A study of the effect of color photostimulation from a cathode-ray tube (CRT) display on photosensitive patients: the effect of alternating red-cyan flicker stimulation

The gamma response to colour hue in humans: Evidence from MEG

It has recently been demonstrated through invasive electrophysiology that visual stimulation with extended patches of uniform colour generates pronounced gamma oscillations in the visual cortex of both macaques and humans. In this study we sought to discover if this oscillatory response to colour can be measured non-invasively in humans using magnetoencephalography. We were able to demonstrate increased gamma (40–70 Hz) power in response to full-screen stimulation with four different colour hues and found that the gamma response is particularly strong for long wavelength (i.e. red) stimulation, as was found in previous studies. However, we also found that gamma power in response to colour was generally weaker than the response to an identically sized luminance-defined grating. We also observed two additional responses in the gamma frequency: a lower frequency response around 25–35 Hz that showed fewer clear differences between conditions than the gamma response, and a higher frequency response around 70–100 Hz that was present for red stimulation but not for other colours. In a second experiment we sought to test whether differences in the gamma response between colour hues could be explained by their chromatic separation from the preceding display. We presented stimuli that alternated between each of the three pairings of the three primary colours (red, green, blue) at two levels of chromatic separation defined in the CIELUV colour space. We observed that the gamma response was significantly greater to high relative to low chromatic separation, but that at each level of separation the response was greater for both red-blue and red-green than for blue-green stimulation. Our findings suggest that the stronger gamma response to red stimulation cannot be wholly explained by the chromatic separation of the stimuli.

The photoparoxysmal response: the probable cause of attacks during video games

Photic stimulation is part of a typical EEG in most countries, especially to check on the photoparoxysmal response (PPR). Interest in this response was enhanced in 1997 when hundreds of Japanese children had attacks while viewing a TV cartoon called "Pokemon." The overall prevalence of the PPR among patients requiring an EEG is approximately 0.8%, but 1.7% in children and 8.87% in patients with epilepsy, more often in Caucasians and females. Autosomal dominant inheritance is indicated, and this response is seen especially at the wavelength of 700 nm or at the flicker frequency of 15-18 Hz. The PPR extending beyond the stimulus carries no increased risk of seizures. Prognosis is generally good, especially after 20 years of age. Attention to PPR has been increased with the advent of video games, and the evoked seizures from these games are likely a manifestation of photosensitive epilepsy. Drug therapy has emphasized valproic acid, but Levetiracetam has also been successful in eliminating the PPR.

Is colour modulation an independent factor in human visual photosensitivity?

Considering that the role of colour in photosensitive epilepsy (PSE) remains unclear, we designed a study to determine the potential of different colours, colour combinations and white light to trigger photoparoxysmal responses (PPRs) under stringent controlled conditions. After assessing their photosensitivity to stroboscopic white light and black and white patterns, we studied 43 consecutive PSE patients (mean age 19 years, 34 women), using a specially designed colour stimulator. Stimuli included: pulse trains between 10 and 30 Hz of white light and of all primary colours, and also isoluminant alternating time-sequences of colours. Illuminance was kept constant at 100 lux. A progressive stepwise increase of the modulation-depth (MD) of the stimuli was used to determine PPRs threshold. Whereas all the 43 patients were found to be sensitive during the stroboscopic and pattern protocol, only 25 showed PPRs (Waltz's score >2) at least in one session when studied with the colour stimulator. Coloured stimuli elicited PPRs in all these patients, whereas white light did so only in 17 patients. Of the primary colours, red elicited more PPRs (54 in 22 patients) and at a lower MD (max Z-score 0.93 at 10 Hz). Of the alternating sequences, the red-blue was the most provocative stimulus, especially below 30 Hz (100% of patients, max Z-score: 1.65 at 15 Hz). Blue-green was the least provocative stimulus, since it elicited only seven PPRs in seven (28%) patients (max Z-score 0.44 at 10 Hz). Sensitivity to alternating colours was not correlated to sensitivity to individual colours. We conclude that colour sensitivity follows two different mechanisms: one, dependent on colour modulation, plays a role at lower frequencies (<30 Hz). Another, dependent on single-colour light intensity modulation correlates to white light sensitivity and is activated at higher frequencies. Our results suggest that the prescription of spectacles with coloured lenses, tailored to the patient, can be an effective preventative measure against visually induced seizures.

Characterizing the Patterned Images That Precipitate Seizures and Optimizing Guidelines To Prevent Them

The use of guidelines to prevent the broadcast of epileptogenic television program content has reduced the incidence of seizures in Britain and Japan. Epileptogenic content includes both flicker and patterns. The guidelines for flicker were developed on the basis of a model that related stimulus parameters to the proportion of patients affected. We here extend the model to pattern stimuli. A set of rules is advocated that keeps the level of risk to a consistent minimum and simplifies compliance. We propose that striped patterns that last > 0.5 s, occupy more than one fourth the area of the screen, and have bright stripes > 50 cd/m2 in luminance be restricted as regards the number of cycles admissible. The guidelines are estimated to protect at least two thirds of susceptible patients.

Photosensitivity and visually induced seizures

PURPOSE OF REVIEW

Interest in visually induced seizures has increased in recent years as a result of the increasing number of precipitants in our modern environment. This review addresses new developments in this field with special attention given to the emergence of new diagnostic, therapeutic and preventive approaches; it also emphasizes the importance of this condition as a public health issue.

RECENT FINDINGS

Current evidence indicates the presence of two different mechanisms of photosensitivity, one dependent on luminance changes and the other on wavelength. Both mechanisms may be active in the same patient, although one may be dominant. Magnetoencephalography studies revealed an enhancement in gamma frequency preceding the development of a paroxysmal response as well as underlying uncomfortable visual illusions, suggesting that a loss of control over high-frequency oscillatory processes may be involved in the genesis of both types of phenomenon. The genetics underlying this trait remain to be determined. More precise definition of different phenotypes should help in this search. Recognition of the risks posed by the audiovisual environment for induction of seizures in photosensitive individuals, who may not even be aware of their condition, will prompt further development of guidelines and devices designed to prevent the occurrence of seizures triggered by dangerous video sequences.

SUMMARY

Photosensitive epilepsy constitutes a unique benchmark model in which to address important issues in human epileptogenesis. The scope of the health risks posed by the modern audiovisual environment is increasingly being recognized, and further development of guidelines and regulations to control exposure to provocative materials are warranted.

A follow-up survey on seizures induced by animated cartoon TV program "Pocket Monster"

PURPOSE

To identify the short-term outcome of patients who had seizures while watching an animated cartoon TV program, "Pocket Monster," on December 16, 1997.

METHODS

One and three years after the incident, questionnaires were sent to physicians of each patient about seizure recurrence, EEGs, and medication.

RESULTS

Among 103 patients in whom epileptic seizures occurred during the TV program and information on the outcomes was available, 25 (24%) patients had a history of unprovoked seizures before the incident (Epilepsy Group), and 78 (76%) did not (Non-Epilepsy Group). Twenty-three (22%) patients were reported to have seizures after the incident, and 15 of them had visually induced seizures. Patients of the Epilepsy Group had more seizure recurrence than did those of the Non-Epilepsy Group (56% vs. 9%; p < 0.0001), either for unprovoked (44% vs. 4%; p < 0.0001) or visually induced seizures (28% vs. 9%; p < 0.05). Of nine patients of the Non-Epilepsy Group who had seizures after the incident, only three developed recurrent unprovoked seizures. In the Non-Epilepsy Group, no difference was found in seizure recurrence between patients in whom valproate (VPA) was prescribed immediately after the incident and in those without medication (one of five (20%) vs. seven of 73 (10%); p > 0.05). EEG was performed at least once in 98 patients after the incident. Photoparoxysmal response (PPR) was present in 45 (46%) patients, and spontaneous epileptiform discharges, in 49 (50%). PPR did not have any correlation with recurrence of seizures, neither spontaneous nor visually induced seizures, whereas spontaneous epileptiform discharges showed a good correlation with seizure recurrence (34% vs. 8%; p < 0.01), including visually induced seizures (24% vs. 2%; p < 0.01).

CONCLUSIONS

Short-term outcomes showed that 70 (68%) of 103 patients who had a seizure during the incident had no seizures before and during < or = 3 years of follow-up.

Emergent properties of CNS neuronal networks as targets for pharmacology: application to anticonvulsant drug action

CNS drugs may act by modifying the emergent properties of complex CNS neuronal networks. Emergent properties are network characteristics that are not predictably based on properties of individual member neurons. Neuronal membership within networks is controlled by several mechanisms, including burst firing, gap junctions, endogenous and exogenous neuroactive substances, extracellular ions, temperature, interneuron activity, astrocytic integration and external stimuli. The effects of many CNS drugs in vivo may critically involve actions on specific brain loci, but this selectivity may be absent when the same neurons are isolated from the network in vitro where emergent properties are lost. Audiogenic seizures (AGS) qualify as an emergent CNS property, since in AGS the acoustic stimulus evokes a non-linear output (motor convulsion), but the identical stimulus evokes minimal behavioral changes normally. The hierarchical neuronal network, subserving AGS in rodents is initiated in inferior colliculus (IC) and progresses to deep layers of superior colliculus (DLSC), pontine reticular formation (PRF) and periaqueductal gray (PAG) in genetic and ethanol withdrawal-induced AGS. In blocking AGS, certain anticonvulsants reduce IC neuronal firing, while other agents act primarily on neurons in other AGS network sites. However, the NMDA receptor channel blocker, MK-801, does not depress neuronal firing in any network site despite potently blocking AGS. Recent findings indicate that MK-801 actually enhances firing in substantia nigra reticulata (SNR) neurons in vivo but not in vitro. Thus, the MK-801-induced firing increases in SNR neurons observed in vivo may involve an indirect effect via disinhibition, involving an action on the emergent properties of this seizure network.

Visual Reflex Seizures Induced by Complex Stimuli

Visual reflex seizures induced by complex stimuli may be triggered by patterned and flashing displays that are now ubiquitous. The seizures may be clinically generalized, but unilateral and bilateral myoclonic attacks also may be triggered, especially in patients with juvenile myoclonic epilepsy, and recently, clearly focal reflex occipital lobe seizures have been described. Some seizure-triggering properties of video displays can be identified, such as perceived brightness, pattern, flicker frequency, and color. Knowledge of these is useful in planning individual treatment and in designing regulations for screen content of television broadcasts or for other video displays. Some subjects will also be sensitive to cognitive or action-programming activation, especially when playing video games, and this can increase the chance of seizure triggering. Nonspecific factors such as sleep deprivation, prolonged exposure, and drug or alcohol use also may play a role in reflex seizure occurrence.

Neuromagnetic responses to chromatic flicker: implications for photosensitivity

Excessive cortical excitation due to visual stimulation often leads to photosensitive epilepsy. Here we demonstrate that even in normal subjects, prolonged stimulation with low-luminance chromatic (equiluminant) flicker evokes neuromagnetic activity in the primary visual cortex, which develops slowly (up to 1000 ms) and depends on the color combination of flicker. This result suggests that chromatic sensitivity is a critical factor of cortical excitation, which can be amplified over time by a flickering stimulus. We further show that transient activity occurs in the parieto-occipital sulcus as early as 100-400 ms after flicker onset, which is negatively correlated with the later occipital activity. The early parieto-occipital activity may reflect a defensive mechanism that suppresses cortical hyperactivity due to chromatic flicker.