Diagnosis Of Seizure Disorders Research Articles

Seizure activity following cochlear implantation: Is it the implant?

ObjectiveCochlear implantation is a successful method of auditory rehabilitation. This procedure has been associated with facial nerve and vestibular end-organ stimulation suggesting potential for extra-cochlear stimulation. The objectives of this study were to investigate the potential relationship between cochlear implantation and seizure activity in the pediatric implant population. MethodsLocal Research Ethics Board approval was obtained. The Hospital for Sick Children's Cochlear Implant Database from 1998 to 2011 was retrospectively reviewed. Based on a multidisciplinary team, patients who received a diagnosis of seizure disorder or had been investigated for seizure-like activity were identified and reviewed. ResultsFifteen children from a group of 816 pediatric cochlear implant users were identified as having suspected seizure-like activity. Eventually 10 children were found to have seizures based on an evaluation by a pediatric neurologist and an electroencephalogram. Of these 10, only 3 children had new onset of seizures after cochlear implantation and 2 of these 3 suffered from global developmental delay and other medical comorbidities. No definite temporal connection was found between cochlear implant use and seizure activity. ConclusionsCochlear implantation in the pediatric population continues to be a reliable and safe intervention for children. Overall the prevalence of post implantation seizure disorders in our population (0.37%) is lower than that of the overall population (0.5–1%). The presence of new-onset seizure activity following cochlear implantation is unusual and while there are theoretic possibilities of how a cochlear implant could be implicated in initiating seizures we were unable to find evidence to support this association.

Athletes With Seizure Disorders

Individuals with seizure disorders have long been restricted from participation in certain sporting activities. Those with seizure disorders are more likely than their peers to have a sedentary lifestyle and to develop obesity. Regular participation in physical activity can improve both physical and psychosocial outcomes for persons with seizure disorders. Seizure activity often is reduced among those patients who regularly engage in aerobic activity. Recent literature indicates that the diagnosis of seizure disorders remains highly stigmatizing in the adolescent population. Persons with seizure disorders may be more accepted by peer groups if they are allowed to participate in sports and recreational activities. Persons with seizure disorders are encouraged to participate in regular aerobic activities. They may participate in team sports and contact or collision activities provided that they utilize appropriate protective equipment. There seems to be no increased risk of injury or increasing seizure activity as the result of such participation. Persons with seizure disorders still are discouraged from participating in scuba diving and skydiving. The benefits of participation in regular sporting activity far outweigh any risk to the athlete with a seizure disorder who chooses to participate in sports.

Predictors and Outcomes of Seizures After Cardiac Surgery: A Multivariable Analysis of 2,578 Patients

Limited data exist regarding the epidemiology and prognosis of seizures in adults after cardiac surgery. The aim of this study was to define preoperative predictors of seizures and impact on postoperative outcomes. A prospective database of 2,578 consecutive adults who underwent cardiac surgery at a single institution between April 2007 and December 2009 was retrospectively analyzed to determine risk factors for postoperative seizures and prognostic impact. No patient received tranexamic acid or aprotinin. Seizures occurred in 31 patients (1%) at a median of 2 days postoperatively (1 patient had a preoperative diagnosis of seizure disorder). Seizures were classified as generalized tonic-clonic (71%), simple/complex partial (26%), or status epilepticus (3%). Incidence differed according to procedure (coronary bypass 0.1%, isolated valve 1%, valve/coronary bypass 3%, aorta 5%; p <0.001). Patients who experienced seizures had nearly a fivefold higher operative mortality than patients who did not (29% versus 6%, p <0.001). Head computed tomography was performed in 26 patients (84%), of whom ischemic strokes were identified in 14 cases (53%). These were embolic in 9 patients (34%), and watershed in 3 (12%). Hemorrhagic strokes were observed in 2 patients (8%). The occurrence of a new postoperative stroke in seizure patients did not significantly increase the likelihood of in-hospital death. Thirteen patients (41%) were discharged without neurologic deficit. Multivariable logistic regression analysis identified three risk factors for seizure: deep hypothermic circulatory arrest, aortic calcification or atheroma, and critical preoperative state. Seizures in adults after cardiac surgery are strong independent predictors of permanent neurologic deficit and increased operative mortality. Early head computed tomography may be indicated to identify treatable pathology.

Rasmussen Encephalitis In A Nigerian Child: A Case Report

INTRODUCTIONSeizure disorder may be caused by a variety of medical conditions. CASE PRESENTATIONWe report a case of Rasmussen encephalitis (RE) in a 7yearold boy of the Yoruba ethnic group in Nigeria. This to the best of our knowledge is the first reported case of this condition in a Nigerian. He had computed tomography (CT) and magnetic resonance imaging (MRI) scan of the brain and electroencephalography (EEG). CONCLUSIONWe want to emphasize the importance of imaging in the diagnosis of seizure disorder, especially when it is intractable. To diagnose RE, the index of clinical suspicion has to be high. It is probable that some cases of this condition will be missed in our environment as a result of inadequate imaging, stemming from availability and cost considerations. RE is extremely rare and many radiologists practicing in sub-Saharan Africa may not see a single case of RE in their practice life as a result of the paucity of MRI facilities (which is required for diagnosis) in this sub-region.

Utility of Noninvasive, Mobile, Continuous Outpatient Rhythm Monitoring to Diagnose Seizure‐Related Arrhythmias

The identification of patients with a diagnosis of seizure disorder who are also at risk for clinically significant bradycardia and/or tachycardia may require long-term cardiac rhythm monitoring. Noninvasive, continuous, outpatient cardiac rhythm monitoring may be useful for such clinical scenarios. The study group consisted of two male patients with a history of seizure disorder involving loss of consciousness. Clinical data and results of electrocardiography, echocardiography, electroencephalography, and continuous, mobile, outpatient cardiac rhythm monitoring are described. In the first patient, while cardiac bradyarrhythmias were secondary to seizures, sinus arrest most likely complicated the episodes by leading to more prolonged states of unconsciousness. In the second patient, permanent pacemaker implantation for AV block averted all clinical events previously attributed to seizures. Despite the different causal relationships between seizures and bradyarrhythmias in these two patients, mobile, cardiac outpatient telemetry was successful in diagnosing the contribution of cardiac dysrhythmia, leading to permanent pacemaker implantation. A diagnostic strategy that incorporates mobile, noninvasive, continuous, outpatient cardiac rhythm monitoring can effectively be utilized to diagnose significant seizure-related arrhythmias.

Listening to people with seizures: How can linguistic analysis help in the differential diagnosis of seizure disorders?

Despite advances in medical technology, the patients' history remains the most crucial tool in the differential diagnosis of epileptic or non-epileptic seizures (NES). The distinction of these two types of seizures is a common and important task for neurologists. Whereas epileptic seizures would be treated with antiepileptic drugs, non-epileptic seizures are thought to be a manifestation of psychological or social distress and can improve with psychotherapy. This paper summarizes the findings of a series of multidisciplinary research studies undertaken at the Bethel Epilepsy Centre and the University of Bielefeld in Germany in which linguistic analysis was carried out to identify and describe linguistic and interactional features in clinical exchanges between doctors and patients with seizures. Two distinct communication profiles emerged in these studies based on the analysis of transcripts of over 110 doctor-patient encounters. Epileptic seizure descriptions are characterized by formulation effort, provide the doctor with a coherent account of individual seizures, relate subjective seizure experiences and use consistent metaphoric conceptualizations. Patients with NES tend not to volunteer subjective seizure symptoms, give accounts of their seizures which are difficult to understand and are inconsistent in their choice of metaphors.

Paraneoplastic limbic encephalitis as a cause of new onset of seizures in a patient with non-small cell lung carcinoma: a case report

IntroductionThe etiology of seizure disorders in lung cancer patients is broad and includes some rather rare causes of seizures which can sometimes be overlooked by physicians. Paraneoplastic limbic encephalitis is a rather rare cause of seizures in lung cancer patients and should be considered in the differential diagnosis of seizure disorders in this population.Case presentationThis case report describes the new onset of seizures in a 64-year-old male patient receiving chemotherapy for a diagnosed stage IV non-small cell lung carcinoma. After three cycles of therapy, he was re-evaluated with a chest computed tomography which showed a 50% reduction in the tumor mass and in the size of the hilar and mediastinal lymphadenopathy. Twenty days after the fourth cycle of chemotherapy, the patient was admitted to a neurological clinic because of the onset of self-limiting complex partial seizures, with motionless stare and facial twitching, but with no signs of secondary generalization. The patient had also recently developed neurological symptoms of short-term memory loss and temporary confusion, and behavioral changes. Laboratory evaluation included brain magnetic resonance imaging, magnetic resonance spectroscopy of the brain, serum examination for 'anti-Hu' antibodies and stereotactic brain biopsy. Based on the clinical picture, the patient's history of lung cancer, the brain magnetic resonance imaging findings and the results of the brain biopsy, we concluded that our patient had a 'definite' diagnosis of paraneoplastic limbic encephalitis and he was subsequently treated with a combination of chemotherapy and oral steroids, resulting in stabilization of his neurological status. Despite the neurological stabilization, a chest computed tomography which was performed after the 6th cycle showed relapse of the disease in the chest.ConclusionParaneoplastic limbic encephalitis is a rather rare cause of new onset of seizures in patients with non-small cell lung carcinoma. Incidence, clinical presentation, laboratory evaluation, differential diagnosis, prognosis and treatment of this entity are discussed.

Differential diagnosis of seizure disorders: A conversation analytic approach

“Taking the history” remains the most important diagnostic tool in the assessment of people who have lost consciousness. The distinction of epileptic and non-epileptic seizures (NES) is particularly difficult and relevant. Whereas epileptic seizures can usually be controlled with antiepileptic drugs, NES are considered an expression of psychosocial distress and may improve with psychotherapy. The recording of typical seizures with simultaneous video and electroencephalography (EEG) can produce almost complete certainty about the diagnosis but access to video-EEG is limited, the test is very expensive and often video-EEG fails to capture typical seizures. A German research group used conversation analysis (CA) to examine patients’ descriptions of seizures to their doctors. They found that certain linguistic and interactional features clustered together and that these clusters were usually concordant with particular medical diagnoses. This study was undertaken to establish whether the observations made in German-speaking patients could be replicated in English speakers presenting to a less specialised epilepsy service. The findings presented here are based on transcripts of interviews with 11 patients admitted to a neurology ward in England because their consultant felt unable to make a clear diagnosis clinically. Transcripts were only analysed if the diagnosis of epilepsy or NES had been proven with video-EEG. The medical diagnosis was only disclosed to the linguist once a linguistic hypothesis of the diagnosis had been formulated to ensure that the linguist's decision would not be influenced by factors not contained in the 30-min-interview between doctor and patient. The linguist predicted the correct diagnosis in all cases.

Thermal Injury in Patients With Seizure Disorders: An Opportunity for Prevention

Serious burn injuries are a potential threat to patients with seizure disorder. There are limited studies addressing this issue. Therefore, a retrospective study was undertaken with two goals: one to develop better understanding of this potential threat and two to create a prevention message regarding seizure-related burns. The burn center registry was reviewed to ascertain the number of patients who sustained burn injury during or directly after a seizure from 2000 to 2005. Thirty-two patients were admitted (44% female, 56% male) with mean age of 39 years (SD +/- 10.4) after sustaining a burn during or after a seizure. Average TBSA was 8.3% (SD +/- 4.8) with 72% of patients experiencing full-thickness burns. The three most prevalent etiologies were falling into a stove while cooking (34%; n = 11), falling on hot pavement (31%; n = 10), and falling into a campfire (9%; n = 3). A full 88% of patients (n = 28) reported a previous diagnosis of seizure disorder, whereas the other 9% (n = 3) reported seizures related to alcohol consumption. Laboratory reports revealed 20 patients (63%) had subtherapeutic levels of antiseizure medication, 1 patient (3%) had toxic levels, and 5 patients (16%) were not being treated for seizures. Upon discharge, 23 patients went home with family, 5 were discharged to skilled nursing, 1 to a homeless shelter, 1 died, and 2 patients were lost to follow-up. Because of the severe burns observed in epileptic burn patients, a burn-prevention brochure was developed and is being distributed to seizure patients and their families.

Value and Limitations of Seizure Semiology in Localizing Seizure Onset

Seizure semiology has been the foundation of clinical diagnosis of seizure disorders. This article discusses the value and the limitations of behavioral features of seizure episodes in localizing seizure onset. Studies have shown that some semiologic features of seizures are highly accurate in the hemispheric lateralization and lobar localization of seizures. There is good agreement between blinded reviewers in lateralizing video-recorded seizures in temporal lobe and extratemporal lobe epilepsies. However, seizure semiology alone should not be used to determine the site of seizure onset. Each semiologic feature may falsely localize seizure onset. Seizure semiology in some patients may signify the site of seizure propagation rather than origination. Moreover, seizure semiology may not be as reliable in multifocal epilepsies as it is in unifocal epilepsies. Many semiologic features of seizures of adults are often missing in seizures of children. Seizure semiology should be analyzed and integrated with EEG and neuroimaging data to localize the seizure focus. A sample of the recorded seizures should be shown to the patient's relatives or friends to verify that it is representative of habitual seizures.

Anticonvulsant Treatment for Psychiatric and Seizure Indications Among Youths

Anticonvulsant Treatment for Psychiatric and Seizure Indications Among Youths

Insulinoma in Differential Diagnosis of Seizure Disorder

Back to table of contents Previous article Next article LETTERFull AccessInsulinoma in Differential Diagnosis of Seizure DisorderAlemdar Murat M.D.Iseri Pervin M.D.Komsuoglu Sezer Sener M.D.,Alemdar Murat M.D.Search for more papers by this authorIseri Pervin M.D.Search for more papers by this authorKomsuoglu Sezer Sener M.D.Search for more papers by this author,Published Online:1 Apr 2006AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail SIR: Hypoglycemia can mimic epileptic seizures, and insulinoma is one of the rarest causes of it. The authors report on a patient with hypoglycemic spells caused by insulinoma misdiagnosed as intractable epilepsy. The medical history of the case highlights the importance of careful management in the seizures of adulthood, especially in those that are atypical and refractory to pharmacotherapy. Case ReportA 42-year-old man was referred to our clinic for evaluation of recurrent seizures which had begun to occur 10 months before and were usually seen in the early morning or during tiring work. He had been diagnosed with epilepsy and anxiety disorder by a neurologist, and phenytoin and alprozolam treatment had been prescribed. The frequency of attacks had increased up to four times a week in the previous 3 months. He was referred to our clinic after these complaints. Also, he had no response to carbamazepine and levetiracetam treatment, and the electroencephalogram (EEG) performed shortly after an episode showed diffuse rhythmic theta activity.The typical attack was seen on the first morning of hospitalization after a fast of 10 hours. It began with fatigue and psychomotor slowing. Some bizarre behaviors, like crying, “I will die” and moving his extremities aimlessly were observed, followed by loss of consciousness. The peripheral glucose level was 30 mg/dl. Upon administration of intravenous glucose solution, he became alert and all symptoms subsided after a few minutes. The blood sample sent for investigations prior to therapy also revealed the low plasma glucose (21 mg/dl) and high circulating insulin level (15 μU/ml). The attacks did not recur with continuous intravenous glucose administration.An abdominal MRI revealed a 17 mm round nodular mass located over the pancreatic tail. Surgical removal of the tumor resulted in complete resolution of the symptoms and reversion of the insulin and glucose levels back to normal levels. The microscopic evaluation of removed material also confirmed the diagnosis of insulinoma.Comment Insulinomas are rare neoplasms recognized by an inappropriately high circulating insulin level, for the ambient blood glucose concentration. The most common neurological feature at presentation is confusion. As the disorder evolves, coma, motor deficits, or convulsions begin to occur. 1 Unless there is the presence of localized abnormalities in the cerebral circulation, low glucose level affects all cerebral neurons, resulting in a generalized dysfunction which may present as diffuse slow activity in EEG and lead the clinician to prescribe antiepileptics, as in our case. The episodic nature of hypoglycemia in insulinoma also causes the symptoms to fluctuate, and delays the diagnosis. Confusion or bizarre behavior which could be misdiagnosed as an epileptic disorder are much more common (approximately 25%), although nearly six percent of the hypoglycemic cases present with seizures. 2 Hypoglycemia itself can also induce unawareness of the autonomic and neuroglycopenic symptoms and decrease the counterregulatory hormonal responses in insulinoma. 3 So, the unawareness of autonomic symptoms might play a critical role in misinterpretation, as in our case. Once diagnosed as a refractory epileptic disorder, a significant proportion of patients receive aggressive and escalating pharmacotherapy. Remembering that the metabolic causes of seizures are almost always curable, and may be fatal if untreated, this report highlights the need for careful assessment of every seizure. The critical importance of assessment of blood glucose level in patients with altered level of consciousness is again impressed. Insulinoma, though uncommon, is a potentially recognizable and treatable disease, as long as there is a high index of suspicion. It should always be considered among the diagnostic possibilities in any patient with unusual or inexplicable neurological features, including atypical seizures refractory to pharmacotherapy.Kocaeli University, Faculty of Medicine, Department of Neurology, Kocaeli, Turkey

Insulinoma in Differential Diagnosis of Seizure Disorder

Insulinoma in Differential Diagnosis of Seizure Disorder

Benign EEG Variants

ABSTRACT.EEG is a valuable tool that assists in the accurate diagnosis of seizure disorders. The precise interpretation of EEG requires an ability to recognize patterns that are benign in nature but may be misinterpreted as indicative of a seizure tendency. This review will summarize benign variants encountered in adult EEGs including: small sharp spikes, wicket spikes, fourteen- and six-hertz positive bursts, six-hertz spike and wave, rhythmic temporal theta bursts of drowsiness, subclinical rhythmic electroencephalographic discharge in adults, and midline theta rhythms. Although most of these patterns are relatively uncommon, it is imperative that the clinical neurophysiologist identifies them as benign variants.

Seizure disorders and trauma.

The prevalence of seizure disorder diagnosis in the general population is between 0.5% and 2.0%. Seizures may be manifested by abnormal motor activity, loss of muscle tone, and changes in mental status. Seizure may increase an individual's risk for traumatic injury by adversely influencing performance in a particular situation. We identified 30 patients admitted to our trauma service over a three-year period with injury related to seizure; 16 were male and 14 were female, with a mean age of 34.8 years. Twenty-eight patients (93%) had a history of seizure activity, with the mean duration of seizure activity of 16.5 years (range, three to 40 years). Both seizure diagnosis and etiology were multifactorial. Multiple drug therapy predominated, phenytoin (Dilantin) being the most frequently used medication. Overall compliance was poor (53%). Only blunt injury occurred in these patients, 50% suffering injury from falls. Injuries from motor vehicle accidents (40%) were the next most frequent (auto crash in seven cases, motorcycle crash in four, and bicycle crash in one case). The remainder of the injuries were burns (10%). Nine patients (30%) required operation. Skeletal injuries predominated (67%). Patients with a history of seizure will be frequently encountered by physicians of all specialties. The patients likely to be at increased risk for injury are noncompliant, have breakthrough seizures (ie, despite therapy), or have the metabolism of their seizure medication altered by alcohol or other drugs. To prevent potentially serious injury, these patients should be identified and counseled.

Severe epilepsy: diagnostic and epidemiological aspects.

Epidemiological parameters of epilepsy have been estimated in a large number of studies. Reported annual incidence rates for recurrent seizures vary between 30 and 50/100,000, and prevalence rates in most studies between 500 and 1000/100,000. Varying findings are mostly due to different case ascertainment methods and definitions of epilepsy applied in different surveys. These aspects will be discussed in this paper. A special emphasis is laid on differential diagnosis of seizure disorders, and on the prevalence and causes of complex partial epilepsy. This epileptic disorder is one of the most common forms of epilepsy, and also difficult to treat in many cases. Many recent reports show that prognosis of seizures in patients with epilepsy is better than suggested in earlier studies. However, 25-30% of epileptics seem to have frequent (greater than 1/month) seizures. Our own study, in accordance with earlier findings suggests that prevalence of patients with severe complex partial epilepsy is about 80-90/100,000. Available literature provides several predictive factors for the prognosis of seizures and assessment of prognosis is possible quite early after the onset of seizures. Treatment choices for patients with intractable epilepsy will be discussed.

Antiepileptic drugs and the electroencephalogram.

The usefulness of electroencephalography (EEG) as an aid to diagnosis of seizure disorders is established, but its role as a guide to monitoring treatment is much less certain. For those patients with classical absences and 3-s spike wave activity there is a very close correlation between control of clinically detected seizures and EEG events. In some, but not all, patients with other seizure disorders there is a positive correlation between numbers of seizures and amount of interictal epileptiform activity (IEA). Intravenous benzodiazepines and phenytoin result in both acute seizure control and suppression of IEA. For seizures other than absences, and antiepileptic drugs (AEDs) given in the medium and long term, there is generally not a clear relationship between control of seizures and IEA. In studies of children whose epilepsy is in remission, persistent IEA has been associated with a higher risk of seizure relapse should AEDs be discontinued, but in adults the relevance of persistent IEA appears to be much less certain. Benzodiazepines and barbiturates result in increased fast activity. All AEDs may result in slowing of the dominant rhythm and increased slow activity. Carbamazepine, in particular, is often associated with apparent deterioration of background activity, even in the face of clinical improvement. Further studies are necessary to determine the mechanisms and significance of AED-induced changes in EEG background activity.

The value of prolonged electroencephalographic and video monitoring in diagnosis of seizure disorders.

Prolonged electroencephalographic and video monitoring of ictal events is useful in aiding the diagnosis of complicated seizure disorders. Forty-eight patients admitted to a neurology service were assessed with this technique. Twenty-five (54%) had their diagnoses changed, six (14%) had their diagnoses confirmed and the remaining patients had inconclusive studies. Therapy is modified by the results and in addition both patient and staff education is enhanced through the use of this equipment.

Cancer Incidence in a Cohort of Patients With Seizure Disorders&lt;xref ref-type="fn" rid="FN1"&gt;2&lt;/xref&gt;

The incidence of cancer was evaluated in a population-based cohort of 959 patients diagnosed with seizure disorders while residents of Rochester, MN, between 1935 and 1979. For all cancer sites combined, there were 65 incidence cases for a standard morbidity ratio of 1.4. Most of the excess was attributable to a 22-fold increase in the incidence of primary brain tumors among these patients. Most of the brain tumors occurred within 5 years of the seizure disorder diagnosis, suggesting that the seizure disorder was due to the brain tumor. The incidence of cancer of other sites, exclusive of brain, was not elevated. There was no evidence of an association of cancer incidence with duration of seizures or with the use of anticonvulsant drugs.

Postictal serum creatine kinase in the diagnosis of seizure disorders.

We prospectively correlated daily serum creatine kinase (CK) levels with the occurrence of different types of epileptic and nonepileptic seizures documented by video EEG recording in 22 hospitalized patients. Prolonged postictal CK elevations, 8.0 to 19.2 times baseline, were seen following six (15%) of 41 generalized tonoclonic seizures. No CK elevations were seen following 147 complex partial, focal motor, absence, and tonic seizures or 55 psychogenic seizures, 89% of which involved vigorous muscular activity. Six of 12 patients with generalized tonoclonic seizures had postictal CK elevations compared with none of six patients with psychogenic seizures and none of 15 patients with complex partial, focal motor, absence, and tonic seizures. Thus, postictal CK determination can serve as an adjunctive test for differentiation between psychogenic and epileptic generalized tonoclonic seizures.