Complex Partial Epilepsy Research Articles

Deep brain stimulation in a pediatric dystonia patient with cochlear implants and mitochondrial disorder: novel application of a frameless stereotactic system and navigating the anesthesia choice and neurosurgical complexities. Illustrative case.

This report presents a case of medically refractory dystonia in a pediatric patient successfully treated with bilateral subthalamic nucleus (STN) deep brain stimulation (DBS) while under general anesthesia by using microelectrode recordings (MERs) with intraoperative computed tomography (CT). The patient was an 18-year-old female with primary dystonia secondary to mitochondrial Leigh syndrome. Her past medical history was significant for complex partial epilepsy and hearing loss treated with cochlear implants. Her cochlear implants precluded anatomical targeting via magnetic resonance imaging. Additionally, the patient could not tolerate awake surgery with MER. The decision was made to proceed with bilateral STN DBS with intraoperative CT with the patient under general anesthesia. The patient's cochlear implants made standard frame placement difficult, so navigation was performed with the Nexframe system. Recordings were obtained with the patient under general anesthesia with ketamine, dexmedetomidine, and remifentanil. At the 3- and 6-month follow-ups, the patient demonstrated marked improvement in dystonia without neurological complications. This is the first case of dystonia secondary to Leigh syndrome treated with DBS. Additionally, the authors describe the novel use of the Nexframe for DBS lead placement in a pediatric patient. This demonstrates that STN DBS with the use of MER and intraoperative CT can be a safe and effective method of treating dystonia in certain pediatric patients.

Factors Affecting Serum Vitamin D Level in Epilepsy

Objective: Our aim was evaluate the relationship between 25-Hydroxyvitamin D (25(OH)D) and old and new generation anti-seizure drugs (ASDs), seizure type and seizure frequency in epilepsy patients.
 Method: A total of 96 individuals aged 18 years and older with epilepsy were included in this study who were followed up in the SBU Adana City Training and Research Hospital Epilepsy outpatient clinic between January 1, 2020 and November 1, 2022 and met the inclusion criteria. Patients were grouped by age, gender, seizure type, frequency, and ASDs usage (according to their relationship with cytochrome P450 enzymes). Complete blood count, kidney functions, serum ASD levels and calcium, magnesium, phosphate and parathormone levels, season when 25(OH)D were measured, and sun exposure time was also obtained from patient file scans.
 Results: 55.2% of the patients were women and the mean age was 32.56±12.90 (Min:18 Max:71). 25(OH)D level was found to be deficient or insufficient in 95.8% of the patients. The 25(OH)D level was statistically significantly lower in patients with generalized and complex partial epilepsy who were exposed to the sun for less than one hour per week compared to the focal type and those exposed to the sun for more than one hour per week. p

The Hematology Profiles of Adults Affiliated with Epilepsy after Receiving Valproic Acid Therapy

AIM: Epilepsy is a socially significant neurological disease spread all over the world. Valproic acid (VPA) is one of the most used antiepileptic drug (AED) for treatment which has some side effects on hematology field. A nowadays update to the adult safety information is needed. The current aim is to conduct a cross-sectional study and to describe the hematology profile of adults with epilepsy treated by VPA. MATERIALS AND METHODS: Data collection was done retrospectively and includes characteristics of the subjects such as age, gender, electroencephalography (EEG) finding, duration of VPA treatment, type of treatment, and hematology profile. We report 50 subjects treated by VPA at least 1 year. RESULTS: The mean age is 46, 4 years, 50% male and 50% female. About 92% were generalized tonic-clonic seizure. Seven percent were partial complex epilepsy. Twenty-four EEG results were abnormal (48%). We found 4 cases (7%) of thrombocytopenia at therapeutic dose and 8 cases (16%) of mild anemia. DISCUSSION: Gender differences were eliminated by having the same number of participants of each gender. The EEG findings were almost equally normal and abnormal. Reported drug reactions due to VPA were thrombocytopenia and anemia. Thrombocytopenia requires discontinuation of VPA.

GABRG2 Variants Associated with Febrile Seizures.

Febrile seizures (FS) are the most common form of epilepsy in children between six months and five years of age. FS is a self-limited type of fever-related seizure. However, complicated prolonged FS can lead to complex partial epilepsy. We found that among the GABAA receptor subunit (GABR) genes, most variants associated with FS are harbored in the γ2 subunit (GABRG2). Here, we characterized the effects of eight variants in the GABAA receptor γ2 subunit on receptor biogenesis and channel function. Two-thirds of the GABRG2 variants followed the expected autosomal dominant inheritance in FS and occurred as missense and nonsense variants. The remaining one-third appeared as de novo in the affected probands and occurred only as missense variants. The loss of GABAA receptor function and dominant negative effect on GABAA receptor biogenesis likely caused the FS phenotype. In general, variants in the GABRG2 result in a broad spectrum of phenotypic severity, ranging from asymptomatic, FS, genetic epilepsy with febrile seizures plus (GEFS+), and Dravet syndrome individuals. The data presented here support the link between FS, epilepsy, and GABRG2 variants, shedding light on the relationship between the variant topological occurrence and disease severity.

Mimicking CA3 Temporal Dynamics Controls Limbic Ictogenesis.

Simple SummaryMesial temporal lobe epilepsy (MTLE) is the most common partial complex epilepsy in adults and the most often refractory to medications. Electrical deep brain stimulation (DBS) has proved effective in controlling seizures in animal models and in drug-refractory MTLE patients. However, there is still no unifying framework for DBS parameters, which are obtained by trial-and-error and based on arbitrary, fixed stimulation frequencies rather than on physiologically relevant patterns. Interictal activity may present the key to devising personalized and physiologically relevant DBS strategies. Interictal activity occurs between seizures and is a hallmark of the hyperexcitability of the epileptic brain; depending on the underlying mechanisms and site of origin, it may promote seizures (pro-ictogenic) or dampen them (anti-ictogenic). In this work, we address the possibility of controlling seizure activity by means of electrical stimulation fashioned as a surrogate interictal pattern known to be anti-ictogenic. We show that this approach can effectively control seizure activity while delivering fewer electrical pulses than fixed-frequency stimulation. Thus, mimicking the temporal dynamics of an anti-ictogenic interictal pattern may represent a straightforward, personalized and more efficient DBS strategy to ameliorate drug-refractory epilepsy. Our work heralds a paradigm shift toward physiologically meaningful rather than arbitrary DBS parameters.Mesial temporal lobe epilepsy (MTLE) is the most common partial complex epilepsy in adults and the most unresponsive to medications. Electrical deep brain stimulation (DBS) of the hippocampus has proved effective in controlling seizures in epileptic rodents and in drug-refractory MTLE patients. However, current DBS paradigms implement arbitrary fixed-frequency or patterned stimuli, disregarding the temporal profile of brain electrical activity. The latter, herein included hippocampal spontaneous firing, has been shown to follow lognormal temporal dynamics. Here, we present a novel paradigm to devise DBS protocols based on stimulation patterns fashioned as a surrogate brain signal. We focus on the interictal activity originating in the hippocampal subfield CA3, which has been shown to be anti-ictogenic. Using 4-aminopyridine-treated hippocampus-cortex slices coupled to microelectrode array, we pursue three specific aims: (1) address whether lognormal temporal dynamics can describe the CA3-driven interictal pattern, (2) explore the possibility of restoring the non-seizing state by mimicking the temporal dynamics of this anti-ictogenic pattern with electrical stimulation, and (3) compare the performance of the CA3-surrogate against periodic stimulation. We show that the CA3-driven interictal activity follows lognormal temporal dynamics. Further, electrical stimulation fashioned as a surrogate interictal pattern exhibits similar efficacy but uses less pulses than periodic stimulation. Our results support the possibility of mimicking the temporal dynamics of relevant brain signals as a straightforward DBS strategy to ameliorate drug-refractory epilepsy. Further, they herald a paradigm shift in neuromodulation, wherein a compromised brain signal can be recreated by the appropriate stimuli distribution to bypass trial-and-error studies and attain physiologically meaningful DBS operating modes.

A-68 Yoga Therapy in Pediatric Epilepsy

Abstract Objective This pilot study examines the effects of yoga therapy on anxiety, depression symptoms, inattention, and seizure frequency in children diagnosed with Epilepsy. Data Selection The sample consisted of 5 participants (4 male, 1 female), ages 7-12 years old, with diagnoses of generalized epilepsy, absence epilepsy, and complex partial epilepsy. Participants all had average cognitive abilities (IQ SS = 100.7; VCI SS = 106.3; PRI SS = 108.3), a diagnosis of Attention Deficit Hyperactivity Disorder (ADHD), and clinically significant levels of anxiety and depression. Participants participated in 30-45-minute-long yoga sessions over a 6-week period with 2-3 home sessions each week. Differences in hyperactivity, anxiety, depression, and inattention were measured via parent rating Likert scales (0-poor, 10-best) at 1 month, 3 months, and 6 months. Participants also completed weekly self-report measures to assess anxiety and depression (Revised Children’s Manifest Anxiety, Second Edition (RCMAS-2) and Children’s Depression Inventory, Second Edition (CDI-2)). Data Synthesis No significant reliable change differences were found between sessions; however, a downward trend was visible in reduction of anxiety (RCMAS-2; first session M = 16.4, last session M = 9.4) and depression symptoms (CDI-2; first session M = 52.8, last session M = 49.2). Further, parents reported a decrease in anxiety (first session M = 4.8, last session M = 6.4). No seizures were reported during the study. Conclusions There is no previous research using pediatric populations and yoga therapy effects on reducing seizure frequency, anxiety, depression, and attention problems. This pilot study showed promising results in reducing anxiety, and depression symptoms. Limitations of study include small sample size and attrition, which are both important to consider when conducting another study.

Characterizing Brain Connectivity From Human Electrocorticography Recordings With Unobserved Inputs During Epileptic Seizures.

Epilepsy is a neurological disorder characterized by the sudden occurrence of unprovoked seizures. There is extensive evidence of significantly altered brain connectivity during seizure periods in the human brain. Research on analyzing human brain functional connectivity during epileptic seizures has been limited predominantly to the use of the correlation method. However, spurious connectivity can be measured between two brain regions without having direct connection or interaction between them. Correlations can be due to the apparent interactions of the two brain regions resulting from common input from a third region, which may or may not be observed. Hence, researchers have recently proposed a sparse-plus-latent-regularized precision matrix (SLRPM) when there are unobserved or latent regions interacting with the observed regions. The SLRPM method yields partial correlations of the conditional statistics of the observed regions given the latent regions, thus identifying observed regions that are conditionally independent of both the observed and latent regions. We evaluate the performance of the methods using a spring-mass artificial network and assuming that some nodes cannot be observed, thus constituting the latent variables in the example. Several cases have been considered, including both sparse and dense connections, short-range and long-range connections, and a varying number of latent variables. The SLRPM method is then applied to estimate brain connectivity during epileptic seizures from human ECoG recordings. Seventy-four clinical seizures from five patients, all having complex partial epilepsy, were analyzed using SLRPM, and brain connectivity was quantified using modularity index, clustering coefficient, and eigenvector centrality. Furthermore, using a measure of latent inputs estimated by the SLRPM method, it was possible to automatically detect 72 of the 74 seizures with four false positives and find six seizures that were not marked manually.

Epilepsia

Epilepsy is a very prevalent condition, requiring a correct identification. Epilepsy patient remains stigmatized socially. In 2017, ILAE has proposed a new classification of epilepsy syndromes and its seizures, provided a universal vocabulary, more practical, operational and flexible. Ambiguous terms (like complex partial, secondarily generalized, psychic and dyscognitive epilepsy) have disappeared. Etiologies are grouped in six categories (genetic, structural, metabolic, immune, infectious and unknown). Anamnesis and electroencephalogram continue to be the essential pillars for the diagnostic of epileptic seizures.

Retrieval of semantic knowledge in language pre-surgical mapping. A MEG study.

Retrieval of semantic knowledge in language pre-surgical mapping. A MEG study.

A Comparison of Vagal Nerve Stimulation and Responsive Neurostimulation for the Treatment of Medically Refractory Complex Partial Epilepsy

Background: Neuromodulatory applications such as vagus nerve stimulation (VNS) and responsive neurostimulation (RNS) are safe and effective strategies for medically intractable epilepsy secondary to complex partial seizures, but researchers have yet to compare their efficacies. Objective: The goal of this study is to compare VNS and RNS efficacy at reducing seizure frequency and complication rates in subjects with medically intractable epilepsy secondary to complex partial seizures. Methods: This is a retrospective chart review of 30 patients with medically intractable complex partial epilepsy, who underwent either VNS or RNS placement at a single institution between June 2012 and January 2016. There was a mean follow-up of 19 months. Seizure frequency reduction and complications were identified. Results: The median seizure frequency reduction was similar for VNS (66%) and RNS (58%). There was no major morbidity or mortality, and the frequency of minor complications was similar between VNS (15%) and RNS (18%). Conclusion: We found that VNS and RNS reduced the median seizure frequency similarly with no difference in morbidity or mortality. Further prospective studies are warranted as VNS and RNS therapy improves over time.

Ictal asystole: a case presentation

BackgroundEpileptic seizures can lead to cardiac arrhythmias. The arrhythmias may be in the form of tachycardia, bradycardia or asystole. Ictal bradycardia and asystole can lead to sudden unexpected death.Case presentationA case report of a 40-year-old male with complex partial temporal lobe epilepsy. He has coincident attacks of fall and pallor. The patient underwent simultaneous electrocardiogram (ECG) and video electroencephalogram (EEG) monitoring. The slow activity in EEG coincide with the appearance of bradycardia in ECG then cardiac asystole which clinically correspond to the patient syncope. After insertion of a cardiac pacemaker, only complex partial attacks develop with a marked reduction in frequency and no more fall attacks.ConclusionEpileptic seizures can present with cardiac arrhythmias, with ictal asystole leading to sudden unexpected death. Simultaneous EEG and ECG are essential for the diagnosis. A cardiac pacemaker can be lifesaving for patients with ictal arrhythmias.

Intractable epilepsy associated with angiographic obliteration of a medial temporal arteriovenous malformation following stereotactic radiosurgery

Abstract We present a case with recurrence of intractable complex partial epilepsy, despite angiographic obliteration of a cerebral arteriovenous malformation in the left medial temporal lobe following gamma knife radiosurgery. Preoperative memory function was normal, with no evidence of hippocampal atrophy by magnetic resonance imaging. Intraoperative electrocorticography demonstrated two independent foci of paroxysmal activity in the lateral and medial temporal lobes. As preoperative magnetic resonance imaging demonstrated subcortical hyperintensity, the lateral temporal lobe was resected. Histologically, there was evidence of subcortical myelin pallor, likely resulting from ischemic damage associated with hemodynamic changes following radiosurgery. As there was a decrease in the frequency of paroxysmal discharges in the hippocampus following arteriovenous malformation nidus removal, the hippocampus was preserved. Histological examination of the nidus revealed that some of the vessels had patent lumina, while ischemia affecting the neighboring hippocampus was considered to show improvement. A good seizure outcome was obtained. In summary, perioperative multimodal examinations, including intraoperative electrocorticography, revealed various epileptogenic mechanisms, probably related to myelin pallor in the lateral temporal lobe and focal ischemia secondary to patent AVM in the medial temporal lobe, of this patient.

Autonomic Dysfunction in Epileptic Patients

Objective: To investigate autonomic symptoms in different types of epilepsy in comparison to control subjects. To observe whether autonomic symptoms cause possible morbidity and mortality and to make a preliminary remedy Patients and Methods: A retrospective chart review was conducted for 28 patients diagnosed with epilepsy including 18 patients with complex partial epilepsy (CPE) and 10 patients with primary generalized epilepsy (PJE). Their autonomic symptoms were assessed using the COMPASS-31 questionnaire in comparison to a control group of 18 subjects. Results: No statistically significant differences were found in autonomic dysfunction symptoms between patients with CPE and patients with PJE. However, constipation and insomnia which autonomic symptoms were statistically significantly more common in epileptic patients compared to the control group. Conclusions: It is important to recognize and watch out for symptoms of autonomic dysfunction in patients with epilepsy. We believe that awareness for these symptoms is essential both to reduce associated disability and develop specific treatment strategies and to predict sudden unexpected death in epileptic patients.

POSTTRAUMATIC EPILEPSY AT A GENERAL HOSPITAL IN CROATIA: TWENTY-YEAR FOLLOW UP

Aim: The aim of the study was to demonstrate that therapy with new generation antiepileptic drugs (AEDs) leads to faster remission of posttraumatic epilepsy (PTE) as compared with therapy complex partial epilepsy od temporal lobe origin. Methods: The study conducted during the 1988-2008 period included 113 PTE patients (47 female and 67 male) and 113 patients (93 female and 20 male) suffering from complex partial seizures of temporal lobe origin as control group. In both groups, epileptic seizure phenotype, brain magnetic resonance imaging (1.5 T and 3.0 T) and electroencephalogram were analyzed within 24 hours of epileptic seizure and after 5 years of treatment. Psychological testing was administered prior to therapy initiation. Results: The patients treated with conventional AEDs achieved remission in 73% of cases as compared with 77% of patients administered new generation AEDs; in the latter, remission was achieved faster (1.85 vs . 1.6 months). In patients group with complex partial epilepsy was not significant difference between new and conventional AEDs. Psychiatric comorbidity prolonged time to remission by 3.4 months in both patient groups. Conclusion: Therapy with new generation AEDs enables achieving faster and complete remission in PTE patients. Key words: epilepsy, etiology, traumatic brain injury, therapy, prognosis

Effects of Jasminum multiflorum leaf extract on rodent models of epilepsy, motor coordination and anxiety

Jasmine flowers and leaves are used extensively in folk medicine in different parts of the world to treat a variety of diseases. However, there are very few published reports on the neuropsychiatric effects of Jasmine extracts. Hence, the objectives of the present study were to examine the effects of an alcohol extract of Jasminum multiflorum leaves on topically-applied bicuculline (a model of acute simple partial epilepsy) and maximal electroshock (MES, a model of generalized tonic-clonic seizure) in male Sprague-Dawley rats. The objectives also included an examination of the anxiolytic properties of the extract using an elevated plus maze and the effect of the extract on motor coordination using a rotarod treadmill. Phytochemical analysis of the extract showed the presence of three flavonoids and four additional compounds belonging to the steroid, terpenoid, phenol or sugar classes of compounds. The Jasmine alcohol extract, diluted with water and given orally or intraperitoneally, reduced the number of bicuculline-induced epileptiform discharges in a dose-dependent manner. The extract did not cause a significant increase in the current needed to induce hind limb extension in MES experiments. The extract significantly affected motor coordination when injected at 500mg/kg but not at 200mg/kg. At the latter dose, the extract increased open-arm entries and duration in the elevated plus maze to a level comparable to that of diazepam at 2mg/kg. We conclude that Jasmine leaf extract has a beneficial effect against an animal model of acute partial complex epilepsy, and significant anxiolytic effect at a dose that does not affect motor co-ordination.

A neurodevelopmental disorder with a nonsense mutation in the Ox-2 antigen domain of the amyloid precursor protein (APP) gene

ABSTRACTWe report a patient, an infant with a neurodevelopmental disorder manifesting intractable complex partial epilepsy, bull's eye maculopathy, microcephaly, bilateral cataracts, truncal hypotonia, and spasticity of all four extremities. Sequencing of genomic DNA revealed mutations in (a) exon 8 (Ox-2 antigen domain) of the amyloid precursor protein (APP) gene: c.1075C>T, p.Arg359* (b) exon 8 of the senataxin (SETX) gene: c.4738C>T, p.Arg1580Cys, and (c) exon 2 of the ceroid-lipofuscinosis, neuronal 8 (CLN8) gene: c.685C>G, p.Pro229Ala. Using a quantitative method for measurement of various APP-mRNA isoforms, we found that the APP-mRNA isoform of 624 bp with a deletion starting after 49 bp of the 5′ end of exon 3 followed by a complete deletion of exons 4–15, mutations in exon 1: c.22C>T, p.L18F, and exon 3: c.269A>G, p.Q90R encoding APP207 isoform was the most abundant one, and would appear to be responsible for the clinical manifestations. This is the first example that may underline the role of the epigenetic regulation in the expression of APP gene leading to a neurodevelopmental disorder resulting from a nonsense mutation in the Ox-2 antigen domain.

Interpretation of the Precision Matrix and Its Application in Estimating Sparse Brain Connectivity during Sleep Spindles from Human Electrocorticography Recordings.

The correlation method from brain imaging has been used to estimate functional connectivity in the human brain. However, brain regions might show very high correlation even when the two regions are not directly connected due to the strong interaction of the two regions with common input from a third region. One previously proposed solution to this problem is to use a sparse regularized inverse covariance matrix or precision matrix (SRPM) assuming that the connectivity structure is sparse. This method yields partial correlations to measure strong direct interactions between pairs of regions while simultaneously removing the influence of the rest of the regions, thus identifying regions that are conditionally independent. To test our methods, we first demonstrated conditions under which the SRPM method could indeed find the true physical connection between a pair of nodes for a spring-mass example and an RC circuit example. The recovery of the connectivity structure using the SRPM method can be explained by energy models using the Boltzmann distribution. We then demonstrated the application of the SRPM method for estimating brain connectivity during stage 2 sleep spindles from human electrocorticography (ECoG) recordings using an [Formula: see text] electrode array. The ECoG recordings that we analyzed were from a 32-year-old male patient with long-standing pharmaco-resistant left temporal lobe complex partial epilepsy. Sleep spindles were automatically detected using delay differential analysis and then analyzed with SRPM and the Louvain method for community detection. We found spatially localized brain networks within and between neighboring cortical areas during spindles, in contrast to the case when sleep spindles were not present.

Silent Strokes is a Risk for Epilepsy in Elderly Population

Purpose: To show the significance of silent strokes among middle age and elderly patients having late onset epilepsy. Methods: This cross-sectional study (survey) was carried out at Rizgary Teaching Hospital, Erbil, Iraq from January to May, 2010. Patients were included in this study if they were middle aged and elderly patients (age range 50 and above) having unprovoked acquired first seizure or multiple seizures, previously or recently diagnosed as epileptic regardless the number of fits which could be single or multiple, having history of recent or old stroke or TIA and now presented with seizure. 100 Iraqi patients were included in this survey. The MRI images were examined and interpreted through collaborative discussions between a consultant Radiologist and a consultant Neurologist (T1, T2 and FLAIR sequences were obtained) and almost all patients had abnormal EEG studies. Data were tabulated and analyzed, the significance of certain parameters was measured using chi square test, p-value of ≤0.05 was considered statistically significant. Key findings: In this study males outnumber females, epilepsy was mostly observed in elderly population (70-79 years) and p value was not significant regarding sex differences in the studied sample. Silent strokes were observed mostly in elderly population (63-67%). Hypertension, hyperlipidemia, smoking, and old strokes are the commonest comorbidities observed in relation to epileptic patients with silent strokes, and partial secondary generalized epilepsy type was the commonest epilepsy variety observed (73%) followed by partial complex epilepsy (12%) and simple partial epilepsy (11%). Significance: Silent strokes were common in elderly patients having epilepsy (53%), especially patients having stroke risk factors like hypertension, and its prevalence increase with age. Silent strokes can be an indirect way to establish the causes of epilepsy in elderly population as having silent cortical ischemia.

Psychotic symptoms in a patient diagnosed with temporal lobe epilepsy and schizoaffective disorder

IntroductionEpilepsy is considered a complex neurological disorder, and its clinical picture can resemble many different cerebral dysfunctions, including those associated to major psychiatric disorders.Case reportWe report the case of a 52-year-old gentleman, with a 30-year history of schizoaffective disorder and of complex partial epilepsy with secondary generalization. He was admitted to an emergency room due to a voluntary overdose with 8 mg of clonazepam. The patient explained how he had recently experienced visual hallucinations and insomnia, symptoms that originally led to the psychotic diagnosis. He had previously presented these symptoms, along with stupor, delusions and lability, as a prodrome of complex motor epileptic decompensations. Thus, he took the overdose not to suffer seizures. After carefully reconstructing the clinical history, psychiatric admissions had shown seizures, and periods of clinical stability had been achieved by regulating antiepileptic medication. Eslicarbazepine and lamotrigine reintroduction, and quetiapine withdrawal, led to symptomatic remission.DiscussionEpilepsy and major psychiatric disorders show a high comorbidity. There has been an effort to even include epilepsy and psychosis in a unique diagnosis (alternant psychosis). Furthermore, polimorphism and restitutio ad integrum may resemble classic cycloid psychosis. In this case, chronological study showed all symptoms could be explained by one disorder.ConclusionEpilepsy includes a variety of neuropsychiatric symptoms. It can be difficult to withdraw psychiatric diagnoses from patients after years of follow-up. However, a carefully taken medical history clarifies temporal criteria.Disclosure of interestThe authors have not supplied their declaration of competing interest.

An 18-Year-Old Woman With Snoring and Refractory Epilepsy

An 18-year-old woman with a history of refractory complex partial epilepsy presented for evaluation of snoring and episodes of gasping for air during sleep. She had uncontrolled epilepsy since the age of 8 years despite trial of multiple antiepileptic medications. She eventually underwent an implantation of a vagus nerve stimulator (VNS) device (model 103; Cyberonics Inc) with gradual adjustment of the VNS settings for better seizure control.