Ictal Coprolalia: Three Cases with Nondominat Frontal Lobe Involvement and Review of the Literature.

Objective: Coprolalia is defined as the involuntary use of obscene, socially unacceptable, and derogatory words. Ictal coprolalia is a rare presentation of epilepsy. This study aimed to determine the localizing and lateralizing value and frequency of ictal coprolalia in epilepsy patients. Methods: Medical files, discharge summaries, and electroencephalography (EEG) reports of 2238 patients were reviewed retrospectively. We identified patients who suffered from ictal coprolalia. Electroencephalography reports, neuroimaging [brain magnetic resonance imaging (MRI), fluorodeoxyglucose positron emission tomography (FDG-PET), single-photon emission computerized tomography (SPECT)] records, F-18 FDG fused on MRI images, and ictal SPECT fused on MRI images were evaluated. Also, original and review articles were identified through a systematic search of Pubmed, Scopus, and Clarivate Analytics. Results: Ictal coprolalia was detected in 3 male (0.15%) patients. In all patients, ictal semiology was extratemporal-frontal type, and potential/proven epileptic focus was non-dominant hemisphere frontal lobe. Topectomy was done in one of the patients, including the suspected dysplastic area plus the area where the electroencephalographic ictal and interictal changes occur, on the left frontal lobe, and the patient had an Engel's classification class IIA. The data depending on the published cases showed that ictal coprolalia was dominant in the male gender and the responsible epileptic area tended to be located in the non-dominant hemisphere frontotemporal region. Conclusion: The rate of ictal coprolalia in the Turkish population is lower compared to other series. Our results are consistent with previous studies in which reported that male preponderance for ictal coprolalia and involvement of non-dominant frontal lobe.

Ictal Asystole During Focal Seizures Due to Left Occipital Glioneuronal Tumor: A Report of Case Treated With Cardiac Neuromodulation.

Ictal asystole (IA) is a rare but potentially life-threatening complication of focal epilepsy. The sudden onset of loss of consciousness and drop attacks in a patient with chronic epilepsy should suggest the possibility of this complication. Once the diagnosis is established, rapid management should be considered, especially in high-risk cases. The approach does not differ between temporal and extratemporal lobe epilepsies. Strategies can be aimed at preventing the emergence of cortical epileptic activity from the beginning (surgery, antiseizure therapy), neutralizing negative chronotropic effects on the heart (cardiac neuromodulation), or restarting the heart rhythm with a pacemaker. Pacemaker implantation is not a completely complication-free treatment, and living with a device that requires care and follow-up throughout life makes alternative treatment methods more valid for young patients with many years to live or cases that could benefit from surgery. In this article, we present a patient with a left occipital glioneuronal tumor and drug-resistant occipital lobe epilepsy. IA was documented by long-term video EEG monitoring (VEM). During about 2 years of follow-up after a cardiac neuromodulation procedure, there were no drop attacks or asystole with seizures, confirmed by long-term VEM.

Ictal crying in epileptic seizures and psychogenic nonepileptic seizures: What are the hints to differentiate them?

OBJECTIVES: Ictal crying (IC) is a quite rare semiological manifestation of epileptic seizures (ESs) and it has been mostly reported in psychogenic nonepileptic seizures (PNESs). However, labeling IC as a pathognomonic sign of PNES can be harmful. We first aimed to investigate IC frequency in ES and PNES and highlight the differences of IC between ES and PNES. Secondly, we aimed to analyze etiology, detailed semiology, treatment options, and outcome of patients with IC in ES in more detail. METHODS: We retrospectively screened all video-EEG monitoring unit reports from Hacettepe University Hospitals' Epilepsy Center over a 20-year period (1996-2017) for the diagnosis of IC. We included the patients with IC who had at least one documented seizure. Patients who had IC with both facial expression and vocalization compatible with crying with or without weeping and subjective feeling of sadness, were included in the study. We classified patients with IC as ES and PNES. Demographic, historical, clinical, neuroimaging, electrophysiological parameters, video-EEG data, treatment options, and prognosis of all patients were recorded. Demographic, clinical, and video-EEG data were compared between ES and PNES. RESULTS: During the study period, 1983 patients were investigated. Six patients (all female) with ES and 37 patients (33 female) with PNES were identified. When we compared patients with PNES and ES with IC, the number of ASMs taken and duration of disease were significantly higher in patients with ES than PNES. Longer duration of seizure, longer duration of crying component, late onset of crying component in seizure, early responsiveness after seizure, not occurring during sleep, accompanied by eye closure and weeping, were found significantly higher in patients with PNES. Besides, if we analyze ES group in more detail, all had medical treatment refractory focal epilepsy and two of them whose IC was seen as an early semiological manifestation of their seizures had good outcome after nondominant anterior temporal lobectomy (ATL)+amygdalohippocampectomy (AH). However, three patients had various cortical lesions apart from temporal lobe on MRI and one patient had focal epilepsy with frontal lobe semiology with negative MRI. CONCLUSION: Although the most common etiology for IC is PNES and it is rarely seen in ES, it can be harmful to label ictal crying as a pathognomonic sign for PNES. We proposed that there are some semiological differences in terms of IC between PNES and ES. These differences may help to distinguish IC in PNES and ES in daily practice. Moreover, it can be speculated that nondominant temporal lobe involvement may be associated with IC in ES.

Birth outcomes in pregnant women with epilepsy: A Nationwide multicenter study from Türkiye.

OBJECTIVE: The present study was aimed at investigating the effects of anti-seizure medications (ASMs), patient demographic characteristics, and the seizure type and frequency on the development of congenital malformations (CMs) in the infants of pregnant women with epilepsy (PWWE). METHODS: PWWE followed up at the neurology outpatient clinic of 21 centers between 2014 and 2019 were included in this prospective study. The follow-up of PWWE was conducted using structured, general pregnant follow-up forms prepared by the Pregnancy and Epilepsy Study Committee. The newborns were examined by a neonatologist after delivery and at 1 and 3 months postpartum. RESULTS: Of the infants of 759 PWWE, 7.2% had CMs, with 5.6% having major CMs. Polytherapy, monotherapy, and no medications were received by 168 (22.1%), 548 (72.2 %), and 43 (5.7 %) patients, respectively. CMs were detected at an incidence of 2.3% in infants of PWWE who did not receive medication, 5.7% in infants of PWWE who received monotherapy, and 13.7% in infants of PWWE who received polytherapy. The risk of malformation was 2.31-fold (95% confidence interval (CI): 1.48-4.61, p < .001) higher in infants of PWWE who received polytherapy. Levetiracetam was the most frequently used seizure medication as monotherapy, with the highest incidence of CMs occurring with valproic acid (VPA) use (8.5%) and the lowest with lamotrigine use (2.1%). The incidence of CMs was 5% at a carbamazepine dose <700 mg, 10% at a carbamazepine dose ≥700 mg, 5.5% at a VPA dose <750 mg, and 14.8% at a VPA dose ≥750 mg. Thus the risk of malformation increased 2.33 times (p = .041) in infants of PWWE receiving high-dose ASMs. SIGNIFICANCE: Birth outcomes of PWWE receiving and not receiving ASMs were evaluated. The risk of CMs occurrence was higher, particularly in infants of PWWE using VPA and receiving polytherapy. The incidence of CMs was found to be lower in infants of PWWE receiving lamotrigine.

Subclinical seizures: The demographic data and scalp video-EEG findings, concordance with the epilepsy type and prognosis.

BACKGROUND: Subclinical seizures(SCSs) are overlooked in clinical practice. This study aims to investigate clinical, electrophysiological features of SCSs detected during video-electroencephalography(EEG) monitorization(VEM), concordance of the epilepsy type and SCSs, and predictors of the concordance. METHODS: The data of drug-resistant epilepsy patients who had undergone video-EEG between 2010 and 2020 were investigated. Ictal activities showing temporospatial evolution lasted ≥ 10 s, without any behavioural changes were considered SCSs. Findings were re-evaluated for ictal localization, lateralization, ictal discharge type, vigilance status, and duration of SCSs to the accompaniment of clinical findings. Additionally, the concordance of epilepsy type and SCSs were analyzed. RESULTS: Fifty-five SCSs were obtained in 24 of 804 patients (2,9 %) who were followed in the VEM unit; the epilepsy type of the patients was temporal in 26 and extratemporal lobe epilepsy in 29 SCSs. Among 55 SCSs recordings, 30 originated from the temporal lobe and 24 from the extratemporal lobe, and seizure localization could not be determined in one. The patients were younger, age at seizure onset was earlier, habitual seizures were more frequent, multiple anti-seizure drug use was higher, seizures more frequently occurred during sleep, cranial MR tended to be abnormal, patients were more likely to have a history of perinatal injury/head trauma, and the concordance of discharge patterns was lower in extratemporal SCSs.The concordance of epilepsy type with localization and lateralization of SCSs was not statistically significant. CONCLUSIONS: SCSs originating from the temporal and extratemporal lobes might show similar characteristics with the epilepsy type, and SCSs might have clinical importance apart from epilepsy surgery.

Electroclinical Presentations of Fixation-off Sensitivity in Adults With Symptomatic Epilepsy.

PURPOSE: Fixation-off sensitivity (FOS) is a discharge pattern on EEG that occurs owing to the loss of central vision or fixation. Knowledge regarding the relationship between FOS and symptomatic epilepsy is limited. Therefore, we aimed to evaluate the electroclinical features of FOS in adult patients with symptomatic epilepsy. METHODS: Outpatient video-EEG records of the Hacettepe University Faculty of Medicine were reviewed from 2009 to 2019. Patients aged >18 years with symptomatic epilepsy with a FOS pattern were included. Demographic, clinical, EEG, and neuroimaging data were retrospectively evaluated from an electronic database and patient files. RESULTS: Eight patients (50% female) were included in this study; seven (87%) had refractory epilepsy. Prominent risk factors were family history of epilepsy in five patients and prenatal/natal insult in four patients. Notable MRI signs included cortical developmental malformation, posterior gliosis, and frontoparietal porencephalic cyst. The FOS pattern was generalized with posterior emphasis in two patients and lateralized or localized in six patients: frontocentroparietal ( n = 1) and temporoparietooccipital ( n = 5). Fixation-off sensitivity discharges were found to be increased by hyperventilation and decreased by drowsiness and sleep in 50% of patients. Fixation-off sensitivity disappeared in one patient with good seizure control. CONCLUSIONS: In this study, the disappearance of FOS in an epileptic patient with a structural lesion and detection of FOS activity related to a frontoparietal porencephalic cyst were remarkable. Family history of epilepsy was also substantially high. Our results indicate that the underlying mechanism of FOS is much more complicated than previously thought.

Sleep disorders and polysomnography findings in patients with autoimmune encephalitis.

BACKGROUND: Sleep disorders in patients with autoimmune encephalitis (AE) are increasingly reported. Early recognition and treatment have significant importance regarding the potential of sleep disorders' effect on morbidity and even mortality. There are a limited number of studies related to polysomnography (PSG) in these patients. Here, we report the clinical and PSG data of patients with AE and sleep disorders, with a particular interest in sleep-related breathing disorders (SRBD). METHODS: Seventeen patients with diagnosed AE and acute or subacute onset sleep complaints who underwent video-electroencephalography-PSG recordings in our tertiary center were investigated. RESULTS: The mean age was 50, with eight females and nine males. The detected antibodies were against leucine-rich glioma-inactivated 1(LGI-1) in 6, anti-contactin-associated protein-2(CASPR2) in 3, voltage-gated potassium channel complex antigens(VGKC) in 1, anti-glycine in 1, dipeptidyl-peptidase-like protein-6(DPPX) in 1, anti-Hu in 1, and anti-amphiphysin in 1. All commercially available and known autoimmune encephalitis-related antibodies were negative in 3 of the patients. Final diagnosis after PSG was circadian rhythm sleep disorder (n = 3), periodic limb movement disorder (n = 3), insomnia (n = 5), central apnea with or without Cheyne-Stokes breathing (CSB) (n = 4), obstructive sleep apnea (OSA) (n = 4), non-rapid eye movement (NREM) and REM parasomnia (n = 8), faciobrachial dystonic seizures (n = 2), and subclinical seizures (n = 1). Sleep microstructure was disrupted in 9, REM periods without atonia occurred in 4, and brief sleep fragments consisting of theta activity interspersed with faster rhythms existed in 7 patients. Nearly half of our patients (47%) had SRBD, and the mean apnea-hypopnea index (AHI) was 14. CONCLUSIONS: Sleep disorders are frequent and essential components of AEs. Systematic clinical questionnaires and routine PSG assessments would significantly impact the correct diagnosis and proper treatment of SRBD and the overall prognosis of AE.

Changes of oxygen saturation in patients with pure temporal lobe epilepsy.

PURPOSE: Ictal hypoxemia is accepted as one of the mechanisms underlying sudden unexpected death in epilepsy (SUDEP). Although ictal hypoxemia is more common in generalized seizures, it also occurs in focal seizures with or without generalization. In this study, we aimed to show the relationship between clinical and electroencephalographic findings of seizures in patients with temporal lobe epilepsy (TLE) with periictal oxygen saturation. METHODS: The data of 55 adult patients who were hospitalized in the Video EEG Monitoring Unit (VEMU) and operated on for drug-resistant TLE between January 2017 and December 2020 were examined. Forty-five seizures from 21 patients with ictal peripheral arterial saturation information and that were seizure-free for at least a year during the follow-up were included in the study. RESULTS: The median patient age was 28 (IQR 25-39.5) years (women: 9, men: 12). Age at epilepsy onset was negatively correlated with saturation at seizure onset. Moreover, the age at VEMU admission was also negatively correlated with saturation at seizure onset and the lowest levels of saturation. The saturation at the end of the seizures and the lowest saturation measured in the periictal period with generalization of EEG were significantly lower than those without generalization. The onset of ictal EEG with the rhythmic theta pattern was significantly associated with the lowest level of saturation (<90%), postictal generalized electroencephalographic suppression (PGES), and the presence of generalization. CONCLUSION: According to the study, rhythmic ictal theta activity, older age, nocturnal seizure, and generalization in ictal EEG might increase the potential risk of SUDEP. Further studies including a greater number of subjects and different epilepsy syndromes may provide more comprehensive information about potential biomarkers for SUDEP.

Relation between orexin A and epileptic seizures.

INTRODUCTION: One of the unknown mechanisms in epilepsy pathogenesis is the involvement of the hypothalamic neuropeptide orexin. Although the relationship between orexin and sleep has been revealed, its effect in epilepsy has not been fully clarified. In this study, we aimed to show the relationship between orexin A and the seizures that occur during sleep and wakefulness. MATERIAL AND METHODS: This study included 40 patients with drug-resistant focal epilepsy and 37 healthy controls. Night basal orexin (NBO) and morning basal orexin (MBO) levels were measured using enzyme-linked immunosorbent assay in patients and controls. Serum samples were collected from patients after epileptic seizures during sleep and wakefulness. RESULTS: In both patients and controls, MBO levels (median: 1039 pg/mL, interquartile ranges [IQR] (899-1078)) were higher than NBO levels (median 989 pq/mL, IQR (893-1078) (p = 0.02). Basal orexin levels were lower in patients than in controls (p < 0.001). However, while the duration of seizures was shortened in awake seizures, the level of orexin increased (p = 0.007). Additionally, orexin levels after nocturnal seizure were higher in patients who had an ictal electroencephalography onset in the left hemisphere or a lesion in the left temporal lobe (p = 0.02; p = 0.01, respectively). There was no relationship between postictal somnolence and orexin levels. Although there was no significant difference, the level of post-seizure orexin increased compared to the basal values, especially in seizures during sleep. DISCUSSION: The increase in serum orexin levels, especially after seizures, suggests that orexin may be associated with the epileptogenic effect. In further studies, determination of orexin from cerebrospinal fluid (CSF) and correlation of CSF and serum orexin levels may provide more useful information regarding the relationship between orexin and epilepsy.

Headache in idiopathic/genetic epilepsy: Cluster analysis in a large cohort.

OBJECTIVE: The link between headache and epilepsy is more prominent in patients with idiopathic/genetic epilepsy (I/GE). We aimed to investigate the prevalence of headache and to cluster patients with regard to their headache and epilepsy features. METHODS: Patients aged 6-40 years, with a definite diagnosis of I/GE, were consecutively enrolled. The patients were interviewed using standardized epilepsy and headache questionnaires, and their headache characteristics were investigated by experts in headache. Demographic and clinical variables were analyzed, and patients were clustered according to their epilepsy and headache characteristics using an unsupervised K-means algorithm. RESULTS: Among 809 patients, 508 (62.8%) reported having any type of headache; 87.4% had interictal headache, and 41.2% had migraine. Cluster analysis revealed two distinct groups for both adults and children/adolescents. In adults, subjects having a family history of headache, ≥5 headache attacks, duration of headache ≥ 24 months, headaches lasting ≥1 h, and visual analog scale scores > 5 were grouped in one cluster, and subjects with juvenile myoclonic epilepsy (JME), myoclonic seizures, and generalized tonic-clonic seizures (GTCS) were clustered in this group (Cluster 1). Self-limited epilepsy with centrotemporal spikes and epilepsy with GTCS alone were clustered in Cluster 2 with the opposite characteristics. For children/adolescents, the same features as in adult Cluster 1 were clustered in a separate group, except for the presence of JME syndrome and GTCS alone as a seizure type. Focal seizures were clustered in another group with the opposite characteristics. In the entire group, the model revealed an additional cluster, including patients with the syndrome of GTCS alone (50.51%), with ≥5 attacks, headache lasting >4 h, and throbbing headache; 65.66% of patients had a family history of headache in this third cluster (n = 99). SIGNIFICANCE: Patients with I/GE can be clustered into distinct groups according to headache features along with seizures. Our findings may help in management and planning for future studies.

Electroclinical spectrum of generalized paroxysmal fast activity in adults without epileptic encephalopathy.

INTRODUCTION: Generalized paroxysmal fast activity (GPFA) is a rare and underreported EEG pattern known to be related to epileptic encephalopathy. We aimed to investigate the electroclinical spectrum of GPFA along with other atypical EEG features in patients without epileptic encephalopathy in routine EEG practice. METHODS: Outpatient EEG records of Hacettepe University Hospital were retrospectively reviewed between 2010 and 2020. Patients ≥ 18 years old with GPFA without epileptic encephalopathy were included. Electroclinical features of GPFA were analyzed. Atypical EEG features, epileptiform K-complexes and sleep spindles, and generalized polyspike train (GPT) were also investigated in this cohort. RESULTS: Most of the 19 included patients had refractory epilepsy (68%), while 16% were seizure-free. Generalized epilepsy (GE) was present in 58% of patients, and the rest had structural-focal epilepsy (26%), combined generalized and focal epilepsy (11%), or childhood occipital epilepsy (COE) (5%). Atypical EEG features with full atypical morphology were found in 91% of patients with GE. All patients with GPFA provoked by sleep had epileptiform K-complexes. The presence of GPT was not different between the GE and non-GE groups and was higher in patients with GPFA occurring only during sleep (p = 0.017). In two patients, GPFA frequency increased postictally. A transition from fixation-off sensitivity to GPFA occurred in a patient with COE. CONCLUSION: In this study, GPFA had a wide diagnostic range from focal to generalized epilepsy. The association of GPFA with other electroclinical features was of importance mostly for sleep outcomes; this finding might lead to a better understanding of epileptogenesis.

Reduced myelin in patients with isolated hippocampal sclerosis as assessed by SyMRI.

PURPOSE: Synthetic MRI (SyMRI) enables to quantify brain tissue and morphometry. We aimed to investigate the WM and myelin alterations in patients with unilateral hippocampal sclerosis (HS) with SyMRI. METHODS: Adult patients with isolated unilateral HS and age-matched control subjects (CSs) were included in this study. The SyMRI sequence QRAPMASTER in the coronal plane perpendicular to the hippocampi was obtained from the whole brain. Automatic segmentation of the whole brain was processed by SyMRI Diagnostic software (Version 11.2). Two neuroradiologists also performed quantitative analyses independently from symmetrical 14 ROIs placed in temporal and extratemporal WM, hippocampi, and amygdalae in both hemispheres. RESULTS: Sixteen patients (F/M = 6/10, mean age = 32.5 ± 11.3 years; right/left HS: 8/8) and 10 CSs (F/M = 5/5, mean age = 30.7 ± 7 years) were included. Left HS patients had significantly lower myelin and WM volumes than CSs (p < .05). Myelin was reduced significantly in the ipsilateral temporal lobe of patients than CSs, greater in left HS (p < .05). Histopathological examination including luxol fast blue stain also revealed myelin pallor in all of 6 patients who were operated. Ipsilateral temporal pole and sub-insular WM had significantly reduced myelin than the corresponding contralateral regions in patients (p < .05). No significant difference was found in WM values. GM values were significantly lower in hippocampi in patients than CSs (p < .05). CONCLUSION: SyMRI revealed myelin reduction in the ipsilateral temporal lobe and sub-insular WM of patients with HS. Whether this finding correlates with electrophysiological features and SyMRI could serve as lateralization of temporal lobe epilepsy need to be investigated.

Cortical connectivity in the face of congenital structural changes-A case of homozygous LAMC3 mutation.

The homozygous LAMC3 gene mutation is associated with severe bilateral smoothening and thickening of the lateral occipital cortex . Despite this and further significant changes in gray matter structure, a patient harboring this mutation exhibited a range of remarkably intact perceptual abilities . One possible explanation of this perceptual sparing could be that the white matter structural integrity and functional connectivity in relevant pathways remained intact. To test this idea, we used diffusion tensor and functional magnetic resonance imaging to investigate functional connectivity in resting-state networks in major structural pathways involved in object perception and visual attention and corresponding microstructural integrity in a patient with homozygous LAMC3 mutation and sex, age, education, and socioeconomically matched healthy control group. White matter microstructural integrity results indicated widespread disruptions in both intra- and interhemispheric structural connections except inferior longitudinal fasciculus. With a few exceptions, the functional connectivity between the patient's adjacent gray matter regions of major white matter tracts of interest was conserved. In addition, functional localizers for face, object, and place areas showed similar results with a representative control, providing an explanation for the patient's intact face, place, and object recognition abilities. To generalize this finding, we also compared functional connectivity between early visual areas and face, place, and object category-selective areas, and we found that the functional connectivity of the patient was not different from the control group. Overall, our results provided complementary information about the effects of LAMC3 gene mutation on the human brain including intact temporo-occipital structural and functional connectivity that are compatible with preserved perceptual abilities.

Temporal encephaloceles can be missed in patients with refractory temporal lobe epilepsy.

Temporal encephaloceles (TEs) are one of the cause of refractory temporal lobe epilepsy (TLE). We reviewed the neuroimaging and video-electroencephalography (EEG) records of epilepsy patients who underwent temporal lobectomy in our center to investigate frequency of TEs. We retrospectively reevaluated 294 patients who underwent epilepsy surgery in our tertiary epilepsy centre between January 2010 and March 2019 and included 159 patients (78 females, 49 %; 81 males) who had temporal lobectomy. Preoperatively, TEs were reported in 3 of 159 patients (1 female, 2 males). After reevaluation 4 more patients with TEs (1 female, 3 males) were added. The ratio of TE in patients who underwent temporal lobectomy increased from 1.8 % (n=3) to 4,4 % (n=7). The median ages were 18 (range 16-22) versus 10 years (range 5-17) at habitual seizure onset and the median of epilepsy duration was 5 (range 3-15) versus 175 (range 11-25) years between patients with and without TE. Habitual seizure onset age was significantly higher (p =, 007) in the patients with encephalocele and epilepsy duration was shorter (p =, 003) than patients without encephalocele. The ictal EEG records of all patients TE rhythmic delta activity which is suggested neocortical temporal lobe onset seizures. 4 of 7 patients' PET imaging showed temporal lobe hypometabolism compatible with ipsilateral to the TEs. The three patients underwent anterior temporal lobectomy without amygdalohippocampectomy and others had anterior temporal lobectomy with amygdalohippocampectomy. We suggested that there might be some clues for temporal encephalocele, an easily overlooked cause in patients with nonlesional temporal lobe epilepsy.TLE patients with TE had relatively late onset of epilepsy and rhythmic delta activity on ictal EEG. Also, temporal hypometabolism on PET may be a useful key to suspicion of TE.

Simultaneous electrocardiogram during routine electroencephalogram: arrhythmia rates through the eyes of the cardiologist.

BACKGROUND: The importance of simultaneous 2-lead electrocardiogram (ECG) recording during routine electroencephalogram (EEG) has been reported several times on clinical grounds. OBJECTIVE: To investigate arrhythmia rates detected by simultaneous 2-lead ECG in our patient sample undergoing routine EEG. Remarkably, we sought to assess the possible expansion of results with a more experienced interpretation of simultaneous ECG. METHODS: Simultaneous 2-lead ECG recordings during routine EEG, performed between January and March, 2016, have been retrospectively analyzed by a cardiology specialist. In addition, EEG reports were screened with the keywords 'arrhythmia, tachycardia, bradycardia, atrial fibrillation, extrasystole' to evaluate the neurologist interpretation. RESULTS: Overall, 478 routine EEG recordings were scanned. The mean age of the patients was 42.8±19.8 (16-95), with a sex ratio of 264/214 (F/M). In 80 (17%) patients, findings compatible with arrhythmia were identified on simultaneous ECG after a cardiologist's evaluation. The detected arrhythmia subtypes were: ventricular extrasystole (n=27; 5.6%), supraventricular extrasystole (n=23; 4.8%), tachycardia (n=9; 1.8%), prolonged QRS duration (n=7; 8.7%), atrial fibrillation (n=6; 1.2%), and block (n=6; 1.2%). On the other hand, keywords related to arrhythmia were present in 45 (9.4%) of EEG reports. The reported statements were tachycardia (3.3%), arrhythmia (2.5%), bradycardia (2.1%), and extrasystole (1.5%). CONCLUSIONS: A considerably high rate of arrhythmia cases was determined on simultaneous ECG during routine EEG after being interpreted by a cardiologist. However, the screening results of EEG reports revealed relatively low arrhythmia rates. These results suggest that the detection rates of ECG abnormalities during routine EEG may be potentially improved.

Simultaneous electrocardiogram during routine electroencephalogram: arrhythmia rates through the eyes of the cardiologist / Eletrocardiograma simultâneo durante eletroencefalograma de rotina: taxas de arritmia pelos olhos do cardiologista

ABSTRACT Background: The importance of simultaneous 2-lead electrocardiogram (ECG) recording during routine electroencephalogram (EEG) has been reported several times on clinical grounds. Objective: To investigate arrhythmia rates detected by simultaneous 2-lead ECG in our patient sample undergoing routine EEG. Remarkably, we sought to assess the possible expansion of results with a more experienced interpretation of simultaneous ECG. Methods: Simultaneous 2-lead ECG recordings during routine EEG, performed between January and March, 2016, have been retrospectively analyzed by a cardiology specialist. In addition, EEG reports were screened with the keywords 'arrhythmia, tachycardia, bradycardia, atrial fibrillation, extrasystole' to evaluate the neurologist interpretation. Results: Overall, 478 routine EEG recordings were scanned. The mean age of the patients was 42.8±19.8 (16-95), with a sex ratio of 264/214 (F/M). In 80 (17%) patients, findings compatible with arrhythmia were identified on simultaneous ECG after a cardiologist's evaluation. The detected arrhythmia subtypes were: ventricular extrasystole (n=27; 5.6%), supraventricular extrasystole (n=23; 4.8%), tachycardia (n=9; 1.8%), prolonged QRS duration (n=7; 8.7%), atrial fibrillation (n=6; 1.2%), and block (n=6; 1.2%). On the other hand, keywords related to arrhythmia were present in 45 (9.4%) of EEG reports. The reported statements were tachycardia (3.3%), arrhythmia (2.5%), bradycardia (2.1%), and extrasystole (1.5%). Conclusions: A considerably high rate of arrhythmia cases was determined on simultaneous ECG during routine EEG after being interpreted by a cardiologist. However, the screening results of EEG reports revealed relatively low arrhythmia rates. These results suggest that the detection rates of ECG abnormalities during routine EEG may be potentially improved.

RESUMO Introdução: A importância do registro simultâneo de eletrocardiograma (ECG) de duas derivações durante o eletroencefalograma (EEG) de rotina foi relatada várias vezes por motivos clínicos. Objetivos: Investigar as taxas de arritmias detectadas em ECG de duas derivações simultâneas em amostra de pacientes submetidos a EEG de rotina, para avaliar impacto nos resultados pela interpretação do ECG simultâneo por examinador experiente. Métodos: Registros simultâneos de ECG de duas derivações durante EEG de rotina realizados entre janeiro e março de 2016 foram analisados retrospectivamente por cardiologista. Adicionalmente, os relatórios de EEG foram selecionados com palavras-chave de 'arritmia, taquicardia, bradicardia, fibrilação atrial, extrassístole', para avaliar a interpretação dos neurologistas. Resultados: 478 registros de EEG de rotina foram digitalizados. A idade média dos pacientes foi de 42,8±19,8 [16-95] anos com uma proporção de sexo de 264/214 (F/M). Em 80 (17%) dos pacientes, achados compatíveis com arritmia no ECG simultâneo foram determinados após avaliação do cardiologista. Os subtipos de arritmia detectados foram extrassístole ventricular (n=27; 5,6%), extrassístole supraventricular (n=23; 4,8%), taquicardia (n=9; 1,8%), duração QRS prolongada (n=7; 8,7%), fibrilação atrial (n=6; 1,2%) e bloqueio (n=6; 1,2%), respectivamente. Por outro lado, palavras-chave relacionadas à arritmia foram citadas em 45 (9,4%) dos relatórios de EEG. As declarações relatadas foram taquicardia (3,3%), arritmia (2,5%), bradicardia (2,1%) e extrassístole (1,5%), respectivamente. Conclusões: Uma taxa consideravelmente alta de casos de arritmia foi determinada em ECG simultâneo durante EEG de rotina, após interpretação por cardiologista. No entanto, triagem dos relatórios de EEG revelaram taxas de arritmia relativamente baixas. Esses resultados sugerem que as taxas de detecção de anormalidades no ECG durante EEG de rotina podem ser melhoradas.

Aphasic status epilepticus in a tertiary referral center in Turkey: Clinical features, etiology, and outcome.

OBJECTIVE: Aphasic status epilepticus (ASE), although rare, may often remain underdiagnosed. We aimed to report the patients diagnosed with ASE and describe their clinical presentation, etiology, electrophysiological findings, neuroimaging, treatment options, and outcome. METHODS: We retrospectively analyzed a series of 28 patients diagnosed with ASE between January 2010 and August 2019 in our tertiary referral center. We reviewed medical files, patient charts, and short- and long-term intermittent electroencephalogram (EEG) recordings. Demographical, historical, clinical, neuroimaging, electrophysiological parameters, administered antiseizure medications, and prognosis of all patients were recorded. Furthermore, EEGs were re-evaluated according to Salzburg criteria. RESULTS: Most patients presented with tumors (n = 11) and cerebrovascular disease (CVD) (n = 11), while the rest were diagnosed with hyperglycemia (n = 2), autoimmune encephalitis (n = 1), remote intracranial abscess (n = 1), mitochondrial encephalomyopathy with lactic acidosis and stroke-like episodes (MELAS) attack (n = 1), or unknown cause (n = 1). Seventy-one percent of patients had prior history of epilepsy. The most common EEG findings were rhythmic delta activity with fluctuation and epileptiform discharges ≤ 2.5 Hz with spatiotemporal evolution (66 %). Magnetic resonance imaging (MRI) and EEG findings indicated dominant hemisphere involvement in all patients. No casualties occurred; 71 % patients exhibited total recovery, while 29 % had mild-moderate sequela aphasia. None of the patients received aggressive treatment for ASE. SIGNIFICANCE: A relatively higher number of ASE patients could be contributed to the literature through this study. ASE should be considered in patients with prolonged unexplained aphasia, especially with pre-existing risk factors, such as prior history of epilepsy, structural lesion, and metabolic disorders accompanied by concordant EEG findings. Although the underlying cause is a determining prognostic factor, this study shows a significant number of patients with complete remission; thus, the prognosis of ASE may be considered more favorable than other types of nonconvulsive status epilepticus.

Long-term effects of vagus nerve stimulation in refractory pediatric epilepsy: A single-center experience.

INTRODUCTION: Vagus nerve stimulation (VNS) has been used as an adjunctive therapy for both children and adults with refractory epilepsy, over the last two decades. In this study, we aimed to evaluate the long-term effects and tolerability of VNS in the pediatric drug-resistant epilepsy (DRE) and to identify the predictive factors for responsiveness to VNS. METHODS: We retrospectively reviewed the medical records of pediatric patients who underwent VNS implantation between 1997 and 2018. Patients with ≥50% reduction of seizure frequency compared with the baseline were defined as "responders". The clinical characteristics of responders and nonresponders were compared. RESULTS: A total of 58 children (male/female: 40/18) with a mean follow-up duration of 5.7 years (3 months to 20 years) were included. The mean age at implantation was 12.4 years (4.5 to 18.5 years). Approximately half (45%) of our patients were responders, including 3 patients (5.8%) who achieved seizure freedom during follow-up. The age of seizure-onset, duration of epilepsy, age at implantation, and etiologies of epilepsy showed no significant difference between responders and nonresponders. Responders were more likely to have focal or multifocal epileptiform discharges (63%) on interictal electroencephalogram (EEG), when compared to nonresponders (36%) (p = .07). Vocal disturbances and paresthesias were the most common side effects, and in two patients, VNS was removed because of local reaction. CONCLUSION: Our series had a diverse etiological profile and patients with transition to adult care. Long-term follow-up showed that VNS is an effective and well-tolerated treatment modality for refractory childhood onset epilepsy. Age at implantation, duration of epilepsy and underlying etiology are not found to be predictors of responsiveness to VNS. Higher response rates were observed for a subset of patients with focal epileptiform discharges.