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Epilepsy is a chronic neurological disorder that has complex relations with social, vocational and psychological functioning. Multiple studies showed that frequency of mood disorders in patients with epilepsy is increased and include depression, anxiety and psychosis. We present data from a neurobiological prospective having clinical relevance for epilepsy and comorbidities, including studies in people with late onset epilepsies. Better understanding of neurobiological mechanisms, anatomical, functional, neuroendocrine and molecular basis of psychiatric comorbidities in persons with epilepsy, can advance therapeutic responses. Epilepsy patients have a significantly higher prevalence of depressive symptoms. Many studies showed that depressive symptoms reduce their quality of life. Psychosis in epilepsy is a rare but severe disorder that usually occurs in patients with early onset of seizures, less localised ictal EEG recordings and seizure clustering. Suicide behavior presents an important problem in managing people with epilepsy. Suicidal ideation is not uncommon, and patients also have an increased risk for suicidal attempt or completed suicide. Psychiatric comorbidities present a significant problem and ask for a multidisciplinary approach to optimize treatment of people with epilepsy., Competing Interests: Declaration of competing interest The author declare no competing financial interests in any aspect of study design, data collection, data analysis, data interpretation, writing the manuscript or decisions of publication., (Copyright © 2024. Published by Elsevier Ltd.)

Suicidality presents a major global health concern and its association with epilepsy has been suggested. The body of evidence is growing due to targeted epidemiological studies, genetic findings, and neuroimaging data, use of specific neuropsychiatric inventories, neuropsychological tests, and metabolic and immunological studies.Suicide tendencies and psychiatric comorbidity such as depression are not uncommon in chronic diseases, especially in epilepsy. Suicide is an important cause of death in epilepsy, and is usually underestimated. Persons with epilepsy have higher risk for suicide than healthy controls. It appears that some epilepsy types have stronger tendencies for suicide, in particular temporal lobe epilepsy. The suicidal risk factors in persons with epilepsy include difficult to treat epilepsies, onset of epilepsy at an earlier age, and comorbid depression.This clinical evidence is mostly based on observational studies in which we found an increased risk of suicidal ideation, suicidal attempts, and completed suicides in persons with epilepsy. However, we lack prospective and longitudinal studies on suicide in epilepsy. In this chapter we will examine recent research in neurobiological mechanisms between suicidality and epilepsy, and comorbid depression., (© 2021. The Author(s), under exclusive license to Springer Nature Switzerland AG.)

We examined whether word processing is associated with subjective self-evaluation of cognition in patients with mesial temporal lobe epilepsy (MTLE) as a function of their depressive symptoms. MTLE patients with (MTLE +d, N = 28) or without (MTLE -d, N = 11) depression were compared to pair-matched healthy control participants on free recall and self-relevance ratings of emotionally valenced words. Correlation and hierarchical analyses were conducted to investigate whether the subjective self-evaluation of cognition in MTLE patients is predicted by the negative emotional bias reflected in task performance. MTLE +d patients endorsed as self-relevant fewer positive words and more negative words than the MTLE -d patients and healthy participants. They also self-evaluated their cognition poorer than the MTLE -d patients. Analyses indicated that recall and self-endorsement of emotional words predicted both self-evaluation of cognition as well as epilepsy duration. Our findings indicate that negative self-relevance emotional bias is observed in MTLE patients and is predictive of subjective self-evaluation of cognition. Application of brief behavioral tasks probing emotional functions could be valuable for clinical research and practice in the patients with MTLE.

Background: In cases undergoing epilepsy surgery, postoperative psychogenic nonepileptic seizures (PNES) may be underdiagnosed complicating the assessment of postsurgical seizures' outcome and the clinical management. We conducted a survey to investigate the current practices in the European epilepsy monitoring units (EMUs) and the data that EMUs could provide to retrospectively detect cases with postoperative PNES and to assess the feasibility of a subsequent postoperative PNES research project for cases with postoperative PNES., Methods: We developed and distributed a questionnaire survey to 57 EMUs. Questions addressed the number of patients undergoing epilepsy surgery, the performance of systematic preoperative and postoperative psychiatric evaluation, the recording of sexual or other abuse, the follow-up period of patients undergoing epilepsy surgery, the performance of video-electroencephalogram (EEG) and postoperative psychiatric assessment in suspected postoperative cases with PNES, the existence of electronic databases to allow extraction of cases with postoperative PNES, the data that these bases could provide, and EMUs' interest to participate in a retrospective postoperative PNES project., Results: Twenty EMUs completed the questionnaire sheet. The number of patients operated every year/per center is 26.7 ( ± 19.1), and systematic preoperative and postoperative psychiatric evaluation is performed in 75% and 50% of the EMUs accordingly. Sexual or other abuse is systematically recorded in one-third of the centers, and the mean follow-up period after epilepsy surgery is 10.5 ± 7.5 years. In suspected postoperative PNES, video-EEG is performed in 85% and psychiatric assessment in 95% of the centers. An electronic database to allow extraction of patients with PNES after epilepsy surgery is used in 75% of the EMUs, and all EMUs that sent the sheet completed expressed their interest to participate in a retrospective postoperative PNES project., Conclusion: Postoperative PNES is an underestimated and not well-studied entity. This is a European survey to assess the type of data that the EMUs surgical cohorts could provide to retrospectively detect postoperative PNES. In cases with suspected PNES, most EMUs perform video-EEG and psychiatric assessment, and most EMUs use an electronic database to allow extraction of patients developing PNES., Competing Interests: Declaration of competing interest None of the authors has any conflict of interest to disclose., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Although subacute sclerosing panencephalitis is almost exclusively a childhood disease, it can occur in adults as well. We present an atypical case of adult-onset subacute sclerosing panencephalitis. The disease was characterized by prolonged insidious course followed by accelerated and aggressive phase, atypical EEG findings, and absence of myoclonic jerks. The diagnostic and treatment-related pitfalls are discussed.

Purpose: Epilepsy patients consider driving issues to be one of their most serious concerns. Ideally, decisions regarding fitness to drive should be based upon thorough evaluations by specialists in epilepsy care. In 2009, an EU directive was published aiming to harmonize evaluation practices within European countries, but, despite these recommendations, whether all epileptologists use the same criteria is unclear. We therefore conducted this study to investigate routine practices on how epileptologists at European epilepsy centers evaluate fitness to drive., Methods: A questionnaire was sent to 63 contact persons identified through the European Epi-Care and the E-pilepsy network. The questionnaire addressed how fitness-to-drive evaluations were conducted, the involvement of different professionals, the use and interpretation of EEG, and opinions on existing regulations and guidelines., Results: The questionnaire was completed by 35 participants (56 % response rate). Results showed considerable variation regarding test routines and the emphasis placed on the occurrence and extent of epileptiform discharges revealed by EEG. 82 % of the responders agreed that there was a need for more research on how to better evaluate fitness-to-drive in people with epilepsy, and 89 % agreed that regulations on fitness to drive evaluations should be internationally coordinated., Conclusion: Our survey showed considerable variations among European epileptologists regarding use of EEG and how findings of EEG pathology should be assessed in fitness-to-drive evaluations. There is a clear need for more research on this issue and international guidelines on how such evaluations should be carried out would be of value., (Copyright © 2020 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Epilepsy is characterized by repeated epileptic seizures, which are manifested in various ways and depend on the location and size of foci in the brain. Long-term seizures with secondary generalization can cause memory problems. Numerous studies demonstrate the connection of memory damage and lateralization in medial temporal lobe epilepsy (TLE). However, the results were not always consistent with the material-specific memory model. A possible explanation for these inconsistent data is the insufficient control of psychological variables that can affect memory. In most of the previous studies in persons with epilepsy, they were not controlled for their emotional states such as anxiety and depression. We used the Rey Complex Figure Test (RCFT) as a measure of visual memory, Beck's depression inventory as a measure of depressive symptoms, and the State-Trait Anxiety Inventory as a measure of anxiety in 57 consecutive participants. Our aim was to investigate whether there is difference in visual memory with respect to the left and right TLE, and whether the participants of different gender with higher anxiety and depression rates would achieve different results on visual memory. Persons with lower levels of depression achieved better scores in the Immediate and Delayed recall subtests of the RCFT. We also explored the potential gender differences. Testing differences between the persons with higher and lower anxiety levels did not reveal any significant differences in any of the measures tested.

In healthy people, a preference in attention maintenance and memory for words with emotional valence comparing to neutral words has been shown. The pattern of emotional stimuli processing may be different in people with mesial temporal lobe epilepsy (MTLE) and it may be sensitive to the presence of depressive symptoms. In order to explore these possibilities, we applied the emotional spatial cueing attentional task and the free recall memory task to participants (N=39) with MTLE and compared them with healthy controls. We hypothesized that the pattern of maintaining attention and remembering emotional words is different in people with MTLE. Current literature indicates that this pattern will change from positive bias in the controls, though no emotional bias in the participants with MTLE without depression (MTLE-d), and in this work we examined this pattern in the participants with MTLE with depressive symptoms (MTLE+d). Our results show that in both attention and memory, control subjects exhibit positive emotional bias, the subjects with MTLE-d show nonemotional bias and the subjects with MTLE+d have bias away from positive words. Participants with MTLE+d maintained attention for positive words shorter than others. Participants with MTLE+d had worse recall for positive words than the participants with MTLE-d and for all words when compared to controls. We found that faster attention disengagement from positive words and worse memory for positive words is associated with elevated levels of depressive symptoms., (Copyright © 2017 Elsevier Inc. All rights reserved.)

This case report presents a patient diagnosed with Tolosa-Hunt syndrome (THS) after an extensive neuro-diagnostic and neuroimaging evaluation. Diagnostic work-up included thorough physical and neurological examination, complete laboratory serum assessments, neuroendocrine and immunohistochemistry analysis, cerebrospinal fluid analysis, neurophysiology assessment, ophthalmologist examination and neuroimaging. Th e most important diagnostic tool in deriving the diagnosis of THS was neuroimaging evaluation that included baseline and follow-up cranial contrast enhanced magnetic resonance imaging (MRI). Baseline cranial contrast enhanced MRI detected a nonspecific inflammatory granulomatous lesion in the right cavernous sinus extending basally towards the right trigeminal cave (Meckel's cave) and anteriorly towards the apex of the right orbit. Systemic intravenous high-dose corticosteroid therapy was administered for 3 consecutive days and then tapered down to lower oral steroid doses. Following therapy, the patient experienced complete regression of symptoms. Follow-up cranial contrast enhanced MRI showed significant regression of inflammatory lesion in the area of right cavernous sinus, thus verifying the efficacy of the treatment applied. This paper shows that an extensive diagnostic schedule for THS must be conducted prior to therapeutic treatment, for the possibility of alternative diagnosis. Patients suspected of having THS require careful evaluation, appropriate treatment, and follow-up.

The aim of this retrospective study (February 2012-September 2014) was to assess the role of head-up tilt-table test in patients with unexplained syncope. It was performed on 235 patients at Clinical Department of Cardiology, Sestre milosrdnice University Hospital Center. Patients were classified according to test indications: group A (convulsive syncope, n = 30), group B (suspected vasovagal syncope, n = 180), and group C (paroxysmal vertigo, n = 25). The groups were analyzed and compared according to demographic data (age and gender), referral specialist (cardiologist, neurologist, and others), and test results (positive/negative) with specific response (cardioinhibitory, vasodepressor, or mixed). Groups A and B were referred most frequently by neurologists and cardiologists (p < 0.05). The test was positive in 34 (14.5%) of all evaluated patients (5 in group A and 29 in group B), of which 13 (38.2%) had cardioinhibitory, 11 (32.4%) mixed and 10 (29.4%) vasodepressor response. In the cardioinhibitory subgroup, three patients (23.1%, 2 males/1 female, mean age 28.5 years) with normal electroencephalography were on antiepileptics. During head-up tilt-table testing, they had bradycardia (heart rate 30.0 ± 5.0 beats/min) and prolonged asystole (13.7 ± 11.0 seconds) with development of typical convulsions. These three subjects got a permanent pacemaker (atrial/ventricular stimulation, heart rate control) and anticonvulsive therapy was slowly withdrawn with no syncope recurrence during 24-month follow up. In conclusion, head-up tilt-table test has an important role in the evaluation of patients with unexplained syncope and in differential diagnosis of vasovagal syncope. The indication for pacemaker implantation, strictly following the European Society of Cardiology guidelines, proved to be effective in preventing syncope relapses in patients with cardioinhibitory convulsive syncope.

A 28-year-old female with a history of situational syncope and a new-onset right sided hemiparesis is described. Tilt-up table test revealed the postural orthostatic tachycardia syndrome followed by vasovagal syncope. Neurological and internal medicine tests showed no particular disorders. The patient underwent autonomic physical training and the tilt-up test performed three months later showed improvement of the autonomic system in terms of lower heart beat rate of the postural orthostatic tachycardia syndrome and longer duration of the test. This case report describes longstanding idiopathic dysautonomia that can be improved by nonpharmacological treatment, while reminding that this medical condition may also be the cause of syncope.

Intracranial arachnoid cysts are congenital lesions that are frequently detected incidentally. About 30% of patients have a symptomatic epileptic seizure as the presenting symptom, occasionally with other focal neurologic signs. A case is presented of a young male patient with medically refractory temporal lobe epilepsy. Following his neurological examination, epileptic zone was defined in the right temporal lobe that correlated with the MRI-detected sylvian arachnoid cyst. Microneurosurgical cyst fenestration with volume reduction was performed, which resulted in a decremental but eventually complete seizure freedom. In conclusion, the arachnoid microsurgical cyst reduction is a safe procedure and may result in complete remission of symptomatic epileptic seizures and favorable outcomes, as reported in other studies.

The aim of the study was to determine whether an acute loss of consciousness, mental status change or related symptoms correlated with the presence of epileptiform abnormalities on urgent EEG. We analyzed 228 consecutive patients admitted to Emergency Room during the past 12 months and referred for urgent EEG evaluation. All patients had either a brief loss of consciousness or acute brain disorder, with a clinical diagnosis of epilepsy, syncope, head trauma, headache, transient ischemic attack (TIA) or vertigo. Statistical analysis was performed using Spearman's rho test for group comparison and multivariate regression analysis. The mean age of patients was 48 +/- 20 years. The frequency of referring clinical diagnoses was as follows: epilepsy 44.7% (102/228), TIA 15.8% (36/228), syncope 15.4% (35/228), headache 11% (25/228), vertigo 7.9% (18/228) and acute head trauma 5.3% (12/228). EEG indicated epileptiform abnormalities in 14.9% (34/228) and focal slowing in 9.2% (21/228) of patients. The majority of them (26%; 21/81) had a clinical diagnosis of epilepsy. There was a significant correlation between clinical diagnosis of epilepsy and epileptiform EEG (Spearman's rho = 0.13; P < 0.04). Multivariate regression analysis showed that there was no predictive value in the clinical diagnosis of epilepsy and epileptiform EEG (beta = 1.483, P = 0.16). In conclusion, epilepsy was the most common clinical diagnosis in patients referred for urgent EEG. There was a significant correlation between the diagnosis and specific EEG abnormalities, however, the diagnosis of epilepsy failed to predict epileptiform activity on EEG. Study results suggested urgent EEG to have a high yield in patients with epilepsy.

Headache occurs more frequently in patients with epilepsy as compared to the general population. Current studies in patients with epilepsy and migraine show that this increased frequency is independent of the seizure type, etiology or age at onset. People with epilepsy are 2.4 times more likely to be diagnosed with migraine. In our study, we evaluated patients' attitudes toward comorbidity of epilepsy and all headache types. Study results showed a significant number of patients to have experienced headaches after being diagnosed with epilepsy, and some of them assumed it was a side effect of their antiepileptic drug. Based on these data, we propose a more detailed assessment of the history of epilepsy including questions on headache, and offer the epilepsy patient a newer antiepileptic drug. In this way, we can significantly decrease the comorbidity of these two neurologic disorders and improve the quality of life in epilepsy patients.

Fifty consecutive and consenting epilepsy patients from the Zagreb Epilepsy Center were examined for the presence of depressive symptoms using the Beck Depression Inventory (BDI). This questionnaire has been previously validated for use in the Croatian population. Mean age of the patients was 30.8 +/- 13.5 years, 60.4% were females. Majority of them were employed (72.9%) and single (62.5%), and 35.4% had a university degree. Most of them had complex partial seizures (n=40, 80%), and 6 (12%) were diagnosed with idiopathic generalized epilepsy. Assessment with the BDI showed that 33.3% of patients had recent depressive symptoms: 6.3% had mild depressive symptoms, 8.4% moderate and 18.6% severe depressive symptoms. Three patients (6.4%) attempted suicide in the past, two of them had current suicidal ideation, and all of them were severely depressed. This is the first and preliminary study assessing mood dysfunction in epilepsy patients in Croatia. Increased prevalence of depression in epilepsy patients suggests specific approach and need for early treatment.

The epilepsies are a complex group of disorders commonly associated with brain dysfunction, social isolation, and vocational difficulty. Each of these factors may contribute to increased prevalence of depressive disorders in epilepsy, but the specific mechanisms are not completely understood. The brain regions commonly involved in various types of epilepsies, such as the hippocampus and amygdala in temporal lobe epilepsy and subcortical nuclei in idiopathic generalized epilepsies, are important components of current models of depression. Increased understanding of mechanisms of depression in epilepsy is not only crucial for improving care of many persons with seizures, but may also yield useful information about principal mechanisms underlying both depression and epileptogenesis.

We present a patient who had progressive cognitive decline and Jackson epileptic seizures and CT scan of nonspecific multiple cortical lesions. Post mortem examination revealed multiple cortical metastases of the brain and primary occult papillary carcinoma of the thyroid gland. Solitary metastases of the left kidney and pulmonary lymphangitic spread were also present. Multiple cortical metastases of the brain from primary occult papillary carcinoma of the thyroid gland with such neurological symptoms have not been reported previously.

Serotonin syndrome usually occurs after treatment with monoamine oxydase inhibitors and drugs that enhance serotoninergic transmission. Serotonin agents, such as Proza, are commonly prescribed drugs; therefore, the serotonin syndrome appears more frequently than before. Clinicians must be able to prevent, recognize, and treat this syndrome in their practice. This review summarizes the literature of case reports of patients who developed the serotonin syndrome.