Diagnostic value of serum prolactin levels in PNES in the epilepsy monitoring unit.

BACKGROUND: This is a retrospective study to determine the usefulness of serum prolactin levels in the epilepsy monitoring unit (EMU) for distinguishing psychogenic nonepileptic seizures (PNES) from epileptic seizures (ES). METHODS: All the records of consecutive patients admitted to the EMU between 2008 and 2012 were reviewed. Patients with a diagnosis of PNES and ES were selected. Serum prolactin level was obtained within 20 minutes for all patients, and an elevated prolactin level was defined as twice the patient's baseline value. A total of 607 records were reviewed, and 389 patients were excluded because of incomplete information or lack of a clinical event. RESULTS: A total of 218 patients were included in the analysis. A further 18 patients were excluded because of simple partial seizures or because the documented time of obtaining serum prolactin was not clear. A total of 146 patients had PNES, of which 42 had elevated prolactin levels, representing a 28.8% false-positive rate. All 22 patients with generalized tonic-clonic seizures had elevated serum prolactin; however, 5 of 32 patients with complex partial seizures did not have an elevated prolactin level, representing a 15.6% false-negative rate. CONCLUSIONS: Serum prolactin levels do not provide any additional support for distinguishing PNES from ES. Furthermore, serum prolactin levels in this setting add unnecessary blood draws and financial burden for the patients. Therefore, prolactin levels should not be obtained routinely in the EMU. CLASSIFICATION OF EVIDENCE: This study provides Class III evidence that postevent elevation of serum prolactin occurs in 84.4% of patients with ES and 28.8% of patients with PNES.

Temporal lobe discharges and glossolalia.

Glossolalia (speaking in tongues) is a religious phenomenon of which there has been only limited scientific investigation. Described here is the case of a 44-year-old woman who had clonic jerking of the left forearm while speaking in tongues. Waking EEG while she was thinking of nothing in particular was normal. After several minutes of silently praying in tongues she manifested right temporal sharp wave discharges and may have been in a state resembling light sleep. Possible relationships between glossolalia, ecstatic religious phenomena, and temporal lobe electrical discharges are discussed.

The efficacy of routine hyperventilation for seizure activation during prolonged video-electroencephalography monitoring.

Hyperventilation (HV) is considered to be one of the activation procedures that provokes epileptic potentials and clinical seizures. However, the true clinical yield of HV is not well established. We retrospectively reviewed the records of all patients admitted to JFK Hospital, Edison, New Jersey, between October 2001 and December 2004 for long-term video-electroencephalography (EEG). A total of 475 patients (193 males; 282 females; age range 5-89 years) were included in the study. All patients underwent routine 3-minute HV as part of the evaluation of their clinical episodes. During the initial assessment, 165 patients did not experience a seizure event, 92 had non-epileptic events, 16 experienced psychogenic non-epileptic seizures (PNES) and six had a clinical event. During HV, of the 43 patients who had primary generalized epilepsy, nine had an abnormal EEG and two experienced seizures; however, out of the 159 patients who had partial seizures, only one patient demonstrated an abnormal EEG. Our study demonstrates that routine HV generally has a very low yield in our Epilepsy-Monitoring Unit. This finding also lends support to the idea that partial seizures are relatively resistant to HV activation.

Long-term outcome of vagus nerve stimulation therapy in patients with refractory epilepsy.

We retrospectively assessed the long-term efficacy of vagus nerve stimulation (VNS) therapy in 31 patients with refractory partial and generalized seizures who were not candidates for resective epilepsy surgery. Following implantation of VNS there was significant improvement in seizure frequency at 6 months. Sixteen patients continued to have sustained response to VNS therapy 4 years later. Adverse effects of VNS therapy were transient and tolerable. The majority of the patients did not gain body weight and some of them had significant weight loss. Therefore VNS is safe and effective therapy and has a long-term sustained effect in refractory epilepsy.

Auditory evoked potentials in the detection of interaural intensity differences in children and adults.

OBJECTIVE: The goal of the current study was to identify neurophysiological indices of binaural processing in children with no history of hearing loss or listening problems. The results will guide our efforts to diagnose children for whom impaired binaural processing may contribute to difficulty understanding speech in adverse listening environments. Our main aim was to document the cortical auditory evoked potentials (AEPs) in response to interaural intensity differences (IIDs) in children. It is well known, however, that the morphology of AEPs is substantially different in children and adults. Comparison of AEPs in response to IIDs between children and adults allowed us to evaluate age-related differences in the AEP waveform of binaural processing. DESIGN: Nine children (ages 7 yr 0 mo to 9 yr 4 mo) and 11 adults (23 to 34 yr) with normal hearing and no known or suspected neurological or academic problems listened to click stimuli under earphones. Click trains consisted of broadband noise of 1-msec duration with a click rate of 100 Hz. In the experimental condition (IID-present) 50-msec intervals containing an interaural intensity difference of 20 dB were introduced periodically in the continuous stream of otherwise diotic click trains. The diotic trains alternated in intensity between 50 and 70 dB peSPL. In the baseline condition (IID-absent), the same continuous diotic click stream utilized in the IID-present condition was presented with no IID. Finally, for comparison with existing literature on AEPs in children and adults, we presented monaural click trains of 50-msec duration, like those used in the IID stimulus (but with no continuous stream) to the left ear at 70 dB peSPL, with an interstimulus interval of 750 msec. Stimuli were presented in separate blocks for each stimulus type and AEPs were recorded in a passive listening condition. RESULTS: A prominent AEP activation was present in both age groups for the IID-present condition; the IID-absent condition did not evoke substantial AEPs. Adult waveform characteristics of the AEPs to monaural clicks and IID-present around 100 and 200 msec were comparable to previous reports. The children demonstrated the expected AEP activation patterns in response to monaural clicks (i.e., positivity around 100 msec, followed by prominent negativity around 250 msec); however their AEP waveforms to IIDs were mainly comprised of a prolonged positivity around 200 to 250 msec after stimulus onset. A two-step temporal-spatial Principal Component Analysis (PCA) was used to evaluate the temporal (time) and spatial (electrode location) composition of the AEP waveforms in children and adults in response to IID-present and IID-absent conditions. Separate repeated-measures ANOVAs with factor scores as the dependent variable were conducted for each temporal factor (TF) representing the waveform deflections around 100, 200 and 250 msec (i.e., TF110, TF200, and TF255) at the frontocentral spatial factor (SF1). Significantly greater negative activation was observed in adults than in children in response to IID-present for TF110. The IID-present condition evoked a significantly greater waveform inflection for TF200 in both age groups than IID-absent. A positive going activation for TF255 was observed in the IID-present condition in children but not in adults. CONCLUSIONS: This study compared obligatory AEPs in response to binaural processing of IIDs in children and adults with normal hearing. The morphology of the AEP waveform in children was different for monaural clicks and IID-present stimuli. The difference between AEPs for monaural clicks and IID-present did not occur in adults. It is likely that polarity reversal of the AEPs in response to the IID accounts for the observed AEP morphology in children.

Eclamptic subarachnoid haemorrhage without hypertension.

Subarachnoid haemorrhage in pregnancy is often the result of aneurysmal rupture or severe hypertension. A young woman with postpartum eclampsia and 'normal' blood pressure developed sudden-onset head pain, and was found to have minor biconvexity subarachnoid hemorrhages. Serial angiograms of the cervicocranial vessels revealed no evidence of aneurysm or arteriovenous malformation. A follow-up angiogram revealed diffuse vessel narrowing, consistent with postpartum angiopathy. Treatment consisted only of nimodipine for the prevention of vasospasm. The patient made an excellent recovery, without residual neurological deficits.

The presence of polyglucosan bodies in temporal lobe epilepsy: its role and significance.

RATIONALE: Mesial temporal sclerosis (MTS) is an important pathology in temporal lobe epilepsy (TLE) and often associated with good surgical outcome, however prognostic factors for surgical outcome are conflicting. The authors examine seizure outcome after surgery for TLE due to MTS, with focus on the presence of polyglucosan bodies (PGBs), and its relation to the epileptogenic process. METHODS: Records of 44 consecutive patients with intractable TLE who underwent anterior temporal lobectomy (ATL) at JFK medical center between 1994-2001 were reviewed. Details of clinical, electrophysiological evaluation, and outcome were collected. All slides were reviewed for the presence of MTS. In twenty-one patients with MTS, detailed histology of surgical specimens was reviewed and relative concentration of PGBs was assessed. The postoperative follow-up duration ranges between 28-74 months. Surgical outcome was evaluated according to Engel's classification. RESULTS: Data of fourteen females (mean age 32.8 years) and 7 males (mean age 34.2) were analyzed. PBGs were identified in 10 patients (8 females and 2 males). All 10 patients had good surgical outcome, with 6 patients (60%) being seizure free (class 1) and 4 patients as class 2. While 11 patients (6 males and 5 females) with absent PGB, 72.8% had good surgical outcome. Of these, 7 (63.8%) had class 1, 1 patient had class 2, and 3 patients had class 3&4. Assessing several risk factors, the only significant difference between the two groups was epilepsy duration, which was significantly longer in patients with PGBs (P = 0.011). CONCLUSION: The histological presence of PGB is associated with long duration of epilepsy and could be the consequence of epilepsy. Despite prolonged duration of epilepsy, the surgical outcome in PGBs +ve is similar to PGBs -ve patients.

Seizures in the elderly: Video/EEG monitoring analysis.

OBJECTIVE: Recently there has been a remarkable increase in the number of elderly people with epilepsy due to the growing size of this segment of the population. The literature provides little information on the characteristics of epileptic and nonepileptic events in the elderly. Therefore we report the results of video/EEG recordings in patients aged 60 or older admitted over 2 consecutive years to an epilepsy monitoring unit (EMU). METHODS: We examined the records of all elderly patients admitted to our EMU between December 1999 and December 2001. Fifty-eight patients were older than 60, constituting 17% of the total admissions to the EMU. All patients underwent continuous video/EEG monitoring. On the basis of reasons for admission, video/EEG reports were categorized into (1) diagnosis of events, (2) characterization and localization of seizures, (3) adjustment of medication, and (4) status epilepticus (nonconvulsive). RESULTS: There were 26 women between the ages of 60 and 91 and 32 men between the ages of 60 and 84. The main reasons for admission were diagnosis of events (57% of patients), followed by characterization and localization of events (36% of patients). There were 6 patients with psychogenic nonepileptic seizures (PNES); 5 were women and 4 of them were >70 years of age. All PNES patients presented with motor symptoms, except for an 87-year-old man who presented with abdominal spasm. Two of these six patients were suspected of having PNES before admission. Two patients were admitted with suspicion of status epilepticus, but neither proved to have status epilepticus. The most frequent diagnosis was physiologic nonepileptic seizures (26 patients; 45%), and 27% of these patients were on antiepileptic drugs, which were discontinued after the diagnosis of nonepileptic seizures. Complex partial seizure was the most frequent seizure type, occurring in 23 patients, 6 of whom (27%) had both complex partial seizures and secondarily generalized seizures. CONCLUSION: In the elderly, video/EEG results in a definitive diagnosis in the majority of cases and can assist in the decision whether antiepileptic drugs are necessary. PNES can occur in the elderly, and video/EEG monitoring can facilitate their recognition and management.

The diagnostic value of EEGs in patients with syncope.

We retrospectively reviewed reports of all EEGs performed at the New Jersey Neuroscience Institute at JFK Hospital between January 1999 and December 2003. Of 9234 EEGs performed, 1094 were of patients with syncope. Among patients with syncope, 67.18% of the EEGs were normal and 28.15% showed diffuse and focal slowing. Only 1.46% of the EEGs showed epileptiform discharges (EDs). This is similar to the incidence of EDs in healthy adults. The presence of EDs did not change the management of these patients. Therefore, EEGs have very low yield and should not be routinely obtained in patients with syncope.

Auditory event-related potentials (P300) in the identification of psychogenic nonepileptic seizures.

The feasibility and conceivable value of postictal event-related potential (ERP) recordings were studied in patients with nonepileptic seizures (NES) admitted for long-term video/EEG monitoring. Ten patients with NES underwent preictal (on hospital admission) and postictal (< or =6 hours after seizure) ERP recordings of an auditory oddball paradigm. Additionally, 10 temporal lobe epilepsy (TLE) patients with partial seizures and secondary generalization underwent preictal, postictal (< 6 hours after seizures), and interictal (7-48 hours after seizure) ERP recordings. We recently reported that ERPs recorded in TLE patients with partial epilepsy undergo a temporary change postictally, while returning to their preictal state during interictal recordings. In the current study intraclass correlations, transformed into z scores, are used to determine test-retest validity of repeated ERP recordings. An independent sample t test with z scores for the comparison of preictal and postictal recordings showed that ERP activation differed between NES and TLE patients (P=0.009). More specifically, ERP recordings in the preictal and postictal states were similar in NES patients, but dissimilar in TLE patients. On the other hand, this dissimilarity in ERPs disappeared when comparing z scores for the preictal and postictal recordings in NES patients with z scores for the preictal and interictal recordings in TLE patients. This further supports the notion that identical waveforms during preictal and postictal recordings in NES patients reflect nonepileptic seizure activity. The current findings suggest that postictal ERP recordings are useful in the diagnosis of NES and differentiate TLE from NES.

Non-voluntary and voluntary processing of emotional prosody: an event-related potentials study.

The present study investigated whether event-related potentials (ERPs) reflect non-voluntary vs voluntary processing of emotional prosody. ERPs were obtained while participants processed emotional information non-voluntarily (i.e. while evaluating semantic characteristics of a stimulus) and voluntarily (i.e. while evaluating emotional characteristics of a stimulus). Results suggest that emotional prosody is processed around 160 ms after stimulus onset under non-voluntary processing conditions (when the attention is diverted from the emotional meaning of the tone of voice); and around 360 ms under voluntary processing conditions. The findings support the notion that emotional prosody is processed non-voluntarily in the comprehension of a spoken message.

The localizing value of auditory event-related potentials (P300) in patients with medically intractable temporal lobe epilepsy.

The localizing value of postictal versus interictal event-related potentials (ERPs) was studied in patients with medically intractable TLE admitted for long-term video EEG monitoring. Ten patients with partial seizures and secondary generalization underwent preictal (upon hospital admission), postictal (

Psychogenic seizures: clinical features and psychological analysis.

Approximately 25-30% of patients referred to epilepsy centers for refractory epilepsy are found to have nonepileptic seizures (NES). In many cases psychological assessments are performed to evaluate for underlying psychiatric disorders. The authors analyzed the clinical features of 23 patients with NES and correlated the features with underlying psychological status. Thirteen of the twenty-three patients (56.5%) had motor manifestations and 10 presented with limpness and unresponsiveness. There was no significant difference in the occurrence of depression, anxiety, posttraumatic stress disorder, or malingering between patients with limpness and those with motor manifestations. However, only patients with motor manifestations had a history of sexual and physical abuse. Those with limp and unresponsive presentations were less likely to have a history of sexual and/or physical abuse. This finding may help treating physicians to choose optimum psychiatric treatment for patients with NES. Additional studies are needed to clarify the association.