Environmental and behavioral interventions

Electrolytes Disturbances and Seizures

Electroencephalographic Cerebral Dysrhythmic Abnormalities in the Trinity of Nonepileptic General Population, Neuropsychiatric, and Neurobehavioral Disorders

Cephalosporin-related neurotoxicity: Metabolic encephalopathy or non-convulsive status epilepticus?

Twenty-six (41%) of 63 consecutive patients with triphasic waves had various types of metabolic encephalopathies while 37 patients (59%) had non-metabolic encephalopathies, usually senile dementia. Triphasic waves were not found to be specific for any single type of metabolic encephalopathy. Etiology was more closely linked to conscious level at recording than any morphological or distributional feature of the triphasic waves themselves. Thus, all 31 alert patients had non-metabolic encephalopathies while all 13 comatose patients had metabolic encephalopathies. The second, positive, component (Wave II) most often had the highest voltage while equally maximal Waves I and II occurred next most commonly. Triphasic waves were most often maximally expressed anteriorly. Among patients with metabolic encephalopathies, a posterior-anterior delay or lag of the wave II peak occurred more commonly than did the better known anterior-posterior lag. Lags occurred with both metabolic and non-metabolic conditions, but were more common with the former. No difference in quantity or mode of appearance existed between the metabolic and non-metabolic groups when matched for conscious level. Prognosis for patients with either metabolic or non-metabolic encephalopathies was unfavourable. Only 4 of 24 metabolic and one of 35 non-metabolic patients were well at follow-up over 2 years later. Forty percent of EEGs with sharp and slow wave complexes (slow spike waves) had sporadically-appearing triphasic waves. The relative amplitudes of the 3 components differed from triphasic waves in other conditions: equally maximal Waves II and III were the most usual form.

Normal brain function depends on normal neuronal metabolism, which is closely related to systemic homeostasis of metabolites, such as glucose, electrolytes, amino acids and ammonia. "Metabolic encephalopathy" indicates diffuse brain dysfunction caused by various systemic derangements. Electroencephalogram (EEG) is widely used to evaluate metabolic encephalopathy since 1937, when Berger first observed slow brain activity induced by hypoglycemia. EEG is most useful in differentiating organic from psychiatric conditions, identifying epileptogenicity, and providing information about the degree of cortical or subcortical dysfunction. In metabolic encephalopathy, EEG evolution generally correlates well with the severity of encephalopathy. However, EEG has little specificity in differentiating etiologies in metabolic encephalopathy. For example, though triphasic waves are most frequently mentioned in hepatic encephalopathy, they can also be seen in uremic encephalopathy, or even in aged psychiatric patients treated with lithium. Spike-and-waves may appear in hyper- or hypo-glycemia, uremic encephalopathy, or vitamin deficiencies, etc. Common principles of EEG changes in metabolic encephalopathy are (1) varied degrees of slowing, (2) assorted mixtures of epileptic discharge, (3) high incidence of triphasic waves, and (4), as a rule, reversibility after treatment of underlying causes. There are some exceptions to the above descriptions in specific metabolic disorders and EEG manifestations are highly individualized.

Electroencephalographic patterns in unresponsive pediatric patients

An electroencephalogram (EEG) has not been routinely utilized in the evaluation of children with attention deficit hyperactivity disorder (ADHD). The utility of the EEG in ADHD is unclear. A recent study in our laboratory using sleep and sleep deprivation routinely found one in four non-epileptic children evaluated for attention deficit disorder has epileptiform discharges in the EEG, more than half focal. The majority of abnormalities (97.5%) occur in sleep and sleep-deprived records compared to 7% in prior wake only records. A review of eight publications showed that laboratories using awake only as routine EEG recordings report a relatively low prevalence of epileptiform discharges, whereas the higher prevalence of epileptiform discharges is seen in those with more prolonged sleep recordings. We have determined that sleep deprivation and sleep are essential to rule out an abnormal EEG in attention deficit disorder. In patients with attention deficit disorder complicated by epilepsy, stimulant therapy is generally safe, provided seizures are controlled by antiepileptic medication. Patients with epilepsy or subclinical electrographic abnormalities not treated with anticonvulsants are at increased risk of seizures when stimulant therapy is introduced, especially extended-release methylphenidate. Apart from an increase in risk of seizures and need for caution in use of stimulants, studies show that epileptiform discharges in the electroencephalogram are linked to a better response of attention deficit to methylphenidate and a higher cognitive performance. Transient cognitive impairment related to subclinical electrographic abnormalities responds to antiepileptic medication. An EEG is important in selected cases of attention deficit disorder and is useful in choice of medication, especially in children with lack of awareness and transient cognitive impairment.

Clinical Neurophysiology: EEG–Video Monitoring

BackgroundIncreasing numbers of reports show the beneficial effects of listening to Mozart music in decreasing epileptiform discharges as well as seizure frequency in epileptic children. There has been no effective method to reduce seizure recurrence after the first unprovoked seizure until now. In this study, we investigated the effect of listening to Mozart K.448 in reducing the seizure recurrence rate in children with first unprovoked seizures.MethodsForty-eight children who experienced their first unprovoked seizure with epileptiform discharges were included in the study. They were randomly placed into treatment (n = 24) and control (n = 24) groups. Children in the treatment group listened to Mozart K.448 daily before bedtime for at least six months. Two patients in the treatment group were excluded from analysis due to discontinuation intervention. Finally, forty-six patients were analyzed. Most of these patients (89.1%) were idiopathic in etiology. Seizure recurrence rates and reduction of epileptiform discharges were compared.ResultsThe average follow-up durations in the treatment and control groups were 18.6 ± 6.6 and 20.1 ± 5.1 months, respectively. The seizure recurrence rate was estimated to be significantly lower in the treatment group than the control group over 24 months (37.2% vs. 76.8%, p = 0.0109). Significant decreases in epileptiform discharges were also observed after 1, 2, and 6 months of listening to Mozart K.448 when compared with EEGs before listening to music. There were no significant differences in gender, mentality, seizure type, and etiology between the recurrence and non-recurrence groups.ConclusionsAlthough the case number was limited and control music was not performed in this study, the study revealed that listening to Mozart K.448 reduced the seizure recurrence rate and epileptiform discharges in children with first unprovoked seizures, especially of idiopathic etiology. We believe that Mozart K.448 could be a promising alternative treatment in patients with first unprovoked seizures and abnormal EEGs. Further large-scaled study should be conducted to confirm the effect.Trial registrationNCT01892605, date: June-19-2013

Risk of Developing Seizures in Children With Abnormal EEG Findings During Polysomnography

Neuroinvasive West Nile virus (WNV) is rare, occurring in less than 1% of those infected, and may manifest as meningitis, encephalitis, and/or acute flaccid paralysis. Patients may present initially with nonspecific symptoms including fevers. Although rare, neuroinvasive WNV is associated with significant morbidity and mortality. The mainstay of treatment is supportive care. Electroencephalography (EEG) allows for identification of nonconvulsive status epilepticus and other epileptiform and nonepileptiform patterns suggestive of underlying cognitive dysfunction. Our aim was to describe specific EEG patterns observed in WNV neuroinvasive disease. A retrospective chart review was conducted. West Nile virus was confirmed with serum and/or cerebrospinal fluid markers. Patients with a history of abnormal EEG were excluded. Electroencephalography reports were classified into categories based on the presence of epileptiform activity, focal slowing, generalized periodic discharges with triphasic morphology, and frontally predominant generalized rhythmic delta activity. In our cohort of 34 patients, 60% of focal EEG abnormalities were anterior-predominant, seen as epileptiform discharges, focal slowing, or frontally predominant generalized rhythmic delta activity. Nonepileptiform EEG patterns included nonspecific slowing and generalized periodic discharges with triphasic morphology. Two patients had electrographic seizures, one arising from the frontocentral head region. EEGs are important in the evaluation of WNV infection to rule out seizures or alternative causes of encephalopathy, and because of the risk of nonconvulsive seizures or status epilepticus in encephalitis. Although an anterior predominance of EEG abnormalities was seen in our cohort, this most likely is more correlative to encephalopathy than WNV itself. Although a specific correlative EEG pattern may not accompany all cases of WNV neuroinvasive disease, WNV should be considered as a possible etiology in patients presenting with an encephalitic or meningitic syndrome in the presence of abnormal EEG findings including encephalopathic patterns, particularly those with anterior predominant EEG changes.

S176. A Mean field model to study the triphasic waves in acute hepatic encephalopathy

Background: While a number of studies in the Western countries have provided estimates of prevalence for child psychiatric morbidity and associated risk factors, relatively little is known about child psychiatric problems and risk factors in developing countries like India. Aim: The aim of this study was to assess the patients' emotional status in an age group of 3–14 years to evaluate children's cooperative potential. Methodology: The Goodman's Strengths and Difficulties Questionnaire assessing the mental health status of the child was distributed to the Vidharbhan population attending the dental hospital. A cross-sectional survey including 168 children aged 3–14 years who were instructed how to fill the questions participated in the study. Results: Overall 53% of the children belonged to the normal category, whereas 33% and 14% were under abnormal and borderline categories, respectively. The abnormal category was slightly higher in the age groups of 3.1–5 (35%) and 11.1–14 (28%) years. Similar to certain studies, the mental health problems with males (52.9%) were higher than that of females (47.6%). Conclusion: Identifying the mental health problems of the child seeking dental treatment will help the dentist to formulate an idea of the child's emotional status at the time of treatment and thereby make proper amendments during the treatment procedure. There is a need for developing programs to train, sensitize, and mobilize teachers and parents regarding children's psychological, emotional, and behavioral problems, with special attention to the common population.

Evaluate the frequency of abnormal electroencephalograph (EEG) records during pediatric polysomnography (PSG) at a tertiary referral center and determine frequency with which these records may predict future seizures and a diagnosis of epilepsy. Retrospective review of all pediatric PSG reports from 2013 was performed. Demographics, medical history, indications, diagnoses, and EEG reports were collected. Patients were evaluated for follow-up of future diagnosis of seizure or epilepsy over a 30-month period. A total of 1,969 studies (56.9% males, median age 7 years) were analyzed. Abnormal EEG results were detected in 314 studies (15.9%); abnormalities included slowing in 75 (3.8%) and interictal epileptiform discharges (IEDs) in 239 (12.1%). Incidental abnormal EEG recordings were found in 186 patients (9.4%) without a prior diagnosis of seizure or epilepsy. Incidental IEDs were recorded in 126 (6.4%) and were most commonly focal (66.7%). Ten patients received follow-up EEG without clinical follow-up, 68 received clinical follow-up without follow-up EEG, and 29 received both within a 30-month period. Follow-up EEG was normal in only 30.8% of cases. Thirteen patients in the 30-month window received a new diagnosis of epilepsy. Each new diagnosis occurred in patients with preexisting neurodevelopmental disorders at high risk for seizures. Abnormal EEG during pediatric PSG without additional history of seizure is a poor prognosticator for a future diagnosis of epilepsy. Abnormalities detected on PSG did not always portend abnormal diagnostic EEG and thus its utility to corroborate findings does not appear to be supported without additional clinical context concerning for seizure.

Generalized periodic patterns with triphasic wave morphology, long referred to as triphasic waves [TWs], had been associated with metabolic encephalopathies, although other neurologic and systemic causes have since been identified. In a recent classification of periodic patterns, TWs were formally grouped with the generalized periodic discharges, which are often associated with ictal activity. The interpretation of generalized periodic patterns with TWs as nonictal can have significant implications in the management of comatose patients in nonconvulsive status epilepticus. Electrographic characteristics that help distinguish nonictal periodic patterns with TWs from generalized periodic discharge ictal patterns include (1) TWs in long runs of periodic bilaterally synchronous and symmetric discharges, maximal in frontocentral or posterior head regions with and without a frontal-to-occipital lag or posterior-to-anterior lag, respectively; (2) recurrent spontaneous and/or low-dose benzodiazepine-induced attenuation and/or suppression of the periodic pattern and replacement with a diffuse slow wave activity throughout a prolonged EEG recording; and (3) stimulation-induced activation and/or increase in frequency and/or organization of TWs. We coined the term of status triphasicus to describe the electrographic periodic pattern of TWs with these three distinct characteristics. In this article, we discuss the advantages and limitations of keeping the status triphasicus pattern as a distinct electrographic entity different from periodic ictal generalized periodic discharge patterns. We discuss the circumstances in which a status triphasicus pattern can be associated with ictal activity and propose a simple pragmatic classification of status triphasicus that encompasses the different clinical scenarios it can be associated with.