James D. Geyer

Nonepileptic Seizure Outcome Varies by Type of Spell and Duration of Illness

Purpose: To determine whether differences in clinical manifestations of psychogenic nonepileptic events are associated with differences in outcome and whether the length of illness before diagnosis correlates with outcome.

The value of pelvic thrusting in the diagnosis of seizures and pseudoseizures

Article abstract We evaluated pelvic thrusting as a potential diagnostic sign and localizing indicator of ictal onset. By reviewing the video-EEG results of patients with temporal lobe epilepsy, frontal lobe epilepsy, generalized epilepsy, and pseudoseizures. Pelvic thrusting occurred in 4% of right and 2% of left temporal lobe epilepsy patients, in 24% of frontal lobe epilepsy patients, and in 17% of patients with pseudoseizures. Pelvic thrusting is relatively common in frontal lobe epilepsy and in pseudoseizures, but also occurs in temporal lobe epilepsy.

Seizure prediction: Methods

Epilepsy, one of the most common neurological diseases, affects over 50 million people worldwide. Epilepsy can have a broad spectrum of debilitating medical and social consequences. Although antiepileptic drugs have helped treat millions of patients, roughly a third of all patients have seizures that are refractory to pharmacological intervention. The evolution of our understanding of this dynamic disease leads to new treatment possibilities. There is great interest in the development of devices that incorporate algorithms capable of detecting early onset of seizures or even predicting them hours before they occur. The lead time provided by these new technologies will allow for new types of interventional treatment. In the near future, seizures may be detected and aborted before physical manifestations begin. In this chapter we discuss the algorithms that make these devices possible and how they have been implemented to date. We also compare and contrast these measures, and review their individual strengths and weaknesses. Finally, we illustrate how these techniques can be combined in a closed-loop seizure prevention system. This article is part of a Supplemental Special Issue entitled The Future of Automated Seizure Detection and Prediction.

Postictal nose-rubbing in the diagnosis, lateralization, and localization of seizures

Background: Semiology is very useful in the diagnosis and classification of seizures. Some clinical signs occur primarily with specific localization-related epilepsies. Objective: To evaluate postictal nose-rubbing as a potential diagnostic sign and a potential lateralizing or localizing indicator. Methods: We reviewed presurgical prolonged video-EEG results of 50 consecutive patients with right temporal lobe epilepsy (TLE), 50 consecutive patients with left TLE, 50 consecutive patients with frontal lobe epilepsy, 11 consecutive patients with generalized epilepsy, and 100 consecutive patients with nonepileptic events. Videotapes of all events were reviewed independently by two investigators who were blinded to the results of the monitoring. The episodes of nose-rubbing and the hand with which the patient rubbed the nose were recorded. Results: Nose-rubbing occurred in 25 of 50 (50%) right TLE patients and in 21 of 50 (42%) left TLE patients. Approximately 90% of patients rubbed his or her nose with the ipsilateral hand. Nose-rubbing occurred in 5 of 50 (10%) frontal lobe epilepsy patients. Nose-rubbing was not seen in any patient with generalized epilepsy or nonepileptic events. Postictal nose-rubbing did not occur after secondarily generalized seizures. Conclusions: Nose-rubbing is an easily observed phenomenon, has high interobserver reliability, and provides useful lateralizing information in patients with TLE. It was less frequently seen in extratemporal lobe epilepsy and was not seen after generalized seizures or nonepileptic events.

Rasmussen's Encephalitis with Concomitant Cortical Dysplasia: The Role of GluR3

Summary: The role of the glutamate receptor GluR3 in Rasmussens encephalitis is actively under investigation. Autoimmune processes with this receptor as the target are currently theorized. We provide an additional case of pathologically proved Rasmussens encephalitis (with concomitant cortical dysplasia) in the presence of antibodies against the GluR3 receptor.

Co-occurring insomnia and obstructive sleep apnea

STUDY OBJECTIVES Prior research investigating co-occurring insomnia/obstructive sleep apnea (CIO) has mainly focused on comparing comorbid patients, obstructive sleep apnea (OSA), and insomnia (INS) to those with OSA alone. This approach is informative but omits the potentially interesting comparison of comorbid patients to those with INS alone. Our study used an incomplete factorial design, crossing OSA (present or absent) with INS (present or absent) to more clearly focus on the question, is comorbid INS an epiphenomenon of OSA or an independent disorder? METHODS Our study was an archival analysis from the database of a sleep center comparing consecutively diagnosed patients characterized as OSA or INS. A third group, CIO, was derived from the OSA group. Our study was conducted at an American Academy of Sleep Medicine-accredited sleep disorders center. We studied 299 patients, including 94 OSA, 97 INS, and 108 CIO. Patients ranged from ages 15 to 86years. RESULTS Groups were compared on polysomnography (PSG), sleep pattern, sleep stages, sleep pathology, self-reported sleep concerns, and self-reported daytime functioning. From a consecutive group of OSA patients, we estimate the prevalence of CIO at 67.4%. Based mainly on multivariate analysis of covariance (MANCOVA) controlling for demographic differences between groups, we found few if any significant differences between CIO and INS alone or between CIO and OSA alone. CONCLUSIONS The clinical presentation of CIO is indistinguishable from INS alone, both with respect to PSG findings and to self-reported sleep onset and sleep maintenance disturbance. We observed a weak relation between OSA severity and co-occurring INS. These data are consistent with the view that INS with co-occurring OSA is an independent, self-sustaining disorder. We hypothesized that in some unknown proportion of cases, OSA initially instigated the INS, but the INS was then perpetuated and reshaped by sleep concerns and self-defeating compensatory behaviors.

Antidepressant medications, neuroleptics, and prominent eye movements during NREM sleep.

Eye movements during stage 2, 3, and 4 sleep have been associated with the use of several selective serotonin reuptake inhibitor (SSRI) medications. This activity has been postulated to be a serotonin effect. The authors identified all cases of nonrapid eye movement (NREM) eye movements observed over a 36-month period in an accredited hospital-based sleep center and then correlated the findings with the patient’s medications. The polysomnogram (PSG) studies of 2,959 consecutive adults were evaluated prospectively to identify all patients with atypical eye movements which occurred during NREM sleep. Standard recording, staging and arousal scoring methods were used. The use of antidepressants and neuroleptic medications was recorded for each patient. Eye movements in NREM sleep were detected in 94 PSGs. Of these, 73 patients (78%) were taking a SSRI at the time of the study, and 6 (6%) had taken a SSRI in the past. Thirty-six percent of patients (73 of 201) taking a SSRI had abnormal NREM eye movements on PSG. Other classes of antidepressants, neuroleptics, and benzodiazepines showed a much lower incidence of NREM eye movements. Mirtazapine was rarely related to NREM eye movements. Clonazepam and zolpidem were not associated with atypical eye movements unless used in combination with SSRI medications. Selective serotonin reuptake inhibitors was associated with atypical NREM eye movements, even when the medication had been discontinued months to years before the PSG. Atypical NREM eye movements appear to be related primarily to serotonin and less prominently to dopaminergic medication effects.

Informed consent, competency, and the neurologist.

BACKGROUND–Obtaining informed consent to treatment is an important medical-legal and clinical aspect of neurological practice. REVIEW SUMMARY–This review discusses the doctrine of informed consent and its role in neurological practice. We first provide an overview of the informed consent doctrine and discuss its historical origins and current modern form. The three component elements of informed consent—being informed, voluntary, and competent– are presented, with a focus placed on the competency element. The increasingly important role of informed consent in everyday neurological practice is profiled, with particular emphasis on patients with dementia. Recent empirical research is presented on loss of consent capacity (competency) in patients with Alzheimer’s disease and Parkinson’s disease. Finally, a conceptually based approach to clinical assessment of competency is presented to assist neurologists dealing with these issues. CONCLUSIONS–The increasing prevalence of patients with neurodegenerative disorders in neurological practice heightens the importance of obtaining valid informed consent to treatment.

Sleep Education for Paradoxical Insomnia

This case study series investigated a new treatment for paradoxical insomnia patients as there is no standard treatment for this patient group at this time. Four paradoxical insomnia patients had a polysomnography (PSG) sleep study, an unsuccessful brief course of behavioral treatment for insomnia, and then a novel sleep education treatment comprising review of their PSG with video and exploration of the discrepancy between their reported and observed sleep experience. Two patients responded well to sleep education, mainly with improved self-reported sleep onset latency, total sleep time, and Insomnia Severity Index scores; and the other two, who exhibited sleep architecture anomalies, were unresponsive. These findings suggest that sleep education holds promise for some paradoxical insomnia patients. Suggestions for future studies are given.

Diagnosis and Management of Childhood Epilepsy

Epilepsy is a relatively common neurologic disorder in children that has important implications for development, parents, and society. Making the correct diagnosis starts with an accurate and complete history that consequently leads to a directed diagnostic workup. This article outlines a diagnostic and management approach to pediatric seizures and epilepsy syndromes. Making the correct diagnosis of epilepsy or nonepileptic imitators allows the practitioner to prescribe appropriate therapy. Initial management for typical epileptic syndromes and seizures and potential adverse effects are discussed. Alternative treatment options for pharmacologically resistant patients such as ketogenic diet, vagal nerve stimulation, and surgery are also discussed. While most children favorably respond to antiepileptic medications, early identification of medication failure is important to ensure optimal neurodevelopment.