Pharmacoresistant partial-onset epilepsy misdiagnosed as panic disorder: a case report.

The clinical differentiation between simple partial epileptic seizures of temporal lobe origin and panic attacks is often difficult on clinical grounds alone, because both conditions are characterized by common symptomatology which includes the feeling of fear, autonomic system dysfunction, disorientation and alternation of the level of consciousness when these conditions evolve clinically. The symptoms stem from common pathophysiologic and anatomic substrates of these two conditions, localized in the limbic system, especially the amygdala. We present the case of a young woman who had a febrile seizure in childhood and subsequent episodes of fear accompanied by tremor and possible alteration of consciousness followed by headache. These spells were diagnosed as panic attacks during her teenage years and she was given Clobazam in order to suppress them. The patient responded well for several years without attacks but her symptoms reappeared following discontinuation of her medication in order to conceive. At that time a detailed history was taken from her spouse and further clinical evaluation raised the suspicion of seizures especially due to the fact that her spells were characterized by alteration of consciousness; she was therefore referred for additional investigations which included admission to a monitoring unit for epilepsy. Long-term video-EEG recording revealed the presence of simple partial seizures with secondary generalization confirming the clinical impression. She was subsequently treated with antiepileptic medications; however the patient's condition worsened to the point where she became pharmacoresistant having failed several antiepileptic drug trials in monotherapy or combination. An MRI scan of the brain revealed the presence of right-sided mesial temporal sclerosis, a known consequence of febrile seizures. Her seizures were nocturnal tonic-clonic and gradually worsened to the point of occurring during most nights. She was therefore referred for a presurgical evaluation which confirmed that the epileptic focus was associated with the area of mesial temporal sclerosis. The epileptic focus was successfully removed from the right anterior temporal lobe and since then she remained free of seizures whereas, in addition, the presumed symptoms of panic attacks also resolved. This case indicates the occasional difficulty in diagnosing simple partial seizures and how it may be confused with psychiatric conditions. Therefore, the treating physician, especially the psychiatrist, should remain vigilant when treating cases of panic attacks, especially when they present with either atypical symptomatology, such as the case described, or when they do not respond to appropriately chosen treatment; such cases may warrant referral for further investigation.

Brainstem lesions may be important in the development of epilepsy in multiple sclerosis patients: an evoked potential study.

OBJECTIVE: Multiple sclerosis (MS) is a chronic inflammatory disease of the central nervous system, with epileptic seizures sometimes observed in the same patients. In this study, we used evoked responses to study the pathogenesis of epilepsy in MS. METHODS: Patients with a diagnosis of definite MS and who had EPs performed (visual (VEP), brainstem auditory (BAEP) and short latency somatosensory (upper (USSEP) and lower (LSSEP))) were retrospectively included in this study. They were divided into three groups; Group I: Patients with no epilepsy and who were not taking anti-epileptic drugs (AED); Group II: Patients with epilepsy and taking AEDs; and Group III: Patients with no epilepsy who were taking AEDs for symptoms related to neuropathic pain. RESULTS: Three hundred and fifty-five patients were included in this study; Group I: 229 patients (64.5%), Group II: 20 patients (5.6%) and Group III: 106 patients (29.9%). The proportion of patients with abnormal BAEP and USSEP was higher in Group II. CONCLUSIONS: A positive association exists between the presence of epilepsy in MS patients and BAEP and USSEP abnormalities. Analysis of Group III ruled out AED use as a factor. SIGNIFICANCE: Brainstem lesions may be the cause of epileptogenicity in MS.

Induction of central-type sleep apnea by vagus nerve stimulation.

Vagus nerve stimulation (VNS) is an acceptable and effective adjunctive therapy for pharmacoresistant epilepsy. It is generally well tolerated and the most frequent side effects reported include respiratory dysfunction. We report the case of a female patient with intractable epilepsy who was implanted with the device and achieved a significant reduction in the number of her seizures. However, she developed central-type sleep apnea documented polysomnographically. Upon reduction of her VNS parameters, the apnea resolved and her sleep study reverted to normal. To our knowledge, this is the first case reported with polysomnographic evidence of VNS induction of central-type sleep apnea.

Epileptic seizures followed by nonepileptic manifestations: a video-EEG diagnosis.

OBJECTIVE: To present and discuss a case of a woman who for many years was presumed to have nonepileptic seizures (NES), but proved to actually have both electrical and non-electrical seizures, the latter occurring in a close temporal association with the former. To also discuss the seimiology her true as well as NES and compare to other cases identified from a literature review on this subject. MATERIALS AND METHODS: Closed-circuit video-EEG monitoring was performed in order to capture and subsequently analyse the patient's events. RESULTS: During video-EEG monitoring, she proved to have short electrical seizures followed by psychogenic elaborations. Her NES had obscured her true seizures for a number of years. CONCLUSIONS: Psychogenic elaboration of an epileptic seizure (ES) may occur in the same patient and the latter may obscure the former. The use of video-EEG monitoring may delineate the correct diagnosis and help clarify the relationship of the two types of events.

Brainstem auditory evoked responses that disappear during sleep: a possible manifestation of a neurogenic vestibular evoked response.

OBJECTIVE: To present a case of unilateral hearing loss in which a brainstem auditory evoked potential (BAEP) disappeared during sleep on the symptomatic side, and to argue that this may actually be a manifestation of a neurogenic vestibular evoked potential (NVESTEP). MATERIAL AND METHOD: Brainstem auditory evoked potentials were performed in the standard manner. RESULT: A poorly organized response was obtained during wakefulness on the symptomatic side that resembled a BAEP. The BAEP for the right ear was better organized. During sleep, the response for the left ear disappeared. CONCLUSIONS: The poor organization of the response of the left ear compared to the right, and its disappearance during sleep, suggests that the response for the left ear was actually an NVESTEP and not a BAEP. The possibility of recording vestibular responses with auditory stimuli may have important implications for BAEP examinations performed during wakefulness that may lead to false negative results, in neonatal screening for hearing loss that use tone stimuli, and also in brain mapping using magnetic resonance imaging (MRI) and positron emission tomography (PET) relating to the auditory cortex.

Click evoked neurogenic vestibular potentials (NVESTEPs): a method of assessing the function of the vestibular system.

OBJECTIVES: To obtain neurogenic vestibular evoked potentials (NVESTEPs) with surface scalp recording using high intensity auditory clicks. The same stimulus is used in myogenic vestibular evoked potentials which has been shown to evoke potentials in the vestibular division of the vestibulocochlear nerve. METHODS: A whole head recording with surface EEG electrodes was performed using high intensity clicks in one normal volunteer to determine the best recording position for vestibular evoked potentials. The results were compared to responses at moderate click intensities used for brainstem auditory evoked potentials (BAEPs). The difference in the location of the two responses on the scalp was assumed to be from the vestibular system. RESULTS: Responses specific to the high intensity clicks were best obtained in the parietal areas, with no reproducible responses obtained in the same area with moderate intensity clicks normally used in BAEPs. Recordings in neurologically normal volunteers showed a consistent response with a negative polarity at around 3 ms, which we therefore called N3. Two case studies are presented. The first case is a patient with unilateral sensorineural hearing loss with NVESTEPs present, suggesting that NVESTEPs is not a cochlear response. The second case is a patient with multiple sclerosis with demyelinating lesions in the pons and an unobtainable NVESTEP response. CONCLUSION: NVESTEPs is a possible new diagnostic technique that may be specific for the vestibular pathway. It has potential use in patients with symptoms of dizziness, subclinical symptoms in multiple sclerosis, and in disorders specific for the vestibular nerve.