Abnormal inpatient EEG predicts seizure occurrence independently of renal function.

Purpose: The study aimed to determine prospectively whether there is a significant relationship between renal function as per the estimated glomerular filtration rate (eGFR), and the occurrence of seizures in patients who have no history of epilepsy and who required an EEG while hospitalized. Methods: Adult patients who were hospitalized at Hôtel-Dieu de France University Hospital in Beirut and who required routine EEGs were included over a period of 13 months. We excluded critical patients or those with history of epilepsy.Data was analyzed depending on the EEG result and according to the baseline eGFR estimated by the CKD-EPI formula. Patients were followed prospectively by phone interview at 6 months for occurrence of seizure or death. Results: Sixty one patients with a mean age of 66 (age range 19 to 95) were included (52 % were females). Of the 23 patients who had normal EEGs, 43.47% had abnormal eGFR, and none of them had a seizure. Of the patients with abnormal EEGs, 71.05% had abnormal eGFR, of which 7 had seizures. A significant relationship was found between having an abnormal EEG and the risk of developing a seizure in the future independently of the baseline eGFR.Whatever the eGFR is, if the EEG is normal, there will be lower risk to develop a seizure at 6 months. Conclusions: While eGFR and the incidence of seizures were not directly related, our study showed that patients with abnormal EEG were more likely to develop seizures regardless of their baseline eGFR.

Rapid response EEG with needle electrodes in an intensive care unit with limited resources.

Objective: Continuous EEG (cEEG) is the gold standard for detecting seizures and rhythmic and periodic patterns (RPPs) in critically ill patients but is often not available in health systems with limited resources. The current study aims to determine the feasibility and utility of low-cost, practical, limited montage, sub-dermal needle electrode EEG in a setting where otherwise no EEG would be available. Methods: The study included all adult patients admitted to the intensive care unit of a single center over a 24-month period. Members of the existing ICU care team, mostly nurses, were trained to place 8 sub-dermal needle EEG electrodes to achieve rapid, limited montage-EEG recording. Clinical outcomes were recorded, including any reported major complications; and the EEG findings documented, including background characterization, RPPs, and seizures. Results: One hundred twenty-three patients, mean age 68 years, underwent an average of 15.6 min of EEG recording. There were no complications of electrode placement. Overall, 13.0% had seizures (8.1% qualifying as status epilepticus [SE]), 18.7 % had generalized periodic discharges (GPDs), 4.9% had lateralized periodic discharges (LPDs), and 11.4 % sporadic epileptiform discharges (sEDs). Greater mortality was observed in patients with worse background EEGs, seizures, LPDs, or sEDs. Conclusions: Rapid, limited montage EEG could be achieved safely and inexpensively in a broad population of critically ill patients following minimal training of existing care teams. Significance: For resource poor centers or centers outside of major metropolitan areas who otherwise have no access to EEG, this may prove a useful method for screening for non-convulsive seizures and status epilepticus.

Ictal and interictal FDG-PET in anti-NMDAR encephalitis with mutism.

We report a case of a 27-year-old right-handed gentleman with mutism and seizures diagnosed with Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis without evidence of underlying malignancy. Brain MRI was unremarkable. Clinical seizures were controlled but long-term video-EEG monitoring was needed for better characterization of his clinical manifestations especially that language partially improved. It was crucial to identify whether this mutism was ictal in origin or not. Ictal brain Positron Emission Tomography with 18 F-fluorodeoxyglucose (FDGPET) scan combined with EEG was done. It revealed left fronto-temporal, parietal, and crossed cerebellar hypermetabolism (or diaschisis) concomitant to the underlying rhythmic focal delta activity on EEG. Beside anti-epileptic drugs he was treated with escalating immunotherapy (intravenous solumedrol then immunoglobulins then full rituximab course). Six months later, EEG combined to FDG-PET scan were repeated, and were normal. At 3 years follow up the patient remains neurologically stable and seizure-free, off anti-epileptics drugs. Performing the FDGPET scan combined to EEG was useful to identify non-convulsive status epilepticus and should be performed early in anti-NMDAR encephalitis to guide treatment.

Impact of epilepsy training on school teachers and counselors: An intervention study in Lebanon.

This study aimed to evaluate the immediate impact of an epilepsy training through the administration of a questionnaire (in Arabic) before and immediately after the intervention in Lebanese public and private schools. This project is part of an awareness campaign applied to 3 groups of teachers and counselors and consisted of a pretest, a unified conference and a posttest. The statistical analysis used the McNemar and Stuart Maxwell tests (statistical significance level of 0.05). 73 participants completed the questionnaires. The majority were female (68.5%), aged less than 39 years (57%) and familiar with epilepsy. A positive impact of the training was found regarding the effect of epilepsy on schooling, seizures manifestations, psychological effects, seizure first aid and the possibility of curing epilepsy with surgery. Most of our participants recognized that children with epilepsy have a comparable IQ to others. They did not exhibit a discriminatory attitude against people with epilepsy in terms of the direct attitude towards them, employment or marriage. This is one of few studies done worldwide demonstrating an immediate positive effect of epilepsy training among school teachers. Future research should be undertaken to develop robust training models to destigmatize epilepsy.

Generalized periodic epileptiform discharges in critically ill children: clinical features, and outcome.

PURPOSE: Generalized periodic epileptiform discharges (GPDs) are a specific periodic EEG pattern, reported as having a poor clinical outcome. The incidence and clinical implications of this EEG pattern in children are not known. In this study, we examined the clinical features of children with GPDs. METHODS: EEG-video monitoring reports of children with critical illness in the intensive care unit were retrospectively reviewed to detect GPDs. The clinical history, hospital course and seizure characteristics were reviewed and outcome was based on the clinical findings at hospital discharge. RESULTS: Twenty one children (age 2-18 years) were identified with GPDs. The most common underlying etiology was encephalitis (N=11). At the time of EEG, a continuous intravenous infusion (cIV) of an anticonvulsant drug was used to treat refractory status epilepticus (RSE). Non-convulsive seizures (NCS) were identified in 15, and clinical seizures in 13 children after GPDs were detected. GPDs occurred after a dose reduction in the cIV in 43%. Neuroimaging done in 16 children showed an acute change in 13/16 (81%) and chronic changes in 2/16 (13%). Five children (23%) died. Seven (33%) children had a favorable outcome, whereas the remaining children had a moderate to severe disability at the time of hospital discharge. CONCLUSION: GPDs are seen during the course of RSE in critically ill children and are associated with seizure recurrence. A lower mortality rate occurs in children with GPDs compared to adult counterparts, likely related to different etiologies. Although the significance of GPDs must be determined within the context of the clinical situation, GPDs suggest a still active epileptic process.

Updates in the management of seizures and status epilepticus in critically ill patients.

Seizures and status epilepticus are common in critically ill patients. They can be difficult to recognize because most are nonconvulsive and require electroencephalogram monitoring to detect; hence, they are currently underdiagnosed. Early recognition and treatment are essential to obtain maximal response to firstline treatment and to prevent neurologic and systemic sequelae. Antiseizure medication should be combined with management of the underlying cause and reversal of factors that can lower the seizure threshold, including many medications, fever, hypoxia, and metabolic imbalances. This article discusses specific treatments and specific situations, such as hepatic and renal failure patients and organ transplant patients.

Advances in the management of seizures and status epilepticus in critically ill patients.

Seizures and status epilepticus are common in critically ill patients. They can be difficult to recognize because most are non-convulsive and require electroencephalogram monitoring to detect; hence, they are currently underdiagnosed. Early recognition and treatment are essential to obtain maximal response to first-line treatment and to prevent neurologic and systemic sequelae. Anti-seizure medication should be combined with management of the underlying cause and reversal of factors that can lower the seizure threshold, including many medications, fever, hypoxia, and metabolic imbalances. This article discusses specific treatments and specific situations, such as hepatic and renal failure patients and organ transplant patients.

The syndrome of irreversible acidosis after prolonged propofol infusion.

INTRODUCTION: Propofol infusion syndrome is described in the pediatric literature as metabolic acidosis, rhabdomyolysis, and bradycardia that results in death. The pathogenesis of this syndrome is thought to be activation of the systemic inflammatory response, which culminates in acidosis and muscle necrosis. MATERIALS AND METHODS: Retrospective chart review of three patients in the Neurological Critical Care Units at Hahnemann and Massachusetts General Hospitals between October 2001 and September 2004. RESULTS: Patient 1: A 27-year-old woman had seizures secondary to hemorrhage from an arteriovenous malformation. Propofol coma was induced for sedation. After initiation of propofol, she developed a metabolic acidosis, hypotension, and bradycardia and expired. Patient 2: A 64-year-old man presented in status epilepticus. After prolonged propofol administration, he developed metabolic acidosis, hypotension, and rhabdomyolysis and expired. Patient 3: A 24-year-old woman presented in status epilepticus secondary to encephalitis. Propofol was added for seizure control. She developed hypotension, metabolic acidosis, and bradyarrhythmias. Despite transvenous pacing, she expired. CONCLUSION: These data show an association between extended propofol use and metabolic acidosis, rhabdomyolysis, and death in adults, as well as children. Risk factors for propofol infusion syndrome in adults include lean body mass index, high dose, and administration of more than 24-hour duration. Creatine phosphokinase, lactic acid levels, electrolytes, and arterial blood gases should be monitored frequently. Both bacterial and fungal cultures should be obtained. If this syndrome is suspected, hemodialysis should be considered. In fatal cases, autopsy should include electron microscopy of cardiac and skeletal muscle to look for mitochondrial dysfunction. Further study is warranted.

Diffusion tensor imaging of the hippocampal formation in temporal lobe epilepsy.

BACKGROUND AND PURPOSE: Diffusion tensor imaging (DTI) is a noninvasive technique that can be used to assess the integrity of cerebral tissue. The purpose of this study was to assess DTI measurements in the hippocampal formation (HF) and to investigate the role of DTI in lateralizing the seizure focus in temporal lobe epilepsy (TLE). METHODS: We evaluated 12 patients with unilateral TLE and 14 healthy subjects. We collected diffusion-weighted images along six different directions with a b value of 1000 s/mm(2), as well as an image acquired without diffusion weighting (b = 0 s/mm(2)). A 1.5-T imager was used to acquire 17 (3-mm) coronal sections covering the temporal lobes. We compared the mean diffusivity (trace D) and fractional anisotropy (FA) from symmetrical voxels by sampling the anterior HF bilaterally. We compared measurements with the EEG, high-resolution MR imaging, and clinical information. RESULTS: The patient group had significantly increased diffusivity and decreased FA in the HF ipsilateral to the seizure focus, as compared with values in the contralateral HF. When compared with healthy subjects, patients had significantly higher mean diffusivity in the ipsilateral HF; ipsilateral FA values were lower and did not reach statistical significance. Measurements in the contralateral HF did not show differences. Left-right and absolute diffusivity indices lateralized the abnormal HF in eight and five of 12 patients, respectively. CONCLUSION: Abnormal DTI measurements and the epileptogenic HF are associated in unilateral TLE. This finding may reflect hippocampal sclerosis and may aid in presurgical evaluation.