Video Electroencephalogram Research Articles

Stiff person syndrome and prior temporal lobectomy: Is it a case of misplaced autoimmunity?

AbstractBackgroundStiff person syndrome (SPS) is a rare autoimmune disorder, characterized by progressive rigidity and muscle spasms affecting the axial and limb muscles. Anti‐glutamic acid decarboxylase (anti‐GAD65) antibodies are linked to pathogenesis of both epilepsy and SPS. We aim to highlight epilepsy surgery as a potential trigger for development of SPS.Case presentationA 35‐year‐old female with medically refractory temporal lobe epilepsy underwent right amygdala‐hippocampectomy in 2009. The patient was seizure‐free until 2019 when she developed spells of severe muscle spasms, palpitations, dyspnea, and restlessness. Examination revealed increased spasticity in bilateral lower extremities, a wide based gait, and hyperreflexia with crossed adductor sign and bilateral Babinski sign. Serum and cerebrospinal fluid (CSF) labs were obtained, and two typical spells occurred during continuous video electroencephalogram (cvEEG) monitoring. Typical spells did not correlate with seizure activity on cvEEG. CSF analysis showed normal opening pressure, Gram stain, culture, cell count, protein, and glucose. Serum and CSF GAD65 antibody levels were 5153 nMol/L and 53 nMol/L, respectively, along with 14 oligoclonal bands in CSF. Diagnosis of SPS was made. Treatment with diazepam caused improvement in spells and myalgia.ConclusionThe diagnosis of SPS can be delayed in a patient with history of epilepsy. Although SPS and epilepsy are often linked by anti‐GAD antibodies as common etiology, it is possible that epilepsy surgery might be a trigger for development of SPS in a small subset. Development of autoimmunity to neuronal GAD65 protein, exposed during surgery, is suspected in pathogenesis.

Predictive semiology of psychogenic non-epileptic seizures in an epilepsy monitoring unit.

IntroductionThe diagnosis of psychogenic nonepileptic seizures (PNES) is a common clinical dilemma. We sought to assess the diagnostic value of four ictal signs commonly used in differentiating PNES from epileptic seizures (ES).MethodsWe retrospectively reviewed consecutive adult video-electroencephalogram (VEM) studies conducted at a single tertiary epilepsy center between May 2009 and August 2016. Each event was assessed by a blinded rater for the presence of four signs: fluctuating course, head shaking, hip thrusting, and back arching. The final diagnosis of PNES or ES was established for each event based on clinical and VEM characteristics. All ES were pooled regardless of focal or generalized onset. We analyzed the odds ratio of each sign in PNES in comparison to ES with adjustment for repeated measures using logistic regression. Additionally, we calculated the sensitivity, specificity, predictive values, and likelihood ratios of each sign to diagnose PNES.ResultsA total of 742 events from 140 VEM studies were assessed. Fluctuating course (odds ratio (OR) 37.37, 95% confidence interval (CI) 13.56–102.96, P < 0.0001), head shaking (OR 2.95, 95% CI 1.26–6.79, P = 0.012), and hip thrusting (OR 4.28, 95% CI 1.21–15.18, P = 0.02) were each significantly predictive of PNES. Fluctuating course had the highest sensitivity (76.16%). Back arching (OR 1.06, 95% CI 0.35–3.20, P = 0.92) was not significantly associated with PNES.ConclusionFluctuating course, head shaking, and hip thrusting are semiological features significantly more common in PNES than ES. Fluctuating course is the most reliable sign. Back arching does not appear to differentiate PNES from ES.

Visual Diagnosis: Abnormal Behavior in a 2-month-old Boy.

Visual Diagnosis: Abnormal Behavior in a 2-month-old Boy.

Inhibition of AMPA (α-Amino-3-Hydroxy-5-Methyl-4-Isoxazole Propionate) Receptor Reduces Acute Blood-Brain Barrier Disruption After Subarachnoid Hemorrhage in Mice.

Activation of α-amino-3-hydroxy-5-methyl-4-isoxazole propionate receptor (AMPAR) is thought to cause acute brain injury, but the role remains poorly understood in subarachnoid hemorrhage (SAH). This study was conducted to evaluate if AMPAR activation induces acute blood-brain barrier (BBB) disruption after SAH. C57BL/6 male adult mice (n = 117) underwent sham or filament perforation SAH modeling, followed by a random intraperitoneal injection of vehicle or two dosages (1mg/kg or 3mg/kg) of a selective noncompetitive AMPAR antagonist perampanel (PER) at 30min post-modeling. The effects were evaluated by mortality, neurological scores, and brain water content at 24-48h and video electroencephalogram monitoring, immunostaining, and Western blotting at 24h post-SAH. PER significantly suppressed post-SAH neurological impairments, brain edema, and BBB disruption. SAH developed epileptiform spikes without obvious convulsion, which were also inhibited by PER. Western blotting showed that the expression of AMPAR subunits GluA1 and GluA2 was unchanged after SAH, but they were significantly activated after SAH. PER prevented post-SAH activation of GluA1/2, associated with the suppression of post-SAH induction of tenascin-C, a causative mediator of post-SAH BBB disruption. Meanwhile, an intracerebroventricular injection of a subtype-selective GluA1/2 agonist augmented the activation of GluA1/2 and the induction of tenascin-C in brain capillary endothelial cells and aggravated post-SAH BBB disruption without increases in epileptiform spikes. Neurological impairments and brain edema were not correlated with the occurrence of epileptiform spikes. This study first showed that AMPAR plays an important role in the development of post-SAH BBB disruption and can be a novel therapeutic target against it.

Application Effect and Value Experienceof Long Range Video Electroencephalogram in Diagnosis of Epilepsy

Application Effect and Value Experienceof Long Range Video Electroencephalogram in Diagnosis of Epilepsy

Recognition of seizure semiology and semiquantitative FDG-PET analysis of anti-LGI1 encephalitis.

AimsAnti‐leucine‐rich glioma‐inactivated 1 (LGI1) autoimmune encephalitis (AE) is characterized by complex manifestations of seizures. Here, we report a new seizure semiology, attempt to classify the disease by semiology type, and explore the metabolic pattern of each group.MethodsAnti‐LGI1 AE patients were retrospectively screened between May 2014 and September 2019 in our tertiary epilepsy center. All enrolled patients had seizures during long‐range video electroencephalogram (EEG) recordings, and all patients (except one) underwent [18F] fluoro‐2‐deoxyglucose (FDG) positron emission tomography (PET) scans. Voxel‐based metabolic analysis and z‐distribution analysis were carried out to determine the metabolic pattern.ResultsThirty‐three patients were enrolled. According to the patients’ seizure semiology, we divided the patients into four groups: focal impaired awareness seizures (FIAS, n = 17), faciobrachial dystonic seizures (FBDS)‐only (n = 6), FBDS‐plus (n = 8), and focal aware motor seizures (FAMS) (n = 2). No significant differences were found in the clinical manifestations or accessory tests except for the onset age (FIAS < FBDS‐plus) and seizure semiology. This was the first study to extensively describe the clinical manifestations and EEG of FAMS in anti‐LGI1 AE patients. In addition, we found that the patients with different semiologies all showed a wide range of abnormal metabolism, which is not limited to the temporal regions and basal ganglia, and extends far beyond our previous interpretation of FDG‐PET data.ConclusionOur results showed that FAMS can serve as a rare indicative seizure semiology of anti‐LGI1 AE and that individuals with this disease exhibited widespread functional network alterations.

A case of 15q11‐q13 duplication syndrome and literature review

BackgroundThe chromosomal 15q11‐q13 regions are structurally complex, and their abnormalities are associated with various neuropsychiatric disorders, including autism spectrum disorder (ASD), epilepsy, Angelman syndrome, and Prader–Willi syndrome.Case descriptionA 6‐year‐old child was admitted to the hospital as a result of an “epileptic status” showing ASD, intractable epilepsy, and total developmental retardation. Chromosome gene detection showed repetitive variation in the 15q11‐q13 regions, and the video electroencephalogram was abnormal. Although children are currently given antiepileptic treatment and rehabilitation training, intermittent seizures can still occur.ConclusionThe clinical phenotypes of 15q11‐q13 repetitive syndrome are complex, and vary in severity. Children with intractable epilepsy, ASD, and language and motor retardation should be considered to have this syndrome, which requires confirmation by multiplex ligation‐dependent probe amplification and gene detection. These approaches can enable early rehabilitation treatment and improve the patients’ quality of life.

Associations of overweight and obesity with drug-resistant epilepsy

BackgroundObesity and overweight have been well established as comorbidities of epilepsy in adults. However, the effects of overweight and obesity on the risk of adult drug-resistant epilepsy (DRE) has not been fully assessed. Thus, the objective of this study was to investigate the relationships between categories of body mass index (BMI) and DRE. MethodsThis was a case-control study. Patients with epilepsy hospitalized for Video electroencephalogram were included in the study from 2015 to 2020. Low/normal weight, overweight, and obesity were defined as BMI<23 and 23-24.9 and ≥25 kg/m2, respectively. The proportions of patients diagnosed with DRE in each category were calculated. ResultsA total of 1272 patients with drug-responsive epilepsy and 345 patients with DRE were included in this study. More men than women had DRE (P=0.012). Higher proportions of patients with DRE had a history of status epilepticus (P<0.001), CNS infection (P=0.027), developmental delay (P=0.001), and comorbidity (P<0.001). Obesity (BMI≥25 kg/m2) was associated with an increased risk of DRE (adjusted OR, 2.339; 95% CI, 1.724-3.171). No significant increase in the risk of DRE was found to be associated with overweight. Further stratified analyses by valproic acid (VPA) treatment attenuated the obesity-DRE relationship, but the associations remained statistically significant (adjusted OR, 1.79; 95% CI, 1.15-2.80). ConclusionObesity, but not overweight, potentially plays a role in DRE, although confounders, such as antiseizure medications (ASMs) use, need to be explored. In the future, well-designed trials are needed to elucidate this issue.

P-EP023. Ictal video electroencephalogram of an amnesic attack on waking in a transient epileptic amnesia patient: evidence for postictal rather than ictal amnesia

Introduction. There have been few reports on the ictal video electroencephalogram (VEEG) of amnesic attacks in patients with transient epileptic amnesia (TEA). TEA attacks often occur on waking, but the reason remains unclear. Results. A 65-year-old man had a three-month history of recurrent episodes of antero- and retrograde amnesia. The episodes lasted for 10–20 minutes and occurred 2-3 times per month. Brief episodes of behavioral arrest were also witnessed. TEA was suspected, but routine EEG was equivocal. Therefore, we performed a long-term VEEG monitoring. On the second night of the monitoring, a focal onset seizure with subtle motor manifestation occurred during N2 sleep. Following sudden onset tachycardia, EEG seizure patterns arose from the right temporal regions, spread to the left, and terminated in about 90 seconds. About 20 seconds after the seizure cessation, he awoke while EEG was almost normal. On awakening, he showed transient amnesia lasting around 30 minutes, which was confirmed by bystanders. Both antero- and retrograde amnesia were observed. The diagnosis of TEA was made. Lacosamide 50 mg twice daily resolved seizures. Conclusion. We provide the first evidence that TEA attacks on waking reflect postictal hippocampal dysfunction due to unrecognized seizures during sleep. This finding is in line with that the duration of TEA episodes is longer than typical temporal lobe seizures.

Football final game as a reason for non-epileptic convulsions: case report

Non-epileptic convulsions, often named psychogenic non-epileptic seizures (PNES), pseudo-seizures are a relatively complex problem of unknown aetiology and prognosis. PNES are defined by modern psychiatry as a conversion disorder which is classified as one of the somatic symptoms and related disorders in DSM V and is considered a subtype of dissociative disorder in ICD 10. These disorders are diagnosed when disruptive changes in behaviour, thinking, or emotion resemble epileptic seizures, but no paroxysmal discharges are seen on electroencephalogram (EEG) and do not originate from another illness. Head trauma, sexual and physical abuse, and physical and psychological stress may also be included as factors dominating as reasons in prevalence of PNES. The golden standard for PNES diagnosis is video electroencephalogram (Video-EEG). Whereas PNES presented in women is 3:1 vs men, the treatment of PNES is still questioned: anti-epileptic medicine vs cognitive behavioural therapy (CBT). We describe a clinical case repot of a die-hard soccer fan, in which PNES manifested after the final 2018 FIFA World Cup game, where the team he was rooting for, Croatia, lost vs France.

Electrophysiological Evaluation in Identifying Unique Sleep Features Among Anti-LGI1 Encephalitis Patients During Active and Recovery Phase.

ObjectiveThe purpose of this study was to illustrate the electrophysiological features of sleep disturbances in patients with anti-leucine-rich glioma-inactivated protein 1 (anti-LGI1) encephalitis in both active and recovery stages.MethodsRetrospectively filed video electroencephalogram (VEEG) and polysomnography (PSG) data in 24 patients with anti-LGI1 encephalitis were analyzed in comparison with that in 20 individuals without sleep disorders as control group.ResultsSleep efficiency (SE) and total sleep time involving REM and NREM sleep were significantly decreased in patients with anti-LGI1 encephalitis during the active stage compared to that during the recovery stage and in the control group. Imbalanced sleep structure was found, demonstrated by elevated N1, decreased N3 and REM components, as well as abnormal N2 structure characterized with significantly lower spindle duration and density during the active stage. These findings were independent of the presence of nocturnal episodic events or sleep hyperkinetic movements (HMs). HMs were present in 11/23 patients throughout NREM and REM sleep (nonspecific in sleep stages) during the active stage. During the recovery stage, SE and sleep structures were dramatically improved, including the percentage of N3 and REM sleep, spindle duration and density. Ten of 11 patients with HMs were followed up. HMs were totally remitted in 3 patients and still persistent in 1, while evolved into REM sleep behavior disorder (RBD) in 4 with comorbid periodic limb movement syndrome (PLMS) in 3/4, and only PLMS in 2.ConclusionSleep disturbances were remarkable and intrinsic features in active anti-LGI1 encephalitis, marked by overall disruptions of both NREM and REM sleep, as well as the presence of HMs, which tend to evolve into RBD or PLMS during the recovery stage. Long-term follow-up with PSG is needed, especially for those patients with severe sleep disturbances during the active phase.

Usefulness of a new semiological classification for characterizing psychogenic nonepileptic seizures.

Nonepileptic events misdiagnosed as epilepsy lead to a risk of iatrogenic morbidity, which increases health costs. Among the patients affected by nonepileptic events, 11-46% are psychogenic nonepileptic seizures (PNESs). To investigate the usefulness of the semiological classification of PNESs among patients diagnosed by means of video electroencephalograms (vEEGs). This was a retrospective review of the medical records of patients admitted to the adult vEEG unit between April 2007 and December 2016, who were diagnosed with PNES that was confirmed through vEEG. Analysis on demographic and clinical data and classification of PNESs according to the Magaudda classification were performed. We identified 143 patients, among whom 31.5% had also epilepsy. According to the Magaudda classification, the events were: hypermotor (58%); subjective symptoms (21.7%); akinetic (14.7%) and focal motor (5.6%). Hypermotor predominated in both genders, followed by subjective symptoms in women (23.9%) and akinetic in men (19.2%). The mean number of antiepileptic drugs (AEDs) prescribed per patient was 2.3. Thirty-two patients (22.4%) required at least one hospitalization for PNESs. 48.3% of the patients had psychiatric comorbidities. The proposed semiological classification of PNESs is a relevant tool that general neurologists can use to characterize these events in their daily practice. Correct use of this classification, together with vEEG and appropriate clinical suspicion, makes it possible to reach an accurate early diagnosis, thus reducing morbidity and, possibly, the high costs associated with PNESs.

A Case of Musicogenic Epilepsy

AbstractMusicogenic epilepsy is a relatively rare form of epilepsy characterized by seizures triggered by specific music experiences, with an estimated prevalence of 1/10,000,000 population. In this article, we reported a case of 12-year-old boy patient with a history of recent onset focal seizures associated with an aura of formed visual hallucinations, feeling of familiarity (déjà vu), and impending fear lasting for seconds to a minute followed by eye blinking, oral automatisms, and unresponsiveness for almost 15 minutes. These episodes, most often, were provoked by music. Video electroencephalogram (EEG) done in our institute was suggestive of reflex musicogenic epilepsy arising from the left anterior temporal lobe. Magnetic resonance imaging of the brain 3T with epilepsy protocol confirmed video EEG findings, with an abnormal signal intensity in the left hippocampal and mesial temporal lobe. Treatment included lifestyle modification and antiepileptic drugs.

Acute withdrawal of new-generation antiepileptic drugs in epilepsy monitoring units: Safety and efficacy

IntroductionAcute withdrawal of antiepileptic drugs (AEDs) is a safe and effective approach to provoking seizures in order to complete video-electroencephalogram (V-EEG) studies in a timely manner. Previous studies have focused only on withdrawal from conventional AEDs, and the effects of withdrawal from new-generation AEDs have not been extensively studied. Materials and MethodsThis study examined adult patients with drug-resistant epilepsy admitted to an epilepsy monitoring unit between 2015 and 2018. Patients were classified according to whether they received conventional AEDs (Con; n = 13) or new-generation AEDs (N-Gen; n = 26). We then compared the effects of withdrawing these two types of AEDs over a period of one week in terms of efficacy (time to complete V-EEG monitoring) and safety, including the incidence of cluster seizures (CS), focal to bilateral tonic-clonic seizures (FBTCS) and status epilepticus (SE). ResultsIn both groups, approximately one week was required to complete V-EEG analysis: N-Gen group (5.6 days) and Con group (6.3 days). No differences were observed between the two groups in terms of the median number of seizures, the onset of the 1st seizure, the distribution of CS, FBTCS, or SE. Following acute withdrawal of medication, a high percentage of patients with a history of CS or FBTCS, respectively, presented CS or FBTCS. ConclusionsWe did not observe significant differences between patients taking new-generation AEDs and those taking conventional AEDs following withdrawal during V-EEG recording. In the current study, we employed a standard protocol for the rapid withdrawal of AEDs (daily dose reduction of 50%), which was sufficient for 80% of patients to complete V-EEG monitoring within one week.

Shuddering attacks in children: A retrospective analysis of 19 cases from a single-center in Turkey

BackgroundShuddering attacks (SA) are one of the most common childhood paroxysmal nonepileptic events (PNEs). These attacks usually start between the first 4th and 6th months of life with rapid tremors of the head and adduction of the arms and knees. A number of factors including eating, breastfeeding, and playing stimulating games have been shown to trigger the attacks; however, the exact pathogenesis remains unknown. It has been stated that there is no need for further research in patients diagnosed, and spontaneous regression is expected. PurposeThis study aimed to identify the causes, accompanying clinical conditions, possible differential diagnosis of SA, and the role of video-electroencephalogram (V-EEG) recording for accurate diagnosis. MethodsNineteen cases with SA have been collected from the database of Erciyes University Pediatric Neurology Clinic, where 52.6% are boys (n = 10) and 47.6% are girls (n = 9). The relationship between the onset and disappearance of SA symptoms and variables including family history, birth history, age, sleep, teething during SA, video-EEG recordings, brain imaging, and accompanying conditions such as epilepsy have been investigated by retrospective analysis. ResultsFour cases were found to have gastroesophageal reflux, one had epilepsy, and one had Marcus Gunn Jaw Winking Syndrome. No accompanying conditions could be identified for rest of the cases. It was observed that onset of symptoms in 15 (78.9%) of 19 cases coincided remarkably with the period of teething. ConclusionWe speculate that there might be an indirect link between SA and teething and teething may be a triggering or an aggravating factor for SA.

Correlation of electroencephalogram background evolution with the degree of brain injury in neonates with hypoxic-ischemic encephalopathy.

To study the correlation of electroencephalogram (EEG) background evolution with the degree of brain injury in neonates with hypoxic-ischemic encephalopathy (HIE). A retrospective analysis was performed for 56 neonates with HIE who underwent continuous video electroencephalogram (cVEEG) and brain magnetic resonance imaging (MRI) examinations. According to clinical symptoms, they were divided into a mild group with 3 neonates, a moderate group with 36 neonates, and a severe group with 17 neonates. EEG background grading and MRI score were determined for each group to analyze the correlation of EEG background evolution with the degree of brain injury. Compared with the moderate group, the severe group had significantly lower gestational age and Apgar score at 5 minutes after birth, a significantly higher resuscitation score, significantly lower base excess in umbilical cord blood or blood gas within 1 hour, a significantly higher proportion of neonates on mechanical ventilation, and a significantly higher incidence rate of short-term adverse outcomes (P<0.05). For the neonates in the mild and moderate groups, MRI mainly showed no brain injury (67%, 2/3) and watershed injury (67%, 16/24) respectively, and EEG showed mild abnormality in 62% (13/21) of the neonates on the 3rd day after birth. For the neonates in the severe group, MRI mainly showed basal ganglia/thalamus + brainstem injury (24%, 4/17) and whole brain injury (71%, 12/17), and EEG showed moderate or severe abnormalities on the 3rd day after birth. EEG background grading was correlated with clinical grading, MRI score, and short-term outcome on days 1, 2, 3 and 7-14 after birth (P<0.01). The highest correlation coefficient between EEG grading and MRI score was observed on the 3rd day after birth (rs=0.751, P<0.001), and the highest correlation coefficients between EEG grading and clinical grading (rs=0.592, P=0.002) and between EEG grading and short-term outcome (rs=0.737, P<0.001) were observed 7-14 days after birth. Among the neonates with severe abnormal EEG, the neonates without brain electrical activity had the highest MRI score, followed by those with status epileptics and persistent low voltage (P<0.05). There is a good correlation between EEG background grading and degree of brain injury in neonates with HIE, which can help to evaluate the degree and prognosis of brain injury in the early stage.

Video electroencephalogram combined with electromyography in the diagnosis of hyperkinetic movement disorders with an unknown cause.

Diagnosis of hyperkinetic movement disorders with an unknown cause is usually challenging. The objective of this study is to learn about video electroencephalogram (VEEG) combined with electromyography (EMG) in the diagnosis of hyperkinetic movement disorders with an unknown cause. We performed an observational cohort study by recruiting consecutive patients with hyperkinetic movements as the main manifestation with an unknown cause for VEEG combined with EMG evaluations. A total of 77 consecutive patients were enrolled for VEEG-EMG examination. Among them, 57 patients changed their diagnosis after VEEG-EMG assessment, with a mean final diagnosis age of 35.4 ± 20.3years (range, 4-74years). The mean duration between initial and final diagnosis was 54.8 ± 71.3months (range 0.5-300months). The most common misdiagnosed hyperkinetic movement disorders were myoclonus (40.4%), followed by tremors (24.6%), dystonia (15.8%), psychogenic movement disorders (10.5%), and periodic leg movement syndrome (PLMS) (7.0%). Outcomes of therapy were significantly improved after VEEG-EMG examination (p = 0.000). Simultaneous VEEG and EMG are important in the diagnosis of hyperkinetic movement disorders with an unknown cause.

Identification of a novel GRIN2D variant in a neonate with intractable epileptic encephalopathy-a case report

BackgroundN-methyl-D-aspartate (NMDA) receptors are ligand-gated ion channels that mediate excitatory synaptic transmission in the central nervous system. The functional NMDA receptors are heterotetramers consisting mainly of two GluN1 and two GluN2 subunits. GluN2 is encoded by the GRIN2D gene. A few case series have shown that GRIN2D variants are linked to developmental and epileptic encephalopathy. In this article, we report a novel GRIN2D variant, namely c.2021C > A (p.T674K) in a neonate with intractable epileptic encephalopathy.Case presentationA 12-day-old boy who had stiffness of the lower and upper extremities since birth was transferred from a local hospital to our department. On admission, the patient presented with head tilting backwards, staring, apnea and hypertonia of limbs. Video electroencephalogram showed continuous, generalized or multi-focal spike-wave and spike-and-slow wave discharges and hypsarrhythmia. A treatment regimen composed of phenobarbital, midazolam, levetiracetam and clonazepam was administered, which however led to only partial control of the seizure. Whole-exome sequencing identified c.2021C > A (p.T674K) in GRIN2D in the patient while such a mutation was not detected in the parents. The patient was hospitalized for 1 month and died of sudden cardio-respiratory arrest 2 weeks after discharge.ConclusionsA novel variant of GRIN2D was identified in a neonate with epileptic encephalopathy. Epilepsy associated with this GRIN2D mutation is refractory to conventional anti-epileptic medications.

A Young Child with Subacute Onset of Behavioral Changes.

1. Sarah Pradhan, MD* 2. Jessica Goldstein, MD† 3. Erin Frank, MD* 4. Allayne Stephans, MD* 1. *Department of Pediatric Hospital Medicine, 2. †Department of Pediatric Neurology, Rainbow Babies and Children’s Hospital, Cleveland, OH 1. Address Correspondence to Sarah Pradhan, MD; E-mail: sarah.pradhan6{at}gmail.com A 5-year-old healthy boy presents with a 3-week history of new onset aggression, obsessive-compulsive behavior, and nocturnal enuresis. One month ago he sustained a minor head trauma when he was sliding down the slide at a local playground. He was initially diagnosed with a mild concussion. His symptoms have now progressed and include frequent night waking, hand wringing, and behavioral outbursts. This prompts his pediatrician to refer him to the emergency department for evaluation. He undergoes computed tomography scan of the head, which is unremarkable. Laboratory evaluations include electrolytes, liver enzymes, complete blood cell count, rapid group A streptococcal antigen, thyroids studies, and heterophile antibody test, which are unremarkable. Urine and blood toxicology screens are negative. He is admitted to the inpatient unit. Vital signs are appropriate for age. He has difficulty answering questions and following commands. He is restless and disoriented. He intermittently gets up to run around the room and occasionally bangs his head on the wall. His cranial nerve, motor, reflexes, sensory, coordination, and gait examinations are normal. Brain magnetic resonance imaging is unremarkable. On video electroencephalogram he has bilateral fronto-temporal spikes that correspond with his abnormal movements and subclinical seizures arising from the right and left frontotemporal areas independently (arrows in Fig 1). Fosphenytoin is started, which controls his seizures, but he continues to have abnormal behavioral outbursts. Over the course of the week, he develops dysarthria, oral-facial …

Automatic Detection of Epileptic Seizures in Neonatal Intensive Care Units Through EEG, ECG and Video Recordings: A Survey

In Neonatal Intensive Care Units (NICUs), the early detection of neonatal seizures is of utmost importance for a timely, effective and efficient clinical intervention. The continuous video electroencephalogram (v-EEG) is the gold standard for monitoring neonatal seizures, but it requires specialized equipment and expert staff available 24/24h. The purpose of this study is to present an overview of the main Neonatal Seizure Detection (NSD) systems developed during the last ten years that implement Artificial Intelligence techniques to detect and report the temporal occurrence of neonatal seizures. Expert systems based on the analysis of EEG, ECG and video recordings are investigated, and their usefulness as support tools for the medical staff in detecting and diagnosing neonatal seizures in NICUs is evaluated. EEG-based NSD systems show better performance than systems based on other signals. Recently ECG analysis, particularly the related HRV analysis, seems to be a promising marker of brain damage. Moreover, video analysis could be helpful to identify inconspicuous but pathological movements. This study highlights possible future developments of the NSD systems: a multimodal approach that exploits and combines the results of the EEG, ECG and video approaches and a system able to automatically characterize etiologies might provide additional support to clinicians in seizures diagnosis.