Diferencijalna dijagnostika vertiga i epilepsije

Vertigo is most commonly a feeling of spinning, usually due to the disturbance in the balance (vestibular) system. It may result from a dysfunction of the vestibular system at any point from the ear to the cerebral cortex. Epileptic vertigo is a rare form of partial seizures, due to epileptic activity in parts of the cortex that represent the vestibular system: the parietal, temporal and frontal cortex. The episodes usually last no more than seconds or minutes. Unconsciousness will follow only if the seizure becomes generalized. Diagnostic tests include EEG and MRI scans of the head. Further diagnostic evaluation in the case of medical intractability would include: video EEG monitoring, intracarotid amytal testing, ictal SPECT, neurophysiogical evaluation and intracranial EEG monitoring. An abnormal EEG is a major criterion for diagnosis. In most patients the abnormality consists of temporal or bitemporal sharp or slow wave foci. In some cases there are associated generalized seizure discharges. Treatment of epileptic vertigo is usually successful with traditional anticonvulsants such as carbamazepine and its relatives. If, after a reasonable trial with appropriate antiepileptic drugs, seizures remain inadequately controlled, a surgery can be considered. Differential diagnosis of epileptic vertigo includes: a basilar type migraine, confusional migraine, benign paroxysmal vertigo of childhood and an aura without a headache. The main differential diagnosis of neocortical temporal lobe seizures is a mesial temporal lobe seizure. Ictal SPECT scanning and MRI can provide diagnostic data not otherwise obtainable. In addition, proton MR spectroscopy and PET studies can be helpful to distinguish the mesial from neocortical temporal lobe seizures.Vertigo je najčešće osjećaj vrtnje, uobičajeno kao posljedica poremećaja osjetila ravnoteže (vestibularnog sustava). Može nastati zbog disfunkcije vestibularnog sustava na bilo kojem mejstu od unutarnjeg uha do kore mozga. Epileptički vertigo je rijetki oblik parcijalnih napada koji nastaje zbog epileptičke aktivnosti u dijelovima korteksa koji predstavljaju vestibularni sustav: parijetalni, temporalni i frontalni korteks. Napadi obično traju nekoliko sekundi do nekoliko minuta, a gubitak svijesti nastaje samo kada se napad generalizira. Dijagnostičke pretrage uključuju EEG i MRI glave. Daljnja dijagnostička obrada u rezistentnim slučajevima uključuje: video EEG monitoriranje, intrakarotidno primjenu amitala, SPECT tijekom napada, neurofiziološku procjenu i intrakranijsko EEG monitoriranje. Poremećeni EEG je glavni kriterij za dijagnozu. U većine bolesnika poremećaji EEG-a uključuju temporalna ili bitemporalna žarišta šiljastih i sporih valova. U nekih slučajeva pridružuju se generalizirana epileptička izbijanja. Terapija epileptičkog vertiga obično je uspješna primjenom tradicionalnih antiepileptika poput karbamazepina i njemu sličnih lijekova. Ukoliko, nakon razumnog roka primjene adekvatnih antiepileptičkih lijekova, napadi nisu adekvatno kontrolirani, mogu se razmotriti i kirurške metode. Diferencijalna dijagnostika epileptičkog vertiga uključuje: bazilarnu migrenu, konfuzijsku migrenu, benigni paroksizmalni vertigo u djetinjstvu i auru bez glavobolje. Najznačajnija ke diferencijalna dijagnoza neokortikalnih temporalnih napada od mezijalnih temporalnih napada. Iktalni SPECT i MRI mogu pružiti dijagnostičke podatke koji se ne mogu dobiti na drugi način. Protonska MR spektroskopija i PET mogu biti od pomoći u razlikovanju mezijalnih od neokortikalnih temporalnih napada

Vrijeme do prvog EEG napadaja tijekom kontinuirane Video/EEG telemetrije

Correlation between time to first scalp EEG seizure during video/EEG telemetry and self-reported seizure frequency was determined in refractory epilepsy patients. Eighty two consecutive epilepsy patients were preoperatively evaluated, as part of a larger study, during their video/EEG monitoring at the Adult Epilepsy Center at Washington University. Self-reported seizure frequency, time to first seizure in the monitoring unit, and clinical variables of age, sex and seizure focus localization were analyzed. Mean age of the patients was 35±11 years and 54.9% were women. In 51 patients with temporal and 19 patients with extra temporal epilepsy, the mean time to first scalp EEG seizure was 44±48 h. Self-reported seizure frequency did not predict the time to first scalp EEG seizure in the seizure monitoring unit. The majority of patients had their first scalp EEG seizure during the first two days of video/EEG telemetry. Self-reported seizure frequency was a poor predictor of time to first scalp EEG seizure. This finding suggests that patients with less frequent self-reported seizure rates should also be considered as good candidates for further evaluation, including scalp and intracranial video/EEG telemetry.Određivala se je korelacija između vremena do prvog napadaja kod EEG vlasišta tijekom Video/EEG telemetrije i učestalosti napadaja koju su navodili sami bolesnici s refraktornom epilepsijom. Prijeoperacijski su obrađena 82 uzastopna bolesnika s epilepsijom, kao dio veće studije, tijekom njihova Video/EEG praćenja u Centru za epilepsiju odraslih pri Sveučilištu u Washingtonu. Analizirana je učestalost napadaja koju su naveli sami bolesnici, vrijeme do prvog napadaja u kabinetu za praćenje, te kliničke varijable za dob, spol i žarišnu lokalizaciju napadaja. Srednja dob bolesnika bila je 35±11 godina, a 54,9% bile su žene. U 51 bolesnika s temporalnom i 19 bolesnika s ekstratemporalnom epilepsijom srednje vrijeme do prvog napadaja na EEG bilo je 44±48 h. Učestalost napadaja koju su navodili sami bolesnici nije predskazala vrijeme do prvog napadaja kod EEG telemetrije. U većine bolesnika prvi je napadaj na EEG nastupio tijekom prva dva dana Video/EEG telemetrije. Učestalost napadaja koju su navodili bolesnici bila je loš predskazatelj vremena do prvog napadaja na EEG. Ova studija ukazuje na to da bolesnike koji navode rjeđu učestalost napadaja treba također smatrati dobrim kandidatima za daljnju procjenu, uključujući Video/EEG telemetriju

Vrijeme do prvog EEG napadaja tijekom kontinuirane Video/EEG telemetrije

Correlation between time to first scalp EEG seizure during video/EEG telemetry and self-reported seizure frequency was determined in refractory epilepsy patients. Eighty two consecutive epilepsy patients were preoperatively evaluated, as part of a larger study, during their video/EEG monitoring at the Adult Epilepsy Center at Washington University. Self-reported seizure frequency, time to first seizure in the monitoring unit, and clinical variables of age, sex and seizure focus localization were analyzed. Mean age of the patients was 35±11 years and 54.9% were women. In 51 patients with temporal and 19 patients with extra temporal epilepsy, the mean time to first scalp EEG seizure was 44±48 h. Self-reported seizure frequency did not predict the time to first scalp EEG seizure in the seizure monitoring unit. The majority of patients had their first scalp EEG seizure during the first two days of video/EEG telemetry. Self-reported seizure frequency was a poor predictor of time to first scalp EEG seizure. This finding suggests that patients with less frequent self-reported seizure rates should also be considered as good candidates for further evaluation, including scalp and intracranial video/EEG telemetry.Određivala se je korelacija između vremena do prvog napadaja kod EEG vlasišta tijekom Video/EEG telemetrije i učestalosti napadaja koju su navodili sami bolesnici s refraktornom epilepsijom. Prijeoperacijski su obrađena 82 uzastopna bolesnika s epilepsijom, kao dio veće studije, tijekom njihova Video/EEG praćenja u Centru za epilepsiju odraslih pri Sveučilištu u Washingtonu. Analizirana je učestalost napadaja koju su naveli sami bolesnici, vrijeme do prvog napadaja u kabinetu za praćenje, te kliničke varijable za dob, spol i žarišnu lokalizaciju napadaja. Srednja dob bolesnika bila je 35±11 godina, a 54,9% bile su žene. U 51 bolesnika s temporalnom i 19 bolesnika s ekstratemporalnom epilepsijom srednje vrijeme do prvog napadaja na EEG bilo je 44±48 h. Učestalost napadaja koju su navodili sami bolesnici nije predskazala vrijeme do prvog napadaja kod EEG telemetrije. U većine bolesnika prvi je napadaj na EEG nastupio tijekom prva dva dana Video/EEG telemetrije. Učestalost napadaja koju su navodili bolesnici bila je loš predskazatelj vremena do prvog napadaja na EEG. Ova studija ukazuje na to da bolesnike koji navode rjeđu učestalost napadaja treba također smatrati dobrim kandidatima za daljnju procjenu, uključujući Video/EEG telemetriju

Kapacitet neverbalnog pamćenja kod osoba oboljelih od epilepsije povezan je s depresijom, a ne s anksioznosti

Epilepsy is characterized by repeated epileptic seizures, which are manifested in various ways and depend on the location and size of foci in the brain. Long-term seizures with secondary generalization can cause memory problems. Numerous studies demonstrate the connection of memory damage and lateralization in medial temporal lobe epilepsy (TLE). However, the results were not always consistent with the material-specific memory model. A possible explanation for these inconsistent data is the insufficient control of psychological variables that can affect memory. In most of the previous studies in persons with epilepsy, they were not controlled for their emotional states such as anxiety and depression. We used the Rey Complex Figure Test (RCFT) as a measure of visual memory, Beck’s depression inventory as a measure of depressive symptoms, and the State-Trait Anxiety Inventory as a measure of anxiety in 57 consecutive participants. Our aim was to investigate whether there is difference in visual memory with respect to the left and right TLE, and whether the participants of different gender with higher anxiety and depression rates would achieve different results on visual memory. Persons with lower levels of depression achieved better scores in the Immediate and Delayed recall subtests of the RCFT. We also explored the potential gender differences. Testing differences between the persons with higher and lower anxiety levels did not reveal any significant differences in any of the measures tested.Epilepsija je obilježena ponavljajućim epileptičnim napadajima koji se manifestiraju na razne načine ovisno o lokaciji i veličini žarišta. Dugotrajni napadaji sa sekundarnom generalizacijom oštećuju i produbljuju probleme s pamćenjem. Brojne studije su dokazale povezanost oštećenja pamćenja i lateralizacije kod epilepsije temporalnog režnja. Međutim, rezultati nisu uvijek bili sukladni modelu pamćenja specifičnog za materijal. Moguće objašnjenje ove nedosljednosti je nedovoljna kontrola psiholoških varijabla koje mogu utjecati na pamćenje. U većini prijašnjih studija s osobama koje ­boluju od epilepsije emocionalna stanja poput anksioznosti i depresivnosti nisu bila kontrolirana. U našem istraživanju smo primijenili Reyev test složenog lika kao mjeru vidnog pamćenja, Beckov inventar depresije (BDI) kao mjeru depresivnosti i Upitnik anksioznosti kao stanja i osobine ličnosti kao mjeru anksioznosti na 57 uzastopnih sudionika. Naš glavni cilj je bio ispitati postoji li razlika u vidnom pamćenju s obzirom na desnostranu i lijevostranu epilepsiju temporalnog režnja, rod sudionika te stupanj anksioznosti i depresivnosti. Sudionici s niskom razinom depresivnosti su postigli bolje rezultate na subtestovima Reyeva složenog lika te na neposrednom i odgođenom dosjećanju. Također smo istražili potencijalne spolne razlike. Nisu utvrđene razlike u vidnom pamćenju niti s obzirom na rod sudionika niti s obzirom na stupanj anksioznosti

Uloga tilt testa u diferencijalnoj dijagnostici neobjašnjene sinkope

The aim of this retrospective study (February 2012 – September 2014) was to assess the role of head-up tilt-table test in patients with unexplained syncope. It was performed on 235 patients at Clinical Department of Cardiology, Sestre milosrdnice University Hospital Center. Patients were classified according to test indications: group A (convulsive syncope, n=30), group B (suspected vasovagal syncope, n=180), and group C (paroxysmal vertigo, n=25). The groups were analyzed and compared according to demographic data (age and gender), referral specialist (cardiologist, neurologist, and others), and test results (positive/negative) with specific response (cardioinhibitory, vasodepressor, or mixed). Groups A and B were referred most frequently by neurologists and cardiologists (p<0.05). The test was positive in 34 (14.5%) of all evaluated patients (5 in group A and 29 in group B), of which 13 (38.2%) had cardioinhibitory, 11 (32.4%) mixed and 10 (29.4%) vasodepressor response. In the cardioinhibitory subgroup, three patients (23.1%, 2 males/1 female, mean age 28.5 years) with normal electroencephalography were on antiepileptics. During headup tilt-table testing, they had bradycardia (heart rate 30.0±5.0 beats/min) and prolonged asystole (13.7±11.0 seconds) with development of typical convulsions. These three subjects got a permanent pacemaker (atrial/ventricular stimulation, heart rate control) and anticonvulsive therapy was slowly withdrawn with no syncope recurrence during 24-month follow up. In conclusion, head-up tilt-table test has an important role in the evaluation of patients with unexplained syncope and in differential diagnosis of vasovagal syncope. The indication for pacemaker implantation, strictly following the European Society of Cardiology guidelines, proved to be effective in preventing syncope relapses in patients with cardioinhibitory convulsive syncope.Cilj ovoga retrospektivnog istraživanja (veljača 2012. – rujan 2014. godine) bio je ispitati ulogu tilt testa u bolesnika s neobjašnjenom sinkopom. Provedeno je na 235 bolesnika u Zavodu za kardiologiju KBC-a “Sestre milosrdnice”. Bolesnici su klasificirani prema indikaciji za izvođenje testa: skupina A (konvulzivna sinkopa, n=30), skupina B (suspektna vazovagalna sinkopa, n=180) i skupina C (paroksizmalni vertigo, n=25). Skupine su analizirane i uspoređivane prema njihovim demografskim podacima (dob, spol), specijalistima koji su ih uputili na pretragu (kardiolozi, neurolozi, ostali) te rezultatima (pozitivan/negativan) i specifičnim odgovorima (kardionhibicija, vazodepresija ili mješoviti) tilt testa. Skupine A i B najčešće je na testiranje uputio neurolog i kardiolog (p<0,05). Test je bio pozitivan u 34 (14,5%) bolesnika (5 u skupini A i 29 u skupini B), od kojih je 13 (38,2%) imalo kardioinhibicijski, 11 (32,4%) mješoviti i 10 (29,4%) vazodepresivni odgovor. U kardioinhibicijskoj podskupini troje bolesnika (23,1%, 2 muškarca/1 žena, srednje dobi 28,5 godina) je imalo normalan nalaz elektroencefalografije i uzimali su antiepileptike. Tijekom izvođenja testa zabilježili smo bradikardiju (30,0±5,0 otkucaja/min) i produženu asistoliju (13,7±11,0 sekunda) uz pojavu tipičnih konvulzija. U sve troje bolesnika ugrađen je trajni elektrostimulator (atrijska/ventrikulska stimulacija, kontrola frekvencije) i ukinuta je antikonvulzivna terapija, nakon čega su tijekom 24 mjeseca praćenja bili bez recidiva sinkope. U zaključku, tilt test ima važnu ulogu u procjeni bolesnika s neobjašnjenom sinkopom i u diferencijalnoj dijagnostici vazovagalne sinkope. Indikacija za ugradnju elektrostimulatora, strogo slijedeći smjernice Europskoga kardiološkog društva, pokazala se učinkovitom u sprječavanju recidiva sinkopa u bolesnika s kardioinhbicijskom konvulzivnom sinkopom

Ortostatska intolerancija: sindrom posturalne ortostatske tahikardije s vazovagalnom sinkopom

A 28-year-old female with a history of situational syncope and a new-onset right sided hemiparesis is described. Tilt-up table test revealed the postural orthostatic tachycardia syndrome followed by vasovagal syncope. Neurological and internal medicine tests showed no particular disorders. The patient underwent autonomic physical training and the tilt-up test performed three months later showed improvement of the autonomic system in terms of lower heart beat rate of the postural orthostatic tachycardia syndrome and longer duration of the test. This case report describes longstanding idiopathic dysautonomia that can be improved by nonpharmacological treatment, while reminding that this medical condition may also be the cause of syncope.Prikazuje se 28-godišnja bolesnica s anamnezom višegodišnje situacijske sinkope i novonastalom desnostranom hemiparezom. Učinjen tilt-up table testom utvrđen je sindrom posturalne ortostatske tahikardije (engl. POTS , postural orthostatic tachycardia syndrome), nakon kojeg je uslijedila vazovagalna sinkopa. Neurološkom i internističkom obradom nije utvrđen eventualan drugi uzrok sinkope. Tijekom slijedeća tri mjeseca bolesnica je u kućnim uvjetima provodila ortostatske vježbe autonomnog sustava, nakon čega je učinjen kontrolni tilt-up table test kojim je objektivizirano poboljšanje statusa autonomnog sustava u smislu nižih vrijednosti frekvencije tahikardije POTS -a i duljeg trajanja testa, odnosno održavanja ortostaze. Ovaj slučaj govori o višegodišnjoj idiopatskoj disautonomiji na koju je moguće utjecati nefarmakološkim metodama te je ujedno i podsjetnik na jedan od mogućih uzroka sinkope

Serotonergic Therapy in Epilepsy

Purpose of review The serotonergic system is implicated in multiple aspects of epilepsy, including seizure susceptibility, sudden unexpected death in epilepsy (SUDEP), and comorbid depression. Despite the complexity of serotonin’s effects on various neuronal networks, ongoing research provides considerable insight into the role of serotonin in human epilepsy. This review explores the potential roles of serotonergic therapies to improve clinical outcomes in epilepsy. Recent findings In recent decades research has markedly increased our knowledge of the diverse effects of serotonin on brain function. Animal models of epilepsy have identified the influence of serotonin on seizure threshold in specific brain regions, serotoninergic augmentation’s protective effects on terminal apnea and mortality in SUDEP, and mechanisms underlying behavioral improvement in some models of comorbid depression. Human clinical studies are largely consistent with animal data, but the translation into definitive treatment decisions has moved less rapidly. Summary Evidence for serotonergic therapy is promising for improvement in seizure control and prevention of SUDEP. For some epilepsies, such as Dravet syndrome, basic research on serotonin receptor agonists has translated into a positive clinical trial for fenfluramine. The cumulative results of safety and efficacy studies support the routine use of SSRIs for comorbid depression in epilepsy