Postictal Confusion Research Articles

Study of Inflammatory Markers in Patients with Uncontrolled Generalized Motor Tonic–Clonic Seizures

Abstract Background Epilepsy is a multifaceted chronic neurological disease characterized by recurrent spontaneous seizures. It affects almost 70 million patients around the globe, making it one of the most common chronic causes of neurological morbidities. Aim of the Work detect an association between some inflammatory markers {C-reactive protein (CRP), Neutrophil-lymphocyte ratio (NLR), and Platelet-lymphocyte ratio (PLR)}and epilepsy in order to detect a pathogenic relation that in turn can influence the course and management of epilepsy. Patients and Methods the current body of evidence recognizes the association between inflammation and epilepsy. Several inflammatory markers have been investigated in relation to different types of epilepsy. This study chose CRP as a convenient and widely used inflammatory marker, together with NLR and PLR, the two novel, readily available indices of inflammation that are yet to be fully investigated in relation to epilepsy. We included 50 patients with uncontrolled generalized motor tonic–clonic seizures. Ages ranged from 18 – 45 years and both genders were represented. Patients were compared with 50 controls of same age and gender. Strict inclusion and exclusion criteria were applied to all volunteers. Results In this study, levels of CRP, NLR and PLR in 50 patients with epilepsy were significantly higher than controls. These results add to the pool of evidence that support the association between epilepsy and inflammatory processes. This study managed to investigate the correlation between inflammatory markers and specific independent variables such as frequency of seizures, time interval between last seizure and presentation, number of status epilepticus per year, number of anti-epileptic medications, duration of postictal confusion, age of onset of seizures, duration of illness, and EEG findings, in addition to age and gender differences. This study found increased levels of CRP, NLR, and PLR in patients with high frequency seizures compared to those with intermittent seizures. Similar results were obtained with increased number of episodes of status epilepticus, number of anti-epileptic medications and shorter time interval between last reported seizure and sample withdrawal. Longer duration of postictal confusion was associated with high values of NLR and PLR. Conclusion systemic inflammatory response has been detected in patients with uncontrolled generalized motor tonic–clonic seizures, which confirms the association between inflammation and epilepsy. This association is specifically correlated to higher seizure frequency, shorter duration between last seizure and blood sample withdrawal, higher number of status epilepticus in the last 12 months, higher number of anti-epileptic medications, longer duration of post-ictal confusion and female gender.

The Effect of Remimazolam on Seizure Profile, Hemodynamics, and Recovery in Patients With Electroconvulsive Therapy Comparison With Propofol and Etomidate: A Retrospective Study.

To compare seizure-related, hemodynamic, and recovery outcomes when using remimazolam for ECT with those of other anesthetics, specifically propofol and etomidate. A total of 49 patients who underwent 405 ECT treatment sessions under general anesthesia were retrospectively analyzed. Remimazolam, propofol, and etomidate were used for 93, 138, and 174 ECT sessions, respectively. The primary outcome was durations of motor and electroencephalogram (EEG) seizure activity, whereas secondary outcomes included hemodynamics (ie, mean arterial pressure [MAP] and heart rate [HR] at various time points from induction to postanesthesia care unit [PACU] discharge), antihypertensive drugs administration after electrical stimulus, and recovery profiles (ie, length of PACU stay and incidence of postictal confusion). Durations of motor and EEG seizures were shorter for remimazolam than etomidate (motor, P < 0.001; EEG, P = 0.003) but similar compared with propofol (motor, P = 0.191; EEG, P = 0.850). During seizure, remimazolam showed a comparable MAP and HR to etomidate (MAP: P = 0.806; HR: P = 0.116). The antihypertensive drug use was lowest for remimazolam (6.8%), followed by propofol (35.6%) and etomidate (65.6%), and the mean length of PACU stay was comparable for remimazolam (19.7 min), propofol (22.8 min), and etomidate (24.5 min). The occurrence of postictal confusion did not differ among the 3 agents (P > 0.050). Remimazolam is a promising anesthetic option for ECT because of its comparable seizure profiles, stable hemodynamics, and comparable PACU stay when compared with propofol and etomidate without additional adverse events.

Extended Delirium Treated as Psychosis

Abstract Delirium is a commonly seen neuropsychiatric disorder that may extend over time, lasting for more than 60 days, thus increasing the risk of cognitive and behavioral outcomes in patients. Electroconvulsive therapy (ECT) is one of the treatment modalities for behavior control but may be associated with rare complications such as tardive seizure, convulsive status epilepticus, and prolonged postictal confusion. We report a case of acute psychosis who was given consecutive 2 ECTs, after which she developed probable tardive seizure in the recovery period, followed by status epilepticus and extended delirium lasting for more than 2½ months, but was misdiagnosed as psychosis and treated with several antipsychotic medications. As there was no improvement in her condition, she was then transferred to a tertiary center for further management.

The Clinical, Etiological, and Demographic Profile of Children Aged 1 to 14 Years with Seizures Attending a Tertiary Care Hospital in Gwalior District, India: A Cross-Sectional Study

Purpose: The clinical profile of seizures among children exhibits ethnic and geographical variations. The objective of this study was to examine the clinical, etiological, and demographic profiles of childhood seizures.Methods: This was a hospital-based, cross-sectional study. Data were collected on the socio-demographic profile, details of the clinical presentation of seizure episodes, past history of meningitis, and neuroimaging (i.e., computed tomography [CT] scans), as well as the history of risk factors. Numbers, percentages, the chi-square test, and the Fisher exact test statistic were calculated. A P value of &lt;0.05 was considered significant.Results: This study included 102 patients, of whom 82 experienced generalized tonic-clonic seizures (GTCS) and the remaining 20 had focal seizures. The most common age at presentation was between 1 and 4 years (55.9%). Approximately 70.0% of the children experienced postictal confusion and drowsiness, 38.2% had fever or sleep deprivation, and 25.5% suffered from headaches or vomiting. Postictal confusion and drowsiness were significantly more prevalent in children with GTCS (76.8%) compared to those with focal seizures (45.0%). Cerebral edema was the most common abnormality detected on CT scans in children with GTCS (n=6). Conclusion: Younger age, neonatal brain insult, and family history were found to be associated with a higher risk of seizure episodes. Postictal confusion and drowsiness were identified as the most common clinical features. Postictal confusion and drowsiness were significantly more prevalent in GTCS compared to focal seizures. Cerebral edema was the most common abnormality observed in GTCS on CT neuroimaging.

Posterior Reversible Encephalopathy Syndrome with Addison’s Disease in a Known Case of Arnold Chiari Malformation

Posterior Reversible Encephalopathy Syndrome (PRES) is a life-threatening neurological disease. The aetiology of Addison’s disease has been modified from infectious to autoimmune pathology. Underlying pathogenesis is insufficient production of glucocorticoids and mineralocorticoids. Case series with PRES syndrome and Cushing’s syndrome have been reported but PRESS with adrenal insufficiency is rarely published. We hereby report an operated case of Arnold Chiari malformation presenting with first episode of generalised tonic clonic seizure and diarrhoea for four days. Postictal confusion was present for two hours. She was previously diagnosed with Addison’s disease. Patient had hypotension and dyselectrolytaemia. Systemic examinations were within normal limits. MRI brain revealed features of PRES. The authors encountered certain challenges in her management which included persistent hypokalaemia, hypocalcaemia and hypotension. Patient is on regular follow-up and she is currently asymptomatic. Prompt diagnosis of PRES and intensive case treatment is a must for the betterment of prognosis.

Can we improve electrocorticography using a circular grid array in brain tumor surgery?

Intraoperative electrocorticography (iECoG) is used as an adjunct to localize the epileptogenic zone during surgical resection of brain tumors in patients with focal epilepsies. It also enables monitoring of after-discharges and seizures with EEG during functional brain mapping with electrical stimulation. When seizures or after-discharges are present, they complicate accurate interpretation of the mapping strategy to outline the brain’s eloquent function and can affect the surgical procedure. Recurrent seizures during surgery requires urgent treatment and, when occurring during awake craniotomy, often leads to premature termination of brain mapping due to post-ictal confusion or sedation from acute rescue therapy. There are mixed results in studies on efficacy with iECoG in patients with epilepsy and brain tumors influencing survival and functional outcomes following surgery. Commercially available electrode arrays have inherent limitations. These could be improved with customization potentially leading to greater precision in safe and maximal resection of brain tumors. Few studies have assessed customized electrode grid designs as an alternative to commercially available products. Higher density electrode grids with intercontact distances less than 1 cm improve spatial delineation of electrophysiologic sources, including epileptiform activity, electrographic seizures, and afterdischarges on iECoG during functional brain mapping. In response to the shortcomings of current iECoG grid technologies, we designed and developed a novel higher-density hollow circular electrode grid array. The 360-degree iECoG monitoring capability allows continuous EEG recording during surgical intervention through the aperture with and without electrical stimulation mapping. Compared with linear strip electrodes that are commonly used for iECoG during surgery, the circular grid demonstrates significant benefits in brain tumor surgery. This includes quicker recovery of post-operative motor deficits (2.4 days versus 9 days, p = 0.05), more extensive tumor resection (92.0% versus 77.6%, p = 0.003), lesser reduction in Karnofsky Performance scale postoperatively (−2 versus −11.6, p = 0.007), and more sensitivity to recording afterdischarges. In this narrative review, we discuss the advantages and disadvantages of commercially available recording devices in the operating room and focus on the usefulness of the higher-density circular grid.

Cerebral amyloid angiopathy-related inflammation (CAARI) and HHV-6 positivity: A case report of a treatment dilemma and a possible relationship (P1-12.003)

<h3>Objective:</h3> To examine the treatment dilemma utilizing high-dose steroids in a patient with cerebral amyloid angiopathy-related inflammation (CAARI) and HHV-6 positivity. Additionally, to question a possible relationship between HHV-6 and CAARI. <h3>Background:</h3> Cerebral amyloid angiopathy-related inflammation (CAARI) has been described as a distinct syndrome with subacute cognitive decline or seizure symptoms. Previous studies have established diagnostic criteria for this entity and proposed a treatment strategy. However, the precipitating factors behind developing CAARI in a subset of patients with CAA are unclear. We present a case of CAARI in a patient with no underlying diagnosis of dementia that was found to be positive for HHV-6 in serum and CSF and treated successfully with steroids. <h3>Design/Methods:</h3> N/A <h3>Results:</h3> An 83-year-old woman presented with a first-time generalized tonic-clonic seizure with postictal confusion. On presentation, her systolic blood pressure was elevated at 150–170, and she was tachycardic to 160 with a temperature of 38.4. A contrasted MRI brain showed multifocal vasogenic edema, sulcal FLAIR hyperintensity, and innumerable lobar microhemorrhages. Black blood contrast MRI brain angiogram was unremarkable, with no evidence of vasculitis. At this point, the patient had clinically improved but remained slightly encephalopathic with word-finding difficulties. Continuous EEG monitoring showed diffuse background slowing. Initial CSF studies revealed an isolated mildly elevated protein of 49 and negative cytology. Therefore, based on the clinical and radiographic evidence, a decision was made to undergo five days of high-dose methylprednisolone for probable CAARI. However, days later, HHV-6 in CSF resulted positive with 249 copies/ml, and a serum sample showed 1100 copies/ml. <h3>Conclusions:</h3> The concurrence of cerebral amyloid angiopathy-related inflammation (CAARI) and HHV-6 in serum and CSF might yield a diagnostic and therapeutic challenge. However, the treatment with high-dose pulsatile steroids with taper did improve the overall clinical picture. Further studies are needed to investigate a potential correlation. <b>Disclosure:</b> Dr. Alshawa has nothing to disclose. Dr. Makkieh has nothing to disclose. Miss Alsakka has nothing to disclose. Dr. Torres-Melendez has nothing to disclose.

Epilepsy diagnosis using a clinical decision tool and artificially intelligent electroencephalography

ObjectiveTo construct a tool for non-experts to calculate the probability of epilepsy based on easily obtained clinical information combined with an artificial intelligence readout of the electroencephalogram (AI-EEG). Materials and MethodsWe performed a chart review of 205 consecutive patients aged 18 years or older who underwent routine EEG. We created a point system to calculate the pre-EEG probability of epilepsy in a pilot study cohort. We also computed a post-test probability based on AI-EEG results. ResultsOne hundred and four (50.7%) patients were female, the mean age was 46 years, and 110 (53.7%) were diagnosed with epilepsy. Findings favoring epilepsy included developmental delay (12.6% vs 1.1%), prior neurological injury (51.4% vs 30.9%), childhood febrile seizures (4.6% vs 0.0%), postictal confusion (43.6% vs 20.0%), and witnessed convulsions (63.6% vs 21.1%); findings favoring alternative diagnoses were lightheadedness (3.6% vs 15.8%) or onset after prolonged sitting or standing (0.9% vs 7.4%). The final point system included 6 predictors: Presyncope (−3 points), cardiac history (−1), convulsion or forced head turn (+3), neurological disease history (+2), multiple prior spells (+1), postictal confusion (+2). Total scores of ≤1 point predicted <5% probability of epilepsy, while cumulative scores ≥7 predicted >95%. The model showed excellent discrimination (AUROC: 0.86). A positive AI-EEG substantially increases the probability of epilepsy. The impact is greatest when the pre-EEG probability is near 30%. SignificanceA decision tool using a small number of historical clinical features accurately predicts the probability of epilepsy. In indeterminate cases, AI-assisted EEG helps resolve uncertainty. This tool holds promise for use by healthcare workers without specialty epilepsy training if validated in an independent cohort.

Medication preventing postictal hypoperfusion and cognitive side-effects in electroconvulsive therapy: A retrospective cohort study.

Electroconvulsive therapy (ECT) is associated with postictal confusion and cognitive side-effects. In rats, acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs) and calcium antagonists decreased postictal cerebral hypoperfusion along with reduction in postictal symptoms. In this study, in ECT-patients, we explore associations between use of these potentially protective medications and occurrence of postictal confusion and cognitive outcome. In this retrospective, naturalistic cohort study, patient-, treatment-, and ECT-characteristics, were collected from medical files of patients treated with ECT for major depressive disorder (MDD) or bipolar depressive episode. To test for associations of use of these medications with occurrence of postictal confusion, 295 patients could be included. Cognitive outcome data were available in a subset of 109 patients. Univariate analyses and multivariate censored regression models were used to test for associations. Occurrence of severe postictal confusion was not associated with use of acetaminophen, NSAIDs or calcium antagonists (n = 295). Regarding the cognitive outcome measure (n = 109), use of calcium antagonists was associated with higher post-ECT cognitive scores (i.e., better cognitive outcome; β = 2.23; p = 0.047), adjusted for age (β = -0.02; p = 0.23), sex (β = -0.21; p = 0.73), pre-ECT cognitive score (β = 0.47; p < 0.0001), and post-ECT depression score (β = -0.02; p = 0.62), but use of acetaminophen (β = -1.55; p = 0.07) as well as NSAIDs (β = -1.02; p = 0.23) showed no associations. This retrospective study does not find arguments for protective effects of acetaminophen, NSAIDs or calcium antagonists against severe postictal confusion in ECT. As a preliminary finding, the use of calcium antagonists was associated with improved cognitive outcome after ECT in this cohort. Prospective controlled studies are necessary.

Case 302: Supratentorial Lymphocytic Inflammation with Parenchymal Perivascular Enhancement Responsive to Steroids.

Part one of this case appeared 4 months previously and may contain larger images. A 21-year-old immunocompetent man who was a long-term resident of Qatar presented to the emergency department with recurrent episodes of unprovoked generalized tonic-clonic seizures lasting 2-3 minutes that spontaneously resolved and were associated with postictal confusion. The patient also had progressive mild diplopia, intermittent dizziness, and numbness in the left arm over the course of 3 months. The patient did not have any other systemic symptoms or chronic medical diseases. He did not have any history of intake of illicit drugs, supplements, or regular medications; he had not received any recent vaccinations; and he had not undergone any surgical procedures. He had no history of travel. At presentation, vital signs were normal. Neurologic examination showed mild left homonymous hemianopia, normal gait with no cerebellar signs, and preserved sensations, power, tone, and reflexes in all four limbs. An electroencephalogram showed no epileptiform discharges. Chest CT and extensive laboratory work-up, including viral, fungal, bacterial, and parasite work-up, thyroid function tests, and immunologic blood tests yielded normal results. Those included normal complete and differential blood counts and normal serum chemistry. Serum analysis was negative for antinuclear antibody, Sjögren syndrome antigens A and B, cytoplasmic antineutrophil cvtoplasmic antibody, and paraneoplastic profile. Serum evaluation was also negative for human immunodeficiency virus type 1 and type 2 RNA, and Brucella, Schistosoma, and toxoplasma antibodies. Venereal Disease Research Laboratory (VDRL) and rapid plasma regain (RPR) test results were negative. Cerebrospinal fluid (CSF) analysis revealed clear fluid and normal pressure and biochemistry, except for elevated protein concentration (0.48 g/L) (normal range, 0.15-0.45 g/L). There were 43 leukocytes/µL (99% lymphocytes) (normal range, 0-5 leukocytes/µL; lymphocytes range, 40%-80%), with no atypical or malignant cells. CSF Gram staining, acid-fast staining, cryptococcal antigen, varicella-zoster virus polymerase chain reaction (PCR), herpes simplex virus PCR, VDRL, and RPR test results were negative. CSF cultures did not show any evidence of growth of bacteria, fungi, or acid-fast bacillus. CSF flow cytometry did not show a monoclonal lymphoid population. No CSF oligoclonal bands were detected. Conventional brain MRI with intravenous administration of contrast material and perfusion study were performed and included different sequences (Figs 1-3).

Severe Postictal Confusion After Electroconvulsive Therapy: A Retrospective Study.

Severe postictal confusion (sPIC) is an important but poorly investigated adverse effect of electroconvulsive therapy (ECT). In this retrospective study, prevalence of sPIC and potential risk factors were explored. Medical charts of 295 ECT patients (mean ± SD age, 57 ± 15 years; male, 36%) were scrutinized for occurrence of sPIC, as well as demographic, clinical, and treatment characteristics. Patients showing sPIC were compared with patients who did not, using univariate statistics. Multivariate analyses with a split-sample validation procedure were used to assess whether predictive models could be developed using independent data sets. O 295 patients, 74 (25.1%) showed sPIC. All patients showing sPIC needed extra medication, 9% (n = 7) required physically restraints, and 5% (n = 4) had to be secluded. Univariate analyses showed several trends: patients with sPIC were more often males (P = 0.05), had more often history of cerebrovascular incident (P = 0.02), did not use concomitant selective serotonin reuptake inhibitors (P = 0.01), received higher median dosage of succinylcholine (P = 0.02), and received pretreatment with flumazenil more often (P = 0.07), but these associations did not remain significant after correction for multiple comparisons. Multiple logistic regression analysis did not result in a model that could predict sPIC in the holdout data set. In this retrospective naturalistic study in 295 ECT patients, the prevalence of sPIC appeared to be 25%. Patients showing sPIC were characterized by male sex, history of cerebrovascular incident, use of higher-dose succinylcholine, and pretreatment with flumazenil. However, multivariate analysis revealed no significant model to predict sPIC in independent data.

Case 302.

History A 21-year-old immunocompetent man who was a long-term resident of Qatar presented to the emergency department with recurrent episodes of unprovoked generalized tonic-clonic seizures lasting 2-3 minutes that spontaneously resolved and were associated with postictal confusion. The patient also had progressive mild diplopia, intermittent dizziness, and numbness in the left arm over the course of 3 months. The patient did not have any other systemic symptoms or chronic medical diseases. He did not have any history of intake of illicit drugs, supplements, or regular medications; he had not received any recent vaccinations; and he had not undergone any surgical procedures. He had no history of travel. At presentation, vital signs were normal. Neurologic examination showed mild left homonymous hemianopia, normal gait with no cerebellar signs, and preserved sensations, power, tone, and reflexes in all four limbs. An electroencephalogram showed no epileptiform discharges. Chest CT and extensive laboratory work-up, including viral, fungal, bacterial, and parasite work-up, thyroid function tests, and immunologic blood tests yielded normal results. Those included normal complete and differential blood counts and normal serum chemistry. Serum analysis was negative for antinuclear antibody, Sjögren syndrome antigens A and B, cytoplasmic antineutrophil cvtoplasmic antibody, and paraneoplastic profile. Serum evaluation was also negative for human immunodeficiency virus type 1 and type 2 RNA, and Brucella, Schistosoma, and toxoplasma antibodies. Venereal Disease Research Laboratory (VDRL) and rapid plasma regain (RPR) test results were negative. Cerebrospinal fluid (CSF) analysis revealed clear fluid and normal pressure and biochemistry, except for elevated protein concentration (0.48 g/L) (normal range, 0.15-0.45 g/L). There were 43 leukocytes/µL (99% lymphocytes) (normal range, 0-5 leukocytes/µL; lymphocytes range, 40%-80%), with no atypical or malignant cells. CSF Gram staining, acid-fast staining, cryptococcal antigen, varicella-zoster virus polymerase chain reaction (PCR), herpes simplex virus PCR, VDRL, and RPR test results were negative. CSF cultures did not show any evidence of growth of bacteria, fungi, or acid-fast bacillus. CSF flow cytometry did not show a monoclonal lymphoid population. No CSF oligoclonal bands were detected. Conventional brain MRI with intravenous administration of contrast material and a perfusion study were performed and included different sequences (Figs 1-3).

Clinical features of automatisms and correlation with the seizure onset zones: A cluster analysis of 74 surgically-treated cases

ObjectivesTo identify semiologic features of automatisms correlating to different seizure onset zones (SOZ). MethodsIn total, 204 seizures from 74 patients with either oral or manual automatisms were assessed. Patients were divided into four groups depending on the SOZ into frontal, posterior, neocortical temporal, and mesial temporal cortex groups. A k-means analysis was applied on 11 semiologic features on a multi-criteria scale. Then, the resulting clinical patterns were correlated with the SOZs determined by presurgical anatomy-electroclinical data (25 cases with stereo-EEG). ResultsFour clinical patterns of automatisms with different accompanying symptoms were identified. The clinical features of clusters 1 and 4 were mostly found in temporal epilepsy whereas clusters 2 and 3 were more frequent in extratemporal epilepsy. Cluster 1 was significantly correlated with mesial temporal lobe epilepsy (p = .017) and was characterised by aura, postictal confusion, short automatisms delay. Cluster 3 included 1/3 patients with frontal lobe epilepsy and was characterised by emotionality. Cluster 4 was related to neocortical temporal lobe epilepsy and characterised by dystonia and short automatism delay (p = .011). ConclusionThe distinct semiologic patterns of automatisms may provide information which may allow clinicians to define the SOZs. These findings could improve diagnostic accuracy and surgical outcome.

CARDIAC CONVULSIONS-POLYMORPHIC VENTRICULAR TACHYCARDIA MASQUERADING AS SEIZURES

TOPIC: Cardiovascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Cardiac arrhythmias can occasionally precipitate convulsions through decreased cardiac output resulting in cerebral hypoxia and epileptiform-like activity. Differentiating a seizure from ventricular arrhythmia is crucial for accurate and timely management. CASE PRESENTATION: A 46-year-old female with a history of breast adenocarcinoma with metastasis to the brain presented with staring and unresponsive episodes. These episodes lasted for a few minutes and were accompanied by jerking of all extremities. Physical examination and laboratory investigations were unremarkable, except for mild hypokalemia of 3.2 mmol/L. She underwent a computerized tomography scan and magnetic resonance imaging of the head that redemonstrated multiple hypodense lesions within the internal capsule and caudate nucleus. The patient subsequently underwent an electroencephalogram (EEG) that did not reveal any epileptiform discharges. She was initiated on anti-epileptic drugs (AEDS). Her hospital course was complicated by recurrent unresponsive episodes similar to presentation despite the use of AEDS. She was lethargic during the episodes, without any post-ictal confusion. She was also tachycardic with a heart rate of 150 beats/min. Review of telemetry showed premature ventricular conduction dependent polymorphic ventricular tachycardia (PMVT), concerning for torsade de pointes. Her baseline EKG revealed a prolonged QTc of 550 msec. Further, it was noted that her recurrent episodes of unresponsiveness coincided with the PMVT events on telemetry. Her PMVT were managed with aggressive electrolyte repletion as well as a lidocaine infusion. DISCUSSION: While the brain metastasis and hypodense lesions on the MRI were a confounder to the patient's true diagnosis, the misdiagnosis of cardiac arrhythmias as convulsions is not uncommon. Since cardiac arrhythmia and convulsive seizures share many common characteristics, identifying the true cause of the patient's presentation is of paramount importance. CONCLUSIONS: All patients who present with neurological symptoms should have a baseline EKG and echo to evaluate for underlying cardiac pathology and ideally should be monitored on telemetry until a clear neurological diagnosis is established. Although torsades de pointe episodes can be short lasting and transient, they have the potential to cause cardiac arrest and death. REFERENCE #1: Sabu J, Regeti K, Mallappallil M, et al. Convulsive Syncope Induced by Ventricular Arrhythmia Masquerading as Epileptic Seizures: Case Report and Literature Review. J Clin Med Res. 2016;8(8):610-615. doi:10.14740/jocmr2583w DISCLOSURES: No relevant relationships by Naga Vaishnavi Gadela, source=Web Response No relevant relationships by Nino Nozadze, source=Web Response No relevant relationships by Mahati Paravathaneni, source=Web Response No relevant relationships by Naveen Sablani, source=Web Response No relevant relationships by Evan Wasserman, source=Web Response

English

Porencephalic cyst is a rare entity in adults with limited cases reported so far. It is usually congenital and seen in neonates. Here, we report a 25-year-old male who presented with post-ictal confusion following an episode of sudden onset of generalised tonic clonic seizure. He was diagnosed to have large cerebrospinal fluid (CSF) density cystic lesion in the right parieto-occipital region communicating with occipital horn on right side side of porencephaly. Porencephaly is an uncommon congenital disorder that occurs due to cystic degeneration and encephalomalacia leading to porencephalic cyst formation.1 They are considered to occur most commonly from focal encephalomalacia due to a localised cerebral insult during early gestation, 2 while the other aetiologies include trauma, infection, antenatal intraparenchymal haemorrhage and perinatal cerebral ischemia.3 If the insult occurs in late third trimester it can lead to gliosis. Porencephalic cysts are typically lined by white matter of brain parenchyma.2 They differ widely in their location and size while the clinical manifestations and presentations range from being asymptomatic to extremely impaired mental function. Generally, the signs and symptoms of porencephaly become apparent in the first year of life. The earliest manifestation being spasticity and seizures. As the age increases there is a delay in development of milestones presenting as language impairment, disability in intellect and motor deficits. Clinically head circumference measurement varies from being normal or small to an enlarged head in cases of synechiae formation that creates a one-way valve effect leading to progressive enlargement of the cyst and expansion of skull or there may be hydrocephalus.4 Radiologically the diagnosis depends on demonstrating a well-defined CSF-filled space occupying lesion lined by white matter and communicating with ventricles on computed tomography (CT) scan or magnetic resonance imaging (MRI) of brain. The prognosis of porencephaly depends on the location and extent of the cyst.5 If the cyst is very large it can cause mass effect in the form of scalloping of adjacent bone, buckling of brain parenchyma, midline shift to contra lateral side and hydrocephalus. On MRI, brain cyst appears well defined and lined by white matter with or without gliosis. Cerebrospinal fluid is the content which is shown as hypointense on T1 and hyperintense on T2.

Efficacious retrial of electroconvulsive therapy (ECT) after a prolonged seizure in an older adult with a history of post ECT confusion

<h3>Introduction</h3> This is a case of a 77-year-old woman with treatment resistant geriatric major depression who was admitted psychiatrically for the 5th time in 1.5 years. She had a history of intensive psychotherapy and psychotropic medication trials with poor efficacy. She had a history of adverse complication to electroconvulsive therapy (ECT) with prolonged seizure and postictal confusion during her 3rd hospitalization. At her 5th hospitalization, due to poor response to routine psychiatric treatment, ECT was pursued. We discuss challenges in pursuing ECT and outcome of retrial of an acute ECT series, in the context of paucity of similar literature in geriatric depression <h3>Methods</h3> Patient was involuntarily admitted to the Older Adult inpatient Unit due to worsening anxiety and depression with suicidal ideation that began 1 month prior to admission. Patient reported having suicidal thoughts on a daily basis. Patient had been experiencing worsening depression since her husband died 3 years ago, had attempted multiple outpatient treatments including psychotherapy and medications. Patient was psychiatrically hospitalized 4 times prior to the current hospitalization. The patient met criteria for major depressive disorder, recurrent, severe, without psychotic features, generalized anxiety disorder with panic attacks. Patient displayed cognitive deficits with executive dysfunction, impairment with problem solving and planning. For diagnostic clarification, patient received neuropsychiatric testing which revealed a mild neurocognitive disorder with potential contribution of her depression. During her 3rd psychiatric admission, she had received an acute series of electroconvulsive therapy. During her 4^th ECT session,the patient had a prolonged central seizure requiring total 2 mg of midazolam to abort the seizure which eventually lasted 489 seconds. This was followed by prolonged post ECT confusion that lasted for 7 days. Medical workup of any other etiology for her prolonged confusion was negative including EEG, CT head. Eventually confusion resolved and interestingly the patient's depression and anxiety also appeared to be in remission. <h3>Results</h3> With the above history influencing her current admission, we were initially hesitant to start an acute series of ECT, however, with continued treatment refractory depression, ECT was recommended to the patient and the family. Since prolonged seizures are not a contraindication for ECT and due to the patient's good response to ECT, we felt this was an appropriate treatment. Long discussion about risks, benefits and side effects occurred with patient, who signed informed consent for acute ECT. Patient received 6 right unilateral treatments three times a week. Patient also received serial Montreal cognitive assessment (MOCA) testing during her acute series. Patients first moca was 15/30 which increased to a 28/30 over 12 days indicating improvement in cognition with improvement in anxious depression. After 6th ECT, patient was deemed to be in remission and was transitioned to maintenance ECT. Per chart review, patient remains in remission after her 5th ECT treatment. After reviewing the literature we could not find evidence of an efficacious retrial of electroconvulsive therapy after a prolonged seizure in an older adult with a history of post ECT confusion. <h3>Conclusions</h3> ECT is an important treatment modality in the geriatric population indicated for severe major depression (1) While the APA quotes no absolute contraindications to ECT and further research has demonstrated that prolonged seizures or acute cognitive impairment are not relative contraindications either, the patient's history and past experiences with treatment are an important part of developing a treatment plan. (2) We present this case to demonstrate efficacy of retrial of ECT in older adults who experience both a prolonged seizure and negative cognitive effects can be an appropriate treatment plan. <h3>References</h3> 1. Electroconvulsive Therapy in Geriatric Psychiatry A Selective Review. 2. https://www.openanesthesia.org/ect_contraindications/. <h3>Funding</h3> none

Status epilepticus of focal impaired-awareness seizures. Russkiy zhurnal detskoy nevrologii

Background. The status epilepticus of focal impaired-awareness seizures (SE FIAS) is a series of focal seizures with loss or change of consciousness, between which there is no complete recovery of consciousness. This status epilepticus occurs in patients with temporal (especially with hippocampal sclerosis) and frontal epilepsy. It is important to differentiate SE FIAS with the absence status epilepticus, with psychiatric disorder, with postictal confusion. As a rule, this status epilepticus is self-terminate, without special treatment.Objective: to study the features of epidemiology, etiology, diagnosis, therapy and prognosis in patients with SE FIAS.Materials and methods. The study included 1350 consecutive patients diagnosed with epilepsy.Results and discussion. A history of SE FIAS was found in 20 patients (14 women and 6 men), it occurred in the age range from 5 to 66 years. 13 patients (65 %) had mesial temporal lobe epilepsy, 5 patients (25 %) had frontal lobe epilepsy, and 2 patients (10 %) had lateral temporal lobe epilepsy. Only in 80 % of patients treatment was adequate before the development of SE FIAS, in 20 % of patients it was inadequate and subsequently caused the development of status epilepticus. In 40 % of patients the occurrence of SE FIAS is associated with their own non-compliance; in 30 % of patients the development of status epilepticus had iatrogenic causes. Measures to prevent the development of status epilepticus were ineffective only in patients with pharmacoresistant symptomatic epilepsy and in non-compliant patients.Conclusions. SE FIAS occurs in 1 % of patients with epilepsy. Among patients, women with temporal or frontal epilepsy dominate; status epilepticus occurs at any age and is often triggered by changes in therapy due to doctors’ recommendations or patient non-compliance. Usually the status is self-terminating. To prevent its recurrence, adequate antiepileptic therapy is necessary. The prognosis in patients with SE FIAS is favorable; however, the general prognosis remains serious due to the severity of the course of epilepsy.

Distinguishing psychogenic nonepileptic, mixed, and epileptic seizures using systemic measures and reported experiences

ObjectivesOur primary objective was to better discern features that can differentiate people with ‘mixed’ symptomatology from those who experience epileptic seizures (ES) or functional/psychogenic nonepileptic seizures (PNES) alone, in a population of patients referred for video-telemetry. We wished to see if we could establish the prevalence of PNES in this population of interest as well as compare both objective (e.g. videotelemetry reports and heart rate measurements) and subjective, patient-centered measures (reported symptoms and experiences). MethodsData were sourced from a database of all video-telemetry patients admitted to the John Radcliffe Hospital (Oxford, UK) between 1st Jan 2014 and 31st Jan 2016; video-electroencephalogram (vEEG) reports for the above patients; neurology clinic letters; multidisciplinary Team (MDT) reports; psychology assessments and patient notes for all vEEG patients referred for surgical work up. Mixed cases with a dual ES/PNES diagnosis were carefully evaluated again by the Consultant Neurologist under whose care each respective patient was, through case-by-case evaluation of EEG and telemetry reports. We compared mean heart rate during attacks captured on vEEG, number of physical symptoms reported, episode length, and postictal confusion between the three groups (ES; PNES; ES and PNES (mixed)). We evaluated the groups in terms of demographic and psychological parameters as well as prescription of anti-seizure medication. Pearson correlation significance was examined at 95% level of significance for p-values corrected for multiple comparisons. ResultsOverall, mixed cases reported experiencing a significantly lower number of physical symptoms compared to PNES cases (p = 0.018). The heart rate of PNES cases was significantly lower than that of mixed cases during the attacks (p = 0.003). ES patients exhibited the highest heart rate of all three groups and a greater degree of postictal confusion (adjusted p = 0.003 and p < 0.001, respectively) compared to those with PNES. There was no statistically significant difference in episode length between mixed and ES cases, while PNES patients had significantly longer episode duration (p = 0.021) compared to the mixed group. We noted that 81.6% of PNES patients were taking at least one anti-seizure medication. ConclusionPatients with mixed seizures seem to be part of a spectrum between ES and PNES cases. Mixed cases are more similar to the ES group with regard to episode length and number of symptoms reported. In the PNES cohort, we found an over-reporting of ictal symptoms (e.g. palpitations, diaphoresis) disproportionate to recorded heart rate, which is lower in PNES than in epileptic attacks. This seems consistent with PNES cases experiencing a degree of impaired interoceptive processing, as part of a functional disorder spectrum. We noted that there was tendency for overmedication in the PNES group. The need for ‘de-prescribing’ should be addressed with measures that include better liaison with the community care team. With regard to potential autonomic dysregulation in the mixed cases, it might be interesting to see if vagus nerve stimulation could be accompanied by normalization of cardiovascular physiology parameters for people with both epileptic and psychogenic nonepileptic seizures.

Prevalence and Predictors of Postictal Confusion After Electroconvulsive Therapy.

ObjectiveTo investigate the prevalence and predictors of postictal confusion (PIC) in patients who received electroconvulsive therapy (ECT).MethodsWe conducted chart reviews for 79 patients who were receiving inpatient ECT. Subjects with PIC were identified. PIC was defined by confusion, disorientation, motor restlessness, purposeless movement, and nonresponse to verbal commands following ECT within an hour, intravenous benzodiazepine was necessary to manage disturbed behavior. Multivariable logistic regression analysis was used to examine the association of PIC with demographic and clinical variables.ResultsPrevalence of PIC was 36.7%. In 912 ECT sessions, the occurrence of PIC was 86 times. Patients with PIC (n = 29) had significant higher body mass index (BMI) (27 ± 6.6 kg/m2 vs 24.1 ± 5.2 kg/m2, t = −2.22, df = 77, p = 0.029) than patients without PIC (n = 50). PIC associated with BMI (Pearson correlation = 0.25, p = 0.029). BMI was significant predictor of PIC after adjusting for other covariates (odds ratio = 0.91, 95% CI= 0.83–0.99, p < 0.035).ConclusionPIC was not uncommon in patients receiving ECT. BMI was an independent predictor of PIC. Psychiatrists should be aware of the risks of PIC in patients with high BMI receiving ECT.

Semiology of epileptic seizures: Assiut University Hospital-based study

BackgroundEpilepsy diagnosis is mainly clinical, as it depends on the detailed analysis of the seizure semiology. This study reviews the systematic way to describe and classify seizure semiology with the help of using electro-clinical methods for better diagnosis and to choose the most effective medical treatment.Patients and methodsThis study was conducted on 60 epileptic patients throughout the period from 1st of October 2016 to 31st of March 2017 in Assiut University Hospital. We excluded patients who lacked eye witness and who had seizures owing to metabolic causes. All patients were subjected to complete general and neurological examination, epilepsy sheet with detailed seizure semiology analysis, and electroencephalogram (EEG).ResultsProdroma was found in 26 (43.3%) cases, and aura was recorded in 34 (56.7%) cases. Forty (66.7%) cases had automatism more in the form of picking cloths and unresponsiveness. Most cases (63.3%) reported loss of contact with surroundings and 28.3% lost their consciousness. Ipsiversive movement was recorded in 13.3% of cases, whole-body myoclonus was presented in 10% of cases, unilateral nonmarching sensory seizure in 3.3%, 23.3% presented with tonic seizure, and 16.7% with tonic–clonic seizure. Postictal amnesia was seen in 60% of cases, postictal confusion in 46.7%, and postictal Todd's paralysis in 6.7%. Distribution of epileptic activity in EEG was mostly in left fronto-temporal area (20%).ConclusionClinical semiology is the starting point of understanding seizure disorder and making the diagnosis of epilepsy. The correlation between analysis of the development and sequence of semiologic features and EEG findings can identify the seizure initiation and propagation.