Single small enhancing computed tomographic (CT) lesions in Indian patients with new-onset seizures. A prospective follow-up in 75 patients

This study was planned to observe the clinical and radiological course of single small enhancing CT lesions in Indian patients presenting with new-onset-seizures. In this study, 75 patients with new-onset seizures and a single enhancing CT lesion were prospectively followed up for 1 year. All patients fulfilled the criteria of cysticercus granuloma. The repeat CT scans were performed 2 months after the first CT scan. Antiepileptic drug therapy was the only form of treatment given. The majority of patients were below 20 years of age. Simple partial seizure, with or without secondary generalization, was the commonest type of seizure encountered in these patients. In follow-up CT scans 84% of patients showed either disappearance or regression in the size of lesion. The proportion of patients showing complete disappearance of CT lesions was 0.73 (95% CI, 0.61-0.80). In 11 (15%) patients the lesions were calcified. In nine patients, in whom the lesion had persisted or regressed, another follow-up CT scan (6 months after the second scan) revealed either complete disappearance or calcification of the lesions. The majority (86.6%) of patients remained seizure free for 1 year after starting antiepileptic drugs. Ten patients experienced seizure recurrences within the first month of therapy. The proportion of patients who remained seizure free was 0.86 (95% CI, 0.76-0.92). Four patients experienced seizure recurrence even after complete disappearance of CT lesions. In the majority of patients the lesions disappeared spontaneously and in a few the lesions calcified; hence these patients did not require anticysticercal therapy. Antiepileptic therapy was helpful in controlling further recurrences of seizures in most of the patients. A few patients experienced seizures even after disappearance of CT lesions.     

Short course of prednisolone in Indian patients with solitary cysticercus granuloma and new-onset seizures

PURPOSE: To evaluate the role of a short course of oral corticosteroids in Indian patients with solitary cysticercus granuloma with seizures. METHODS: In this open-label, randomized, prospective follow-up study, 97 patients with new-onset seizures and a single enhancing computed tomography (CT)-detected lesion of cysticercosis were randomly divided in two groups to receive either antiepileptic monotherapy alone (n = 48) or antiepileptic monotherapy with prednisolone (n = 49). The patients in the latter group received prednisolone, 1 mg/kg/day for 10 days, followed by tapering over next 4 days. The patients were followed up for 6 months. Repeated CT scans were performed after 1 and 6 months. RESULTS: The majority of patients were young. Simple partial seizure, with or without secondary generalization, was the commonest seizure type encountered. Follow-up CT scans at 1 and 6 months demonstrated a significantly better response for prednisolone as far as complete resolution of CT lesion was concerned. Kaplan-Meier analysis suggested significantly less probability of seizure recurrence for prednisolone-treated patients. At 6 months, Kaplan-Meier estimated risk of seizure after first seizure was 2% in prednisolone-treated patients in comparison to 13% for those who were not given prednisolone. CONCLUSIONS: Short-term prednisolone therapy helps in rapid resolution of solitary cysticercus granuloma in Indian patients with new-onset seizures. Resolution of lesions is associated with improved seizure-related prognosis.     

Role of antiparasitic therapy for seizures and resolution of lesions in neurocysticercosis patients: An 8 year randomised study

Neurocysticercosis is a common cause of acquired seizure disorder in developing countries, including India. The role of antiparasitic (albendazole) therapy for seizure control and resolution of lesions is still controversial due to a lack of adequately controlled studies. The objective of the present study was to evaluate the role of albendazole therapy for neurocysticercosis patients with two or more lesions to achieve seizure-free status and resolution of lesions. This was a randomised controlled study in which patients suffering from neurocysticercosis were prospectively followed up for more than 5 years (from January 1997 to January 2005). Patients were divided into two groups: patients in group A (n=150) were treated with a combination of tapered doses of dexamethasone and albendazole, plus antiepileptic drugs; patients in group B (n=150) were treated with antiepileptic drugs plus a placebo control. Patients were followed up every month for the first 6 months and then at 3-month intervals thereafter up to 5 years. Variables of interest were (i) recurrence of seizures; (ii) encephalopathy (headache/vomiting/altered sensorium); (iii) need for subsequent hospital admission; (iv) death; (v) resolution of lesions on follow-up CT. During the first 6 months and at intervals thereafter, increased seizure frequency and hospital readmissions, and increased incidence of encephalopathy were observed in group A (p=0.01), and two patients in this group died with intractable seizures and encephalopathy. A greater proportion of lesions completely resolved in group B (p=0.05), whereas a greater proportion of lesions calcified in group A (p=0.05). Albendazole plus antiepileptic drugs did not have greater beneficial effects than antiepileptic drugs alone, but may have an adverse effect with respect to seizure control, encephalopathy, recurrent hospital admissions, calcification of lesions and cost of treatment.     

Disappearing CT Lesions in Epilepsy

A striking but reversible computed tomographic (CT) lesion corresponding to seizure activity is reported in a series of 46 epileptic patients. None of these patients had evidence of tuberculosis or cysticercosis, and all were treated with antiepileptic drugs only. Maximal radiological changes occurred in the area of maximal epileptic discharge; however, multiple lesions were seen in three cases. The CT lesion reappeared with recurrence of the ictus in four cases during follow-up, and this, too, disappeared after complete arrest of the seizures. The clinical, CT scan, and other investigatory findings suggest that the seizures may occasionally cause a CT-demonstrable focal abnormality, probably cerebral edema, a consequence of abnormal vascular permeability. Awareness of this radiological entity should avoid misdiagnosis of cerebral tumor, infarction or tuberculoma in patients with seizure disorder.     

Acute symptomatic seizures due to single CT lesions: how long to treat with antiepileptic drugs?

The duration of anti epileptic drug therapy for single small enhancing CT lesions (SSECTL) presents a major dilemma. We studied the efficacy of short duration (6 months) antiepileptic drug therapy as compared to long duration (2 years) drug therapy. Seventy three patients presenting with seizures and showing SSECTL on cranial CT scans (plain and contrast) were randomized into group A (6 months therapy) and group B (2 years therapy). There were 47 patients in group A and 26 patients in group B. Patients were followed up for one year after withdrawal of anti epileptic drugs. CT Head (plain and contrast) was repeated after 3 months, or earlier in cases of recurrence to rule out reinfection. 53.2% in group A and 53.8% in group B showed complete resolution and were seizure free on one year follow up. Punctate residual calcification was seen in 46.8% in group A and 46.2% in group B. Eight patients (17%) in group A and three (11.5%) in group B had a recurrence. The difference in recurrence of seizure between the two groups was not statistically significant (p<0.77) in the calcified lesion subset. Since none of the patients in total resolution subset showed recurrence, the difference between calcified and total resolution subset was highly significant. The study shows that a short duration (6 months) AED therapy in patients with total resolution of lesion on follow up scan, may be adequate in comparison to those who have calcific speck as a residue. However, a longer duration of therapy in case of calcific group probably does not alter their chances of recurrence.     

Intravenous methyl prednisolone in patients with solitary cysticercus granuloma: a random evaluation.

PURPOSE: To evaluate the role of intravenous methyl prednisolone in patients with solitary cysticercus granuloma with new-onset seizures. METHODS: In this open-label, randomized, prospective, follow-up study, 52 patients with new-onset seizures and a single enhancing CT lesion of cysticercus were randomly divided in two groups to receive either intravenous methyl prednisolone for 5 days along with antiepileptic drug (n=25) or antiepileptic drug monotherapy (n=27) alone. The patients were followed up for at least for 9 months. Repeat CT scans were performed after 2 months. RESULTS: After 2 months, lesion disappeared in 60% patients of intravenous methyl prednisolone group and 18.5% patients receiving only antiepileptic drug (p=0.001). As far as seizure recurrence was concerned, a lower number (16% versus 33%) of intravenous methyl prednisolone treated patient had recurrence, the difference was insignificant. CONCLUSION: Intravenous methyl prednisolone therapy helps in early resolution of solitary cysticercus granuloma.     

Seizure recurrence in children with focal seizures and single small enhancing computed tomographic lesions: prognostic factors on long-term follow-up.

Single small enhancing computed tomographic (CT) lesions are common in children with focal seizures. There is a paucity of information regarding their long-term outcome and prognostic factors for seizure recurrence. The objective of this work was to study the frequency of seizure recurrence in children with single small enhancing computed tomographic lesions and to identify prognostic factors, if any, for seizure recurrence. A prospective long-term follow-up was conducted at the Advanced Pediatric Center, Postgraduate Institute of Medical Education and Research, an urban tertiary care teaching hospital. Sixty-three children between 2 and 12 years of age with focal seizures for less than 3 months and single small enhancing computed tomographic lesions were enrolled in a randomized, double-blind, placebo-controlled trial of albendazole therapy and followed up for 4 years. On long-term follow-up, the albendazole and placebo groups were left with 29 and 28 children, respectively. After several months of seizure-free period, antiepileptic drug was tapered off. Children with relapse underwent magnetic resonance imaging examination. All children were followed up for at least 18 months after stopping of the antiepileptic drug. Seizure recurrence was seen in three children each in both groups, after a mean interval of 6.4 weeks after stopping the antiepileptic drug. Magnetic resonance imaging revealed persistent chronic granuloma in 2 and calcified granuloma in 4 children. Residual lesions were significantly correlated with seizure recurrence. In children whose lesions completely disappeared, no seizure recurrence was seen even during shorter periods of antiepileptic drug treatment. Seizure recurrence was seen in a small number of children with focal seizures and single small enhancing computed tomographic lesions. It appears to be related to either a persistent or a calcified lesion.     

Syphilitic cerebral gumma with HIV infection.

We describe two human immunodeficiency virus (HIV)-infected patients with syphilitic cerebral gummas. Both patients presented with a seizure disorder associated with an isolated, peripherally located, contrast-enhancing lesion of the brain on CT. Cranial MRI performed on one patient revealed dural thickening in the region of the lesion. A brain biopsy in that patient revealed a lymphoplasmacytic infiltrate with extensive perivascular inflammation. Clinical manifestations, radiographic resolution of the lesions, and a decline in nontreponemal serologic tests for syphilis followed high-dose aqueous penicillin therapy in both patients. These patients illustrate that (1) cerebral mass lesions occurring with HIV infection may result from syphilis; (2) seizures may be the presenting manifestation of this form of neurosyphilis; and (3) high-dose, intravenous, aqueous penicillin is effective in treating these lesions.     

Single small enhancing CT Lesions,with special reference to neurocysticercosis: How I treat

Single small enhancing CT lesions (SSECTL) have been very commonly encountered in clinical practice. These lesions typically are small (often < 20 mm), enhancing as a ring lesion or a disc and with varying amounts of surrounding edema. Most SSECTL present as focal seizures. Once the diagnosis of SSECTL and likely to be a solitary cysticercus lesion is made, the patient is given appropriate AED therapy. Depending on the resolution pattern on repeat imaging performed at intervals not less than six months if patient remains asymptomatic, cysticidal therapy is instituted along with AEDs. Any deviation from the classical clinical or radiological patterns needs further evaluation and other etiologies described for the SSECTL will need to be ruled out, including that of tuberculosis. Largely these lesions resolve and the clinical condition remains benign and in most patients AEDs can be withdrawn in two to three years period.     

Long-Term Follow-Up of Stereotactic Lesionectomy in Partial Epilepsy: Predictive Factors and Electroencephalographic Results

We performed an extended follow-up study assessing the efficacy of stereotactic lesionectomy in 23 patients with foreign-tissue lesions and intractable partial epilepsy. Sixteen lesions involved functional or eloquent cortex as determined by anatomic localization. By definition, the surgical objective in these patients was excision of the lesion, and not the surrounding cerebral cortex. The mean duration of follow-up was 48.5 months (range 26-69 months). Seventeen patients (74%) had a significant reduction in seizures (greater than or equal to 90%) after lesionectomy. Thirteen patients (56%) had a class I operative outcome (seizure-free, single seizure episode, or auras only). Five of these patients were successfully discontinued from antiepileptic drug (AED) therapy. Patients with temporal lobe lesions were statistically less likely to be rendered seizure-free (p less than 0.05). Age at operation, duration of epilepsy, and underlying pathology were not significant predictors of seizure outcome. The anatomic distribution of extracranial EEG recorded epileptiform activity did not appear to be an important determinant of outcome. The absence of interictal epileptiform activity in the 3-month postoperative EEG correlated with a significant reduction in seizures. Long-term follow-up indicates that lesionectomy may be effective in select patients with medically refractory partial seizure disorders.     

Prognosis and Treatment of eizures in Children with Acute Lymphoblastic Leukemia

Summary: We reviewed the records of 127 consecutive pediatric patients with acute lymphoblastic leukemia (ALL) to determine the incidence, timing, etiologies, and recurrence rate of seizures in this population. Patients with ALL and seizures were identified retrospectively by review of the records of all pediatric ALL patients who were diagnosed and treated during the years 1983 through March 1993 in a large tertiary-care hospital. Seventeen patients (13%) developed one or more seizures. In 16 patients, seizures occurred during antileukemic treatment, and in almost all of them seizures were related to intrathecal methotrexate (IT MTX) or subcutaneous L-asparaginase treatment. One patient who developed a seizure while not receiving chemotherapy had a history of cerebral infarctions. In 8 patients, 47%), the initial seizure episode was associated with a cerebral lesion. One or more seizures recurred in 6 patients. Four of these patients had an isolated recurrence, in 3 patients %ge;3 months and in 1 patient >6 months after the initial event. Two patients (12%) with static encephalopathy and neurological deficits developed a chronic seizure disorder. There is a significant risk of acute symptomatic seizures in pediatric ALL patients. Most seizures in these patients occur during the acute treatment phase and are most frequently related to side effects of chemotherapy. The longterm recurrence risk is low; recurrence occurs most often in patients with evidence of cerebral structural lesions and neurological deficits. Long-term antiepileptic drug (AED) therapy should be restricted to such patients.     

Corticosteroids versus albendazole for treatment of single small enhancing computed tomographic lesions in children with neurocysticercosis

Single small enhancing computed tomographic (CT) lesions representing cysticercus granuloma are a common cause of focal seizures in children. Controversy exists regarding the efficacy of various modalities of treatment. We conducted a randomized prospective trial to evaluate the efficacy of corticosteroids, albendazole, and corticosteroids with albendazole in children with focal seizures and single small enhancing CT lesions. The study population consisted of 133 children with focal seizures of recent onset (< 3 months) and single small enhancing CT lesions who presented to the Neurocysticercosis Clinic of Pediatric Neurology Services at the Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, an urban teaching and tertiary care hospital in Chandigarh, North India. All children were randomly assigned to receive corticosteroids (group S), albendazole (group A), or both corticosteroids and albendazole (group SA) for 28 days. CT was done at 3 and 6 months after enrollment in the study. Of the 133 patients enrolled, 23 were lost to follow-up. Of the remaining 110 patients, 38 patients were in group S, 37 in group A, and 35 in group SA. All children were followed up for at least 18 months. Disappearance of the lesion on CT scan was noted in 52.6% of patients in group S, 59.5% in group A, and 62.9% in Group SA (P > .1) at the 3-month follow-up. After the 6-month follow-up, disappearance of the lesion was noted in 76.3% in group S, 75.7% in group A, and 74.2% in group SA (P > .1). Twenty-three patients had seizure recurrence while on antiepilepsy drugs: 36.8% of patients in group S, 13.5% in group A, and 11.4% in group SA (P < .05). Seizure recurrence after antiepilepsy drug withdrawal was seen in seven children (three in group S and two each in groups A and SA). In conclusion, there was no significant difference in resolution of CT lesions in the three therapy groups at 3 and 6 months of follow-up. Children in the corticosteroid group had significantly more seizure recurrences while on antiepilepsy drugs.     

Cognitive epilepsy: ADHD related to focal EEG discharges

This study was undertaken to determine the effect of antiepileptic treatment on a child with attention-deficit-hyperactivity disorder and subclinical electroencephalographic discharges without seizures. We performed a longitudinal follow-up study correlating clinical, neuropsychologic, and electroencephalographic features with antiepileptic drug therapy. The results revealed a temporal relation between subclinical epileptiform discharges and cognitive dysfunction and a significant effectiveness of antiepileptic drugs on attention-deficit-hyperactivity disorder and electroencephalographic discharges. The practice of monitoring antiepileptic treatment limited to seizure control should be revised; cognitive impairments also need to be taken into account even without occurrence of seizure. The classical principle of treating only seizures needs to be reconsidered.     

Epilepsy in adults

The past decade has seen advances in the management of patients with epilepsy. The development of practical long-term electroencephalographic techniques, with or without simultaneous video recording, has increased the accuracy of diagnosis of seizure types. The technique also provides clinicians and investigators with a method for establishing the clinical efficacy of antiepileptic drugs and determining their therapeutic serum concentrations. Computerized tomography has enhanced the identification of structural brain lesions. Most of the reported CT abnormalities consist of diffuse and focal atrophies, mild ventricular dilatations, and porencephalies. CT has detected tumors in 8 to 10% of the patients regardless of age or type of seizure involved. New concepts of antiepileptic drug therapy have developed from the recognition of pharmacological properties peculiar to each agent. Determination of serum antiepileptic drug levels has to be utilized to reduce the problem of pharmacokinetic variability from one patient to another and in the same patient at different times, so that dosage can be individualized to achieve maximum therapeutic effects with least toxicity. Review of the literature on pregnancy in epileptic women shows that a third to half experienced more seizures during gestation. Reduced serum levels of most antiepileptic drugs have recently been observed during gestation. Infants of epileptic women taking antiepileptic drugs have a two to three times greater risk for congenital anomalies than infants of nonepileptic women. However, with the exception of oxazolidinediones, evidennce to date has not proved the teratogenicity of antiepileptic drugs. The role of genetic factors and the effect of seizures during pregnancy have not been determined. Modest progress has been made in epilepsy rehabilitation, but serious problems still remain. The unemployment rate of persons with epilepsy is twice the national average. Half of those who are successfully employed did not disclose their disorder at the time of employment. Several prognostic indicators have been reported, but the validity of many of these indicators is questionable. For example, does shorter life expectancy apply to all subgroups, or does it vary according to seizure type and cause? The life expectancy, treatment response, and proability of remission in epileptic persons must be reevaluated after consistent applications of current methods of epilepsy management.     

Single parenchymal brain cysticercus in the acute encephalitic phase: definition of a distinct form of neurocysticercosis with a benign prognosis.

Fifty four patients with a single parenchymal brain cysticercus in the acute encephalitic phase were studied to outline the features of this form of the disease. Seizures were the presenting symptom in all cases. Twenty six patients had a single seizure and 28 had several seizures before admission. Neurological examination was normal in 45 patients and showed focal signs in nine. All patients had a single enhancing CT lesion; all but three lesions were < 20 mm. Anticonvulsants were started in every patient. Forty five patients were followed up for 18 (SD 6) months. Thirty seven of these 45 patients received albendazole. Four weeks after the trial, CT showed resolution of lesions in all cases. The remaining eight patients refused albendazole, and CT showed persistence of lesions by 16 weeks in six cases. At the end of the follow up, all patients who received albendazole were free of seizures as opposed to three of eight patients who did not receive the drug. Focal signs improved in the nine patients with these signs (all received albendazole). Recognition of this form of neurocysticercosis permits early treatment with albendazole that greatly improves the prognosis.     

Electroconvulsive therapy in patients with epilepsy

There are scant published data to guide the clinician about safe and effective use of electroconvulsive therapy (ECT) in epileptic patients who suffer from psychiatric disorders. In this report, we describe our experience treating 43 epileptic patients with ECT. Seven of the patients may have had spontaneous seizures during the course of treatments, although the possibility of pseudoseizures or nonictal phenomena seemed quite likely in several of these cases. For the majority of patients, adequate seizures could be obtained during ECT despite concomitant treatment with antiepileptic medications, although dose reductions were required in a few cases. Most patients enjoyed moderate to marked reductions in psychiatric symptoms with ECT, and one patient seemed to have a marked reduction in spontaneous seizure frequency for several weeks after completion of the ECT course. We conclude that most epileptic patients can be treated with ECT without dose adjustment in antiepileptic medications and provide general recommendations for safe use of ECT in this population.     

Treatment of children with simple febrile seizures: the AAP practice parameter. American Academy of Pediatrics

Febrile seizures are the most common seizure disorder in childhood, occurring in 2-5% of children. Despite their frequency, there has been little unanimity of opinion regarding the need for long-term antiepileptic therapy. As such, the American Academy of Pediatrics formulated a subcommittee to study the subject. A Practice Parameter was developed that addressed the issue of whether continuous or intermittent antiepileptic therapy is necessary for children with simple febrile seizures. The committee determined that with the exception of a high rate of recurrence, no long-term adverse effects of simple febrile seizures have been identified. The risk of developing epilepsy is extremely low and, even in those patients who do, there is no evidence that recurrent simple febrile seizures produce structural central nervous system damage. Also, there is no evidence that recurrent simple febrile seizures cause either learning problems or premature death. The committee concluded that although there is the evidence that continuous antiepileptic therapy with phenobarbital or valproic acid and intermittent therapy with diazepam are effective in reducing the risk of recurrence, the potential toxicities associated with antiepileptic therapy outweigh the relatively minor risks associated with simple febrile seizures. As such, long-term treatment is not recommended.     

Seizure-inducing effects of antiepileptic drugs: a review

Seizure-inducing effects can be observed in the treatment of epileptic patients with antiepileptic drugs (AED). This may be a paradoxical reaction (for example the increase of complex focal seizures due to carbamazepine, vigabatrin or phenytoin treatment) or a result of AED-induced encephalopathy (commonly induced by valproate in patients with complex focal seizures). A seizure increase during intoxication with AEDs is a rare phenomenon, thus, it is not directly related to this condition. An incorrect choice of drugs in the treatment of an epileptic syndrome or seizure type may provoke seizures (as for example the provocation of absences due to carbamazepine or phenytoin). The possible seizure-inducing effect of AEDs has to be differentiated from seizure occurrence due to the natural course of epilepsy. This may be especially difficult in patients suffering from West syndrome or Lennox-Gastaut syndrome, in whom seizure frequency may vary even without medication. However, especially in these patients, drug-induced worsening of seizure manifestation is often observed. In general, a seizure-inducing effect of antiepileptic drugs has to be considered when a seizure increase is observed soon after the initiation of therapy, when a stepwise increase of the dosage is followed by a further increase of seizures, a decrease of seizures is seen with tapering of the dosage and a renewed increase of seizures can be observed after this therapy has been reestablished. Finally, one knows that the clinical condition of encephalopathy due to valproate or carbamazepine is accompanied by seizure increase. In spite of these clinical aspects, the underlying mechanisms of seizure increase mostly remain unclear. From animal experiments it is obvious that especially carbamazepine and phenytoin may provoke generalized seizures as absences or myoclonic seizures. A seizure increase during vigabatrin therapy has been attributed to the increase of the cerebral amount of gamma-amino-butyric acid, which is known to possibly exhibit inhibitory or excitatory neuronal effects. The occurrence of tonic seizures in patients with Lennox-Gastaut syndrome has been attributed to the sedative effect of the drugs; however, this conclusion is controversial. From a clinical point of view, one should consider young age of the patient, mental retardation, antiepileptic polytherapy, high frequency of seizures or prominent epileptic activity in the electroencephalogram previous to medication as risk factors for a possible seizure-inducing effect of antiepileptic drugs.     

Neurocysticercosis in children

Neurocysticercosis is a major cause of neurologic disease worldwide. The clinical presentations are pleomorphic depending on the stage and location of cysts in the nervous system. Most children (> 80%) present with seizures, particularly partial seizures; headache and vomiting are seen in about a third of cases. Diagnosis is made by either computed tomography (CT) or magnetic resonance imaging. Single enhancing lesions are the most common finding. Visualization of a scolex confirms the diagnosis. Some cases have multiple cysts; the "starry-sky" appearance in cases with innumerable cysts is characteristic. Most children require anticonvulsants. Corticosteroids are indicated in those with cerebral edema. The efficacy of cysticidal therapy continues to be debated. Controlled studies suggest that cysticidal therapy helps in increased and faster resolution of CT lesions, but there is no conclusive evidence that it improves long-term seizure control. The prognosis in cases with single lesions is good; seizure control is achieved with a single anticonvulsant, and the recurrence rate is low. Children with multiple lesions have recurrent seizures. Extraparenchymal neurocysticercosis is rare in children and carries a poor prognosis. Neurocysticercosis must be considered in the differential diagnosis of seizures and a wide variety of neurologic disorders, particularly in endemic areas.