Simulated driving in the epilepsy monitoring unit: Effects of seizure type, consciousness, and motor impairment.

People with epilepsy face serious driving restrictions, determined using retrospective studies. To relate seizure characteristics to driving impairment, we aimed to study driving behavior during seizures with a simulator. Patients in the Yale New Haven Hospital undergoing video-electroencephalographic monitoring used a laptop-based driving simulator during ictal events. Driving function was evaluated by video review and analyzed in relation to seizure type, impairment of consciousness/responsiveness, or motor impairment during seizures. Fifty-one seizures in 30 patients were studied. In terms of seizure type, we found that focal to bilateral tonic-clonic or myoclonic seizures (5/5) and focal seizures with impaired consciousness/responsiveness (11/11) always led to driving impairment; focal seizures with spared consciousness/responsiveness (0/10) and generalized nonmotor (generalized spike-wave bursts; 1/19) usually did not lead to driving impairment. Regardless of seizure type, we found that seizures with impaired consciousness (15/15) or with motor involvement (13/13) always led to impaired driving, but those with spared consciousness (0/20) or spared motor function (5/38) usually did not. These results suggest that seizure types with impaired consciousness/responsiveness and abnormal motor function contribute to impaired driving. Expanding this work in a larger cohort could further determine how results with a driving simulator may translate into real world driving safety.

A Systematic Review of the Efficacy of Levetiracetam in Neonatal Seizures.

OBJECTIVE: Seizures are the most common neurological complication in neonatal intensive care units. Phenobarbital (PB) remains the first-line antiepileptic drug (AED) for neonatal seizures despite known neurotoxicity. Levetiracetam (LEV) is a newer AED not approved for neonates. Retrospective and pilot studies have investigated the use of LEV in neonatal seizures. Our objective was to compare the efficacy of LEV to PB in neonatal seizures based upon published data. METHODS: We searched PubMed to perform a systematic review. We found no studies of LEV with comparison or control groups; therefore, we utilized data from two randomized controlled trials of PB as our comparison group. RESULTS: Five studies of LEV met all inclusion/exclusion criteria. The pooled sample size for LEV was 102 (48 received primary LEV, 54 received secondary LEV). The pooled sample size for primary PB was 52. Complete or near-complete seizure cessation was achieved as follows: primary LEV 37/48 (77%), secondary LEV 34/54 (63%), and primary PB 24/52 (46%). CONCLUSION: Our findings suggest that LEV may be at least as or more effective for neonatal seizures as PB. Our review, though limited, is the first to examine LEV efficacy compared with PB in neonates.

Prospective assessment of ictal behavior using the revised Responsiveness in Epilepsy Scale (RES-II).

Impaired consciousness in epilepsy has a significant negative impact on patients' quality of life yet is difficult to study objectively. Here, we develop an improved prospective Responsiveness in Epilepsy Scale-II (RES-II) and report initial results compared with the earlier version of the scale (RES). The RES-II is simpler to administer and includes both verbal and non-verbal test items. We evaluated 75 seizures (24 patients) with RES and 34 seizures (11 patients) with RES-II based on video-EEG review. The error rate per seizure by test administrators improved markedly from a mean of 2.01 ± 0.04 with RES to 0.24 ± 0.11 with RES-II. Performance during focal seizures showed a bimodal distribution, corresponding to the traditional complex partial vs. simple partial seizure classification. We conclude that RES-II has improved accuracy and testing efficiency compared with the original RES. Prospective objective testing will ultimately lead to a better understanding of the mechanisms of impaired consciousness in epilepsy.

Multiple Cranial Nerve Palsies in a Pediatric Case of Lemierre's Syndrome due to Streptococcus viridans.

BACKGROUND: Lemierre's syndrome is a rare condition of internal jugular vein thrombosis following oropharyngeal infection. While it usually results from Fusobacterium necrophorum infection, atypical cases associated with other pathogens have been reported. OBJECTIVE: To describe a unique case of pediatric Lemierre's syndrome with Streptococcus viridans infection resulting in cavernous sinus thrombosis and oculomotor, trochlear, and abducens nerve palsies. Case Report. A 14-year-old female initially presented after six days of fever, myalgias, and sore throat and was admitted for hyperbilirubinemia and acute kidney injury. She developed a fixed, dilated pupil with complete ophthalmoplegia, ptosis, and severe pain. Imaging revealed retromandibular space abscess, external and internal jugular vein thrombosis, cavernous sinus thrombosis, internal carotid artery stenosis, pulmonary embolism, and bilateral pneumonia. She was diagnosed with Lemierre's syndrome with cultures positive for Streptococcus viridans and treated with a combination of antibiotics and anticoagulation. Conclusion and Relevance. Both antibiotics and anticoagulation were effective management for this Lemierre's syndrome patient with cavernous sinus thrombosis. Early diagnosis and treatment of Lemierre's syndrome is essential. A multidisciplinary treatment team is beneficial for managing the sequelae of this condition.

Parkinson's Disease With Visual Hallucinations Is Associated With Epileptiform Activity on EEG.

Background: Visual hallucinations (VHs) in Parkinson's disease (PD) are the cardinal symptoms which declare the onset of PD psychosis (PDP). The anthropomorphic and zoomorphic VHs of PD resemble those of Charles Bonnet syndrome and temporal lobe epilepsy. In both of these disorders electroencephalography (EEG) abnormalities have been described. We therefore sought to examine whether VHs in PD were associated with similar EEG abnormalities. Methods: This retrospective observational study searched the medical records of 300 PD patients and filtered for those containing clinical 20-min scalp EEGs. Remaining records were separated into two groups: patients with reported VHs and those without. The prevalence of epileptiform discharges in the EEGs of both groups was identified. Results: Epileptiform discharges were present in 5 of 13 (38.5%) PD patients with VHs; all localized to the temporal lobe. No epileptiform discharges were observed in the EEGs of the 31 PD patients without VHs. Conclusion: The significantly high incidence of temporal lobe epileptiform discharges in PD patients with VHs as compared to those without VHs lends to the possibility of an association visual cortex epileptogenic focus. Accordingly, for treatment-refractory patients, antiepileptic drugs might be considered, as in the case of Charles Bonnet syndrome, temporal lobe epilepsy and migraine with visual aura. Future prospective studies involving larger samples and multi-center cohorts are required to validate these observational findings.

BASP1 labels neural stem cells in the neurogenic niches of mammalian brain.

The mechanisms responsible for determining neural stem cell fate are numerous and complex. To begin to identify the specific components involved in these processes, we generated several mouse neural stem cell (NSC) antibodies against cultured mouse embryonic neurospheres. Our immunohistochemical data showed that the NSC-6 antibody recognized NSCs in the developing and postnatal murine brains as well as in human brain organoids. Mass spectrometry revealed the identity of the NSC-6 epitope as brain abundant, membrane-attached signal protein 1 (BASP1), a signaling protein that plays a key role in neurite outgrowth and plasticity. Western blot analysis using the NSC-6 antibody demonstrated multiple BASP1 isoforms with varying degrees of expression and correlating with distinct developmental stages. Herein, we describe the expression of BASP1 in NSCs in the developing and postnatal mammalian brains and human brain organoids, and demonstrate that the NSC-6 antibody may be a useful marker of these cells.

A novel inherited SCN1A mutation associated with GEFS+ in benign and encephalopathic epilepsy.

Generalized epilepsy with febrile seizures plus (GEFS+) is an autosomal dominant condition often caused by mutations in SCN1A that usually first manifests as childhood simple febrile seizures but may progress to a variety of afebrile generalized seizure types. Here, we describe the case of an 8-year-old boy with a novel SCN1A mutation who developed febrile seizures at 10months of age which eventually advanced to frequent afebrile tonic-clonic seizures. His condition was unresponsive to several antiepileptic drugs and the ketogenic diet, and he experienced gradual cognitive decline. The patient's father carries the same novel mutation, but he only experienced childhood simple febrile seizures. SCN1A mutations display incomplete penetrance and variable expressivity, and the resulting severity may depend on the location and type of mutation, whether the mutation was spontaneous or inherited, and the effect of modifying alleles. The identification of novel pathogenic SCN1A mutations may eventually advance therapeutic development and prognostic capabilities.

Clinical Correlates and Prognostic Significance of Lateralized Periodic Discharges in Patients Without Acute or Progressive Brain Injury: A Case-Control Study.

PURPOSE: Lateralized periodic discharges (LPDs, also known as periodic lateralized epileptiform discharges) in conjunction with acute brain injuries are known to be associated with worse prognosis but little is known about their importance in absence of such acute injuries. We studied the clinical correlates and outcome of patients with LPDs in the absence of acute or progressive brain injury. METHODS: This is a case-control study of 74 patients with no acute brain injury undergoing continuous EEG monitoring, half with LPDs and half without, matched for age and etiology of remote brain injury, if any, or history of epilepsy. RESULTS: Lateralized periodic discharges were found in 145/1785 (8.1%) of subjects; 37/145 (26%) had no radiologic evidence of acute or progressive brain injury. Those with LPDs were more likely to have abnormal consciousness (86% vs. 57%; P = 0.005), seizures (70% vs. 24%; P = 0.0002), and functional decline (62% vs. 27%; P = 0.005), and were less likely to be discharged home (24% vs. 62%; P = 0.002). On multivariate analysis, LPDs and status epilepticus were associated with abnormal consciousness (P = 0.009; odds ratio = 5.2, 95% CI = 1.60-20.00 and P = 0.017; odds ratio = 5.0, 95% CI = 1.4-21.4); and LPDs were independently associated with functional decline (P = 0.001; odds ratio = 4.8, 95% CI = 1.6-15.4) and lower likelihood of being discharged home (P = 0.009; odds ratio = 0.2, 95% CI = 0.04-0.6). CONCLUSIONS: Despite absence of acute or progressive brain injury, LPDs were independently associated with abnormal consciousness and worse outcome at hospital discharge.

Similarity of lateralized rhythmic delta activity to periodic lateralized epileptiform discharges in critically ill patients.

IMPORTANCE: The increasing use of continuous electroencephalography (EEG) monitoring in the intensive care unit has led to recognition of new EEG patterns that are of unclear or unknown significance. OBJECTIVE: To describe an EEG pattern, lateralized rhythmic delta activity (LRDA), encountered in critically ill subjects and determine its clinical significance in this setting. DESIGN, SETTING, AND PARTICIPANTS Retrospective review at an academic medical center of EEG recordings, medical records, and imaging studies of critically ill patients with LRDA and comparison with subjects with lateralized periodic discharges (also known as periodic lateralized epileptiform discharges), subjects with focal nonrhythmic slowing, and controls. INTERVENTION: Electroencephalography or continuous electroencephalography. MAIN OUTCOMES AND MEASURES: Cross-sectional prevalence of lateralized rhythmic delta activity; EEG characteristics; etiology, clinical, and radiological correlates; and risk of early seizures. RESULTS: We identified LRDA in 4.7%of acutely ill subjects undergoing EEG or continuous EEG monitoring. It was often associated with other focal EEG abnormalities, including lateralized periodic discharges in 44%of cases. The most common conditions associated with LRDA were intracranial hemorrhage and subarachnoid hemorrhage. Lateralized rhythmic delta activity was an independent predictor of acute seizures, with 63%of subjects having seizures during their acute illness, a proportion similar to subjects with lateralized periodic discharges (57%) and significantly higher than associated with focal nonrhythmic slowing (20%) or in control subjects (16%). Most patients (80%-90%) in the LRDA and lateralized periodic discharges groups who had seizures while undergoing continuous EEG monitoring had only nonconvulsive seizures, whereas this was the case for only 17%of patients in the other groups. Lateralized rhythmic delta activity and lateralized periodic discharges were both associated with lesions involving the cortex or juxtacortical white matter. CONCLUSIONS AND RELEVANCE: Lateralized rhythmic delta activity in critically ill patients has a similar clinical significance as lateralized periodic discharges. It reflects the presence of a focal lesion and is associated with a high risk of acute seizures, especially nonconvulsive.

Magnetic resonance spectroscopy identifies neural progenitor cells in the live human brain.

The identification of neural stem and progenitor cells (NPCs) by in vivo brain imaging could have important implications for diagnostic, prognostic, and therapeutic purposes. We describe a metabolic biomarker for the detection and quantification of NPCs in the human brain in vivo. We used proton nuclear magnetic resonance spectroscopy to identify and characterize a biomarker in which NPCs are enriched and demonstrated its use as a reference for monitoring neurogenesis. To detect low concentrations of NPCs in vivo, we developed a signal processing method that enabled the use of magnetic resonance spectroscopy for the analysis of the NPC biomarker in both the rodent brain and the hippocampus of live humans. Our findings thus open the possibility of investigating the role of NPCs and neurogenesis in a wide variety of human brain disorders.

Neural potential of a stem cell population in the hair follicle.

The bulge region of the hair follicle serves as a repository for epithelial stem cells that can regenerate the follicle in each hair growth cycle and contribute to epidermis regeneration upon injury. Here we describe a population of multipotential stem cells in the hair follicle bulge region; these cells can be identified by fluorescence in transgenic nestin-GFP mice. The morphological features of these cells suggest that they maintain close associations with each other and with the surrounding niche. Upon explantation, these cells can give rise to neurosphere-like structures in vitro. When these cells are permitted to differentiate, they produce several cell types, including cells with neuronal, astrocytic, oligodendrocytic, smooth muscle, adipocytic, and other phenotypes. Furthermore, upon implantation into the developing nervous system of chick, these cells generate neuronal cells in vivo. We used transcriptional profiling to assess the relationship between these cells and embryonic and postnatal neural stem cells and to compare them with other stem cell populations of the bulge. Our results show that nestin-expressing cells in the bulge region of the hair follicle have stem cell-like properties, are multipotent, and can effectively generate cells of neural lineage in vitro and in vivo.

Stem cell therapy for central nervous system demyelinating disease.

Recent advances in cell-based therapies for demyelinating central nervous system diseases have demonstrated the ability to restore damaged neuronal architecture and function. Demyelinated axons in patients with multiple sclerosis can spontaneously remyelinate over time; however, the rate and extent at which remyelination occurs is inadequate for complete recovery. Previous attempts aimed at regenerating myelin-forming cells have been successful but limited by the multifocal nature of the lesions and the inability to produce large numbers of myelin-producing cells in culture. Stem cell-based therapy can overcome these limitations to some extent and may prove useful in the future treatment of demyelinating diseases.

Nitric oxide and multiple sclerosis.

Nitric oxide (NO) is a free radical signaling molecule with remarkably complex biochemistry. Its involvement in multiple sclerosis (MS) had been postulated soon after the discovery of the critical role NO plays in inflammation. However, the extent of NO's contribution to MS is not yet understood, party due to the often opposing roles that NO can play in cellular processes. This review briefly covers new developments in the area of NO that may be relevant to MS. It also describes recent progress in understanding the role of NO in MS, new potential targets of the action of NO in the cell, and prospects for NO-based therapies.

Resident nestin+ neural-like cells and fibers are detected in normal and damaged rat myocardium.

The present study examined whether nestin+ neural-like stem cells detected in the scar tissue of rats 1 week after myocardial infarction (MI) were derived from bone marrow and/or were resident cells of the normal myocardium. Irradiated male Wistar rats transplanted with beta-actin promoter-driven, green fluorescent protein (GFP)-labeled, unfractionated bone marrow cells were subjected to coronary artery ligation. Three weeks after MI, GFP-labeled bone marrow cells were detected in the infarct region, and a modest number were associated with nestin immunoreactivity. The paucity of GFP+/nestin+ cells in the scar tissue provided the impetus to explore whether neural-like stem cells were derived from cardiac tissue. Nestin mRNA and immunoreactivity were detected in normal rat myocardium, and transcript levels were increased in the damaged heart after MI. In primary-passage, cardiac tissue-derived neural cells, filamentous nestin staining was associated with a diffuse, cytoplasmic glial fibrillary acidic protein signal. Unexpectedly, in viable myocardium, numerous nestin+/glial fibrillary acidic protein+ fiberlike structures of varying length were detected and observed in close proximity to neurofilament-M+ fibers. The infarct region was likewise innervated, and the preponderance of neurofilament-M+ fibers appeared to be physically associated with nestin+ fiberlike structures. These data highlight the novel observation that the normal rat heart contained resident nestin+/glial fibrillary acidic protein+ neural-like stem cells, fiberlike structures, and nestin mRNA levels that were increased in response to myocardial ischemia. Cardiac tissue-derived neural stem cell migration to the infarct region and concomitant nestin+ fiberlike innervation represent obligatory events of reparative fibrosis in the damaged rat myocardium.

Calnexin regulates mammalian Kv1 channel trafficking.

Voltage-gated Kv1 channels are key factors regulating excitability in the mammalian central nervous system. Diverse posttranslational regulatory mechanisms operate to determine the density, subunit composition, and localization of Kv1 channel complexes in the neuronal plasma membrane. In this study, we investigated the role of the endoplasmic reticulum chaperone calnexin in the intracellular trafficking of Kv1 channels. We found that coexpressing calnexin with the Kv1.2alpha subunit in transfected mammalian COS-1 cells produced a dramatic dose-dependent increase in cell surface Kv1.2 channel complexes. In calnexin-transfected COS-1 cells, the proportion of Kv1.2 channels with mature N-linked oligosaccharide chains was comparable to that observed in neurons. In contrast, calnexin coexpression exerted no effects on trafficking of the intracellularly retained Kv1.1 or Kv1.6alpha subunits. We also found that calnexin and auxiliary Kvbeta2 subunit coexpression was epistatic, suggesting that they share a common pathway for promoting Kv1.2 channel surface expression. These results provide yet another component in the elaborate repertoire of determinants regulating the density of Kv1 channels in the plasma membrane.

Kv beta subunit oxidoreductase activity and Kv1 potassium channel trafficking.

Voltage-gated Kv1 potassium channels consist of pore-forming alpha subunits and cytoplasmic Kv beta subunits. The latter play diverse roles in modulating the gating, stability, and trafficking of Kv1 channels. The crystallographic structure of the Kv beta2 subunit revealed surprising structural homology with aldo-keto reductases, including a triosephosphate isomerase barrel structure, conservation of key catalytic residues, and a bound NADP(+) cofactor (Gulbis, J. M., Mann, S., and MacKinnon, R. (1999) Cell 90, 943-952). Each Kv1-associated Kv beta subunit (Kv beta 1.1, Kv beta 1.2, Kv beta 2, and Kv beta 3) shares striking amino acid conservation in key catalytic and cofactor binding residues. Here, by a combination of structural modeling and biochemical and cell biological analyses of structure-based mutations, we investigate the potential role for putative Kv beta subunit enzymatic activity in the trafficking of Kv1 channels. We found that all Kv beta subunits promote cell surface expression of coexpressed Kv1.2 alpha subunits in transfected COS-1 cells. Kv beta1.1 and Kv beta 2 point mutants lacking a key catalytic tyrosine residue found in the active site of all aldo-keto reductases have wild-type trafficking characteristics. However, mutations in residues within the NADP(+) binding pocket eliminated effects on Kv1.2 trafficking. In cultured hippocampal neurons, Kv beta subunit coexpression led to axonal targeting of Kv1.2, recapitulating the Kv1.2 localization observed in many brain neurons. Similar to the trafficking results in COS-1 cells, mutations within the cofactor binding pocket reduced axonal targeting of Kv1.2, whereas those in the catalytic tyrosine did not. Together, these data suggest that NADP(+) binding and/or the integrity of the binding pocket structure, but not catalytic activity, of Kv beta subunits is required for intracellular trafficking of Kv1 channel complexes in mammalian cells and for axonal targeting in neurons.