Ictal Psychosis under Disguise of Mania: How to Unravel

Background: Ictal psychosis without remarkable cognitive impairment is uncommon occurrence, presents diagnostic challenges to clinicians, often misdiagnosed as functional psychosis. Case Presentation: We present 3 cases of young adult men admitted to psychiatric ward as functional psychosis. They presented with irritability, physical aggression and mild cognitive impairment with intense emotional symptoms, and persecutory ideas and delusions. Two were wrongly diagnose as mania while the third was mimicking schizophrenia in its presentation. They received antipsychotic treatment and misdiagnosed as functional psychosis. They did not respond well to such treatment, until, series electroencephalograms were taken which revealed evidence of ictal psychosis. All, thence, responded well to addition of antiepileptic treatment. This, not only, proves to be effective, but also determined future management and prognosis. Conclusion: These cases shine light onto the role of the frontal cortex in the genesis of quasi-manic episodes and highlight the importance of EEG investigations in first episode of acute psychosis.

Brain Rattled, Heart Shackled: Ictal Asystole in a Patient without Prior History of Epilepsy or Arrhythmia

We present a case of ictal asystole in an 81-year-old female, with no prior history of epileptic activity, or cardiac history suggestive of arrhythmia, who suffered several seemingly unrelated epileptic and asystolic episodes prior to finally having a witnessed seizure followed by an asystolic event. Following this event, all atrioventricular (AV) nodal blockers, and medications with potential seizure threshold lowering activity were stopped, and anti-epileptic medication was optimized. Due to the wishes of the patient’s family, no invasive interventions were pursued.However, the patient continued to be medically treated with anti-epileptic therapy and had no further asystolic events. Unfortunately, the patient’s overall clinical status deteriorated, and she subsequently passed during her hospital stay after being made do not resuscitate and do not intubate (DNR/DNI) by the family and then subsequently comfort care. Prior to her passing, however, she had remained free of epileptic events for 10 days and free of asystolic events for 21 days.

Ictal hypersalivation as a prominent symptom in a girl with insulo-opercular epilepsy

Introduction:Hypersalivation has been associated with Rolandic epilepsy and other childhood epilepsy syndromes.However,pure salivatory seizures are a rare type of focal seizure in which ictal hypersalivation is the dominant feature throughout the seizures.Case presentation:We present a case of pure salivatory seizures originating from the right post-central operculum cortex,confirmed by the favorable surgical outcome.We attempt to analyze the symptom from behavioral and neural network perspectives and propose a possible mechanism to generate ictal hypersalivation and pure salivatory seizures.Conclusion:Based on previous reports in the literature and our case,we emphasize the importance of the operculum in patients with ictal hypersalivation,particularly in patients with pure salivatory seizures.

De novo ADGRV1 variant in a patient with ictal asystole provides novel clues for increased risk of SUDEP

Background Various cardiac and autonomic manifestations are frequently reported during seizures.Among the seizure-related arrhythmia,ictal tachycardia is the most common,followed by ictal bradycardia,with ictal asystole being the rarest.The occurrence of ictal asystole may obscure the clinical presentation and delay the diagnosis,representing a life-threatening presentation of epilepsy,with an elevated risk of sudden unexpected death in epilepsy patients(SUDEP).These cardiac abnormalities are being increasingly recognized as the key to elucidating the mechanisms of SUDEP.Case presentation We present a 35-year-old man with a history of focal-onset seizures with impaired consciousness since his mid-20 s.He developed different types of seizures for 2 years,described as tonic seizure and atonic seizure(drop attack).During such clinical events,he suffered from falls and cardiac arrest.However,thorough cardiac electrophysiology and imaging workup failed to reveal a cardiac etiology.Subsequent video electroencephalograph(EEG)monitoring was performed,and ictal bradycardia and ictal asystole were discovered.A cardiac pacemaker was implanted,and at 3-year follow-up,the patient did not suffer more atonic seizures,or falls.Genetic tests discovered a de novo variant of Adhesion G Protein-Coupled Receptor V1(ADGRV1),which may provide a clue for the patient’s ictal asystole and the increased risk of SUDEP.Conclusions Considering the important impact of ictal bradycardia and asystole on the morbidity and potential mortality of epileptic patients,it is important to simultaneously utilize EEG and electrocardiogram to confirm the diagnosis.This case report highlights the link between the de novo variant of ADGRV1 and the ictal bradycardia/asystole phenotype and implicates the importance of genetic testing in adult epilepsy patients.

Interictal and Ictal MEG in presurgical evaluation for epilepsy surgery

Although presurgical evaluation of patients with pharamacoresistent focal epilepsies provides essential information for successful epilepsy surgery,there is still a need for further improvement.Developments of noninvasive electrophysiological recording and analysis techniques offer additional information based on interictal and ictal epileptic activities.In this review,we provide an overview on the application of ictal magnetoencephalography(MEG).The results of a literature research for published interictal/ictal MEG findings and experiences with own cases are demonstrated and discussed.Ictal MEG may provide added value in comparison to interictal recordings.The results may be more focal and closer to the invasively determined seizure onset zone.In some patients without clear interictal findings,ictal MEG could provide correct localization.Novel recording and analysis techniques facilitate ictal recordings.However,extended recording durations,movement and artifacts still represent practical limitations.Ictal MEG may provide added value regarding the localization of the seizure onset zone but depends on the selection of patients and the application of optimal analysis techniques.

Ictal semiology,functional anatomy and multimodal diagnostic in patients with insular epilepsies

Background:The insula is a hidden part in the cerebral cortex.Insular epilepsy is underrecognized and it bears a special risk for misdiagnosis with regard to nonepileptic seizures or wrong localization of epileptic seizures.Case presentations:The manuscript describes 2 cases with ictal semiology of paresthesia and pain followed by hyperkinetic movements,noninvasive findings of source localization and/or invasive SEEG exploration.Conclusion:Magnetic source imaging,ictal SPECT as noninvasive and invasive recordings with depth electrodes(SEEG)can provide important preoperative information for the involvement of insular and periinsular regions in focal pharmacoresistant epilepsies.The optimal use of these methods presupposes extensive knowledge of ictal semiology and other clinical characteristics.The clinical localization hypothesis can be optimally proofed by SEEG exploration.

Lateralizing value of ictal face wiping in patients with mesial temporal lobe epilepsy

Objective To investigate the lateralizing value of ictal face wiping(FW)in patients with refractory mesial temporal lobe epilepsy(MTLE).Methods Presurgical video types were retrospectively reviewed among 96 patients who were seizure-free for at least 3 years after temporal lobectomy between 1997 and 2012.Attention

癫痫发作后全面性脑电波抑制及其在癫痫性猝死中的意义

癫痫性猝死(sudden unexpected death in epilepsy,SUDEP)是癫痫患者意外死亡的主要原因。癫痫发作后全面性脑电波抑制(postictal generalized EEG suppression,PGES)与SUDEP具有一定的相关性;PGES的出现具有显著的个体差异,其发生与患者年龄、发作类型、强直性发作/肌强直、发作时及发作后呼吸功能障碍、发作时和发作后的自主神经功能障碍相关。全面性强直-阵挛发作作中阵挛期进行性慢波(progressive slowing of clonic phase,PSCP)是PGES发生和延长的独立预测因子。

癫痫发作的两种模式

通过分析临床癫痫脑电的最大Lyapunov指数,研究了多种不同诱发背景的癫痫在各个时期(间期、前期、发作期、发作后期4个时段)的最大Lyapunov指数的时域变化规律,提出癫痫发作具有两种响应模式:(1)睡眠、清醒等状态下的自发癫痫,大脑受到随机信号的干扰,脑内各子系统之间需经过较复杂的协调作用才能进入高度同步放电状态;(2)闪光刺激等状态下的诱发癫痫,大脑受到外加高频信号的干扰,脑内各子系统将被快速驱动进入高度同步放电状态。

尿激酶治疗以偏瘫为主的急性脑梗塞160例疗效观察

本文报告急性脑梗塞260例,其中160例急性脑梗塞应用尿激酶10万~U+N·S100ml,静脉滴注,q12h×10天;100例应用Svate-Ⅲ 2~U+N·S100ml,静脉滴注一次/日×15天,两组同时应用Ca^(++)拮抗剂,稀释疗法及脑细胞赋形剂治疗。结果尿激酶组基愈率为65%,显效率90.63%,总有效率达96.26%,非常显著优于Svate-Ⅲ的51%、75%及89%。结果提示尿激酶治疗急性脑梗塞在注意出血倾向发生时是安全、有效的。

局部脑血流SPECT显像与其他影像对癫痫定位诊断比较的研究

目的:研究癫痫发作期与发作间期同侧对照99mTc-ECD局部脑血流(rCBF)单光子发射计算机体层摄影术(SPECT)显像对癫痫灶的定位诊断价值。方法:对54例癫痫患者行发作间期显像,其中10例行发作期显像,并与皮层脑电图(EEG)、计算机断层扫描或磁共振显像(CT/M RI)、深部皮层脑电图(EcoG)结果进行对比分析。结果:癫痫发作期与发作间期rCBF SPECT显像对癫痫灶具有较高的检出率和定位率,优于EEG、CT/M RI,低于EcoG,但rCBF在发作期与发作间期的比较差异无显著性(P>0.05)。结论:发作间期rCBF SPECT显像可以成为癫痫灶方便而有效的定位方法,若加上发作期rCBF显像则定位更佳。

地西泮终止大鼠晚期癫痫持续状态的效果观察

目的观察大鼠癫痫持续状态(SE)4h以后时间窗时,地西泮终止其发作的疗效。方法SD雄性大鼠,随机分为3组:对照组、持续棘波发放期(3期,1h)给药组和晚期周期性痫性波发放期(5期,PED,4h)给药组。采用氯化锂-匹罗卡品化学药物诱发大鼠SE,行为学观察和脑电图(EEG)记录持续到SE开始后5h。结果3组中SE1、2期的时长没有统计学差异,但地西泮能明显缩短SE3、4期的时长。即使在SE5期,给予地西泮后绝大多数SE大鼠能成功地终止其行为学和EEG上的痫性发作。结论(1)地西泮终止SE4h以后发作的效果比早期更为容易,提示癫痫持续的时间越长越不容易终止发作的结论在SE早期适用,可能并不适用于SE晚期;(2)在大鼠SE模型,海马与皮质EEG一样,也显现出5个特异性波形期。

MF-DFA在癫痫发作期及发作强度检测中的应用

癫痫患者的脑电特征是临床诊断、分类和预报癫痫的重要依据。作为测度时间序列内在模式变化的近似熵和样本熵成为一种临床癫痫分类和发作预报的重要方法,由于受到序列长度、嵌入维数以及阈值设置的影响,难以准确检测序列内模式突变的时刻。为准确检测脑电癫痫样放电时刻及其强度,提出了一种癫痫发作及强度检测的多分形去趋势波动分析方法(MF-DFA),并与基于样本熵的癫痫放电检测作进一步比较分析。采用头皮表面脑电与颅内脑电临床数据做测试实验,结果表明:MF-DFA能够精确捕捉到发作时刻,并能够定量刻画癫痫发作强度。

发作期直流电漂移与难治性伴海马硬化内侧颞叶癫痫的相关性研究

目的探讨发作期直流电漂移(ictal DC shift)在难治性伴海马硬化的内侧颞叶癫痫(MTLE-HS)中的定位价值。方法回顾性分析18例MTLE-HS患者的临床资料,进行非侵袭性和侵袭性术前评估,对发作起始区分别使用传统频段颅内电极脑电(iEEG)技术和基于宽频脑电技术的ictal DC shift进行定位,比较两组之间的时空分布差异及其与术后病理和预后之间的关系。结果 Ictal DC shift组空间分布明显较iEEG组更为局限,时间分布晚于iEEG组。结论 Ictal DC shift可能为致痫灶的电生理标志物。

Arrhythmogenic epilepsy and pacing need: A matter of controversy

There is increasing awareness among the cardiology community regarding ictal bradyarrhythmias as a cause of loss of consciousness. A high degree of suspicion is necessary when diagnosing ictal bradyarrhythmias, and delay in diagnosing this condition may lead to morbidity associated with falls and trauma. Ictal bradyarrhythmias have also been suggested to be associated with sudden unexplained death in epilepsy, although evidence related to this association is limited. There is no guidelinedirected therapy for symptomatic ictal bradyarrhythmias due to a lack of randomized, controlled trials. Cardiac pacemaker therapy is commonly used for these patients; however, currently, there is no universal agreement on the pacing indications for these patients. In this review, we focus on the pathophysiology and clinical presentation of ictal bradyarrhythmias and then discuss the pacing need based on the available literature data.

结节性硬化所致婴儿痉挛症发作期脑电局灶或一侧优势现象31例报告

目的：探讨结节性硬化症（TS）所致婴儿痉挛症患者发作期脑电活动局灶改变及其分布优势侧的特征现象，以及与术后疗效的关系。方法：回顾分析了31例TS术前脑电图定位在发作期呈现的局灶、一侧多灶，或双侧均有病灶而以一侧占优势的脑电图现象，并结合术后随访结果对比分析其差异。结果：局灶性放电（单灶）6例，一侧多灶14例，双侧改变以一侧占优势的11例。经统计学处理，局灶与一侧多灶比较差异有显著意义（P〈0．05）．与两侧均有以一侧占优势相比差异有极显著意义（P〈0．01）。结论：TS所致婴儿痉挛症患者间歇期表现为多灶性弥散放电甚至高度失律，但发作期起源灶相对明确，呈现局灶、一侧多灶或者两侧均有以一侧占优势，给外科干预提供有力的依据，并获得良好疗效，尤其对于发作期局灶改变者效果尤好。

发作期及发作间期痫性放电对癫痫的诊断价值

目的探讨发作期及发作间期脑电图对癫痫诊断的意义。方法对５６例癫痫患者常规脑电图（ＲＥＥＧ）与２４ｈ脑电图（ＡＥＥＧ）进行比较研究。结果①ＲＥＥＧ的阳性率为３０％，而ＡＥＥＧ的阳性率为８６％；②不同类型癫痫在发作期和发作间期大脑活动的规律和特点，ＲＥＥＧ无１例记录到癫痫发作，而ＡＥＥＧ有２７例（４８％）记录到癫痫发作全过程的大脑电活动变化。结论发作期的ＥＥＧ对确定癫痫类型有重要意义，全身性癫痫在发作的同时发作波在两侧半球同时出现，而部分性发作患者在临床发作的同时ＥＥＧ常局限在某一脑叶有单个棘波发放，此棘波处是癫痫的病灶的部位，这种局限棘波可扩散至全脑而临床出现全身阵挛发作，此类患者为部分性癫痫并非全身性癫痫。

婴儿发作性事件发作期动态脑电图监测

目的探讨动态脑电图(AEEG)监测对婴儿发作性事件诊断与鉴别诊断的意义。方法应用动态脑电图监测仪 ,对53例婴儿发作性事件进行发作期脑电监测分析。结果癫组31例中 ,AEEG监测时出现临床发作130次 ,发作期性放电阳性率为96.8 %(30/31例) ;性放电起源部位分布于颞区、额区、中央区、枕区或全脑 ,出现时间以非快速眼动睡眠第1、2期为多。癫样组22例中 ,AEEG监测时出现临床发作99次 ,经脑电活动同步分析均无性放电 ,为非癫性发作。结论应用AEEG对发作期脑电活动进行监测分析 ,有助于婴儿发作性事件的诊断与鉴别诊断。

长程脑电图监测诊断婴幼儿发作性事件的价值

目的 研究长程脑电图监测对不能依靠临床症状、体征及常规脑电图诊断的婴幼儿发作性事件的诊断价值.方法 近3年半来因发作性事件首次在西安交通大学医学院第二附属医院儿科门诊及住院诊治,不能依靠临床症状、体征及常规脑电图诊断的2岁以下婴幼儿136例.给予长程脑电图监测得到初步诊断为癫痫事件或非癫痫事件,再根据症状、体征、头颅CT、血糖、血氨、心肌酶谱、心电图、骨碱性磷酸酶、甲状腺功能,以及用抗癫痫药物治疗后的反应等,得到确定诊断.结果 ①长程脑电图初诊癫痫发作 81例（59.6%）,非癫痫发作 55例（40.4%）;53例（39.0%）监测到发作性事件的婴幼儿中有22例（41.5%）有发作时同步的痫样放电,初诊为癫痫发作,有31例（58.5%）发作时无同步痫样放电,且这31例中12例（38.7%）有发作间期痫样放电,初诊为非癫痫发作;83例（61.0%）未监测到发作性事件出现的婴幼儿中有59例（71.1%）在发作间期有痫样放电,初诊为癫痫发作,24例（28.9%）未见痫样放电,初诊为非癫痫发作.②80例（58.8%）患儿确诊为癫痫发作,56例（41.2%）确诊为非癫痫发作.③癫痫发作错诊及漏诊均发生在83例未监测到发作性事件的婴幼儿中,长程脑电图监测初诊的59例癫痫发作中有3例（5.1%）被排除,非癫痫发作24例中有2例（8.3%）被诊断为癫痫发作.长程脑电图诊断癫痫发作及非癫痫发作的诊断符合率分别为96.3%和96.4%,比较无统计学差异（χ^2=0.197,P〉0.05）,总体诊断符合率为96.3%.结论 发作性事件就诊的婴幼儿,如果不能依靠临床症状、体征及常规脑电图明确诊断,应进行长程脑电图监测诊断或排除癫痫事件.

地西泮终止大鼠晚期癫痫持续状态的效果观察

目的观察大鼠癫痫持续状态(SE)4h以后时间窗时,地西泮终止其发作的疗效。方法 SD雄性大鼠,随机分为3组:对照组、持续棘波发放期(3期,1h)给药组和晚期周期性痫性波发放期(5期,PED,4h)给药组。采用氯化锂-匹罗卡品化学药物诱发大鼠SE,行为学观察和脑电图(EEG)记录持续到SE开始后5h。结果 3组中SE1、2期的时长没有统计学差异,但地西泮能明显缩短SE3、4期的时长。即使在SE5期,给予地西泮后绝大多数SE大鼠能成功地终止其行为学和EEG上的痫性发作。结论 (1)地西泮终止SE4h以后发作的效果比早期更为容易,提示癫痫持续的时间越长越不容易终止发作的结论在SE早期适用,可能并不适用于SE晚期;(2)在大鼠SE模型,海马与皮质EEG一样,也显现出5个特异性波形期。