New-onset Focal Seizures Research Articles

A Prospective Comparative Evaluation of Surgery and Conservative Treatment for Compound Depressed Skull Fractures

The Brain Trauma Foundation issued level III evidence guidelines for surgical management of compound depressed fractures. However, some patients undergo successful conservative treatment. This study compares these 2 treatment modalities. This prospective study included 67 patients with compound depressed skull fractures with surgical indications and a minimum follow-up of 6 months. Depressed fractures in front of the hairline (operated on for cosmetic reasons) and associated with significant intracranial injuries were excluded. Those who gave consent for surgery were included in the surgical group, and those who denied were included in the conservative group. The surgical group had 38 patients and the conservative group had 29. Both groups were comparable in mean age, gender, Glasgow Coma Scale score, head injury severity, depth of fractures, and follow-up duration. Focal neurologic deficits were observed in 19 patients at presentation and were higher in the surgical group. Mean hospital stay was significantly shorter in the conservative group. Mean Glasgow Outcome Scale score at follow-up was statistically similar in both groups (P= 0.13). Focal neurologic deficits improved equally in both groups (P= 0.67). The severity of traumatic brain injury (P= 0.004) and the presence of focal neurologic deficits (P < 0.001) affected the neurologic outcomes. The age, gender, mode of treatment (surgery vs. conservative), surgical site infections, and seizures did not affect neurologic outcomes. The overall complication rates were similar among groups (P= 0.50). New-onset focal neurologic deficits, seizures, and infection rates were not significantly different among the groups (P= 0.98, P= 0.72, P= 0.69). Conservative management has equivalent neurologic outcomes and complications compared with surgical management.

OTHR-15. Papillary tumor of the pineal region: case series of this rare pediatric entity

BACKGROUND: The optimal management of pediatric papillary tumors of the pineal region (PTPR) is not yet established. We report three cases, as an addition to the existing literature. PATIENT 1: A 22-month-old female presented with progressive ataxia and incoordination, found to have an enhancing solid and cystic mass centered within the pineal region, with associated obstructive hydrocephalus. Tumor biopsy revealed PTPR, prompting a subsequent subtotal resection. No adjuvant therapy was recommended. Patient has remained without evidence of disease progression for 92 months, since resection. PATIENT 2: An 8-year-old female presented with progressive headaches and new-onset generalized seizures, found to have a heterogeneously enhancing pineal lesion, with associated obstructive hydrocephalus. Following a biopsy demonstrating PTPR, patient underwent subtotal resection of the tumor. A second resection was completed 6 months later followed by focal irradiation. Targeted next-generation sequencing (NGS) demonstrated two non-targetable genomic alterations (CREBBP and MLL2). The patient remains without tumor recurrence, now 37 months, since irradiation. PATIENT 3: A 7-year-old male with Autism spectrum disorder presented with new-onset focal complex seizures. A brain MRI showed a heterogeneously enhancing lesion in the region of the pineal gland, with associated obstructive hydrocephalus. A tumor biopsy revealed PTPR, prompting a subsequent gross total resection (GTR). NGS demonstrated no reportable genomic alterations. Methylome profiling classified the tumor as PTPR, group B. Post-operative imaging with no residual tumor and he has remained without tumor progression, now eight months, since resection. CONCLUSION: PTPR are extremely rare in the pediatric setting, and were initially introduced in the WHO 2007 classification as grade II-III pineal gland tumors with distinct morphologic and immunohistochemical features. GTR is the mainstay of treatment but post-surgical management remains controversial. The clinical course is characterized by frequent local recurrence, hence, adjuvant chemotherapy and/or irradiation may be necessary upon disease progression.

New-Onset Seizures as an Acute Presentation With Atypical EEG Findings in a Previously Healthy Child With Asymptomatic COVID-19 Infection

Coronavirus disease 2019 (COVID-19) infection is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). This infection usually presents with upper respiratory symptoms; however, it can also present with a wide variety of other multisystem and neurological symptoms, including seizures. There are several proposed mechanisms by which COVID-19 can cause systemic signs of infections, including neurological complications and seizures.This case report describes a pediatric patient without a previously documented history of epilepsy who was admitted for new-onset focal seizures with impaired consciousness. No other cause and triggers of seizures were found, and the child was tested positive for COVID-19 infection. The patient had six electroclinical seizures during EEG. Video EEG findings showed atypical features of onset of intermittent rhythmic delta activity (IRDA) slowing over the left hemisphere with evolution/generalization of rhythmic delta/theta activity and without clear typical generalized epileptiform discharges. These EEG findings correlated with a clinical change of behavior arrest, staring, and yawning. Similar spells were reported multiple times a day prior to the admission, and past EEG was normal. A review of current literature on COVID-19 and neurological manifestations in children, including new seizures and prior diagnosis of epilepsy, is also provided in this case report.The clinical experience in children with newly diagnosed or chronic epilepsy suggests that exacerbation of seizures, especially from systemic effects such as those caused by severe COVID-19 infection, will be a major concern.

When should we test patients with epilepsy for autoimmune antibodies? Results from a French retrospective single center study.

Seizures represent a core symptom of autoimmune encephalitides with specific therapeutic issues. To date, patients with new-onset seizures or established epilepsy are not systematically tested for autoimmune antibodies. We aimed to identify clinical and paraclinical criterion that could help to select patients requiring additional autoimmune antibodies serum and cerebrospinal fluid (CSF) detection. In this retrospective single center study from the French Salpêtrière Hospital, data from 286 adult patients with epilepsy who received an autoantibody assay for the first time were analyzed. All patients were evaluated at our institution between January 2007 and December 2018 for assessment of new-onset epilepsy (n = 90) or established epilepsy (n = 196). We only analyzed patients that were screened for autoimmune antibodies. Demographic, clinical and neuroimaging measures were compared between patients with and without autoimmune encephalitis using Fisher's exact test for categorical variables and Welch's t test for continuous variables. Our primary goal was to identify significant factors that differentiated patients with and without autoimmune encephalitis. We identified 27 patients with autoimmune epilepsy (9.4% of the patients who had been tested for autoantibodies). The significant factors differentiating patients with and without autoimmune encephalitis were: (i) the existence of a new-onset focal epilepsy + (e.g., newly diagnosed epilepsy < 6months associated with additional symptoms, mainly cognitive or psychiatric symptoms), (ii) the presence of faciobrachial dystonic seizures very suggestive of anti- Leucine-rich glioma inactivated 1 (LGI1) encephalitis, and (iii) the presence of magnetic resonance imaging (MRI) abnormalities suggestive of encephalitis. New-onset focal seizures combined with cognitive or psychiatric symptoms support the test for autoimmune antibodies. Further clinical already known red flags for an autoimmune origin are the presence of faciobrachial dystonic seizures and MRI signal changes consistent with encephalitis. On the other hand, isolated new-onset seizures and chronic epilepsy, even with associated symptoms, seem rarely linked to autoimmune encephalitis and should not lead to systematic testing.

Systemic Inflammation Is Associated With Neurologic Involvement in Pediatric Inflammatory Multisystem Syndrome Associated With SARS-CoV-2.

ObjectivePediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 (PIMS-TS) is a severe immune-mediated disorder. We aim to report the neurologic features of children with PIMS-TS.MethodsWe identified children presenting to a large children's hospital with PIMS-TS from March to June 2020 and performed a retrospective medical note review, identifying clinical and investigative features alongside short-term outcome of children presenting with neurologic symptoms.ResultsSeventy-five patients with PIMS-TS were identified, 9 (12%) had neurologic involvement: altered conciseness (3), behavioral changes (3), focal neurology deficits (2), persistent headaches (2), hallucinations (2), excessive sleepiness (1), and new-onset focal seizures (1). Four patients had cranial images abnormalities. At 3-month follow-up, 1 child had died, 1 had hemiparesis, 3 had behavioral changes, and 4 completely recovered. Systemic inflammatory and prothrombotic markers were higher in patients with neurologic involvement (mean highest CRP 267 vs 202 mg/L, p = 0.05; procalcitonin 30.65 vs 13.11 μg/L, p = 0.04; fibrinogen 7.04 vs 6.17 g/L, p = 0.07; d-dimers 19.68 vs 7.35 mg/L, p = 0.005). Among patients with neurologic involvement, these markers were higher in those without full recovery at 3 months (ferritin 2284 vs 283 μg/L, p = 0.05; d-dimers 30.34 vs 6.37 mg/L, p = 0.04). Patients with and without neurologic involvement shared similar risk factors for PIMS-TS (Black, Asian and Minority Ethnic ethnicity 78% vs 70%, obese/overweight 56% vs 42%).ConclusionsBroad neurologic features were found in 12% patients with PIMS-TS. By 3-month follow-up, half of these surviving children had recovered fully without neurologic impairment. Significantly higher systemic inflammatory markers were identified in children with neurologic involvement and in those who had not recovered fully.

AIDS Presenting in an Adolescent Male With Persistent Conjunctivitis and Eye Pain

An adolescent male with persistent conjunctivitis and an episcleral nodule presented with new-onset focal seizures and headaches. The patient was found to have cotton wool spots and papilledema on retinal examination. He was ultimately diagnosed with HIV retinopathy and AIDS. Ocular manifestations are rare presenting symptoms of AIDS among adolescents in the United States. Ocular disease in pediatric HIV/AIDS patients is most often caused by opportunistic infections. HIV retinopathy, the most common cause of blindness in patients with HIV, is usually a late disease manifestation. It is important for providers caring for adolescents to be aware of the potential ocular manifestations of HIV/AIDS. Teenagers are less likely to be aware of their HIV status and less likely to be tested for HIV, despite high risk exposures, and therefore, universal and routine HIV screening is recommended for all patients.

COVID-19, de novo seizures, and epilepsy: a systematic review.

ObjectiveWe discuss the evidence on the occurrence of de novo seizures in patients with COVID-19, the consequences of this catastrophic disease in people with epilepsy (PWE), and the electroencephalographic (EEG) findings in patients with COVID-19.MethodsThis systematic review was prepared according to the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. MEDLINE, Scopus, and Embase from inception to August 15, 2020 were systematically searched. These key words were used: “COVID” AND “seizure” OR “epilepsy” OR “EEG” OR “status epilepticus” OR “electroencephalography”.ResultsWe could identify 62 related manuscripts. Many studies were case reports or case series of patients with COVID-19 and seizures. PWE showed more psychological distress than healthy controls. Many cases with new-onset focal seizures, serial seizures, and status epilepticus have been reported in the literature. EEG studies have been significantly ignored and underused globally.ConclusionMany PWE perceived significant disruption in the quality of care to them, and some people reported increase in their seizure frequency since the onset of the pandemic. Telemedicine is a helpful technology that may improve access to the needed care for PWE in these difficult times. De novo seizures may occur in people with COVID-19 and they may happen in a variety of forms. In addition to prolonged EEG monitoring, performing a through metabolic investigation, electrocardiogram, brain imaging, and a careful review of all medications are necessary steps. The susceptibility of PWE to contracting COVID-19 should be investigated further.

Brain astrocytoma misdiagnosed as anti-NMDAR encephalitis: a case report

BackgroundAnti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis, which is the most common type of autoimmune encephalitis, is caused by the production of autoantibodies against NMDA receptor. Anti-NMDAR encephalitis patients present with various non-specific symptoms, such as abnormal psychiatric or behaviour, speech dysfunction, cognitive dysfunction, seizures, movement disorders, decreased level of consciousness, and central hypoventilation or autonomic dysfunction.Case presentationA 67-year-old man presented with new-onset focal seizures. The brain magnetic resonance imaging (MRI) plain scan and enhanced scan showed abnormal signal on the proximal midline frontoparietal junction region. Anti-NMDAR antibody was detected in cerebrospinal fluid (CSF) and serum using a commercial kit (Euroimmune, Germany) by indirect immunofluorescence testing (IIFT) according to the manufacturer’s instructions for twice. Both of the test results were positive in CSF and serum. The patient was diagnosed as anti-NMDAR encephalitis and then was treated repeatedly with large dose of intravenous corticosteroids and gamma globulin. Accordingly, the refractory nature of seizures in this case may be attributed to NMDAR autoantibodies. When the patient presented at the hospital for the third time, the brain MRI revealed an increase in the size of the frontal parietal lesion and one new lesion in the left basal ganglia. The patient underwent a surgical biopsy and astrocytoma was confirmed by histopathology.ConclusionsAlthough the sensitivity and specificity of anti-NMDAR-IgG antibodies in CSF to diagnose anti-NMDAR encephalitis are close to 100%, it is not absolute. Anti-NMDAR antibodies were positive, which might make the diagnosis more complex. The diagnosis of atypical presentation of anti-NMDAR encephalitis requires reasonable exclusion of other disorders.

Glioblastoma Multiforme Arising From Dysembryoplastic Neuroepithelial Tumor in a Child in the Absence of Therapy

Dysembryoplastic neuroepithelial tumors (DNETs) are considered as low-grade tumors commonly associated with intractable seizures. We report a case of an unusual hemispheric DNET in a young child presenting with new-onset focal seizures. The tumor was notable for its atypical neuroimaging features and very rapid malignant transformation into a glioblastoma multiforme in the absence of radiation or chemotherapy, 1-year postdiagnosis. Our case highlights the malignant potential of atypical DNETs in the absence of therapy.

Comprehensive analysis of the association of SCN1A gene polymorphisms with the retention rate of carbamazepine following monotherapy for new‐onset focal seizures in the Chinese Han population

The aim of the present study was to investigate whether single nucleotide polymorphisms (SNPs) in the sodium channel a subunit type 1 (SCN1A) gene affect the retention rate of carbamazepine (CBZ) used to treat seizures in Chinese Han patients with epilepsy. In total, 448 patients were genotyped for SNPs selected in the SCN1A gene. The tag SNPs were selected using Haploview version 4.2 software (http://www.broad.mit.edu/haploview/haploview, accessed 18 Sept 2009). Monotherapy with CBZ was administered to patients with new-onset focal seizures. In the present study, the retention rate of CBZ was defined as the percentage of patients with epilepsy who had continued with CBZ treatment in the preceding 3months. Potential confounding variables were analysed to evaluate the risk factors for non-retention. When adjusted for potential confounding factors (e.g. age, sex, body mass index, seizure type etc.), the presence of the A allele of SNP rs3812718 predicted non-retention (P=0.015; odds ratio (OR)=3.122; 95% confidence interval (CI)=1.823-4.893). Beyond 12months of treatment in those that continued with CBZ (retention cohort), analysis of covariance indicated that the maintenance dose (P=0.025) and serum CBZ levels (P=0.021) were significantly higher in carriers of the rs3812718 AA genotype than in those with the GG genotype. The results of the present study indicate that the rs3812718 SNP in the SCN1A gene is significantly associated with the retention rate of CBZ monotherapy in Chinese Han patients with focal epilepsy.

Supernumerary phantom limb as a rare symptom of epileptic seizures—case report and literature review

Supernumerary phantom limbs, that is, the awareness of an illusory extra limb is a fascinating neurologic symptom that has been described in a number of neurologic diseases including stroke, spinal injury, and epilepsy. Herein we report a case of a 70-year-old male patient with new-onset focal seizures with left-sided supernumerary phantom arm and leg as the only seizure manifestation. Ictal single-photon emission computed tomography (SPECT) revealed a hyperperfusion in the right temporoparietal junction and allowed localization of the seizure-onset zone. This report is accompanied by a discussion of phenomenology and terminology in the context of existing literature.

Case 1: Neonate with seizures and hypocalcemia

A 10-day-old boy born in September was admitted with new-onset focal seizures. In the previous six days, his parents had noted left-sided arm and leg twitching, right-sided head turning and lip smacking. These episodes lasted for approximately 30 s, and their frequency had increased to seven times per hour before admission. There was no history of fever, trauma, sick contacts or neonatal sepsis risk factors. The baby was breastfed and supplemented with formula. The pregnancy was unremarkable and the baby was born at term by an uncomplicated caesarian section because of a previous caesarian section. His birth weight was 4.1 kg (75th to 95th percentile). The mother was originally from Ecuador. The boy’s family history was otherwise noncontributory. On admission, focal seizures, as described, were witnessed. The baby’s weight was 4.1 kg. He was afebrile with normal vital signs. He had no dysmorphic features and his physical examination was otherwise unremarkable. Initial blood work showed normal renal function and electrolytes, with hypocalcemia (total calcium 1.80 mmol/L [normal 1.96 mmol/L to 2.66 mmol/L] and ionized calcium 0.82 mmol/L [normal 1.14 mmol/L to 1.29 mmol/L]) and hyperphosphatemia 3.30 mmol/L (normal 1.62 mmol/L to 3.10 mmol/L). His blood glucose level was within normal limits at 4.3 mmol/L. The diagnosis was revealed after further maternal history and blood tests.

Benign Partial Seizures of Adolescence

Eight patients matching the description of benign partial seizures of adolescence (BPSA), as described by Loiseau et al in 1978, were found among 92 teenagers, including 37 with new-onset focal seizures, enrolled in a prospective first-seizure study at the University of Melbourne, Victoria, Australia.

Benign partial seizures of adolescence.

A benign syndrome of partial seizures in adolescents (BPSA) was described by Loiseau et al. in 1978, but confirmation of this syndrome has been lacking. We sought to identify BPSA among teenagers with new-onset focal seizures enrolled in our prospective first-seizure study and to assess the EEG and magnetic resonance imaging (MRI) findings. We searched the study database for patients aged between 10 and 20 years with focal seizures who did not have idiopathic partial epilepsies, epileptogenic lesions on MRI, or recurrent tonic-clonic seizures during 2 years of follow-up. The database contained 92 adolescents, including 37 with partial epilepsy, of whom eight (22%) patients matched the description of BPSA. All eight patients had seizures with a sensory/motor "march." Six had a secondarily generalized seizure and two had simple partial seizures alone. Epileptiform abnormalities were documented in five cases but lacked a distinctive morphology or distribution. No lesions were seen on MRI. BPSA can be provisionally diagnosed in teenagers with unprovoked focal seizures characterized by a march of sensory/motor symptoms, whose MRI is normal. The psychosocial consequences of chronic epilepsy in adolescence are considerable, so early recognition of this benign syndrome is important.