Postictal Confusion Research Articles

Astrocytoma with clinical features of complex focal seizures and post-operative psychosis

Case report of a patient with Astrocytoma in parahippocampal region of the left hemisphere who developed schizophreniform psychosis after resection of the left temporal lobe. Mental and neurological status; Scale for positive and negative schizophrenic syndrome (PASS) assessment; MINI (Mini international neuropsychiatric interview, version 4.4; N subcategory for psychotic contents; Scheehan Disability Scale (SDS); Hamilton Depression Rating Scale; Montgomery-Asberg Depression Rating Scale; EEG; standard and upon sleep deprivation registration; CT and NMR scans of endocranium. A female patient 51 years old has had epileptic seizures since the age of 12; the seizures were defined as simple and complex focal in a form of fixed gaze, motor and ambulatory automatisms with rare secondary generalization, and postictal confusion. After having a NMR scan of endocranium determining a tumour in the left parahippocampal formation, a resection of left temporal lobe was performed identifying a grade II Astrocytoma. After the intervention, a development of polymorph symptomatology occurred with domination of paranoid-depressive syndromes and epileptic seizures with aura consisted of feeling of fear, spatio-temporal disorientation and loss of consciousness. The patient was treated with rational antiepileptic polytherapy and neuroleptics resulting in clinical improvement of psychosis features and decrease of the epileptic seizures frequency. The development of 'de novo psychosis' with clinical features of schizophreniform epileptic psychosis coincided with the temporal lobectomy.

Postictal Confusion Was Associated with Improvement After Electroconvulsive Therapy in Depression

Postictal Confusion Was Associated with Improvement After Electroconvulsive Therapy in Depression

Epilepsy in the elderly: Special considerations and challenges.

The elderly are generally defined as those over 60 or 65 years old, but they are a heterogeneous group and may be subdivided into categories based on age and health status. The incidence of epilepsy is highest in the elderly. With a progressive increase in life expectancy, this is the fastest growing segment of patients with epilepsy. Older patients most often have focal seizures, with less prominent auras and automatisms, and longer duration of postictal confusion compared to younger patients. Status epilepticus is common and has a high mortality. The most common specific etiology is cerebrovascular disease, but the cause remains unknown in many patients. Diagnosis can be challenging because of several patient-related, physician-related and investigation-related factors. Over-diagnosis and under-diagnosis are common. Treatment is complicated by the presence of physiological changes related to aging, co-morbidities and cognitive problems as well as concerns regarding drug interactions and medication adherence. Seizures can be controlled in most patients with low doses of a single anti-epileptic drug (AED). Tolerability is an important factor in selection of an AED, as elderly patients tend to be highly sensitive to side effects. Drug-resistant epilepsy is uncommon. Epilepsy surgery, especially temporal lobectomy, can be performed in older patients with good results. More studies addressing the pathophysiological mechanisms of epilepsy in this age group, and greater inclusion of the elderly in clinical trials, as well as development of comprehensive care models are needed to provide optimal care to these patients.

Pediatric Seizures

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

Data Support Shock Therapy for Major Mood Disorders

Data Support Shock Therapy for Major Mood Disorders

Temporal Lobe Epilepsy with Sexual Manifestation, a Case Report

BackgroundTemporal lobe epilepsy with prevalence of 0.003 is the most common type of epilepsy in adulthood. 20-60% of these patients have psychiatric co morbidity and 30% of them have a history of admission in psychiatric hospitals, before referring to neurologist. Case presentation: The case is a 22 years old, single and high school educated man who developed his first epileptic episode four years ago when he was student in spiritual sciences center, so he was captured and suspended his education because of sexual manifestation of epilepsy. Then he was referred to a psychiatrist for management as a case of psychiatric illness but there was no improvement after one year of psychopharmacotherapy and following a suicidal attempt he was admitted in hospital and took ECT with the impression of mood disorder but in out patient service follow up he talked about the true nature of his problem and in a case conference session with the presence of psychiatrists and neurologist, we noticed that he is a case of epilepsy that his epileptic episodes usually occur in public places, 2-3 times in a year, no matter what is the victim sexuality. Each episode lasts about few minutes with postictal confusion and the patient has no memory about the episodes. Between the episodes the patient suffers from anxiety and depression. EEG was abnormal but brain CT scan and MRI with contrast were normal. After antiepileptic management the patient had no epileptic episode during one year follow up period. Conclusionevaluation of sexual manifestation in the context of anxiety and depressive state need more consideration because it could be a distinct entity rather than a psychological manifestation.

A 67‐Year‐Old Woman Receiving Tumor Necrosis Factor α Inhibitor Therapy Presenting With Neurologic Dysfunction

A 67‐Year‐Old Woman Receiving Tumor Necrosis Factor α Inhibitor Therapy Presenting With Neurologic Dysfunction

Acute postictal confusion and violence: Two cases with unfortunate outcomes.

Patients with temporal lobe epilepsy (TLE) often have a brief postictal state characterized by confusion and disorientation. Less common postictal behaviors include wandering and violence — both reactive and spontaneous. We describe two male patients with left TLE and unusual postictal states that led to unfortunate outcomes. The first patient's postictal state included an intense urge to peregrinate, as well as reactive violence. When a frightened houseguest prevented the patient from exiting his bedroom during a postictal state, the patient climbed out the window and fell to his death. The second patient's postictal state included menacing posturing, loud exclamation of guttural sounds or profanities, clapping or smacking his hands together, and punching nearby objects. During a postictal state at home, he grabbed a bat and destroyed furnishings. After he had two seizures at work followed by his typical postictal state, he was dismissed because of his perceived threat to coworkers.

Tardive Seizure With Postictal Aphasia

Electroconvulsive therapy (ECT) is a highly effective treatment for certain psychiatric disorders with relatively few serious adverse effects or complications. Tardive seizures are one of these rare but potentially fatal complications. Recognizing and treating tardive seizures is essential to prevent prolonged postictal confusion, progression to status epilepticus and associated soft tissue injury, anoxia, aspiration, and death. Currently, there is an unknown prevalence of their occurrence and an overall lack of clinical description of their phenomenology. We describe a case in which a patient develops a tardive seizure followed by a receptive and expressive aphasia, thought to be a variant of Todd's postictal paralysis. This case is further unique in that there was a lateralization of a motor seizure presumably to the hemisphere contralateral to the right unilateral electrode placement.

Delayed onset and prolonged interictal delirium following electroconvulsive therapy

Electroconvulsive therapy is safe and effective in the treatment of depression in older individuals. Minor cognitive side effects of electroconvulsive therapy include acute postictal confusion and reversible short-term memory deficits. However, interictal delirium is uncommon in absence of risk factors. Herein, we report the case a depressed male patient without any known risk factors who developed interictal delirium 2 days after his sixth electroconvulsive therapy session. Interictal delirium improved with treatment within 1 week.

Decreasing Adverse Outcomes of Unmodified Electroconvulsive Therapy

Electroconvulsive therapy (ECT) is far and away the most effective treatment for depression and quite effective for a range of other psychiatric conditions that are unresponsive to medication. Electroconvulsive therapy in the developed world has been administered with anesthesia, muscle relaxants, and ventilation since the mid-1950s following 20 years of unmodified treatment. However, in much of the developing world, ECT continues to be administered unmodified because of lack of resources. We review the efficacy of unmodified compared with modified treatment. We also review the potential drawbacks of unmodified treatment including fear and anxiety, worse postictal confusion, fracture risk, and the negative effects of unmodified treatment on how ECT is perceived in the general community. Finally, we consider potential solutions in developing countries to minimize adverse outcomes of unmodified treatment by pretreating patients either with low-dose benzodiazepines or sedating, but not anesthetizing, dosages of anesthetic agents. Randomized controlled trials are necessary before either of these options could be considered an acceptable alternative to completely unmodified treatment when modified treatment is unavailable.

Acute confusional state of unknown cause in the elderly: A study with continuous EEG monitoring

IntroductionAcute confusional state (ACS) is a frequent cause of emergency consultation in the elderly. Many causes of ACS are also risk factors for seizures. Both non-convulsive seizures and status epilepticus can cause acute confusion. The yield of routine EEG may not be optimal in case of prolonged post-ictal confusion. We thus, sought to evaluate the yield of CEEG in identifying seizures in elderly patients with ACS of unknown origin. MethodsWe reviewed our CEEG database for patients over 75years with ACS and collected EEG, CEEG and clinical information. ResultsThirty-one percent (15/48) of the CEEG performed in elderly patients were done for ACS. Routine EEG did not reveal any epileptic anomalies in 7/15 patients. Among those, CEEG identified interictal epileptiform discharges (IED) in 2 and NCSE in 1. In 8/15 patients, routine EEG revealed epileptiform abnormalities: 3 with IED (including 1 with periodic lateralized discharges), 3 with non-convulsive seizures (NCSz) and 2 with non-convulsive status epilepticus (NCSE). Among patients with only IED, CEEG revealed NCSz in 1 and NCSE in 2. ConclusionThis retrospective study suggests that NCSz and NCSE may account for more cases of ACS than what was previously thought. A single negative routine EEG does not exclude this diagnosis. Continuous EEG (CEEG) monitoring is more revealing than routine EEG for the detection of NCSE and NCSz in confused elderly. The presence of IED in the first routine EEG strongly suggests concomitant NCSz or NCSE. Prospective studies are required to further determine the role of CEEG monitoring in the assessment of ACS in the elderly and to establish the incidence of NCSz and NCSE in this setting.

A 48-Year-Old Man With Syncope and Diffuse Muscle Twitches

A 48-year-old Haitian man with a history of hypertension presented to our hospital following an episode of loss of consciousness. The episode occurred while the patient was standing at a sink, and was preceded by several hours of non-exertional chest discomfort and a brief period of dizziness. He regained consciousness on the floor and felt diffusely weak. There were no lateralized symptoms, post-ictal confusion, incontinence, or tongue contusions. When he returned to a standing position, he saw prominent “beating, pulsating” movements of his periorbital and perioral muscles in the mirror, and also noted some blurred vision. There was additional muscle twitching involving the hands, legs, chin and neck, which the patient described as “a heart beating under the skin”. There was no associated pain, weakness, or numbness. The patient revealed that he had experienced intermittent but frequent abnormal beating of the periorbital muscles for approximately two months prior to presentation. He initially thought it was secondary to anxiety. One month after the onset of these symptoms, he developed similar sensations in his fingers and legs bilaterally, and then in the perioral muscles. In addition to these symptoms he had diarrhea as well as an unintentional 25 pound weight loss over three months, due to anorexia. He had not had fevers. He reported hyperlacrimation which he felt was the result of frequently rubbing his eyes. He denied dysphagia, paresthesias, muscle cramps, headaches, or difficulty with balance. He had had a few episodes of near syncope in the two months prior to presentation, which were not associated with falls. Past medical history included essential hypertension which had been diagnosed five years prior to presentation, as well as vitiligo of the bilateral hands and lips which had been noticeable for six months prior to presentation. He denied neonatal or childhood infections and achieved normal developmental milestones. There was no personal or family history of seizures or other neurological disease. Medications included nifedipine, hydrochlorothiazide, and lisinopril, and there had been no recent medication changes. On initial evaluation, the patient was afebrile, with supine blood pressure 90/50 and heart rate 65, and standing blood pressure 74/50 and heart rate 82. General examination revealed a thin but well developed man in no acute distress. Cardiac rhythm was regular without murmurs. Depigmented patches of skin were noted on the lips and dorsal surfaces of the fingers and hands. The lungs were clear and there was no costovertebral angle tenderness. The abdomen was not tender and no abdominal masses were palpated. There was no extremity edema. Neurological exam revealed normal cognition, language, and memory. There was mild ptosis of the right upper eyelid with no additional ptosis following sustained upward gaze. There was no dysarthria or inability to clear oral secretions, and speech was not nasal in quality or effortful. Muscle bulk, tone, and power were normal. Posture was normal with no rigidity. Continuous arrhythmic undulating myokymic muscle spasms were seen in the bilateral periorbital and perioral muscles, as well as within individual muscle fibers of the right forearm, bilateral hands, and interosseous muscles of the right fifth toe. These abnormal muscle contractions were not painful or bothersome to the patient. Deep tendon reflexes were symmetric and diffusely diminished, and no pathological reflexes were seen. Sensation was normal to all modalities and there was no dysmetria.

Evidence‐based electroconvulsive therapy

Evidence‐based electroconvulsive therapy

Recurrent Self-Limited Hyperthermia Following ECT for Catatonia in a Young Man with Cerebral Palsy

Electroconvulsive therapy (ECT) is a safe and highly effective treatment for certain major mental disorders, including major depressive disorder, bipolar disorder, and certain forms of schizophrenia. The most frequently reported side effects are anterograde amnesia, post-ictal confusion, nausea, headache, myalgia, oral lacerations, and dental injuries. Hyperthermia is not commonly described as a side-effect of ECT. Examination of older texts find reports of fevers occurring after seizures, 1 but the occurrence of hyperthermia after ECT has not been reported since then. We report the case of a patient who experienced four transient high-grade fever episodes following ECT. We provide a differential diagnosis of fever in this particular clinical setting and raise the hypothesis of a neurogenic fever induced by ECT.

Safety and Efficacy of Electroconvulsive Therapy for the Treatment of Agitation and Aggression in Patients With Dementia

Noncognitive behavioral disturbances including agitation and aggression frequently accompany the cognitive symptoms of dementia accounting for much of dementia's morbidity, yet treatment options are currently limited. The authors examine the safety and efficacy of Electroconvulsive Therapy (ECT) for agitation and aggression in dementia patients. Retrospective systematic chart review. McLean Hospital's geriatric neuropsychiatry unit. Sixteen patients with a diagnosis of dementia treated with ECT for agitation/aggression during 2004-2007. Clinical charts were rated on the Pittsburgh Agitation Scale as the primary outcome, the Clinical Global Impression scale and the Global Assessment of Functioning pre- and post-ECT. 16 patients of mean age 66.6 ± 8.3 years were studied. Their average overall and pre-ECT lengths of stay were 59.7 ± 39.7 days and 23 ± 15.7 days, respectively. Patients received a mean of 9 ECT treatments, mostly bilateral. Patients showed significant reductions in their total Pittsburgh Agitation Scale scores from baseline after ECT (from 11.0 ± 5.0 to 3.9 ± 4.3 [F = 30.33, df = 1, 15, p < 0.001]). Clinical Global Impression scale decreased significantly (from 6.0 ± 0.6 pre-ECT to 2.1 ± 1.6 post-ECT [F = 112.97, df = 1, 15, p < 0.001]). Global Assessment of Functioning change was not significant (from 23.0 ± 4.9 to 26.9 ± 6.9 [F = 5.73, df = 1, 13, p = 0.32]). Only one patient, in whom ECT was discontinued following 11 bilateral treatments, showed no improvement. Eight patients showed transient postictal confusion, which typically resolved within 48 hours. Two patients showed more severe postictal confusion that required modification of treatment. These results suggest that ECT is an effective and safe treatment for agitation and aggression in dementia. Further prospective studies are warranted.

Peculiarity of Epilepsy in Elderly People: A Review

Incidence of epilepsy in elderly patients is higher than in any other group. The diagnosis of epilepsy in old age is particularly challenging and is often overlooked or missed. Selection of appropriate antiepileptic drugs (AEDs) for this group of patient also requires more attention than younger patients. To summarise the clinical presentation, aetiology, diagnosis, treatment, and neuropsychiatric complications of epilepsy in old age. Systematic review of existing literature on epilepsy in the elderly was carried out using original articles, review articles, meta-analysis, case reports, standard neurology text and the Cochrane library data. Stroke and neurodegenerative disorders account for most causes of epilepsy in older patients. Simple partial and complex seizures are common modes of clinical manifestation. Post-ictal confusion and memory lapses are particularly prolonged in the elderly. The presence of other co-morbidities, age-related changes in pharmacokinetics and possible risk of drug-drug interaction needs to be considered before commencement of medication. Older AEDs like phenobarbitone and phenytoin should be avoided in the elderly because of their pharmacological profiles. Although newer AEDs have better tolerability, there is no evidence that they are advantageous over the older ones in terms of seizure control and should be used as add-on pills. The older AEDs have the advantages of being cheaper and being readily available in developing countries. The goal of epilepsy management in the elderly goes beyond attainment of seizure control but should include improvement in quality of life. AEDs should be introduced cautiously based on patient's frailty and starting with lower dosage.

The Dorsal Hippocampal Commissure: When Functionality Matters

The Dorsal Hippocampal Commissure: When Functionality Matters

Transient hyperammonemia associated with postictal state in generalized convulsion

Previous studies revealed that transient hyperammonemia was noted after generalized convulsion. This study was undertaken to analyze the association between postictal state and serum ammonia levels. Adult patients presenting to the emergency department with seizures were included. Serum ammonia and other blood tests were compared between patients with full recovery of consciousness after generalized convulsion and those who had not completely regained consciousness. Patients who had not completely regained consciousness (7 of 7, 100%) had higher rate ( p = 0.035) of hyperammonemia compared with patients who had fully regained consciousness (4 of 10, 40%) and higher level of serum ammonia (246 ± 96 μg/dL vs. 102 ± 99 μg/dL, p = 0.006). All patients who showed postictal consciousness level impairment on arrival at the emergency department had elevated serum ammonia at that time. Transient hyperammonemia is associated with postictal confusion.

Extensive Basal Ganglia Calcification Related to Hypoparathyroidism in a Young Woman

A 23-year-old woman with medical problems significant for primary hypoparathyroidism presented with generalized tonic clonic seizure. She did not have history of seizures. She was taking food supplement containing 133 IU vitamin D, 250 mg calcium and 140 mg phosphorus in each tablet. She used to take 4 tablets of food supplement, but stopped taking her supplement 2 months ago. Neurologic examination was significant for postictal confusion that lasted for a few hours. Chvostek and trousseau signs were negative.