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BACKGROUND: An abnormal EEG is pivotal in diagnosis, exclusion of mimickers and prognosticating epilepsy in Autoimmune Encephalitis (AE). However, little is known about the short and long term electroencephalographic outcomes and predictors of epilepsy in AE. This study aims to describe the seizure characteristics and electrophysiological markers of various AE subtypes and assess the clinical and electrophysiological predictors of autoimmune epilepsy. METHODS: Clinical features and EEGs in 74 patients (acute phase=39 and post-acute phase defined after a minimum eight weeks after acute phase=35) of AE fulfilling the proposed criteria were reviewed in their respective acute phases and at six months follow-up. RESULTS: The mean age of presentation (N = 74, 45 females) was 21.8 (21.8 ± 17.0) years. 38 (51 %) patients were <18 years. Seizures were present in 55 (74 %) patients with poor response to ASMs (p = 0.039). 39 (52.7 %) EEGs were abnormal in acute phase. Anti-NMDAR AE had most frequently abnormal EEG (63.4 %). Poor background reactivity and theta range slowing were most common abnormalities. FIRDA, EDB and delta range slowing were seen in seropositive AE (P = 0.003). Mutism, psychiatric features and incontinence correlated with abnormal EEG (p = 0.013, p = 0.028 and p = 0.025). Background slowing and epileptiform discharges predicted worse cognitive scores at follow-up (p = 0.012). Eight (11.9 %) patients developed epilepsy. Status epilepticus at presentation (p = 0.009), seronegative status (p = 0.0020), delayed initiation of immunotherapy (p = 0.012), abnormal MRI (p = 0.003) and abnormal EEG (p = 0.004) at onset indicate development of autoimmune epilepsy CONCLUSIONS: FIRDA, EDB and delta range slowing with refractory seizures suggest AE. Epileptiform abnormalities, status epilepticus and seronegativity predict autoimmune epilepsy.
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OBJECTIVE: The alpha rhythm has been a subject of research for the past few decades. Right-left alpha amplitude asymmetry is a common phenomenon. Several explanations have been proposed to explain this asymmetry, including differences in skull thickness. Our research aims to improve our understanding of the relationship between alpha asymmetry and skull thickness as measured by CT/MRI images. METHODS: We analyzed EEGs to study alpha rhythm characteristics. Alpha rhythm amplitude was measured using peak-to-peak values in O1 and O2 reference channels. Significant alpha asymmetry was defined as exceeding 20%. Skull thickness differences at corresponding locations were determined through CT/MRI scans. We examined the correlation between alpha and skull thickness asymmetry using Kruskal-Wallis, Spearman correlation, and median regression. RESULTS: We examined 401 EEGs and images, categorizing patients into three groups based on alpha asymmetry. Group 1(n= 211) had less than 20 percent alpha asymmetry, Group 2(n=107) showed higher right-side alpha amplitudes, and Group 3(n= 83) displayed higher left-side alpha amplitudes. Our analysis revealed a significant association between groups with asymmetry and skull thickness differences (p<0.001), with a Spearman correlation (Rs) of -0.25 (p<0.001), indicating a significant negative correlation. After adjusting for age, sex, and handedness, Median Regression confirmed a statistically significant variation in skull thickness difference among the groups. SIGNIFICANCE: The present study involving a large cohort, the first of its kind, demonstrated a significant relationship between alpha amplitude asymmetry and skull thickness.
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Ritmo alfa , Imagen por Resonancia Magnética , Cráneo , Tomografía Computarizada por Rayos X , Humanos , Masculino , Femenino , Imagen por Resonancia Magnética/métodos , Cráneo/anatomía & histología , Cráneo/diagnóstico por imagen , Adulto , Tomografía Computarizada por Rayos X/métodos , Persona de Mediana Edad , Ritmo alfa/fisiología , Adulto Joven , Electroencefalografía , Anciano , Adolescente , Lateralidad Funcional/fisiologíaRESUMEN
Background: Fluorodeoxyglucose-positron emission tomography (FDG-PET) in autoimmune encephalitis (AE) as an adjunctive investigation helps in characterizing the type of AE based on characteristic metabolic patterns. Objectives: We aimed to study the following: (i) the sensitivity of FDG-PET in the diagnosis of AE, (ii) describe abnormal patterns of metabolism of various subtypes of AE, and (iii) correlate serum serology with FDG-PET abnormalities. Materials and Methods: This study was conducted at a tertiary university hospital in South India. The demographic profile, clinical features, and investigations (FDG-PET, magnetic resonance imaging (MRI) brain, electroencephalography (EEG), cerebrospinal fluid (CSF)) were reviewed. The nuclear medicine physician performed blinded qualitative visual and semi-quantitative analysis of the 18-FDG-PET (fluorine 18-FDG-PET) findings of these patients. Results: Twenty-nine (M:F: 11:18) patients were recruited; among them, 22 (75.8%) patients had autoimmune antibodies; the rest seven (24.1%) patients were seronegative. Among the 22 seropositive patients, 9 (31%) patients were positive for anti-N-methyl-D-aspartate receptor (NMDAR), 8 (28%) for anti-leucine-rich glioma inactivated 1 (LGI-1), 4 (14%) for anti-contactin-associated protein 2 (CASPR2), 1 (3%) for anti-glutamic acid decarboxylase (GAD)-65, and rest 7 (24%) patients were seronegative. The patterns most commonly observed were isolated hypermetabolism (41%), isolated hypometabolism (41%), and combined hypermetabolism with hypometabolism (18%). The fraction of abnormalities was lower for MRI (17/22; 73.9%) than for FDG-PET (27/29; 93.1%). FDG-PET correlated with serology in 10 (34%) cases [NMDAR: 6 (60%) and LGI-1: 4 (40%)]. The sensitivity of FDG-PET was 94.1% when compared with MRI. Discussion and Conclusion: FDG-PET correlated with serology in only one-third of patients. The most consistent pattern in both seropositive and seronegative AE is characterized by parieto-occipital hypometabolism and fronto-temporal with basal ganglia hypermetabolism.
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OBJECTIVE: P300 is an event-related potential, being explored as an objective tool to assess cognition. This study aimed to investigate the characteristics of auditory and visual P300 in patients with TLE having unilateral HS using electroencephalography (EEG) and to study its correlation with cognition. METHODS: This is a cross-sectional case-control study, where P300 characteristics in thirty patients with unilateral hippocampal sclerosis with refractory epilepsy were compared with fifteen age-, gender-, and years of education-matched healthy controls (M: F-10:5, mean age-28⯱â¯4.76â¯years). Among patients, 15 belonged to the right HS group (M: F-9:6, age at onset-12.92⯱â¯10.22â¯years, duration of epilepsy-16.67⯱â¯9.38â¯years) and 15 to the left HS group (M: F-8:7, age at onset-10.62⯱â¯7.18â¯years, duration of epilepsy-15.53⯱â¯10.14â¯years). All subjects underwent EEG-based auditory and visual oddball tasks and cognitive assessment. The P300 latencies (in milliseconds) as well as amplitudes (in microvolts) were predicted in EEG and were correlated with cognitive scores. Source localization of P300 was performed with the CLARA algorithm. RESULTS: The auditory P300 latencies in controls, right HS, and left HS were 323.93⯱â¯40.28, 351.06⯱â¯47.23, and 328.80⯱â¯36.03, respectively (pâ¯=â¯0.18) and its amplitudes were 2.3040⯱â¯1.46, 2.77⯱â¯1.19, and 2.68⯱â¯1.78, respectively (pâ¯=â¯0.48). Visual P300 latencies in controls, right HS, and left HS were 365.87⯱â¯47.37, 359.67⯱â¯64.45, and 376.00⯱â¯60.06, respectively (pâ¯=â¯0.51) and its amplitudes were 3.93⯱â¯2.28, 2.09⯱â¯1.45, and 3.56⯱â¯1.74, respectively (pâ¯=â¯0.014). Further, when compared to the control group the cognitive scores were lower in the patient group (pâ¯<â¯0.05). SIGNIFICANCE: In comparison to the controls, patients with right HS recorded lesser amplitude on visual P300 and lower scores on cognitive tests. P300 and cognitive parameters exhibited varied relationship. P300 could be a complementary objective tool to assess cognition in patients with TLE.
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Epilepsia del Lóbulo Temporal , Estudios de Casos y Controles , Cognición , Estudios Transversales , Electroencefalografía , Epilepsia del Lóbulo Temporal/complicaciones , Epilepsia del Lóbulo Temporal/patología , Hipocampo/patología , Humanos , Esclerosis/patologíaRESUMEN
BACKGROUND: The recommended treatment for refractory status epilepticus (RSE) is the use of anesthetic agents, but evidence regarding the agent of choice is lacking. This study was designed to compare target-controlled infusion of propofol versus midazolam for the treatment of RSE regarding seizure control and complications. METHODS: This prospective, randomized study recruited 23 adult patients with RSE due to any etiology and treated with either propofol or midazolam titrated to clinical seizure cessation and gradual tapering thereafter. The primary outcome measure was seizure control and the secondary outcomes were duration of the Intensive Care Unit stay and duration of mechanical ventilation, occurrence of super RSE (SRSE), and complications. RESULTS: We recruited 23 patients (male:female = 18:5) into this study (propofol Group-11; midazolam Group-12). Overall, seizure control was noted in 34.8%, with successful seizure control in 45% of patients in the propofol group and 25% in midazolam group (P = 0.4). Mortality was similar in both the groups (propofol group [8/11; 72.7%] compared to the midazolam group [7/12; 58.3%] [P = 0.667]). The duration of hospital stay was significantly shorter in the propofol group compared to midazolam (P = 0.02). The overall incidence of SRSE was 69.5% in this study. The complication rate was not significantly different between the groups. CONCLUSIONS: The choice of anesthetic agent does not seem to affect the overall outcome in RSE and SRSE. Target-controlled propofol infusion was found to be equal in its efficacy to midazolam for the treatment of RSE. High mortality might be due to SRSE secondary to the underlying brain pathology.
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OBJECTIVE: This study was conducted to compare the efficacy of phenytoin, valproate and levetiracetam in patients with GCSE. METHODS: This randomised controlled prospective study was conducted on 150 patients to compare the efficacy of phenytoin (n = 50), valproate (n = 50) and levetiracetam (n = 50) along with lorazepam in patients with GCSE. All recruited patients received i.v. lorazepam (0.1mg/kg) followed by one of the 3 AEDs viz. phenytoin (20 mg/kg), valproate (30 mg/kg), and levetiracetam (25 mg/kg). Those who remained uncontrolled with 1st AED, received the other two AEDs sequentially. Clinical, imaging, EEG, etiological factors were analysed. Predictors of poor seizure control and outcome at discharge and at one month follow-up were assessed. RESULTS: In the phenytoin subgroup, the seizures could be controlled in 34 (68%) with lorazepam+phenytoin infusion. In the valproate subgroup (n = 50), seizures could be controlled in 34 (68%) with lorazepam+valproate infusion. In the levetiracetam subgroup (n = 50), seizures could be controlled in 39 (78%) with lorazepam+levetiracetam infusion. There was no statistically significant difference between the subgroups (p = 0.44). Overall, following lorazepam and 1st AED, 107/150 (71.3%) were controlled; with addition of 2nd AED, 130/150 (86.7%) and by adding 3rd AED, 138/150 (92%) were controlled. Fifteen out of 110 (13.6%) expired within 1 month of SE: phenytoin-6; valproate-4; and levetiracetam-5. Interestingly, 3 patients in the levetiracetam had post-ictal psychosis. SIGNIFICANCE: Phenytoin, valproate, and levetiracetam are safe and equally efficacious following lorazepam in GCSE. The choice of AEDs could be individualised based on co-morbidities. SE could be controlled in 92% of patients with AEDs only and anaesthetics were not required in them.