Recurrent episodes of falls and amnestic confusional states as diagnostic challenge in the elderly.

New-onset paroxysmal events in patients over 60 years of age are often diagnostically challenging owing to atypical presentation. Recurrent falls and transient states of confusion are especially common in the elderly population, yet their causes often remain undiagnosed due to concomitant cognitive deficits and motor impairments. We present an elderly patient with newly occurring 'blackouts' without obvious triggers and transient states of confusion for which he was amnestic. All neurological exams including brain MRI scan and routine electroencephalography (EEG) were normal. Long-term ECG monitoring using an event recorder captured an asystole during a habitual episode, leading to the diagnosis of syncope and pacemaker implantation. A subsequent video EEG monitoring performed due to ongoing unexplained confusional states revealed both bradycardia and long-lasting confusional states to be caused by unrecognised temporal lobe seizures. Ictal video EEG monitoring may play a crucial role in establishing a diagnosis of atypical temporal lobe seizures in the elderly.

Spread of ictal activity in focal epilepsy.

PURPOSE: Latencies between seizure onset, propagation of ictal activity, and initial clinical symptoms and signs are critically important for the successful implementation of detection-based intervention systems in the treatment of epilepsy. This study analyzes intracranial EEG-recordings for temporal characteristics of ictal spread and its dependence on focus localization. METHODS: Intracerebral EEG recordings of 215 seizures from 43 patients with pharmacoresistant focal epilepsy were evaluated based on site of first propagation, latencies between EEG seizure onset, early propagation, and clinical seizure onset. Seizure onset was mesial temporal in 15 patients, neocortical temporal in 15 patients, and frontal in 13 patients. RESULTS: Periods during which ictal activity remained confined to the seizure onset area showed significant differences between the patient groups. Median latencies between electrographic seizure onset and early propagation were significantly longer for patients with mesial temporal (5 s in seizure-based analysis/10 s in patient-based analysis) as compared to neocortical temporal (3 s/5 s) and frontal seizure focus (1 s/2 s; p < 0.01). Concordantly, median latencies to onset of clinical symptomatology were significantly longer for patients with mesial temporal (17 s/19 s) as compared to neocortical temporal (11 s/17 s) and frontal seizure focus (4 s in seizure-based analysis and 6 s in patient-based analysis; p < 0.01). CONCLUSIONS: The speed of propagation of ictal activity and the latencies until initial clinical seizure symptoms differ significantly depending on focus localization. Extended spread often occurred within the time window during which current detection systems operate. This suggests that inclusion criteria of patients suitable for testing the efficacy of detection-based seizure intervention strategies should be based on focus localization and patient-individual propagation patterns.

Dissociative seizures: a challenge for neurologists and psychotherapists.

BACKGROUND: The prevalence of dissociative seizures is between 2 and 33 sufferers per 100,000 persons. 70% of sufferers are women. Dissociative seizures markedly impair quality of life. Their close superficial resemblance to epileptic seizures makes them hard to diagnose. METHODS: Selective literature search in PubMed and PsycINFO. RESULTS: Persons with dissociative seizures constitute a mixed group with a wide variety of predisposing, precipitating, and maintaining factors. Some 90% have comorbid psychiatric disorders such as depression, anxiety, somatoform disorders, personality disorders, or post-traumatic stress disorder. Video-EEG monitoring enables highly reliable diagnosis. Psychotherapy is considered the treatment of first choice; in prospective studies, it has been found to lower the frequency of dissociative seizures by at least 50%, or to eliminate them completely, in 50% to 80% of patients. An individually tailored combination of behavioral therapeutic, imagery-based, and psychodynamic approaches seems reasonable. For the treatment of psychiatric comorbidities, psychotherapy is indicated, in combination with psychoactive drugs if necessary. Before any treatment is provided, the diagnosis should be communicated to the patient in an appropriate way, ideally by both the neurologist and the psychotherapist, so that the patient can develop an alternative disease model. CONCLUSION: When the diagnosis of dissociative seizures has been made, psychotherapy is indicated, possibly in combination with psychoactive medication, in the setting of long-term treatment provided in collaboration by the neurologist, psychiatrist, psychotherapist, and family physician. Further randomized trials are needed to determine which treatments are best for which subgroups of patients.

Latencies to first typical generalized spike-wave discharge in idiopathic generalized epilepsies during video-EEG monitoring.

To assess latencies to the first typical generalized spike-wave discharge (GSWD) and clinically manifest seizure during long-term video-EEG monitoring (VEM) in patients with idiopathic generalized epilepsy (IGE). This is a retrospective analysis of continuous long-term VEM of 39 patients (25 women; mean age, 28.7 years). Mean duration of VEM was 3 days (1-11 days). Latencies from start of VEM to the first appearance of GSWD and the first clinically manifest seizure were analyzed for IGE subsyndrome. Overall, mean latency from the beginning of VEM to the first typical GSWD was 853 minutes (range, 3-7,305 minutes). In 38.5% of the patients, the first typical GSWD occurred during the first hour of VEM and in 87.2% during the first day. Latencies were significantly shorter in juvenile absence epilepsy than in juvenile myoclonic epilepsy, epilepsy with generalized tonic-clonic seizures only, and IGE not further classified (P = 0.001). In 38.5% of the patients, clinically manifest seizures were recorded. Overall, mean latency to the first seizure was 1,984 minutes (range, 3-8,123 minutes). There were no significant differences in latencies to the first seizure between IGE syndromes. One day of VEM is sufficient for classification as IGE in the majority of patients. Patients with juvenile absence epilepsy had particularly low latencies to the appearance of the first typical GSWD. There is, however, a group of patients (12.8% in our sample) requiring a prolonged VEM period to achieve sufficient electroclinical evidence for syndromatic classification.