Dacrystic seizures: Demographic,semiologic, and etiologic insights from a multicenter study in long‐term video‐EEG monitoring units

Purpose: To provide an estimate of the frequency of dacrystic seizures in video‐electroencephalography (EEG) long‐term monitoring units of tertiary referral epilepsy centers and to describe the clinical presentation of dacrystic seizures in relationship to the underlying etiology. Methods: We screened clinical records and video‐EEG reports for the diagnosis of dacrystic seizures of all patients admitted for video‐EEG long‐term monitoring at five epilepsy referral centers in the United States and Germany. Patients with a potential diagnosis of dacrystic seizures were identified, and their clinical charts and video‐EEG recordings were reviewed. We included only patients with: (1) stereotyped lacrimation, sobbing, grimacing, yelling, or sad facial expression; (2) long‐term video‐EEG recordings (at least 12 h); and (3) at least one brain magnetic resonance imaging (MRI) study. Key Findings: Nine patients (four female) with dacrystic seizures were identified. Dacrystic seizures were identified in 0.06–0.53% of the patients admitted for long‐term video‐EEG monitoring depending on the specific center. Considering our study population as a whole, the frequency was 0.13%. The presence of dacrystic seizures without other accompanying clinical features was found in only one patient. Gelastic seizures accompanied dacrystic seizures in five cases, and a hypothalamic hamartoma was found in all of these five patients. The underlying etiology in the four patients with dacrystic seizures without gelastic seizures was left mesial temporal sclerosis (three patients) and a frontal glioblastoma (one patient). All patients had a difficult‐to‐control epilepsy as demonstrated by the following: (1) at least three different antiepileptic drugs were tried in each patient, (2) epilepsy was well controlled with antiepileptic drugs in only two patients, (3) six patients were considered for epilepsy surgery and three of them underwent a surgical/radiosurgical or radioablative procedure. Regarding outcome, antiepileptic drugs alone achieved seizure freedom in two patients and did not change seizure frequency in another patient. Radiosurgery led to moderately good seizure control in one patient and did not improve seizure control in another patient. Three patients were or are being considered for epilepsy surgery on last follow‐up. One patient remains seizure free 3 years after epilepsy surgery. Significance: Dacrystic seizures are a rare but clinically relevant finding during video‐EEG monitoring. Our data show that when the patient has dacrystic and gelastic seizures, the cause is a hypothalamic hamartoma. In contrast, when dacrystic seizures are not accompanied by gelastic seizures the underlying lesion is most commonly located in the temporal cortex.     

Disobedience and driving in patients with epilepsy

ObjectiveMotor vehicle accidents direct legislators to ensure pubic safety. We attempted to characterize and quantify driving risk in patients with seizures (PWS).MethodsWe delivered 12-question surveys to 287 consecutive PWS at an epilepsy clinic in Florida. Illegal and disobedient driving practices were analyzed.ResultsEighty-three of 236 (35.2%) PWS were eligible to drive and 62.3% were ineligible with a seizure in < 6 months (P < 0.001, 95% CI: 0.57–0.70). Among the ineligible responders, 23.8% (35/147) of ineligible responders were illegally driving (14.83% of cohort); 11.86% (28/236) of PWS were disobedient refusing to obey the law, and 8.9% (21/236) of PWS were defiant and knew the law. Sadness (75/236, 31.8%) was the most common reaction to restriction, but disobedient PWS were angry (10/28, 35.7%).ConclusionOverall, a small number of PWS are disobedient and illegally driving. A targeted approach to high-risk drivers with repeated verbal and supplemental driving information may help avoid unnecessary universal physician reporting for PWS.     

Chronic headache and pituitary tumors

Pituitary tumors come to clinical attention due to endocrine dysfunction, distortion of local structures surrounding the pituitary fossa, or as an incidental finding during neuroimaging for headache. Explanations for pituitary tumor-associated headache include stretching of the dura mater and invasion of pain-producing structures within the cavernous sinus. However, small functional pituitary lesions may present with severe headache without cavernous sinus invasion or suprasellar extension. Prolactinomas and growth hormone-secreting tumors have a high prevalence of rare headache phenotypes with or without autonomic features, suggesting that biochemical abnormalities within the hypothalamo-pituitary axis may play a role in headache. Somatostatin analogues may be highly effective at aborting headache associated with functionally active pituitary lesions, particularly in the case of acromegaly. A proposed mechanism for this is inhibition of nociceptive peptides. This article summarizes the clinical features, pathophysiology, and potential treatment approaches to pituitary tumor-associated headache.     

Participation in cancer trials: recruitment of underserved populations

One approach to address cancer health disparities is to focus on the under-representation by minority populations in cancer trials. Recruitment strategies include: 1) characterizing the target populations, 2) involve members of the population in planning, 3) take the message to the population, 4) give something back to the community, 5) enhance credibility with a community spokesperson, 6) identify and remove barriers, 7) improve staff sensitivity, and 8) educate the population about the trial. To recruit minorities to clinical trials, we have developed the Accrual to Clinical Trials (ACT) framework for understanding and enhancing the recruitment of participants to cancer trials.     

Short-lasting unilateral neuralgiform headache with conjunctival injection and tearing syndrome: a review

The clinical features of short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) syndrome have been reviewed in 50 patients reported in the English language literature. SUNCT syndrome is a rare condition that predominates slightly in men. The mean age at onset is 50 years. It is characterized by strictly unilateral attacks centered on the orbital or periorbital regions, forehead, and temple. Generally, the pain is severe and neuralgic in character. The usual duration ranges from 5 to 250 seconds, although the reported range of duration is 2 seconds to 20 minutes. Ipsilateral conjunctival injection and lacrimation are present in most, but not all patients. Most patients are thought to have no refractory periods and this has probably been unreported in the past. Episodic and chronic forms of SUNCT exist. The attack frequency varies from less than one attack daily to more than 60 attacks per hour. The attacks are predominantly diurnal, although frequent nocturnal attacks can occur in some patients. A functional magnetic resonance imaging study in SUNCT syndrome has demonstrated ipsilateral hypothalamic activation. SUNCT was thought to be highly refractory to treatment. However, recent open-label trials of lamotrigine, gabapentin, topiramate, and intravenous lidocaine have produced beneficial therapeutic responses. These results offer the promise of better treatments for this syndrome, but require validation in controlled trials.     

Incarcerated fathers and parenting: importance of the relationship with their children

This study examined the relationships of incarcerated fathers (n = 185) with their children while in a maximum security prison. Despite the attention to parental incarceration and at-risk children, the child welfare and corrections literature has focused mostly on imprisoned mothers and children. Demographic, sentence, child-related, and program participation factors were investigated for their influence on father-child relationships. Multiple regression analyses indicated race and sentence contributed to the father's positive perceptions of contacts with their children. Most important, many, though serving lengthy sentences, valued and perceived a positive father-child relationship. Results are discussed in light of implications for future research and social policy.     

Trigeminal autonomic cephalalgias: current and future treatments

The trigeminal autonomic cephalgias include cluster headache, paroxysmal hemicrania, and short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT). The evidence for the current treatment options for each of these syndromes is considered, including oxygen, sumatriptan, and verapamil in cluster headache, indomethacin in paroxysmal hemicrania, and intravenous lidocaine and lamotrigine in SUNCT. Some treatments such as topiramate have an effect in all of these, as well as in migraine and other pain syndromes. The involvement of the hypothalamus in functional imaging studies implies that this may be a substrate for targeting treatment options in the future.