Cognition-induced epilepsy

Emotional stimuli-provoked seizures potentially misdiagnosed as psychogenic non-epileptic attacks: A case of temporal lobe epilepsy with amygdala enlargement

The association between emotional stimuli and temporal lobe epilepsy (TLE) is largely unknown. Here, we report the case of a depressed, 50-year-old female complaining of episodes of a “spaced out” experience precipitated by emotional stimuli. Psychogenic non-epileptic attacks were suspected. However, video-EEG coupled with emotional stimuli-provoked procedures and MRI findings of amygdala enlargement, led to the diagnosis of left TLE. Accurate diagnosis and explanation improved her subjective depression and seizure frequency. This case demonstrated that emotional stimuli can provoke seizures in TLE and suggested the involvement of the enlarged amygdala and the modulation of emotion-related neural circuits.

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Emotional stimuli provoked seizures in TLE with amygdala enlargement.

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Amygdala enlargement may be associated with the mechanism that elicits seizures.

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Optimizing anti-seizure drugs and emotional stimuli management were crucial.

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A correct diagnosis may resolve the distress of patients with PNEA and/or TLE.

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Thorough investigation is needed before the diagnosis of PNEA is confirmed.

Comparison of precipitating factors for mania and partial seizures: Indicative of shared pathophysiology?

OBJECTIVES

Mania in bipolar disorder (BD) and partial (focal) seizures (PS) arising from the temporal lobes, have a number of similarities. Typically, a chronic course of the disorders is punctuated by acute illness episodes. Common features of episodes may include sensory, perceptual, cognitive and affective changes. Both respond to anticonvulsant treatment. Common mechanisms imputed include neurotransmitters and kindling processes. Further investigation may improve understanding of the occurrence of both mania and PS, casting light on the relevance of temporal lobe mediated processes and pathology. One avenue of investigation is to compare aetiological factors and determine the extent of overlap which may indicate shared brain localization or pathophysiology. Aetiology includes predisposing, precipitating or perpetuating factors. This paper examines the literature on precipitating factors of mania, first or subsequent episode, and of PS in diagnosed epilepsy, which is the second or subsequent seizure, to identify the extent and nature of their overlap.

METHOD

Narrative review based on a literature search of PubMed and Google Scholar.

RESULTS

Precipitating factors for both mania and PS were stress, sleep deprivation, antidepressant medication and, tentatively, emotion. For mania alone, goal-attainment events, spring and summer season, postpartum, and drugs include steroids and stimulants. For PS alone, winter season, menstruation and specific triggers in complex reflex epilepsies. Those not substantiated include lunar phase and menopause. A wide range of chemicals may provoke isolated seizures but by definition epilepsy requires at least two seizures.

CONCLUSIONS

The overlap of precipitating factors in mania and PS imply that common brain processes may contribute to both, consistent with findings from neuroscience research.

EEG activation by neuropsychological tasks in idiopathic generalized epilepsy of adolescence

THE AIM OF THE STUDY

To evaluate the effects of neuropsychological activation (NPA) tasks on epileptiform discharges in adolescents with idiopathic generalized epilepsy (IGE) and their possible relationship to clinical epilepsy-related factors, also to compare the effects of the NPA to the habitual methods of electroencephalographic (EEG) activation.

METHODS/SUBJECTS

Fifty-nine patients with IGE aged 14-17 years underwent baseline video-EEG recording with habitual activation procedures followed by NPA tasks, and sleep EEG after sleep deprivation on the next day.

RESULTS

At least one task of NPA showed provocative effect in 18.6% of cases. There was no difference between the provocative effects of action-programming and thinking NPA task groups as well as among individual NPA tasks. The provocative effects of NPA tasks were more prevalent in photosensitive cases, especially the tasks of action-programming type (p=0.04). The provocative NPA effects showed no relationship to gender, age, age at seizure onset, duration of epilepsy, treatment status, presence of myoclonias, recent generalized tonic-clonic seizures, family history of epilepsy. The provocative effects of NPA were comparable to those of hyperventilation (23.7%) and intermittent light stimulation (30.5%) (p>0.05).

CONCLUSIONS

Although the provocative effects NPA tasks on epileptiform discharges on EEG did not outweigh the effects of the habitual activation procedures, NPA activation might be helpful as an additional diagnostic tool in adolescents with IGE in selected cases when routine EEG is not informative enough or when sleep EEG is readily unavailable, also in photosensitive cases. It may also help in providing advice for patients on safety issues.

Reflex epilepsy induced by playing Go-stop or Baduk games

PURPOSE

Seizures can be triggered by complex mental activities. The aim of this study was to investigate the clinical characteristics of reflex epilepsy induced by playing Go-stop or Baduk games.

METHODS

The study comprised 11 patients with this type of reflex epilepsy identified from our patient database. We collected data on clinical features, EEG, and brain MRI as well as seizure outcomes.

RESULTS

The patients had a late age of onset (range, 43-65 years, except for one patient with an age of onset of 11 years). An MRI abnormality and interictal EEG abnormalities were found in one patient respectively. The seizures exhibited diverse semiological features suggesting a focal or generalized onset. No myoclonic seizures were observed. Individualized strategies such as avoiding the precipitating game or reducing exposure to the stimulus were most effective in preventing the seizures.

CONCLUSION

The pathophysiological mechanisms underlying Go-stop- or Baduk-induced seizures may be different from other cognition-associated reflex epileptic phenomena. This type of reflex epilepsy may be a heterogeneous syndrome manifesting in a range of diverse semiological features.

Cognition-induced epilepsy associated with specific emotional precipitants

A 32-year-old woman with primary generalized epilepsy described absence events precipitated by talking about childhood sexual abuse, her epilepsy, or her father's difficulties with schizophrenia. She was referred for assessment of suspected psychogenic nonepileptic events. During simultaneous video/EEG monitoring, 30 absence seizures were recorded, 28 of which occurred while discussing one of these three specific precipitants. No nonepileptic events were seen. This finding highlights the importance of thorough investigation of ambiguous events, and confirms that specific emotional precipitants can induce seizures in susceptible people with epilepsy.

Idiopathic epileptic syndromes and cognition

Epilepsy is frequently associated with cognitive impairments which result from various interacting factors. The present paper deals with the contribution of neuropsychology to the characterization of the type of epilepsy and the possible mechanisms underlying idiopathic epileptic syndromes. The non-lesional, so-called idiopathic epilepsies, constitute an interesting model for assessing the relationship between epileptiform EEG discharges and cognition. Among the idiopathic generalized epilepsies, disorders of social integration and personality have been frequently reported in juvenile myoclonic epilepsy (JME). Since similar disturbances are observed in frontal-lobe-lesioned patients, impairments in other frontal lobe functions (e.g. executive functions) might be expected in JME. This gives rise to speculation about the possible underlying pathophysiological mechanisms in JME. With regard to partial idiopathic epilepsies, benign childhood epilepsy with centrotemporal spikes (BCECTS) may provide a useful model for the study of the relationship between epileptiform EEG discharges in the peri-sylvian region and language functions. Furthermore, the description of mild cognitive dysfunctions in BCECTS, and their persistence into adulthood, can provide information about compensatory mechanisms and may allow for the generation of remedial strategies. Thus, 'lesional' neuropsychology has given way to 'dynamic' neuropsychology based on specific postulates. By using the cognitive profile to specify the mechanism underlying the behavioral disturbances observed in different types of epilepsy, neuropsychology may eventually contribute to a revision of the present classification of epileptic syndromes. In addition, the neuropsychological data may help predict the extent and limits of functional recovery and cerebral plasticity.