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1.
World Neurosurg ; 136: 357-363.e2, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-32001414

RESUMO

BACKGROUND: Deep brain stimulation (DBS) of the anterior nucleus of the thalamus (ANT) is a recently approved therapy for patients with drug-resistant epilepsy. To date, there is a poor understanding of the mechanism of action and lack of in vivo biomarkers. We propose a method for investigating the in vivo stimulation effects using blood-oxygen-level-dependent (BOLD) magnetic resonance imaging (MRI) and present the brain activation pattern associated with ANT DBS. METHODS: Two patients undergoing ANT DBS for epilepsy underwent BOLD MRI using a block design after the DBS was programmed to alternate ON/OFF in 30-second blocks. The scanner was triggered using surface electrophysiologic recordings to detect the DBS cycle. Nine total runs were obtained and were analyzed using a general linear model. RESULTS: Active ANT stimulation produced activation within several areas of the brain, including the thalamus, bilateral anterior cingulate and posterior cingulate cortex, precuneus, medial prefrontal cortex, amygdala, ventral tegmental area, hippocampus, striatum, and right angular gyrus. CONCLUSIONS: Using block-design BOLD MRI, we were able to show widespread activation resulting from ANT DBS. Overlap with multiple areas of both the default mode and limbic networks was shown, suggesting that these nodes may modulate the effect of seizure control with ANT DBS.


Assuntos
Núcleos Anteriores do Tálamo , Estimulação Encefálica Profunda/métodos , Adulto , Núcleos Anteriores do Tálamo/diagnóstico por imagem , Núcleos Anteriores do Tálamo/cirurgia , Mapeamento Encefálico , Epilepsia Resistente a Medicamentos/diagnóstico por imagem , Epilepsia Resistente a Medicamentos/terapia , Feminino , Humanos , Processamento de Imagem Assistida por Computador , Modelos Lineares , Imagem por Ressonância Magnética , Pessoa de Meia-Idade , Rede Nervosa/diagnóstico por imagem , Procedimentos Neurocirúrgicos/métodos , Oxigênio/sangue , Estudos Prospectivos , Técnicas Estereotáxicas , Resultado do Tratamento
2.
World Neurosurg ; 133: e448-e451, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31526890

RESUMO

BACKGROUND: Vagal nerve stimulation (VNS) is an alternative palliative therapy for pharmacoresistant epilepsy. It has been reported to be effective for both focal and generalized epilepsy; however, most of the relevant studies have involved children or young patients. Some patients develop intractable epilepsy after stroke, despite taking antiepileptic drugs (AEDs). In this study, we investigated the efficacy of VNS for pharmacoresistant poststroke epilepsy (PPSE). METHODS: We retrospectively studied 10 patients who underwent vagal nerve stimulator implantation for poststroke epilepsy after the seizures had proved refractory to appropriate AEDs. The seizure outcome was evaluated using the McHugh classification 2 years after the implantation. RESULTS: In total, 4 patients (40%) remained seizure-free throughout the 2-year duration. In addition, seizures were reduced by >50% after 2 years in 6 patients (60%). McHugh classification was class I for 5 patients and class II for 5 patients. Neither intraoperative complications nor postoperative adverse effects were reported. The average intensity of VNS was 1.75 mA. CONCLUSIONS: In this small study, VNS proved to be a safe and effective therapy for PPSE. Patients with poststroke epilepsy experience physical or mental decline; therefore, it is important to control seizures in them to avoid deterioration in their quality of daily life.


Assuntos
Epilepsia Resistente a Medicamentos/terapia , Acidente Vascular Cerebral/complicações , Estimulação do Nervo Vago , Adulto , Idoso , Anticonvulsivantes/uso terapêutico , Resistência a Medicamentos , Epilepsia Resistente a Medicamentos/etiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do Tratamento , Adulto Jovem
3.
J Clin Neurophysiol ; 36(6): 437-442, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31688327

RESUMO

Invasive vagus nerve stimulation (VNS) is an approved treatment for drug-resistant epilepsy. Besides recognized clinical efficacy in about 60% of patients, there are major drawbacks such as invasiveness and common side effects including hoarseness, sore throat, shortness of breath, and coughing. Invasive VNS applies electrical stimulation to the left cervical branch of the vagus nerve and excites thick-myelinated afferent nerve fibers. Peripheral vagus nerve afferent volley initiates brainstem activity in the nucleus of the solitary tract and provokes typical brainstem and cerebral activation patterns that mediate the anticonvulsive mode of action. Whereas invasive VNS is an established neuromodulatory treatment in drug-resistant epilepsy, transcutaneous VNS (tVNS) of the auricular branch of the vagus nerve is suggested to be an alternative access path to the same neuronal network without invasiveness. Preclinical and clinical studies indicate that especially the cymba conchae of the auricle is selectively supplied by the auricular branch of the vagus nerve. Recent anatomical data demonstrate existence and quantity of thick-myelinated afferent nerve fibers of the left auricular branch of the vagus nerve that carries 21% of thick-myelinated afferent nerve fibers counted in the left thoracic vagus nerve in humans. Projection of auricular branch of the vagus nerve afferents from the auricle to the nucleus of the solitary tract is known from histochemical and electrophysiological experiments in rodents and confirmed in humans by functional imaging. Cerebral activation patterns triggered by invasive and tVNS resemble each other in appearance. Clinical trials in patients address safety and performance of tVNS and provide evidence for application in drug-resistant epilepsy.


Assuntos
Epilepsia Resistente a Medicamentos/terapia , Estimulação Elétrica Nervosa Transcutânea/métodos , Estimulação do Nervo Vago/métodos , Animais , Epilepsia Resistente a Medicamentos/fisiopatologia , Humanos , Nervo Vago/fisiologia
4.
Neurology ; 93(22): e2021-e2031, 2019 11 26.
Artigo em Inglês | MEDLINE | ID: mdl-31645468

RESUMO

OBJECTIVE: Using electronic diaries as part of a randomized controlled trial of stress reduction for epilepsy, we evaluated factors associated with successful seizure self-prediction. METHODS: Adults with medication-resistant focal epilepsy were recruited from 3 centers and randomized to treatment with progressive muscle relaxation or control focused attention. An 8-week baseline was followed by 12 weeks of double-blind treatment. Twice daily, participants rated the likelihood of a seizure in the next 24 hours on a 5-point scale from very unlikely to almost certain, along with mood, premonitory symptoms, stress ratings, and seizure counts. We analyzed the association of mood, premonitory symptoms, stress, and circadian influences on seizure self-prediction. RESULTS: Sixty-four participants completed the trial (3,126 seizures). Diary entry adherence was >82%. Participant self-prediction was associated with seizure occurrence at 6, 12, and 24 hours (p < 0.0001). Odds ratio (OR) of seizure prediction increased systematically with participants' prediction of seizure likelihood (p < 0.0001, all levels of prediction and all time intervals). For the 12-hour prediction window, median specificity for seizure prediction was 0.94 and negative predictive value 0.94; median sensitivity was 0.10 and positive predictive value 0.13. A subset of 13 participants (20% of sample) met criteria for good predictors (median OR for seizure prediction 5.25). Mood, stress, premonitory symptoms, seizure time, and randomized group were not associated with seizure occurrence. CONCLUSION: In this prospective study, participants' prediction of a high probability of seizure was significantly associated with subsequent seizure occurrence within 24 hours. Future studies should focus on understanding factors that drive self-prediction. CLINICALTRIALSGOV IDENTIFIER: NCT01444183.


Assuntos
Afeto , Treinamento Autógeno/métodos , Autoavaliação Diagnóstica , Epilepsia Resistente a Medicamentos/terapia , Convulsões , Estresse Psicológico/terapia , Adulto , Anticonvulsivantes/uso terapêutico , Método Duplo-Cego , Epilepsia Resistente a Medicamentos/psicologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Estresse Psicológico/psicologia , Adulto Jovem
5.
Stereotact Funct Neurosurg ; 97(3): 176-182, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31533117

RESUMO

Deep brain stimulation (DBS) has provided new treatment options for refractory epilepsy; however, treatment outcomes of DBS in refractory epilepsy patients previously treated with vagus nerve stimulation (VNS) have not been clarified. Herein, treatment outcomes of DBS of the anterior nucleus of the thalamus (ANT-DBS) in patients who had previously experienced VNS failure are reported. Seven patients who had previously experienced VNS failure underwent ANT-DBS device implantation. VNS was turned off before DBS device implantation. Monthly seizure counts starting from baseline to 12-18 months after DBS were analyzed. Five (71.3%) of the 7 patients experienced a >50% reduction of seizure counts after DBS; 1 responder reached a seizure-free status after DBS therapy. Of the 2 nonresponders, 1 subject showed improvement in seizure strength and duration, which lessened the impact of the seizures on the patient's quality of life. This is the first study in which favorable outcomes of ANT-DBS surgery were observed in individual patients with refractory epilepsy who had not responded to prior VNS. Further studies with a larger number of subjects and longer follow-up period are needed to confirm the feasibility of ANT-DBS in patients who have previously experienced VNS failure.


Assuntos
Núcleos Anteriores do Tálamo/fisiologia , Estimulação Encefálica Profunda/métodos , Epilepsia Resistente a Medicamentos/diagnóstico , Epilepsia Resistente a Medicamentos/terapia , Estimulação do Nervo Vago/métodos , Adulto , Criança , Epilepsia Resistente a Medicamentos/fisiopatologia , Feminino , Humanos , Masculino , Qualidade de Vida , Falha de Tratamento , Resultado do Tratamento , Adulto Jovem
6.
Med. infant ; 26(3): 267-271, sept. 2019. Tab
Artigo em Espanhol | LILACS | ID: biblio-1023724

RESUMO

Introducción: El estado epiléptico (EE) es la emergencia neurológica más frecuente en pediatría. Los pacientes que no responden al tratamiento estándar con dosis adecuadas de benzodiacepinas seguido de una droga antiepiléptica aceptable son definidos como Estado epiléptico Refractario (ER). Objetivo: caracterizar la población de niños con EE que ingresan a UCIP y determinar qué factores son predictores de refractariedad en esta población. Métodos: Estudio de casos y controles, retrospectivo. Población: niños con EE internados en UCIP desde Febrero 2015 a Febrero 2017. Casos: Estado epiléptico Refractario (ER). Controles: Estado epiléptico No Refractario (ENR). Se calculó el Odds Ratio (OR) individual para las distintas variables en Med Calc. Resultados: Se internaron 35 pacientes de los cuales 12 fueron casos y 23 controles. Hubo fiebre en 77% de los pacientes. En el total de niños estudiados hubo 11% con antecedente de convulsión febril, 11% con antecedente de epilepsia y 9% con antecedente de malformación del SNC. Los niños con antecedente de convulsión febril tuvieron 2,5 veces mayor riesgo de ER (OR: 2,58; IC 95%: 1,17-5,68). Los niños con EE que tenían antecedentes de enfermedad neurológica previa presentaron riesgo de ER 2,6 veces mayor que el grupo control (OR 2,60; IC 95%: 1,24-5,42). Discusión: Dado el aumento en la mortalidad de los pacientes con ER sería importante disponer de más herramientas para predecir este desenlace e iniciar tratamiento oportuno. Resultaría útil entrenar a los padres de niños con antecedente de convulsión febril en la aplicación de medicación antiepiléptica prehospitalaria, esto podría prevenir la farmacorresistencia, el daño neurológico y las complicaciones que acarrea el ingreso a UCIP. (AU)


Introduction: Status epilepticus (SE) is the most common neurologic emergency in children. Patients that do not respond to standard treatment with adequate doses of benzodiazepines followed by an acceptable antiepileptic drug are defined as having refractory status epilepticus (RSE). Objective: To characterize the population of children with SE admitted to the PICU and to determine predictive factors for refractoriness in this population. Methods: A retrospective case-control study was conducted. Population: Children with SE admitted to the PICU between February 2015 and February 2017. Cases: Refractory status pilepticus (RSE). Controls: Non-refractory status epilepticus (NRSE). Individual Odds Ratio (OR) was calculated for different variables using Med Calc. Results: 35 patients were admitted of whom 12 were cases and 23 controls. Overall, 77% of the patients had fever. Of all the children, 11% had a history of febrile seizures, 11% had history of epilepsy and 9% had a CNS malformation. Children with a history of febrile seizures had a 2.5-fold higher risk of developing RSE (OR: 2.58; 95% CI: 1.17-5.68). Children with SE that had a history of neurologic disease had a 2.6-fold higher risk of developing RSE than controls (OR 2.60; 95% CI: 1.24-5.42). Discussion: Given the increased mortality in children with RSE, availability of tools to predict this outcome in order to initiate early treatment is important. It would be useful to train the parents of children with a history of febrile seizures in the prehospital administration of antiepileptic drugs as this may prevent pharmaco-resistance, neurologic damage, and complication related to PICU admission (AU)


Assuntos
Humanos , Recém-Nascido , Lactente , Pré-Escolar , Criança , Adolescente , Estado Epiléptico/complicações , Estado Epiléptico/etiologia , Estado Epiléptico/tratamento farmacológico , Resistência a Medicamentos , Unidades de Terapia Intensiva Pediátrica , Convulsões Febris/tratamento farmacológico , Epilepsia Resistente a Medicamentos/terapia , Anticonvulsivantes/uso terapêutico , Estudos de Casos e Controles , Estudos Retrospectivos
7.
Nat Commun ; 10(1): 3572, 2019 08 08.
Artigo em Inglês | MEDLINE | ID: mdl-31395890

RESUMO

How are memories transferred from short-term to long-term storage? Systems-level memory consolidation is thought to be dependent on the coordinated interplay of cortical slow waves, thalamo-cortical sleep spindles and hippocampal ripple oscillations. However, it is currently unclear how the selective interaction of these cardinal sleep oscillations is organized to support information reactivation and transfer. Here, using human intracranial recordings, we demonstrate that the prefrontal cortex plays a key role in organizing the ripple-mediated information transfer during non-rapid eye movement (NREM) sleep. We reveal a temporally precise form of coupling between prefrontal slow-wave and spindle oscillations, which actively dictates the hippocampal-neocortical dialogue and information transfer. Our results suggest a model of the human sleeping brain in which rapid bidirectional interactions, triggered by the prefrontal cortex, mediate hippocampal activation to optimally time subsequent information transfer to the neocortex during NREM sleep.


Assuntos
Hipocampo/fisiologia , Consolidação da Memória/fisiologia , Modelos Psicológicos , Córtex Pré-Frontal/fisiologia , Sono de Ondas Lentas/fisiologia , Adulto , Epilepsia Resistente a Medicamentos/diagnóstico , Epilepsia Resistente a Medicamentos/terapia , Eletrodos Implantados , Eletroencefalografia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Polissonografia , Adulto Jovem
8.
Epileptic Disord ; 21(4): 379-384, 2019 Aug 01.
Artigo em Inglês | MEDLINE | ID: mdl-31403465

RESUMO

We report the first patient to die from refractory convulsive status epilepticus (SE) after the removal of a stimulator. The removal occurred after a two-year period of successful control of super-refractory convulsive SE with deep brain stimulation of the bilateral anterior nucleus of the thalamus (ANT-DBS). The female patient, born in 1990, suffered from high fever and seizures, and was diagnosed with viral encephalitis in 2005. After four weeks of medical treatment, she recovered with no neurological disabilities, but suffered from monthly seizures. Ten years later, the patient presented with convulsive SE, while four months pregnant in February of 2015. Her SE remained super-refractory to drugs despite the termination of pregnancy. Therefore, ANT-DBS was performed in March of 2015. The patient became SE-free following activation of an ANT-DBS stimulator. However, the stimulation treatment was terminated according to the family's request when a tremor developed two years after the treatment had begun. Subsequently, four SE episodes occurred and the tremor did not improve. The stimulator and electrodes were removed in August of 2017. The patient died of an uncontrolled SE two months later. This case demonstrates the effectiveness of ANT-DBS for emergency super-refractory convulsive SE with both positive and negative outcomes.


Assuntos
Estimulação Encefálica Profunda , Epilepsia Resistente a Medicamentos/terapia , Convulsões/terapia , Estado Epiléptico/terapia , Núcleos Anteriores do Tálamo , Estimulação Encefálica Profunda/métodos , Eletrodos Implantados , Feminino , Humanos , Masculino , Resultado do Tratamento
9.
Eur J Paediatr Neurol ; 23(5): 749-754, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31446001

RESUMO

Febrile infection-related epilepsy syndrome (FIRES) is a severe epilepsy disorder that affects previously healthy children. It carries high likelihood of unfavourable outcome and putative aetiology relates to an auto-inflammatory process. Standard antiepileptic drug therapies including intravenous anaesthetic agents are largely ineffective in controlling status epilepticus in FIRES. Deep brain stimulation of the centromedian thalamic nuclei (CMN-DBS) has been previously used in refractory status epilepticus in only a few cases. The use of Anakinra (a recombinant version of the human interleukin-1 receptor antagonist) has been reported in one case with FIRES with good outcome. Here we describe two male paediatric patients with FIRES unresponsive to multiple anti-epileptic drugs, first-line immune modulation, ketogenic diet and cannabidiol. They both received Anakinra and underwent CMN-DBS. The primary aim for CMN-DBS therapy was to reduce generalized seizures. CMN-DBS abolished generalized seizures in both cases and Anakinra had a positive effect in one. This patient had a favourable outcome whereas the other did not. These are the first reported cases of FIRES where CMN-DBS has been used.


Assuntos
Encefalopatia Aguda Febril/terapia , Terapia Combinada/métodos , Estimulação Encefálica Profunda/métodos , Epilepsia Resistente a Medicamentos/terapia , Proteína Antagonista do Receptor de Interleucina 1/uso terapêutico , Encefalopatia Aguda Febril/complicações , Anticonvulsivantes/uso terapêutico , Criança , Epilepsia Resistente a Medicamentos/etiologia , Humanos , Masculino , Estado Epiléptico/etiologia , Estado Epiléptico/terapia , Núcleos Talâmicos/fisiologia , Resultado do Tratamento
10.
Seizure ; 70: 63-70, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31288205

RESUMO

PURPOSE: Focal epilepsy in children may be refractory to pharmacological treatment and surgical resection may be an appropriate option. When invasive electroencephalogram is required in the presurgical evaluation, depth electrodes can be used to create focal lesions in the epileptogenic zone using radiofrequency thermocoagulation (RFTC), to disrupt the epileptogenic zone. METHODS: This study aimed to assess the efficacy and safety of RFTC in a paediatric population of 46 patients. RESULTS: The mean age of onset was 3.3 years and the mean age at SEEG was 8.2 years. MRI lesions were identified in 71.7% of the series, among them 60% of malformation of cortical development. 43.5% of the patients were seizure free at 1 month, 26.1% were responders. The mean duration of improvement was 6.8 months. 8 children were seizure free for >8 months and among them, 6 are currently seizure free for 8-24 months. 5 patients had functional deficits post-procedures, transient in 4 patients and prolonged in one of whom. 3/5 were anticipated following the results of cortical stimulation. Multivariate analysis found 3 independent criteria linked to RFTC efficiency one month after RFTC: frequency of the seizures before RFTC, age and number of contacts used. CONCLUSION: RFTC is a safe method for the paediatric population providing important predictive information for surgical resection. An improvement in seizure frequency, often transient, is seen in 2/3 of our patients. RTFC could be useful as a palliative technique for children with an epileptogenic zone overlapping with eloquent areas, with minimal risk of sequelae.


Assuntos
Epilepsia Resistente a Medicamentos/terapia , Eletrocoagulação , Epilepsias Parciais/terapia , Terapia por Radiofrequência , Adolescente , Encéfalo/fisiopatologia , Criança , Pré-Escolar , Epilepsia Resistente a Medicamentos/fisiopatologia , Epilepsias Parciais/fisiopatologia , Estudos de Viabilidade , Humanos , Lactente , Estudos Prospectivos , Qualidade de Vida , Convulsões/fisiopatologia , Convulsões/terapia , Resultado do Tratamento
11.
Medicina (B Aires) ; 79(3): 225-231, 2019.
Artigo em Espanhol | MEDLINE | ID: mdl-31284260

RESUMO

The ketogenic diet is an established, effective and well-tolerated treatment in refractory epilepsy. This paper provides practical information on the administration of ketogenic diet. It goes over the standardized protocols and the new ones that allow to broaden the scope regarding the clinical management of the ketogenic diet. It addresses issues such as the implementation, counseling and follow-up as well as the application and how to proceed in special situations such as anesthesia or acute illness. Finally, the aim of this paper is to highlight the relevance of the multidisciplinary teamwork and the family support throughout this laborious but interesting treatment.


Assuntos
Dieta Cetogênica , Epilepsia Resistente a Medicamentos/dietoterapia , Epilepsia Resistente a Medicamentos/terapia , Dieta Rica em Proteínas e Pobre em Carboidratos , Dieta Cetogênica/efeitos adversos , Dieta Cetogênica/classificação , Humanos , Estudos Interdisciplinares
12.
Acta Neurol Scand ; 140(4): 244-251, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31165476

RESUMO

OBJECTIVES: The medical and social care of drug-resistant epilepsy (DRE) entails significant costs. Approximately 30 to 40 percent of patients with DRE who underwent vagus nerve stimulator (VNS) implantation achieve an above 50 percent reduction in seizure frequency. The study objective was to analyze the effect of VNS on clinical effects improvement and therapy cost reduction in patients with DRE over a 2-year follow-up period. The second purpose of the study was to compare average costs of VNS treatment of patients with DRE in selected countries, taking into account the purchasing power parity. MATERIALS AND METHODS: The study included all the patients who had VNS implanted at our department between 2014 and 2018. Data on clinical events and medical costs were collected prospectively and obtained from medical documentation. We also reviewed relevant literature on costs of VNS therapy in patients with DRE from the last 18 years. RESULTS: Resource utilization and epilepsy-related events were reduced during the follow-up period compared to the baseline. Average total cost was estimated at EUR 7703.59 in year 1 and at EUR 7108.38 in year 2 following VNS implantation. Average direct costs of VNS treatment of patients with DRE over the last 18 years varied between the countries and ranged from EUR 24 790.43 in the United States to EUR 64.84 in the United Kingdom. CONCLUSION: Vagus nerve stimulator is a cost-effective therapy yielding measurable clinical and therapeutic outcomes over the long term. Moreover, the analysis contained in this review highlights the poor consensus of methodological approaches.


Assuntos
Análise Custo-Benefício/métodos , Epilepsia Resistente a Medicamentos/economia , Epilepsia Resistente a Medicamentos/terapia , Estimulação do Nervo Vago/economia , Adolescente , Adulto , Epilepsia Resistente a Medicamentos/epidemiologia , Europa (Continente)/epidemiologia , Feminino , Recursos em Saúde/economia , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Resultado do Tratamento , Adulto Jovem
13.
Brain Stimul ; 12(5): 1121-1126, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31196836

RESUMO

BACKGROUND: An ecstatic phenomenon is an altered state of consciousness with a sense of "hyper-reality", and a complete present-moment awareness with a feeling of union with the Universe. A better understanding of the network mechanisms underlying this fascinating subjective experience may help to unravel some mysteries of human consciousness. Insula has been recently proposed to be a key region to elicit these symptoms. OBJECTIVE/HYPOTHESIS: We studied functional connectivity changes in several brain areas during the induction of ecstatic auras by direct electrical stimulation of the dorsal anterior insular cortex in patients with refractory focal epilepsy implanted with intracerebral electrodes (stereotactic-EEG, SEEG) in the context of their pre-surgical evaluation. METHODS: Three patients were selected on the basis of the occurrence of ecstatic symptoms triggered by direct intracerebral electrical stimulation (ES) of the antero-dorsal part of the insula. ES was performed (50 Hz, 1.5-2.1 mA, in a bipolar fashion to each contact in the gray matter during a 3 s period) to map functional cortices and trigger habitual seizures. One stimulation inducing ecstatic changes in each patient was analyzed. Functional connectivity analysis was performed by measuring interdependencies (nonlinear regression analysis based on the h2 coefficient) between SEEG signals before and after stimulations. RESULTS: In all patients, only the stimulation of dorsal anterior insula was able to reproduce an ecstatic aura. We observed a significant increase of functional connectivity values between several brain regions in the immediate period following stimulations. The most commonly implicated region was the dorsal anterior insula. Out-degrees (a measure intended to identify leading structures in a network) identified the dorsal anterior insula as the most common leading region in the induced networks. CONCLUSION(S): Our findings bring additional support in favor of a major role played by the dorsal anterior insula in ecstatic experiences.


Assuntos
Córtex Cerebral/fisiologia , Estimulação Encefálica Profunda/métodos , Epilepsia Resistente a Medicamentos/fisiopatologia , Emoções/fisiologia , Epilepsias Parciais/fisiopatologia , Adolescente , Adulto , Estado de Consciência/fisiologia , Epilepsia Resistente a Medicamentos/diagnóstico por imagem , Epilepsia Resistente a Medicamentos/terapia , Epilepsias Parciais/diagnóstico por imagem , Epilepsias Parciais/terapia , Feminino , Humanos , Masculino , Adulto Jovem
16.
Brain Stimul ; 12(5): 1101-1110, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31126871

RESUMO

RATIONALE: Refractory status epilepticus (RSE) is the persistence of status epilepticus despite second-line treatment. Super-refractory SE (SRSE) is characterized by ongoing status despite 48 h of anaesthetic treatment. Due to the high case fatality in RSE of 16-39%, off label treatments without strong evidence of efficacy in RSE are often administered. In single case-reports and small case series totalling 28 patients, acute implantation of VNS in RSE was associated with 76% and 26% success rate in generalized and focal RSE respectively. We performed an updated systematic review of the literature on efficacy of VNS in RSE/SRSE by including all reported patients. METHODS: We systematically searched EMBASE, CENTRAL, Opengre.eu, and ClinicalTrials.gov, and PubMed databases to identify studies reporting the use of VNS for RSE and/or SRSE. We also searched conference abstracts from AES and ILAE meetings. RESULTS: 45 patients were identified in total of which 38 were acute implantations of VNS in RSE/SRSE. Five cases had VNS implantation for epilepsia partialis continua, one for refractory electrical status epilepticus in sleep and one for acute encephalitis with refractory repetitive focal seizures. Acute VNS implantation was associated with cessation of RSE/SRSE in 74% (28/38) of acute cases. Cessation did not occur in 18% (7/38) of cases and four deaths were reported (11%); all of them due to the underlying disease and unlikely related to VNS implantation. Median duration of the RSE/SRSE episode pre and post VNS implantation was 18 days (range: 3-1680 days) and 8 days (range: 3-84 days) respectively. Positive outcomes occurred in 82% (31/38) of cases. CONCLUSION: VNS can interrupt RSE and SRSE in 74% of patients; data originate from reported studies classified as level IV and the risk for reporting bias is high. Further prospective studies are warranted to investigate acute VNS in RSE and SRSE.


Assuntos
Ensaios Clínicos como Assunto/métodos , Epilepsia Resistente a Medicamentos/diagnóstico , Epilepsia Resistente a Medicamentos/terapia , Estado Epiléptico/diagnóstico , Estado Epiléptico/terapia , Estimulação do Nervo Vago/métodos , Adulto , Anticonvulsivantes/uso terapêutico , Bases de Dados Factuais , Epilepsia Resistente a Medicamentos/fisiopatologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Sono/fisiologia , Estado Epiléptico/fisiopatologia
17.
Stereotact Funct Neurosurg ; 97(2): 132-136, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31055582

RESUMO

Deep brain stimulation of the anterior thalamic nucleus is one of the promising therapeutic options for epilepsy. Several studies are still under way to further strengthen and clarify the mechanism, efficacy, and complications. Contrary to hardware-related and operation-related events, the stimulation-related adverse effect is mild, target-dependent, and adjustable. We present a case of relapsing herpes simplex encephalitis (HSE) as a newly reported and potentially fatal stimulation-related adverse effect following stimulation of the anterior thalamic nucleus (ANT-DBS) accompanied by fever, confusion, and cognitive impairment in a 32-year-old epileptic patient with a history of herpes meningoencephalitis 31 years earlier. The T2-weighted/FLAIR high-signal intensity in the temporal lobe developed at a "distance" from the stimulation target. The positive polymerase chain reaction of herpes virus deoxyribonucleic acid in the cerebrospinal fluid confirmed the diagnosis. The condition improved partially on acyclovir and stimulation stopped. Seizures disappeared and then returned after few months. The unique case report presents a rationale for considering history of herpes encephalitis as a relative contraindication for ANT-DBS, and HSE relapse should be suspected in patients with post-stimulation fever and/or altered consciousness.


Assuntos
Núcleos Anteriores do Tálamo/fisiologia , Estimulação Encefálica Profunda/efeitos adversos , Epilepsia Resistente a Medicamentos/terapia , Encefalite/etiologia , Adulto , Estimulação Encefálica Profunda/métodos , Epilepsia Resistente a Medicamentos/diagnóstico por imagem , Encefalite/diagnóstico por imagem , Humanos , Imagem por Ressonância Magnética , Masculino , Recidiva
18.
Seizure ; 69: 251-257, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31128468

RESUMO

PURPOSE: Epilepsy is the most common neurological disorder requiring medical treatment during pregnancy. However, very few studies are specially dedicated to pregnant women with refractory epilepsy. This study was carried out with the aim of describing obstetrical and neurological outcomes of pregnant women with refractory epilepsy in Brazil. METHODS: Pregnant women with refractory epilepsy were enrolled in longitudinal cohort study between January 2005 and January 2018. They were regularly followed by a neurologist until the end of pregnancy. Neurological outcomes included seizure control, status epilepticus and adherence to antiepileptic medications. Obstetrical outcomes included major congenital malformations and obstetrical complications. RESULTS: A total of eighty two patients with a mean age of 24.5 ± 5.5 were included in our study. A significant number of women experienced an increase in seizure frequency and the prevalence of status epilepticus was 8.5%. More than half were non-adherent to antiepileptic drugs. Most of patients required treatment changes during pregnancy, in dose and/or in number of antiepileptic drugs. Cesarean section was the preferred way of delivery and five cases of major congenital malformations were detected. Obstetrical complications were significantly associated with polytherapy, multiple comorbidities, poor adherence to treatment and seizure deterioration during pregnancy (p < 0.05). CONCLUSIONS: Women with refractory epilepsy can have a significant risk of obstetric and neurological complications during pregnancy. Treatment of refractory epilepsy in pregnancy is a real challenge for neurologists.


Assuntos
Epilepsia Resistente a Medicamentos/complicações , Epilepsia Resistente a Medicamentos/terapia , Complicações na Gravidez/terapia , Adulto , Anticonvulsivantes/uso terapêutico , Brasil , Comorbidade , Epilepsia Resistente a Medicamentos/epidemiologia , Feminino , Seguimentos , Humanos , Estudos Longitudinais , Adesão à Medicação , Gravidez , Complicações na Gravidez/epidemiologia , Resultado da Gravidez , Estudos Prospectivos , Fatores de Risco , Convulsões/epidemiologia , Convulsões/terapia , Resultado do Tratamento , Adulto Jovem
19.
Seizure ; 69: 218-220, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31108410

RESUMO

PURPOSE: External trigeminal nerve stimulation is an emerging noninvasive therapy for drug resistant epilepsy (DRE). The aim of this study is to describe the long-term outcome of a series of patients treated with eTNS. METHODS: We present a retrospective observational study of patients with DRE who received eTNS treatment, comparing the monthly seizure frequency during the 3-months period before eTNS initiation with the monthly seizure frequency at 6, 12, 24, 36 and 48 months after eTNS. We analyze the responder rate, the retention rate and the tolerability. RESULTS: 17 patients with highly drug-resistant epilepsy were included. Mean follow-up was 2194 [6-56] months. The responder rate was 35% at 6 months and 12 months, 23% at 24 months, 19% at 36 months, and 14% at 48 months. Retention rates at the same periods were 88%, 53%, 41%, 37.5% and 28.5%. There were no reports of serious adverse events. Four patients reported improvement in sleep and better mood. CONCLUSION: The effectivity of eTNS is similar to some of the new treatments available, with a retention rate of 52% in the first year and 285% at 4 years. Tolerability is excellent with only mild effects reported by a minority of patients.


Assuntos
Epilepsia Resistente a Medicamentos/terapia , Terapia por Estimulação Elétrica , Adolescente , Adulto , Criança , Epilepsia Resistente a Medicamentos/complicações , Terapia por Estimulação Elétrica/métodos , Seguimentos , Humanos , Pessoa de Meia-Idade , Cooperação do Paciente , Estudos Retrospectivos , Convulsões/etiologia , Convulsões/terapia , Resultado do Tratamento , Nervo Trigêmeo , Adulto Jovem
20.
Continuum (Minneap Minn) ; 25(2): 362-380, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30921014

RESUMO

PURPOSE OF REVIEW: Drug-resistant epilepsy is a potentially life-threatening condition affecting one-third of people living with epilepsy. Despite existing evidence of improved outcomes in patients who received surgical treatment compared to continued medical treatment, epilepsy surgery remains underused in patients with drug-resistant epilepsy. This article discusses the gap between evidence and practice and common misconceptions about epilepsy surgery and reviews the current diagnostic and therapeutic surgical options. RECENT FINDINGS: Three randomized controlled trials comparing the medical versus surgical treatment for patients with drug-resistant epilepsy have shown the superiority of surgery in controlling seizures and improving patients' quality of life. In addition to resective surgery, neuromodulation through devices such as responsive neurostimulation and vagal nerve stimulation have also shown efficacy in seizure control that increases over time. Diagnostic and therapeutic surgical tools are tailored to the needs of each patient. SUMMARY: Appropriate patients with drug-resistant epilepsy benefit more from epilepsy surgery than from continuing medical treatment. These patients should be referred to comprehensive epilepsy centers where a thorough presurgical workup and surgical options can be provided. The gap between evidence and practice can be bridged by education, community outreach, and providers' earnest efforts to improve the quality of life of patients with epilepsy.


Assuntos
Epilepsia Resistente a Medicamentos/diagnóstico , Epilepsia Resistente a Medicamentos/terapia , Epilepsia Resistente a Medicamentos/cirurgia , Humanos
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