Terminology of psychogenic nonepileptic seizures.

Several different terms have been used to describe "psychogenic nonepileptic seizures" (PNES) in the literature. In this study, we evaluated the most common English terms used to describe PNES on Google and in PubMed using multiple search terms (https://www.google.com and http://www.ncbi.nlm.nih.gov/pubmed). The information prevalence of the five terms most frequently used to refer to PNES in PubMed were: psychogenic non(-)epileptic seizure(s), followed by pseudo(-)seizure(s), non(-)epileptic seizure(s), psychogenic seizure(s), and non(-)epileptic event(s). The five most frequently adopted terms to describe PNES in Google were: psychogenic non(-)epileptic seizure(s), followed by non(-)epileptic event(s), psychogenic attack(s), non(-)epileptic attack(s), and psychogenic non(-)epileptic attack(s). The broad spectrum of synonyms used to refer to PNES in the medical literature reflects a lack of internationally accepted, uniform terminology for PNES. In addition to "seizure(s)," lay people use the word "attack(s)" to describe PNES. Although considered obsolete, some terms, e.g., pseudoseizure(s), are still used in the recent medical literature. Adopting a uniform terminology to describe PNES could facilitate communication between epileptologists, physicians without specific expertise in epilepsy, and patients.

Epilepsy-related stigma in European people with epilepsy: correlations with health system performance and overall quality of life.

We aimed to relate the percentages of encountered epilepsy-related stigma in people with epilepsy with quantitative indicators of the quality of health systems and quality of life by country in Europe. The epilepsy-related stigma percentages were obtained from the largest population-based study in people with epilepsy available. We correlated percentages of people with perceived stigma per European country with data on the country's overall health system performance, health expenditure per capita in international dollars, and the Economist Intelligence Unit's quality-of-life index. We found a nonsignificant trend towards negative correlation between the epilepsy-related stigma percentage and the overall health system performance (r=-0.16; p=0.57), the health expenditure per capita in international dollars (r=-0.24; p=0.4), and the Economist Intelligence Unit's quality-of-life index (r=-0.33; p=0.91). Living in a European country with a better health system performance and higher health expenditure per capita does not necessarily lead to a reduction in perceived epilepsy-related discrimination, unless the public health system invests on awareness programs to increase public knowledge and reduce stigma.

An educational campaign about epilepsy among Italian primary school teachers. 2. The results of a focused training program.

A cohort of 582 Italian primary school teachers underwent a questionnaire survey to test their knowledge and attitudes toward epilepsy and verify whether an intensive and focused educational program could result in improvement of knowledge and attitudes. The program consisted of a presentation of the clinical manifestations of epilepsy and the distribution of informative brochures and an educational kit on the disease and its management to be used with their students. After several months, 317 teachers were retested using the same questions. Upon retest, the number of "don't know" answers decreased significantly for almost all questions. This was not the case for negative attitudes. The same holds true for teachers believing that epilepsy is a source of learning disability and social disadvantage. These findings support the beliefs that education on epilepsy is more likely to affect ignorance than prejudice and that stronger interventions are needed to counteract stigmatizing behaviors.

Why do people Google epilepsy? An infodemiological study of online behavior for epilepsy-related search terms.

Millions of people worldwide use the Internet daily as a source of health information. Google is the most popular search engine and is used by patients and physicians to search for online health-related information. This study aimed to evaluate changes in web search behavior occurring in English-speaking countries over time for terms related to epilepsy and epileptic seizures. Using Google Trends, data on global search queries for the terms "epilepsy", "seizure", and "seizures" between January 2004 and September 2013 were analyzed. The reduction over time in search queries for the term "epilepsy" (and, to a lesser extent, "seizures") was counterbalanced by an increased trend in searches for the term "seizure". Most terms associated with the search queries were related to symptoms of seizures, especially tonic-clonic seizures, and to seizures occurring in children. Three peaks in search volume over the period studied corresponded to news of celebrities having seizures. The volume of searches for the term "epilepsy SUDEP" was found to be enormously increased over time. Most people appear to use search engines to look for terms related to epilepsy to obtain information on seizure symptoms, possibly to aid initial self-diagnosis. Fears and worries about epileptic seizures and news on celebrities with epilepsy seem to be major factors that influence online search behavior.

When one plus one makes three: the quest for rational antiepileptic polytherapy with supraadditive anticonvulsant efficacy.

The experimental and clinical evidence in support of "rational polytherapy" is sparse, and to date, no clear evidence-based indications can be made to help physicians in their choice of a specific drug combination against specific forms of epilepsy. This article briefly reviews the data available in the literature and obtained from studies conducted in humans to evaluate which main AED combinations might possess supraadditive, synergistic effects in terms of efficacy, with infraadditive toxicity. By far, the most documented association resulting in supraadditive anticonvulsant effects against focal seizures is that of VPA and LTG. There are some indications that combinations of drugs with different primary mechanisms of action may be more effective than combining drugs with the same mechanisms of action. However, further animal and human research studies that focus both on toxicity and anticonvulsant effects of various combinations of AEDs are required.

Seizure heralding tuberculous meningitis.

Seizures may frequently occur during tuberculous meningitis. We describe a patient with an apparent generalised tonic-clonic seizure, initially not associated with any magnetic resonance imaging (MRI) abnormality, which was the presenting symptom of tuberculous meningitis. Follow-up MRI, performed after gadolinium administration, showed signs of meningeal involvement. Seizures may be the presenting symptoms of tuberculous meningitis even in the absence of evident intracerebral lesions on MRI. Therefore, contrast-enhanced brain MRI should be performed in the diagnostic workup for each first seizure, especially in patients with a clinical suspicion of CNS infectious disease. The term "heraldic seizure", indicating a subset of acute symptomatic seizures presenting at the onset of a brain/systemic injury or preceding the full clinical manifestation of a cerebral insult, may be helpful to classify these seizures retrospectively, based initially on unknown aetiology.

Brain natriuretic peptide at altitude: relationship to diuresis, natriuresis, and mountain sickness.

BACKGROUND: Acute mountain sickness (AMS) affects some new arrivals above an altitude of 2500 m. Hypobaric hypoxia is known to produce diuresis and has natriuretic effects due to the release of natriuretic peptides. We tested the hypothesis that increases in brain natriuretic peptide (BNP) at altitude correlates with increased urination and natriuresis as well as symptomatic AMS. METHODS: Subjects were 14 mountaineers who undertook a Himalayan expedition that began at 100 m and passed through 3440 m en route to a final altitude of 5050 m. We measured the severity of AMS (Lake Louise Score), BNP values, nocturnal urine volume, and urine sodium concentration. RESULTS: Nocturnal urine volume increased from 490 +/- 90 mi at 3440 m to 1100 +/- 104 ml at 5050 m. BNP levels at the higher altitude were 10.6 +/- 4.7 pg x ml(-1) and were correlated with the severity of AMS in all mountaineers (Lake Louise Score 4 +/- 0.5 for AMS subjects). However, AMS severity did not correlate with urine volume or urine sodium concentration. CONCLUSIONS: Our results suggest that BNP secretion is not the cause of high-altitude diuresis. Further studies are needed to evaluate the possible role of BNP in individual responses to high altitude.

Cortical silent period following TMS in a patient with supplementary sensorimotor area seizures.

The cortical silent period (CSP) following transcranial magnetic stimulation (TMS) was evaluated in a patient with a dysembrioplastic neuroepithelial tumor (DNET) in the lateral portion of the right superior frontal gyrus (SFG) who suffered from supplementary sensorimotor area (SSMA) seizures. CSP duration was shortened on the affected side. Ipsilateral alterations of motor cortex excitability with TMS in epileptogenic DNET located outside the PMA argue in favour of cortico-cortical connections to primary motor cortex from SSMA. This functional connectivity should be taken into consideration to better understand the pathophysiology of ictal motor manifestations.

Right temporal cerebral dysfunction heralds symptoms of acute mountain sickness.

Acute mountain sickness (AMS) can occur during climbs to high altitudes and may seriously disturb the behavioral and intellectual capacities of susceptible subjects. During a Himalayan expedition 32 mountaineers were examined with electroencephalography (EEG) and transcranial doppler sonography (TCD) to assess relative changes of middle cerebral artery velocity in relation to end-expiratory CO2 (EtCO2), peripheral saturation (SaO2), and symptoms of AMS. We tested the hypothesis that O2 desaturation and EtCO2 changes precede the development of AMS and result in brain dysfunction and compensatory mechanisms which can be measured by EEG and TCD, respectively. Contrary to our hypothesis, we found that subjects who later developed symptoms of AMS between 3,440 m and 5,050 m altitude exhibited an increase of slow cerebral activity in the right temporal region already at 3,440 m. Cerebral blood flow increased in these mountaineers in the right middle cerebral artery at 5,050 m. These findings indicate that regional brain dysfunction, which can be documented by EEG, heralds the appearance of clinical symptoms of AMS.

Severe meningoencephalitis caused by human herpesvirus 6 type B in an immunocompetent woman treated with ganciclovir.

Human herpesvirus 6 (HHV-6), the causative agent of exanthema subitum in childhood, can also induce meningoencephalitis in immunocompromised individuals. In contrast, HHV-6 encephalitis in immunocompetent patients is rare, and the clinical syndrome not well defined. We report a case of meningoencephalitis caused by HHV-6 type B in an otherwise healthy woman.

Information-seeking behaviour for epilepsy: an infodemiological study of searches for Wikipedia articles.

Millions of people worldwide use the internet daily as a source of health information. Wikipedia is a popular free online encyclopaedia used by patients and physicians to search for health-related information. Our aim was to evaluate information-seeking behaviour of English-speaking internet users searching Wikipedia for articles related to epilepsy and epileptic seizures. Using Wiki Trends, which provides quantitative information on daily viewing of articles, data on global search queries for Wikipedia articles related to epilepsy and seizures were analysed. The daily Wikipedia article views on syncope, psychogenic non-epileptic seizures, migraine, and multiple sclerosis served as comparative data. The period of analysis covered was from January 2008 to December 2014. Overall, the Wikipedia article "epilepsy and driving" was found to be more frequently visited than the articles "epilepsy and employment" or "epilepsy in children". Since January 2008, the Wikipedia article "multiple sclerosis" was more often visited compared to the articles "epilepsy", "syncope", "psychogenic non-epileptic seizures" or "migraine"; the article "epilepsy" ranked 3,779 and was less frequently visited than "multiple sclerosis", ranked at 571, in traffic on Wikipedia. The highest peak in search volume for the article "epilepsy" coincided with the news of a celebrity having seizures. Fears and worries about epileptic seizures, their impact on driving and employment, and news about celebrities with epilepsy might be major determinants in searching Wikipedia for information.

Regional differences in the cerebral blood flow velocity response to hypobaric hypoxia at high altitudes.

Symptoms of acute mountain sickness (AMS) may appear above 2,500 m altitude, if the time allowed for acclimatization is insufficient. As the mechanisms underlying brain adaptation to the hypobaric hypoxic environment are not fully understood, a prospective study was performed investigating neurophysiological changes by means of near infrared spectroscopy, electroencephalograpy (EEG), and transcranial doppler sonography at 100, 3,440 and 5,050 m above sea level in the Khumbu Himal, Nepal. Fourteen of the 26 mountaineers reaching 5,050 m altitude developed symptoms of AMS between 3,440 and 5,050 m altitude (Lake-Louise Score ⩾3). Their EEG frontal beta activity and occipital alpha activity increased between 100 and 3,440 m altitude, i.e., before symptoms appeared. Cerebral blood flow velocity (CBFV) in the anterior and middle cerebral arteries (MCAs) increased in all mountaineers between 100 and 3,440 m altitude. During further ascent to 5,050 altitude, mountaineers with AMS developed a further increase in CBFV in the MCA, whereas in all mountaineers CBFV decreased continuously with increasing altitude in the posterior cerebral arteries. These results indicate that hypobaric hypoxia causes different regional changes in CBFV despite similar electrophysiological changes.

Subclinical rhythmic electroencephalogram discharge of adults occurring during sleep: a diagnostic challenge.

Subclinical rhythmic electroencephalogram discharge of adults (SREDA) is an electroencephalogram (EEG) pattern of uncertain significance, which occurs without any correlation with epilepsy. It resembles epileptiform activity, and is therefore likely to be misinterpreted as an authentic epileptiform pattern. We describe the occurrence of SREDA during stage II nonrapid eye movement (NREM) sleep and discuss the diagnostic difficulties that may arise when such a pattern is encountered during sleep EEG recordings. SREDA may occur during sleep, leading to difficulties in correct identification of this pattern, as the patient is unconscious and unable to report any symptoms. Although there are rather distinctive EEG features, the lack of changes in electrocardiogram rhythm and the absence of ocular/muscular artifacts suggest a nonepileptic phenomenon. The ultimate diagnosis, and the correct identification of SREDA, may be achieved by a comparison of EEG features between the pattern occurring during sleep and that recorded in the awake state.

The diagnostic value of urinary incontinence in the differential diagnosis of seizures.

PURPOSE: Urinary incontinence may occur both in epileptic seizures (ES) and in non-epileptic events (NEE) such as psychogenic nonepileptic events (PNEEs) and syncope. A comprehensive search of the literature to determine the accuracy of this physical finding and its prevalence in epileptic seizures and syncope is still lacking. To undertake a systematic review to determine sensitivity, specificity and likelihood ratios (LR) of urinary incontinence in the differential diagnosis between ES and NEEs (including syncope and PNEEs). METHODS: Studies evaluating the presence of urinary incontinence in ES and NEEs were systematically searched. Sensitivity, specificity, positive and negative likelihood ratio (pLR, nLR) of incontinence were determined for each study and for the pooled results. RESULTS: Five studies (221 epilepsy patients and 252 subjects with NEEs) were included. Pooled accuracy measures of urinary incontinence (ES versus NEEs) were: sensitivity 38%, specificity 57%, pLR 0.879 (95% CI 0.705-1.095) and nLR 1.092 (95% CI 0.941-1.268). For each comparison (epileptic seizures versus NEEs; ES versus syncope; ES versus PNEEs), pooled accuracy measures for urinary incontinence showed a statistically not significant pLR (the 95% CI of the pooled value included 1, and the LR value of 1 has no discriminatory value). CONCLUSIONS: A pooled analysis of data from the literature shows that urinary incontinence has no value either in the differential diagnostic between ES and syncope/PNEEs. Systematic reviews with pooled analyses of data from the literature allow an increase in statistical power and an improvement in precision, representing a useful tool to determine the accuracy of a certain physical finding in the differential diagnosis between ES and other paroxysmal events.

Clinical utility of ictal eyes closure in the differential diagnosis between epileptic seizures and psychogenic events.

The presence of ictal eye closure (IEC) has been considered to represent an additional clinical sign supporting the diagnosis of psychogenic non-epileptic events (PNEEs). We undertook a systematic review to evaluate sensitivity, specificity and likelihood ratios (LR) of IEC in the differential diagnosis between PNEEs and epileptic seizures. Six studies (total of 1496 events; 1021 epileptic seizures and 475 PNEEs) were included. Pooled accuracy measures of IEC for the diagnosis of PNEE were: sensitivity 58% (0.579) (95% CI 0.534-0.623), specificity 80% (0.895) (95% 0.875-0.9131)%, pLR 5.524 (95% CI 4.546-6.714) and nLR 0.47 (95% CI 0.422-0.524). However, a sensitivity analysis including only the studies performing an IEC assessment blinded to the diagnoses yielded results indicative of a rather low diagnostic value of IEC (pLR 3.056) compared with the analysis including unblinded studies (pLR 12.754). Further studies evaluating the occurrence of IEC through direct observation by means of video-EEG recording and blind to both EEG tracings and patient diagnosis are therefore required to definitely estimate the diagnostic utility of this sign in the differential diagnosis between epileptic seizures and PNEEs.

Trigemino-cervical reflex abnormalities in patients with migraine and cluster headache.

BACKGROUND: Head pain arises within the trigeminal nociceptive system. Current theories propose that the trigeminal system is intimately involved in the pathogenesis of migraine. Short-latency responses can be recorded in sternocleidomastoid muscles after stimulation of the trigeminal nerve (trigemino-cervical reflex). This brainstem reflex could be a suitable method to evaluate the trigeminal system in migraine and CH. OBJECTIVE: The aim of the present study was to further elucidate the pathophysiology of migraine and cluster headache (CH) with special reference to the involvement of the central trigeminal system in the different forms of primary headache. METHODS: The trigemino-cervical reflex was investigated in 15 healthy subjects, in 15 patients having migraine with aura, in 15 patients with migraine without aura, and in 10 patients with CH. RESULTS: Significant abnormalities were observed in a great number of patients with both types of migraine and CH during the headache attacks, but only in migraine patients during the interictal period. The alterations are bilateral in migraine, unilateral in CH. CONCLUSIONS: Our results further support the relevance of brainstem mechanisms in the pathogenesis of migraine rather than of CH. These data, taken together with that from experimental head pain and functional imaging studies, demonstrate that primary headache syndromes may be distinguished on a functional basis by areas of activation specific to the clinical syndrome.