Cessation Of Seizure Activity Research Articles

Constant rate infusion of diazepam or propofol for the management of canine cluster seizures or status epilepticus.

Cluster seizures (CS) and status epilepticus (SE) in dogs are severe neurological emergencies that require immediate treatment. Practical guidelines call for constant rate infusion (CRI) of benzodiazepines or propofol (PPF) in patients with seizures not responding to first-line treatment, but to date only few studies have investigated the use of CRI in dogs with epilepsy. Retrospective clinical study. Dogs that received CRI of diazepam (DZP) or PPF for antiepileptic treatment during hospitalization at the Veterinary Teaching Hospital of the University of Turin for CS or SE between September 2016 and December 2019 were eligible for inclusion. Favorable outcome was defined as cessation of clinically visible seizure activity within few minutes from the initiation of the CRI, no seizure recurrence within 24 h after discontinuation of CRI through to hospital discharge, and clinical recovery. Poor outcome was defined as recurrence of seizure activity despite treatment or death in hospital because of recurrent seizures, catastrophic consequences of prolonged seizures or no return to an acceptable neurological and clinical baseline, despite apparent control of seizure activity. Comparisons between the number of patients with favorable outcome and those with poor outcome in relation to type of CRI, seizure etiology, reason for presentation (CS or SE), sex, previous AED therapy and dose of PPF CRI were carried out. A total of 37 dogs, with 50 instances of hospitalization and CRI administered for CS or SE were included in the study. CRI of diazepam (DZP) or PPF was administered in 29/50 (58%) and in 21/50 (42%) instances of hospitalization, respectively. Idiopathic epilepsy was diagnosed in 21/37 (57%), (13/21 tier I and 8/21 tier II); structural epilepsy was diagnosed in 6/37 (16%) of which 4/6 confirmed and 2/6 suspected. A metabolic or toxic cause of seizure activity was recorded in 7/37 (19%). A total of 38/50 (76%) hospitalizations were noted for CS and 12/50 (24%) for SE. In 30/50 (60%) instances of hospitalization, the patient responded well to CRI with cessation of seizure activity, no recurrence in the 24 h after discontinuation of CRI through to hospital discharge, whereas a poor outcome was recorded for 20/50 (40%) cases (DZP CRI in 12/50 and PPF CRI in 8/50). Comparison between the number of patients with favorable outcome and those with poor outcome in relation to type of CRI, seizure etiology, reason for presentation (CS or SE), sex and previous AED therapy was carried out but no statistically significant differences were found. The present study is the first to document administration of CRI of DZP or PPF in a large sample of dogs with epilepsy. The medications appeared to be tolerated without major side effects and helped control seizure activity in most patients regardless of seizure etiology. Further studies are needed to evaluate the effects of CRI duration on outcome and complications.

New onset refractory status epilepticus after BNT162b2 nCoV-19

Coronavirus is a pathogen that caused fatal pneumonia cases in Wuhan province of China in December 2019 [1]. It was declared as a pandemic in March 2020 by the World Health Organization [2]. The disease is a severe acute respiratory syndrome with multi-organ involvement, including the cardiovascular system, musculoskeletal system, gastrointestinal and neurological system. Neurological manifestations may be common in COVID-19 patients [3]. Among these, several autoimmunity-affecting syndromes that may result in encephalitis and new-onset refractory status epilepticus (NORSE) have been described. New-onset refractory status epilepticus (NORSE) is an uncommon clinical entity with a mortality rate of 16-27% in adults and significant long-term neurological sequelae. Approximately 50% of patients with NORSE have an unknown aetiology. There is a lack of consensus regarding the best treatment options available for managing patients with NORSE. However, immediate cessation of seizure activity, early institution of continuous infusion of anaesthetic agents, and immunotherapies can play an important role in reducing morbidity and mortality in NORSE.

Absent Words, Present Person

Hundreds of distinct epilepsy-causing genes have been identified.1 The vitamin B6-dependent epilepsies are a heterogeneous group of genetic disorders due to incomplete formation, transport, or inactivation of pyridoxal 5′-phosphate (PLP).2 The ALDH7A1 , PNPO , ALPL , ALDH4A1 , and more recently PLPBP genes have been implicated.3 Characteristic presentation of vitamin B6-dependent epilepsies includes neonatal onset of encephalopathy and seizures refractory to first-line antiseizure medications (ASMs) followed by cessation or dramatic improvement of seizures after administration of pyridoxine or PLP. Because initiation of proper treatment is essential for seizure control, timely diagnosis is critical to optimizing clinical outcome. We describe the case of a 3-year-old boy who presented with progressively worsening refractory seizures starting at 14 months of age and was subsequently diagnosed with pyridoxal phosphate homeostasis protein (PLPHP) deficiency via rapid genome sequencing during a critical care hospitalization for status epilepticus. He was started on pyridoxine with immediate cessation of seizure activity and has remained seizure-free. We review the diagnosis, management, and outcome of PLPHP deficiency, as well as implications for use of rapid genetic testing in the acute care setting.

The Surgical and Cognitive Outcomes of Focal Cortical Dysplasia.

Focal cortical dysplasia (FCD) is the major cause of intractable focal epilepsy in childhood leading to epilepsy surgery. The overall seizure freedom after surgery ranges between 50–75% at 2 years after surgery and the long-term seizure freedom remain relatively stable. Seizure outcome after surgery depends on a various factors such as pathologic etiologies, extent of lesion, and types of surgery. Therefore, seizure outcome after surgery for FCD should be analyzed carefully considering cohorts’ characteristics. Studies of pediatric epilepsy surgery emphasize the early surgical intervention for a better cognition. Early surgical intervention and cessation of seizure activity are important for children with intractable epilepsy. However, there are limited data on the cognitive outcome after surgery in pediatric FCD, requiring further investigation. This paper reviews the seizure and cognitive outcomes of epilepsy surgery for FCD in children. Several prognostic factors influencing seizure outcome after surgery will be discussed in detail.

Status epilepticus after C-4 ingestion: using liquid chromatography to quantify toxicity

Context: C-4, a commonly used explosive in military operations, is sometimes consumed by soldiers as a rite of passage. The primary component of C-4 is cyclotrimethylenetrinitramine, or Research Department Explosive (RDX), which causes euphoria along with nausea, vomiting, renal injury, encephalopathy and convulsions when consumed in toxic amounts. We present a case of status epilepticus caused by known ingestion of C-4, in which serum levels of the compound were measured with high-performance liquid chromatography (HPLC).Case details: A 22-year-old active-duty male with no prior medical history was brought to the ED with convulsions that only minimally improved traditional anti-epileptic treatment. EEG showed persistent epileptiform activity despite initial management. Continuous propofol infusion, lacosamide and levitiracetam eventually broke the seizures. The patient eventually reported consuming a piece of C-4 four hours prior to the start of his seizure activity.Results: HPLC showed a peak RDX concentration of 3.06 μg/ml. RDX concentration at cessation of seizure activity was 2.43 μg/ml.Conclusion: Per our review of the literature, this is the first case where the explosive's toxicity could directly be measured over time in a human patient. C-4 poisoning must be considered when assessing sudden onset epileptiform activity in soldiers with access to this substance.

S187. Cerebral oxygen saturation and cytochrome oxidase redox state in children with epilepsy: A pilot study - MULTICHANNEL NIRS for epilepsy seizure detection

Epilepsy remains a significant healthcare problem associated with significant morbidity and mortality. Electroencephalograms (EEGs) provide a means of identifying ongoing seizures. However, specialized equipment is needed to obtain and interpret data. There remains a need for technologies that are easily utilized and interpreted for the purpose of monitoring children in the time periods before, during and after seizure activity. NIRS cerebral oximetry works as a noninvasive measurement that allows continuous measurement of cerebral oxygen availability. This monitor serves as a surrogate to invasive measures of venous pO2, often obtained from the jugular vein to estimate cerebral oxygen levels. We recently published NIRS-EEG data with a limited number of NIRS probes in four patients with medically refractory epilepsy undergoing pre-surgical evaluation with ages ranging from 5 to 17 years. The purpose of this pilot study is to describe the relationship of regional cerebral oximetry and cytoximetry, measured using MULTICHANNEL NIRS (near-infrared spectroscopy) in the peri-ictal period in children with epilepsy. The hypothesis is: 1. Regional cerebral saturation of oxygen and/or cytochrome oxidase redox state will increase prior to the onset of seizure activity; 2. Regional cerebral saturation of oxygen and/or cytochrome oxidase redox state will have a varied response during seizure activity depending on the seizure type; 3. Regional cerebral saturation of oxygen and/or cytochrome oxidase redox state will return to baseline following cessation of seizure activity. The three goals for the research study are to: 1. Quantify the magnitude and direction of change of cerebral oxygen saturation and cytochrome oxidase redox state during the peri-ictal period in children with epilepsy; 2. Quantify the temporal relationship, magnitude and direction of change of cerebral oxygenation and cytochrome oxidase redox state in relationship to seizure type; 3. Measure the association of cerebral oxygenation and cytochrome oxidase redox state with systemic oxygen saturation, EEG findings and clinical status. Study subjects will include pediatric patients from birth to 18 years of age with a known seizure disorder who are being admitted to the epilepsy monitoring unit (EMU) or the ICU at CHW for further workup or medication management of their epilepsy. Children will be monitored per standard of care for the duration of their hospitalization, which typically is 3–5 days with the additional NIRS-EEG array added to their monitoring. Preliminary data shows varied regional cerebral oxygen saturation and/or cytochrome oxidase redox state during interictal period and seizure activity depending on the seizure type. The increased blood flow clearly coincided with epileptiform activity and continued to increase as the epileptiform activity built up. Regional cerebral oxygen saturation increased in the epileptogenic focus, perhaps due to loss of cerebrovascular autoregulation.

A multicentre randomised controlled trial of levetiracetam versus phenytoin for convulsive status epilepticus in children (protocol): Convulsive Status Epilepticus Paediatric Trial (ConSEPT) - a PREDICT study

BackgroundConvulsive status epilepticus (CSE) is the most common life-threatening childhood neurological emergency. Despite this, there is a lack of high quality evidence supporting medication use after first line benzodiazepines, with current treatment protocols based solely on non-experimental evidence and expert opinion. The current standard of care, phenytoin, is only 60% effective, and associated with considerable adverse effects. A newer anti-convulsant, levetiracetam, can be given faster, is potentially more efficacious, with a more tolerable side effect profile. The primary aim of the study presented in this protocol is to determine whether intravenous (IV) levetiracetam or IV phenytoin is the better second line treatment for the emergency management of CSE in children.Methods/Design200 children aged between 3 months and 16 years presenting to 13 emergency departments in Australia and New Zealand with CSE, that has failed to stop with first line benzodiazepines, will be enrolled into this multicentre open randomised controlled trial. Participants will be randomised to 40 mg/kg IV levetiracetam infusion over 5 min or 20 mg/kg IV phenytoin infusion over 20 min. The primary outcome for the study is clinical cessation of seizure activity five minutes following the completion of the infusion of the study medication. Blinded confirmation of the primary outcome will occur with the primary outcome assessment being video recorded and assessed by a primary outcome assessment team blinded to treatment allocation. Secondary outcomes include: Clinical cessation of seizure activity at two hours; Time to clinical seizure cessation; Need for rapid sequence induction; Intensive care unit (ICU) admission; Serious adverse events; Length of Hospital/ICU stay; Health care costs; Seizure status/death at one-month post discharge.DiscussionThis paper presents the background, rationale, and design for a randomised controlled trial comparing levetiracetam to phenytoin in children presenting with CSE in whom benzodiazepines have failed. This study will provide the first high quality evidence for management of paediatric CSE post first-line benzodiazepines.Trial registrationProspectively registered with the Australian and New Zealand Clinical Trial Registry (ANZCTR): ACTRN12615000129583 (11/2/2015). UTN U1111–1144-5272. ConSEPT protocol version 4 (12/12/2014).

Young Investigator Award 2013

In 2006, the Foundation Acta Paediatrica instituted Young Investigator award. The Swedish award is given by the Swedish Paediatric Society, and the candidates are selected by the same society. The candidates for the award should not be older than 40 years and be the first authors of articles published in the Acta Paediatrica last year. The Award for 2013 is shared between Karin Persson and Martin Lundqvist. Both authors have carried out their studies during the general internship (AT). They will receive their diploma at the meeting of the Swedish Paediatric Society in Malmoe April 8, 2014. Karin Persson has published an article entitled ‘Vitamin D deficiency at the Arctic Circle – a study in food-allergic adolescents and controls’ Acta Paediatr 2013; 102:644–9 together with Inger Öhlund, Lisbeth Nordström, Anna Winberg, Eva Rönmark and Christina West. They report that as many as 82% of the adolescents living in Norbotten counties, at the Arctic Circle, are vitamin D deficient in the winter, even though vitamin D intake meets current national recommendations. The vitamin D deficiency was found to be as common in controls as in food-allergic adolescents who had eliminated vitamin D containing foods (milk, egg and/or fish). These results are important as they suggest that the current national recommendations on vitamin D intake are insufficient especially in the northern parts of Sweden. The other awarded study by Martin Lundqvist and co-authors Johan Ågren, Lena Hellström-Westas, Roland Flink and Ronny Wickström is entitled ‘Efficacy and safety of lidocaine for treatment of neonatal seizures’ Acta Paediatr 2013; 102:863–7. Martin Lundqvist et al. have evaluated the efficacy and safety of lidocaine as a second-line treatment. The infants had been previously treated with benzodiazepine. Lidocaine treatment resulted in cessation of seizure activity in half of the included infants. Lidocaine should probably be used to a higher extent than is the case today.

Buccal midazolam or rectal diazepam for treatment of residential adult patients with serial seizures or status epilepticus

To compare the efficacy and tolerability of buccal midazolam with rectal diazepam as emergency treatment in residential adults with convulsive or non-convulsive serial seizures or status epilepticus (SE), and ascertain the preference between the two treatment options among the patients and the nursing staff. The nursing staff of our residential epilepsy centre treated 80 episodes of serial seizures or SE lasting more than 5 min alternating with rectal diazepam or buccal midazolam. The dose of each study drug was tailored individually. The primary outcome measure was defined as cessation of seizure activity within 10 min without seizure relapse within 2 h. Convulsive SE was treated promptly, after a mean of 6.2 min, and terminated faster with buccal midazolam than with rectal diazepam; i.e. after a mean of 2.8 vs 5.0 min, respectively (n = 0.012). The other subcategories of emergency situations were treated after a mean of 25.0 min, and the seizure activity ceased after a mean of 7.4 min in the diazepam group and 7.6 min in the midazolam group (NS). The success rate was 83.3% in the diazepam group and 74.4% in the midazolam group (NS). The difference was mostly due to slightly more seizure relapses during the first 2 h in the midazolam group. Both treatment options were well tolerated, temporary tiredness being the most frequently occurring adverse effect. All the nursing staff and six of the seven patients who gained experience with both treatment options favoured the buccal route. Buccal midazolam appeared to be at least as effective as rectal diazepam with little or no side effects. The buccal administration was easy to handle and socially more acceptable than the rectal route.

Intravenous levetiracetam: Treatment experience with the first 50 critically ill patients

Levetiracetam (LEV) is a broad-spectrum antiepileptic drug with no known interactions and a favorable profile of adverse events. These properties make it a good candidate for use in critically ill patients. An intravenous formulation of LEV was recently approved. The present study retrospectively assesses the safety and efficacy of LEV in the first 50 critically ill patients treated with intravenous LEV. Indications for use were seizure prophylaxis, acute symptomatic seizures, and all forms of status epilepticus. There were no major adverse effects, although less prominent changes may have been masked by the already severely compromised condition of these patients. Two patients (4%) had transiently lowered platelet counts (55,000 and 82,000, respectively). Efficacy, defined as cessation of seizure activity or prevention of its recurrence, was observed in 41 of 50 patients (82%). Antiepileptic treatment of critically ill patients with LEV seems to be effective and safe according to the data for this small cohort, but this observation warrants further prospective investigation in a larger number of patients.

Effect of systemic and intracortical administration of phenytoin in two genetic models of absence epilepsy

1. Spontaneous 7-10 Hz spike-wave discharges (SWDs) are the electroencephalographic hallmark of absence seizures, as can be observed in WAG/Rij as well as in GAERS, two commonly used well-validated genetic rat models of absence epilepsy. A local upregulation of sodium channels within the perioral region of the primary somatosensory cortex indicated an initiation site for SWDs in WAG/Rij rats, in line with a new theory that assumes that SWDs have a cortical focal origin in the perioral region of the somatosensory cortex. We tested whether bilateral microinfusion at this focal site of the sodium channel blocker phenytoin, which is known to aggravate SWDs after systemic administration, reduces SWDs in both models. 2. WAG/Rij rats and GAERS, chronically provided with cortical EEG electrodes and bilateral cortical cannula's, were used. The EEGs were recorded before and after or systemic or bilateral infusion of phenytoin. 3. Microinfusion of phenytoin at the perioral region of the somatosensory cortex produced an immediate cessation of seizure activity in WAG/Rij rats, while systemic injection produced an increase in both genetic models. Microinfusion of the same and higher concentrations of phenytoin in GAERS at the same stereotactic coordinates showed no effect. Phenytoin was effective in GAERS 2 mm more posteriorly.4. The data suggest that both genetic models have a cortical area at which diametrically opposite effects of phenytoin can be found compared to systemic injections: a decrease after local microinfusion and aggravation after systemic administration, although the exact cortical location may be different. Moreover, a deficit in sodium channels might be an ethiological factor underlying an increased probability for the initiation of SWDs in the somatosensory cortex.

Right‐sided vagus nerve stimulation inhibits induced spinal cord seizures

We have previously shown that left-sided vagus nerve stimulation results in cessation of induced spinal cord seizures. To test our hypothesis that right-sided vagus nerve stimulation will also abort seizure activity, we have initiated seizures in the spinal cord and then performed right-sided vagus nerve stimulation in an animal model. Four pigs were anesthetized and placed in the lateral position and a small laminectomy performed in the lumbar region. Topical penicillin, a known epileptogenic drug to the cerebral cortex and spinal cord, was next applied to the dorsal surface of the exposed cord. With the exception of the control animal, once seizure activity was discernible via motor convulsion or increased electrical activity, the right vagus nerve previously isolated in the neck was stimulated. Following multiple stimulations of the vagus nerve and with seizure activity confirmed, the cord was transected in the midthoracic region and vagus nerve stimulation performed. Right-sided vagus nerve stimulation resulted in cessation of spinal cord seizure activity in all animals. Transection of the spinal cord superior to the site of seizure induction resulted in the ineffectiveness of vagus nerve stimulation in causing cessation of seizure activity in all study animals. As with left-sided vagus nerve stimulation, right-sided vagus nerve stimulation results in cessation of induced spinal cord seizures. Additionally, the effects of right-sided vagus nerve stimulation on induced spinal cord seizures involve descending spinal pathways. These data may aid in the development of alternative mechanisms for electrical stimulation for patients with medically intractable seizures and add to our knowledge regarding the mechanism for seizure cessation following peripheral nerve stimulation.

Vagus nerve stimulation for induced spinal cord seizures: insights into seizure cessation

Vagus nerve stimulation is known to decrease the frequency, duration, and intensity of some types of intracranial seizures in both humans and animals. Although many theories abound concerning the mechanism for this action, the true cause remains speculative. To potentially elucidate a pathway in which vagus nerve stimulation aborts seizure activity, seizures were initiated not in the cerebral cortex but in the spinal cord and then vagus nerve stimulation was performed. Ten pigs were anesthetized and placed in the lateral position, and a small laminectomy was performed in the lumbar region. Topical penicillin, a known epileptogenic drug to the cerebral cortex and spinal cord, was applied to the dorsal surface of the exposed cord. With the exception of two animals that were used as controls, once seizure activity was discernible via motor convulsion or increased electrical activity the left vagus nerve, which had been previously isolated in the neck, was stimulated. Following multiple stimulations of the vagus nerve and with seizure activity confirmed, the cord was transected in the midthoracic region and vagus nerve stimulation was performed. Vagus nerve stimulation resulted in cessation of spinal cord seizure activity in all (87.5%) but one experimented animal. Transection of the spinal cord superior to the site of seizure induction resulted in the ineffectiveness of vagus nerve stimulation to cause cessation of seizure activity in all study animals. The effects of vagus nerve stimulation on induced spinal cord seizures involve descending spinal pathways. The authors believe that this experiment is the first to demonstrate that spinal cord neuronal hyperactivity can be suppressed by stimulation of a cranial nerve. These data may aid in the development of alternative mechanisms for electrical stimulation in patients with medically intractable seizures. Further studies are now necessary to isolate which specific tracts, nuclei, and neurotransmitters are involved in this process.

Cortical-area specific block of genetically determined absence seizures by ethosuximide

Absence epilepsy is characterised by a paroxysmal loss of consciousness, of abrupt onset and termination, and is associated with a bilateral synchronous spike and wave discharge (SWD) on the electroencephalogram. Absence seizures involve an interplay between thalamic and cortical structures, although most research has so far focussed on sensory thalamic nuclei and the reticular thalamic nucleus (RTN). Thus, microinfusion of ethosuximide (ETX), a first choice anti-absence drug, into either the ventrobasal thalamus or RTN of the genetic absence epilepsy rat from Strasbourg (GAERS), a validated rat model of absence epilepsy, does not produce immediate cessation of seizure activity, as is seen following systemic administration. As recent evidence indicates a seizure initiation site within the peri-oral region of the primary somatosensory cortex (S1po), we have now applied ETX into S1po as well as the somatosensory cortex forelimb region (S1FL) and the motor cortex (M1) of freely moving GAERS. Microinfusion of 10 or 20 nmol/side of ETX into S1po produced an immediate cessation of seizure activity. A less marked response was produced when even a higher dose (200 nmol/side) was infused into S1FL. No reduction of SWD was seen when ETX was infused into M1. Microinfusion of CGP 36742 (5 nmol/side), a GABA B antagonist, produced immediate cessation of seizure activity in both S1po and M1 and a delayed effect in S1FL. These data suggest that the ability of ETX to abolish genetically determined absence seizures is cortical-area specific and support the involvement of S1po in the initiation of SWDs.

New-onset absence status epilepsy presenting as altered mental status in a pediatric patient

Absence status epilepsy (ASE) is an uncommon seizure disorder in children. The primary presentation of new-onset ASE in a pediatric patient is an unusual cause of altered mental status in the emergency department. We describe a previously healthy 8-year-old child who presented with an acutely altered mental state. The patient was awake but confused, with a fluctuating level of alertness and an inability to perform simple routine tasks. The results of general physical and neurologic examination, with the exception of mental status, were normal. Head computed tomography and laboratory test results were normal. Electroencephalographic testing revealed seizure activity consistent with ASE. Administration of intravenous diazepam caused cessation of seizure activity and a return to the patient’s baseline mental function. Although rare, ASE should be considered in the differential diagnosis of altered mental status in children. [Benson PJ, Klein EJ. New-onset absence status epilepsy presenting as altered mental status in a pediatric patient. Ann Emerg Med. April 2001;37:402-405.]

低マグネシウム血症によりけいれん発作と意識障害を来した１例

A 37-year-old pregnant woman at 35 weeks gestation was admitted to the OB-GYN service because of fever and sore throat. During hospitalization, she underwent artificial abortion because of fetal death. Since renal failure developed in addition to fever and sore throat, she was transferred to our hospital. After she receiving parenteral fluids and diuretics, her renal failure improved. Seizures and unconsciousness developed, however, in spite of improvement of renal function. Blood chemistry data showed that the serum calcium and magnesium values decreased to 2.6mEq/l and 1.2mg/dl respectively. The serum calcium did not return to normal even after administration calcium gluconate and magnesium supplementation (MgSO4; Mg 480mg/day) was initiated which resulted in cessation of seizure activity and return of lucidity. This report emphasizes the role of hypomagnesemia in causing seizures and disturbance of consciousness during pregnancy.

Apical left ventricular lipoma presenting as syncope

1 I-second pause (Fig. 1). After the sinus pause, a marked decrease in waveform amplitude was noted bilaterally on the EEG followed by low-amplitude generalized fast activity, which corresponded clinically to tonic-clonic seizure activity. Thirty seconds after the onset of the seizure and the return of the heart rate to baseline, there was cessation of seizure activity clinically and on EEG. A permanent VVI pacemaker was implanted the following day without complications. Telemetry monitoring after insertion of a pacemaker revealed no further episodes of bradycardia. The patient has had no further episodes of syncope or seizure activity during 14 months of follow-up. Although loss of consciousness as a result of inadequate cardiac output is a common symptom associated with cardiac arrhythmias, frank seizure activity is a rare occurrence.z-s This is the first report in which a seizure precipitated by a period of asystole was documented by standard, simultaneous EEG and ECG recordings. As illustrated by this case, a marked reduction in EEG amplitude after the period of asystole is characteristic of cerebral ischemia and is the likely precipitant of the seizure. Without the use of simultaneous EEG and ECG monitoring, a correct diagnosis could not have been made. Thus all adults with a newonset seizure disorder, in whom routine EEG is nondiagnostic, should have a careful cardiac and neurologic evaluation, This is particularly relevant in elderly persons who may have unsuspected conduction system disease. The use of simultaneous EEG and ECG recordings or ambulatory EEG and ECG monitoring may provide useful diagnostic information and allow the physician to institute appropriate therapy.

The start-stop-start phenomenon of subdurally recorded seizures

Defined as a pair of sequential ictal potentials separated by complete or almost complete cessation of seizure activity, the start-stop-start (SSS) phenomenon was found on subdural recordings in 23 (23%) of 98 patients. The two phases were morphologically similar. Thirty-six (58%) of 62 SSS seizures showed a complete stop, a return to interictal morphology being more common than a postictal pattern. Twenty-two (35%) of 62 seizures in 8 (35%) of 23 patients restarted in a different location than the first start. When in different locations, the start, not the restart, correlated with non-SSS origin. SSS seizures arose in the same region as non-SSS seizures in 22 of 23 patients.

The effect of modified electroconvulsive therapy on vasopressin release and haemostasis in man

Plasma concentrations of plasminogen activator activity (PAA) and factor VIII are partly controlled by circulating adrenaline and vasopressin. Acute rises in PAA and factor VIII occur during electroconvulsive therapy (ECT). To investigate the relationships between vasopressin (aVP), adrenaline and changes in PAA and factor VIII during ECT, 8 female and 2 male patients, median age 57 years (range 39-75) undergoing modified ECT had venous blood samples taken before and at 2 min, 15 min, 60 min and 24 h after cessation of seizure activity. AVP rose from 0.5 before ECT to 35.5 pg/ml at 2 min (P less than 0.005) and fell thereafter. PAA (10(6)/ECLT2) increased from 22 to 69 units (P less than 0.005) over the same time and fell to 13 units at 24 h (P less than 0.02). Tissue plasminogen activator activity (tPA) rose from 162 before to 1447 mIU/ml at 2 min. (P less than 0.005) and its inhibition activity fell from 8 to 3.75 IU/ml (P less than 0.005) over the same time and rose to 10.4 IU/ml after 24 h (P less than 0.02). There were no changes in adrenaline, noradrenaline, factor VIIIc, vWF or fibrinopeptides A and B beta 15-42. AVP correlated with tPA (rs = 0.64, P = 0.0022) and PAA (rs = 0.61, P = 0.004). These results support the hypothesis that aVP has a role in the regulation of fibrinolytic activity mediated by an increase in tPA. The absence of a factor VIII response may indicate that adrenaline is more important in the regulation of factor VIIIc and vWF.

Hyperglycaemic non‐ketotic focal epilepsy

AbstractFocal motor neurological disturbances may be the presenting symptom of diabetic non‐ketotic hyperglycaemia (Refs 1–12). In such circumstances, the hyperglycaemia is not severe and serum osmolality is characteristically only mildly elevated. The sodium is usually normal or slightly raised. Further metabolic deterioration is reported to result in cessation of seizure activity and development of coma. Such convulsions are not seen in diabetic ketoacidosis, possibly because ketones have an anti‐epileptic effect. We report a case of focal motor epilepsy in a patient presenting with severe hyperglycaemia, marked hyponatraemia and acidosis. Ketones were present in both serum and urine.