INTRODUCTION: Refractory epilepsy accounts for 20 to 30% of epilepsy cases and remains a challenge for neurologists. Vagus nerve stimulation (VNS) is an option for palliative treatment. OBJECTIVE: It was to study the efficacy and tolerability of VNS in patients implanted with a stimulator at the Curitiba Institute of Neurology (INC). METHODS: A case study of six patients with refractory epilepsy submitted to a VNS procedure at the INC in the last four years was described and discussed. RESULTS: Mean age at time of implantation was 29 years. Mean follow-up was 26.6 months. Seizure frequency decreased in all patients (40-50% (n=2) and >80% (n=4)). Three patients no longer required frequent hospitalizations. Two patients previously restricted to wheelchairs started to walk, probably because of improved mood. CONCLUSION: In this population, VNS proved to be a sound therapeutic option for treating refractory epilepsy.

.ABSTRACT -Partial and generalized tonic-clonic reflex seizures related to hot water bathing have been described as temperature-related. We describe three cases of bathing epilepsy: a 28 year-old white male and a 30 year-old white female with spells triggered either by warm or hot water, and a 32 year-old female with spells triggered by hot water. The later two of the three cases presented localized epilepsy and a familial history of epilepsy. A complex tactile stimuli might play the most relevant role on seizure triggering, as well as water temperature with an additive effect over cutaneous stimulation.KEY WORDS: epilepsy, epilepsy-generalized, epilepsy-localized, seizures-reflex, hot-water epilepsy.Epilepsia do banho quente, do banho morno, ou apenas do banho? Relato de três casos e considerações sobre um velho tema RESUMO -Crises reflexas a banhos quentes, tônicas-clônicas parciais e generalizadas foram descritas como relacionadas à temperatura. Descrevemos três casos de epilepsia do banho quente: um homem de 28 anos e uma mulher de 30 anos com crises provocadas por contato com água morna ou quente e uma mulher de 32 anos com crises ao contato com água quente. Os últimos dois casos apresentaram epilepsia localizada e um histórico familiar de epilepsia. Nesta forma de epilepsia, um estímulo táctil complexo parece ter o p a p e l mais relevante na precipitação das crises, sendo potencializado pela temperatura da água. PALAVRAS-CHAVE: epilepsia, epilepsia generalizada, epilepsia localizada, crises reflexas, epilepsia do banho quente.Hot water epilepsy has been previously studied and re p o rted, occurring mainly in India 1 , 2 , 3 . Both partial and generalized tonic-clonic seizures related to hot water bathing have been described as tempera t u re -related, often triggered by temperatures ranging from 40 to 50 o C 1 -3 . As in many other types of re f l e x s e i z u res, the same stimulus (hot water) triggers either generalized tonic-clonic or partial seizures, suggesting that generalized and localized epilepsies might be influenced by the same aff e rent pathways.We describe three cases of bathing epilepsy, one t r i g g e red by hot water, and the other two either by w a rm or hot water. The pathophysiological significance of seizure triggering by warm water and the proper denomination of this syndrome is discussed. CASESCase 1 -A 28 year-old white male started having seiz u res at the age of 7. Seizures would start with dizziness, followed by left hemiclonic seizures starting on his left arm . He had had birth anoxia, and his brother also had epileps y. Seizures were initially controlled with phenobarbital, but re c u rred at the age of 14, when partial seizures characterized by bilateral headache, cephalic paresthesia, and a negative motor phenomenon on his left upper limb w e re triggered either by warm (but not cold) or hot water. Symptoms lasted about 5 minutes. The CT was normal, but an interictal EEG showed a right rolandic focus and an independent left temporal spiking. Carbamazepine 1200mg/day...

Quarenta e três pacientes com epilepsia refratária ao tratamento medicamentoso foram submetidos à cirurgia de epilepsia do lobo temporal no Instituto de Neurologia de Curitiba, entre os anos de 1998 a 2003. Trinta e nove (90,6%) pacientes apresentavam esclerose mesial temporal, e quatro (9,4%), tumores cerebrais. Dos trinta e sete pacientes que possuíam avaliação pós-operatória completa, 83,7% apresentaram classificação I, segundo Engel (livres de crises incapacitantes). Complicações pós-operatórias ocorreram em 18,6%: uma infecção da ferida operatória, um caso de hidrocefalia, um de fístula liquórica, dois casos de paralisia transitória do IV nervo craniano e um de hemiparesia transitória. Não houve nenhum óbito relacionado à cirurgia de epilepsia no presente estudo.

A localização de áreas corticais cerebrais em pacientes candidatos a uma cirurgia excisional do cé-rebro é útil para antecipar o risco de perda funcional com o procedimento, para guiar o cirurgião na limitação das bordas da excisão e para ajudar a determinar a localização de áreas cerebrais anormais (ex. foco epiléptico) no pré-operatório RESUMO -A ressonância magnética funcional (RMF) é uma nova técnica capaz de detectar pequenas alterações no fluxo sanguíneo e oxigenação de tecidos cerebrais em que ocorre ativação neuronal. O seu emprego na avaliação pré-cirúrgica de pacientes com epilepsia portadores de esclerose mesial temporal está atualmente em avaliação em alguns centros de neurologia. O principal objetivo é encontrar o melhor paradigma de ativação na avaliação das funções de linguagem e memória, visando a substituição do teste de Wada, largamente utilizado nos dias de hoje. Para formular um paradigma já adaptado ao nosso idioma, apresentamos a nossa experiência em uma tarefa comportamental de fluência verbal na determinação da lateralização da área cerebral da linguagem. Avaliaram-se os exames de RMF de uma clínica de imagem particular em Curitiba por período de aproximadamente dois anos. Dos 19 pacientes estudados, obteve-se sucesso no exame em 16 e, destes, todos apresentavam dominância hemisférica cerebral da linguagem à esquerda. Em um subgrupo com 5 pacientes foi possível comparar os resultados obtidos com a técnica de Wada e RMF, havendo concordância entre as técnicas. A partir deste estudo e de vários outros semelhantes na literatura, acreditamos que a RMF está progressivamente conquistando seu espaço na prática médica. PALAVRAS-CHAVE: ressonância magnética funcional, epilepsia, linguagem, teste de Wada. Functional magnetic resonance imaging in the determination of dominant language cerebral areaABSTRACT -Functional magnetic resonance imaging (fMRI) is a technique for detecting minimal changes in brain perfusion and oxygenation secondary to neuronal activation. Its application in the pre-surgical evaluation of epileptic patients with temporal mesial sclerosis is currently being under investigation in several centers. This study aims to describe an activation paradigm for the evaluation of language and memory functions, as an alternative to the worldwide used Wada test, which is an invasive procedure. In order to propose a paradigm adapted to the Portuguese language, we report our experience in determining the dominant cerebral area for language through fMRI with a verbal fluency task. The results of the fMRI from 19 patients studied in Curitiba in a period of approximately two years were studied. Sixteen of them presented with left hemispheric cerebral language dominance. In five patients, results from fMRI and Wada test could be compared and agreed in localization. Our results reinforce the view that fMRI may become an essential tool for medical practice, perhaps for the determination of eloquent areas in the evaluation of candidates for epilepsy surgery.

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Background: Salivatory seizures are a singularly rare condition, which can occur both in idiopathic and symptomatic epilepsies. Objectives: To describe and discuss the case of an adolescent patient with sleep-triggered "pure" salivatory seizures associated with a subtle cortical malformation of the right parietal cortex. Case report: Herein, we report a 17-year-old female who started to present salivatory paroxysms, which occasionally secondarily generalized, shortly after falling asleep, at the age of eight years. Video-electroencephalographic monitoring with scalp electrodes failed to show any epileptiform activity during the several recorded clinical events. Brain MRI and curvilinear reconstruction revealed, in the three orthogonal planes, a subtle cortical thickening, limited to a single gyrus in the right parietal cortex, suggestive of a focal cortical malformation. After antiepileptic drug therapy was optimized, the patient became seizure-free. Conclusion: An epilepsy diagnosis should be pursued in patients presenting isolated, paroxysmal hypersalivation, despite possible negative scalp EEG studies.

-Syncope is a condition often misdiagnosed as epileptic seizures. However, the diff e rential diagnosis between both conditions can be quite difficult, even for well-trained physicians. Four cases of epilepsy and/or syncope are reported, to exemplify this situation. Each case is discussed individually, and the confounding factors are analyzed.KEY WORDS: epilepsy, syncope, seizures, differential diagnosis, non-epileptic events.Síncopes ou crises epilépticas? Alguns exemplos de fatores de confusão diagnóstica RESUMO -Síncope é uma condição freqüentemente diagnosticada equivocadamente como crise epilépti-ca. No entanto, existem algumas situações nas quais a diferenciação entre ambas pode ser difícil até mesmo para alguns médicos ou especialistas bastante familiarizados com essas condições. Quatro casos de pacientes com epilepsia e/ou síncope procuraram os autores para elucidação diagnóstica. Cada caso é discutido individualmente, assim como os potenciais fatores de confusão são analisados.

846Letters by the tumor mass, such as anterior pituitary dysfunctions, visual field alterations, cephalalgia and ophthalmoplegia [1][2][3][4] , the last two present in this patient. The association of ophthalmoplegia and cephalalgia is described as a sign of probable metastasis 5 . Pituitary metastases are rare, but should be included in the differential diagnosis of invasive sellar lesions, especially if associated with ophthalmoplegia, ptosis and DI. The intracarotid amobarbital procedure (IAP), known as "Wada-test" is a useful tool in the investigation of patients who are candidates for temporal lobectomy or amygdala-hippocampectomy. Etomidate is a viable alternative to amobarbital. However, may induce epileptiform activity. We report on the emergence of irritative activity in epilepsy surgery candidates, during a modified Wada procedure using etomidate, and discuss this finding based on available literature 1-4 . REFERENCESCASE Case 1 -35-year-old female with uncontrolled secondarily generalized seizures since the age of 14 years. Her magnetic resonance images (MRI) revealed right hippocampus sclerosis, and her video-EEG disclosed left-sided temporal interictal intermittent delta activity (TIRDA) and spiking, and an epileptogenic zone at the anterior aspects of the left temporal lobe. On the e-SAM shortly after etomidate injection on the right internal carotid artery there was slowing of the EEG tracing on the right hemisphere, associated with repetitive rhythmic sharp theta activity (Fig 1A). The patient remained hemiplegic on the contralateral side for four minutes, and the EEG recovered its original features 1.5 minutes after motor strength recovery (Fig 1B). When the study was performed on the left side the same abnormal features on EEG tracing were observed right after injection (Fig 1C). Memory and language cognitive tests were performed on both sides under abnormal EEG tracings and there were no signs of compromise of the neuropsychological evaluation as a consequence of the observed irritative EEG activity triggered by etomidate.Case 2 -A 58 years-old female, suffered from seizures since the age of 34 years. Her MRI had disclosed a right-sided hippocampus sclerosis. An interictal SPECT had revealed a left temporal lobe hypoperfusion. Her Video-EEG recordings showed a right temporal interictal intermittent delta activity, and the recorded seizures revealed an anterior right temporal lobe epileptogenic zone. After etomidate injection on the left side, a slowing of the EEG background activity with associated TIRDA activity ensued on the ipsilateral hemisphere (Fig 2A). The patient remained hemiplegic on the contralateral side and aphasic for 7.5 minutes. Her EEG tracing, however, remained abnormal for a further minute after motor strength and speech normalization. When etomidate was injected in the right side an ipsilateral irritative activity was observed (Fig 2B) and remained during the