Subacute postictal aggression in patients with epilepsy

Three men with epilepsy (age range, 38-62) who exhibited brief episodes of violent behavior during the postictal period are described. Disease duration ranged from 27 to 44 years. Patients had both complex partial seizures and secondarily generalized tonic-clonic seizures, which were refractory to antiepileptic drugs. Postictal aggression occurred shortly after a seizure and lasted 5-30 minutes. The patients displayed physically and verbally aggressive behavior toward others, but regained consciousness promptly and showed regret afterward. Interictal EEGs revealed temporal spikes, SPECT showed hypoperfusion in the temporal and frontal areas in two patients, and neuropsychological examination revealed poor frontal lobe function in two patients. Characteristics of our cases are consistent with subacute postictal aggression (SPA) reported previously. Epilepsy of prolonged duration and brain dysfunction involving a broad area including the temporal and frontal lobes may be associated with the occurrence of subacute postictal aggression.     

Violence and Epilepsy: A Close Relation Between Violence and Postictal Psychosis

Summary: Purpose: We investigated the incidence of well-directed violent behavior and suicide attempts in patients with temporal lobe epilepsy, with special attention to postictal psychosis.
Methods: We compared 57 episodes of postictal psychosis with 62 episodes of acute interictal (or alternative) psychosis and with 134 complex partial seizures. All patients were matched for age and for age at onset of seizures.
Results: The incidence of well-directed violent behavior against human beings was significantly higher (23%) during postictal psychotic episodes than during acute interictal episodes (5%) and postictal confusion (1%). Suicide attempts were also more frequent during postictal psychosis (7%) than during either acute interictal psychosis (2%) or postictal confusion (0%).
Conclusions: Our study showed that well-directed violent and self-destructive behavior was not a feature of epileptic psychosis in general but a specific hallmark of postictal psychosis.     

Postictal Psychosis: A Comparison with Acute Interictal and Chronic Psychoses

Summary: We studied 30 patients with postictal psychosis and compared them with 33 patients with acute interictal psychosis and 25 patients with chronic psychosis. All patients had either complex partial seizures (CPS) or EEG temporal epileptogenic foci. Patients with postictal psychosis had a high incidence of psychic auras and nocturnal secondarily generalized seizures. The most striking feature that distinguished postictal psychosis from both acute interictal and chronic psychoses was phenomenological: the relatively frequent occurrence of grandiose delusions as well as religious delusions in the setting of markedly elevated moods and feeling of mystic fusion of the body with the universe. In addition, postictal psychosis exhibited few schizophreniform psychotic traits such as perceptual delusions or voices commenting. Reminiscence, mental diplopia, and a feeling of impending death were also fairly frequent complaints of patients with postictal psychosis. Interictal acute psychosis and chronic epileptic psychosis were psychopathologically similar. Although acute interictal and chronic epileptic psychoses could simulate schizophrenia, postictal psychosis results in a mental state quite different from that of schizophrenic psychosis.     

SPECT findings during postictal psychoses: predominance of relative increase of perfusion in right temporal lobe

To identify brain regions activated during episodes of postictal psychoses (PIP), we investigated single-photon emission computed tomography (SPECT) data obtained from five patients treated at our institutions and also reviewed four previous studies. Therefore, SPECT findings in a total of 19 cases were analyzed, including 16 patients with temporal lobe epilepsy (TLE). During nonpsychotic states, the laterality of epileptic foci was judged as left-sided in nine episodes, right-sided in six episodes, and nonlateralized in four episodes. In PIP states, 88% of the patients showed a relative increase of right temporal perfusion (increased right temporal or decreased left temporal perfusion). Regardless of whether right- or left-sided pathology was suspected during a nonpsychotic state, SPECT findings obtained during PIP episodes revealed a trend of right-sided temporal predominance.     

Postictal syndrome: The forgotten continent. An overview of the clinical,biochemical and imaging features

Postictal syndrome (PIS) encompasses the clinical, biological, electroencephalographic (EEG) and magnetic resonance imaging (MRI) signs that follow the termination of a seizure. These signs occur as soon as the epileptic discharge ends, but might remain for a substantially long period of time, making them amenable to clinical observation. As a direct consequence, neurologists and intensivists are more frequently attending patients with PIS than during their seizure. Moreover, careful PIS documentation may help physicians to diagnose epileptic seizure from other non-epileptic disorders. Careful analysis of PIS could also be helpful to better characterize the seizure (seizure subtypes, and to some extent, the localization and/or lateralization of the seizure). This article aims to review the main clinical, biological, EEG and MRI components of PIS, discuss differential diagnoses and propose a general clinical attitude, based on the acronym “WAITTT”: W for “Watch”, to monitor and investigate PIS in order to provide relevant information on seizure, AIT for “Avoid Inappropriate Treatment”, to underscore the risk carrying out unnecessary drug injections and intensive care procedures in the setting of a self-limited symptomatology, and TT for “Take Time”, to keep in mind that time remains the clinician's best ally for treating patients with PIS.     

The expression of interictal, preictal, and postictal facial-wiping behavior in temporal lobe epilepsy: a neuro-ethological analysis and interpretation

By videotape recordings analysis we investigated the frequencies of interictal, preictal, and postictal wiping or rubbing movements targeting the face region (face wiping, FW) in 17 right and 13 left mesial temporal lobe epilepsy (MTLE) patients. Patients' data were compared with FW frequencies obtained in 22 healthy controls listening to a presentation. Results showed that: (1) FW movements were present in both controls and patients; however, the patient groups showed lower interictal and preictal FW rates relative than controls; (2) right and left temporal lobe seizures were followed by a marked increase in the expression of wiping activities directed to the nose as well as to other face regions with respect to the interictal-preictal period; (3) during the first 5min postictal FW was performed preferentially with the hand ipsilateral to the seizure focus; (4) postictal examination of the patient by an observer, especially if of the opposite sex, resulted in a higher incidence of FW acts. After temporal lobe seizures there is an exaggerated expression of movements targeting the face region, and not exclusively directed to the nose. According to an ethological interpretation of the FW behavior as a motor behavior present throughout the phylogenetic scale, from rodents to primates, we suggest the postictal emergence of an innate action pattern modulated by external emotional-cognitive stimuli.     

Acute Psychosis During Intracranial EEG Monitoring: Close Relationship Between Psychotic Symptoms and Discharges in Amygdala

PURPOSE: This report examined the underlying mechanism of psychosis associated with epilepsy. METHODS: An adult patient with epilepsy manifesting acute psychosis during long-term EEG monitoring is presented, together with a literature review on this subject. RESULTS: A 25-year-old woman with intractable temporal lobe epilepsy developed acute psychosis while she underwent long-term intracranial EEG monitoring. After a clustering of seizures, she manifested psychotic symptoms including hallucination, stupor, and repeated fear. The transition of psychotic symptoms corresponded to the changes in frequency and morphology of seizure discharges restricted to the left amygdala. Improvement of psychosis coincided with disappearance of seizure discharges. CONCLUSIONS: This case confirmed a close relationship between psychotic symptoms and seizure discharges in the left amygdala. It is suggested that paroxysmal bombardment of the medial temporal lobe structure may be a pathogenetic factor of acute psychosis associated with epilepsy.     

中老年复杂部分性发作癫痫持续状态的临床特征及误诊分析

目的 分析中老年复杂部分性发作癫痫持续状态(CPSE)的临床特点及误诊原因.方法 收集广州医学院第二附属医院神经内科自2008年1月至12月收治、曾被外院误诊的中老年CPSE患者的临床资料,进行视频脑电图(EEG)、头颅MR、生化检查,根据国际抗癫痫联盟的CPSE诊断标准进行诊断,并随访3个月以上. 结果 本组患者7例,均为女性,其中额叶癫痫(FLE)2例,颞叶癫痫(TLE)5例;CPSE患者临床症状和视频EEG表现多样化;经抗癫痫药物(AEDs)治疗后3例至少3个月无发作,3例仍有CPSE发作,1例仍有反复CPSE. 结论 由于CPSE患者临床症状和EEG表现欠典型,常合并其他系统疾病和社会因素的影响易被误诊,应及早做视频EEG检查以明确诊断;口服AEDs治疗可取得良好效果.     

New-onset mesial temporal lobe epilepsy in a 90-year-old: clinical and EEG features

Although there is a peak in the incidence of epilepsy in the elderly compared with the general population, complex partial seizures represent less than 15% of the seizure types reported. We report on a 92-year-old woman with a 2-year history of daily complex partial seizures. Prolonged video/EEG recording showed bilateral anterior mesial temporal interictal spikes, which predominated on the left, and two typical seizures arising from the left temporal area. Cranial MRI scanning showed multiple lacunar infarcts without temporal lobe involvement or mesial temporal atrophy. Our case appears to be oldest patient in the literature with newly diagnosed mesial temporal lobe epilepsy confirmed by video/EEG recording.     

Insight into illness in patients with mania,mixed mania,bipolar depression and major depression with psychotic features

Dell'Osso L, Pini S, Cassano GB, Mastrocinque C, Seckinger RA, Saettoni M, Papasogli A, Yale SA, Amador XF. Insight into illness in patients with mania, mixed mania, bipolar depression and major depression with psychotic features. Bipolar Disord 2002: 4: 315–322. © Blackwell Munksgaard 2002 Background: Poor insight into illness is a common feature of bipolar disorder and one that is associated with poor clinical outcome. Empirical studies of illness awareness in this population are relatively scarce with the majority of studies being published over the previous decade. The study reported here sought to replicate previous report findings that bipolar patients frequently show high levels of poor insight into having an illness. We also wanted to examine whether group differences in insight exist among bipolar manic, mixed and unipolar depressed patients with psychotic features. Methods: A cohort of 147 inpatients with DSM‐III‐R bipolar disorder and 30 with unipolar depression with psychotic features, were evaluated in the week prior to discharge using the Structured Clinical Interview for DSM‐III‐R‐Patient Edition (SCID‐P), the Brief Psychiatric Rating Scale (BPRS) and the Scale to assess Unawareness of Mental Disorder (SUMD). Results: Insight into specific aspects of the illness was related to the polarity of mood episode: patients with mania showed significantly poorer insight compared with those with mixed mania, bipolar depression and unipolar depression. A linear regression analysis using SUMD score as the dependent variable and symptoms of mania as the independent variable found that specific manic symptoms did not account for level of insight. Similar results were obtained when the mean insight scores of patients with and without grandiosity were contrasted. Conclusions: We hypothesize that the lack of association between level of insight and total number of manic symptoms or with specific manic symptoms may be related to the persistence of subsyndromal symptoms in patients remitting from a manic episode.     

75例额叶癫痫的临床特点及发作期发作间期脑电图分析

目的回顾性分析额叶癫痫(FLE)的临床及发作期和发作间期脑电图特点,为临床早期识别和治疗提供依据。方法详细整理75例FLE患者的临床资料,发作期及发作间期脑电图改变和影像学表现,并进行总结分析。结果 (1)临床表现:一种发作类型25例(33%);两种或两种以上发作类型50例(67%);发作时意识清醒者20例(27%);丛集性发作27例(36%);夜间发作36例(48%)。(2)脑电图表现:1发作间期脑电:50例FLE行长程视频脑电监测中异常者47例(94%);2发作期脑电:监测到临床发作22例;3睡眠期痫性放电阳性率高于清醒期(P0.01)。(3)影像学表现:影像学检查异常且病灶位于额叶者36例(54%);非额叶病灶者5例(7.6%);神经影像学未见异常者25例(33%)。结论 FLE临床表现复杂多样,运动症状常见;意识恢复快,多无发作后状态;FLE多于夜间发作,发作时间短暂,呈丛集性发作;FLE脑电图特异性差,长程视频脑电较普通脑电易于检测出痫性放电,睡眠期脑电图阳性率高于清醒期;FLE脑电显示多无侧别提示。     

The Relationship Between Sleep and Epilepsy in Frontal and Temporal Lobe Epilepsies: Practical and Physiopathologic Considerations

Summary: Purpose: The influence of sleep on the incidence of seizures and the reciprocal effects of epilepsy on sleep were analyzed in 30 patients with intractable partial seizures, all candidates for surgery.
Methods: The patients were classified into two groups of 15 patients according to the documented site of the epileptogenic zone: frontal lobe epilepsy (FLE) and medial temporal lobe epilepsy (TLE). Frequency and waking-sleep distribution of seizures were evaluated by continuous video-EEG monitoring for 5 days, under defined antiepileptic drug (AED), sleep, and sleep deprivation regimens. Sleep organization was analyzed by polysomnography prior to the presurgical protocol.
Results: Significant differences were found between the two groups in sleeping-waking distribution of seizures under varied conditions, and in the quality of sleep organization. In FLE patients, seizures most often occurred during sleep, although sleep organization was normal. In TLE patients, most seizures occurred while patients were awake, and sleep organization was characterized by a low efficiency index. The difference in seizure distribution between FLE and TLE persisted under all conditions investigated, i.e., after AED discontinuation and sleep deprivation.
Conclusions: Sleep recording may be useful for diagnosis of FLE, and monitoring after sleep deprivation for that of TLE. We speculate that sleep-related seizures in FLE may depend on interaction between frontal lobe areas with the thalamus cortical synchronization system and the acetylcholine regulatory system of waking.     

Gelastic seizures: Incidence,clinical and EEG features in adult patients undergoing video‐EEG telemetry

This study aimed to determine clinical features of adult patients with gelastic seizures recorded on video –electroencephalography (EEG) over a 5‐year period. We screened video‐EEG telemetry reports for the occurrence of the term “gelastic” seizures, and assessed the semiology, EEG features, and duration of those seizures. Gelastic seizures were identified in 19 (0.8%) of 2,446 admissions. The presumed epileptogenic zone was in the hypothalamus in one third of the cases, temporal lobe epilepsy was diagnosed in another third, and the remainder of the cases presenting with gelastic seizures were classified as frontal, parietal lobe epilepsy or remained undetermined or were multifocal. Gelastic seizures were embedded in a semiology, with part of the seizure showing features of automotor seizures. A small proportion of patients underwent epilepsy surgery. Outcome of epilepsy surgery was related to the underlying pathology; two patients with hippocampal sclerosis had good outcomes following temporal lobe resection and one of four patients with hypothalamic hamartomas undergoing gamma knife surgery had a good outcome.     

Hyperkinetic seizures in patients with temporal lobe epilepsy: clinical features and outcome after temporal lobe resection

Purpose: Temporal lobe epilepsy (TLE) is usually associated with automatisms. Hyperkinetic seizures are supposed to be unusual. Because we witnessed several patients with TLE and ictal hyperkinetic symptoms, we retrospectively assessed the number, clinical findings, and seizure outcome in such patients who had undergone temporal lobe resection. Methods: We reviewed medical history, video–electroencephalography (EEG) recording and neuroimaging of adult patients who underwent epilepsy surgery for TLE at the Kork Epilepsy Center over the last 20 years with a minimum postoperative follow‐up of 12 months. Key Findings: Among 294 patients who were resected exclusively in the temporal region, we identified 17 (6%) who presented with hyperkinetic semiology such as violent vocalization, complex movements of the proximal segments of the limbs, rotation of the trunk, pelvic thrusting, or early tonic or dystonic posturing. Most of the patients had a preceding aura. Ictal EEG activity was located in the corresponding temporal region, usually with a wide distribution over temporal electrodes with fast spread to unilateral frontal electrodes and to the contralateral side. Neuroimaging revealed extended lesions in the temporal lobe involving mesial and neocortical structures. Most of the patients underwent classical anterior temporal lobe resection including amygdalo‐hippocampectomy. Fourteen patients (82%) became completely seizure‐free (Engel class Ia). Histopathology showed mainly focal cortical dysplasia plus hippocampal sclerosis. Significance: Hyperkinetic seizure semiology may occasionally occur in patients with TLE and is, therefore, no contradiction to the hypothesis of TLE if scalp EEG patterns and neuroimaging findings correspond. The postoperative seizure outcome is favorable in such patients and not different from outcome data in classical TLE.     

颞叶癫痫脑电图分析及病灶超微结构观察

目的 研究影像学检查无异常的颞叶癫痫患者,电生理异常与皮层棘波灶及海马超微病变的关系.方法 选择经CT或MRI检查未见异常的颞叶癫痫患者7例,术前做脑电图或24h视频脑电监测,术中在脑电监测下取颞叶大脑皮质棘波灶和海马组织,做电镜观察.结果 7例患者电生理检查均可见典型痫样放电.颞叶皮质痫灶和海马可见不同程度的神经元固缩,胶质细胞变性,胶质增生,突触数量及突触结构改变,血脑屏障破坏等改变.结论 影像学无异常的颞叶癫痫患者颞叶皮层痫灶和海马超微结构病理变化明显,特别是突触的变化,是导致癫痫患者脑电生理机能异常及癫痫反复自发性发作的形态学基础.     

Frontal lobe tumoral epilepsy: clinical,neurophysiologic features and predictors of surgical outcome

PURPOSE: To review the clinical, neurophysiologic features and surgical outcomes in patients with frontal lobe tumors and chronic intractable seizures. METHODS: Medical records of patients with intractable epilepsy who underwent resection or stereotactic biopsy of frontal lobe tumor (confirmed by surgical pathology) seen between 1985 and 1999 at Yale University School of Medicine Epilepsy Center were reviewed for age at diagnosis, age at onset of seizures, delay between seizure onset and tumor diagnosis, types and frequencies of seizures, EEG results, use of anticonvulsants, extent of surgery, pathological diagnosis, and tumor recurrence. RESULTS: Thirty-seven patients were included. Mean age at seizure onset was 31.6 years, and at tumor diagnosis was 36.2 years. Mean duration between onset of seizures and tumor diagnosis was 6.1 years. Seventeen patients had auras. Seizure frequency averaged 7.6 seizures per week, with 58% of patients having more than one seizure type. All patients used anticonvulsants, with 90% eventually using polytherapy. All patients eventually underwent at least one surgical procedure. Only 13 (35.1%) patients were class I. Twelve (32.4%) patients were class II, seven (18.9%) class III, and five (13.5%) class IV. No statistically significant differences were seen between good and poor long-term seizure outcome in relation to specific tumor pathology, seizure types, or type of resection. CONCLUSIONS: Long-term surgical outcomes in tumoral frontal lobe epilepsy are more favorable than those in nontumoral intractable frontal lobe epilepsy (65% class I or II) and less favorable than those in other tumoral epilepsy (overall, 70% class I). Frontal location of intracranial neoplasm may predict a less favorable long-term epilepsy prognosis than tumoral epilepsy in general, an observation for which several explanations are proposed.     

Symptomatic and functional outcome 12 months after a first episode of psychotic mania: barriers to recovery in a catchment area sample

OBJECTIVE: Recent studies have shown that outcome in mania is worse than previously thought. Such studies have been conducted in selected samples with restrictive measures of outcome. We aimed to explore outcome and its predictors in a catchment area sample of first-episode psychotic mania of DSM-III-R bipolar I disorder. METHODS: Prospective 6 and 12 months follow-up was conducted with 87 DSM-III-R first-episode psychotic mania patients admitted to Early Psychosis Prevention and Intervention Centre between 1989 and 1997. Syndromic and symptomatic outcome were determined with the Brief Psychiatric Rating Scale; functional outcome with the Quality of Life Scale and Premorbid Adjustment Scale subitems. RESULTS: Symptomatic outcome was assessed in 67 patients at 6 months and 61 patients at 12 months, and functional outcome in 56 patients at 6 months and 49 patients at 12 months. Logistic regressions were conducted on 46 and 43 patients, respectively, to explore predictors of outcome. While 90% of patients achieved syndromic recovery at 6 and 12 months, 40% had not recovered symptomatically at 6 and 12 months, still presenting with anxiety or depression. A total of 66% of patients at 6 months and 61% of patients at 12 months failed to return to previous level of functioning. Age at intake, family history of affective disorder, illicit drug use and functional recovery at 6 months predicted functional outcome at 12 months. CONCLUSIONS: This study confirms poor symptomatic and functional outcome after first-episode psychotic mania. It suggests possible usefulness of early intervention strategies in bipolar disorders and need for developing specific interventions addressing anxiety, depression and substance abuse comorbidity.     

Single Photon Emission Computed Tomography (SPECT) in a Patient with Bilateral Temporal Seizures: Correlation Between Ictal EEG and Postictal/Ictal SPECT

Summary: We report a patient with bilateral independent temporal lobe seizures in whom two [^99mTc]HMPAO single photon emission computed tomograph (SPECT) scans were performed during two different seizures. In the first perüctal SPECT, [^99mTc]HMPAO was injected in the interval between two closely spaced seizures (one localized in the left temporal lobe and the other in the right temporal lobe). SPECT images showed hypoperfusion in the left lateral temporal lobe, hyper-perfusion of the left mesial temporal region, and pronounced hyperperfusion in the right anterior temporal lobe. These results suggest both a postictal left temporal SPECT pattern and an ictal right temporal pattern. In the second periictal SPECT, [^99mTc]HMPA was injected immediately after a right temporal lobe seizure and showed right lateral temporal lobe hypoperfusion and right mesial hyperperfusion, suggesting a postictal right temporal SPECT pattern. Interpretation of the periictal SPECT should take into account EEG changes at the time or in the minutes immediately after injection of [^99mTc] HMPAO.     

Neurogenesis in temporal lobe epilepsy: Relationship between histological findings and changes in dentate gyrus proliferative properties

Objective

The relationship between hippocampal histopathological abnormalities, epileptogenesis and neurogenesis remains rather unclear.

Methods

Tissue samples including the subgranular zone of dentate gyrus (DG) were freshly collected for tissue culture for neurospheres generation in 16 patients who underwent surgery for drug-resistant temporal lobe epilepsy. Remaining tissues were histologically examined to assess the presence of mesial temporal sclerosis (MTS) and focal cortical dysplasia.

Results

MTS was detected in 8 cases. Neurospheres were formed in 10/16 cases. Only three out of these 10 cases exhibited MTS; on the contrary 5/6 cases lacking neurosphere proliferation presented MTS. There was a significant correlation between presence of MTS and absence of proliferation (p = 0.0389). We also observed a correlation between history of febrile seizures (FS) and presence of MTS (p = 0.0004) and among the 6 cases lacking neurosphere proliferation, 4 cases (66.6%) had experienced prolonged FS. Among “proliferating” cases the percentage of granular cells pathology (GCP) was lower (20% vs 50%) compared to “non proliferating” cases.

Conclusion

A decreased potential to generate neurosphere from the SGZ is related to MTS and to alterations of dentate gyrus granule cells, especially in MTS type 1b and GCP type 1. These histological findings may have different prognostic implications, regarding seizure and neuropsychological outcome, compared to patients with other epileptogenic lesions (such as FCD, glioneuronal tumours, vascular lesions).