Postictal Serum Research Articles

Allopregnanolone and progesterone in relation to a single electroconvulsive therapy seizure and subsequent clinical outcome: an observational cohort study

BackgroundElectroconvulsive therapy (ECT) is an important treatment for several severe psychiatric conditions, yet its precise mechanism of action remains unknown. Increased inhibition in the brain after ECT seizures, mediated by γ-aminobutyric acid (GABA), has been linked to clinical effectiveness. Case series on epileptic patients report a postictal serum concentration increase of the GABAA receptor agonist allopregnanolone. Serum allopregnanolone remains unchanged after a full ECT series, but possible transient effects directly after a single ECT seizure remain unexplored. The primary aim was to measure serum concentrations of allopregnanolone and its substrate progesterone after one ECT seizure. Secondary aims were to examine whether concentrations at baseline, or postictal changes, either correlate with seizure generalization or predict clinical outcome ratings after ECT.MethodsA total of 130 participants (18–85 years) were included. Generalization parameters comprised peak ictal heart rate, electroencephalographic (EEG) seizure duration, and prolactin increase. Outcome measures were ratings of clinical global improvement, perceived health status and subjective memory impairment. Non-parametric tests were used for group comparisons and correlations. The prediction analyses were conducted with binary logistic and simple linear regression analyses.ResultsAllopregnanolone and progesterone remained unchanged and correlated neither with seizure generalization nor with clinical outcome. In men (n = 50), progesterone increased and allopregnanolone change correlated negatively with EEG seizure duration. In a subgroup analysis (n = 62), higher baseline allopregnanolone and progesterone correlated with postictal EEG suppression.ConclusionsECT seizures have different physiologic effects than generalized seizures in epilepsy. Progesterone might have implications for psychiatric illness in men.

Diagnostic role of serum prolactin level in different kinds of seizure and seizure-like episode in children: A hospital-based study

Background: Serum prolactin level has been previously used in distinguishing epileptic seizure from non-epileptic seizure, as prolactin level usually rises following an epileptic seizure in children. Aims and Objectives: We conducted this study to determine the role of serum prolactin as a surrogate marker of seizure disorder and whether serum prolactin level varies between different types of seizure, febrile seizure, and seizure mimics. Materials and Methods: This cross-sectional comparative study was conducted for 1 year among 113 children between 6 months and 16 years of age of either sex. They were divided into 3 groups (1) epileptic seizure, (2) febrile seizure, and (3) seizure mimics. The blood sample was collected within 1 h of the occurrence of seizure for estimation of serum prolactin level. Each child was investigated and treated according to the protocol. Results: Mean post-ictal prolactin level was found significantly higher in epileptic seizure (29.94±7.97 ng/mL) compared to febrile seizure (10.21±0.94 ng/mL), and seizure mimics (8.73±0.67 ng/mL). Among group 1, serum prolactin levels significantly elevated in children with generalized tonic-clonic seizure (GTCS) (34.18±2.76 ng/mL) and complex partial seizure (CPS) (31.38±1.59 ng/mL) compared to simple partial seizure (SPS) (14.36±2.33 ng/mL). Post-ictal serum prolactin levels remain elevated for a longer duration in GTCS (54.26±5.19 min) and CPS (45.19±1.73 min) compared to children with SPS (26.76±2.33 min). Conclusion: Estimation of serum prolactin level within 1 h after a seizure can be used for screening purposes to distinguish between epileptic and non-epileptic seizures. A high prolactin level is suggestive of GTCS or CPS whereas a low level is indicative of SPS, febrile convulsion, or seizure mimics with a prolactin cutoff taken 24 ng/mL in our study.

Serum prolactin level and lactate dehydrogenase activity in patients with epileptic and nonepileptic seizures: A cross-sectional study.

It is important to diagnose epilepsy in a timely and accurate manner, and also to distinguish it from non-epileptic conditions. The present study was aimed at determining postictal serum prolactin levels and lactate dehydrogenase (LDH) activities in patients with new-onset seizure admitted to the emergency department in order to assess whether they could be used in the differentiation of epileptic seizure (ES) from nonepileptic seizure (NES).Eighty-five patients were included prospectively in this study. Patients were divided into 2 groups with respect to epilepsy diagnosis, and the final groups were comprised of 36 patients with ES and 49 patients with NES. Blood samples were obtained within 1 hour of seizure.No significant differences between groups were observed in prolactin levels and in the percentage of patients with abnormal prolactin level (P = .569 and .239, respectively). The median LDH activity was significantly higher in those with ES compared with those with NES (P = .031). The percentage of patients with elevated LDH levels was similar between 2 groups (P = .286).This was the first study to examine LDH activities in terms of its role in differentiation of seizure origin in the postictal period in patients hospitalized with seizure. Our study demonstrated that serum LDH activities within 1 hour after the seizure appear to be increased in patients with ES compared with those with NES, suggesting the potential role of LDH activities as a diagnostic tool in distinction of seizure types. Our study supports the hypothesis that LDH-antagonists may have a role in the management of seizure and epilepsy.

Postictal serotonin levels are associated with peri-ictal apnea

To determine the relationship between serum serotonin (5-HT) levels, ictal central apnea (ICA), and postconvulsive central apnea (PCCA) in epileptic seizures. We prospectively evaluated video EEG, plethysmography, capillary oxygen saturation (SpO2), and ECG for 49 patients (49 seizures) enrolled in a multicenter study of sudden unexpected death in epilepsy (SUDEP). Postictal and interictal venous blood samples were collected after a clinical seizure for measurement of serum 5-HT levels. Seizures were classified according to the International League Against Epilepsy 2017 seizure classification. We analyzed seizures with and without ICA (n = 49) and generalized convulsive seizures (GCS) with and without PCCA (n = 27). Postictal serum 5-HT levels were increased over interictal levels for seizures without ICA (p = 0.01), compared to seizures with ICA (p = 0.21). In patients with GCS without PCCA, serum 5-HT levels were increased postictally compared to interictal levels (p < 0.001), but not in patients with seizures with PCCA (p = 0.22). Postictal minus interictal 5-HT levels also differed between the 2 groups with and without PCCA (p = 0.03). Increased heart rate was accompanied by increased serum 5-HT levels (postictal minus interictal) after seizures without PCCA (p = 0.03) compared to those with PCCA (p = 0.42). The data suggest that significant seizure-related increases in serum 5-HT levels are associated with a lower incidence of seizure-related breathing dysfunction, and may reflect physiologic changes that confer a protective effect against deleterious phenomena leading to SUDEP. These results need to be confirmed with a larger sample size study.

Association Analysis of Interleukin-1β, Interleukin-6, and HMGB1 Variants with Postictal Serum Cytokine Levels in Children with Febrile Seizure and Generalized Epilepsy with Febrile Seizure Plus.

Background and PurposeFebrile seizure (FS) is a unique type of seizure that only occurs during childhood. Genelized epilepsy with febrile seizure plus (GEFS+) is a familial epilepsy syndrome associated with FS and afebrile seizure (AFS). Both seizure types are related to fever, but whether genetic susceptibility to inflammation is implicated in them is still unclear. To analyze the associations between postictal serum cytokine levels and genetic variants in the cytokine genes interleukin (IL)-1β, IL-6, and high mobility group box-1 (HMGB1) in FS and GEFS+.MethodsGenotyping was performed in 208 subjects (57 patients with FS, 43 patients with GEFS+, and 108 controls) with the SNaPshot assay for IL-1β-31 (rs1143627), IL-1β-511 (rs16944), IL-6-572 (rs1800796), and HMGB1 3814 (rs2249825). Serum IL-1β, IL-6, and HMGB1 levels were analyzed within 2 hours after seizure attacks using the ELISA in only 68 patients (38 FS, 10 GEFS+, and 20 controls). The allele distribution, genotype distribution, and correlations with serum cytokine levels were analyzed.ResultsNear-complete linkage disequilibrium exists between IL-1β-31 and IL-1β-511 variants. CT genotypes of these variants were associated with significantly higher postictal serum IL-1β levels than were CC+TT genotypes in FS (both p<0.05). CT genotypes of IL-1β-31 and IL-1β-511 variants were more strongly associated with FS than were CC+TT genotypes (odds ratio=1.691 and 1.731, respectively). For GEFS+, serum IL-1β levels after AFS for CT genotypes of IL-1β-31 and IL-1β-511 were also higher than for CC+TT genotypes. No significant associations were found for IL-6 and HMGB1.ConclusionsGenetic variants located in IL-1β-31 and IL-1β-511 promotor regions are correlated with higher postictal IL-1β levels in FS. These results suggest that IL-1 gene cluster variants in IL-1β-31 and IL-1β-511 are a host genetic factor for provoking FS in Korean children.

The diagnostic value of serum UCHL-1 and S100-B levels in differentiate epileptic seizures from psychogenic attacks

ObjectiveTo assess the value of postictal serum Ubiquitin C-terminal hydrolase (UCHL-1), a neuronal biomarker, and S100-B, a glial biomarker, levels, in differentiate epileptic seizures (ES) form psychogenic attacks. MethodsIn this analytical cross-sectional study, serum UCHL-1 and S100-B levels were measured within six hours of occurring seizure, in 43 patients with ES, 20 patients with psychogenic non-epileptic seizures (PNES) and 19 healthy individuals by electrochemiluminescence immunoassay. ResultsBoth serum UCHL-1 and S100-B levels were significantly higher in patients with ES than PNES (P < 0.05) and controls (P < 0.01). PNES patients had significantly higher serum S100-B levels compared to controls (P < 0.01). There was a significant correlation between the serum UCHL-1 and S100-B levels in patients with ES (r = 0.46, P = 0.002). ConclusionsOur study showed that serum UCHL-1 level could be potentially used in differentiate ES from PNES (sensitivity 72%, specificity 59%). Serum S100-B level had lower value compared to UCHL-1 (AUC 0.68 for UCHL-1 v/s 0.59 for S100B). Post-seizure serum UCHL-1 and S100-B levels could be used in future studies to better understand the underlying mechanism of seizures and may offer as an adjunctive diagnostic test in differentiate ES from PNES.

Serum NT-pro CNP levels in epileptic seizure, psychogenic non-epileptic seizure, and healthy subjects.

Epileptic seizure is the result of uncontrollable neural excitation in the brain. The C-type natriuretic peptide is a member of natriuretic peptide hormone family and is synthesized by brain and blood vessels in CNS. NT-pro CNP is an amino-terminal fragment of C-type natriuretic peptide and is more stable compared to its predecessor. In this study, we aimed to evaluate the role of NT-pro CNP in psychogenic non-epileptic seizures, epileptic seizures, and normal subjects. Thirty-three patients with epilepsy and 43 patients with psychogenic non-epileptic seizures were enrolled in this study. The control group consisted of 28 healthy subjects. Post-ictal serum levels of NT-pro CNP were acquired from all participants. Statistically significant differences between patient groups and controls regarding serum levels of NT-pro CNP were sought. NT-pro CNP levels were significantly lower in the epilepsy group than the psychogenic non-epileptic seizure group and control group with no significant difference between the psychogenic non-epileptic seizure and control group (p < 0.05). Post-ictal serum NT-pro CNP levels were lower in epileptic seizures compared to psychogenic non-epileptic seizures as well as healthy controls. We think that such a difference is associated with C-type natriuretic peptide-related neural mechanisms such as altered microcirculation, increased brain-blood barrier permeability, and synaptic stabilization.

Serum Prolactin Level in Children with Febrile Seizure and Epileptic Seizure; Comparative Study

Introduction: Transient hyperprolactinaemia has been reported to follow unprovoked seizures, a finding proposed to be useful in the differential diagnosis of epilepsy. On this basis we conducted a study with an objective to compare the postictal serum prolactin level in children with febrile seizures (FS) and epileptic seizures (ES) to evaluate, whether serum prolactin (PL) could be used a predictor in the diagnosis of ES.Material and Methods: This was a prospective comparative study was conducted on 52 children (26 in febrile seizures group and 26 in epileptic seizure group) in the age group of six months to five years. Children with CNS infection, developmental delay, structural CNS defects or neurological abnormality, metabolic disorders and those on drugs, known to have altered serum prolactin level were excluded. Blood for estimation of serum prolactin was collected within 180 minutes of occurrence of seizure. Level of serum prolactin was quantitatively assayed by chemiluminescence method and the levels were considered high, if values were greater than 23 ng/ml, which is the upper limit of normal for all age groups and both sex.Results: The mean serum prolactin level in epileptic seizures group was 25 ng/ml and that of febrile seizures group was 10.72 ng/ml. High level of serum prolactin was noted in 17 children (77.2%) with GTCS and 3 children (75%) with CPS. None of the children with febrile seizures had significant raise in the level of serum prolactin.Conclusion: There is a significant rise in serum prolactin level in children with epileptic seizures compared to febrile seizures, if measured within 3 hours of occurrence of seizures. Thus, the post-ictal serum prolactin level can be used as an additional investigation to diagnose or predict epileptic seizures in children.

Early postictal serum lactate concentrations are superior to serum creatine kinase concentrations in distinguishing generalized tonic-clonic seizures from syncopes.

Concentrations of serum creatine kinase (CK) and serum lactate are frequently measured to help differentiate between generalized tonic-clonic seizures (GTCS) and syncope. The aim of this prospective cohort study was to systematically compare these two markers. The primary outcome is the measurement of serum lactate and CK in blood samples drawn within 2h of the event in patients admitted with either a GTCS (n=49) or a syncope (n=36). Furthermore, the specificity and sensitivity of serum lactate and CK are determined as diagnostic markers in distinguishing between GTCS and syncope. GTCS patients have significantly higher serum lactate levels compared to syncope patients (p<0.001). In contrast, CK does not differ between groups at admission. Regarding the first hour after the seizure, we identify a cut-off for serum lactate of 2.45mmol/l for diagnosing GTCS as the cause of an impairment of consciousness with a sensitivity of 0.94 and a specificity of 0.93 (AUC: 0.97; 95% CI 0.94-1.0). In the second hour after the event, the ROC analysis yields similar results (AUC: 0.94; 95% CI 0.85-1.0). Serum lactate is a sensitive and specific diagnostic marker to discriminate GTCS from syncope and is superior to CK early after admission to the emergency department.

Serum prolactin for differentiating epileptic seizures in children

Background Serum prolactin level has been used as a marker to differentiate epileptic from non-epileptic seizures in adults. Electroencephalogram (EEG) examination is the primary diagnostic tool used to assess seizures. However, EEGs are quite difficult to perform in children and have sensitivity of only 50%- 55%, with 96% specificity. Objective To assess the diagnostic potential of serum prolactin level as an alternative tool for children for differentiating between epileptic and non-epileptic seizures. Methods This diagnostic study was performed between January 2013 and December 2013. Thirty patients aged 3 months to 15 years with seizures and without fever who visited the Emergency Department of Arifin Ahmad Hospital, Pekanbaru, Riau, were included. Blood specimens were collected within 2 hours after seizure. Subjects underwent serum prolactin measurements and EEG examinations. Results Fifteen subjects had normal EEGs and 15 subjects had abnormal EEGs. Post-ictal serum prolactin levels were significantly higher in the epileptiform EEG group. The mean serum prolactin levels were 23.78 (SD 21.86) ng/mL and 10.57 (SD 5.62)ng/mL in patients with epileptic and non-epileptic patients, respectively. Using a prolactin cut-off point of 17.2 ng/mL, serum prolactin had a 73.3% sensitivity and 93.3% specificity for differentiating between epileptic and non-epileptic seizures. Conclusion Our findings suggest that serum prolactin level increases after an epileptic seizure, but not after a non-epileptic seizure. Post-ictal prolactin elevation within 2 hours may be useful in differentiating epileptic seizures from non-epileptic seizures.

Postictal serum creatine kinase for the differential diagnosis of epileptic seizures and psychogenic non-epileptic seizures: a systematic review.

The aim of this review was to evaluate the sensitivity and specificity of postictal creatine kinase (CK) levels in the differential diagnosis of epileptic seizures (ES) and psychogenic non-epileptic seizures (PNES). A systematic search was conducted for studies that evaluated postictal CK levels in patients with ES (all types) and PNES. Sensitivity and specificity with 95% confidence intervals were determined for each study, taking into account: (a) the upper limits adopted; and (b) the 95.7th percentile values, which are recently proposed practical upper reference limits for CK activity. Four studies, comprising a total of 343 events (248 ES and 95 PNES), were available for analysis. Most patients (47/78, 60%) with ES considered had primarily or secondarily generalized tonic-clonic seizures. The sensitivity of increased postictal CK levels for ES ranged from 14.6 to 87.5, whereas specificity ranged from 85.0 to 100.0. At the 95.7th percentile threshold, sensitivity ranged from 14.6 to 62.5 and specificity was 100.0. The limited number of studies available, their small sample size, and lack of individual event data prevented further stratification analysis by seizure type. Despite the clinical heterogeneity and the limitations of the included studies, increased postictal CK levels are highly specific for the diagnosis of ES, although no definite conclusion on its role in differentiating between convulsive and non-convulsive ES can be drawn. Postictal serum CK levels can provide valuable retrospective information at the later stages of the differential diagnosis of ES and PNES. Due to low sensitivity, normal postictal CK levels do not exclude ES.

Serum Zinc Level in Children With Simple Febrile Convulsions

Dear Editor, Febrile convulsions are the most common convulsive seizures in infants and preschool children (1, 2). Such events, have great impact on the parents and are a leading cause of parental anxiety and family disruption (3). Pathophysiology of febrile convulsions has not been known.2 Genetics and environment have been implicated in their generation (4). Trace elements have been hypothesised to involve in the pathophysiology of febrile convulsions. Recent studies have shown lower post ictal serum zinc levels in children with febrile convulsions (5). Considering the importance of febrile convulsions in our province (south west of Iran) and the theorised implication of hypozincemia in their occurrence, we carried out a case-control study to determine post ictal serum zinc level in a group of children with simple febrile convulsions comparing by those of a control group of febrile children with the same age. To be enrolled children had to be between 6 months and 5 years old and had to meet the diagnostic criteria of simple febrile convulsions according to the International League against Epilepsy definition (6). Excluded were those who received zinc supplements. The control group was comprised of children less than 5 years who were seen in the outpatient clinic or emergency department because of a febrile illness other than central nervous system infection. Informed consent was obtained from the parents of all children before enrolment into the study. Blood samples (2 ml) were drawn by venipuncture from the antecubital vein using a disposal plastic syringe with a 23 gauge needle in the morning between 8:00 and 10:00 am. All children with febrile convulsions were at least 24 hours seizure-free from the sampling time. Blood samples were centrifuged at 1500 RPM for 10 min, and the serum was stored at -86oC until the time of analysis. Serum zinc concentration was measured by the graphite furnace flame atomic absorption spectrophotometry (AAS; SpectrAA 220, GTA 110, Varian, Australia) technique. Serum zinc concentration was reported as microgr/dl. Statistical analysis was performed using SPSS version 16.0 statistical software (SPSS, Inc, Chicago, IL). Categorical variables were analysed using the χ2 test. Continuous variables were analysed using independent sample t-test, or Mann-Whitney Rank Sum test when appropriate. A P 0.05). In both groups the most frequent cause of fever was otitis media and other upper respiratory tract infections. No significant difference was found between two groups in terms of aetiology of fever. In the patients’ group, serum zinc level (median; 70 microgr/dl) was significantly lower than the control group (median; 90 microgr/dl) (P < 0.001) (Figure 1). Figure 1. Serum Zinc Level Was Significantly Lower in Children With Febrile Convulsion (40) Than Children With Fever (40) (P < 0.001) In both groups, no relation was found between serum zinc level and age. In both groups, no relation was found between serum zinc level and aetiology of fever. Our results indicate that low or reduced postictal serum zinc level in children with febrile convulsion is a reproducible finding in different geographical regions of the world. Moreover, no relation was found between aetiology of fever and serum zinc level. Recently, hypozincemia and reduced levels of CSF zinc have been reported in children who had febrile convulsions (5). However, exact role of the zinc in the pathogenesis of febrile convulsions is still unknown. Previous studies have been proposed a theory about induction of febrile convulsions with a reduced level of serum zinc level. Based on this theory, hypozincemia activates the NMDA receptor, one of the glutamate families of receptors, which may play an important role in inducting epileptic discharge.5 Moreover, zinc has a regulatory effect on glutamic acid decarboxylase and this enzyme is the core in the synthesis of GABA. Decreased function of the mentioned enzyme has been hypothesized in hypozincemia. Therefore, hypozincemia could lead to reduced levels of GABA in the brain and finally seizure threshold could be reduced in conditions with hypozincemia. The major limit of this study was that we only measured serum zinc level during a febrile illness; therefore we could not compare the serum zinc level of our participants during illness and healthy states. Few studies with the same methods were conducted in different countries to measure the serum zinc level in children with febrile convulsions. In all of these studies, results were shown that children with simple febrile convulsions had serum zinc levels lower than that of febrile children with the same age (7, 8). In conclusion, a considerable body of evidence now exists that shows hypozincemia in children with febrile convulsions during an episode of seizure. We think it is valuable to design large prospective trials to assess the serum zinc level in children at risk for the occurrence of febrile convulsions during healthy states and before a seizure occurrence.

Transient hyperammonemia associated with postictal state in generalized convulsion

Previous studies revealed that transient hyperammonemia was noted after generalized convulsion. This study was undertaken to analyze the association between postictal state and serum ammonia levels. Adult patients presenting to the emergency department with seizures were included. Serum ammonia and other blood tests were compared between patients with full recovery of consciousness after generalized convulsion and those who had not completely regained consciousness. Patients who had not completely regained consciousness (7 of 7, 100%) had higher rate ( p = 0.035) of hyperammonemia compared with patients who had fully regained consciousness (4 of 10, 40%) and higher level of serum ammonia (246 ± 96 μg/dL vs. 102 ± 99 μg/dL, p = 0.006). All patients who showed postictal consciousness level impairment on arrival at the emergency department had elevated serum ammonia at that time. Transient hyperammonemia is associated with postictal confusion.

Serum creatine phosphokinase is helpful in distinguishing generalized tonic–clonic seizures from psychogenic nonepileptic seizures and vasovagal syncope

Objective Distinguishing epileptic generalized tonic–clonic seizures (GTCS) from either psychogenic nonepileptic seizures (PNES) or vasovagal syncope (VVS) is important. In this study, we investigated the use of postictal serum creatine phosphokinase (CPK) concentrations in distinguishing between these events. Methods Patients admitted to the Neurology Ward at Namazi Hospital in Shiraz, Iran, with an attack of transient loss of consciousness and abnormal movements witnessed by a neurologist were studied. We categorized the patients into three groups: 20 patients with GTCS, 22 with VVS, and 20 with PNES. A group of 20 normal healthy individuals were included in the study as the control group. Serum CPK concentration was measured 12–15 h after the attack in all patients and at one time in the control group. A P value less than 5% was considered significant. Results There were no significant differences between the four groups with respect to age and sex. Mean CPK concentrations statistically significantly differed between the four groups, with higher levels in patients with GTCS ( P = 0.0001). Serum CPK concentration had a sensitivity of 75% and specificity of 86% for the diagnosis of GTCS. CPK concentration was above 160 mg/dl in 75% of patients with GTCS, 15% of patients with PNES, 13.6% of patients with VVS, and 15% of the control group ( P = 0.0001). The PNES, VVS, and control groups did not statistically significantly differ with respect to CPK concentrations. Conclusion In patients with a recent loss of consciousness and abnormal movements, serum CPK concentration is a useful, practical, and relatively accurate parameter to assist in the differentiation of epileptic seizures from either VVS or PNES.

Postictal serum nucleotidases activities in patients with epilepsy

Adenosine, a potent anticonvulsant, can be produced in the body by the hydrolysis of adenine nucleotides through the action of ecto- or soluble nucleotidases. Changes in nucleotide hydrolysis occur after pentylenetetrazol-induced epileptic events. We evaluated serum ATP, ADP and AMP hydrolysis rates and soluble nucleotide phosphodiesterase (PDEase) activity at 5, 10, 15, 30 and 60 min, and 12h following an epileptic event. Fifteen patients (seven female, eight male; mean age 15.5 years) were included in the study. The type of seizure was generalized in four patients and was localization related in the remaining 11. There were no differences in adenine nucleotide hydrolysis rates between patients and healthy subjects in the interictal stage. In comparison with controls, ATP, ADP and AMP hydrolysis rates were significantly increased at 5 min (53+/-1.4%, 79.2+/-2.8% and 37.0+/-2.6%, respectively) and up to 30 min following the epileptic event. In contrast to ADP and AMP, ATP hydrolysis remained significantly increased at 60 min (71.4+/-1.6%), returning to the basal level after 12h. Serum PDEase activity was also significantly higher in the patients than in healthy subjects, peaking at 15 min (61+/-2.9%) and remaining significantly increased up to 60 min (4.6+/-1.2%) following the epileptic episode. Globally, the variations in the postictal serum ADP hydrolysis rate almost overlapped those of AMP hydrolysis, whereas changes in the ATP hydrolysis rate overlapped those of PDEase activity. The clinical significance of this elevation in postictal soluble serum nucleotidase activity remains to be clarified. However, it is possible to hypothesize that the higher nucleotidase activity might play a role in the modulation of epileptic events.

Convulsions with propofol

We present a rare but potentially harmful adverse reaction of propofol. A 50-year-old patient was posted for laparoscopic cholecystectomy, developed generalized convulsions after few seconds of propofol administration at anesthesia induction. Convulsions subsided with intravenous administrations of thiopentone and midazolam. Patient remained hemodynamically stable and surgery was uneventful. Blood sugar, serum electrolytes and arterial blood gas analysis were normal. Postoperatively, there was no evidence of postictal phase, serum electrolytes and postoperative computerized tomographic scanning of the head were normal. Patient had uneventful recovery. The administration of propofol has been associated with abnormal movements collectively termed as seizure-like phenomenon. Despite the claims that propofol may have proconvalsant activity, there is significant amount of evidence to the contrary also. The pathophysiological mechanisms behind the neuroexcitatory symptoms with propofol are unknown. Propofol alters the conscious state, the transition from the conscious state to anesthesia or vice versa may be a particularly vulnerable period and may be prolonged after the end of propofol administration.

Do cytokines have any role in epilepsy?

We analyzed cytokines levels in patients with epilepsy and new onset seizure and correlated it with various parameters. After obtaining consent, serum samples from 100 patients with epilepsy or new onset seizure were prospectively collected in the immediate post-ictal phase. In 16 patients, a second sample was collected during the seizure-free period. The serum cytokine levels [TNF-alpha, IFN-gamma, IL-1beta, IL-2, IL-4, and IL-6] were assessed (ELISA) in these patients and 100 matched healthy controls. CSF analysis was carried out in 9 patients of this cohort, when clinically indicated. The type of seizures (n=100) was major (45), partial (41) and status epilepticus (SE=14), while the epilepsy syndromes were idiopathic generalized (53) and localization related (47). The detectable serum cytokines in the patient group (n=100) were: IL-6 (42), TNF-alpha (36), IL-2 (22), IL-4 (22), IFN-gamma (20) and IL-1 (11) compared to the controls. CSF IL-6 and IL-1 was detectable in 4/9 and 2/9 patients, respectively while, IL-2, IL-4, IFN-gamma was detectable 1 in each patient. Correlations were noted between male gender and IL-1beta (p=0.04), positive family history and IL-1beta (p=0.001), "no alcohol use" and TNF-alpha (p=0.05), more than one year history of epilepsy and IL-1beta (p=0.02), status epilepticus (SE) and IL-6 (p=0.04). There was no difference between the new onset seizures vs. epilepsy group. Serial analysis during the seizure-free period revealed a decrease in cytokine levels: TNF-alpha (25% to 12.5%), IFN-gamma (12.5% to 0%), IL-1 (25% to 0) and IL-2 (6.2% to 6.2%), IL-4 (18.8% to 0%) and IL-6 (18.8% to 6.2%). We found increased post-ictal serum cytokine levels in patients with several epilepsy syndromes.

Soluble Telencephalin in the serum of Children after Febrile Seizures

Sirs: Febrile seizures (FS) affect 3–5 % of all children. Although FS are generally considered as benign, there is an ongoing debate whether they are a risk factor for later development of temporal lobe epilepsy (TLE) [2]. Telencephalin (TLN) – intercellular adhesion molecule-5 (ICAM-5) – is a neuronal glycoprotein. It is unique among the family of five identified ICAMs because only TLN is expressed on somatodendritic membranes of neo-cortical neurons in the most rostral segment of the mammalian brain [6]. Increased concentration of soluble TLN (sTLN) in serum and cerebral spinal fluid has been reported in adults with temporal lobe epilepsy [5] and acute encephalitis [4, 5]. No significant elevations of TLN were found in other neurological diseases such as generalized epilepsy, Alzheimer’s disease or multiple sclerosis [5]. In order to obtain further information about the potential role of sTLN as a neuronal marker, we investigated postictal serum levels of TLN in 48 children (21 female, 27 male) aged five to 63 months (mean 28.3 ± 14.9) with a first or second FS. The study was approved by the ethics committee of the University of Munster. All patients were followed for at least 36 months up to 42 months. The control group consisted of 43 age and sex matched children with fever but without FS. Samples were collected within 24 hours following the seizure. Soluble TLN was measured with a sensitive sandwich immunoassay with two mouse monoclonal antibodies to the extracellular domains of human telencephalin. We compared serum concentrations with a standard curve generated from recombinant telencephalin. As in previous publications we considered sTLN levels under 8 ng/ml as normal values [4], between 8 and 30 ng/ml as modest elevation and above 30 ng/ml as significantly increased. The mean and standard deviations were calculated for continuous variables. Increased values of sTLN were detected in nine children with FS and in nine of the control group without any significant differences between the two groups (Fig. 1). No significant correlation between the sTLN values and the following variables was demonstrated: age at onset of the FS, family history considering FS or epilepsy, seizure duration, seizure classification (generalized vs. focal), temperature at admission, simple FS vs. complex FS. During the follow-up five children had at least one more febrile seizure and in four patients diagnosis of epilepsy was established because of recurrent afebrile seizures. In all those children as well as in the group with recurrent FS no association with sTLN levels could be established. Published data on TLN suggest that this protein may be an indicator for neocortical neuron damage. The fact that TLN serum values were significantly increased in patients with temporal lobe epilepsy but not in adults with generalized epilepsies suggests ongoing pathophysiological events mainly in the mesiotemLETTER TO THE EDITORS

Post-ictal circulating levels of allopregnanolone in children with partial or generalized seizures

Introduction: Allopregnanolone (3α-hydroxy-5α-pregnan-20-one) is a neurosteroid with a potent modulating activity on the gamma-aminobutyric acid (GABA) a receptor complex. It plays a key role in the epileptogenesis of partial seizures. Serum allopregnanolone concentrations significantly increase in the postcritical phase. In the present study we investigated the post-ictal serum allopregnanolone levels in children with partial seizures and generalized seizures, respectively. Patients and methods: Three groups of subjects were included in the study. Group 1 consisted of 18 children affected by complex partial seizures. Group 2 consisted of 11 children presenting with generalized epilepsy. Group 3 consisted of 20 healthy age-matched subjects. Serum allopregnanolone levels were assayed in the inter-ictal phase and within 30 min after an epileptic event. Results: The data we obtained suggest that circulating allopregnanolone level significantly increases in the post-ictal phase. However, we found no significant differences in the post-ictal serum allopregnanolone concentrations between patients with partial seizures and those with generalized seizures. Conclusions: Further studies are needed to establish if allopregnanolone is a reliable circulating marker of epileptic seizures. However, our observations seem to indicate that post-ictal circulating allopregnanolone level is not useful in differentiating focal and generalized epilepsy events.

Postictal serum levels of antiepileptic drugs for detection of noncompliance

Medication noncompliance (NC) is thought to be a major cause of insufficient seizure control. In an explorative study we investigated whether postictal serum levels (PISLs) of antiepileptic drugs (AEDs) are a reliable indicator of NC. Young adults with epilepsy on a stable AED regimen were asked to contact medical service as soon as possible when a seizure occurred to obtain serum levels of their AEDs. PISLs were compared with the mean value of two routine serum levels of the same medication. PISLs lower than 50% of the individual reference value were regarded as an indicator of NC. PISL samples in 61 seizures of 52 patients treated mainly with carbamazepine, valproic acid, or lamotrigine were evaluated. A drop in serum levels >50% indicating NC was noted in 44.3% of the seizures. Determination of PISLs seems to be a simple and useful method for detecting or ruling out irregular intake patterns as a cause of “breakthrough” seizures.