Crises não-epilépticas: clínica e terapêutica

Discutir as crises ou os eventos paroxísticos que simulem crises epilépticas, enfatizando as diferenças semiológicas entre elas e as perspectivas terapêuticas. Realizamos uma revisão da literatura, selecionando artigos nas bases de dados Medline e Bireme, a partir dos unitermos: "non-epileptic seizures", "psychogenic seizures". As crises não-epilépticas (CNE) podem ser classificadas em fisiológicas (síncope, migrânea, ataque isquêmico transitório) e em psicogênicas (voluntárias ou não). O padrão-ouro para a diferenciação entre as crises epilépticas e as CNE é o videoeletroencefalograma, mas vários dados semiológicos podem auxiliar esse processo. O tratamento das CNE baseia-se em psicoterapia e em farmacoterapia direcionadas aos transtornos psiquiátricos comórbidos. Apesar de a alta prevalência das CNE e de sua elevada morbidade, são escassos os estudos na literatura nacional. São muitos os desafios diagnósticos e terapêuticos. Assim, o psiquiatra atentar-se à sua ocorrência, evitando iatrogenia, como o uso desnecessário de drogas antiepilépticas.

Monitorização vídeo-EEG prolongada em crises não epilépticas: semiologia clínica

O objetivo deste estudo foi mostrar a contribuição da monitorização vídeo-EEG prolongada (MVEP) no diagnóstico de crises não epilépticas (CNE) e estimar sua prevalência em um centro terciário de atendimento à Epilepsia (EP). Foram observados 47 pacientes com diagnóstico de CNE com crises espontâneas ou provocadas. Foram instituídos protocolos direcionados à história clínica e à semiologia das crises. A análise estatística baseou-se no teste de Fisher e na análise de cluster. Os resultados evidenciaram prevalência de 10% de CNE. Houve predominância do sexo feminino (63,8%); em 57% dos pacientes as crises foram espontâneas. A média de idade foi 32,5 ± 11anos. O sinal semiológico mais freqüente foi o sono aparente (87,2%). em 9% dos pacientes observaram-se tanto EP como CNE. Três agrupamentos resultaram da análise de cluster: CNE hipermotora das extremidades com alteração de tônus; CNE com automatismos e CNE axial com movimentos oculares. em conclusão, o estudo da semiologia clínica das CNE durante a MVEP contribui para o diagnóstico desta entidade nosológica e para o diagnóstico diferencial com EP; o teste provocativo auxilia na obtenção das crises.

Período ovulatório e crises epilépticas

We prospectively follow up 80 mentally healthy women at menacme age, with chronic epilepsy and had had least one seizure in the month preceding the study. We selected 59 patients from whom we were able to observe at least three regular menstrual cycles with seizures. We defined regular, irregular cycle, perimenstrual and ovulation period. According to our concepts we have got 19, 30 and 6 patients with respectively severe, moderate and mild exacerbation of perimenstrual seizures. Using our definitions 6, 20 and 17 patients showed severe, moderate and mild accentuation of seizures during ovulation, while 15 patients showed no ovulatory accentuation. Our attention was drawn to the great number of perimenstrual and ovulatory exacerbation of seizures, according to our criteria. From 55 patients with perimenstrual accentuation of seizures 44 (74.54%) showed exacerbation during the ovulatory period. In our opinion, these data speak out in favor of the hormonal theory to explain these occurrences. We discuss these data based on the avaiable literature. We think the strogen peak is probably the main cause of the increased frequency of epileptic seizures during the ovulation period. New studies, documenting objectively the ovulation and seizures are mandatory to clarify the relationship of these aspects of the female endocrine reproductive physiology in epileptics.

Análise espectral com wavelets do ECoG em crises epilépticas

Dissertação para obtenção do Grau de Mestre em Engenharia Biomédica

Hemiparesia congênita e adquirida na criança: interrelação entre presença de crises epilépticas, os achados eletrencefalográficos e de neuroimagem por ressonância nuclear magnética

The purpose of this paper was to study patients with congenital and acquired hemiparesis, their clinical aspects, the presence or not of epileptic seizures, and electroencephalographic (EEG) and Magnetic Resonance Imaging (MRI) findings. We analyzed the interrelation between etiology, the presence and seriousness of epileptic seizures (ES) and the possible causes of refractoriness. This is a prospective study using the clinical diagnosis of a child neurologist, who attested to the presence of unilateral motor lesions. We compared the electroencephalographic findings in patients with or without epileptic seizures, and investigated if among the former, these seizures were controlled or not, their likely etiology and risks of refractoriness. EEG background activity on the lesion and contralateral side was analyzed, in addition to the presence of concomitant epileptiform activity. Encephalon MRIs of all the patients were studied to correlate etiology and the control or not of epileptic seizures. The disorganization of bilateral EEG activity correlated with the difficult-to-control epileptic seizures. Suitably organized background activity contralateral to the lesion is a good prognosis in relation to epileptic seizures. Focal epileptogenic activity does not necessarily predispose to epileptic manifestation. The MRI is more important in determining etiology than in prognosing epileptic seizures. This study used a multidisciplinary approach involving child neurologists, a physical therapist and a neuroradiologist. This meets the criteria of multidisciplinarity of the Postgraduate Program in Health Sciences

Efeitos de crises crônicas e agudas induzidas por pentilenotetrazol sobre a hidrólise de nucleotídeos púricos em soro de ratos adultos

A adenosina tem sido descrita como tendo importante efeito neuromodulatório em SNC, inibindo a liberação de neurotransmissores excitatórios através da ativação dos receptores A1. Agonistas de receptores A1, bem como adenosina e seus análogos, tem sido descritos como supressores de crises epilépticas. Uma das vias de produção de adenosina é a hidrólise extra-celular completa do ATP envolvendo as enzimas ATP difosfoidrolase (CD39) e 5’-nucleotidase (CD73). Embora esta associação enzimática já esteja bem descrita, o envolvimento da enzima fosfodiesterase não pode ser descartado, uma vez que esta hidrolisa nucleotídeos como ATP e ADP, além de outros substratos. Recentemente, foi demonstrado em nosso laboratório um aumento das atividades ATP difosfoidrolase e 5’-nucleotidase em sinaptossomas de ratos após a indução de 2 diferentes modelos de epilepsia de lobo temporal. Neste trabalho, nós investigamos o efeito de crises agudas e crônicas induzidas pelo agente pró-convulsivante pentilenotetrazol (PTZ) sobre a hidrólise dos nucleotídeos ATP, ADP e AMP em soro de ratos, uma vez que formas solúveis de nucleotidases já estão descritas. No modelo agudo os animais receberam apenas 1 injeção de PTZ ou salina, sendo mortos por decapitação em diferentes tempos após a injeção da droga. A hidrólise dos nucleotídeos ATP, ADP e AMP apresentaram aumento significativo de 40 –50% nos ratos tratados em relação aos ratos controle até 24 após a última injeção. Em 48 horas, este efeito foi abolido. Já, a hidrólise do substrato artificial p-Nph-5’-TMP usado como marcador para a fosfodiesterase, não apresentou nenhum aumento significativo em ratos tratados quando comparado aos animais controle. No modelo crônico (kindling), os animais recebiam doses inicialmente subconvulsivantes que resultam em crises progressivamente mais intensas ao longo das subseqüentes estimulações. Para descartar o efeito da injeção aguda, os ratos foram mortos 48 horas após a última estimulação. Com exceção do substrato artificial para a fosfodiesterase, a hidrólise dos nucleotídeos testados aumentou de maneira significativa (cerca de 40% - 45%) em soro de ratos submetidos ao modelo de kindling. Estes resultados demonstram o envolvimento de nucleotidases solúveis no controle dos níveis do neurotransmissor ATP e do neuromodulador adenosina, sendo estas respostas presentes tanto em situações patológicas agudas, como em situações patológicas crônicas que envolvem o fenômeno de plasticidade sináptica.

Interferindo com oscilações de alta frequência no hipocampo epiléptico: consequências para as crises espontâneas

Conselho Nacional de Desenvolvimento Científico e Tecnológico

Edema pulmonar neurogênico: relato de dois casos

Neurogenic pulmonary edema is a rare and serious complication in patients with head injury. It also may develop after a variety of cerebral insults such as subarachnoid hemorrhage, brain tumors and after epileptic seizures. Thirty six patients with severe head injury and four patients with cerebrovascular insults treated in Intensive Care Unit of HC-UNICAMP from January to September 1995 were evaluated. In this period there were two patients with neurogenic pulmonary edema, one with head injury and other with intracerebral hemorrhage. Diagnosis was made by rapid onset of pulmonary edema, severe hypoxemia, decrease of pulmonary complacence and diffuse pulmonary infiltrations, without previous history of tracheal aspiration or any other risk factor for developement of adult respiratory distress syndrom. In the first case, with severe head trauma, neurogenic pulmonary edema was diagnosed at admission one hour after trauma, associated with severe systemic inflammatory reaction, and good outcome in three days. The second case, with hemorragic vascular insult, developed neurogenic pulmonary edema the fourth day after drenage of intracerebral hematom and died.

A pilot study of topiramate in children with Lennox-Gastaut syndrome

We conducted an open, add-on study with topiramate (TPM) as adjunctive therapy in Lennox-Gastaut syndrome (LGS), to assess the long-term efficacy and safety and to evaluate quality of life (QL) measurements in the chronic use of TPM. We studied 19 patients (11 male; age ranging from 4 to 14 years) with uncontrolled seizures receiving 2-3 anti-epileptic drugs. Patients were followed up to 36 months of treatment. A questionnaire was used to query parents about QL. Seven patients completed the study at 36 months and seizure frequency was reduced > 75% in 4, and < 50% in 3 patients. Two children became seizure free for more than 24 months. Most side effects were CNS related, with the most frequent being somnolence and anorexia. These were generally transient. One patient dropped-out due to powder in the urine. None of the patients required hospitalization. At 36 months, patients' alertness (2/7), interaction with environment (5/7), ability to perform daily activities (5/7), and verbal performance (6/7) improved on TPM. We conclude that TPM may be useful as adjunctive therapy in the treatment of LGS. The efficacy of TPM was maintained in long-term treatment in more than 40% of patients, long term safety was confirmed and QL improved on TPM.

Relação dose-dependente do uso crônico de fenitoína e atrofia cerebelar em pacientes com epilepsia

The chronic treatment with phenytoin or the acute intoxication by this drug may cause permanent cerebellar injury with atrophy of cerebellum vermis and hemispheres, which can be detected by neuroimaging studies. The aim of the present study was to investigate the correlation between the dosage and duration of treatment with phenytoin and the occurrence of cerebellar atrophy. Sixty-six patients were studied and had their tomographies analyzed for cerebellar atrophy. Of the 66 patients studied, 18 had moderate/severe atrophy, 15 had mild atrophy and 33 were considered to be normal. The patients with moderate/severe atrophy were those with higher exposure to phenytoin (longer duration of treatment and higher total dosage) showing statistically significant difference when compared to patients with mild atrophy or without atrophy (p=0.02). Further, the patients with moderate/severe atrophy had serum levels of phenytoin statistically higher than those of patients with mild atrophy or without atrophy (p = 0.008). There was no association between other antiepileptic drugs dosage or duration of treatment and degree of cerebellar atrophy. We also found that older patients had cerebellar atrophy more frequently, indicating that age or duration of the seizure disorder may also be important in the determination of cerebellar degeneration in these patients. We conclude that although there is a possibility that repeated seizures contribute to cerebellar damage, long term exposure to phenytoin, particularly in high doses and toxic serum levels, cause cerebellar atrophy.

Epilepsias parciais familiares

OBJECTIVE: To investigate the clinical and genetic characteristics of familial partial epilepsies. METHOD: Family history of seizures was questioned in all patients followed in our epilepsy clinics, from October 1997 to December 1998. Those with positive family history were further investigated and detailed pedigrees were obtained. All possibly affected individuals available underwent clinical evaluation. Seizures and epilepsy syndromes were classified according to the ILAE recommendations. Whenever possible, EEG and MRI were performed. RESULTS: Positive family history was identified in 32 unrelated patients. A total of 213 possibly affected individuals were identified, 161 of whom have been evaluated. The number of affected subjects per family ranged from two to 23. Temporal lobe epilepsy (TLE) was identified in 22 families (68%), frontal lobe epilepsy in one family (3%), partial epilepsy with centrotemporal spikes in five families (15%), and other benign partial epilepsies of childhood in four families (12%). Most of the affected individuals in the TLE families (69%) had clinical and/or EEG characteristics of typical TLE. However, the severity of epilepsy was variable, with 76% of patients with spontaneous seizure remission or good control with medication and 24% with refractory seizures, including 7 patients that underwent surgical treatment. In the other 10 families, we identified 39 possibly affected subjects, 23 of whom were evaluated. All had good seizure control (with or without medication) except for one patient with frontal lobe epilepsy. Pedigree analysis suggested autosomal dominant inheritance with incomplete penetrance in all families. CONCLUSION: Family history of seizures is frequent among patients with partial epilepsies. The majority of our families had TLE and its expression was not different from that observed in sporadic cases. The identification of genes involved in partial epilepsies may be usefull in classification of syndromes, to stablish prognosis and optimal treatment.

Interictal hyposexuality in male patients with epilepsy

The purpose of this study was to compare the serum levels of androgens between hyposexual and non-hyposexual patients with epilepsy. Adult male patients with epilepsy were investigated. Serum levels of testosterone (T) and free-T, estradiol, and sex hormone binding globulin (SHBG) were measured and the free androgen index (FAI) was calculated. While there were no differences between hyposexual and non-hyposexual patients in the serum levels of T, free-T, and estradiol, or to the FAI, the serum levels of SHBG were significantly higher in hyposexual patients than in non-hyposexual patients. Thus, the effects of increased SHBG upon serum levels of testosterone biologically active in patients with epilepsy and hyposexuality were not detected by the methods used in this study. Four (44%) of nine hyposexual patients who were re-evaluated after two years follow-up improved sexual performance. Thus, clinical treatment that results in good seizure control may improve sexual performance in some patients with epilepsy.

Qualidade de vida em epilepsia e percepção de controle de crises

The individual affective-cognitive evaluations are important factors that control the way he feels the disease impact in his life. Then, the perception of seizure control is a more important factor to evaluate Quality of Life (QoL) than the illness characteristics, such as the severity, type, sickening period and seizure frequency. This study searched for the relationship among the subjective variables (perception of seizure control) and the illness characteristics to evaluate QoL. The sample consisted of 60 individuals with chronic epilepsy, aging 18 to 70 (M=37.05; SD=11.25), chosen at randon from the ambulatory of epilepsy - HC/UNICAMP, by the Questionnaire 65. The illness characteristics were not significant, except the seizures frequency, when associated to the impairment in QoL among controlled seizures and seizures with frequency higher than 10 per month (p=0.021). The perception of control was significantly associated to QoL (p=0.005).

Questionário de qualidade de vida na epilepsia: resultados preliminares

Seizures happen for brief periods of time, but the feelings of anxiety and helplessness, adaptation to the restrictions impose by the life-style and variety of other problems affect more the quality of life in epilepsy. This study proposes a protocol that regards the objectives of a quality of life assessment in health and is applied to a population that attends a university hospital. It contains 65 items and assesses the psychosocial performance, physical limitation, cognitive aspects, perception of control, self-concept, as well as perception of health and quality of life. The results of reliability and validity are discussed.

Machado de assis's epilepsy

Machado de Assis (1839-1908) is considered the most important Brazilian writer and a great universal literary figure. Little is know about his medical, personal and family history. He hid his «disease» as much as possible. Machado referred to «strange things» having happened to him in his childhood. He described seizures as «nervous phenomena», «absenses», «my illness». Laet observed a seizure and described it as: «... when Machado approached us and spoke to me in disconnected words. I looked at him in surprise and found his features altered. Knowing that from time to time he had nervous problems,... and only permitted Machado take the Laranjeiras Street car, when I saw that he was completely well». A photographically documented seizure is shown. Alencar wrote, «The preoccupation with health was frequent: either he was having the consequences of a fit or was foreboding one». It is clear that Machado presented localized symptomatic epilepsy with complex partial seizures secondarily generalized of unknown etiology. The seizures which began in infancy or childhood had remission in adolescence and then recurred in his thirties and became more frequent in his later years. His depression got markedly worse with age. In our opinion, the greatest consequence of Machado's epilepsy, was his psychological suffering due to the prejudice of the times. Despite this Machado showed all his genius, which is still actual and universal.