Seizure Subtypes Research Articles

Cardiogenic cerebral infarction in the parietal lobe predicts the development of post-stroke epilepsy

PurposePost-stroke epilepsy (PSE) is a major late complication of cardioembolic cerebral infarction. However, few studies have examined the epileptogenicity and characteristics of first-occurrence cardioembolic cerebral infarctions. MethodsThis retrospective study included 93 consecutive patients with old cardioembolic cerebral infarctions who were classified into two groups based on their epileptic history: patients presenting with PSE or stroke without seizure (SWS). Each patient was diagnosed with an epileptic seizure subtype and treated with appropriate anti-epileptic therapy after admission. We evaluated clinical characteristics, laboratory results, and intracranial infarct areas. The sizes of these areas were measured using MRI diffusion-weighted image (DWI) of each patient after their first stroke. The volume was calculated by multiplying the total slice area with the slice thickness. ResultsPSE was diagnosed in 43 (46.2 %) of 93 patients. The mean (± SD) time from infarction onset to the first seizure in the PSE group was 22.5 ± 31.6 months. The PSE group exhibited significantly more atrial fibrillation (p = 0.022) and higher glucose levels (p < 0.001) compared with the SWS group. The most common PSE seizure type was focal to bilateral tonic-clonic seizure (61.0 %). Although DWI did not reveal any significant differences in the volume of infarctions between the two groups, the involvement of the parietal lobe in infarction of the PSE group (69.8 %) upon first admission was significantly higher (p = 0.006) than that of the SWS group (40.0 %). Multiple logistic regression analysis revealed that parietal lobe involvement in infarction (OR 4.95; 95 % CI 1.25–19.60; p = 0.023) was a significant independent predictor of PSE. ConclusionThe involvement of the parietal lobe in infarction was a significant independent predictor of PSE. Dysfunction of the parietal lobe might play a critical role in the epileptogenesis of PSE.

Modulation of posttraumatic epileptogenesis in aquaporin‐4 knockout mice

To determine the role of aquaporin-4 (AQP4) in posttraumatic epileptogenesis using long-term video-electroencephalographic (vEEG) recordings. Here, differences in EEG were analyzed between wild-type (WT) and AQP4 knockout (KO) mice and between mice with and without posttraumatic epilepsy (PTE). WT and AQP4 KO mice were subjected to a single controlled cortical impact traumatic brain injury (TBI) in the frontal cortex, and vEEG was recorded in the ipsilateral hippocampus at 14, 30, 60, and 90days postinjury (dpi). Intrahippocampal electrical stimulation was also used to assess electrographic seizure threshold and electrographic seizure duration (ESD). The mean seizure frequency per day for WT mice was 0.07±0.07, 0.11±0.07, 0.26±0.13, and 0.12±0.10 at 14, 30, 60, and 90dpi, respectively. The mean seizure frequency per day for AQP4 KO mice was 0.45±0.27, 0.29±0.12, and 0.26±0.19 at 14, 30, and 60dpi, respectively. The mean seizure duration was 15±2seconds and 24±3seconds for WT and AQP4 KO mice, respectively. The percentage of mice that developed PTE were 28% and 37% for WT and AQP4 KO mice, respectively. Power spectral density (PSD) analysis revealed alterations in EEG frequency bands between sham and TBI in both genotypes. Additionally, PSD analysis of spontaneous recurrent seizures revealed alterations in delta power between genotypes. Morlet wavelet analysis detected heterogeneity in EEG seizure subtypes and dynamic EEG power patterns after TBI. Compared with AQP4 KO mice, a significant increase in ESD was observed in WT mice at 14dpi. Posttraumatic seizures (PTSs) may be modulated by the astrocyte water channel AQP4. Absence of AQP4 increases the number of spontaneous seizures, increases seizure duration, and alters EEG power patterns of PTSs.

Clinico-Biochemical Abnormalities in Hospitalized Neonates with or without Seizure

Introduction: To determine the clinical types and etiological factors and to assess the biochemical abnormalities in neonates with seizure.&#x0D; Materials and Methods: This was a Cross-sectional, comparative hospital based study. Ninety neonates, age up to 28 days of both sexes were evaluated for clinical types, etiological factors and biochemical abnormalities with seizure and compared with those having no seizures. The variables were analyzed using student t- test. All the data was processed and analyzed by computer software SPSS version 15.0. Level of significance was considered as p value less than 0.05.&#x0D; Results: Most of the neonates having seizures (72%) within 3 days of life. The seizures were common in male babies (62%). 35% of the mother of baby with seizure gave history of prolonged labour. HIE was diagnosed 56.67% neonates with seizure whereas infection were found in 25% cases with seizure. Among the seizure subtypes, subtle seizures were 58% followed by clonic seizures 30%. Significant biochemical changes we found in 43.34% of neonates with seizures. Hypocalcemia (46%) was most common followed by hypoglycemia(38%).&#x0D; Conclusion: Hypoxic ischemic encephalopathy was the commonest cause of neonatal seizure followed by neonatal infections including meningitis and sepsis.. Biochemical abnormalities are more common in neonates with seizure than neonates free from seizure. Among the biochemical abnormalities hypocalcaemia and hypoglycemia occurs most commonly followed by hyponatraemia and hypomagnesaemia.&#x0D; Medicine Today 2020 Vol.32(1): 37-41

Spectral organization of focal seizures within the thalamotemporal network.

ObjectiveTo investigate dynamic changes in neural activity between the anterior nucleus of the thalamus (ANT) and the seizure onset zone (SOZ) in patients with drug‐resistant temporal lobe epilepsy (TLE) based on anatomic location, seizure subtype, and state of vigilance (SOV).MethodsEleven patients undergoing stereoelectroencephalography for seizure localization were recruited prospectively for local field potential (LFP) recording directly from the ANT. The SOZ was identified using line length and epileptogenicity index. Changes in power spectral density (PSD) were compared between the two anatomic sites as seizures (N = 53) transitioned from interictal baseline to the posttermination stage.ResultsAt baseline, the thalamic LFPs were significantly lower and distinct from the SOZ with the presence of higher power in the fast ripple band (P < 0.001). Temporal changes in ictal power of neural activity within ANT mimic those of the SOZ, are increased significantly at seizure onset (P < 0.05), and are distinct for seizures that impaired awareness or that secondarily generalized (P < 0.05). The onset of seizure was preceded by a decrease in the mean power spectral density (PSD) in ANT and SOZ (P < 0.05). Neural activity correlated with different states of vigilance at seizure onset within the ANT but not in the SOZ (P = 0.005).InterpretationThe ANT can be recruited at the onset of mesial temporal lobe seizures, and the recruitment pattern differs with seizure subtypes. Furthermore, changes in neural dynamics precede seizure onset and are widespread to involve temporo‐thalamic regions, thereby providing an opportunity to intervene early with closed‐loop DBS.

Burden of illness in patients with possible Lennox–Gastaut syndrome: A retrospective claims-based study

ObjectiveLennox–Gastaut syndrome (LGS) is a severe and treatment-resistant epilepsy syndrome characterized by multiple subtypes of intractable seizures, moderate to severe cognitive impairment, and slow spike–wave complexes on electroencephalographic (EEG) recordings. Lennox–Gastaut syndrome is also associated with increased risk for injury, reduced quality of life, long-term disability, and early mortality. By evaluating private and public US medical insurance claims, we quantified healthcare utilization and direct costs in patients with possible LGS. MethodsCommercial and Medicaid insurance claims (Truven Health Analytics) from October 2010 to September 2015 were queried to identify patients with intractable epilepsy, intellectual disability, ≥1 prescription for selected antiepileptic drugs (AEDs), and ≥2 years of continuous enrollment. To identify patients with LGS in the absence of a specific International Classification of Diseases ICD-9 diagnosis code, current or prior rufinamide use was selected as a disease indicator of LGS per previously published methodology. Characteristics significantly predictive of rufinamide use were identified with multivariate regression by comparing groups with and without LGS, then assessed in non-rufinamide users fulfilling all other inclusion criteria. Controls without epilepsy, seizures, or prescriptions for selected AEDs were matched to patients with possible LGS by age, gender, US region, and dates of insurance coverage. Average healthcare utilization and costs per patient per year (PPPY) were evaluated for a 2-year postindex period and compared between the cohort with LGS and controls by insurance type. Costs were normalized to 2017 dollars at 3% per annum. ResultsIn the study, 6019 patients with possible LGS (53% male, mean age of 13 years, in both insurance groups) were identified: 2270 with commercial insurance and 3749 with Medicaid. The cohort with LGS used >8 times more services and >7 times more drugs than controls (all p < 0.001) in both insurance groups. The biggest contributors to service use PPPY were outpatient physician visits and home health services in the commercial-insured cohort with LGS and other outpatient visits and home health services in the Medicaid-insured cohort with LGS. Average total costs PPPY (services + drugs) were significantly higher for the cohort with LGS vs. controls: $65,026 (SD $34,324) vs. $2442 (SD $10,670) for commercial-insured and $63,930 (SD $45,761) vs. $3849 (SD $13849) for Medicaid-insured patients. The biggest cost contributors PPPY were inpatient care in the commercial-insured cohort with LGS and home health services in the Medicaid-insured cohort with LGS. ConclusionsPatients with possible LGS have significantly higher healthcare utilization and costs than patients without epilepsy or seizures. Our results suggest that direct costs associated with LGS are substantial and highlight the need for new and effective treatments.

F01. Paroxysmal fast activity and genetic generalized epilepsies

Paroxysmal fast activity is the hallmark of “symptomatic generalized” epilepsy of the Lennox Gastaut type, often occurring with slow spike-wave complexes. Generalized, synchronous epileptiform discharges are considered the typical abnormality on EEG in genetic generalized epilepsy (GGE). Recent literature suggests that generalized paroxysmal fast activity (GPFA) may occur in the context of GGE, and may contribute to clinical heterogeneity. Here, we present three patients with generalized fast spike-wave discharges and polyspikes with concurrent GPFA. Institutional databases of EEG tracings and the electronic medical records were reviewed for cases of GPFA with an electro-clinical diagnosis of GGE. All three patients had onset of their seizures in childhood from age 8–13. Two of the three had mild cognitive impairment. MRI of all three patients were unremarkable. Their seizures were all medically intractable, requiring at least 3–5 broad spectrum antiepileptic drugs, and all 3 were recommended to pursue or chose to have a vagal nerve stimulator implanted. Seizure subtypes included generalized tonic clonic (most frequent) followed by automotor, myoclonic, and astatic seizures. All three EEGs showed brief generalized spike-wave complexes at 3–6 Hz lasting 1–4 s, and generalized paroxysmal fast activity (12–20 Hz) lasting 5–20 s. One tracing showed evolution of GPFA to polyspikes that correlated to a clinical myoclonic seizure. GPFA is classically associated with symptomatic generalized epilepsies of the Lennox-Gastaut type, but these three cases demonstrate GPFA can be seen in GGE. Such patients may be more refractory than the usual GGE, and may belong on a continuum between GGE and LGS.

Electroclinical characteristics and syndromic associations of “eye-condition” related visual sensitive epilepsies—A cross-sectional study

PurposeThe systematic study of visual phenomena such as eye closure (ECLS), eye-closed/fixation-off sensitivity (FOS) [terminology proposed as eye-condition sensitive (ECS) epilepsy] distinct from photosensitivity is rarely explored in literature. MethodsClinical, electroencephalographic (EEG) and imaging records of patients attending an epilepsy clinic were screened. Inclusion criterion was demonstrable electrographic visual sensitivitiy in the form of ECS parameters with/without photosensitivity. Subsequently, detailed analysis of their data was undertaken. ResultsFifty two patients had one or more ECS parameters. Mean age of onset of epilepsy of the cohort was 10.26 ± 7.79 yrs. A family history of seizures was noted in 17% of the cohort. ECLS, FOS, combination of both, co-existent scotosensitivity and photosensitivity were noted in 32.6%, 48.1%, 19.2%, 23.1% and 30.8% respectively. Epilepsy syndromes included late-onset childhood occipital epilepsy-Gastaut variant (23.1%), reflex occipital lobe epilepsy with ECS without photosensitivity (21.2%), idiopathic photosensitive occipital epilepsy (13.5%), genetic generalized epilepsy (13.5%) and symptomatic epilepsy (28.7%) predominated by patients with posterior cortex gliosis or who were imaging negative. The idiopathic group also had lower seizure score and marked sleep activation of epileptiform abnormalities. Co-existent phostosensitivity was associated with a significantly higher predisposition for female gender, ECLS, generalized seizures and spikes with lower prevalence of FOS and extra-occipital spikes. Parieto-occipital spikes were noted in 88.4% patients. ConclusionSyndromic heterogeneity is evident in ECS epilepsies. These form a unique subset of visual-sensitive epilepsy syndromes with focal or generalized seizure subtypes of idiopathic or symptomatic etiologies, with and without associated photosensitivity.

Study of Relationship between Post Stroke Epilepsy and Solar Activity

Objective: Symptomatic seizure or post-stroke seizure are the most common seizure subtypes among the elderly. The purpose of our study was to better understand post-stroke epilepsy in relation to their cerebral location, and to find a possible link between epileptic seizure after stroke debut and the differences in solar activity. Methods: This retrospective chart review of patients who died from hemorrhagic stroke in Ulaanbaatar, Mongolia. Only patients with a hemorrhagic stroke from periods with relatively high solar activity (2000-2002 and 2013-2015) and relatively low solar activity (2008-2010) were considered. Results: Hemorrhagic stroke affected mainly patients between 45-59 years of age. Post-stroke epilepsy was less prevalent less during decreased solar activity years. Post-stroke epilepsy was more prevalent in patients with subarachnoid hemorrhage and brainstem hematoma and even more prevalent in patients with diabetes (p&lt;0.01). Conclusion: Post-stroke epilepsy was less frequent during low solar activity years. Post-stroke epilepsy with concomitant brainstem hematoma resulted in poor outcomes following stroke.

A self-completed questionnaire study of attitudes and perceptions of paramedic and prehospital practitioners towards acute seizure care in Northern Ireland

IntroductionParamedics are increasingly expected to take on wider roles in the management of epilepsy in the community by making nonconveyance decisions after patients have had seizures. Studies have identified barriers to the successful implementation of this clinical role. We sought to determine levels of confidence, training, perceived barriers, and self-identified learning needs and methods to address these needs regarding seizure management. Methods and materialsA questionnaire was developed by consensus and administered to 63 paramedic and prehospital clinicians at various mandatory training days occurring at the central headquarters of the regional ambulance service in Northern Ireland. Participants had no foreknowledge of the questionnaire, which was self-completed and returned immediately. ResultsA 75% return rate was obtained after 63 questionnaires were distributed. Paramedics had a mean of 11.5years of experiences, and 49% had treated 1–10 seizures in the last year. The Joint Royal Colleges Ambulance Liaison Committee guideline on seizure management is the most commonly utilized clinical guideline (100%). All could recall formal training on seizures in their qualification course. They identified a need to develop their knowledge in certain aspects of drug management and seizure subtype identification, including nonepileptic attack disorder (NEAD). Seventy percent of paramedics had a limited understanding of NEAD.Overall, paramedics rated their confidence as higher in drug treatment and the process of managing a seizure but rated their confidence lower in recognizing different seizure types as well as making nonconveyance decisions. The two factors which were cited as instilling high confidence included clinical experience and good use of provided protocols. Other barriers identified included lack of access to intramuscular midazolam, poor information availability in the prehospital setting, and a lack of a feedback mechanism to ensure follow-up. The methods by which learning needs would be addressed included tutorials, e-Learning, and simulation, with 30% preferring a combination of these methods. ConclusionsWe identified that the paramedic workforce feels a reasonable to high level of confidence in the management of acute seizures. However, there are areas where they experience less confidence including making nonconveyance decisions and the identification of nontonic–clonic seizure subtypes.

Comparative sensitivity of quantitative EEG (QEEG) spectrograms for detecting seizure subtypes

PurposeTo assess the sensitivity of Persyst version 12 QEEG spectrograms to detect focal, focal with secondarily generalized, and generalized onset seizures. MethodsA cohort of 562 seizures from 58 patients was analyzed. Successive recordings with 2 or more seizures during continuous EEG monitoring for clinical indications in the ICU or EMU between July 2016 and January 2017 were included. Patient ages ranged from 5 to 64 years (mean = 36 years). There were 125 focal seizures, 187 secondarily generalized and 250 generalized seizures from 58 patients analyzed. Seizures were identified and classified independently by two epileptologists. A correlate to the seizure pattern in the raw EEG was sought in the QEEG spectrograms in 4–6 h EEG epochs surrounding the identified seizures. A given spectrogram was interpreted as indicating a seizure, if at the time of a seizure it showed a visually significant departure from the pre-event baseline. Sensitivities for seizure detection using each spectrogram were determined for each seizure subtype. ResultsOverall sensitivities of the QEEG spectrograms for detecting seizures ranged from 43% to 72%, with highest sensitivity (402/562,72%) by the seizure detection trend. The asymmetry spectrogram had the highest sensitivity for detecting focal seizures (117/125,94%). The FFT spectrogram was most sensitive for detecting secondarily generalized seizures (158/187, 84%). The seizure detection trend was the most sensitive for generalized onset seizures (197/250,79%). ConclusionsOur study suggests that different seizure types have specific patterns in the Persyst QEEG spectrograms. Identifying these patterns in the EEG can significantly increase the sensitivity for seizure identification.

Cerebrospinal Fluid Pleocytosis in Critical Care Patients With Seizures.

To assess the etiology of cerebrospinal fluid (CSF) pleocytosis in critical care patients with seizure(s) or status epilepticus (SE). Many previous studies, some performed decades ago, concluded that CSF pleocytosis may be entirely attributable to seizure activity. We undertook a retrospective chart review of adult patients with an admitting or acquired diagnosis of seizure(s) or SE in critical care units at the Winnipeg Health Sciences Centre between 2009 and 2012. Patients were identified through a critical care information database at a tertiary care center. We limited our study to patients who had lumbar punctures at our center within 5 days of seizure(s) or SE. Of 426 patients with seizures in critical care units, 51 met the inclusion criteria. Seizure subtypes included focal seizures (5 or 10%), generalized seizures (14 or 27%), and SE (32 or 63%). Twelve (seven with SE) of the 51 (24%) were found to have CSF pleocytosis. A probable etiological cause for the CSF pleocytosis was identified in all 12 cases. We conclude that seizures do not directly induce a CSF pleocytosis. Instead, the CSF pleocytosis more likely reflects the underlying acute or chronic brain process responsible for the seizure(s). This was not readily apparent in early studies without magnetic resonance imaging (MRI) of the brain and currently available laboratory investigations. An etiological cause of CSF pleocytosis must always be sought when patients present with seizures and it should never be assumed that seizures are the cause.

Comparison of ILAE 2010 and semiological seizure classification in children with epilepsy

ObjectiveThe aim of this study was to compare both ILAE 2010 and semiological seizure classification (SSC) in terms of their applicability and utility and to predict epileptogenic zone in children with epilepsy. MethodsBoth ILAE 2010 classification and SSC which is a part of five dimensional classification were applied for a total 138 children by dividing into younger (≤6y/o) and older (>6y/o) age groups over the last two years as retrospectively. After the assessment of the seizures types, epilepsy syndromes, and etiologies; the data were also compared to evaluate if having correlation between epileptogenic zone and seizure subtypes in both ILAE 2010 and SSC. ResultsILAE 2010 indicated that 66.7% of the patients had focal seizures, 15.9% had generalized seizures, and 14.4% had seizures of unknown origin. The SSC revealed that the most frequent seizure type was simple seizures (56.5%), second frequent one was complex motor seizures (46.4%) and dialeptic seizures (39.9%). To predict epileptogenic zone, SSC was found to be more specific than ILAE in terms of the more subgroups of SSC were related to the more subgroups of epileptogenic zone (p<0.05). Furthermore, there was a clear correlation between focal foci and specific seizure types in older ages, while many foci caused to same seizure types and tend to no clear focal foci with generalized onset in younger ages. On the other hand, the relationship between epileptogenic zone and etiology was more remarkable in the five dimensional classification. SignificancePreference of seizure classification system is unique for each patient and depends on requirements. Therefore, one dimension cannot be sufficient for evaluation the nature of the seizures in some patients. Furthermore, age related evolution of the seizure types should not be ignored due to ongoing maturation state of the brain. ILAE 2010 and SSC have weak and strong points compared to each other. Semiological seizure classification is more informative in terms of identifying the epileptogenic zone which may be important in specific occasions like pre-surgical work up, while ILAE is simple and easier method which can be applied for seizure description and their characteristics in daily practice.

Drug refractory faciobrachial dystonic seizures successfully treated with multiple apheresis

Faciobrachial dystonic epileptic seizures usually precede the cognitive impairment associated with non-paraneoplastic limbic encephalitis secondary to voltage gated potassium channel complex (VGKC) antibodies, specifically to leucine-rich glioma inactivated 1 (LGI1) antibodies. Testing for VGKC-complex/LGI1 antibodies should be initiated with the recognition of faciobrachial dystonic seizures. This seizure subtype is refractory to treatment with the anti-epileptic drugs, but has been shown to be immunotherapy responsive. Early initiation of immunotherapy has been shown to fasten the time to recovery and also in minimizing the cognitive impairment.

Sleep-wake distribution and circadian patterns of epileptic seizures in children.

Epilepsy is one of the most common chronic neurologic disorders. Daily periodicity of epileptic seizures has been known for over a century. The diurnal patterns of epileptic seizures have also been observed in studies. To investigate the sleep/wake cycle, day/night, and 24-h periodicity of various seizure subtypes and seizure onset localizations in children. We analyzed the clinical seizures of 170 consecutive epilepsy patients who underwent video-electroencephalography (EEG) monitoring over the last 5 years. Semiology of the seizures was classified according to the semiological seizure classification. Origin of the seizures was defined by the onset of ictal activity on EEG. Seizures were evaluated in terms of occurrence during the day (06:00-18:00h) or night (18:00-06:00h), in wakefulness or in sleep, and within a 3-h time interval throughout 24h. A total of 909 seizures were analyzed. Auras, dialeptic, myoclonic, hypomotor, atonic seizures, and epileptic spasms occurred more frequently in wakefulness; tonic, clonic, and hypermotor seizures occurred more frequently in sleep. Auras, dialeptic, and atonic seizures and epileptic spasms occurred more often during daytime; hypermotor seizures occurred more often at night. Generalized seizures were seen most frequently in wakefulness (between 12:00 and 18:00h); frontal lobe seizures were seen at night and in sleep (between 24:00 and 03:00h); temporal lobe seizures were seen in wakefulness (between 06:00 and 09:00h and between 12:00 and 15:00h); occipital seizures were seen during daytime and in wakefulness (between 09:00 and 12:00h and between 15:00 and 18:00h, respectively); parietal seizures were seen mostly during daytime. Seizures in children occur in specific circadian patterns and in specific sleep/wake distributions depending on seizure onset location and semiology.

Risk associated to subtypes of seizure disorders in dementia patients

IntroductionSeizure disorders have been identified in patients suffering from different types of dementia. However, the risks associated with the subtypes of those seizures have not been characterized.Objective/aimTo compare the occurrence of seizure disorders (partial and generalized) between patients with and without a dementia diagnosis from the OPTUM database.MethodsAll ages, and patients with full eligibility between January of 2005 to December of 2014, were included. Data from OPTUM, a de-identified, HIPAA compliant database, made up of 40.7 million private insured patient individual electronic health records from the US, were utilized. Using ICD-9 diagnoses, the occurrence of generalized or partial seizure disorders was identified. A comparison between patients with and without dementia was performed.ResultsA total of 150,516 patient records had a dementia diagnosis, and, 56.38% of them were females. Patients with dementia when compared to those without dementia had higher risk for seizure disorders [odds ratio (OR) = 6.5 95% CI = 4.4–9.5]; grand mal status (OR = 6.5, 95% CI = 5.7–7.3); partial seizures (OR = 6.0, 95% CI = 5.5–6.6); motor simple partial status (OR = 5.6, 95% CI = 3.5–9.0); epilepsy (OR = 5.0, 95% CI = 4.8–5.2); complex partial epileptic seizures (OR = 4.9, 95% CI = 4.6–5.2); generalized convulsive epilepsy (OR = 4.8, 95% CI = 4.5–5.0); localization-related epilepsy (OR = 4.5, 95% CI = 4.1–4.9); petit mal status (OR = 4.2, 95% CI = 2.9–6.1); fits convulsions (OR = 3.5, 95% CI = 3.4–3.6); and complex febrile seizure (OR = 2.5, 95% CI = 1.6–3.9).ConclusionsThe present study confirms that patients with dementia have higher risks for either generalized or partial seizures disorders when compared with patients without dementia.Disclosure of interestThe authors have not supplied their declaration of competing interest.

History versus. Epilepsy Monitoring Unit Evaluation for Diagnosing Seizures: A Concordance Study

History is of paramount importance in the diagnosis of epilepsy. Accurate history can help select patients who require a comprehensive Epilepsy Monitoring Unit (EMU) evaluations, i.e. long term EEG monitoring, dedicated structural/functional neuroimaging and neuropsychological evaluation. A detailed history could help delineate seizure subtype and may obviate the need for a comprehensive evaluation, and be cost effective. We compared epilepsy diagnosis made in outpatients using historical information to comprehensive EMU evaluation. We reviewed seizure/spell diagnosis on consecutive patients made on the basis of history and compared to the final diagnosis following comprehensive EMU evaluation. This study was conducted in King Fahad Medical City, Riyadh, Saudi Arabia. Ninety Six patients (Male-51, Female-45) with mean (±SD) age 24(±10.1) years and duration of epilepsy 11(±9.7) years were recruited following outpatient evaluation probable diagnosis of focal seizure was made in 37, generalised in 29, Paroxysmal Non Epileptiform Seizures (PNES) in 6, and evaluation was inconclusive for seizure type in 24 patients. Following EMU evaluation diagnosis of focal epilepsy was made in 61, generalized epilepsy in 26, and PNES in 10 patients. Outpatient diagnosis was concordant to comprehensive EMU evaluation in 45% (43/96), which was 44% (27/61) for focal seizure, 42% (11/26) for generalised and 50% (5/10) for PNES. Concordance was seen in less than half of the patients recruited and was similar for all seizure subtypes. This study highlights the deficiency of accurate history probably related to the language barrier and or lack of health and educational literacy and signifies the importance of EMU evaluation in our population.

Epilepsy After Febrile Seizures: Twins Suggest Genetic Influence

BackgroundA history of complex febrile seizures can increase the risk of epilepsy, but the role of genetic factors is unclear. This analysis evaluated the relationship between febrile seizures and epilepsy. MethodsInformation on the history of seizures was obtained by a questionnaire from twin pairs in the Mid-Atlantic, Danish, and Norwegian Twin Registries. The information was verified using medical records and detailed clinical and family interviews. The initial study evaluated the genetic epidemiology of febrile seizures in this population. Further information was analyzed and used to evaluate genetic associations of different febrile seizure subtypes. ResultsHistories of febrile seizures were validated in 1051 twins in 900 pairs. The febrile seizure type was classified as simple, complex, or febrile status epilepticus. There were 61% simple, 12% complex, and 7% febrile status epilepticus. There were 78 twins who developed epilepsy. The highest rate of epilepsy (22.2%) occurred in the febrile status epilepticus group. Concordance was highest in simple group. ConclusionA twin with febrile status epilepticus is at the highest risk of developing epilepsy, but simple febrile seizures gave the highest risk for the unaffected twin to develop seizures or other neurological issues. These results are consistent with previous findings. There is a subgroup of febrile seizures that can be associated with long-term consequences. This subgroup can be associated with a significant financial and emotional burden. It is currently not possible to accurately identify which children will develop recurrent febrile seizures, epilepsy, or neuropsychological comorbidities.

P52 – 2932: Sleep-wake distribution and circadian patterns of epileptic seizures in children

Objective To investigate the sleep/wake cycle, day/night and 24-hour periodicity of various seizure subtypes and seizure onset localizations in children. Methods We analyzed the clinical seizures of 170 consecutive epilepsy patients who underwent video-electroencephalography (EEG) monitoring over the last 5-year period. Semiology of the seizures was classified according to the semiological seizure classification. Origin of the seizures was defined by the onset of ictal activity in EEG. Seizures were evaluated in terms of occurence during the day (06:00–18:00) or night (18:00–06:00), in wakefulness or sleep and within the 3-hour time interval throughout 24 hours. Results A total of 909 seizures were analyzed. While auras, dialeptic, myoclonic, hypomotor, atonic seizures and epileptic spasms occurred more frequently in wakefulness; tonic, clonic, hypermotor seizures occurred more frequently in sleep. Auras, dialeptic, atonic seizures and epileptic spasms occurred more often during daytime, hypermotor seizures occurred more often at night. Generalized seizures were seen most frequently in wakefulness (between 12:00–18:00 h), frontal lob seizures were seen at night and in sleep (between 24:00–6:00 h), temporal lobe seizures were seen in wakefulness (between 06:00–09:00 h and 12:00 am-15:00 h), occipital seizures were seen during daytime and in wakefulness (between 09:00–12:00 h and 15:00–18:00 h), parietal seizures were seen mostly during daytime. Conclusion Seizures in children occur in specific circadian patterns and in specific sleep/wake distributions depending on seizure onset location and semiology. Recognition of these daily patterns of seizures provides new diagnostic and therapeutic options. To investigate the sleep/wake cycle, day/night and 24-hour periodicity of various seizure subtypes and seizure onset localizations in children. We analyzed the clinical seizures of 170 consecutive epilepsy patients who underwent video-electroencephalography (EEG) monitoring over the last 5-year period. Semiology of the seizures was classified according to the semiological seizure classification. Origin of the seizures was defined by the onset of ictal activity in EEG. Seizures were evaluated in terms of occurence during the day (06:00–18:00) or night (18:00–06:00), in wakefulness or sleep and within the 3-hour time interval throughout 24 hours. A total of 909 seizures were analyzed. While auras, dialeptic, myoclonic, hypomotor, atonic seizures and epileptic spasms occurred more frequently in wakefulness; tonic, clonic, hypermotor seizures occurred more frequently in sleep. Auras, dialeptic, atonic seizures and epileptic spasms occurred more often during daytime, hypermotor seizures occurred more often at night. Generalized seizures were seen most frequently in wakefulness (between 12:00–18:00 h), frontal lob seizures were seen at night and in sleep (between 24:00–6:00 h), temporal lobe seizures were seen in wakefulness (between 06:00–09:00 h and 12:00 am-15:00 h), occipital seizures were seen during daytime and in wakefulness (between 09:00–12:00 h and 15:00–18:00 h), parietal seizures were seen mostly during daytime. Seizures in children occur in specific circadian patterns and in specific sleep/wake distributions depending on seizure onset location and semiology. Recognition of these daily patterns of seizures provides new diagnostic and therapeutic options.

Early Posttraumatic Seizures in the Pediatric Population.

Early posttraumatic seizure is a paramount clinical issue in pediatric traumatic brain injury patients as it is a common occurrence, yet an understudied entity at present. Recent literature recognizes several posttraumatic seizure subtypes based on time of presentation and the underlying pathophysiology: impact, immediate, delayed early, and late/posttraumatic epilepsy. Appropriate classification of pediatric posttraumatic seizure subtypes can be helpful for appropriate management and prognosis. This review will focus on early posttraumatic seizures, and the subtypes of early posttraumatic seizure. Incidence, risk factors, diagnosis, seizure semiology, status epilepticus, management, risk of recurrence, and prognosis were reviewed. The integration of continuous electroencephalographic (EEG) monitoring into pediatric traumatic brain injury management may hold the key to better characterizing and understanding pediatric early posttraumatic seizures. Topics for future research pertaining to pediatric early posttraumatic seizure are identified.

YouTube as a potential learning tool to help distinguish tonic–clonic seizures from nonepileptic attacks

Medical students are increasingly turning to the website YouTube as a learning resource. This study set out to determine whether the videos on YouTube accurately depict the type of seizures that a medical student may search for. Two consultant epileptologists independently assessed the top YouTube videos returned following searches for eight terms relating to different categories of seizures. The videos were rated for their technical quality, concordance of diagnosis with an epileptologist-assigned diagnosis, and efficacy as a learning tool for medical education. Of the 200 videos assessed, 106 (63%) met the inclusion criteria for further analysis. Technical quality was generally good and only interfered with the diagnostic process in 8.5% of the videos. Of the included videos, 40.6–46.2% were judged to depict the purported diagnosis with moderate agreement between raters (75% agreement, κ=0.50). Of the videos returned after searching “tonic–clonic seizure”, 28.6–35.7% were judged to show nonepileptic seizures with almost perfect interrater agreement (92.9% agreement, κ=0.84). Of the videos returned following the search “pseudoseizure”, 77.8–88.9% of videos were judged to show nonepileptic seizures with substantial agreement (88.9% agreement, κ=0.61). Across all search terms, 19.8–33% of videos were judged as potentially useful as a learning resource, with fair agreement between raters (75.5% agreement, κ=0.38). These findings suggest that the majority of videos on YouTube claiming to show specific seizure subtypes are inaccurate, and YouTube should not be recommended as a learning tool for students. However, a small group of videos provides excellent demonstrations of tonic–clonic and nonepileptic seizures, which could be used by an expert teacher to demonstrate the difference between epileptic and nonepileptic seizures.