Video game-related seizures: a report on 10 patients and a review of the literature.

OBJECTIVE: To further describe the features, postulated pathophysiology, treatment, and outcome of seizures occurring while playing or watching video games (video game-related seizures (VGRS)). DESIGN: We evaluated retrospectively 10 patients with VGRS seen by us and reviewed 25 reported cases. RESULTS: The 35 patients ranged in age from 1 to 36 years (mean: 13.2); and 26 subjects (74%) were male. Eight individuals (29%) had prior infrequent nonfebrile seizures, 4 (11%) had febrile convulsions, and 2 (6%) had a family history of epilepsy. VGRS consisted of generalized tonic-clonic seizures in 22 of 35 individuals (63%); absences in 2 (6%); simple partial seizures in 6 (19%); complex partial seizures in 4 (11%); and other manifestations in 4. Neurologic examination and computed tomographic and magnetic resonance imaging scans were normal. Electroencephalograms demonstrated generalized or focal, interictal or ictal epileptic patterns in 11 of 21 patients (52%) and photoparoxysmal responses in 17 of 32 (53%). Eleven of 15 individuals (73%) treated with video game (VG) abstinence alone, 3 of 6 who received anticonvulsants but played VGs, and 7 of 12 treated with combined VG abstinence and anticonvulsants had no further seizures. CONCLUSIONS: We postulate that a special convulsive susceptibility of selected neurons in striate, peristriate, infratemporal, and posterior parietal cortices to particular visual stimuli plays a major role in VGRS. VG abstinence is the treatment of choice of VGRS. Anticonvulsant medication is suggested only for those individuals who continue to play VGs or suffer from seizures triggered by other, unavoidable visual stimuli, or from unprovoked attacks.

X-linked adrenoleukodystrophy: adult cerebral variant.

We report a unique case of a 43-year-old architect with adult-onset adrenoleukodystrophy who presented primarily with intellectual decline and no evidence of adrenal insufficiency. Serial MRIs taken over a number of months demonstrated the evolution of demyelination starting in the frontal white matter then shifting to the occipital white matter and finally resolving without any therapeutic intervention. Clinically, over this same period of time, the patient's symptoms resolved and he was able to return to work. The proband, his brother, and his nephew were found to have a color-vision defect. Each of these individuals had a red/green gene array that contained a 5' green-red 3' hybrid known to be associated with deutan color-vision defects. The proband's brother and nephew were otherwise normal. The gene that causes adrenoleukodystrophy appears not to be as close to the red/green color vision gene array on the X chromosome as previously reported.

Antidepressants and convulsions.

We reviewed available computer records and clinical charts in an estimated 42,000 recipients of antidepressant drugs. The study was restricted to persons with no known condition predisposing to convulsions. Only 16 study subjects developed a convulsive disorder that we judged could have been caused by an antidepressant. We conclude that the frequency of convulsions caused by these drugs used at usual prescribed doses in the settings studied is substantially less than one per 1,000 recipients who have no conditions predisposing to convulsions.

Neurologic events following diphtheria-tetanus-pertussis immunization.

The frequency of serious neurologic events following the administration of 106,000 doses of diphtheria-tetanus-pertussis vaccine at Group Health Cooperative of Puget Sound was determined using a population-based case-control study with disease ascertainment through pharmacy and hospitalization records. There were no cases of acute unexplained encephalopathies in close temporal relation to vaccination. There was the new onset of one serious seizure disorder in the three days following immunization, with 1.13 expected on the basis of chance alone.

Diphtheria-tetanus-pertussis immunization and sudden infant death syndrome.

We compared the recency of diphtheria-tetanus-pertussis (DTP) immunization in healthy children with birthweights greater than 2500 gms who died of sudden infant death syndrome (SIDS) to that of age-matched reference children, using a modified case-control analysis. Focusing on very narrow time intervals following immunization, we found the SIDS mortality rate in the period zero to three days following DTP to be 7.3 times that in the period beginning 30 days after immunization (95 per cent confidence interval, 1.7 to 31). The mortality rate of non-immunized infants was 6.5 times that of immunized infants of the same age (95 per cent CI, 2.2 to 19). The latter result and to some extent the former appear to be ascribable to known risk factors for SIDS. Although the mortality ratios for SIDS following DTP, as estimated from this study, are high the period of apparently elevated risk was very short, so that only a small proportion of SIDS cases in infants with birthweights greater than 2500 gms could be associated with DTP.

Lymphoma and leukemia manifested by steroid-responsive polyneuropathy.

Subacute polyneuropathy that responded to prednisone was the initial symptom in two patients, one of whom was later found to have histiocytic lymphoma and the other, chronic lymphocytic leukemia. Sural nerve biopsy specimens in both showed extensive segmental demyelination. In the first patient, there was invasion of the myelinated axons by macrophage processes, and the later course of the neuropathy appeared to parallel that of the lymphoma. In the second patient, there was diffuse lymphocytic infiltration of the perineurium and endoneurium, lymphocytes were found beneath the basal lamina, and the demyelination was characterized by extensive vesicular degeneration of the myelin sheath. The demyelination appeared to be cell mediated in the first patient. This was probably the mechanism in the second patient as well, but simple mechanical compression by infiltrating leukemic cells was another possible explanation.

Power spectral analysis of the neonatal primate electroencephalogram during acute hypoxemia.

The effect of acute graded hypoxemia on the electroencephalogram (EEG) of five prematures and five full term Macaca nemestrina in the neonatal period was determined using power spectral analysis--a technique that obviates the limitations of visual inspection. The EEG of selected epochs was analyzed by a Fast Fourier Transform program (POWER) during the 20 min of each trial of hypoxemia and compared with simultaneous arterial oxygen tensions. Levels of hypoxemia were graded as profound (PaO2=15-25 Torr); severe (PaO2=26-35 Torr), moderate (PaO2=36-50 Torr), or mild (PaO2=51-75 Torr). The EEG during normoxemia had a band width of 0.5 to 10 Hz and a peak power at 1-3 Hz. During mild hypoxemia, an increase in power in the delta range (0-3.5 Hz) occurred in the oldest animals. At moderate hypoxemia, the youngest animals showed a depression of absolute power in the delta band. A slowing of the EEG and decrease in power in the theta frequency range (4-8 Hz) followed when severe hypoxemic levels are reached. During profound hypoxemia, all animals at each postnatal age exhibited a significant decrease in EEG power at the delta and theta frequencies (P less than 0.025) except 3-wk-old full term animals in which there was no significant change in the delta band. These results clarify and extend previously reported effects of hypoxemia on the neonatal EEG.

Chronic vitamin A intoxication in infants fed chicken liver.

Twin female infants were fed 120 gm of chicken liver homogenate daily for four months. They developed irritability, vomiting, and bulging anterior fontanelles. Computed tomograms of the brain revealed enlarged ventricles in both infants and dilated subarachnoid spaces in one. Plasma vitamin A concentrations were elevated. After all sources of vitamin A intake were stopped, the infants recovered without sequelae. The chicken liver homogenate contained 36,000 IU of vitamin A per 120 gm. Since infants often receive 4,000 units of vitamin A daily from fortified milk and vitamin supplements, they probably cannot be fed 60 gm of chicken liver safely more often than once weekly.

Neonatal paroxysmal monorhythmic alpha activity.

Thirteen infants with neonatal seizures showed paroxysmal monorhythmic electrographic activity, predominantly in the alpha range (8 to 13 Hz) and localized to the rolandic cortical areas. This rhythmic discharge, which is commonly lateralized, represents an electrical seizure discharge. Such discharges may exist as the only electrographic seizure activity, but in the majority of cases (8/13) independent epileptiform discharges are observed in other cortical areas. All infants with paroxysmal monorhythmic alpha activity had clinically observed seizures. Computerized tomography performed six or more weeks after observing the electrographic abnormality demonstrated diffuse as well as localized cortical atrophy in a distribution similar to the monorhythmic alpha activity. In other cases, localized monorhythmic alpha activity was correlated on subsequent evaluations with focal neurological abnormalities (eg, hemiparesis and hemiatrophy) and a high incidence of microcephaly (83%). On the basis of these findings, we suggest that encephalomalacia may be important in the pathogenesis of paroxysmal monorhythmic alpha seizures in the neonate.

Cerebral responses to electrical tooth pulp stimulation in man. An objective correlate of acute experimental pain.

The pulp of individual teeth of 17 normal adult volunteers was electrically stimulated via pairs of electrodes implanted into dentine. Computer-summated responses recorded from the surface of the head were composed of two concurrent sequences of events, one of which was seen maximally over midline areas and the other over the lower portions of the postcentral regions. Appropriate tests demonstrated that these wave forms represented cerebral tooth pulp-evoked potentials. Because tooth pulp-evoked potentials represent objective, quantifiable, nonverbal concomitants of central events associated with the perception of noxious stimuli, they may prove helpful in investigating acute experimental pain in man.