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Toprani S, Jaradeh S, Falco-Walter JJ. Epileptic Seizure Induced by Head-Up Tilt: A Case Series Study. J Clin Neurophysiol 2023; 40:582-588. [PMID: 35394972 DOI: 10.1097/wnp.0000000000000926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
PURPOSE Epilepsy and syncope can be difficult to distinguish, with misdiagnosis resulting in unnecessary or incorrect treatment and disability. Combined tilt-table and video EEG (vEEG) testing (tilt-vEEG) is infrequently used to parse these entities even at large centers. Because of the discovery of a rare case of epileptic seizure induced by head-up tilt (HUT) (no prior cases have been published), the authors sought to verify the rarity of this phenomenon. METHODS An observational, retrospective case series study of all combined tilt-vEEG studies performed at Stanford Health Care over a 2-year period was performed. Studies were grouped into categories: (1) abnormal tilt and normal vEEG; (2) abnormal vEEG and normal tilt; (3) abnormal vEEG and abnormal tilt; (4) normal tilt and normal vEEG, with neurologic symptoms; and (5) normal tilt and normal vEEG without neurologic symptoms. RESULTS Sixty-eight percent of patients had an abnormal study (categories A-C), with only 3% having both an abnormal tilt and an abnormal EEG (category C). Of these, one patient had a focal epileptic seizure induced by HUT. With HUT positioning, the patient stopped answering questions and vEEG showed a left temporal seizure; systolic blood pressure abruptly dropped to 89 mm Hg (64 mm Hg below baseline); heart rate did not change, but pacemaker showed increased firing (threshold: <60 bpm). CONCLUSIONS Combined tilt-table and vEEG evaluation was able to identify a previously unreported scenario-head-up tilt provocation of an epileptic seizure-and improve treatment. Combined tilt and vEEG testing should be considered for episodes that persist despite treatment to confirm proper diagnosis.
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Affiliation(s)
- Sheela Toprani
- Department of Neurology, Division of Epilepsy, Stanford University Medical Center, Stanford, California, U.S.A
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Kozlowska K, Chudleigh C, Cruz C, Lim M, McClure G, Savage B, Shah U, Cook A, Scher S, Carrive P, Gill D. Psychogenic non-epileptic seizures in children and adolescents: Part I - Diagnostic formulations. Clin Child Psychol Psychiatry 2018; 23:140-159. [PMID: 28956448 PMCID: PMC5757410 DOI: 10.1177/1359104517732118] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Psychogenic non-epileptic seizures (PNES) are a nonspecific, umbrella category that is used to collect together a range of atypical neurophysiological responses to emotional distress, physiological stressors and danger. Because PNES mimic epileptic seizures, children and adolescents with PNES usually present to neurologists or to epilepsy monitoring units. After a comprehensive neurological evaluation and a diagnosis of PNES, the patient is referred to mental health services for treatment. This study documents the diagnostic formulations - the clinical formulations about the probable neurophysiological mechanisms - that were constructed for 60 consecutive children and adolescents with PNES who were referred to our Mind-Body Rehabilitation Programme for treatment. As a heuristic framework, we used a contemporary reworking of Janet's dissociation model: PNES occur in the context of a destabilized neural system and reflect a release of prewired motor programmes following a functional failure in cognitive-emotional executive control circuitry. Using this framework, we clustered the 60 patients into six different subgroups: (1) dissociative PNES (23/60; 38%), (2) dissociative PNES triggered by hyperventilation (32/60; 53%), (3) innate defence responses presenting as PNES (6/60; 10%), (4) PNES triggered by vocal cord adduction (1/60; 2%), (5) PNES triggered by activation of the valsalva manoeuvre (1/60; 1.5%) and (6) PNES triggered by reflex activation of the vagus (2/60; 3%). As described in the companion article, these diagnostic formulations were used, in turn, both to inform the explanations of PNES that we gave to families and to design clinical interventions for helping the children and adolescents gain control of their PNES.
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Affiliation(s)
- Kasia Kozlowska
- 1 Department of Psychological Medicine, The Children's Hospital at Westmead, NSW, Australia.,2 Brain Dynamics Centre at at Westmead Institute for Medical Research, NSW, Australia.,3 Sydney Medical School, The University of Sydney, NSW, Australia
| | - Catherine Chudleigh
- 1 Department of Psychological Medicine, The Children's Hospital at Westmead, NSW, Australia
| | - Catherine Cruz
- 1 Department of Psychological Medicine, The Children's Hospital at Westmead, NSW, Australia
| | - Melissa Lim
- 1 Department of Psychological Medicine, The Children's Hospital at Westmead, NSW, Australia
| | - Georgia McClure
- 1 Department of Psychological Medicine, The Children's Hospital at Westmead, NSW, Australia
| | - Blanche Savage
- 1 Department of Psychological Medicine, The Children's Hospital at Westmead, NSW, Australia
| | - Ubaid Shah
- 3 Sydney Medical School, The University of Sydney, NSW, Australia.,4 TY Nelson Department of Neurology, The Children's Hospital at Westmead, NSW, Australia.,5 Lady Cilento Children's Hospital, Queensland, Australia
| | - Averil Cook
- 1 Department of Psychological Medicine, The Children's Hospital at Westmead, NSW, Australia.,6 Child and Adolescent Mental Health Service Macarthur (ICAMHS) Macarthur, NSW, Australia
| | - Stephen Scher
- 3 Sydney Medical School, The University of Sydney, NSW, Australia.,7 Department of Psychiatry, Harvard Medical School, McLean Hospital, Belmont, MA, USA
| | - Pascal Carrive
- 8 Department of Anatomy, School of Medical Sciences, University of NSW, Australia
| | - Deepak Gill
- 3 Sydney Medical School, The University of Sydney, NSW, Australia.,4 TY Nelson Department of Neurology, The Children's Hospital at Westmead, NSW, Australia
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Abstract
OBJECTIVE To review the literature on self-induced epileptic seizures and apply psychiatric knowledge to define possible causes and treatment recommendations. METHODS A review of MEDLINE literature on self-induced epileptic seizures was conducted, followed by cross-referencing with the relevant neurologic, psychiatric and paediatric books and journals. RESULTS The reported prevalence of self-induction varies depending on the setting. In most instances, self-inducers are people affected by photosensitive primary generalized epilepsy, in whom self-induction is by intermittent photic stimulation or, more rarely, pattern stimulation or eye closure. Self-induced seizures are most commonly absences with spike-wave, though eyelid myoclonia and generalized myoclonic jerks occur. Earlier studies indicate that the majority of self-inducers were of subnormal intelligence but more recent ones indicate that as a group they could not be considered mentally retarded. Monitoring in a well-lit environment is indicated in any therapy-resistant photosensitive patient to determine whether or not self-induction occurs. Self-induced epilepsy is notoriously resistant to therapy and reasons for this resistance are discussed. An explanatory model for the initiation and maintenance of self-induction behaviour is also included. CONCLUSIONS It is difficult to determine from published papers just what level of clinical difficulty self-induction of seizures actually posed to the patients and clinicians. In some cases there is contradictory evidence as to the degree of willfulness or self-induction. Self-induced epileptic seizures may be an important aspect of poor seizure control in a subgroup of epilepsy sufferers. These seizures might be modifiable by psychiatric intervention or behavioural modification.
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Affiliation(s)
- Beng-Yeong Ng
- Department of General Psychiatry, Woodbridge Hospital and Institute of Mental Health, 10 Buangkuk View, Singapore, 539749.
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Guerrini R, Genton P, Dravet C, Viallat D, Bureau M, Horton EJ, Roger J. Compulsive somatosensory self-stimulation inducing epileptic seizures. Epilepsia 1992; 33:509-16. [PMID: 1592029 DOI: 10.1111/j.1528-1157.1992.tb01701.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Three children who had been diagnosed as having infantile spasms with major psychomotor retardation were referred for the persistence of series of spasm-like seizures, which were resistant to antiepileptic drug treatment, beyond infancy. Serial seizures were elicited by a compulsive self-stimulating behavior that was documented by long-term video-polygraphy. These behaviors implicated proprioceptive inputs: tapping on the chin in one case, flexion and external rotation of the leg with dislocation of the femur in one case, a particular posturing of the body followed by rhythmic shaking of the head in the last case. This clinical picture seems to constitute a particular type of outcome for infantile spasms and is particularly resistant to therapy.
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Peine HA, Liu L, Blakelock H, Jenson WR, Osborne JG. The use of contingent water misting in the treatment of self-choking. J Behav Ther Exp Psychiatry 1991; 22:225-31. [PMID: 1804857 DOI: 10.1016/0005-7916(91)90021-v] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
A 25-year-old, deaf-blind, mentally retarded male was treated for chronic self-choking using water mist treatment and positive reinforcement. During pre-treatment baseline, self-chokes occurred at a rate of 2.09 per minute. During treatment sessions each self-choke was followed by water misting of the subject's face paired with a forceful "No!". Periods of 20 sec absent of self-chokes were positively reinforced with liquids and/or social contacts. Treatment procedures were generalized from the initial therapists, location, and absence of other clients and staff to other locations, and the presence of other clients and staff. Water mist treatment was associated with at least a 10-fold and as much as a 100-fold reduction of self-choking (i.e. to 0.02-0.20 self-chokes per min) across treatment and generalization phases. Eight-month follow-up observations showed that self-choke rates were at zero.
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Abstract
A series of technological advances have made it possible to closely monitor electrophysiological and behavioural manifestations of episodic clinical events over prolonged periods of time, with the ability to review the records at leisure or to submit them to computer analysis. The more promising techniques are time-locked video/EEG monitoring, cable telemetry, radiotelemetry, ambulatory cassette recording, intensive plasma anti-epileptic drug monitoring and continuous neuropsychological monitoring. The greatest promise of these techniques is for the diagnosis, research and management of epilepsy. For psychiatry, they offer additional help in the differential diagnosis of non-epileptic events from epilepsy, the most important of which are psychogenic seizures and episodes of aggression. This paper discusses the potential role of these techniques in the assessment of non-epileptic events and transient cognitive impairment in clinical psychiatry.
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Affiliation(s)
- P S Sachdev
- Neuropsychiatric Institute, Prince Henry Hospital, Little Bay, New South Wales
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Gastaut H, Zifkin B, Rufo M. Compulsive respiratory stereotypies in children with autistic features: polygraphic recording and treatment with fenfluramine. J Autism Dev Disord 1987; 17:391-406. [PMID: 3654490 DOI: 10.1007/bf01487068] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Syncopes due to compulsive respiratory stereotypies were studied in eight patients with autistic features. Most had been referred for episodes thought to be intractable epileptic seizures. Polygraphic recording showed two types of syncope, one induced by prolonged apnea and the other by a prolonged Valsalva maneuver. Fenfluramine, 1.5-3 mg/kg per day, was given in an open trial. In four of five cases with frequent Valsalva maneuvers, respiratory stereotypies and syncopes were suppressed for 2-18 months. Patients with periodic apneas were more severely retarded and had less clear benefit. Side effects consisted of dose-dependent sedation and mild weight loss which stabilized without interrupting treatment. We suggest that these syncopes are volitional and may be associated with pleasant sensations. A double-blind placebo-controlled trial of fenfluramine seems warranted in such patients.
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Affiliation(s)
- H Gastaut
- Institut de Recherches Neurologiques, Faculte de Medecine, Marseille, France
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