Summary:Purpose: To determine whether differences in clinical manifestations of psychogenic nonepileptic events are associated with differences in outcome and whether the length of illness before diagnosis correlates with outcome.Methods: We reviewed ictal videotapes and EEGs in 85 patients diagnosed with exclusively nonepileptic psychogenic seizures during inpatient CCTV-EEG monitoring at the University of Michigan between June 1994 and December 1996. They were classified into groups of similar ictal behaviors. Fifty-seven of these patients were available to respond to a follow-up telephone survey about their condition 2 4 years after discharge. We examined demographics, baseline EEG abnormalities, and outcome of treatment interventions. We also evaluated whether interventions were more likely to succeed if patients were diagnosed early in the course of the illness.Results: We found that the largest groups consisted of patients with motionless unresponsiveness ("catatonic," n = 19) and asynchronous motor movements with impaired responsiveness ("thrashing," n = 19). Infrequent signs included tremor, automatisms, subjective events with amnesia, and intermittent behaviors. There was a higher incidence of baseline EEG abnormalities in the thrashing group (31%) than in the catatonic group (0%). There was a higher incidence of complete remission of spells in the catatonic group (53%) than in the thrashing group (21%). Patients who had a more recent onset of seizures [most often within 1 year) were much more Likely to have remission of spells after diagnosis. Conclusions: Classification of nonepileptic seizures is useful in predicting outcome and may be valuable in further investigation of this complex set of disorders. Key Words: Nonepileptic events-Outcome-Personality testing-Pseudoseizures.Carefully refined classification systems for both seizures and epilepsy syndromes have substantially improved the diagnosis and management of patients with epilepsy (1,2). These tools provide a level of detail that suggests separate etiologies and possibly even separate mechanisms of pathogenesis. A new set of revisions in these systems incorporating new knowledge is being developed (3). Observing patients with psychogenic nonepileptic spells, distinct patterns also seem to emerge. These spells are as disabling as epilepsy and tend to be even more refractory to several modes of treatment. The largest outcome study to date (4) documented a 60% refractory rate. On the basis of our observations that patients with minor motor manifestations seemed to fare better than others, we undertook this study to begin to identify potentially separate syndromes with distinguishable etiologies and natural histories.For several years, clinicians studying psychogenic nonepileptic events have discerned differences in predispositions and MMPT profiles that they believed warranted division of their groups into ''convulsive'' or %on-convulsive" patterns (3, or major versus minor motor episodes. Most patients have relatively stereotyped episodes, althou...

Epilepsy, one of the most common neurological diseases, affects over 50 million people worldwide. Epilepsy can have a broad spectrum of debilitating medical and social consequences. Although antiepileptic drugs have helped treat millions of patients, roughly a third of all patients have seizures that are refractory to pharmacological intervention. The evolution of our understanding of this dynamic disease leads to new treatment possibilities. There is great interest in the development of devices that incorporate algorithms capable of detecting early onset of seizures or even predicting them hours before they occur. The lead time provided by these new technologies will allow for new types of interventional treatment. In the near future, seizures may be detected and aborted before physical manifestations begin. In this chapter we discuss the algorithms that make these devices possible and how they have been implemented to date. We also compare and contrast these measures, and review their individual strengths and weaknesses. Finally, we illustrate how these techniques can be combined in a closed-loop seizure prevention system.

Because interictal temporal lobe delta activity (TLDA) has been described in 30 to 90% of patients with temporal lobe epilepsy (TLE) but has not been investigated in patients with extratemporal epilepsy, we sought to determine the localizing significance of TLDA. We compared the presurgical interictal scalp EEG results of 47 consecutive patients who received extratemporal resection (40 frontal and 7 parietal-occipital) for intractable epilepsy with 43 consecutive patients who received anterior temporal lobectomy. We defined lateralized TLDA as runs of lower than 4-Hz waveforms that were easily distinguished from the background rhythms and were maximal at electrodes T4, F8, and T6 or T3, F7, and T5. The lateralized TLDA was subcategorized as temporal intermittent rhythmic delta activity (TIRDA) or temporal intermittent polymorphic delta activity (TIPDA). A chi-square test was used to determine the association of the lobe of the epileptogenic zone with TIRDA and TIPDA. We found TIRDA in 12 (28%) and TIPDA in 8 (19%) patients in the temporal lobe group, and TIRDA in 2 (4%) and TIPDA in 9 (19%) patients in the extratemporal group. TIRDA was strongly associated with TLE (p < 0.003), whereas TIPDA occurred at an equal rate in both groups. Similar to anterior temporal epilepsy, lateralized TIPDA is present in up to 20% of patients with extratemporal epilepsy. The presence of TIRDA strongly suggests TLE but may infrequently occur in extratemporal epilepsy. Caution should be used when using lateralized TLDA as a presurgical localizing finding.

We evaluated pelvic thrusting as a potential diagnostic sign and localizing indicator of ictal onset. By reviewing the video-EEG results of patients with temporal lobe epilepsy, frontal lobe epilepsy, generalized epilepsy, and pseudoseizures. Pelvic thrusting occurred in 4% of right and 2% of left temporal lobe epilepsy patients, in 24% of frontal lobe epilepsy patients, and in 17% of patients with pseudoseizures. Pelvic thrusting is relatively common in frontal lobe epilepsy and in pseudoseizures, but also occurs in temporal lobe epilepsy.

Summary:The role of the glutamate receptor GluR3 in Rasmussen's encephalitis is actively under investigation. Autoimmune processes with this receptor as the target are currently theorized. We provide an additional case of pathologically proved Rasmussen's encephalitis (with concomitant cortical dysplasia) in the presence of antibodies against the GluR3 receptor. Key Words: Rasmussen's encephalitis-GluR3 receptor-Cortical dysplasia-Glutamate.Rasmussen's encephalitis is characterized by medically intractable partial seizures and progressive neurologic deficits (1). On microscopic examination of brain tissue in involved patients, there are a perivascular lymphocytic infiltrate, microglial nodules, and astrogliosis (2). Neuronal loss and cortical atrophy may be pronounced (2). Although this histopathologic constellation is strongly suggestive of an infectious etiology, none has been elucidated. Recent studies indicated a relation between Rasmussen's encephalitis and anti-GluR3 antibodies (3). These studies postulated a glutamate-involved autoimmune process in the etiology of this condition. We present an unusual case of Rasmussen's encephalitis with concomitant focal cortical dysplasia (dual pathology) and summarize the known roles of GluR3 in this situation. CASE REPORTA 2.5-year-old girl had a 4-month history of worsening partial seizures and a progressive left hemiparesis. The seizures consisted of left face and arm tonic-clonic activity lasting 10-60 s and were often associated with dystonic posturing of the left arm and hand. No aura or postictal state was associated with the seizures. The sei-