Left Temporal Seizure Research Articles

Cerebral Vasculitis in a patient receiving Risankizumab, an Inhibitor of Interleukin-23: First Case Report (P12-3.013)

<h3>Objective:</h3> NA <h3>Background:</h3> Iatrogenic neuroinflammation has been frequently reported in recent years owing to expanding biologic therapies for the treatment of a wide range of disorders including Psoriasis. Here we report a case of Central Nervous System (CNS) vasculitis after initiation of Risankizumab, a monoclonal antibody against Interleukin-23 (IL23) used to treat Psoriasis. <h3>Design/Methods:</h3> Case report. <h3>Results:</h3> A 29-year-old female with moderate psoriasis who was started on Risankizumab about one month prior, presented with encephalopathy and left temporal lobe focal seizures with refractory status epilepticus. Her MRI showed punctate infarcts and areas of enhancement in the left temporal lobe and leptomeninges overlying the left convexity. Extensive work up revealed increased Erythrocyte Sedimentation Rate (72 mm/hr) and positive Cardiolipin (IgM and IgG) and Beta-2 Glycoprotein (IgM and IgG) antibodies suggesting antiphospholipid syndrome (APS) for which she was started on anticoagulation. Lumbar puncture revealed normal opening pressure, glucose, protein and five nucleated cells. Oligoclonal bands, meningitis/encephalitis and autoimmune encephalitis panels were negative. Subsequent brain MRI showed new areas of ischemic lesions. Cerebral angiogram was unremarkable. Biopsy revealed focal perivascular lymphocytes (CD45 and CD3 immunohistochemical stained) infiltration in dural vessels consistent with small-vessel vasculitis. She was treated with high dose steroids with clinical improvement and subsequently planned to treat with Cyclophosphamide. Risankizumab was discontinued due to possible association. <h3>Conclusions:</h3> Iatrogenic neuroinflammation has been increasingly recognized during the new era of biological molecules and monoclonal antibodies for systemic inflammatory disorders and malignancies. Tumor necrosis factor inhibitors and immune checkpoint inhibitors are more commonly associated with neuroinflammation. To the best of our knowledge, this is the first reported case of APS and CNS vasculitis possibly associated with the initiation of IL23 inhibitor Risankizumab. Although causality cannot be established with a single case, it suggests a possible association. <b>Disclosure:</b> Dr. Cabrera Pulla has nothing to disclose. Dr. Amirjanyan has nothing to disclose. Qian Wu has nothing to disclose. Dr. Mui has nothing to disclose. Dr. Imitola has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Novartis . The institution of Dr. Imitola has received research support from biogen. Dr. Imitola has a non-compensated relationship as a Board Member with National MS Society that is relevant to AAN interests or activities. Dr. Imitola has a non-compensated relationship as a Committee Member with International Society for Stem Cell Research that is relevant to AAN interests or activities. Dr. Coban has nothing to disclose.

Epileptic Seizure Induced by Head-Up Tilt: A Case Series Study.

Epilepsy and syncope can be difficult to distinguish, with misdiagnosis resulting in unnecessary or incorrect treatment and disability. Combined tilt-table and video EEG (vEEG) testing (tilt-vEEG) is infrequently used to parse these entities even at large centers. Because of the discovery of a rare case of epileptic seizure induced by head-up tilt (HUT) (no prior cases have been published), the authors sought to verify the rarity of this phenomenon. An observational, retrospective case series study of all combined tilt-vEEG studies performed at Stanford Health Care over a 2-year period was performed. Studies were grouped into categories: (1) abnormal tilt and normal vEEG; (2) abnormal vEEG and normal tilt; (3) abnormal vEEG and abnormal tilt; (4) normal tilt and normal vEEG, with neurologic symptoms; and (5) normal tilt and normal vEEG without neurologic symptoms. Sixty-eight percent of patients had an abnormal study (categories A-C), with only 3% having both an abnormal tilt and an abnormal EEG (category C). Of these, one patient had a focal epileptic seizure induced by HUT. With HUT positioning, the patient stopped answering questions and vEEG showed a left temporal seizure; systolic blood pressure abruptly dropped to 89 mm Hg (64 mm Hg below baseline); heart rate did not change, but pacemaker showed increased firing (threshold: <60 bpm). Combined tilt-table and vEEG evaluation was able to identify a previously unreported scenario-head-up tilt provocation of an epileptic seizure-and improve treatment. Combined tilt and vEEG testing should be considered for episodes that persist despite treatment to confirm proper diagnosis.

Deep Learning of Simultaneous Intracranial and Scalp EEG for Prediction, Detection, and Lateralization of Mesial Temporal Lobe Seizures.

In people with drug resistant epilepsy (DRE), seizures are unpredictable, often occurring with little or no warning. The unpredictability causes anxiety and much of the morbidity and mortality of seizures. In this work, 102 seizures of mesial temporal lobe onset were analyzed from 19 patients with DRE who had simultaneous intracranial EEG (iEEG) and scalp EEG as part of their surgical evaluation. The first aim of this paper was to develop machine learning models for seizure prediction and detection (i) using iEEG only, (ii) scalp EEG only and (iii) jointly analyzing both iEEG and scalp EEG. The second goal was to test if machine learning could detect a seizure on scalp EEG when that seizure was not detectable by the human eye (surface negative) but was seen in iEEG. The final question was to determine if the deep learning algorithm could correctly lateralize the seizure onset. The seizure detection and prediction problems were addressed jointly by training Deep Neural Networks (DNN) on 4 classes: non-seizure, pre-seizure, left mesial temporal onset seizure and right mesial temporal onset seizure. To address these aims, the classification accuracy was tested using two deep neural networks (DNN) against 3 different types of similarity graphs which used different time series of EEG data. The convolutional neural network (CNN) with the Waxman similarity graph yielded the highest accuracy across all EEG data (iEEG, scalp EEG and combined). Specifically, 1 second epochs of EEG were correctly assigned to their seizure, pre-seizure, or non-seizure category over 98% of the time. Importantly, the pre-seizure state was classified correctly in the vast majority of epochs (>97%). Detection from scalp EEG data alone of surface negative seizures and the seizures with the delayed scalp onset (the surface negative portion) was over 97%. In addition, the model accurately lateralized all of the seizures from scalp data, including the surface negative seizures. This work suggests that highly accurate seizure prediction and detection is feasible using either intracranial or scalp EEG data. Furthermore, surface negative seizures can be accurately predicted, detected and lateralized with machine learning even when they are not visible to the human eye.

Autoimmune encephalitis and sleep: Polysomnographic data in the subacute phase of the disease

Autoimmune encephalitis (AE) is frequently associated with manifold sleep disturbances, but limited information on sleep structure is available. Polysomnographic (PSG) features were analyzed in a 32-year-old woman with AE manifesting with subacute behavioral anomalies, confusion, aphasia and focal left temporal seizures. Anti-thyreoperoxidase antibodies were detected on cerebrospinal fluid.

Volumetric glutamate imaging (GluCEST) using 7T MRI can lateralize nonlesional temporal lobe epilepsy: A preliminary study.

IntroductionDrug‐resistant epilepsy patients show worse outcomes after resection when standard neuroimaging is nonlesional, which occurs in one‐third of patients. In prior work, we employed 2‐D glutamate imaging, Glutamate Chemical Exchange Saturation Transfer (GluCEST), to lateralize seizure onset in nonlesional temporal lobe epilepsy (TLE) based on increased ipsilateral GluCEST signal in the total hippocampus and hippocampal head. We present a significant advancement to single‐slice GluCEST imaging, allowing for three‐dimensional analysis of brain glutamate networks.MethodsThe study population consisted of four MRI‐negative, nonlesional TLE patients (two male, two female) with electrographically identified left temporal onset seizures. Imaging was conducted on a Siemens 7T MRI scanner using the CEST method for glutamate, while the advanced normalization tools (ANTs) pipeline and the Automated Segmentation of the Hippocampal Subfields (ASHS) method were employed for image analysis.ResultsVolumetric GluCEST imaging was validated in four nonlesional TLE patients showing increased glutamate lateralized to the hippocampus of seizure onset (p = .048, with a difference among ipsilateral to contralateral GluCEST signal percentage ranging from −0.05 to 1.37), as well as increased GluCEST signal in the ipsilateral subiculum (p = .034, with a difference among ipsilateral to contralateral GluCEST signal ranging from 0.13 to 1.57).ConclusionsThe ability of 3‐D, volumetric GluCEST to localize seizure onset down to the hippocampal subfield in nonlesional TLE is an improvement upon our previous 2‐D, single‐slice GluCEST method. Eventually, we hope to expand volumetric GluCEST to whole‐brain glutamate imaging, thus enabling noninvasive analysis of glutamate networks in epilepsy and potentially leading to improved clinical outcomes.

A description of verbal and gestural communication during postictal aphasia

Patients suffering from drug-resistant temporal lobe epilepsy show substantial language deficits (i.e., anomia) during their seizures and in the postictal period (postictal aphasia). Verbal impairments observed during the postictal period may be studied to help localizing the epileptogenic zone. These explorations have been essentially based on simple tasks focused on speech, thus disregarding the multimodal nature of verbal communication, particularly the fact that, when speakers want to communicate, they often produce gestures of various kinds. Here, we propose an innovative procedure for testing postictal language and communication abilities, including the assessment of co-speech gestures. We provide a preliminary description of the changes induced on communication during postictal aphasia.We studied 21 seizures that induced postictal aphasia from 12 patients with drug-refractory epilepsy, including left temporal and left frontal seizures. The experimental task required patients to memorize a highly detailed picture and, briefly after, to describe what they had seen, thus eliciting a communicative meaningful monologue. This allowed comparing verbal communication in postictal and interictal conditions within the same individuals. Co-speech gestures were coded according to two categories: “Rhythmic” gestures, thought to be produced in support of speech building, and “illustrative” gestures, thought to be produced to complement the speech content.When postictal and interictal conditions were compared, there was decreased speech flow along with an increase of rhythmic gesture production at the expense of illustrative gesture production. The communication patterns did not differ significantly after temporal and frontal seizures, yet they were illustrated separately, owing to the clinical importance of the distinction, along with considerations of interindividual variability.A contrast between rhythmic and illustrative gestures production is congruent with previous literature in which rhythmic gestures have been linked to lexical retrieval processes. If confirmed in further studies, such evidence for a facilitative role of co-speech gestures in language difficulties could be put to use in the context of multimodal language therapies.

Memory in children with epilepsy: Utility of the WRAML-2 in generalized and focal epilepsy syndromes

The material-specific model for memory impairment predicts that verbal memory deficits are seen with left temporal seizures, and visual memory deficits are seen with right temporal seizures (Henkin et al., 2005). In pediatric epilepsy, seizure pathology has not always yielded the expected material-specific memory profiles. This study used the Wide Range Assessment of Memory and Learning—Second Edition (WRAML-2) to assess memory functioning among pediatric patients with epilepsy. The WRAML-2 was administered to 180 youth with epilepsy during their neuropsychological evaluations. Memory and recognition scores correlated significantly with epilepsy severity variables. There were no significant differences in verbal and visual memory and recognition index scores among patients with generalized epilepsy or among those with lateralized or localized electroencephalography (EEG) patterns and lesions on imaging. However, clinically meaningful verbal versus visual discrepancy scores were significantly related to lateralized abnormalities on EEG and magnetic resonance imaging (MRI) results. Most patients with right hemisphere pathology showed the expected material-specific visual memory deficits, while fewer than 15% of the left hemisphere cases showed the expected verbal memory deficits. Over one-third of those with identified left-sided pathology showed clinically significant deficits in visual memory. Findings are incongruent with the material-specific memory model and reflect the fact that early developmental neurological insults can lead to functional reorganization/crowding effects in children with left hemisphere epilepsy. On exploratory analyses, there were no significant differences in discrepancy scores among participants with left, right, and bilateral languages on Wada and functional MRI (fMRI). However, those with right and bilateral language dominance were more likely to show discrepancies that were incongruent with the material-specific model.

Running-down phenomenon captured with chronic electrocorticography.

SummaryThe running‐down phenomenon refers to 2 analogous but distinct entities that may be seen after epilepsy surgery. The first is clinical, and denotes a progressive diminution in seizures after epilepsy surgery in which the epileptogenic zone could not be completely removed (Modern Problems of Psychopharmacology 1970;4:306, Brain 1996:989). The second is electrographic, and refers to a progressive deactivation of a secondary seizure focus after removal of the primary epileptogenic zone. This progressive decrease in epileptiform activity may represent a reversal of secondary epileptogenesis, where a primary epileptogenic zone is postulated to activate epileptiform discharges at a second site and may become independent.3 The electrographic running‐down phenomenon has been reported in only limited numbers of patients, using serial postoperative routine scalp electroencephalography (EEG) (Arch Neurol 1985;42:318). We present what is, to our knowledge, the most detailed demonstration of the electrographic running‐down phenomenon in humans, made possible by chronic electrocorticography (ECoG). Our patient's left temporal seizure focus overlapped with language areas, limiting the resection to a portion of the epileptogenic zone, followed by implantation of a direct brain‐responsive neurostimulator (RNS System, NeuroPace Inc.) to treat residual epileptogenic tissue. Despite the limited extent of the resection, the patient remains seizure‐free more than 2 years after surgery, with the RNS System recording ECoG without delivering stimulation. We reviewed the chronic recordings with automated spike detection and inspection of electrographic episodes marked by the neurostimulator. These recordings demonstrate progressive diminution in spiking and rhythmic discharges, consistent with an electrographic running‐down phenomenon.

Subfield-specific tractography of the hippocampus in epilepsy patients at 7 Tesla

PurposeMRI-negative epilepsy patients could benefit from advanced imaging techniques such as high-resolution diffusion magnetic resonance imaging (dMRI). Our aim was to perform hippocampal subfield-specific tractography and quantify connectivity of the subfields in MRI-negative patients. Abnormal connectivity of the hippocampal subfields may help inform seizure focus hypothesis and provide information to guide surgical intervention. MethodsHippocampal structural imaging and dMRI was acquired in 25 drug resistant MRI-negative patients and 25 healthy volunteers. The hippocampi of each subject was segmented on high-resolution structural images and dMRI-based probabilistic tractography was performed in each subfield. The degrees of connectivity and fiber densities of the hippocampal subfields were quantified and compared between epilepsy patients and healthy volunteers. ResultsWe were able to perform subfield-specific hippocampal tractography in each subject that participated in this study. These methods identified some hippocampal subfields that are abnormally connected in MRI-negative patients. In particular patients suspected of left temporal seizure focus exhibited increased connectivity of certain ipsilateral subfields, especially the subiculum, presubiculum, and parasubiculum, and reduced connectivity of some contralateral subfields, such as CA1 and subiculum. ConclusionsOur data suggest that the hippocampal subfields are connected in distinct ways in different types of epilepsy. These results may provide important information that could help inform seizure focus hypothesis and in the surgical treatment of MRI-negative patients. These observations suggest that high-resolution dMRI-based tractography of the hippocampal subfields can detect subtle abnormalities in otherwise normal-appearing MRI-negative patients.

F17. EEG findings and seizure patterns in three infants with type 1 citrullinemia

Citrullinemia is a urea cycle disorder which leads to toxic accumulation of ammonia and other metabolites. While it is widely accepted that citrullinemia is associated with seizures, there is no literature describing the typical EEG findings. Furthermore, there are no data available on long-term seizure outcomes. We report herein EEG findings and clinical courses in 3 patients with type 1 citrullinemia. We reviewed EEG records to identify patients with type 1 citrullinemia who had EEG studies at the Montefiore Medical Center. The EEG findings, clinical history and course in these patients were reviewed. We identified 3 patients with type 1 citrullinemia with infantile onset of symptoms who had EEG studies. The initial EEG studies were done between 4 days and 3 weeks of life; all patients had subsequent follow-up EEGs. Patient 1 presented with abnormal movements and severe hyperammonemia (921 μmol/L) at 3 weeks of life. EEG demonstrated independent left and right central electrographic and electroclinical seizures. She received emergent dialysis, lorazepam, levetiracetam, sodium phenylacetate and sodium benzoate. She had no further seizures, and at last follow-up at age 9 months, she was seizure-free off all anti-epileptic drugs (AEDs), on dietary modification and treatment with glycerol phenylbutyrate. Patient 2 presented on day 4 of life with lethargy and poor feeding. She suffered a cardiac arrest and was found to have severe hyperammonemia (>2000 μmol/L). EEG demonstrated many independent left and right temporal electrographic seizures requiring phenobarbital boluses and midazolam infusion. She had no further seizures and was tapered off of phenobarbital at 6 months of age. She remains on dietary modification and treatment with arginine and sodium phenylbutyrate. Patient 3 presented with neonatal seizures. An EEG performed on day 7 of life demonstrated independent left and right central electrographic seizures. She was initially treated with levetiracetam, phenobarbital, and hemodialysis. She is now 10 years old and has been seizure-free for 3 years. She is currently on levetiracetam, dietary modification and treatment with arginine and sodium phenylbutyrate. Our 3 patients with type 1 citrullinemia all presented in the neonatal period with independent electrographic seizures in homologous regions in both hemispheres. One patient also had bilateral independent electroclinical seizures. Our findings suggest that bilateral independent electrographic seizures are a characteristic EEG finding in neonatal-onset type 1 citrullinemia. Two of our patients had no further seizures after the initial presentation and are now off AEDs. The third patient has been seizure-free for 3 years on levetiracetam as the only AED. These findings suggest that patients with citrullinemia may not have further seizures once their metabolic state is controlled and, therefore, may not require long-term AEDs.

T160. Magnetoencephalography findings of benign epileptiform transients of sleep on scalp EEG in three patients with temporal lobe epilepsy

Introduction Benign epileptiform transients of sleep (BETS) is a finding on electroencephalography, defined as monophasic or diphasic transients with low amplitude ( μ V) and short duration ( Methods Patient 1, a 37-year-old right-handed male, was diagnosed with left TLE. Complex partial seizures started from age 15 years. Video-EEG (VEEG) showed interictal left anterior and posterior temporal sharp waves, and left temporal seizure onset was suggested. Magnetic resonance (MR) imaging revealed a mass lesion in the left lateral temporal lobe, suspected to be dysembryoplastic neuroepithelial tumor. Patient 2, a 38-year-old right-handed male, was diagnosed with left TLE. Complex partial seizures started from age 20 years. VEEG showed interictal bilateral independent temporal spikes, and left temporal seizure onset was suggested. MR imaging showed no abnormalities. Patient 3, a 33-year-old right-handed female, was diagnosed with right TLE. Complex partial seizures with oral automatism started from age 20 years. VEEG showed interictal right anterior temporal spikes, and right temporal seizure onset was suggested. MR imaging showed no abnormalities. All three patients underwent simultaneous EEG-MEG recording. EEG electrode placement used the 10–10 system with additional anterior temporal electrodes. MEG used a 200 channel whole-head system (MEGvision PQA160C, Ricoh Company, Ltd., Tokyo, Japan). The study investigated MEG activities correlated with EEG findings concordant with BETS. Results In Patient 1, MEG spikes correlated with BETS in the left temporal lobe had epileptic form, with high amplitude spike activity followed by slow wave activity. The source as evaluated with equivalent current dipoles was estimated around the left temporal lesion. In Patient 2, MEG spikes correlated with BETS in the right temporal lobe had epileptic form, with high amplitude spike activity followed by slow wave activity. No activity fulfilling the definition of BETS was detected in the left hemisphere. In Patient 3, no apparent MEG activity correlated with BETS was seen in the right temporal lobe. Conclusion The present study demonstrated variations in MEG findings correlated with EEG BETS in patients with TLE. These results may indicate heterogeneous background of BETS, so that only some BETS have an epileptic mechanism.

T71. 24-Hour video EEG in the evaluation of the first unprovoked seizure

Introduction In subjects with epilepsy, the sensitivity to detect epileptiform discharges in EEG recordings increases with the duration of the recording. Whether this rule applies also to EEGs performed for the assessment of a first unprovoked seizure is not clear yet. The optimal EEG duration in this scenario is not known, although this test is crucial in quantifying the risk of seizure recurrence in the absence of abnormalities on neurological examination or neuroimaging studies. At our center, some patients with a first seizure underwent 24-h video EEG (VEEG) monitoring at the request of their neurologists. Methods We retrospectively identified patients who underwent 24-h VEEG with “first seizure” as an indication. We excluded subjects with obvious abnormalities on neurological examination or neuroimaging studies. In addition to demographic and disease related variables, we noted the presence or absence of epileptiform discharges in the VEEG study, the latency for the appearance of such discharges, their distribution, and the behavioral state they appear in. Other less specific EEG abnormalities were also tabulated. Results We identified 11 such patients (six women, five men) between May 2016 and November 2017, with an age range of 15–50. They had all experienced a first unprovoked seizure of the generalized tonic-clonic type by description; eight during wakefulness. The VEEG was performed two days to six months after the seizure. Four studies showed focal epileptiform discharges; two exhibited interictal epileptiform abnormalities (right frontal spike/wave and left fronto-temporal sharp waves) within 15 min from the start of the recording (the routine EEG few months earlier was normal for one of them), while the other two recorded actual subtle seizures (one case had two left fronto-temporal subtle seizures 18 h into the recording, during sleep, without earlier interictal discharges, another case had a subtle left temporal seizure during wakefulness three hours into the recording, followed by the activation of left temporal sharp waves). Two additional patients exhibited less specific EEG abnormalities, in the form of focal or generalized slowing. The remaining five studies were normal. Conclusion This pilot experience is too small to adequately assess the value of 24-h VEEG in the evaluation of the first seizure, but in at least two of the 11 patients the epileptiform discharges occurred many hours into the recording and would have been missed in a shorter routine EEG. Another patient had an initial normal routine EEG, but the abnormality appeared within minutes in the following VEEG study, implying that a second routine EEG instead would have probably been equally diagnostic. The four patients with ictal and interictal epileptiform discharges were subsequently started on anti-seizure medications, based mainly on the VEEG information. A larger study is needed to answer the question about the optimal duration of EEG recordings in the context of a first seizure.

Ictal asystole: A systematic review.

To comprehensively analyze ictal asystole (IA) on a large number of subjects. We performed a systematic review of case report studies of patients diagnosed with IA (1983-2016). Each included case was characterized with respect to patient history, IA seizure characteristics, diagnostic workup, and therapy. In addition, comparative analyses were also carried out: two alignments were developed based on the delay between epilepsy onset and IA onset ("new-onset" if <1 year, "late-onset" if ≥1 year) and asystole duration (asystole was "very prolonged" if lasted >30 s). One hundred fifty-seven cases were included. All patients had focal epilepsy. In 7% of cases IA developed during a secondary generalized tonic-clonic seizure. Both the seizure-onset zone and the focal seizure activity at asystole beginning were usually temporal (p < 0.001 and p = 0.001, respectively) and were lateralized to the left hemisphere in 62% (p = 0.005 and p = 0.05, respectively). Asystole duration was 18 ± 14 s (mean±SD) (range 3-96 s); 73% of patients had late-onset, 27% had new-onset IA. Compared to late-onset IA, new-onset IA was associated with female gender (p = 0.023), preexisting heart condition (p = 0.014), focal seizure activity at asystole beginning (p = 0.012), normal neuroimaging (p = 0.013), normal interictal EEG (p < 0.001), auditory aura (p = 0.012), and drug-responsive epilepsy (p < 0.001). "Very prolonged" asystole was associated with secondary generalized tonic-clonic seizures (p = 0.003) and tended to occur in extratemporal lobe seizures (p = 0.074). No IA-related death was reported. Characteristics considered to be typical of IA (focal, left temporal seizures appearing on grounds of a long-lasting, intractable epilepsy) seem only partially legitimate. We suggest that in new-onset IA, female gender and a preexisting heart condition could serve as predispositions in an otherwise benign epilepsy. We speculate that in late-onset IA, male-predominant changes in neuronal networks in chronic, intractable epilepsy and an accompanying autonomic dysregulation serve as facilitating factors.

Evaluating persistent altered mental status after status epilepticus.

I read with interest the case report by Newey et al.1 At the time of admission, EEG showed left hemispheric periodic lateralized epileptiform discharges (PLEDs) and left temporal seizures. By the time the 18F-FDG PET was carried out (13 days after admission), EEG still showed PLEDs (maximally left temporal). The clinical significance of PLEDs has …

Ictal analgesia in temporal lobe epilepsy – The mechanism of seizure-related burns

Seizure-related injuries have major impact in the excess mortality and morbidity of epilepsy patients. Experimental data suggest that analgesia may develop during seizures contributing to the severity of seizure-related accidents, especially burns. We aimed to identify those seizure-types that may lead to burn-injuries by seizure-related analgesia.In our tertiary epilepsy centre, we asked 100 epilepsy patients having a history of seizure-related injury, to complete our burn-and-pain questionnaire. Fifty-one patients completed the survey; their epileptology data were collected and those with a seizure-related burn were interviewed.Forty-two out of the 51 patients (82%) had partial epilepsy and 9 (18%) had idiopathic generalised epilepsy. Twenty-six persons (51%) reported decreased pain perception during or after seizures in general. Twelve patients (23%) had suffered one or more seizure-related burn. Five of them fell onto a hot surface or fire accidentally, during generalized tonic–clonic seizures. Seven out of the 12 burnt patients (58%) grasped a hot object or reached into boiling fluid during complex partial seizures; without experiencing-, or reacting in response to pain. These patients had temporal lobe epilepsy, 5 of them had left temporal seizure onset.Our hypothesis based on the circumstantial analysis of our patients’ burn-injuries; is that temporal lobe seizures may cause ictal/postictal analgesia. It may be caused by the seizure-related epileptic facilitation of the periaqueductal gray matter; the central pain-inhibiting structure of the brain. Seizure-related endogenous opioid-release my have a contributory role in inhibiting pain-perception.Ictal analgesia warrants better burn-prevention in temporal lobe epilepsy patients. Understanding the mechanism of ictal analgesia and specifying those seizures-types prone to cause it; may help indentifying human pain-inhibiting pathways.

Ictal asystole and ictal syncope: insights into clinical management.

Ictal asystole is a rare, serious, and often treatable cause of syncope. There are currently limited data to guide management. Characterization of ictal syncope predictors may aid in the selection of high-risk patients for treatments such as pacemakers. We searched our epilepsy monitoring unit database from October 2003 to July 2013 for all patients with ictal asystole events. Clinical, electroencephalogram, and ECG data for each of their seizures were examined for their relationships with ictal syncope events. In 10 patients with ictal asystole, we observed 76 clinical seizures with 26 ictal asystole episodes, 15 of which led to syncope. No seizure with asystole duration≤6 s led to syncope, whereas 94% (15/16) of seizures with asystole duration>6 s led to syncope (P=0.02). During ictal asystole events, 4 patients had left temporal seizure onset, 4 patients had right temporal seizure onset, and 2 patients had both. Syncope was more common with left temporal (40%) than with right temporal seizures (10%; P=0.002). Treatment options included antiepileptic drug changes, epilepsy surgery, and pacemaker implantation. Eight patients received pacemakers. During follow-up of 72±95 months, all patients remained syncope free. Ictal asystole>6 s is strongly associated with ictal syncope. Ictal syncope is more common in left than in right temporal seizures. A permanent pacemaker should be considered in patients with ictal syncope if they are not considered good candidates for epilepsy surgery.

COMPULSIVE VERSIFYING IN TRANSIENT EPILEPTIC AMNESIA

Compulsive production of verse is an unusual form of hypergraphia that has been reported mainly in patients with right temporal lobe seizures. We present a patient with transient epileptic amnesia (TEA) and a left temporal seizure focus, who developed isolated compulsive versifying, producing multiple rhyming poems, following seizure cessation induced by lamotrigine. Functional neuroimaging studies in the healthy brain implicate left frontotemporal areas in generating novel verbal output and rhyme, while dysregulation of neocortical and limbic regions occurs in temporal lobe epilepsy (TLE). Our patient9s compulsive versifying after seizure cessation may have occurred through disinhibitory facilitation following normalisation of left temporal activity, or via enhanced connections between neocortical and limbic areas due to reorganisation of cerebral networks as a result of longstanding seizure activity. Our case complements previous observations of emergence of altered behaviour with reduced seizure frequency in patients with TLE. Such cases support the notion that reduced seizure frequency has the potential not only to stabilise or improve memory function, but also to initiate complex, specific behaviour patterns, in patients with TEA or TLE.

Compulsive versifying after treatment of transient epileptic amnesia

Compulsive production of verse is an unusual form of hypergraphia that has been reported mainly in patients with right temporal lobe seizures. We present a patient with transient epileptic amnesia and a left temporal seizure focus, who developed isolated compulsive versifying, producing multiple rhyming poems, following seizure cessation induced by lamotrigine. Functional neuroimaging studies in the healthy brain implicate left frontotemporal areas in generating novel verbal output and rhyme, while dysregulation of neocortical and limbic regions occurs in temporal lobe epilepsy. This case complements previous observations of emergence of altered behavior with reduced seizure frequency in patients with temporal lobe epilepsy. Such cases suggest that reduced seizure frequency has the potential not only to stabilize or improve memory function, but also to trigger complex, specific behavioral alterations.

Creative innovation with temporal lobe epilepsy and lobectomy

ObjectivesSome patients with left temporal degeneration develop visual artistic abilities. These new artistic abilities may be due to disinhibition of the visuo-spatially dominant right hemisphere. Many famous artists have had epilepsy and it is possible that some may have had left temporal seizures (LTS) and this left temporal dysfunction disinhibited their right hemisphere. Alternatively, unilateral epilepsy may alter intrahemispheric connectivity and right anterior temporal lobe seizures (RTS) may have increased these artists' right hemisphere mediated visual artistic creativity. MethodsTo test the disinhibition versus enhanced connectivity hypotheses we studied 9 participants with RTS and 9 with left anterior temporal seizures (LTS) who underwent unilateral lobectomy for the treatment of medically refractory epilepsy. Creativity was tested using the Torrance Test of Creative Thinking (TTCT). Results and conclusionsThere were no between group differences in either the verbal or figural scores of the TTCT, suggesting that unilateral anterior temporal ablation did not enhance visual artistic ability; however, for the RTS participants' figural creativity scores were significantly higher than verbal scores. Whereas these results fail to support the left temporal lobe disinhibition postulate of enhanced figural creativity, the finding that the patients with RTS had better figural than verbal creativity suggests that their recurrent right hemispheric seizures lead to changes in their right hemispheric networks that facilitated visual creativity. To obtain converging evidence, studies on RTS participants who have not undergone lobectomy will need to be performed.

Parasympathetic alteration during sub-clinical seizures

IntroductionAutonomic instability is considered a contributing factor in sudden unexpected death in epilepsy (SUDEP). The aim of this pilot study was to measure parasympathetic activity in sub-clinical seizures to investigate autonomic instability. Materials and methodsA prospective study based on Video-electroencephalography (EEG)/electrocardiography (ECG)/oxygen saturation (SAO2) recordings was selected from patients having sub-clinical seizures during stage 3 or 4 sleep. We analysed R–R intervals in the ECG from 1-min prior to the electrographic onset to the end of sub-clinical seizures. Matched non-ictal R–R baseline measurements were selected from stages 3 or 4 sleep. R–R interval data were analysed using NeuroScope software providing a cardiac index of parasympathetic activity (CIPA). BioSignal short-term heart rate variability (HRV) software was used to analyse the same R–R interval data previously analysed using NeuroScope except that sub-clinical seizure data was embedded within 5-min epochs and compared to 5-min epochs of non-ictal measurements. ResultsA total of 33 sub-clinical seizures were recorded from 11 patients comprising 19 generalised sub-clinical seizures (2 patients), 9 right temporal lobe sub-clinical seizures (5 patients) and 5 left temporal lobe sub-clinical seizures (4 patients) were compared to matched non-ictal measurements. Parasympathetic activity was clearly altered during total sub-clinical seizures in terms of the CIPA (p<0.001) and 5-min HRV high frequency (HF) % (p=0.026) measures. Generalised sub-clinical seizures resulted in increased cardiac parasympathetic activity whereas temporal lobe seizures were associated with a decrease in parasympathetic activity. ConclusionThis pilot study indicates that parasympathetic changes occur during sub-clinical seizures. Generalised sub-clinical seizures may be associated with more autonomic instability compared to temporal lobe sub-clinical seizures.