In-hospital seizures occur in 0.4% of all TBI patients. Although infrequent, seizure occurrence is associated with higher rates of hospital complications such as pneumonia and ARDS and is an independent predictor of longer hospital stay and worse hospital outcome.

SUMMARYObjective: To determine the lateralization and localization values of ictal motor sequences in the setting of focal epilepsy ending with a secondarily generalized motor seizure. Methods: Retrospectively, the ictal motor sequences were analyzed in patients with focal epilepsy ending with a secondarily generalized motor seizure by three readers blinded to all clinical and electrographic data. One representative seizure per patient was selected. Prevalence, positive predictive value (PPV), and Fleiss Kappa for the following motor signs were calculated: version, unilateral limb tonic posturing, unilateral limb clonic seizure, figure-of-4, M2e, hand dystonia, clonic asymmetric ending, and Todd's paralysis. Sequences of signs with a PPV ≥ 80% were then analyzed to determine their lateralization and localization values. Results: A total of 47 seizures were studied. The "reliable" motor signs with a robust lateralizing value (PPV > 80%) were version, unilateral tonic posturing, M2e, unilateral clonic seizure, asymmetric clonic ending, and Todd's paralysis. Figure-of-4 and hand dystonia had a relatively low PPV, and therefore were not included in the following sequence analysis, which included only 38 patients with two or more motor signs of high PPV. Multiple combinations of temporal progression of motor signs were seen in these 38 patients, with version being the most common initial motor sign (29 of 38 patients) usually followed by M2e (15 of 29 patients), and/or a focal tonic seizure (7 of 29 patients). Accurate lateralization of the epileptogenic zone (EZ) with a PPV of 100% can be predicted when two or more reliable motor signs point to the same side. However, the various sequences of reliable motor signs did not differentiate between temporal and extratemporal epilepsy. Significance: The presence of reliable ictal motor signs in focal epilepsy is extremely valuable in lateralizing the EZ, but not in determining the localization of the EZ. This is especially useful when epilepsy surgery is indicated. KEY WORDS: Focal epilepsy, Semiology, Lateralization, Epileptogenic zone.Analysis of seizure semiology is the first step in evaluating patients with epilepsy. Despite all the advances in clinical epilepsy, it remains the only tool to study and predict the symptomatogenic zone.There is a rich ictal semiology literature, going back to the times of Tissot, Esquirol, Todd, Jackson, and many others in the 18th and 19th centuries.1-4 Many seizure components including auras and motor signs were studied extensively, and their values in lateralization and localization of the symptomatogenic zone and the epileptogenic zone (EZ) have been well described. [5][6][7][8][9][10] However, to our knowledge, no attempt has been made to put together two or more motor signs in a sequence and

Spontaneous dissection of the major arteries of the neck is known to increase the risk of stroke or transient ischaemic attack in young and middle-aged adults. Most of the reported cases of arterial dissections in the neck involve one or both paired extracranial carotid or vertebral arteries. Spontaneous dissection of the bilateral internal carotid and vertebral arteries is extremely rare. We report a case of spontaneous bilateral internal carotid artery and vertebral artery dissection while using a prescribed pill for weight loss which contained amphetamine derivative. A review of literature is also provided.

BackgroundEpilepsy monitoring unit (EMU) is a growing service that allows physicians to evaluate, diagnose, and manage epilepsy in a safe and cost-effective way. However, observations have indicated that the EMU is being underutilized by general neurology practice, possibly due to the lack of access and specific criteria known to all neurologists. There is limited data as of yet to support these observations. This study reviewed the rate of referral to the EMU from outpatient general neurology clinics at our institution. MethodsIn this retrospective study, records of 350 patients, 18 years or older with a diagnosis or diagnostic workup of epilepsy, managed by neurologists who did not specialize in epilepsy, were reviewed. We classified patients into three groups: ineligible for EMU referral, eligible and referred to EMU, and eligible but not referred to EMU based on six criteria namely characterization, classification, localization, determination of seizure frequency, medication adjustment, and differentiation between seizures and medication side effects. ResultsOur results demonstrated that 36.7% of patients who did meet the criteria were not referred to EMU. The most common criteria for patient referral in both groups, referred and not referred, was the characterization of seizures as epileptic or functional. ConclusionOur results show that EMU is underutilized by our general neurology clinics. Providing more information and increased awareness about criteria for long-term monitoring in EMU can improve the utility of this valuable tool and would be beneficial to patient care.

Mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes (MELAS) is a complex group of disorders with multisystem involvement that have a wide range of biochemical and genetic defects. The earliest symptoms of MELAS typically include easy fatigability, muscle weakness, encephalopathy with stroke-like episodes, recurrent headaches and seizures. The pathogenesis of stroke-like episodes manifesting as focal deficits like acute cortical blindness is not fully understood. We present an eight-yearold, right-handed boy with MELAS confirmed by the presence of pathogenic missense variant mutation (mt.3243A>G) presenting with acute intermittent reversible episodes of cortical blindness and Anton-Babinski Syndrome secondary to concurrent occipital lobe seizures captured during video electroencephalography (V-EEG) monitoring, in addition to the neuro-imaging which was not consistent with acute ischemic stroke. This case highlights the importance of the V-EEG monitoring besides clinical testing and radiographic correlation during acute cortical blindness episodes in MELAS as occipital lobe seizures could be a part of the symptomatology.