Abuhuziefa Abubakr

Psychogenic seizures: clinical features and psychological analysis

Approximately 25-30% of patients referred to epilepsy centers for refractory epilepsy are found to have nonepileptic seizures (NES). In many cases psychological assessments are performed to evaluate for underlying psychiatric disorders. The authors analyzed the clinical features of 23 patients with NES and correlated the features with underlying psychological status. Thirteen of the twenty-three patients (56.5%) had motor manifestations and 10 presented with limpness and unresponsiveness. There was no significant difference in the occurrence of depression, anxiety, posttraumatic stress disorder, or malingering between patients with limpness and those with motor manifestations. However, only patients with motor manifestations had a history of sexual and physical abuse. Those with limp and unresponsive presentations were less likely to have a history of sexual and/or physical abuse. This finding may help treating physicians to choose optimum psychiatric treatment for patients with NES. Additional studies are needed to clarify the association.

The diagnostic value of EEGs in patients with syncope.

We retrospectively reviewed reports of all EEGs performed at the New Jersey Neuroscience Institute at JFK Hospital between January 1999 and December 2003. Of 9234 EEGs performed, 1094 were of patients with syncope. Among patients with syncope, 67.18% of the EEGs were normal and 28.15% showed diffuse and focal slowing. Only 1.46% of the EEGs showed epileptiform discharges (EDs). This is similar to the incidence of EDs in healthy adults. The presence of EDs did not change the management of these patients. Therefore, EEGs have very low yield and should not be routinely obtained in patients with syncope.

Non-voluntary and voluntary processing of emotional prosody: an event-related potentials study

The present study investigated whether event-related potentials (ERPs) reflect non-voluntary vs voluntary processing of emotional prosody. ERPs were obtained while participants processed emotional information non-voluntarily (i.e. while evaluating semantic characteristics of a stimulus) and voluntarily (i.e. while evaluating emotional characteristics of a stimulus). Results suggest that emotional prosody is processed around 160 ms after stimulus onset under non-voluntary processing conditions (when the attention is diverted from the emotional meaning of the tone of voice); and around 360 ms under voluntary processing conditions. The findings support the notion that emotional prosody is processed non-voluntarily in the comprehension of a spoken message.

Long-term outcome of vagus nerve stimulation therapy in patients with refractory epilepsy

We retrospectively assessed the long-term efficacy of vagus nerve stimulation (VNS) therapy in 31 patients with refractory partial and generalized seizures who were not candidates for resective epilepsy surgery. Following implantation of VNS there was significant improvement in seizure frequency at 6 months. Sixteen patients continued to have sustained response to VNS therapy 4 years later. Adverse effects of VNS therapy were transient and tolerable. The majority of the patients did not gain body weight and some of them had significant weight loss. Therefore VNS is safe and effective therapy and has a long-term sustained effect in refractory epilepsy.

Seizures in the elderly: Video/EEG monitoring analysis

OBJECTIVE Recently there has been a remarkable increase in the number of elderly people with epilepsy due to the growing size of this segment of the population. The literature provides little information on the characteristics of epileptic and nonepileptic events in the elderly. Therefore we report the results of video/EEG recordings in patients aged 60 or older admitted over 2 consecutive years to an epilepsy monitoring unit (EMU). METHODS We examined the records of all elderly patients admitted to our EMU between December 1999 and December 2001. Fifty-eight patients were older than 60, constituting 17% of the total admissions to the EMU. All patients underwent continuous video/EEG monitoring. On the basis of reasons for admission, video/EEG reports were categorized into (1) diagnosis of events, (2) characterization and localization of seizures, (3) adjustment of medication, and (4) status epilepticus (nonconvulsive). RESULTS There were 26 women between the ages of 60 and 91 and 32 men between the ages of 60 and 84. The main reasons for admission were diagnosis of events (57% of patients), followed by characterization and localization of events (36% of patients). There were 6 patients with psychogenic nonepileptic seizures (PNES); 5 were women and 4 of them were >70 years of age. All PNES patients presented with motor symptoms, except for an 87-year-old man who presented with abdominal spasm. Two of these six patients were suspected of having PNES before admission. Two patients were admitted with suspicion of status epilepticus, but neither proved to have status epilepticus. The most frequent diagnosis was physiologic nonepileptic seizures (26 patients; 45%), and 27% of these patients were on antiepileptic drugs, which were discontinued after the diagnosis of nonepileptic seizures. Complex partial seizure was the most frequent seizure type, occurring in 23 patients, 6 of whom (27%) had both complex partial seizures and secondarily generalized seizures. CONCLUSION In the elderly, video/EEG results in a definitive diagnosis in the majority of cases and can assist in the decision whether antiepileptic drugs are necessary. PNES can occur in the elderly, and video/EEG monitoring can facilitate their recognition and management.

The localizing value of auditory event-related potentials (P300) in patients with medically intractable temporal lobe epilepsy

The localizing value of postictal versus interictal event-related potentials (ERPs) was studied in patients with medically intractable TLE admitted for long-term video EEG monitoring. Ten patients with partial seizures and secondary generalization underwent preictal (upon hospital admission), postictal (</=6h after seizure), and interictal (7-48h after seizure) ERP recordings of an auditory oddball paradigm. Preictal ERPs were compared to postictal and interictal recordings. Intraclass correlations, transformed into z scores, were utilized to analyze amplitude differences between electrodes placed on the hemisphere ipsilateral versus contralateral to the epileptogenic focus. The results showed that in 9 out of 10 patients the ERP amplitude was reduced in postictal compared to preictal recordings for electrodes placed ipsilateral to the epileptogenic focus (P<0.0001). However, there was no difference in amplitude between ipsilateral and contralateral electrodes in preictal and interictal recordings. These findings suggest that postictal ERPs are of localizing value in patients with TLE while interictal ERPs are not.

The efficacy of routine hyperventilation for seizure activation during prolonged video-electroencephalography monitoring.

Hyperventilation (HV) is considered to be one of the activation procedures that provokes epileptic potentials and clinical seizures. However, the true clinical yield of HV is not well established. We retrospectively reviewed the records of all patients admitted to JFK Hospital, Edison, New Jersey, between October 2001 and December 2004 for long-term video-electroencephalography (EEG). A total of 475 patients (193 males; 282 females; age range 5-89 years) were included in the study. All patients underwent routine 3-minute HV as part of the evaluation of their clinical episodes. During the initial assessment, 165 patients did not experience a seizure event, 92 had non-epileptic events, 16 experienced psychogenic non-epileptic seizures (PNES) and six had a clinical event. During HV, of the 43 patients who had primary generalized epilepsy, nine had an abnormal EEG and two experienced seizures; however, out of the 159 patients who had partial seizures, only one patient demonstrated an abnormal EEG. Our study demonstrates that routine HV generally has a very low yield in our Epilepsy-Monitoring Unit. This finding also lends support to the idea that partial seizures are relatively resistant to HV activation.

The presence of polyglucosan bodies in temporal lobe epilepsy: its role and significance

RATIONALE Mesial temporal sclerosis (MTS) is an important pathology in temporal lobe epilepsy (TLE) and often associated with good surgical outcome, however prognostic factors for surgical outcome are conflicting. The authors examine seizure outcome after surgery for TLE due to MTS, with focus on the presence of polyglucosan bodies (PGBs), and its relation to the epileptogenic process. METHODS Records of 44 consecutive patients with intractable TLE who underwent anterior temporal lobectomy (ATL) at JFK medical center between 1994-2001 were reviewed. Details of clinical, electrophysiological evaluation, and outcome were collected. All slides were reviewed for the presence of MTS. In twenty-one patients with MTS, detailed histology of surgical specimens was reviewed and relative concentration of PGBs was assessed. The postoperative follow-up duration ranges between 28-74 months. Surgical outcome was evaluated according to Engels classification. RESULTS Data of fourteen females (mean age 32.8 years) and 7 males (mean age 34.2) were analyzed. PBGs were identified in 10 patients (8 females and 2 males). All 10 patients had good surgical outcome, with 6 patients (60%) being seizure free (class 1) and 4 patients as class 2. While 11 patients (6 males and 5 females) with absent PGB, 72.8% had good surgical outcome. Of these, 7 (63.8%) had class 1, 1 patient had class 2, and 3 patients had class 3&4. Assessing several risk factors, the only significant difference between the two groups was epilepsy duration, which was significantly longer in patients with PGBs (P = 0.011). CONCLUSION The histological presence of PGB is associated with long duration of epilepsy and could be the consequence of epilepsy. Despite prolonged duration of epilepsy, the surgical outcome in PGBs +ve is similar to PGBs -ve patients.

Auditory event-related potentials (P300) in the identification of psychogenic nonepileptic seizures

The feasibility and conceivable value of postictal event-related potential (ERP) recordings were studied in patients with nonepileptic seizures (NES) admitted for long-term video/EEG monitoring. Ten patients with NES underwent preictal (on hospital admission) and postictal (< or =6 hours after seizure) ERP recordings of an auditory oddball paradigm. Additionally, 10 temporal lobe epilepsy (TLE) patients with partial seizures and secondary generalization underwent preictal, postictal (< 6 hours after seizures), and interictal (7-48 hours after seizure) ERP recordings. We recently reported that ERPs recorded in TLE patients with partial epilepsy undergo a temporary change postictally, while returning to their preictal state during interictal recordings. In the current study intraclass correlations, transformed into z scores, are used to determine test-retest validity of repeated ERP recordings. An independent sample t test with z scores for the comparison of preictal and postictal recordings showed that ERP activation differed between NES and TLE patients (P=0.009). More specifically, ERP recordings in the preictal and postictal states were similar in NES patients, but dissimilar in TLE patients. On the other hand, this dissimilarity in ERPs disappeared when comparing z scores for the preictal and postictal recordings in NES patients with z scores for the preictal and interictal recordings in TLE patients. This further supports the notion that identical waveforms during preictal and postictal recordings in NES patients reflect nonepileptic seizure activity. The current findings suggest that postictal ERP recordings are useful in the diagnosis of NES and differentiate TLE from NES.

Diagnostic value of serum prolactin levels in PNES in the epilepsy monitoring unit: Table

Background:This is a retrospective study to determine the usefulness of serum prolactin levels in the epilepsy monitoring unit (EMU) for distinguishing psychogenic nonepileptic seizures (PNES) from epileptic seizures (ES). Methods:All the records of consecutive patients admitted to the EMU between 2008 and 2012 were reviewed. Patients with a diagnosis of PNES and ES were selected. Serum prolactin level was obtained within 20 minutes for all patients, and an elevated prolactin level was defined as twice the patients baseline value. A total of 607 records were reviewed, and 389 patients were excluded because of incomplete information or lack of a clinical event. Results:A total of 218 patients were included in the analysis. A further 18 patients were excluded because of simple partial seizures or because the documented time of obtaining serum prolactin was not clear. A total of 146 patients had PNES, of which 42 had elevated prolactin levels, representing a 28.8% false-positive rate. All 22 patients with generalized tonic-clonic seizures had elevated serum prolactin; however, 5 of 32 patients with complex partial seizures did not have an elevated prolactin level, representing a 15.6% false-negative rate. Conclusions:Serum prolactin levels do not provide any additional support for distinguishing PNES from ES. Furthermore, serum prolactin levels in this setting add unnecessary blood draws and financial burden for the patients. Therefore, prolactin levels should not be obtained routinely in the EMU. Classification of evidence:This study provides Class III evidence that postevent elevation of serum prolactin occurs in 84.4% of patients with ES and 28.8% of patients with PNES.