Diagnostic yield and limitations of in-hospital documentation in patients with epilepsy

OBJECTIVE

To determine the diagnostic yield of in-hospital video-electroencephalography (EEG) monitoring to document seizures in patients with epilepsy.

METHODS

Retrospective analysis of electronic seizure documentation at the University Hospital Freiburg (UKF) and at King's College London (KCL). Statistical assessment of the role of the duration of monitoring, and subanalyses on presurgical patient groups and patients undergoing reduction of antiseizure medication.

RESULTS

Of more than 4800 patients with epilepsy undergoing in-hospital recordings at the two institutions since 2005, seizures with documented for 43% (KCL) and 73% (UKF).. Duration of monitoring was highly significantly associated with seizure recordings (p < .0001), and presurgical patients as well as patients with drug reduction had a significantly higher diagnostic yield (p < .0001). Recordings with a duration of >5 days lead to additional new seizure documentation in only less than 10% of patients.

SIGNIFICANCE

There is a need for the development of new ambulatory monitoring strategies to document seizures for diagnostic and monitoring purposes for a relevant subgroup of patients with epilepsy in whom in-hospital monitoring fails to document seizures.

Peri-ictal heart rate changes in patients with epilepsy

Background

Heart rate (HR) changes associated with seizures are promising biomarkers in epilepsy.

Aims

The aim of our study is to reveal possible HR changes in the peri-ictal period.

Methods

Long-term video-EEG monitorization records of generalized and focal epilepsy patients were reviewed. HRs were calculated in the pre-ictal (2 min before the first seizure activity in EEG), ictal (the time from the first seizure activity on the EEG to the end of the seizure), and in the interictal period (at least 2 h before or 12 h after the seizure). Interictal, pre-ictal, and ictal HRs were compared with each other. In addition, it was investigated whether peri-ictal HR changes differ between generalized and focal seizure patients.

Results

Focal motor seizures were observed in 21, and generalized tonic-clonic seizures were observed in 18 of 39 (22 female and 17 male) patients studied. HRs in the pre-ictal and ictal periods were significantly higher than in the interictal period. This significant increase in HR was validated separately in both focal and generalized seizure groups and was not different between the two groups.

Conclusion

Our study supports previous studies showing the presence of increased peri-ictal HR and also provides new insights by comparing focal and generalized motor seizures. We think that our findings may contribute to the development of early warning signs in epilepsy patients.

Epileptic nystagmus as clinical manifestation of self-limited focal epilepsy: Rethinking etiology and prognostic value and literature review

Epileptic nystagmus (EN) is an uncommon ictal clinical manifestation characterized by rapid, repetitive eyeballs movements. Few cases of EN have been reported and, in most cases, electro-clinical correlation showed a focal EEG activity, mainly in the occipital and temporo-occipital areas. Although EN occurs both in idiopathic and non-idiopathic epilepsy, the most frequent cause appears to be inborn or acquired alteration of brain structures. We report of a 12-year-old girl with EN as ictal manifestation of self-limited focal seizures. We described clinical manifestations, electroencephalographic features, treatment, and follow-up, presenting the ictal video-EEG phenomenon. Alongside, we reviewed the reported clinical features of the few pediatric cases (seven patients) with idiopathic epileptic nystagmus through a systematic literature review. Isolated Epileptic Nystagmus (IEN) is much rarer than EN, as it is more frequently associated with other types of seizures, and can be idiopathic, especially in children. Epilepsy prognosis is usually favorable with appropriate treatment, and ASM discontinuation seems to be successful after few years of treatment.

Musicogenic epilepsy in paraneoplastic limbic encephalitis: a video-EEG case report

Musicogenic epilepsy (ME), a peculiar form of reflex epilepsy, represents a neurological rarity and yet another demonstration of the extraordinary power of music on the human brain. Despite the heterogeneity of the reported musical triggers, the patients' emotional response to music is thought to play a crucial role in provoking seizures. Accordingly, the mesial temporal structures (especially of the non-dominant hemisphere) appear most involved in seizure generation, although a more complex fronto-temporal epileptogenic network was documented in some cases. Autoimmune encephalitis has been recently included among the many possible etiologies of ME thanks to few reports of music-induced seizures in patients with anti-glutamic acid decarboxylase 65 antibodies. Here we describe the case of a 25-year-old man, with long-term music education, who suffered from drug-resistant temporal lobe epilepsy following seronegative limbic encephalitis related to non-Hodgkin lymphoma. Along with spontaneous events, the patient also developed musicogenic seizures later in the disease course. After detecting five music-induced episodes via 24-h ambulatory EEG, we performed a prolonged video-EEG monitoring during which the patient presented a right temporal seizure (characterized by déjà-vu, piloerection and gustatory hallucinations) while listening to a hard-rock song (never heard before) through headphones. This observation allowed us to confirm the provoking effect of music on our patient's seizures, despite the lack of any emotional drive, which suggests that a "cognitive" trigger was more likely in this case. Our report further highlights that autoimmune encephalitis should be investigated as a novel potential cause of musicogenic epilepsy, regardless of autoantibody status.

Epileptic spasms in infants: can video-EEG reveal the disease's etiology? A retrospective study and literature review

Objective

Epileptic spasms are a type of seizure defined as a sudden flexion or extension predominantly of axial and/or truncal limb muscles that occur with a noticeable periodicity. Routine electroencephalogram supports the diagnosis of epileptic spasms, which can occur due to different causes. The present study aimed to evaluate a possible association between the electro-clinical pattern and the underlying etiology of epileptic spasms in infants.

Materials and methods

We retrospectively reviewed the clinical and video-EEG data on 104 patients (aged from 1 to 22  months), admitted to our tertiary hospital in Catania and the tertiary hospital in Buenos Aires, from January 2013 to December 2020, with a confirmed diagnosis of epileptic spasms. We divided the patient sample into structural, genetic, infectious, metabolic, immune, and unknown, based on etiology. Fleiss' kappa (К) was used to assess agreement among raters in the electroencephalographic interpretation of hypsarrhythmia. A multivariate and bivariate analysis was conducted to understand the role of the different video-EEG variables on the etiology of epileptic spasms. Furthermore, decision trees were constructed for the classification of variables.

Results

The results showed a statistically significant correlation between epileptic spasms semiology and etiology: flexor spasms were associated with spasms due to genetic cause (87.5%; OR < 1); whereas mixed spasms were associated with spasms from a structural cause (40%; OR < 1). The results showed a relationship between ictal and interictal EEG and epileptic spasms etiology: 73% of patients with slow waves and sharp waves or slow waves on the ictal EEG, and asymmetric hypsarrhythmia or hemi hypsarrhythmia on the interictal EEG, had spasms with structural etiology, whereas 69% of patients with genetic etiology presented typical interictal hypsarrhythmia with high-amplitude polymorphic delta with multifocal spike or modified hypsarrhythmia on interictal EEG and slow waves on the ictal EEG.

Conclusion

This study confirms that video-EEG is a key element for the diagnosis of epileptic spasms, also playing an important role in the clinical practice to determine the etiology.

Myoclonic status epilepticus in patients with juvenile myoclonic epilepsy: Case reports and review of the literature

Content available: Video

In Vivo Injection of Anti-LGI1 Antibodies into the Rodent M1 Cortex and Hippocampus Is Ineffective in Inducing Seizures

Autoimmune encephalitis (AIE) associated with antibodies directed against the leucine-rich glioma inactivated 1 (LGI1) protein is the second most common AIE and is responsible for deleterious neocortical and limbic epileptic seizures. Previous studies demonstrated a pathogenic role of anti-LGI1 antibodies via alterations in the expression and function of Kv1 channels and AMPA receptors. However, the causal link between antibodies and epileptic seizures has never been demonstrated. Here, we attempted to determine the role of human anti-LGI1 autoantibodies in the genesis of seizures by analyzing the impact of their intracerebral injection in rodents. Acute and chronic injections were performed in rats and mice in the hippocampus and primary motor cortex, the two main brain regions affected by the disease. Acute infusion of CSF or serum IgG of anti-LGI1 AIE patients did not lead to the emergence of epileptic activities, as assessed by multisite electrophysiological recordings over a 10 h period after injection. A chronic 14 d injection, coupled with continuous video-EEG monitoring, was not more effective. Overall, these results demonstrate that acute and chronic injections of CSF or purified IgG from LGI1 patients are not able to generate epileptic activity by themselves in the different animal models tested.

Clinical seizure semiology is subtle and identification of seizures by parents is unreliable in infants with tuberous sclerosis complex

OBJECTIVE

The objectives of this study were to assess the accuracy of parental seizure detection in infants with antenatally diagnosed tuberous sclerosis complex (TSC), and to document the total seizure burden (clinical and subclinical) in those patients who met criteria for prolonged electroencephalography (EEG) recording.

METHODS

Consecutive infants at a single institution with antenatally diagnosed TSC who met criteria for prolonged video-EEG (vEEG) were recruited to this study. The vEEG data were reviewed and when a seizure was identified on EEG, the video and audio recording was assessed for evidence of clinical seizure and, if present, whether there was evidence of parent seizure identification.

RESULTS

Nine infants were enrolled, for whom 674 focal seizures were identified in eight of nine patients across 24 prolonged vEEG recordings, with vEEG total duration of 634 h 49 min (average seizure frequency of 1 focal seizure/h). Only 220 of 674 (32.6%) were clinical seizures, 395 of 674 (58.6%) were subclinical seizures, and 59 of 674 seizures could not be classified. Only 63 of 220 clinical seizures (28.6%) were identified by parents, with 157 of 220 (71.4%) not identified. Thirty clusters of epileptic spasms were detected in one patient. At least one clinical epileptic spasm occurred in 2 of 30 clusters (6.7%), 24 of 30 clusters of epileptic spasms (80%) were electrographic only, and classification was uncertain for 4 of 30 clusters (13.3%). No clinical epileptic spasms were detected by parents. Clinical seizure frequency was significantly underestimated by parents for all patients.

SIGNIFICANCE

This study demonstrates that in infants with TSC who met criteria for prolonged vEEG, (1) parents significantly under recognize total clinical seizure count, (2) parents fail to identify epileptic spasms, and (3) seizure frequency is high. This highlights that epilepsy treatment decisions should not be based solely on parental clinical seizure identification. Prolonged vEEG monitoring may have an important role in the routine epilepsy care of infants with TSC, as demonstrating undetected high clinical seizure frequency may allow improved epilepsy management decisions.

"Temporal" intermittent rhythmic delta activity: the true localizing nature of TIRDA

Temporal lobe epilepsy is the most common form of focal epilepsy and is frequently resistant to antiseizure medication. Non-invasive biomarkers are crucial when resective epilepsy surgery is considered in order to guide diagnostic work-up and management. Interictal epileptiform discharges, when concordant with ictal EEG recording and a focal abnormality on functional imaging or anatomic MRI in patients with temporal lobe epilepsy, portend a favorable outcome with resective or ablative surgery. An interictal non-epileptiform feature on EEG believed to have the same localizing potential as epileptiform discharges is temporal intermittent rhythmic delta activity (TIRDA). The precise localization of TIRDA has been a subject of debate, but has been associated with seizures that arise from the temporal region. We report a 64-year-old female who underwent unsuccessful right anterior temporal lobectomy for drug-resistant focal epilepsy, suspected to originate from the right temporal lobe. Subsequent video-EEG monitoring revealed right, greater than left, TIRDA and interictal epileptiform discharges arising from the temporal regions bilaterally, despite a generous temporal lobectomy demonstrated by brain MRI. Further, using EEG source localization, we identified TIRDA using scalp EEG in sensor space, localized to the ipsilateral orbitofrontal region. We discuss the proposed localization of TIRDA in this case and address the importance of characterizing TIRDA in the presurgical evaluation of patients with epilepsy.

Lateralized Periodic Discharges in a Patient With Dural Arteriovenous Fistula: SPECT and DWI Studies Suggest They are Ictal

Lateralized periodic discharges (LPDs) are unilateral electroencephalography (EEG) waveforms, recurring at regular intervals. There has been a long-lasting debate about whether they represent ictal or interictal phenomena. Very few patients in the literature have been investigated with multimodal functional imaging techniques. Here, we present a 58-year-old male patient with symptomatic epilepsy who had cerebral venous sinus thrombosis in the right temporo-parietal area and dural arteriovenous fistula (dAVF) over the left fronto-parietal region. He developed acute speech disturbances and altered mental status after a generalized tonic-clonic seizure. Video-EEG monitoring (VEEGM) demonstrated LPDs over the left fronto-central area, overlapping in part with the dAVF. Diffusion-weighted imaging (DWI) and apparent diffusion coefficient (ADC) sequences revealed restricted diffusion compatible with cytotoxic edema, whereas single-photon emission computed tomography (SPECT) indicated hyperperfusion in the same region, leading to the conclusion that he was having possible nonconvulsive status epilepticus (NCSE). An increase in antiseizure medications led to gradual improvement in clinical status and the disappearance of LPDs.

Bilateral temporal lobe epilepsy: How many seizures are required in chronic ambulatory electrocorticography to estimate the laterality ratio?

OBJECTIVE

This study was undertaken to measure the duration of chronic electrocorticography (ECoG) needed to attain stable estimates of the seizure laterality ratio in patients with drug-resistant bilateral temporal lobe epilepsy (BTLE).

METHODS

We studied 13 patients with drug-resistant BTLE who were implanted for at least 1 year with a responsive neurostimulation device (RNS System) that provides chronic ambulatory ECoG. Bootstrap analysis and nonlinear regression were applied to model the relationship between chronic ECoG duration and the probability of capturing at least one seizure. Laterality of electrographic seizures in chronic ECoG was compared with the seizure laterality ratio from Phase 1 scalp video-electroencephalographic (vEEG) monitoring. The Kaplan-Meier estimator was used to evaluate time to seizure laterality ratio convergence.

RESULTS

Seizure laterality ratios from Phase 1 scalp vEEG monitoring correlated poorly with those from RNS chronic ECoG (r = .31, p = .30). Across the 13 patients, average electrographic seizure frequencies ranged from 1.4 seizures/month to 5.1 seizures/day. A 50% probability of recording at least one electrographic seizure required 9.1 days of chronic ECoG, and 90% probability required 44.3 days of chronic ECoG. A median recording duration of 150.9 days (5 months), corresponding to a median of 16 seizures, was needed before confidence intervals for the seizure laterality ratio reliably contained the long-term value. The median recording duration before the point estimate of the seizure laterality ratio converged to a stationary value was 236.8 days (7.9 months).

SIGNIFICANCE

RNS chronic ECoG overcomes temporal sampling limitations intrinsic to inpatient Phase 1 vEEG evaluations. In patients with drug-resistant BTLE, approximately 8 months of chronic RNS ECoG are needed to precisely estimate the seizure laterality ratio, with 75% of people with BTLE achieving convergence after 1 year of RNS recording. For individuals who are candidates for unilateral resection based on seizure laterality, optimized recording duration may help avert morbidity associated with delay to definitive treatment.

Minimum standards for inpatient long-term video-electroencephalographic monitoring: A clinical practice guideline of the International League Against Epilepsy and International Federation of Clinical Neurophysiology

The objective of this clinical practice guideline is to provide recommendations on the indications and minimum standards for inpatient long-term video-electroencephalographic monitoring (LTVEM). The Working Group of the International League Against Epilepsy and the International Federation of Clinical Neurophysiology develop guidelines aligned with the Epilepsy Guidelines Task Force. We reviewed published evidence using the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analysis) statement. We found limited high-level evidence aimed at specific aspects of diagnosis for LTVEM performed to evaluate patients with seizures and nonepileptic events. For classification of evidence, we used the Clinical Practice Guideline Process Manual of the American Academy of Neurology. We formulated recommendations for the indications, technical requirements, and essential practice elements of LTVEM to derive minimum standards used in the evaluation of patients with suspected epilepsy using GRADE (Grading of Recommendations Assessment, Development, and Evaluation). Further research is needed to obtain evidence about long-term outcome effects of LTVEM and to establish its clinical utility.

Video game-induced reflex seizures via a smartphone

Reflex seizures are consistently evoked by a specific afferent stimulus or by patient activity. Patients experiencing reflex seizures when playing a game on a mobile phone are rarely reported. We describe a boy with reflex seizures after prolonged exposure to the game, Cut the rope, on his mobile phone. The video-EEG documented electroclinical events characterized by distal myoclonic jerks of the upper limbs, in combination with irregular, diffuse spike-and-wave and polyspike-and-wave discharges on EEG, followed by a tonic-clonic seizure. Playing video games on mobile phones may potentially induce reflex seizures, similar to other commonly used platforms such as docking stations connected to video screens.

[Invasive EEG for temporal lobe epilepsy: selection of technique]

BACKGROUND

Non-invasive EEG reveals epileptogenic zone in 70% of patients. In other cases, invasive EEG monitoring is indicated. Various implantation strategies and techniques of intracranial EEG (icEEG) potentially provide different outcomes. Choosing the optimal icEEG technique may be challenging.

OBJECTIVE

To analyze the results of icEEG in adults with temporal lobe epilepsy and to determine the algorithm for selection of optimal invasive EEG technique.

MATERIAL AND METHODS

The study included 82 patients with temporal lobe epilepsy who underwent invasive EEG. Effectiveness of invasive EEG was determined by detection of epileptogenic zone and post-resection outcomes. Postoperative results were analyzed throughout more than 6-month follow-up period using the Engel grading system. Statistical analysis was conducted using the Fisher's exact test.

RESULTS

Epileptogenic zone was revealed in 72 (88%) cases. Invasive EEG was supplemented by another modality in 3 (4%) patients. Mean follow-up period after resection was 17 months in 45 patients. Favorable outcomes were achieved in 31 (69%) cases. Statistical analysis showed that identification of epileptogenic zone depends existing of lesion and symptoms of seizures. Selection algorithm for optimal technique of invasive EEG was determined considering own results and literature data.

CONCLUSION

Invasive EEG results and post-resection outcomes demonstrated favorable efficacy of original algorithm. The last one may be used in decision-making on optimal technique of invasive EEG in adults with temporal lobe epilepsy.

Elective inpatient video-EEG monitoring during the COVID-19 pandemic

To evaluate the safety and feasibility of admission for elective video-EEG monitoring during the SARS-CoV-2 pandemic. We performed a retrospective review of elective inpatient epilepsy monitoring unit admissions at our institution from May 3^rd, 2020 to August 12^th, 2020. All patients were screened by telephone for symptoms concerning infection or recent diagnosis of SARS-CoV-2 or excess medical risk prior to admission. Patients deemed eligible for admission underwent testing via a nasopharyngeal swab for SARS-CoV-2 within three days of admission, and were directed to self-quarantine between testing and admission. The community seven-day case rate for SARS-CoV-2 (new cases per 100,000 population) ranged from 2.8 to 28.9 during the study period in our region. A total of 95 patients (63 adults and 32 children) were admitted. One adult patient developed mild SARS-CoV-2 infection and one adult patient tested positive for asymptomatic SARS-CoV-2 infection. These findings illustrate that inpatient epilepsy monitoring can be safely performed in carefully selected patients when appropriate processes are in place, even in the setting of the SARS-CoV-2 pandemic. There is a risk of nosocomial spread, and the potential benefits of admission should be balanced against the risks of infection.

Musicogenic epilepsy in paraneoplastic limbic encephalitis: a video-EEG case report

Musicogenic epilepsy (ME), a peculiar form of reflex epilepsy, represents a neurological rarity and yet another demonstration of the extraordinary power of music on the human brain. Despite the heterogeneity of the reported musical triggers, patients' emotional response to music is thought to play a crucial role in provoking seizures. Accordingly, the mesial temporal structures (especially of the non-dominant hemisphere) appear most involved in seizure generation, although a more complex fronto-temporal epileptogenic network was documented in some cases. Autoimmune encephalitis has been recently included among the many possible aetiologies of ME based on a few reports of music-induced seizures in patients with anti-glutamic acid decarboxylase 65 antibodies. Here, we describe the case of a 25-year-old man, educated in music over a long period of time, who had suffered from drug-resistant temporal lobe epilepsy following seronegative limbic encephalitis related to non-Hodgkin lymphoma. Along with spontaneous events, the patient also developed musicogenic seizures later in the disease course. After detecting five music-induced episodes via 24-hour ambulatory EEG, we performed prolonged video-EEG monitoring during which the patient presented a right temporal seizure (characterized by déjà-vu, piloerection and gustatory hallucinations) while listening to a hard rock song through headphones (which he had not previously heard). This observation allowed us to confirm the provoking effect of the music on our patient's seizures, despite the lack of any emotional drive, which suggests that a "cognitive" trigger was more likely in this case. Our report further highlights that autoimmune encephalitis should be investigated as a novel potential cause of musicogenic epilepsy, regardless of autoantibody status.

Seizures triggered by eating: a rare form of reflex epilepsy

Eating epilepsy is rare and comprises reflex seizures induced by food intake presenting with broad clinical manifestations. Despite this heterogeneity, a unique focal impaired awareness seizure semiology localizing to specific brain regions has been noted. Here, we present a case with video-EEG depicting this characteristic clinical presentation and its informative electrographic correlate. [Published with video sequence].

True abdominal epilepsy is clonic jerking of the abdominal musculature

Abdominal epilepsy (AE) has long been reported as a rare phenomenon in children with various episodic gastrointestinal sensory and painful symptoms suspected to be due to epileptic seizures. Originally, AE was diagnosed when abdominal sensory or painful symptoms were associated with pain, temporal lobe origin, an epileptiform or paroxysmal EEG pattern, and a clinical response to antiseizure medication. AE has also been associated with non-epileptic etiologies such as migraine. Reports of abdominal epilepsy based on an abnormal EEG or clinical response to antiseizure medication without diagnosis confirmation by video-EEG are at best speculative, and at worst, misdiagnoses. We describe three adult patients with focal aware motor seizures manifesting as recurrent, isolated prolonged painless rhythmic clonic jerking of the abdominal musculature including epilepsia partialis continua. All patients had a contralateral structural lesion on high-resolution brain MRI in the abdominal region of the motor homunculus. Standard EEG was unrevealing and only after extra EEG electrodes and video-EEG monitoring was the ictal origin confirmed. Historically, AE has been described as a disorder involving subjective sensory symptoms including vague abdominal pain, instead of epileptic motor signs of abdominal clonic jerking. We recommend replacing the use of vague terms such as AE with International League Against Epilepsy terminology along with diagnostic confirmation validated by video-EEG monitoring. [Published with video sequence].

Importance of access to epilepsy monitoring units during the COVID-19 pandemic: consensus statement of the International League Against Epilepsy and the International Federation of Clinical Neurophysiology

Restructuring of healthcare services during the COVID‐19 pandemic has led to lockdown of epilepsy monitoring units (EMUs) in many hospitals. The ad‐hoc taskforce of the International League Against Epilepsy (ILAE) and the International Federation of Clinical Neurophysiology (IFCN) highlights the detrimental effect of postponing video‐EEG monitoring of patients with epilepsy and other paroxysmal events. The taskforce calls for action for continued functioning of EMUs during emergency situations, such as the COVID‐19 pandemic. Long‐term video‐EEG monitoring is an essential diagnostic service. Access to video‐EEG monitoring of the patients in the EMUs must be given high priority. Patients should be screened for COVID‐19, before admission, according to the local regulations. Local policies for COVID‐19 infection control should be adhered to during the video‐EEG monitoring. In cases of differential diagnosis in which reduction of antiseizure medication is not required, home video‐EEG monitoring should be considered as an alternative in selected patients.

Musicogenic epilepsy with ictal asystole: a video-EEG case report

Musicogenic seizures and ictal asystole are two rare features mainly encountered in temporal lobe epilepsy. We present the first case of musicogenic epilepsy with ictal asystole in a patient with right temporal lobe epilepsy, confirmed by video-EEG. The pathophysiological mechanism of both conditions remains uncertain. These two features appeared after many years of epilepsy in our patient, and although this association might be coincidental, common mechanisms could be involved, including remodelling of neural connections or seizure propagation to a singular zone. This case also highlights the need for precise electroclinical assessment of seizures that change clinically over time, particularly when falls occur after a certain period of latency, suggesting cardiac consequences of the seizures.

Focal Cortical Resection and Hippocampectomy in a Cat With Drug-Resistant Structural Epilepsy

Epilepsy surgery is a common therapeutic option in humans with drug-resistant epilepsy. However, there are few reports of intracranial epilepsy surgery for naturally occurring epilepsy in veterinary medicine. A 12-year-old neutered male domestic shorthair cat with presumed congenital cortical abnormalities (atrophy) in the right temporo-occipital cortex and hippocampus had been affected with epilepsy from 3 months of age. In addition to recurrent epileptic seizures, the cat exhibited cognitive dysfunction, bilateral blindness, and right forebrain signs. Seizures had been partially controlled (approximately 0.3–0.7 seizures per month) by phenobarbital, zonisamide, diazepam, and gabapentin until 10 years of age; however, they gradually became uncontrollable (approximately 2–3 seizures per month). In order to plan epilepsy surgery, presurgical evaluations including advanced structural magnetic resonance imaging and long-term intracranial video-electroencephalography monitoring were conducted to identify the epileptogenic zone. The epileptogenic zone was suspected in the right atrophied temporo-occipital cortex and hippocampus. Two-step surgery was planned, and a focal cortical resection of that area was performed initially. After the first surgery, seizures were not observed for 2 months, but they then recurred. The second surgery was performed to remove the right atrophic hippocampus and extended area of the right cortex, which showed spikes on intraoperative electrocorticography. After the second operation, although epileptogenic spikes remained in the contralateral occipital lobe, which was suspected as the second epileptogenic focus, seizure frequency decreased to <0.3 seizure per month under treatment with antiseizure drugs at 1.5 years after surgery. There were no apparent complications associated with either operation, although the original neurological signs were unchanged. This is the first exploratory study of intracranial epilepsy surgery for naturally occurring epilepsy, with modern electroclinical and imaging evidence, in veterinary medicine. Along with the spread of advanced diagnostic modalities and neurosurgical devices in veterinary medicine, epilepsy surgery may be an alternative treatment option for drug-resistant epilepsy in cats.

Value of smartphone videos for diagnosis of seizures: Everyone owns half an epilepsy monitoring unit

The diagnosis of epilepsy is primarily based on the history and the verbal description of the events in question. Smartphone videos are increasingly used to assist in the diagnosis. The purpose of this study is to evaluate their value for the diagnosis of seizures. We prospectively collected smartphone videos from patients who presented to our epilepsy center over two years. The video-based diagnosis was then compared to the eventual diagnosis based on video-electroencephalographic (EEG) monitoring with recorded episodes. Video-EEG studies and smartphone videos were reviewed by two separate physicians, each blinded to the other's interpretation. Fifty-four patients were included in the final analysis (mean age = 34.7 years, SD = 17 years). Data (either smartphone video or video-EEG monitoring) were inconclusive in 18 patients. Of the 36 patients with conclusive data, 34 (94%) were in agreement. Smartphone video interpretation can be a useful adjunctive tool in the diagnosis of seizure-like events.

Neonatal presentation of genetic epilepsies: Early differentiation from acute provoked seizures

OBJECTIVE

Although most seizures in neonates are due to acute brain injury, some represent the first sign of neonatal onset genetic epilepsies. Delay in recognition and lack of expert assessment of neonates with epilepsy may result in worse developmental outcomes. As in older children and adults, seizure semiology in neonates is an essential determinant in diagnosis. We aimed to establish whether seizure type at presentation in neonates can suggest a genetic etiology.

METHODS

We retrospectively analyzed the clinical and electroencephalographic (EEG) characteristics of seizures in neonates admitted in two Level IV neonatal intensive care units, diagnosed with genetic epilepsy, for whom a video-EEG recording at presentation was available for review, and compared them on a 1:2 ratio with neonates with seizures due to stroke or hypoxic-ischemic encephalopathy.

RESULTS

Twenty neonates with genetic epilepsy were identified and compared to 40 neonates with acute provoked seizures. Genetic epilepsies were associated with pathogenic variants in KCNQ2 (n = 12), KCNQ3 (n = 2), SCN2A (n = 2), KCNT1 (n = 1), PRRT2 (n = 1), and BRAT1 (n = 2). All neonates with genetic epilepsy had seizures with clinical correlates that were either tonic (18/20) or myoclonic (2/20). In contrast, 17 of 40 (42%) neonates with acute provoked seizures had electrographic only seizures, and the majority of the remainder had clonic seizures. Time to first seizure was longer in neonates with genetic epilepsies (median = 60 h of life) compared to neonates with acute provoked seizures (median = 15 h of life, p < .001). Sodium channel-blocking antiseizure medications were effective in 13 of 14 (92%) neonates with tonic seizures who were trialed at onset or during the course of the epilepsy.

SIGNIFICANCE

Seizure semiology is an easily accessible sign of genetic epilepsies in neonates. Early identification of the seizure type can prompt appropriate workup and treatment. Tonic seizures are associated with channelopathies and are often controlled by sodium channel-blocking antiseizure medications.

Unmasking the entity of 'drug-resistant' perioral myoclonia with absences: the twitches, darts and domes!

Perioral myoclonia with absences (POMA) is not recognized as a unique electro-clinical syndrome and studies suggest its inclusion under the genetic generalized epilepsy (GGE) spectrum. The aim of this study was to explore the prevalence and electro-clinical homogeneity of this disorder in an epilepsy monitoring unit. Between 2013 and 2019, among drug-resistant epilepsy patients who were referred for video-telemetry, those diagnosed with POMA based on the presence of documented absences with prominently observed peri-oral muscular contractions accompanied by generalized EEG features were included. Among 62 patients who were diagnosed with absence epilepsy, five finally met the criteria for POMA (8.1%) with late childhood or adolescent onset of epilepsy. Four (80%) had a referral diagnosis of focal epilepsy based on historical focal features with exacerbation of seizures on oxcarbazepine. All five patients demonstrated brief absences with orbicularis oris muscle contractions accompanied by subtle focal phenomenology. One patient had concurrent axial-appendicular myoclonic jerks precipitated by hyperventilation. While four patients had strikingly identical interictal and ictal characteristics of typical absence epilepsy, one patient demonstrated additional atypical generalized polyspike discharges without a "dart-dome" morphology. Therapeutic response to introduction of sodium valproate was noted in all five patients. Features that were not consistent with the diagnosis were apparent in one patient who was re-classified with combined focal and generalized epilepsy. Differentiating aspects in this patient included multifocal discharges, background slowing, fast-recruiting ictal rhythms and valproate resistance. This is one of the largest case series of POMA. This entity, which falls under the spectrum of GGE, remains under-diagnosed and its distinctive electro-clinical features need to be recorded in order to prevent misclassification as focal epilepsy of probable opercular origin. Background-slowing, atypical ictal rhythms and valproate unresponsiveness are not consistent with the diagnosis of this unique absence epilepsy. [Published with video sequences].

Television-induced electronegative photoparoxysmal response: an extratemporal seizure mimic?

Video-EEG monitoring is an established gold-standard procedure for diagnosis and differentiation of epileptic and non-epileptic seizures. Epilepsy misdiagnosis, to which factors such as EEG artifact misinterpretation contribute to, is common, and can have long-lasting iatrogenic repercussions to the clinical management of affected patients. Among the many types of responses to photic stimulation, artifacts and physiologic and epileptic responses are possible. All of these can interfere with EEG interpretation when provoked by a source of illumination. Photic-induced responses are of increasing relevance given the ubiquity of screens and other light-emitting electronics in our modern world. One of these, the photoparoxysmal response, is a frequent finding in photosensitive patients with genetic generalized epilepsies. Various responses beyond abnormal occurrence of cortical spikes or spike-and-wave discharges are known to occur on EEG in response to intermittent photic stimulation (IPS), with different clinical implications. To our knowledge, we report a unique electronegative photoparoxysmal response during video-EEG monitoring induced by fluctuating illumination caused by a distant television screen. This response mimicked an extratemporal seizure in a young woman with frontal lobe epilepsy, admitted for presurgical evaluation. Novel electronegative responses to electronic devices during video-EEG monitoring merit consideration by EEG interpreters to help avoid misdiagnosis.

Systematic analysis and comparison of commercial seizure-detection software

OBJECTIVE

To determine if three different commercially available seizure-detection software packages (Besa 2.0, Encevis 1.7, and Persyst 13) accurately detect seizures with high sensitivity, high specificity, and short detection delay in epilepsy patients undergoing long-term video-electroencephalography (EEG) monitoring (VEM).

METHODS

Comparison of sensitivity (detection rate), specificity (false alarm rate), and detection delay of three commercially available seizure-detection software packages in 81 randomly selected patients with epilepsy undergoing long-term VEM.

RESULTS

Detection rates on a per-patient basis were not significantly different between Besa (mean 67.6%, range 0-100%), Encevis (77.8%, 0-100%) and Persyst (81%, 0-100%; P = .059). False alarm rate (per hour) was significantly different between Besa (mean 0.7/h, range 0.01-6.2/h), Encevis (0.2/h, 0.01-0.5/h), and Persyst (0.9/h, 0.04-6.5/h; P < .001). Detection delay was significantly different between Besa (mean 30 s, range 0-431 s), Encevis (25 s, 2-163 s), and Persyst (20 s, 0-167 s; P = .007). Kappa statistics showed moderate to substantial agreement between the reference standard and each seizure-detection software (Besa: 0.47, 95% confidence interval [CI] 0.36-0.59; Encevis: 0.59, 95% CI 0.47-0.7; Persyst: 0.63, 95% CI 0.51-0.74).

SIGNIFICANCE

Three commercially available seizure-detection software packages showed similar, reasonable sensitivities on the same data set, but differed in false alarm rates and detection delay. Persyst 13 showed the highest detection rate and false alarm rate with the shortest detection delay, whereas Encevis 1.7 had a slightly lower sensitivity, the lowest false alarm rate, and longer detection delay.

Gelastic seizures: a retrospective study in five tertiary hospital centres

This study aimed to characterize, clinically and neurophysiologically, a series of patients with gelastic seizures (GS), including both adults and children. We retrospectively collected patients with GS from epilepsy clinics of five tertiary hospital centres within a single country. Patients were selected through relatives'/caregivers' descriptions, home video and/or video-EEG monitoring. GS were identified through ictal semiology. Thirty-five patients were enrolled; 62.9% had initial GS in infancy, 14.3% in adolescence and 22.8% at adult age. Twenty-six had abnormal MRI: eight presented with hypothalamic hamartoma (HH) and 16 non-HH lesions that included different structural aetiologies and genetic, metabolic and immune aetiologies. All patients with HH had their first GS in infancy or adolescence. For the remaining aetiologies, GS started in infancy in 59.3%, in adolescence in 11.1% and at adult age in 29.6%. Video-EEG data was available for analysis in 11 patients, including seven patients with a non-HH MRI lesion. The ictal onset topography on scalp video-EEG was usually concordant with the MRI lesion (in 6/7 patients) and the most frequent ictal onset was fronto-temporal. In two patients, both video-EEG and MRI suggested a parietal and occipital epileptogenic zone. Aetiologies and patterns of affected topography unrelated to HH are common in patients with GS, and all age groups may manifest with this type of ictal semiology. This ictal manifestation has no lateralizing value and, despite a clear preponderance for hypothalamic, frontal and temporal lobe origins, other brain areas, namely the parietal and occipital lobes, should be considered.

The COVID-19 outbreak and approaches to performing EEG in Europe

The coronavirus SARS-CoV-2 disease (COVID-19) pandemic affects availability and performance of neurophysiological diagnostic methods, including EEG. Our objective was to outline the current situation regarding EEG-based investigations across Europe. A web-based survey was distributed to centres within the European Reference Network on rare and complex epilepsies (ERN EpiCARE). Responses were collected between April 9 and May 15, 2020. Results were analysed with Microsoft Excel, Python Pandas and SciPy. Representants from 47 EpiCARE centres from 22 countries completed the survey. At the time of completing the survey, inpatient video-EEGs had been stopped or restricted in most centres (61.7% vs. 36.2% for adults, and 38.3% vs. 53.2% for children). Invasive investigations and epilepsy surgery were similarly affected. Acute EEGs continued to be performed, while indications for outpatient EEGs were limited and COVID-19 triage put in place. The strictness of measures varied according to extent of the outbreak in a given country. The results indicate a profound impact of COVID-19 on neurophysiological diagnostics, especially inpatient video-EEGs, invasive investigations, and epilepsy surgery. The COVID-19 pandemic may hamper care for patients in need of EEG-based investigations, particularly patients with seizure disorders. ERN EpiCARE will work on recommendations on how to rapidly adapt to such situations in order to alleviate consequences for our patients.

Lingual epilepsia partialis continua: a detailed video-EEG and neuroimaging study

Motor epilepsia partialis continua (EPC) is a frequent and widely described variant of simple focal motor status epilepticus. However, lingual EPC is an unusual epileptic condition. We present a case of lingual EPC secondary to low-grade glioma in which the EEG and neuroimaging features were particularly remarkable. The video-EEG showed lateralized periodic discharges with superimposed rhythmic activity and frequent recurrent focal epileptic seizures. Moreover, brain magnetic resonance imaging showed a right temporo-insular cortico-subcortical lesion which was hyperintense on FLAIR, suggestive of low-grade glioma. In addition, diffusion-weighted imaging and arterial spin labelling series showed restricted diffusion in the right temporo-insular and parietal cortex and increased cerebral flow, respectively. All these findings are in keeping with changes related to persistent focal status epilepticus. Finally, we review the literature and discuss the differential diagnosis of this rare epileptic entity. [Published with video sequence].

Status Epilepticus Manifested as Continuous Epileptic Spasms

Objective: The etiology and outcome of status epilepticus with continuous epileptic spasms have not been fully understood; and only rare cases have been reported in the literature. Here, we described 11 children, who manifested continuous epileptic spasms with various etiologies and different outcomes. Methods: This is a case series study designed to systematically review the charts, video-electroencephalography (video-EEG), magnetic resonance images, and longitudinal follow-up of patients who presented continuous epileptic spasms lasting more than 30 min. Results: Median age at onset was 2 years old, ranging from 2 months to 5.6 years. The etiology of continuous epileptic spasms for these 11 cases consisted of not only some known electro-clinical epilepsy syndromes like West Syndrome and Ohtahara Syndrome, but also secondary symptomatic continuous epileptic spasms, caused by acute encephalitis or encephalopathy, which extends the etiological spectrum of continuous epileptic spasms. The most characteristic feature of these 11 cases was prolonged epileptic spasms, lasting for a median of 13.00 days (95% CI: 7.26-128.22 days). The interictal EEG findings typically manifested as hypsarrhythmia or its variants, including burst suppression. Hospital stays were much longer in acute symptomatic cases than in primary epileptic syndromic cases (59.67 ± 50.82 vs. 15.00 ± 1.41 days). However, the long-term outcomes were extremely poor in the patients with defined electro-clinical epilepsy syndromes, including severe motor and intellectual developmental deficits (follow-up of 4.94 ± 1.56 years), despite early diagnosis and treatment. Continuous epileptic spasms were refractory to corticosteroids, immuno-modulation or immunosuppressive therapies, and ketogenic diet. Conclusion: Continuous epileptic spasms were associated with severe brain impairments in patients with electro-clinical syndromes; and required long hospital stays in patients with acute symptomatic causes. We suggest to include continuous epileptic spasms in the international classification of status epilepticus, as a special form. Further investigations are required to better recognize this condition, better understand the etiology, as well as to explore more effective treatments to improve outcomes.

Epilepsia partialis continua and cortical motor control: insights into physiology

Motor epilepsia partialis continua is a widely described variant of simple focal motor status epilepticus. However, few studies have addressed associated pathophysiological anomalies that may help us understand the cortical organization, basic functioning and control of voluntary movement. We describe the clinical, video-EEG and neuroimaging findings from two cases of motor epilepsia partialis continua that support the hypothesis of the coexistence of both classic body and complex motor map models in the cortical organization of voluntary movement in humans. [Published with video sequence].

Defecation reflex seizures: a case report with long-term VEEG monitoring, neuroimaging and comprehensive epilepsy evaluation

Reflex seizures are consistently elicited by a specific afferent sensory stimulus or an activity undertaken by the patient. Among many known stimuli, defecation has rarely been reported. We describe the case of a child with reflex seizures triggered by defecation, considering the diagnostic challenge, epilepsy evaluation with video-EEG monitoring, as well as impact on neuropsychology, behaviour and quality of life. The child was a 10-year-old boy with seizure onset at age four with epilepsy diagnosis established one and a half years later. Seizures were focal with impaired awareness triggered by defecation. Video-EEG and structural and functional neuroimaging were performed and all pointed to the left temporal region. The patient became seizure-free with carbamazepine and valproic acid. Neuropsychological and quality of life assessments suggested global impairment, both before and after seizure control. This is the third case of epilepsy induced by defecation reported in the literature. The rarity of this entity may be a diagnostic challenge and postpone specific treatment. Reporting of cases of defecation reflex epilepsy may provide a better understanding of its physiopathology and optimize effective treatment, avoiding cognitive, behavioural and poor social consequences. [Published with video sequence].

Tonic status epilepticus in a centenarian woman

Generalized tonic status epilepticus (TSE) is a rare epileptic condition. It occurs usually in the context of symptomatic generalized epilepsy, in particular, in subjects with a diagnosis of Lennox-Gastaut syndrome, atypical forms of idiopathic (genetic) generalized epilepsy, or as a paradoxical effect during treatment with diverse antiepileptic drugs. Herein, we describe the case of an elderly woman on chronic treatment with psychotropic drugs who developed an episode of generalized TSE. Motor manifestations were subtle and difficult to recognize as seizures, and a detailed video-EEG importantly contributed to accurate and prompt diagnosis. TSE was initially refractory to conventional anti-seizure drug therapy including levetiracetam and valproate but was finally controlled with lacosamide. Our case indicates a potential therapeutic effect of lacosamide on TSE in the elderly after treatment failure with first-line anti-seizure drugs. [Published with video sequence on www.epilepticdisorders.com].

Diagnostic and prognostic value of noninvasive long-term video-electroencephalographic monitoring in epilepsy surgery: A systematic review and meta-analysis from the E-PILEPSY consortium

OBJECTIVE

The European Union-funded E-PILEPSY network (now continuing within the European Reference Network for rare and complex epilepsies [EpiCARE]) aims to harmonize and optimize presurgical diagnostic procedures by creating and implementing evidence-based guidelines across Europe. The present study evaluates the current evidence on the diagnostic accuracy of long-term video-electroencephalographic monitoring (LTM) in identifying the epileptogenic zone in epilepsy surgery candidates.

METHODS

MEDLINE, Embase, CENTRAL, and ClinicalTrials.gov were searched for relevant articles. First, we used random-effects meta-analytical models to calculate pooled estimates of sensitivity and specificity with respect to postsurgical seizure freedom. In a second phase, we analyzed individual patient data in an exploratory fashion, assessing diagnostic accuracy within lesional and nonlesional temporal lobe epilepsy (TLE) and extratemporal lobe epilepsy (ETLE) patients. We also evaluated seizure freedom rate in the presence of "localizing" or "nonlocalizing" LTM within each group. The quality of evidence was assessed using the QUADAS-2 tool and the GRADE approach.

RESULTS

Ninety-four studies were eligible. Forty-four were included in sensitivity meta-analysis and 34 in specificity meta-analysis. Pooled sensitivity was 0.70 (95% confidence interval [CI] = 0.60-0.80) and specificity was 0.40 (95% CI = 0.27-0.54). Subgroup analysis was based on individual data of 534 patients (41% men). In lesional TLE patients, sensitivity was 0.85 (95% CI = 0.81-0.89) and specificity was -0.19 (95% CI = 0.13-0.28). In lesional ETLE patients, a sensitivity of 0.47 (95% CI = 0.36-0.58) and specificity of 0.35 (95% CI = 0.21-0.53) were observed. In lesional TLE, if LTM was localizing and concordant with resection site, the seizure freedom rate was 247 of 333 (74%), whereas in lesional ETLE it was 34 of 56 (61%). The quality of evidence was assigned as "very low."

SIGNIFICANCE

Long-term video-electroencephalographic monitoring is associated with moderate sensitivity and low specificity in identification of the epileptogenic zone. Sensitivity is remarkably higher in lesional TLE compared to lesional ETLE. Substantial heterogeneity across the studies indicates the need for improved design and quality of reporting.

Rapid antiepileptic drug withdrawal may obscure localizing information obtained during presurgical EEG recordings

Withdrawal of antiepileptic drugs (AEDs) is a standard procedure during presurgical epilepsy assessment. Rapid and, at times, even pre-hospital withdrawal of medication is performed in some centres to enhance the yield of recorded seizures during video-EEG monitoring. AED withdrawal, however, affects the propensity and speed of propagation of epileptic activity, may evoke more severe seizures, and may cause pitfalls in EEG interpretation. We report a case which had been recommended to undergo intracranial EEG recordings in order to clarify apparently discordant MRI findings and ictal EEG patterns when monitoring was performed following complete AED withdrawal. Re-evaluation to assess scalp EEG patterns at several drug levels during slow AED tapering showed a loss of localizing information with AED withdrawal due to contralateral and bitemporal spread of frontal epileptic activity. Our report demonstrates that in individual cases, rapid AED withdrawal during presurgical video-EEG monitoring can impair the validity of EEG recordings and lead to unnecessary risks and investigations during workup.

[Neonatal seizures. Clinical and electroencephalographic diagnosis]

Neonatal seizures are common expression of acute brain injury in the perinatal period and could potentiate the degree of neuronal injury. The majority of events are electroencephalographic and the clinical seizures can be subtle and difficult to identify by medical personnel. Neonatal seizures are usually short and frequent at onset and have a tendency to subside after a short period. Continuous video-EEG monitoring is the gold standard to detect seizures, but amplitude integrated EEG is a useful tool when conventional EEG is not available. EEG monitoring is important not only to monitor frequency and duration of seizures but to provide important prognostic information.

Insight into the precuneus: a novel seizure semiology in a child with epilepsy arising from the right posterior precuneus

To date, there is limited understanding of the role of the precuneus. fMRI studies have suggested its involvement in a wide spectrum of highly integrated tasks, including spatially-guided behaviour, visuo-spatial imagery, and consciousness. We present a patient with intractable parietal lobe epilepsy arising from a lesion localized to the right precuneus. Two seizure types with distinct semiologies were captured on video-EEG monitoring. The first type consisted of an urge described as a "feeling of wanting to move". On video analysis, the patient is seen to turn his head and body to his left. He remains conscious, he is able to answer questions and when asked, he can look to his right. This seizure was associated with an ictal pattern localized to the right parieto-occipital region. The second seizure type consisted of reading-induced visual distortion with macropsia and micropsia. Interictally, intermittent rhythmic slowing and spikes were seen and localized to the parietal midline and the right parieto-occipital regions. Our patient's seizures are positive phenomena of the right precuneus and its related processing network. They represent unique seizure semiologies that offer further insight into the role of the precuneus in spatial awareness, visuo-spatial processing and consciousness.

Psychogenic seizures: long-term outcome in patients with and without epilepsy

OBJECTIVES

Psychogenic non-epileptic seizures (PNES) may resemble epileptic events. Epileptic and non-epileptic seizures are not mutually exclusive phenomena and may coexist in the same patient. The aim of this study was to evaluate the long-term outcome of psychogenic events in patients with PNES alone and those with both PNES and epilepsy (PNES + EPI) as diagnosed by video-EEG (vEEG) monitoring.

MATERIALS AND METHODS

All adult admissions to the Tel-Aviv Medical Center's vEEG unit between 2004 and 2009 were screened for the presence of PNES. We retrospectively retrieved data from their medical files and supplemented the follow-up by a telephonic questionnaire.

RESULTS

Eligible patients (n = 51) were divided into those with PNES + EPI (n = 24) and those with PNES alone (n = 27). The follow-up period was 4.8 ± 0.3 and 4.3 ± 0.3 years, respectively. Both groups had similar female predominance and similar age at admission to the vEEG unit. Time from PNES onset to hospitalization was longer in PNES patients compared to those with PNES + EPI. The majority of subjects in each group reported a history of at least one major stressful life event. Opisthotonus was significantly more frequently observed in PNES patients, and they had more events during vEEG hospitalization. Psychogenic events ceased during the follow-up period in 22% of the PNES patients and in 58% of the PNES + EPI patients (P > 0.001).

CONCLUSION

Our results indicate that following vEEG-based diagnosis of PNES, the long-term outcome of PNES cessation may be more favorable for patients with concomitant epilepsy than for patients without epilepsy.

Psychogenic nonepileptic seizures: EEG and investigation

In the investigation of psychogenic nonepileptic seizures (PNES), the main differential diagnoses are between convulsive PNES and tonic-clonic seizures, between swoon PNES and syncope, and between pseudoabsence PNES and absence seizures. For the best diagnostic certainty, events must be captured, ideally using video-electroencephalogram (EEG), including an electrocardiographic channel. The "video" part of video-EEG allows EEG changes (or lack of them) to be interpreted in the appropriate clinical context. When the diagnosis is based on less good data (e.g., video alone or EEG alone), then the limitations and constraints of the tests should borne in mind, and a lesser degree of certainty must be accepted. Tests such as serum prolactin (PRL) level and postictal EEG should be regarded as adjunctive rather than definitive. Excluding additional epilepsy with a good probability is not possible using investigations alone. In particular, one standard interictal EEG recording is of little value in excluding additional epilepsy, though multiple or prolonged recordings may offer additional sensitivity.

Nonepileptic seizures - objective phenomena

This chapter describes the evaluation process for the diagnosis of psychogenic nonepileptic seizures (PNES), which is determined based on concordance of the composite evidence available, including historic and physical exam findings, seizure semiology, and ictal/interictal electroencephalogram (EEG). No single clinical feature is pathognomonic of PNES. The diagnosis of PNES can be at times challenging, such as when seizure documentation on video-EEG cannot be readily achieved. A multicomponent approach to the diagnosis of PNES, with use of all available evidence, may facilitate diagnosis and then care of patients with PNES. Emerging evidence supports the use of symptom identification by the patient as part of the treatment of these patients. With advances in diagnostic methods and criteria, the diagnosis of PNES can be made reliably.

Lateralizing value of semiology in medial temporal lobe epilepsy

OBJECTIVES

Analysing the clinical characteristics of seizures constitutes a fundamental aspect of the presurgical evaluation of patients with medial temporal lobe epilepsy and unilateral hippocampal sclerosis (MTLE-HS), the most frequent form of focal epilepsy accessible to surgery. We sought to retrospectively determine whether objective manifestations could have a reliable lateralizing value in a large population of MTLE-HS patients and if their presence could help to identify those patients who would be seizure free after surgery.

MATERIAL AND METHODS

We analysed the frequency and predictive lateralizing value of objective ictal and postictal signs in 391 patients with MTLE-HS (183 left/208 right). Data were derived from chart review and not from blinded videoEEG analysis. Correlation between the presence of reliable lateralizing signs and postoperative outcome was performed in a subgroup of 302 patients who underwent surgery.

RESULTS

Contralateral dystonic posturing was the most frequent and reliable lateralizing sign that correctly lateralized the focus in 96% of patients. Unilateral head/eye deviation was noted in 42% of the patients and predicted unilateral focus in 67%. Ipsilateral postictal nose wiping, contralateral clonus and hypokinesia correctly lateralized the focus in 75%, 81%, respectively, and 100 of patients but were less frequently depicted. Postictal aphasia was a strong lateralizing sign for left MLE-HS. The presence of reliable lateralizing signs was not a predictor of seizure freedom.

CONCLUSION

Seizure semiology is a simple tool that may permit reliable lateralization of the seizure focus in MTLE-HS. The presence of reliable lateralizing signs is not associated with a better postoperative outcome.

Narcolepsy Type 1 and Idiopathic Generalized Epilepsy: Diagnostic and Therapeutic Challenges in Dual Cases

STUDY OBJECTIVES

The aim of this study is to describe the possible co-occurrence of narcolepsy type 1 and generalized epilepsy, focusing on diagnostic challenge and safety of dual treatments.

METHODS AND RESULTS

Four patients with comorbidity for narcolepsy type 1 and idiopathic generalized epilepsy are reported: in three cases the onset of epilepsy preceded narcolepsy type 1 appearance, whereas in one case epileptic spells onset was subsequent. Patients presented with absences, myoclonic and tonic-clonic seizure type: in the patient with tonic-clonic seizures the dual pathology was easily recognized, in the other cases the first diagnosis caused the comorbid disease to be overlooked, independent of the time-course sequence. All four patients underwent neurological examination, video-electroencephalogram during which ictal and interictal epileptic discharges were recorded, and sleep polysomnographic studies. Repeated sleep onset rapid eye movement periods (SOREMPs) were documented with the multiple sleep latency test (MLST) in all the four cases. All patients had unremarkable brain magnetic resonance imaging studies and cerebrospinal hypocretin-1 was assessed in two patients, revealing undetectable levels. The association of antiepileptic drugs and substances currently used to treat narcolepsy type 1, including sodium oxybate, was effective in improving seizures, sleep disturbance, and cataplexy.

CONCLUSIONS

Narcolepsy type 1 may occur in association with idiopathic generalized epilepsy, leading to remarkable diagnostic and therapeutic challenges. Electrophysiological studies as well as a comprehensive somnologic interview can help confirm the diagnosis in patients with ambiguous neurological history. Sodium oxybate in combination with antiepileptic drugs is safe and effective in treating cataplexy and excessive daytime sleepiness.

A Case of Hemiabdominal Myoclonus

Myoclonus consists of sudden, brief, involuntary jerky muscular contractions. Central and peripheral nervous system lesions are involved in the pathogenesis of this movement disorder. Symptomatic or secondary spinal myoclonus is the most common form. A 68-year-old woman was diagnosed with hemiabdominal spinal myoclonus. Occasional and very mild involuntary repetitive movements of the hemiabdomen began immediately after surgery for uterine cancer. After surgery for laparocele, secondary to the uterine cancer surgery, performed under spinal anesthesia, there was severe worsening of movements. Neuroradiological investigations failed to demonstrate spinal injury, while neurophysiological studies showed impairment of the right central somatosensory pathway. Considering the low resolution of magnetic resonance imaging in the evaluation of thoracic level, we suggest an extensive neurophysiological evaluation in patients with spinal myoclonus.

Episodes of loss of consciousness in a patient with a background of cerebral venous thrombosis

Episodes of loss of consciousness are common, even in young, healthy people, and can sometimes represent a diagnostic challenge. The main diagnoses to consider are syncope and epileptic seizures, both of which may have similar symptomatology such as dizziness, loss of consciousness, falls, or "convulsive" phenomena. We present the case of a young male patient with a background of two venous thrombosis episodes (superior vena cava thrombosis and cerebral venous thrombosis), attributed to protein C and S deficiency and complicated by high intracranial pressure. A lumboperitoneal shunt was performed and anticoagulant therapy was initiated. He did not experience any medical problems until several years later, when he suddenly began to develop frequent, repetitive, transient episodes of dizziness, followed by loss of consciousness. Simultaneous video-EEG and ECG performed during these events showed a typical pattern normally observed during syncope. Due to the absence of changes in heart rate or blood pressure, and taking into account his medical history, intracranial hypertension was considered as a possible cause of cerebral hypoperfusion. Cerebral arteriography demonstrated chronic thrombosis of all the cerebral sinuses, and the lumbar puncture an intracranial pressure of 47 mm Hg. The lumboperitoneal shunt was replaced and the patient has since not presented with any episodes. The use of simultaneous video-EEG and ECG is a reliable and efficient approach to differentiate between syncope and seizure and in this case, was the key to finding the cause of these episodes. [Published with video sequences].

Gastaut type idiopathic childhood occipital epilepsy

Gastaut type idiopathic childhood occipital epilepsy is an uncommon epileptic syndrome characterised by frequent seizures, most commonly presenting as elementary visual hallucinations or blindness. Other occipital (non-visual) symptoms may also occur. Interictal EEG typically shows occipital paroxysms, often with fixation-off sensitivity. Ictal EEG is usually characterised by interruption by paroxysms and sudden appearance of low-voltage, occipital, fast rhythm and/or spikes. Despite well described clinical and EEG patterns, to our knowledge, there are very few reports in the literature with video-EEG recording of either seizure semiology or fixation-off phenomena. We present a video-EEG recording of a 12-year-old girl with Gastaut type epilepsy, illustrating the interictal and ictal aspects of this syndrome. Our aim was to demonstrate the clinical and neurophysiological pattern of a typical seizure of Gastaut type epilepsy, as well as the fixation-off phenomena, in order to further clarify the typical presentation of this syndrome. [Published with video sequences].