Analysis of periictal vegetative signs characteristics of the epileptogenic zone in temporal lobe epilepsies

Cilj: Vegetativni znaci tokom epileptičkih napada (periiktalni vegetativni znaci, PIVZ), predstavljaju prirodni eksperiment koji pruža jedinstven uvid u funkcionisanje ljudskog autonomnog nervnog sistema. Iako vegetativni znaci kod epilepsija nisu retki i mogu čak dominirati kliničkom slikom napada, ove manifestacije se često previde. Glavni cilj našeg istraživanja bio je da se analizira značaj PIVZ za lokalizaciju i lateralizaciju epileptogene zone kod pacijenata sa fokalnom farmakorezistentnom epilepsijom koji su podvrgnuti prehirurškom ispitivanju. Metodologija: Analizirali smo video-EEG zapise kod 170 bolesnika (82 muškarca i 88 žena), starosti 13-66 godina (34,67 ±11,10; Med=35,00) sa farmakorezisetntnom fokalnom epilepsijom. Svi pacijenti su prošli kompletno prehirurško ispitivanje u Centru za epilepsije u Beogradu, koje se sastojalo od višednevne neinvazivne video-EEG telemetrije, snimanja nuklearnom magnetnom rezonancom, interiktalne pozitronske emisione tomografije fluorodeoksiglukozom i interiktalne i/ili iktalne HMPAO jednofotonske emisione kompijuterizovane tomografije. Dijagnoza fokalnog epileptičkog sindroma je postavljena na osnovu korelacije kliničkih karakteristika napada, iktalnih EEG nalaza i neuroradioloških nalaza. Dominantnost hemisfere kod svakog pacijenta je odredjena na osnovu Edinbruškog testa za dominantnost ruke, neuropsihološke procene i funkcionalne nukelarne magnetne rezonance gde je bilo neophodno. Kod svih bolesnika smo analizirali video zapis kliničke semiologije napada sa ciljem odredjivanja učestalosti javljanja i tipova PIVZ kod fokalnih epilepsija, njihovog lokalizacionog značaja za epilepsije temporalnog režnja (TLE) vs. ekstratemporalne epilepsije (ETLE) i njihovog lateralizacionog značaja (epilepsija nedominantne vs. dominantne hemisfere). Takodje smo analizirali evoluciju vegetativnih simptoma (epigastrična aura, AE) u neki od PIVZ i njen prediktivni značaj za dijagnozu mezijalne temporalne epilepsije (MTLE). Rezultati: Uočili smo deset različitih tipova PIVZ kod 69 od ukupno 170 bolesnika (40%). Najčešći PIVZ su bili postiktalno brisanje nosa (28,8%) i periiktalni kašalj (12,9%). Pokazali smo da su PIVZ pouzdan lokalizacioni znak za TLE vs. ETLE (50,0% vs. 23,2%; p=0,001). Najvažniji lokalizacioni znaci su bili postiktalno brisanje nosa (p=0,008), periiktalno pijenje vode (p=0,035) i hipersalivacija (p=0,048). Takodje smo našli da je pojava PIVZ češća kod bolesnika sa epilepsijom nedominantne hemisfere, posebno kod bolesnika sa MTLE, ali ova razlika nije dostigla punu statističku značajnost (64,3% vs. 47,1%; p=0,175). Kod bolesnika sa evolucijom EA u neki od PIVZ, verovatnoća za MTLE je bila veoma visoka (96,77%)...Purpose: Vegetative signs during epileptic seizures (periictal vegetative signs, PIVS) represent an experiment of nature that provides a unique window on the functioning of the human autonomic nervous system. Although vegetative manifestations of epilepsy are not rare, and may even overshadow other semiological signs, these manifestations are frequently overlooked. The main purpose of our investigation was to analyze localization and lateralization value of PIVS for the epileptogenic zone in patients with focal pharmacoresistant epilepsies who were undergone presurgical evaluation. Methodology: We analyzed video-EEG recordings of 170 patients (82 men and 88 women), age ranged 13-66 years (mean 34.67 ±11.10; Med=35.00) with medically intractable focal epilepsy. All of the patients underwent a complete presurgical evaluation in the Belgrade Epilepsy Center, comprising long-term noninvasive video-EEG telemetry, magnetic resonance imaging, interictal fluorodeoxyglucose positron emission tomography and interictal and/or ictal HMPAO single-photon emission computed tomography. The diagnosis of lobar epilepsy was established according to the correlation of clinical seizure semiology, ictal EEG findings and neuroradiology findings. The hemisphere dominance was determined according to the Edinburgh handedness inventory, neuropsychological assessment and functional magnetic resonance imaging for speech lateralization when needed. In all patients we analyzed video recordings of clinical seizure semiology in order to determine the frequency and types of PIVS in focal epilepsies, their localizing value for temporal lobe epilepsies (TLE) vs. extratemporal lobe epilepsies (ETLE), and their lateralizing value (seizures from nondominant vs. dominant hemisphere). We also evaluated the evolution of seizure semiology from vegetative symptoms (epigastric aura, EA) to PIVS and it's predictive value for the diagnosis of mesial temporal lobe epilepsy (MTLE). Results: Ten different types of PIVS occurred in 69 of the 170 patients (40%). The most frequent PIVS were postictal nose rubbing (28.8%) and periictal cough (12.9%). We found PIVS were reliable localizing signs for TLE vs. ETLE (50.0% vs. 23.2%; p=0.001). The most valuable localizing signs were postictal nose rubbing (p=0.008), periictal water drinking (p=0.035) and hypersalivation (p=0.048). We also found the occurence of PIVS more common among the patients with nondominant hemisphere epilepsy, especially in patients with MTLE, but this difference was not statistically significant (64.3% vs. 47.1%; p=0.175). In patients with EA evolving into any other PIVS, the probability of MTLE was extremely high (96.77%)..

Pragmatic study of efficiency of controlled-release carbamazepine (TEGRETOL CR 400) in the treatment of patients with partial seizures

In patients with partial seizures controlled-release vs. conventional carbamazepine had better efficiency, based on an excellent tolerance favorable daily dosage and superior compliance

Concussive convulsions as differential diagnosis of posttraumatic epilepsy

Concussive convulsions are motor manifestations in acute head injury. This clinical phenomenon should be distin- guished from epileptic seizures. We present two young men with motor and convulsive manifestations in acute head injury. Patient 1. A18-year old basketball player felt on the parquet during a game. Initially he was struck on the right shoulder which caused brief and vigorous twitch of the head towards the ground and additional temporal impact. At the moment of impact he lost consciousness and developed tonic leg and arm posturing with both clenched fists. His legs were extended during next 20 seconds. Thereafter he was still and his loss of consciousness lasted 3 minutes. Patient 2. A 26-year old man felt on the wooden ground from a 4 m high ferry. He got head impact and lost consciousness. In a few seconds he had tonic/clonic convulsions for the next 10-15 seconds. Ten minutes later he awaked. Results of subsequent neurological examination, electroencephalography and cerebral magnetic resonance imaging studies were normal in both patients. They returned to their occupations after four weeks without problems for a further one year. Conclusion. Described motor manifestations present concussive convulsions. These clinical features are due to transient functional decerebration and corticomedullary dissociation during cerebral concussion. Concussive convulsions are a non-epileptic phenomenon, they are not associated with structural brain injury and have good prognosis. Antiepileptic treatment is not indicated

The first film presentation of REM sleep behavior disorder precedes its scientific debut by 35 years

The perplexing and tantalizing disease of rapid eye movement (REM) sleep behavior disorder (RBD) is characterized by peculiar, potentially dangerous behavior during REM sleep. It was described both in animals and humans. RBD in mammals was first described by Jouvet and Delorme in 1965, based on an experimental model induced by lesion in pontine region of cats [1]. In 1972, Passouant et al. described sleep with eye movements and persistent tonic muscle activity induced by tricyclic antidepressant medication [2], and Tachibana et al., in 1975, the preservation of muscle tone during REM sleep in the acute psychosis induced by alcohol and meprobamate abuse [3]. However, the first formal description of RBD in humans as new parasomnia was made by Schenck et al in 1986 [4-7]. Subsequently, in 1990, the International Classification of Sleep Disorders definitely recognized RBD as new parasomnia [8]. To our knowledge, arts and literature do not mention RBD. Except for the quotation, made by Schenck et al [6] in 2002, of Don Quixote de la Mancha whose behavior in sleep strongly suggested that Miguel de Servantes actually described RBD, no other artistic work has portrayed this disorder. Only recently we become aware of the cinematic presentation of RBD which by decades precedes the first scientific description. The first presentation of RBD on film was made prior to the era of advanced electroencephalography and polysomnography, and even before the discovery of REM sleep by Aserinsky and Kleitman in 1953. [9]. The artistic and intuitive presentation of RBD was produced in Technicolor in a famous film "Cinderella" created by Walt Disney in 1950, some 35 years prior to its original publication in the journal "Sleep" [2]. Since there is an earlier version of the film initially produced in 1920, presumably containing this similar scene, we can only speculate that the first cinematic presentation of RBD might precede its scientific debut by 65 years. In a scene in a barn, clumsy and goofy dog Bruno is, as dogs usually do, lying on a mat deeply asleep and obviously dreaming of his enemy cat Lucifer. This is clearly implied by a preceding scene showing Lucifer being extremely frightened while observing the dreaming dog in action. The cat Lucifer is instantly aware that the dog is chasing him in a dream and is horrified (Pictures 1-3). In a film sequence lasting only 16 seconds, we see Cinderella being aware that Bruno is firmly asleep, apparently having a terrible dream. While lying on the ground with total absence of any muscle atonia, the dog Bruno chases the cat Lucifer in his dream. He is running and barking, and when in his dream he catches Lucifer, he tries to devour the cat. Cinderella tries to wake him up by calling his name twice, first gently and then more vigorously, as she becomes aware of the content of Lucifer’s dream and his intention. The dog is deeply asleep and does not awake in spite of being exposed to sunlight through the opening door of the barn, and called by name by Cinderella (Pictures 4-14). For such a behavior he is reprimanded by Cinderella who definitely recognized the content of his dream (Pictures 15-36). Immediately upon awakening, Bruno shows his good natured temper and amiable character (Pictures 37-40). The film shows that the producer (Walt Disney) and film directors (Wilfred Jackson, Clyde Geronimi and Hamilton Luske) were obviously aware that a dog might enact the content of a dream. It also implies that their observation from day-to-day (better to say night-to-night) life of the dream enactment is not a rare phenomenon, and that it deserves to be shown in the film. These authors were also aware that dogs having RBD were good-natured during wakefulness and that only in dreams they showed unrestrained aggression; while awake, dog Bruno was only an opponent or enemy to the cat Lucifer, but in dreams the animosity grew to aggression. Disney noticed this peculiar kind of sleep behavior and most probably was aware of its frequency and importance, and certainly not knowing it is a disease, he used it to color his cartoon character making it more likable to the observer. Since the film was nominated for Best Score, Best Song and Best Sound, it not only reflected the artistic and observational abilities of the producer, but also his sense of the importance of the phenomenon, awareness of its frequency and presence in animals. The onlooker is tempted to speculate that Disney, while obviously having been aware of such a behavior in animals, might also have knowledge of its presence in humans. Even more, since Disney’s films frequently present different sleep disturbances (e.g., obstructive sleep apnea (OSA) in dwarfs, hypersomnolence in the dwarf Sleepy, or jactatio capitis nocturna in the dwarf Dopey in film "The Snow White"), it seems plausible that he first observed RBD in man, and then artistically transferred it to his cartoon animal characters. Since the whole incident took place during the day, we assume that Bruno, apart from suffering from RBD, had another sleep disorder causing daytime REM intrusions (possibly narcolepsy and probably not OSA, as is frequent in Disney’s films, since there is no excessive daytime sleepiness). The odd thing about RBD is that it may easily, as it probably did for centuries, go as peculiar behavior in sleep – rather than disease. While Lucifer was presented as sober and prudent cat, Bruno was clumsy and forgetful dog. We will refrain from speculating that dog’s clumsy nature could be the consequence of the CNS involvement by neuro-degenerative disease (i.e., synucleinopathy). Although we are aware that, in interpreting this episode we assumed to be at least as imaginative as the cartoon films of Walt Disney are, the fact remains that the artistic film presentation of RBD precedes its scientific description by at least 35 years

PRINCIPLES AND FUNCTIONS OF POLITICAL MANAGEMENT

In the modern democratic society the politics is considered to be a skill of governing, that is, conquering and maintaining the political governance and the inevitable activity in all spheres of human activities. In the sense of negotiations the contemporary politics is "the maximal in the sphere of the possible", when, in a terrible struggle using arguments and other democratic means, one comes from the maximalistic request to the solution acceptable for both sides. Political activities would mean putting every political subject in the function of the efficient and economical satisfaction of the political needs and desires, aspirations and volitions of the political public. If the political scene is represented by the free market of political ideas, then there could be established the strategy of sensible and responsible managing in the political structures of the community, which is based on the previously researched and familiar expectations of the political public