Post-concussion syndrome and pre-existing mood disorder: A case report.

Sport-related concussions in youth and adolescent athletes most commonly resolve within one week without residual symptoms, with athletes resuming full participation following return to play guidelines. A small percentage of athletes have persistent symptoms that cause significant morbidity, some of whom are ultimately diagnosed with post-concussion syndrome. In these athletes, symptoms in the emotional domain can be more prolonged than other domains, with athletes reporting anxiety and depression months to years following injury. A prior personal or family history of pre-existing mood disorder or attention-deficit/hyperactivity disorder increases the risk of a prolonged duration of symptoms. In this case series, we discuss two cases of post-concussion syndrome in adolescent athletes with a past personal or family history of attention-deficit/hyperactivity disorder, anxiety, and depression treated by a combination of cognitive behavioral therapy and medication with ongoing persistent symptoms. There is increased need for mental health screening in all athletes to identify individuals at risk for post-concussion syndrome. Early identification of at-risk individuals allows the interdisciplinary care team to discuss expectations for the athlete and family regarding duration of symptoms.

A child with ictal vocalizations and generalized epilepsy.

Ictal vocalizations in the form of both articulate speech and non-speech vocalizations have been described in focal epilepsies, with seizures originating mainly from the frontal and temporal lobe, however, this phenomenon has not been described in generalized epilepsies. We report the case of an adolescent boy with juvenile-onset generalized epilepsy who presented with ictal "ovine vocalizations" (resembling the bleating of sheep). The ictal EEG revealed a clear correlate of vocalizations with time-locked generalized spikes and polyspike discharges. The 3T cerebral MRI ruled out any focal lesion. The boy is currently seizure-free under valproic acid, after twelve months of follow-up. We conclude that ictal non-speech vocalizations may be observed not only in focal or structural epilepsies, but also in generalized epilepsies; the exact underlying mechanism of this phenomenon needs to be further delineated. [Published with video sequence].

Social behavior impairment in offspring exposed to maternal seizures in utero.

Human and animal models have demonstrated that maternal seizures in utero could be deleterious to the development of the offspring. This study focused on the social behavior of offspring exposed to seizures in utero. A pilocarpine model of temporal lobe epilepsy was induced in female Wistar rats that were mated after the first spontaneous seizure. Early after birth, pups from an epileptic mother were reared by a control mother. To evaluate the influence of the adoption process, two other groups were added: rat pups from control mothers cross-fostered with other control mothers, and rat pups reared by their birth mother. Animals exposed to seizures in utero showed impaired social behavior with no signs of anxiety-like behavior. This study demonstrated that epileptic seizures during pregnancy could be harmful to brain development and may increase the risk of developing neurodevelopmental disorders. The mechanisms underlying the abnormalities of social behavior are not well understood, and further studies in this field are warranted.

Actin dynamics in development of behavioral sensitization after withdrawal from long-term ethanol administration to mice.

BACKGROUND AND METHODS: The present study investigated the role of actin depolymerizing factor (ADF) in the brain of mice after withdrawal from continuous ethanol (EtOH) vapor inhalation for 9 days using C57BL/6J and ADF mutant mice. RESULTS: C57BL/6J mice with withdrawal signs 10 hours after withdrawal from EtOH vapor inhalation showed transient and significant enhancement of locomotor activity by a single injection of EtOH (2 g/kg, i.p.) and of EtOH-induced place preference 3 days after withdrawal from EtOH vapor inhalation, suggesting the development of sensitization of locomotion activity to EtOH and of place preference 3 days after withdrawal from EtOH in C57BL/6J mice with EtOH physical dependence. The levels of ADF and G-actin in the ventral tegmental area, including a little bit of surrounding tissues, increased immediately (0 hours), 10 hours, and 3 days after withdrawal from EtOH vapor. F-actin, synaptic vesicle-associated protein 38, and postsynaptic density 95 increased 0 hours and 3 days after withdrawal with their decreases 10 hours after withdrawal from EtOH vapor. An F-actin stabilizing agent phalloidin (3 nmol/mouse/d, i.c.v., once a day) administered daily for 3 days after withdrawal from continuous EtOH vapor inhalation for 9 days significantly suppressed the increase in both EtOH-induced place preference and locomotor activity by a single injection of EtOH 3 days after withdrawal from long-term EtOH vapor inhalation for 9 days. In addition, the changes in behavioral sensitization in ADF mutant mice were significantly weaker than those observed in C57BL/6J mice (wild-type mice for ADF mutant mice). CONCLUSIONS: The findings presented here suggest that withdrawal from EtOH physical dependence causes behavioral sensitization to EtOH, which may be, at least in part, mediated by alternation of actin dynamics.

Cannabinoid receptor 1 inhibition causes seizures during anesthesia induction in experimental sepsis.

We report on seizures during anesthesia induction in animals treated with a cannabinoid receptor 1 (CB1R) antagonist for experimental sepsis. Animals received surgery for colon ascendens stent peritonitis-induced sepsis or sham surgery followed by treatment of CB1R antagonist, CB1R agonist, or placebo. Fourteen hours later, animals received pentobarbital or ketamine for anesthesia induction and animal behavior was observed. Tonic-clonic seizures were observed in 5 of 12 septic animals (42%) treated with CB1R antagonist after induction of anesthesia with pentobarbital. The data suggest that CB1R inhibition in combination with pentobarbital may increase the incidence of anesthetic-induced seizures in the case of sepsis.

Maintenance ECT as a therapeutic approach to medication-refractory epilepsy in an adult with mental retardation: case report and review of literature.

BACKGROUND: Electroconvulsive therapy (ECT) raises the seizure threshold. This physiological change may benefit patients with seizure disorders. Whereas ECT has recently been used to terminate medication-refractory status epilepticus, there is little current literature on its planned administration as a specific maintenance treatment for medication-refractory epilepsy. METHODS: We used maintenance ECT to treat an 18-year-old man with a long-standing generalized tonic-clonic seizure disorder who had shown poor response to several antiepileptic drugs administered in combination with antiepileptic medication compliance confirmed through drug level monitoring. RESULTS: A total of 52 ECTs were administered across nearly 20 months at a mean frequency of once in nearly 12 days. From the very outset, ECT dramatically decreased the frequency of spontaneous seizures from approximately 6 to 24 per week at baseline to approximately 1 to 2 per week after ECT initiation. The efficacy of maintenance ECT in spontaneous seizure prophylaxis was greater when the ECT treatment interval was narrower. Improvement with ECT was associated with improved behavior and improved psychosocial functioning on clinical report. No cognitive or other adverse effects were reported or clinically ascertained. The ECT charge administered at the last 10 treatment sessions was 1434 millicoulombs. This is probably the highest electrical stimulus dose recorded in literature. CONCLUSIONS: Maintenance ECT may reduce the frequency of breakthrough seizures in patients with seizure disorder that is inadequately responsive to antiepileptic medication regimes. Very high ECT seizure thresholds may be observed when many antiepileptic drugs are concurrently administered in high doses.

Dreaming experience as a useful diagnostic clue for syncopal episodes.

BACKGROUND: The differential diagnosis between epileptic seizures and syncopes is a common occurrence in clinical practice. The manifestations of seizure and syncope sometimes overlap, and available diagnostic testing often not provides a conclusive answer. Syncope is often preceded by a symptom complex characterized by lightheadedness, generalized muscle weakness, giddiness, visual blurring, tinnitus, and gastrointestinal symptoms. These subjective symptoms are very important in guiding the diagnosis. In our experience, the impression of coming out of a dream after the syncopal episode is a subjective symptom commonly reported by patients, if questioned. METHODS: To verify the occurrence of dreaming experience after syncope and after generalized tonic-clonic seizures (GTCS) and its diagnostic value in differential diagnosis, we asked 100 patients with GTCS and diagnosis of idiopathic generalized epilepsy (Group 1) and 100 patients with a certain diagnosis of syncope (Group 2) whether they have never felt the impression of coming out of a dream after the loss of consciousness (GTCS or syncope, respectively). RESULTS: In Group 1, nobody referred the dreaming experience, whereas in the syncope group, 19% of patients referred this subjective symptom. CONCLUSIONS: Dreaming experience seems to be an additional useful diagnostic clue for syncopal episodes, helping the clinician to differentiate them from seizures.

Cognitive and behavioral functioning in Coffin-Siris syndrome and epilepsy: a case presentation.

The authors characterized the cognitive, adaptive, and behavioral sequelae of Coffin-Siris (CS) syndrome and epilepsy in a 7.5-year-old child. Little is known about the early neurobehavioral presentation of CS. Clinical features consistent with this genetic anomaly include underdeveloped tips and nails of the fifth fingers, extended infranasal depression, and craniofacial abnormalities. MRI findings often reveal callosal agenesis. The authors conducted a neuropsychological evaluation and obtained parental ratings of behavioral and adaptive functioning. Attentional abilities were limited. As assessed by the Mullen Scales of Early Learning, receptive language abilities (age equivalent [AE]: 3-3) were relatively stronger than expressive skills (AE: 1-4). Adaptive functioning was low across all domains (Vineland Adaptive Behavior Composite AE: 1-9). On the Behavior Assessment for Children (BASC-2), social skills dysfunction, stereotyped and self-stimulatory behaviors, restricted interests, ritualistic play, and inappropriate object usage were noted. No significant mood disturbances were endorsed. Study findings indicate a diffuse pattern of neurobehavioral deficits in a child with CS and epilepsy. Further clinical assessment and research should include multidimensional assessment techniques, including evaluation of adaptive behavior, in an effort to capture the full range developmental sequelae in children with CS.

Cortical and subcortical networks in human secondarily generalized tonic-clonic seizures.

Generalized tonic-clonic seizures are among the most dramatic physiological events in the nervous system. The brain regions involved during partial seizures with secondary generalization have not been thoroughly investigated in humans. We used single photon emission computed tomography (SPECT) to image cerebral blood flow (CBF) changes in 59 secondarily generalized seizures from 53 patients. Images were analysed using statistical parametric mapping to detect cortical and subcortical regions most commonly affected in three different time periods: (i) during the partial seizure phase prior to generalization; (ii) during the generalization period; and (iii) post-ictally. We found that in the pre-generalization period, there were focal CBF increases in the temporal lobe on group analysis, reflecting the most common region of partial seizure onset. During generalization, individual patients had focal CBF increases in variable regions of the cerebral cortex. Group analysis during generalization revealed that the most consistent increase occurred in the superior medial cerebellum, thalamus and basal ganglia. Post-ictally, there was a marked progressive CBF increase in the cerebellum which spread to involve the bilateral lateral cerebellar hemispheres, as well as CBF increases in the midbrain and basal ganglia. CBF decreases were seen in the fronto-parietal association cortex, precuneus and cingulate gyrus during and following seizures, similar to the 'default mode' regions reported previously to show decreased activity in seizures and in normal behavioural tasks. Analysis of patient behaviour during and following seizures showed impaired consciousness at the time of SPECT tracer injections. Correlation analysis across patients demonstrated that cerebellar CBF increases were related to increases in the upper brainstem and thalamus, and to decreases in the fronto-parietal association cortex. These results reveal a network of cortical and subcortical structures that are most consistently involved in secondarily generalized tonic-clonic seizures. Abnormal increased activity in subcortical structures (cerebellum, basal ganglia, brainstem and thalamus), along with decreased activity in the association cortex may be crucial for motor manifestations and for impaired consciousness in tonic-clonic seizures. Understanding the networks involved in generalized tonic-clonic seizures can provide insights into mechanisms of behavioural changes, and may elucidate targets for improved therapies.

Morphological and molecular correlates of altered hearing sensitivity in the genetically audiogenic seizure-prone hamster GASH/Sal.

Rodent models of audiogenic seizures, in which seizures are precipitated by an abnormal response of the brain to auditory stimuli, are crucial to investigate the neural bases underlying ictogenesis. Despite significant advances in understanding seizure generation in the inferior colliculus, namely the epileptogenic nucleus, little is known about the contribution of lower auditory stations to the seizure-prone network. Here, we examined the cochlea and cochlear nucleus of the genetic audiogenic seizure hamster from Salamanca (GASH/Sal), a model of reflex epilepsy that exhibits generalized tonic-clonic seizures in response to loud sound. GASH/Sal animals under seizure-free conditions were compared with matched control hamsters in a multi-technical approach that includes auditory brainstem responses (ABR) testing, histology, scanning electron microscopy analysis, immunohistochemistry, quantitative morphometry and gene expression analysis (RT-qPCR). The cochlear histopathology of the GASH/Sal showed preservation of the sensory hair cells, but a significant loss of spiral ganglion neurons and mild atrophy of the stria vascularis. At the electron microscopy level, the reticular lamina exhibited disarray of stereociliary tufts with blebs, loss or elongated stereocilia as well as non-parallel rows of outer hair cells due to protrusions of Deiters' cells. At the molecular level, the abnormal gene expression patterns of prestin, cadherin 23, protocadherin 15, vesicular glutamate transporters 1 (Vglut1) and -2 (Vglut2) indicated that the hair-cell mechanotransduction and cochlear amplification were markedly altered. These were manifestations of a cochlear neuropathy that correlated to ABR waveform I alterations and elevated auditory thresholds. In the cochlear nucleus, the distribution of VGLUT2-immunolabeled puncta was differently affected in each subdivision, showing significant increases in magnocellular regions of the ventral cochlear nucleus and drastic reductions in the granule cell domain. This modified inputs lead to disruption of Vglut1 and Vglut2 gene expression in the cochlear nucleus. In sum, our study provides insight into the morphological and molecular traits associated with audiogenic seizure susceptibility in the GASH/Sal, suggesting an upward spread of abnormal glutamatergic transmission throughout the primary acoustic pathway to the epileptogenic region.

Eye movement desensitization and reprocessing in an adolescent with epilepsy and mild intellectual disability.

Intellectual disability is a comorbid condition in epilepsy. People with epilepsy and intellectual disability are at high risk of developing behavioral problems. Among the many contributors to behavioral problems in people with epilepsy and intellectual disability are those of traumatic experiences. As such, behavioral problems can be seen as a reflection of these traumatic experiences. Among established trauma therapies, eye movement desensitization and reprocessing (EMDR) is an emerging treatment that is effective in adults and also seems to be effective in children. This article is a case report of EMDR in an adolescent with epilepsy and mild intellectual disability, in whom the EMDR children's protocol was used. The aim was to assess whether clinical trauma status significantly diminished to nonclinical status posttreatment. Change in trauma symptoms was evaluated with the Reliable Change Index (RCI). Results showed a significant decrease in trauma symptoms toward nonclinical status from pretreatment to posttreatment. EMDR consequences for epilepsy and intellectual disability are discussed.

[Epilepsy by bovine (zebu) goring: a case report in Burkina Faso]. / Epilepsie par encornement bovin (zébu): a propos d'un cas au Burkina Faso.

The post-traumatic epilepsy is responsible for 20% of the symptomatic epilepsies. Accidents on public highway constitute more than 70% of the causes. We report a singular case of fronto-polar post-traumatic epilepsy by zebu goring which appeared two years after the traumatism. The neurological examination of the patient was normal apart from a inconspicuous expansiveness of humor underlined by an excess of familiarity and hypersyntony. The cerebral scanner revealed a left fronto-basal cortico-under-cortical low density up to the homolateral fronto-polar area. The electroencephalogram (EEG) showed some left fronto-polar bursts of spike and wave on a normal bottom line. This clinical observation draws our attention on the fact that in Sahelian tropical environment where bovine breeding holds a major place, the cranio-encephalic traumatism by goring is not rare and can be responsible for epilepsy in the same way as accidents on public highway, or ballistic traumatism.

Coping with a child with Dravet syndrome: insights from families.

Dravet syndrome is a truly catastrophic childhood-onset epilepsy. Families are faced with repeated episodes of status epilepticus, intractable seizures, mental handicap, behavior disorders, and a life of dependency; understandably, coping with Dravet syndrome is very difficult. Twenty-four families with a child with Dravet syndrome were interviewed and identified some practical suggestions to improve their daily life. These included inserting an indwelling venous access device, creating a portable microenvironment, writing an emergency department protocol, establishing emergency routines for the family, assigning a parent on call to lessen the effect on siblings, creating personal time to decrease parental stress, finding respite care, and contacting an Internet support group. Unresolved and common issues included transition to adult care, the utility of early diagnosis, and social isolation. These solutions and issues may be helpful to many families with a child with Dravet syndrome and possibly other severe childhood-onset epilepsies.

Musical hallucinations after left temporal lobectomy.

BACKGROUND: Musical hallucinations (MHs) are rare and most often described in patients with hearing loss, female sex, older age, and various brain pathologies, including epilepsy. CASE HISTORY: We describe a unique case in which, after successful left temporal lobectomy for refractory epilepsy and subsequent ototoxic therapies, a 49-year-old man experienced the onset of songs replaying constantly in his mind for days to weeks. He had intractable partial epilepsy since age 26. Presurgical neurodiagnostic evaluations revealed a left temporal focus, left hippocampal magnetic resonance imaging abnormalities, bilateral language representation, and cognitive deficits lateralized to the left hemisphere. He underwent a partial left temporal lobectomy but required repeated antibiotic courses for postoperation bone flap infections, resulting in tinnitus. Surgery led to near seizure-freedom, plus improved cognitive and emotional function. Pathology revealed focal cortical dysplasia. Six months postsurgery, during antibiotic treatment, he began to hear songs replaying in his head, which increased in frequency over ensuing years. CONCLUSIONS: We report, to our knowledge, the first case of MHs associated with temporal lobectomy for epilepsy. This patient had multiple risk factors for these unwanted musical experiences, including epilepsy, mild neuropsychiatric dysfunction, and tinnitus plus hearing loss. Possible mechanisms for MHs are discussed.

Head turning as a prominent motor symptom in status epilepticus.

Head and eye turning is frequently observed during seizures. Versions with tonic and/or clonic symptoms can be differentiated from smooth head deviations. Head turning as a prominent symptom of status epilepticus has not previously been reported. We present eight case reports, (7 women/1 man, mean age 41 years, median 41.5, range 10 to 74), of status epilepticus (SE), with head turning as a prominent motor symptom. Six were accompanied by continuous frontal, occipital and temporal ictal epileptiform discharges. Furthermore, two patients had absence status with rhythmic and clonic head versions. While the localizing significance of head turnings in SE is low, in our cases, the direction was away from the discharging hemisphere in all cases of focal SE regardless of whether the turning was classified as version (three cases) or deviation (three cases). In this small series of SE, the classical observation of a patient looking away from the discharging hemisphere is still valid.

Posterior reversible encephalopathy syndrome during sunitinib therapy.

A case of posterior reversible encephalopathy syndrome (PRES) occurring in a women treated by sunitinib for an ovarian metastatis of a renal cell carcinoma is described. This is the third case described in the literature. The three cases are very similar except for the delay to onset of the PRES (one week to five months). Both antiangiogenic and prohypertensive effects of sunitinib are probably involved in the pathophysiology of PRES. Physicians should be aware of this potentially life-threatening side-effect of sunitinib easily controlled by withdrawing sunitinib and symptomatic treatment.

[Visual auras in idiopathic generalized epilepsy]. / Auras visuelles dans les épilepsies généralisées idiopathiques.

Visual auras are reported to be uncommon or rare in patients with idiopathic generalized epilepsy. We describe three patients who experienced visual auras just before generalized tonic-clonic seizures. This study indicates that in idiopathic generalized epilepsy, visual auras manifest as flashes, lighting or the impression of seeing the sun. Unlike auras in occipital lobe epilepsy, they are very brief.

Verbal and visual memory impairment in children with epilepsy.

Verbal and visual memory performances were evaluated in 60 epileptic children and 60 normal control subjects with Signoret's Memory Battery scale. Eighteen patients had idiopathic generalized epilepsy and 42 had partial epilepsy, mostly of the temporal (n = 28) and frontal (n = 10) lobes. Memory scores were statistically lower in epileptics than in controls and significant differences were found within each group: (1) children with idiopathic generalized epilepsy had a slight depression of visual memory; (2) memory disorder was more severe in partial epilepsy; and (3) children with left and right temporal lobe epilepsy had marked memory deficits related to hemispheric specialization.