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An epidemic of seizures and psychosis in a sudanese village — A challenging experience
Abstracts / Journal of the Neurological Sciences 333 (2013) e1–e64
Abstract — WCN 2013 No: 1016 Topic: 1 — Epilepsy Infantile spasm in children: Clinical features and outcome T. Sultan. Child Neurology, The Children Hospital & Institute of Child Health, Lahore, Pakistan Objective: Clinical features and outcome of children with infantile spasms. Study design: Interventional and observational study. Place and duration of study: The Department of Neurology, Children's Hospital, Lahore, Pakistan, from April 2008 to March 2013. Methodology: Children aged b2 years presented with history of infantile spasms were assessed. Clinical presentation, EEG findings and response of anti-epileptic drugs was analyzed. Results: We enrolled 450 infants with infantile spasms at their first presentation. Out of 450 children, 76% presented at age of b6 month, 72% presented due to infantile spasms and 18% because of global developmental delay. Spasm types were mixed (38%), flexors (44%), extensor (16%) and asymmetric (2%). Hypsarrhythmia (67%) was the predominant EEG finding followed by modified hypsarrhythmia (24%) and other forms of epileptic discharges in 9% children. Majority of children were receiving oral Phenobarbitone, Carbamazepine or Valproate sodium. We initiate the management with oral Prednisolone followed by Clonazepam or valproate acid. ACTH therapy was administered in only 5 children. Conclusion: Infantile spasms are one of the refractory epilepsy in children. Abnormal EEG findings predominantly the hypsarrhythmia or modified hypsarrhythmia are the hallmark. Majority of children received conventional AED with poor response. Oral prednisolone is proved to be the most effective AED. These children should be referred to the tertiary care pediatric neurology centers. doi:10.1016/j.jns.2013.07.069
Abstract — WCN 2013 No: 911 Topic: 1 — Epilepsy Continuous EEG in critically ill patients: Experience at a single tertiary care center H. Arif, S.M. LaRoche. Neurology, Emory University, Atlanta, GA, USA Background: Continuous EEG (cEEG) can provide critical information about brain function including detection of causes of secondary injury such as seizures. Although recent advances have led to widespread use of cEEG in this population, there is limited data on current clinical practices. Objective: To describe clinical findings in critically ill patients undergoing cEEG at a tertiary care center over a three year period. Patients and methods: We retrospectively reviewed data from 1305 cEEG monitoring sessions from 2009 to 2011. Patients were selected to undergo cEEG at the discretion of the treating physician. Indications for monitoring, EEG findings, neurologic diagnosis and outcome at discharge were assessed. Results: The primary indication for cEEG was the detection of subclinical seizures (72.3%), followed by characterization of spells (18.5%). The three most common neurologic diagnoses were subarachnoid hemorrhage (16.5%), altered mental status (16.0%) and new-onset seizure (10.1%). Seizures were reported in 17.9% (216/1202 patient encounters) and 51% (110/216) were exclusively electrographic. High rates of nonconvulsive seizures were seen in patients with CNS infection (36.4%, n = 4/11), CNS neoplasm (16.4%, n = 11/67), vascular malformation (16.7%, n = 1/6) and intracerebral hemorrhage (10.4%, n = 10/96). Good outcome (discharge to home or rehab) was seen in
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46% of all patient encounters and 48% of patients who experienced seizures during cEEG. Conclusion: Subclinical seizures are common in critically ill patients with a variety of underlying neurologic diagnoses. Prospective studies are needed to determine the incidence and predictors of seizures in a non-selected population as well as the impact of seizures on outcome. doi:10.1016/j.jns.2013.07.070
Abstract — WCN 2013 No: 1045 Topic: 1 — Epilepsy An epidemic of seizures and psychosis in a sudanese village — A challenging experience O. Seidi. Neurosciences, Soba University Hospital, University of Khartoum, Khartoum, Sudan Background: In January 2010, a wave of pathological laughter, crying and bizarre behavior affected about 122 people in a remote village in the far North West State of Kordofan in Sudan. Patients, methods and results: Detailed investigation of the clinical presentations and possible underlying causes was done with provision of medical treatment. Children constituted 52% and were more severely affected than adults. The main presentations were visual hallucinations, uncontrolled laugher, twisting movements, delirium, and convulsions. No vascular manifestations were detected. Males were affected more than females (60%). In a few of the severely affected patients a lumbar puncture was performed (7/122). The patients were treated symptomatically with benzodiazepines. Carbamazepine was used in those presenting with recurrent seizures. Routine urine, blood and CSF basic parameters were within normal limits for routines, but the toxicology screen of urine missed the critical period for detection of the suspected toxic substances. Samples from the water sources were clear, but the wheat consumed by the villagers grew the fungus Claviceps purpurea in abundance. Further tests on the fungi revealed their production of very high level of LSD-like ergot alkaloids. No long term neurological sequelae were noticed on follow up. The wheat came from stores in Darfur which is near the affected village. The epidemic was contained and a public education campaign was launched to avoid recurrence of the event. This paper includes videos and a literature review. Conclusions: This study draws attention to the importance of vigilance about neurotoxins as causes of bizarre presentations. doi:10.1016/j.jns.2013.07.071
Abstract — WCN 2013 No: 1047 Topic: 1 — Epilepsy The sensitivity of the long term eeg and sleep eeg in the diagnosis of epilepsy I. Uludag, L. Ocek, Y. Zorlu, F. Tokucoglu. Neurology, Tepecik Educational and Research Hospital, Izmir, Turkey Background: Long term video-EEG monitorization (LTEEG) is a very valuable diagnostic tool in the differential diagnosis of epileptic and non-epileptic seizures, in the classification of epileptic seizures and in the evaluation of surgical candidacy in patients with medically refractory seizure disorders. When there is diagnostic uncertainty as to the diagnosis of epilepsy, LTEEG is used to detect interictal epileptiform abnormalities. Sleep-EEG may also reveal interictal epileptiform abnormalities in patients with an initial negative routine EEG.
Abstract — WCN 2013 No: 1016 Topic: 1 — Epilepsy Infantile spasm in children: Clinical features and outcome T. Sultan. Child Neurology, The Children Hospital & Institute of Child Health, Lahore, Pakistan Objective: Clinical features and outcome of children with infantile spasms. Study design: Interventional and observational study. Place and duration of study: The Department of Neurology, Children's Hospital, Lahore, Pakistan, from April 2008 to March 2013. Methodology: Children aged b2 years presented with history of infantile spasms were assessed. Clinical presentation, EEG findings and response of anti-epileptic drugs was analyzed. Results: We enrolled 450 infants with infantile spasms at their first presentation. Out of 450 children, 76% presented at age of b6 month, 72% presented due to infantile spasms and 18% because of global developmental delay. Spasm types were mixed (38%), flexors (44%), extensor (16%) and asymmetric (2%). Hypsarrhythmia (67%) was the predominant EEG finding followed by modified hypsarrhythmia (24%) and other forms of epileptic discharges in 9% children. Majority of children were receiving oral Phenobarbitone, Carbamazepine or Valproate sodium. We initiate the management with oral Prednisolone followed by Clonazepam or valproate acid. ACTH therapy was administered in only 5 children. Conclusion: Infantile spasms are one of the refractory epilepsy in children. Abnormal EEG findings predominantly the hypsarrhythmia or modified hypsarrhythmia are the hallmark. Majority of children received conventional AED with poor response. Oral prednisolone is proved to be the most effective AED. These children should be referred to the tertiary care pediatric neurology centers. doi:10.1016/j.jns.2013.07.069
Abstract — WCN 2013 No: 911 Topic: 1 — Epilepsy Continuous EEG in critically ill patients: Experience at a single tertiary care center H. Arif, S.M. LaRoche. Neurology, Emory University, Atlanta, GA, USA Background: Continuous EEG (cEEG) can provide critical information about brain function including detection of causes of secondary injury such as seizures. Although recent advances have led to widespread use of cEEG in this population, there is limited data on current clinical practices. Objective: To describe clinical findings in critically ill patients undergoing cEEG at a tertiary care center over a three year period. Patients and methods: We retrospectively reviewed data from 1305 cEEG monitoring sessions from 2009 to 2011. Patients were selected to undergo cEEG at the discretion of the treating physician. Indications for monitoring, EEG findings, neurologic diagnosis and outcome at discharge were assessed. Results: The primary indication for cEEG was the detection of subclinical seizures (72.3%), followed by characterization of spells (18.5%). The three most common neurologic diagnoses were subarachnoid hemorrhage (16.5%), altered mental status (16.0%) and new-onset seizure (10.1%). Seizures were reported in 17.9% (216/1202 patient encounters) and 51% (110/216) were exclusively electrographic. High rates of nonconvulsive seizures were seen in patients with CNS infection (36.4%, n = 4/11), CNS neoplasm (16.4%, n = 11/67), vascular malformation (16.7%, n = 1/6) and intracerebral hemorrhage (10.4%, n = 10/96). Good outcome (discharge to home or rehab) was seen in
e17
46% of all patient encounters and 48% of patients who experienced seizures during cEEG. Conclusion: Subclinical seizures are common in critically ill patients with a variety of underlying neurologic diagnoses. Prospective studies are needed to determine the incidence and predictors of seizures in a non-selected population as well as the impact of seizures on outcome. doi:10.1016/j.jns.2013.07.070
Abstract — WCN 2013 No: 1045 Topic: 1 — Epilepsy An epidemic of seizures and psychosis in a sudanese village — A challenging experience O. Seidi. Neurosciences, Soba University Hospital, University of Khartoum, Khartoum, Sudan Background: In January 2010, a wave of pathological laughter, crying and bizarre behavior affected about 122 people in a remote village in the far North West State of Kordofan in Sudan. Patients, methods and results: Detailed investigation of the clinical presentations and possible underlying causes was done with provision of medical treatment. Children constituted 52% and were more severely affected than adults. The main presentations were visual hallucinations, uncontrolled laugher, twisting movements, delirium, and convulsions. No vascular manifestations were detected. Males were affected more than females (60%). In a few of the severely affected patients a lumbar puncture was performed (7/122). The patients were treated symptomatically with benzodiazepines. Carbamazepine was used in those presenting with recurrent seizures. Routine urine, blood and CSF basic parameters were within normal limits for routines, but the toxicology screen of urine missed the critical period for detection of the suspected toxic substances. Samples from the water sources were clear, but the wheat consumed by the villagers grew the fungus Claviceps purpurea in abundance. Further tests on the fungi revealed their production of very high level of LSD-like ergot alkaloids. No long term neurological sequelae were noticed on follow up. The wheat came from stores in Darfur which is near the affected village. The epidemic was contained and a public education campaign was launched to avoid recurrence of the event. This paper includes videos and a literature review. Conclusions: This study draws attention to the importance of vigilance about neurotoxins as causes of bizarre presentations. doi:10.1016/j.jns.2013.07.071
Abstract — WCN 2013 No: 1047 Topic: 1 — Epilepsy The sensitivity of the long term eeg and sleep eeg in the diagnosis of epilepsy I. Uludag, L. Ocek, Y. Zorlu, F. Tokucoglu. Neurology, Tepecik Educational and Research Hospital, Izmir, Turkey Background: Long term video-EEG monitorization (LTEEG) is a very valuable diagnostic tool in the differential diagnosis of epileptic and non-epileptic seizures, in the classification of epileptic seizures and in the evaluation of surgical candidacy in patients with medically refractory seizure disorders. When there is diagnostic uncertainty as to the diagnosis of epilepsy, LTEEG is used to detect interictal epileptiform abnormalities. Sleep-EEG may also reveal interictal epileptiform abnormalities in patients with an initial negative routine EEG.