Postictal Confusion Research Articles

Hair Burning Syncope

We read the report "Hair-Grooming Syncope Seizures" by our colleagues Drs Lewis and Frank (Pediatrics. 1993;91:836-838), and waxed nostalgic regarding a cluster of similar cases which we aptly named "hair burning syncope." During an 18-month period in the late 1980s, several girls came to our outpatient clinic and emergency departments with generalized seizure activity following or in the midst of hair grooming using a hot curling (or uncurling) iron. After the first few cases, a clear pattern emerged: the patients were all black girls, aged 8 to 14 years; hair-grooming with a hot iron and various hair "gels" was always involved; the patient was seated or standing, with the groomer behind the patient; the parent was not directly supervising the activity; seizures were generalized, brief, and associated with brief postictal confusion.

Ultrasonic antidepressant therapy might be more effective than electroconvulsive therapy (ECT) in treating severe depression

ECT is widely acknowledged as an effective treatment for severe depression (I), but its drawbacks of entailing a seizure, general anesthesia, post-ictal confusion and memory disturbance can be problematical to the extent of preventing some patients from undergoing the treatments often enough to sustain relief. According to Higgins et al (2), stimulation of specific points on the surface of the temporal lobes reliably produces a pleasure response without causing a seizure, confusion or memory impairment. Due to reciprocal inhibition between the brain’s reward and punishment pathways (3), such a response might be expected to relieve depression. Work done by Velling and Shklyaruk with animals, specifically rabbits, (4) suggests that much stimulation could be produced in humans through the intact skull and scalp by using ultrasound focused from outside of the head. Ultrasound transducers contained in water-filled, baglike stimulators, like those used by Gavrilov (5) to stimulate auditory nerves through intact skull, when placed in contact with the outside of the head, would eliminate the need for conductive gel, which can be messy. Since there would be no pain or other tactile sensation, anaesthesia would be unnecessary. Hence, externally-focused ultrasound could provide the same benefit as ECT, that is, relief of depression, without

Prolonged confusion following convulsions due to generalized nonconvulsive status epilepticus

Among patients with a prolonged confusional state after convulsive seizure, we diagnosed 8 cases as generalized nonconvulsive status epilepticus. Six had a history of seizures, and 2 had new onset. The convulsive seizures were generalized in 6 and focal in two. The postictal confusion lasted up to 36 hours in the most prolonged case, and a delayed response to anticonvulsant medications occurred in all cases. The clinical symptoms ranged from mild confusion to coma. Psychiatric manifestations or automatisms were rare. The presumed etiology was due to diverse causes, but a withdrawal state was the most common. EEG demonstrated continuous or nearly continuous generalized ictal discharges of variable morphology. These cases call attention to the fact that some prolonged confusional states following convulsive seizures are in fact due to persistent seizure activity that can be diagnosed by EEG.

Prolonged Postictal Encephalopathy

Prolonged postictal confusion lasting from four to ten days is reported in 11 patients (ages 7½ to 40 years) from the Epilepsy Research Center, Department of Neurology, University of Minnesota and MINCEP Epilepsy Care, P.A., Minneapolis.

Prolonged postictal encephalopathy

Eleven patients (6 males, 5 females; ages 7.5 to 40 years, mean 27.8) had prolonged postictal confusion lasting from 4 to 10 days. During that time, the EEG showed a typical encephalopathic pattern. Comprehensive evaluation ruled out the possibility of metabolic, toxic, drug-related, or ongoing nonconvulsive status epilepticus. We have designated this syndrome as prolonged postictal encephalopathy (PPIE). Nine of 11 patients were mildly to borderline mentally retarded. Ten had previous episodes of status epilepticus. Nine of 11 had minimal structural abnormalities (mainly diffuse cortical atrophy). Nine patients had multiple recurrent episodes of PPIE. All episodes occurred following a cluster of seizures: in 8 patients after a cluster of generalized tonic-clonic seizures, in 2 after complex partial seizures, and in 1 patient after a cluster of atypical absence seizures. This series suggests that vulnerability to develop PPIE exists in patients with diffuse structural abnormalities, mild to borderline mental retardation, a history of status epilepticus, and a tendency of seizures to cluster.

Acute Postictal Psychosis: A Stereo EEG Study

An acute psychosis characterized by auditory hallucinations and paranoid delusions developed in a 19-year-old man with temporal lobe epilepsy after he had a cluster of seizures when antiepileptic drugs (AEDs) had been gradually discontinued. Continuous sterotactic depth and epidural EEG recordings confirmed that this was a postictal rather than an ictal event. Acute postictal psychosis is a self-limited condition phenomenologically distinct from ictal or postictal confusion.

Water quality criteria for hexahydro-1,3,5-trinitro-1,3,5-triazine (RDX)

The occurrence of the munitions compound hexahydro-1,3,5-trinitro-1,3,5-triazine (RDX) in groundwater surrounding Army ammunition plants may result in contamination of local drinking water supplies. RDX exerts its primary toxic effect in humans on the central nervous system, but also involves gastrointestinal and renal effects. Symptomatic effects following acute exposure include hyperirritability, nausea, vomiting, generalized epileptiform seizures, and prolonged postictal confusion and amnesia. Health effects data were analyzed for RDX, and although no controlled human studies exist concerning the acute or chronic toxic effects of exposure to RDX, sufficient animal toxicity data are available to derive an ambient water quality criterion for the protection of human health. This paper summarizes the available literature on metabolism of RDX and human and animal toxicity. Based on noncarcinogenic mammalian toxicity data, and following the methodologies of the U.S. Environmental Protection Agency, an ambient water quality criterion for the protection of human health of 103 μg/liter is proposed for ingestion of drinking water and aquatic foodstuffs. A criterion of 105 μg/liter is proposed for ingestion of drinking water alone.

Firing patterns of human limbic neurons during stereoencephalography (SEEG) and clinical temporal lobe seizures

Comparisons of the patterns of neuronal firing and stereoencephalography (SEEG) recorded from the same microelectrodes chronically implanted in the human limbic system were made in order to study neuronal electrogenesis at onset and during propagation of focal partial complex seizures. Alert or sleeping patients were monitored during spontaneous subclinical seizures (no alterations in consciousness detectable), during auras reported by the patients as typical, and during clinical seizures with loss of consciousness, movements and post-ictal confusion. During subclinical SEEG seizures (ipsilateral, normal consciousness), few neurons increased firing (estimated at only 7%) either at the focus or at propagated sites. During auras, with altered consciousness, there were relatively few neurons that increased firing, with the estimate about 14% or twice as many as during a subclinical seizure. During the onset of a clinical seizure that involved loss of consciousness, movements and post-ictal confusion, many neurons were recruited into increased firing, with an estimate of approximately 36%. During this increased electrogenesis, neurons fired briefly in association with high-frequency local SEEG; however, the bursts were shorter than the SEEG seizure pattern. Apparently, other local neurons were recruited to fire in bursts to sustain sufficient axonal driving for widespread propagation of the seizure. When the focal SEEG slowed, the units stopped firing, which suggested that the ‘focal’ seizure need not be sustained for more than several seconds because propagated seizure activity was self-sustaining at distant structures. The data lead to the conclusion that SEEG seizures can be generated focally by synchronous firing of fewer than 10% of neurons in the ‘epileptic pool’. However, when greater percentages of neurons are recruited in the ‘epileptic focus’ there is greater propagation to widespread sites, especially contralaterally, which will produce clinical partial complex seizures.

Neuropsychological Aspects Of Disorientation

Patients were asked twelve orientation questions before ECT and during the recovery period (the postictal confusion:al state) following ECT. Disorientation was more severe in the elderly. The different orientation items did not recover simultaneously; different recovery times may enable patients to give responses that are logical contradictions. While certain models (e.g., “person” versus “place” versus “time”) may be useful in describing the differential recovery of orientation items, other models based on memory will probabily prove more useful in delineating what causes this differential recovery. Patients gave responses to age and current year that were displaced backwards in years from the correct response. It is suggested that this displacement represents retrograde amnesia. As the postictal confusional state cleared, however, these backwardly displaced responses decreased in years of remoteness, thus showing a pattern of “shrinkage” that is similar to shrinking retrograde amnesia following headinjury.. It is suggested that this result supports Ribot's law of regression.

Complex partial status epilepticus presenting as gelastic seizures: A case report

A middle-aged man, who presented to the emergency room because of bizarre outbursts of laughter, was found to be in partial complex status epilepticus. His seizure disorder had been misdiagnosed, at various times, as a variety of “functional” psychiatric disorders. Despite proper diagnosis and aggressive treatment, management was difficult, being complicated by postictal agitation and confusion, postictal psychosis, and interictal compulsive and paranoid personality features. This case is described, and issues of diagnosis and management in partial complex epilepsy are briefly discussed. The importance of not overlooking organic and especially epileptic factors, despite the presence of prior psychiatric illness, psychologic contributors, and environmental stressors, is emphasized.

Hysterical seizures: Suggestion as a provocative EEG test

We studied 57 patients with poorly controlled or atypical seizures to identify hysterical attacks with a provocative test consisting of initiation and termination of an attack with suggestion and saline injection during electroencephalographic (EEG) monitoring. Using this method, we diagnosed 48 patients as having hysterical attacks. Three additional patients had spontaneous hysterical attacks during routine recordings. Of the 51 patients with hysterical attacks, 78% were female. Two-thirds of the patients were between the ages of 20 and 35 years. Thirty-two patients had taken anticonvulsants before the study. Each patient's hysterical attack, aura, and postictum was stereotyped, and the 6 patients subject to both hysterical and organic seizures described the two types of attacks as different stereotyped behaviors. Tongue laceration, urinary incontinence, and postictal confusion were common. Twelve patients had evidence of past or present neurological disease. Abnormal EEGs were recorded in 37% but only 12% had spike or spike and wave discharges. The provocative EEG test employing saline and suggestion is a useful tool in the diagnosis of hysterical "seizures."

Effects of Stimulation in the Mesial Temporal Lobe in Persons with Bitemporal Epilepsy

Persons suffering from intractable bitemporal epilepsy present one of the most difficult therapeutic problems. This report concerns five patients with intractable bitemporal epilepsy who have been followed over a number of years and who have not responded to drug therapy. Because recurrence of the seizures repeatedly produced serious physical and psychological limitations in the life of these patients, depth electrodes were implanted in each temporal lobe in the amygdala and hippocampal areas in an effort to determine a possible focal site for the origin of their clinical seizures. Detailed EEG recordings and direct electrical stimulations of the temporal lobe were carried out. Only the effects of stimulation will be reported here. Electrical stimulation was carried out in the amygdala and hippocampal regions while the patients were alert and cooperative. Stimulation of the amygdala produced motor, sensory, autonomic and memory and emotional changes. These changes included adversive head and eye movements, olfactory sensations, vasoconstriction, tachycardia, confusion and feelings of fear. Hippocampal stimulation resulted in motor movements, sensory changes such as paresthesias and contralateral paresthesias. Simultaneous stimulation of the hippocampal regions resulted in a complex motor and sensory change associated with postictal confusion. Unilateral stereotactic lesions of the temporal lobe involved in the clinical focus have resulted in definite improvement in the frequency of seizures in three of the patients. No serious complications have been noted related to the procedure with the longest follow-up now 5 years.

Diagnostic factors in adult males following initial seizures. A three-year follow-up.

Seventy-seven navy enlisted men with a mean age of 23.2 years (range, 17 of 48) were admitted to the hospital after their first seizure and given a provisional diagnosis of convulsive disorder. The subjects were followed-up for three years to see if reliable predictors of subsequent seizures and diagnosis could be obtained at the first examination. If not readmitted because of a second seizure, each patient was recalled at the end of his first and third year in the study for follow-up examinations. Following a second seizure and readmission to the hospital, 39% were diagnosed as having a convulsive disorder, 18% a psychiatric disorder, and 5% a neurological illness. Thirty-six percent never had a second seizure. Of those experiencing a second seizure 77% were readmitted during the first year. Three variables were used as predictors of second seizures and final diagnoses: type of seizure (major motor); electroencephalographic classification (spikes with or without slow waves); and presence of postictal confusion and disorientation.

JUVENILE MIGRAINE, PRESENTING AS AN ACUTE CONFUSIONAL STATE

In the literature, complicated migraine usually connotes paroxysmal unilateral headache and vomiting associated with neurological signs, such as hemiplegia, hemianopsia, aphasia, ophthalmoplegia, or syncope. A not uncommon form of complicated migraine in childhood is the presentation with an acute confusional state. Four cases are described. Emphasis is placed on the initial presentation with disturbed sensorium and consciousness, with varying degrees of agitation, and the difficulty for the clinician in distinguishing from other causes of acute mental disturbance, such as toxic-metabolic psychoses due to drug ingestion or known metabolic disease, encephalitis, acute toxic encephalopathy, and epilepsy, particularly petit mal status and postictal confusion. The diagnosis of migraine was made only after the acute episode, when the usual clinical criteria for making a diagnosis of migraine was established in retrospect or by subsequent course. In all cases the episodes of confusion were single ones, with no repetition of similar attacks, although the classic or common types of migraine often reoccurred.