Occipital seizures presenting with bilateral visual loss

Transient visual loss may occur with occipital seizures as an ictal or post-ictal phenomenon. Its duration varies from less than one minute to days, or can be permanent. We describe a 61-year-old man presenting with headache, vomiting and bilateral visual loss. EEG revealed persistent spike discharge in the occipital lobes suggesting occipital seizures. His vision improved with carbamazepine

Coughing and choking in motor neuron disease

OBJECTIVES—To assess the frequency and severity of coughing and choking episodes, possible related factors, and their association with chest infections in patients with motor neuron disease (MND).
METHODS—Thirty seven patients with MND and 23 healthy volunteers were studied. Cough was assessed using a questionnaire and a 3 day diary, and volitional cough quantified by peak cough flow and sound intensity. Other clinical symptoms, smoking habit, affective state, oral secretions, bulbar signs, and quantitative assessments of swallowing and respiratory function were documented.
RESULTS—Patients with MND coughed and choked significantly more often and to a greater degree than the healthy volunteers (26 of 37patients with MND and 2 of 23 volunteers, p<0.001). Female sex, older age, abnormal speech, reduced swallowing capacity, and low forced vital capacity (FVC)% predicted were each significantly associated with excessive coughing and choking episodes in patients with MND. Smokers had significantly more severe and prolonged episodes of coughing and choking than non-smokers (p<0.05). Patients with upper motor neuron bulbar signs had a greater tendency to severe and prolonged episodes of coughing and choking than those without (p<0.05). Chest infections were reported only rarely among the patients who coughed and choked.
CONCLUSIONS—Coughing and choking episodes are common in patients with MND but infrequently associated with overt chest infection. Upper motor neuron bulbar signs may both promote factors (for instance, dysphagia) which trigger cough and reduce volitional capacity to suppress it.


Approach to the patient with epilepsy in the outpatient department

Epilepsy is common and serious (prevalence 750 per 100 000) and has an impact upon employment, education, and driving. The diagnosis requires a detailed history including witness account. Clinicians must distinguish seizures particularly from syncope and psychogenic attacks. Electroencephalography and magnetic resonance brain scanning help to identify causes and classification of epilepsy, but alone rarely provide the diagnosis. Antiepileptic drug treatment is required long term and is potentially hazardous; patients should start treatment only after informed discussion with an epilepsy specialist. Patients require reliable written information, particularly the driving regulations, and the impact of seizures on employment, education, and leisure. Women must understand the potential drug teratogenic effects. Certain patient groups benefit from targeted epilepsy services, for example, learning disabled, children, teenagers, and elderly. People with epilepsy require long term specialist follow up. Although this is currently provided in mainly in secondary care (including nurse led clinics), improved liaison with primary care should enable improved access to epilepsy services. Epilepsy care should be multidisciplinary and long term, linking primary and secondary care, and empowering patients towards improved management of their condition

Raised intracranial pressure presenting with spontaneous periorbital bruising: two case reports

The venous drainage of the orbit is known to be via the ophthalmic and vortex veins which communicate with the cavernous sinus. We describe two patients with raised intracranial pressure presenting with periorbital bruising. In one patient dural venous sinus thrombosis was demonstrated and it is suspected that the cause of the raised intracranial pressure may have been the same in the second. We suggest that the abrupt rise of pressure in the cerebral venous system was transmitted via the cavernous sinus to the orbital venous system

The investigation of syncope

Patients with syncope are usually referred to either neurology or cardiology clinics, yet the facilities for detailed syncope investigation are mostly in cardiac units. The diagnosis rests principally upon the history, but investigations may be required to support the clinical diagnosis. Close collaboration between the epilepsy clinician and a cardiologist is essential for effective investigation and safe management of syncope. It is frequently misdiagnosed and often erroneously treated as epilepsy. Furthermore, it is potentially a marker of sudden death when associated with certain cardiac disorders. Here we review the main syncope types and explore diagnostic approaches

The postictal state — What do we know?

This narrative review provides a broad and comprehensive overview of the most important discoveries on the postictal state over the past decades as well as recent developments. After a description and definition of the postictal state, we discuss postictal sypmtoms, their clinical manifestations, and related findings. Moreover, pathophysiological advances are reviewed, followed by current treatment options

Ocular complications of neurological therapy

Treatments used for several neurological conditions may adversely affect the eye. Vigabatrin-related retinal toxicity leads to a visual field defect. Optic neuropathy may result from ethambutol and isoniazid, and from radiation therapy. Posterior subcapsular cataract is associated with systemic corticosteroids. Transient refractive error changes may follow treatment with acetazolamide or topiramate, and corneal deposits and keratitis with amandatine. Intraocular pressure can be elevated in susceptible individuals by anticholinergic drugs, including oxybutynin, tolterodine, benzhexol, propantheline, atropine and amitriptyline, and also by systemic corticosteroids and by topiramate. Nystagmus, diplopia and extraocular muscle palsies can occur with antiepileptic drugs, particularly phenytoin and carbamazepine. Ocular neuromyotonia can follow parasellar radiation. Congenital ocular malformations can result from in utero exposure to maternally prescribed sodium valproate, phenytoin and carbamazepine. Neurologists must be aware of potential ocular toxicity of these drugs, and appropriately monitor for potential adverse events