Seizures in neurofibromatosis 1

Neurofibromatosis 1 is a common, genetically transmitted neurodevelopmental disorder with a high potential to cause subcortical focal brain lesions. Although seizures occasionally complicate neurofibromatosis 1, they have not been characterized adequately in the disease. Other phacomatoses with attendant subcortical focal brain lesions have been associated with an evolution from generalized to focal-onset epilepsy. This evolution may be related to the cortical dysplasias that also appear in such disorders. Cortical dysplasias, although occasionally found in neurofibromatosis 1 epileptic patients, are not as frequent as in other phacomatoses. The authors retrospectively screened 499 neurofibromatosis 1 patients for the prevalence and etiology of seizures, their response to therapy, and the evolution of seizure type over time. The prevalence of epileptic seizures (4.2%) was about twice the prevalence in the general population. There were no significant cortical dysplasias identified radiographically nor was there a relationship among the presence of subcortical focal brain lesions and seizure type, response to treatment, or evolution of epilepsy in the neurofibromatosis 1 population. The authors’ data do not suggest an ontogeny of epilepsy in neurofibromatosis 1 that is different from the general epileptic population.     

Should alcohol withdrawal seizures be treated with anti-epileptic drugs?

Seizures and delirium tremens were recorded among 292 randomly selected patients admitted to an in-patient alcoholism program. Despite the almost routine prophylactic use of anticonvulsant and sedative drugs the incidence of seizures and delirium tremens during detoxification in hospital was 3%. However, as most alcohol withdrawal seizures occurred immediately before admission, the overall seizure incidence was higher (10%). Those patients who developed seizures during detoxification admitted previous abuse of benzodiazepines or erratic use of phenytoin. The results suggest that prescribing of anticonvulsants to alcoholics may increase their seizure problems, because they are prone to erratic drug taking, and because of drug-alcohol interactions, increased drug metabolism and abuse of the sedative anticonvulsants.     

Epileptic seizures and alcohol withdrawal: Significance of additional use (and misuse) of drugs and electroencephalographic findings

In a retrospective study, the prevalence of epileptic seizures during alcohol withdrawal was studied in 906 chronic alcoholic patients admitted for detoxification: the prevalence rate for seizures was 15.0%; no sex differences could be found. There was a history of additional drug abuse (predominantly of benzodiazepines) in 41.3% of all patients. These findings were corroborated by chemical—toxicological urinary control. Alcoholics with additional drug abuse suffered significantly more often from epileptic seizures than alcoholics without drug abuse (p < 0.001). Most EEG findings showed no abnormalities; specific paroxysmal discharges could not be found at all. Nonspecific EEG findings could be found significantly more often in patients with epileptic seizures (p < 0.001) rather than in seizure-free alcoholics.     

Parietal and Occipital Lobe Epilepsy: A Review

Summary: Parietal and occipital seizures have been investigated relatively little. Recent interest in seizures of frontal lobe origin has led to a definition of several well-identifiable clinical patterns of frontal lobe seizures. A similar delineation of the clinical and EEG pattern of parietal and occipital epilepsy, using modern investigations, appears appropriate, not least because the few reported series of surgical treatment in parietal and occipital epilepsy have indicated that operation may be relevant in selected cases, not only for removal of space-occupying lesions. Such a study is currently being undertaken at the National Hospital for Neurology and Neurosurgery and The Chalfont Centre for Epilepsy with the aim of developing and evaluating diagnostic criteria for these seizures. From the existing literature we can conclude that precise incidence and prevalence are largely unknown. A recent community-based study of 252 subjects with partial epileptic seizures in an epileptic population of 594, showed that parietal seizures and seizures of posterior origin each comprised 6.3% and central or sensory-motor seizures comprised 32.5% of focal seizures in the 160 cases in which seizures could be subclassified (Manford et al., 1992). This incidence seems low for occipital seizures as compared with the 1953 study by Gibbs and Gibbs, who observed occipital epileptiform activity in 8% of subjects with focal epilepsy. The most prominent clinical manifestations of parietal epilepsy are elementary sensory phenomena at the beginning of seizures and elementary visual hallucinations in occipital epilepsy. These symptoms are not associated solely with posterior hemisphere epilepsy, however, and more studies are obviously needed to define how close this relation is. Scalp EEG is frequently negative or maybe misleading; further-more, spread of epileptic discharges from the parietal and occipital lobes to frontal and temporal regions may obscure seizure origin. Because of these controversial symptoms, diagnostic criteria may be difficult to define. The wide difference in clinical and EEG manifestations between reported series of parietal and occipital epilepsy also reflects a considerable problem with patient sampling. Classification of epilepsy according to the anatomic division of the brain may be arbitrary, and it may be appropriate to define epileptic syndromes such as sensorimotor seizures or occipitotemporal seizures that cross such artificial divides.     

Cerebral seizures, alcoholism, and deliria (author's transl)]

The occurrence of cerebral seizures in alcoholics was investigated in case histories of 84 delirious and nondelirious male patients. Eighteen patients had seizures before they became alcoholics; the frequency of the seizures increased during abuse. Twelve had no deliria at all up to the moment of this investigation; in 66 of the patients the occurrence of seizures was assumed to be caused by alcohol abuse alone. Seventy-one patients had seizures irrespective of deliria and nearly 40% of them had no deliria at all. In 21% we observed only deliria with seizures; in 16% only deliria without seizures; and 24% had deliria both with and without seizures. The remaining 13 patients of 84 had only deliria complicated by cerebral seizures; only 3 had deliria without seizures. The seizures occurred as grand mal in 94% of the alcoholics, in all patients with genuine epilepsy, and in 60% of the patients with post-traumatic epilepsy.     

Alcohol and Marijuana: Effects on Epilepsy and Use by Patients with Epilepsy

We review the safety of alcohol or marijuana use by patients with epilepsy. Alcohol intake in small amounts (one to two drinks per day) usually does not increase seizure frequency or significantly affect serum levels of antiepileptic drugs (AEDs). Adult patients with epilepsy should therefore be allowed to consume alcohol in limited amounts. However, exceptions may include patients with a history of alcohol or substance abuse, or those with a history of alcohol-related seizures. The most serious risk of seizures in connection with alcohol use is withdrawal. Alcohol withdrawal lowers the seizure threshold, an effect that may be related to alcohol dose, rapidity of withdrawal, and chronicity of exposure. Individuals who chronically abuse alcohol are at significantly increased risk of developing seizures, which can occur during withdrawal or intoxication. Alcohol abuse predisposes to medical and metabolic disorders that can lower the seizure threshold or cause symptoms that mimic seizures. Therefore, in evaluating a seizure in a patient who is inebriated or has abused alcohol, one must carefully investigate to determine the cause. Animal and human research on the effects of marijuana on seizure activity are inconclusive. There are currently insufficient data to determine whether occasional or chronic marijuana use influences seizure frequency. Some evidence suggests that marijuana and its active cannabinoids have antiepileptic effects, but these may be specific to partial or tonic-clonic seizures. In some animal models, marijuana or its constituents can lower the seizure threshold. Preliminary, uncontrolled clinical studies suggest that cannabidiol may have antiepileptic effects in humans. Marijuana use can transiently impair short-term memory, and like alcohol use, may increase noncompliance with AEDs. Marijuana use or withdrawal could potentially trigger seizures in susceptible patients.     

Medical and social aspects of epilepsy (author's transl)]

A review of social aspects of epilepsy is given. Similar to the own experience the literature shows only little social prestige given to patients with epilepsy, an experience known from persons with psychiatric disorders. The prevalence rate for chronic epilepsy is 0.5%. So called genuine seizures decreased with diagnostic progress during the last years (about 50%). Lower social classes and negative social patterns are characteristic of employees with epileptic fits. Unemployed persons show normal social structure. A relation to social class and onset of epilepsy exists. Epileptics are socially immobile. Like other persons with chronic diseases epilepsy produces a special social attitude and often negative therapeutic motivation. In contrast to the literature non-hospitalized epileptics show normal intelligence. Neurotic symptoms are seen in many cases however (about 40%). Often social disturbances origin from broken home situations. There is no specific social and mental defect. According to the own experience social integration of epileptics depends upon the local economic structure. The common prejudice varies with the local area. Social drop-outs are not due to the seizures, but occur mainly in mentally retarded persons who are not able to follow therapeutic regimens. Delinquency is increased among the own patients (18%). The causes are psychoorganic syndromes, often in connection with negative therapeutic motivation and alcoholism. The tendency to specific crimes, known from the literature, could not be confirmed. Forensic problems in direct connection with epileptic fits are rare. Medical problems concerning ability to drive often occur. Many patients possess a driver licence (46.5%), gained after onset of epilepsy in 50%. But the accident rate is lower than in the general population. Special outpatient departments and therapeutic groups for epileptics--affiliated to neurological centers--can improve the exact diagnosis, therapeutic motivation and social integration.     

Prevalence and Prognosis of Epilepsy in Patients with Multiple Sclerosis

An analysis of 599 clinically definite multiple sclerosis (MS) patients including all known cases of the southern province of Finland in January 1, 1979 revealed epileptic seizures in 21 (3.5%) patients. On that date, 12 patients needed treatment (2.0%). The age-adjusted prevalence of active epilepsy was significantly higher than that in the general population. The percentage of partial seizures (67%) was significantly increased in proportion to a series of 100 adult epilepsy patients, with a comparable age distribution. In 10 patients (including three patients with symptomatic epilepsy), the attacks appeared before the MS symptoms. The mean follow-up after the first seizures was 19.3 years. In 10 patients, the seizures disappeared totally during the surveillance until September 1985. Our results show an increased comorbidity between MS and epilepsy. In most cases, however, the prognosis of epilepsy was good and there seemed not to be any clear correlation between the severity of MS and epilepsy.     

Neurobiology of Behavior: Anatomic and Physiological Implications Related to Epilepsy

Summary: Controversy exists concerning whether epileptic seizures can produce enduring alterations in neuronal function that cause interictal behavioral disturbances. Although arguments favoring the occurrence of epilepsy-induced disorders of behavior must not be presented in a way that adds to the stigmata associated with epilepsy, it is not in the best interest of epileptic patients to deny this possible relationship and overlook an opportunity to prevent or treat a major cause of disability. There is evidence to suggest that psychosocial factors cannot account for all the behavioral problems suffered by patients with epilepsy. Behavioral disturbances ascribed to antiepileptic drugs and specific structural lesions may also be due, in part, to epileptogenic mechanisms. Some interictal behavioral disturbances may actually reflect unrecognized ictal events. Most importantly, data obtained from clinical research and animal investigations suggest testable hypotheses of how recurrent epileptic seizures can alter neuronal function in ways that would predispose to specific disruptive interictal behaviors, such as aggression, depression and schizophrenia.     

Expanding the theory of symptom modeling in patents with psychogenic nonepileptic seizures

Symptom modeling has been used to explain the development of psychogenic nonepileptic seizures (PNES) in predisposed patients, but has been understood only in the context of individuals who have both PNES and epileptic seizures. Our aim in the study described here was to learn whether this concept applies to patients with PNES who do not have epileptic seizures, that is, to determine whether the prevalence of having personally witnessed a seizure prior to the occurrence of their event differs in patients with PNES and those with epileptic seizures. We interviewed 27 patients with PNES and 35 patients with epileptic seizures. A significantly larger number of patients with PNES (66%) admitted to having witnessed a seizure prior to their event compared with patients with epileptic seizures (11%) (P < 0.001). This suggests that symptom modeling plays a key role in the development of PNES, even among individuals without a coexisting history of 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.     

Alcoholism and panic disorder: is the comorbidity more than coincidence?

Studies on alcoholic patients have found a higher than expected prevalence of panic disorder, and suggest a positive correlation between the level of alcohol consumption and severity of anxiety. Conversely, there is an increased prevalence of alcoholism among patients with panic disorder and their blood relatives. A comparison of symptoms, physiological and neurochemical changes known to occur in both alcohol withdrawal and panic disorder reveals a degree of similarity between the 2 conditions. Based on the data, we propose that the chemical and cognitive changes occurring as the result of repeated alcohol withdrawals may kindle and condition coincidence of panic attacks in susceptible individuals. Implications of our postulates for treatment of alcohol withdrawal and panic disorder in alcoholics and for future studies are discussed.     

Seizures in fetal alcohol spectrum disorders: Evaluation of clinical,electroencephalographic, and neuroradiologic features in a pediatric case series

Seizures are observed with a frequency of 3–21% in children with fetal alcohol spectrum disorders (FASD). However, clinical, neuroradiologic, and electroencephalography (EEG) features are poorly described. In this study, 13 patients with FASD and epilepsy or seizures were identified retrospectively from the databases of seven Italian pediatric neurology divisions. Eleven children were affected by epilepsy, and two had at least one documented seizure. Both generalized and focal seizures were observed. EEG showed diffuse or focal epileptic activity; two children developed electric status epilepticus during sleep (ESES). Structural brain anomalies, including polymicrogyria, nodular heterotopia, atrophy, and Arnold‐Chiari type 1 malformation, were discovered in almost 50% of patients. Control of seizures was not difficult to obtain in 11 cases; one patient showed pharmacoresistant epilepsy. EEG and clinical follow‐up are recommended in children with FASD and epilepsy, since severe conditions requiring aggressive treatment, such as in ESES, may develop. Neuroradiological evaluation is warranted because several types of brain anomalies could be associated with maternal alcohol consumption during pregnancy. A PowerPoint slide summarizing this article is available for download in the Supporting Information section here .     

Frequency of provocative factors in epileptic patients admitted for seizures: a prospective study in Singapore.

Intractable epilepsy is commonly believed to be the main cause of uncontrolled seizures and hospitalization in epileptic patients. We study frequency and types of potential provocative factors in epileptic patients admitted with seizures, and suggest methods to decrease seizure occurrence and hospitalization. Over 6 months we prospectively studied all epileptic patients hospitalized for seizures. A structured interview and laboratory investigations were used to determine type and number of potential seizure precipitants. Precipitants thought to be avoidable through actions taken by the patient or physicians were termed potentially preventable provocative factors (PPPF). Patients' awareness and knowledge of seizure precipitants were also assessed. Three quarters of all seizures leading to admission were associated with PPPF, the commonest being non-compliance (71%), sub-therapeutic doses of antiepileptic drugs (26%) and sleep deprivation (9%). Only one patient had intractable epilepsy. Patients' knowledge of seizure precipitants was poor. The majority of hospital admissions for seizures in epileptic patients are associated with potentially preventable causes amenable to education programmes. Patient education involving epilepsy nurse educators may play an important role in decreasing seizure occurrence and possibly unnecessary hospital admissions.     

Epilepsy surgery in patients with additional psychogenic seizures.

OBJECTIVE: To assess whether surgery to reduce or control epileptic seizures is safe and effective in patients known to have additional psychogenic seizures. DESIGN: We reviewed our computerized database of 1342 patients examined for epilepsy surgery and identified 13 patients with both epileptic and psychogenic seizures on whom postoperative outcome data were available. Data were gathered from the patients' records. Mean postoperative follow-up was 56 months. RESULTS: Epilepsy surgery led to clinically relevant improvements in 11 of 13 patients. Seven patients became free of epileptic and psychogenic seizures, 2 patients became free of epileptic seizures but continued to have infrequent psychogenic seizures, 1 patient reported more than an 80% improvement in epileptic seizure frequency and an abolishment of psychogenic attacks, and in 1 patient nondisabling epileptic seizures persisted at lower frequency but psychogenic seizures stopped. In 2 of 13 patients, epilepsy surgery failed to produce notable improvements. Although 1 patient became free of epileptic attacks and the other had fewer than 3 epileptic seizures per year, the severity or frequency of psychogenic seizures and pseudo-status epilepticus increased postoperatively. One of these patients had a preoperative diagnosis of somatization disorder; in the other, pathological illness behavior had been noted. CONCLUSION: A diagnosis of additional psychogenic seizures should not be considered an absolute contraindication to epilepsy surgery, although patients should undergo careful preoperative psychiatric evaluation.     

Seizures in multiple sclerosis

PURPOSE: In patients with multiple sclerosis (MS), epileptic seizures occur more frequently than in the general population. The aim of this study was to analyze clinical characteristics of epilepsy in patients with MS, potential correlation between the semiology of seizures, EEG and magnetic resonance imaging (MRI) findings in these patients, as well as to examine the response to anticonvulsant therapy. METHODS: In a series of 268 consecutive patients with definite MS hospitalized at the Institute of Neurology, Belgrade, we identified 20 (7.5%) patients with seizures or epilepsy. All patients with seizures or epilepsy were submitted to standard EEG and brain MRI with gadopentetate dimeglumine. RESULTS: In four patients, epilepsy occurred 1-5 years before other clinical manifestations of MS. Eight patients had seizures only during MS relapses (provoked seizures). In two of them, seizures were the only manifestations of relapse. In 12 patients, seizures occurred regardless of the phase of MS (chronic epilepsy). In the majority of patients, seizures were partial with secondary generalization. Five patients experienced episodes of status epilepticus, and they all had dementia. Abnormal EEG pattern was found in 11 patients. Brain MRI disclosed cortical-subcortical lesions in nine patients and focal cortical atrophy in one, whereas in the remaining patients, findings were inconclusive. Probable EEG-MRI-seizure type correlation existed in 10 patients. CONCLUSIONS: Our data suggest that epilepsy may represent an initial symptom of MS and a single clinical manifestation of a relapse, and further support the assumption of the existing correlation between the presence of cortical-subcortical lesions and epileptic seizures or epilepsy in patients with MS.     

A house-to-house survey of epileptic seizures in an urban community of Rio de Janeiro,Brazil

OBJECTIVE: To carry out a prevalence study about epileptic seizures and epilepsy in an urban low-income population. METHOD: Prevalence study in a two-phase model: screening and diagnosis confirmation. It was applied a structured questionnaire in 982 people all effectively resident on March 1st 2000 based on a population census previously carried out by the Nurse Faculty. One neurologist interviewed all the suspected cases. RESULTS: It was detected 176 suspected cases of epileptic seizures: 156 with non-epileptic events, and 20 with epileptic seizures. The lifetime point prevalence was of 16.3 cases per 1000 inhabitants, and of active epilepsy, 5.1 / 1000. If we consider false negative diagnosis from the screening procedures, the lifetime point-prevalence rates until 20.8/1000. CONCLUSION: The prevalence data of epilepsy shows less impressive than in other Latin-American studies and even some Brazilian, but similar to other Brazilian studies. This suggests geographical diversity and/or methodological differences among studies. Anyway, probably the epilepsy prevalence in Rio de Janeiro is not so high as that found in the Latin countries rural areas.     

Is Schizophrenia a Risk Factor for Epilepsy or Acute Symptomatic Seizures?

PURPOSE: The precise prevalence of epilepsies and seizures in patients with schizophrenia remains unclear. METHODS: To assess the prevalence of epilepsy and of acute symptomatic seizures in schizophrenics, we conducted a survey in a urban sector of Marseilles that includes 56,910 inhabitants, among whom 1,154 had been treated for psychiatric disorders, including 460 for schizophrenia or paranoid disorder (PD) (DSM III-R 295 and 297.1, respectively; mean age, 41.9 years; range, 17-79 years; 215 men and 245 women). RESULTS: All 460 patients were receiving long-term neuroleptic drug therapy, and 397 had been hospitalized at least once in the past year, whereas 63 were followed up as outpatients only. Seizures were present in the history of 12 patients: five had various forms of chronic epilepsy (four men, one woman; DSM III-R 295.1, one case; 295.3, two cases; 295.9, two cases), and three of these experienced seizures only after the onset of their psychiatric condition; five had acute symptomatic seizures (four men, one woman; 295.1, two cases; 295.3, 295.9, and 297.1, one case), and two had only pseudoepileptic events (both 295.3). CONCLUSIONS: This survey shows that the prevalence of epilepsy and acute symptomatic seizures is comparatively low in patients with schizophrenia or PD (10.8 per thousand each, respectively), and that the prevalence of a history of seizures (21.7 per thousand in this study) is not particularly increased in this middle-aged population. In contrast to childhood-onset autistic disorders, schizophrenia or PD are not major risk factors for epilepsy or acute symptomatic epileptic seizures.     

The characteristics of epilepsy in a largely untreated population in rural Ecuador.

A house-to-house survey of epileptic seizures covering a population of 72,121 persons was carried out in a rural area of northern Ecuador. A cascade system of diagnosis was used to identify all cases of epileptic seizures in this population. 1029 cases were found, of whom 881 were considered to be definite cases and 148 were possible cases. Of the 1029 cases, 56% had active epilepsy. The lifetime prevalence rate was found to lie between 12.2 and 19.5/1000 and the prevalence of active cases between 6.7 and 8.0/1000. An annual incidence rate of between 122/100,000 and 190/100,000 was estimated. Seizure type was classified without EEG data and almost half of the cases had partial seizures. In 27% of cases an aetiology was proposed on clinical grounds. This is one of few reported studies of a population that has been largely unexposed to antiepileptic drugs, providing an opportunity to study the natural history of the untreated condition. It has been suggested that treatment in newly developing epilepsy will prevent its development to a chronic condition. Only 37% of the 1029 cases had ever received antiepileptic drugs, and only 12% of the cases were taking them at the time of the survey. Despite this, a high rate of inactivity was observed, with 44% of all cases free of seizures. Nearly two thirds of the inactive cases identified had never received treatment with antiepileptic drugs. In a subgroup of untreated cases with an active condition, treatment with antiepileptic drugs was initiated and was highly effective even in cases with a long previous history. Thus the findings from this study suggest that the development of epilepsy resistant to therapy is not always associated with a long duration of untreated epilepsy.