Postictal Confusion Research Articles

Focal and generalized: both here and there.

Generalized-Onset Seizures with Secondary Focal Evolution. Williamson R, Hanif S, Mathews GC, Lagrange AH, Abou-Khalil B. Epilepsia 2009;50(7):1827–1832. The international seizure classification recognizes that partial-onset seizures can become secondarily generalized, but generalized-onset seizures are expected to remain generalized. We report six patients who had recorded seizures with generalized onset, but subsequent evolution into a focal discharge. The clinical seizure onset was generalized absence or myoclonic, and the most common subsequent clinical pattern was prolonged behavioral arrest with mild automatisms, and then postictal confusion. The ictal discharge started with generalized spike-and-wave activity and then acquired a focal predominance. Interictal epileptiform activity was generalized. There were no focal magnetic resonance imaging abnormalities. Four patients were misdiagnosed with complex partial seizures. All patients were initially refractory, but three became seizure-free and three improved after treatment with antiepileptic medications appropriate for absence or myoclonic seizures. Generalized-onset seizures that acquire focal features are easily misdiagnosed as complex partial. These seizures have a more favorable response to medications effective against generalized absence and myoclonic seizures.

Association of apolipoprotein E polymorphisms with temporal lobe epilepsy in a Chinese Han population

Apolipoprotein E (ApoE) has been implicated as one of the susceptibility genes for temporal lobe epilepsy (TLE). Previous studies indicate that ApoE ɛ4 is associated with several disease-related traits including the increased risk of late posttraumatic seizures, earlier onset of TLE, refractory complex partial seizures, and postictal confusion. Contradictory data were also reported regarding the association between ApoE polymorphisms and TLE. The present study was designed to investigate whether ApoE ɛ4 is a risk factor for TLE and the above clinical variables, as well as to determine whether -491A/T polymorphism may independently alter the risk for TLE in a Chinese Han population. The ApoE and -491A/T polymorphisms were genotyped in 558 controls and 735 patients including 560 TLE patients using polymerase chain reaction-restriction fragment length polymorphism. A significant association was detected between prior trauma and the ApoE ɛ4 allele in TLE patients. However, no significant differences were observed in the genotype and haplotype distributions and allele frequencies of these two polymorphisms between cases and controls. Furthermore, there were no significant associations between these two polymorphisms and the other clinical variables examined. The study illustrates that the ApoE ɛ4 allele may be involved in the development of TLE in those patients with prior trauma in the Chinese Han population.

Paroxysmal Nonkinesigenic Dyskinesia With Depression Treated by Bilateral Electroconvulsive Therapy

ranged from 10 to 20 times a day, including brief movements of the right shoulder. We diagnosed his right shoulder and upper limb movement as dyskinesia by ictal video EEG recordings. His consciousness during the seizure was maintained, and there was no postictal confusion. The precipitating factor seemed to be tense situations. Ictal EEG showed no epileptic discharge or electrodecremental pattern in all leads during the seizure. Before, during, and after the ictal period, a 9 –10 Hz background rhythm in the occipital area continued, and movement artifacts were seen. Interictal, ictal, and postictal EEG showed no other abnormality (e.g., theta or delta waves). An MRI showed no abnormality, and interictal SPECT (ECD) showed slightly lowered perfusion in the bilateral parietal area. We found no blood electrolyte imbalances or biochemical abnormalities. We tried phenytoin, clonazepam, zoni

Post-ictal alpha activity in supplementary motor seizures mimics nonepileptic seizures

Supplementary motor area seizures may present with bilateral tonic–clonic movements with no loss of consciousness and no postictal confusion, and patients may be erroneously thought to have psychogenic nonepileptic seizures. We describe the rapid emergence of alpha activity in the immediate postictal period in patients with supplementary motor area seizures as an additional confounding factor that may lead to the erroneous diagnosis of nonepileptic seizures in these patients. We present two cases of patients with intractable supplementary motor area seizures investigated with video/EEG monitoring. Their postictal EEG records revealed an immediate postictal recovery of alpha activity, mimicking the pattern seen with psychogenic nonepileptic seizures. Prolonged video/EEG monitoring is mandatory in establishing the diagnosis of supplementary motor area seizures and in distinguishing this condition from nonepileptic seizures.

The Safety and Efficacy of Benzodiazepine-Modified Treatments as a Special Form of Unmodified ECT

Muscle relaxants reduce musculoskeletal morbidity with electroconvulsive therapy (ECT) but need to be administered under general anesthesia. The administration of anesthesia is not always possible for patients prescribed ECT. Consequently, unmodified ECT is still widely practiced, especially in developing countries. We prospectively assessed musculoskeletal morbidity in consecutive patients who received unmodified bitemporal ECT during a part or the whole of their ECT course. All patients were pretreated with an intravenous benzodiazepine (usually diazepam, 10 mg) to effect sedation, anxiolysis, and limited skeletal muscle relaxation. Anteroposterior and lateral digital x-rays of the thoracolumbar spine were obtained after the last unmodified treatment. Fifty-six patients aged 11 to 49 years and with a mean body mass index of 23.0 received a total of 162 (mean, 2.9) unmodified ECTs. There was significant attenuation of psychopathology ratings. Against our expectations, no patient developed clinical or radiological evidence of orthopedic morbidity; however, in 2 patients, the x-rays revealed old spinal fractures. Twelve patients had spots of oral bleeding after ECT. Whereas 5 patients experienced mild, transient, self-limiting postictal confusion, only one had confusion which required medical termination. Five patients complained of body ache and one of memory impairment. There were no other adverse events. The complete absence of orthopedic morbidity with benzodiazepine-modified ECT contrasts with historical descriptions of a 20% to 40% risk with unmodified ECT. We speculate that the limited muscle relaxant action of the pre-ECT parenteral benzodiazepine may have had protective effects. If so, if ECT is urgently indicated but anesthesia and hence conventional muscle relaxants cannot be administered, benzodiazepine-modified ECT may be a safer alternative to unmodified ECT. This suggestion merits wide attention because of its public health importance in countries with poor medical infrastructure, where unmodified ECT is still widely practiced.

Bupropion-Induced Status Epilepticus and Retrograde Amnesia

Back to table of contents Previous article Next article LETTERFull AccessBupropion-Induced Status Epilepticus and Retrograde AmnesiaThomas SkripuletzNiklas Garde,Christian Vidal,Hermann Mueller-VahlReinhard DenglerKarin Weissenborn,Thomas SkripuletzSearch for more papers by this authorNiklas GardeSearch for more papers by this author,Christian VidalSearch for more papers by this author,Hermann Mueller-VahlSearch for more papers by this authorReinhard DenglerSearch for more papers by this authorKarin WeissenbornSearch for more papers by this author,Published Online:1 Jan 2010https://doi.org/10.1176/jnp.2010.22.1.123.e29AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail To the Editor: We present a clinical case of a status epilepticus and retrograde amnesia caused at therapeutic-dose levels of bupropion. Initially marketed as an effective antidepressant, bupropion has more recently been licensed in many countries as an aid to smoking cessation. 1 It is a generally well-tolerated drug. Adverse effects include headache, dry mouth, dizziness, nausea, tremor, constipation, drowsiness, agitation, insomnia, tachycardia, hallucination, allergic reactions, and altering of the seizure threshold. 2 – 4 Bupropion is associated with a dose-dependent increased incidence of seizures. Since the maximum dose has been reduced to 300 mg/day, the seizure rate has decreased to 0.1%. 2Case ReportA 50-year-old man was found unconscious beside his car at 5:00 a.m., about 300 meters from his work. His wife reported that he usually would not leave home before 5:30 a.m. At 11:30 a.m. he had a generalized tonic-clonic seizure, which was successfully treated with diazepam. He experienced postictal lethargy, confusion, and mild dysarthria. Neurological examination revealed ataxia in finger-to-nose testing. Plantar responses were extensor on both feet. Gait examination was not possible because of undirected ataxia, and he also showed trunk ataxia while sitting. The remainder of the neurological examination was unremarkable. EEG showed beta activity. Retrospectively the alteration of unconscious at 5:00 a.m. was considered postictal.At 2:30 p.m. the patient was cooperative but not oriented to time, place, and situation. While taking the history, we saw an abrupt tonic contraction of all muscles with a loud “initial cry,” followed by a clonic phase. The complete seizure lasted about 1 minute during which bladder incontinence occurred. Between 5:00 p.m. and 8:00 p.m. four additional tonic-clonic seizures were seen. A bolus dose of valproate, 800 mg, was given intravenously and continuously thereafter (3,200 mg on first day) and the seizure activity finished. After 2:30 p.m., he remained somnolent and confused.The patient had amnesia for the remainder of the day and had had it for the four preceding days. His wife remembered that he had continuously taken a sustained-release formulation of bupropion (Zyban 150 retard) during the last 14 days. One week prior to the seizures the dose had been doubled to 300 mg bupropion per day. There was no history of seizures, head trauma, alcohol consumption, or liver or kidney diseases. Brain CT and MRI scans of the brain were unremarkable. CSF analysis showed a normal cell count (1.3/mm 3 ) as well as normal erythrocyte count (0.7/mm 3 ). PCR for viruses (HSV, CMV, EBV, VZV, and enterovirus) were negative. There was no evidence for infection with Borrelia burgdorferi or syphilis. CSF-Protein was elevated to 0.73 g/liter (reference 0.17–0.52) as well as CSF-Lactat to 3.35 mmol/liter (reference 1.1–1.9). DiscussionThere is good evidence to state that bupropion was the reason for the patient’s symptoms. To our knowledge, such severe symptoms, including status epilepticus and retrograde amnesia for 5 days with no other risk factors than taking bupropion, have not been described before. Bupropion appears to be effective in ameliorating symptoms of smoking withdrawal, but physicians should be aware that there is an increased risk for seizures. We suggest performing an EEG prior to bupropion administration.Department of Neurology, Hannover Medical School, Hannover, GermanyDepartment of Clinical Chemistry, Hannover Medical SchoolDepartment of Neurology, Hannover Medical School

Face-Related Ictal Hallucinations and Illusions and Reflex-Type Phenomena

Face-Related Ictal Hallucinations and Illusions and Reflex-Type Phenomena

Generalized‐onset seizures with secondary focal evolution

The international seizure classification recognizes that partial-onset seizures can become secondarily generalized, but generalized-onset seizures are expected to remain generalized. We report six patients who had recorded seizures with generalized onset, but subsequent evolution into a focal discharge. The clinical seizure onset was generalized absence or myoclonic, and the most common subsequent clinical pattern was prolonged behavioral arrest with mild automatisms, and then postictal confusion. The ictal discharge started with generalized spike-and-wave activity and then acquired a focal predominance. Interictal epileptiform activity was generalized. There were no focal magnetic resonance imaging abnormalities. Four patients were misdiagnosed with complex partial seizures. All patients were initially refractory, but three became seizure-free and three improved after treatment with antiepileptic medications appropriate for absence or myoclonic seizures. Generalized-onset seizures that acquire focal features are easily misdiagnosed as complex partial. These seizures have a more favorable response to medications effective against generalized absence and myoclonic seizures.

Medial Temporal Lobe Epilepsy with Severe Pain Sensation

1st MHAT-Department of Neurology, Sofia, BulgariaIctal pain is one of several types of somatic sensations felt during partial seizures. As a solesymptom, ictal pain is extremely rare and it is uncommon for temporal lobe epilepsy. In a casereport we present a patient with temporal lobe seizures with the basic symptoms of severe left legpain and muscles cramps. A 29-year-old man was admitted to the hospital because of probableepilepsy. After sport trauma (left leg injury) 10 years ago, he had seizures of severe pain 1–4 timesdaily, muscle cramps spread throughout his left leg, often “saw stars” after physical overfatigue andwhen he was feeling cold. Seizures lasted one to two minutes. He had never lost consciousness.Seven years ago he was misdiagnosed as having orthopaedic disorder. In the last two years thesecomplaints were rarely preceded by lower lip trembling. He had no family history of epilepsy. Thetreatment with carbamazepine (CBZ) monotherapy, valproate (VPA) monotherapy and combinationCBZ+VPA did not show any seizure reduction. Routine interictal EEG recordings showed normalbackground activity. Video-EEG revealed ictal onset consisted of rhythmic 7.5 Hz activity of thetawaves over the left midtemporal region, which spread to the right midtemporal region, followed bydiffuse spike-waves with 7 Hz, but predominated on the left midtemporal. It was the clinical start ofthe seizure. During the seizure the patient had a tortured face and screamed, because of the pain.There was no consciousness impairment and postictal confusion. The seizure lasted one minute.Fluid-attenuated inversion recovery (FLAIR) magnetic resonance and interictal SPECT demonstrateleft hippocampus changes. We started treatment with CBZ 600 mg/daily and levetiracetam (LEV)2500 mg/daily, seizures reduced to only once a month. This case shows that seizure semiology oftemporal lobe epilepsies could be quite different and often misdiagnosed as other disorders.

Epilepsy surgery in the elderly

Epilepsy surgery is increasingly well-supported as an effective treatment for patients with intractable epilepsy. It is most often performed on younger patients and the safety and efficacy of epilepsy surgery in elderly patients are not frequently described. We report a case of a 75-year-old right-handed man who underwent a left fronto-temporal craniotomy for resection of a suprasellar meningioma in 2002. Immediately following hospital discharge, he began to experience complex partial seizures. He continued to have frequent seizures despite treatment with multiple combinations of antiepileptic medications. He presented with status epilepticus every two or three months, and required long periods of hospitalization on each occasion for post-ictal confusion and aphasia. Scalp EEG showed continuous spikes and polyspikes and persistent slowing in the left temporal area, as well as spikes in the left frontal area. EEG telemetry recorded multiple seizures, all with a clear focus in the left temporal area. MRI scan showed an area of encephalomalacia in the left temporal lobe, as well as post-surgical changes in the left frontal area. Neuropsychological testing showed bilateral memory impairment with no significant cognitive decline expected after unilateral temporal lobe resection. A left anteromesial temporal lobectomy was performed with intraoperative electrocorticography. Since surgery, the patient was not seizure-free (Engel class II-b), but had no further episodes of status epilepticus in one year and two months of follow-up. This is one of the oldest patients reported in the literature with epilepsy surgery and supports the possibility of epilepsy surgery in elderly patients for particular cases. In addition, few cases with such a malignant evolution of temporal lobe epilepsy have been described in this age group.

ApoE ɛ4 is not associated with posictal confusion in patients with mesial temporal lobe epilepsy with hippocampal sclerosis

A previous report found an association between ApoE isoforms and postictal confusion in medically intractable temporal lobe epilepsy (TLE). We performed a molecular epidemiology study in an independent sample of 77 TLE patients. We failed to replicate the original allelic association between ApoE epsilon4 allele and postictal confusion in our population (chi(2)=1.67; d.f.=1; p=0.2). Thus, the association between ApoE epsilon4 allele and postictal confusion still needs to be fully investigated in different and independent populations.

Generalized tonic-clonic seizure after a taser shot to the head

During a police chase on foot, a previously well police officer was hit mistakenly by a taser shot meant for the suspect. The taser gun had been fired once, sending 2 barbed darts into his upper back and occiput. Within seconds, the officer collapsed and experienced a generalized tonic-clonic seizure with loss of consciousness and postictal confusion. Subsequent magnetic resonance imaging scans of the head and electroencephalograms were normal. The patient has experienced no recurrence of seizure over more than a year of follow-up. This report shows that a taser shot to the head may result in a brain-specific complication such as generalized tonic-clonic seizure. It also suggests that seizure should be considered an adverse event related to taser use.

History and seizure semiology in distinguishing frontal lobe seizures and temporal lobe seizures

This study aimed to determine the reliability of clinical history and seizure semiology for distinguishing between frontal lobe seizures (FLS) and temporal lobe seizures (TLS). FLS patients (n=23) were consecutively identified through an epilepsy surgery database. TLS patients (n=27) were selected randomly from 238 patients who had undergone temporal lobe surgery for epilepsy. The criterion standard for seizure localization was the location of resective epilepsy surgery that controlled seizures for a minimum of 2 years. Blinded comparisons of 13 historical information items (HII) and 19 video-recorded semiologic features (VSF) were made. We identified 3 HII (sex, history of febrile convulsions, and history of generalized tonic-clonic seizures) and 2 VSF (fencing posturing and postictal confusion) that significantly distinguished between FLS and TLS. The multivariate analysis model correctly identified 87% of FLS patients and 74% of TLS patients. No single HII or VSF is sufficient for distinguishing between FLS and TLS. A model integrating multiple HII and VSF may assist in this differentiation, but some patients still may be misclassified.

APOE ɛ4 is associated with postictal confusion in patients with medically refractory temporal lobe epilepsy

This study examined the relationship between the APOE epsilon4 allele and postictal confusion in patients with medically intractable temporal lobe epilepsy (TLE). Patients with at least one epsilon4 allele (n=22) were three times more likely to exhibit postictal confusion (68%) than the 63 patients without epsilon4 (43%). These preliminary results demonstrate that APOE epsilon4 is associated with an increased risk of postictal confusion in patients with medically intractable TLE, suggesting possible dysfunction in neuronal recovery mechanisms.

Bilateral mesial temporal polymicrogyria: a case report

Polymicrogyria is a malformation of cortical organisation morphologically marked by an irregular brain surface with multiple excessively folded small gyri. Cortical thickness is reduced but appears increased in some areas...

Frontal encephalocele in a middle-aged woman with first seizure

A 48-year-old woman with a history only of chronic sinus symptoms presented with her first seizure. Coworkers witnessed a staring spell and speech interruption for approximately 30 seconds followed by a generalized convulsion lasting 2 minutes. After brief postictal confusion, her neurologic examination was normal. Laboratory studies showed no abnormalities. There …

Case 2: Fever with abdominal distension

A previously well 13-year-old girl presented to hospital with a right focal seizure involving the hand, mouth and eye, which progressed to a secondary, generalized, tonic-clonic seizure lasting 10 min. Subsequent to this, she suffered postictal confusion and a generalized headache.

Thinking outside the Box

A 35-year-old man with advanced AIDS presented to the emergency department after a witnessed syncopal event. He felt light-headed after walking from the bathroom to his chair. While speaking to his partner, he suddenly became unresponsive and lost motor tone, and his breathing appeared shallow and labored, prompting his partner to call 911. He regained consciousness after approximately two minutes and had no recollection of the event. There was no evidence of tonic–clonic seizure activity or postictal confusion.

AHA/ACCF Scientific Statement on the Evaluation of Syncope

AHA/ACCF Scientific Statement on the Evaluation of Syncope

Fainting painting

SYNCOPE Fainting (syncope) is temporary loss of consciousness and posture due to impaired cerebral perfusion. Vasovagal syncope, the commonest form, typically is situational (bathroom at night, or hot, crowded environments)...