The duration of successive epileptic seizures is monotonically correlated in neonates.

OBJECTIVE: Prolonged neonatal seizures are often due to severe acute brain injuries and are known to be harmful to the brain. No predictors have yet been identified to distinguish at an early time-point between brief and long seizures. We investigated the duration of seizures in neonates to determine the relationship between the duration of a seizure and that of subsequent seizures. METHODS: We retrospectively reviewed video-electroencephalogram confirmed seizures of 30 preterm and 36 full-term neonates selected from patients admitted to the neonatal intensive care unit of Parma University Hospital. The duration and relationship between successive seizures were investigated. Statistical models were performed to evaluate the risk of long-lasting ictal events among neonates with seizures. RESULTS: A positive monotonic relationship between the duration of successive seizures was identified. Most seizures were brief. No significant differences in seizure duration were found between preterm and full-term neonates, although a borderline significance emerged. CONCLUSION: Neonatal seizures are usually brief, and as the seizure duration increases, the duration of the subsequent seizures tends to increase. We also suggest that full-term neonates could be at higher risk of experiencing long seizures compared to preterm neonates. In summary, estimating the seizure duration is critical to evaluating the optimal timing of therapeutic interventions and can help to predict how seizures evolve.

Atypical duration of epileptic and psychogenic nonepileptic events.

OBJECTIVES: We aimed to estimate the frequency of epileptic seizures (ES) and psychogenic nonepileptic seizures (PNES) with atypical duration in our epilepsy monitoring unit (EMU), in order to raise awareness of atypical durations of both types of events. MATERIALS & METHODS: We retrospectively reviewed all consecutive video-electroencephalogram (vEEG) recordings in our medical center's EMU from January 2013 to December 2017 and identified patients with seizures with atypical duration. Short PNES were defined as those lasting fewer than 2 min and long ES as those lasting for more than 5 min. RESULTS: The files of 830 adult (age >16 years) patients were reviewed, of whom 26 patients (3.1%, mean age: 33.3 ±â€¯9.8 years, 12 females) were diagnosed as having an unusual seizure duration. Among 432 patients with ES during monitoring, fourteen patients [3.2% (95% confidence interval (CI): 1.5%-5.0%), mean age: 33.0 ±â€¯12.2, 5 females [had long ES durations (exceeding 5 min). In 64% of patients with long ES, the events were provoked by antiepileptic drug (AED) withdrawal during vEEG, 62% had focal lesion on brain imaging, and 64% had a frontotemporal or a temporal seizure focus. Among 223 patients diagnosed with PNES, 12 patients [5.4% (95% CI: 2.2%-8.6%), mean age: 33.6 ±â€¯6.6, 7 females] had short PNES durations (less than 2 min) and demonstrated motor (9/12, 75%), altered responsiveness (6/12, 50%), and vocalization (5/12, 42%) as the most prominent clinical features. CONCLUSIONS: The data from our case files highlight two main considerations in the diagnosis of paroxysmal events: prolonged event can be due to ES, while short events can be psychogenic.

Semiological characteristics of patients with psychogenic nonepileptic seizures: Gender-related differences.

Psychogenic nonepileptic seizures (PNES) are more prevalent among women, and diagnosis may sometimes be delayed by as much as seven years. Understanding the effect of gender on the presentation of a PNES may assist with diagnosis based on semiological details in the clinical setting. Although video-EEG monitoring (VEM) is the gold standard for diagnosing PNES, determining gender-related seizure semiology through careful history may prevent diagnostic delay while waiting for VEM. The aim of this study was to investigate gender-related differences in the semiology of PNES. Patients, all aged at least 16 years, diagnosed with PNES following VEM between December 2005 and November 2016 were included in this study. All patients' medical records and video-EEG-documented PNES were reviewed, and the presence or absence of semiological signs was recorded for each documented attack. Demographic features and semiological signs of PNES were compared between female and male patients. Forty-one patients (31 females, 10 males) aged 27.2 ±â€¯12.2 years (range: 16-65) were included in the study. Mean age at onset of PNES was higher for female patients than males, at 24.3 ±â€¯11.5 versus 17.5 ±â€¯3.2 years (p = 0.005). The median duration of PNES was longer for female patients than males, at 10 min (range: 5 s-120 min) versus 2 min (range: 10 s-60 min) (p = 0.016). The most common symptom was forced eye closure in both genders. No significant gender-specific differences were observed in terms of the type or semiology of PNES. Although there are no major gender-related differences in PNES semiology, our findings highlight the importance of greater caution, especially in male patients, when diagnosing PNES, remembering that onset may also occur at young ages and that a short seizure duration does not exclude PNES.

Comparison of postictal semiology and behavior in psychogenic nonepileptic and epileptic seizures.

BACKGROUND: The available information on postictal semiology and behavior in patients with psychogenic nonepileptic seizure (PNES) is limited. In this study, we explore the differences in postictal semiology and behavior between patients with epileptic seizure (ES) and PNES and focus on clinical features that may be helpful in differentiating these two conditions. METHODS: In this retrospective study, video-electroencephalograph (video-EEG) of 144 seizures from 64 patients with PNES and 66 seizures from 42 patients with ES were reviewed. Three novel postictal behaviors were compared between the two groups: a) abrupt, brief, and rapid blinking or shaking of the head as if regaining sensorium or "coming out" of the ictal event; b) looking around the room with a scanning and uncertain look; c) posing a question of "what happened?" or a similar question to the others present in the room. In addition, differences in several other postictal characteristics were studied. RESULTS: At least one of the three specific postictal behaviors was seen in 20.1% of patients with PNES but none of the patients with ES resulting in 100% specificity and 36% sensitivity. While mean ictal duration was significantly longer in patients with PNES (175.3 ±â€¯168 s) compared to ES (105.4 ±â€¯102.9 s), the interval between the end of ictal episode and first correct verbal response (74.5 ±â€¯126.2 s versus 139.4 ±â€¯185.4 s), or first followed command (84.1 ±â€¯133.8 s versus 141.1 ±â€¯192.1 s) were shorter. In the group with PNES, 59.7% of patients demonstrated a whispering or altered voice during the first correct verbal response versus 21.2% of patients in the group with ES. The first followed command was slow or erroneous in 49.3% of the patients with PNES and in 19.7% of the patients with ES. CONCLUSION: In this study, we found significant differences between postictal semiology and behavior of patients with PNES and ES that can be helpful tools in distinguishing between these two conditions. Specifically, three novel postictal behaviors were studied and were found to have a high specificity, but low sensitivity, in distinguishing PNES from ES.

Inhibition of adenosine metabolism induces changes in post-ictal depression, respiration, and mortality in genetically epilepsy prone rats.

A major cause of mortality in epilepsy patients is sudden unexpected death in epilepsy (SUDEP). Post-ictal respiratory dysfunction following generalized convulsive seizures is most commonly observed in witnessed cases of human SUDEP. DBA mouse models of SUDEP are induced by audiogenic seizures (AGSz) and show high incidences of seizure-induced death due to respiratory depression. The relatively low incidence of human SUDEP suggests that it may be useful to examine seizure-associated death in an AGSz model that rarely exhibits sudden death, such as genetically epilepsy-prone rats (GEPR-9s). Adenosine is released extensively during seizures and depresses respiration, which may contribute to seizure-induced death. The present study examined the effects of inhibiting adenosine metabolism on the durations of post-ictal depression (PID) and respiratory distress (RD), changes in blood oxygen saturation (% SpO2), and the incidence of post-seizure mortality in GEPR-9s. Systemic administration of adenosine metabolism inhibitors, erythro-9-(2-hydroxy-3-nonyl) adenine (EHNA, 30 mg/kg) with 5-Iodotubericidin (5-ITU, 3mg/kg) in GEPR-9s resulted in significant changes in the duration of AGSz-induced PID as compared to vehicle in both genders. These agents also significantly increased the duration of post-seizure RD and significantly decreased the mean% SpO2 after AGSz, as compared to vehicle but only in females. Subsequently, we observed that the incidences of death in both genders 12-48 h post-seizure were significantly greater in drug vs. vehicle treatment. The incidence of death in females was also significantly higher than in males, which is consistent with the elevated seizure sensitivity of female GEPR-9s developmentally. These results support a potentially important role of elevated adenosine levels following generalized seizures in the increased incidence of death in GEPR-9s induced by adenosine metabolism inhibitors. These findings may also be relevant to human SUDEP, in light of the elevated adenosine levels that occur post-ictally in humans and its respiratory depressant actions.

Comparison of Intracranial Ictal EEG Patterns between Medial and Lateral Temporal Lobe Epilepsy / 대한간질학회지

BACKGROUND AND OBJECTIVES: Temporal lobe epilepsy is the most common uncontrolled epileptic condition and is increasingly treated with surgery. In the absence of definitive results from noninvasive procedures, patients undergo implantation of intracranial electrodes. Intracranial EEG recordings are more accurate than scalp EEG recordings because of minimal artifact and closer approximation to the area of seizure onset. Intracranial EEG patterns between the medial and the lateral temporal lobe epilepsy were thought to have a little differences. METHODS: The authors compared the morphological pattern of seizure onset area, spread pattern, termination pattern and duration of the intracranial EEG manifestation of spontaneous seizures recorded from combined depth and subdural electrodes in 25 intractable temporal lobe epilepsy patients. RESULTS: Sixteen cases were medial temporal onset, six cases were neocortical onset and three cases were multifocal onset. The morphological onset pattern of medial temporal seizures was more likely to have high frequency rhythmic discharge (>13 Hz) and tended to show repetitive spikes prior to the seizure, whereas neocortical seizures were characterized by slow (4-to 10-Hz) and fast frequencies (>35 Hz), without evidence of repetitive spikes. The mean ictal duration at seizure onset of complex partial seizure of medial onset seizure was 121 seconds and was not different from those of neocortical seizures which were 115 seconds. Neocortical seizures take more time to propagate than medial seizures. Propagation to the opposite side of neocortical onset seizure takes 45.53 seconds, whereas medial temporal onset seizure takes 27.92 seconds. In case of second generalization, neocortical seizures continued longer than medial seizures. Of the medial onset temporal lobe seizures, except the simple partial seizures, the 35.2% of seizures initially spread to ipsilateral neocortex, and the 28.2% of seizures initially spread to the contralateral medial temporal lobe and the 25% of seizures simultaneously propagated to the ipsilateral neocortex and contralateral medial temporal lobe. Among the seizures initiated from the neocortex, 79.3% of seizures initially spread to the ipsilateral medial temporal area, but never initially spread to opposite neocortex. The termination pattern of seizures was divided into three types according to their location. In case of medial temporal lobe seizures, the mean of 31% of seizures was diffusely terminated , 38% of seizures terminated at the onset region and 38% of seizures were elsewhere within onset region. On the other hand, 48.6% of neocortical temporal lobe seizure were terminated at seizure onset region. CONCLUSIONS: The pattern of ictal intracranial EEG provides distinguishable differences between the medial temporal seizure and the neocortical temporal seizure.