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Purpose: Electroencephalogram is used for prognostication and diagnosis in critically ill patients and is vital in developing clinical management algorithms. Unique waveforms on EEG may distinguish neurological disorders and define a potential for seizures. To better characterize zeta waves, we sought to define their electroclinical spectrum., Methods: We performed a systematic review using MEDLINE, Embase, Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Review [through Ovid], Scopus, Science Citation Index Expanded and Emerging Sources Citation Index [through the Web of Science], and Epistemonikos. Grey literature resources were searched., Results: Five hundred thirty-seven articles were identified. After excluding duplicates and reviewing titles, abstracts, and bodies and bibliographies of articles, four studies reported 64 cases describing data from patients with zeta waves, with a prevalence of 3 to 4%. Various and often incomplete clinical, neuroimaging, and EEG data were available. 57 patients (89.1%) had a focal cerebral lesion concordant with the location of zeta waves on EEG. 26 patients (40.6%) had clinical seizures, all but one being focal onset. Thirteen patients (20%) had epileptiform activity on EEG. Typically, zeta waves were located in the frontal head regions, often with generalized, frontal, predominant, rhythmic delta activity and associated with focal EEG suppression., Conclusions: Zeta waves frequently represent an underlying focal structural lesion. Their presence suggests a heightened risk for seizures. The small number of retrospective cases series in the literature reporting zeta waves might be an underrepresentation. We suggest a need for prospective studies of cEEG in critically ill patients to determine their clinical significance., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2022 by the American Clinical Neurophysiology Society.)

This educational topical review and Task Force report aims to address learning objectives of the International League Against Epilepsy (ILAE) curriculum. We sought to extract detailed features involving semiology from video recordings and interpret semiological signs and symptoms that reflect the likely localization for focal seizures in patients with epilepsy. This glossary was developed by a working group of the ILAE Commission on Diagnostic Methods incorporating the EEG Task Force. This paper identifies commonly used terms to describe seizure semiology, provides definitions, signs and symptoms, and summarizes their clinical value in localizing and lateralizing focal seizures based on consensus in the published literature. Video-EEG examples are included to illustrate important features of semiology in patients with epilepsy.

The objective of this clinical practice guideline is to provide recommendations on the indications and minimum standards for inpatient long-term video-electroencephalographic monitoring (LTVEM). The Working Group of the International League Against Epilepsy and the International Federation of Clinical Neurophysiology develop guidelines aligned with the Epilepsy Guidelines Task Force. We reviewed published evidence using The Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement. We found limited high-level evidence aimed at specific aspects of diagnosis for LTVEM performed to evaluate patients with seizures and nonepileptic events (see Table S1). For classification of evidence, we used the Clinical Practice Guideline Process Manual of the American Academy of Neurology. We formulated recommendations for the indications, technical requirements, and essential practice elements of LTVEM to derive minimum standards used in the evaluation of patients with suspected epilepsy using GRADE (Grading of Recommendations, Assessment, Development, and Evaluation). Further research is needed to obtain evidence about long-term outcome effects of LTVEM and establish its clinical utility., Competing Interests: Declaration of Competing Interest S.B. has been an invited lecturer for Natus Medical Incorporated. D.G. is an evidence-based medicine consultant. J.J.H. serves as a consultant for Takeda Pharmaceuticals and SK Life Sciences. W.O.T. has received personal compensation as a stipend from Elsevier as Editor-in- Chief of Epilepsy Behavior Reports. He serves as a consultant for BioSerenity and Medtronics, and holds patents/patents pending for intraoperative monitoring sensor devices (#62527896; #62770362). Royalties from publications include Demos Publishers and Springer Publishing. Honoraria for speaking engagements include American Academy of Neurology, American Epilepsy Society, and American Clinical Neurophysiology Society. He has received research support from Mayo Clinic, the Martin Family Foundation, the McKelvey Foundation, and the Epilepsy Foundation for data collected during intracranial monitoring, and Xenon, Esai, Engage, Cerevel, and LivaNova. None of the other authors has any conflict of interest to disclose. We confirm that we have read the Journal's position on issues involved in ethical publication and affirm that this report is consistent with those guidelines., (Copyright © 2021 International Federation of Clinical Neurophysiology, International League Against Epilepsy. Published by Elsevier B.V. All rights reserved.)

Background: The pathogenesis of glioma-related seizures (GRS) is poorly understood. Here in, we aim to identify putative molecular pathways that lead to the development of GRS., Methods: We determined brain transcriptome from intraoperative human brain tissue of patients with either GRS, glioma without seizures (non-GRS), or with idiopathic temporal lobe epilepsy (iTLE). We performed transcriptome-wide comparisons between disease groups tissue from non-epileptic controls (non-EC) to identify differentially-expressed genes (DEG). We compared DEGs to identify those that are specific or common to the groups. Through a gene ontology analysis, we identified molecular pathways enriched for genes with a Log-fold change ≥1.5 or ≤-1.5 and p-value <0.05 compared to non-EC., Results: We identified 110 DEGs that are associated with GRS vs. non-GRS: 80 genes showed high and 30 low expression in GRS. There was significant overexpression of genes involved in cell-to-cell and glutamatergic signaling (CELF4, SLC17A7, and CAMK2A) and down-regulation of genes involved immune-trafficking (CXCL8, H19, and VEGFA). In the iTLE vs GRS analysis, there were 1098 DEGs: 786 genes were overexpressed and 312 genes were underexpressed in the GRS samples. There was significant enrichment for genes considered markers of oncogenesis (GSC, MYBL2, and TOP2A). Further, there was down-regulation of genes involved in the glutamatergic neurotransmission (vesicular glutamate transporter-2) in the GRS vs. iTLE samples., Conclusions: We identified a number of altered processes such as cell-to-cell signaling and interaction, inflammation-related, and glutamatergic neurotransmission in the pathogenesis of GRS. Our findings offer a new landscape of targets to further study in the fields of brain tumors and seizures., (Copyright © 2021. Published by Elsevier B.V.)

The objective of this clinical practice guideline (CPG) is to provide recommendations for healthcare personnel working with patients with epilepsy, on the use of wearable devices for automated seizure detection in patients with epilepsy, in outpatient, ambulatory settings. The Working Group of the International League Against Epilepsy and the International Federation of Clinical Neurophysiology developed the CPG according to the methodology proposed by the ILAE Epilepsy Guidelines Working Group. We reviewed the published evidence using The Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement and evaluated the evidence and formulated the recommendations following the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. We found high level of evidence for the accuracy of automated detection of generalized tonic-clonic seizures (GTCS) and focal-to-bilateral tonic-clonic seizures (FBTCS) and recommend use of wearable automated seizure detection devices for selected patients when accurate detection of GTCS and FBTCS is recommended as a clinical adjunct. We also found moderate level of evidence for seizure types without GTCs or FBTCs. However, it was uncertain whether the detected alarms resulted in meaningful clinical outcomes for the patients. We recommend using clinically validated devices for automated detection of GTCS and FBTCS, especially in unsupervised patients, where alarms can result in rapid intervention (weak/conditional recommendation). At present, we do not recommend clinical use of the currently available devices for other seizure types (weak/conditional recommendation). Further research and development are needed to improve the performance of automated seizure detection and to document their accuracy and clinical utility., (Copyright © 2021 International Federation of Clinical Neurophysiology, Inc., International League Against Epilepsia. Published by Elsevier B.V. All rights reserved.)

The objective of this clinical practice guideline (CPG) is to provide recommendations for healthcare personnel working with patients with epilepsy on the use of wearable devices for automated seizure detection in patients with epilepsy, in outpatient, ambulatory settings. The Working Group of the International League Against Epilepsy (ILAE) and the International Federation of Clinical Neurophysiology (IFCN) developed the CPG according to the methodology proposed by the ILAE Epilepsy Guidelines Working Group. We reviewed the published evidence using The Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement and evaluated the evidence and formulated the recommendations following the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. We found high level of evidence for the accuracy of automated detection of generalized tonic-clonic seizures (GTCS) and focal-to-bilateral tonic-clonic seizures (FBTCS) and recommend the use of wearable automated seizure detection devices for selected patients when accurate detection of GTCS and FBTCS is recommended as a clinical adjunct. We also found a moderate level of evidence for seizure types without GTCS or FBTCS. However, it was uncertain whether the detected alarms resulted in meaningful clinical outcomes for the patients. We recommend using clinically validated devices for automated detection of GTCS and FBTCS, especially in unsupervised patients, where alarms can result in rapid intervention (weak/conditional recommendation). At present, we do not recommend clinical use of the currently available devices for other seizure types (weak/conditional recommendation). Further research and development are needed to improve the performance of automated seizure detection and to document their accuracy and clinical utility., (© 2021 International League Against Epilepsy.)

Video-EEG monitoring is an established gold-standard procedure for diagnosis and differentiation of epileptic and non-epileptic seizures. Epilepsy misdiagnosis, to which factors such as EEG artifact misinterpretation contribute to, is common, and can have long-lasting iatrogenic repercussions to the clinical management of affected patients. Among the many types of responses to photic stimulation, artifacts and physiologic and epileptic responses are possible. All of these can interfere with EEG interpretation when provoked by a source of illumination. Photic-induced responses are of increasing relevance given the ubiquity of screens and other light-emitting electronics in our modern world. One of these, the photoparoxysmal response, is a frequent finding in photosensitive patients with genetic generalized epilepsies. Various responses beyond abnormal occurrence of cortical spikes or spike-and-wave discharges are known to occur on EEG in response to intermittent photic stimulation (IPS), with different clinical implications. To our knowledge, we report a unique electronegative photoparoxysmal response during video-EEG monitoring induced by fluctuating illumination caused by a distant television screen. This response mimicked an extratemporal seizure in a young woman with frontal lobe epilepsy, admitted for presurgical evaluation. Novel electronegative responses to electronic devices during video-EEG monitoring merit consideration by EEG interpreters to help avoid misdiagnosis.

Introduction: 20.8% of the United States population and 67% of the European population speak two or more languages. Intraoperative different languages, mapping, and localization are crucial. This investigation aims to address three questions between BL and ML patients: (1) Are there differences in complications (i.e. seizures) and DECS techniques during intra-operative brain mapping? (2) Is EOR different? and (3) Are there differences in the recovery pattern post-surgery?, Methods: Data from 56 patients that underwent left-sided awake craniotomy for tumors infiltrating possible dominant hemisphere language areas from September 2016 to June 2019 were identified and analyzed in this study; 14 BL and 42 ML control patients. Patient demographics, education level, and the age of language acquisition were documented and evaluated. fMRI was performed on all participants., Results: 0 (0%) BL and 3 (7%) ML experienced intraoperative seizures (P = 0.73). BL patients received a higher direct DECS current in comparison to the ML patients (average = 4.7, 3.8, respectively, P = 0.03). The extent of resection was higher in ML patients in comparison to the BL patients (80.9 vs. 64.8, respectively, P = 0.04). The post-operative KPS scores were higher in BL patients in comparison to ML patients (84.3, 77.4, respectively, P = 0.03). BL showed lower drop in post-operative KPS in comparison to ML patients (- 4.3, - 8.7, respectively, P = 0.03)., Conclusion: We show that BL patients have a lower incidence of intra-operative seizures, lower EOR, higher post-operative KPS and tolerate higher DECS current, in comparison to ML patients.

Importance: Misdiagnosis of epilepsy is common. Video electroencephalogram provides a definitive diagnosis but is impractical for many patients referred for evaluation of epilepsy., Objective: To evaluate the accuracy of outpatient smartphone videos in epilepsy., Design, Setting, and Participants: This prospective, masked, diagnostic accuracy study (the OSmartViE study) took place between August 31, 2015, and August 31, 2018, at 8 academic epilepsy centers in the United States and included a convenience sample of 44 nonconsecutive outpatients who volunteered a smartphone video during evaluation and subsequently underwent video electroencephalogram monitoring. Three epileptologists uploaded videos for physicians from the 8 epilepsy centers to review., Main Outcomes and Measures: Measures of performance (accuracy, sensitivity, specificity, positive predictive value, and negative predictive value) for smartphone video-based diagnosis by experts and trainees (the index test) were compared with those for history and physical examination and video electroencephalogram monitoring (the reference standard)., Results: Forty-four eligible epilepsy clinic outpatients (31 women [70.5%]; mean [range] age, 45.1 [20-82] years) submitted smartphone videos (530 total physician reviews). Final video electroencephalogram diagnoses included 11 epileptic seizures, 30 psychogenic nonepileptic attacks, and 3 physiologic nonepileptic events. Expert interpretation of a smartphone video was accurate in predicting a video electroencephalogram monitoring diagnosis of epileptic seizures 89.1% (95% CI, 84.2%-92.9%) of the time, with a specificity of 93.3% (95% CI, 88.3%-96.6%). Resident responses were less accurate for all metrics involving epileptic seizures and psychogenic nonepileptic attacks, despite greater confidence. Motor signs during events increased accuracy. One-fourth of the smartphone videos were correctly diagnosed by 100% of the reviewing physicians, composed solely of psychogenic attacks. When histories and physical examination results were combined with smartphone videos, correct diagnoses rose from 78.6% to 95.2%. The odds of receiving a correct diagnosis were 5.45 times greater using smartphone video alongside patient history and physical examination results than with history and physical examination alone (95% CI, 1.01-54.3; P = .02)., Conclusions and Relevance: Outpatient smartphone video review by experts has predictive and additive value for diagnosing epileptic seizures. Smartphone videos may reliably aid psychogenic nonepileptic attacks diagnosis for some people.

Objective: To evaluate intraoperative use of a novel high-density circular grid in detecting after-discharges (AD) on electrocorticography (ECoG) during functional brain mapping (FBM)., Methods: FBM during glioma surgery (10/2016 to 5/2019) recorded ADs using a 22-channel circular grid compared to conventional strip electrodes. ADs were analyzed for detection, duration, amplitude, morphology, histology, direction, and clinical signs., Results: Thirty-two patients (mean age 54.2 years; r = 30-75) with glioma (WHO grade II-IV; 20 grade IV) had surgery. ADs during FBM were more likely in patients with wild-type as opposed to IDH-1 mutants (p < 0.0001) using more contacts compared with linear strip electrodes (p = 0.0001). More sensors tended to be involved in ADs detected by the circular grid vs strips (6.61 vs 3.43; p = 0.16) at lower stimulus intensity (3.14 mA vs 4.13 mA; p = 0.09). No difference in the number of cortical stimulations before resection was present (38.9 mA vs 47.9 mA; p = 0.26). ADs longer than 10 seconds were 32.5 seconds (circular grid) vs 58.4 (strips) (p = 0.12)., Conclusions: High-density circular grids detect ADs in 360 degrees during FBM for glioma resection. Provocation of ADs was more likely in patients with wild-type than IDH-1 mutation., Significance: Circular grids offer high-resolution ECoG during intraoperative FBM for detection of ADs., Competing Interests: Declaration of Competing Interest Drs. Quinones-Hinojosa, ReFaey and Tatum, have filed a patent application disclosing this device and technology., (Copyright © 2020 International Federation of Clinical Neurophysiology. Published by Elsevier B.V. All rights reserved.)

Purpose: To examine the occurrence of glioma-related preoperative seizures (GPS) and post-operative seizure control (PSC) with respect to patients characteristics including five commonly tested tumor molecular markers (TMMs)., Methods: A single-center retrospective cohort study of patients with glioma evaluated at the Mayo Clinic, Florida between 2016 and 2018., Results: 68 adult patients (mean age = 51-years, 45-males) were included. 46 patients had GPS. 57 patients underwent intra-operative electrocorticography during awake craniotomy-assisted glioma resection. All patients underwent glioma resection (53, gross-total resection) with histologies of pilocytic astrocytoma (n = 2), diffuse astrocytoma (n = 4), oligodendroglioma (n = 14), anaplastic astrocytoma (n = 16), anaplastic oligodendroglioma (n = 1), and glioblastoma (n = 31). 31 (67%) patients had PSC (median follow-up = 14.5 months; IQR = 7-16.5 months). IDH1 mutation (IDH1 mut ) was present in 32, ARTX retention in 53, MGMT gene promotor methylation in 15, 1p/19q co-deletion in 15, and over-expression of p53 in 19 patients. Patients with IDH1 mut were more likely to have GPS (p = 0.037) and PSC (p = 0.035) compared to patients with IDH1 wild-type. Patients with MGMT gene promoter methylation were also likely to have PSC (p = 0.032). GPS or PSC did not differ by age, sex, extent of surgery, glioma grade, location, and histopathological subtype, p53 expression, ARTX retention, or 1p/19q co-deletion status., Conclusions: GPS and PSC may be associated with IDH1 mutation and MGMT gene promoter methylation status but not other glioma characteristics including tumor grade, location, or histopathology. Prospective studies with larger sample size are needed to clarify the exact mechanisms of GPS and PSC by the various TMMs to identify new treatment targets., (Published by Elsevier Ltd.)

Objective: To evaluate EEG abnormalities, particularly development of temporal intermittent rhythmic delta activity (TIRDA) after laser interstitial thermal therapy (LITT) and assess the role of further surgery after LITT., Methods: We retrospectively identified consecutive cases of LITT for the prevalence of post-operative TIRDA. We assessed baseline demographics, clinical variables including age of seizure onset, age at surgery, pre-operative and post-operative EEG changes., Results: 40 patients underwent LITT for drug-resistant temporal lobe epilepsy (TLE), 29 met inclusion criteria. Median duration of follow-up was 15 months. Ten patients had post-LITT ipsilateral TIRDA, another two demonstrated post-operative TIRDA but they occurred contralateral to the side of ablation. None of the patients with TIRDA on their post-LITT EEG became seizure-free. Six out of 29 patients (21%) eventually required anterior temporal lobectomy (ATL), and of those 6 patients 4 (66%) had evidence of TIRDA on their post-LITT follow up EEG. The sensitivity and specificity of post-LITT TIRDA in predicting surgical failure was 57.14% and 100% respectively., Conclusions: Post-LITT TIRDA may serve as a biomarker to predict unsuccessful seizure outcome following LITT and be an early indicator for ATL., Significance: The presence of TIRDA following LITT should prompt early consideration for reoperation., (Copyright © 2018 International Federation of Clinical Neurophysiology. Published by Elsevier B.V. All rights reserved.)

Purpose: To evaluate clinical, radiographic, and electrophysiological features in the development and prognosis of ischemic post-stroke seizures (PSS)., Method: A retrospective study of 1119 patient records was performed between January 2006 and December 2016. After selection, 42 patients with seizures due to ischemic stroke were matched to a control group of 60 patients where seizures were absent. Stroke size and severity were analyzed using ASPECTS and NIHSS, respectively. Hemorrhagic transformation graded by ECASS III classification. Outcomes were assessed using the modified Rankin Scale. Fisher's exact test assessed categorical variables, and Mann-Whitney tested continuous variables., Results: Forty-two patients experienced PSS (22 females; median age 72.5 years) and were matched with 60 control subjects that had ischemic stroke without seizures. Focal seizures were present in 42.9% (18/42), and focal to bilateral convulsions in 57.1% (24/42). Stroke localization and severity did not differ (p = 0.6 and 0.21, respectively). Stroke size in anterior circulation was larger in PSS patients (median ASPECTS 6 vs 8 [p = 0.01]). Posterior circulation stroke size was similar in both groups. The presence of hemorrhage was the primary risk factor for PSS (61.9%) compared to controls (36.7%), p = 0.01. The presence of laminar necrosis (LN) (47.6% vs 21.6%, p = 0.005) and hemosiderin deposition (38.1% vs 18.3%, p = 0.02) were most predictive. PSS patients demonstrated worse outcomes than the controls (median mRS 3 vs 2, [p=<0.001]) with a median follow up of 14.8 and 20.7 months, respectively., Conclusions: The size of anterior infarction, presence of blood products within the infarct bed, and especially LN predicted PSS., (Copyright © 2018 British Epilepsy Association. Published by Elsevier Ltd. All rights reserved.)

Electroencephalography (EEG) remains an essential diagnostic tool for people with epilepsy (PWE). The International Federation of Clinical Neurophysiology produces new guidelines as an educational service for clinicians to address gaps in knowledge in clinical neurophysiology. The current guideline was prepared in response to gaps present in epilepsy-related neurophysiological assessment and is not intended to replace sound clinical judgement in the care of PWE. Furthermore, addressing specific pathophysiological conditions of the brain that produce epilepsy is of primary importance though is beyond the scope of this guideline. Instead, our goal is to summarize the scientific evidence for the utility of EEG when diagnosing and monitoring PWE., (Copyright © 2018 International Federation of Clinical Neurophysiology. Published by Elsevier B.V. All rights reserved.)

Purpose: Stereotactic laser ablation (SLA) is a novel form of epilepsy surgery for patients with drug-resistant focal epilepsy. We evaluated one hundred consecutive surgeries performed for patients with epilepsy to address the impact of SLA on our therapeutic approach, as well as patient outcomes., Methods: A retrospective, single center analysis of the last one hundred neurosurgeries for epilepsy was performed from 2013 to 2015. Demographics, surgical procedures, and postoperative measures were assessed up to 5years to compare the effect of SLA on outcome. Confidence intervals (CI) and comparative tests of proportions compared outcomes for SLA and resective surgery. Procedural categorical comparison used Chi-square and Kaplan-Meier curves. Student t-test was utilized for single variables such as age at procedure and seizure onset., Results: One hundred surgeries for epilepsy yielded thirty-three SLAs and twenty-one resections with a mean of 21.7-month and 21.3-month follow-up, respectively. The temporal lobe was the most common target for SLA (92.6%) and resection (75%). A discrete lesion was present on brain magnetic resonance imaging (MRI) in 27/32 (84.4%) of SLA patients compared with 7/20 (35%) of resection patients with a normal MRI. Overall, 55-60% of patients became seizure-free (SF). Four of five patients with initial failure to SLA became SF with subsequent resection surgery. Complications were more frequent with resection although SF outcomes did not differ (Chi square; p=0.79). Stereotactic laser ablation patients were older than those with resections (47.0years vs. 35.4years, p=0.001). The mean length of hospitalization prior to discharge was shorter for SLA (1.18days) compared with open resection (3.43days; SD: 3.16 days) (p=0.0002)., Conclusion: We now use SLA as a first line therapy at our center in patients with lesional temporal lobe epilepsy (TLE) before resection. Seizure-free outcome with SLA and resection was similar but with a shorter length of stay. Long-term follow-up is recommended to determine sustained SF status from SLA., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Purpose: To assess and compare peak, multimodal ictal vital signs (iVS) during epileptic seizures (ES) and psychogenic nonepileptic seizures (PNES)., Methods: Between 4/1/2010 and 4/1/2011, 183 adults had video-EEG monitoring, with 96 consecutive patients meeting inclusion criteria. Heart rate (HR), oxygen saturation (SaO2), and blood pressure (BP) were obtained at baseline and during an ictus. The motor semiology of each ES and PNES was also assessed. Student t-test, Fischer's Test, Wilcoxon Test (p=<0.05), and linear regression provided statistical correlation., Results: The 46 patients with ES and 50 patients with PNES had similar baseline VS. Generalized tonic-clonic ES had the highest absolute iVS. ES yielded a higher absolute ictal HR (p=0.0004) and lower SaO2 nadir (p=0.003) than PNES. Systolic and diastolic BP did not differ between groups (p=NS). The upper ranges of iS-BP attained a maximum value of 195/135mm Hg in ES and 208/128mmHg in PNES. For ES, the change in ictal HR was inversely correlated with a reduction in ictal SaO2 (CC= -0.4; p=0.003). In PNES, ictal HR correlated with systolic BP (CC=0.6; p=<0.0001), but not ictal SaO2., Conclusion: The inverse relationship between ictal HR and ictal SaO2 in ES suggests a neurobiological difference, and the concept of intrinsic cardio-respiratory dysfunction in patients with epilepsy. The significantly raised peak elevations in ictal HR and ictal systolic BP during PNES demonstrates the potential for serious adverse outcomes if attacks are prolonged., (Copyright © 2016 British Epilepsy Association. Published by Elsevier Ltd. All rights reserved.)

The purpose of this case-matched study was to determine how frequently fibromyalgia is associated with different paroxysmal neurological disorders and explore the utility of fibromyalgia as a predictor for the diagnosis of psychogenic non-epileptic seizures. The billing diagnosis codes of 1,730 new, non-selected patient encounters were reviewed over a three-year period for an epileptologist in a neurology clinic to identify all patients with historical diagnoses of fibromyalgia. The frequency with which epileptic seizures, psychogenic non-epileptic seizures, and physiological non-epileptic events were comorbid with fibromyalgia was assessed. Age and gender case-matched controls were used for a between-group comparison. Wilcoxon tests were used to analyse interval data, and Chi-square was used to analyse categorical data (p<0.05). Fibromyalgia was retrospectively identified in 95/1,730 (5.5%) patients in this cohort. Females represented 95% of the fibromyalgia sample (age: 53 years; 95% CI: 57, 51). Forty-three percent of those with fibromyalgia had a non-paroxysmal, neurological primary clinical diagnosis, most commonly chronic pain. Paroxysmal events were present in 57% of fibromyalgia patients and 54% of case-matched controls. Among patients with fibromyalgia and paroxysmal disorders, 11% had epileptic seizures, 74% had psychogenic non-epileptic seizures, and 15% had physiological non-epileptic events, compared to case-matched controls with 37% epileptic seizures, 51% psychogenic non-epileptic events, and 12% physiological non-epileptic events (p = 0.009). Fibromyalgia was shown to be a predictor for the diagnosis of psychogenic non-epileptic seizures in patients with undifferentiated paroxysmal spells. However, our results suggest that the specificity and sensitivity of fibromyalgia as a marker for psychogenic non-epileptic seizures in a mixed general neurological population of patients is less than previously described.

Objective: Most patients with localization-related epilepsy (LRE) and genetic generalized epilepsy (GGE) are classified based on semiology and video-EEG, but both features occasionally fail to provide a definitive diagnosis. Several reliable lateralizing signs have been described, although hand and finger posturing has received little attention. We sought to investigate the frequency of index-finger pointing (IFP) during generalized motor convulsions as a lateralizing semiology in LRE., Methods: We retrospectively analyzed 98 videos of generalized convulsions in 64 consecutive patients who were admitted for diagnostic video-EEG (vEEG). Demographics were recorded, and IFP ipsilateral, contralateral, and bilateral to vEEG ictal correlate was compared between LRE, GGE, and nonepileptic attacks (NEAs). The angle of IFP was measured to quantify the mean degree of IFP in "pointers" versus "nonpointers". Statistical analysis was completed using JMP 9.0., Results: Index-finger pointing was more common in epileptic GTC seizures than in convulsive NEAs (83.6% vs 12.0%; p<0.001) and was more common in LRE compared with GGE (96% vs 56.6%; p≤0.001). The frequency of contralateral, ipsilateral, or bilateral IFP did not differ between LRE and GGE. The average angle at the MCP joint in "pointers" was 35.8° (SD 22.0°) and in "nonpointers" 3.0° (SD 7.2°)., Significance: This is the first study to examine hand and finger postures as a clinical sign to help classify epilepsy type. The presence of IFP was more common in patients with LRE than in patients with GGE and very rarely occurred in NEA. Index-finger pointing and other hand semiologies are potentially quantifiable localizing signs to aid in the characterization of patients with GTC seizures., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: To characterize patients with seizures that only occur without their awareness (SWA)., Methods: Twenty-four patients with SWA were retrospectively identified by chart review and subsequently underwent video-EEG monitoring (VEM). Eleven patients met selection criteria for SWA and were never aware of any seizures. A case-matched control group of patients who were always aware (SA) was used for comparison. Statistical analysis included Pearson's Chi-square, Fisher's Exact, and Mann-Whitney., Results: Patients with SWA were older at seizure diagnosis than those with SA (p=0.04), were less often referred for evaluation of seizures or epilepsy (p=0.04), and were referred faster for VEM, despite SWA were significantly less likely to include motor manifestations (p=0.0004). SWA more often had temporal lobe onsets (p<0.0001) with left lateralization on ictal EEG (p<0.0001). At final follow up, patients with SWA had tried fewer antiseizure drugs (p=0.03), but reported seizure freedom as often as patients with SA (p=0.4)., Significance: We suggest that patients with SWA have a unique epilepsy syndrome. Patients with absent recall were older, referred later, had fewer motor signs, and dominant hemisphere limbic localization than patients with SA, but fewer antiseizure drugs are used in treatment. Patients with SWA can be detected from the clinical history, though serial VEM is needed to validate effective management., (Copyright © 2014 Elsevier B.V. All rights reserved.)

Epilepsy is a common disorder that may be caused by wide ranging etiologies. Historically a significant number of people with epilepsy have idiopathic epilepsy without a definitive etiology. More recently, auto-antibodies have been discovered to be associated with numerous conditions affecting the nervous system, including epilepsy. With this increased understanding of the potential for immune-based etiologies for epilepsy it is important to recognize the associated EEG patterns in such cases. This report presents the EEG findings in epilepsy patients with one or more auto-antibodies.

Purpose: To provide an estimate of the frequency of dacrystic seizures in video-electroencephalography (EEG) long-term monitoring units of tertiary referral epilepsy centers and to describe the clinical presentation of dacrystic seizures in relationship to the underlying etiology., Methods: We screened clinical records and video-EEG reports for the diagnosis of dacrystic seizures of all patients admitted for video-EEG long-term monitoring at five epilepsy referral centers in the United States and Germany. Patients with a potential diagnosis of dacrystic seizures were identified, and their clinical charts and video-EEG recordings were reviewed. We included only patients with: (1) stereotyped lacrimation, sobbing, grimacing, yelling, or sad facial expression; (2) long-term video-EEG recordings (at least 12 h); and (3) at least one brain magnetic resonance imaging (MRI) study., Key Findings: Nine patients (four female) with dacrystic seizures were identified. Dacrystic seizures were identified in 0.06-0.53% of the patients admitted for long-term video-EEG monitoring depending on the specific center. Considering our study population as a whole, the frequency was 0.13%. The presence of dacrystic seizures without other accompanying clinical features was found in only one patient. Gelastic seizures accompanied dacrystic seizures in five cases, and a hypothalamic hamartoma was found in all of these five patients. The underlying etiology in the four patients with dacrystic seizures without gelastic seizures was left mesial temporal sclerosis (three patients) and a frontal glioblastoma (one patient). All patients had a difficult-to-control epilepsy as demonstrated by the following: (1) at least three different antiepileptic drugs were tried in each patient, (2) epilepsy was well controlled with antiepileptic drugs in only two patients, (3) six patients were considered for epilepsy surgery and three of them underwent a surgical/radiosurgical or radioablative procedure. Regarding outcome, antiepileptic drugs alone achieved seizure freedom in two patients and did not change seizure frequency in another patient. Radiosurgery led to moderately good seizure control in one patient and did not improve seizure control in another patient. Three patients were or are being considered for epilepsy surgery on last follow-up. One patient remains seizure free 3 years after epilepsy surgery., Significance: Dacrystic seizures are a rare but clinically relevant finding during video-EEG monitoring. Our data show that when the patient has dacrystic and gelastic seizures, the cause is a hypothalamic hamartoma. In contrast, when dacrystic seizures are not accompanied by gelastic seizures the underlying lesion is most commonly located in the temporal cortex., (Wiley Periodicals, Inc. © 2012 International League Against Epilepsy.)

The misdiagnosis of epilepsy may occur from the misinterpretation of a routine scalp EEG. Typically, interictal epileptiform discharges are misidentified on EEGs because of the overinterpretation of normal variants or variations in normal electrocerebral activity. Most reports of misinterpretation have arisen from patients diagnosed with psychogenic nonepileptic attacks using in-patient video-EEG monitoring. However, because seizures are rarely captured in the routine performance of EEG in the outpatient setting, ictal overinterpretation is much less likely to occur. However, some physiologic conditions may also occur with paroxysmal hypersynchronous patterns on EEG and lead to a misdiagnosis of epilepsy. We report an adult woman with untreated obstructive sleep apnea and major depressive disorder that was self-referred for the evaluation of seizures. Brief episodes of delayed responsiveness associated with prolonged reading demonstrated the "generalized paroxysmal pattern" that was misinterpreted as a seizure during routine EEG at an outside institution. Subsequently, in-patient video-EEG monitoring reproduced multiple nonepileptic physiologic paroxysmal hypersynchronous arousals after prolonged reading. Treatment of the underlying sleep apnea, psychologic support, and limited prolonged reading lead to remission of her nonepileptic "spells" and successful discontinuation of antiepileptic drugs.

Purpose: While an abnormal pre-operative high-resolution brain MRI portends a favorable outcome in patients undergoing resective epilepsy surgery for medically intractable localization-related epilepsy (LRE), a normal MRI is less favorable. Ascertaining desirable pre-operative predictors for successful anterior temporal lobectomy (ATL) in LRE patients with a normal brain MRI is essential to better anticipate surgical outcome., Methods: Patients with LRE and normal temporal structures on MRI underwent ATL at two epilepsy centers in the southeastern US (FL and NC). Outcome was separated into those patients that were seizure free (SF), and those that were not seizure free (NSF), and those NSF were stratified in accordance with the Engel classification system. Those with a pre-operative history of clinical risk factors, unilateral anterior temporal interictal epileptiform discharges (IEDs), well localized scalp ictal EEG with rhythmic temporal theta at onset, localized PET/ictal SPECT, and Wada asymmetry with >2.5/8, were evaluated for the purpose of predicting outcome. Where appropriate, data is presented as a median (mean +/- S.D.)., Results: Thirty-nine patients, median age 33 years, were followed up 2 years (3+/-1.2) after ATL. Overall, 22/39 (56.4%) patients were identified as SF, and 17/39 (43.6%) patients were NSF. Ictal EEG with rhythmic temporal theta at onset was the only predictive measure of seizure-free outcome (p=0.001, Fisher's exact test), and also favorably correlated with seizure reduction (p=0.0001, r(2)=0.34, multiple regression analysis). None of the other predictors examined added greater predictive value., Conclusions: ATL is a favorable option for patients with LRE even when high-resolution brain MRI reveals normal temporal structures. Normal brain MRI patients with localizing pre-operative scalp ictal EEG, have better outcomes following ATL.

To analyze the yield of short-term outpatient EEG video monitoring, the authors reviewed data on all patients who underwent this procedure at their center. All patients were suspected of having psychogenic nonepileptic seizures (PNES) on clinical grounds. The total number of cases of short-term outpatient EEG video monitoring was 74. In 49 (66%) cases, the suspected diagnosis of PNES could be confirmed, thereby obviating the need for prolonged inpatient EEG video monitoring.

The overinterpretation of EEGs is a known problem that has not been reported specifically. The authors report a series of EEGs on patients who were diagnosed eventually with psychogenic nonepileptic seizures and who had an EEG read as epileptiform. Of the 15 actual records available for review, the overread patterns were wicket spikes (n = 1), hypnagogic hypersynchrony (n = 1), and hyperventilation-induced slowing (n = 1). In the other 12 records, the overread patterns were simple fluctuations of sharply contoured background rhythms or fragmented alpha activity. Rather than well-described normal variants, the overinterpreted patterns tend to be normal fluctuations of background activity.

The proportion of patients with psychogenic nonepileptic seizures (PNES) who also have epilepsy has been reported to vary from 10% to over 50%. The authors reviewed all 32 patients diagnosed with PNES in our EEG-video monitoring unit over a period of 1 year, and only 3 (9.4%) had interictal epileptiform discharges to support a coexisting diagnosis of epilepsy. Thus, the authors believe that only a small proportion of patients with PNES have coexisting epilepsy.

The diagnosis of psychogenic nonepileptic seizures (PNES) can only be made with EEG-video monitoring. The authors describe a provocative technique without placebo. Patients with a clinical suspicion for PNES underwent an activation procedure using suggestion, hyperventilation, and photic stimulation. Of 19 inductions performed, 16 (84%) were successful in inducing the habitual episode. The authors' technique had a sensitivity comparable to those using placebo (e.g., saline injection), but does not have disadvantages.