Search

Objective: Short‐term outcomes of deep brain stimulation of the anterior nucleus of the thalamus (ANT‐DBS) were reported for people with drug‐resistant focal epilepsy (PwE). Because long‐term data are still scarce, the Medtronic Registry for Epilepsy (MORE) evaluated clinical routine application of ANT‐DBS. Methods: In this multicenter registry, PwE with ANT‐DBS were followed up for safety, efficacy, and battery longevity. Follow‐up ended after 5 years or upon study closure. Clinical characteristics and stimulation settings were compared between PwE with no benefit, improvers, and responders, that is, PwE with average monthly seizure frequency reduction rates of ≥50%. Results: Of 170 eligible PwE, 104, 62, and 49 completed the 3‐, 4‐, and 5‐year follow‐up, respectively. Most discontinuations (68%) were due to planned study closure as follow‐up beyond 2 years was optional. The 5‐year follow‐up cohort had a median seizure frequency reduction from 16 per month at baseline to 7.9 per month at 5‐year follow‐up (p <.001), with most‐pronounced effects on focal‐to‐bilateral tonic–clonic seizures (n = 15, 77% reduction, p =.008). At last follow‐up (median 3.5 years), 41% (69/170) of PwE were responders. Unifocal epilepsy (p =.035) and a negative history of epilepsy surgery (p =.002) were associated with larger average monthly seizure frequency reductions. Stimulation settings did not differ between response groups. In 179 implanted PwE, DBS‐related adverse events (AEs, n = 225) and serious AEs (n = 75) included deterioration in epilepsy or seizure frequency/severity/type (33; 14 serious), memory/cognitive impairment (29; 3 serious), and depression (13; 4 serious). Five deaths occurred (none were ANT‐DBS related). Most AEs (76.3%) manifested within the first 2 years after implantation. Activa PC depletion (n = 37) occurred on average after 45 months. Significance: MORE provides further evidence for the long‐term application of ANT‐DBS in clinical routine practice. Although clinical benefits increased over time, side effects occurred mainly during the first 2 years. Identified outcome modifiers can help inform PwE selection and management. [ABSTRACT FROM AUTHOR]

Introduction: Circadian rhythms (CRs) orchestrate intrinsic 24-hour oscillations which synchronize an organism's physiology and behaviour with respect to daily cycles. CR disruptions have been linked to Parkinson's Disease (PD), the second most prevalent neurodegenerative disorder globally, and are associated to several PD-symptoms such as sleep disturbances. Studying molecular changes of CR offers a potential avenue for unravelling novel insights into the PD progression, symptoms, and can be further used for optimization of treatment strategies. Yet, a comprehensive characterization of the alterations at the molecular expression level for core-clock and clock-controlled genes in PD is still missing. Methods and analysis: The proposed study protocol will be used to characterize expression profiles of circadian genes obtained from saliva samples in PD patients and controls. For this purpose, 20 healthy controls and 70 PD patients will be recruited. Data from clinical assessment, questionnaires, actigraphy tracking and polysomnography will be collected and clinical evaluations will be repeated as a follow-up in one-year time. We plan to carry out sub-group analyses considering several clinical factors (e.g., biological sex, treatment dosages, or fluctuation of symptoms), and to correlate reflected changes in CR of measured genes with distinct PD phenotypes (diffuse malignant and mild/motor-predominant). Additionally, using NanoStringⓇ multiplex technology on a subset of samples, we aim to further explore potential CR alterations in hundreds of genes involved in neuropathology pathways. Discussion: CLOCK4PD is a mono-centric, non-interventional observational study aiming at the molecular characterization of CR alterations in PD. We further plan to determine physiological modifications in sleep and activity patterns, and clinical factors correlating with the observed CR changes. Our study may provide valuable insights into the intricate interplay between CR and PD with a potential to be used as a predictor of circadian alterations reflecting distinct disease phenotypes, symptoms, and progression outcomes. [ABSTRACT FROM AUTHOR]

The PreEpiSeizures project was created to better understand epilepsy and seizures through wearable technologies. The motivation was to capture physiological information related to epileptic seizures, besides Electroencephalography (EEG) during video-EEG monitorings. If other physiological signals have reliable information of epileptic seizures, unobtrusive wearable technology could be used to monitor epilepsy in daily life. The development of wearable solutions for epilepsy is limited by the nonexistence of datasets which could validate these solutions. Three different form factors were developed and deployed, and the signal quality was assessed for all acquired biosignals. The wearable data acquisition was performed during the video-EEG of patients with epilepsy. The results achieved so far include 59 patients from 2 hospitals totaling 2,721 h of wearable data and 348 seizures. Besides the wearable data, the Electrocardiogram of the hospital is also useable, totalling 5,838 h of hospital data. The quality ECG signals collected with the proposed wearable is equated with the hospital system, and all other biosignals also achieved stateof-the-art quality. During the data acquisition, 18 challenges were identified, and are presented alongside their possible solutions. Though this is an ongoing work, there were many lessons learned which could help to predict possible problems in wearable data collections and also contribute to the epilepsy community with new physiological information. This work contributes with original wearable data and results relevant to epilepsy research, and discusses relevant challenges that impact wearable health monitoring. [ABSTRACT FROM AUTHOR]

Head and neck free-flap microvascular surgeries are complex and resource-intensive procedures where proper conduct of anaesthesia plays a crucial role in the outcome. Flap failure and postoperative complications can be attributed to multiple factors, whether surgical- or anaesthesia-related. The anesthesiologist should ensure optimised physiological conditions to guarantee the survival of the flap and simultaneously decrease perioperative morbidity. Institutions employ different anaesthetic techniques and results vary across centres. In our institution, two different total intravenous approaches have been in use: a remifentanil-based approach and a multimodal opioid-sparing approach, which is further divided into an opioid-free anaesthesia (OFA) subgroup. We studied every consecutive case performed between 2015 and 2022, including 107 patients. Our results show a significant reduction in overall complications (53.3 vs. 78.9%, p = 0.012), length of stay in the intensive care unit (3.43 ± 5.51 vs. 5.16 ± 4.23 days, p = 0.046), duration of postoperative mechanical ventilation (67 ± 107 vs. 9 ± 38 h, p = 0.029), and the need for postoperative vasopressors (10% vs. 46.6%, p = 0.001) in the OFA group (vs. all other patients). The multimodal and OFA strategies have multiple differences regarding the fluid therapy, intraoperative type of vasopressor used, perioperative pathways, and various drug choices compared to the opioid-based technique. Due to the small number of cases in our study, we could not isolate any attitude, as an independent factor, from the success of the OFA strategy as a whole. Large randomised controlled trials are needed to improve knowledge and help define the ideal anaesthetic management of these patients. [ABSTRACT FROM AUTHOR]

Background: Cerebrovascular disease (CVD) is a major contributor to epilepsy; however, patients with epilepsy also have a significantly increased risk of stroke. The way in which epilepsy contributes to the increased risk of stroke is still uncertain and is ill‐characterized in neuropathological studies. A neuropathological characterization of cerebral small vessel disease (cSVD) in patients with chronic epilepsy was performed. Methods: Thirty‐three patients with refractory epilepsy and hippocampal sclerosis (HS) submitted to epilepsy surgery from a reference center were selected between 2010 and 2020 and compared with 19 autopsy controls. Five randomly selected arterioles from each patient were analyzed using a previously validated scale for cSVD. The presence of CVD disease imaging markers in pre‐surgical brain magnetic resonance imaging (MRI) was studied. Results: There were no differences in age (43.8 vs. 41.6 years; p = 0.547) or gender distribution (female gender 60.6% vs. male gender 52.6%; p = 0.575) between groups. Most CVD findings in brain MRI were mild. Patients had a mean time between the epilepsy onset and surgery of 26 ± 14.7 years and were medicated with a median number of three antiseizure medication (ASMs) [IQR 2–3]. Patients had higher median scores in arteriolosclerosis (3 vs. 1; p < 0.0001), microhemorrhages (4 vs. 1; p < 0.0001) and total score value (12 vs. 8.9; p = 0.031) in comparison with controls. No correlation was found between age, number of years until surgery, number of ASMs or cumulative defined daily dosage of ASM. Conclusion: The present study provides evidence supporting the increased burden of cSVD in the neuropathological samples of patients with chronic epilepsy. [ABSTRACT FROM AUTHOR]

There is currently no evidence to support the use of antiseizure medications to prevent unprovoked seizures following stroke. Experimental animal models suggested a potential antiepileptogenic effect for eslicarbazepine acetate (ESL), and a Phase II, multicenter, randomized, double‐blind, placebo‐controlled study was designed to test this hypothesis and assess whether ESL treatment for 1 month can prevent unprovoked seizures following stroke. We outline the design and status of this antiepileptogenesis study, and discuss the challenges encountered in its execution to date. Patients at high risk of developing unprovoked seizures after acute intracerebral hemorrhage or acute ischemic stroke were randomized to receive ESL 800 mg/d or placebo, initiated within 120 hours after primary stroke occurrence. Treatment continued until Day 30, then tapered off. Patients could receive all necessary therapies for stroke treatment according to clinical practice guidelines and standard of care, and are being followed up for 18 months. The primary efficacy endpoint is the occurrence of a first unprovoked seizure within 6 months after randomization ("failure rate"). Secondary efficacy assessments include the occurrence of a first unprovoked seizure during 12 months after randomization and during the entire study; functional outcomes (Barthel Index original 10‐item version; National Institutes of Health Stroke Scale); post‐stroke depression (Patient Health Questionnaire‐9; PHQ‐9); and overall survival. Safety assessments include the evaluation of treatment‐emergent adverse events; laboratory parameters; vital signs; electrocardiogram; suicidal ideation and behavior (PHQ‐9 question 9). The protocol aimed to randomize approximately 200 patients (1:1), recruited from 21 sites in seven European countries and Israel. Despite the challenges encountered, particularly during the COVID‐19 pandemic, the study progressed and included a remarkable number of patients, with 129 screened and 125 randomized. Recruitment was stopped after 30 months, the first patient entered in May 2019, and the study is ongoing and following up on patients according to the Clinical Trial Protocol. [ABSTRACT FROM AUTHOR]

Objective: Epilepsy is a neurological disease that affects ~50 million people worldwide, 30% of which have refractory epilepsy and recurring seizures, which may contribute to higher anxiety levels and poorer quality of life. Seizure detection may contribute to addressing some of the challenges associated with this condition, by providing information to health professionals regarding seizure frequency, type, and/or location in the brain, thereby improving diagnostic accuracy and medication adjustment, and alerting caregivers or emergency services of dangerous seizure episodes. The main focus of this work was the development of an accurate video‐based seizure‐detection method that ensured unobtrusiveness and privacy preservation, and provided novel approaches to reduce confounds and increase reliability. Methods: The proposed approach is a video‐based seizure‐detection method based on optical flow, principal component analysis, independent component analysis, and machine learning classification. This method was tested on a set of 21 tonic–clonic seizure videos (5–30 min each, total of 4 h and 36 min of recordings) from 12 patients using leave‐one‐subject‐out cross‐validation. Results: High accuracy levels were observed, namely a sensitivity and specificity of 99.06% ± 1.65% at the equal error rate and an average latency of 37.45 ± 1.31 s. When compared to annotations by health care professionals, the beginning and ending of seizures was detected with an average offset of 9.69 ± 0.97 s. Significance: The video‐based seizure‐detection method described herein is highly accurate. Moreover, it is intrinsically privacy preserving, due to the use of optical flow motion quantification. In addition, given our novel independence‐based approach, this method is robust to different lighting conditions, partial occlusions of the patient, and other movements in the video frame, thereby setting the base for accurate and unobtrusive seizure detection. [ABSTRACT FROM AUTHOR]

Introduction: Deep brain stimulation of the anterior nucleus of thalamus (ANT-DBS) is an approved procedure for drug-resistant epilepsy. However, the preferred location inside ANT is not well known. In this study, we investigated the relationship between stereotactical coordinates of stimulated contacts and clinical improvement, in order to define the ideal target for ANT-DBS. Methods: Individual contact's coordinates were obtained in the Montreal Neurological Institute (MNI) 152 space, with the utilization of advanced normalization tools and co-registration of pre- and postoperative MRI and CT images in open-source toolbox lead-DBS with the "Atlas of the Human Thalamus." Each contact's pair was either classified as a responder (≥50% seizure reduction and absence of intolerable adverse effects) or nonresponder, with a minimum follow-up of 11 continuous months of stimulation. Results: A total of 19 contacts' pairs were tested in 14 patients. The responder rate was 9 out of 14 patients (64.3%). In 4 patients, a change in contacts' pairs was needed to achieve this result. A highly encouraging location inside ANT (HELIA) was delimited in MNI space, corresponding to an area in the anterior and inferior portion of the anteroventral (AV) nucleus, medially to the endpoint of the mammillothalamic tract (ANT-mtt junction) (x [3.8; 5.85], y [−2.1; −6.35] and z [6.2; 10.1] in MNI space). Statistically significant difference was observed between responders and nonresponders, in terms of the number of coordinates inside this volume. Seven responders and two nonresponders had at least 5 of 6 coordinates (2 electrodes) inside HELIA (77.8% sensitivity and 80% specificity). In 3 patients, changing to contacts that were better placed inside HELIA changed the status from nonresponder to responder. Conclusions: A relationship between stimulated contacts' coordinates and responder status was observed in drug-resistant epilepsy. The possibility to target different locations inside HELIA may help surpass anatomical variations and eventually obtain increased clinical benefit. [ABSTRACT FROM AUTHOR]

Stroke is the leading cause of seizures and epilepsy in older adults. Patients who have larger and more severe strokes involving the cortex, are younger, and have acute symptomatic seizures and intracerebral haemorrhage are at highest risk of developing post-stroke epilepsy. Prognostic models, including the SeLECT and CAVE scores, help gauge the risk of epileptogenesis. Early electroencephalogram and blood-based biomarkers can provide information additional to the clinical risk factors of post-stroke epilepsy. The management of acute versus remote symptomatic seizures after stroke is markedly different. The choice of an ideal antiseizure medication should not only rely on efficacy but also consider adverse effects, altered pharmacodynamics in older adults, and the influence on the underlying vascular co-morbidity. Drug–drug interactions, particularly those between antiseizure medications and anticoagulants or antiplatelets, also influence treatment decisions. In this review, we describe the epidemiology, risk factors, biomarkers, and management of seizures after an ischaemic or haemorrhagic stroke. We discuss the special considerations required for the treatment of post-stroke epilepsy due to the age, co-morbidities, co-medication, and vulnerability of stroke survivors. [ABSTRACT FROM AUTHOR]

Our goal was to assess the interrater agreement (IRA) of photoparoxysmal response (PPR) using the classification proposed by a task force of the International League Against Epilepsy (ILAE), and a simplified classification system proposed by our group. In addition, we evaluated IRA of epileptiform discharges (EDs) and the diagnostic significance of the electroencephalographic (EEG) abnormalities. We used EEG recordings from the European Reference Network (EpiCARE) and Standardized Computer‐based Organized Reporting of EEG (SCORE). Six raters independently scored EEG recordings from 30 patients. We calculated the agreement coefficient (AC) for each feature. IRA of PPR using the classification proposed by the ILAE task force was only fair (AC = 0.38). This improved to a moderate agreement by using the simplified classification (AC = 0.56; P =.004). IRA of EDs was almost perfect (AC = 0.98), and IRA of scoring the diagnostic significance was moderate (AC = 0.51). Our results suggest that the simplified classification of the PPR is suitable for implementation in clinical practice. [ABSTRACT FROM AUTHOR]

Summary: Objective: Electroencephalography (EEG) can identify biomarkers of epileptogenesis and ictogenesis. However, few studies have used EEG in the prediction of poststroke seizures. Our primary aim was to evaluate whether early EEG abnormalities can predict poststroke epilepsy. Methods: A prospective study of consecutive acute anterior circulation ischemic stroke patients, without previous epileptic seizures, who were admitted to a stroke unit over 24 months and followed for 1 year. All patients underwent standardized clinical and diagnostic assessment during the hospital stay and after discharge. Video‐EEG was performed in the first 72 h (first EEG), daily for the first 7 days, in case of neurological deterioration, at discharge, and at 12 months after stroke. The occurrence of epileptic seizures in the first year after stroke (primary outcome) was evaluated clinically and neurophysiologically during the hospital stay and at 12 months. A telephone interview was also performed at 6 months. The primary outcome was the occurrence of at least one unprovoked seizure (poststroke epilepsy). Secondary outcomes were the occurrence of at least one acute symptomatic seizure and (interictal and/or ictal) epileptiform activity on at least one EEG during the hospital stay for acute stroke. The first EEG variables were defined using international criteria/terminology. Bivariate and multivariate analyses with adjustment for age, admission National Institutes of Health Stroke Scale (NIHSS) score, and Alberta Stroke Program Early CT Score (ASPECTS) were performed. Results: A total of 151 patients were included; 38 patients (25.2%) had an acute symptomatic seizure and 23 (16%) had an unprovoked seizure. The first EEG background activity asymmetry and first EEG with interictal epileptiform activity were independent predictors of poststroke epilepsy during the first year after stroke (P = 0.043 and P = 0.043, respectively). No EEG abnormality independently predicted acute symptomatic seizures. However, the presence of periodic discharges on the first EEG was an independent predictor of epileptiform activity (p = 0.009) during the hospital stay. Significance: An early poststroke EEG can predict epilepsy in the first year after stroke, independently from clinical and imaging‐based infarct severity. [ABSTRACT FROM AUTHOR]

Background: The goal of the present study is the evaluation of the long-term clinical outcome of epilepsy in patients with mesial temporal lobe sclerosis (MTLS) submitted to amygdalohippocampotomy (AHCo). AHCo consists of the lateral ablation of the amygdala and the peri-hippocampal disconnection instead of amygdalohippocampectomy (AHC), which involves the removal of both structures. We previously reported the short-term results of AHCo, so we here present the long-term results (> 5 years of follow-up) of the patients operated on with AHCo. Method: Since 2007, 35 patients (22 females) aged 20-61 years (mean: 42 years) were operated on with the AHCo technique, 17 patients on the left side and 18 on the right. Of these patients, 21 (14 females) have been followed up > 5 years (5 to 7.5 years, mean 6.5 years). We compare the present results with those observed shortly after surgery and with the patients operated on with AHC. Findings: In all 21 cases, the diagnosis was mesial temporal lobe sclerosis (histology confirmed in 20), 11 on the left side and 10 on the right. Epilepsy results after 5 years were good/very good in 18 patients (85.7%), with Engel class IA-B in 15 (71.4%) and II in 3 (14.3%), and bad in 3 patients, with Engel Class III in 2 (9.5%) and class IV in 1 (4.8%). Concerning morbidity, one patient had hemiparesis (hypertensive capsular hemorrhage 24 h after surgery), two verbal memory worsening, two quadrantanopia and three late depression that was reversed with medication. Comparatively, the AHC long-term results were 87% Engel class I, 8% Engel class II and 5% Engel class III-IV. The morbidity was equally small. Conclusions: The good/very good results of AHCo 5 years after surgery are 86%, which is not distinct from the AHC results. So AHCo seems to be effective and potentially safer than AHC in long-term follow-up. [ABSTRACT FROM AUTHOR]

Summary: Objective: Seizures and electroencephalographic (EEG) abnormalities have been associated with unfavorable stroke functional outcome. However, this association may depend on clinical and imaging stroke severity. We set out to analyze whether epileptic seizures and early EEG abnormalities are predictors of stroke outcome after adjustment for age and clinical/imaging infarct severity. Methods: A prospective study was made on consecutive and previously independent acute stroke patients with a National Institutes of Health Stroke Scale (NIHSS) score ≥ 4 on admission and an acute anterior circulation ischemic lesion on brain imaging. All patients underwent standardized clinical and diagnostic assessment during admission and after discharge, and were followed for 12 months. Video‐EEG (<60 min) was performed in the first 72 h. The Alberta Stroke Program Early CT Score quantified middle cerebral artery infarct size. The outcomes in this study were an unfavorable functional outcome (modified Rankin Scale [mRS] ≥ 3) and death (mRS = 6) at discharge and 12 months after stroke. Results: Unfavorable outcome at discharge was independently associated with NIHSS score (p = 0.001), EEG background activity slowing (p < 0.001), and asymmetry (p < 0.001). Unfavorable outcome 1 year after stroke was independently associated with age (p = 0.001), NIHSS score (p < 0.001), remote symptomatic seizures (p = 0.046), EEG background activity slowing (p < 0.001), and asymmetry (p < 0.001). Death in the first year after stroke was independently associated with age (p = 0.028), NIHSS score (p = 0.001), acute symptomatic seizures (p = 0.015), and EEG suppression (p = 0.019). Significance: Acute symptomatic seizures were independent predictors of vital outcome and remote symptomatic seizures of functional outcome in the first year after stroke. Therefore, their recognition and prevention strategies may be clinically relevant. Early EEG abnormalities were independent predictors and comparable to age and early clinical/imaging infarct severity in stroke functional outcome discrimination, reflecting the concept that EEG is a sensitive and robust method in the functional assessment of the brain. [ABSTRACT FROM AUTHOR]

Cerebrovascular disease is the leading cause of epilepsy in adults, although post-stroke seizures reported frequency is variable and few studies used EEG in their identification. To describe and compare EEG and clinical epileptic manifestations frequency in patients with an anterior circulation ischaemic stroke. Prospective study of acute anterior circulation ischaemic stroke patients, consecutively admitted to a Stroke Unit over 24 months and followed-up for 1 year. All patients underwent standardized clinical and diagnostic assessment. Seizure occurrence was clinically evaluated during hospitalization and by a telephone interview at 6 months and a clinical appointment at 12 months after stroke. Video-EEG was performed in the first 72 h (1st EEG), daily after the 1st EEG for the first 7 days after the stroke, or later if neurological worsening, at discharge, and at 12 months. 151 patients were included (112 men) with a mean age of 67.4 (11.9) years. In the 1st year after stroke, 38 patients (25.2%) had an epileptic seizure. During hospitalization, 27 patients (17.9%) had epileptiform activity (interictal or ictal) in the EEG, 7 (25.9%) of them electrographic seizures. During the first week after stroke, 22 (14.6%) patients had a seizure and 4 (2.6%) non-convulsive status epilepticus criteria. Five (22.7%) acute symptomatic seizures were exclusively electrographic. At least one remote symptomatic seizure occurred in 23 (16%) patients. In the first 7 days after stroke, more than one-fifth of patients with seizures had exclusively electrographic seizures. Without a systematic neurophysiological evaluation the frequency of post-stroke seizures are clinically underestimated. [ABSTRACT FROM AUTHOR]

View Supplementary Video 1 View Supplementary Video 2 View Supplementary Video 3 [ABSTRACT FROM AUTHOR]

Pure alexia (PA) has been associated with visual deficits or a failure to activate the visual word form area (VWFA). We report a patient with pure alexia due to posterior cortical atrophy, in whom event-related potentials revealed a delay in the P100 component and an absent N170 compared with controls. Furthermore, there was a tendency for a larger delay in P100 latencies associated with incorrectly read words. This suggests that some cases of PA might result from deficits in visual perception, signaled by the P100 early potential which could lead to an inability to consistently activate the VWFA, marked by the absent N170. [ABSTRACT FROM AUTHOR]

Pure alexia (PA) has been associated with visual deficits or a failure to activate the visual word form area (VWFA). We report a patient with pure alexia due to posterior cortical atrophy, in whom event-related potentials revealed a delay in the P100 component and an absent N170 compared with controls. Furthermore, there was a tendency for a larger delay in P100 latencies associated with incorrectly read words. This suggests that some cases of PA might result from deficits in visual perception, signaled by the P100 early potential which could lead to an inability to consistently activate the VWFA, marked by the absent N170. [ABSTRACT FROM AUTHOR]

Mesial temporal lobe seizures can be misdiagnosed as panic attacks. There is a spectrum of symptoms that are common to both, like fear sensation. We report a case of a young woman, initially diagnosed as having panic attacks of short duration. The symptoms persisted for two years despite treatment with SSRIs. Epileptic seizures were suggested when the patient started reporting involuntary limb movements during some of the episodes. Further investigations showed mesial temporal sclerosis on MRI and epileptic activity in EEG, and she began antiepileptic treatment. In some patients with panic attacks, particularly if associated with atypical features, the possibility of epilepsy should be considered. [ABSTRACT FROM AUTHOR]

The aim of the present study was to evaluate the correlation between the end of an Oxford sleep resistance (OSLER) test session and a neurophysiological marker of sleep onset in Parkinson's disease (PD) patients. Single center study was conducted in PD patients with excessive daytime sleepiness [Epworth sleepiness scale (ESS) >9]. The OSLER test was conducted with a concomitant electroencephalography (EEG), electromyography (mentalis), right and left electroculogram, and video monitoring. Neurophysiological (NP) sleep onset was defined according to AASM criteria (2005). Five PD patients with mean ESS of 14 (10-16) were included. OSLER test duration was shorter than 40 min in all patients (mean duration 20 min and 39 s). No patient fulfilled neurophysiological criteria to sleep onset at the time of OSLER test termination. In 13 OSLER sessions that ended before 40 min, eight had microsleeps in the last 30 s before the end of the test. NP monitoring showed signs of sleepiness in all patients. In PD patients, the early termination of an OSLER test session may not correspond to NP criteria of sleep onset. However, in all PD patients with abnormal OSLER results, there were EEG signs of sleepiness, which do not exclude the potential utility of OSLER test to evaluate the risk of falling asleep. [ABSTRACT FROM AUTHOR]

The aim of the present study was to evaluate the correlation between the end of an OSLER test session and a neurophysiological marker of sleep onset in Parkinson's disease (PD) patients. Single center study was conducted in PD patients with EDS (Epworth Sleepiness Scale (ESS) >9). The OSLER test was conducted with a concomitant electroencephalography, EMG (mentalis), right and left electroculogram and video monitoring. Neurophysiologic (NP) sleep onset was defined according to AASM criteria (2005). Five PD patients with mean ESS of 14 (10 to 16) were included. OSLER test duration was shorter than 40 minutes in all patients (mean duration 20 minutes and 39 seconds). No patient fulfilled neurophysiological criteria to sleep onset at the time of OSLER test termination. In 13 OSLER sessions that ended before 40 minutes, eight had microsleeps in the last 30 seconds before the end of the test. NP monitoring showed signs of sleepiness in all patients. In PD patients, the early termination of an OSLER test session may not correspond to NP criteria of sleep onset. However, in all PD patients with abnormal OSLER results there were EEG signs of sleepiness, which do not exclude the potential utility of OSLER test to evaluate the risk of falling asleep. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to the article "Epileptic seizures as a presentation of central nervous system involvement in TTR Val30Met-FAP" by Ana Franco and colleagues in the October 11, 2016 issue.

Sleep-related eating disorder (SRED) is characterised by eating episodes during the first period of the night sleep with partial loss consciousness, and amnesia. It can rarely be induced by some drugs, including zolpidem. We present a video report of a patient with a 1-year history of SRED caused by zolpidem causing important repercussions in the sleep structure and life quality. The night eating episodes ceased promptly with discontinuation of zolpidem. Upon the follow-up, the sleep structure improved and the daily consequences disappeared. As in few reported cases of zolpidem-induced SRED, our patient was suffering from the parasomnia for a long time before the diagnosis. Active exclusion of symptoms suggestive of SRED in patients under zolpidem treatment can avoid the deleterious effect of the sleep disorder. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate morning dream recall frequency and content in patients with temporal lobe epilepsy (TLE). Methods: Fifty-two patients with pharmacoresistant TLE submitted to a written dream diary during five consecutive days and continuous video-electroencephalographic (video-EEG) monitoring. A matched control group of 41 healthy subjects completed the same diary at home. The number of recalled dreams (including long dreams) and nonrecalled dream mentation were collected, and the Dream Recall Rate (DRR) was calculated. Hall and Van de Castle dream content analysis was performed. Key Findings: Greater than 70% of patients with TLE (37 of 52) recall their dreams, but DRR rate in these patients is lower than in controls (p ≤ 0.001). Dream recall does not appear to be influenced by the presence of neuropsychological deficits nor seizure frequency. In dreams descriptions, TLE patients (vs. controls) have a higher percentage of familiarity in settings and fewer dreams with at least one success. Significance: Onirical activity of patients with TLE is different from that of healthy subjects. Our results support the role of mesial and neocortical temporal structures in dream experience. The selective activation of dysfunctional mesial structures may be responsible for some of the observed variability. However, dream content changes can also mirror social and psychological comorbidities of patients with epilepsy. [ABSTRACT FROM AUTHOR]

To gain new insights into the clinical presentation, causes, treatment and prognosis of epilepsia partialis continua (EPC), and to develop hypotheses to be tested in a prospective investigation. In this retrospective multicenter study, all cases were included that fulfilled these criteria: constantly repeated fragments of epileptic seizures, with preserved consciousness, lasting ≥1 h and representing locally restricted motor or sensory epileptic activity. Single episodes were included when they lasted for a minimum of 1 day. EPC with Rasmussen syndrome and acute stroke were excluded. Three time courses with two subtypes each were distinguished, that is, EPC as a solitary event (de novo or in preexistent epilepsy); chronic repetitive nonprogressive EPC (with frequent or rare episodes); and chronic persistent nonprogressive EPC (primarily or evolving out of an episodic course). These were unrelated to etiologies (morphologic lesions 34%, inflammatory 29%, systemic disorders 9%, idiopathic 5%, unknown 23%). Precipitation and inhibition of seizures is a frequent feature of EPC. Levetiracetam and topiramate have improved the possibilities for pharmacotherapy. Topiramate seems to be particularly effective with dysontogenetic etiologies. The existence of several clearly distinct courses of nonprogressive EPC is a new finding. These distinctions will be further investigated in a prospective study with precise protocols for electroencephalography (EEG), imaging, and other studies. This should better establish the relation of motor and somatosensory EPC; further clarify the relations, pathogenesis, and significance of the different types and their etiologies; and possibly identify more semiologic variants. It should also provide more precise knowledge about therapy and modification of ictogenesis by external stimuli. [ABSTRACT FROM AUTHOR]

Psychogenic non epileptic seizures (PNES) are clinical events of psychological nature. Video-electroencephalography monitoring (V-EEGM) is a valuable method for the diagnosis of PNES and may be combined with provocative tests to induce seizures. The use of placebo in provocative tests for the diagnosis of PNES is controversial because of associated deception, and contrasts with the use of truly decreasing epileptogenic threshold techniques such as hyperventilation and photo stimulation. We present a clinical case of a pregnant woman with a past history of refractory epilepsy, admitted in the obstetric department due to unremitting seizures. In this clinical context, non-deceiving provocative tests such as hyperventilation and photo stimulation could be potentially harmful, nevertheless, the use of intravenous saline injection presented as a safer alternative to diagnose PNES and hence obviate an urgent caesarean. This case illustrates a disproportionate risk of causing harm when telling the truth, in comparison with the benefit of avoiding such risk, although deceiving the patient. This is a clinical example of how considerations concerning the use of placebo must be evaluated in an individual basis. [ABSTRACT FROM AUTHOR]

BACKGROUND: Fibrillation/sharp-waves (fibs-sw) are considered an essential neurophysiological marker in Amyotrophic Lateral Sclerosis (ALS). We investigated how frequently an initial electrophysiological (EMG) evaluation, performed in ALS patients, revealed no fibs-sw. METHODS: The initial EMG studies from 68 ALS patients were analysed. The presence of fibs-sw in at least two muscles of each limb and two cranial-innervated muscles was assessed. RESULTS: We observed no fibs-sw in cranial-innervated muscles, and 7/15 bulbar-onset patients had no fibs-sw in limb muscles. Two of 28 upper-limb-onset patients, who had a short history before EMG, showed no fibs-sw. All lower-limb-onset patients had fibs-sw. Generally patients with no fibs-sw had diffuse abundant fasciculations. CONCLUSIONS: The absence of fibs-sw should not necessarily preclude the neurophysiological diagnosis of ALS in bulbar-onset patients. Early affected upper-limb-onset patients might show no fibs-sw, but profuse fasciculations associated with mild to moderate denervation–reinnervation in weak muscles are found. (Amyot Lat Scler 1999: 1:29–32). [ABSTRACT FROM AUTHOR]

Introduction and Objectives: The study of complex refractory epilepsies frequently requires data form invasive EEG. The regions of interest can be monitored with depth electrodes. These electrodes are usually implanted with stereotactic frames or robotized systems that are not readily available in many centres with a smaller surgery volume. Over the last years, neuronavigation has proven to be a valuable tool capable of replacing classic stereotactic frames in less precision demanding surgeries. In this work we analyse the precision of non-frame based system for the implantation of stereo-EEG (SEEG) electrodes in our centre. Material and Methods: The retrospective analysis included all patients with medically refractory focal epilepsy who underwent implantation of depth electrodes for extraoperative EEG monitoring between June 2012 and January 2016. Trajectory planning was done with either Cranial? 4 or Synergy Cranial? 2.2 from Medtronic® and implantation of Dixi® or Alcis® electrodes was done with Mayfield® head clamp and Vertek® II articulated arm. All patients underwent early post-operative image control of implantation that was fused with pre-operative imaging. Analysis of demographics included entry-point and target accuracy, depth of each trajectory, procedure-related complications and quality of EEG recording. Results: Fifty-one SEEG electrodes were implanted in 6 patients. Their mean age was 27.5 years (8-49 years old). On average, 8.25 electrodes were implanted per patient. The average time of implantation planning was 45 minutes. The average operative time was 141 minutes (range 104-178 minutes) with an average of 17 minutes per electrode (range 14.86-19.17 minutes). Measured accuracy obtained from entry point in 4 patients (35 electrodes) and target in 5 patients (45 electrodes) demonstrated a median entry point error of 2.41 mm and a median target point error of 2.51 mm. Planned target regions were reached in all 51 trajectories and there weren't any procedure-related complications. Seizures were detected in more than one electrode in all 6 patients and a strategy was possible to delineate with data obtained from this SEEG. Discussion and Conclusions: This technique of implantation of SEEG depth electrodes has the necessary accuracy to achieve the goals of this type of EEG monitoring. In spite of having a lower accuracy compared to the classic systems, knowing the error margin allows us to establish security boundaries in order to avoid vascular structures. The simpler workflow of the neuronavigated implantation of depth electrodes can make this kind of investigation readily available in more epilepsy centres, improving their ability to treat even more complex cases. [ABSTRACT FROM AUTHOR]

Introduction: Patients with a neuronal migration disordered characterized by subcortical band heterotopia are prone to develop refractory epilepsy. Some attempts have been made to treat this condition surgically with Stereo-EEG and focal resections with discouraging results. In our series of deep brain stimulation of anterior nuclei of the thalamus (DBS-ANT), from 12 patients, 2 were due to this development disorder. Case Study: Seizure outcome was reviewed now at 12 and 18 months en patient 1 and 2. Both patients showed a greater than 50% decrease in seizure frequency and an increase in seizure free time. After surgery they both had a transient depressive syndrome that responded to anti-depressive medication. Discussion: Deep brain stimulation of ANT has shown a good seizure outcome in these two cases. We propose that this procedure could be considered in the treatment of patients with subcortical band heterotopia with refractory epilepsy. The etiology of depression is probably multifactorial but might be a transient adverse event of DBS-ANT. [ABSTRACT FROM AUTHOR]

Introduction: Deep Brain Stimulation (DBS) of the Anterior Nuclei of Thalami (ANT) has a growing interest as a palliative surgery for refractory epilepsy. The bilateral ANT-DBS may have a place in focal epilepsies when no focal resection is indicated or when patients refuse resective surgery. Material and Methods: The Epilepsy Surgery Group of the Hospital de Santa Maria (CHLN) started this approach in January 2011, and we have operated 12 patients (7 females) so far. Median time of epilepsy before implantation was 26 years (7-46) and median number of seizures per month 15 seizures/month (3-39). All patients have already tried 3 or more antiepileptic drugs. Three patients had previous epilepsy surgeries, one a VNS and other two resective surgeries. Electrodes were implanted with Leksell® stereotactic frame with targets and trajectories obtained from FrameLink® Medtronic's software. Both 3387 and 3389 electrodes were used through a trans-ventricular cannulated approach in the majority of the patients (9/12). Post-operative control of electrode contacts was done with CT fused with pre-operative MRI and compared to published stereotactic atlases. Results: All 12 patients have at least one contact in one ANT and 11 in both anterior nuclei. Two patients required additional surgeries due to slippage of electrode(s) to the III ventricle during a trans-ventricular approach. No intraventricular bleeding was seen in post-operative CT of all patients and no major complications related to surgery were recorded. Seizure frequency reduction was seen in more than half of the patients but almost all reported a decrease in severity of their seizures. Approximately one third of the patients developed a newly or aggravated depression early after stimulation initiation that required medication. No suicidal ideation was found in any of them. Discussion and Conclusions: The ideal candidates for ANT-DBS is yet to be found but the low incidence of major complications from this surgery and the reversibility of those related to stimulation makes this neuromodulation technique an option to treat otherwise difficult refractory epilepsy cases. Multicenter studies allow us to collect more cases faster but single center series with their more standardized approach may also add some important information. [ABSTRACT FROM AUTHOR]