Focal drug-resistant epilepsy: Progress in care and barriers, a Morroccan perspective.

INTRODUCTION: The aim of this study is to determine the clinical, paraclinical, therapeutic and outcome aspects of drug resistant patients with epilepsy in our region and consequently to discuss methods that may improve the management of these patients. PATIENTS AND METHODS: This paper presents a retrospective study of 25 adult patients that were followed for focal drug resistant epilepsy in epileptology unit of the University Hospital of Fez, Morocco. RESULTS: This study recorded 25 patients including 48% of males and 52% of females. The mean age of patients was 24years-old. Hippocampal sclerosis was present in 28.5% of patients (7 cases); brain malformations were found in 19% of patients (5 cases); tumors were found in 24% of patients (6 cases); post-traumatic, post-surgical and anoxic-ischemic lesions were found in 28.5% of patients (7 cases). Resective epilepsy surgery was performed in 28,5% of patients (7 cases). Post surgical outcome was good for 5/7 patients (Engel I and II). CONCLUSION: The clinical characteristics, etiologies and clinical course of medically refractory focal epilepsy in our region are similar to that reported in the global literature. We also demonstrated a long delay between onset of seizures and surgery (15years range 8-34years) and barriers to epilepsy surgery.

Cerebral venous thrombosis: a Moroccan retrospective study of 30 cases.

Cerebral venous thrombosis (CVT) is a rare origin of stroke, the clinical presentation and etiologies vary. The prognosis is shown to be better than arterial thrombosis. Magnetic Resonance Imaging (MRI) and MR Venograpgy (MRV) are currently important tools for the diagnosis. We studied 30 cases of CVT diagnosed in the department of neurology at the University Hospital of Fez (Morocco). Patients diagnosed with CVT signs between January 2003 and October 2007 were included in the study. Cerebral CT-scan was performed in 27 cases (90%) while the MRI examination was done in 18 patients (67%); and most patients (90%) received anticoagulant therapy. The mean age of our patients was of 29 years (age range between 18 days and 65 years). A female predominance was observed (70%). The clinical presentation of patients was dominated by: headache in 24 cases (80%), motor and sensory disability in 15 cases (50%), seizures in 10 cases (33%), consciousness disorder in 10 cases (33%). CVT was associated to post-partum in 10 cases (33%), infectious origin in 8 cases (26%), Behçet disease in 2 cases (7%), pulmonary carcinoma in 1 case, thrombocytemia in 1 case and idiopathic in 7 cases (23%). The evolution was good in 20 cases (67%), minor squelaes were observed in 6 patients (20%), while major squelaes were observed in 2 cases. Two cases of death were registered. The CVT is a pathology of good prognosis once the diagnosis is promptly established and early heparin treatment initiated.

Psychiatric disorders revealing multiple sclerosis after 20 years of evolvement.

Previous research indicates that the onset of psychiatric disorders is sometimes associated with multiple sclerosis (MS) evolving several years later. However, information on why this might occur, and on the outcomes of such patients, is still lacking. We aim to discuss these limitations with the current paper. We describe a 51-year-old female who demonstrated severe anxiety disorder and depression years before developing MS neurological symptoms. The patient was treated for these psychiatric disorders over 20 years. In the last 3 years of her treatment, the patient demonstrated a choreic-type of movement disorder in all her limbs. This disorder is consistent with relapsing-remitting MS. Clinical and magnetic resonance imaging (MRI) examinations demonstrated aspects of MS, without MS being diagnosed conclusively. The visual evoked potential indicated a diagnosis of conduction abnormalities. The established diagnosis was slow relapsing MS. The patient underwent methylprednisolone bolus (1 g/day). This case-study suggests that health professionals should conduct a full neurological assessment when they find atypical psychiatric symptoms in a patient. This would make sure that patients receive a better standard of care, and thus experience a better quality of life.

Syphilitic limbic encephalitis revealed by status epilepticus.

Limbic encephalitis (LE) is an inflammatory disorder of the limbic system; the clinical features are diverse, characterised by the development of neuropsychiatric symptoms, its aetiologies are various; syphilis is a rare entity. We report the case of a 50-year-old-man with syphilitic LE revealed by an inaugural status epilepticus. Diagnosis was made considering clinical, biological and radiological arguments. The patient received specific treatment for neurosyphilis. Evolution was marked by improved neuropsychological symptoms, the negativity of venereal disease research laboratory test in blood and cerebrospinal fluid and regression of the mesiotemporal signal abnormalities on MRI.

Midbrain hematoma presenting with isolated bilateral palsy of the third cranial nerve in a Moroccan man: a case report.

INTRODUCTION: Bilateral third nerve palsy secondary to a hemorrhagic stroke is exceptional. To the best of our knowledge, no similar case has been reported in the literature. CASE PRESENTATION: We describe the case of a 69-year-old Moroccan man who presented with isolated sudden bilateral third nerve palsy. Computed tomography (CT) of the brain revealed a midbrain hematoma. The oculomotor function gradually and completely improved over eight months of follow-up. CONCLUSION: Stroke should be included in the differential diagnosis of sudden isolated oculomotor paralysis even when it is bilateral because of the severity of the underlying disease and the importance of its therapeutic implications.

Hemichorea-hemiballismus as an initial manifestation in a Moroccan patient with acquired immunodeficiency syndrome and toxoplasma infection: a case report and review of the literature.

Neurologic signs and symptoms may represent the initial presentation of AIDS in 10-30% of patients. Movement disorders may be the result of direct central nervous system infection by human immunodeficiency virus (HIV) or the result of opportunistic infections. We report the case of a 59 years old woman who had hemichorea-hemiballismus subsequently found to be secondary to a cerebral toxoplasmosis infection revealing HIV infection. Movement disorders, headache and nausea were resolved after two weeks of antitoxoplasmic treatment. Brain MRI control showed a marked resolution of cerebral lesion. Occurrence of hemichorea-ballismus in patient without familial history of movement disorders suggests a diagnosis of AIDS and in particular the diagnosis of secondary cerebral toxoplasmosis. Early recognition is important since it is a treatable entity.

Infectious endocarditis complicated by an ischemic stroke and revealing Marfan syndrome.

Marfan syndrome is a systematic genetic disease of the connective tissue. The cardiac affection would predict the prognosis and ischemic stroke might complicate it. The purpose of this work is to discuss the mechanisms of the ischemic stroke in Marfan syndrome which have to be considered in all young patients of ischemic strokes. We report the case of a 17-year-old male patient who presented with right hemiparesis with brachio-facial dominance, hemihypoesthesia and Broca's aphasia; these symptoms were followed by partial right somato-motor epileptic seizure. The cerebral computed tomographic (CT) scan demonstrated early signs of ischemic stroke in the left Sylvian artery. Cardiovascular examination revealed a systolic murmur in the mitral site. Marfan syndrome with infectious endocarditis complicated by ischemic stroke was diagnosed. However, the family pathological history was negative. The Marfan syndrome diagnosis was approved considering the following criteria: Ligamentous hyperlaxity, crystalline ectopia and mitral valve prolapsus with mitral insufficiency. The patient benefited of antibiotherapy for 4 weeks. The patient underwent sessions of motor physical therapy and orthophonic rehabilitation. Then, cardiac surgery was carried out and valvuloplasty was performed. The surgical treatment confirmed the presence of mitral insufficiency and prolapsus of the big mitral valve and multiple friable anterior-posterior vegetations with broken cordage of the small mitral valve. Replacement of the mitral valve was achieved, and the post-surgery follow-ups were simple. The diagnosis of Marfan syndrome was based on well-defined criteria. The evolution of the patient was marked by a complete improvement of the cardiac and motor deficits, and disappearance of the Broca's aphasia. A fibroelastic disease such Marfan syndrome has to be considered in unexplained ischemic stroke in all young patients. Hence, the diagnosis of Marfan syndrome involves an anticipation of the neurovascular complications by early cardiovascular care.

Thyroiditis of Hashimoto and myotonia.

Hypothyroidism is frequently associated with different neuromuscular disorders. However, myotonia is rarely a revealing feature. We report a case of hypothyroidism secondary to Hashimoto's thyroiditis and myotonia. The patient is a 45-year-old woman who consulted for a progressive myotonia. Blood and thyroid assessments revealed peripheral hypothyroidism with low free thyroxine, high thyroid-stimulating hormone levels and high titers of anti-thyroperoxidase antibodies. Outcome was favorable with thyroid hormone substitution. Hashimoto's thyroiditis is a common cause of hypothyroidism. The frequency of myopathy during hypothyroidism ranges from 30-80%. The main symptoms related are weakness, muscular cramps, and myalgia. Myotonia may reveal hypothyroidism. The pathogenic mechanism of this myotonia is still unknown. Good outcome of hypothyroid manifestations with thyroid hormone substitution requires systematic thyroid hormone screening in patients presenting with neuromuscular manifestations.