Photosensitivity and visually induced seizures

Visually sensitive seizures: An updated review by the Epilepsy Foundation

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.

Stroboscopic light effects during electronic dance music festivals and photosensitive epilepsy: a cohort study and case report

OBJECTIVES

Electronic dance music (EDM) concerts are becoming increasingly popular. Strong stroboscopic light effects are commonly part of these shows, and may provoke seizures in individuals with photosensitive epilepsy. This study aims to examine the risk of epileptic seizures during EDM concerts.

SETTING

28 EDM concerts taking place in The Netherlands.

PARTICIPANTS

We describe a young man who experienced a seizure during an EDM concert, and who later showed a positive electroencephalographic provocation test during exposure to video footage of the same concert. Subsequently, we performed a cohort study of 400 343 visitors to EDM concerts, divided in those exposed (concert occurring in darkness) versus unexposed (concert in daylight) to stroboscopic light effects.

RESULTS

In total, 400 343 EDM concert visitors were included: 241 543 (representing 2 222 196 person hours) in the exposed group and 158 800 (representing 2 334 360 person hours) in the control group. The incidence density ratio of epileptic seizures in exposed versus unexposed individuals was 3.5 (95% CI: 1.7 to 7.8; p<0.0005). Less than one-third of cases occurred during use of ecstasy or similar stimulant drugs.

CONCLUSION

Stroboscopic light effects during EDM concerts occurring in darkness probably more than triple the risk of epileptic seizures. Concert organisers and audience should warn against the risk of seizures and promote precautionary measures in susceptible individuals.

Photosensitivity and epilepsy: Current concepts and perspectives-A narrative review

The authors review the influence of photic stimuli on the generation of epileptic seizures, addressing the first descriptions of the phenomenon and its subsequent exploration. Initially defined in the 1950's, links between intermittent photic stimulation (IPS) and seizures were well understood by the 1970. Since then the increasing exposure to photic stimuli associated with modern life (for instance through TVs, patterns, computer games and electronic instruments with flickering displays) has led to an increased interest in this issue. Diverse stimulation procedures have been described and difference in the effects of stimulation frequencies and types, colour and lighting have been recognised. Approximately 5% of patients with epilepsy have photosensitive epilepsy (PSE). PSE is commoner in younger individuals, more frequent in women, often time-limited, generally easy to treat and closely related to generalised epilepsies, especially Juvenile Myoclonic Epilepsy (JME). Structural and functional studies of PSE indicate abnormalities beyond the frontal lobes and evidence for the role of the visual cortex in human PSE. A reduction in connectivity between prefrontal and frontopolar regions and increased connectivity between occipital cortex and the supplementary motor area may be the basis for triggering motor seizures in JME. Due to the changes observed in such areas, it is hypothesised that photoparoxysmal responses (PPR) could be a final expression of pathogenic phenomena in the striato-thalamocortical system, and possibly a core feature of JME as system epilepsy. The familial transmission of epileptiform responses to IPS is well-recognised, but no clear relation between PSE and specific genes has emerged. Although the influence of ethnic factors on PSE has been widely studied, clear conclusions are still lacking. Pharmacological therapeutic approaches are beyond the scope of this review although preventive measures allowing patients to avoid PS seizure initiation and/or generalisation are discussed. Given the gender/age group most commonly affected by PSE, the risks and benefits of drug treatment need to be carefully weighed up.

Genetics of reflex seizures and epilepsies in humans and animals

INTRODUCTION

Reflex seizures are epileptic events triggered by specific motor, sensory or cognitive stimulation. This comprehensive narrative review focuses on the role of genetic determinants in humans and animal models of reflex seizures and epilepsies.

METHODS

References were mainly identified through MEDLINE searches until August 2015 and backtracking of references in pertinent studies.

RESULTS

Autosomal dominant inheritance with reduced penetrance was proven in several families with photosensitivity. Molecular genetic studies on EEG photoparoxysmal response identified putative loci on chromosomes 6, 7, 13 and 16 that seem to correlate with peculiar seizure phenotype. No specific mutation has been found in Papio papio baboon, although a genetic etiology is likely. Mutation in synaptic vesicle glycoprotein 2A was found in another animal model of photosensitivity (Fayoumi chickens). Autosomal dominant inheritance with incomplete penetrance overlapping with a genetic background for IGE was proposed for some families with primary reading epilepsy. Musicogenic seizures usually occur in patients with focal symptomatic or cryptogenic epilepsies, but they have been reported in rare genetic epilepsies such as Dravet syndrome. A single LGI1 mutation has been described in a girl with seizures evoked by auditory stimuli. Interestingly, heterozygous knockout (Lgi1(+/-)) mice show susceptibility to sound-triggered seizures. Moreover, in Frings and Black Swiss mice, the spontaneous mutations of MASS1 and JAMS1 genes, respectively, have been linked to audiogenic seizures. Eating seizures usually occur in symptomatic epilepsies but evidences for a genetic susceptibility were mainly provided by family report from Sri Lanka. Eating seizures were also reported in rare patients with MECP2 duplication or mutation. Hot water seizures are genetically heterogeneous but two loci at chromosomes 4 and 10 were identified in families with likely autosomal dominant inheritance. Startle-induced seizures usually occur in patients with symptomatic epilepsies but have also been reported in the setting chromosomal disorders or genetically inherited lysosomal storage diseases.

DISCUSSION

The genetic background of reflex seizures and epilepsies is heterogeneous and mostly unknown with no major gene identified in humans. The benefits offered by next-generation sequencing technologies should be merged with increasing information on animal models that represent an useful tool to study the mechanism underlying epileptogenesis. Finally, we expect that genetic studies will lead to a better understanding of the multiple factors involved in the pathophysiology of reflex seizures, and eventually to develop preventive strategies focused on seizure control and therapy optimization.

Evaluation of the Effects of Charged Amino Acids on Uncontrolled Seizures

Introduction. Epilepsy is one of the most common diseases of the central nervous system. The prevalence of epilepsy throughout the world is 0.5 to 1%, and the same rate is 7.8 per 1000 in Kerman. Almost 20 to 30% of epileptic patients do not respond properly to common medications. The present study investigated patients who did not respond to common and, even in some cases, adjuvant therapies, with two seizures or more per week, regardless of the type of the inflicted epilepsy. Methodology. The participants of the present double-blind study were randomly selected into three 10-member groups of uncontrolled epileptic patients (arginine, glutamic acid, and lysine). The patients used amino acid powder dissolved in water (three times the daily need) every day for two weeks before breakfast. The number of seizures was recorded one week prior to commencing amino acid use, as well as the first and the second weeks subsequent to use. Results. A total of 32 patients were studied in three groups. The decline rates of seizures were 53%, 41%, and 13%, and the P value was 0.013, 0.027, and 0.720, respectively. Conclusion. Administration of the charged amino acids, arginine, and glutamic acid can decrease the seizures of patients suffering from uncontrolled epilepsy.

Do reflex seizures and spontaneous seizures form a continuum? - triggering factors and possible common mechanisms

Recent changes in the understanding and classification of reflex seizures have fuelled a debate on triggering mechanisms of seizures and their conceptual organization. Previous studies and patient reports have listed extrinsic and intrinsic triggers, albeit their multifactorial and dynamic nature is poorly understood. This paper aims to review literature on extrinsic and intrinsic seizure triggers and to discuss common mechanisms among them. Among self-reported seizure triggers, emotional stress is most frequently named. Reflex seizures are typically associated with extrinsic sensory triggers; however, intrinsic cognitive or proprioceptive triggers have also been assessed. The identification of a trigger underlying a seizure may be more difficult if it is intrinsic and complex, and if triggering mechanisms are multifactorial. Therefore, since observability of triggers varies and triggers are also found in non-reflex seizures, the present concept of reflex seizures may be questioned. We suggest the possibility of a conceptual continuum between reflex and spontaneous seizures rather than a dichotomy and discuss evidence to the notion that to some extent most seizures might be triggered.

Maximal variability of phase synchrony in cortical networks with neuronal avalanches

Ongoing interactions among cortical neurons often manifest as network-level synchrony. Understanding the spatiotemporal dynamics of such spontaneous synchrony is important because it may (1) influence network response to input, (2) shape activity-dependent microcircuit structure, and (3) reveal fundamental network properties, such as an imbalance of excitation (E) and inhibition (I). Here we delineate the spatiotemporal character of spontaneous synchrony in rat cortex slice cultures and a computational model over a range of different E-I conditions including disfacilitated (antagonized AMPA, NMDA receptors), unperturbed, and disinhibited (antagonized GABA(A) receptors). Local field potential was recorded with multielectrode arrays during spontaneous burst activity. Synchrony among neuronal groups was quantified based on phase-locking among recording sites. As network excitability was increased from low to high, we discovered three phenomena at an intermediate excitability level: (1) onset of synchrony, (2) maximized variability of synchrony, and (3) neuronal avalanches. Our computational model predicted that these three features occur when the network operates near a unique balanced E-I condition called "criticality." These results were invariant to changes in the measurement spatial extent, spatial resolution, and frequency bands. Our findings indicate that moderate average synchrony, which is required to avoid pathology, occurs over a limited range of E-I conditions and emerges together with maximally variable synchrony. If variable synchrony is detrimental to cortical function, this is a cost paid for moderate average synchrony. However, if variable synchrony is beneficial, then by operating near criticality the cortex may doubly benefit from moderate mean and maximized variability of synchrony.

Spectral properties of induced and evoked gamma oscillations in human early visual cortex to moving and stationary stimuli

In two experiments, magnetoencephalography (MEG) was used to investigate the effects of motion on gamma oscillations in human early visual cortex. When presented centrally, but not peripherally, stationary and moving gratings elicited several evoked and induced response components in early visual cortex. Time-frequency analysis revealed two nonphase locked gamma power increases-an initial, rapidly adapting response and one sustained throughout stimulus presentation and varying in frequency across observers from 28 to 64 Hz. Stimulus motion raised the sustained gamma oscillation frequency by a mean of approximately 10 Hz. The largest motion-induced frequency increases were in those observers with the lowest gamma response frequencies for stationary stimuli, suggesting a possible saturation mechanism. Moderate gamma amplitude increases to moving versus stationary stimuli were also observed but were not correlated with the magnitude of the frequency increase. At the same site in visual cortex, sustained alpha/beta power reductions and an onset evoked response were observed, but these effects did not change significantly with the presence of motion and did not correlate with the magnitude of gamma power changes. These findings suggest that early visual areas encode moving and stationary percepts via activity at higher and lower gamma frequencies, respectively.

A descriptive analysis of seizure events among adults who participated in a computer-based assessment

The purpose of this study was to document seizure events associated with the use of a computer-based assessment and to describe the contextual factors surrounding these seizure episodes. Study participants were adults with epilepsy who were enrolled at research sites in Atlanta and Boston. Subjects were asked to complete a computer-based assessment at 3 time points. Fourteen seizure events were documented; they occurred during 1.6% of all completed assessments (896) and affected 4.4% of the participants (320). The mean age of participants who experienced seizure events was 41.4 years; about 70% were female, and 70% were white. A variety of possible precipitating factors for seizure events included hunger, fatigue, stress, and medication changes. Participants indicated computer use could have triggered their seizures in 2 instances. These findings suggest use of computer-based assessments may pose minimal risks for adults with epilepsy, particularly those without a history of photosensitivity epilepsy.

Exploration of the Genetic Architecture of Idiopathic Generalized Epilepsies

PURPOSE

Idiopathic generalized epilepsy (IGE) accounts for approximately 20% of all epilepsies and affects about 0.2% of the general population. The etiology of IGE is genetically determined, but the complex pattern of inheritance suggests an involvement of a large number of susceptibility genes. The objective of the present study was to explore the genetic architecture of common IGE syndromes and to dissect out susceptibility loci predisposing to absence or myoclonic seizures.

METHODS

Genome-wide linkage scans were performed in 126 IGE-multiplex families of European origin ascertained through a proband with idiopathic absence epilepsy or juvenile myoclonic epilepsy. Each family had at least two siblings affected by IGE. To search for seizure type-related susceptibility loci, linkage analyses were carried out in family subgroups segregating either typical absence seizures or myoclonic and generalized tonic-clonic seizures on awakening.

RESULTS

Nonparametric linkage scans revealed evidence for complex and heterogeneous genetic architectures involving linkage signals at 5q34, 6p12, 11q13, 13q22-q31, and 19q13. The signal patterns differed in their composition, depending on the predominant seizure type in the families.

CONCLUSIONS

Our results are consistent with heterogeneous configurations of susceptibility loci associated with different IGE subtypes. Genetic determinants on 11q13 and 13q22-q31 seem to predispose preferentially to absence seizures, whereas loci on 5q34, 6p12, and 19q13 confer susceptibility to myoclonic and generalized tonic-clonic seizures on awakening.

Epileptogenic neocortical networks are revealed by abnormal temporal dynamics in seizure-free subdural EEG

Long-term video electroencephalographic (EEG) recording is currently a routine procedure in the presurgical evaluation of localization-related epilepsies. Cortical epileptogenic zone is usually localized from ictal recordings with intracranial electrodes, causing a significant burden to patients and health care. Growing literature suggests that epileptogenic networks exhibit aberrant dynamics also during seizure-free periods. We examined if neocortical epileptogenic regions can be circumscribed by quantifying local long-range temporal (auto-)correlations (LRTC) with detrended fluctuation analysis of seizure-free ongoing subdural EEG activity in 4 frequency bands in 5 patients. We show here with subdural EEG recordings that the LRTC are abnormally strong near the seizure onset area. This effect was most salient in neocortical oscillations in the beta frequency band (14-30 Hz). Moreover, lorazepam, a widely used antiepileptic drug, exerted contrasting effects on LRTC (n = 2): lorazepam attenuated beta-band LRTC near the epileptic focus, whereas it strengthened LRTC in other cortical areas. Our findings demonstrate that interictal neuronal network activity near the focus of seizure onset has pathologically strong intrinsic temporal correlations. The observed effect by lorazepam on beta-band activity suggests that the antiepileptic mechanism of benzodiazepines may be related to the normalization of LRTC within the epileptic focus. We propose that this method may become a promising candidate for routine invasive and noninvasive presurgical localization of epileptic foci.

Massively Multiplayer Online Role-Playing Game-Induced Seizures: ANeglected Health Problem in Internet Addiction

As the Internet has become rapidly and widely integrated into society, Internet addiction has become a growing psychosocial problem. However, epileptic seizure, another out-of-the-ordinary health problem, is often neglected in this regard. Ten patients who experienced epileptic seizures while playing the newest genre of electronic games -- Massively Multiplayer Online Role-Playing Games (MMORPGs) -- were investigated. Patients were predominantly male young adults, and most of the events were generalized tonic-clonic seizures, myoclonic seizures, and absences. These patients should be categorized into idiopathic generalized epilepsies. Even though photosensitivity was an important factor, behavioral and higher mental activities also seemed to be significant seizure precipitants. Results demonstrated that MMORPG-induced seizures were not analogous to the ordinary video game-induced seizures. Significantly, an epileptic seizure warning did not always appear on the websites of MMORPGs and instructions for the software. While the prevalence of MMORPG-induced seizures remains unknown, it may exceed our expectations and impact our society. Not only for clinical neurologists but also for the primary physicians, educators, sociologists, and global online game publishers, there should be an awareness of this special form of reflex seizures in order to provide an appropriate health warning to MMORPG players.

Association of BRD2 polymorphisms with photoparoxysmal response

A trait locus for electroencephalographic photoparoxysmal response (PPR) has been mapped to the chromosomal region 6p21 near a susceptibility locus for juvenile myoclonic epilepsy (JME). Linkage disequilibrium mapping revealed strong associations between JME and polymorphisms of the gene encoding the bromodomain-containing protein 2 (BRD2). The present association study tested whether genetic variation of BRD2 confers also susceptibility to PPR. All study participants were of German descent, comprising 187 subjects exhibiting PPR (types I-IV) and 666 healthy controls. Genotypes of each study participant were assessed for seven single nucleotide polymorphisms and one dinucleotide repeat polymorphism, covering the genomic BRD2 sequence. Allelic and haplotypic associations were found between PPR and six BRD2 polymorphisms (P: 0.0075-0.035). Considering the strong neurobiological association of JME and PPR, the present results support evidence that PPR and JME share epileptogenic pathways, for which BRD2 might be an underlying susceptibility gene.

Candidate gene analysis of the succinic semialdehyde dehydrogenase gene (ALDH5A1) in patients with idiopathic generalized epilepsy and photosensitivity

Succinic semialdehyde dehydrogenase (SSADH) is involved in the degradation of the inhibitory neurotransmitter GABA and about 50% of patients with SSADH deficiency suffer from seizures. The gene encoding SSADH (gene symbol: ALDH5A1) maps in proximity to susceptibility loci for juvenile myoclonic epilepsy (JME) and photosensitivity on chromosome 6p22. The present study tested whether variation of the ALDH5A1 gene confers susceptibility to common syndromes of idiopathic generalized epilepsy (IGE) and an abnormal photoparoxysmal response (PPR). Mutation screening of the ALDH5A1 coding sequence of 35IGE/PPR patients and four healthy control subjects identified 17 sequence variants, of which three resulted in an exchange of amino acids (H180Y, P182L, A237S). Association analysis was carried out for six single nucleotide polymorphisms (SNPs) and one trinucleotide repeat polymorphism (TNR, intron 1), covering the genomic ALDH5A1 sequence. The study sample comprised 566 unrelated German IGE patients, including 218 JME and 95 photosensitive IGE patients, 78 PPR probands without IGE, and 662 German population controls. None of the investigated ALDH5H1 polymorphisms showed evidence for an allelic or genotypic association with either IGE, JME, or PPR, when corrected for multiple tests. A tentative haplotypic association of the two-marker haplotype (rs1883415-TNR) covering the 5'-regulatory region in IGE patients (chi2=11.65, d.f.=3, P=0.009) warrants further replication studies. The present results do not provide evidence that any ALDH5A1 missense variant itself contributes a common and substantial susceptibility effect (RR>2) to IGE syndromes or an increased liability to visually-induced cortical synchronization.

Game-related seizures presenting with two types of clinical features

We evaluated 22 patients with epileptic seizures in which the seizures were triggered by various games or game-related materials. Based on whether spontaneous seizure coexisted or not, these 22 patients were divided into two groups. Ten patients who experienced seizures exclusively while playing or watching specific games were referred to as Group I, while 12 patients that had both game-induced and spontaneous seizures were classified as Group II. The patients in Group I had a middle-age onset (39.1 years) with a male predominance (90%). The electroencephalogram (EEG) or brain magnetic resonance imaging revealed non-specific abnormalities in 60%, and the partial onset seizure was recognized in 30% of patients. Antiepileptic drugs had uncertain benefits in this group. In Group II, patients had a male predominance (67%), with onset during adolescence (16.3 years). Most of them had generalized tonic-clonic seizures, myoclonic seizures, and absences, and 42% showed epileptiform discharge on EEG. These 12 patients were categorized into idiopathic generalized epilepsies. Although photosensitivity was an important factor, higher mental activity seemed to be significant precipitants of seizures in Group II. Antiepileptic drugs were necessary and valproic acid alone or combined with clonazepam was effective in this group. The results showed that game-related seizures are not a unique and homogeneous syndrome and may consist of different mechanisms. Teenage onset, coexistent spontaneous seizure, and associated idiopathic generalized epilepsies were crucial factors in the determination of antiepileptic drug therapy. Moreover, avoiding the related games altogether may be a more productive preventive measure.

Photic- and pattern-induced seizures: a review for the Epilepsy Foundation of America Working Group

PURPOSE

This report summarizes background material presented to a consensus conference on visually provoked seizures, convened by the Epilepsy Foundation of America.

METHODS

A comprehensive review of literature was performed.

RESULTS

Photosensitivity, an abnormal EEG response to light or pattern stimulation, occurs in approximately 0.3-3% of the population. The estimated prevalence of seizures from light stimuli is approximately 1 per 10,000, or 1 per 4,000 individuals age 5-24 years. People with epilepsy have a 2-14% chance of having seizures precipitated by light or pattern. In the Pokemon cartoon incident in Japan, 685 children visited a hospital in reaction to red-blue flashes on broadcast television (TV). Only 24% who had a seizure during the cartoon had previously experienced a seizure. Photic or pattern stimulation can provoke seizures in predisposed individuals, but such stimulation is not known to increase the chance of subsequent epilepsy. Intensities of 0.2-1.5 million candlepower are in the range to trigger seizures. Frequencies of 15-25 Hz are most provocative, but the range is 1-65 Hz. Light-dark borders can induce pattern-sensitive seizures, and red color also is a factor. Seizures can be provoked by certain TV shows, movie screen images, video games, natural stimuli (e.g, sun on water), public displays, and many other sources.

CONCLUSIONS

Recommendations on reducing risk of seizures have been developed by agencies in the United Kingdom, Japan, and the International Telecommunications Union, affiliated with the United Nations. The Epilepsy Foundation of America has developed a consensus of medical experts and scientists on this subject, reported in an accompanying work.

Phase clustering of high frequency EEG: MEG components

The study of phase consistency of high frequency EEG/MEG components can reveal properties of neuronal networks that are informative about their excitability state. The clue is that these properties are easier to put in evidence when the response of the neuronal networks is evoked by an adequate stimulation paradigm. The latter may be considered a probe of neuronal excitability state capable of revealing hidden information contained in the phase structure of neuronal activities. In this context the high frequency band components appear to be the most reactive signals.