Odgođeni učinak VNS-a na interiktalna epileptiformna izbijanja i farmakorezistentnost u bolesnice s refraktornom perinatalnom postishemijskom epilepsijom

A 20-year-old female with refractory perinatal postischemic catastrophic epilepsy and frequent daily generalized atonic, tonic, tonic-clonic and focal seizures was hospitalized in the progressive phase of illness. The diagnosis was confirmed by semiology, interictal electroencephalogram (EEG), long-term video EEG monitoring, and brain magnetic resonance imaging. Repeated interictal EEG findings showed generalized spike and slow wave complexes with a 2-3 Hz frequency. Interictal EEG showed evidence of electroclinical epileptic status on several occasions. She was treated with various antiepileptic drugs without improvement. After verification of her incompetence for normal autonomous living, which resulted in very low quality of life, this patient with refractory epilepsy underwent implantation of vagus nerve stimulator (VNS). In this case report, we present delayed effect of VNS on interictal epileptiform discharges and pharmacoresistance.Mlada žena u dobi od 20 godina s farmakorezistentnom perinatalnom postishemijskom epilepsijom i svakodnevnim učestalim generaliziranim atoničkim, toničkim, toničko-kloničkim te žarišnim napadima hospitalizirana je u pogoršanoj fazi bolesti. Dijagnoza je potvrđena kliničkom slikom, interiktalnim elektroencefalogramom (EEG), video EEG monitoriranjem te magnetskom rezonancom (MR) mozga. Ponavljani interiktalni nalazi EEG-a pokazali su generalizirana izbijanja šiljakval kompleksa frekvencije 2-3 Hz. U više navrata u interiktalnom EEG-u je evidentiran i elektroklinički epileptički status. Bolesnica je liječena različitim antiepilepticima, ali bez poboljšanja stanja. Zbog učestalih napada bolesnica nije bila sposobna za samostalan život, što je rezultiralo vrlo niskom kvalitetom života te je bolesnica podvrgnuta ugradnji vagusnog stimulatora (VNS). U ovom prikazu slučaja opisujemo odgođeni učinak VNS-a na interiktalna epileptiformna izbijanja i farmakorezistentnost

Lažna farmakorezistencija - stvarni problem

Pharmacoresistant epilepsy poses a great burden to patients, their families, and the whole healthcare system, with numerous social, economic, physical, and psychical consequences. Hence, it is a diagnosis that has to be made only in cases of high certainty, after all potential causes of epilepsy have been evaluated. One of the important causes of pharmacoresistant epilepsy is false pharmacoresistance, an entity that implies a condition in which poor disease control is not a consequence of the biology of the disease itself, antiepileptic drug inefficacy, and/or patient specificity. It is a consequence of human error and strongly depends on the experience of the treating physician, as well as on the attitude of the patient. Despite its ‘falseness’, this entity is accompanied by real consequences for the patient and his family, and at the same time, it delays appropriate treatment of the actual disease from which the patient is suffering. In order to introduce appropriate treatment and avoid unnecessary and harmful diagnostic procedures, false pharmacoresistance is a condition that has to be ruled out in any patient with difficult-to-treat seizures.Farmakorezistentna epilepsija, dijagnoza koju prate brojne društvene, ekonomske, fizičke i psihičke posljedice, predstavlja veliko opterećenje za bolesnike, njihove obitelji, ali i cjelokupni zdravstveni sustav. Stoga je farmakorezistentnu epilepsiju opravdano dijagnosticirati samo u slučajevima u kojima je liječnik siguran u dijagnozu nakon što su procijenjeni svi mogući uzroci. Jedan od uzroka farmakorezistentne epilepsije je takozvana lažna farmakorezistencija, entitet koji podrazumijeva stanje u kojem loša kontrola bolesti nije posljedica biologije same bolesti, antiepileptičkih lijekova i karakteristika bolesnika. Ona je posljedica ljudske pogreške i izravno ovisi o iskustvu liječnika koji liječi, ali i o stavu bolesnika prema liječenju. Unatoč „lažnosti“ ovaj entitet prate stvarne posljedice za bolesnika i njegovu obitelj, a istodobno odgađa odgovarajuće liječenje stvarne bolesti od koje bolesnik boluje. Kako bi se osiguralo uspješno liječenje te izbjegli nepotrebni i štetni dijagnostički postupci, lažna farmakorezistencija je stanje koje se mora isključiti kod svakog bolesnika s epileptičkim napadajima koji se teško kontroliraju

Incidencija akutnih simptomatskih napadaja kod bolesnika s COVID-19: monocentrično istraživanje

The most common neurological symptoms in patients with SARS-CoV-2 infection are headache, myalgia, encephalopathy, dizziness, dysgeusia and anosmia, making more than 90 percent of neurological manifestations of COVID-19. Other neurological manifestations such as stroke, movement disorder symptoms or epileptic seizures are rare but rather devastating, with possible lethal outcome. The primary aim of this study was to estimate the prevalence of acute symptomatic seizures among COVID-19 patients, while secondary aim was to determine their possible etiology. Out of 5382 patients with COVID-19 admitted to Dubrava University Hospital from November 1, 2020 until June 1, 2021, 38 (seizure rate 0.7%) of them had acute symptomatic seizures. Of these 38 patients, 29 (76.3%) had new-onset epileptic seizures and nine (23.7%) patients with previous epilepsy history had breakthrough seizures during COVID-19. Although acute symptomatic seizures are an infrequent complication of COVID-19, seizure risk must be considered in these patients, particularly in the group of patients with a severe course of the disease. Accumulation of proinflammatory cytokines may contribute to the occurrence of seizures in patients with COVID-19, but seizures may also be secondary to primary brain pathology related to COVID-19, such as stroke or encephalitis.Najčešći neurološki simptomi kod bolesnika s infekcijom SARS-CoV-2 su glavobolja, mialgija, encefalopatija, vrtoglavica, disgeuzija i anosmija, a čine više od 90% neuroloških manifestacija ove bolesti. Ostala neurološka zbivanja poput moždanog udara, poremećaja pokreta ili epileptičkih napada nisu česta, ali su potencijalno teške komplikacije s mogućim smrtnim ishodom. Primarni cilj ove studije bio je procijeniti učestalost akutnih simptomatskih napadaja kod bolesnika s COVID-19, dok je sekundarni cilj bio utvrditi njihovu moguću etiologiju. Od ukupno 5382 bolesnika hospitaliziranih u Kliničkoj bolnici Dubrava od 1. studenoga 2020. godine do 1. lipnja 2021. njih 38 (0,7%) je imalo akutne simptomatske napadaje. Od tih 38 bolesnika 29 (76,3%) ih je imalo novonastale epileptičke napadaje bez ranije anamneze epilepsije, dok je njih 9 (23,7%) imalo anamnezu dobro kontrolirane epilepsije uz pojavu epileptičkih napadaja tijekom bolesti COVID-19. Iako su akutni simptomatski napadaji rijetka komplikacija bolesti COVID-19, treba razmišljati o epileptičkim napadajima kod ovih bolesnika, osobito kod onih s teškim oblikom bolesti. Nakupljanje proupalnih citokina može doprinijeti pojavi napadaja u bolesnika s COVID-19, ali napadaji mogu također biti posljedica primarnog zbivanja na mozgu uslijed bolesti COVID-19, poput moždanog udara ili encefalitisa

Ischemic stroke in a patient with giant fusiform aneurysm of dolichoectatic basilar artery and Covid-19 infection

Coronavirus disease (Covid-19) can manifest with numerous neurological disorders. We present a case of stroke in a patient with acute intraluminal thrombus in giant basilar tip fusiform aneurysm. A 71- year- old woman with past medical history of arterial hypertension and dilated cardiomyopathy was hospital- ized in intensive care unit (ICU) because of decreased consciousness (GCS 6) and a right- sided hemiple- gia which occurred twelve hours before admission. Five days earlier she was tested positive for Covid-19. ECG revealed new-onset atrial fibrillation (AF). She was intubated and mechanically ventilated. Brain CT and CT angiography of the head and neck vessels revealed dolichoectatic BA with giant fusiform an- eurysm of the tip of BA. BA lumen was partially filled with hyperdense, acute thrombus. Hypodensity of superior cerebellar artery (SCA) irrigation was consistent with acute ischemic stroke. She was treated with low molecular weight heparin, acetylsalicylic acid and corticosteroid therapy. During hospitalization her respiratory function deteriorated, and she died. To our knowledge this is the first case of stroke caused by acute thrombus in a giant tip of the BA aneurysm in patient with Covid-19 infection. It is important to increase prehospital stroke awareness since stroke in patients with Covid-19 is related to worse outcomes, and in appropriate time window can be treated with acute recanalization techniques

Usporedba Conconijevog i ventilacijskog anaerobnog praga određenog kratkim i standardnim protokolom testa na pokretnoj traci

The purpose of this study was to compare two methods for determination of anaerobic threshold from two different treadmill protocols. Forty-eight Croatian runners of national rank (ten sprinters, fifteen 400-m runners, ten middle distance runners and thirteen long distance runners), mean age 21.7}5.1 years, participated in the study. They performed two graded maximal exercise tests on a treadmill, a standard ramp treadmill test (TSR, speed increments of 1 km•h-1 every 60 seconds) and a fast ramp treadmill test (TFR, speed increments of 1 km•h-1 every 30 seconds) to determine and compare the parameters at peak values and at heart rate at the deflection point (HR DP) and ventilation threshold (VT ). There were no significant differences between protocols (p>0.05) for peak values of oxygen uptake (VO2max, 4.48±0.43 and 4.44±0.45 L•min-1), weight related VO2max (62.5±6.2 and 62.0±6.0 mL•kg-1•min-1), pulmonary ventilation (VE max, 163.1}18.7 and 161.3}19.9 L•min-1) and heart rate (HR max, 192.3}8.5 and 194.4}8.7 bpm) (TFR and TSR, respectively). Moreover, no significant differences between TFR and TSR where found for VT and HR DP when expressed as VO2 and HR . However, there was a significant effect of ramp slope on running speed at VO2max and at the anaerobic threshold (AnT) , independent of the method used (VT : 16.0}2.2 vs 14.9}2.2 km•h-1;HR DP: 16.5}1.9 vs 14.9±2.0 km•h-1 for TFR and TSR respectively). Linear regression analysis revealed high between-test and between-method correlations for VO2, HR and running speed parameters (r=0.78-0.89, p<0.01). The present study has indicated that the VT and HR DP for running (VO2, ventilation, and heart rate at VT /HR DP) are independent of test protocol, while there is a significant effect of ramp slope on VT and HR DP when expressed as running speed. Moreover, this study demonstrates that the point of deflection from linearity of heart rate may be an accurate predictor of the anaerobic threshold in trained runners, independently of the protocol used.Cilj istraživanja bio je usporediti dvije metode za utvrđivanje anaerobnog praga u dva različita protokola opterećenja. U istraživanju je sudjelovalo 48 trkača hrvatskog nacionalnog ranga (10 sprintera na 100 m, 15 sprintera na 400 m, 10 srednjeprugaša i 13 dugoprugaša) srednje dobi 21,7}5,1 god. Ispitanici su testirani dvama različitim protokolima maksimalnog opterećenja na pokretnoj traci: standardnim progresivnim protokolom opterećenja (TSR, brzina trake povećava se svake minute za 1 km/h) i brzo-rastućim progresivnim testom opterećenja (TFR, brzina trake povećava se za 1 km/h svakih 30 sekunda), u cilju mjerenja i usporedbe vršnih vrijednosti i vrijednosti pri ventilacijskom anaerobnom pragu (VT ) i točki defleksije frekvencije srca (HR DP). Vršne vrijednosti izmjerene u dva protokola (TFR :TSR) nisu se značajno razlikovale za primitak kisika (VO2max, 4,48:4,44 L/min), relativni VO2max (62,5:62,0 mL/kg/min), minutni volumen disanja (VE max, 163,1:161,3 L/min) i frekvenciju srca (192,3:194,4 otkucaja/min). Značajne razlike između TFR i TSR nisu utvrđene niti za VT i HR DP izražene primitkom kisika i frekvencijom srca. Međutim, utvrđen je značajan utjecaj protokola testa (akceleracije brzine trake) na brzine trčanja pri maksimumu i pri anaerobnom pragu, neovisno o primijenjenoj metodi (VT : 16,0±2,2 prema 14,9±2,2 km•h-1; HRDP: 16,5±1,9 prema 14,9±2,0 km•h-1 za TFR i TSR). Linearnom regresijskom analizom utvrđene su visoke pozitivne korelacije između protokola i između metoda određivanja praga za parametre primitka kisika, frekvencije srca i brzine trčanja (r=0,78-0,89, p<0,01). Rezultati rada pokazuju da su VT i HR DP za trčanje (VO2, VE i HR pri VT /HR DP) neovisni o protokolu testa, dok je značajan utjecaj protokola (brzine porasta brzine trake) na VT i HRDP izražene brzinom trčanja. Nadalje, ovo istraživanje pokazuje da se točka defleksije frekvencije srca (Conconijev test) može pouzdano koristiti za predviđanje anaerobnog praga u treniranih trkača neovisno o primijenjenom protokolu testa

Prediktivni čimbenici za rano prepoznavanje farmakorezistentne epilepsije

Epilepsy is one of the most common neurologic diseases. Despite improved diagnostic and therapeutic possibilities seizures remain refractory in more than 30% of patients with epilepsy. The aim of this study was to analyze the possible predictive factors for the development of pharmacoresistance in cryptogenic partial complex epilepsy. Patients were divided into two groups based on the number of seizures, clinical response to antiepileptic drugs and duration of the disease. One group consisted of patients resistant to anticonvulsant drugs and the other group of patients with well controlled seizures. Disease onset, electroencephalographic (EEG) findings and frequency of secondary generalization of partial complex seizures were analyzed in both groups. The results obtained showed a statistically significantly earlier occurrence of first epileptic seizure in the group of patients with pharmacoresistant epilepsy. The group of pharmacoresistant patients also had a statistically significantly higher proportion of secondary generalization of complex partial seizures as well as a higher proportion of patients with focal changes in EEG. These findings suggest that the onset of the disease at an earlier age, focal changes in EEG and secondary generalization of partial seizures may be early predictive factors for the development of pharmacoresistance in patients with cryptogenic partial complex epilepsy.Epilepsija je jedna od najučestalijih neuroloških bolesti. Usprkos napretku dijagnostičkih i terapijskih mogućnosti epileptični napadaji ostaju refraktorni u više od 30% bolesnika s epilepsijom. Cilj ovoga istraživanja bio je analizirati moguće prediktivne čimbenike za razvoj farmakorezistencije kod bolesnika s kriptogenom parcijalnom kompleksnom epilepsijom. Na temelju broja napadaja, učinkovitosti antiepileptične terapije te duljine trajanja bolesti bolesnike s parcijalnom kompleksnom epilepsijom podijelili smo u dvije skupine. Jednu skupinu su činili bolesnici s medikamentno rezistentnim oblikom bolesti, dok su drugu skupinu činili bolesnici s dobrim odgovorom na antiepileptičnu terapiju. U obje skupine se ispitivala dob početka bolesti, analizirao se nalaz elektroencefalograma (EEG) te učestalost sekundarne generalizacije parcijalnih kompleksnih napadaja. Dobiveni rezultati su pokazali da je u skupini bolesnika s farmakorezistentnim oblikom bolesti statistički značajna ranija dob pojave prvog napadaja. Također je utvrđeno da je u skupini farmakorezistentnih bolesnika statistički značajno veći udio bolesnika kod kojih dolazi do sekundarne generalizacije parcijalnih kompleksnih napadaja, kao i veći udio bolesnika sa žarišnim promjenama u EEG-u. Dobiveni rezultati ukazuju na to da ranija dob početka bolesti, žarišne promjene u EEG-u i sekundarna generalizacija parcijalnih epileptičnih napadaja mogu biti rani prediktivni čimbenici za razvoj medikamentne rezistencije u bolesnika s kriptogenom parcijalnom kompleksnom epilepsijom