Clinical Neurophysiology: EEG–Video Monitoring

Abstract

1 Elaine C. Wirrell, and 2 Christina Cheung ( 1 Pediatrics and Clinical Neurosciences, University of Calgary, Calgary, AB, Canada ; and 2 Faculty of Medicine, Queens University, Kingston, ON, Canada ) Rationale: Adolescent perception of physical and social impact of chronic illness was assessed to determine a) is there greater prejudice toward epilepsy than other chronic disease, b) do adolescents with chronic disease have less prejudice towards similarly affected peers with all, or just their specific chronic disease. Methods: Cohort study. Setting: Outpatient clinics of a tertiary care pediatric hospital. Participants: Cognitively normal teens aged 13–18 without chronic disease (n = 41) and with epilepsy (n = 32), asthma (n = 38), diabetes (n = 21) and migraine (n = 17). Main Outcome Measures: Perceived physical and social impact of 8 chronic diseases (epilepsy, asthma, diabetes, Down's syndrome, arthritis, migraine, leukemia, HIV infection). Results: Epilepsy was perceived to have more adverse physical impact than all chronic illnesses except Down's syndrome. The perception was that it more frequently caused mental handicap, injured the afflicted individual and bystanders and led to death. Epilepsy was also perceived to have more negative social impact particularly on behavior, honesty, popularity, adeptness at sports and fun. Significantly more adolescents' expressed reluctance to befriend peers with epilepsy both from their own and their perceived parental perspectives.Having a chronic disease did not generally alter adolescents' perceptions of peers with chronic disease. However cases with epilepsy ranked this disease to have less social impact than teens with other chronic diseases. Conclusions: Adolescents consider epilepsy to have a greater physical and social impact than most chronic diseases. Educational efforts should focus on the “normality” of most persons with epilepsy, and emphasize the low risk of injury when proper first aide is followed. 1 Tonicarlo R. Velasco, 1 Veriano Alexandre Jr., 1 Marino M. Bianchin, 1 Roger Walz, 1 Charles L. Dalmagro, 1 Regina M.F. Fernandes, 1 Juliana S. Lage, and 1 Americo C. Sakamoto ( 1 Neurology, CIREP, Ribeirao Preto, Sao Paulo, Brazil ) Rationale: Fourteen and six positive spiking is an electroencephalographic phenomenon first described by Gibbs and Gibbs in 1951 as bursts of arch‐shaped surface positive waves at 14 & 6 Hz seen during drowsiness in the posterior temporal leads. It was originally associated with headache, head trauma, epilepsy, behavioral disorders, vomiting and dizziness. However, it can be accepted as a pattern appearing in normal children and adolescents. Here we describe a series of patients with unilateral temporal lobe epilepsy (MTLE) which revealed 14 and 6 Hz positive spikes during video‐EEG. We analyze the relative frequency and lateralization value of this EEG pattern. Methods: Video‐EEG analysis. Electrodes were placed over the scalp according to the international 10–20 system, added to temporal electrodes positioned according to the 10–10 system and sphenoidal electrodes. 14 and 6 Hz positive spikes definition. The EEG was visually assessed by a board‐certified electroencephalographer (TRV) for the presence of 14 & 6 Hz positive spikes, defined as arch shaped waves at 13–17 and/or 5–7 Hz seen generally over the posterior temporal region. The sharp peaks of its component need to be positive in respect to other regions. Side of epileptogenic temporal lobe (TL). The side of epileptogenic TL was defined by high resolution MRI, ictal SPECT, and neuropsychological examination, and ictal video‐EEG. The ictal onset zone (IOZ) was assessed on ictal video‐EEG by two investigators, and when the results were discordant, they were reviewed together to achieve agreement about the localization and lateralization of seizure onset. When the IOZ could not be localized noninvasively, intracranial EEG recordings were performed. Results: From 359 patients examined, 22 had 14 & 6 Hz positive spikes (6,12%). The localization of EEG pattern was in the lateral posterior temporal leads, with maximum amplitude in the T5‐T6 and P7‐P8 electrodes. In the temporal lobe the mesio‐basal region discloses the minimum amplitude (sphenoidal electrodes). In one patient with foramen ovale electrode, we observed high amplitude 14 and 6 Hz positive spikes, probably related to intracranial positioning of electrodes than due to mesio‐basal origin. In 21 patients, 14 and 6 Hz positive spikes were lateralized contralateral to the side of MTLE (p < 0.01). Conclusions: Our findings indicate that 14 & 6 Hz positive spikes are uncommon. The high frequency of lateralized pattern in patients with unilateral MTLE and the fact that occurred consistently in the TL contralateral to the side of hipocampal sclerosis is in agreement with the theory that 14 & 6 Hz positive spikes can be a normal EEG pattern and suggest that the origin of 14 & 6 Hz positive spikes locate in temporal lobe. Although uncommon, the EEG pattern is a reliable method for lateralization of epileptogenic temporal lobe. (Supported by Fapesp, CAPES and CnPq.) 1 Amir M. Arain, and 1 Bassel W. Abou‐Khalil ( 1 Neurology, Vanderbilt University Medical Center, Nashville, TN ) Rationale: Hyperventilation (HV) is used routinely to provoke absence seizures, but is less effective for precipitation of partial seizures. Hyperventilation may also be effective in precipitating nonepileptic seizures. This study was undertaken to determine the effectiveness of hyperventilation in consecutive patients undergoing prolonged video EEG monitoring. Methods: We prospectively used hyperventilation in consecutive patients admitted to our epilepsy monitoring unit for long‐term video‐EEG monitoring. Patients underwent 3 min of hyperventilation on a daily basis (1–6 days). We excluded children younger than 12 and mentally retarded individuals. Results: We evaluated 56 consecutive patients. Their ages ranged from 12 to 85 years. 36 (66%) had localization‐related epilepsy, 19 (34%) had nonepileptic spells, and one had both partial onset seizures and nonepileptic seizures. Events were activated in 5 patients with epilepsy (2 auras, 2 complex partial seizures and 1 secondarily generalized tonic clonic seizure), and in 9 patients with nonepileptic seizures (all were nonepileptic events). The patient with both epileptic and nonepileptic seizures had a nonepileptic spell activated. Spontaneous and activated epileptic seizures did not differ in their clinical characteristics. Conclusions: Voluntary HV is effective in inducing seizures as well as nonepileptic spells during monitoring. The effectiveness of HV in localization‐related epilepsy was higher than expected, possibly due to increased seizure tendency from medication withdrawal. This study suggests that daily HV may be effective in shortening the duration of video‐EEG monitoring, both in patients with epilepsy and those with nonepileptic seizures. 1 Adriana C. Bermeo, 1 Dileep R. Nair, 1 Prakash Kotagal, 1 Mark Bej, 1 Imad Najm, and 1 Hans O. Lüders ( 1 Neurology, Cleveland Clinic Foundation, Cleveland, OH ) Rationale: We studied the changes related to cardiac rhythm in patients with generalized tonic‐clonic seizures (GTCS) as it relates to episodes of apnea and during the motor and premotor phase of the seizure. Methods: Patients in the epilepsy monitoring unit were recruited if they experienced a GTCS. We assessed the heart rate as well as the oxygen saturation in 24 GTCS experienced in 18 patients (2 bitemporal, 2 right temporal, 5 left temporal, 3 focal epilepsy not otherwise localizable, and 2 left hemisphere, 2 left frontal, and 2 primary generalized epilepsy). One of the 24 seizures was excluded because in this seizure we were unable to define the onset of the motor component. In three seizures the baseline heart rate was already in the tachycardic range (defined as >90 beats/min). A significant heart rate escalation (tachycardic response TR) was defined as an escalation of heart rate response during a seizure that was higher than the baseline variability of the patient's interictal heart rate by a third (TR> (interictal HR +1/3 interictal HR)). The slope of the tachycardic response was classified as a fast slope if the maximum heart rate value during the premotor component was achieved in less than 90 seconds and as slow slope if the time to get from baseline to peak was greater than this time. The time of peak hypoxemia was also determined for each seizure. A heart rate deceleration was defined as a drop in heart rate of more than 20bpm within the first minute after the peak hypoxemia (sat O2< 80%). Results: Of the 23 seizures analyzed, 18 (78%) showed a TR in the premotor phase. In this phase the maximum heart rate ranged from 62 to 155 beats/min. Sixteen out of 20 (80%) seizures achieved TR in the premotor phase. A fast slope TR was noted in 10 seizures, which include 5 seizures originating from the right temporal lobe, one seizure originating from the left temporal lobe and four extratemporal seizures. A slow slope response was seen in 7 seizures arising from left temporal lobe and three extratemporal seizures. A heart rate deceleration associated with hypoxemia was seen in 18 out of 24 seizures (75%). There was also a statistically higher variability in the heart rate in the postictal phase as compared to the preictal phase in 20 out of 24 seizures (83%). Conclusions: A TR in the premotor phase of GTCS occured frequently. We were able to demonstrate a difference in the morphology of the TR slope as it relates to the lateralization of the seizure focus in temporal lobe epilepsy. Rapid heart rate decelerations following the ictal tachycardia seem associated with the peak hypoxemia. There was a greater heart rate variability in the postical period as compared with the preictal period in GTCS. These findings may be related to central lateralization of autonomic control and might be speculated to contribute to the mechanisms involved in SUDEP. 2 Elizabeth A. Boles, 1 Melissa F. Brown, 1 Teresa J. Long‐Henson, and 2 Cormac A. O'Donovan ( 1 Diagnostic Neurology, Wake Forest University Baptist Medical Center, Winston‐Salem, NC ; and 2 Department of Neurology, Wake Forest University Baptist Medical Center, Winston‐Salem, NC ) Rationale: Bradycardia and asystole occurring during seizures are thought to be possible risk factors for SUDEP in patients with epilepsy. Pacemaker implantation has been carried out in most patients because of concerns of potential cardiac morbidity and mortality. Literature review of patients reported to have ictal asystole and pacemakers implanted show them to have a long history of seizures and better control of seizures following diagnosis and change in treatment resulting in lack of pacemaker activation. We report a patient with ictal asystole on VEEG who failed prior montherapy that was subsequently treated with Levetiracetam (LEV) and did not undergo pacemaker implantation. Methods: The case is a 27 year old female with a 4 year history of spells consisting of an aura of deja vu and fear followed by loss of consciousness for less than 30 seconds. She was also described as becoming limp with tongue biting and incontinence but no tonic clonic activity. Due to lack of response to Topiramate and need to characterize spells, she underwent VEEG monitoring. Results: VEEG recording of 2 events were done. The two events were preceded by tachycardia which was up to 200 beats per minute(bpm) followed by asystole for 20 seconds in one and tachycardia of 120 bpms followed by bradycardia of 30 seconds in the other. (VEEG will be shown at meeting).There was brief right temporal theta seziure activity seen preceding the second event. SPECT injection was normal. The patient was placed on LEV and underwent a Reveal Loop recorder implantation for continuous EKG recording. The patient has been seizure free for 6 months with no cardiac arrhythmias detected. Conclusions: Ictal asystole has not been associated with increased mortality from epilepsy. The occurrence of asystole during seizures in patients with longstanding epilepsy and reports that seizures may respond to antiepileptic medication supports this concept. Patterns of heart rate change leading to ictal asystole appear unique and will be discussed. Further studies looking at larger numbers of patients with comprehensive cardiac evaluation are needed to further understand the concept of SUDEP rather than single aspects such as bradyarrhythmias. This case suggests that ictal asystole may not necessitate pacemaker implantation. 1 Luis Otavio S. Caboclo, 1 Henrique Carrete Jr., 1 Ricardo S. Centeno, 1 Elza Marcia T. Yacubian, and 1,2 Americo C. Sakamoto ( 1 Neurology and Neurosurgery, Universidade Federal de São Paulo, São Paulo, São Paulo, Brazil ; and 2 Neurology, Universidade de São Paulo, Ribeirão Preto, São Paulo, Brazil ) Rationale: Patients with temporal lobe epilepsy (TLE) and unilateral severe hippocampal sclerosis (HS) may have contralateral temporal scalp ictal onset. This has recently been called “burned‐out hippocampus,” which is believed to be a rare entity (1). In this study we report four patients with unilateral hippocampal sclerosis and contralateral ictal onset registered by scalp‐sphenoidal electrodes. We discuss the importance of such cases in pre‐surgical evaluation of patients with TLE, as well as possible strategies used for evaluation of these particular cases. Methods: We reviewed charts from all patients with TLE submitted to pre‐surgical evaluation, which included high resolution MRI and prolonged video‐EEG monitoring, during a two‐year period (2003–2004). We searched for patients who only had seizures that were clearly contralateral in location to the atrophic hippocampus. Results: Four patients fulfilled the criteria above. All four had unilateral HS with severely atrophic hippocampus, confirmed by volumetric measures. Two of these patients went through semi‐invasive video‐EEG monitoring with foramen ovale (FO) electrodes, which revealed seizures originating from the atrophic hippocampus, hence confirming false lateralization in the scalp EEG. These patients were submitted to surgical treatment – anterior temporal lobectomy – and had favorable prognosis after surgery. The other two patients are still going through pre‐surgical evaluation. Conclusions: Burned‐out hippocampus syndrome may not be as rare as it was previously believed. Further studies will be necessary before one can affirm that patients with unilateral HS and scalp ictal EEG showing contralateral ictal onset may be operated without confirmation of the epileptogenic zone by invasive monitoring. In these patients, semi‐invasive monitoring with FO electrodes might be an interesting alternative.REFERENCE1. Mintzer S, Cendes F, Soss J, Andermann F, Engel J Jr., Dubeau F, Olivier A, Fried I. . Epilepsia 2004;45: 792–802. (Supported by FAPESP (Fundação de Amparo à Pesquisa do Estado de São Paulo) and CAPES (Coordenação de Aperfeiçoamento de Pessoal de Nível Superior)/CNPq (Conselho Nacional de Desenvolvimento Científico e Tecnológico).) 1 David R. Chabolla ( 1 Neurology, Mayo Clinic Jacksonville, Jacksonville, FL ) Rationale: To determine if whispering or feeble motor displays in response to commands during the initial post‐ictal recovery of responsiveness can help to differentiate epileptic from psychogenic seizures. Methods: Video‐EEG recordings from 100 consecutive adult admissions to the EMU during 2003 and 2004 were reviewed. The medical history and clinical follow‐up after EMU dismissal were also reviewed. Cases were divided into three diagnostic categories: 1) epileptic seizures (ES), 2) physiological events (phyE) that included movement disorders, parasomnias, and syncope, 3) psychogenic nonepileptic seizure (pNES) that included the somatoform, dissociative, and anxiety disorders with panic attacks. Cases without a recorded spell or with only brief subjective symptoms without loss of responsiveness were excluded from the analysis. Specific attention was paid to the behaviors occurring during the first 1 to 2 minutes of verbal and motor responsiveness in the post‐ictal recovery phase. Whispery verbal responses were identified by low volume, soft speech using breath instead of phonation. A feeble motor response to command involved movement of the correct limb in a manner lacking force, strength, or effectiveness and typically not completing the task. Results: Twenty five (25%) had pNES, 43 (43%) had ES, 9 (9%) had phyE, and 23 (23%) had no recorded symptoms or only brief subjective symptoms without loss of responsiveness. PNES cases consisted of 21 (84%) somatoform or dissociative disorder (all females) and 4 (16%) anxiety disorder with panic attacks (1 female). No cases of malingering or facticious disorder were diagnosed. The 25 pNES patients experienced approximately 240 events (range 1–22/patient).The initial 1 to 2 minutes of verbal or motor response in the post‐ictal recovery phase were associated with whispering or feeble motor responses to command in 16 (21%) of all cases and 76% of pNES cases due to a somatoform or dissociative disorder. These signs were not seen in any of the panic disorder, phyE, or ES cases. In 132 (73%) of the seizures in patients with a somatoform or dissociative disorder, both seizures with motor manifestations as well as those with loss of responsiveness without motor manifestations, one or both of these signs were observed. The 5 pNES patients who did not display a whispery voice or feeble movements, and did not have a panic disorder, showed previously reported signs of indifference, telegraphic speech, or regression to child‐like speech patterns post‐ictally. Conclusions: Psychogenic seizures due to somatoform or dissociative disorders are commonly associated with the presence of a whispery voice or feeble motor responses to commands during the initiation of post‐ictal recovery of responsiveness. These signs were not commonly seen after epileptic seizures. A prospective study of a larger population would be helpful to determine the predictive value of these signs. 1 William S. Corrie, and 1 Venkata V. Jakkampudi ( 1 Department of Neurology, Virginia Commonwealth University, Richmond, VA ) Rationale: Individuals contemplating admission to an epilepsy monitoring unit wish an estimate of the time they should plan to stay and the likelihood that the stay will lead to a diagnosis. We sought to provide data that will aid in answering these questions. Methods: We reviewed all patients 18 years or older who were referred for diagnosis of seizures and seizure‐like behavior in the last five years. From admission history and descriptions of witnesses, we defined a particular seizure pattern or behavior pattern as the event we were asked to assess. We call this the “target event.” Most patients had all anticonvulsant medications discontinued beginning with the morning dose on the day of admission. Some did not take medications with long half‐lives for a longer period before admission. Sometimes, we are asked to identify the nature of a new pattern that occurs with patients on medications, and these patients continue their home medications. On occasion, we found that the “target event” was non‐epileptic, on other occasions it was epileptic. Some patients had additional “non‐target” events. We considered an admission as “not successful” when we did not record the event that represented the current chief complaint and/or the event that the patient's physician needed clarified. Results: We found 180 men and 352 women who were monitored as described above. We observed “target events” in 316 of them. Duration of monitoring was variable. Thus, we report the patients having their first “target event” in a day as a percentage of patients who entered that day without having one in an earlier session. We found that 27.8% had a “target event” on the first day, 13% within the first six hours. The second day, 25.7% had their first event; the third day, 18.6%; the fourth day, 17.1% and 10.0%on the fifth day. Although we recorded only twenty patients yet to have an event on the sixth day, two of them had their first target event on that day. Conclusions: A single day of monitoring will only lead to a diagnosis in about one quarter of admitted adult patients. Three days of monitoring will provide at least one diagnostic event in about one half of the patients. If we recorded no “target events” after four days of monitoring, we have a chance of recording such data in only 10% of these remaining patients. This suggests that four days of monitoring may be a point of diminishing returns. 1,2 Maria Luiza C. Dal‐Cól, 2 Vera Cristina Terra‐Bustamante, 2 Tonicarlo R. Velasco, 1 José Antônio C. De Oliveira, 1,2 Poliana Bertti, 2 Américo C. Sakamoto, and 1 Norberto Garcia‐Cairasco ( 1 Physiology, Ribeirão Preto School of Medicine, University of São Paulo, Ribeirão Preto, São Paulo, Brazil ; and 2 Neurology, Psychiatry and Psychology, Ribeirão Preto School of Medicine, University of São Paulo ‐ FMRP/USP, Ribeirão Preto, São Paulo, Brazil ) Rationale: The aim of this work was to differentiate behavioral pattern of human right (RTLE) and left (LTLE) temporal lobe seizures with a neuroethological method used and validated in our laboratory for animal models of epilepsy. Methods: We analyzed 14 seizures of 7 patients in each group. Patients were monitorized at CIREP/FMRP/USP between 1997 and 2002. Videos were observed and all patients' behaviors annotated second/second. Data were analyzed using Ethomatic software and displayed as flowcharts including frequency, duration and sequential dyads statistic interaction. (X2≥10.827; >p < 0.001). Results: Pre‐ictal period of both goups were similar, with patients awakened or sleeping. In this case, awakening was the starting point of a seizure. Behaviors as ictal speech; mouth, throat and abdominal clonia; positive verbal command for speech (VC+S) and normal speech (FANO); deglutition automatism; beak and left upper limb paresis; face and eye right hand wiping occurred only in RTLE group. Left hand automatism; eye deviation to the right; right hand tonic posture and relaxing and right upper limb immobility occurred only in LTLE group. Behaviors that happened mostly in the RTLE group: positive verbal command for action (VC+A; 69,2%); left hand dystonia (81,81%); global movements (71,43%). Mostly in the LTLE group: negative verbal command (VC‐; 79,41%), right hand dystonia (76,92%), hip raising (70,97%), left cephalic deviation (69,23%) and left leg automatisms (76,19%). Interaction analysis showed strong interaction (interactions shown, p < 0,001) between global tonic contraction, tremor and global clonic contraction in the LTLE group and more variable clonic and tonic postures in the RTLE, with prominence to left hemibody tonic postures or clonic movements. In the LTLE group we can verify right hand dystonia, and in the RTLE group, an interesting progression from left hand dystonia to left leg dystonia. In the post ictal period, patients from RTLE group present great interaction between CIREP equip questions (INRE) and VC+A, besides VC+S and FANO. In the LTLE group, interactions are mostly between INRE and VC‐. Other interesting feature of the RTLE group is eye, mouth, nose and face wiping with the right hand. Conclusions: We confirmed various behaviors with lateralizatory value described in the literature. Also, recording of all behaviors second‐by‐second permits the observation of novel behaviors that may have predictive value. Interaction analysis permits the observation of possible preferential spread circuits, such as the progression of dystonia or seizure generalization. Studies with other epileptic syndroms are planned. (Supported by FAPESP, CNPq, FAEPA, PROAP‐CAPES, PRONEX and FAEPA.) 1 Martin Del Campo, 1 Richard Wennberg, 2 Taufik Valiante, and 3 Richard Farb ( 1 Neurology, Krembil Neuroscience Centre, University Health Network, University of Toronto, Toronto, ON, Canada ; 2 Neurosurgery ; and 3 Medical Imaging ) Rationale: In the presurgical EEG evaluation of patients with epilepsy it is often necessary to conduct intracranial recordings (IR), the purpose of which is to accurately localize the epileptogenic zone(s) when surface recordings are insufficient. Reported morbidity includes infection, cerebral edema and hemorrhage. However, the relevant literature has not emphasized the possibility of falsely localizing data produced by transient focal seizures (TFS) that may appear early in the post‐implantation phase and spontaneously subside. Published reports are scant and sometimes in journals not likely to be read by epileptologists. Methods: Once aware of the possibility of transient epileptogenic foci associated with subdural electrode placement (Clin Neurophysiol 1999; 110:419–23), we examined 26 consecutive patients undergoing IR. Visual analysis of the IR was performed by MdC and/or RW. The simultaneous video data was analyzed and patients were questioned about any symptoms surrounding the times during which TFS occurred. Brain CT/MRI and direct observation at the time of surgery was carried out to look for blood or any other change associated with the presence of TFS during the IR. Results: Seventeen of the 26 patients were implanted with subdural grid and/or strip electrodes. The remainder had depth electrodes. Three patients developed TFS distant from the ultimately identified clinically relevant epileptogenic zone. Localized near the border regions of subdural grids, these TFS were very frequent at first and subsided within 3 days of implantation. Thin layers of blood were found underlying the grids on CT or at surgery. Another patient had morphologically distinct TFS recorded from a basal temporal subdural strip which subsided after evacuation of a subdural hematoma in the area. Clinically relevant seizures appeared 3 days later arising from the same region but exhibiting very different electrographic features. None of the 4 patients was symptomatic or demonstrated any behavioural changes during the TFS which lasted up to 8 minutes, preceeded by long periods of continuous rhythmic spike or sharp wave activity. Conclusions: Transient areas of focal epileptogenesis may develop as a discrete irritative phenomenon distant from areas of clinical relevance. This occurred in our patients in association with the presence of blood under subdural grids or strips. Recognition of this infrequent complication of IR will avoid mislocalization of areas to be included in surgical resection. It is also important that patients not be inappropriately denied surgery should TFS appear close to eloquent cortex or as one of several foci.The occurence of frequent focal electrographic seizures preceeded by long periods of rhythmic spiking early in the post‐implantation period should alert the electroencephalographer to this phenomenon and the likely presence of subdural blood in the region. 1 Carl B. Dodrill, and 1 Mark D. Holmes ( 1 Neurology, University of Washington School of Medicine, Seattle, WA ) Rationale: Investigators commonly identify epileptic seizures (EPI) and psychological non‐epileptic events (NES) during EEG monitoring, but in most cases no reference is made to reports of “seizures” by patients which are purely subjective (SUB) and which have neither EEG nor clinical changes. This is true even though there is the recent suggestion in the literature that SUB (Epilepsia 1998; 39:857–862) is both important and largely independent of EPI and NES. Methods: All 857 adults (age 16–76) with EEG monitoring (average of 5.83 days) during an 8.5 year period were included. All were reported to have episodes which possibly or probably represent epilepsy. Monitoring established the nature of the episodes reported, and suitability for various forms of treatment including surgery. All patients had also completed the WAIS‐R, much or all of an expanded Halstead‐Reitan neuropsychological battery, the MMPI, and the WPSI (Washington Psychosocial Seizure Inventory). The types of events and their frequencies among the 857 patients were as follows: EPI only 298; NES only 120; SUB only 128; EPIL+SUB 135; SUB+NES 51; EPIL+NES 13; EPIL+NES+SUB 7; no events of any type, 106. ANOVAs run across the groups with one type of event and with two types events on the variables of interest constituted the primary analyses. Results: Biodata variables evaluated included age (no differences across the groups), gender (SUB and NES were similar with about 70% female; EPI 50%; p < .001), and years of education (SUB slightly but not significantly better educated than NES and EPI). Medical history/monitoring variables included age at onset of seizures (EPI much earlier than NES and SUB which were similar; p < .001), psychiatric history (NES and SUB similar and much higher than EPI; p < .001), neurological history other than seizures (n.s.), total episodes recorded during monitoring (n.s.), and days of monitoring required (SUB > NES, EPI intermediate; p < .001). Mental ability variables showed EPI patients to be below NES and SUB in many cases, with SUB often being slightly but non‐significantly better than NES. WAIS‐R VIQ, PIQ, FSIQ, and overall percent of neuropsychological tests outside normal limits were all significantly different across the groups (p < .01–p < .001). Emotional adjustment variables from the MMPI showed SUB to be more depressed than NES and EPI (p < .001) but with similar scores which were higher than EPI on scales emphasizing somatic focus and unusual thought patterns (p < .01–p < .001). Psychosocial variables from the WPSI showed scores which were worse for SUB than for either NES or EPI (Family Background, p < .001; Emotional Adjustment, p < .001; Overall Psychosocial Adjustment, p < .01). Conclusions: Reports of “seizures” during EEG monitoring without either the electrographic changes of EPI or the behavioral changes of NES need to be routinely recorded as they have substantially different characteristics. The investigation of such spells may lead to new insights in several areas. 1 Pradeep Modur, and 1 Fred Dunda ( 1 Neurology, University of Louisville Hospital, Louisville, KY ) Rationale: Short‐term video‐EEG monitoring (SVEM) and long‐term video‐EEG monitoring (LVEM) are extremely helpful in the diagnosis of intractable seizures (JNNP 2004 75:771–2; Epilepsia 2004 45:928–32; Epilepsia 2004 45:1150–3). However, there is little information regarding their usefulness when performed in conjunction with routine EEG (REEG), or serially in the same cohort of patients. Methods: Retrospective analysis of data from all the patients with intractable seizures evaluated at the University of Louisville Comprehensive Epilepsy Center over a 2‐year period (October 2002–2004) was performed. Patients underwent either SVEM (4‐hour duration) or LVEM (1–8 day/s duration). At the beginning of each SVEM and during the first day of each LVEM, a 20‐min segment of EEG with video was acquired as baseline recording using appropriate activation procedures (hyperventilation, photic stimulation, and sleep when possible); this baseline segment was designated REEG since its protocol was similar to the routine outpatient EEG performed in our center. In those patients who underwent both SVEM and LVEM (at different dates), the baseline segment obtained at the time of SVEM was considered as REEG. In patients suspected of psychogenic nonepileptic seizures, suggestion was used for induction. Interpretation for each REEG, SVEM and LVEM was categorized into one or more of the following: partial epilepsy (PE), generalized epilepsy (GE), and nonepileptic seizures (NES); the designation, non‐diagnostic (ND), was used when none of the above categories was applicable. NES comprised of psychogenic seizures and all other paroxysmal attacks. Results: There were 336 patients (223 females, 66%) in the age range of 11 to 86 years (mean 38 years). As shown in the table, the diagnostic yield was highest (78%) for LVEM, lowest for REEG (14%) and intermediate for SVEM (44%). Eighteen patients underwent LVEM after an earlier SVEM. In 15 of these, the interpretation was non‐diagnostic after SVEM; in 8 of these 15 patients (53%), definitive diagnosis was established at the conclusion of LVEM, with NES being the most predominant category in 6 (40%) patients. Eight patients (5%) were considered for VNS implantation after SVEM while 37 patients (18%) were evaluated for epilepsy surgery after LVEM. Conclusions: In the evaluation of intractable seizures, routine EEG is not helpful and LVEM provides the highest diagnostic yield. With SVEM, there are 7‐fold and 2.5‐fold increases in the diagnostic yield of nonepileptic seizures and generalized epilepsy respectively. In a given cohort of patients, LVEM after a non‐diagnostic SVEM is most likely to establish the diagnosis of nonepileptic seizures. ND, n (%) PE, n (%) GE, n (%) NES, n (%) REEG, n = 336 288 (86) 52 (16) 12 (4)   2 (<1)  SVEM, n = 151 84 (56) 35 (23) 21 (14) 11 (7)   LVEM, n = 203 45 (22) 84 (41)  9 (4)  73 (36)  ND SVEM → LVEM, n = 15  7 (47)  1 (7)   1 (7)   6 (40)  1 Luiz K. Ferreira, 1 Leandro R. Teles, 1 Rosa Maria F. Valerio, 1 Carmen L. Jorge, 2 Paula R. Arantes, 2 Carla R. Ono, and 1 Luiz Henrique M. Castro ( 1 Neurology, Faculdade de Medicina USP, Sao Paulo, Sao Paulo, Brazil ; and 2 Radiology, Faculdade de Medicina USP, Sao Paulo, Sao Paulo, Brazil ) Rationale: Hypothalamic hamartoma (HH) is associated with refractory epilepsy with multiple seizure types. Few studies have addressed the ictal findings in non‐gelastic seizures. Methods: Adult patients with MRI diagnosed HH and epilepsy underwent continuous video‐eeg monitoring to document all seizure types and ictal SPECT. Seizures were classified acccording to clinical and ictal EEG findings. Data were correlated with MRI and ictal SPECT. Results: Six patients (ages 18–39 years; 4 men) with sessile HHs, measuring 0.178 to 9.952cm3. Four were right lateralized and two left. Four had posterior, one middle HHs. The remaining HH was unclassifiable. Three seizure types were seen: gelastic (GS), complex partial (CPS) and asymmetric tonic postural (ATPS). GS were associated with other seizure types. An individual patient could present either CPS or ATPS. GS were present in five patients. Ictal EEG in GS showed no or nonspecific changes. Four patients had ATPS. In three, ATPS were associated with GS. The other patient had isolated ATPS; ictal EEG showed diffuse attenuation or paroxysmal fast activity, followed by right frontal ictal activity in one patient. The remaing two patients had CPS with automatisms; ictal EEG showed unilateral temporal activity. In both, CPS were associated with GS. A generalized tonic‐clonic seizure was seen in four patients, always preceded by another seizure type. The two smallest HH were associated with CPS and not to ATPS. The HH's side correlated with EEG lateralization during CPS. We found no correlation between the middle/posterior HH location and seizure type. Ictal SPECT was performed in five patients and showed increased flow in two (increased right temporal flow in one CPS and increased left frontal and HH flow in one GS/ATPS, concordant with hamartoma lateralization). Accepting HH intrinsic epileptogenicity, we propose that seizure progression from GS to other seizure types is due to seizure activity spread from the HH to other brain areas. Electroclinical differences between CPS and ATPS suggest a different ictal spread. CPS could result from temporal lobe involvement (“horizontal spread”) and ATPS from midline structures (“vertical spread”). Horizontal spread correlated with HH lateralization and only occured in the smallest HHs. Vertical spread was seen in the larger HH with features of frontal/midline involvement. There was no association between HH/mamillary body relationship and seizure spread pattern. Conclusions: Seizure types in HH were limited to three specific seizure types. The pattern of clinical seizure types in each patient, ictal EEG and SPECT findings suggest ictal onset in the HH, with horizontal spread in CPS (in smaller HHs) or vertical spread in ATPS (in the larger HHs). Seizure and HH lateralization was seen in both seizure types. (Supported by FAPESP (The State of São Paulo Research Foundation).) 1 James D. Geyer, 2 Paul R. Carney, and 3 Frank G. Gilliam ( 1 The Clinical Neurophysiology Laboratories, Southern Sleep Specialists, Tuscaloosa, AL ; 2 Department of Pediatrics, Neurology, Neuroscience, and Bioengineering, University of Florida, Gainesville, FL ; and 3 Columbia Comprehensive Epilepsy Center, Columbia Medical Center, New York, NY ) Rationale: Dyshormia or epileptiform spikes occurring within K‐complexes has been described in patients with generalized epilepsy, with one study reporting that generalized spikes occurred frequently in association with K‐complexes. We report the rate and laterality of focal dyshormia in localization‐related epilepsy. Methods: Pre‐surgical or diagnostic long‐term video‐EEG results of 40 consecutive patients with epilepsy (13 patients with right temporal lobe epilepsy, 20 patients with left temporal lobe epilepsy, and 7 patients with frontal lobe epilepsy) were reviewed. Sleep samples were reviewed and the numbers of K‐complexes, spikes and spikes within K‐complexes were recorded. The comparison group consisted of 40 consecutive patients with non‐epileptic events who were monitored with long‐term video EEG. Results: Focal dyshormia occurred in 2 of 13 (15%) right temporal lobe epilepsy patients, 6 of 20 (30%) left temporal lobe patients and 3 of 7 (42%) extratemporal lobe epilepsy patients. In most patients with focal dyshormia, spikes occurring during K‐complexes were relatively rare.The epileptiform activity occurred ipsilateral to the primary epileptogenic zone in each case. Not only did more patients with frontal lobe epilepsy have focal dyshormia but the percentage of K‐complexes with associated focal epileptiform activity tended to be higher in these patients than in patients with temporal lobe epilepsy. Conclusions: We identified focal dyshormia, or spikes occurring during K‐complexes, in patients with localization‐related epilepsy. The sharply contoured components of K‐complexes or associated sleep spindles may obscure focal spikes within K‐complexes. Nevertheless, K‐complexes may be associated with focal epileptiform discharges. Several authors suggested that dyshormia occurs only in patients with primary generalized epilepsy. We report focal dyshormia occurring ipsilateral to the primary epileptogenic zone, associated with localization related epilepsy. Given the predilection of the epileptiform discharges associated with K‐complexes to occur ipsilateral to the side of ictal onset, the presence of focal dyshormia may assist in the identification of the primary epileptogenic zone. In general, there was a trend toward more K‐complexes being associated with spikes in frontal lobe epilepsy than in temporal lobe epilepsy.Malow et al. reported the presence of sleep spindles recorded from the hippocampus and the association with epileptiform activity in one patient. The association of K‐complexes with epileptiform activity may also represent an effect of temporal modulation of the typical features of stage II sleep. 1 Christine M. Heath, and 1 Charles M. Epstein ( 1 Neurology, Emory University School of Medicine, Atlanta, GA ) Rationale: Posterior dislocation/fracture of the humerus is a known, but rare, complication of generalized convulsions. Methods: Observational. Results: Over the course of 53 days, we observed three humeral fractures during generalized seizures in a single epilepsy monitoring unit during acute withdrawal of anticonvulsants. Patients had been on anticonvulsants for 16 to 48 years. Ages were 31 to 55 years. All were in bed during seizures, and none fell. Conclusions: This striking cluster of humeral fractures, which represents 3% of monitored patients over a short time interval, may represent in part vulnerability from long‐term anticonvulsants in epileptic patients. However, it may also represent a tendency to more severe generalized convulsions during acute withdrawal. An increased incidence of fractures may be part of the additional morbidity associated with rapid anticonvulsant taper. 1 Heidi L. Henninger, and 2 Donald L. Schomer ( 1 Department of Neurology, Maine Medical Center, Portland, ME ; and 2 Department of Neurology, Harvard Medical School, Beth Isreal Deaconess Medical Center, Boston, MA ) Rationale: Inpatient, video‐EEG monitoring is often considered the “gold standard” for evaluating patients with medically refractory epilepsy. Access to inpatient epilepsy monitoring units is improving as more non‐academic centers are providing this service. There are still large numbers of patients for whom access is a major barrier. We evaluated the diagnostic utility of ambulatory, digital video‐EEG monitoring in patients with refractory “epilepsy” without access to an in‐patient monitoring unit. Methods: Data from a consecutive cohort of fifty patients with a presumptive diagnosis of medically refractory epilepsy for whom ambulatory video‐EG monitoring was ordered were retrospectively analyzed. A study was considered “positive” if typical spells were recorded, epileptic or not, or if inter‐ictal (ii)EEG abnormalities were identified which clarified seizure type when prior baseline EEGs were normal. “Negative” studies were those where no spells were recorded or when the iiEEG provided no additional data compared to prior EEGs. Results: Of the 50 patients, 36 underwent testing for diagnostic purposes and 14 for presurgical screening. Mean evaluation period was 2.2 days. Mean number of seizures recorded per patient was 3. Positive diagnostic information was obtained in 60% of studies. In the diagnostic group, positive yield was 53%. The yield in the presurgical group was 78.5%. No seizures were recorded in 46% of patients (n = 23), but of these, 30% had iiEEG abnormalities that helped clarify diagnosis, and hence were considered diagnostic. Medical management was changed on the basis of the ambulatory video‐EEG study in 60% of patients. Conclusions: The development of ambulatory, digital video‐EEG monitoring can allow for diagnosis, seizure classification and even presurgical screening for patients without access to in‐patient monitoring. In addition, the ambulatory video‐EEG study may be appropriate for some patients who might find it difficult to comply with in‐patient monitoring, such as pediatric patients, patients with heavy smoking, child care issues or in those where it is thought that environmental stimuli are triggers for targeted episodes. The shorter monitoring duration maybe responsible for the slightly lower rate of “positive studies” compared to recent studies looking at this issue in in‐patient monitoring (1), but the cost savings is substantial. Therefore, for many patients, ambulatory digital video‐EEG monitoring is a cost‐effective alternative to in‐patient video‐EEG studies.1 Ghougassian D. F., et. al., Epilepsia 45(8):928–932, 2004 (Supported by SleepMed/DigiTrace (Peabody, MA 01960).) 1 Luciana M. Inuzuka, 1 Vera C.T. Bustamante, 1 Sandra S. Funayama, 1 Marino M. Bianchin, 1 Sara R.E. Rosset, 1 Helio R. Machado, 1 Americo C. Sakamoto, and 1 Regina M.F. Fernandes ( 1 CIREP, Hospital das Clinicas de Ribeirao Preto ‐ USP, Ribeirao Preto, Sao Paulo, Brazil ) Rationale: Ketogenic diet (KD) is a long‐time known treatment, effective for seizure control, and often indicated for patients with refractory epilepsy.We carried out the present study in order to speculate how KD should be introduced, and further evaluate its effect over several electrophysiological parameters as well as its efficacy for seizure control. Methods: We evaluated prospectively clinical and neurophysiologic parameters of a group of patients submitted to KD treatment in our hospital. For this purpose, 27 patients with refractory epilepsy were selected and submitted to the classic KD. All patients had detailed previous video‐EEG studies and 2 optimized anti‐epileptic drugs before the beginning of KD treatment. The patients were randomly assigned to 2 groups and were submitted to two different modalities of KD introduction: First group of patients (n = 13) was submitted to KD after 24 hours of fasting. The second one was submitted to KD without fasting (n = 14). Both groups were compared by age of beginning of the DC, gender, age of epilepsy onset and introduction of KD, time to reach large urinary ketosis, types of epileptic seizures and syndromes, adverse events, efficacy of the KD for seizures control after 2, 6 and 12 months of treatment. Additionally, complete data of an historical series of 13 patients previously submitted to KD after prolonged fasting (24 to 72 hours) in our center were analyzed and included in this study. Results: There were no differences in age of KD introduction, age, gender, age of epilepsy onset, and epilepsy syndrome (focal or generalized) and time to reach strong ketosis among the three groups of patients. Also, there were no differences for seizure control after 2 or 6 months of follow‐up among the three groups analyzed. After 6 months and 12 months, the KD was effective in controlling focal or generalized seizures in 46.9% and 37.5% of patients respectively. Corresponding to 25.0% (6 months) and 21.8% (12 months) of patients seizure free or improvement of seizures more than 90%. During KD period, 19 patients were submitted to video‐EEG monitoring and 26.3% of them showed improvement on clinical and electroencephalographic parameters. During the introduction of the diet and along the first following days, no differences in the incidence of adverse effects were observed in regard to previous fasting or not. Conclusions: The introduction of KD without a previous fasting period was equally effective in provoking large urinary ketosis as compared to patients submitted to fasting. The incidence of adverse effects of KD was also not different between those groups. Moreover, a fasting period before KD did not affect long‐term seizure control. Taken together, our results support the concept that a fasting period before the introduction of KD is not clinically relevant. 1 Soo Yeon Park, 1 Hee Hwang, 1 Jong Hee Chae, 1 Ji Eun Choi, 1 Ki Joong Kim, and 1 Yong Seung Hwang ( 1 Pediatrics, Seoul National University Hospital, Seoul, Korea ) Rationale: Although atonic seizures are not uncommon in infants and children, the precise ictal semiology and EEG have not been characterized. This study was performed to demonstrate the clinical and electrophysiological characteristics of atonic seizures in infants and children. Methods: Twenty six patients (19 males and 7 females) showed atonic seizures during long‐term video‐EEG monitoring (VEM). The mean age on VEM was 37 months. Ictal semiology, interictal and ictal EEG, and brain imaging findings were analyzed. Results: The brain MRI findings were normal in 14 (53.8%) and abnormal in 11 patients (42.3%). Thirteen patients (50%) had atonic seizures only, while the other 13 patients (50%) showed other type of seizures in addition. The types of accompanying seizures were myoclonic seizures in 5, atypical absence seizures in 4, partial seizures in 3, tonic spasms in 2, and generalized tonic‐clonic seizures in 1 patient. In the patients with atonic seizures only, 12 showed generalized epileptiform discharges as ictal rhythm such as diffuse or bilateral polyspike/spike and wave complexes (9) or diffuse theta or delta bursts (1) sometimes followed by diffuse attenuation of the background activity (2). One patient showed hemispheric polyspike wave bursts. Abnormalities in the interictal EEG were as follows; 1) 15 showed abnormal background activity, 2) interictal epileptiform discharges included generalized spike or spike wave in 9, generalized with multifocal spike in 7, focal or multifocal spike in 7. Conclusions: Fifty percent of the patients with atonic seizures experienced other types of seizures. In some cases, interictal EEG showed focal or multifocal epileptiform discharges. Therefore, VEM can be helpful for accurate diagnosis and classification of atonic seizures. 1 Mohamad Z. Koubeissi, 1 Gregory K. Bergey, 1 Christophe Jouny, and 1 Piotr Franaszczuk ( 1 Neurology, Johns Hopkins University, Baltimore, MD ) Rationale: Cingulate seizures are poorly understood because their patterns of propagation may confound both the classification of clinical semiology and attempts at seizure localization. The anterior cingulate gyrus is known to have anatomic connections to temporal lobe structures, but projections from the posterior cingulate area are less established. We present a detailed analysis of seizure dynamics from intracranial recordings of repetitive seizures originating from the right posterior cingulate region and producing secondary seizure activity in the right mesial temporal structures. Methods: Depth electrode recordings were made of complex partial seizures (CPS) in a 22 year‐old man with one year history of medically intractable epilepsy. His seizures were characterized by staring, automatisms, and incomprehensible speech. MRI revealed an 8.5 X 7 mm lesion of the right parietal cingulate region. PET revealed decreased activity of the right lateral temporal lobe. With scalp EEG, his CPS revealed a buildup of right temporal rhythmic spikes at 8–9 Hz. Depth electrode arrays were then placed in the right amygdala, hippocampus and cingulate lesion. Three stereotyped CPS were recorded. Ictal recordings were analyzed using the matching pursuit method which allows for detailed time‐frequency decomposition of rapidly changing signals. In addition the Gabor atom density (GAD) was calculated for all seizures. GAD is a composite measure of signal complexity that has been shown to increase during epileptic seizures. Results: Each of the seizures had a stereotyped pattern of ictal dynamics. The seizures began with a right cingulate sentinel spike followed by low voltage, 40‐hz activity. After 20–30 seconds, the mesial temporal depth contacts developed prominent secondary organized rhythmic activity of 6–8 Hz frequency, typical for mesial temporal lobe generators. The patient continued normal activities until the secondary right temporal involvement. GAD revealed a significant change of complexity from baseline during the earliest phase of the cingulate gamma activity and also a consistent pattern of complexity changes from both cingulate and mesial temporal contacts. Conclusions: These recurrent seizures did not produce clinical symptoms until secondary involvement of ipsilateral mesial temporal structures. This suggests connectivity between posterior cingulate regions and the temporal lobe and supports previous observations that cingulate seizures may not produce clinical symptoms without propagation to other brain regions. The dynamic analysis of the seizures revealed a stereotyped pattern of both time‐frequency changes and complexity. The mesial temporal ictal evolution was a secondary pattern distinct from but always following the cingulate ictal onset. This activity can be clearly delineated by dynamical analyses. The patient is presently seizure free early after resection of this benign lesion. (Supported by NIH grant NS 33732.) 1 George R. Lee, 1 Noel P. Lim, 1 Amir Arain, and 1 Bassel W. Abou‐Khalil ( 1 Neurology, Vanderbilt University Medical Center, Nashville, TN ) Rationale: We observed distinctive non‐clonic unilateral rhythmic hand motions during seizures in several patients with temporal lobe epilepsy undergoing seizure monitoring. We initially considered these rhythmic hand movements to be automatisms, but noted they were contralateral to the seizure focus. Automatisms usually have no lateralizing value in temporal lobe epilepsy, but will be ipsilateral to the seizure focus if there is contralateral hand dystonic posturing. We studied these RINCH motions systematically in a consecutive series of patients. Methods: We identified thirteen patients with epilepsy who demonstrated RINCH motions and reviewed video‐EEG recordings of all their seizures. We recorded time of clinical and EEG onset, time and duration of the rhythmic motions, specific character and laterality of these motions, association with other ictal signs, proportion of seizures that involved this activity, and laterality of the seizure focus. Results: RINCH motions were unilateral, rhythmic, non‐clonic hand motions. The description of the movements varied between patients, but was consistent in each patient. They were either low amplitude milking, grasping, fist clenching, pill‐rolling, or large amplitude opening‐closing motions. The mean duration of the motions was 24 seconds with a range of 6–128 seconds. RINCH motions occurred 0–72 (mean 17.5) seconds following the onset of the electrographic seizure and 0–50 (mean 13) seconds following the onset of the clinical seizure.In the thirteen patients studied, RINCH motions were noted in 28 of 91 seizures analyzed. All patients with RINCH motions had temporal lobe epilepsy (TLE). RINCH motions were followed or accompanied by posturing (dystonic or tonic) in every patient (though not in every seizure). They involved the hand contralateral to the temporal lobe of seizure onset in 12/13 patients. Only one patient demonstrated rhythmic hand movements ipsilateral to the seizure onset, and that patient had bilateral dystonic posturing consistent with contralateral seizure spread. Interestingly, RINCH motions affected the right hand in 89% (25/28) of the seizures and 10/13 patients. For each individual, the proportion of seizures with these rhythmic hand movements ranged from 6% to 100%. Based on a limited survey, we estimated that RINCH motions occur in ∼ 10% of patients with TLE. Conclusions: RINCH motions are a distinct ictal sign associated with posturing. They appear to be a lateralizing contralateral sign in temporal lobe epilepsy, unless bilateral dystonic posturing is present. RINCH motions are to be distinguished from automatisms, which are more likely to be ipsilateral to the seizure focus, involving the arm not affected by dystonic posturing. The mechanism of RINCH motions is unknown; evaluation of these motions in patients with implanted electrodes may help in understanding their mechanism. 1 Lawrence D. Morton, 1 Venkata V. Jakkampudi, 1 Lydia Kernitsky, 1 Alan R. Towne, and 1 William S. Corrie ( 1 Department of Neurology, Virginia Commonwealth University, Richmond, VA ) Rationale: Patients with reports of ongoing seizures are often recommended for admission to an Epilepsy Monitoring Unit for Phase I evaluation to determine next most appropriate care, including possible surgical candidacy. Pressures exist from both patients and third party payers for this assessment to be carried out in the most efficient manner. Antiseizure medications are frequently withdrawn to increase the chance that sufficient events will be captured in a timely fashion. Data is limited regarding safety of this practice. Methods: All patients 18 years and older referred for seizures and seizure‐like events admitted from 1/1/2000 through 12/31/2004 were reviewed. Data obtained included age, gender, admission seizure type, captured seizure type(s), including non‐epileptic events, duration of admission, baseline antiseizure medications and additional medications administered (including rescue medications for acute seizures, staus epilepticus and impending status epilepticus). Patients with intracranial monitoring or history of status epilepticus were excluded from evaluation. Results: A total of 532 patients who were monitored (180 male, 352 female) had medications withdrawn or reduced. 316 patients experienced target events. 191 patients experienced seizures. A total of 29 patients received rescue therapy ‐ 23 received lorazepam, 2 received diazepam, 2 received clonazepam, 2 received fosphenytoin. Almost all received therapy because the study was completed as an added measure was provided for safety while medications were reinstated or because, patient completed the study and was experiencing seizures above baseline frequency in a crescendo fashion. Only one patient required therapy for impending status. No one was treated for status epilepticus. One patient developed spike wave stupor which resolved spontaneously without treatment. This occurred overnight with no technologist present. Conclusions: Drug withdrawal for Phase I long term video eeg monitoring is safe. Impending status epilepticus or status epilepticus is a rare event that may be aborted with appropriate therapy. However, appropriate safeguards must be in place including intravenous access when withdrawing medication, and an ability to assess and treat rapidly. In addition, as it becomes increasingly difficult to have qualified technologists present 24 hours/day, there is a risk of nonconvulsive seizures occurring with a delay in diagnosis and hence treatment. 1 Rickey J. Reynolds, 2 Muhammad Al‐Kaylani, and 3 Bassel Abou‐Khalil ( 1 Neurophysiology, Vanderbilt Medical Center, Nashville, TN ; 2 Neurophysiology, Vanderbilt Medical Center, Nashville, TN ; and 3 Neurophysiology, Vanderbilt Medical Center, Nashville, TN ) Rationale: Patients with mesial temporal lobe epilepsy evaluated for epilepsy surgery commonly have bilateral independent interictal epileptiform discharges (IED) during prolonged EEG monitoring. This finding raises the possibility of independent epileptogenic foci. There are no established criteria to distinguish IED associated with ictal onsets from those that are not. This study is an attempt to find neurophysiological IED indicators in the pre‐surgical evaluation to help distinguish a primary focus from a mirror focus which does not generate seizures. Methods: We retrospectively studied 75 patients who underwent epilepsy surgery at Vanderbilt Medical Center for mesial temporal lobe epilepsy and who demonstrated successful post‐surgical outcomes defined as being seizure free for at least two years. From these 75 patients, 14 were found to have bilateral IED. Only ten patients had recordings available for review. The IED were evaluated by frequency of occurrence, amplitude, and field. A side to side comparison was made for the entire group. The IED incidence, average amplitude, maximum amplitude, average field and maximum field were compared with a two‐tailed t‐test for the primary epileptogenic focus and the mirror focus. Results: The mean IED incidence was higher on the epileptogenic side (ratio was 7.2 to 3; p < 0.0002). In addition, the epileptogenic side demonstrated a higher mean IED amplitude (p < 0.05) as well as maximum IED amplitude (p < 0.005). The mean IED field was not significantly different for the two sides, but the maximum field was wider on the epileptogenic side (p = 0.02). Conclusions: Even though this study had a small sample size, it demonstrated that in addition to the expected higher IED incidence on the epileptogenic side, mean and maximum IED amplitude, as well as maximum IED field were greater on the epileptogenic side. It is hopeful that this data may encourage a larger prospective study to determine more accurately the significance of these easily assessed values in the pre‐surgical evaluation of patients with mesial temporal lobe epilepsy. 1 Alcibiades J. Rodriguez, and 2 Elson L. So ( 1 Sleep Disorders Center/Neurology Department‐Epilepsy Division, Mayo Clinic, Rochester, MN ; and 2 Neurology Department‐Epilepsy Division, Mayo Clinic, Rochester, MN ) Rationale: Temporal lobe epilepsy is the most common type of intractable seizure disorder. Seizure semiology has been shown to improve the localization of seizures for the purpose of selecting candidates for temporal lobectomy. There are no studies to date that compare the clinical manifestations of seizures occurring during wakefulness with those of seizures arising from sleep in the same temporal lobe epilepsy patient. Methods: Inclusion study criteria were: 1) excellent outcome following left or right temporal lobectomy; 2) age of >5 years; 3) both wake and sleep seizures recorded by video‐EEG; 4) recordings available for review; 5) no other seizure focus identified. Thirty patients from our epilepsy surgery database consecutively met the inclusion criteria.Video‐EEG recordings of wake and sleep seizures were reviewed and compared in detail. Results: Subjects consisted of 12 males and 18 females. Nineteen had left temporal lobectomy. Average age was 29.7 years. There was no statistically significant difference in the following semiologic manifestations: early unforced head turn, unilateral automatism, contralateral immobile limb, ictal speech retention, dystonic limb, tonic limb, clonic activity, late forced head turn, “fencing” posture, “Figure 4” posture, second late forced head turn, asymmetric clonic ending, Todd's paresis, postictal nose wiping or postictal dysphasia. Mean seizure duration was 71.7 seconds during wakefulness vs. 88.7 seconds during sleep. The difference was not statistically significant (p > 0.05). Conclusions: Within each temporal lobe epilepsy surgery patient, there is no difference in semiology between seizures that occurred during wakefulness and seizures that occurred during sleep. Temporal lobe seizures arising from sleep has localizing value similar to that of temporal lobe seizures occurring during wake. 1 Lori A. Schuh, 1 David E. Burdette, and 1 Brian Silver ( 1 Neurology, Henry Ford Hospital, Detroit, MI ) Rationale: The most effective methods for providing resident neuroscience instruction are not established. Performance on the Neurology Residency Inservice Training Exam (RITE) is predictive of performance on the American Board of Psychiatry and Neurology (ABPN) Part I, which is a measure of the quality of residency training (Goodman JC, et al. Neurology 2002; 58:1144–1146). We previously demonstrated the superiority of an education intervention consisting of resident presentations with weekly quizzing when the format was team oriented, emphasized performance in front of peers, and offered an incentive over a similar intervention with weekly written quizzes, confidential results, and no incentive (Schuh L, Burdette D. Neurology 2005; 64(S6):A31). We sought to confirm the effectiveness of this intervention in Neurophysiology. Methods: A prospective cohort of 17 residents from 2004–2005 were studied. The control group consisted of 44 resident data points from the RITE from 1998–2002. Residents were equally divided between 3 years of training. All residents from 1998–2005 received a minimum of 3 months training in EEG and EMG over 3 years of training and participated in the same lecture series. The additional educational program for the study cohort was a resident‐prepared weekly lecture from a chosen text. Residents were divided into 2 teams. Weekly oral quizzes required every team member to answer in turn; the team with the highest cumulative points was given an incentive. Percent correct scores, individual year to year change and historical first year performance in Neurophysiology were compared with controls. Statistics used mean, standard deviation and t‐test. Results: Results are presented in the Table. The study group demonstrated superior performance on the Neurophysiology section of the RITE compared to the historical control, with superior year to year improvement, but not superior first year resident performance. Conclusions: We confirmed the success of an educational format consisting of resident presentations with weekly quizzing when the format was team oriented, emphasized performance in front of peers, and offered an incentive. This format may be used by other residencies with a desire to improve RITE performance and document measurable learning under the core competency “Medical Knowledge.” We plan to continue using this format in other courses and eventually analyze effect on ABPN pass rate. Neurophysiology Performance on RITE 
Control Group 
Study Group Statistical 
Significance Mean Percent Correct 49.4 ± 12.8 63.6 ± 17.0 p < 0.001 Mean Year to Year Difference  8.5 ± 10.7 19.2 ± 14.0 p < 0.02  Mean Historical First Year Performance 41.6 ± 9.2  44.2 ± 7.1  p = 0.7   Means presented; statistical analysis performed with individual data points. 1 Romila Mushtaq, and 1 Linda M. Selwa ( 1 Comprehensive Epilepsy Center, Department of Neurology, University of Michigan, Ann Arbor, MI ) Rationale: Ictal SPECT (single photon emission computed tomography) is a valuable diagnostic tool for localization of seizures in a presurgical evaluation of refractory epilepsy patients. At our institution, trained neurophysiology technicians are placed directly at the patient's bedside to monitor for seizure onset in order to obtain optimal ictal SPECT injection times. This creates additional demands on the institution for personnel and for financial resources. We proposed to analyze patients admitted for ictal SPECT to assess: 1)the success rate of obtaining an ictal SPECT study, 2)average time to record seizure that was injected for SPECT, 3)and average time of actual injection measure from seizure onset. Methods: A retrospective analysis was performed on all patients admitted for ictal SPECT scan between 2002–2004 utilizing inpatient charts, VEEG monitoring data, and monitoring reports generated by physicians. Patients are designated prior to admission to obtain an ictal SPECT. All patients have one seizure recorded prior to obtaining an ictal SPECT to characterize seizures. Day 1 was started as the time of admission until 11:59PM on that day. Patient admissions were analyzed to: 1) quantify the total number of successful ictal SPECT obtained, 2)duration to record the first seizure, 3)time between first and second seizure, 4)time to capture seizure for injection for ictal SPECT, and 5)time to actual injection of tracer from onset of seizure. Results: A total of 93 patients were admitted over 118 admissions to obtain ictal SPECT. Out of 118 admissions, only 23(19%) were unsuccessful at obtaining an ictal SPECT scan. The most common reason was failure to capture seizure during specific hours when SPECT can be performed. The average time to capture the first seizure was on day 2.1. The average time to capture seizure for injection was on day 4.5. Time to actual injection of tracer was calculated from the onset of clinical or EEG changes, whichever occurred first. Data was available in 80/97 successful injections, and the average injection time was 13 seconds. A total of 90% of injections occurred within 30 seconds of seizure onset. Conclusions: Early ictal SPECT injections minimize the problem of seizure propagation and of non‐localization due to an early switch from ictal hyperperfusion to postictal hypoperfusion. At our institution, 81% of admissions for ictal SPECT were successfully performed, and 90% of these patients were injected with tracer within 30 seconds of seizure onset. We feel that this data justifies the utilization of trained neurophysiology personnel to monitor patients for seizure onset at the bedside when admitted for ictal SPECT scans. 1 Sona K. Shah, 1 Susan Hawes Ebesole, 1 James Tao, 1 Maria Baldwin, and 1 John Ebersole ( 1 Adult Epilepsy Center, University of Chicago, Chicago, IL ) Rationale: Non‐invasive localization of epileptogenic foci by means of EEG dipole source modeling depends on there being a definable relationship between the cerebral source of an EEG spike or seizure potential and the scalp EEG voltage field that is used for the inverse solution. Validating this relationship can best be performed by simultaneously recording both intracranial and scalp EEG and correlating source location to scalp field. Determining scalp voltage fields correlated with selective sublobar sources would benefit from a technique to increase the “signal” of the epileptiform activity from the “noise,” which in this case is the ongoing EEG. Methods: We selected data from eight patients who had simultaneous EEG recordings from both an array of subdural electrodes encircling the temporal lobe and at least 24 scalp electrodes, including subtemporal locations bilaterally. Intracranial EEG spikes or seizure potentials of similar morphology from various circumscribed temporal lobe sources (base, tip, anterior infero‐lateral, anterior and posterior lateral) were identified and used as a trigger to average the scalp EEG and thus enhance the signal to noise of any correlated scalp potential. Voltage topographic maps and single moving dipole models of the averaged scalp potentials were then calculated. Results: Discrete, sublobar intracranial EEG spikes and seizure potentials often did not have a scalp EEG correlate that was recognizable in ongoing EEG activity. Signal averaging usually resulted in a definable scalp voltage field for even small cortical sources. Temporal sources from different sublobar areas produced distinctive scalp voltage fields that were modeled by dipoles of different location and orientation. Dipole orientation, in particular, distinguished the various sublobar surfaces. Conclusions: There is a direct and definable relation between the location and orientation of a cortical spike or seizure source and the scalp voltage field it produces. Dipole and other source models of scalp EEG are therefore reasonable approaches to non‐invasive localization of epileptogenic foci. Sublobar resolution should be possible given our findings. 1,3 C. A. Smith, 2 W. Trescher, 1 D. Boatman, 3 C. French, 3 K. Walsh, and 1 E. P. Vining ( 1 Neurology, Johns Hopkins Medical School ; 2 Neurology, Kennedy Krieger Institute ; and 3 Neuropsychology, Mt Washington Pediatric Hospital ) Rationale: The study investigates the stability of neuropsychological test performance of children with Benign Epilepsy with Central‐Temporal Spikes (BECTS). Children with BECTS generally have normal cognition; however, recent studies have demonstrated difficulties in various cognitive domains. It is unclear, however, whether the reported cognitive deficits are due to a fixed underlying cerebral dysfunction or if the deficits change over time, possibly related to fluctuations in interictal sharp activity. It was hypothesized that cognition would remain relatively stable over the course of 2 months. Methods: Four children were tested, ages 7–12, 2 girls and 2 boys. All were right handed and of average intelligence (FSIQ 97–112) with no history of developmental delays, learning or psychological disorders, and observed seizures within one month of initiating the study. Clinical criteria for the diagnosis of BECTS was met, including EEG sharp activity greater than 100 microvolts with a central or central‐temporal distribution, and no evidence of focal slowing. Continuous EEG recordings were obtained on the same day as the neuropsychological evaluation. Subjects underwent assessment of attention, visual/verbal working memory, visual/verbal memory, receptive/expressive language, verbal fluency, visuospatial discrimination and motor abilities in a within subject, repeated‐measures design. Subjects underwent repeat testing at 1–1:5 month intervals for 2 sessions (1 subject) or for 3 sessions (3 subjects). No changes in medication between sessions occurred. Results: Three subjects showed impaired visual attention across sessions (>2SD). Impaired performance (>2SD) was observed in immediate/delayed memory, visuospatial skills, response time, and auditory attention in select subjects and sessions. All subjects demonstrated significant variability (>1SD) across sessions in multiple cognitive domains of receptive/expressive language, visual/verbal memory, attention, response time, and executive abilities. Three subjects had central or central‐temporal sharp activity on 1or more EEG recordings on the testing day. The observed variability in performance was not related to abnormal EEG activity or practice effect. One subject had normal EEG activity with impaired cognitive performance. The youngest, most recent onset subject had no overall impairment despite abnormal EEG; however, significant variability between sessions was noted. Conclusions: These preliminary results suggest that children with BECTS have significantly fluctuating cognition (>1SD difference) affecting attention, memory, visuospatial, and executive skills that can adversely affect their development and education. Even in a child who demonstrated no cognitive impairment, fluctuation of greater than 1SD was present, predicting alteration in academics, behavioral, and emotional functioning. 1 Christian A. Sonnefeld, 1 Adriana Palade, and 1 John F. Brick ( 1 Department of Neurology, West Virginia University, Morgantown, WV ) Rationale: Ictal aggression is extremely rare. We report the video EEG of two cases of aggressive behavior occurring during temporal lobe seizures. Methods: Case 1 involved a 20 year old man with a 3 year history of poorly controlled complex partial seizures. His MRI and neurological exam were normal. Interictal EEG revealed frequent right temporal sharp waves. Several seizures were captured on video EEG during which the patient exhibited destructive manifestations, improper language, and semi‐purposefully striking and throwing objects. In one unprovoked typical event he struck a wall and attempted to strike his father. His language during this consisted of swearing and inappropriate words. Electrographically, rhythmic lateralized theta activity seen best over the anterior right temporal electrodes was present and began 7 seconds prior to the event. This progressed into higher frequency activity with superimposed spikes and poly‐spikes over a 2 minute period.Case 2 involved a 39 year old man with a 4 year history of complex partial seizures and right temporal lobe tumor. Video EEG monitoring revealed the patient getting out of bed, turning toward his wife and motioning with his arms as if to shoot a bow and arrow at her while he makes a shooting noise. He then moves in towards her and appears to strangle her briefly. She cried out and he stepped back with a dazed look over his face. Electrographically, the seizure began with rhythmic theta activity over the right temporal electrodes, which gradually increased in amplitude and sharpness. Results: Both patients were amnestic of the events. In the second case the behavior was not the patient's typical event, having been induced by medication withdrawal. Conclusions: Ictal aggression is extremely rare, but does occur with temporal lobe seizures and probably can lead to injury to the patient or others. Medication withdrawal may lead to a new seizure type for an individual patient, including ictal aggressive behavior. 1 Patricia S. Sousa, 1 Katia Lin, 1 Gerardo M. Araujo Filho, 1 Americo C. Sakamoto, and 1 Elza Marcia T. Yacubian ( 1 Neurology, UNIPETE‐UNIFESP‐EPM Hospital São Paulo, Sao Paulo, Sao Paulo, Brazil ) Rationale: Juvenile myoclonic epilepsy (JME) is the most common idiopathic generalized epilepsy. Patients with JME are very sensitive to precipitants factors (PF) such as sleep deprivation, excess of alcohol intake, and photic stimulation. More recently, other unusual PF, such as praxis, reading, writing, calculating, decision‐making, speaking and playing musical instruments have been identified in patients with JME. Activation of specific cortical areas of the brain by cognitive stimuli is known to induce seizure in patients with JME. Objective: To examine the effects of higher mental activity in patients with JME, monitored with video‐EEG during neuropsychological activation. Methods: Sixty‐one patients with JME (35 females), treated and non‐treated, underwent video‐EEG recording during performance of neuropsychological tasks, which involved reading, speaking, writing, written and mental arithmetic calculation, and spatial construction. These tasks were compared to other activation methods during video‐EEG: photic stimulation, hyperventilation, opening/closure of the eyes, and sleep after the tasks (without sleep deprivation). Results: All but 7 patients were treated with anti‐epileptic drugs at the time of video‐EEG examination. Overall, 18 patients (29.5%) had epileptiform discharges (ED) activation during at least one neuropsychological task. All non‐treated patients had ED activation related to these tasks. Among 54 treated patients, 11 (20.4%) showed EEG activation. When photic stimulation and hyperventilation were included as activation methods, 35 patients (57.5%) showed increase of ED in EEG. Praxis was the most effective task (11 patients) followed by reading and writing (6) and mathematic calculation (4). Seizure was precipitated during the tests in 28 (45,9%) patients; the most common were myoclonus (22 patients – 36.1%). Conclusions: Neuropsychological EEG activation is a useful instrument in the evaluation of treated and non‐treated JME patients. It may confirm the existence of PFs and identify reflex seizures in these patients. (Supported by CAPES and FAPESP from Brazil and DAAD from Germany.) 1 Tiffany N. Townsend, 1 Beate Diehl, 1 Richard C. Burgess, and 1 Hans O. Lüders ( 1 Neurology, Cleveland Clinic Foundation, Cleveland, OH ) Rationale: Epileptologists have observed that considerable differences exist between the time of first ictal EEG activity and the initial clinical manifestations of a seizure. Recording from intracranial electrodes currently offers us the earliest view of this ictal electrical activity. The window of time between ictal EEG and clinical onset is of interest because, if long enough, it might be used to accomplish some intervention, thereby aborting a seizure or diminishing the harm accompanying unavoidable seizures. Methods: A retrospective review was performed on all patients with focal epilepsy who underwent intracranial video‐EEG monitoring (ICEEG) at the Cleveland Clinic Foundation between January 2003 and January 2005. For each patient demographic data was collected and the ICEEG seizure recordings were reviewed. To calculate the time difference from ictal EEG onset to clinical seizure onset, only those seizures with both clear focal EEG onsets as well as a clear clinical onsets were used. Clinical onsets were defined as one of the following: 1) patient self‐report of an aura or pressing seizure button, 2)clear change in facial expression, 3) change in responsiveness as determined by interaction with others, 4)onset of automatisms 5)onset of motor seizure. In the group of patients who had >1 seizure that was analyzed, we then calculated the percentage of patients in that group who had a minimum time from EEG to clinical seizure onset of ≥ 10s in at least 80% of their seizures. Results: 31 patients who had a total of 268 seizures were studied. The mean age was 26.6, range [7–48]. The mean number of seizures recorded/patient was 8.65 (SD8.68), range [1–50]. The mean number of seizures/patient with both clear focal EEG onset and clear clinical onset was 3.32 (SD 2.81), range [0–9]. The mean time from ictal EEG onset to clinical seizure onset was 35.13s (SD 87.90), range [‐2.14 to 432.42]. The subgroup of patients who had >1 seizure with both clear focal EEG onset and clear clinical onset consisted of 20 patients. In this group, 40% (n = 8) had a time from EEG to clinical seizure onset of ≥10s in at least 80% of their analyzed seizures. These patients represent 27% of the total study population. Conclusions: Our study shows that in about 27% of patients with focal epilepsy who undergo ICEEG there is a considerable time difference (>10s) between ictal ICEEG onset and clincal onset in at least 80% of their seizures. This information is useful in that it supports the rationale for creating EEG based interventions that may warn of, or prevent clinical seizure onset. 1 Amit Verma, and 1 Ian L. Goldsmith ( 1 Peter Kellaway Section of Neurophysiology, Department of Neurology, Baylor College of Medicine, Houston, TX ) Rationale: Vartiations in heart rate have been described during seizures by numerous authors. All this information is based on recorded seizures in patients with onset in either the dominant or nondominant hemisphere. No case has ever been reported, to our knowledge, where individual seizure onset in either hemisphere produced a different effect on heart rate in a single patient. We report a patient with bilateral seizure onset where seizure onset in the dominant (left) hemisphere was associated with asystole, while a tachycardia was seen during seizure onset from the nondominant (right) hemisphere. Methods: DK is a 35 year old right handed female with a history of a febrile convulsion at age 1 year. The patient began to experience seizures when she was in college. She initially reported having complex partial seizures associated with a “bad taste in her mouth..” VideoEEG monitoring with bilateral sphenoidal electrodes performed in 1996 demonstrated seizure onset in the right temporal region. An MRI scan, however, demonstrated an enhancing lesion in the left frontal operculum. The patient underwent a partial resection of this lesion. The pathology was consistent with a ganglioglioma. The patient continued to have seizures, but then developed a second seizure type which she described as “blackout spells.” Repeat video EEG monitoring in 2001 demonstrated two seizure types: 1) Seizures with onset in the left temporal region which were associated with bradycardia and asystole and 2) Seizures with onset in the right temporal region which were associated with slight increase in heart rate. Results: The patient subsequently underwent placement of a on‐demand cardiac pacemaker to prevent episodes of asystole. She reported an elimination of her “blackout spells” but continued to have her seizures associated with the “bad taste in her mouth.” The patient had failed multiple antiepileptic drugs and subsequently underwent placement of a vagus nerve stimulator (VNS). This did not appreciably change her seizure frequency. Since the cardiac pacemaker had been implanted in the left infraclavicular region, the VNS was implanted in the right infraclavicular region with the VNS lead attached to the left vagus nerve. Conclusions: We believe this case is important to report for a variety of reasons. First, to our knowledge, no single case has ever been reported where independent seizure onset in both hemispheres has been associated with differential effects on heart rate. A volume of information exists about heart rate changes, but is all based on single sides of seizure onset in large cohorts of patients. This case may help provide more insite into the mechanism of Sudden Unexpected Death in patients with Epilepsy. Secondly, this also illustrates the safety of implantation of the VNS battery pack in the right infraclavicular region while stimulating the right vagus nerve. (Supported by Peter Kellaway Foundation For Research.) 1 Norman C. Wang, 1 Juan Ros‐Escalante, and 2 Yu‐tze Ng ( 1 Neurology, Barrow Neurological Institute, Phoenix, AZ ; and 2 Pediatric Neurology, Barrow Neurological Institute, Phoenix, AZ ) Rationale: Scalp video‐EEG (Phase I) studies often do not clearly localize seizure onsets. Depth wire recordings improve accuracy; however, invasive (Phase II) studies carry significant risks including, infection, hemorrhage and stroke. Earlier, non‐invasive identification of nonsurgical candidates is warranted. One such population is patients with seizures arising from both left and right hemispheres independently. Various characteristics of this group of patients were examined to determine any noninvasive predictors of independent, bilateral onset seizures (IBOS) in cases that were subsequently confirmed on depth wire studies. Methods: All video‐EEG monitoring reports from our epilepsy monitoring unit from 11/92 to 12/04 were reviewed. These included phase I and phase II monitored patients. Depth wire reports were examined for evidence of IBOS. Corresponding scalp EEG reports were obtained. Both reports for each patient were examined for the following data points: (1) ictal and interictal activity on scalp EEG recording, (2) MRI results, (3) seizure semiologies and (4) PET scans. Results: Of 2496 total reports, 299 depth wire cases were identified. Twenty‐three (7.7%) of these demonstrated IBOS during Phase II and 3 cases were excluded due to lack of Phase I data. Twenty patients were reviewed in detail. During Phase I studies, 6 suggested IBOS with 5 showing interictal epileptiform discharges from both sides. None of 20 MRI reports had evidence of bilateral structural changes. PET scans revealed bilateral hypometabolism in only 2 of 15 cases. Thirteeen (65%) patients had two or more different seizure semiologies. During Phase II exams, there was a characteristic seizure semiology for each side of onset in only 2 patients. However, in 5 cases, the 2 observed semiology types did not correspond with a particular side of onset, and in 7 cases, there was only one seizure type despite varying onset lateralizations. More than 2 semiologies were seen in 6 cases. Conclusions: A surprisingly high number (7.7%) of patients undergoing depth electrode monitoring have IBOS. Certain noninvasive evidence suggests the findings of IBOS in Phase II studies. IBOS on scalp recordings were suggested in less than one‐third of these patients but may indicate that depth wires are not indicated in this group. Further cohort studies would be necessary to determine the specificity to support this conclusion. Functional (PET) rather than structural (MRI) imaging appears more sensitive for these cases although this also occurred in a minority of cases (13.3%). Most patients (65%) had at least 2 different seizure semiologies with 6 patients (30%) having 3 or more semiologies and this may be predicitive of IBOS, although the seizure semiologies themselves did not consistently correlate with side of onset, varying widely between patients. Better recognition of patients with IBOS would prevent unnecessary depth electrode placements. 1,2,3 Randall J. Wright, 1,2,3 Amit Verma, 1,2,3 Ian L. Goldsmith, and 1–4 Eli M. Mizrahi ( 1 Peter Kellaway Section of Neurophysiology, Department of Neurology, Baylor College of Medicine, Houston, TX ; 2 Baylor Comprehensive Epilepsy Center at The Methodist Hospital, Baylor College of Medicine, Houston, TX ; 3 Department of Neurophysiology, The Methodist Hospital, Houston, TX ; and 4 Section of Pediatric Neurology, Department of Pediatrics, Baylor College of Medicine, Houston, TX ) Rationale: A variety of techniques are utilized to localize epileptic seizure onset in patients with complex partial seizures in order to co‐register non‐neurophysiologic parameters with ictal EEG findings. Some techniques such as positron emission computerized tomography (SPECT) are based on detecting an increase in regional blood flow in the area of seizure onset. Very little is known about changes in larger diameter blood vessels during seizures. Such changes in cerebral blood flow were investigated utilizing ictal transcranial doppler (TCD). Methods: Transcranial doppler was recorded during EEG‐video monitoring in 2 adult patients undergoing evaluation for anterior temporal lobectomy. Bilateral TCD sensors were held in place over the temporal regions utlizing a fixed halo. Standard EEG‐video monitoring protocols utlizing scalp electrodes were not altered from clinical practice for this study. Results: One seizure each was recorded from each patient. For each, there was an increase in mean blood flow velocities on the side ipsilateral to the seizure onset as determined by ictal EEG. Conclusions: This preliminary data suggests that blood flow changes during TCD monitoring during complex partial seizures may correlate to the side of seizure onset. This may provide another tool in the evaluation of candidates for epilepsy surgery allowing another non‐neurophysiologic method for co‐registration of functional data. In addition, since TCD reflects changes in blood flow velocities in larger diameter blood vessels, this technique may provide further insight into blood flow patterns in larger blood vessels during partial seizures. (Supported in part by the Peter Kellaway Research Endowment, Baylor College of Medicine and National Service Award Training Grant T32 NS07399, National Institutes of Neurological Disorders and Stroke, NIH.) 1 Elza M.T. Yacubian, 1 Luis O.S.F. Caboclo, 1 Katia Lin, 1 Eliana Garzon, and 1 Americo C. Sakamoto ( 1 Neurology, UNIFESP/EPM, Sao Paulo, Sao Paulo, Brazil ) Rationale: Ictal spitting is considered to be a rare event in epileptic seizures (1, 2), being most frequently observed in patients with temporal lobe epilepsy (TLE). It may represent a lateralizing sign of non‐dominant temporal lobe seizures (3). Ictal spitting may, however, be observed in seizures originating in the dominant temporal lobe (1). We report three cases of right‐handed patients with TLE, with ictal spitting in seizures originating in the left temporal lobe, as confirmed by video‐EEG monitoring. Methods: We reviewed charts from all patients with TLE submitted to pre‐surgical evaluation, which included high resolution MRI and prolonged video‐EEG monitoring, during a two‐year period (2003–2004). We searched for patients who presented ictal spitting during monitoring. Results: Three patients fulfilled the criteria above. All three reported spitting automatisms in the initial clinical evaluation. The first patient was a twenty‐nine year‐old right‐handed man with seizures since the age of two. MRI showed a severely atrophic left hippocampus. During video‐EEG with scalp‐sphenoidal electrodes, twelve seizures were recorded, with ictal onset clearly lateralized to the right temporal lobe. In one seizure he presented ictal spitting. Due to discordance between neurophysiologic and imaging data, the patient was submitted to a new video‐EEG monitoring with foramen ovale (FO) electrodes. He had three seizures with ictal onset in the contacts of the left FO electrode, which confirmed the hypothesis of false lateralization in surface EEG, and was submitted to left anterior temporal lobectomy; after 18 months of follow‐up, he is seizure‐free. The second patient was a nineteen year‐old right‐handed man with history of febrile seizures at the age of two, and onset of epileptic seizures at the age of nine. MRI revealed left hippocampal sclerosis (HS). The patient had six seizures during video‐EEG monitoring, all with ictal onset over the left temporal lobe; in all seizures he had spitting automatisms. The third patient was a twenty‐six year‐old right handed woman with onset of epilepsy at the age of sixteen. MRI showed left HS. She had three seizures during video‐EEG monitoring, with ictal onset localized over the left temporal lobe. In one of the seizures, she presented ictal spitting. Conclusions: Spitting is an uncommon automatism in temporal lobe seizures. As we have shown in this work, it should not be considered a lateralizing sign to nondominant temporal lobe, since it may occur as a clinical manifestation of seizures originating in the left temporal lobe. (Supported by FAPESP (Fundação de Amparo à Pesquisa do Estado de São Paulo) and CAPES (Coordenação de Aperfeiçoamento de Pessoal de Nível Superior)/CNPq (Conselho Nacional de Desenvolvimento Científico e Tecnológico).) 1 Alexei E. Yankovsky, 1 Frederick Andermann, and 1 Francois Dubeau ( 1 Neurology and Neurosurgery, Montreal Neurological Hospital and Institute, McGill University, Montreal, QC, Canada ) Rationale: Yawning, an autonomic phenomenon, has surprisingly rarely been described in association with seizures and has not previously been documented by video‐EEG. Methods: We studied a 48‐year‐old woman with a long history of non‐dominant centro‐parietal seizures who developed forceful repetitive post‐ictal yawning. Results: The patient began having intractable epileptic attacks at age 18. She described five types of seizures. At 30, she underwent invasive EEG studies, which showed epileptiform abnormalities over the right parietal operculum. Brain CT and MRI were normal. A right inferior parietal and posterior temporal resection did not lead to improvement. At 31, she had a second resection at the temporal edge of the previous operation again with no improvement. The tissue showed no definite abnormality.Yawning appeared late (approximately 24 years after onset of her seizures). It was repetitive, irresistible and forceful starting from 1 to 30 seconds after the seizure offset and lasting from 5 to 60 seconds. During video telemetry it was observed after most (86%) focal sensory‐motor seizures and after one third of simple sensory attacks. She was alert during all yawning episodes. A video will be presented. Conclusions: Yawning may be added to the other autonomic peri‐ictal symptoms such as spitting, water drinking, vomiting, urinary urgency or coughing. There is evidence suggesting that such symptoms involve primarily the nondominant hemisphere and this may be the case for yawning as well.