical connectivity atlas of the male Japanese quail reveals 34 labeled fiber tracts and the existence of structural differences between the connectivity patterns characterizing the two lines. Thus, the link between the male Japanese quail's connectivity and its underlying anatomical structures has reached a better understanding.

When should we test patients with epilepsy for autoimmune antibodies? Results from a French retrospective single center study.

BACKGROUND AND PURPOSE: Seizures represent a core symptom of autoimmune encephalitides with specific therapeutic issues. To date, patients with new-onset seizures or established epilepsy are not systematically tested for autoimmune antibodies. We aimed to identify clinical and paraclinical criterion that could help to select patients requiring additional autoimmune antibodies serum and cerebrospinal fluid (CSF) detection. METHODS: In this retrospective single center study from the French Salpêtrière Hospital, data from 286 adult patients with epilepsy who received an autoantibody assay for the first time were analyzed. All patients were evaluated at our institution between January 2007 and December 2018 for assessment of new-onset epilepsy (n = 90) or established epilepsy (n = 196). We only analyzed patients that were screened for autoimmune antibodies. Demographic, clinical and neuroimaging measures were compared between patients with and without autoimmune encephalitis using Fisher's exact test for categorical variables and Welch's t test for continuous variables. Our primary goal was to identify significant factors that differentiated patients with and without autoimmune encephalitis. RESULTS: We identified 27 patients with autoimmune epilepsy (9.4% of the patients who had been tested for autoantibodies). The significant factors differentiating patients with and without autoimmune encephalitis were: (i) the existence of a new-onset focal epilepsy + (e.g., newly diagnosed epilepsy < 6 months associated with additional symptoms, mainly cognitive or psychiatric symptoms), (ii) the presence of faciobrachial dystonic seizures very suggestive of anti- Leucine-rich glioma inactivated 1 (LGI1) encephalitis, and (iii) the presence of magnetic resonance imaging (MRI) abnormalities suggestive of encephalitis. CONCLUSION: New-onset focal seizures combined with cognitive or psychiatric symptoms support the test for autoimmune antibodies. Further clinical already known red flags for an autoimmune origin are the presence of faciobrachial dystonic seizures and MRI signal changes consistent with encephalitis. On the other hand, isolated new-onset seizures and chronic epilepsy, even with associated symptoms, seem rarely linked to autoimmune encephalitis and should not lead to systematic testing.

Hippocampal sclerosis linked to epilepsy: clinical consequences, histopathology and evolution with aging / Sclérose hippocampique associée à l'épilepsie : conséquences cliniques, histopathologie et évolution avec l'âge

Hippocampal sclerosis is the most frequent etiology of patients with drug-resistant mesial temporal lobe epilepsy, which is the most frequent localization for focal epilepsy. Hippocampal sclerosis is the consequence of a cerebral aggression during early childhood, called the initial precipitating event, the most frequent of which are: febrile seizure, intracranial infection, hypoxia, or cranial trauma. The epilepsy onset usually occurs a few years after this event, with an association of focal temporal seizures and rarer secondarily generalized tonic-clonic seizures. Most patients have a drug-resistant focal epilepsy, with a failure of two different and adequate antiepileptic drugs to achieve seizure freedom. Patients also demonstrated with cognitive impairment, with a typical episodic memory impairment affecting both verbal and non-verbal episodic memory. Cognitive impairment is however more diffuse than the sole episodic memory impairment, and also affects language, visuo-spatial processing, and executive functions. With aging, subjects demonstrated a progressive cognitive decline, that appears to parallel the decline associated with normal aging, but starts earlier and from a lower global cognitive functioning with less cognitive reserve. Patients may therefore reach an impairment threshold sooner than healthy subjects, and are much more vulnerable to any other disease that impairs cognitive functioning. Patients exhibited cortical and subcortical atrophy patterns on volumetric brain MRI similar to normal aging in its distribution, but with an earlier pattern of atrophy (4.5 years sooner in patients than in healthy subjects). Hippocampal sclerosis is associated with amyloid and tau deposits inside the hippocampus, which increases with the subjects' age. Those deposits pattern is close to the one observed in patients with tau / amyloïd neurodegenerative diseases, which demonstrates a bilateral relationship between epilepsy, hippocampal sclerosis, and neurodegenerative diseases. Clinical consequences of such a relationship are yet to be precisely determined.

La sclérose hippocampique est l'étiologie la plus fréquente de l'épilepsie focale temporale mésiale. Elle est souvent la conséquence d'un évènement initial précipitant durant la petite enfance (crises fébriles, infection intracrânienne, hypoxie cérébrale, traumatisme crânien…). L'épilepsie débute ensuite, après un intervalle libre de quelques années, vers la fin de l'enfance ou le début de l'adolescence, et est très souvent pharmacorésistante. Il s'y associe des troubles mnésiques s'étendant au-delà d'une atteinte hippocampique isolée, avec une atteinte des fonctions exécutives, visuo-spatiales et du langage. Avec l'âge, les fonctions cognitives de ces sujets suivent une trajectoire évolutive parallèle à celle observée dans le vieillissement physiologique, mais avec un maximum de performance plus faible et un déclin plus précoce de quelques années, ce qui induit une réserve cognitive moins importante. La distribution de l'atrophie liée à l'âge est identique à celle des sujets sains, mais décalée dans le temps (plus précoce de 4,5 ans). De plus, la sclérose hippocampique est associée à la présence de dépôts intra-hippocampiques de protéines Tau et de peptide amyloïde, ressemblant à ce qui est observé chez les patients souffrant d'une pathologie neurodégénérative tau/amyloïde, augmentant avec l'âge et dont les conséquences cliniques restent encore à déterminer.

Distinctive neuropsychological profiles of lateral temporal lobe epilepsy.

OBJECTIVE: Lateral temporal lobe epilepsies (LTLE) are poorly characterized heterogeneous epilepsies. As the lateral temporal lobe supports distinct functions, we hypothesized that neuropsychological profiles could differ according to the localization of the seizure focus within the lateral temporal lobe. METHODS: We retrospectively examined the neuropsychological characteristics of 74 consecutive patients with refractory LTLE assessed in the context of a presurgical investigation at the Pitié-Salpêtrière Hospital in Paris between 1998 and 2018. Precise localization of the epileptic focus was correlated with scores on tests of intelligence (Global, Verbal and Performance IQ), working memory, episodic memory (verbal and visual learning and forgetting), executive functions, and language abilities. RESULTS: We demonstrated an impact of the localization of the epileptic focus within the lateral temporal lobe with worse learning and/or executive performances depicted in the infero-basal and pure pole LTLE groups and greater language difficulties in the posterior LTLE group, Antiepileptic drugs had a greater effect than parameters related to the epilepsy itself as the lesion or the disease duration, and finally as in medial TLE, the age, education, and sex influenced some cognitive performances. CONCLUSION: Our findings show that the lateral temporal neocortex is also part of the neural substrate for memory processing and executive functions and suggest that this involvement could be related to functions devoted to specific subregions of the temporal lobe (i.e., temporal pole, inferior and basal regions) that support language and semantic processing.

The wide spectrum of COVID-19 neuropsychiatric complications within a multidisciplinary centre.

A variety of neuropsychiatric complications has been described in association with COVID-19 infection. Large scale studies presenting a wider picture of these complications and their relative frequency are lacking. The objective of our study was to describe the spectrum of neurological and psychiatric complications in patients with COVID-19 seen in a multidisciplinary hospital centre over 6 months. We conducted a retrospective, observational study of all patients showing neurological or psychiatric symptoms in the context of COVID-19 seen in the medical and university neuroscience department of Assistance Publique Hopitaux de Paris-Sorbonne University. We collected demographic data, comorbidities, symptoms and severity of COVID-19 infection, neurological and psychiatric symptoms, neurological and psychiatric examination data and, when available, results from CSF analysis, MRI, EEG and EMG. A total of 249 COVID-19 patients with a de novo neurological or psychiatric manifestation were included in the database and 245 were included in the final analyses. One-hundred fourteen patients (47%) were admitted to the intensive care unit and 10 (4%) died. The most frequent neuropsychiatric complications diagnosed were encephalopathy (43%), critical illness polyneuropathy and myopathy (26%), isolated psychiatric disturbance (18%) and cerebrovascular disorders (16%). No patients showed CSF evidence of SARS-CoV-2. Encephalopathy was associated with older age and higher risk of death. Critical illness neuromyopathy was associated with an extended stay in the intensive care unit. The majority of these neuropsychiatric complications could be imputed to critical illness, intensive care and systemic inflammation, which contrasts with the paucity of more direct SARS-CoV-2-related complications or post-infection disorders.

Sleep scoring based on video-electroencephalography monitoring in an Epileptology Unit: Comparison with polysomnography.

The aim of the study was to compare the performance of video- electroencephalography (EEG) monitoring and standard polysomnography for sleep scoring in an Epileptology Unit. We calculated the level of agreement between two methods of sleep scoring, using either 27-electrode video-EEG or polysomnography for 1 night in 22 patients admitted to our Epileptology Unit. Independent experts manually scored sleep using the American Academy of Sleep Medicine 2017 guidelines. We evaluated the number of sleep cycles and their distribution on hypnogram, total sleep time, sleep efficiency, sleep and rapid eye movement sleep-onset latency, wake after sleep-onset, and sleep stages. We then extracted sub-samples of recordings to examine the agreement in microarousal and rapid eye movement scoring. We used Bland and Altman plots and Cohen's kappa test to measure agreement. Bland and Altman plots showed at least 95% agreement for all studied sleep parameters with the exception of wake after sleep onset, where there was an 11 min difference. Cohen's kappa test showed an agreement for the recognition of microarousal (0.89) and of rapid eye movements (0.96) in sub-samples. Video-EEG represents an acceptable alternative tool for sleep architecture study in patients admitted to an Epileptology Unit.

The temporal pole: From anatomy to function-A literature appraisal.

Historically, the anterior part of the temporal lobe was labelled as a unique structure named Brain Area 38 by Brodmann or Temporopolar Area TG by Von Economo, but its functions were unknown at that time. Later on, a few studies proposed to divide the temporal pole in several different subparts, based on distinct cytoarchitectural structure or connectivity patterns, while a still growing number of studies have associated the temporal pole with many cognitive functions. In this review, we provide an overview of the temporal pole anatomical and histological structure and its various functions. We performed a literature review of articles published prior to September 30, 2020 that included 112 articles. The temporal pole has thereby been associated with several high-level cognitive processes: visual processing for complex objects and face recognition, autobiographic memory, naming and word-object labelling, semantic processing in all modalities, and socio-emotional processing, as demonstrated in healthy subjects and in patients with neurological or psychiatric diseases, especially in the field of neurodegenerative disorders. A good knowledge of those functions and the symptoms associated with temporal pole lesions or dysfunctions is helpful to identify these diseases, whose diagnosis may otherwise be difficult.

Ketamine reduces temporal expectation in the rhesus monkey.

RATIONALE: Ketamine, a well-known general dissociative anesthetic agent that is a non-competitive antagonist of the N-methyl-D-aspartate receptor, perturbs the perception of elapsed time and the expectation of upcoming events. OBJECTIVE: The objective of this study was to determine the influence of ketamine on temporal expectation in the rhesus monkey. METHODS: Two rhesus monkeys were trained to make a saccade between a central warning stimulus and an eccentric visual target that served as imperative stimulus. The delay between the warning and the imperative stimulus could take one of four different values randomly with the same probability (variable foreperiod paradigm). During experimental sessions, a subanesthetic low dose of ketamine (0.25-0.35 mg/kg) was injected i.m. and the influence of the drug on movement latency was measured. RESULTS: We found that in the control conditions, saccadic latencies strongly decreased with elapsed time before the appearance of the visual target showing that temporal expectation built up during the delay period between the warning and the imperative stimulus. However, after ketamine injection, temporal expectation was significantly reduced in both subjects. In addition, ketamine also increased average movement latency but this effect could be dissociated from the reduction of temporal expectation. CONCLUSION: In conclusion, a subanesthetic dose of ketamine could have two independent effects: increasing reaction time and decreasing temporal expectation. This alteration of temporal expectation could explain cognitive deficits observed during ketamine use.

Temporal pole epilepsy surgery-Sparing the hippocampus.

Temporal pole epilepsy (TPE) is a poorly known and difficult to individualize subtype of temporal lobe epilepsy. Consequently, in drug-resistant TPE, there is still a debate on the need for a large surgical removal of the temporal pole and mesial temporal structures or a limited resection of the temporal pole. We reviewed all patients who underwent presurgical evaluation for drug-resistant epilepsy over a 17-year period, and report here 19 patients with proven drug-resistant temporal pole epilepsy who underwent a selective temporal pole resection with respect to mesial structures. Most (15) TPE patients exhibited seizures resembling mesiotemporal seizures, whereas the others exhibited nocturnal hyperkinetic seizures or an association of both seizure types. MRI revealed a temporal pole lesion in 58% of patients. Long-term postoperative outcome after a conservative surgery was excellent: 63% of patients were seizure-free (International League Against Epilepsy [ILAE] 1) at 1-year postsurgery and 78% at 5 years. These results show that TPE has no specific electroclinical features but is a distinct type of temporal lobe epilepsy allowing a conservative surgery. Respecting the mesiotemporal structures is a valid surgical approach for drug-resistant temporal pole epilepsy.

Guillain-Barré Syndrome During Platinum-Based Chemotherapy: A Case Series and Review of the Literature.

Platinum-based chemotherapy is commonly associated with toxic sensory neuropathies, but also, although rarely, with Guillain-Barré syndrome (GBS). We describe five patients who developed GBS while receiving platinum-based chemotherapy for a solid tumor and report the five cases published so far. Most patients had received cumulative platinum doses below known neurotoxic levels, and all of them had an optimal outcome after platinum discontinuation, associated in most cases with administration of intravenous immunoglobulin. Clinical presentation, electroneuromyography, and cerebrospinal fluid analysis help clinicians to differentiate GBS from toxic neuropathy. Platinum compounds are the only chemotherapeutic agents used for solid tumors that have been associated to GBS. Thus, we propose that GBS may constitute a non-dose-dependent side effect of platinum drugs and that awareness needs to be raised among oncologists on this rare but potentially life-threatening complication of platinum chemotherapy. IMPLICATIONS FOR PRACTICE: Many patients on platinum-based chemotherapy for solid tumors develop sensory neuropathy, a common dose-dependent side effect. The authors propose that Guillain-Barré syndrome may constitute an immune-mediated, non-dose-related side effect of platinum-based chemotherapy. Prompt diagnosis of Guillain-Barré syndrome and distinction from classical toxic neuropathy are crucial for optimal treatment. Platinum discontinuation, associated if needed to intravenous immunoglobulin administration, radically changes the course of the disease and minimizes neurological sequelae.

Peripheral neuropathy in glycogen storage disease type III: Fact or myth?

INTRODUCTION: The aim of this study was to assess whether peripheral neuropathy is a feature of glycogen storage disease type IIIa (GSD IIIa) in adult patients. METHODS: Medical records of a cohort of adult GSD IIIa patients who underwent electromyography (EMG) and nerve conduction studies (NCS) were reviewed, and the results were correlated with physical examination findings. RESULTS: Sixteen patients underwent EMG and NCS; 4 complained of exercise intolerance, 1 of foot paresthesia, and 11 of muscle weakness (3 proximal, 8 distal). None of the patients had sensory deficits on clinical examination. All motor and sensory conduction velocities and sensory amplitudes were within reference ranges. EMG showed myopathic motor unit potentials in 15 of the 16 patients. CONCLUSIONS: Based on the clinical examination and the NCS and EMG results, we did not identify any peripheral nerve involvement in our adult patients diagnosed with GSD III.

Contrast-enhanced ultrasonography in Takayasu arteritis: watching and monitoring the arterial inflammation.

A 43-year-old man was diagnosed with Takayasu arteritis, and treated with methotrexate and corticosteroids. While under treatment and with normal biological inflammatory parameters, he experienced an ischaemic stroke, successfully treated with intravenous thrombolysis (alteplase). The B-mode ultrasound examination revealed circumferential wall thickening of the left common carotid artery. Contrast-enhanced ultrasonography showed a progressive arterial wall enhancement of the left common carotid artery. This pathological enhancement indicates neovascularisation of the arterial wall, which is supposed to correlate with active vascular inflammation. After an increase in immunosuppressive treatment, follow-up contrast-enhanced ultrasonography no longer showed artery wall enhancement. Contrast-enhanced ultrasound examination is an inexpensive, reproducible and minimally invasive method, providing dynamic information on arterial wall neovascularisation and thus inflammation. This case illustrates that contrast-enhanced ultrasonography can be a useful tool for the management and follow-up of Takayasu arteritis, and its use as a marker of disease activity and arterial inflammation in Takayasu arteritis should be evaluated in further studies.

Choking during sleep: can it be expression of arousal disorder?

BACKGROUND: Choking during sleep may be caused by various respiratory and non-respiratory problems. OBJECTIVE: We aimed at documenting a new, rare cause of hallucinatory choking. METHODS: We documented the clinical and video-polysomnographic features of 11 adult patients referred for swallowing and choking during sleep. We conducted a systematic search for similar sensations in 68 consecutive adult patients with sleepwalking/sleep terrors and in 37 patients with obstructive sleep apnea. RESULTS: The 11 patients with sleep-related swallowing and choking were all current or former sleepwalkers. The symptoms occurred during the first third of the night. The patients consistently reported a frequent hallucinatory feeling of swallowing an unusual object (ring, nails, pebble, chewing gum, spoon, fork, electrical cables, lizard tail, needles, brush, computer, or gas container) that blocked the upper airways during sleep, followed by attempts to unblock them by spitting or swallowing water. When monitored, the choking sensations were not stereotypic, and occurred exclusively during arousals from N3 sleep, despite normal airway patency and absence of epileptic activity. The patients demonstrated simultaneous intense adrenergic stimulation and emotional distress. Of the 68 sleepwalkers, 13% had occasional choking sensations and 4% once inhaled a fictitious object. In the sleep apnea group, choking was never the motive of referral, but 38% of patients had occasional choking sensations, and 5% once inhaled something fictitious. CONCLUSION: Although insular seizure could also be discussed, these results suggest that sleep-related swallowing and choking syndrome may be a rare, specialized variant of the arousal disorders in some cases.

Evidence that non-dreamers do dream: a REM sleep behaviour disorder model.

To determine whether non-dreamers do not produce dreams or do not recall them, subjects were identified with no dream recall with dreamlike behaviours during rapid eye movement sleep behaviour disorder, which is typically characterised by dream-enacting behaviours congruent with sleep mentation. All consecutive patients with idiopathic rapid eye movement sleep behaviour disorder or rapid eye movement sleep behaviour disorder associated with Parkinson's disease who underwent a video-polysomnography were interviewed regarding the presence or absence of dream recall, retrospectively or upon spontaneous arousals. The patients with no dream recall for at least 10 years, and never-ever recallers were compared with dream recallers with rapid eye movement sleep behaviour disorder regarding their clinical, cognitive and sleep features. Of the 289 patients with rapid eye movement sleep behaviour disorder, eight (2.8%) patients had no dream recall, including four (1.4%) patients who had never ever recalled dreams, and four patients who had no dream recall for 10-56 years. All non-recallers exhibited, daily or almost nightly, several complex, scenic and dreamlike behaviours and speeches, which were also observed during rapid eye movement sleep on video-polysomnography (arguing, fighting and speaking). They did not recall a dream following sudden awakenings from rapid eye movement sleep. These eight non-recallers with rapid eye movement sleep behaviour disorder did not differ in terms of cognition, clinical, treatment or sleep measures from the 17 dreamers with rapid eye movement sleep behaviour disorder matched for age, sex and disease. The scenic dreamlike behaviours reported and observed during rapid eye movement sleep in the rare non-recallers with rapid eye movement sleep behaviour disorder (even in the never-ever recallers) provide strong evidence that non-recallers produce dreams, but do not recall them. Rapid eye movement sleep behaviour disorder provides a new model to evaluate cognitive processing during dreaming and subsequent recall.

Sleepiness in Idiopathic REM Sleep Behavior Disorder and Parkinson Disease.

OBJECTIVE: To determine whether patients with idiopathic and symptomatic RBD were sleepier than controls, and if sleepiness in idiopathic RBD predicted earlier conversion to Parkinson disease. METHODS: The Epworth Sleepiness Scale (ESS) and its determinants were compared at the time of a video-polysomnography for an RBD diagnosis in patients with idiopathic RBD, in patients with Parkinson disease, and in controls. Whether sleepiness at time of RBD diagnosis predicted an earlier conversion to neurodegenerative diseases was retrospectively analyzed in the followed-up patients. RESULTS: The 75 patients with idiopathic RBD were sleepier (ESS: 7.8 ± 4.6) at the time of RBD diagnosis than 74 age- and sex-matched controls (ESS: 5.0 ± 3.6, P < 0.0001). They reached the levels of 114 patients with Parkinson disease (ESS: 8.7 ± 4.8), whether they had (n = 78) or did not have (n = 36) concomitant RBD. The severity of sleepiness in idiopathic RBD correlated with younger age, but not with sleep measures. Among the 69 patients with idiopathic RBD who were followed up for a median 3 years (1-15 years), 16 (23.2%) developed parkinsonism (n = 6), dementia (n = 6), dementia plus parkinsonism (n = 2), and multiple system atrophy (n = 2). An ESS greater than 8 at time of RBD diagnosis predicted a shorter time to phenoconversion to parkinsonism and dementia, from RBD onset, and from RBD diagnosis (when adjusted for age and time between RBD onset and diagnosis). CONCLUSIONS: Sleepiness is associated with idiopathic REM sleep behavior disorder and predicts more rapid conversion to parkinsonism and dementia, suggesting it is an early marker of neuronal loss in brainstem arousal systems.

Sleep-related declarative memory consolidation and verbal replay during sleep talking in patients with REM sleep behavior disorder.

OBJECTIVE: To determine if sleep talkers with REM sleep behavior disorder (RBD) would utter during REM sleep sentences learned before sleep, and to evaluate their verbal memory consolidation during sleep. METHODS: Eighteen patients with RBD and 10 controls performed two verbal memory tasks (16 words from the Free and Cued Selective Reminding Test and a 220-263 word long modified Story Recall Test) in the evening, followed by nocturnal video-polysomnography and morning recall (night-time consolidation). In 9 patients with RBD, daytime consolidation (morning learning/recall, evening recall) was also evaluated with the modified Story Recall Test in a cross-over order. Two RBD patients with dementia were studied separately. Sleep talking was recorded using video-polysomnography, and the utterances were compared to the studied texts by two external judges. RESULTS: Sleep-related verbal memory consolidation was maintained in patients with RBD (+24±36% words) as in controls (+9±18%, p=0.3). The two demented patients with RBD also exhibited excellent nighttime consolidation. The post-sleep performance was unrelated to the sleep measures (including continuity, stages, fragmentation and apnea-hypopnea index). Daytime consolidation (-9±19%) was worse than night-time consolidation (+29±45%, p=0.03) in the subgroup of 9 patients with RBD. Eleven patients with RBD spoke during REM sleep and pronounced a median of 20 words, which represented 0.0003% of sleep with spoken language. A single patient uttered a sentence that was judged to be semantically (but not literally) related to the text learned before sleep. CONCLUSION: Verbal declarative memory normally consolidates during sleep in patients with RBD. The incorporation of learned material within REM sleep-associated sleep talking in one patient (unbeknownst to himself) at the semantic level suggests a replay at a highly cognitive creative level.