Paroxysmal arousal in epilepsy associated with cingulate hyperperfusion

A patient with nocturnal frontal lobe epilepsy characterized by paroxysmal motor attacks during sleep had brief paroxysmal arousals (PAs), complex episodes of nocturnal paroxysmal dystonia, and epileptic nocturnal wandering since childhood. Ictal SPECT during an episode of PA demonstrated increased blood flow in the right anterior cingulate gyrus and cerebellar cortex with hypoperfusion in the right temporal and frontal associative cortices.     

Paroxysmal movement disorders in severe myoclonic epilepsy in infancy

We report on the electroclinical findings and the results of a molecular genetic study of a patient with typical severe myoclonic epilepsy in infancy (TSME) and three with borderline SME (BSME) who showed paroxysmal movement disorders, such as choreoathetosis, dystonia and ballismus, during their clinical course. BSME was defined as a clinical entity that shares common characteristics with TSME but lacks myoclonic seizures associated with ictal EEG changes. When the paroxysmal movement disorders were first observed, all the patients in this study were being treated with polytherapy including phenytoin (PHT), and these abnormal movements disappeared when PHT was discontinued or reduced. However, on other occasions, two of our cases also showed the same abnormal movements even when not being treated with PHT. One patient with TSME and two of the three patients with BSME had SCN1A gene mutations that lead to truncation of the associated protein. We conclude that paroxysmal movement disorders seen in SME patients were closely related to their AED therapy, especially the use of PHT. It is thought that patients with both TSME and BSME have some predisposition toward paroxysmal movement disorders, and that this predisposition is partly related to sodium channel dysfunction, although some other factors might influence the occurrence of this phenomenon.     

Paroxysmal nocturnal activity in partial epilepsy in the adult

Thirty-four adults with partial epilepsy underwent polysomnographic sessions. Three sub-groups of patients were determined by timing their EEG paroxysmal activities (PA) according to the possible increase in PA related to their sleeping or awake state. Twenty-seven had an increase in PA when sleeping, 5 when awake and no significant difference was found in two other patients. Patients who suffered from nocturnal or partial elementary epileptic seizures were those who showed a PA increase when in a sleep state. These patients had a lower PA density during a waking state than the patients with a PA increase when awake. The more synchronized (stages 3 + 4) and desynchronized (waking) cortical states influence the PA densities in such a way that there is a significant difference between both sub-groups. The PA density modulation found with the slow-wave sleep stages adds to that induced by sleep and waking states.     

Paroxysmal visual disturbances of epileptic origin and occipital epilepsy in children

A special form of partial occipital epilepsy clinically resembling migraine and possibly related to the benign focal epilepsies of childhood has recently attracted attention (Gastaut 1982) but its existence is still debated. To approach this problem, in a group of 195 children with idiopathic partial or generalized epilepsy we have studied those who had visual complaints as part of their seizures (twelve children) and those who also had migraine (four children). The clinical and electroencephalographic features of these children were analyzed together with those of another group of thirty children diagnosed as migraine accompagnée in which an EEG had been obtained (3/30, i.e. 10% had paroxysmal spike-waves: one centrotemporal focus, two generalized spike-waves). One child with the type of epilepsy described by Gastaut (1982) as partial benign occipital epilepsy (phosphenes, moving lights, headaches and occipital high voltage biphasic spike-waves blocked by eye opening on the EEG) was found in the epileptic group whereas the other children of this group, including those with associated migraine, had other types of epilepsy. This "new" type of epileptic syndrome can be distinguished from symptomatically resembling entities but its place needs to be further defined.     

Paroxysmal kinesigenic choreoathetosis: autonomic disease or reflex epilepsy?

Motor attacks induced by voluntary movements are infrequent. Paroxysmal kinesigenic choreoathetosis (PKC) is rare and has only recently been individualized (Kertesz, 1967). We report the case of an 8 year-old boy who developed unilateral or bilateral attacks of abnormal, choreoathetotic movements during certain voluntary movements, especially when rising after a rest. The attacks were short (13 to 18 seconds) and frequent. Neurological examination was normal, as were the intelligence quotient, the inter-critical and critical EEG: CT and MRI. The patient's mother had suffered from the same disorder. The attacks disappeared during treatment with phenytoin but reappeared when it was stopped. This case is concordant with data from the literature, with male predominance, age from 6 to 15 years at the onset, shortness of the attacks (less than 1 minute in 80% of the cases) and normality of investigations in almost every patient. A familial factor has been found in 50% of the cases. The frequency of epilepsy in the family is above average. PKC can easily be distinguished from Mount and Reback' syndrome where the attacks are choreoathetotic but longer and unprovoked by movements and where there is also a familial factor. The relationship of PKC with epilepsy is asserted by some authors and denied by others, and in the literature the distinction between movement-induced tonic seizures and PKC is not always clear. Some authors have blamed a disturbance in the maturation of basal ganglia. To sum up, PKC is a very rare condition which is easy to diagnose, has a good prognosis and readily responds to antiepileptic drugs.     

Paroxysmal autonomic alterations mimicking epilepsy: a case report.

A 22-year-old male patient presented with paroxysmal hyperhidrosis, mydriasis, hypertension, and tachycardia. Cranial and cervical MRI revealed focal atrophy in the high order zone of the central autonomic network and syringomyelia. His physical and neurological examinations were unremarkable. Physiological testing included EEG, SPECT, serum/urine tests and autonomic testing. A poor response was achieved with the medical and interventional procedures employed. As the central autonomic network is an integral component of the internal regulation system of the brain, any lesion, no matter where in the network, may lead to paroxysmal autonomic alterations mimicking epilepsy (Published with videosequences).     

Paroxysmal tonic upgaze of childhood with co-existent absence epilepsy.

Paroxysmal tonic upgaze (PTU) is a childhood oculomotor syndrome of unclear etiology characterized by episodic tonic upward eye deviation with neck flexion. Neuroimaging findings are often normal and the electroencephalography during episodes is typically normal. We describe a 2-year-old boy who presented with macrocephaly, hypotonia, developmental delay and episodes of eye fluttering, head nodding and unresponsiveness. Video-EEG captured absence seizures and he was treated with valproate, which led to improvement of his seizures. However, two weeks after treatment, he developed paroxysmal episodes of "eyes up and chin down" movements lasting for hours at a time which were captured by home video. The episodes were relieved by sleep and exacerbated by fever, stress and even tactile stimulation. Increasing the dose of valproate resulted in increased frequency of the episodes. A repeat video-EEG disclosed the non-epileptic nature of these events. Discontinuation of valproate dramatically decreased the episodes. This case illustrates that paroxysmal tonic upgaze of childhood may co-exist with early onset absence epilepsy. Furthermore, valproate treatment may be associated with the development or unmasking of PTU suggesting that the pathophysiology of PTU may involve abnormal GABA neurotransmission. [Published with videosequences].     

Paroxysmal genital pain: an unusual manifestation of epilepsy.

A male patient who is now 15 years old has experienced a seizure disorder since age 9 years. The seizures were expressed as episodes of excruciating pain localized to the genital region. Appropriate anticonvulsant medication has controlled both pain and seizures.     

Electroclinical study of partial complex epilepsy. Paroxysmal need to drink

A particular history of a man aged 51 with a right fronto-temporal tumor is analyzed. The main complaint is a paroxysmal need to drink water. Surface electrode electroencephalography and video-telemetry recordings sometimes demonstrated evidence of temporal epileptic abnormalities and therefore seem to have localizing significance. Waterdrinking may thus be added to the widening range of behavioral manifestations associated with epileptic discharges arising in man's temporal lobes.     

Paroxysmal motor disorders of sleep: the clinical spectrum and differentiation from epilepsy

The diagnosis of paroxysmal events in sleep represents a significant challenge for the clinician, with the distinction of nocturnal epilepsy from nonepileptic sleep disorders often the primary concern. Diagnostic error or uncertainty is not uncommon in this situation, particularly with respect to nocturnal frontal lobe epilepsy (NFLE), which has a variable and often unusual presentation. Such errors can be minimized if the range of nonepileptic disorders with motor activity in sleep is fully appreciated. Here we review these disorders, before discussing the important clinical and electrographic features that allow their accurate differentiation from seizures. Particular emphasis is placed on the differentiation of nocturnal frontal lobe epilepsy from non-rapid eye movement (NREM) arousal disorders and other parasomnias. The value of recording episodes with video EEG polysomnography is discussed.     

Paroxysmal discharges in the EL mouse, a genetic model of epilepsy

The EL/Suz (EL) mouse is a strain that is highly susceptible to convulsive seizures after repeated sensory stimulation. Its control strain, DDY/Jc1 (DDY), is less susceptible under similar conditions. The seizure prone phenotype is the result of differences at several genetic loci. In vivo electrical recordings from the seizure prone EL mouse brain have shown that the appearance of abnormal discharges in the hippocampus are critical to the onset of generalized seizures, indicating that the hippocampus plays an important role in EL mouse seizure activity. In the present study, electrophysiological differences between EL and DDY mice (9–15 weeks of age) were examined by comparing field potentials recorded from the dentate granule cell layer of hippocampal brain slices from mice that had not been stimulated to induce seizures. In control physiological solution, no significant differences were observed in characteristics of perforant path evoked field potentials or in paired pulse depression of evoked field potentials using 20 to 300 ms interstimulus intervals. After 60 min of disinhibition following bicuculline (10 μM) exposure, however, prolonged large amplitude potentials, paroxysmal discharges, were evoked by perforant path stimulation in the dentate gyrus of EL mice but were absent in the DDY strain. Paroxysmal discharges were curtailed by APV and were similar to responses recorded from the dentate gyrus in hippocampal brain slices from temporal lobe epileptic patients. The field response to hilar stimulation was identical in both strains and was composed of a single population spike before and after bicuculline exposure. Mossy fiber terminals were not present in the molecular layer of either strain. We propose that the mechanisms leading to a greater likelihood of paroxysmal discharge generation in EL mouse may be important in the development and/or generation of epileptic seizures in this mouse strain and may be a significant phenotypic difference between the EL mouse and its parent strain.     

Paroxysmal sympathetic hyperactivity and the later development of epilepsy in a chemotherapy-associated brain damage

BackgroundChemotherapy in childhood leukemia potentially induces brain lesions and neurological sequelae. Paroxysmal sympathetic hyperactivity (PSH) is known as a treatment-associated complication; however, the full clinical spectra of PSH remain to be elusive.Case reportA 5-year-old girl was diagnosed of acute myeloid leukemia (AML) M5. After the intensification therapy, she developed recurrent symptoms of episodic tachycardia, hypertension and perspiration lasting for several hours per day. The low-frequency-high-frequency ratio on Holter electrocardiography was rapidly increased from 0.84 to 2.24 at the onset of the paroxysmal event, whereas the video-monitoring electroencephalography (EEG) never identified ictal patterns of epileptiform discharges during the episodes. Thus, the diagnosis of PSH was given at 7 years of age. Myoclonic and generalized tonic-clonic seizures frequently appeared from 10 years of age, which poorly responded to anticonvulsants. EEG showed diffuse slow-wave bursts with multifocal spikes. Serial head magnetic resonance imaging (MRI) revealed diffuse cerebral and hippocampal atrophy, but not inflammatory lesions in the limbic system.ConclusionWe first demonstrate a pediatric case with PSH who developed drug-resistant epilepsy 3 years after the onset of PSH. Our data suggest the pathophysiological link of persistent PSH with chemotherapy-associated brain damage.