Photic- and Pattern-induced Seizures: Expert Consensus of the Epilepsy Foundation of America Working Group

Termination of convulsion seizures by destabilizing and perturbing seizure memory engrams

Epileptogenesis, arising from alterations in synaptic strength, shares mechanistic and phenotypic parallels with memory formation. However, direct evidence supporting the existence of seizure memory remains scarce. Leveraging a conditioned seizure memory (CSM) paradigm, we found that CSM enabled the environmental cue to trigger seizure repetitively, and activating cue-responding engram cells could generate CSM artificially. Moreover, cue exposure initiated an analogous process of memory reconsolidation driven by mammalian target of rapamycin-brain-derived neurotrophic factor signaling. Pharmacological targeting of the mammalian target of rapamycin pathway within a limited time window reduced seizures in animals and interictal epileptiform discharges in patients with refractory seizures. Our findings reveal a causal link between seizure memory engrams and seizures, which leads us to a deeper understanding of epileptogenesis and points to a promising direction for epilepsy treatment.

The Frequency and Precipitating Factors for Breakthrough Seizures in Children with Epilepsy

Background and Purpose

To determine the common precipitating factors for breakthrough seizures in children with epilepsy.

Methods

This retrospective study reviewed the charts of children with epilepsy who were followed up in the pediatric neurology clinic of King Fahad Hospital in Al-Baha region, Saudi Arabia, between January 2015 and August 2022. Children between 1 to 14 years of age who had epilepsy, as per the International League Against Epilepsy definition and received anti-seizure medication with a seizure-free period of at least 2 months before breakthrough seizure episode, were included in the study.

Results

Of the 108 children included in the study, the mean age was 6.8±1.6 years, and among them (55.5%) were male. Most parents (69.5%) were unaware of the triggering factors of seizure. The majority of patients (88%) reported at least one precipitating factor for breakthrough seizures and the most common one was systemic infection associated with fever (52.8%), and then non-compliance to medications in (34.3%) of the patients. In terms of the electroencephalogram, around 84 patients (77.8%) had abnormal electroencephalogram. Finally, monotherapy was maintained in 63.9% of patients.

Conclusions

We conclude that the most common trigger for breakthrough seizure is a systemic infection associated with fever and non-compliance to anti-seizure medications. Increasing the level of awareness by different methods may help limit or even prevent seizures from occurring. Randomized controlled trials could shed light on the adjustment of anti-seizure medications temporarily by increasing the dosage or giving extra doses during the infection to avoid breakthrough seizures.

Photosensitive Accessibility for Interactive Data Visualizations

Accessibility guidelines place restrictions on the use of animations and interactivity on webpages to lessen the likelihood of webpages inadvertently producing sequences with flashes, patterns, or color changes that may trigger seizures for individuals with photosensitive epilepsy. Online data visualizations often incorporate elements of animation and interactivity to create a narrative, engage users, or encourage exploration. These design guidelines have been empirically validated by perceptual studies in visualization literature, but the impact of animation and interaction in visualizations on users with photosensitivity, who may experience seizures in response to certain visual stimuli, has not been considered. We systematically gathered and tested 1,132 interactive and animated visualizations for seizure-inducing risk using established methods and found that currently available methods for determining photosensitive risk are not reliable when evaluating interactive visualizations, as risk scores varied significantly based on the individual interacting with the visualization. To address this issue, we introduce a theoretical model defining the degree of control visualization designers have over three determinants of photosensitive risk in potentially seizure-inducing sequences: the size, frequency, and color of flashing content. Using an analysis of 375 visualizations hosted on bl.ocks.org, we created a theoretical model of photosensitive risk in visualizations by arranging the photosensitive risk determinants according to the degree of control visualization authors have over whether content exceeds photosensitive accessibility thresholds. We then use this model to propose a new method of testing for photosensitive risk that focuses on elements of visualizations that are subject to greater authorial control - and are therefore more robust to variations in the individual user - producing more reliable risk assessments than existing methods when applied to interactive visualizations. A full copy of this paper and all study materials are available at https://osf.io/8kzmg/.

Second-order texture gratings produce overestimation of height in depictions of rectangles and steps

The horizontal-vertical illusion (HVI) has been proposed as a method to increase the perceived height of steps, increase toe clearance and prevent falls. High contrast vertical stripes are placed on the step riser abutting a horizontal edge-highlighter creating 'T' junctions which are thought to promote the illusion. Various configurations of the HVI were tested including luminance gratings (L) and second-order modulations of contrast (CM), spatial frequency (FM) and orientation (OM). Observers were asked to compare the apparent height of gratings with that of either filled, unmodulated rectangles or unfilled rectangles. Rectangles were presented alone or as part of a step with a highlighter. In some conditions highlighters matched the properties of the grating; in others or not. In one critical experiment, the HVI was compared for steps with highlighters that were separated from the riser by a thin line and those where the risers and highlighters were continuous. All gratings except FM appeared taller when presented in the step configuration with a continuous, matching highlighter. This effect was greatly reduced when a thin line separated the grating from the highlighter and abolished for mis-matched highlighters and risers. In the rectangle conditions, all cues appeared taller than blank rectangles and L and CM appeared taller than filled-unmodulated rectangles. In conclusion, second-order cues may be useful for inducing the HVI onto steps. However, the ability of vertical stripes and edge-highlighters to accentuate perceived step height may be due to aggregation of the highlighter into the grating rather than the normal horizontal-vertical illusion.

Visually sensitive seizures: An updated review by the Epilepsy Foundation

Light flashes, patterns, or color changes can provoke seizures in up to 1 in 4000 persons. Prevalence may be higher because of selection bias. The Epilepsy Foundation reviewed light-induced seizures in 2005. Since then, images on social media, virtual reality, three-dimensional (3D) movies, and the Internet have proliferated. Hundreds of studies have explored the mechanisms and presentations of photosensitive seizures, justifying an updated review. This literature summary derives from a nonsystematic literature review via PubMed using the terms "photosensitive" and "epilepsy." The photoparoxysmal response (PPR) is an electroencephalography (EEG) phenomenon, and photosensitive seizures (PS) are seizures provoked by visual stimulation. Photosensitivity is more common in the young and in specific forms of generalized epilepsy. PS can coexist with spontaneous seizures. PS are hereditable and linked to recently identified genes. Brain imaging usually is normal, but special studies imaging white matter tracts demonstrate abnormal connectivity. Occipital cortex and connected regions are hyperexcitable in subjects with light-provoked seizures. Mechanisms remain unclear. Video games, social media clips, occasional movies, and natural stimuli can provoke PS. Virtual reality and 3D images so far appear benign unless they contain specific provocative content, for example, flashes. Images with flashes brighter than 20 candelas/m² at 3-60 (particularly 15-20) Hz occupying at least 10 to 25% of the visual field are a risk, as are red color flashes or oscillating stripes. Equipment to assay for these characteristics is probably underutilized. Prevention of seizures includes avoiding provocative stimuli, covering one eye, wearing dark glasses, sitting at least two meters from screens, reducing contrast, and taking certain antiseizure drugs. Measurement of PPR suppression in a photosensitivity model can screen putative antiseizure drugs. Some countries regulate media to reduce risk. Visually-induced seizures remain significant public health hazards so they warrant ongoing scientific and regulatory efforts and public education.

SSVEP-EEG Feature Enhancement Method Using an Image Sharpening Filter

Steady-state visual evoked potential (SSVEP) is widely used in brain computer interface (BCI), medical detection, and neuroscience, so there is significant interest in enhancing SSVEP features via signal processing for better performance. In this study, an image processing method was combined with brain signal analysis and a sharpening filter was used to extract image details and features for the enhancement of SSVEP features. The results demonstrated that sharpening filter could eliminate the SSVEP signal trend term and suppress its low-frequency component. Meanwhile, sharpening filter effectively enhanced the signal-to-noise ratios (SNRs) of the single-channel and multi-channel fused signals. Image sharpening filter also significantly improved the recognition accuracy of canonical correlation analysis (CCA), filter bank canonical correlation analysis (FBCCA), and task-related component analysis (TRCA). The tools developed here effectively enhanced the SSVEP signal features, suggesting that image processing methods can be considered for improved brain signal analysis.

The effects of visual discomfort and chromaticity separation on neural processing during a visual task

Visual stimuli that are uncomfortable to look at evoke a large neural response suggesting altered processing. While there is some evidence linking uncomfortable achromatic stimuli to impaired visual processing, the effect of uncomfortable chromatic patterns on visual cognition has yet to be explored. Large differences in chromaticity separation (e.g. red and blue) elicit visual discomfort, larger metabolic responses, larger visual evoked potentials, and greater alpha suppression compared to small chromaticity separations (e.g. pink and purple). We investigated the impact of stimuli that varied in their chromaticity separation (calculated in perceptual color space) on a visual task and their effect on neural responses across the cortex. Thirty participants completed a continuous pairs task (letters changed at 3 Hz) while grating patterns that differed in their chromaticity separation alternated with a grey screen at 5 Hz. The different temporal frequencies allowed for steady-state visual evoked potentials (SSVEPs) to the two stimulus-types to be measured simultaneously using electroencephalography (EEG). A subset of participants rated the gratings on a 9-point scale of discomfort. We observed greater ratings of discomfort and increased power at 5 Hz with the larger chromaticity separations. The increase in 5 Hz power with greater chromaticity separation was evident across the cortex. However, there was no significant effect of chromaticity separation on power at 3 Hz, or on reaction times, and no consistent effect on behavioral accuracy. Despite eliciting heightened neural responses across the cortex, short term exposure to uncomfortable chromatic stimuli does not adversely impact visual task performance.

An image-computable model for the stimulus selectivity of gamma oscillations

Gamma oscillations in visual cortex have been hypothesized to be critical for perception, cognition, and information transfer. However, observations of these oscillations in visual cortex vary widely; some studies report little to no stimulus-induced narrowband gamma oscillations, others report oscillations for only some stimuli, and yet others report large oscillations for most stimuli. To better understand this signal, we developed a model that predicts gamma responses for arbitrary images and validated this model on electrocorticography (ECoG) data from human visual cortex. The model computes variance across the outputs of spatially pooled orientation channels, and accurately predicts gamma amplitude across 86 images. Gamma responses were large for a small subset of stimuli, differing dramatically from fMRI and ECoG broadband (non-oscillatory) responses. We propose that gamma oscillations in visual cortex serve as a biomarker of gain control rather than being a fundamental mechanism for communicating visual information.

Photosensitivity in generalized epilepsies

Photosensitivity, which is the hallmark of photosensitive epilepsy (PSE), is described as an abnormal EEG response to visual stimuli known as a photoparoxysmal response (PPR). The PPR is a well-recognized phenomenon, occurring in 2-14% of patients with epilepsy but its pathophysiology is not clearly understood. PPR is electrographically described as 2-5Hz spike, spike-wave, or slow wave complexes with frontal and paracentral prevalence. Diagnosis of PPR is confirmed using intermittent photic stimulation (IPS) as well as video monitoring. The PPR can be elicited by certain types of visual stimuli including flicker, high contrast gratings, moving patterns, and rapidly modulating luminance patterns which may be encountered during e.g., watching television, playing video games, or attending discotheques. Photosensitivity may present in different idiopathic (genetic) epilepsy syndromes e.g. juvenile myoclonic epilepsy (JME) as well as non-IGE syndromes e.g. severe myoclonic epilepsy of infancy. Consequently, PPR is present in patients with diverse seizure types including absence, myoclonic, and generalized tonic-clonic (GTC) seizures. Across syndromes, abnormalities in structural connectivity, functional connectivity, cortical excitability, cortical morphology, and behavioral and neuropsychological function have been reported. Treatment of photosensitivity includes antiepileptic drug administration, and the use of non-pharmacological agents, e.g. tinted or polarizing glasses, as well as occupational measures, e.g. avoidance of certain stimuli.

Altered recovery from inhibitory repetitive transcranial magnetic stimulation (rTMS) in subjects with photosensitive epilepsy

OBJECTIVE

To investigate functional changes underlying photosensitivity, we studied the response of the visual cortex to low-frequency, inhibitory repetitive transcranial magnetic stimulation (rTMS) in drug-free patients with photosensitive seizures and healthy volunteers.

METHODS

Visual evoked potentials (VEPs) triggered by grating stimuli of different contrasts were recorded in both hemispheres before and after transient functional inactivation of the occipital cortex of one side via low-frequency rTMS (0.5Hz for 20'). VEPs were recorded before (T0), immediately after (T1) and 45' following the completion of rTMS (T2).

RESULTS

Baseline amplitudes of the early VEP components (N1 and P1) were enhanced in photosensitive patients. At T1, rTMS produced an inhibitory effect on VEPs amplitudes at all contrasts in the targeted side and a concurrent facilitation of responses in the contralateral hemisphere. Compared with PSE subjects, VEP amplitudes remained persistently dampened in the stimulated hemisphere of controls (Holm-Sidak post-hoc method, p<0.05). In the contralateral hemisphere, we found a clear enhancement of VEP amplitude in photosensitive subjects but not controls at T2 (Holm-Sidak test, p<0.001).

CONCLUSIONS

Visual responses recovered more quickly in the stimulated hemisphere, and disinhibition persisted in the contralateral side of photosensitive subjects.

SIGNIFICANCE

The rapid recovery of excitability and the persistent transcallosal disinhibition following perturbation of cortical activity may play a role in the pathophysiology of photosensitive epilepsy.

Reduction of seizure occurrence from exposure to auditory stimulation in individuals with neurological handicaps: a randomized controlled trial

BACKGROUND

The purpose of this work was to determine in a clinical trial the efficacy of reducing or preventing seizures in patients with neurological handicaps through sustained cortical activation evoked by passive exposure to a specific auditory stimulus (particular music). The specific type of stimulation had been determined in previous studies to evoke anti-epileptiform/anti-seizure brain activity.

METHODS

The study was conducted at the Thad E. Saleeby Center in Harstville, South Carolina, which is a permanent residence for individuals with heterogeneous neurological impairments, many with epilepsy. We investigated the ability to reduce or prevent seizures in subjects through cortical stimulation from sustained passive nightly exposure to a specific auditory stimulus (music) in a three-year randomized controlled study. In year 1, baseline seizure rates were established. In year 2, subjects were randomly assigned to treatment and control groups. Treatment group subjects were exposed during sleeping hours to specific music at regular intervals. Control subjects received no music exposure and were maintained on regular anti-seizure medication. In year 3, music treatment was terminated and seizure rates followed. We found a significant treatment effect (p = 0.024) during the treatment phase persisting through the follow-up phase (p = 0.002). Subjects exposed to treatment exhibited a significant 24% decrease in seizures during the treatment phase, and a 33% decrease persisting through the follow-up phase. Twenty-four percent of treatment subjects exhibited a complete absence of seizures during treatment.

CONCLUSION/SIGNIFICANCE

Exposure to specific auditory stimuli (i.e. music) can significantly reduce seizures in subjects with a range of epilepsy and seizure types, in some cases achieving a complete cessation of seizures. These results are consistent with previous work showing reductions in epileptiform activity from particular music exposure and offers potential for achieving a non-invasive, non-pharmacologic treatment of epilepsy.

TRIAL REGISTRATION

Clinicaltrials.gov NCT01459692.

Aura interruption: the Andrews/Reiter behavioral intervention may reduce seizures and improve quality of life - a pilot trial

Patients with epilepsy frequently experience depression and emotional stress and these may function as seizure triggers in epileptogenic frontotemporal cortex, which serves in emotional processing. Eight patients enrolled in a pilot trial of a 6-month epilepsy-specific behavioral approach comprising counseling and relaxation to recognize and eliminate emotional seizure triggers. Potential participants with psychogenic seizures were excluded by long-term EEG and/or the MMPI profile. One participant became seizure free, another had an approximately 90% reduction in seizures, and two additional participants achieved a greater than 50% reduction in seizure frequency (total responder rate=50%), stable during 6 months of observation after the intervention. All completers showed marked and stable improvement of quality of life (Quality of Life in Epilepsy-89 inventory) and temporary improvement in the Profile of Mood States. An adequately powered randomized controlled trial is needed to confirm our findings, which suggest that behavioral approaches may hold promise for motivated patients with epilepsy.

Three-dimensional entertainment as a novel cause of takotsubo cardiomyopathy

Takotsubo cardiomyopathy (TC) is an uncommon entity. It is known to occur in the setting of extreme catecholamine release and results in left ventricular dysfunction without evidence of angiographically definable coronary artery disease. There have been no published reports of TC occurring with visual stimuli, specifically 3-dimensional (3D) entertainment. We present a 55-year-old woman who presented to her primary care physician's office with extreme palpitations, nausea, vomiting, and malaise <48 hours after watching a 3D action movie at her local theater. Her electrocardiogram demonstrated ST elevations in aVL and V1, prolonged QTc interval, and T-wave inversions in leads I, II, aVL, and V2-V6. Coronary angiography revealed angiographically normal vessels, elevated left ventricular filling pressures, and decreased ejection fraction with a pattern of apical ballooning. The presumed final diagnosis was TC, likely due to visual-auditory-triggered catecholamine release causing impaired coronary microcirculation.

Photosensitive epilepsy and image safety

Photosensitive epilepsy came to prominence in the 1950s with the advent of television. Photosensitive epilepsy occurs in 1 in 4000 of the population. The incidence is 1.1 per 100,000 per annum, however amongst 7-19 year-olds the incidence is more than five times as common. Photosensitive epilepsy is twice as common in females as in males. The onset is around puberty, but less than 25 per cent of patients lose their photosensitivity in their twenties. Patients are investigated in the EEG laboratory using intermittent photic stimulation. Peak sensitivity is between 16 and 20 flashes/s but 49 per cent of patients are sensitive to 50 flashes/s, explaining the sensitivity to PAL television systems. From 1993 the development of broadcast guidelines was developed restricting both flash rates and the areas of screen involved, as well as the use of long-wavelength red. Automatic analysis systems can now test material for compliance with guidelines in real time.

Steady-state visually evoked potentials: focus on essential paradigms and future perspectives

After 40 years of investigation, steady-state visually evoked potentials (SSVEPs) have been shown to be useful for many paradigms in cognitive (visual attention, binocular rivalry, working memory, and brain rhythms) and clinical neuroscience (aging, neurodegenerative disorders, schizophrenia, ophthalmic pathologies, migraine, autism, depression, anxiety, stress, and epilepsy). Recently, in engineering, SSVEPs found a novel application for SSVEP-driven brain-computer interface (BCI) systems. Although some SSVEP properties are well documented, many questions are still hotly debated. We provide an overview of recent SSVEP studies in neuroscience (using implanted and scalp EEG, fMRI, or PET), with the perspective of modern theories about the visual pathway. We investigate the steady-state evoked activity, its properties, and the mechanisms behind SSVEP generation. Next, we describe the SSVEP-BCI paradigm and review recently developed SSVEP-based BCI systems. Lastly, we outline future research directions related to basic and applied aspects of SSVEPs.

A descriptive analysis of seizure events among adults who participated in a computer-based assessment

The purpose of this study was to document seizure events associated with the use of a computer-based assessment and to describe the contextual factors surrounding these seizure episodes. Study participants were adults with epilepsy who were enrolled at research sites in Atlanta and Boston. Subjects were asked to complete a computer-based assessment at 3 time points. Fourteen seizure events were documented; they occurred during 1.6% of all completed assessments (896) and affected 4.4% of the participants (320). The mean age of participants who experienced seizure events was 41.4 years; about 70% were female, and 70% were white. A variety of possible precipitating factors for seizure events included hunger, fatigue, stress, and medication changes. Participants indicated computer use could have triggered their seizures in 2 instances. These findings suggest use of computer-based assessments may pose minimal risks for adults with epilepsy, particularly those without a history of photosensitivity epilepsy.

Scotosensitive and Photosensitive Myoclonic Seizures in an Infant with Trisomy 13

We describe a male carrier of trisomy 13 with scotosensitive and photosensitive myoclonic seizures appearing at the age of 8 months and persisting until death at 20 months. The seizures consisted of massive myoclonic jerks induced both by switching the room light suddenly on or off or by IPS with a frequency of 1 s. Spontaneous seizures were absent. The child also presented from the same age with breath-holding spells. This is interesting because it represents a rare example of the co-occurrence of scotosensitive and photosensitive seizures. Furthermore, a possible association to locus on 13q31.3 has been reported for photosensitivity, while for scotosensitivity there is no previous genetic information.

Is colour modulation an independent factor in human visual photosensitivity?

Considering that the role of colour in photosensitive epilepsy (PSE) remains unclear, we designed a study to determine the potential of different colours, colour combinations and white light to trigger photoparoxysmal responses (PPRs) under stringent controlled conditions. After assessing their photosensitivity to stroboscopic white light and black and white patterns, we studied 43 consecutive PSE patients (mean age 19 years, 34 women), using a specially designed colour stimulator. Stimuli included: pulse trains between 10 and 30 Hz of white light and of all primary colours, and also isoluminant alternating time-sequences of colours. Illuminance was kept constant at 100 lux. A progressive stepwise increase of the modulation-depth (MD) of the stimuli was used to determine PPRs threshold. Whereas all the 43 patients were found to be sensitive during the stroboscopic and pattern protocol, only 25 showed PPRs (Waltz's score >2) at least in one session when studied with the colour stimulator. Coloured stimuli elicited PPRs in all these patients, whereas white light did so only in 17 patients. Of the primary colours, red elicited more PPRs (54 in 22 patients) and at a lower MD (max Z-score 0.93 at 10 Hz). Of the alternating sequences, the red-blue was the most provocative stimulus, especially below 30 Hz (100% of patients, max Z-score: 1.65 at 15 Hz). Blue-green was the least provocative stimulus, since it elicited only seven PPRs in seven (28%) patients (max Z-score 0.44 at 10 Hz). Sensitivity to alternating colours was not correlated to sensitivity to individual colours. We conclude that colour sensitivity follows two different mechanisms: one, dependent on colour modulation, plays a role at lower frequencies (<30 Hz). Another, dependent on single-colour light intensity modulation correlates to white light sensitivity and is activated at higher frequencies. Our results suggest that the prescription of spectacles with coloured lenses, tailored to the patient, can be an effective preventative measure against visually induced seizures.

Video game epilepsy in the twentieth century: a review

INTRODUCTION

Visually evoked seizures have been reported for almost 2,000 years. This source of seizure activity, however, seems to have increased recently with the advent of new technologies used for television and computer games.

METHODS

The present paper reviews the literature regarding this interesting phenomenon.

RESULTS

After our review, it does appear that visually evoked seizures have increased in frequency during the twentieth century.

CONCLUSIONS

We believe that knowledge of visually evoked seizures may aid neuroscientists in further exploration of the pathophysiology of seizure activity and its related preventive measures. Further studies are necessary to prove the etiology of such seizure activity.

Photic- and pattern-induced seizures: a review for the Epilepsy Foundation of America Working Group

PURPOSE

This report summarizes background material presented to a consensus conference on visually provoked seizures, convened by the Epilepsy Foundation of America.

METHODS

A comprehensive review of literature was performed.

RESULTS

Photosensitivity, an abnormal EEG response to light or pattern stimulation, occurs in approximately 0.3-3% of the population. The estimated prevalence of seizures from light stimuli is approximately 1 per 10,000, or 1 per 4,000 individuals age 5-24 years. People with epilepsy have a 2-14% chance of having seizures precipitated by light or pattern. In the Pokemon cartoon incident in Japan, 685 children visited a hospital in reaction to red-blue flashes on broadcast television (TV). Only 24% who had a seizure during the cartoon had previously experienced a seizure. Photic or pattern stimulation can provoke seizures in predisposed individuals, but such stimulation is not known to increase the chance of subsequent epilepsy. Intensities of 0.2-1.5 million candlepower are in the range to trigger seizures. Frequencies of 15-25 Hz are most provocative, but the range is 1-65 Hz. Light-dark borders can induce pattern-sensitive seizures, and red color also is a factor. Seizures can be provoked by certain TV shows, movie screen images, video games, natural stimuli (e.g, sun on water), public displays, and many other sources.

CONCLUSIONS

Recommendations on reducing risk of seizures have been developed by agencies in the United Kingdom, Japan, and the International Telecommunications Union, affiliated with the United Nations. The Epilepsy Foundation of America has developed a consensus of medical experts and scientists on this subject, reported in an accompanying work.