Video recording of seizures with and without EEG is considered essential in epileptology and is firmly established. Diagnostics, research and didactics would be unthinkable without the recording possibilities, Prof. Peter Wolf, MD, from the Filadelfia Epilepsy Clinic, Denmark, pointed out. The best video in Interlaken was an entry by Sandra Tölle, MD, from Zurich.
derts, video recording made its way into medicine, and epileptologists were among the first to recognize its possibilities. The technology is now so well established, standardized and widespread that even competitions can be held. At the video forum in Interlaken, the direction and setting of the submitted contributions were not judged, but there were criteria such as the special features of the case and the didactic value of the presentation.
Peter Hopp, MD, of Radeberg, Germany, presented a case of nocturnal paroxysmal dystonia. A 51-year-old motorist showed movement attacks at night, which were extremely violent. Unfortunately, both the ictal EEG and other examinations were o.b.. Only the fact that the attacks were brief, seizure-like, and uniform suggested an epileptic genesis; all other factors suggested a subcortical genesis.
The “bathing epilepsy” phenomenon
Seizures triggered by bathing or rubbing are apparently not that uncommon in pediatric epileptology. As many as three groups presented videos at the three-country meeting with such cases. Gert Wiegand, MD, from Kiel, Germany, gave an overview of the characteristics of “bathing epilepsy.”
- Frequent temporal seizure onset (limbic).
- Mostly autonomic seizures
- Not bathing itself is triggering
- Complex triggers
- Rare in total
- Onset usually at a very early age.
One of the cases presented was about a boy, already almost four years old, with mild ADHD problems, who always developed apnea to the point of unconsciousness after showering. Variations of bathing or showering were unsuccessful; some prevention could be achieved through distraction. A diagnosis of “Rub Epilepsy” was eventually made and the trigger zone was localized to the right arm or thorax. The case presented by Wilhelm Frenck, MD, also involved “seizure-like conditions always after bathing” that occurred in a nine-month-old child. Again, the trigger was rubbing the right arm, which led to a seizure with right arm weakness.
Pupils angry for no reason?
Sandra Tölle, MD, and her research group from the Children’s Hospital in Zurich presented the case of a three-year-old boy from Ghana with ataxia and multiple daily falls with facial injuries. During the seizure, the patient was not unconscious, and no ictal pattern was seen on the EEG. There was no response to anticonvulsants such as valproic acid, levetiracetam, ethosuximide, vigabatrin, clonazepam. Extensive laboratory investigations were inconclusive (including glucose transporter defect). As it progressed, there was an increase in ataxia, polytopic myoclonias, and irritability. The ultimate landmark test was for CSF for 5-methyltetrahydrofolic acid, which was not measurably low. The boy was unable to transport folic acid to the CNS due to a homozygous mutation in the FOLR1 gene. The result: cerebellar atrophy and lack of myelination on cranial MRI. Therapy with folinic acid (Leucovorin®) is crucial in such a case. Dr. Tölle received the first prize in the competition for this video entry.
Finally, the patient presented as a case by Susanne Schubert-Bast, MD, described himself as “angry for no reason.” This was an eleven year old boy who was normally a good student, but was exhibiting increasingly frequent outbursts of anger. Close EEG examination revealed 37 seizures within 24 hours, and the seizure patterns were subclinical. Consequently, the explanation of these “freak-outs” was epileptological.
On display were other cases with difficult differential diagnoses and findings, such as that paroxysmal confusion in the elderly does not always have to be epilepsy. This was illustrated by the case presented by Kerstin Franke, MD. The differential diagnosis of syncope and epileptic seizure is always difficult. However, it gets even trickier when ictal asystole occurs – here it is usually unclear whether it is syncope or seizure, what is cause and what is effect.
Source: 8th Three-Country Meeting on Epilepsy, May 8-11, 2013, Interlaken.
