Echographia as a symptom of interictal state in an epileptic patient: A case report

Abstract Echographia is a phenomenon in which a patient continuously translates verbal stimuli into writing. We encountered a patient with epilepsy who developed visual echographia during interictal periods. In this case, echographia was observed during two different periods, namely the period of disturbed consciousness after the epileptic seizure and the period of clear consciousness after suppression of the seizures. Disinhibition due to disturbance of the consciousness is considered to have been the cause of echographia in the former period. In the latter period, it is considered that echographia was caused by the release of lower function from suppression of upper function by brain dysfunction, as the after effect of status epilepticus. As echographia can be observed in epileptic patients, attention and careful observation by epileptologists is needed.     

癫(癎)患者先兆症状的研究

目的 探讨癫(癎)患者先兆症状的发生比例、临床表现,为正确诊断治疗癫(癎)提供依据.方法 回顾性研究1028例癫(癎)患者的临床资料,分析癫(癎)患者的先兆发生率、临床表现、脑电图和神经影像学结果.比较伴或不伴先兆的部分性发作癫(癎)患者的发病年龄、性别、脑电图、神经影像学的差异以及腹部先兆在颞叶内外侧癫(癎)出现比例的差异.结果 部分性癫(癎)725例,484例(66.8 % )出现先兆;全面性发作者303例,无一例患者出现先兆.64例患者出现2种或2种以上的先兆表现;14例出现持续性先兆的癫(癎)患者.1028例患者中脑电图异常547例(53.2 % ),影像学异常217例(21.1 % ).484例有先兆症状的患者中286例脑电图异常(59.1 % ),126例(26.0 % )影像学异常.伴或不伴先兆的部分性发作癫(癎)患者的首次发病年龄差异无统计学意义,腹部先兆在颞叶内外侧癫(癎)出现的比例差异有统计学意义(x2=170.877,P<0.01).结论 癫(癎)患者先兆症状多样,分析先兆症状对于癫(癎)分型、病灶定位以及合理治疗有指导意义.     

The colchicine experimental epileptic focus: an intracellular study

A new experimental epileptic focus is described in which colchicine is topically applied to neocortex. Stable epileptiform discharges developed, with bursts of action potentials, coincident with the surface epileptiform events. There were depolarizing and hyperpolarizing neuronal potentials and glial depolarizations concomitantly with the surface epileptic spikes.     

The "sensed presence": an epileptic aura with religious overtones

"Sensed presence," a religious emotion, has been the focus of recent neurotheological research because it has been claimed that weak transcranial magnetic stimulation can evoke such experiences. Some researchers have recently questioned this claim. However, religion and epilepsy have been linked through history, clinical observations, and research. This article describes the "sensed presence" as an aura in one patient who did not interpret his experience in a religious way. He had bilateral hypoperfusion of the temporal lobes when investigated by SPECT, and hypoplasia of the dorsal part of the left hippocampus when examined by magnetic resonance imaging. This case report illustrates that "sensed presence" can occur as an epileptic aura with or without religious interpretation.     

Palinopsia as sensory epileptic phenomenon

Visual perseveration (VP) is defined as persistence or recurrence of visual images, when the stimulus is no longer present. We report three patients with occipital cortical lesions in the right hemisphere and VP. Electroencephalography showed epileptic abnormalities in all cases. In one patient synchronous electroencephalic recordings during the onset of palinopsia - a subtype of VP - revealed, that VP was associated with a clear cut right occipital seizure with a secondary diffusion of the discharge over both hemispheres, which has not been reported in combination with the onset of palinopsia heretofore. In all three patients sensory seizures have to be considered as probable cause of VP.     

Secretion of natriuretic peptides caused by an epileptic attack

OBJECTIVE: To describe clinical features of a patient with secretions of atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP) during an epileptic attack. PATIENT: A 65-year-old woman experienced frequent bouts of polyuria, pyrexia and general fatigue after several years of a cerebral contusion involving the left fronto-temporal lobe caused by a traffic accident. Her urine output and urinary sodium excretion increased, and plasma ANP and BNP concentrations were markedly high during each attack. Electroencephalography (EEG) showed serial seizure discharge in the left anterior temporal region during the attacks, indicative of epileptic focus. CONCLUSION: ANP and BNP secretions probably were triggered by epileptic stimulation on the diencephalon beyond the focus.     

Modulation of epileptiform EEG discharges in juvenile myoclonic epilepsy: an investigation of reflex epileptic traits

Purpose: Previous studies have suggested that cognitive tasks modulate (provoke or inhibit) the epileptiform electroencephalography (EEG) discharges (EDs) in patients with juvenile myoclonic epilepsy (JME). Their inhibitory effect was found to be especially frequent (64–90%). These studies arbitrarily defined modulation as a >100% increase or >50% decrease of the EDs compared with baseline, which may not sufficiently distinguish from spontaneous fluctuations. The aim of our study was to assess the modulation of EDs and the precipitation of myoclonic seizures by cognitive tasks and by conventional provocation methods, taking into account also the spontaneous fluctuation of EDs. Method: Sixty patients with JME underwent video‐EEG recordings including 50‐min baseline, sleep, hyperventilation, intermittent photic stimulation (IPS), and cognitive tasks. To account for spontaneous fluctuations of the EDs we divided the baseline period into 5‐min epochs and calculated the 95% confidence interval for the baseline EDs in each patient. Modulation was assumed when the number of EDs during any 5‐min test period was outside the 95% confidence interval. Key Findings: Using the arbitrary method, our results were similar to previous publications: Cognitive tasks seemed to inhibit the EDs in 94% of the patients, and to provoke them in 22%. However, when the spontaneous fluctuations were accounted for, inhibition was found in only 29% of the patients and provocation in 18%. A nonspecific effect of any cognitive task seemed to account for the observed significant inhibition in two‐thirds of the cases, but was observed in only one of the patients with significant provocation. Photoparoxysmal response was observed in 23% of the patients. When accounting for the spontaneous occurrence of EDs, IPS had provocative effect in 10% of the patients. Hyperventilation and sleep had provocative effect on EDs to an extent similar to the cognitive tasks (hyperventilation: 22%; sleep: 18%). The conventional provocation methods tended to be more efficient in patients who were not seizure free. Myoclonia were recorded most often during the cognitive tasks (10 patients). Significance: Spontaneous fluctuations of EDs account for most of the previously described inhibitory effect of the cognitive tasks. The provocative effect of the cognitive tasks is task‐specific, whereas the inhibitory effect seems to be related to cognitive activation in general.     

Widespread epileptic networks in focal epilepsies: EEG-fMRI study

Purpose: To assess the extent of brain involvement during focal epileptic activity, we studied patterns of cortical and subcortical metabolic changes coinciding with interictal epileptic discharges (IEDs) using group analysis of simultaneous electroencephalography and functional magnetic resonance imaging (EEG‐fMRI) scans in patients with focal epilepsy. Methods: We selected patients with temporal lobe epilepsy (TLE, n = 32), frontal lobe epilepsy (FLE, n = 14), and posterior quadrant epilepsy (PQE, n = 20) from our 3 Tesla EEG‐fMRI database. We applied group analysis upon the blood oxygen–level dependent (BOLD) response associated with focal IEDs. Key Findings: Patients with TLE and FLE showed activations and deactivations, whereas in PQE only deactivations occurred. In TLE and FLE, the largest activation was in the mid–cingulate gyri bilaterally. In FLE, activations were also found in the ipsilateral frontal operculum, thalamus, and internal capsule, and in the contralateral cerebellum, whereas in TLE, we found additional activations in the ipsilateral mesial and neocortical temporal regions, insula, and cerebellar cortex. All three groups showed deactivations in default mode network regions, the most widespread being in the TLE group, and less in PQE and FLE. Significance: These results indicate that different epileptic syndromes result in unique and widespread networks related to focal IEDs. Default mode regions are deactivated in response to focal discharges in all three groups with syndrome specific pattern. We conclude that focal IEDs are associated with specific networks of widespread metabolic changes that may cause more substantial disturbance to brain function than might be appreciated from the focal nature of the scalp EEG discharges.     

托吡酯添加治疗难治性癫(疒间)的有效性和安全性

目的探讨托吡酯添加治疗难治性癫疒间的有效性和安全性。方法对115例难治性癫疒间患者应用托吡酯小剂量逐渐添加的开放性自身对照研究,第8周达最大耐受量后维持1~3年或以上。评定托吡酯的长期疗效、安全性及其与剂量的关系。结果治疗第8周、6个月、1年、2年和3年发作频率减少百分比的中位数:成人分别为56.0%、75.8%、76.1%、77.3%、78.1%,儿童分别为32.1%、66.7%、68.9%、70.1%、70.8%。部分性发作的有效率(70.6%)高于全面性发作(37.5%,P<0.05),其中10例(11.3%)无发作>2年。有效组维持剂量成人为(129.3±54.3)mg/d,儿童为(3.1±1.4)mg/(kg.d)。1年、2年及3年托吡酯保留率分别为72.2%、62.5%和56.1%。33例(28.7%)出现不良反应,大部分出现在加量期,最常见的为胃纳差。因不良反应退出6例(8.2%),因疗效不佳退出16例(21.9%)。结论托吡酯添加治疗难治性癫疒间长期有效、安全,对部分性发作效果更佳。剂量个体化可使不良反应轻微和可耐受。     

Acute psychosis and epileptic seizures as the presenting symptom of late-onset epilepsy

We report two patients with no history of psychosis or epilepsy presenting with acute psychosis and epileptic seizures as the initial symptom of late-onset epilepsy. Seizures and psychosis resolved with phenytoin. Case 1 presented a recurrence of both psychosis and seizures following abrupt withdrawal of antiepileptic drugs.     

Pattern-sensitive epilepsy: electroclinical characteristics, natural history, and delineation of the epileptic syndrome

PURPOSE: To elucidate the electroclinical features and long-term outcome of patients with pattern-sensitive epilepsy. METHODS: We reviewed the clinical and electroencephalographic (EEG) findings of 73 (43 female and 30 male) patients in whom pattern-sensitive epilepsy was diagnosed at Mayo Clinic (Rochester, Minnesota, U.S.A.) from 1950 through 1999. We contacted patients and their relatives by letter or telephone to obtain the latest seizure and quality-of-life outcomes. RESULTS: The median age at onset of seizures was 12.8 years (range, 0.6-32.9 years). Most patients had absence, myoclonic, or generalized tonic-clonic seizures. Interictal epileptiform discharges in the EEG were detected in 61 (83.6%) patients and were generalized in 54 (74%). Paroxysmal epileptiform discharges in the EEG elicited with standard patterns were all generalized in two thirds of patients but were restricted to the posterior head region in one-third. Eight (11%) patients did not exhibit photosensitivity. Television was the most common precipitant [30 patients (41%)]. Twenty-nine patients gave a clear history of one or more seizures precipitated while viewing environmental patterns such as window screens, garments, tablecloths, and ceiling tiles; the rest of the patients admitted that they preferred to avoid looking at patterned objects because these objects made them uncomfortable. The electroclinical features suggested juvenile myoclonic epilepsy in 14 patients, progressive myoclonus epilepsy in three, progressive familial cerebellar ataxia with myoclonus in two, and severe myoclonic epilepsy of infancy in one. During a median follow-up period of 15.7 years, 25 (45.5%) of 55 patients who were followed up for > or =5 years achieved complete seizure remission. The median age at remission was 24.4 years. The absence of progressive neurologic disease was correlated significantly with remission; a family history of seizures showed a trend in favor of remission. More than two thirds of the patients did not consider the seizures an impediment to their family life or to educational and occupational achievements. CONCLUSIONS: Although pattern sensitivity as a trait occurs in various epileptic syndromes, pattern-sensitive epilepsy is a readily distinguishable subtype of the visually provoked reflex epilepsies. In our opinion, the location and extent of the excitable region or regions within the visual cortex concerned with different attributes of visual function dictate susceptibility to a specific trigger (intermittent light, pattern, or color) or closely related multiple triggers and the resultant electroclinical phenomenon.     

The self-induction of epileptic seizures by eye closure

Of 22 consecutive epileptic patients sensitive to intermittent photic stimulation, 7 were found to induce paroxysmal activity and/or seizures by a slow closure of the lids accompanied by eye rolling, which in 6 of the 7 was totally different from the movement normally carried out on voluntary eye closure to command. To identify the syndrome it may be necessary to monitor the EEG and oculogram for some 10 min or longer with the eyes open in a well-lit environment.     

Ictal onset localization of epileptic seizures by magnetoencephalography

OBJECTIVES: The aim of this study was to localize the ictal onset zone of focal epileptic seizures by magnetoencephalography (MEG) and to compare the results with interictal MEG localizations, ictal and interictal electroencephalography (EEG) results and magnetic resonance imaging (MRI) in epilepsy surgery candidates. MATERIALS AND METHODS: Data of 13 patients with partial seizures during MEG recording were analysed. Measurements were performed with a Magnes II dual unit system. RESULTS: In six of 13 cases, the ictal onset zone could be localized by MEG, with all interictal MEG findings being confirmed by ictal MEG results. In four cases, the ictal MEG localization results were corresponding to the ictal EEG localization results. In two cases, EEG yielded no comparable information. CONCLUSION: Ictal onset localization is feasible with MEG. Both interical and ictal MEG contribute valuable information to the presurgical assessment of epilepsy patients.     

Auditory aura in frontal opercular epilepsy: sounds from afar

Auditory auras are typically considered to localize to the temporal neocortex. Herein, we present two cases of frontal operculum/perisylvian epilepsy with auditory auras. Following a non‐invasive evaluation, including ictal SPECT and magnetoencephalography, implicating the frontal operculum, these cases were evaluated with invasive monitoring, using stereoelectroencephalography and subdural (plus depth) electrodes, respectively. Spontaneous and electrically‐induced seizures showed an ictal onset involving the frontal operculum in both cases. A typical auditory aura was triggered by stimulation of the frontal operculum in one. Resection of the frontal operculum and subjacent insula rendered one case seizure‐ (and aura‐) free. From a hodological (network) perspective, we discuss these findings with consideration of the perisylvian and insular network(s) interconnecting the frontal and temporal lobes, and revisit the non‐invasive data, specifically that of ictal SPECT.     

Similarity of symptoms between transient epileptic amnesia and Lewy body disease

Epilepsy with the main symptom of amnesia is known as transient epileptic amnesia (TEA). Dementia with Lewy bodies (DLB) is the second most common form of neurodegenerative dementia. The concept that Lewy body disease includes Parkinson's disease with dementia and dementia with Lewy bodies was proposed in the 2005 revision of the Clinical Diagnostic Criteria. Here, we describe a woman with cognitive impairment, olfactory dysfunction, and reduced ¹²³I‐meta‐iodobenzylguanidine uptake on myocardial scintigraphy. The patient and her family and friends were unaware of parkinsonism, visual hallucinations, or epilepsy for a long period. After syncope occurred twice within a short interval, electroencephalography revealed sharp waves from the bilateral frontal to parietal lobes, indicating a diagnosis of TEA. The present case prompted us to compare the symptoms of TEA with the clinical diagnostic criteria for dementia with Lewy bodies, revealing their similarities. We also discuss whether Lewy body disease may cause TEA rather than having an incidental association with it.