Neurocisticercose e epilepsia do lobo temporal mesial associada à esclerose hipocampal : um estudo em uma coorte de 731 pacientes com epilepsia

Base teórica: A epilepsia é uma doença neurológica frequente, caracterizada por uma predisposição para gerar crises epilépticas espontâneas e tem inúmeras consequências neurobiológicas, cognitivas e psicossociais. A epilepsia do lobo temporal mesial associada à esclerose hipocampal (ELTM-EH) é a epilepsia focal mais comum em adultos e a neurocisticercose (NCC), causada pela infeção da Taenia solium no sistema nervoso central (SNC), é um dos agentes etiológicos mais comuns de epilepsia focal. A patogênese da ELTMEH não é completamente elucidada, sendo a teoria mais aceita de o dano hipocampal estar associado a um insulto precipitante inicial (IPI). Os IPIs mais estudados são traumatismo craniano, crise convulsiva febril prolongada e infecções bacterianas e virais do SNC. Recentemente, estudos têm sugerido uma possível relação entre NCC e ELTM-EH e que a infeção pelo cisticerco no SNC pode atuar como um IPI, contribuindo para o desenvolvimento da ELTM-EH. Objetivo: Estudar a prevalência de NCC, suas características e uma possível associação entre NCC e ELTM-EH em uma coorte de pacientes com epilepsia. Métodos: Neste estudo, foi realizado revisão dos prontuários de 731 pacientes com epilepsia acompanhados no ambulatório de epilepsia do Hospital de Clínicas de Porto Alegre (HCPA), durante o período de 2019 e 2020. Neste ambulatório, todos os pacientes são atendidos pelo menos uma vez por ano e, portanto, todos os pacientes com diagnóstico de epilepsia que estão em acompanhamento foram incluídos neste estudo. Foram estudados os aspectos clínicos, eletrofisiológicos e de neuroimagem desses pacientes. Resultados: De 731 pacientes, 42 (5,75%) tinham NCC. As lesões de NCC foram mais frequentes em mulheres, ocorrendo em 33 (78,6%) pacientes do sexo feminino e somente em 09 pacientes do sexo masculino (21,4%) (p=0,001). A NCC ocorreu com frequência significativamente maior em pacientes que começaram com epilepsia mais tarde na vida (p=0,025), em pacientes mais velhos (p<0,001) e em pacientes que tiveram mais tempo de epilepsia (p=0,015). Uma causa pós-infecciosa de epilepsia que não NCC foi observada em 45 (6,2%) pacientes. Outras causas de epilepsia focal foram epilepsia pós-AVC, observada em 36 (4,9%) pacientes, e epilepsia associada à malformação vascular, observada em 10 (1,4%) pacientes. Dos 731 pacientes, 93 (12,7%) apresentaram ELTM-EH, sendo que a NCC estava presente em 25 (26,9%) desses pacientes. Dos 638 pacientes com outros tipos de epilepsia exceto ELTM-EH, NCC foi observado em apenas 17 (2,7%) deles. Essa proporção foi quase dez vezes menor do que a proporção de NCC observada em pacientes com ELTM-EH (O.R.=14,29; IC 95%=7,13-33,33; p<0,0001). Conclusão: Esse estudo demonstra uma associação significativa de NCC e ELTM-EH, uma observação que concorda com a hipótese de que a infecção pelo cisticerco no SNC pode contribuir com o desenvolvimento de ELTM-EH em muitos pacientes. Desse modo, em áreas endêmicas para NCC, os pacientes com epilepsia devem idealmente ser avaliados por meio de tomografia computadorizada (TC) de crânio, para investigação de lesões calcificadas de NCC (NCCc), e com ressonância magnética (RM) de crânio, para investigação de esclerose hipocampal (EH), além da avaliação dos aspectos clínicos e do exame eletroencefalográfico.Background: Epilepsy is a frequent neurological disease, characterized by a predisposition to generate spontaneous epileptic seizures and has numerous neurobiological, cognitive, and psychosocial consequences. Mesial temporal lobe epilepsy with hippocampal sclerosis (MTLE-HS) is the most common form of focal epilepsies in adults and neurocysticercosis (NCC), caused by Taenia solium infection of the central nervous system (CNS), is one of the most common etiological agents of focal epilepsy. The pathogenesis of MTLE-HS is not fully elucidated, and the most accepted theory is that hippocampal damage is associated with an initial precipitating insult (IPI). The most studied IPIs are head trauma, prolonged febrile seizures, and bacterial and viral infections of the CNS. Recently, studies have suggested a possible association between NCC and MTLE-HS and that CNS cysticercus infection can act as an IPI, contributing to the development of MTLE-HS. Objective: To study the prevalence of NCC, its characteristics and a possible association between NCC and MTLE-HS in a cohort of patients with epilepsy. Methods: In this study, a review of charts of 731 patients with epilepsy followed at the epilepsy outpatient clinic of the Hospital de Clínicas de Porto Alegre was carried out, between 2019 and 2020. In this clinic, all patients are evaluated at least once a year and therefore all patients diagnosed with epilepsy who are being followed up were included in this study. The clinical, electrophysiological and neuroimaging aspects of these patients were studied. Results: Among 731 patients, 42 (5.75%) had NCC. NCC lesions were more frequent in women, occurring in 33 (78.6%) female patients and in only 09 male patients (21.4%) (p=0.001). NCC also occurred significantly more frequently in patients who started with epilepsy later in life (p=0.025), in older patients (p<0.001) and in patients who had a longer history of epilepsy (p=0.015). A post infectious cause of epilepsy other than NCC was observed in 45 (6.2%) patients. Other causes of focal epilepsy were post-stroke epilepsy, observed in 36 (4.9%) patients, and epilepsy associated with vascular malformation, observed in 10 (1.4%) patients. Of the 731 patients, 93 (12.7%) had MTLE-HS and NCC was present in 25 (26.9%) of these patients. Of 638 patients with other types of epilepsy except MTLE-HS, NCC was seen in only 17 (2.7%) of them. This proportion was almost ten times smaller than the proportion of NCC observed in patients with MTLE-HS (OR=14.29; 95% CI=7.13-33.33; p<0.0001). Conclusion: This study demonstrates a significant association of NCC and MTLE-HS, an observation that agrees with the hypothesis that CNS cysticercus infection may contribute to the development of MTLE-HS in many patients. Thus, in NCC-endemic areas, patients with epilepsy should ideally be evaluated with cranial computed tomography scan, for investigation NCC calcified lesions (cNCC), and with magnetic resonance imaging, for evaluating hippocampal sclerosis (HS), in addition to clinical and electrophysiological assessment

Evaluating the association of calcified neurocysticercosis and mesial temporal lobe epilepsy with hippocampal sclerosis in a large cohort of patients with epilepsy

Background: Neurocysticercosis (NCC) is a parasitic infection of the central nervous system that has been associated with mesial temporal lobe epilepsy with hippocampal sclerosis (MTLE-HS). However, this association has not been completely established. Objective: To evaluate the prevalence of calcified NCC (cNCC), its characteristics and a possible association between cNCC and MTLE-HS in a cohort of 731 patients with epilepsy. Methods: We review clinical, EEG and neuroimaging findings of 731 patients with epilepsy. From these, 659 had CT-scans and 441 patients had complete neuroimaging with CT-scans and MRI. In these patients, we review the prevalence and characteristic of epilepsy in cNCC and in MTLE-HS patients. Results: Forty-two (6.4%) of the 659 patients studied with CT-scans had cNCC. cNCC lesions were more frequent in women than in men (n = 33–78.6% vs. n = 09–21.4%, respectively; OR = 3.64;(95%CI = 1.71–7.69); p < 0.001). cNCC was more often in patients who developed epilepsy later in life, in older patients, in patients who had a longer history of epilepsy, and in those with a lower educational level. MTLE–HS was observed in 93 (21.1%) of 441 patients that had complete neuroimaging, and 25 (26.9%) of these 93 patients also had cNCC. Calcified NCC was observed in only 17 (4.9%) of the remaining 348 patients that had other types of epilepsy rather than MTLE-HS. Thus, in our cohort, cNCC was more frequently associated with MTLE-HS than with other forms of epilepsy, O.R. = 11.90;(95%CI = 6.10–23.26); p < 0.0001). Conclusions: As expected, in some patients the epilepsy was directly related to cNCC lesional zone, although this was observed in a surprisingly lower number of patients. Also, cNCC lesions were observed in other forms of epilepsy, a finding that could occur only by chance, with epilepsy probably being not related to cNCC at all. In this cohort, cNCC was very commonly associated with MTLE-HS, an observation in agreement with the hypothesis that NCC can contribute to or directly cause MTLE-HS in many patients. Given the broad world prevalence of NCC and the relatively few studies in this field, our findings add more data suggesting a possible and intriguing frequent interplay between NCC and MTLE-HS, two of the most common causes of focal epilepsy worldwide

Editorial: Development of stroke systems of care across the globe

Rehabilitation services; Telestroke programsServeis de rehabilitació; Programes de teleictusServicios de rehabilitación; Programas de teleictu

Risk factors for epilepsy after thrombolysis for ischemic stroke : a cohort study

The effects of thrombolysis in seizure and epilepsy after acute ischemic stroke have been poorly explored. In this study, we examine risk factors and consequences of intravenous rt-PA for treatment of acute ischemic stroke. In a retrospective cohort study we evaluate risk factors for seizure and epilepsy after stroke thrombolysis, as well as the impact of seizures and epilepsy in outcome of stroke patients. In our cohort, mean age of patients was 67.2 years old (SD = 13.1) and 79 of them (51.6%) were male and. Initial NIHSS mean score were 10.95 (SD = 6.25). Three months NIHSS mean score was 2.09 (SD = 3.55). Eighty seven (56.9%) patients were mRS of 0–1 after thrombolysis. Hemorrhagic transformation was observed in 22 (14.4%) patients. Twenty-one (13.7%) patients had seizures and 15 (9.8%) patients developed epilepsy after thrombolysis. Seizures were independently associated with hemorrhagic transformation (OR = 3.26; 95% CI = 1.08–9.78; p = 0.035) and with mRS >= 2 at 3 months after stroke (OR = 3.51; 95% CI = 1.20–10.32; p = 0.022). Hemorrhagic transformation (OR = 3.55; 95% CI = 1.11–11.34; p = 0.033) and mRS >= 2 at 3 months (OR = 5.82; 95% CI = 1.45–23.42; p = 0.013) were variables independently associated with post-stroke epilepsy. In our study, independent risks factors for poor outcome in stroke thrombolysis were age (OR = 1.03; 95% CI = 1.01–1.06; p = 0.011), higher NIHSS (OR = 1.08; 95% CI = 1.03– 1.14; p = 0.001), hemorrhagic transformation (OR = 2.33; 95% CI = 1.11–4.76; p = 0.024), seizures (OR = 3.07; 95% CI = 1.22–7.75; p = 0.018) and large cortical area (ASPECTS <= 7) (OR = 2.04; 95% CI = 1.04–3.84; p = 0.036). Concluding, in this retrospective cohort study, the neurological impairment after thrombolysis (but not before) and hemorrhagic transformation remained independent risk factors for seizures or post-stroke epilepsy after thrombolysis. Moreover, we observed that seizures emerged as an independent risk factor for poor outcome after thrombolysis therapy in stroke patients (OR = 3.07; 95% CI = 1.22–7.75; p = 0.018)

Irreversible coma in a patient with paranoid schizophrenia : Wernicke encephalopathy after refeeding syndrome: a case report

Encefalopatia de Wernicke (EW) e síndrome de realimentação (SR) são duas condições frequentemente coexistentes, subdiagnosticadas e que podem implicar prognóstico reservado após sua instalação. Sua identificação precoce representa um desafio para os intensivistas, haja vista a falta de sensibilidade e especificidade das manifestações clínicas. Apresenta-se um relato de caso de uma paciente portadora de esquizofrenia paranoide, sem histórico de abuso de álcool, que desenvolveu quadro de coma irreversível após greve de fome, sendo feito diagnóstico tardio de EW associada a SR. Descreve-se a evolução clínica e neuropsiquiátrica com o intuito de enfatizar a necessidade crucial de alta suspeição diagnóstica, com reposição vitamínica imediata, vigilância de distúrbios eletrolíticos e progressão parcimoniosa do aporte nutricional.Wernicke encephalopathy (WE) and refeeding syndrome (RFS) are two often coexisting, underdiagnosed conditions that may involve a poor prognosis after their onset. Early identification represents a challenge for intensivists, given the lack of sensitivity and specificity of clinical manifestations. We report a case of a patient with paranoid schizophrenia, without a history of alcohol abuse, who developed irreversible coma after a hunger strike, with a late diagnosis of WE associated with RFS. The clinical and neuropsychiatric outcomes are described herein in order to emphasize the crucial need for a high diagnostic suspicion, with immediate vitamin replacement, monitoring of electrolyte disorders, and gradual progression of nutritional support

Methylation of BDNF and SLC6A4 gene promoters in Brazilian patients with temporal lobe epilepsy presenting or not psychiatric comorbidities

The relationship between epilepsy and psychiatric comorbidities has been recognized for centuries, but its pathophysiological mechanisms are still misunderstood. It is biologically plausible that genetic or epigenetic variations in genes that codify important neurotransmitters involved in epilepsy as well as in psychiatric disorders may influence the development of the latter in patients with epilepsy. However, this possibility remains poorly investigated. The aim of this study was to evaluate the methylation profile of the BDNF and SLC6A4, two genes importantly involved in neuroplasticity, in patients with temporal lobe epilepsy (TLE) regarding the development or not of psychiatric comorbidities. One hundred and thirty-nine patients with TLE, 90 females and 45 males, were included in the study. The mean age of patients was 44.0 (+12.0) years, and mean duration of epilepsy was 25.7 (+13.3) years. The Structured Clinical Interview for DSM-IV shows that 83 patients (59.7%) had neuropsychiatric disorders and 56 (40.3%) showed no psychiatric comorbidity. Mood disorders were the most common psychiatric disorder observed, being present in 64 (46.0%) of all 139 patients. Thirtythree (23.7%) patients showed anxiety disorders, 10 (7.2%) patients showed history of psychosis and 8 (5.8%) patients showed history of alcohol//drug abuse. Considering all 139 patients, 18 (12.9%) demonstrated methylation of the promoter region of both BDNF and SLC6A4 genes. A significant decreased methylation profile was observed only in TLE patients with mood disorders when compared with TLE patients without a history of mood disorders (O.R. = 3.45; 95% C.I. = 1.08–11.11; p = 0.04). A subanalysis showed that TLE patients with major depressive disorder mostly account for this result (O.R. = 7.20; 95% C.I. = 1.01–56.16; p = 0.042). A logistic regression analysis showed that the independent factors associated with a history of depression in our TLE patients was female sex (O.R. = 2.30; 95% C.I. = 1.02–5.18; p = 0.044), not controlled seizures (O.R. = 2.51; 95% C.I. = 1.16–5.41; p = 0.019) and decreased methylation in BDNF and SLC6A4 genes (O.R. = 5.32; 95% C.I. = 1.14–25.00; p = 0.033). Our results suggest that BDNF or SLC6A4 genes profile methylation is independently associated with depressive disorders in patients with epilepsy. Further studies are necessary to clarify these matters

Home-based transcranial direct current stimulation for the treatment of symptoms of depression and anxiety in temporal lobe epilepsy : a randomized, double-blind, sham-controlled clinical trial

We conducted a double-blind randomized clinical trial in order to examine the effects and the safety of home-based transcranial direct current stimulation (tDCS) on depressive and anxious symptoms of patients with temporal lobe epilepsy (TLE). We evaluated 26 adults with TLE and depressive symptoms randomized into two different groups: active tDCS (tDCSa) and Sham (tDCSs). The patients were first submitted to 20 sessions of tDCS for 20 min daily, 5 days a week for 4 weeks and then received a maintenance tDCS application in the research laboratory once a week for 3 weeks. The intensity of the current was 2 mA, applied bilaterally over the dorsolateral prefrontal cortex, with the anode positioned on the left side and the cathode on the right side. Participants were evaluated on days 1, 15, 30, and 60 of the study using the Beck Depression Inventory II (BDI). A follow-up evaluation was performed 1 year after the end of treatment. They were also evaluated for quality of life and for anxious symptoms as secondary outcomes. The groups did not differ in clinical, socioeconomic or psychometric characteristics at the initial assessment. There was no statistically significant difference between groups regarding reported adverse effects, seizure frequency or dropouts. On average, between the 1st and 60th day, the BDI score decreased by 43.93% in the active group and by 44.67% in the Sham group (ΔBDIfinal – initial = -12.54 vs. -12.20, p = 0.68). The similar improvement in depressive symptoms observed in both groups was attributed to placebo effect and interaction between participants and research group and not to tDCS intervention per se. In our study, tDCS was safe and well tolerated, but it was not effective in reducing depressive or anxiety symptoms in patients with temporal lobe epilepsy

Reperfusion therapy for acute ischemic stroke: where are we in 2023?

Over the last three decades, stroke care has undergone significant transformations mainly driven by the introduction of reperfusion therapy and the organization of systems of care. Patients receiving treatment through a well-structured stroke service have a much higher chance of favorable outcomes, thereby decreasing both disability and mortality. In this article, we reviewed the scientific evidence for stroke reperfusion therapy, including thrombolysis and thrombectomy, and its implementation in the public health system in Brazil