Psychiatric patients showing irregular beta activities in EEGs and treatment with antiepileptic drugs: a report of 15 cases

Fifteen psychiatric cases are reported who were clinically diagnosed as schizophrenic, affective disorders, or neurotic, but resisted standard medication regimens, all showing irregular beta activities on EEGs. The cases tended to display symptoms in common, such as dysphoria, emotional instability or frequent physical complaints. These characteristic symptoms share something mutually with the symptoms shown in some epileptic patients or psychiatric patients with epileptic EEG abnormalities without clinical seizures. Antiepileptic drugs seemed more specifically effective to the above symptoms. More than half of these cases showed improvement on EEG findings such as a decrease in irregular beta activities and an increase in rhythmicity or regularity of alpha activities along with clinical improvement with the administration of adjunctive antiepileptic drugs. These results suggest that the adjunctive administration of antiepileptic drugs to patients with irregular beta activities on EEGs is clinically useful and an EEG examination has much value in psychiatric practice to find the criteria of drug therapy.     

The Diagnostic Value of the Sleep EEG With and Without Sleep Deprivation in Patients With Atypical Absences

Hitherto it has not been known whether or not the sleep EEG after sleep deprivation is more effective than the simple or drug-induced sleep EEG. To investigate this, we recorded for 32 patients both sleep EEGs without sleep deprivation and, on the following day, sleep EEGs after 24 h of sleep deprivation. All the patients had atypical absences which were almost exclusively combined with generalized seizures or some other seizure types. All patients were receiving antiepileptic therapy. Sleep without sleep deprivation was induced by oral administration of 2 mg/kg body weight Protactyl (promazine hydrochloride). In patients showing no epileptic activity in the routine EEG, epileptic discharges could be provoked in 78% without sleep deprivation and in 72% after sleep deprivation. Epileptic activity was already seen in 28.1% of the cases in the awake EEG without sleep deprivation, recorded immediately before the sleep EEG, and in 50% of the cases in the awake EEG after sleep deprivation. It is unlikely that promazine hydrochloride in the dose used here has an additional inherent provocative effect. Generalized spike-and-wave complexes or sharp slow wave complexes which were combined twice with foci and runs of rapid spikes were recorded. In the sleep EEG without sleep deprivation, epileptic discharges were seen in the somewhat shallower stages (C leads to A leads to B leads to D) and, in the sleep EEG after sleep deprivation, in the somewhat deeper stages (D leads to C leads to B leads to A). Fewer epileptic discharges were elicited in patients who were older at the time of their first seizure. The illness was mild in patients whose sleep EEGs showed no epileptic activity. It is concluded that, as a rule, it is not necessary to record an EEG after sleep deprivation in patients with atypical absences whose routine EEGs show no epileptic activity; the drug-induced sleep EEG shows the same provocative effect.     

The effect of lamotrigine on the EEGs of children and adolescents with epilepsy

Lamotrigine (LTG) is one of the newer-generation antiepileptic drugs (AEDs) with broad-spectrum efficacy against a variety of seizures and epileptic syndromes. We retrospectively evaluated the effects of LTG as add-on therapy on EEGs of children and adolescents. The EEGs of 53 patients (mean age: 12.5 years) with primarily pharmacoresistant epilepsy were reviewed prior to and after LTG add-on therapy. Multiple seizure types were seen in 25, generalized seizures in 15, and complex partial seizures in 13 of the patients. Preceding LTG therapy, the baseline EEG was abnormal because of slow background in 60.3% and localized spikes in 35.8%, generalized spikes in 28.3%, or both in 24.5%. The EEG analysis during the 2-year follow-up period showed improvement in the background in 21.9%, interictal activity in 37.8%, and ictal pattern in 41.1% of the EEG recordings. Overall, LTG resulted in improvement in electrographic features which paralleled the clinical improvement.     

Preoperative EEG predicts memory and selective cognitive functions after temporal lobe surgery.

Preoperative and postoperative cognitive and memory functions, psychiatric outcome, and EEGs were evaluated in 32 epileptic patients who underwent temporal lobe surgery. The presence and location of preoperative slow wave focus in routine EEG predicted memory functions of the non-resected side after surgery. Neuropsychological tests of the function of the frontal lobes also showed improvement. Moreover, psychiatric ratings showed that seizure free patients had significantly less affective symptoms postoperatively than those who were still exhibiting seizures. After temporal lobectomies, successful outcome in postoperative memory functions can be achieved in patients with unilateral slow wave activity in preoperative EEGs. This study suggests a new role for routine EEG in preoperative evaluation of patients with temporal lobe epilepsy.     

Complex partial status epilepticus following myelography with metrizamide

Complex partial status epilepticus developed in two patients following myelography with metrizamide. The status epilepticus was manifested by confusion and complex motor symptoms, and electroencephalograms (EEGs) showed ictal activity alternating independently over both hemispheres. Immediate clinical improvement occurred with antiepileptic treatment, and to date no sequelae have been observed. Neither patient had a previous history of epileptic seizures, but both had preexisting EEG abnormalities.     

Usefulness of the Head-Upright Tilt Test for Distinguishing Syncope and Epilepsy in Children

PURPOSE: Episodic loss of consciousness in children, whether or not associated with hypertonia or short-duration clonic movements, presents a diagnostic challenge to the pediatrician and child neurologist. We provide some evidence of the usefulness of the head-upright tilt test for investigating the causes of transient loss of consciousness in children, and for distinguishing between syncope, convulsive syncope, and epilepsy. METHODS: We studied nine children previously diagnosed as epileptic on the basis of compatible clinical events and epileptiform findings in routine EEGs who were treated over the long term with antiepileptic drugs, but whose clinical records suggested syncope or convulsive syncope rather than epilepsy on reevaluation. All subjects underwent head-upright tilt testing. RESULTS: The tilt-test result was positive in all nine cases, with the patients reporting the same symptoms as in the previously considered epileptic attacks. CONCLUSIONS: Inadequate histories and misuse/overinterpretation of EEG results often lead to misdiagnosis of epilepsy in children. The head-upright tilt test is a useful and reliable diagnostic technique, allowing syncopal events to be induced and evaluated under controlled conditions. In a subset of patients, it may help to distinguish epilepsy from simple or convulsive syncope.     

A case of infantile epileptic encephalopathy with frequent focal motor status convulsivus: successful treatment with zonisamide]

We reported a 41-day-old girl starting with partial status convulsivus. She had suffered from infantile epileptic encephalopathy manifesting with recurrent focal motor status convulsivus, eventually requiring general anesthesia for the treatment. She had had never myoclonic seizures nor tonic spasms. The examinations including brain MRI scan and metabolic screening tests were all negative. The ictal EEGs showed the onset of the seizures from the left frontal region. Interictal EEG demonstrated multifocal spike discharges as well as discontinuous abnormal EEG pattern resembling suppression-burst during sleep. The seizures were resistant to the multiple antiepileptic drugs, but zonisamide achieved full seizure control as well as improvement of the EEG. Her psychomotor development was severely retarded at 3 years of age.     

Diagnostic Reliability and Significance of Irregular Beta Patterns

Abstract: We designated EEGs with marked and irregular beta waves in basic patterns as "irregular beta patterns" on the basis that these patterns are related with particular symptoms such as dysphoria, irritability and autonomic symptoms and they implicate choice of therapeutic agents. Because of good response to antiepileptic agents in patients with "irregular beta patterns" along with EEG characteristics, we hypothesized that the prevalence of "irregular beta patterns" is higher in epileptics than in other psychiatric patients. In the present study, we tested this hypothesis, investigating actual frequencies of these patterns among different diagnostic categories for all patients whose EEG were recorded in all the first-visit patients to the Outpatient Clinic, Deparmtent of Neuropsychiatry of the Tokyo University Hospital during one year period of 1986. Before starting this investigation, we checked the interrater reliability for these patterns. Therefore, two studies are reported here. In Study 1, five raters judged 98 EEG recordings blindly (43 epileptics and 55 healthy subjects). As a result, the generalized Kappa of 0.473 was obtained, indicating our agreement level was moderate or fair. This result lends support to our contention that irregular beta patterns are reliably judged. In Study 2, we judged the EEG recordings (137 schizophrenics, 62 affective disorders, 43 epileptics and 55 healthy controls) and calculated the prevalence rate of "irregular beta patterns" among the diagnostic categories. The results show that the prevalence rates of "irregular beta patterns" among psychiatric disorders and normal controls were 13% (18/137) in schizophrenics, 11% (7/62) in affective disorders, 14% (6/43) in epileptics and 4% (2/55) in healthy controls. These rates did not differ significantly among the three disorders. Thus, our hypothesis was not supported. The clinical significance of these patterns is discussed.     

Bromide therapy for pediatric seizure disorder intractable to other antiepileptic drugs

Triple bromide elixir was used as an adjunctive antiepileptic drug in 11 children whose seizure disorders were intractable to other antiepileptic therapy. The patients' ages ranged from 2 to 17 years. The seizure disorders treated included photosensitive epilepsy (one case), acquired epileptic aphasia (one case), Lennox-Gastaut syndrome (three cases), and symptomatic localization-related epilepsies (six cases). Two patients' seizures completely stopped with bromide therapy. Four patients had a significant and sustained improvement on bromide therapy, while three more had a transient improvement. In these six patients with complete or significant control, the mean therapeutic dose was 33 mg bromide/kg daily, and the mean therapeutic serum concentration was 14.1 mmol/L (range, 4 to 30.5 mmol/L). The combination of bromide with valproate appeared to be particularly effective in these patients. Toxicity was minimal, and in only one patient was the medication stopped, because of anorexia and weight loss. Given the low cost, long half-life, and minimal toxicity when serum bromide concentrations are followed, bromide therapy should be considered as adjunctive antiepileptic drug therapy for patients whose seizures are intractable to other drugs.     

Assessing quantitative EEG spectrograms to identify non‐epileptic events

Aims. To evaluate the sensitivity and specificity of quantitative EEG (QEEG) spectrograms in order to distinguish epileptic from non‐epileptic events. Methods. Seventeen patients with paroxysmal non‐epileptic events, captured during EEG monitoring, were retrospectively assessed using QEEG spectrograms. These patients were compared to a control group of 13 consecutive patients (ages 25‐60 years) with epileptic seizures of similar semiology. Assessment of raw EEG was employed as the gold standard against which epileptic and non‐epileptic events were validated. QEEG spectrograms, available using Persyst 12 EEG system integration software, were each assessed with respect to their usefulness to distinguish epileptic from non‐epileptic seizures. The given spectrogram was interpreted as indicating a seizure if, at the time of the clinically identified event, it showed a visually significant change from baseline. Results. Eighty‐two clinically identified paroxysmal events were analysed (46 non‐epileptic and 36 epileptic). The “seizure detector trend analysis” spectrogram correctly classified 33/46 (71%) non‐epileptic events (no seizure indicated during a clinically identified event) vs. 29/36 (81%) epileptic seizures (seizure indicated during a clinically identified event) (p=0.013). Similarly, “rhythmicity spectrogram”, FFT spectrogram, “asymmetry relative spectrogram”, and integrated‐amplitude EEG spectrogram detected 28/46 (61%), 30/46 (65%), 22/46 (48%) and 27/46 (59%) non‐epileptic events vs. 27/36 (75%), 25/36 (69%), 25/36 (69%) and 27/36 (75%) epileptic events, respectively. Conclusions. High sensitivities and specificities for QEEG seizure detection analyses suggest that QEEG may have a role at the bedside to facilitate early differentiation between epileptic seizures and non‐epileptic events in order to avoid unnecessary administration of antiepileptic drugs and possible iatrogenic consequences.     

Clinical factors associated with the yield of routine outpatient scalp electroencephalograms: A retrospective analysis from a tertiary hospital

The routine outpatient electroencephalogram (EEG) is most often used in the diagnosis and classification of epilepsy. The diagnostic yield of outpatient EEGs is low and the clinical factors contributing to the EEG outcome have not been well established. In this study, we sought to determine the yield and the factors predicting the EEG outcome. We retrospectively analyzed 1092 routine adult EEGs that were performed in a tertiary referral center over a period of 1 year. Patient demographics, sources of referral, and indications for EEG were recorded. The majority of the referrals were from neurologists (54.7%), followed by the emergency department (15.4%). The indications for requesting an EEG included patients with a provisional or established diagnosis of epilepsy (56.3%), first seizure (10.7%), and seizure mimickers (29.1%). The majority (66.7%) of the EEGs were normal, whereas 13.2% demonstrated epileptiform discharges. At the time of recording, epileptic seizures occurred in 0.6% of the cases. With logistic regression analysis, three factors were found to be significantly associated with an abnormal (epileptiform) EEG: no antiepileptic drug therapy, the age of the patient, and indication for EEG (pre-test provisional diagnosis). Patients who are not on antiepileptic drug therapy and with a diagnosis of epilepsy or seizures are more likely to have epileptiform abnormalities in EEGs. Our findings suggest that careful selection of patients is likely to improve the diagnostic yield and cost-effectiveness of routine outpatient EEG.     

Epilepsy and Folic Acid

With 15 cases of epilepsy as the subject, studies were made of the therapeutic effects of folic acid on psychiatric symptoms and clinical seizures. Folic acid proved effective for a part of chronic and prolonged psychiatric symptoms shown by epileptic patients and brought on slight improvement in hyperexcitability, aggressiveness, bad humor and slowness of psychomotor activities. Improvement in mood was also observed. However, incidence of clinical fits increased in three cases. Electroencephalograms showed the desyn-chronizing phenomenon following oral administration of folic acid. Appearance or increase of spikes was noted in six cases. The epileptic group showed significantly low folic acid level in both serum and spinal fluid compared with the non-epileptic group. When folic acid was administered orally to the epileptic group, the serum folic acid level increased easily but the folic acid level in spinal fluid hardly increased.     

Epilepsy and folic acid.

With 15 cases of epilepsy as the subject, studies were made of the therapeutic effects of folic acid on psychiatric symptoms and clinical seizures. Folic acid proved effective for a part of chronic and prolonged psychiatric symptoms shown by epileptic patients and brought on slight improvement in hyperexcitability, aggressiveness, bad humor and slowness of psychomotor activities. Improvement in mood was also observed. However, incidence of clinical fits increased in three cases. Electroencephalograms showed the desynchronizing phenomenon following oral administration of folic acid. Appearance or increase of spikes was noted in six cases. The epileptic group showed significantly low folic acid level in both serum and spinal fluid compared with the non-epileptic group. When folic acid was administered orally to the epileptic group, the serum folic acid level increased easily but the folic acid level in spinal fluid hardly increased.     

Sleep EEG with or without sleep deprivation? Does sleep deprivation activate more epileptic activity in patients suffering from different types of epilepsy?

A sleep EEG of 190 patients without sleep deprivation was recorded, followed by a sleep EEG after 24 h of sleep deprivation on the next day. The patients suffered from various types of epilepsy, in their routine EEGs no epileptic discharges were seen. Both sleep EEGs were recorded under the same antiepileptic drugs. A waking EEG was recorded immediately before each sleep EEG. The activation rates of epileptic activity in 52.6% (without sleep deprivation) and 53.2% (with sleep deprivation) of the patients showed no significant differences. Also on classifying the epileptic discharges no real difference was found between the 2 methods (generalized: 29.5 vs. 29.5%, generalized with lateral emphasis: 11.1 vs. 9.5%, focal: 12.1 vs. 14.2%). Only in the waking EEG, recorded immediately before the sleep EEG after sleep deprivation, a few more patients showed epileptic discharges (33.6 vs. 27.4%). Without there being any significant differences between the 2 methods there were some different results in comparing the EEG with the clinical findings: significantly more epileptic activity was shown in patients who had their first seizure before the age of 20 (55.6 and 55.6% vs. 26.3 and 31.6%), amongst females (59.8 and 61.9% vs. 45.2 and 44.1%), in awakening grand mal (= primary generalized tonic-clonic seizures, 76.5 and 70%) and in absences (69 and 72.4%). The higher activation rates in young subjects, in patients with a family history of seizures, with pathological neurological findings, mental retardation and delayed psychomotoric development in early childhood, were not statistically significant.(ABSTRACT TRUNCATED AT 250 WORDS)     

Clinical implications of benign epileptiform transients of sleep

One hundred electroencephalograms (EEGs) with benign epileptiform transients of sleep (BETS) were reviewed. The incidence of epileptic seizures, syncope, headaches, transient ischemic attacks (TIAs), dizziness and psychiatric complaints was determined. The incidence of these symptoms was similarly ascertained for another group of patients whose sleep EEGs had preceded (96 patients) or followed (96 patients) each of the BETS EEGs. These patients formed 2 separate internal control groups. No significant differences in the demographic composition of the 3 groups or in the incidence of symptoms or diagnoses were noted. The patients with BETS were also divided into 2 groups according to whether their EEGs were otherwise normal or abnormal. Each of these 2 groups was compared with their respective control group (pre- or post-BETS patients with normal or abnormal EEGs). No significant differences in the incidence of seizures were noted. Benign temporal epileptiform transients of sleep appear to be an occasional but clinically unimportant finding in sleep tracings.     

发作性运动障碍的临床特征及发病机制

目的 探讨发作性运动障碍（PMD）的临床特征及发病机制。方法 回顾性分析5例发作性运动诱发舞蹈手足徐动症（PKC）和2例发作性持续运动诱发肌张力障碍（PED）患者的临床资料。结果 5例PKC发作均南突然运动诱发,表现肌肉僵直、肌张力增高3例,表现肢体扭动、肌张力不全3例（其中1例先为肢体僵直后扩展为周身扭动）。2例PED由持续运动诱发,表现为肢体不自主运动,持续数秒至数分钟缓解。脑电图（EEG）或动态脑电图（AEEG）示痫样放电5例,头部CT或MRI检查正常5例,异常2例。4例PKC予卡马西平治疗有效,1例PED予较大剂晕丙戊酸钠有效。结论PMD表现为发作性锥体外系症状,多由突然运动诱发。大部分病例的EEG有痢样放电,抗癫痫药物治疗有效。提示PMD的发病机制可能与癫痫类似或相同。     

Diagnostic reliability and significance of irregular beta patterns.

We designated EEGs with marked and irregular beta waves in basic patterns as "irregular beta patterns" on the basis that these patterns are related with particular symptoms such as dysphoria, irritability and autonomic symptoms and they implicate choice of therapeutic agents. Because of good response to antiepileptic agents in patients with "irregular beta patterns" along with EEG characteristics, we hypothesized that the prevalence of "irregular beta patterns" is higher in epileptics than in other psychiatric patients. In the present study, we tested this hypothesis, investigating actual frequencies of these patterns among different diagnostic categories for all patients whose EEG were recorded in all the first-visit patients to the Outpatient Clinic, Department of Neuropsychiatry of the Tokyo University Hospital during one year period of 1986. Before starting this investigation, we checked the interrater reliability for these patterns. Therefore, two studies are reported here. In Study 1, five raters judged 98 EEG recordings blindly (43 epileptics and 55 healthy subjects). As a result, the generalized Kappa of 0.473 was obtained, indicating our agreement level was moderate or fair. This result lends support to our contention that irregular beta patterns are reliably judged. In Study 2, we judged the EEG recordings (137 schizophrenics, 62 affective disorders, 43 epileptics and 55 healthy controls) and calculated the prevalence rate of "irregular beta patterns" among the diagnostic categories. The results show that the prevalence rates of "irregular beta patterns" among psychiatric disorders and normal controls were 13% (18/137) in schizophrenics, 11% (7/62) in affective disorders, 14% (6/43) in epileptics and 4% (2/55) in healthy controls. These rates did not differ significantly among the three disorders. Thus, our hypothesis was not supported. The clinical significance of these patterns is discussed.     

Proposition: limbic encephalitis may represent limbic status epilepticus. A review of clinical and EEG characteristics

Limbic encephalitis (LE) with waxing and waning neuropsychiatric manifestations including behavioral, personality, psychiatric, and memory changes can evolve over days to months. Many features of LE show remarkable overlap with the characteristics of mesial-temporal (limbic) status epilepticus (MTLSE or LSE). With LE, these prolonged impaired states are assumed not to be due to ongoing epileptic activity or MTLSE, because scalp EEGs usually show no epileptiform spike-wave activity; cycling behavioral and motor changes are attributed to LE; there may be little immediate improvement with antiepileptic drugs (AEDs); and of course, implanted electrodes are rarely used. Conversely, it is known that in pre-surgical patients with refractory limbic epilepsy, implanted electrodes have revealed limbic seizures that cannot be seen at the scalp. This paper assembles a chain of inferences to advance the proposition that refractory LE might represent LSE more often than is thought, and that implanted electrodes should be considered in some cases. We present two cases that suggest that LE was also LSE, one of which warranted implanted electrodes (case 1).     

一组特殊的良性儿童部分性癫(癎)的临床和脑电图特征

目的 分析一组特殊的良性儿童部分性癫(癎)的临床特征,探讨其病理生理机制.方法 对在我院癫(癎)中心门诊就诊的儿童部分性癫(癎)进行随访观察,纳入符合良性部分性癫(癎)诊断者,排除能够分类的其他类型,分析患者的临床和脑电图特征.结果 入组的44例患者中,38.6%(17/44)的患儿每天均有发作,额叶失神、偏转是最常见的发作症状,觉醒脑电图有局灶、多灶、全面性棘慢波爆发3种表现,且以额部为著;睡眠时双侧同步化.截止随访日,88.6%(39/44)完全无发作,22.7%(10/44)脑电图完全恢复正常.结论 有一组特殊的良性儿童部分性癫(癎),可能是起源于额叶.     

Varied responses to benzodiazepine treatment in cephalosporin‐related generalized periodic discharges

Although benzodiazepines (BZDs) are used as the first‐line treatment for status epilepticus, previous studies have shown inconsistent responses to BZDs in patients with cephalosporin‐related non‐convulsive status epilepticus. In this study, we investigated nine patients with cephalosporin‐related impaired consciousness and their EEGs all showed generalized periodic discharges (GPDs). One of the patients received repetitive BZD injections without discontinuing cephalosporins, and neither his clinical symptoms nor GPDs on EEG responded to BZDs. Seven of the patients received BZDs after discontinuation of cephalosporins, but only two of them responded immediately to BZD administration. One of the patients did not receive BZDs or antiepileptic drugs, and this patient spontaneously recovered consciousness in one day after cephalosporins were discontinued. The changes in consciousness were reversible in all of the nine patients after cephalosporins were withdrawn. The administration of intravenous BZDs in cases with impairment of consciousness and GPDs secondary to cephalosporins may help in only a small number of patients. Cephalosporin withdrawal is ultimately mandatory in these patients.