Stereotypy of psychogenic nonepileptic seizures: Insights from video‐EEG monitoring

Purpose: To systematically study the semiology of psychogenic nonepileptic seizures (PNES) captured by video–electroencephalography (EEG) monitoring (VEM) and categorize the typical patterns observed. Methods: VEM records of patients who underwent evaluation from January 2002 to June 2007 were reviewed to identify those who had PNES with or without a background of epilepsy. The semiology of each event was visually analyzed and entered into a statistical database. Type of movement, anatomic distribution, synchrony, symmetry, onset, offset, course, duration, vocalization, hyperventilation, eye movements, and responsiveness were evaluated. PNES were classified into distinct groups according to the predominant motor manifestation. Results: A total of 330 PNES from 61 patients were studied. Based on semiology, six different types of PNES were observed as follows: (1) rhythmic motor PNES characterized by rhythmic tremor or rigor‐like movements (46.7%); (2) hypermotor PNES characterized by violent movements (3.3%); (3) complex motor PNES characterized by complex movements such as flexion, extension, abduction, adduction, rotation, with or without clonic‐like and myoclonic‐like components of varying combinations and anatomic distribution (10%); (4) dialeptic PNES characterized by unresponsiveness without motor manifestations (11.2%); (5) nonepileptic auras characterized by subjective sensations without any external manifestations, marked in the VEM records as “seizure button presses” (23.6%); and (6) mixed PNES where combinations of above seizure types were seen (5.2%). In a given patient, all the seizures belonged to a single type of PNES in 82% of cases. Discussion: PNES can be classified into six stereotypic categories. Contrary to common belief, PNES demonstrates stereotypy both within and across patients.     

Yield and cost‐effectiveness of tilt table tests combined with video‐EEG

Aim. To study the outcomes of a series of consecutive tilt table tests combined with video‐EEG (TTVE) at a single center, and assess their cost‐effectiveness compared with other neurophysiological tests. Methods. We retrospectively reviewed medical records of patients who underwent TTVE studies between March 1^st, 2013 to April 1^st, 2018. Detailed clinical history, including patient demographics, reasons for referral, anti‐seizure medications, and neurophysiological studies obtained prior to the TTVE studies were extracted from chart reviews. The fee for each neurophysiological test was identified from the Centers for Medicare & Medicaid Services. Results. Fifty‐two patients underwent TTVE studies. Thirteen patients (25%) were diagnosed with vasovagal syncope, two (3.8%) were diagnosed with postural orthostatic tachycardia syndrome, and three (5.8%) had psychogenic non‐epileptic events during the test. Four out of 12 patients stopped anti‐seizure medication(s) after the TTVE. Prior to referral for TTVE, an average of $3,748 per person was spent on neurophysiological tests, which were inconclusive. The average fee for one TTVE test was $535.32, and the fee per test affecting diagnosis or management (defined as the cost divided by the yield of the test) was $1,547. Conclusions. The TTVE test is cost‐effective in evaluating refractory episodes of loss of consciousness, atypical of epileptic seizures. In addition to diagnosing syncope, TTVE can be valuable in identifying psychogenic events.     

Self‐induction seizures in sunflower epilepsy: a video‐EEG report

Seizures triggered by visual stimuli are the most common type of reflex seizure. Self‐induced seizures produced by stimulation of natural light are rare and self‐induction is a mode of seizure precipitation employed by either intellectually disabled or healthy photosensitive individuals. Absences and myoclonic jerks are the most common seizure types in self‐induction. We report on a girl with normal intelligence who self‐induced seizures by waving her outspread fingers in front of a bright light. This situation is called sunflower epilepsy. [Published with video sequences]     

A comparison of continuous video‐EEG monitoring and 30‐minute EEG in an ICU

Aim. To determine whether there is added benefit in detecting electrographic abnormalities from 16–24 hours of continuous video‐EEG in adult medical/surgical ICU patients, compared to a 30‐minute EEG. Methods. This was a prospectively enroled non‐randomized study of 130 consecutive ICU patients for whom EEG was requested. For 117 patients, a 30‐minute EEG was requested for altered mental state and/or suspected seizures; 83 patients continued with continuous video‐EEG for 16–24 hours and 34 patients had only the 30‐minute EEG. For 13 patients with prior seizures, continuous video‐EEG was requested and was carried out for 16–24 hours. We gathered EEG data prospectively, and reviewed the medical records retrospectively to assess the impact of continuous video‐EEG. Results. A total of 83 continuous video‐EEG recordings were performed for 16–24 hours beyond 30 minutes of routine EEG. All were slow, and 34% showed epileptiform findings in the first 30 minutes, including 2% with seizures. Over 16–24 hours, 14% developed new or additional epileptiform abnormalities, including 6% with seizures. In 8%, treatment was changed based on continuous video‐EEG. Among the 34 EEGs limited to 30 minutes, almost all were slow and 18% showed epileptiform activity, including 3% with seizures. Among the 13 patients with known seizures, continuous video‐EEG was slow in all and 69% had epileptiform abnormalities in the first 30 minutes, including 31% with seizures. An additional 8% developed epileptiform abnormalities over 16–24 hours. In 46%, treatment was changed based on continuous video‐EEG. Conclusion. This study indicates that if continuous video‐EEG is not available, a 30‐minute EEG in the ICU has a substantial diagnostic yield and will lead to the detection of the majority of epileptiform abnormalities. In a small percentage of patients, continuous video‐EEG will lead to the detection of additional epileptiform abnormalities. In a sub‐population, with a history of seizures prior to the initiation of EEG recording, the benefits of continuous video‐EEG in monitoring seizure activity and influencing treatment may be greater.     

Seizures in the intrahippocampal kainic acid epilepsy model: characterization using long‐term video‐EEG monitoring in the rat

Objective – Intrahippocampal injection of kainic acid (KA) in rats evokes a status epilepticus (SE) and leads to spontaneous seizures. However to date, precise electroencephalographic (EEG) and clinical characterization of spontaneous seizures in this epilepsy model using long‐term video‐EEG monitoring has not been performed. Materials and Methods – Rats were implanted with bipolar hippocampal depth electrodes and a cannula for the injection of KA (0.4 μg/0.2 μl) in the right hippocampus. Video‐EEG monitoring was used to determine habitual parameters of spontaneous seizures such as seizure frequency, severity, progression and day–night rhythms. Results – Spontaneous seizures were detected in all rats with 13 out of 15 animals displaying seizures during the first eight weeks after SE. A considerable fraction (35%) of the spontaneous seizures did not generalize secondarily. Seizure frequency was quite variable and the majority of the KA‐treated animals had less than one seizure per day. A circadian rhythm was observed in all rats that showed sufficient seizures per day. Conclusions – This study shows that the characteristics of spontaneous seizures in the intrahippocampal KA model display many similarities to other SE models and human temporal lobe epilepsy.     

The prevalence of seizures in comatose children in the pediatric intensive care unit: A prospective video‐EEG study

Purpose: Studies in adult and neonatal intensive care units (ICUs) report a high prevalence of epileptic seizures in comatose patients. The prevalence of seizures in pediatric ICUs is variably reported in a few retrospective studies using different electroencephalography (EEG) methods. We aimed to determine prospectively the prevalence of epileptic seizures (clinical and subclinical) in comatose children in the pediatric ICU using continuous video‐EEG (v‐EEG) monitoring. Methods: We performed v‐EEG in consecutive children aged 2 months to 17 years admitted to the pediatric ICU with sustained depressed consciousness over a period of 15 months. Results: We monitored 100 comatose children, 69% within 24 h of ICU admission. Median length of ICU stay was 5 days. Median duration of v‐EEG was 20 h. Epileptic seizures were identified in only seven patients, of whom six had a history of epilepsy with witnessed seizures immediately prior to v‐EEG. All epileptic seizures were recorded in the first 3 h of v‐EEG. Seizures were suspected by ICU staff in 18 monitored patients, only four of whom had confirmed epileptic seizures. Discussion: The lower prevalence of epileptic seizures and the shorter length of ICU stay in children compared to adults and neonates suggest a different spectrum of disease and neurologic response. Short‐duration v‐EEG in patients with a history of prior seizures, epilepsy, or clinical events suspected to be seizures seems more appropriate than routine v‐EEG in all comatose children in the pediatric ICU.     

Lingual epilepsia partialis continua: a detailed video‐EEG and neuroimaging study

Motor epilepsia partialis continua (EPC) is a frequent and widely described variant of simple focal motor status epilepticus. However, lingual EPC is an unusual epileptic condition. We present a case of lingual EPC secondary to low‐grade glioma in which the EEG and neuroimaging features were particularly remarkable. The video‐EEG showed lateralized periodic discharges with superimposed rhythmic activity and frequent recurrent focal epileptic seizures. Moreover, brain magnetic resonance imaging showed a right temporo‐insular cortico‐subcortical lesion which was hyperintense on FLAIR, suggestive of low‐grade glioma. In addition, diffusion‐weighted imaging and arterial spin labelling series showed restricted diffusion in the right temporo‐insular and parietal cortex and increased cerebral flow, respectively. All these findings are in keeping with changes related to persistent focal status epilepticus. Finally, we review the literature and discuss the differential diagnosis of this rare epileptic entity. [Published with video sequence].     

Occurrence of epileptiform activity in the routine EEG of epileptic patients

In a retrospective study, the occurrence of epileptiform activity (EA) in routine EEG records of epileptic patients was investigated. Data were obtained from 1078 EEGs of 373 patients (199 men and 174 women; aged 17-87 (mean 34.2 +/-14.7)). The percentage of 38% of patients with EA in a single EEG could be increased to 77% by repeated records. After the 5th record however, the gain in new information decreased remarkably. No differences between seizure types could be detected. There was a relationship between EA and nonspecific EEG abnormalities. High EA rates were found for short time intervals since last seizure, young patients, long durations of the seizure disorder and for high seizure frequencies.     

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.     

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.     

Rapid loading of intravenous lacosamide: Efficacy and practicability during presurgical video‐EEG monitoring

Purpose: This study investigates immediate efficacy and safety of intravenous application of de novo lacosamide (LCM) as add‐on therapy in patients with pharmacoresistant focal epilepsy. Methods: During presurgical video–electroencephalography (EEG) monitoring, 17 adult inpatients received LCM infusion (200 mg every 12 h for 2–3 days) followed by oral formulation with the same regimen. Before and after intravenous application of LCM, seizures and interictal epileptiform discharges (IEDs) recorded with continuous video‐EEG monitoring were analyzed, and an assessment of adverse events (AEs) was performed daily. To evaluate the midterm tolerability and efficacy, follow‐up visits were conducted 1 and 3 months after discharge from hospital. Key Findings: In the acute phase, intravenous initiation of LCM was well tolerated with few mild or moderate AEs (3 of 17, 17.6%). A significant reduction of seizure frequency in the treatment phase as compared to mean seizure frequency in the 2‐day baseline phase was achieved (p < 0.05 for the first treatment day, and p < 0.005 for the second treatment day). On the first treatment day, 61.5% of the patients were seizure free, and 84.6% on the second treatment day. IED reduction after intravenous application of LCM was not significant. After 1 month, the 50% responder rate was 46.6% and after the 3‐month period, 42.8%. Significance: Our data suggest that rapid intravenous initiation of de novo LCM is safe and may protect against seizures in a rapid and midterm time window.     

Noninvasive continuous functional near‐infrared spectroscopy combined with electroencephalography recording of frontal lobe seizures

Purpose: To investigate spatial and metabolic changes associated with frontal lobe seizures. Methods: Functional near‐infrared spectroscopy combined with electroencephalography (EEG‐fNIRS) recordings of patients with confirmed nonlesional refractory frontal lobe epilepsy (FLE). Key Findings: Eighteen seizures from nine patients (seven male, mean age 27 years, range 13–46 years) with drug‐refractory FLE were captured during EEG‐fNIRS recordings. All seizures were coupled with significant hemodynamic variations that were greater with electroclinical than with electrical seizures. fNIRS helped in the identification of seizures in three patients with more subtle ictal EEG abnormalities. Hemodynamic changes consisted of local increases in oxygenated (HbO) and total hemoglobin (HbT) but heterogeneous deoxygenated hemoglobin (HbR) behavior. Furthermore, rapid hemodynamic alterations were observed in the homologous contralateral region, even in the absence of obvious propagated epileptic activity. The extent of HbO activation adequately lateralized the epileptogenic side in the majority of patients. Significance: EEG‐fNIRS reveals complex spatial and metabolic changes during focal frontal lobe seizures. Further characterization of these changes could improve seizure detection, localization, and understanding of the impact of focal seizures.     

Defecation reflex seizures: a case report with long‐term VEEG monitoring,neuroimaging and comprehensive epilepsy evaluation

Reflex seizures are consistently elicited by a specific afferent sensory stimulus or an activity undertaken by the patient. Among many known stimuli, defecation has rarely been reported. We describe the case of a child with reflex seizures triggered by defecation, considering the diagnostic challenge, epilepsy evaluation with video‐EEG monitoring, as well as impact on neuropsychology, behaviour and quality of life. The child was a 10‐year‐old boy with seizure onset at age four with epilepsy diagnosis established one and a half years later. Seizures were focal with impaired awareness triggered by defecation. Video‐EEG and structural and functional neuroimaging were performed and all pointed to the left temporal region. The patient became seizure‐free with carbamazepine and valproic acid. Neuropsychological and quality of life assessments suggested global impairment, both before and after seizure control. This is the third case of epilepsy induced by defecation reported in the literature. The rarity of this entity may be a diagnostic challenge and postpone specific treatment. Reporting of cases of defecation reflex epilepsy may provide a better understanding of its physiopathology and optimize effective treatment, avoiding cognitive, behavioural and poor social consequences. [Published with video sequence]