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Purpose To review the literature, for cases of hypoglycaemia misdiagnosed as epilepsy, including our interesting case of a patient with Type 1 Diabetes Mellitus, diagnosed with focal epilepsy. Methods A literature search was completed. 20 of 473 studies, with a total of 22 cases found using specified search terms were relevant to this review. The papers identified and reviewed were those that dealt with hypoglycaemia misdiagnosed as epilepsy. The majority are isolated case reports given the rarity of this entity. Results An underlying insulinoma is the most common cause for hypoglycaemic episodes to be misdiagnosed as epilepsy. Early morning seizures were prominent in 9 of the 22 cases. Conclusion Although rare, hypoglycaemia is an important differential diagnosis for drug-resistant epilepsy and early morning events may be an indication. We report the first case of recurrent hypoglycaemia from exogenous insulin, misdiagnosed as focal epilepsy with an available video EEG. The unusual presentation appeared clinically indistinct from recurrent focal seizures.

Long-term video-electroencephalographic (LTVEM) monitoring is a valuable tool in the evaluation of paroxysmal clinical events. However, vEEG itself is costly. Hence, we aimed to establish if longer duration of monitoring (DOM) is associated with higher diagnostic yield. A retrospective review of patients admitted into the epilepsy monitoring unit (EMU) for the diagnostic evaluation of paroxysmal events was performed. Patients' demographic, clinical characteristics, and vEEG data were analyzed. In the cohort of patients with DOM > 7 days, the reasons for prolonged DOM were identified and the differences in clinical characteristics and vEEG data between conclusive and inconclusive studies were analyzed. A total of 501 patients were included. Four hundred and thirty-six (87 %) patients had conclusive studies. Of these patients, 67.9 % patients with conclusive studies received diagnosis within the first 7 days of monitoring with the highest on day 7. The likelihood of conclusive studies decreased beyond 7 days. A total of 175 had DOM > 7 days, of which 140 (80 %) had conclusive studies. In the cohort with DOM > 7 days, patients with previous abnormal routine EEG, previous vEEG monitoring, first event recorded before day 5 of admission and ≥1 events recorded during vEEG monitoring were more likely to have conclusive studies. The most common reason for prolonging DOM beyond 7 days was to adequately record multiple semiologically distinctive events (76 %). Our study supports that longer DOM is associated with an increase in diagnostic yield. More than one-third of our cohort were monitored beyond 7 days with majority (80 %) being conclusive. Our findings may guide clinicians in planning the DOM and predicting the likelihood of conclusive vEEG studies in patients with prolonged DOM based on the clinical characteristics and vEEG data.

Highlights • Recurrent catamenial status epilepticus may occur in generalized and focal epilepsy. • Documenting the menstrual cycles and perimenstrual video-EEG help the diagnosis. • Hormonal treatment including menstrual suppressive therapies may be used.

Summary Epilepsy and psychogenic non-epileptic seizures (PNES) can co-exist and may present in 2 forms: sequential and simultaneous. In sequential presentations, epileptic seizures (ES) are treated and PNES emerge later. Simultaneous recording of ES and PNES by video electroencephalogram (vEEG) is less well described. We retrospectively reviewed all patients diagnosed with PNES by vEEG following standard seizure induction practices over a 21-month period. Within this cohort, we established the prevalence of co-existing epilepsy using clinical and electrographic data acquired from our epilepsy-specific patient record (EPR). We identified patients with simultaneous PNES and ES recorded during a single vEEG admission, establishing the frequency and emergent timing of each type. Of our 262 monitored patients, 59 were diagnosed with PNES. 19 of the patients with PNES had co-existing epilepsy (prevalence rate of 7.3% or 32% of those with PNES). 16 patients had PNES and ES recorded during the same admission and the remaining 3 patients had sequential PNES following successful treatment of ES. PNES occurred earlier (mean, within 1.21 days), with ES occurring later (mean, within 4.86 days). The simultaneous occurrence of PNES and ES recorded during a single admission is more common than previously reported. Identifying this group of patients may require a significantly longer period of vEEG monitoring and a detailed analysis of each individual's historical seizure events. This article is protected by copyright. All rights reserved.

Introduction Primary asystole occurs when the cardiac purkinje fibers intrinsically fail to generate a ventricular depolarization. This is preceded by a bradyarrhythmia due to complete heart block, sick sinus syndrome, or both. Ictal asystole occurs due to synchronization of cardiac autonomic neural discharges with ictal epileptiform activity. Both types of asystole can cause similar events with loss of consciousness and collapse, and are important to differentiate from one another. Ictal asystole has been reported in as many as 0.4% of video-EEG monitored patients (Scheule et al., 2007), and is more common in temporal lobe epilepsies, where ictal bradycardia can evolve into asystole. In patients with intractable focal epilepsy, in whom a loop recorder had been placed, the incidence of significant bradycardia or asystole has been found to be much higher (up to 21% of these individuals) then previously suspected (Rugg-Gunn et al., 2004). Methods We report the video-electrographic, clinical, and semiological features of two cases who were seen at our institution for diagnostic evaluation. Results The first individual was 43 year-old lady with a 33-year history of recurrent events. The events were characterised by speech arrest, staring ahead, and subjective visual disturbance, and sometimes by sudden collapse without any focal features or tonic/clonic movements. The second patient was a 35-year old man who presented with recurrent episodes of ringing in his ears, and a feeling of derealisation, with confusion afterward. The same events would frequently evolve with collapse, and/or generalised tonic-clonic movements. Both patients had asystole noted during a period of video-telemetry, one with asystole associated with a focal EEG seizure, and one with primary asystole with no ictal EEG change. Conclusion We present the clinical and EEG findings in both patients. We will discuss relevant clinical features and semiology that can alert the treating clinician to the need for cardiac monitoring and video-EEG telemetry in order to discern attacks of cardiac from those of ictal origin.

A 79-year-old woman with a history of partial thyroidectomy for multinodular goiter presented with acute onset episodic left ear pain followed by collapse with loss of awareness and limb jerking. Video EEG captured stereotyped episodes (video, [links.lww.com/WNL/A287][1]) with corresponding bradycardia and asystole for several seconds without ictal changes. A diagnosis of vagoglossopharyngeal neuralgia was made. She became symptom-free with eslicarbazepine and pacemaker insertion. [1]: http://links.lww.com/WNL/A287

Perineuritis is an unusual cause of direct peripheral nerve injury. We describe the clinicopathologic features of a 56-year-old man with mononeuritis multiplex due to Lyme disease; sural nerve biopsy demonstrated florid perineuritis. Treatment with intravenous ceftriaxone resulted in marked neurologic improvement. This study supports the notion that perineuritis forms part of the pathogenesis in acute Lyme neuroborreliosis.

A 72-year-old woman presented with first onset of seizure with no prior history of cognitive dysfunction. EEG revealed focal non-convulsive status epilepticus. MRI brain showed a left temporal non-enhancing lesion. Temporal pole biopsy showed acute neuronal necrosis and astrocyte hyperplasia together with extensive amyloid plaques and neurofibrillary tangles. Perivascular oligodendroglial hyperplasia was present. Postmortem examination revealed extensive plaque and tangle disease. Perivascular oligodendroglial hyperplasia was limited to the left temporal area. The presence of focal perivascular oligodendroglial hyperplasia in the left temporal cortex, combined with extensive plaque and tangle disease may have contributed to the focal status epilepticus in this patient. Although the presence of focal perivascular oligodendroglial hyperplasia has been reported in cases of temporal lobe epilepsy, it has not been reported as a cause of seizure in patients with Alzheimer’s disease previously. Further studies for clinical-pathologic correlation would be required to confirm this hypothesis.

Perineuritis is an unusual cause of direct peripheral nerve injury. We describe the clinicopathologic features of a 56-year-old man with mononeuritis multiplex due to Lyme disease; sural nerve biopsy demonstrated florid perineuritis. Treatment with intravenous ceftriaxone resulted in marked neurologic improvement. This study supports the notion that perineuritis forms part of the pathogenesis in acute Lyme neuroborreliosis.