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Migralepsy is a nosographical entity depicting a clinical event whose occurrence seems rather exceptional in view of the comorbidity observed between epilepsy and migraine. Defined more precisely as a migraine aura-triggered epileptic seizure (within the time limit of one hour), it is susceptible to numerous diagnoses by excess, undoubtedly stimulated by the elegance of the term diagnosis coined by Lennox and Lennox in 1960. This review points to the main criticisms, which were given to it, but also to the international recognition brought by the International Classification of Headache Disorders (ICHD 3). In fact, there are undoubtedly clinical cases falling under the strict definition of migralepsy, cases which are rare but relevant for understanding the pathophysiology of the two colliding events: migraine aura and epileptic seizure involving the occipital lobe.

Resume Oliver Sacks (1933–2015) etait un ecrivain important et un neurologue brillant, bien que sa carriere scientifique soit restee modeste. A travers ses livres, les lecteurs prennent connaissance, dans le detail et avec une grande profondeur, de troubles neurologiques divers. Dans quelle mesure ces lectures peuvent avoir oriente la vocation de neurologue etait une question que nous avons souhaite aborder a l’aide d’un questionnaire en ligne destine a des neurologues francais. Un total de 113 participants ont repondu a l’enquete. Parmi eux, une grande majorite (67 %) avait lu et apprecie au moins un livre de Sacks (« l’homme qui… »). Bien qu’apparaissant non decisive pour leur choix d’orientation dans la specialite, la lecture de Sacks semble avoir surtout suscite un interet plus marque par les recits detailles des histoires de cas, et le gout pour l’etude de la cognition.

Prophylaxis or treatment of tumor-associated seizures is adaily concern in neurosurgical practice but is often guided by the surgeon's habits rather than evidence from clinical trials, which is lacking. The present study reviews the literature on the incidence, clinical aspects and treatment of epilepsy and epileptic seizures in patients undergoing surgery for meningioma. Based on the published data, we then performed a French nationwide survey of neurosurgeons' practices regarding perioperative management of meningioma-related epilepsy and epileptic seizures.

Pratique neurologique - FMC - In Press.Proof corrected by the author Available online since lundi 17 aout 2015

Le diagnostic d’etat de mal refractaire est souvent incorrect, avec un nombre consequent de patients presentant un tableau de « pseudo-status », c’est-a-dire une crise non epileptique psychogene (CNEP) prolongee, reproduisant certaines caracteristiques de l’etat de mal convulsif. L’absence d’identification clinique de ce diagnostic et la faible disponibilite de l’EEG en urgence peuvent expliquer ce taux eleve d’admissions inappropriees dans les unites de reanimation. Cet article propose de retenir dix « drapeaux rouges » permettant d’amener le clinicien a porter un diagnostic positif de « pseudo-status » (CNEP) et de prevenir des procedures eventuellement dommageables : 1) manifestations palpebrales ; 2) postures axiales anormales soutenues ; 3) motricite influencable ; 4) variabilite semiologique ; 5) absence d’organisation neurologique ; 6) bonne tolerance clinique ; 7) absence de fiabilite du score de Glasgow ; 8) nombre important d’intervenants ; 9) inefficacite du traitement antiepileptique, passee et presente ; 10) pas de profil specifique.

I movimenti anomali secondari (distonie, mioclonie, tremori, discinesie) costituiscono un insieme composito, non soltanto sul piano semeiologico, ma anche per la grande varieta delle loro eziologie, la cui caratteristica comune e quella di derivare, il piu delle volte, da disfunzioni all’interno dei circuiti motori dei gangli della base. L’iter diagnostico generale, di fronte a un movimento anomalo secondario, predilige l’osservazione clinica, arricchita da registrazioni video. Questa fase e il preliminare indispensabile all’indagine eziologica, la cui esaustivita e la migliore garanzia dell’identificazione di una patologia causale (ipossia-ischemia, sclerosi multipla, infezioni, autoimmunita, disturbi metabolici, intossicazioni ed effetti collaterali di farmaci). La gestione terapeutica dei movimenti anomali secondari, spesso molto specialistica e multidisciplinare, si basa innanzitutto sulla valutazione della loro ripercussione funzionale con l’ausilio di scale cliniche adeguate, completate, se necessario, con l’analisi video e con alcuni dati neurofisiologici. I trattamenti sono molteplici, poiche i farmaci tradizionali o piu recenti sono sempre piu spesso associati, in funzione della natura, della topografia e del contesto eziologico dei movimenti anomali secondari, con la tossina botulinica, la neurochirurgia funzionale e le misure di medicina fisica e riabilitativa.

L’electroencephalographie (EEG) occupe une place particuliere au sein des investigations complementaires disponibles dans le cadre de la medecine d’urgence: aisement disponible, mobilisable au lit du patient, non invasif, il fournit des informations importantes sur le fonctionnement cerebral et permet certains diagnostics de facon formelle, conduisant a la mise en place de therapeutiques appropriees. Cet article fait le point sur les principales indications de l’EEG demande « en urgence » ou « des que possible », a partir des donnees recueillies dans la litterature concernant des situations specifiques, rencontrees dans les services d’urgence.

Astasia-abasia is defined as the inability to stand and to walk, despite sparing of motor function underlying the required balance and gestures. Initially, astasia-abasia was considered a psychogenic gait disorder, but later on, the description of "high-order" gait disorders mimicking this pure functional deficit led authors to refer to "astasia-abasia" as a pure descriptive term, without a presupposed etiological or anatomical substrate. In this paper, the main clinical characteristics of both psychogenic and non-psychogenic astasia-abasia are presented and discussed.

Oxytocin is required for lactation by promoting milk expulsion. Oxytocin has also been reported to exert a positive role in social attachment. The postpartum period has been shown to be crucial for maternal behavior initiation, and required self-trust reinforcement. However, this period is also remarkable for the high risk exposure of either psychic or physical stress. A negative impact on young mother is suspected, both in the short, medium or long term, which can even be deleterious for child-mother relationships. During lactation in female rats and sheep, oxytocin production has been proved to decrease stress-induced hormonal changes and later consequences. In human beings, only the first hour after breast-feeding seems to protect against physical or psychic stress. Oxytocin improves the stress-induced response by reducing the ACTH and cortisol secretion thus representing a potential therapeutic pathway in post-partum pathologies such as depression. Thus, this review of recent literature about oxytocin and stress during post-partum period, leads to the assumption that oxytocin, at the moment of installation of breastfeeding, acts not only on the physiological condition, but also on the psychic condition of the mother.

In a young woman presenting with severe coma, the EEG helped diagnosing baclofen overdose. In this patient, the first EEG showed continuous multifocal pseudoperiodic sharp waves. The diagnosis was confirmed by the plasma dosage providing an 8-fold increase above normal baclofen therapeutic range. Following symptomatic therapy, the patient improved within a few days and the EEG normalised. Few other drugs may be responsible for such EEG changes, namely lithium, cephalosporin, and bismuth. In such cases, EEG contribution to the diagnosis should not be ignored.

Resume Les mouvements anormaux secondaires (dystonies, myoclonies, tremblements, dyskinesies) representent un ensemble composite, non seulement au plan semiologique, mais aussi par la grande diversite de leurs etiologies, traduisant le plus souvent une anomalie au sein des circuits moteurs des ganglions de la base. La demarche diagnostique generale devant un mouvement anormal secondaire va privilegier l'observation clinique, enrichie par les enregistrements video, prealable a l'enquete etiologique dont l'exhaustivite est le meilleur garant de l'identification d'une pathologie causale (hypoxie-ischemie, sclerose en plaques, infections, auto-immunite, troubles metaboliques, intoxications, medicaments). La prise en charge therapeutique des mouvements anormaux secondaires, souvent tres specialisee et multidisciplinaire, s'appuie d'abord sur l'evaluation de leur retentissement fonctionnel a l'aide d'echelles cliniques adaptees, completees par l'analyse video et certaines donnees neurophysiologiques. Les traitements sont multiples, les medicaments classiques ou plus recents etant de plus en plus souvent associes, en fonction de la nature, de la topographie et du contexte etiologique des mouvements anormaux secondaires, avec la toxine botulique, la neurochirurgie fonctionnelle et les mesures de reeducation-readaptation.

Auteur correspondant : L. Oujamaa, service de reeducation postreanimation, hopital Michalon, BP 217, 38043 Grenoble cedex 09, France. Adresse e-mail : Un homme de 86 ans fut victime d'une chute accidentelle avec traumatisme crânien (TC) sans perte de connaissance le 15 juillet 2011. Le patient fut admis aux urgences du CHU de Grenoble. On nota dans ses antecedents une arythmie complete par fibrillation auriculaire pour laquelle il etait traite par aspirine. L'evolution clinique spontanee fut marquee par une somnolence dans les heures suivant le TC. Le scanner cerebral sans injection etait normal. De fait, le trouble de la vigilance s'amenda spontanement et le patient sortit apres 24 heures de surveillance. Il fut a nouveau admis, deux mois plus tard en raison d'une hemiparesie gauche d'installation progressive en quelques jours. Le scanner cerebral mis en evidence un hematome sous-dural droit responsable d'un effet de masse sur le ventricule lateral droit et d'une deviation de la ligne mediane (Fig. 1). L'evacuation chirurgicale de l'hematome fut realisee en urgence. La periode postoperatoire fut compliquee d'une crise tonico-clonique generalisee en phase d'eveil, conduisant a la realisation d'un controle scannographique qui retrouva un œdeme cerebral diffus. Le patient fut de ce fait maintenu sous anesthesie generale durant 48 heures. A l'arret de la sedation et sous traitement antiepileptique (levetiracetam), il persistait des troubles de la vigilance (score de Glasgow a 5). Le scanner cerebral ne retrouva pas d'anomalie. Devant le defaut de reveil, un EEG fut realise. L'EEG montra un trace de fond ralenti de maniere diffuse dans la bande theta. La stimulation douloureuse etait a l'origine de l'apparition d'ondes a front raide diffuses a 2 Hz, transitoires et asymptomatiques, realisant un aspect de « SIRPIDS » (stimulus-induced rythmic, periodic or ictal discharges, Fig. 2).

Resume Les criteres d’eligibilite pour le traitement chirurgical des epilepsies partielles pharmaco-resistantes sont representes par les elements cliniques et paracliniques justifiant la mise en œuvre, couteuse, parfois invasive, d’explorations complementaires visant a determiner l’operabilite des patients. Ils doivent etre distingues des criteres d’operabilite qui relevent d’une competence multidisciplinaire des centres specialises. Ces criteres doivent, idealement, etre soumis a une evaluation de leur pertinence, c’est-a-dire de leur sensibilite (capacite a detecter dans la population les sujets dont l’epilepsie peut etre guerie chirurgicalement sans engendrer de deficit) et de leur specificite (capacite a exclure les patients pour lesquels les explorations sont inutiles). Dans l’etat de connaissances, il n’existe pas de criteres etablis de facon consensuelle, et aucun n’a fait l’objet d’etudes prospectives. Ce travail de revue de la litterature porte essentiellement sur les criteres utilises en pratique dans les etudes controlees, ou multicentriques, et les criteres predictifs du resultat chirurgical, qui sont, theoriquement, des criteres candidats.

Resume La presence d’une pharmacoresistance est consideree comme la condition prealable indispensable a l’instauration d’une demarche chirurgicale dans le traitement d’une epilepsie. Il n’existe toutefois pas de consensus international concernant la definition de ce concept, ou les criteres requis pour le diagnostic. A travers une revue de la litterature publiee sur ce sujet, nous degageons les propositions principales, soit qu’elles relevent de l’avis d’experts, soit qu’elles representent des attitudes pratiques, utilisees dans les etudes controlees ou multicentriques. Une demarche par etape est proposee a l’issue de cette revue.

Electroencephalography allows the functional analysis of electrical brain cortical activity and is the gold standard for analyzing electrophysiological processes involved in epilepsy but also in several other dysfunctions of the central nervous system. Morphological imaging yields complementary data, yet it cannot replace the essential functional analysis tool that is EEG. Furthermore, EEG has the great advantage of being non-invasive, easy to perform and allows control tests when follow-up is necessary, even at the patient's bedside. Faced with the advances in knowledge, techniques and indications, the Société de Neurophysiologie Clinique de Langue Française (SNCLF) and the Ligue Française Contre l'Épilepsie (LFCE) found it necessary to provide an update on EEG recommendations. This article will review the methodology applied to this work, refine the various topics detailed in the following chapters. It will go over the summary of recommendations for each of these chapters and underline proposals for writing an EEG report. Some questions could not be answered by the review of the literature; in those cases, an expert advice was given by the working and reading groups in addition to the guidelines.

Myoclonus, defined as shock-like involuntary movement, may be physiological or caused by a very wide variety of hereditary and acquired conditions. Because myoclonus can originate from different disorders and lesions affecting quite varied levels of the central and peripheral nervous systems, it represents from many points of view a diagnostic challenge. Moreover, new entities have been recently individualized, such as cortical tremor, which deserve renewed attention. The aim of this review is to propose a rationale for a diagnostic approach based on clinical and electrophysiological grounds. In this setting, we successively address 1) the clinical features allowing a positive diagnosis of myoclonus; 2) the clinical clues to the etiology; 3) the relevance of the clinical context to the diagnosis; and 4) the contribution of neurophysiology. Differentiating myoclonus from tics, spasm, chorea and dystonia can be difficult, and a careful reappraisal of clinical features allowing precise identification is presented. Moreover, the topographical distribution of myoclonus, the temporal pattern of muscle recruitment, the condition of occurrence and the rhythm of the event, may provide clinical clues relevant to the diagnosis. Myoclonus without associated epilepsy, myoclonus with epilepsy, myoclonus with encephalopathy, parkinsonism and/or dementia represent overlapping clinical categories, although they remain useful for the diagnostic approach. Using electrophysiology (including back-averaging EEG, MEG, SEP, C-reflex studies) to determine the origin of myoclonus may not allow us to focus on the underlying condition. Indeed, in many instances, the myoclonus is cortical in origin, but the pathology is found elsewhere.

During the past decade, a large amount of work on transcranial magnetic stimulation (TMS) has been performed, including the development of new paradigms of stimulation, the integration of imaging data, and the coupling of TMS techniques with electroencephalography or neuroimaging. These accumulating data being difficult to synthesize, several French scientific societies commissioned a group of experts to conduct a comprehensive review of the literature on TMS. This text contains all the consensual findings of the expert group on the mechanisms of action, safety rules and indications of TMS, including repetitive TMS (rTMS). TMS sessions have been conducted in thousands of healthy subjects or patients with various neurological or psychiatric diseases, allowing a better assessment of risks associated with this technique. The number of reported side effects is extremely low, the most serious complication being the occurrence of seizures. In most reported seizures, the stimulation parameters did not follow the previously published recommendations (Wassermann, 1998) [430] and rTMS was associated to medication that could lower the seizure threshold. Recommendations on the safe use of TMS / rTMS were recently updated (Rossi et al., 2009) [348], establishing new limits for stimulation parameters and fixing the contraindications. The recommendations we propose regarding safety are largely based on this previous report with some modifications. By contrast, the issue of therapeutic indications of rTMS has never been addressed before, the present work being the first attempt of a synthesis and expert consensus on this topic. The use of TMS/rTMS is discussed in the context of chronic pain, movement disorders, stroke, epilepsy, tinnitus and psychiatric disorders. There is already a sufficient level of evidence of published data to retain a therapeutic indication of rTMS in clinical practice (grade A) in chronic neuropathic pain, major depressive episodes, and auditory hallucinations. The number of therapeutic indications of rTMS is expected to increase in coming years, in parallel with the optimisation of stimulation parameters.

Psychogenic nonepileptic seizures are clinical events that mimic epileptic seizures but are not associated with electroencephalographic discharges. These seizures are seldom reported in children in the literature and could be misinterpreted as generalized tonicoclonic seizures. We report the case of a child, already treated for epilepsy, who presented at 8 years of age with several psychogenic seizures leading to pseudostatus epilepticus. After several hospitalizations, the diagnosis of pseudostatus was established on the basis of clinical semiology, lack of EEG abnormalities during the seizures, and a positive provocation maneuver, which elicited and blocked the manifestations. The clinical spectrum of psychogenic seizures is wide and it is particularly difficult to differentiate psychogenic seizures from epileptic seizures, especially when occurring in children, some of whom are already treated for epilepsy. Well-described clinical features can suggest the diagnosis of psychogenic seizure. It is important and necessary to make the diagnosis as soon as possible in order to rapidly begin appropriate treatment including psychotherapy. In fact, the long-term prognosis in children is better than in the adult population. Associated risk factors, such as anxiety as reported in the present case, have to be sought. Recognizing psychogenic seizures will thus avoid their fixation in the child's personality and the risk of inappropriate and escalating treatments leading to iatrogenic complications.

Astasia-abasia is defined as the inability to stand and to walk, despite sparing of motor function underlying the required balance and gestures. Initially, astasia-abasia was considered a psychogenic gait disorder, but later on, the description of "high-order" gait disorders mimicking this pure functional deficit led authors to refer to "astasia-abasia" as a pure descriptive term, without a presupposed etiological or anatomical substrate. In this paper, the main clinical characteristics of both psychogenic and non-psychogenic astasia-abasia are presented and discussed.

The surgical treatment of intractable epilepsies involving eloquent areas of the cortex is still challenging. Deep-brain stimulation could be an alternative to resective surgery because it can modulate the remote control systems of epilepsy, such as the thalamus and basal ganglia. The surgical experience acquired in the field of movement disorder surgery and the low morbidity of this technic could allow one to apply DBS to intractable epilepsies, such as generalized, motor and bitemporal epilepsies. Here we discuss the main experimental and clinical data reported so far in the literature and taken from our own experience.

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