Continuous video-EEG Monitoring Research Articles

Auditory hallucinations as ictal phenomena in a patient with voltage‐gated potassium channel antibody‐associated limbic encephalitis

Limbic encephalitis involving anti-voltage-gated potassium channel antibodies (VGKC-LE) has become increasingly recognised, with seizures and psychotic features, such as hallucinations being typical clinical manifestations. Though the literature supports auditory hallucinations as ictal phenomena, there are no reported cases of these hallucinations correlating with electrographic seizure for this disease entity. Early recognition of auditory hallucinations as seizures could alter treatment and subsequently affect short-term outcomes in these patients. We report the case of a patient with auditory hallucinations and progressive cognitive decline, as well as serological evidence of VGKC antibodies, in whom ictal hallucinations were identified by continuous video-EEG monitoring. This case highlights the subtlety of this entity, in both clinical and electrographic detection. [Published with video sequences].

Subclinical early posttraumatic seizures detected by continuous EEG monitoring in a consecutive pediatric cohort

Traumatic brain injury (TBI) is an important cause of morbidity and mortality in children, and early posttraumatic seizures (EPTS) are a contributing factor to ongoing acute damage. Continuous video-EEG monitoring (cEEG) was utilized to assess the burden of clinical and electrographic EPTS. Eighty-seven consecutive, unselected (mild - severe), acute TBI patients requiring pediatric intensive care unit (PICU) admission at two academic centers were monitored prospectively with cEEG per established clinical TBI protocols. Clinical and subclinical seizures and status epilepticus (SE, clinical and subclinical) were assessed for their relation to clinical risk factors and short-term outcome measures. Of all patients, 42.5% (37/87) had seizures. Younger age (p = 0.002) and injury mechanism (abusive head trauma - AHT, p < 0.001) were significant risk factors. Subclinical seizures occurred in 16.1% (14/87), while 6.9% (6/87) had only subclinical seizures. Risk factors for subclinical seizures included younger age (p < 0.001), AHT (p < 0.001), and intraaxial bleed (p < 0.001). SE occurred in 18.4% (16/87) with risk factors including younger age (p < 0.001), AHT (p < 0.001), and intraaxial bleed (p = 0.002). Subclinical SE was detected in 13.8% (12/87) with significant risk factors including younger age (p < 0.001), AHT (p = 0.001), and intraaxial bleed (p = 0.004). Subclinical seizures were associated with lower discharge King's Outcome Scale for Childhood Head Injury (KOSCHI) score (p = 0.002). SE and subclinical SE were associated with increased hospital length of stay (p = 0.017 and p = 0.041, respectively) and lower hospital discharge KOSCHI (p = 0.007 and p = 0.040, respectively). cEEG monitoring significantly improves detection of seizures/SE and is the only way to detect subclinical seizures/SE. cEEG may be indicated after pediatric TBI, particularly in younger children, AHT cases, and those with intraaxial blood on computerized tomography (CT).

Pediatric Seizures

On the basis of strong evidence, treatment is highly dependent on the seizure semiology results, electroencephalography (EEG) findings, and origin. • On the basis of moderate evidence and consensus, vigorous use of video EEG recordings and home video cameras should be used to delineate the epileptic syndromes. • On the basis of strong evidence, pediatric epilepsy syndromes have common comorbidities. As a consensus, some pediatric epilepsy centers consider referral to a neuropsychologist to be first-line care in these patients. • On the basis of strong evidence and consensus, antiepileptic drug therapy has its own complications and should be discontinued after an appropriate treatment course. • On the basis of moderate evidence and consensus, uncontrolled seizures put patients at risk for significant morbidity and mortality.

The contribution of voxel-based morphometry in the detection of cortical dysplasia in patients with PET positive MR negative epilepsy

Methods. We evaluated prospectively 596 patients with pharmacoresistant seizures. All these patients underwent continuous video-EEG monitoring. In consenting patients, we used suggestive seizure provocation. The seizure semiology, inter-ictal EEG, brain MRI, psychiatric co-morbidities, and the impact of the provocative testing and other parameters on the seizure outcome were assesed. Results. In the sample of 596 monitored patients, we detected 111 (19.3%) patients with PNES. Of the 111 patients with PNES, 86.5% had spontaneous and 76.5% had provoked seizures. The five most typical symptoms – initially closed eyelids (67.6%), rapid tremor (47.7%), asynchronous limb movement (37.8%), preictal pseudosleep (33.3%), and side-to-side head movement (32.4%) – were presented on video. Inter-ictal EEG was rated as abnormal in 46.2% and with epileptiform abnormality in 9%. Brain MRI was abnormal in 32 (28.8%) patients. Personality disorders (46.8%), anxiety (39.6%), and depression (12.6%) were the most frequent additional psychiatric co-morbidities. Psychogenic non-epileptic seizures outcome after at least 2 years is reported; 22.5% of the patients were seizure-free; one third had markedly reduced seizure frequency. The provocative testing had no negative impact on the seizure outcome. We determined eight variables which could affect the seizure outcome. The trend to be the predictor of worse results was PNES duration before appropriate diagnosis (pb0.013). Conclusions. Video-EEG monitoring with suggestive seizure provocation supported by clinical psychiatric and psychological evaluations sig

4. ICU EEG study

Prolonged EEG monitoring in the ICU is now common. Studies suggest that the prevalence of seizures and nonconvulsive status epilepticus (NCSE) is 10% or more. However, the selection criteria for monitoring remain ambiguous, and the impact of prolonged EEG monitoring on treatment is unclear. We addressed these questions by performing prolonged EEG on patients for whom a routine 30-min or prolonged EEG was requested by ICU staff. During a prospective but not randomized 22-month study, EEGs were requested by ICU staff on 130 patients, with diagnoses of trauma, tumor, stroke, metabolic derangement, cerebral hemorrhage, and hypoxic–ischemic injury. Patients were placed in three groups. Group 1 : 34 patients received a 30-min EEG, because for various reasons long-term recording could not be done. Group 2 : 83 patients for whom staff requested a 30-min EEG, instead received 16–24 h of continuous video-EEG monitoring. Group 3 : 13 patients, with known epilepsy, for whom continuous video-EEG monitoring was requested, received 16–24 h of recording to monitor suspected status epilepticus. Epileptologists compared the first 30 min of EEG with the subsequent recording to see if any additional information was obtained, and if it impacted treatment. Group 1: 34 patients had a routine 30-min EEG. One was normal, 27 were slow or poorly reactive, and six (18%) showed epileptiform activity, including one with electrographic seizures. Group 2: 83 patients were monitored with video-EEG for 16–24 h. All EEGs were abnormal with slowing and poor reactivity. 28/83 patients (34%) showed epileptiform findings in the first 30 min, including periodic epileptiform discharges (PEDs), generalized or focal epileptiform discharges, burst suppression, triphasic waves, and 2 patients had clinical seizures. 5/28 developed additional epileptiform changes overnight, including two more with clinical seizures. 55/83 patients (66%) had no epileptiform findings in the first 30 min, but 7/55 developed these overnight, including two with electrographic and one with clinical seizures. Overall, in 12/83 patients additional epileptiform abnormalities developed overnight, and in 7/83 treatment was changed based on prolonged as opposed to routine EEG. 3/7 patients in whom treatment was changed showed improvement. Group 3: 13 patients known to have epilepsy, who presented with seizures, were deliberately placed on long term video-EEG monitor. 9/13 (69%) showed epileptiform abnormalities in the first 30 min including three with NCSE and one with focal seizures. Overnight two more evolved into NCSE, and prolonged EEG influenced therapy in 6/13. In 83 unselected ICU patients, overnight video-EEG, as opposed to a 30-min EEG, detected additional epileptiform abnormalities in 12 patients (14%), and 7/83 patients (8%) had changes in treatment based on findings from prolonged as opposed to routine EEG. In contrast, patients with epilepsy who presented with seizures were more likely than other ICU patients to have NCSE, and prolonged EEG influenced treatment in 6/13 (46%). This study suggests that long-term EEG monitoring in an unselected ICU population rarely influences treatment or outcome. In a selected population with known epilepsy the benefit may be larger.

Rapamycin Attenuates the Development of Posttraumatic Epilepsy in a Mouse Model of Traumatic Brain Injury

Posttraumatic epilepsy is a major source of disability following traumatic brain injury (TBI) and a common cause of medically-intractable epilepsy. Previous attempts to prevent the development of posttraumatic epilepsy with treatments administered immediately following TBI have failed. Recently, the mammalian target of rapamycin complex 1 (mTORC1) pathway has been implicated in mechanisms of epileptogenesis and the mTORC1 inhibitor, rapamycin, has been proposed to have antiepileptogenic effects in preventing some types of epilepsy. In this study, we have tested the hypothesis that rapamycin has antiepileptogenic actions in preventing the development of posttraumatic epilepsy in an animal model of TBI. A detailed characterization of posttraumatic epilepsy in the mouse controlled cortical impact model was first performed using continuous video-EEG monitoring for 16 weeks following TBI. Controlled cortical impact injury caused immediate hyperactivation of the mTORC1 pathway lasting at least one week, which was reversed by rapamycin treatment. Rapamycin decreased neuronal degeneration and mossy fiber sprouting, although the effect on mossy fiber sprouting was reversible after stopping rapamycin and did not directly correlate with inhibition of epileptogenesis. Most posttraumatic seizures occurred greater than 10 weeks after TBI, and rapamycin treatment for one month after TBI decreased the seizure frequency and rate of developing posttraumatic epilepsy during the entire 16 week monitoring session. These results suggest that rapamycin may represent a rational treatment for preventing posttraumatic epilepsy in patients with TBI.

Safety and Efficacy of Intravenous Lacosamide for Adjunctive Treatment of Refractory Status Epilepticus: A Comparative Cohort Study

Refractory status epilepticus (RSE) is an emergency with high mortality requiring neurointensive care. Treatment paradigms include first-generation antiepileptic drugs (AEDs) and anesthetics. Lacosamide (LCM) is a new AED, holding promise as a potent treatment option for RSE. High-level evidence regarding safety and efficacy in the treatment of RSE is lacking. The objective of the study was to evaluate the safety profile and efficacy of intravenous (i.v.) LCM as an add-on treatment in adult RSE patients. All consecutive RSE patients treated in the intensive care units (ICUs) of an academic tertiary care center between 2005 and 2011 were included. Severity of status epilepticus (SE) was graded by the SE Severity Scale (STESS), and SE etiology was categorized according to the guidelines of the International League Against Epilepsy (ILAE). Outcomes were seizure control, RSE duration, and death. Of 111 RSE patients, 53 % were treated with LCM. Twenty-five patients with hypoxic-ischemic encephalopathy were excluded. Mortality was 30 %. Mean number of AEDs, duration, severity, and etiology of SE, as well as critical medical conditions did not differ between patients with and without LCM. While age tended to be higher, critical interventions, such as the use of anesthetics and mechanical ventilation, tended to be less frequent in patients with LCM. Seizure control tended to be achieved more frequently in patients with LCM (odds ratio, OR 2.34, 95 % CI 0.5-10.1, p = 0.252). Among patients with LCM, 51 % received LCM as the last AED (including hypoxic-ischemic encephalopathy), allowing the reasonable assumption that LCM was responsible for seizure control, which was achieved in 91 %. Multivariable analysis revealed a decreased mortality in patients with LCM (OR 0.34, 95 % CI 0.1-0.9, p = 0.035). A possible confounder in this context was the implementation of continuous video-electroencephalography (EEG) monitoring 6 months prior to the first use of i.v. LCM. There were no serious LCM-related adverse events. LCM had a favorable safety profile as adjunctive treatment for RSE. Its use was associated with decreased mortality of RSE-a finding that might have been confounded by the implementation of continuous video-EEG monitoring in the ICU prior to the use of i.v. LCM, leading to heightened awareness as well as earlier diagnosis and treatment of SE. Randomized trials are warranted to further strengthen the evidence of efficacy of LCM for RSE treatment.

Tiagabine-induced stupor in patients with psychogenic nonepileptic seizures: Nonconvulsive status epilepticus or encephalopathy?

BackgroundNonconvulsive status epilepticus has been rarely reported with tiagabine (TGB) use. MethodsWe report findings from continuous video-EEG monitoring and serial neurological examinations during prolonged episodes of stupor associated with TGB use in three patients who did not have epilepsy. ResultsAll three patients had emergence of new type of events after starting TGB treatment. All three patients had gradual decline in responsiveness to verbal stimuli, intermittent twitching of the upper extremities, and urinary incontinence. The corresponding EEG showed gradual build-up of generalized bisynchronous delta-wave activity with subsequent intermingled sharp transients. Two patients did not respond to IV lorazepam, one of whom also did not respond to IV phenytoin. The EEG slowly normalized in conjunction with associated clinical improvement. Habitual seizures were found to be psychogenic, with no interictal evidence for epilepsy. ConclusionTiagabine-related stupor may represent a form of toxic encephalopathy in some cases rather than nonconvulsive status epilepticus.

MRI changes and complement activation correlate with epileptogenicity in a mouse model of temporal lobe epilepsy

The complex pathogenesis of temporal lobe epilepsy includes neuronal and glial pathology, synaptic reorganization, and an immune response. However, the spatio-temporal pattern of structural changes in the brain that provide a substrate for seizure generation and modulate the seizure phenotype is yet to be completely elucidated. We used quantitative magnetic resonance imaging (MRI) to study structural changes triggered by status epilepticus (SE) and their association with epileptogenesis and with activation of complement component 3 (C3). SE was induced by injection of pilocarpine in CD1 mice. Quantitative diffusion-weighted imaging and T2 relaxometry was performed using a 16.4-Tesla MRI scanner at 3h and 1, 2, 7, 14, 28, 35, and 49days post-SE. Following longitudinal MRI examinations, spontaneous recurrent seizures and interictal spikes were quantified using continuous video-EEG monitoring. Immunohistochemical analysis of C3 expression was performed at 48h, 7days, and 4months post-SE. MRI changes were dynamic, reflecting different outcomes in relation to the development of epilepsy. Apparent diffusion coefficient changes in the hippocampus at 7days post-SE correlated with the severity of the evolving epilepsy. C3 activation was found in all stages of epileptogenesis within the areas with significant MRI changes and correlated with the severity of epileptic condition.

Management of epilepsy in resource-limited settings: establishing an epileptic surgery program in Southern Iran

Introduction: The most common treatment modality for epileptic patients is antiepileptic drug (AED) therapy. However, more than 30% of epileptic patient suffers from drug-resistant epilepsy despite the use of appropriate AEDs. Surgery is a common option for these patients. Epilepsy surgery requires sophisticated medical technologies, many of them not available in Iran. The authors of the present study aim to report the clinical and technical issues of establishing an epilepsy surgery protocol in Iran and the limitations and recommendations for further development. Methods: Medically-refractory epileptic patients underwent common imaging techniques (mainly brain MRI using a specific temporal lobe protocol) as well as continuous video EEG monitoring. A specialized committee consisting of epileptologists, neurologists, neurosurgeons and radiologists discussed the eligibility of each patient, and defining treatment plans for the surgery. Results: A total of 22 committee sessions were hold to discuss 140 cases with medically-refractory seizures during March 2009 to May 2012. Eighty-eight patients (62%) underwent the surgery, 35 patients (25%) were considered not appropriate for surgery, and 17 patients (12%) refused to undergo surgery. The most common cause of intractable seizures was mesial temporal sclerosis (36%), brain tumors (21%), cortical malformations (6%), and encephalomalacia (4%). Among 81 operated patients, 39.5% had anterior temporal lobectomy, 34.5% corpus callosotomy, and 30% underwent lesionectomy. Conclusion: The success of epilepsy surgery depends on the accurate identification of good surgical candidates based on available resources and technologies without jeopardizing safety. The key step in establishing a successful plan is having access to trained epileptologist and neurosurgeon.

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

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

Rapid epileptogenesis in the mouse pilocarpine model: Video-EEG, pharmacokinetic and histopathological characterization

Temporal lobe epilepsy (TLE) is the most common form of drug-resistant epilepsy and several rodent models allow studying the pathophysiology of this disorder. One of the best characterized models of TLE is the pilocarpine model. The model has been widely used in rats, but relatively few studies report data obtained with mice. This triggered the present study to perform a comprehensive characterization of the mouse pilocarpine model. We used male NMRI mice (28–32g) and first established the dose–response relationship for pilocarpine (250–400mg/kg; ip) to induce status epilepticus (SE). This enabled to define the optimal dose (300mg/kg) producing the highest SE response (50%) associated with the best survival rate of the animals (90%). The impact of different durations of SE (0.5–3.0h) on the time to the onset of the first spontaneous recurrent seizures (SRS) was recorded during 5-day continuous video monitoring following the SE. Virtually no “latent” period was observed as the seizures appeared already within 24–48h after the pilocarpine-induced SE and 0.5h duration of the SE was sufficient to trigger SRS. Pharmacokinetics assessment showed that these seizures were not associated with residual pilocarpine exposure as it was cleared from the blood and brain already within 24h post-injection. Consistent with previous reports from the rat pilocarpine model we observed that the extent of hippocampal reorganization and neuronal loss correlates with the duration of SE. However, the shorter durations of SE (0.5–2.0h) appeared to produce cell loss restricted mainly to the hilus of the dentate gyrus. Interestingly, we also observed that the number of seizures occurring within 5days after SE appeared to correlate with the degree of hippocampal damage. Continuous 7-week video-EEG monitoring after the SE revealed that SRS were expressed in a particular pattern of clusters. Taken together, the current study provides an in-depth characterization of the mouse pilocarpine model and confirms several features of the epileptogenesis process previously reported from the rat pilocarpine model. However, the mouse pilocarpine model differs by the rapid onset of seizures and an apparent correlation between their numbers and the degree of histopathological changes. Our findings highlight that the pilocarpine model of TLE in mice is associated with brain pathology akin to different stages of human disease and may provide a valuable tool for the discovery of future antiepileptic drugs with disease-modifying properties.

Circadian patterns of generalized tonic–clonic evolutions in pediatric epilepsy patients

ObjectiveTo investigate the sleep/wake, day/night, and 24-h periodicity of pediatric evolution to generalized tonic–clonic seizures (GTC). MethodsCharts of 407 consecutive patients aged 0–21years undergoing continuous video-EEG monitoring for epilepsy were reviewed for the presence of GTC evolution. Seizures were characterized according to 2001 ILAE terminology. Charts were reviewed for EEG seizure localization, MRI lesion, and for seizure occurrence in 3-h time blocks, out of sleep or wakefulness, and during the day (6AM–6PM) or night. Analysis was done with binomial testing. Regression models were fitted using generalized estimating equations with patients as the cluster level variable. Results71 patients (32 girls, mean age 12.63±5.3 years) had 223 seizures with GTC evolution. Sleep/wake seizure distribution predicted tonic–clonic evolution better than time of day, with more occurring during sleep (p<0.001). Tonic–clonic evolution occurred most frequently between 12–3AM and 6–9AM (p<0.05). Patients with generalized EEG onset had more tonic–clonic evolution between 9AM and 12PM (p<0.05). Patients with extratemporal focal seizures were more likely to evolve during sleep (p<0.001); this pattern was not found in patients with temporal or generalized seizure onset on EEG. Patients without MRI lesions were more likely to evolve between 12AM and 3AM (p<0.05), in the sleeping state (p<0.001), and at night (p<0.05). Logistic regression revealed that sleep and older patient age were the most important predictors of GTC evolution. ConclusionGTC evolution occurs most frequently out of sleep and in older patients. Our results may assist in seizure prediction, individualized treatment patterns, and potentially complication and SUDEP prevention.

Gaucher disease: successful treatment of myoclonic status epilepticus with levetiracetam

We present the first reported case of a rapid clinical and electroencephalographic response to intravenous levetiracetam infusion of myoclonic status epilepticus in a patient with progressive myoclonus epilepsy due to Gaucher disease. Under continuous video-EEG monitoring, the clinical myoclonic status and the electrographic ictal discharges resolved within 10 minutes after the infusion was initiated. The patient tolerated the treatment well without any reported side effects. This case suggests that levetiracetam may be a safe, effective, and well tolerated intravenous drug in patients with metabolic myoclonic status epilepticus such as Gaucher disease.

Reflex Eating Induced Seizures (REIS) with a Genetic Twist (P04.020)

Objective: We are reporting a case of familial REIS affecting two sisters. Background Reflex seizures are characterized by consistent seizure precipitation by specific sensory stimulus or cognitive activity. REIS are relatively uncommon. Seizures are typically complex partial spells of temporo-limbic origin. The coexistence of seizures induced by other forms of buccal stimulation such as tooth brushing in the same patient has been documented but familial occurrence of REIS has not been reported. We are reporting the case of a woman with REIS whose younger sister suffers from tooth brushing and occasional eating induced seizures. Design/Methods: A 38 year old professional woman of Ethiopian descent presented with history of complex partial seizures triggered by eating since age 27. Her neurological examination was normal as was the brain MRI (3T) performed according to seizure protocol. Her younger sister (age 31) began experiencing seizures induced by tooth brushing with onset at about the same age as herself. The patient was admitted to the hospital and continuous video-EEG monitoring was carried out. Routine and special activation techniques were employed. Results: The baseline EEG showed frequent interictal spikes involving the left anterior- mid temporal regions and activation by eating resulted in induction of clinical seizures with ictal onset from the same areas. Systematic testing confirmed that the seizures were induced by chewing and swallowing of solid food, and not by its sight, smell or taste. The patient9s sister who lives in another city could not be directly tested but her history was reliably verified by the authors by telephone. Conclusions: Video-EEG monitoring confirmed the diagnosis of REIS in our patient. The positive family history highlights the probable genetic basis in some variants of this disorder with inheritance of cortical neuronal hyperexcitability involving the oropharyngeal sensory projection areas. Disclosure: Dr. Patil has nothing to disclose. Dr. Ramani has nothing to disclose.

Diurnal and Sleep/Wake Patterns of Evolutions to Tonic-Clonic Seizures in Pediatric Epilepsy (P04.019)

Objective: To investigate the sleep/wake and 24-hour periodicity of evolutions into generalized tonic-clonic seizures. Background Generalized tonic-clonic seizures may evolve from seizures of variable semiology. These seizures constitute a risk factor for accidents, status epilepticus and sudden unexpected death in epilepsy. Design/Methods: Charts of 407 consecutive patients with epilepsy aged 0-21 years undergoing continuous video-EEG monitoring were reviewed for the presence of evolution into generalized tonic-clonic seizures. Seizures were characterized according to 2001 ILAE terminology. Charts were reviewed for EEG localization, MRI lesions, and seizure timing in 3-hour time blocks, out of sleep or wakefulness, and during the day (6AM-6PM) or night. Analysis was done with binomial testing. Results: Seventy-one patients (32 girls, mean age 12.63±5.3 years) had 223 seizures with evolutions into tonic-clonic semiology. Sleep/wakefulness was more related to seizure evolution than time of day, with more evolutions during sleep (p Conclusions: Evolutions to generalized tonic-clonic seizures from focal epilepsy occur more frequently out of sleep and in the morning. These findings contribute to the pathophysiological understanding of seizures and towards individualized therapies, including differential dosing and light therapy. Disclosure: Dr. Ramgopal has nothing to disclose. Dr. Shah has nothing to disclose. Dr. Vendrame has nothing to disclose. Dr. Zarowski has nothing to disclose. Dr. Alexopoulos has received personal compensation for activities with UCB Pharma as a speaker. Dr. Wyllie has nothing to disclose. Dr. Kothare has nothing to disclose. Dr. Loddenkemper has received personal compensation for activities with Eisai Inc. as a consultant. Dr. Loddenkemper has received research support from NIH/NINDS, The Epilepsy Foundation of America, CIMIT/DOD, Harvard Medical School Office of Faculty Development, and the Children9s Hospital Program for Patient Safety and Quality Improvement.

Combination of Ictal EEG and Seizure Semiology Provides 24-Hour Seizure Susceptibility Profile (P04.018)

Objective: To investigate the occurrence of seizures based on sleep/wake status and electrographic localization in pediatric epilepsy. Background We previously described diurnal and sleep/wake patterns of seizures based on clinical presentation and electrographic localization. In this study, we investigated in a larger patient series whether the sleep/wake state of seizure onset can predict EEG localization of seizures with different semiology. Design/Methods: Charts of 955 consecutive patients with epilepsy undergoing continuous video-EEG monitoring were reviewed for EEG localization, seizure occurrence out of wakefulness or sleep and for clinical seizure type. Seizures were characterized according to 2001 ILAE terminology. Proportions were compared using binomial methods. Odds ratios were used to compare seizure localization based sleep/wake state. Results: 407 patients aged 0-21 (194 girls, mean age 9.2 ± 6.0 years) had 1,754 seizures. The majority of seizures occurred out of wakefulness (58%, p Conclusions: Sleep/wake states at seizure onset can predict EEG localization of seizures with certain semiology. Clonic, dyscognitive and myoclonic seizures have more likely a generalized EEG onset when occurring during wakefulness, and a focal EEG onset when occurring out of sleep. Disclosure: Dr. Ramgopal has nothing to disclose. Dr. Loddenkemper has received personal compensation for activities with Eisai Inc. as a consultant. Dr. Loddenkemper has received research support from NIH/NINDS, The Epilepsy Foundation of America, CIMIT/DOD, Harvard Medical School Office of Faculty Development, and the Children9s Hospital Program for Patient Safety and Quality Improvement. Dr. Vendrame has nothing to disclose. Dr. Shah has nothing to disclose. Dr. Zarowski has nothing to disclose. Dr. Alexopoulos has received personal compensation for activities with UCB Pharma as a speaker. Dr. Wyllie has nothing to disclose. Dr. Kothare has nothing to disclose.

Baboon model of generalized epilepsy: Continuous intracranial video-EEG monitoring with subdural electrodes

The baboon provides a natural non-human primate model for photosensitive, generalized epilepsy. This study describes an implantation procedure for the placement of subdural grid and strip electrodes for continuous video-EEG monitoring in the epileptic baboon to evaluate the generation and propagation of ictal and interictal epileptic discharges. Subdural grid, strip and depth electrodes were implanted in six baboons, targeting brain regions that were activated in functional neuroimaging studies during photoparoxysmal responses. The baboons were monitored with continuous video-EEG monitoring for 2-21 (mean 9) days. Although the animals were tethered, the EEG signal was transmitted wirelessly to optimize their mobility. Spontaneous seizures, interictal epileptic discharges (IEDs), and responses to intermittent light stimulation (ILS) were assessed. Due to cortical injuries related to the electrode implantation and their displacement, the procedure was modified. Habitual myoclonic and generalized tonic-clonic seizures were recorded in three baboons, all associated with a generalized ictal discharge, but were triggered multiregionally, in the frontal, parietal and occipital cortices. IEDs were similarly expressed multiregionally, and responsible for triggering most generalized spike-and-wave discharges. Generalized photoparoxysmal responses were activated only in one baboon, while driving responses recorded in all three photosensitive baboons were 2.5 times the stimulus rate. In contrast to previous intracranial investigations in this model, generalized ictal and interictal epileptic discharges were triggered by parietal and occipital, in addition to the frontocentral cortices. Furthermore, targeted visual areas responded differently to ILS in photosensitive than nonphotosensitive baboons, but further studies are required before mechanisms can be implicated for ILS-induced activation of the epileptic networks.

Initial EEG predicts outcomes in a trial of levetiracetam vs. fosphenytoin for seizure prevention

Continuous electroencephalography (cEEG) is increasingly used to detect both clinical and subclinical seizures in patients with traumatic brain injury (TBI) or subarachnoid hemorrhage (SAH). We assess whether EEG findings predict outcomes in TBI/SAH patients enrolled in a levetiracetam (LEV) vs. fosphenytoin (fos-PHT) seizure prevention trial (NCT00618436). This prospective, single-blinded, comparative trial randomized 52 patients with TBI or SAH to receive prophylactic LEV or fos-PHT. Continuous video EEG monitoring was conducted for the initial 72h of medication administration. The association between EEG findings (degree of generalized and focal slowing, presence and frequency of epileptiform discharges and seizures) and outcomes (Glasgow Outcomes Scale—Extended (GOS-E) and Disability Rating Scale (DRS)) at discharge, 3 and 6months was assessed using a generalized linear model. Severity of generalized slowing tended to be associated with outcomes in both treatment groups (discharge DRS, p=0.042; discharge GOS-E, p=0.026; 3month DRS, p=0.051). The presence of focal slowing, the presence and frequency of epileptiform discharges and the presence of seizures were not predictive of outcome in either treatment group (all p>0.15). While it has been shown that LEV is associated with better outcome than fos-PHT when used as seizure prophylaxis in brain injury, aside from severity of generalized slowing, electrographic findings of focal slowing, epileptiform discharges, and seizures were not themselves associated with outcomes in patients with TBI or SAH enrolled in a randomized clinical trial.

Psychogenic non-epileptic seizures: our video-EEG experience

<title/>Objective: The aim of our study was to assess the number of psychogenic non-epileptic seizures (PNES) in our patients with a refractory seizure disorder, to determine the ‘typical’ PNES semiology using video-EEG monitoring and describe other PNES parameters.Methods: We evaluated prospectively 596 patients with pharmacoresistant seizures. All these patients underwent continuous video-EEG monitoring. In consenting patients, we used suggestive seizure provocation. We assessed seizure semiology, interictal EEG, brain MRI, psychiatric co-morbidities, personality profiles, and seizure outcome.Results: In the sample of 596 monitored patients, we detected 111 (19·3%) patients with PNES. Of the 111 patients with PNES, 86·5% had spontaneous and 76·5% had provoked seizures. The five most typical symptoms were: initially closed eyelids (67·6%), rapid tremor (47·7%), asynchronous limb movement (37·8%), preictal pseudosleep (33·3%), and side-to-side head movement (32·4%). Interictal EEG was rated as abnormal in 46·2% and with epileptiform abnormality in 9%. Brain MRI was abnormal in 32 (28·8%) patients. Personality disorders (46·8%), anxiety (39·6%), and depression (12·6%) were the most frequent additional psychiatric co-morbidities. PNES outcome after at least 2 years is reported; 22·5% patients was seizure-free; one-third had markedly reduced seizure frequency. We have not seen any negative impact of the provocative testing on the seizure outcome.Discussion: Video-EEG monitoring with suggestive seizure provocation supported by clinical psychiatric and psychological evaluation significantly contributes to the correct PNES diagnosis, while interictal EEG and brain MRI are frequently abnormal. Symptoms typical for PNES, as opposed to epileptic seizures, could be distinguished.