Faculty Bibliography

Ibogaine is an alkaloid with putative effect in acute opioid withdrawal. Thirty-three cases of treatments for the indication of opioid detoxification performed in non-medical settings under open label conditions are summarized involving an average daily use of heroin of .64 +/- .50 grams, primarily by the intravenous route. Resolution of the signs of opioid withdrawal without further drug seeking behavior was observed within 24 hours in 25 patients and was sustained throughout the 72-hour period of posttreatment observation. Other outcomes included drug seeking behavior without withdrawal signs (4 patients), drug abstinence with attenuated withdrawal signs (2 patients), drug seeking behavior with continued withdrawal signs (1 patient), and one fatality possibly involving surreptitious heroin use. The reported effectiveness of ibogaine in this series suggests the need for systematic investigation in a conventional clinical research setting

The pharmacokinetics and adverse effects of an oral loading dose of carbamazepine administered in tablet or suspension form were studied. Patients on a hospital epilepsy unit who were to receive carbamazepine as a discharge medication were randomly assigned to receive either an oral 8-mg/kg loading dose of the tablet formulation or the same dose of the suspension on an empty stomach. Blood samples were drawn before and at intervals up to 12 hours after the loading dose. Adverse effects were evaluated subjectively and objectively. Total and free serum carbamazepine and carbamazepine-10, 11-epoxide (CBZE) concentrations were determined by high-performance liquid chromatography. Six adult patients were enrolled in and completed the study. All the patients achieved therapeutic total carbamazepine levels; the suspension group did so within two hours and the tablet group within five hours. Maximum serum carbamazepine concentrations ranged from 7.10 to 9.92 mg/L, area under the concentration-versus-time curve from 54.85 to 82.23 micrograms.hr/L, and terminal elimination half-life from 14.05 to 15.71 hours. Adverse effects were mild, few, and short-lived; none of the patients developed gastrointestinal toxicity. Adverse effects were not associated with total or free carbamazepine and CBZE concentrations or with total or free CBZE:carbamazepine ratios. An oral loading dose of carbamazepine 8 mg/kg achieved therapeutic levels within two hours when given as a suspension and within five hours when given as tablets and was well tolerated in all patients

The authors examined interhemispheric memory transfer in 32 patients with lateralized temporal lobe complex partial epilepsy (15 right onsets, 17 left onsets). Visually presented verbal, nonverbal, and two types of dually encodable stimuli were displayed during amobarbital anesthesia, and recognition memory was tested with verbal and nonverbal (pointing) response modalities. No relationship was found between the material specificity of stimuli and response modality. The only significant findings were for poorer recognition memory after injection of the hemisphere contralateral to the seizure focus. Visual information presented predominantly to one hemisphere during anesthesia is available to the other hemisphere for recognition memory on clearing

The authors investigated cognition in juvenile myoclonic epilepsy (JME), focusing on frontal functions as suggested by maximal spatial distribution of epileptiform activity seen over frontocentral regions. Fifteen patients with JME (mean age, 34.3 years; mean estimated IQ 101) were administered a battery of tests sensitive to frontal dysfunction. The number of patients with impaired test performance and the frequency of impairment per test were calculated. Performance on selected tests was compared with that of 15 patients with temporal lobe epilepsy (TLE) who were matched for estimated IQ using paired t-tests. Although the performance of the group with JME was not uniform--some patients showed marked impairment whereas others showed little or no deficit--a high frequency of impairment was found on tests of concept formation-abstract reasoning and mental flexibility, cognitive speed, and planning and organization. Significant differences were found between the group with JME and the group with TLE on tests requiring mental flexibility and concept formation-abstract reasoning. In conjunction with studies demonstrating intractable seizures in approximately 20% of patients, the results from this study suggest that JME is not a uniformly benign condition. Frontal deficits may have maladaptive behavioral consequences suggestive of personality dysfunction, as described anecdotally by previous investigators

PURPOSE: We examined the dimensionality of the item content of the Dissociative Experiences Scale (DES) in relation to the clinical diagnosis of conversion nonepileptic seizures (C-NES) versus complex partial epilepsy (CPE). METHODS: The DES was administered to a sex- and age-matched sample of 132 patients with C-NES and 169 with CPE and was factor analyzed with principal components analysis (PCA) with varimax rotation. RESULTS: The mean total DES score was 15.1 in the C-NES group and 12.7 in the CPE group (p = 0.079). The factors obtained by PCA differentiated the CPE and C-NES groups more strongly than did the total DES score. The factor accounting for the most variance, interpreted as 'depersonalization-derealization,' was significantly greater in C-NES than CPE (p = 0.005). An 'absorption-imaginative involvement' factor, which included some of the clinical features of posttraumatic stress disorder was elevated only in subjects reporting histories of childhood abuse (p = 0.001) regardless of the diagnosis of CPE or C-NES. An 'amnestic' factor appearing to represent memory problems related to neurologic impairment showed a trend toward elevation in CPE (p = 0.056) and may have confounded the CPE versus C-NES distinction using total DES scores. CONCLUSIONS: The DES has separate underlying dimensions that appear to relate distinctively to depersonalization and derealization, childhood trauma, and neurologic impairment. The heterogeneous item content of the DES is a potential confound that should be appreciated when this instrument is used to study dissociation in neuropsychiatric populations

Multiple subpial transections (MST) were made in language cortex in 13 patients with medically refractory partial epilepsy. Transections were made in posterior language cortex in 12 patients and in both anterior and posterior language areas in 1. Eleven patients had additional resective surgery in the anterior temporal (n = 10) or anterior temporal and frontopolar (n = 1) regions. Eleven of the 13 patients had at least 90% reduction in seizure frequency. Dysnomia was present >6 months postoperatively in 9 patients (mild, 6; moderate, 3). Other deficits included impaired memory (mild, 3; moderate, 1) and reading (mild, 2). We compared the postoperative neuropsychologic findings in 7 patients with MST and temporal lobectomy with those in 14 patients who underwent only dominant temporal lobectomy. MST patients had significantly (p < 0.05) poorer postoperative naming, verbal fluency, and oral reading than patients with dominant temporal resections that spared language functions. MST in language areas can contribute to or cause language disorders that persist >1 year postoperatively. (C) 1997 by Elsevier Science Inc. All rights reserved

We studied 21 patients who underwent multiple subpial transections (MST) for the surgical treatment of intractable partial-onset seizures in whom the epileptogenic focus overlapped with primary sensorimotor or language cortex. All patients had intracranial EEG localization of seizures and functional mapping with electrical stimulation before surgery. Eighteen patients had cortical resections in addition to MST, At an average follow-up of 21 months, 13 patients either are seizure-free or are experiencing auras or simple partial seizures (SPS) only, 6 patients have had greater than 50% reduction in seizure frequency, 1 patient has had a modest reduction in seizures, and 1 patient is unchanged. MST in the 3 patients who did not undergo cortical resections reduced seizure frequency in all 3, although none are seizure-free. MST, combined with cortical resection, appears to be a safe and effective alternative to subtotal resection of the epileptogenic zone. MST alone, although not curative, reduced seizure frequency in all patients who underwent the procedure. (C) 1997 Elsevier Science Inc

Transient paralysis is an uncommon seizure symptom. We report two new cases of inhibitory motor status and review 24 previously cases of inhibitory seizures. Among the 22 adult patients, 14 (64%) had a frontoparietal lesion (tumor, 7; stroke, 7); 5 (23%) had mesiotemporal sclerosis (MTS), and 3 (14%) had no identified lesion. In contrast, all 4 pediatric patients had no identified brain lesions. Inhibitory motor seizures were associated most commonly with lesions in frontoparietal primary and supplementary motor-sensory area and, less often, in the mesial temporal lobe. Inhibitory motor seizures arising from frontoparietal foci are often more prolonged (>2-3 min) than those arising from the mesial temporal area (<1.5 min). Patients with temporal lobe seizure foci manifest ictal flaccidity of an extremity during a complex partial seizure (CPS), which may represent motor neglect rather than ictal weakness since strength cannot be accurately assessed when consciousness is impaired. Inhibitory motor seizures from sensorimotor cortex seizure foci are probably more common than is recognized. (C) 1997 by Elsevier Science Inc

Few studies have examined the clinical features of neocortical temporal lobe epilepsy (NTLE) in carefully selected patients. We reviewed records from 21 patients with NTLE, defined by intracranial electroencephalogram (EEG), who have been seizure free for 1 year or more following temporal lobectomy. The mean age of onset at the time of first seizure was 14 years (range, 1-41 years). Febrile seizures were reported in only 2 patients (9.5%). In contrast to prior mesial temporal lobe epilepsy (MTLE) studies, seizure-free intervals between the initial cerebral insult or first seizure and habitual seizures were uncommon. Possible or known risk factors for epilepsy were reported in 13 of 21 patients (62%). Fifteen (71%) patients reported auras, with experiential phenomena being the most common type. Magnetic resonance imaging was normal or nonspecific in 15 patients, revealed mild hippocampal atrophy in 2, tumors in 2, and heterotopic gray matter and hippocampal atrophy in 1, and cortical dysgenesis in 1. Neuropsychological testing showed deficits consistent with the seizure focus in 13 patients (62%), and Wada test showed ipsilateral memory deficits in 10 (48%). The most common behavioral manifestation was a motionless stare at ictal onset (48%). In contrast to prior studies of MTLE, only 1 NTLE patient had frequent independent, contralateral temporal lobe epileptiform spikes on scalp EEG