So-called “Petit Mal Status”: Epileptic syndrome or seizure type?

In 1945, Lennox was the first to describe the epileptic states mainly expressed by various degrees of consciousness disturbance, which have their onset in children who present epileptic absences correlated with ictal EEG patterns of spike-wave complex discharges at about 3 Hz. As the clinical picture seemed to be similar to an uninterrupted series of absences, this led to the definition “Petit Mal Status” (PMS). Many authors have subsequently reported that PMS can occur in epileptic subjects who have never presented absences (and even in subjects without a previous history of epilepsy) and that the related EEG pictures were characterised by paroxysmal generalized activity of various morphology, but hardly ever consisted of the continuous rhythmic spike-wave or polyspike-wave complexes at 3 Hz found in petit mal absences. Finally, in reporting the onset and recurrence of this condition typically in adults and the elderly, some authors have proposed the existence of a particular form of PMS (dependent on different types of pathologic factors and characterising a specific syndrome of this age) that is different from that of the “real PMS” typical of childhood and related to petit mal absences. This paper describes fifteen patients in whom the onset of the condition occurred at different ages, and who seem to exemplify the various possible clinical expressions of PMS, with the aim of making a contribution towards the better nosographic definition of this epileptic condition. On the basis of our study, we sustain that the so-called PMS is a seizure type of Idiopathic Generalized Epilepsy which may appear at nearly all ages, and may occur in isolation or in association with other epileptic manifestations, but cannot itself be considered as characterising one or more age-dependent syndromes.     

A Comparison Between Etomidate and Methohexital for Anesthesia in ECT

Twenty patients were enrolled in a prospective, randomized, open vial, within-patient, crossover design study of methohexital and etomidate anesthesia for electroconvulsive therapy (ECT). Methohexital (1.0 mg/kg) and etomidate (0.3 mg/kg) were each given for two ECTs. While there were no differences in hemodynamics between the etomidate and methohexital groups, etomidate had a 24% longer mean wakeup time than methohexital. There was no difference between etomidate and methohexital in recovery room stay, induction time, or seizure duration. There was no difference in cardiac rhythms. More patients had pain on injection with etomidate than with methohexital. Increased incidence of pain on injection and a longer initial wakeup time are drawbacks to etomidate, but etomidate compared favorably to methohexital in hemodynamics. Etomidate is an acceptable alternative to methohexital, especially when barbiturates may be contraindicated.     

EEG-Monitored ECT: A Comparison of Seizure Duration under Anesthesia with Etomidate and Thiopentone

Electroencephalogram-monitored electroconvulsive therapy (ECT) was carried out in 20 depressed inpatients. Before treatment, patients were randomly allocated to treatment using etomidate (Hypnomidat) (n = 10) or thiopentone (n = 10) for anesthesia. The groups were matched for sex, age, weight, and type and severity of depression. The seizure duration (seconds) was measured by electroencephalography (EEG), and the electrical energy (Joules, J) was determined for each treatment. A ratio of seizure duration:electrical energy (s/J) was computed. Both seizure duration and seizure duration:electrical energy were greater in the etomidate group than in the thiopentone group, whereas electrical energy did not differ significantly. The number of treatments in the etomidate group did not differ from that in the thiopentone group, as may be expected, perhaps because of the small size.     

The decision to use ECT: A retrospective study

There is a paucity of literature on electroconvulsive therapy (ECT) utilization in hospitals. No mention occurs in major psychiatric texts.^1,2 Fink³ found only three studies.^4–6 Hedlund et al.⁷ reported on the declining use of ECT in Missouri from 1971 to 1975. All these studied agree that there are low use rates in public hospitals (0.1%–1.7%) and much higher rates in private hospitals (5.2%–28.0%).ECT has been used in two different settings at Long Island Jewish-Hillside Medical Center, a private, nonprofit voluntary hospital. The Hillside Division has 202 psychiatric beds with treatment provided by salaried staff. Long Island Jewish (LIJ) has 490 beds, 20 of which are for treating psychiatric inpatients by private attending physicians. Between April 17, 1973, and July 19, 1976, 69 of 4,236 Hillside inpatients (1.16%) and 115 of 969 LIJ inpatients (12.1%) received at least one ECT treatment. The Hillside rate was indistinguishable from the public hospital rate and significantly different (χ² ? 247.5, df = 1, p < 0.0001) from the higher LIJ rate which was consistent with rates found in private hospitals.This retrospective study was undertaken to assess preliminarily what factors may have affected the decision to use ECT at the Medical Center, with the expectation that it might help explain the different utilization rates reported in the literature.Another purpose for the study related to the problem of predicting improvement from using ECT. Attempts at predicting improvement have met with variable success.^8–11 Mendel^12–15 has developed and validated a weighted factor index to predict improvement which appeared promising. We attempted to replicate his approach on the Hillside sample. Replication for the LIJ ECT-treated patients was not possible due to insufficient data.     

The sham ECT literature: implications for consent to ECT

The author reviewed the placebo-controlled literature on electroconvulsive therapy (ECT) for depression. No study demonstrated a significant difference between real and placebo (sham) ECT at 1 month posttreatment. Many studies failed to find a difference between real and sham ECT even during the period of treatment. Claims in textbooks and review articles that ECT is effective are not consistent with the published data. A large, properly designed study of real versus sham ECT should be undertaken. In the absence of such a study, consent forms for ECT should include statements that there is no controlled evidence demonstrating any benefit from ECT at 1 month posttreatment. Consent forms should also state that real ECT is only marginally more effective than placebo.     

Movement-Induced Seizures: A Case Report

: Reflex seizures induced by movement are typically evoked by sudden or unattended motor actions. However, tonic seizures may also be triggered by slow movements as observed in nonketotic hyperglycemia or in “praxis-induced epilepsy.” We report the case of a young, nondiabetic patient affected by recurrent partial tonic postural seizures precipitated by slow movements which were unrelated to cognitive tasks. Ictal EEG did not permit location of the epileptogenic brain region. However, the clinical features suggest possible involvement of the supplementary motor area.     

A Systems-Level Approach to Human Epileptic Seizures

Epileptic seizures are due to the pathological collective activity of large cellular assemblies. A better understanding of this collective activity is integral to the development of novel diagnostic and therapeutic procedures. In contrast to reductionist analyses, which focus solely on small-scale characteristics of ictogenesis, here we follow a systems-level approach, which combines both small-scale and larger-scale analyses. Peri-ictal dynamics of epileptic networks are assessed by studying correlation within and between different spatial scales of intracranial electroencephalographic recordings (iEEG) of a heterogeneous group of patients suffering from pharmaco-resistant epilepsy. Epileptiform activity as recorded by a single iEEG electrode is determined objectively by the signal derivative and then subjected to a multivariate analysis of correlation between all iEEG channels. We find that during seizure, synchrony increases on the smallest and largest spatial scales probed by iEEG. In addition, a dynamic reorganization of spatial correlation is observed on intermediate scales, which persists after seizure termination. It is proposed that this reorganization may indicate a balancing mechanism that decreases high local correlation. Our findings are consistent with the hypothesis that during epileptic seizures hypercorrelated and therefore functionally segregated brain areas are re-integrated into more collective brain dynamics. In addition, except for a special sub-group, a highly significant association is found between the location of ictal iEEG activity and the location of areas of relative decrease of localised EEG correlation. The latter could serve as a clinically important quantitative marker of the seizure onset zone (SOZ).     

Propofol interruption of ECT seizure to reduce side-effects: A pilot study

Fifteen depressed subjects received six bitemporal electroconvulsive therapy (ECT) treatments under etomidate anesthesia. They were randomized to blindly either receive propofol 0.5 mg/kg 15 s post-stimulus or not. Propofol infusion significantly prevented long seizures, and prevented cognitive decrements in most neuropsychological tests, several significantly. Propofol interruption may clinically help reduce ECT side-effects.     

Posttraumatic Pilomotor Seizures: A Case Report

Pilomotor epilepsy is a rare phenomenon. A 35-year-old man suffered a traumatic contusion of the right temporal lobe and subsequently developed spells characterized by diffuse piloerection and sweating. We believe this to be the first reported association between pilomotor epilepsy and posttraumatic head injury. Although pilomotor seizures may result from diverse etiologies, they appear to have a common involvement of temporolimbic structures.