الفهرس 
EpilepsyOnly 14 pages are availabe for public view
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Abstract
The ILAE defined DRE in the 2010 version as failure of adequate trials of two tolerated, appropriately chosen and used AEDs schedules (whether as monotherapies or in combination) to achieve sustained seizure freedom. DRE is associated with excessive drug burden and significant cognitive deterioration. Despite the introduction of many novel AEDs over recent years, approximately one third of epileptic patients will never achieve complete remission. Adequate seizures control in patients with DRE needs further testing to confirm diagnosis of epilepsy and exclude epilepsy mimics as well as better definition of epilepsy syndrome and underlying classification. The present study was a prospective observational one that was conducted on 67 patients with DRE attended the epilepsy clinic in Neuropsychiatry Department, Psychiatry and Neurology Center as well as New Tanta Educational Hospital, Tanta University Hospitals, Tanta, Egypt, from December 1, 2015 to November 30, 2017. The aim of this work was to study the role of long-term video EEG monitoring and 18FDG PET scan in evaluating DRE patients with nonconclusive 1.5 Tesla MRI brain and ordinary EEG. All patients in the current study were subjected to detailed epilepsy history, general systemic examination, neurological examination, neuropsychological assessment, routine laboratory investigations, available free and total serum level of AEDs, long-term video EEG, higher field strength MRI brain with epilepsy protocol, 18FDG PET scan of brain. Patients were divided into two groups: group I: Included 43 patients who were presented by true-DRE. group II: Included 24 patients who were presented by pseudo-DRE. According to the seizures semiology, patients in group I were subdivided into: 1. Twenty- three patients presented by TLE included 12 patients with Rt. TLE and 11 patients with Lt. TLE. 2. Seventeen patients presented by FLE included 8 patients with Rt. FLE and 9 patients with Lt. FLE. 3. Three patients presented by OLE. Patients in group II were subdivided according to their clinical presentation into: 1. Nine patients presented by PNES. 2. Ten patients presented by NEPE. 3. Five patients presented by concomitant epileptic seizures with frequent PNES. The present study revealed that: There were no statistically significant differences between the two main groups regarding age and sex of the patients but the female sex was predominant among patients with PNES. group I patients had statistically significant increase in each of incidence of family history of epilepsy, positive history of febrile convulsions and duration of epilepsy. On the other hand patients in group II had statistically significant increase in each of frequency of seizures and psychiatric comorbidities. Patients with PNES had several clinical semiology (either one presentation or in combinations) as hyperventilation, frequent blinking, side to side movement of head with intense rotation in bed, pelvis thrusting, crying, opisthotonos position and minimally traumatized tip tongue biting. While patients with NEPE were presented by syncope, REM sleep behavior disorder, vertigo and migraine. Patients with PNES had a considerable diagnostic delay reached up to 10 years. The most common psychiatric manifestations among patients with PNES were depressive and anxiety symptoms. Patients with TLE commonly presented by aura mostly gastrointestinal, autonomic and psychic aura while patients with FLE commonly presented by somatosensory and autonomic aura. Durations of seizures were longer in patient with TLE than FLE, while the frequencies of these seizures were higher in FLE than TLE and these results had statistically significant difference. The most common types of automatism in TLE patients were oroalimentary, hand picking and fidgeting and ictal spitting while truncal movements, bicycling and bipedalism predominated among patients with FLE. Patients with TLE had variable motor, autonomic and speech manifestations with no statistically significant difference between Rt. and Lt. side except post ictal aphasia which predominated among Lt. TLE patients with statistically significant difference. Patients with FLE had several semiology in the form of clonic motor phenomena, tonic motor phenomena, dystonic limb posturing, postictal paresis, head version, early eye and head turning, ictal vocalization and automatism with no statistically significant difference between Rt. and Lt. side. Ictal and/ or interictal long-term video EEG results were abnormal among all patients with true-DRE and 21% of patients with pseudo-DRE. 11% of patients with PNES had interictal Lt. focal frontotemporal epileptic activity but the seizure semiology of this patient was concordant with PNES, on the contrary, one patient with concomitant true and pseudo-seizures had normal ictal EEG which was diagnostic to PNES. The most common type of epileptiform activities that were found in EEG record were sharp slow waves followed by spike slow waves and focal polymorphic delta slowing. There were no specific pattern of EEG abnormalities that could be related to the localization of epileptogenic zone. Despite exclusion of patients with evident structural MRI brain abnormalities by ordinary MRI machines, the results of MRI by 1.5 and 3 Tesla MRI machine with epilepsy protocol showed that 65% of patients with true-DRE had MRI brain abnormalities. Patients with true-DRE and normal 3 Tesla MRI brain were investigated by 18FDG PET scan of brain that revealed that 87% of these patients had abnormal PET scan results in the form of regional hypometabolism. Few number of patients with PNES had structural MRI brain abnormalities which were not going with their seizure semiology of pseudoseizure. The highest concordance rate between long-term video EEG results and seizure semiology was found among patients with unilateral temporal or frontal epileptic activities while the concordance rate decreased among patients with multifocal epileptic activities. Also, patients with unilateral MTS had higher concordance rate with EEG results than patients with FCD. Concordance between the sites of 18FDG PET scan regional hypometabolism and different types of epilepsy (according to their semiology and EEG results) in patients with normal 3 Tesla MRI brain were variable. The concordance rate was the highest among patients with TLE followed by patients with FLE and lastly patients with OLE.