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Electroencephalography (EEG) is a useful adjunct to clinical neurological examination, particularly as it may detect subtle or subclinical disturbance of cerebral function and it allows monitoring of cerebral activity over time. Continuous EEG combined with quantitative analysis and machine learning may help identify changes in real time, before the emergence of clinical signs and response to interventions. EEG is rarely pathognomonic in encephalopathy/encephalitis but when interpreted correctly and within the clinical context, certain phenotypes may indicate a specific pathophysiology (eg, lateralised periodic discharges in HSV-1, generalised periodic discharges in sporadic Creutzfeldt-Jakob disease, and extreme delta brushes in anti-n-methyl-D-aspartate receptor autoimmune encephalitis). EEG is included in some specialist guidelines for disease assessment, monitoring and prognostication (ie, hepatic, cancer immunotherapy, viral, prion, autoimmune encephalitis and hypoxic ischaemic encephalopathy). EEG is invaluable for confirming or excluding non-convulsive seizures or status epilepticus, particularly in critically ill patients, and in understanding new concepts such as epileptic encephalopathy and the ictal-interictal continuum. [ABSTRACT FROM AUTHOR]

Aims: Seizures and status epilepticus (SE) are detected in almost a third of the comatose cardiac arrest survivors. As the literature is quite exhaustive regarding SE with motor symptoms in those patients, little is known about nonconvulsive SE (NCSE). Our aim was to compile the evidence from the literature of the frequency and outcome of NCSE in adult patients remaining in coma after resuscitation. Methods: The medical search PubMed was screened for most relevant articles reporting the emergence and outcome of NCSE in comatose post-resuscitated adult patients. Results: We identified 11 cohort studies (four prospective observational, seven retrospective) including 1092 patients with SE in 29–96% and NCSE reported in 1–20%. EEG evaluation started at a median of 9.5 h (range 7.5–14.8) after cardiac arrest, during sedation and targeted temperature management (TTM). Favorable outcome after NCSE occurred in 24.5%. We found no study reporting EEG to detect or exclude NCSE in patients remaining in coma prior to the initiation of TTM and without sedation withing the first hours after ROSC. Discussion: Studies on NCSE after ROSC are scarce and unsystematic, reporting favorable outcome in every fourth patient experiencing NCSE after ROSC. This suggests that NCSE is often overlooked and outcome after NCSE is not always poor. The low data quality does not allow firm conclusions regarding the effects of NCSE on outcome calling for further investigation. In the meantime, clinicians should avoid equating NCSE after ROSC with poor prognosis. [ABSTRACT FROM AUTHOR]

Status epilepticus (SE) is the state of continuous or repetitive seizures, which can occur with or without convulsions. Evolving definitions of SE take into account the concept that neuronal injury may occur at different times in different types of SE.SE that does not respond to initial treatment may become refractory or even super-refractory. Nonconvulsive SE is increasingly recognized in comatose patients in critical care units, with the growing use of continuous electroencephalogram monitoring. SE is a neurologic emergency that carries a high risk of mortality and morbidity. [ABSTRACT FROM AUTHOR]

• Repetitive miniature spikes (RMS) represent a rare focal EEG pattern characterized by a voltage less than 50 µV. • RMS are mainly reported with invasive EEG recordings and received less attention in scalp EEG. • Although frequently reported in focal cortical dysplasia, RMS can be associated with other localized cortical lesions. Low-voltage repetitive spikes are mainly described with invasive recordings and considered highly suggestive for focal cortical dysplasia (FCD). This EEG pattern has received less attention in routine scalp EEG. Prospective collection of EEGs with low-voltage (<50 µV) repetitive spikes (repetitive miniature spikes – RMS) between July 1982 and July 2017 at the EEG laboratory of the Medical University of Innsbruck. We analyzed patterns of RMS on routine scalp EEG recordings and examined the relationship to clinical and brain imaging data. Overall, RMS were seen in 38 patients representing zero to four observations out of 5000 records per year. RMS occurred rhythmically in 14, periodically in 17 and irregularly in seven patients. The EEG pattern appeared with a frontal and central predominance. All but five patients had epilepsies; eleven patients had non-convulsive status epilepticus. Cerebral magnetic resonance imaging (cMRI) detected malformations of cortical development in eleven patients, including six patients with focal cortical dysplasias. RMS are rare EEG patterns indicating focal epilepsy. Their observation on routine scalp EEGs should prompt further clinic-radiologic investigation. RMS resemble a clearly recognizable pattern in routine EEG, which is highly associated with focal epilepsy. The term is descriptive and can be added to the red flags, which can be found on routine EEG indicating underlying structural brain pathology, often in form of focal cortical dysplasia. [ABSTRACT FROM AUTHOR]

A recent assessment of the classification of nonconvulsive status epilepticus (NCSE) has incorporated the specific electroencephalographic (EEG) patterns on a syndromic basis. Such a clinical EEG syndromic approach may enable more accurate and expedited diagnosis of particular subtypes of NCSE so as to improve therapy. Herein, we review the characteristics of subacute encephalopathy with seizures in alcoholics syndrome, a subtype of focal NCSE occurring in chronic alcoholism with specific features, including encephalopathy, lateralized periodic discharges on the EEG, chronic microvascular ischemia on neuroimaging studies, and possible recurrence when chronic antiseizure treatment is stopped. [ABSTRACT FROM AUTHOR]

Summary: Objective: To characterize a critically ill cohort with status epilepticus (SE) by the illness severity scoring systems SAPS II (Simplified Acute Physiology Score II), APACHE II (Acute Physiology and Chronic Health Evaluation II), and SOFA (Sequential Organ Failure Assessment), and to compare their performance with the STESS (Status Epilepticus Severity Score) for outcome prediction. Methods: The prospective cohort study was carried out at the University Hospital Basel, a Swiss tertiary academic medical care center. Consecutive adult SE patients hospitalized in the intensive care units from 2011 to 2016 were included. Illness severity scores and additional clinical data were recorded. Logistic regression models using automated variable selection were applied to identify scores associated with no return to functional and neurological baseline and death. Measures of discrimination and calibration were assessed. Results: Among 184 patients, 33% returned to baseline. Median scores of the illness severity scores were within the lowest third of the possible scoring ranges, and all differed significantly between patients with and without return to baseline. The areas under the receiver operating curves for the prediction of no return to baseline and death ranged from 0.64 to 0.73, with the highest value for the STESS predicting no return to baseline. Measures of calibration revealed adequate model fit for all analyses. Among integral components of the scoring systems, only the Glasgow Coma Scale (GCS) differed significantly between patients with and without return to baseline. In multivariable analyses, decreasing GCS and increasing STESS had the strongest associations (odds ratio [OR] = 0.84, 95% confidence interval [CI] = 0.77‐0.93 and OR = 1.34, 95% CI = 1.05‐1.68, respectively) with no return to baseline independent of all other scoring systems, whereas the APACHE II revealed the strongest association with death (OR = 1.15, 95% CI = 1.06‐1.25). Significance: Although complex illness severity scoring systems in SE patients facilitate benchmarking and comparisons with other severely ill patient cohorts, they offer no advantages over the STESS and GCS regarding prediction of no return to baseline. [ABSTRACT FROM AUTHOR]

Searching for evidence of consciousness in outwardly unresponsive patients presents significant clinical challenges as the spectrum of disorders of consciousness has become more clearly defined, with clinical examination, functional MRI, and electrophysiologic tests having complementary roles in the investigation of minimally conscious patients, those in a locked-in state, coma, or in a vegetative state. Serial bedside electrophysiologic testing can probe for higher order cortical responses temporally and spatially propagated through cortical networks, while long-latency event-related potentials may help differentiate patients with coma or vegetative state from a state of residual consciousness. Transcranial magnetic stimulation coregistered to high-density EEG may reveal widespread pulse-stimulated cortical activation of various brain regions. These emerging electrophysiologic techniques show promise as powerful diagnostic, prognostic, and therapeutic tools. [ABSTRACT FROM AUTHOR]

Objective To investigate the ability of the evolution and termination patterns to distinguish stimulus-induced rhythmic, periodic, or ictal discharges (SIRPIDs) from spontaneous electrographic seizures, a challenge to the neurophysiologist and clinician. Methods We screened the prospectively collected database of patients undergoing continuous EEG (cEEG) and identified 25 cases of SIRPIDs. We compared patients with SIRPIDs to 25 patients with spontaneous seizures. Two experienced neurophysiologists graded the termination pattern of both on fast fourier transform (FFT) as “abrupt” or “sputtering.” Results The identification of a “sputtering” or cyclical tapering pattern accurately discriminated SIRPIDs from spontaneous seizures with 88% sensitivity and 87% specificity, yielding a positive predictive value of 82% for SIRPIDs when the pattern was present (negative predictive value 87% when the sputtering termination was not seen). Similarly, the identification of an “abrupt” termination pattern identified clinically determined seizures with 84% sensitivity and 88% specificity. Conclusions The termination pattern quickly and accurately distinguishes SIRPIDs from spontaneous seizures, suggesting that at least some SIRPIDs have an underlying mechanism distinct from that of spontaneous seizures. Significance If validated in other studies, the use of evolution and termination patterns to classify EEG patterns as epileptiform seizures versus SIRPIDs will help guide treatment of these patients. [ABSTRACT FROM AUTHOR]

Objective Approximately 25 million individuals older than age 15 identify as transgender, representing about 0.3-0.9% of the world's population. The aim of this paper is to identify and describe important medical and social considerations facing transgender persons with epilepsy. Methods We performed literature searches on the following terms: transgender AND epilepsy, transgender AND neurology, gender dysphoria AND epilepsy, gender dysphoria AND neurology. We also performed literature searches for common feminizing or masculinizing treatment regimens, and searched for interactions of those treatment regimens with antiepileptic drugs ( AEDs) and with seizures. Results There are multiple bidirectional interactions between AEDs and the commonly used treatments for aligning external sex characteristics with identified gender. The scope of the transgender population with epilepsy remains to be elucidated. Significance Transgender patients with epilepsy face significant social and medical challenges. Interactions between medical gender-affirming treatments and AEDs are common, and management must depend on knowledge of these interactions to provide appropriate treatment. [ABSTRACT FROM AUTHOR]

Prognostication after cardiac arrest often depends primarily on neurological function, and characterizing the extent of neurological injury hinges on neurophysiological testing and clinical neurological examination. The presence of early posthypoxic myoclonus (PHM) following cardiac arrest had been invariably associated with poor outcome, but more recent studies have shown that those with early PHM may survive with good neurological function. Electroencephalographic patterns suggestive of severe brain injury may be more valuable than the presence of PHM itself in portending poor functional status, and phenotyping PHM may also be useful in delineating benign and malignant forms. Patients with early PHM should be evaluated similarly to others who suffer cardiac arrest by using a multimodal approach in determining prognosis until further studies are performed that better characterize early PHM subtypes and their outcomes. [ABSTRACT FROM AUTHOR]

The accurate diagnosis and classification of seizures is critical in informing prognosis and determining appropriate antiseizure treatments for patients with epilepsy. The electroencephalogram is the gold standard for diagnosis. Obtaining a thorough history, performing a careful physical examination, and selecting appropriate diagnostic studies are also essential in determining the underlying seizure etiology. The authors provide clinical pearls and pitfalls in the diagnosis and management of epilepsy. [ABSTRACT FROM AUTHOR]

Objectives To confirm the previously identified EEG characteristics for HSV encephalitis and to determine the diagnostic and predictive value of electroencephalography (EEG) features for etiology and outcome of acute encephalitis in adults. In addition, we sought to investigate their independence from possible clinical confounders. Methods This study was performed in the Intensive Care Units of two academic tertiary care centers. From 1997 to 2011, all consecutive patients with acute encephalitis who received one or more EEGs were included. Examination of the diagnostic and predictive value of EEG patterns regarding etiology, clinical conditions, and survival was performed. The main outcome measure was in-hospital death. Results Of 103 patients with encephalitis, EEGs were performed in 76 within a median of 1 day (inter quartile range 0.5–3) after admission. Mortality was 19.7%. Higher proportions of periodic discharges (PDs) ( p = 0.029) and focal slowing ( p = 0.017) were detected in Herpes Simplex virus (HSV) encephalitis as compared to non-HSV encephalitis, while clinical characteristics did not differ. Normal EEG remained the strongest association with a low relative risk for death in multivariable analyses (RR < 0.001, p < 0.001) adjusting for confounders as coma, global cerebral edema and mechanical ventilation. None of the patients with a normal EEG had a GCS of 15. Conclusions Normal EEG predicted survival independently from possible confounders, highlighting the prognostic value of EEG in evaluating patients with encephalitis. EEG revealed higher proportions of PDs along with focal slowing in HSV encephalitis as compared to other etiologies. Significance EEG significantly adds to clinical, diagnostic and prognostic information in patients with acute encephalitis. [ABSTRACT FROM AUTHOR]

Status epilepticus refractory to first-line and second-line antiepileptic treatments challenges neurologists and intensivists as mortality increases with treatment refractoriness and seizure duration. International guidelines advocate anesthetic drugs, such as continuously administered high-dose midazolam, propofol, and barbiturates, for the induction of therapeutic coma in patients with treatment-refractory status epilepticus. The seizure-suppressing effect of anesthetic drugs is believed to be so strong that some experts recommend using them after benzodiazepines have failed. Although the rationale for the use of anesthetic drugs in patients with treatment-refractory status epilepticus seems clear, the recommendation of their use in treating status epilepticus is based on expert opinions rather than on strong evidence. Randomized trials in this context are lacking, and recent studies provide disturbing results, as the administration of anesthetics was associated with poor outcome independent of possible confounders. This calls for caution in the straightforward use of anesthetics in treating status epilepticus. However, there are still more questions than answers, and current evidence for the adverse effects of anesthetic drugs in patients with status epilepticus remains too limited to advocate a change of treatment algorithms. In this overview, the rationale and the conflicting clinical implications of anesthetic drugs in patients with treatment-refractory status epilepticus are discussed, and remaining questions are elaborated. This article is part of a Special Issue entitled “Status Epilepticus” . [ABSTRACT FROM AUTHOR]

Acute encephalopathy is a clinical conundrum in neurocritical care facing physicians with diagnostic and therapeutic challenges. Encephalopathy arises from several concurrent causes, and delayed diagnosis adds to its grim prognosis. Diagnosis is reached by melding clinical, neurophysiological and biochemical features with various neuroimaging studies. We aimed to compile the pathophysiology of acute encephalopathies in adults, and the contribution of cerebral CT, MRI, MR spectroscopy (MRS), positron emission tomography (PET) and single-photon emission CT (SPECT) to early diagnosis, treatment and prognostication. Reports from 1990 to 2013 were identified. Therefore, reference lists were searched to identify additional publications. Encephalopathy syndromes best studied by neuroimaging emerge from hypoxic-ischaemic injury, sepsis, metabolic derangements, autoimmune diseases, infections and rapidly evolving dementias. Typical and pathognomonic neuroimaging patterns are presented. Cerebral imaging constitutes an important component of diagnosis, management and prognosis of acute encephalopathy. Its respective contribution is dominated by rapid exclusion of acute cerebral lesions and further varies greatly depending on the underlying aetiology and the range of possible differential diagnoses. CT has been well studied, but is largely insensitive, while MRI appears to be the most helpful in the evaluation of encephalopathies. MRS may provide supplementary biochemical information and determines spectral changes in the affected brain tissue. The less frequently used PET and SPECT may delineate areas of high or low metabolic activity or cerebral blood flow. However, publications of MRS, PET and SPECT are limited only providing anecdotal evidence of their usefulness and sensitivity. [ABSTRACT FROM AUTHOR]

Proceeding from the proposed classification of status epilepticus syndromes by Shorvon in 1994, we performed a systematic search for reports presenting electroencephalography ( EEG) patterns of nonconvulsive status epilepticus ( NCSE) on all syndromes in the classification, where possible. Using the online medical search engine Pub Med for 22 different search strategies, EEG patterns supporting a diagnosis of NCSE were sought. From a total of 4,328 search results, 123 cases with corresponding EEG patterns could be allocated to underlying epilepsy syndromes. Based on the characteristic EEG patterns found for the different NCSE syndromes, we present a synthesis of the significant EEG morphologies and evolutions in the individual NCSE syndromes. [ABSTRACT FROM AUTHOR]

In adult patients with status epilepticus (SE)-a life-threatening state of ongoing or repetitive seizures--the current evidence regarding outcome prediction is based on clinical, biochemical and EEG determinants. These predictors of outcome involve clinical features such as age, history of prior seizures or epilepsy, SE aetiology, level of consciousness, and seizure type at SE onset. The clinical risk-benefit calculation between the danger of undertreated persistent seizure activity and, conversely, the potential damage from unwarranted aggressive treatments remains a constant challenge. Improved knowledge of outcome determinants, as well as increased availability of reliable outcome prediction models early in the course of SE, is paramount for optimization of treatment of patients who develop this disorder. In this Review, we discuss the major prognostic determinants of outcome in SE. Through consideration of studies that provide measures of association between predictors of SE outcome and death, we propose a detailed--but as yet unvalidated--paradigm for assessment of these predictors during the course of SE. Such an algorithm could guide the organization of results from existing trials and provide direction with regard to the parameters that should be monitored in future studies of SE. [ABSTRACT FROM AUTHOR]

In adult patients with status epilepticus (SE)—a life-threatening state of ongoing or repetitive seizures-the current evidence regarding outcome prediction is based on clinical, biochemical and EEG determinants. These predictors of outcome involve clinical features such as age, history of prior seizures or epilepsy, SE aetiology, level of consciousness, and seizure type at SE onset. The clinical risk-benefit calculation between the danger of undertreated persistent seizure activity and, conversely, the potential damage from unwarranted aggressive treatments remains a constant challenge. Improved knowledge of outcome determinants, as well as increased availability of reliable outcome prediction models early in the course of SE, is paramount for optimization of treatment of patients who develop this disorder. In this Review, we discuss the major prognostic determinants of outcome in SE. Through consideration of studies that provide measures of association between predictors of SE outcome and death, we propose a detailed–but as yet unvalidated–paradigm for assessment of these predictors during the course of SE. Such an algorithm could guide the organization of results from existing trials and provide direction with regard to the parameters that should be monitored in future studies of SE. [ABSTRACT FROM AUTHOR]

Over the last decade, significant improvements have been made in understanding and categorizing coma and disorders of consciousness. Although imaging techniques have been paramount in exploring disorders of consciousness, electrophysiologic techniques continue to be important for studying brain function in behaviorally unresponsive patients. In acute coma, electroencephalogram and evoked potentials have important roles in excluding nonconvulsive seizures, determining prognosis, monitoring for signs of improvement or worsening, and examining for markers of conscious response to external stimuli. Absence of cortical SSEPs is the most specific marker of poor prognosis after cardiac arrest. Recognition of stimulus-induced epileptiform discharges and clinical seizures has further blurred the lines along the ictal--interictal spectrum in coma. For chronic disorders of consciousness, more experimental techniques, such as cognitive event-related potentials and long-latency evoked potentials, have demonstrated an expanded role in determining prognosis and examining for indicators of consciousness. Like functional magnetic resonance imaging, these specialized techniques have demonstrated signs of preserved cognition in patients who otherwise appear unconscious. Future directions for clinical electrophysiologic testing in disorders of consciousness are likely to include automated and quantitative signal processing techniques and better standardization of cognitive event-related potentials. [ABSTRACT FROM AUTHOR]

There have been many attempts at defining the electroencephalography (EEG) characteristics of nonconvulsive status epilepticus (NCSE) without a universally accepted definition. This lack of consensus arises because the EEG expression of NCSE does not exist in isolation, but reflects status epilepticus under the variety of pathologic conditions that occur with age, cerebral development, encephalopathy, and epilepsy syndrome. Current NCSE definitions include 'boundary conditions,' in which electroencephalographic seizure activity occurs without apparent clinical seizures. Furthermore, what appears to one interpreter as status epilepticus, is not to another reader, reflecting the 'art' of EEG interpretation. Seizures and epilepsy syndromes have undergone an evolution that has moved beyond a classification of focal or generalized conditions into a syndromic approach. It seems appropriate to make similar changes in the EEG analysis of the syndromes of NCSE. In effect, the literature on epilepsy classification has progressed to incorporate the different NCSE types with clinical descriptions, but the specific EEG evidence for these types is found largely in individual reports, and often by description only. NCSE classification of EEG patterns should derive from the aggregate of published EEG patterns in the respective clinical subtype, supported by an analysis of these EEG studies. The analysis that follows presents clinical descriptions and EEG patterns of NCSE in the neonatal period, infancy, childhood, adulthood, and late adulthood from a syndromic perspective based on age, encephalopathy, cerebral development, etiology, and syndrome. Proceeding from the proposed classification of status epilepticus syndromes in 'Status epilepticus: its clinical features and treatment in children and adults' (published in 1994 by Cambridge University Press, New York), we have performed a systematic search for reports presenting EEG patterns of NCSE using the online medical search engine PubMed for 22 different search strategies. EEG patterns were reviewed by two board-certified epileptologists who reached consensus regarding presence of NCSE. From a total of 4,328 search results, 123 cases with corresponding EEG patterns could be allocated to underlying epilepsy syndromes. Typical characteristic, prominent electrographic patterns, and sequential arrangements are elucidated for the different NCSE syndromes. This compendium of patterns by NCSE syndrome classification with illustration of EEGs, and delineation of electroencephalographic features helps define the characteristics and semiologic borderlines among the types of NCSE. [ABSTRACT FROM AUTHOR]

Abstract: Limbic encephalitis (LE) with waxing and waning neuropsychiatric manifestations including behavioral, personality, psychiatric, and memory changes can evolve over days to months. Many features of LE show remarkable overlap with the characteristics of mesial-temporal (limbic) status epilepticus (MTLSE or LSE). With LE, these prolonged impaired states are assumed not to be due to ongoing epileptic activity or MTLSE, because scalp EEGs usually show no epileptiform spike-wave activity; cycling behavioral and motor changes are attributed to LE; there may be little immediate improvement with antiepileptic drugs (AEDs); and of course, implanted electrodes are rarely used. Conversely, it is known that in pre-surgical patients with refractory limbic epilepsy, implanted electrodes have revealed limbic seizures that cannot be seen at the scalp. This paper assembles a chain of inferences to advance the proposition that refractory LE might represent LSE more often than is thought, and that implanted electrodes should be considered in some cases. We present two cases that suggest that LE was also LSE, one of which warranted implanted electrodes (case 1). [Copyright &y& Elsevier]

Abstract: There is a long-recognized association between obsessive–compulsive disorder (OCD) and chronic epilepsy, most notably refractory temporal lobe epilepsy (TLE). The literature documents this association with case reports, patient series, and some larger controlled studies that reveal that almost a quarter of patients with TLE exhibit OCD features, which may go unrecognized. Obsession features with ordering, symmetry, exactness, handwashing, and religiosity occur more often in persons with right- or left-sided epileptic foci than in those with idiopathic generalized epilepsies or controls. Neurobiological and social factors suggest abnormalities of the frontal–thalamic–pallidal–striatal–anterior cingulate–frontal circuits stemming from the observation that certain diseases, damage, or surgery along these circuits may produce or, conversely, reduce OCD in TLE. This review explores the literature on case reports, case series, and larger retrospective controlled studies and looks at the associations of epilepsy with OCD. Contemporary speculation on the theoretical neurobiological underpinnings provides some basis on how and where to direct treatment. Invasive deep brain stimulation has triggered recent controversy on newer treatment modalities. [Copyright &y& Elsevier]

Abstract: Stuttering is a repetitive, iterative disfluency of speech, and is usually seen as a developmental problem in childhood. Acquired causes in adults include strokes and medications. When stuttering occurs with seizure-like events, it is usually attributed to psychogenic nonepileptic seizures. We describe an elderly man who experienced personality change and bouts of stuttering, followed by anarthria with preserved writing and then aphasia affecting written and uttered language, and ending with confusion. EEG recordings showed nonconvulsive status epilepticus (NCSE) with focality in the left frontal region followed by bifrontal NCSE. This case enlarges our understanding of the behavioral correlates of focal frontal seizures to include simple partial seizures with speech and then language output disturbances (aphemia, then aphasia), progressing to complex partial phenomenology in the setting of frontal NCSE. [Copyright &y& Elsevier]

Abstract: Objectives: To investigate the clinical correlates of frontal intermittent rhythmic delta activity (FIRDA). Methods: we prospectively assessed all EEG studies recorded in our center over 3months for the presence of frontal intermittent rhythmic delta activity (FIRDA). The FIRDA group was compared with a randomly selected control group from among EEGs recorded during the same period. Comparisons among FIRDA and non-FIRDA groups were performed using uni- and multi-variate analyses. Results: We found 36 patients with FIRDA among 559 EEG recordings (6%); the control group consisted of 80 subjects. While epilepsy was more frequent in the control group, structural brain lesions and encephalopathy were independently associated with the occurrence of FIRDA, but we could not identify any specific etiology. Asymmetric FIRDA was associated with an underlying brain lesion. Occasionally, FIRDA was recorded in otherwise healthy subjects during hyperventilation. Conclusion: FIRDA appears more common than previously reported, and is associated with a wide range of lesions and encephalopathic conditions. Significance: FIRDA occurrence should prompt investigations for toxic-metabolic disturbances and for structural lesions (particularly if asymmetric), but does not suggest an epileptic predilection. [Copyright &y& Elsevier]

In clinical practice, a classification of seizures based on clinical signs and symptoms leads to an improved understanding of epilepsy-related issues and therefore strongly contributes to a better patient care. The inverse problem involves inferring the anatomical brain localization of a seizure from the scalp surface EEG, a concept we apply here to correlate seizure origin with seizure semiology. The spheres of senso-rium, motor features, consciousness changes and autonomic alterations during ictal and postictal manifestations are reviewed, including several subdivisions used to better categorize particular features. Particular attention is given to behavioral features, as well as to features occurring in idio-pathic generalized epileptic syndromes and psychogenic nonepileptic spells. [ABSTRACT FROM AUTHOR]

Abstract: Women with epilepsy (WWE) face particular challenges during their pregnancy. Among the several obstetric issues for which there is some concern and the need for further investigation are: the effects of seizures, epilepsy, and antiepileptic drugs on pregnancy outcome and, conversely, the effects of pregnancy and hormonal neurotransmitters on seizure control and antiepileptic drug metabolism. Obstetric concerns include preclampsia/eclampsia, preterm delivery, placental abruption, spontaneous abortion, stillbirth, and small-for-date babies in WWE whether or not they are taking antiepileptic drugs. The role of nutritional health elements, including body mass index, caloric and protein intake, vitamins and iron, and phytoestrogens, warrants further study. During the course of obstetric management, there is a need for a fuller understanding by neurologists of the risk–benefit calculations for various types and frequencies of fetal imaging, including CT, MRI, and ultrasound, as well as for the screening standards of care. As part of the Health Outcomes in Pregnancy and Epilepsy (HOPE) project, this expert panel provides a brief overview of these concerns, offers some approaches to management, and outlines potential areas for further investigation. More detailed information and guidelines are available elsewhere. [Copyright &y& Elsevier]

Lithium therapy can cause a confusional state by direct toxicity, precipitation of nonconvulsive status epilepticus, or by interplay with other neuroleptic medications to produce neuroleptic malignant syndrome or serotonin syndrome. These conditions resemble each other clinically, but EEG may help differentiate among them. We reviewed the EEG patterns with triphasic waves or rhythmic delta activity in lithium toxic patients and discuss clinical and EEG differentiation among syndromes. Lithium toxicity poses significant diagnostic challenges from EEG and clinical perspectives. [ABSTRACT FROM AUTHOR]

EEG recording in the intensive care setting presents a number of technical challenges. It is essential to differentiate artifact from pathophysiologic EEG changes that would suggest encephalopathy, epileptiform activity, or seizures. There are particular patterns typical of deepening encephalopathy, as well as, coma patterns that have diagnostic and prognostic significance (e.g., spindle coma, alpha coma, burst suppression activity, and triphasic waves). Epileptiform patterns, including periodic lateralized epileptiform discharges (PLEDs), bilateral independent periodic lateralized epileptiform discharges (BIPLEDs), and generalized periodic epileptiform discharges (GPEDs), present particular challenges as there is a gray-zone between interictal patterns and the evolving (usually faster) patterns of nonconvulsive seizures. Accurate use of' EEG in the intensive care unit requires optimal EIZG technical expertise in performing the study, and appropriate interpretation by a trained electrophysiologist. [ABSTRACT FROM AUTHOR]