Insomnia in people with epilepsy: A review of insomnia prevalence, risk factors and associations with epilepsy-related factors.

BACKGROUND: Insomnia is a common sleep complaint in the general population, and sleep loss may be a trigger for epileptic seizures. OBJECTIVES: To conduct a comprehensive review of the literature of insomnia symptoms and insomnia disorder, their prevalence and epilepsy-related risk factors in people with epilepsy (PWE). METHODS: A PUBMED search was performed for articles indexed to June 2016 involving human subjects, excluding papers in languages other than English, Spanish and Portuguese and case reports. Eligible studies were those using a clear definition of insomnia and reporting quantitative data on prevalence rates and risk factors. The search included the following terms: insomnia, sleep disorder(s), sleep disturbance(s) and sleep-wake in the title and abstract; and epilep* in the title. 425 papers were reviewed and 31 were selected for the final analysis (21 adult and 10 paediatric). Twenty-one studies used a control group. Two reviewer authors independently extracted all data and a third author resolved disagreements. RESULTS: Most studies were hospital-based, cross-sectional and evaluated convenience samples representing highly select populations. Various insomnia inventories were used. Fourteen assessed insomnia (10 in adults, four, children), but only five as primary outcome (none in children). Four evaluated insomnia disorder based on international classification criteria (International Classification of Sleep Disorders - ICSD-2-in 3, and DSM-IV-TR, in 1). In adults, insomnia prevalence was 28.9-51% based on the Insomnia Severity Index ≥15 and 36-74.4% based on DSM-IV-TR or ICSD-2. The prevalence of insomnia in children was 13.1-31.5% using the Sleep Disturbance Scale for Children and 11% based on ICSD-2 diagnostic criteria. Compared to control groups, PWE usually had higher frequencies of insomnia symptoms and disorder. Insomnia was associated with greater impairment in quality of life and higher degree of depressive symptoms in several studies, and was inconsistently related to female gender, poor seizure control and antiepileptic drug polytherapy. In children, insomnia was associated with developmental delay, focal epilepsies and poor seizure control. CONCLUSION: Insomnia symptoms and insomnia disorder are highly prevalent among PWE based on a limited number of studies with variable inclusion criteria and methodology. Excessive daytime sleepiness (EDS) was not found to be related to insomnia disorder or symptoms, and the exclusion of individuals with EDS may explain the higher frequencies of insomnia found in some studies. Additional investigations are needed given the potential impact of insomnia on seizure control, mood and QOL in PWE.

Esclerose múltipla pseudotumoral: relato de caso e revisão de literatura / Pseudotumoral form of multiple sclerosis: case report and review of literature

A forma pseudotumoral de esclerose múltipla é extremamente rara e possui uma grande variedade de diagnósticos diferenciais, o que a torna um desafio na prática neurológica. Neste artigo, apresentamos um caso desta manifestação incomum de esclerose múltipla, que foi avaliado em uma clínica especializada no Rio de Janeiro. O caso é de um individuo do sexo masculino de 21 anos que apresentou apenas crises convulsivas. Apresentou curso benigno da doença.

Pseudotumoral forms of multiple sclerosis are very and have a great variety of differential diagnosis, which poses it as a great challenge in neurological practice. In this paper, we report one case of this uncommon manifestation of multiple sclerosis, which was assessed in a specialized clinic in Rio de Janeiro. The case is a 21 year old male patient that had only seizures. He presented a benign course of the disease.

Schwanoma gigante do VIII nervo craniano de evolução subaguda: relato de caso / Subacute evolution of giant schwannoma of VIII cranial nerve: case report

O schwanoma vestibular é uma neoplasia que se origina das células de Schwann da porção vestibular do VIII nervo craniano e que corres- ponde a cerca de 10% dos tumores intracranianos e a 80% a 90% daqueles localizados no ângulo pontocerebelar. Apesar do crescimento lento e evolução em geral benigna, estes tumores podem evoluir de maneira desfavorável devido à localização em compartimento anatômico relativamente reduzido no crânio (fossa posterior), o que pode levar a compressão de estruturas nobres (como o tronco encefálico) e a desenvolvimento de hidrocefalia obstrutiva, especialmente nos raros casos de schawanomas gigantes (> 40 mm). Apresentamos relato de caso de paciente com quadro de tinnitus e hipoacusia à esquerda que evoluiu de forma subaguda com alterações do humor, da cognição e da marcha cujo diagnóstico final foi de schwanoma gigante do VIII nervo craniano.

Vestibular schwannoma is a Schwann cells neoplasia of the vestibular branch of the VIII cranial nerve and it accounts for 10% of intracranial tumours and to 80%-90% of those located at the cerebellopontine angle. Despite slow growth and usual benign evolution, unfavourable outcomes may occur, especially in the rare cases of giant schwanno- mas (> 40mm). Owing the fact that this tumours are located in a relatively narrow space (posterior fossa), giant schwannomas may compress noble areas (as the brainstem), which can also cause obstructive hydrocephalus. We discuss a case report of a 48 years old woman complaining of left-sided hearing loss and tinnitus that developed a subacute cognitive impairment, mood disorder and gait disturbance, diagnosed with giant schwannoma of the VIII nerve.

Isolated Central Nervous System Vasculitis as a Manifestation of Neurosarcoidosis.

A 62-year-old male presented to our clinic with recurrent fever, skin lesions (petechiae), scleral wounds, and hilar adenomegaly. A diagnosis of sarcoidosis was established, which resolved with corticosteroid treatment. After a few months, the patient developed confusion and behavioral changes, with few objective neurological deficits. Brain magnetic resonance imaging showed slight focal meningeal enhancement (prepontine region). The level of angiotensin-converting enzymes was normal in the serum and increased in the cerebrospinal fluid. The patient was diagnosed with neurosarcoidosis, and corticosteroid treatment was prescribed, yielding good clinical response. Nine months later, the patient presented with multiple ischemic strokes, and arteriography demonstrated multiple distal irregularities in all arterial territories, suggesting cerebral vasculitis. Even with corticosteroids, cyclophosphamide, and intravenous immunoglobulin, the patient died. Vasculitis is rarely seen in association with sarcoidosis, and in this case, no systemic manifestation was observed at the time that the patient developed vasculitis.

Insomnia current diagnosis: an appraisal / Diagnóstico atual de insônia: uma apreciação

Chronic insomnia is the most common sleep disorder in adults andits diagnosis is fundamental for adequate clinical management. The aim of this paper is to present recently published definitions of insomnia according to current international classifications, such as the International Classification of Sleep Disorders - Third Edition and the Diagnostic and Statistical Manual of Mental Disorders - Fifth Edition. For the first time, these classifications are congruent related to thei rdiagnostic criteria; both present insomnia as a distinct disorder and divide it into acute, chronic and other. This emphasizes the necessityof a specific insomnia approach. Furthermore, it is necessary torecognize those insomniacs with physiological hyperarousal, whichmay be identified by objective measures (short total sleep time, forinstance). These patients may have poorer outcome, as they are athigher risk of developing cardiometabolic conditions and neurocognitive impairment. Diagnosis is primarily made on a clinical basis (anamnesis and physical examination), while sleep diaries and questionnaires (such as Insomnia Severity Index) can help evaluate these patients. Objective measures, such as polysomnography, arenot required in most cases, except when suspicion of another sleep disorder arises.

A insônia crônica é o transtorno do sono mais comum em adultos,e seu diagnóstico é fundamental para o manejo clínico adequado.O principal objetivo deste trabalho é apresentar, em relação à insônia,as definições publicadas recentemente segundo as novas classificações internacionais, como a Classificação Internacional de Distúrbios do Sono - Terceira Edição e o Manual Diagnóstico e Estatístico de Transtornos Mentais - Quinta Edição. Pela primeira vez, essas classificações são congruentes a respeito de seus critérios diagnósticos,pois ambas apresentam a insônia como uma doença em si ea dividem em aguda, crônica e outras. Isso enfatiza a necessidade de uma abordagem específica da insônia. Além do mais, é necessário reconhecer os insones com estado fisiológico de hiper alerta que podem ser identificados por medidas objetivas (tempo total de sono curto, por exemplo). Esses pacientes podem ter pior prognóstico, por causa do maior risco de desenvolver condições cardiometabólicas e comprometimento neurocognitivo. O diagnóstico da insônia é feito principalmente com base em dados clínicos (anamnese e exame físico),e o uso de diário de sono e questionários (tais como o Índice de Gravidade de Insônia) pode ajudar na avaliação desses pacientes.Análises objetivas, como aquelas obtidas pela polissonografia, não são rotineiramente necessárias na maioria dos casos, exceto quando há a suspeita de outro distúrbio do sono.