Bilateral fracture of the shoulders following epileptic seizures: a case report / Fratura bilateral de ombros após convulsões epilépticas: relato de caso

Convulsive seizures caused by hyponatremia occur when this condition is severe and develops quickly, resulting in a brain's adaptive inability to contain brain swelling. Seizures are rarely the cause of shoulder fractures. This is a case report of bilateral humerus fracture following a single epileptic seizure caused by drug hyponatremia, an unconventional event in medical practice. A 69-year-old woman was admitted to the emergency room after a single tonic-clonic seizure with spontaneously ceased sphincter relaxation, showing Glasgow 6. No falls or restraint were reported by observers. When alert, the patient reported pain and difficulty moving both arms. During examination, the movement was li- mited to the right and left. Anteroposterior radiographs revealed bilateral fracture at the neck of humerus. To complement inves- tigation for further lesions, a computed tomography confirmed bilateral fracture-dislocation with impaction of the humeral head with the glenoid. Atraumatic bilateral fracture-dislocation of the humerus after epileptic seizure is a very rare event. It is believed that some of these diagnoses have been neglected due to the difficulty of characterizing the patient's pain in a postictal state. The importance of a detailed physical examination shall be emphasized in risk groups such as the polymedicated elderly.

Convulsive seizures caused by hyponatremia occur when this condition is severe and develops quickly, resulting in a brain's adaptive inability to contain brain swelling. Seizures are rarely the cause of shoulder fractures. This is a case report of bilateral humerus fracture following a single epileptic seizure caused by drug hyponatremia, an unconventional event in medical practice. A 69-year-old woman was admitted to the emergency room after a single tonic-clonic seizure with spontaneously ceased sphincter relaxation, showing Glasgow 6. No falls or restraint were reported by observers. When alert, the patient reported pain and difficulty moving both arms. During examination, the movement was li- mited to the right and left. Anteroposterior radiographs revealed bilateral fracture at the neck of humerus. To complement inves- tigation for further lesions, a computed tomography confirmed bilateral fracture-dislocation with impaction of the humeral head with the glenoid. Atraumatic bilateral fracture-dislocation of the humerus after epileptic seizure is a very rare event. It is believed that some of these diagnoses have been neglected due to the difficulty of characterizing the patient's pain in a postictal state. The importance of a detailed physical examination shall be emphasized in risk groups such as the polymedicated elderly.

Four patients with infarction in key areas of the Papez circuit, with anterograde amnesia as the main manifestation.

The Papez circuit is an important brain structure that is closely associated with learning and memory. In this report, we present four patients with anterograde amnesia as the main manifestation induced by Papez circuit infarction. In addition, we review the distribution of the responsible arteries in key and rare regions to investigate the pathogenesis of these infarctions.

Long-term outcomes in temporal lobe epilepsy with glutamate decarboxylase antibodies.

OBJECTIVE: To assess the long-term outcomes of patients with temporal lobe epilepsy and CSF anti-glutamate decarboxylase antibodies (GAD65-Abs). METHODS: We retrospectively analyzed the clinical records of 35 patients with temporal lobe epilepsy and CSF GAD65-Abs, collected from January 1993 to December 2016 and assessed cognitive impairment and seizure activity at last visit. Cognitive impairment was considered significant if impacting on daily life activities. Immunohistochemistry on rat brain slices and ELISA were used for antibody detection and titration. RESULTS: Median age was 30 years (range 2-63), 32/35 (91%) patients were female, and median follow-up was 68 months (range 7-232). At presentation, 20 patients had isolated temporal lobe epilepsy and 15 patients had other limbic symptoms, including anterograde amnesia (n = 10) and behavioral disturbances (n = 5). Progressive clinical deterioration over follow-up was reported in 28/35 patients (80%), including gradual increase of memory impairment (n = 25), and apparition of behavioral disturbances (n = 4) or mood disorders (n = 18). At last follow-up, 24/35 (69%) patients had cognitive disturbances with an impact on patient's daily life activities, and 28/35 (80%) still had active seizures. CONCLUSION: Most patients with temporal lobe epilepsy and CSF GAD65-Abs develop a chronic disease with progressive cognitive impairment and refractory epilepsy regardless of the presence of additional limbic symptoms at onset.

A Teenager With Acute Anterograde Amnesia.

Isolated amnesia is an uncommon presenting complaint in the pediatric age group. We report the case of an 18-year-old woman who presented with the acute onset of memory difficulty and an otherwise normal neurologic examination. Brain magnetic resonance imaging demonstrated inflammation in the bilateral temporal lobes. Serum and cerebrospinal fluid testing ultimately revealed a diagnosis of autoimmune encephalitis. Although rare, the acute onset of isolated amnesia deserves a prompt, comprehensive evaluation.

Pure topographical disorientation in novel environments without anterograde amnesia: a case study.

Topographical disorientation (TD) in novel environments is considered to be a part of anterograde amnesia. A 56-year-old woman presented with pure TD only in novel environments following limbic encephalitis. She could not remember directions inside the hospital on weekly outpatient visits; however, her verbal and visual anterograde memories were normal. In the test of learning photographs of scenes, faces, and objects, only her scores for landscapes were worse than those in healthy controls. These findings suggested that her TD specific to landscapes and directions in novel environments was caused by category-specific memory impairment related to bilateral hippocampal and parahippocampal dysfunction.

Retrosplenial cortex damage produces retrograde and anterograde context amnesia using strong fear conditioning procedures.

Contextual fear conditioning relies upon a network of cortical and subcortical structures, including the hippocampus and the retrosplenial cortex (RSC). However, the contribution of the hippocampus is parameter-dependent. For example, with "weak" training procedures, lesions of the hippocampus produce both retrograde and anterograde context amnesia. However, with "strong" training procedures (e.g., more trials and/or higher levels of footshock), lesions of the hippocampus produce retrograde context amnesia but not anterograde amnesia (Wiltgen et al., 2006). Likewise, prior studies have shown that with weak training, RSC lesions produce both retrograde and anterograde context amnesia (Keene & Bucci, 2008). The purpose of the current study was to examine the effects of RSC damage on contextual fear conditioning following strong training. In Experiment 1, lesions of the RSC resulted in both retrograde and anterograde context amnesia following strong training using the same unsignaled fear conditioning procedures described by Wiltgen et al. (2006). In Experiment 2, using a signaled fear conditioning procedure, we replicated these effects on context memory observing both retrograde and anterograde context amnesia. In contrast, there were no lesion effects on tone-fear memory. Thus, unlike lesions of the hippocampus, lesions of RSC produce both retrograde and anterograde context amnesia even when rats undergo strong fear conditioning. These findings suggest that the RSC has an essential role in contextual fear conditioning and that other systems or pathways are unable to compensate for the loss of RSC function.

Isolated seizures are a common early feature of paraneoplastic anti-GABAB receptor encephalitis.

OBJECTIVE: To report the clinical features and long-term outcome of 22 newly diagnosed paraneoplastic patients with GABAB receptor antibodies (GABABR-Abs). METHODS: Retrospective clinical study of CSF-confirmed cases of GABABR-Abs encephalitis. RESULTS: We identified 22 patients (4 female) with GABABR-Abs, with a median age of 64 years (range 55-85). All were paraneoplastic: 20 small-cell lung cancer, one malignant thymoma, and one uncharacterized lung mass. The most frequent first symptom was the isolated recurrent seizures without cognitive inter-ictal impairment in 17 patients (77%). In the other, three presented the first behavioral disorders and two presented de novo status epilepticus (SE). After a median delay of 10 days (range 1-30), the recurrent seizures' phase was followed by an encephalitic phase characterized by confusion in 100% of cases and SE in 81% (n = 17), with 53% (n = 9) non-convulsive SE. Dysautonomic episodes were frequent (36%, n = 8, bradycardia and central apnea) and killed three patients. CSF study was abnormal in 95% of the cases (n = 21). At the encephalitic phase, MRI showed a temporal FLAIR hypersignal in 73% (n = 16) of the cases. First-line immunotherapy was initiated after a median delay of 26 days (range 6-65) from disease onset, and a partial response was observed in 10 out of 20 patients (50%). There was no complete response. Two years after onset, a massive anterograde amnesia affected all still alive patients. Nine patients died from cancer progression (median survival: 1.2 years). CONCLUSION: Paraneoplastic GABABR-Abs encephalitis is characterized by a stereotype presentation with an epilepsy phase before an encephalitic phase with dysautonomia. The functional prognosis is poor.

College student knowledge of blackouts and implications for alcohol intervention: A qualitative analysis.

Blackouts (periods of alcohol-induced anterograde amnesia) are common among young adults and place individuals at significant risk for alcohol-related harm; thus, researchers have advocated for increased efforts to educate young adults on blackouts. This qualitative study examined college student knowledge of blackouts as well as their ideas for intervening on blackout drinking behavior in order to inform prevention and intervention efforts. College students who had experienced a blackout in the past 6 months participated in eight focus groups, stratified by gender (N = 50, five to eight/group, 56% female). Discussions followed a semistructured agenda. Audio recordings were transcribed verbatim and coded using applied thematic analysis. Themes related to knowledge were reviewed in comparison to the empirical literature. Empirically derived risk factors for blackouts included biology (e.g., genetics, biological sex), drinking behavior (i.e., rate of consumption), other drug use, and "indirect" influences (e.g., pregaming, drinking location). Participants' knowledge of the risk factors for blackout was inconsistent and, in some cases, inaccurate. While participants generally understood the behavioral risk factors for blackouts, they demonstrated less understanding of the role of genetics, biological sex, drinking speed (vs. quantity), and other drug use. They also identified dehydration and sleep as perceived risk factors for blackout. They suggested avenues for intervention at the policy (e.g., amnesty policies), peer (e.g., expressing concern), and individual (e.g., education) levels. College students with a history of blackout have limited understanding of the biological risk factors for blackout. These knowledge gaps represent targets for intervention. Findings indicate promise for blackout-specific interventions. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Persistent anterograde amnesia due to the artery of Percheron occlusion: a case report.

Bilateral thalamic infarction involving the artery of Percheron (AOP) can cause diagnostic difficulties due to the varying clinical presentations. AOP infarcts presented with isolated memory impairment are not common and the factors affecting the persistence of memory disorders are still unknown. A 41-year-old male patient was hospitalized with acute unconsciousness. MRI disclosed bilateral paramedian thalamic infarction The patient had isolated memory deficit and his anterograde amnesia continued without any change in the past decade. More cases might answer the questions concerning the intra- and extra-thalamic structures responsible for the amnesic syndrome and the factors affecting the persistence of the symptoms.

Utility of Retrograde Amnesia Assessment Alone, Compared with Anterograde Amnesia Assessment in Determining Recovery After Traumatic Brain Injury: Prospective Cohort Study.

BACKGROUND: Posttraumatic amnesia (PTA) after traumatic brain injury (TBI) comprises anterograde amnesia (AA), disorientation, and retrograde amnesia (RA). However, RA is often neither assessed nor emphasized. A recent study demonstrated that although AA and disorientation were both present in non-TBI inpatients uniformly taking opioids, RA was absent. This suggests potentially significant utility with RA assessment alone since opioids are commonly prescribed post TBI. METHODS: We compared RA recovery with AA recovery in a prospective cohort post TBI. The Galveston Orientation and Amnesia Test (GOAT) represented a crude test for PTA (GOAT <75). AA was primarily assessed using the Westmead PTA Scale, and RA was assessed using the GOAT. All patients were prescribed oxycodone. RESULTS: Results were obtained (n = 31). While RA recovery coincided with a GOAT recovery in 19/31 (61%), AA recovery coincided with GOAT recovery in only 6/31 (19%), (χ2 = 11.5, P < 0.001). RA recovery preceded AA recovery in 15/31 (48%), while AA recovery preceded RA recovery in 7/31 (23%) (χ2 = 8.6, P = 0.003). Where RA recovery less frequently followed AA recovery, temporal lobe contusions were more frequent. RA recovery preceded/coincided with AA recovery in 100% of those who recovered when AA was defined as ×3 consecutive 12/12 scores (as is current widespread practice). AA recovery typically followed RA recovery with minimal delay. CONCLUSIONS: In the presence of potential in-hospital confounders including opioids, RA recovered significantly sooner after TBI than AA and was predictive of imminent AA recovery. RA assessment alone therefore had significant and novel utility in post-TBI assessment. RA assessment should be routinely recorded in all PTA assessment. Given its simplicity and resilience to common confounders, RA assessment should also be incorporated into the Glasgow Coma Scale.

Acute Onset Vascular Dementia with Bi-Thalamic Infarct in an HIV-Positive Subject.

BACKGROUND Bi-thalamic infarctions are rare and marked by clinical polymorphism. Their association with HIV has never been reported. CASE REPORT We report a 51-year-old right-handed man with no medical history, who presented an acute onset vascular dementia associated with an antero-retrograde amnesia, a word-finding difficulty, and a dysexecutive syndrome. The CT scan was normal. Brain MRI revealed a paramedian and bi-thalamic infarction, evoking an occlusion of the Percheron artery. The electrocardiogram, transthoracic and transesophageal cardiac ultrasound, and Doppler echo of cervical arteries gave normal results. The biological work-up revealed a positive serology to HIV1. The patient was lost to follow-up and was reported dead 2 months later from an unknown cause. CONCLUSIONS This case illustrates the need to perform an HIV serology in the presence of a bi-thalamic infarction with no obvious cause, particularly in a young subject.

A Case of Bariatric Surgery-related Wernicke-Korsakoff Syndrome with Persisting Anterograde Amnesia.

OBJECTIVE: To describe the theoretical and clinical implications of the neuropsychological evaluation of a case of bariatric surgery-related Wernicke-Korsakoff syndrome. METHOD: The patient was a 37-year old, female, bilingual, bachelor's degree educated, Mexican American public relations consultant without preexisting psychiatric, neurological, or substance abuse history. Recovery from laparoscopic sleeve gastrectomy surgery for morbid obesity was complicated by intraabdominal abscess, multibacterial infection, and prolonged nausea and vomiting. About 15 weeks post-surgery she was diagnosed with Wernicke's encephalopathy. She had a positive response to thiamine supplement but was left with persisting self-reported memory problems that were confirmed by family members. Multiple neuroimaging studies were all normal. RESULTS: A neuropsychological evaluation at 14 months post-surgery revealed anterograde amnesia for verbal and visual-perceptual material. There was no clear period of temporally graded retrograde amnesia. Scores on tests of visual-perceptual, language, fine motor, and executive functions were unimpaired. She had awareness of her neurocognitive impairment, but did not exhibit emotional distress. Follow-up neuropsychological evaluation at 17 months showed a similar neurocognitive profile with increased emotional distress. CONCLUSIONS: Her preserved executive functioning is theoretically important as it supports arguments that such impairment in alcohol use-related Korsakoff syndrome derives from the toxic effects of the prolonged misuse of alcohol and not vitamin deficiency. From a clinical perspective, neuropsychological evaluation of thiamine treated, bariatric surgery-related, Wernicke's encephalopathy cases is indicated if there is suspicion of residual memory impairment.

Human herpes virus-6 encephalitis causing severe anterograde amnesia associated with rituximab, azathioprine and prednisolone combination therapy for dermatomyositis.

Human herpes virus-6 (HHV-6) reactivation is a well-recognised complication following haematological stem cell transplantation, but it is novel in the context of combination immunomodulatory therapy for autoimmune disease. We report a case of severe anterograde amnesia caused by HHV-6 encephalitis in a young female patient on rituximab, azathioprine and prednisolone for dermatomyositis (DM). The use of targeted biologic treatments for systemic autoimmune connective tissue diseases (CTDs) is increasing, particularly when refractory to conventional management. The anti-CD20 B cell depleting monoclonal antibody, rituximab is now increasingly used, often in combination with conventional immunomodulatory treatments, in certain autoimmune neurological conditions and systemic CTDs including DM. Physicians should be aware of the possibility of HHV-6 in those who develop encephalitis while CD20 B cell deplete, especially in the presence of additional immunomodulatory therapies. Prompt diagnosis and treatment of HHV-6 encephalitis with evidence-based anti-viral therapy may help reduce the extent of irreversible morbidity such as amnesia.

Anterograde Amnesia during Electroconvulsive Therapy: A Prospective Pilot-Study in Patients with Major Depressive Disorder.

Electroconvulsive therapy (ECT) is considered an effective treatment for major depression with melancholic features. However, neurocognitive side-effects such as anterograde amnesia still regularly occur. The present study aims to evaluate the severity and course of anterograde amnesia in severely depressed patients undergoing ECT. In a prospective naturalistic study, anterograde memory function was assessed among inpatients who underwent ECT (n = 11). Subjects met DSM-IV criteria for major depressive disorder. Recruitment took place between March 2010-March 2011 and March 2012-March 2013. Controls treated with antidepressants (n = 9) were matched for age, gender and depression severity. Primary outcome measure was immediate recall; secondary outcome measures were delayed recall, recognition, and visual association. Differences were tested using repeated measures ANOVA and paired t-tests. Correlations with hypothesized covariates were calculated. In patients with major depressive disorder, ECT had a significant effect on delayed memory function (p<0.01 with large effect sizes). Findings on immediate recall were less consistent. Four weeks after treatment discontinuation, these memory functions had recovered. Age was identified as a very important covariate. The main limitations of our study are its naturalistic design, possibly compromising internal validity, and its small sample size. However, if these findings can be reproduced in a more comprehensive study group, then the possible induction of anterograde amnesia is not a justifiable reason for clinicians to disregard ECT as a treatment option.