Episodes of status epilepticus in young adults: etiologic factors, subtypes, and outcomes.

The aim of this study was to evaluate the type, duration, etiology, treatment, and outcome of status epilepticus (SE) episodes, among patients aged 16-50 years. A total of 101 SE episodes in 88 young adult patients fulfilled our criteria. The mean age was 32 years. Status epilepticus episodes were most frequently observed in patients 21-30 years of age. A total of 53% of the patients were male, and 57% had pre-existing epilepsy. Seventy of the 101 episodes were convulsive SE. The most common etiology was withdrawal of or change in antiepileptic drugs (AEDs), seen in 31% of the SE episodes. This study included treatment of SE with traditional AEDs. Sixty-six episodes were treated successfully with intravenous infusion of 18-mg/kg phenytoin, and six episodes were treated with 10-mg/kg phenytoin. A total of 28% of the SE episodes remained refractory to first-line treatment, which was related to the duration of SE and mortality. The outcome was death in 14% of the patients due to underlying etiologies in the hospital.

Clinical experience: Outcomes of mesenchymal stem cell transplantation in five stroke patients.

Stem cell therapy, which has promising results in acute disorders such as stroke, supports treatment by providing rehabilitation in the chronic stage patients. In acute stroke, thrombolytic medical treatment protocols are clearly defined in neurologic emergencies, but in neurologic patients who miss the "thrombolytic treatment intervention window," or in cases of hypoxic-ischemic encephalopathy, our hands are tied, and we are still unfortunately faced with hopeless clinical implementations. We consider mesenchymal stem cell therapy a viable option in these cases. In recent years, novel research has focused on neuro-stimulants and supportive and combined therapies for stroke. Currently, available treatment options are limited, and only certain patients are eligible for acute treatment. In the scope of our experience, five stroke patients were evaluated in this study, who was treated with a single dose of 1-2 × 106 cells/kg allogenic umbilical cord-mesenchymal stem cells (UC-MSCs) with the official confirmation of the Turkish Ministry of Health Stem Cell Commission. The patients were followed up for 12 months, and clinical outcomes are recorded. NIH Stroke Scale/Scores (NIHSS) decreased significantly (p = 0.0310), and the Rivermead Assessment Scale (RMA) increased significantly (p = 0.0234) for all patients at the end of the follow-up. All the patients were followed up for 1 year within a rehabilitation program. Major clinical outcome improvements were observed in the overall clinical conditions of the UC-MSC treatment patients. We observed improvement in the patients' upper extremity and muscle strength, spasticity, and fine motor functions. Considering recent studies in the literature together with our results, allogenic stem cell therapies are introduced as promising novel therapies in terms of their encouraging effects on physiological motor outcomes.

The analgesic effect of gabapentin as a prophylactic anticonvulsant drug on postcraniotomy pain: a prospective randomized study.

BACKGROUND: Gabapentin is an anticonvulsant drug that has analgesic properties for acute postoperative pain. However, the analgesic effect of gabapentin as an antiepileptic prophylactic drug on patients undergoing craniotomy is unclear. In this study, we evaluated the postoperative effectiveness of gabapentin on acute postoperative pain when it is used for antiepileptic prophylaxis in patients undergoing craniotomy for supratentorial tumor resection. METHODS: Eighty patients undergoing craniotomy for supratentorial tumor resection were randomly assigned into two groups. Patients in Group G (n = 40) received oral gabapentin (3 x 400 mg), and patients in Group P (n = 40) received oral phenytoin (3 x 100 mg) for 7 days before the operation and postoperatively. An identical anesthesia protocol was performed for both the groups. Anesthesia was maintained with propofol and remifentanil infusion. Patient-controlled analgesia with morphine was used, and pain levels were measured. The antiepileptic-related side effects, anesthetic consumption, duration of anesthesia and surgery, tracheal extubation time, postoperative pain scores, morphine consumption, and sedation scores were recorded. RESULTS: Thirty-seven patients in Group G and 38 patients in Group P completed the study. During the preoperative period in Group G, one patient had severe fatigue, one had severe dizziness, and one patient's surgical procedure was changed. The median plasma levels of gabapentin were 34 micromol/mL (range, 23-51 micromol/mL) in 34 patients. In Group P, one patient withdrew from the study preoperatively and one developed transient neurological symptoms postoperatively. The demographic data and mean duration of anesthesia and surgery were similar in both the groups. The total propofol and remifentanil consumption in Group G (1847 +/- 548 mg/3034 +/- 1334 microg) was significantly less than that of Group P (2293 +/- 580 mg/4287 +/- 1282 microg) (P = 0.01). However, tracheal extubation could be done earlier in Group P (4.5 +/- 2 min) than in Group G (16.6 +/- 22 min) (P < 0.001). Pain scores were significantly higher in Group P at 15 min, 30 min, and 1 h (P < 0.001). The total morphine consumption was also significantly higher in Group P (33 +/- 17 mg vs 24 +/- 19 mg) (P = 0.01). The postoperative sedation scores were significantly higher in Group G at 15 min, 30 min, 1 h, and 2 h (P < 0.001). CONCLUSIONS: The administration of gabapentin to patients undergoing craniotomy for supratentorial tumor resection was effective for acute postoperative pain. It also decreased analgesic consumption after surgery. However, it may lead to side effects such as delayed tracheal extubation and increased sedation postoperatively.

Reversible valproate-induced choreiform movements.

Valproate is an anticonvulsive drug whose mechanism of action is based on GABAergic systems. One of the infrequent adverse effects of valproate is choreiform movements. In our study, we report a patient having head trauma history with partial and secondary generalized seizures taking 1500 mg/day valproate. During the second month of the therapy, generalized chorea was observed. Since other aetiologic causes of chorea were excluded, acutely occurring chorea in the patient was thought to be related with valproate usage because of persistence of choreiform movements for days without any fluctuation. Valproate was stopped slowly and lamotrigine was added at a dose of 400 mg/day. Within a two-month period after cessation of the valproate, choreiform movements had disappeared. We thought that the history of head trauma and another antiepileptic drug usage were the risk factors for the occurrence of valproate-induced choreiform movements.

The paramedian supracerebellar-transtentorial approach to the entire length of the mediobasal temporal region: an anatomical and clinical study. Laboratory investigation.

OBJECT: The exploration of lesions in the mediobasal temporal region (MTR) has challenged generations of neurosurgeons to achieve an appropriate approach. To address this challenge, the extensive use of the paramedian supracerebellar-transtentorial (PST) approach to expose the entire length of the MTR, as well as the fusiform gyrus, was investigated. METHODS: The authors studied the microsurgical aspects of the PST approach in 20 cadaver brains and 5 cadaver heads under the operating microscope. They evaluated the features, advantages, difficulties, and limitations of the PST approach and refined the surgical technique. They then used the PST approach in 15 patients with large intrinsic MTR tumors (6 patients), tumor in the posterior fusiform gyrus with mediobasal temporal epilepsy (MTE) (1 patient), cavernous malformations in the posterior MTR including the fusiform gyrus (2 patients), or intractable MTE with hippocampal sclerosis (6 patients) from December 2007 to May 2010. Patients ranged in age from 11 to 63 years (mean 35.2 years), and in 9 patients (60%) the lesion was located on the left side. RESULTS: In all patients with neuroepithelial tumors or cavernous malformations, the lesions were completely and safely resected. In all patients with intractable MTE with hippocampal sclerosis, the anterior two-thirds of the parahippocampal gyrus and hippocampus, as well as the amygdala, were removed selectively through the PST approach. There was no surgical morbidity or mortality in this series. Three patients (20%) with high-grade neuroepithelial tumors underwent postoperative radiotherapy and chemotherapy but needed a second surgery for recurrence during the follow-up period. In all patients with MTE, antiepileptic medication could be decreased to a single drug at lower doses, and no seizure activity has occurred until this point. CONCLUSIONS: The PST approach provides the surgeon precise anatomical orientation when exposing the entire length of the MTR, as well as the fusiform gyrus, for removing any lesion. This is a novel technique especially for removing tumors involving the entire MTR in a single session without damaging neighboring neural or vascular structures. This approach can also be a viable alternative for selective removal of the parahippocampal gyrus, hippocampus, and amygdala in patients with MTE due to hippocampal sclerosis.

Assessment of the corticospinal tract alterations before and after resection of brainstem lesions using Diffusion Tensor Imaging (DTI) and tractography at 3T.

The purpose of the study was to investigate the role of Diffusion Tensor Imaging (DTI) and Diffusion Tensor Tractography (DTT) on the corticospinal tract alterations due to space occupying lesions in the brainstem before and after surgical resection. Pre- and post-surgical DTI data were acquired in 14 patients undergoing surgical resection of brainstem lesions. Patterns of corticospinal tract (CST) alteration on DTT were compared with the neurological exams of the patients pre- and post-operatively. DTT, especially in 3D movie format, seemed very helpful for evaluating the relationship of the lesions with the corticospinal tracts for surgical approach. None of the patients developed additional motor deficit related to surgery except one patient who presented with cerebellar ataxia after surgery. All of the patients with normal CST on DTT presented without motor deficit on neurological exam. The sensitivity, specificity, positive predictive and negative predictive values of DTT before surgery were 100%, 63.6%, 42.9% and 100%, and the corresponding values after surgery were 100%, 96%, 75% and 100% respectively. Although it has low specificity before surgery, DTT is a potentially useful technique in evaluating the effects of brainstem lesions and surgical resection on the relevant corticospinal tracts with high negative predictive value and higher specificity after surgery.

Spinal accessory nerve monitoring in posterior fossa surgery.

The role of intraoperative monitoring of lower cranial nerves is not well established. In this study, the authors retrospectively analyzed the intraoperative monitoring data and the clinical outcome of the spinal accessory nerve (SAN) in patients who have undergone posterior fossa surgery. SAN was monitored in 19 patients. Subcutaneous needle electrodes were placed in the trapezius, and any abnormal spontaneous activity was documented for duration and amplitude. A bipolar stimulation probe was used for triggered electromyogram, with a maximum stimulation intensity of 3 mA. All patients were clinically evaluated for SAN dysfunction postoperatively 24 hours and 7 days. Neurotonic discharges, lasting between 3 and 90 minutes were seen in 84% of the patients. Continuous discharges lasting longer than 5 minutes were seen in 36% of the patients. The SAN was stimulated in 57.8% of the patients. With clinical examination, none of our patients had postoperative SAN dysfunction. Long lasting dense neurotonic discharges and high stimulation thresholds have been correlated with postoperative facial nerve injury; however, this does seem be true in the case of SAN monitoring. Neurotonic discharges are commonly false-positive and stimulation intensity up to 3 mA can be related with a good outcome. The intraoperative monitoring of SAN may not be valuable as much as facial nerve monitoring.

Significance of atypical triphasic waves for diagnosing nonconvulsive status epilepticus.

The aim of the study described here was to analyze findings in 15 cases who were admitted with nonconvulsive status epilepticus (NCSE) and whose EEGs featured atypical triphasic waves (ATWs). We also investigated whether ATWs are useful for diagnosing this condition. Mental status was assessed, and EEGs were recorded during/after the antiepileptic drug treatment. Eight patients had metabolic disorders and nine had intracranial pathology. The ATWs were unilateral focal in 5 cases and bilaterally asymmetrical focal in 10 cases. In 11 of the 15 cases, the ATWs disappeared and mental status improved after treatment. NCSE should be considered in any individual who presents in an acute confusional state and whose EEG reveals either unilateral or bilaterally asymmetric ATWs.

Seizure recognition on epilepsy feature tensor.

With a goal of automating visual analysis of electroencephalogram (EEG) data and assessing the performance of various features in seizure recognition, we introduce a mathematical model capable of recognizing patient-specific epileptic seizures with high accuracy. We represent multi-channel scalp EEG using a set of features. These features expected to have distinct trends during seizure and non-seizure periods include features from both time and frequency domains. The contributions of this paper are threefold. First, we rearrange multi-channel EEG signals as a third-order tensor called an Epilepsy Feature Tensor with modes: time epochs, features and electrodes. Second, we model the Epilepsy Feature Tensor using a multilinear regression model, i.e., Multilinear Partial Least Squares regression, which is the generalization of Partial Least Squares (PLS) regression to higher-order datasets. This two-step approach facilitates EEG data analysis from multiple electrodes represented by several features from different domains. Third, we identify which features are more significant for seizure recognition. Our results based on the analysis of 19 seizures from 5 epileptic patients demonstrate that multiway analysis of an Epilepsy Feature Tensor can detect (patient-specific) seizures with classification accuracy ranging between 77-96%.