We conducted a multicenter, double-blind, randomized, parallel, placebo-controlled trial in 190 patients to evaluate the safety and efficacy of three dosages of topiramate (600, 800, and 1,000 mg/day) as adjunctive therapy for patients with refractory partial epilepsy. During an 18-week double-blind treatment period, median percent reductions from baseline in average monthly seizure rates were 1% for placebo, 41% for topiramate 600 mg/day and topiramate 800 mg/day, and 38% for topiramate 1,000 mg/day. There was a 50% or greater reduction from baseline in seizure frequency in 9% of patients in the placebo group and in 44% for topiramate 600 mg/day, 40% for topiramate 800 mg/day, and 38% for topiramate 1,000 mg/day. No placebo patients were improved by 75 to 100% in seizure frequency, whereas 20% of the topiramate patients were improved to this degree. All intent-to-treat drug-placebo comparisons including seizure reduction, percent responders, and investigator and patient global evaluations significantly (p < or = 0.02) favored topiramate. Treatment-emergent adverse events consisted mainly of neurologic symptoms commonly observed during antiepileptic drug (AED) therapy. Sixteen percent of patients on topiramate discontinued therapy due to adverse events. Results of this study indicate that topiramate is a highly efficacious and generally well tolerated new AED. When large groups of patients are compared, incremental efficacy in the add-on setting is not observed at topiramate dosages above 600 mg/day; however, higher doses may prove beneficial to individual patients who tolerate them.

cases of agnosia for sound and music have been reported for more than 80 years,1-10 such defects were invariably observed to be associated with at least a mild impairment in language recognition, ie, auditory verbal agnosia. According to Nielsen,11 only one case of an agnosia for sounds without evidence of aphasia either in the history or in the present clinical picture has so far been on record. This patient was a 52-year-old Mexican man who was examined with the aid of an interpreter.12 An older vascular lesion had caused a left hemiparesis in this patient, and a more recent lesion resulted in a total loss of light perception, disorientation in space, loss of ability to visualize, incapacity to form nonlanguage concepts through sensory impressions, and unawareness of the left side of the body. The patient denied the loss of vision and in doing so would, eg, maintain that it was light when it was dark and vice versa. His ability to speak and to compre¬ hend spoken language was reportedly undis¬ turbed: "He carried on intelligent conversations in Spanish. He had never known more than a few words of English but what he had known was still familiar to him." This patient did not "recognize water by its splash, a metal pitcher by its ring, or other recognizable sounds, but at one time he did identify a watch by its tick." He was not able to identify tobacco by its odor or an apple by odor or taste, nor was he able to identify objects by touch. Thus, it appears that the patient's impairment in recognition extended over several sense modalities and was difficult to evaluate because of the patient's tendency to confabulate.A 65-year-old right-handed man was hospitalized in March 1963, with complaints of "nerves" and frontal headaches. Neither complaint represented a new de¬ velopment. Both problems had appeared following a left hemiparetic episode that occurred in 1960 and represented a continuing but not increasing disturb¬ ance.The left hemiparesis developed in July 1960 as the patient was reading a newspaper. No prodrome of headache was reported, and there was no hypertension. Five weeks later the patient was discharged from the hospital, at which time he was able to walk with assistance. By the summer of 1961 he was capable of mowing small areas of his yard. At the time of his admission here he was able to walk with a cane.Left-sided clonic seizures were first noted in January 1961. They were reported to begin in the left hand with rapid flexion and extension movements of all fingers and progressively involve the left arm and sometimes the left leg. The right side was not in¬ volved. Brief periods of unresponsiveness were said to be associated with some of these spells. No postictal increase in the left hemiparesis was noted. Diphenylhydantoin (Dilantin) had controlled these attacks effectively since August 1962.Although the patient's wife felt that his memory and thinking had not been severely disturbed by the stroke, she commented that he read little more than the headlines of the newspapers since July 1960. Pri¬ ...

No abstract

Although transient increases in heart rate typically occur, bradycardia has infrequently been noted in association with partial seizures. Five patients with temporal lobe epilepsy are described in whom sinus bradyarrhythmias and syncope were prominent manifestations of seizure activity. Partial improvement occurred in one of two patients in whom a permanent pacemaker was implanted before a diagnosis of epilepsy was established. Treatment with phenytoin or carbamazepine resulted in nearly complete resolution of symptoms in all five patients. Because pacemaker implantation does not prevent recurrent symptoms, but anticonvulsant therapy does, this experience underscores the importance of considering the diagnosis of partial epilepsy in selected patients with sinus bradyarrhythmias and syncope.

The authors describe a case of aspergillosis with carotid-cavernous sinus thrombosis diagnosed by use of magnetic resonance imaging (MRI). MRI may aid in early detection of intracranial fungal infection and potentially help decrease morbidity and mortality through the institution of early medical and surgical therapy.