Wavelength dependency of photoparoxysmal responses in photosensitive nonepileptic subjects

Light-emitting-diode and Grass PS 33 xenon lamp photic stimulators are equivalent in the assessment of photosensitivity: Clinical and research implications

The assessment of the effect of photic stimulation is an integral component of an EEG exam and is especially important in patients referred for ascertained or suspected photosensitivity with or without a diagnosis of epilepsy. A positive test result relies on eliciting a specific abnormality defined as the "photoparoxysmal response". Reliability of this assessment is strongly influenced by technical and procedural variables, a critical one represented by the physical properties of the stimulators used. Established clinical norms are based on data acquired with the "gold-standard" Grass PS stimulators. These are no longer commercially available and have been replaced by stimulators using light emitting diode (LED) technology. To our knowledge no comparative study on their efficacy has been conducted. To address this gap, we recruited 39 patients aged 5-54 years, referred to two specialized centers with confirmed of suspected diagnosis of photosensitive epilepsy or generalized epilepsy with photosensitivity in a prospective randomized single-blind cross-over study to compare two commercially available LED-bases stimulation systems (FSA 10® and Lifeline® stimulators) against the Grass PS 33 xenon lamp device. Our findings indicate that the LED systems tested are equivalent to the Grass stimulator both in identifying the PPR in affected individuals.

The photoparoxysmal response: the probable cause of attacks during video games

Photic stimulation is part of a typical EEG in most countries, especially to check on the photoparoxysmal response (PPR). Interest in this response was enhanced in 1997 when hundreds of Japanese children had attacks while viewing a TV cartoon called "Pokemon." The overall prevalence of the PPR among patients requiring an EEG is approximately 0.8%, but 1.7% in children and 8.87% in patients with epilepsy, more often in Caucasians and females. Autosomal dominant inheritance is indicated, and this response is seen especially at the wavelength of 700 nm or at the flicker frequency of 15-18 Hz. The PPR extending beyond the stimulus carries no increased risk of seizures. Prognosis is generally good, especially after 20 years of age. Attention to PPR has been increased with the advent of video games, and the evoked seizures from these games are likely a manifestation of photosensitive epilepsy. Drug therapy has emphasized valproic acid, but Levetiracetam has also been successful in eliminating the PPR.

Human photosensitivity: from pathophysiology to treatment

Photosensitivity is a condition detected on the electroencephalography (EEG) as a paroxysmal reaction to Intermittent Photic Stimulation (IPS). This EEG response, elicited by IPS or by other visual stimuli of daily life, is called Photo Paroxysmal Response (PPR). PPRs are well documented in epileptic and non-epileptic subjects. Photosensitivity rarely in normal individuals evolves into epilepsy. Photosensitive epilepsy is a rare refex epilepsy characterized by seizures in photosensitive individuals. The development of modern technology has increased the exposition to potential seizure precipitants in people of all ages, but especially in children and adolescents. Actually, videogames, computers and televisions are the most common triggers in daily life of susceptible persons. The mechanisms of generation of PPR are poorly understood, but genetic factors play an important rule. The control of visually induced seizures has, generally a good prognosis. In patients known to be visually sensitive, avoidance of obvious source and stimulus modifications are very important and useful to seizure prevention, but in the large majority of patients with epilepsy and photosensitivity antiepileptic drugs are needed.

Photosensitivity and epilepsy

Photosensitive epilepsy is a well-known condition characterized by seizures in patients who show photoparoxysmal responses on electroencephalography (EEG) elicited by intermittent photic stimulation. Photoparoxysmal responses can be defined as epileptiform EEG responses to intermittent photic stimulation or to other visual stimuli of everyday life and are frequently found in nonepileptic children. The modern technologic environment has led to a dramatic increase in exposure to potential trigger stimuli; nowadays, television and video games are among the most common triggers in daily life. There is ample evidence for genetic transmission of photoparoxysmal responses; systematic family studies have provided data for an autosomal dominant mode of inheritance with age-dependent penetrance for photosensitivity. The age of maximum penetrance is between 5 and 15 years. The prognosis for control of seizures induced by visual stimulation is generally very good. The large majority of patients do not need anticonvulsant therapy, but, when needed, the drug of choice is valproate. Stimulus avoidance and stimulus modification can be an effective treatment in some patients and can sometimes be combined with antiepileptic drug treatment.

Can police car colored flash light induce electroencephalographic discharges and seizures?

AIM

To explore the epileptogenic potential of a newly introduced police car flash light device (930 Heliobe Lightbar).

METHODS

A 930 Heliobe Lightbar was installed in the EEG laboratory. Thirty patients with known epilepsy, 30 subjects with chronic headache who were otherwise healthy and 15 healthy volunteers were examined.

RESULTS

All the subjects signed an informed consent and underwent an EEG during which photostimulation was performed with the standard stroboscope and later with the Police lightbar. In all 75 examined the lightbar did not induce clinical or electrographic seizures. In a single patient with epilepsy the lightbar enhanced epileptiform activity induced by standard photic stimulation.

CONCLUSION

In this study the new Police lightbar was found to be non-epileptogenic.

Long-wavelength red light emission from TV and photosensitive siezures

PURPOSE

We investigated a role of long-wavelength red light emission from TV in the induction of photosensitive seizures by an animated TV program called "Pocket Monsters".

METHODS

The luminance energy of recorded color bar was measured by a spectroradiometer in cathode-ray tubes (CRTs) of photosensitive patients with and without seizures on the program (induced patients and photosensitive controls).

RESULTS

The mean ratio of long-wavelength red light to total visible range was significantly higher in the CRTs of induced patients than in the CRTs of photosensitive controls. The ratio of luminance energy between at turn-on and at 60 min after turn-on of the CRTs indicated that luminance energy in long-wavelength red range from the CRTs of induced patients increased significantly after turn-on of CRTs.

CONCLUSIONS

High amounts of long-wavelength red light emitted from CRTs might play an important role in induction of photosensitive seizures in "Pokemon" incident.

Wavelength dependence of photoparoxysmal responses in photosensitive patients with epilepsy

PURPOSE

We tried to specify the relation between the photoparoxysmal response (PPR) and the wavelength spectra of flashing light in various photosensitive epileptic syndromes in the physiologic state.

METHODS

Intermittent photic stimulation (IPS) by a Grass PS22 photic stimulator was performed with wavelength-specific optical filters in photosensitive patients with epilepsy (idiopathic generalized epilepsy, IGE; hereditary dentatorubral-pallidoluysian atrophy, DRPLA) and photosensitive subjects without epilepsy.

RESULTS

Five of 19 normal trichromat patients with IGE and an IGE patient with deuteranomaly showed wavelength-dependent PPRs. The wavelength-dependent PPRs were elicited only by IPS containing wavelength spectra approximately 700 nm in the normal trichromat patients. Two of four patients with DRPLA showed wavelength-dependent PPRs, and two other DRPLA patients showed quantity-of-light-dependent PPRs. Quantity-of-light-dependent PPRs are elicited by IPS containing more than a certain quantity of light, independent of the wavelength composition of the flashing light. Two of five subjects without epilepsy showed wavelength-dependent PPRs.

CONCLUSIONS

There are wavelength-dependent and quantity-of-light-dependent pathophysiologic mechanisms for eliciting PPRs by low-luminance IPS. Consideration of the quantity and wavelength composition of light from electronic screens will lead to the prevention of photosensitive seizures induced by electronic screen games.