When the Crown has Thorns - Epileptic Spike-Wave Discharges over the Vertex.

Epileptiform abnormalities that arise over the midline can sometimes be confused with normal sleep transients, such as vertex sharp waves, because of their location and their activation during sleep. However, epileptiform transients can be distinguished from sleep architecture by their waveform and their occurrence during wakefulness. Here, we report a 24-year-old man with drug-resistant epilepsy whose seizures began with tonic posturing of the left leg before progressing to bilateral tonic-clonic activity. During presurgical scalp video-EEG monitoring, his interictal background showed focal spike-wave discharges maximal over the vertex (phase reversal at Cz), with a more-well-defined field over the right parasagittal region (C4/F4), that were present during both sleep and awake states. The discharges met the IFCN criteria for focal interictal epileptiform discharges (spiky morphology, duration shorter than background activity, asymmetric waveform, after-going slow wave, and physiologic distribution) and appeared to be distinct from the patient's vertex sharp waves. Prior to electroclinical seizures, these discharges would increase in prevalence and appear as repetitive spike-wave discharges. When distinguishing epileptiform from nonepileptiform transients, it is critical to consider both their morphology, especially the degree of background disruption and presence of an after-going slow wave, and their variability with state changes.

Lack of Continuous Video EEG Surveillance Results in Delayed Event Reporting.

Although real-time event detection during video EEG recording is required to ensure patients' safety, it is limited by the technologists' availability. We sought to explore the efficiency of real-time event detection by the EEG technologists in a single tertiary academic center. We retrospectively reviewed events from continuous inpatient video EEGs (cEEGs) and epilepsy monitoring unit (EMU) recordings in January 2017, when real-time surveillance was only available during the night shift, and June 2017, when a dedicated neurodiagnostic EEG technologist was available for real-time monitoring during all shifts. The events were categorized into those detected immediately (eyes-on), later in the same shift (delayed) or identified on the subsequent shift (missed). Chi-square and Fisher's exact tests were used for statistical comparisons. In January 2017, there were 25 patients (117 days of monitoring) in the EMU and 54 inpatients (146 days of monitoring) on cEEG with 92 total events, (39% seizures). In June 2017, there were 30 patients (133 days of monitoring) in the EMU and 47 additional inpatients (80 days of monitoring) on cEEG with 110 total events, (39% seizures). The number of events identified in real time was low and did not significantly differ among shifts regardless of the availability of the monitoring technologist. Most events were identified at the time of subsequent EEG scanning by the EEG technologist. Partial staffing for continuous video EEG surveillance is insufficient to identify events in real time. EEG technologists are able to identify events during regular EEG scanning.

An unusual presentation of severe obstructive sleep apnea with nocturnal seizure-like movements: A case report.

Key Clinical Message: This study suggests that severe obstructive sleep apnea can present as sleep-related epileptic or non-epileptic seizures. A detailed history and physical examination, along with polysomnography and video electroencephalography findings can lead to the correct diagnosis. Abstract: Obstructive sleep apnea (OSA) is defined by recurrent episodes of the upper airway complete or partial collapse while sleeping. The obstructive episodes result in gradual suffocation that increases breathing attempts till the person is awakened. The main manifestations are excessive daytime sleepiness, snoring, observed episodes of stopped breathing, and abrupt awakenings accompanied by gasping or choking. Nevertheless, there are very few reports of patients with OSA, manifesting other symptoms such as seizure-like movements. Differentiating OSA with nocturnal seizures could be challenging due to their overlapping features. A 53-year-old man presented to the clinic, experiencing seizure-like involuntary movements during nocturnal sleep for the past 2 years with a frequency of 2-3 times per night. Neurologic examinations were normal. Further evaluation with polysomnography revealed impaired arousal followed by seizure-like movements during sleep. Video electroencephalography (EEG) did not show any epileptiform discharges, ruling out the nocturnal seizure diagnosis. The patient was diagnosed with OSA. Subsequently, continuous positive airway pressure (CPAP) treatment resolved all symptoms.

Determinants of successful ictal SPECT injection in phase 1 epilepsy presurgical evaluation: Findings from the pediatric epilepsy research consortium surgery database project.

OBJECTIVES: The main goal of presurgical evaluation in drug-resistant focal epilepsy is to identify a seizure onset zone (SOZ). Of the noninvasive, yet resource-intensive tests available, ictal single-photon emission computed tomography (SPECT) aids SOZ localization by measuring focal increases in blood flow within the SOZ via intravenous peri-ictal radionuclide administration. Recent studies indicate that geographic and center-specific factors impact utilization of these diagnostic procedures. Our study analyzed successful ictal SPECT acquisition (defined as peri-ictal injection during inpatient admission) using surgery-related data from the Pediatric Epilepsy Research Consortium (PERC) surgery database. We hypothesized that a high seizure burden, longer duration of video EEG monitoring (VEEG), and more center-specific hours of SPECT availability would increase the likelihood of successful ictal SPECT. METHODS: We identified study participants (≤18 years of age) who underwent SPECT as part of their phase 1 VEEG from January 2018 to June 2022. We assessed association between ictal SPECT outcomes (success vs. failure) and variables including patient demographics, epilepsy history, and center-specific SPECT practices. RESULTS: Phase 1 VEEG monitoring with ictal SPECT injection was planned in 297 participants and successful in 255 participants (85.86%). On multivariable analysis, the likelihood of a successful SPECT injection was higher in patients of non-Hispanic ethnicity (p = 0.040), shorter duration VEEG (p = 0.004), and higher hours of available SPECT services (p < 0.001). Higher seizure frequency (p = 0.033) was significant only in bivariate analysis. Patients treated at centers with more operational hours were more likely to experience pre-admission protocols prior to VEEG (p = 0.002). SIGNIFICANCE: There is inter-center variability in protocols and SPECT acquisition capabilities. Shorter duration of EEG monitoring, non-Hispanic ethnicity (when on private insurance), extended operational hours of nuclear medicine as noted on multivariate analysis and higher seizure frequency in bivariate analysis are strongly associated with successful ictal SPECT injection. PLAIN LANGUAGE SUMMARY: In pediatric patients with drug-resistant epilepsy, single-photon emission computed tomography (SPECT) scans can be helpful in localizing seizure onset zone. However, due to many logistical challenges described below, which include not only the half-life of the technetium isotope used to inject intravenously during a seizure (called the ictal SPECT scan) but also available nuclear scanner time in addition to the unpredictability of seizures, obtaining an ictal SPECT during a planned elective inpatient hospital stay is not guaranteed. Thus, as healthcare costs increase, planning a prolonged hospital stay during which an ictal SPECT scan is not feasible is not optimal. We leveraged our prospective surgery database to look at center-specific factors and patient-specific factors associated with an ictal SPECT injection in the first, pediatric-focussed, large-scale, multicenter, prospective, SPECT feasibility study. We found that longer availability of the scanner is the most important center-specific factor in assuring ictal SPECT injection. Although seizure frequency is an important patient-specific factor on bivariate analysis, this factor lost statistical significance when other factors like patient insurance status and video EEG duration were also considered in our multivariable logistical model.

Ictal Fear or Panic Attack, This Is the Question-A Video-EEG Study.

Panic disorder (PD) and focal epilepsy, in particular, temporal lobe epilepsy, often present diagnostic challenges due to overlapping clinical manifestations. This article describes the case of a 25-year-old female, misdiagnosed with PD for 15 years, whose recurring episodes of sudden fear, palpitations, and nausea were later identified as manifestations of focal epilepsy. Initially unresponsive to conventional anti-anxiety medications, the patient's correct diagnosis was only established through comprehensive electro-clinical, neuropsychological, and neuroimaging evaluations during her admission to our research hospital. Long-term video-EEG monitoring (LTVEM) played a pivotal role in identifying the epileptic nature of her episodes, which were characterized by paroxysmal activity in the right temporal and zygomatic regions, consistent with the location of a dysplastic lesion in the right amygdala, as revealed by high-resolution magnetic resonance imaging. These findings underline the importance of considering focal epilepsy in the differential diagnosis of PD, especially in cases refractory to standard psychiatric treatments. The misdiagnosis of epilepsy as PD can lead to significant delays in appropriate treatment, potentially exacerbating the patient's condition and affecting their quality of life. This case emphasizes the necessity of a multidisciplinary approach and the utilization of advanced diagnostic tools like LTVEM in elucidating the underlying causes of paroxysmal psychiatric symptoms.

A generalized seizure type: Myoclonic-to-tonic seizure.

BACKGROUND AND PURPOSE: To test the hypothesis that myoclonic seizures can evolve to tonic seizures, we documented the electroclinical features of this under-recognized seizure type. METHODS: We observed a distinct seizure pattern starting with myoclonus without returning to an interictal state, which subsequently evolved into generalized tonic seizures. The detailed symptomatic and electroencephalographic characteristics of this seizure were extracted, and the clinical manifestations, drug curative responses in patients with this seizure were reviewed and analyzed. RESULTS: The onset of all seizures was characterized by a preceding period of myoclonus and bursts of generalized spike or poly-spike slow wave discharges with high amplitude. This was closely followed by the occurrence of tonic seizures, which were distinguished by bursts of generalized fast activity at 10 Hz or higher frequency. This under-recognized seizure type has been designated as myoclonic-to-tonic (MT) seizure. The number of patients identified with MT seizures in this study was 34. The prevalence rate of MT seizures was found to be higher in males. While MT seizures typically included a tonic component, it should be noted that some patients experiencing this seizure type never presented with isolated tonic seizures. Generalized Epilepsy not further defined (GE) accounted for approximately one-third of the diagnosed cases, followed by Lennox-Gastaut syndrome and Epilepsy with Myoclonic-Atonic seizures. In comparison to other types of epilepsy, GE with MT seizures demonstrated a more favorable prognosis. CONCLUSIONS: The classification of myoclonic-to-tonic seizure represents a novel approach in comprehending the ictogenesis of generalized seizures and can provide valuable assistance to clinicians in epilepsy diagnosis.

Efficacy of verbal suggestion, verbal suggestion with a tuning fork, and verbal suggestion with a cotton swab for inducing the paroxysmal event during video-EEG recording in children with suspected psychogenic nonepileptic seizures.

INTRODUCTION: Video-electroencephalogram (EEG) with suggestion is widely considered the gold standard for diagnosing psychogenic nonepileptic seizures (PNES). However, ethical concerns and uncertainties persist regarding the most minimally invasive and least deceptive suggestion approach. MATERIALS AND METHODS: In an open-label randomized controlled trial, we evaluated the effectiveness of three suggestion methods (verbal suggestion, verbal suggestion with a tuning fork, and verbal suggestion with a cotton swab) during short-term video-EEG (STVEEG) recordings to induce PNES in children aged 5-18 years. If the paroxysmal event couldn't be elicited with the assigned method, alternative techniques were employed. RESULTS: Out of 97 initially screened children, 75 were enrolled, with 25 in each group. The efficacy of all three suggestion methods was comparable in reproducing paroxysmal events (success rate of 16/25, 17/25 and 17/25 in verbal suggestion only, verbal suggestion with tuning fork and sterile cotton swab group respectively, p = 0.83) and the time required for induction (median of 2, 3 and 3 min respectively, p = 0.21). After trying alternative methods, 20 %, 12 %, and 12 % more patients in these three groups, respectively, were able to reproduce the paroxysmal event, with the differences not reaching statistical significance (p = 0.74). The assigned induction method or the success/failure of event reproduction did not significantly impact clinical outcomes at 12 weeks, and none of the patients in whom PNES could not be reproduced during STVEEG were later found to have an organic cause. Only the presence of psychiatric comorbidity independently predicted successful event reproduction during STVEEG, with statistical significance even after adjusting for other variables (p = 0.03). CONCLUSION: The efficacy of verbal suggestion alone in inducing paroxysmal nonepileptic seizures is on par with using a tuning fork or cotton swab in conjunction with verbal suggestion during STVEEG.

Idiopathic generalized epilepsies in the epilepsy monitoring unit: Systematic quantification of focal EEG and semiological signs.

OBJECTIVE: Focal seizure symptoms (FSS) and focal interictal epileptiform discharges (IEDs) are common in patients with idiopathic generalized epilepsies (IGEs), but dedicated studies systematically quantifying them both are lacking. We used automatic IED detection and localization algorithms and correlated these EEG findings with clinical FSS for the first time in IGE patients. METHODS: 32 patients with IGEs undergoing long-term video EEG monitoring were systematically analyzed regarding focal vs. generalized IEDs using automatic IED detection and localization algorithms. Quantitative EEG findings were correlated with FSS. RESULTS: We observed FSS in 75% of patients, without significant differences between IGE subgroups. Mostly varying/shifting lateralizations of FSS across successive recorded seizures were seen. We detected a total of 81,949 IEDs, whereof 19,513 IEDs were focal (23.8%). Focal IEDs occurred in all patients (median 13% focal IEDs per patient, range 1.1 - 51.1%). Focal IED lateralization and localization predominance had no significant effect on FSS. CONCLUSIONS: All included patients with IGE showed focal IEDs and three-quarter had focal seizure symptoms irrespective of the specific IGE subgroup. Focal IED localization had no significant effect on lateralization and localization of FSS. SIGNIFICANCE: Our findings may facilitate diagnostic and treatment decisions in patients with suspected IGE and focal signs.

Current practice and safety measures in epilepsy monitoring units in the Gulf Cooperation Council Countries: A cross-sectional study.

BACKGROUND: An increasing number of Epilepsy Monitoring Units (EMU) display various practices and safety protocols. EMU settings should meet clear, standardized safety protocols to avoid seizure adverse events (SAE). We aim to provide the foundational framework facilitating the establishment of unified evidence-based safety regulations to address the practices and safety measures implemented within the Gulf Cooperation Council (GCC). METHODS: In this cross-sectional study, EMU directors in the GCC were contacted directly by phone to personally complete an electronic 37-item questionnaire sent via text messages and email. From January 2021-December 2021. RESULTS: Seventeen EMUs from six GCC countries participated in the study. All EMU directors responded to the study. Twelve (70.6%) EMUs monitored adults and children, five (29.4%) monitored adults, and none monitored children only. The number of certified epileptologists in the EMUs ranged from one to eight per unit. Fifteen (88.2%) EMUs applied a continuous observation pattern, whereas two (11.8%) performed daytime only. The precautions most commonly used in the video Electroencephalogram (EEG) were seizure pads and bedside oxygen in 15 EMUs (88.2%). For invasive EEG, seizure pads were used in 9 EMUs (52.9%), %) and IV access in 8 EMUs (47.1%). The occurrence of adverse events varied among EMUs. The most common conditions were postictal psychosis 10 (58.8%), injuries 7 (41.2%), and status epilepticus 6 (35.3%). Falls were mainly related to missed seizures or delayed recognition by video monitors in 8 EMUs (47.1%). The extended EMU stay was because of an insufficient number of recorded seizures in 16 EMUs (94.1%), poor seizure lateralization and localization in 10 (58.8%), and re-introduction of AEDs in nine (52.9%). All EMUs had written acute seizure and status epilepticus management protocols. A postictal psychosis management protocol was available for 10 (58.8%). Medications were withdrawn before admission in 6 EMUs (35.3%). The specific medication withdrawal speed protocol upon admission was available in 7 EMUs (41.2%). Pre-admission withdrawal of medication demonstrated a shorter length of stay in both video and invasive EEG, which was statistically significant (ρ (15) = -.529, p =.029; ρ (7) = -.694, p =.038; respectively). CONCLUSION: The practice and safety regulations of EMUs in the GCC vary widely. Each EMU reported the occurrences of SAE and injuries. Precautions, protective measures, and management protocols must be reassessed to minimize the number of SAEs and increase the safety of the EMU.

Prevalence of Electrographic Seizures in Hospitalized Patients With Altered Mental Status With No Significant Seizure Risk Factors Who Underwent Continuous EEG Monitoring: A Retrospective Study.

OBJECTIVES: The objective of this study is to evaluate the prevalence of electrographic seizures in hospitalized patients with altered mental status and no significant risk factors for seizures. METHODS: We retrospectively reviewed over a six-year period (2013-2019) the medical records of all adults admitted at Ohio State University Wexner Medical Center (OSUWMC), who underwent continuous electroencephalography (cEEG) monitoring for > 48 hours. Our primary objective was to identify the prevalence of electrographic seizures in patients with altered mental status and no significant acute or remote risk factors for seizures. RESULTS: A total of 1966 patients were screened for the study, 1892 were excluded (96.2%) and 74 patients met inclusion criteria. Electrographic seizures were identified in seven of 74 patients (9.45%). We found a significant correlation between electrographic seizures and a history of hepatic cirrhosis, n= 4 (57%), (p=0.035), acute chronic hepatic failure during admission, 71% (n=5), (p=0.027), and hyperammonemia (p =0.009). CONCLUSION: In this retrospective study of patients with altered mental status and no significant acute or remote risk factors for seizures who underwent cEEG monitoring for > 48 hours, electrographic seizures were identified in 9.45%. Electrographic seizures were associated with hepatic dysfunction and hyperammonemia. Based on our results, cEEG monitoring should be considered in patients with altered mental status and hepatic dysfunction even in the absence of other seizure risk factors.

The usefulness of NDDI-E and QOLIE-10 scales for the screening of major depressive disorders in patients with epilepsy in video-EEG units.

OBJECTIVE: Mood disorders in patients with epilepsy are common, with depression being the most prevalent. However, this comorbidity is often underdiagnosed. The systematic use of scales such as NDDI-E and QOLIE-10 in prolonged video-EEG monitoring units could be a useful tool for the detection of this comorbidity. METHODS: Descriptive cross-sectional study of a series of patients with epilepsy evaluated in a prolonged video-EEG monitoring unit. RESULTS: Three hundred forty-nine patients were included. The mean age was 49.1 years, and 49.3% were female. 66.2% had focal epilepsy. 20.4% had pharmacoresistant epilepsy. 38.7% of patients had NDDI-E > 13. 43% of patients with focal epilepsy had NDDI-E > 13 versus 21.8% of patients with idiopathic generalized epilepsy (p = .015). Patients with focal temporal epilepsy had the highest rate of NDDI-E > 13 (48.5%). Significant association was found between patient-perceived mood and NDDI-E score (p < .001). However, in the group of patients with NDDI-E > 13, 37.6% had reported feeling "very good" or "good" in mood. Likewise, in the group that had reported feeling "very good" or "good" 21.6% had NDDI-E > 13. In 50.5% of patients with NDDI-E > 13 some kind of therapeutic intervention aimed at this comorbidity was performed. Perceived quality of life as measured by the QOLIE-10 scale was lower in patients with NDDI-E > 13 (p < .001). SIGNIFICANCE: The use of scales such as the NDDI-E and QOLIE-10 at the time of admission in video-EEG monitoring units allows screening for major depressive disorders in patients with epilepsy, which subsequently needs to be confirmed by formal assessment by a psychiatrist. Their systematic use in these units prevents some patients from going undiagnosed. Detection of these disorders allows targeted therapeutic intervention.

Pure amnestic seizure: A clinico-intracranial EEG study.

OBJECTIVE: Enduring anterograde amnesia is caused by lesions in bilateral mesial temporal lobes. However, whether transient dysfunction of bilateral mesial temporal regions induces reversible amnesia has not been proven. We investigated this association in patients with epilepsy and analyzed the electroclinical correlation during pure amnestic seizures (PAS). PAS are defined as seizures with anterograde amnesia as the only ictal manifestation, accompanied by preserved responsiveness and other cognitive functions. METHODS: We retrospectively searched our intracranial EEG database to find PAS. Pure ictal amnesia was confirmed by immediate and comprehensive ictal examinations. RESULTS: Among 401 patients who underwent intracranial EEG recording, three patients with temporal lobe epilepsy (TLE) manifesting PAS were identified. The patients talked and behaved normally during seizure but did not remember the episodes afterwards. Ictal discharges were confined to bilateral mesial temporal regions, with no or mild involvement of surrounding structures. Spread of low-voltage fast activities to bilateral mesial temporal regions corresponded to onset of ictal anterograde amnesia. Two patients underwent unilateral mesial temporal resection and became seizure-free with improvement in cognitive functions. SIGNIFICANCE: PAS is a rare ictal semiology in TLE. Bilateral mesial temporal regions that play a critical role in memory encoding are presumably the symptomatogenic zones for PAS.

The ENCEVIS algorithm in the EMU and the factors affecting its performance: Our experience.

The study's purpose was to assess the seizure detection performance of ENCEVIS 1.7, identify factors that may influence algorithm performance, and explore its potential for implementation and application in long-term video EEG monitoring units. The study included video-EEG recordings containing at least one epileptic seizure. Forty-three recordings, encompassing 112 seizures, were included in the analysis. True positive, false negative, and false positive seizure detections were defined. Factors that may influence algorithm performance were studied. ENCEVIS demonstrated an overall sensitivity of 71.2%, significantly higher (75.1%) in focal compared to generalized seizures (62%). Ictal patterns rhythmicity (rhythmic 59.4 %, arrhythmic 41.7 %), seizure duration (<10 sec 6.3 %, >60 sec. 63.9 % (p < 0.05)) and patient age (<18 years 39.5 %, >18 years 58.1 % (P < 0.05)) influenced ENCEVIS sensitivity. The coexistence of extracerebral signal changes did not influence sensitivity. ENCEVIS with 79.1% accuracy annotates at least one seizure in those recordings containing epileptic seizures. ENCEVIS seizure detection performance was reasonable for generalized/focal to bilateral tonic-clonic seizures and seizures with temporal lobe onset. Rhythmic ictal patterns, longer seizure duration, and adult age positively influenced algorithm performance. ENCEVIS can be a valuable tool for identifying recordings containing seizures and can potentially reduce the workload of neurophysiologists.

Video-electroencephalographic findings and clinical characteristics of bathing seizures in children.

Objective: To explore the electroencephalogram (EEG) and clinical characteristics of childhood bathing epilepsy. Methods: We conducted a prospective summary of the clinical data from 10 children with bathing epilepsy who were admitted to Hunan Children's Hospital from April 2019 to November 2023 and analyzed their EEGs and clinical characteristics. Results: Our 10 patients included eight males and two females, with seizure-onset ages ranging from 4 months and 20 days to 14 months. Nine cases showed normal intellectual development, and one case manifested delayed development. The Video-EEG (VEEG) findings showed that nine cases exhibited normal background with no interictal epileptic discharge. The seizures were characterized by lip cyanosis, tachycardia or bradycardia, weakness, paleness, and loss of consciousness. Ictal EEG revealed rhythmic fast waves, spike waves, spike-slow waves, or slow and sharp-wave activity over the temporal region (eight cases) or the occipital and temporal regions (one case), finally evolving into a delta rhythm that lasted for 57-201 s. These children exhibited no seizures after discontinuing bathing and were not administered antiseizure medication. The interictal EEG of one case reflected mild slow background and focal interictal epileptic discharge; and her semiology was eyes gazing to right, with clonic movements of the right face and lips, lip cyanosis, bradycardia, and impaired consciousness. Ictal EEG showed spike-wave and spike-slow-wave rhythms over the left central, parietal, and temporal regions; these then spread to the left hemisphere, lasting for approximately 104 s. This patient did not exhibit bathing seizures after stopping her bathing but later experienced frequent spontaneous and drug-resistant seizures. The interictal EEG background slowed down, while focal epileptic discharge increased. Her intellectual development was significantly delayed, and a novel pathogenic mutation in the SMC1A gene, c.298+2T>C, was detected. She was diagnosed with developmental and epileptic encephalopathy. Conclusion: A majority of children with bathing epilepsy in our study showed focal autonomic seizures accompanied by impaired consciousness. Stopping bathing could control the seizures and showed a good prognosis. A few infants manifested a poor prognosis, and we posit that bathing seizure rarely constitute the early manifestations of developmental and epileptic encephalopathy. VEEG findings and clinical features can also indicate the prognosis.

Ictal Asystole During Focal Seizures Due to Left Occipital Glioneuronal Tumor: A Report of Case Treated With Cardiac Neuromodulation.

Ictal asystole (IA) is a rare but potentially life-threatening complication of focal epilepsy. The sudden onset of loss of consciousness and drop attacks in a patient with chronic epilepsy should suggest the possibility of this complication. Once the diagnosis is established, rapid management should be considered, especially in high-risk cases. The approach does not differ between temporal and extratemporal lobe epilepsies. Strategies can be aimed at preventing the emergence of cortical epileptic activity from the beginning (surgery, antiseizure therapy), neutralizing negative chronotropic effects on the heart (cardiac neuromodulation), or restarting the heart rhythm with a pacemaker. Pacemaker implantation is not a completely complication-free treatment, and living with a device that requires care and follow-up throughout life makes alternative treatment methods more valid for young patients with many years to live or cases that could benefit from surgery. In this article, we present a patient with a left occipital glioneuronal tumor and drug-resistant occipital lobe epilepsy. IA was documented by long-term video EEG monitoring (VEM). During about 2 years of follow-up after a cardiac neuromodulation procedure, there were no drop attacks or asystole with seizures, confirmed by long-term VEM.

Diagnostic utility of prolonged ambulatory video-electroencephalography monitoring.

OBJECTIVES: Ambulatory video-electroencephalography (video-EEG) represents a low-cost, convenient and accessible alternative to inpatient video-EEG monitoring, however few studies have examined their diagnostic yield. In this large-scale retrospective study conducted in Australia, we evaluated the efficacy of prolonged ambulatory video-EEG recordings in capturing diagnostic events and resolving the referring question. METHODS: Sequential adult and paediatric ambulatory video-EEG reports from April 2020 to June 2021 were reviewed retrospectively. Data collection included patient demographics, clinical information, and details of events and EEG abnormalities. Clinical utility was assessed by examining i) time to first diagnostic event, and ii) ability to resolve the referring questions - seizure localisation, quantification, classification, and differentiation (differentiating seizures from non-epileptic events). RESULTS: Of the 600 reports analysed, 49 % captured at least one event, and 45 % captured interictal abnormalities (epileptiform or non-epileptiform). Seizures, probable psychogenic events (mostly non-convulsive), and other non-epileptic events occurred in 13 %, 23 % and 21 % of recordings respectively, with overlap. Unreported events were captured in 53 (9 %) recordings, and unreported seizures represented more than half of all seizures captured (51 %, 392/773). Nine percent of events were missing clinical, video or electrographic data. A diagnostic event occurred in 244 (41 %) recordings, of which 14 % were captured between the fifth and eighth day of recording. Reported event frequency ≥ 1/week was the only significant predictor of diagnostic event capture. In recordings with both seizures and psychogenic events, unrecognized seizures were frequent, and seizures may be missed if recording is terminated early. The referring question was resolved in 85 % of reports with at least one event, and 53 % of all reports. Specifically, this represented 46 % of reports (235/512) for differentiation of events, and 75 % of reports (27/36) for classification of seizures. CONCLUSION: Ambulatory video-EEG recordings are of high diagnostic value in capturing clinically relevant events and resolving the referring clinical questions.

Early discontinuation of ambulatory vEEG among individuals with intellectual disabilities: A retrospective chart review.

OBJECTIVE: This retrospective chart review aims to quantify the rate of patients with intellectual disability (ID) accessing an Australian ambulatory EEG service, and understand the clinical implications of discontinuing studies prematurely. METHODS: Electronic records of referrals, patient monitoring notes, and EEG reports were accessed retrospectively. Each referral was assessed to determine whether the patient had an ID. For each study where patients were discharged prematurely, the outcomes of their EEG report were assessed and compared between the ID and non-ID groups. Exploratory analysis was performed assessing the effects of age, the percentage of the requested monitoring undertaken, and outcome rates as a function of monitoring duration. RESULTS: There were significantly more patients in the ID group with early disconnection than the non-ID group (Chi squared test, p = 0.000). There was no significant difference in the rates of clinical outcomes between the ID and non-ID groups amongst patients who disconnected early. CONCLUSIONS: Although rates of early disconnection are higher in those with ID, study outcomes are largely similar between patients with and without ID in this retrospective analysis of an ambulatory EEG service. SIGNIFICANCE: Ambulatory EEG is a viable modality of EEG monitoring for patients with ID.