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Journal of Clinical EEG & Neuroscience, January, 2008Table of ContentsThe Photoparoxysmal Response: The Probable Cause of Attacks During Video GamesABSTRACT Photic stimulation is part of a typical EEG in most countries, especially to check on the photoparoxysmal response (PPR). Interest in this response was enhanced in 1997 when hundreds of Japanese children had attacks while viewing a TV cartoon called “Pokemon.” The overall prevalence of the PPR among patients requiring an EEG is approximately 0.8%, but 1.7% in children and 8.87% in patients with epilepsy, more often in Caucasians and females. Autosomal dominant inheritance is indicated, and this response is seen especially at the wavelength of 700nm or at the flicker frequency of 15-18 Hz. The PPR extending beyond the stimulus carries no increased risk of seizures. Prognosis is generally good, especially after 20 years of age. Attention to PPR has been increased with the advent of video games, and the evoked seizures from these games are likely a manifestation of photosensitive epilepsy. Drug therapy has emphasized valproic acid, but Levetiracetam has also been successful in eliminating the PPR. Vertebrobasilar Artery Insufficiency and ElectroencephalogramABSTRACT This is a renewed diagnostic approach to vertebrobasilar artery insufficiency (VBI) — a condition which stood in the focus of this author’s interest several decades ago. The time for a revisitation has come. The EEG findings consist mainly of generally reduced voltage output and enhanced photic driving response. There is also some theta activity over anterior temporal and midtemporal region, but this finding is common in the early stage of all cerebrovascular disorders. Dysfunction of the pontine portion of the ascending reticular formation might be the cause of the lowered voltage output. The enhanced photic driving might be due to very light hypoxia of the visual cortex. EEG Infraslow Activity in Absence and Partial SeizuresABSTRACT It is currently assumed that for recording of infraslow activity (ISA) DC-coupled amplifiers are required. This report will demonstrate that this may not be the case and presents some data about its potential clinical usefulness. Archived EEGs of 29 seizures from 6 children with absence attacks, accompanied by 3 Hz classical spike-wave discharges (SW), were compared with 20 partial seizures from 10 adult patients. The data from the children were acquired on a Bio-logic system, those from the adults on a Grass-Telefactor instrument. In the children the original 30-minute routine EEG was used while in the adults stored videomonitored data were excerpted to provide 20-minute segments which included the preictal, ictal and postictal state. All data were analyzed with the BESA software package. The seizures were evaluated separately on conventional filter settings, full band of 0.01-to the upper limit of the instrument, and 0.01-0.1 Hz (infraslow activity, ISA). Filter settings of 0.01-0.1 Hz provided a better assessment of ISA than when the full band was evaluated. Absence seizures showed bilateral essentially synchronous ISA with a negative positive sequence in the frontal areas and opposite polarity in the posterior head regions. In partial seizures when seizure onset was clearly lateralizeable from conventional frequency settings ISA corresponded to that hemisphere, but the electrode position could be displaced to a neighboring one from the one which was maximally involved on conventional settings. Topographic analysis showed two types of ISA: one with focal spread only and the other where there was in addition an element of synchrony especially in the frontal areas. It is concluded that ISA can be recovered from conventional EEG recordings and may be helpful not only in determining the area(s) of seizure onset but can also differentiate truly focal seizures from those where an additional generalized seizure tendency is present. This is likely to be important when epilepsy surgery is performed in absence of a demonstrable structural lesion. Ictal Scalp EEG Findings in Patients With Mesial Temporal Lobe EpilepsyABSTRACT The syndrome of mesial temporal lobe epilepsy (MTLE) is a well-defined clinical entity that responds to surgical treatment in a considerable number of patients. Although it has been subjected to intensive clinical research, few investigators have published the ictal scalp EEG findings and looked for specific features that might predict postoperative outcome. This study was designed to examine ictal scalp EEG characteristics in detail, in a group of patients with pathologically confirmed hippocampal sclerosis (HS). Patients who underwent long-term video-EEG monitoring at our center during a 3-year period and were diagnosed to have MTLE and pathologically proven HS were included in this retrospective study. All ictal scalp EEGs were investigated in a common reference montage, paying attention to the localization, morphology and frequency of ictal discharges that were accepted to represent a specific phase if the findings were sustained for at least 3 seconds. Any significant change in localization, morphology or frequency of discharges was said to represent a different phase. The ictal EEG patterns in different phases were later compared among seizures of different patients. In addition, the ictal EEG characteristics of the patients in Group I (Engel's classification) were compared with the ictal EEG findings in patients who were included in another group. All the patients have been followed for more than 5 years. Seventy-one ictal EEGs were investigated in 25 adult patients (11 M, 14 F). Onset patterns were lateralized in 81.7% and localized in 76% of the seizures. Thirteen different patterns of onset were detected, the most common of which was the cessation of interictal discharges (35.2%). The most common ictal pattern following the initial changes was ipsilateral temporal rhythmic theta-delta activity (85.2%) that occurred on the average 13.4 seconds after onset. Nonlocalized/lateralized seizure onset of all the seizures or bilateral independent onset was present in 75% of the patients in Groups II-III, whereas this ratio was 14.3% in the patients in Group I (p=0.031). In conclusion, ictal scalp EEG in MTLE allows correct lateralization and localization in most of the seizures. Onset patterns may vary considerably; however, a later significant pattern consisting of rhythmic ipsilateral temporal build-up develops in the majority of seizures. Some ictal EEG characteristics may be related to post-operative outcome. Midline SpikesABSTRACT Midline spikes are characterized by spike foci recorded at Cz, Fz, or Pz with amplitude ranging from 20 to 350 microvolts. Out of 7,929 EEGs performed at the Neurodiagnostics Laboratory, Kaiser Permanente Medical Center, Anaheim, California, between 1996 and 2006, 17 EEGs (0.21%) were identified as having interictal midline spikes with or without other epileptiform discharges. Eight EEGs showed midline spikes at Cz, 2 at Fz, 2 at Cz and Fz, 1 at Cz and C3, 1 at Cz, C3, and P3, 1 at Cz and F8, 1 at Cz and T4, and 1 at Cz with 2 Hz generalized spike and slow wave complex. Midline spikes were recorded in 10 males and 7 females. The age ranged from 4 days to 38-years-old with a mean age of 10.8 years. Twelve patients (70.6%) were children. Twelve patients (70.6%) had generalized tonic-clonic seizures and 5 had partial motor seizures. Of the 17 patients, 14 had no known causes, 1 had an agenesis of corpus callosum, 1 had a left frontal arteriovenous malformation, and 1 had a left frontal area stroke. We postulate that the mechanism for the genesis of midline spikes may be heterogeneous. Midline spikes may be triggered by thalamocortical network in a generalized tonic-clonic seizure, or may originate in the parasagittal cortex in a partial motor seizure. Focal EEG Findings in Juvenile Absence Syndrome and the Effect of Antiepileptic DrugsABSTRACT The presence of focal EEG abnormalities in juvenile absence syndrome (JAS) may cause it to be misdiagnosed as focal epilepsy. The purpose of our study was to determine the presence of focal EEG abnormalities in patients with JAS and to ascertain whether some clinical features or antiepileptic drugs (AEDs) have an effect on focality. Serial EEGs of 52 consecutive patients with JAS were retrospectively analyzed. The patients were divided into two groups according to whether they were treated with valproic acid and/or lamotrigine (VA-LTG) or not during the times of these EEG recordings. The relationship between the presence of EEG focality and the use of AEDs in addition to other risk factors was examined. Two or three consecutive EEGs (total 100) of the 52 patients were evaluated. Among these, the rates of focal EEG abnormalities were 18%, 36%, and 25% during the follow-up EEGs without AEDs (5/27) and first (16/45) and second EEGs (7/28) with AEDs, respectively. The last two EEGs showed a tendency towards a higher proportion of EEG focality in patients who received other AEDs (47%-45%) compared with those that received VA-LTG (13%-12%). The proportion of JAS patients with focal EEG findings in serial EEGs tended to decrease with an increasing rate of VA-LTG use. As a hypothetical explanation, changes in EEG focality may reflect the effect of AEDs other than VA and/or LTG, in addition to a developing hyperexcitable cortical area. Akinesia and the Frontal LobeABSTRACT A report of severe akinetic episodes in patients with Parkinson disease (PD) has been the stimulus for the following discussion of akinesia and its variants. Severe persistent akinesia may occur in frontal lobe impairment. Therefore, it is likely that extension of the Parkinsonian dysfunction into the frontal lobe causes severe akinesia which should be separated from the very common Parkinsonian hypokinesia. Another very common clinical phenomenon of PD is sudden freezing. Hence the frontal lobe — hardly regarded as a region of special interest in the realm of PD — can be the cause of severe and dangerous complications of PD. The term “arrest reaction” or “motor arrest” denotes a similar freezing. It is recommended to restrict these terms to certain forms of frontal lobe epilepsy. This discussion of hypokinetic and akinetic states should also include catatonia: a form of schizophrenia with a special type of akinesia. Though without major neuropathological substratum, this condition can, in extremely rare cases, lead to severe hyperthermia and fatal outcome (presumably via hypothalamic dysfunction). Ictal/Interictal EEG Patterns and Functional Neuroimaging Findings in Subcortical Band Heterotopia:
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