Video-EEG combined with EEG mapping
M.M.* Radionova, D.B. Chavdarov, R.S. Velizarova, I.G. Kojuharov, Medical
Purpose: To avoid the difficulties of the simultaneous observation
of the flowing multichannel EEG and the patients behavior on video EEG,
and to present the EEG data as time series maps corresponding to the dynamics
of the clinical manifestation.
Methods: In patients with different ictal phenomena, the EEG
recording is divided in time series corresponding to the succeeding episodes
of the ictal evolution. After artifact are eliminated, different techniques
for signal processing and mapping presentation (series of momentary potential
field maps, successive power maps, maps series of the field maximum, etc.)
are applied. The simultaneous presentation of EEG and patient behavior
is compared with the picture of the processed signal.
Results: The diagnostic importance of the video-EEG is in the
simultaneous examination of the ictal EEG pattern and the clinical manifestation.
The limitations of the technique are in the assessment of the EEG finding
for the ictal evolution and the difficult correlation of EEG topography
with the clinical manifestation. The EEG mapping analyses give the opportunity
for different data processing and mapping presentations, according to
duration and characteristic of the successive episodes of seizure evolution.
The advantages of the video EEG mapping are: the opportunity to detect
focal findings masked by the diffuse permanent or transient activity;
to reveal any discrepancy between the suspected (according to the clinical
evolution) and the real focus found with the EEG mapping; correlation
between the movements' succession and the propagation of the discharges.
The disadvantages of the technique are that it is an off-line and time-consuming
processing, artifacts disturb the analyses, choice of an adequate mapping
Conclusions: Video-EEG combined with EEG mapping analyses makes
the comparison between the epileptiform EEG phenomena and the patient's
behavior easier, and provides an opportunity for a better understanding
of the clinical-EEG relationships.
Stereotypical behavior of a patient with Williams
Derya Uluduz*, Veysi Demirbilek*, Aysin Dervent*. * Department of Neurology,
Cerrahpasa University, Istanbul, Turkey
We present aspects of long-lasting stereotypical behaviour of a patient
with Williams syndrome.
The patient is the second son, born in Nov., 1997, from a non-consanguinous,
healthy couple. The first son was normal until he died at ten months of
age, and diagnosed as having SIDS. There is a healthy sister, 11 years
old. There are no other medical problems in the family. The patient developed
normally until 6 months of age when he started to present the following
behaviour (paroxsysmal, long-lasting, stereotypical events). His development
then, has started to slow down and was regressing by the end of the first
year of life. His vocabulary decreased from 20-25 words to 3-4 after that
time, and his attention to the environment and toys was minimized and
he no longer took any interest in independant walking. Sterotypes as turning
around, preoccupation with turning objects became manifest. The condition
was diagnosed as epilepsy and autism based upon on the parents' reports
and an EEG, at 16 months of age. Behavioral therapy, in addition to VPA
was started. The patient has started to present a slow improvement since
then, in both motor and cognitive/psychosocial development, and the paroxsysmal
events progressively decreased in frequency and severity. VPA was continued
for a few months. The patient was referred to us a year ago. He had typical
features of Williams syndrome. Genetic tests revealed missing material
on chromosome 7, including the gene that makes the protein elastine. He
has no autistic stereotypes now. He has moderate motor and mental deficiency
which is improving and has good social contact. The present video-clip
was recorded during his referral to our laboratory for a video-EEG in
March 1999, when the patient was 16 months old. (Video): the episodes
were about half to an hour's duration. They would be precipitated by frustration,
following painful stimuli or during times of physical disturbances such
as gastro-intestinal distress with nausea, vomiting and diarrhoea. He
would become inattentive but conscious, would sterotypically flex his
legs, squeeze his hand in between the legs, strain, hold his breath, utter
some screaming sounds, perform bizarre mimics. He would pay interest to
toys given but not sufficient to be distracted from the ongoing behaviour.
His synchronized EEG was normal during these events. His inter-ictal EEG
was normal during waking, it had some asynchronous and asymmetrical vertex-sharp-like
activity in both fronto-central leads.
The patient was considered as having atypical masturbatory episodes
which had been previously misdiagnosed as epilepsy. This case seems a
good example of the wide-range variability of the abnormal paroxsysmal
behaviour during infancy.
Epileptic negative myoclonus as a parodoxical
effect of carbamazepine in benign rolandic epilepsy
M.A. Perez-Jimenez*, M.L. Ruiz-Falco f, M.C. Fournier
del Castillc #. * Clinical Neurophysiology, f Neuropediatric,
and # Neuropsychology Units. "Nifio Jesus" Hospital, Madrid,
Introduction: We have documented the reversible worsening of
the electroclinical picture in a little girl with an unusual presentation
of benign epilepsy with centro-temporal spikes (BECTS) related to carbamazepine
Case record: The patient is a 4 year and 3 month-old girl, studied
by means of clinical observation, video-EEG map studies, neuropsychology
and neuroimaging evaluations. At the age of 2 years and 9 months, she
began to suffer from occasional, very brief diurnal, clustered, focal
motor seizures (tonic/clonic), affecting her left hand and arm, eventually
spreading to the mouth. Epileptiform activity was observed on the right
central region, and CBZ was introduced. With middle-range serum CBZ levels,
she experienced an increase of her usual seizures and the appearance of
focal akinetic seizures lasting a few minutes. After further increasing
the CBZ dosage, the clinical picture worsened, with appearance of transitory
paresis of the left arm after awakening and sudden, intermittent left
arm drops during the day. The video-EEG study revealed almost continuous
benign epileptiform discharges of childhood, and slow-waves on the right
hemisphere, at a maximum over the centro-parietal region, and repetitive
epileptic negative myoclonus of the left arm. After CBZ tapering, and
VPA introduction, the whole clinical picture reversed, without relapse
after a follow-up of 1.8 year. Neurological, neuropsychological and MRI
examinations were normal.
Conclusions: The recognition of unusual BECTS presentations,
as well as the detection of a paradoxical effect of CBZ in these children,
are critical to avoid erroneous therapeutic strategies. The early withdrawal
of CBZ may prevent a more serious, atypical evolution.
A case presentation: alternating hemiplegia of
Sema Saltik*, Turkan Uslu*, Aysun Kayaci*, Aysin Dervent*. *Department
of Neurology, Cerrahpasa Medical Faculty, Istanbul, Turkey
A scene from a long-lasting episode characterized by bizarre movements
in an infant with alternating hemiplegia of childhood will be presented
here. Symptoms of increasing severity will be highlighted and they will
be discussed with regard to the involvement of different modalities of
Psychogenic status epilepticus in children and
M. Savani*, Vassilakin, C. Kotsalis, H. Bazigou, E. Paraskevoulakos,
A. Papavasiliou. Department of Neurology, Pendeli Children, Hospital Athens,
The aim of the study was to examine epilepsy features, psychiatric profile
and social risk factors in children and adolescents with psychogenic status
epilepticus (PSE). We present six patients with prolonged psychogenic
seizures (PCS) >= 30 min or repetitive PCS simulating status epilepticus.
They were three boys and three girls with mean age of 12.1 (5 to 15) years
old. All had epilepsy and, in addition, one patient had right hemiplegia,
one had speech delay and two had pervasive development disorder. There
were three with symptomatic partial epilepsy, two with cryptogenic generalized
and one with idiopathic generalized. They were all on anticonvulsants
(ACVs). The EEGs prior to the PSE were abnormal. Some showed generalized
slowing, others had lateralized slowing, and most of them had epileptic
discharges. The brain MRIs were abnormal in two patients, one with left
hemisphere atrophy and one with celebellar atrophy. Psychiatric assesment
after PSE demonstrated the following profiles: three with pervasive development
disorder, two with depression-anxiety disorder and one with obsessive-compulsive
disorder. All patients received IV and/or rectal ACVs prior to the diagnosis
of PSE. The diagnosis was confirmed via prolonged video-EEG monitoring,
which established the absence of epileptogenic activity during alleged
seizures. Provocation and placebo therapy techniques were used in some
patients for confirmation of seizures under video-EEG. There were no adverse
reactions with IV ACVs. In conclusion, we stress the occurrence of PSE
in children and adolescents even in those cases with well established
neurological and epilepsy syndromes, and the necessity of prompt diagnosis.
Although psycogenic status epilepticus is unusual and less frequent in
younger age groups compared to adults, the possibility of iatrogenic complications
and delay in psychiatric management are the main risks of late diagnosis.
The significance of video-electroencephalography
monitoring in differentiating epileptic and non-epileptic events
V. Kapitzoglou-Logothetis*, K. Garganis, J. Mylonas B'department of
Neurology, Aristotelian University, Thessaloniki, Greece
The primary objective of the study was the differential diagnosis between
epileptic seizures (ES) and non-epileptic events (NEE) in the era of long-term
video-electroencephalography (EEG) monitoring. We studied 23 patients
(8 males and 15 females) with ES and 25 patients (10 males and 15 females)
with NEE, which included 16 patients with psychogenic and 9 patients with
somatic events. Comparing the two groups, a younger age was observed for
seizure onset in the ES group as opposed to the NEE group. Risk factors
(febrile convulsions, perinatal injuries, head trauma) were present in
the ES group. Clinical features of the epileptic seizures were simple
or complex partial seizures, often with preceding aura, with or without
secondary generalization. In the NEE group there was no aura. In this
group, 64% of the events were psychogenic, manifesting as conversion reaction
or other episodic behavioral disorders, and 36% were physiological or
somatic, manifesting as somatic complaints. There was loss of consciousness
in the epileptic event group (26%), while mild confusion was found in
both groups. Postictal confusion was found in the ES group. Psychiatric
disorders occurred prior to seizure onset in the NEE group, while in the
ES group, the psychiatric disorders were observed after seizure onset.
The event onset in the psychogenic NEE group was gradual, the termination
was rather abrupt and the event duration variable, in contrast to the
ES group. There was increased event frequency in the NEE group despite
the antiepileptic drugs used, in contrast to the ES group. Neuroimaging
findings were seen in 40% of the ES group, mainly in the hippocampal regions
(30%), while in the NEE group the findings were of undetermined significance
(33%). Interictal video-EEG abnormalities were seen in 87% of the ES patients
and in none of the NEE patients. There were ictal-EEG abnormalities in
all patients with epileptic seizures, in contrast with the NEE patients.
In conclusion, in our study the contribution of the long term video-EEG
monitoring was essential in confirming the diagnosis of non-epileptic
Non-epileptic seizures amongst patients referred
for "intractable epilepsy": a video-EEG study
S. Giannakodimos*, F. Sekeri, G. Hatzidaki, C.E. Karageorgiou. Epilepsy
Clinic, Neurology Department, General Hospital of Athens "G. Gennimatas",
Objective: Non-epileptic seizures (NES) may account for considerable
misdiagnosis of paroxysmal events. It is well known even from studies
of candidates for epilepsy surgery that a small proportion of them in
fact turns out to suffer from NES and not epilepsy. The increased use
of video-EEG in the evaluation of patients with intractable epilepsies
has helped the identification of NES amongst them. We present our video-EEG
study regarding NES in patients referred to our center as "uncontrolled
Methods: Over the last three years, we have perform prolonged
video-EEG monitoring in patients referred a diagnosis of uncontrolled
epilepsy in order to capture seizures either for diagnostic reasons or
as a part of presurgical evaluation. We tried to apply specific stimuli
if seizures were provoked or we perform prolonged monitoring sessions
with parallel AED reduction.
Results: Amongst those patients undergoing video-EEGs, there
were 50 patients with uncontrolled seizures, including 6 surgical candidates.
Nine patients (3 female) had non-epileptic seizures captured on video-EEG
(none of them was a candidate for surgery). Their mean (range) age was
23.9 (17-30) years. Six patients had psychogenic seizures, two had sleep
disorders, and one hypoglycemic episodes. None of these patients had concomitant
epileptic seizures and in all, AED were successfully discontinued and
appropriate treatment administered instead.
Conclusion: Non-epileptic seizures are a significant reason for
intractability in patients seen in outpatient epilepsy clinics. Video-EEG
must be performed in every case where there is suspicion of NES, because
appropriate diagnosis has crucial therapeutic and prognostic consequences.
Temporal lobectomy for intractable epilepsy:
E. Martin, M.D. Weinand. Division of Neurosurgery, Department of Surgery,
Arizona Comprehensive Epilepsy Program, University of Arizona College
of Medicine, Tucson, Arizona, USA
The operative technique as performed at the University of Arizona, for
temporal lobectomy in intractable epilepsy may be divided into four main
parts. Firstly, a frontal-temporal craniotomy is performed. The dura is
opened in a cruciate fashion and the lateral temporal cortex is resected
as a single specimen. From the anterior middle fossa, the lateral cortical
specimen measuring 4.5 cm and 6.0 cm, in the hemispheres dominant and
non dominant for language function, respectively. Secondly, the temporal
horn is exposed along the trajectory of the Sylvian fissure and in the
white matter in the plane of the sulcus, separating the superior and middle
temporal gyri. The temporal horn is unroofed from posterior to anterior
and the choroidal fissure is identified. Thirdly, further medial and lateral
cortical dissection is performed. The operating microscope is introduced
and the superior temporal gyrus white matter is removed from the Sylvian
fissure using subpial dissection. The parahippocampal gyrus is resected.
Fourthly, a complete amygdalohippocampectomy is performed. The amygdala
is resected, during which the third cranial nerve is identified. With
the choroidal fissure as the superior-most boundary, the hippocampus is
resected en bloc and posteriorly with the CUSA (Cavitron Ultrasonic Surgical
Aspirator), during which the posterior cerebral artery and cerebral peduncle
are identified. The lateral temporal cortex and hippocampus are routinely
preserved for basic neuroscience research in accordance with the institutional
Human Subjects Committee protocol. The dura is closed and covered with
biological collagen to facilitate dural healing. The bone flap is replaced
using nylon suture. The temporlis fascia, galea and scalp are closed in
layers. The patient is admitted to the intensive care unit overnight and
is routinely discharged home within 1 to 3 days post-operatively. Anticonvulsant
medication is maintained throughout the hospitalization and post-operatively
for at least 2 years, even in seizure-free patients.
Ictal epileptogenic manifestation provoked by
Stefano Ricci, Marta Piccioli, Dorothee Kasteleijn-Nolst Trenite Federico
Vigevano. Epilepsy center, Neurol. Sciences, University of Rome la Sapienza,
Italy, Neurology, MCA, Alkmaar, the Netherlands, Child Neurology, Bambino
Gesu' Childrens' Hospital IRCCS, Roma, Italy
Objectives: Seizures provoked by video-games (VG) are frequently
reported, but the precise clinical and electroencephalographic features
are not yet well known. Furthermore, it is unknown whether these ictal
manifestations are similar to the ones evoked by intermittent photic stimulation
Methods: Out of a total of 29 children (12 M, 17 F) investigated
with IPS and VG provocation, 16 (8 M, 8 F) showed generalised epileptiform
activity (EA) during VG provocation. IPS and a total series of twelve
video-games were tested in 13 of the 16 patients (5 M, 8 F). Simultaneous
3-way video-EEG recording, while playing each game for 5 minutes at a
distance of 1 metre from a 50-Hz screen, made it possible to detect and
compare signs and symptoms related to EA evoked by video-games and IPS.
Results: Seven patients had a history of partial seizures (idiopathic
occipital lobe epilepsy) and 8 migrainous complaints. All patients presented
ictal manifestations during both IPS and VG playing. Overall, the maximum
duration of the EA during play was longer than during IPS. The vast majority
of evoked EA was related to clinical signs. Three types of ictal events
could be detected: absences, myoclonic jerks and focal seizures. The same
signs, seen during IPS, could also be detected during VG playing; the
EA lasting > 14 sec was always evoked by VG playing and clearly focal
Conclusions: Ictal manifestations during VG playing are basically
similar to the ones evoked by IPS. VG playing, in addition, provokes longer
lasting, focal seizures.
The clinical phenotype of typical absence seizures
and absence epilepsies in childhood
Aim: The purpose of this video presentation is to improve classification
of absence seizures and add to their prognosis by using appropriate clinical
and EEG criteria.
Methods: All children had prolonged sleep-wake video-EEG recordings
after partial or complete overnight sleep deprivation. Hyperventilation
was encouraged appropriately, according to the age group. Photosensitivity
was assessed using a GRASS PS33 photostimulator and correct methodology.
Material: The video presentation will start with typical absence
seizures in childhood and subsequently present cases, which are not "childhood
absence epilepsy". These are: A. Absences in early infancy (< 3 years)
and their characteristics: myoclonic versus non-myoclonic.
B. Myoclonic absence epilepsy (facial or other jerks).
C. Eyelid myoclonia with absences (Jeavon's syndrome).
D. Absences induced by photic stimulation.
E. Phantom absences.
F. Absences in juvenile myoclonic epilepsy.
G. Absences in self-induced photosensitive patients.
Conclusion: Lumping typical absence seizures under the heading
"childhood absence epilepsy" discourages diagnostic precision and does
not help geneticists to elucidate the molecular basis of «typical»
absence epilepsy and syndromes. The prognosis of the above absence-spectrum
varies and some of the absence syndromes are not expected to remit early.
Impairment of consciousness during hyperventilation
in children: is it epileptic?
A. Covanis, A. loannidou, K. Skiadas, A. Vassou, N. Loli, V. Theodorou
In children, hyperventilation-induced high amplitude rhythmic delta
activity (HIHADA) is considered normal if spikes are not intermixed.
Purpose: To evaluate the significance of absence-like episodes
observed during HIHADA in some epileptic and non-epileptic children, normal
or subnormal and to discuss possible underlying mechanisms.
Methods: Absence-like episodes were observed in 17 non-epileptic
and 14 epileptic children (77% girls), aged 2 to 13 years. Of the 17 non-epileptic
children, 14 were evaluated for headaches, "Tummy aches": and "vague looks".
Family history was positive for epilepsy in four children. The 14 epileptic
children had idiopathic generalized or partial epileptic syndromes/epilepsies
and exhibited unresponsive behavior during hyperventilation (HV), at different
stages of their assessment. All children had video-EEG recordings. Hyperventilation
was encouraged for 3 minutes or longer. Blood samples for glucose, acid-base
balance and ionized calcium (Ca2+) were taken in 19 children,
prior to HV and during HIHADA.
Results: In all children, HIHADA was recorded in 5 to 20 second
bursts. The associated absence-like episodes consisted of cessation of
over-breathing, restlessness, automatisms, yawning, unresponsiveness to
verbal recall, or inability to recall a word or a sequence of words after
the event. Five non-epileptic children received valproate (VPA) for 3
months and the EEG became normal in three children. The ionized Ca2+
in 12 epileptic and in 7 non-epileptic children, was 0.82 ± 0.35
versus 0.94 ± 0.30 mmol/l during HIHADA and 1.01 ± 0.30
versus 1.09 ± 0.20 mmol/l prior to HV respectively (Normal:
Conclusions: Absence-like episodes are considered a borderline
epileptic phenomenon, related to typical absences, which do not occur
spontaneously and have a benign course. Treatment is not needed. The underlying
trigger factor may be the low ionized Ca2+, induced by hyperventilation.
West Syndrome and autism
Istanbul Univ., Cerrahpasa Med. Fac., Neurology Dept, Child Neurology
The majority of the studies on West Syndrome (WS) are oriented towards
the clinical, imaging and EEG expressions of spasms and partial seizures,
as well as types of hypsarrhythmia, with regard to etiological, therapeutic
and prognostic implications. Non-epileptic manifestations such as behavioral
disturbances and cognitive problems, that are frequently encountered in
these patients, are, however, commonly overlooked by the epileptologist,
and are often referred to related specialties for consultation of either
the etiology, or more, the management Yet, there are some patients with
WS whose spasms are either preceeded or immediately followed by either
apparently non-epileptic motor manifestations such as dyskinesias, simple
repetitive acts, trans-like states mimicking atypical absence seizures,
and/or ritualistic, complicated behavioral changes. These events may take
place within a cluster of epileptic spasms. Sometimes, partial seizures
may also be present and increase the complexity of interpretation. Minor
spasms during such an episode may be subtle and go unnoticed if the video-EEC
is not carefully analyzed.
Whatever the nature of the motor and psychological phenomena accompanying
the spasms, they seem to be closely time-linked to the inter-spasm period.
While some patients may outgrow such behavioural patterns after infancy,
others may develop established autism in addition to their epilepsy.
This subject seems to deserve further attention from a pathophysiological
point of view, and possible cortico-subcortical circuits may be questioned
in the relation of seizures, spasms and stereotypes.
A video-display of some such episodes occurring in our patients with
WS is presented here.