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Yılmaz Erol T, Cerrahoğlu Şirin T, Görkem Şirin N, Bebek N, Baykan B. Long-term prognosis of patients with photosensitive idiopathic generalized epilepsy. Seizure 2024; 117:235-243. [PMID: 38520962 DOI: 10.1016/j.seizure.2024.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Revised: 02/21/2024] [Accepted: 02/23/2024] [Indexed: 03/25/2024] Open
Abstract
OBJECTIVE The long-term prognosis of photosensitive idiopathic generalized epilepsy (p-IGE) is generally considered favorable; however, its specific characteristics remain unclear. Our objective was to investigate the extended prognosis of p-IGE. METHODS We analyzed the demographics, clinical, and electroencephalographic (EEG) data of consecutive patients who were diagnosed as having p-IGE, who were under follow-up for a minimum of 10 years and exhibited a photoparoxysmal response (PPR) in their EEGs. Prognostic data, epilepsy course types, and electroclinical variables were compared using appropriate statistical methods. RESULTS The mean follow-up duration for 108 consecutive patients with p-IGE (74.1 % female) was 16.8 ± 6.5 years. The main syndromes within this cohort included juvenile myoclonic epilepsy (37 %), juvenile absence epilepsy (15.7 %), and epilepsy with eyelid myoclonia (EEM) (14.8 %). In terms of epilepsy course types, 27.8 % were in the relapse-remission group, and 13.9 % had never experienced remission. A low early remission rate (5.6 %) was evident, with the remaining half of the cohort categorized as the late remission group. Several significant poor prognostic factors were identified including self-induction, clinical symptoms accompanying PPR, asynchrony and focal findings in EEG discharges, a wide frequency range of PPR, the coexistence of three seizure types, the presence of accompanying focal seizure features, and a history of convulsive status epilepticus. CONCLUSIONS Our long-term follow-up study, conducted within a substantial p-IGE group, unveiled newly proposed course types within this epilepsy category and highlighted significant poor prognostic factors related to photosensitivity. These findings furnish valuable insights for precise prognosis counselling and effective management strategies for patients with p-IGE.
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Affiliation(s)
- Tülay Yılmaz Erol
- Departments of Neurology and Clinical Neurophysiology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey.
| | - Tuba Cerrahoğlu Şirin
- Departments of Neurology and Clinical Neurophysiology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey; Department of Neurology, SBU Sisli Hamidiye Etfal Education and Training Hospital, Istanbul, Turkey.
| | - Nermin Görkem Şirin
- Departments of Neurology and Clinical Neurophysiology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey.
| | - Nerses Bebek
- Departments of Neurology and Clinical Neurophysiology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey.
| | - Betül Baykan
- Departments of Neurology and Clinical Neurophysiology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey; Department of Neurology, EMAR Medical Center, Istanbul, Turkey.
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2
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Daquin G, Bonini F. The landscape of drug resistant absence seizures in adolescents and adults: Pathophysiology, electroclinical spectrum and treatment options. Rev Neurol (Paris) 2024; 180:256-270. [PMID: 38413268 DOI: 10.1016/j.neurol.2023.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 11/17/2023] [Accepted: 11/21/2023] [Indexed: 02/29/2024]
Abstract
The persistence of typical absence seizures (AS) in adolescence and adulthood may reduce the quality of life of patients with genetic generalized epilepsies (GGEs). The prevalence of drug resistant AS is probably underestimated in this patient population, and treatment options are relatively scarce. Similarly, atypical absence seizures in developmental and epileptic encephalopathies (DEEs) may be unrecognized, and often persist into adulthood despite improvement of more severe seizures. These two seemingly distant conditions, represented by typical AS in GGE and atypical AS in DEE, share at least partially overlapping pathophysiological and genetic mechanisms, which may be the target of drug and neurostimulation therapies. In addition, some patients with drug-resistant typical AS may present electroclinical features that lie in between the two extremes represented by these generalized forms of epilepsy.
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Affiliation(s)
- G Daquin
- Epileptology and Cerebral Rythmology, AP-HM, Timone hospital, Marseille, France
| | - F Bonini
- Epileptology and Cerebral Rythmology, AP-HM, Timone hospital, Marseille, France; Aix Marseille Univ, Inserm, INS, Inst Neurosci Syst, Marseille, France.
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3
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Sinha R, Singh S. Sunflower Syndrome. J Pediatr 2024; 266:113871. [PMID: 38092087 DOI: 10.1016/j.jpeds.2023.113871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Revised: 12/05/2023] [Accepted: 12/06/2023] [Indexed: 01/05/2024]
Affiliation(s)
- Rahul Sinha
- Department of Pediatrics and Pediatric Neurology, Command Hospital, Chandimandir, Panchkula, India
| | - Sonali Singh
- Department of Pediatrics, Institute of Neurosciences, Kolkata, India
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4
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Baumer FM, Julich K, Friedman J, Nespeca M, Thiele EA, Bhatia S, Joshi C. Sunflower Syndrome: A Survey of Provider Awareness and Management Preferences. Pediatr Neurol 2024; 152:177-183. [PMID: 38295719 DOI: 10.1016/j.pediatrneurol.2023.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 09/06/2023] [Accepted: 11/27/2023] [Indexed: 02/20/2024]
Abstract
BACKGROUND Sunflower syndrome is a rare photosensitive pediatric epilepsy characterized by stereotyped hand-waving in response to bright lights. These stereotyped movements with maintained awareness can be mistaken for a movement disorder. This study assessed neurology providers' diagnostic reasoning, evaluation, and treatment of Sunflower syndrome. METHODS A 32-question anonymized electronic survey, including a clinical vignette and video of hand-waving in sunlight, was distributed to child neurology providers to assess (1) initial diagnosis and evaluation based on clinical information, (2) updated diagnosis and management after electroencephalography (EEG), and (3) prior experience with Sunflower syndrome. RESULTS Among 277 viewed surveys, 211 respondents provided information about initial diagnosis and evaluation, 200 about updated diagnosis, 191 about management, and 189 about prior clinical experience. Most providers (135, 64%) suspected seizure, whereas fewer suspected movement disorders (29, 14%) or were unsure of the diagnosis (37, 22%). EEG was recommended by 180 (85%). After EEG, 189 (95%) diagnosed epilepsy, 111 of whom specifically diagnosed Sunflower syndrome. The majority (149, 78%) recommended antiseizure medications (ASMs) and sun avoidance (181, 95%). Only 103 (55%) had managed Sunflower syndrome. Epileptologists and those with prior clinical experience were more likely to suspect a seizure, order an EEG, and offer ASMs than those without prior experience. CONCLUSIONS Although many providers had not managed Sunflower syndrome, the majority recognized this presentation as concerning for epilepsy. Epilepsy training and prior clinical experience are associated with improved recognition and appropriate treatment. Educational initiatives that increase awareness of Sunflower syndrome may improve patient care.
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Affiliation(s)
- Fiona M Baumer
- Department of Neurology & Neurological Sciences, Stanford University School of Medicine, Stanford, California.
| | - Kristina Julich
- Department of Neurology, The University of Texas at Austin Dell Medical School, Austin, Texas
| | - Jennifer Friedman
- Department of Neurosciences, University of California San Diego, San Diego, California
| | - Mark Nespeca
- Department of Neurosciences, University of California San Diego, San Diego, California
| | - Elizabeth A Thiele
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
| | - Sonal Bhatia
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
| | - Charuta Joshi
- Department of Pediatrics, Children's Medical Center Dallas, University of Texas Southwestern, Dallas, Texas
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Sourbron J, Proost R, Jansen K, Riva A, Eschermann K, Barnett JR, Lagae L. A novel GABRG2 variant in Sunflower syndrome: A case report and video EEG monitoring. Epileptic Disord 2023; 25:815-822. [PMID: 37632399 DOI: 10.1002/epd2.20154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 08/20/2023] [Accepted: 08/21/2023] [Indexed: 08/28/2023]
Abstract
OBJECTIVE Sunflower syndrome is a unique photosensitive epilepsy, characterized by heliotropism and stereotyped seizures associated with handwaving. These handwaving events (HWE) are thought to be an ictal phenomenon, although current data are contrasting. Photosensitive epilepsy occurs in 2%-5% of the epilepsy forms and several pathogenic gene variants have been associated with photosensitive epilepsy. However, the genetic etiology of Sunflower syndrome remains unknown. Antiseizure medications (ASM) efficacious in treating photosensitive epilepsy are valproic acid (VPA) and levetiracetam (LEV) although some forms, such as Sunflower syndrome, can be drug-resistant. METHODS AND RESULTS Here, we report an 8-year-old boy with an early onset of episodes of HWE that was initially categorized as behavioral problems for which risperidone was started. However, the medical history was suggestive of Sunflower syndrome, and subsequent video EEG showed focal mostly temporal and frontotemporal (right and left) epileptiform activity and confirmed the epileptic nature of the HWE. Thus, VPA was started and initially led to seizure frequency reduction. Molecular analyses showed a pathogenic variant in GABRG2 (c.1287G>A p.(Trp429Ter)), which has been associated with photosensitive and generalized epilepsy. SIGNIFICANCE Overall, clinicians worldwide should be cautious by interpreting HWE and/or other tic-like movements, since an epileptic origin cannot be ruled out. A prompt and correct diagnosis can be made by performing a video EEG early on in the diagnostic process when epileptic seizures are part of the differential diagnosis. Even though the genetic etiology of Sunflower syndrome remains poorly understood, this constellation supports further genetic testing since the detection of a pathogenic variant can help in making correct decisions regarding ASM management.
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Affiliation(s)
- Jo Sourbron
- Section Pediatric Neurology, Department of Development and Regeneration, University Hospital KU Leuven, Leuven, Belgium
- Center for Medical Genetics, Ghent University Hospital, Ghent, Belgium
| | - Renee Proost
- Section Pediatric Neurology, Department of Development and Regeneration, University Hospital KU Leuven, Leuven, Belgium
| | - Katrien Jansen
- Section Pediatric Neurology, Department of Development and Regeneration, University Hospital KU Leuven, Leuven, Belgium
| | - Antonella Riva
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Genoa, Italy
- IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Kirsten Eschermann
- Research Institute for Rehabilitation, Transition and Palliation, Paracelsus Medical University, Salzburg, Austria
- Department of Pediatrics, University Hospital of the Paracelsus Medical University, Salzburg, Austria
- Clinic for Neuropediatrics and Neurological Rehabilitation, Epilepsy Center for Children and Adolescents, Schön Klinik Vogtareuth, Vogtareuth, Germany
| | - James Richard Barnett
- Pediatric Epilepsy, Program Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Lieven Lagae
- Section Pediatric Neurology, Department of Development and Regeneration, University Hospital KU Leuven, Leuven, Belgium
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6
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Ballarà Petitbò M, González Alguacil E, Gutiérrez Delicado E, Ortiz Cabrera NV, Duat Rodríguez A, García Peñas JJ, Soto Insuga V. Neuropsychiatric comorbidities and cognition in epilepsy with eyelid myoclonia: A retrospective pediatric case series. Epileptic Disord 2023; 25:758-768. [PMID: 37584565 DOI: 10.1002/epd2.20148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 08/06/2023] [Accepted: 08/07/2023] [Indexed: 08/17/2023]
Abstract
OBJECTIVE Epilepsy with eyelid myoclonia (EEM) is a rare epileptic syndrome classified within the Genetic Generalized Epilepsies of childhood. It is characterized by a high drug resistance, and little is known about prognostic factors and neurodevelopmental comorbidities. The aim of this study was to describe the clinical features, cognitive profile, and prognostic factors in a series of children with EEM. METHODS This is a retrospective observational study of patients diagnosed with EEM from 2012 to 2022 in a tertiary pediatric hospital. RESULTS Seventeen patients were analyzed (mean age at symptom onset 5.8 years). Neuropsychiatric comorbidities were present in 76.4% (attention deficit hyperactivity disorder 58.8%, behavioral disorder 11.8%, autism spectrum disorder 11.8%, and psychotic outbreaks 11.8%). Neurocognitive assessment was performed in 75%, revealing cognitive impairment in 66.6% (62.5% with borderline intellectual function and 37.5% with -IQ <70-), with predominant difficulties in executive functions, comprehensive language, and motor skills. Cognitive deterioration was observed in one patient in parallel onset with psychotic symptoms. High refractoriness to antiseizure medication (ASM) was observed, with only 23.5% of the patients being seizure-free after a mean follow-up of 7 years. The most effective ASM was valproic acid, and two of them received ketogenic diet with good response. Regarding prognostic factors, psychotic symptoms were associated with a greater number of antiseizure medication (p < .05) implying a more drug-resistant epilepsy. SIGNIFICANCE In our study, we found a high rate of cognitive and psychiatric comorbidities and high refractoriness. These data support the concept of EEM as an intermediate entity between idiopathic generalized epilepsy and epileptic and/or neurodevelopmental encephalopathy. Making a proper diagnosis and management of these comorbidities is necessary to improve prognosis and quality of life in EEM.
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Affiliation(s)
| | | | - Eva Gutiérrez Delicado
- Video-EEG Monitoring Unit, Hospital Universitario Infantil del Niño Jesús, Madrid, Spain
| | | | - Anna Duat Rodríguez
- Neurology Department, Hospital Universitario Infantil del Niño Jesús, Madrid, Spain
| | | | - Victor Soto Insuga
- Neurology Department, Hospital Universitario Infantil del Niño Jesús, Madrid, Spain
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7
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Verma AK, Matthews RE, Dsouza S. A 6-Year-Old With Episodes of Hand-Waving and Loss of Attention. Pediatr Ann 2023; 52:e309-e312. [PMID: 37561827 DOI: 10.3928/19382359-20230613-08] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/12/2023]
Abstract
A 6-year-old girl was referred to pediatric neurology because of concerns about her behavior. Her mother had noticed episodes in which the girl would wave her hand in front of her face and lose awareness of her surroundings several times per day. These episodes usually occurred when she was outdoors and had caused the child to walk into objects and stop in traffic. The patient otherwise had no neurological deficits or cognitive impairment, and there was no family history of neuropsychiatric disorders. Although the patient was aware of her behavior, she could not explain why she performed these hand-waving motions. A neurological workup revealed that these behaviors were not complex stereotypies but rather a rare and unusual disorder. This case highlights the role of neurology in assessing complex motor behaviors and offers insight into when a practicing pediatrician should consider a neurological workup for complex stereotypies. [Pediatr Ann. 2023;52(8):e309-e312.].
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8
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Celdran de Castro A, Nascimento FA, Beltran-Corbellini Á, Toledano R, Garcia-Morales I, Gil-Nagel A, Aledo-Serrano Á. Levetiracetam, from broad-spectrum use to precision prescription: A narrative review and expert opinion. Seizure 2023; 107:121-131. [PMID: 37023625 DOI: 10.1016/j.seizure.2023.03.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 03/18/2023] [Accepted: 03/22/2023] [Indexed: 04/07/2023] Open
Abstract
Levetiracetam (LEV) is an antiseizure medication (ASM) whose mechanism of action involves the modulation of neurotransmitters release through binding to the synaptic vesicle glycoprotein 2A. It is a broad-spectrum ASM displaying favorable pharmacokinetic and tolerability profiles. Since its introduction in 1999, it has been widely prescribed, becoming the first-line treatment for numerous epilepsy syndromes and clinical scenarios. However, this might have resulted in overuse. Increasing evidence, including the recently published SANAD II trials, suggests that other ASMs are reasonable therapeutic options for generalized and focal epilepsies. Not infrequently, these ASMs show better safety and effectiveness profiles compared to LEV (partially due to the latter's well-known cognitive and behavioral adverse effects, present in up to 20% of patients). Moreover, it has been shown that the underlying etiology of epilepsy is significantly linked to ASMs response in particular scenarios, highlighting the importance of an etiology-based ASM choice. In the case of LEV, it has demonstrated an optimal effectiveness in Alzheimer's disease, Down syndrome, and PCDH19-related epilepsies whereas, in other etiologies such as malformations of cortical development, it may show negligible effects. This narrative review analyzes the current evidence related to the use of LEV for the treatment of seizures. Illustrative clinical scenarios and practical decision-making approaches are also addressed, therefore aiming to define a rational use of this ASM.
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9
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Patel S, Geenen KR, Dowless D, Bruno PL, Thiele EA. Follow-up to low-dose fenfluramine for Sunflower syndrome: A non-randomized controlled trial. Dev Med Child Neurol 2022. [PMID: 36562419 DOI: 10.1111/dmcn.15492] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 11/08/2022] [Accepted: 11/10/2022] [Indexed: 12/24/2022]
Abstract
AIM This study reports on the long-term results for an initial cohort of patients with Sunflower syndrome who enrolled in an open-label study of low-dose fenfluramine as well as the short-term results of a second cohort. METHOD We conducted a single-center, open-label study at the Massachusetts General Hospital. We analyzed the effect of fenfluramine on handwaving seizure frequency at monthly intervals during a 4-month core study period for the second patient cohort, and we evaluated the long-term (>2 years) effect of fenfluramine for the initial patient cohort. RESULTS Eight of the 10 patients from the second cohort provided analyzable seizure data. These patients experienced a 33% median reduction in seizure frequency during the core study, as compared to the previously reported 79% for the initial cohort (n = 9). Of the seven patients from the first cohort who remain on fenfluramine in the extension study, five continue to experience benefit. Fenfluramine was overall well tolerated with minimal side effects, reduced appetite and fatigue being the primary adverse events, and no evidence of cardiac valvulopathy or pulmonary hypertension. INTERPRETATION This study suggests fenfluramine can be an effective, durable, and well-tolerated antiseizure medication option for patients with Sunflower syndrome.
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Affiliation(s)
- Sandip Patel
- Pediatric Epilepsy Program, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Kennedy R Geenen
- Pediatric Epilepsy Program, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Dana Dowless
- Pediatric Epilepsy Program, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Patricia L Bruno
- Pediatric Epilepsy Program, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Elizabeth A Thiele
- Pediatric Epilepsy Program, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
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10
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Strzelecka J, Mazurkiewicz DW, Skadorwa T, Gąsior JS, Jóźwiak S. Photo-Dependent Reflex Seizures—A Scoping Review with Proposal of Classification. J Clin Med 2022; 11:jcm11133766. [PMID: 35807051 PMCID: PMC9267825 DOI: 10.3390/jcm11133766] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 06/10/2022] [Accepted: 06/28/2022] [Indexed: 02/07/2023] Open
Abstract
Children and adolescents are the largest at-risk group for the appearance of reflex seizures or epilepsy syndromes with a photoparoxysmal response. The aim of this study was to present an overview of the literature regarding photo-dependent reflex seizures. Epilepsy with seizures provoked by intermittent light stimulation is a distinct group of epilepsies; therefore, we focused on reflex seizures provoked by different factors whose common feature is the patient’s response to intermittent photic stimulation. A qualitative search of PubMed/MEDLINE, Scopus, EBSCO, and Cochrane Library electronic databases for selected terms was carried out for scientific articles published up to May 2020 outlining the outcomes of control, observational, and case studies. This scoping review was developed and followed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. The review of the qualitative evidence for the synthesis of photosensitive epilepsy allowed us to distinguish the following categories: light-induced seizures and light-deprived seizures. Differentiating between intermittent photic stimulation-related epilepsy syndromes and seizures is essential in order to determine the length of appropriate treatment. Photo-dependent reflex seizures make up the majority of this type of disorder among reflex seizures. Since there are many seizures provoking factors in the world around us, it is important to distinguish amongst them in order to be able to protect the patient exposed to this factor. It is recommended that the photostimulation procedure be performed during a routine electroencephalogram study.
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Affiliation(s)
- Jolanta Strzelecka
- Department of Pediatric Neurology, Medical University of Warsaw, 02-091 Warsaw, Poland;
- Correspondence: ; Tel.: +48-605-598-644
| | | | - Tymon Skadorwa
- Department of Descriptive and Clinical Anatomy, Medical University of Warsaw, 02-091 Warsaw, Poland;
| | - Jakub S. Gąsior
- Department of Pediatric Cardiology and General Pediatrics, Medical University of Warsaw, 02-091 Warsaw, Poland;
| | - Sergiusz Jóźwiak
- Department of Pediatric Neurology, Medical University of Warsaw, 02-091 Warsaw, Poland;
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11
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Specchio N, Wirrell EC, Scheffer IE, Nabbout R, Riney K, Samia P, Guerreiro M, Gwer S, Zuberi SM, Wilmshurst JM, Yozawitz E, Pressler R, Hirsch E, Wiebe S, Cross HJ, Perucca E, Moshé SL, Tinuper P, Auvin S. International League Against Epilepsy classification and definition of epilepsy syndromes with onset in childhood: Position paper by the ILAE Task Force on Nosology and Definitions. Epilepsia 2022; 63:1398-1442. [PMID: 35503717 DOI: 10.1111/epi.17241] [Citation(s) in RCA: 270] [Impact Index Per Article: 135.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Revised: 03/16/2022] [Accepted: 03/17/2022] [Indexed: 12/30/2022]
Abstract
The 2017 International League Against Epilepsy classification has defined a three-tier system with epilepsy syndrome identification at the third level. Although a syndrome cannot be determined in all children with epilepsy, identification of a specific syndrome provides guidance on management and prognosis. In this paper, we describe the childhood onset epilepsy syndromes, most of which have both mandatory seizure type(s) and interictal electroencephalographic (EEG) features. Based on the 2017 Classification of Seizures and Epilepsies, some syndrome names have been updated using terms directly describing the seizure semiology. Epilepsy syndromes beginning in childhood have been divided into three categories: (1) self-limited focal epilepsies, comprising four syndromes: self-limited epilepsy with centrotemporal spikes, self-limited epilepsy with autonomic seizures, childhood occipital visual epilepsy, and photosensitive occipital lobe epilepsy; (2) generalized epilepsies, comprising three syndromes: childhood absence epilepsy, epilepsy with myoclonic absence, and epilepsy with eyelid myoclonia; and (3) developmental and/or epileptic encephalopathies, comprising five syndromes: epilepsy with myoclonic-atonic seizures, Lennox-Gastaut syndrome, developmental and/or epileptic encephalopathy with spike-and-wave activation in sleep, hemiconvulsion-hemiplegia-epilepsy syndrome, and febrile infection-related epilepsy syndrome. We define each, highlighting the mandatory seizure(s), EEG features, phenotypic variations, and findings from key investigations.
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Affiliation(s)
- Nicola Specchio
- Rare and Complex Epilepsy Unit, Department of Neuroscience, Bambino Gesù Children's Hospital, Scientific Institute for Research and Health Care, Full Member of EpiCARE, Rome, Italy
| | - Elaine C Wirrell
- Divisions of Child and Adolescent Neurology and Epilepsy, Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Ingrid E Scheffer
- Austin Health and Royal Children's Hospital, Florey Institute, Murdoch Children's Research Institute, University of Melbourne, Melbourne, Victoria, Australia
| | - Rima Nabbout
- Reference Center for Rare Epilepsies, Department of Pediatric Neurology, Necker-Sick Children Hospital, Public Hospital Network of Paris, member of EpiCARE, Imagine Institute, National Institute of Health and Medical Research, Mixed Unit of Research 1163, University of Paris, Paris, France
| | - Kate Riney
- Neurosciences Unit, Queensland Children's Hospital, South Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, South Brisbane, Queensland, Australia
| | - Pauline Samia
- Department of Pediatrics and Child Health, Aga Khan University, Nairobi, Kenya
| | | | - Sam Gwer
- School of Medicine, Kenyatta University, and Afya Research Africa, Nairobi, Kenya
| | - Sameer M Zuberi
- Paediatric Neurosciences Research Group, Royal Hospital for Children and Institute of Health & Wellbeing, member of EpiCARE, University of Glasgow, Glasgow, UK
| | - Jo M Wilmshurst
- Department of Paediatric Neurology, Red Cross War Memorial Children's Hospital, Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Elissa Yozawitz
- Isabelle Rapin Division of Child Neurology of the Saul R. Korey Department of Neurology, Montefiore Medical Center, Bronx, New York, USA
| | - Ronit Pressler
- Programme of Developmental Neurosciences, University College London National Institute for Health Research Biomedical Research Centre Great Ormond Street Institute of Child Health, Department of Clinical Neurophysiology, Great Ormond Street Hospital for Children, London, UK
| | - Edouard Hirsch
- Neurology Epilepsy Units "Francis Rohmer", INSERM 1258, FMTS, Strasbourg University, Strasbourg, France
| | - Sam Wiebe
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Helen J Cross
- Programme of Developmental Neurosciences, University College London National Institute for Health Research Biomedical Research Centre Great Ormond Street Institute of Child Health, Great Ormond Street Hospital for Children, and Young Epilepsy Lingfield, London, UK
| | - Emilio Perucca
- Department of Neuroscience, Monash University, Melbourne, Victoria, Australia.,Department of Medicine, Austin Health, University of Melbourne, Heidelberg, Victoria, Australia
| | - Solomon L Moshé
- Isabelle Rapin Division of Child Neurology, Saul R. Korey Department of Neurology, and Departments of Neuroscience and Pediatrics, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York, USA
| | - Paolo Tinuper
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy.,Institute of Neurological Sciences, Scientific Institute for Research and Health Care, Bologna, Italy
| | - Stéphane Auvin
- Robert Debré Hospital, Public Hospital Network of Paris, NeuroDiderot, National Institute of Health and Medical Research, Department Medico-Universitaire Innovation Robert-Debré, Pediatric Neurology, University of Paris, Paris, France
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12
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Fisher RS, Acharya JN, Baumer FM, French JA, Parisi P, Solodar JH, Szaflarski JP, Thio LL, Tolchin B, Wilkins AJ, Kasteleijn-Nolst Trenité D. Visually sensitive seizures: An updated review by the Epilepsy Foundation. Epilepsia 2022; 63:739-768. [PMID: 35132632 DOI: 10.1111/epi.17175] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 01/10/2022] [Accepted: 01/12/2022] [Indexed: 12/19/2022]
Abstract
Light flashes, patterns, or color changes can provoke seizures in up to 1 in 4000 persons. Prevalence may be higher because of selection bias. The Epilepsy Foundation reviewed light-induced seizures in 2005. Since then, images on social media, virtual reality, three-dimensional (3D) movies, and the Internet have proliferated. Hundreds of studies have explored the mechanisms and presentations of photosensitive seizures, justifying an updated review. This literature summary derives from a nonsystematic literature review via PubMed using the terms "photosensitive" and "epilepsy." The photoparoxysmal response (PPR) is an electroencephalography (EEG) phenomenon, and photosensitive seizures (PS) are seizures provoked by visual stimulation. Photosensitivity is more common in the young and in specific forms of generalized epilepsy. PS can coexist with spontaneous seizures. PS are hereditable and linked to recently identified genes. Brain imaging usually is normal, but special studies imaging white matter tracts demonstrate abnormal connectivity. Occipital cortex and connected regions are hyperexcitable in subjects with light-provoked seizures. Mechanisms remain unclear. Video games, social media clips, occasional movies, and natural stimuli can provoke PS. Virtual reality and 3D images so far appear benign unless they contain specific provocative content, for example, flashes. Images with flashes brighter than 20 candelas/m2 at 3-60 (particularly 15-20) Hz occupying at least 10 to 25% of the visual field are a risk, as are red color flashes or oscillating stripes. Equipment to assay for these characteristics is probably underutilized. Prevention of seizures includes avoiding provocative stimuli, covering one eye, wearing dark glasses, sitting at least two meters from screens, reducing contrast, and taking certain antiseizure drugs. Measurement of PPR suppression in a photosensitivity model can screen putative antiseizure drugs. Some countries regulate media to reduce risk. Visually-induced seizures remain significant public health hazards so they warrant ongoing scientific and regulatory efforts and public education.
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Affiliation(s)
- Robert S Fisher
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, California, USA
| | - Jayant N Acharya
- Department of Neurology, Penn State Health, Hershey, Pennsylvania, USA
| | - Fiona Mitchell Baumer
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, California, USA
| | - Jacqueline A French
- NYU Comprehensive Epilepsy Center, Epilepsy Foundation, New York, New York, USA
| | - Pasquale Parisi
- Department of Neuroscience, Mental Health, and Sensory Organs, Sapienza University, Rome, Italy
| | - Jessica H Solodar
- American Medical Writers Association-New England Chapter, Boston, Massachusetts, USA
| | - Jerzy P Szaflarski
- Department of Neurology, Neurobiology and Neurosurgery, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama, USA
| | - Liu Lin Thio
- Department of Neurology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Benjamin Tolchin
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut, USA
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13
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Burlo F, Barbi E, Carrozzi M, Zanus C. Case report: A relevant misdiagnosis: Photosensitive epilepsy mimicking a blinking tic. Front Pediatr 2022; 10:918420. [PMID: 36467468 PMCID: PMC9709211 DOI: 10.3389/fped.2022.918420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 10/18/2022] [Indexed: 11/18/2022] Open
Abstract
Blinking in children is most frequently a functional and transient symptom. Nonetheless, sometimes it is the first clinical manifestation of a neurological disorder. The differential diagnosis between voluntary actions, tics and other neurological disorders among which seizures may be challenging and misdiagnosis is common. A 6-year-old girl in good health was admitted for a recent history of bilateral eye blinking. Blinking did not interfere with the girl's activities. The patients reported that blinking seemed to be triggered by sunlight exposure and that girl sometimes seemed to be attracted by the sunlight. Ophthalmological diseases had been already excluded. The girl was addressed to our hospital for neurological consultation, as tic disease was considered the most probable hypothesis. Neurological examination was negative. In the field of differential diagnosis of photosensitive abnormal eyelid movements, the hypothesis of seizures was explored and further investigated with a video-EEG recording with light stimulation. This exam demonstrated a photoparoxysmal response (PPR) to intermittent photic stimulation with appearance on EEG of bilateral spike and polyspike waves associated with eyelid jerks. This girl suffers from generalized epilepsy with photosensitivity. Photosensitivity is a common feature of many epilepsy syndromes, mainly occurring in children and adolescents. To control the seizures, it is essential to avoid the triggering stimulus, by wearing specific glasses. Additional antiseizures treatment is often necessary, at first with valproate and levetiracetam, and ethosuximide, lamotrigine, and benzodiazepines as the second choice. Overlapping phenomenology of seizures and movement disorders is well known in paediatric clinical practice. Moreover, epilepsy and movement disorder may coexist, mainly in children. Seizures with semeiology limited to eye motor manifestations may mimic functional blinking, tics, and other motor events frequently observed in childhood. Differentiating seizures from other non-epileptic paroxysmal movements may be challenging and specialist evaluation is needed for proper treatment and prognostic counselling.
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Affiliation(s)
- Francesca Burlo
- Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy
| | - Egidio Barbi
- Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy.,Institute for Maternal and Child Health - IRCCS Burlo Garofolo, Trieste, Italy
| | - Marco Carrozzi
- Institute for Maternal and Child Health - IRCCS Burlo Garofolo, Trieste, Italy
| | - Caterina Zanus
- Institute for Maternal and Child Health - IRCCS Burlo Garofolo, Trieste, Italy
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14
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Geenen KR, Doshi SP, Patel S, Sourbron J, Falk A, Morgan A, Vu U, Bruno PL, Thiele EA. Fenfluramine for seizures associated with Sunflower syndrome. Dev Med Child Neurol 2021; 63:1427-1432. [PMID: 34216017 DOI: 10.1111/dmcn.14965] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/19/2021] [Indexed: 11/30/2022]
Abstract
AIM To determine the efficacy of fenfluramine on seizure frequency in patients with Sunflower syndrome. Secondary endpoints were changes in electroencephalogram (EEG) characteristics, cognitive functioning, executive functioning, and quality of life. METHOD In this open-label study, patients underwent a 4-week baseline period, followed by 3 months of treatment. An oral solution of fenfluramine was administered twice daily for 3 months. The dose was titrated up to a maximum dose of 0.7mg/kg/day or 26mg/day. Cardiac safety was monitored by transthoracic echocardiogram and electrocardiogram. EEGs, abbreviated neuropsychological testing, and questionnaires were administered before starting the study medication and again at the end of the treatment period. RESULTS Ten patients (eight females, two males; mean age 13y 4mo [SD 4y 11mo], range 7-24y) were enrolled in the study. Nine of the 10 patients completed the core study, eight of whom met the primary endpoint. There were no observations of cardiac valvulopathy or pulmonary hypertension during the study. INTERPRETATION Treatment with low-dose fenfluramine resulted in a clinically significant reduction in seizure frequency, including hand-waving episodes. Fenfluramine may be an effective treatment option for patients with Sunflower syndrome. What this paper adds Nine patients with Sunflower syndrome were treated with fenfluramine. Eight patients were responders, displaying a ≥30% reduction in seizure activity. Six patients experienced a ≥70% reduction in hand-waving episodes. Improvements on electroencephalogram were observed after treatment with fenfluramine. None of the patients developed evidence of cardiac valvulopathy or pulmonary hypertension.
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Affiliation(s)
- Kennedy R Geenen
- Pediatric Epilepsy Program, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Samarth P Doshi
- Pediatric Epilepsy Program, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Sandip Patel
- Pediatric Epilepsy Program, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Jo Sourbron
- Department of Development and Regeneration, Section Pediatric Neurology, University Hospital KU Leuven, Leuven, Belgium
| | - Amy Falk
- Pediatric Epilepsy Program, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Amy Morgan
- Pediatric Epilepsy Program, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Uyen Vu
- Pediatric Epilepsy Program, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Patricia L Bruno
- Pediatric Epilepsy Program, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Elizabeth A Thiele
- Pediatric Epilepsy Program, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
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15
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Belcastro V, Casellato S, Striano P, Capovilla G, Savasta S, Foiadelli T, Sofia V, Giuliano L, Riva A, Elia M, Cesaroni E, Bonaventura CD, Giallonardo T, Striano S, Gambardella A, Ferlazzo E, Verrotti A. Epilepsy in "Sunflower syndrome": electroclinical features, therapeutic response, and long-term follow-up. Seizure 2021; 93:8-12. [PMID: 34653789 DOI: 10.1016/j.seizure.2021.09.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 08/26/2021] [Accepted: 09/02/2021] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Sunflower syndrome (SFS) is a rare childhood-onset generalized epilepsy characterized by photosensitivity, heliotropism, and drug-resistant stereotyped seizures maybe self-induced by hand-waving maneuvers. Data on the long-term prognosis are scantly and evidence over best treatment strategies is lacking. METHODS We retrospectively describe the electroclinical features, and therapeutic response in a group of 21 patients with SFS, without intellectual disability. RESULTS 16 patients were female (67%), with a median age at onset of 7 years. In all patients, ictal episodes began with sun-staring, and hand-waving in front of the sunlight, accompanied by brief typical absence seizures. 17 patients (81%) showed interictal EEG abnormalities, mainly characterized by spike and polyspike-and-wave discharges. Ictal epileptiform activity occurred approximately less than one second after the start of hand-waving. At the last follow-up (median length 8.2 years), 12 patients (57%) were drug-resistant. Nine of them (75%) achieved seizure control with the use of tainted lenses, either alone or compared with anti-seizure medications (ASM). Disappearance of seizures was associated with EEG improvement/normalization when tinted glasses were used during EEG recordings. CONCLUSION While the clinical and EEG characteristics of SFS are well defined, the best therapeutic approaches are still under debate. Our data confirms a high rate of drug-resistance and frequent need of polytherapy. Of note, in drug-resistant patients, lenses (but not ASM) were able to suppress PPR in our patients while wearing lenses. Regarding the role of lenses, we do not only rely on the PPR reduction but also clinically by the reduction of seizures. Although additional data are needed, lenses seem to have a powerful potential role for the management of SFS.
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Affiliation(s)
| | - Susanna Casellato
- Child Neuropsychiatry Unit, Epilepsy Center, University of Sassari, Sassari, Italy
| | - Pasquale Striano
- Department of Neurosciences, Rehabilitation, Ophtalmology, Genetics, Maternal and Child Health, University of Genoa, "G. Gaslini" Institute, Genova, Italy; Pediatric Neurology and Muscular Diseases Unit, IRCCS "G. Gaslini" Institute, Genova, Italy
| | - Giuseppe Capovilla
- Child Neuropsychiatry Department, Epilepsy Center, C. Poma Hospital, Mantova; Fondazione Poliambulanza, Brescia, Italy
| | | | - Thomas Foiadelli
- Department of clinical, surgical, diagnostic and pediatric sciences, University of Pavia, Pavia, Italy
| | - Vito Sofia
- Department of Medical and Surgical Sciences and Advanced Technologies "G.F. Ingrassia"; University of Catania, Catania, Italy
| | - Loretta Giuliano
- Department of Medical and Surgical Sciences and Advanced Technologies "G.F. Ingrassia"; University of Catania, Catania, Italy
| | - Antonella Riva
- Department of Neurosciences, Rehabilitation, Ophtalmology, Genetics, Maternal and Child Health, University of Genoa, "G. Gaslini" Institute, Genova, Italy; Pediatric Neurology and Muscular Diseases Unit, IRCCS "G. Gaslini" Institute, Genova, Italy
| | - Maurizio Elia
- Unit of Neurology and Clinical Neurophysiopathology, Oasi Research Institute, IRCCS, Troina, EN, Italy
| | | | - Carlo Di Bonaventura
- Epilepsy Unit, Department of Human Neurosciences, "Sapienza" University of Rome, Rome, Italy
| | - Teresa Giallonardo
- Epilepsy Centre, Department of Neuroscience, Reproductive and Odontostomatological Sciences, Federico II University, Naples, Italy
| | - Salvatore Striano
- Department of Medical and Surgical Sciences, Magna Græcia University; Institute of Molecular Bioimaging and Physiology, National Research Council, Catanzaro, Italy
| | - Antonio Gambardella
- Department of Medical and Surgical Sciences, Magna Græcia University; Institute of Molecular Bioimaging and Physiology, National Research Council, Catanzaro, Italy
| | - Edoardo Ferlazzo
- Department of Medical and Surgical Sciences, Magna Græcia University; Institute of Molecular Bioimaging and Physiology, National Research Council, Catanzaro, Italy; Regional Epilepsy Centre, Great Metropolitan "Bianchi-Melacrino-Morelli" Hospital, Reggio, Italy
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16
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Brinciotti M, Wilkins AJ, Penacchio O, Matricardi M. Pattern-sensitive patients with epilepsy use uncomfortable visual stimuli to self-induce seizures. Epilepsy Behav 2021; 122:108189. [PMID: 34252828 DOI: 10.1016/j.yebeh.2021.108189] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 06/07/2021] [Accepted: 06/24/2021] [Indexed: 10/20/2022]
Abstract
Sensory stimuli can induce seizures in patients with epilepsy and predisposed subjects. Visual stimuli are the most common triggers, provoking seizures through an abnormal response to light or pattern. Sensitive patients may intentionally provoke their seizures through visual stimuli. Self-induction methods are widely described in photo-sensitive patients, while there are only a few reports of those who are pattern-sensitive. We analyzed 73 images of environmental visual triggers collected from 14 pattern-sensitive patients with self-induced seizures. The images were categorized according to their topics: 29 Objects (43%); 19 Patterns (28%); 15 External scenes (22%); 4 TV or computer screens (6%). Six photos were of poor quality and were excluded from analysis. Images were analyzed by an algorithm that calculated the degree to which the Fourier amplitude spectrum differed from that in images from nature. The algorithm has been shown to predict discomfort in healthy observers. The algorithm identified thirty-one images (46%) as "uncomfortable". There were significant differences between groups of images (ANOVA p = .0036; Chi2 p < .0279), with higher values of difference from nature in the images classified as "Objects" (mean 6,81E+11; SD 6,72E+11; n.17, 59%) and "Pattern" (mean 9,05E+11; SD 6,86E+11; n.14, 74%). During the semi-structured face-to-face interviews, all patients described the visual triggers as 'uncomfortable'; the appearance of enjoyable visual epileptic symptoms (especially multi-colored hallucinations) transformed uncomfortable images into pleasant stimuli. Patients considered self-induction as the simplest and most effective way to overcome stressful situations, suggesting that self-inducing pattern-sensitive patients often use uncomfortable visual stimuli to trigger their seizures. Among the reasons for the self-inducing behavior, the accidental discovery of pleasurable epileptic symptoms related to these "uncomfortable" visual stimuli should be considered.
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Affiliation(s)
- Mario Brinciotti
- Department of Human Neuroscience, Sapienza University of Rome, Italy.
| | | | - Olivier Penacchio
- School of Psychology and Neuroscience, University of St Andrews, United Kingdom.
| | - Maria Matricardi
- Department of Human Neuroscience, Sapienza University of Rome, Italy.
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17
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Rösche J, Dudek MIR, Kohnen O. [Self-induced epileptic seizures: Prevalence, Causes and Treatment]. FORTSCHRITTE DER NEUROLOGIE-PSYCHIATRIE 2021; 90:147-162. [PMID: 34198356 DOI: 10.1055/a-1484-0118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Self-induced seizures were first described in 1827. A majority of authors found that in unselected patients with epilepsy, the prevalence rate of these seizures was 1%. In patients with photosensitive epilepsy, there was roughly a 25% prevalence. Apart from visual stimulation, many other mechanisms of self-induction have been described. A feeling of pleasure or relaxation during seizures may be a reason for self-inductive behaviour. But often the procedure of self-induction is experienced as involuntary. Treatment is always difficult. Behavioral therapy has been proven effective in some patients. In patients with photosensitive epilepsy, sunglasses are recommended. Fenfluramine, clonazepam and valproate seem to be a bit more effective than other drugs. After all, the treatment effect depends on the motivation of the patient to change the condition.
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Affiliation(s)
- Johannes Rösche
- Klinik, Hephata Diakonie, Schwalmstadt-Treysa, Germany.,Klinik und Poliklinik für Neurologie, Universitätsmedizin Rostock, Rostock, Germany
| | - Maria Iracema Rocha Dudek
- Klinik für Psychiatrie und Psychotherapie/Ludwig-Noll-Krankenhaus Klinikum Kassel GmbH, Kassel, Germany
| | - Oona Kohnen
- Schweizerische Epilepsieklinik, Klinik Lengg AG, Zürich, Switzerland
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18
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Barnett JR, Fleming BM, Doshi SP, Freedman J, Ambrosio NR, Geenen KR, Bruno PL, Thiele EA. Understanding Sunflower syndrome: Results of an online questionnaire. Epilepsy Behav 2021; 117:107856. [PMID: 33639438 DOI: 10.1016/j.yebeh.2021.107856] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 02/03/2021] [Accepted: 02/08/2021] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To characterize the clinical phenotype, treatments, and impact on quality of life of Sunflower syndrome. METHODS A 138-question survey was created focusing on seizure description, disease course, treatment history, medical history, family history, and aspects of quality of life of individuals with Sunflower syndrome. The survey was administered to individuals with Sunflower syndrome who experience hand waving episodes (HWE) and/or their caregivers via Research Electronic Data Capture (REDCap). RESULTS Sixty-eight responses were included in analysis. Seventy-one% of respondents were female. The mean age of participants was 13.6 years, with 84% of respondents under the age of 18. The average age of onset of HWE was 6.7 years. HWE frequency varied from a few episodes per week to multiple episodes per hour. Sixty-two% of participants experienced other seizure types. Participants had been on an average of 1.9 anti-seizure medications with varying efficacy. Other methods to reduce HWE included wearing a hat or sunglasses, hand holding, using special tinted lenses, and avoiding the sun and bright lights. Sixty-nine% of participants reported anxiety or depression related to their epilepsy, and 65% said their HWE affected their social life. SIGNIFICANCE Sunflower syndrome is a highly stereotyped, refractory epilepsy which significantly impacts the lives of affected individuals. It remains underrecognized and poorly understood. These results characterize Sunflower syndrome in a large population of affected individuals and provides a basis for future research to better understand the epilepsy and improve clinical care.
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Affiliation(s)
- James R Barnett
- Pediatric Epilepsy Program, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Bradley M Fleming
- Pediatric Epilepsy Program, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Samarth P Doshi
- Pediatric Epilepsy Program, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Jason Freedman
- Pediatric Epilepsy Program, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Nicholas R Ambrosio
- Pediatric Epilepsy Program, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Kennedy R Geenen
- Pediatric Epilepsy Program, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Patricia L Bruno
- Pediatric Epilepsy Program, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Elizabeth A Thiele
- Pediatric Epilepsy Program, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA.
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19
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Geenen KR, Patel S, Thiele EA. Sunflower syndrome: a poorly understood photosensitive epilepsy. Dev Med Child Neurol 2021; 63:259-262. [PMID: 33135153 DOI: 10.1111/dmcn.14723] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/02/2020] [Indexed: 11/30/2022]
Abstract
Sunflower syndrome is a rare photosensitive epilepsy which has received little attention in recent medical literature. The historical cases documenting the epilepsy's stereotyped handwaving motion in front of light characterized the behavior as self-inducing seizures via mimic of stroboscopic effect. However, the relationship between handwaving episodes and attendant generalized electroencephalogram abnormalities, and an appreciation of the compulsive attraction the sun and other light sources hold for these patients, suggest the handwaving motion may be a part of the seizure rather than a mechanism of self-induction. The lack of awareness of Sunflower syndrome often leads to misdiagnosis. The seizures are often refractory to traditional anticonvulsant medication, and patients resort to behavioral intervention, such as hats and sunglasses, to reduce handwaving episodes. Further study is required to determine the syndrome's natural history and to identify more effective treatment options. WHAT THIS PAPER ADDS: Sunflower syndrome is a rare condition that is often misdiagnosed. Awareness of the clinical and electroencephalogram characteristics of Sunflower syndromemay reduce the prevalence of misdiagnosis.
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Affiliation(s)
- Kennedy R Geenen
- Pediatric Epilepsy Program, Massachusetts General Hospital, Boston, MA, USA
| | - Sandip Patel
- Pediatric Epilepsy Program, Massachusetts General Hospital, Boston, MA, USA
| | - Elizabeth A Thiele
- Pediatric Epilepsy Program, Massachusetts General Hospital, Boston, MA, USA
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20
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Yuan Y, Yang F, Huo L, Fan Y, Liu X, Wu Q, Wang H. Case Report: A Case of Eyelid Myoclonic Status With Tonic-Clonic Seizure and Literature Review. Front Pediatr 2021; 9:671732. [PMID: 33968862 PMCID: PMC8100049 DOI: 10.3389/fped.2021.671732] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 03/15/2021] [Indexed: 11/29/2022] Open
Abstract
Eyelid myoclonus with or without absence epilepsy is a rare and usually misdiagnosed disease in the neurology department. It is an idiopathic general epileptic syndrome, the onset period is 6-8 years, and is more common in girls. It is characterized by rapid abnormal eye blinking, accompanied by upward rolling of the eye and slight backward movement of the head, with eye closure sensitivity and photosensitivity. The seizure is frequent and short, dozens or even hundreds of times a day; a small number of patients may have eyelid myoclonus status. We report a patient who visits the hospital for the first time with eyelid myoclonic problem; the patient continued to wink the eyes, eye rolled up, and backward movement of the head, accompanied by impairment of consciousness. Video electroencephalography (VEEG) suggests continued spike slow-wave, polyspike slow-wave. After the patient had 2, 4, 6, 8, 10, 12, and 14 Hz of intermittent photic stimulation (IPS), her seizures and epileptic discharges reduced or stopped. Seven min after giving stimulation at 20 Hz, the child developed an occipital-initiated tonic-clonic seizure, which demonstrated that after sufficient IPS stimulation, the occiput cortex became excited and initiated a brain network, leading to diffuse brain discharge and tonic-clonic seizures. At 1 h after onset, the child developed a nonconvulsive state, with impairment of consciousness despite no eyelid myoclonic movements, and VEEG suggested a large number of epileptic discharges. After 10 min of administrating midazolam, the patient's EEG immediately became normal, and the patient regained consciousness. Therefore, this paper presents an eyelid myoclonus status patient with occipital origin seizure, we recorded the whole course of the disease and the treatment effect, and reviewed the literature accordingly.
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Affiliation(s)
- Yujun Yuan
- Department of Pediatrics, Shengjing Hospital of China Medical University, Shenyang, China
| | - Fenghua Yang
- Department of Pediatrics, Shengjing Hospital of China Medical University, Shenyang, China
| | - Liang Huo
- Department of Pediatrics, Shengjing Hospital of China Medical University, Shenyang, China
| | - Yuying Fan
- Department of Pediatrics, Shengjing Hospital of China Medical University, Shenyang, China
| | - Xueyan Liu
- Department of Pediatrics, Shengjing Hospital of China Medical University, Shenyang, China
| | - Qiong Wu
- Department of Pediatrics, Shengjing Hospital of China Medical University, Shenyang, China
| | - Hua Wang
- Department of Pediatrics, Shengjing Hospital of China Medical University, Shenyang, China
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21
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Sourbron J, Ayub N, Luo Y, Thiele EA. Ictal EEG in sunflower syndrome: Provoked or unprovoked seizures? Epilepsy Behav 2020; 113:107470. [PMID: 33070054 DOI: 10.1016/j.yebeh.2020.107470] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Revised: 08/27/2020] [Accepted: 08/30/2020] [Indexed: 12/01/2022]
Abstract
Sunflower syndrome (SS) is a rare, photosensitive epilepsy characterized by an attraction to light and highly stereotyped seizures with associated hand-waving (HW). It is controversial whether HW is part of the seizure or a provoking factor; therefore, we aimed to characterize the ictal electroencephalogram (EEG) in patients with SS. Video-EEG (vEEG) and charts of five patients with SS with HW during vEEG from Massachusetts General Hospital's Pediatric Epilepsy Program were reviewed and analyzed. In four out of five patients, the ictal EEG showed high amplitude (500-700 μV) 3-4 Hz generalized spike/polyspike-and-slow wave discharges, lasting 1.63-24.41 s. One hundred and twelve of 126 HW episodes, correlating to epileptiform activity (vEEG), had a lag time of less than 1.00 s (88.89%) between onset of HW and appearance of epileptiform activity. This suggests that HW does not induce seizure activity. Awareness of the ictal EEG features of this syndrome is important, as patients are frequently described as "self-inducing" their seizures.
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Affiliation(s)
- Jo Sourbron
- Department of Development and Regeneration, Section Pediatric Neurology, University Hospital KU Leuven, Leuven, Belgium
| | - Neishay Ayub
- Clinical Neurophysiology and Epilepsy Program, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Yancheng Luo
- Pediatric Epilepsy Program, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Elizabeth A Thiele
- Pediatric Epilepsy Program, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA.
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22
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Longardner K, Desai S, Nespeca M, Bainbridge M, Friedman J. Photosensitive Epilepsy Syndromes Mimicking Motor Tics. Mov Disord Clin Pract 2020; 7:S89-S92. [PMID: 33015234 DOI: 10.1002/mdc3.13053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Revised: 05/03/2020] [Accepted: 05/18/2020] [Indexed: 12/23/2022] Open
Affiliation(s)
- Katherine Longardner
- Department of Neurosciences University of California San Diego San Diego California USA
| | - Soaham Desai
- Pramukhswami Medical College Karamsad India.,Shree Krishna Hospital Gokal Nagar India
| | - Mark Nespeca
- Department of Neurosciences University of California San Diego San Diego California USA.,Department of Pediatrics University of California San Diego San Diego California USA.,Division of Neurology Rady Children's Hospital San Diego San Diego California USA
| | | | - Jennifer Friedman
- Department of Neurosciences University of California San Diego San Diego California USA.,Department of Pediatrics University of California San Diego San Diego California USA.,Division of Neurology Rady Children's Hospital San Diego San Diego California USA.,Rady Children's Institute of Genomic Medicine San Diego California USA
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23
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A rare self-induced reflex epilepsy: sunflower syndrome. Acta Neurol Belg 2019; 119:617-618. [PMID: 30047041 DOI: 10.1007/s13760-018-0970-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 06/28/2018] [Indexed: 10/28/2022]
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