We discuss an epileptic incident in an undiagnosed 13-year old girl participating in a clinical study investigating the effects of transcranial direct current stimulation in healthy children and adolescents. This incident poses important research ethics questions with regard to study design, especially pertaining to screening and gaining informed consent. Potential benefits and problems of the incident also need to be considered. The ethical analysis of the case presented in this paper has been informed by an in-depth interview conducted after the (...) incident with the child and the accompanying parent. We discuss the ethical implications of the epileptic incident, the need for improving screening procedures for studies with minors and for providing more effective communication. This case also underscores the problem of undetected teenage epilepsy in neuropsychological clinical studies and the necessity of raising more awareness of this issue. Since research in tDCS is an active and expanding field, we conclude with providing some recommendation that could ensure that future research on tDCS, or other therapies and neuro-interventions where there is a risk of triggering an epileptic seizure, take into account the specifics of teenage epilepsy and the need for more thorough provision of information during the process of gaining informed consent. (shrink)

Psychogenic non epileptic seizures (PNES) are clinical events of psychological nature. Video-electroencephalography monitoring (V-EEGM) is a valuable method for the diagnosis of PNES and may be combined with provocative tests to induce seizures. The use of placebo in provocative tests for the diagnosis of PNES is controversial because of associated deception, and contrasts with the use of truly decreasing epileptogenic threshold techniques such as hyperventilation and photo stimulation. We present a clinical case of a pregnant woman with a (...) past history of refractory epilepsy, admitted in the obstetric department due to unremitting seizures. In this clinical context, non-deceiving provocative tests such as hyperventilation and photo stimulation could be potentially harmful, nevertheless, the use of intravenous saline injection presented as a safer alternative to diagnose PNES and hence obviate an urgent caesarean. This case illustrates a disproportionate risk of causing harm when telling the truth, in comparison with the benefit of avoiding such risk, although deceiving the patient. This is a clinical example of how considerations concerning the use of placebo must be evaluated in an individual basis. (shrink)

ECOG data obtained from a patient under conditions of resting brain, sleep and epileptic seizure were analyzed. Contrary to some theorists, the seizure state was found to be informationally the most complex of the three states. Normal 0 false false false EN-US X-NONE X-NONE /* Style Definitions */ table.MsoNormalTable {mso-style-name:"Table Normal"; mso-tstyle-rowband-size:0; mso-tstyle-colband-size:0; mso-style-noshow:yes; mso-style-priority:99; mso-style-qformat:yes; mso-style-parent:""; mso-padding-alt:0in 5.4pt 0in 5.4pt; mso-para-margin:0in; mso-para-margin-bottom:.0001pt; mso-pagination:widow-orphan; font-size:11.0pt; font-family:"Calibri","sans-serif"; mso-ascii-font-family:Calibri; mso-ascii-theme-font:minor-latin; mso-fareast-font-family:"Times New Roman"; mso-fareast-theme-font:minor-fareast; mso-hansi-font-family:Calibri; mso-hansi-theme-font:minor-latin; mso-bidi-font-family:"Times New Roman"; mso-bidi-theme-font:minor-bidi;}.

Neurophenomenology (Varela 1996) is not only philosophical but also empirical and experimental. Our purpose in this article is to illustrate concretely the efficiency of this approach in the field of neuroscience and, more precisely here, in epileptology. A number of recent observations have indicated that epileptic seizures do not arise suddenly simply as the effect of random fluctuations of brain activity, but require a process of pre-seizure changes that start long before. This has been reported at two different levels (...) of description: on the one hand, the epileptic patient often experiences some warning symptoms that precede seizures from several minutes to hours in the form of very specific lived events. On the other hand, the analyses of brain electrical activities have provided strong evidence that it is possible to detect a pre-seizure state in the neuronal dynamics several minutes before the electro-clinical onset of a seizure. We review here some of the ongoing work of our research group concerning seizure anticipation. In particular, we discuss experimental evidence of upward (local-to-global) formation of conscious experience and its neural substrate, but also of the downward (global-to-local) determination of local neuronal activity by situated conscious activity and its substrate large-scale neural assemblies. This causal role of conscious experience may lead to new kinds of therapy for epileptic patients. (shrink)

In the automatic detection of epileptic seizures, the monitoring of critically ill patients with time varying EEG signals is an essential procedure in intensive care units. There is an increasing interest in using EEG analysis to detect seizure, and in this study we aim to get a better understanding of how to visualize the information in the EEG time-frequency feature, and design and train a novel random forest algorithm for EEG decoding, especially for multiple-levels of illness. Here, we propose (...) an automatic detection framework for epileptic seizure based on multiple time-frequency analysis approaches; it involves a novel random forest model combined with grid search optimization. The short-time Fourier transformation visualizes seizure features after normalization. The dimensionality of features is reduced through principal component analysis before feeding them into the classification model. The training parameters are optimized using grid search optimization to improve detection performance and diagnostic accuracy by in the recognition of three different levels epileptic of conditions (healthy subjects, seizure-free intervals, seizure activity). Our proposed model was used to classify 500 samples of raw EEG data, and multiple cross-validations were adopted to boost the modeling accuracy. Experimental results were evaluated by an accuracy, a confusion matrix, a receiver operating characteristic curve and an area under the curve. The evaluations indicated that our model achieved the more effective classification than some previous typical methods. Such a scheme for computer-assisted clinical diagnosis of seizures has a potential guiding significance, which not only relieves the suffering of patient with epilepsy to improve quality of life, but also helps neurologists reduce their workload. (shrink)

The purpose of this paper is to show through the concrete example of epileptic seizure anticipation how neuro-dynamic analysis and “pheno-dynamic” analysis may guide and determine each other. We will show that this dynamic approach to epileptic seizure makes it possible to consolidate the foundations of a cognitive non pharmacological therapy of epilepsy. We will also show through this example how the neuro-phenomenological co-determination could shed new light on the difficult problem of the “gap” which separates subjective experience from neurophysiological (...) activity. (shrink)

The purpose of this paper is to show through the concrete example of epileptic seizure anticipation how neuro-dynamic analysis and “pheno-dynamic” analysis may guide and determine each other. We will show that this dynamic approach to epileptic seizure makes it possible to consolidate the foundations of a cognitive non pharmacological therapy of epilepsy. We will also show through this example how the neuro-phenomenological co-determination could shed new light on the difficult problem of the “gap” which separates subjective experience from neurophysiological (...) activity. (shrink)

Rationale: High-frequency oscillations in intracranial EEG are used to delineate the epileptogenic zone during presurgical diagnostic assessment in patients with epilepsy. HFOs are historically divided into ripples, fast ripples, and their co-occurrence. In a previous study, we had validated the rate of FRandRs during deep sleep to predict seizure outcome. Here, we ask whether epileptic FRandRs might be confounded by physiological FRandRs that are unrelated to epilepsy.Methods: We recorded iEEG in the medial temporal lobe MTL in 17 patients while they (...) performed cognitive tasks. The three cognitive tasks addressed verbal working memory, visual working memory, and emotional processing. In our previous studies, these tasks activated the MTL. We re-analyzed the data of these studies with the automated detector that focuses on the co-occurrence of ripples and FRs.Results: For each task, we identified those channels in which the HFO rate was modulated during the task condition compared to the control condition. However, the number of these channels did not exceed the chance level. Interestingly, even during wakefulness, the HFO rate was higher for channels within the seizure onset zone than for channels outside the SOZ.Conclusion: Our prospective definition of an epileptic HFO, the FRandR, is not confounded by physiological HFOs that might be elicited by our cognitive tasks. This is reassuring for the clinical use of FRandR as a biomarker of the EZ. (shrink)

Although the study of epileptic absence seizures has the potential to contribute a great deal to the scientific understanding of consciousness, this potential has yet to be fully exploited. There have been a number of insightful discussions of consciousness in the context of epileptic seizures, but the basic conceptual issues are still poorly understood and many empirical questions remain unexplored. In this paper I review a number of questions that are of interest to consciousness scientists and identify ways (...) in which the study of absence seizures might bear on their investigation. (shrink)

Current research suggests that stressful life experiences and situations create a substantive effect in the development of the initial manifestations of psychotic disorders and may influence temporo-limbic epileptic-like activity manifesting as cognitive and affective seizure-like symptoms in non-epileptic conditions. The current study assessed trauma history, hair cortisol levels, epileptic-like manifestations and other psychopathological symptoms in 56 drug naive adult young women experiencing their initial occurrence of psychosis. Hair cortisol levels among patients experiencing their initial episode of psychosis, were significantly correlated (...) with stress symptoms measured by Trauma Symptom Checklist-40, and complex partial seizure-like symptoms measured by the Complex Partial Seizure-Like Symptoms Inventory and LSCL-33. Hair cortisol levels were not found to be significantly correlated with symptoms of anxiety and depression measured by Beck depression Inventory and Zung Anxiety Scale. These findings suggest a significant relationship between epileptic-like symptoms and stress responses demonstrated by patients in their first psychotic episode. These findings may suggest the potential for research to explore usefulness of anticonvulsant treatment in patients who do not respond to usual psychotropic medication. (shrink)

Soman, an anticholinesterasic neurotoxic drug, induces epileptic seizures during severe intoxication. Their trigger conditions still remain unknown and a great variability between animals is observed. The butterfly model in the catastrophe theory has been used to explain these triggering conditions.We have developed a technique allowing, in freely moving rats, the « in vivo » determination of three sets of neurophysiological data, followed before and during a soman intoxication. For the same rat, we associated cortical acetylcholinesterase (AChE) activity by microdialysis (...) with both the assay of extracellular acetylcholine (ACh) concentrations and electroencephalographic (EEG) recording and power spectrum analysis (gamma band). Data have been analysed to define the critical parameters which lead to the epileptic fit. (shrink)

We investigate the long-term evolution of degree-degree correlations (assortativity) in functional brain networks from epilepsy patients. Functional networks are derived from continuous multi-day, multi-channel electroencephalographic data, which capture a wide range of physiological and pathophysiological activities. In contrast to previous studies which all reported functional brain networks to be assortative on average, even in case of various neurological and neurodegenerative disorders, we observe large fluctuations in time-resolved degree-degree correlations ranging from assortative to dissortative mixing. Moreover, in some patients these fluctuations (...) exhibit some periodic temporal structure which can be attributed, to a large extent, to daily rhythms. Relevant aspects of the epileptic process, particularly possible pre-seizure alterations, contribute marginally to the observed long-term fluctuations. Nevertheless, our findings suggest that physiological and pathophysiological activity may modify functional brain networks in a different and process-specific way. We evaluate factors that possibly influence the long-term evolution of degree-degree correlations. (shrink)

Motivation: There is an ongoing search for definitive and reliable biomarkers to forecast or predict imminent seizure onset, but to date most research has been limited to EEG with sampling rates <1,000 Hz. High-frequency oscillations have gained acceptance as an indicator of epileptic tissue, but few have investigated the temporal properties of HFOs or their potential role as a predictor in seizure prediction. Here we evaluate time-varying trends in preictal HFO rates as a potential biomarker of seizure prediction.Methods: HFOs were (...) identified for all interictal and preictal periods with a validated automated detector in 27 patients who underwent intracranial EEG monitoring. We used LASSO logistic regression with several features of the HFO rate to distinguish preictal from interictal periods in each individual. We then tested these models with held-out data and evaluated their performance with the area-under-the-curve of their receiver-operating curve. Finally, we assessed the significance of these results using non-parametric statistical tests.Results: There was variability in the ability of HFOs to discern preictal from interictal states across our cohort. We identified a subset of 10 patients in whom the presence of the preictal state could be successfully predicted better than chance. For some of these individuals, average AUC in the held-out data reached higher than 0.80, which suggests that HFO rates can significantly differentiate preictal and interictal periods for certain patients.Significance: These findings show that temporal trends in HFO rate can predict the preictal state better than random chance in some individuals. Such promising results indicate that future prediction efforts would benefit from the inclusion of high-frequency information in their predictive models and technological architecture. (shrink)

One of the most curious events in Othello is the titular character’s epileptic fit, which does not appear in the story by Cinthio that is the accepted source of the play’s plot. Why does Shakespeare invent such an incident? The easiest direction to take is the equation of epilepsy with demonic possession, a common belief in the early modern period. In this essay, however, I argue from textual and critical evidence for a philosophical interpretation of Othello’s epilepsy: namely, that his (...) seizure, particularly in relation to the play’s conflict of reason and emotion, can be seen as a challenge to early modern orthodoxy concerning the mind-body problem, in that it conflates the distinction between body and soul. (shrink)

From epileptic seizures to depressive symptoms, predictive neurotechnologies are used for a large range of applications. In this article we focus on advisory devices; namely, predictive neurotechnology programmed to detect specific neural events (e.g., epileptic seizure) and advise users to take necessary steps to reduce or avoid the impact of the forecasted neuroevent. Receiving advise from a predictive device is not without ethical concerns. The problem with predictive neural devices, in particular advisory ones, is the risk of seeing one’s (...) autonomous choice supplanted by the predictions instead of being supplemented by it. For users, there is a potential shift from being assisted by the system to being over-dependent on the technology. In other terms, it introduces ethical issues associated with epistemic dependency. In this article, we examine the notion of epistemic authority in relation to predictive neurotechnologies. Section 1 of our article explores and defines the concept of epistemic authority. In section 2, we illustrate how predictive devices are best conceived of as epistemic authorities and we explore the subject-device epistemic relationship. In section 3, we spell out the risk of harms interconnected with epistemic deferral. We conclude by stressing a set of preliminary measures to prepare users for the authoritative nature of predictive devices. (shrink)

What altered states of consciousness—the dissolution of feelings of time and self—can tell us about the mystery of consciousness. During extraordinary moments of consciousness—shock, meditative states and sudden mystical revelations, out-of-body experiences, or drug intoxication—our senses of time and self are altered; we may even feel time and self dissolving. These experiences have long been ignored by mainstream science, or considered crazy fantasies. Recent research, however, has located the neural underpinnings of these altered states of mind. In this book, neuropsychologist (...) Marc Wittmann shows how experiences that disturb or widen our everyday understanding of the self can help solve the mystery of consciousness. Wittmann explains that the relationship between consciousness of time and consciousness of self is close; in extreme circumstances, the experiences of space and self intensify and weaken together. He considers the emergence of the self in waking life and dreams; how our sense of time is distorted by extreme situations ranging from terror to mystical enlightenment; the experience of the moment; and the loss of time and self in such disorders as depression, schizophrenia, and epilepsy. Dostoyevsky reported godly bliss during epileptic seizures; neurologists are now investigating the phenomenon of the epileptic aura. Wittmann describes new studies of psychedelics that show how the brain builds consciousness of self and time, and discusses pilot programs that use hallucinogens to treat severe depression, anxiety, and addiction. If we want to understand our consciousness, our subjectivity, Wittmann argues, we must not be afraid to break new ground. Studying altered states of consciousness leads us directly to the heart of the matter: time and self, the foundations of consciousness. (shrink)

Michael Fried’s unexpected contribution to defining the ontological status of video art includes an intriguing claim that projective art is particularly suited to the ‘staging’ of empathic projection. Fried applies Stanley Cavell’s notion of empathic projection, developed in relation to skepticism of ‘other minds’, to moving image installations that not only exploit the beholder’s capacity for empathically projecting, but do so in such a way as to reveal the mechanism at play. In developing this claim, I compare Fried’s key example (...) of Douglas Gordon’s Play Dead; Real Time with Bill Viola and Kira Perov’s Martyrs, a work that likewise elicits an emotional response but without a compensatory foregrounding of the underlying structuring mechanism. However, the comparison suggests that the staging of empathic projection should not be interpreted as an anti-theatrical strategy, but rather as an exemplary manifestation of what I am calling the configurational encounter – a revealing of the artwork’s conditions of existence. I reference Paul Sharits’s Epileptic Seizure Comparison, an important precursor to Gordon’s staging of empathic projection. Finally, I consider Chris Welsby’s landscape films in the light of the capacity of technology to reveal psychological mechanisms of projection, tracing such processes of projection to early childhood experiences of differentiating the human from the non-human. (shrink)

“Altered State of Consciousness” (ASC) has been defined as a changed overall pattern of conscious experience, or as the subjective feeling and explicit recognition that one's own subjective experience has changed. We argue that these traditional definitions fail to draw a clear line between altered and normal states of consciousness (NSC). We outline a new definition of ASC and argue that the proper way to understand the concept of ASC is to regard it as a representational notion: the alteration that (...) has happened is not an alteration of consciousness (or subjective experience) per se, but an alteration in the informational or representational relationships between consciousness and the world. An altered state of consciousness is defined as a state in which the neurocognitive background mechanisms of consciousness have an increased tendency to produce misrepresentations such as hallucinations, delusions, and memory distortions. Paradigm examples of such generally misrepresentational, temporary, and reversible states are dreaming, psychotic episodes, psychedelic drug experiences, some epileptic seizures, and hypnosis in highly hypnotizable subjects. The representational definition of ASC should be applied in the theoretical and empirical studies of ASCs to unify and clarify the conceptual basis of ASC research. (shrink)

The conventional paradigm for developing new treatments for disease mainly involves either the discovery of new drug targets, or finding new, improved drugs for old targets. However, an ion channel found only in invertebrates offers the potential of a completely new paradigm in which an established drug target can be re‐engineered to serve as a new candidate therapeutic agent. The L‐glutamate‐gated chloride channels (GluCls) of invertebrates are absent from vertebrate genomes, offering the opportunity to introduce this exogenous, inhibitory, L‐glutamate receptor (...) into vertebrate neuronal circuits either as a tool with which to study neural networks, or a candidate therapy. Epileptic seizures can involve L‐glutamate‐induced hyper‐excitation and toxicity. Variant GluCls, with their inhibitory responses to L‐glutamate, when engineered into human neurons, might counter the excitotoxic effects of excess L‐glutamate. In reviewing recent studies on model organisms, it appears that this approach might offer a new paradigm for the development of candidate therapeutics for epilepsy. (shrink)

The parents of Charlie Gard, who was born August 4, 2016, with an exceedingly rare and incurable disease called mitochondrial DNA depletion syndrome, fought a prolonged and heated legal battle to allow him access to experimental treatment that they hoped would prolong his life and to prevent his doctors from withdrawing life-sustaining care. Charlie's clinicians at the Great Ormond Street Hospital in London believed that the brain damage Charlie had suffered as a result of frequent epileptic seizures, along with (...) many other severe disabilities, would render any innovative therapy futile, and they disagreed with his parents’ wishes to use an experimental therapy. They felt it in Charlie's best interest that he be allowed to die. A battle ensued among Charlie's parents, his doctors, and a guardian who had been appointed to represent him that drew the attention of politicians and prominent persons from all over the world. The case was much in the news over the past year, but it has also been frequently misunderstood. (shrink)

In early 2011, news emerged that United States authorities had begun to apply injections of pentobarbital, a substance provided by Danish pharmaceutical company Lundbeck, when executing capital punishments. Lundbeck reported to be appalled by such unintended usage of pentobarbital, which is licensed for treatment of refractory forms of epilepsy and for usage as an anaesthetic.The human rights NGOs Reprieve and Amnesty International urged Lundbeck to ensure that pentobarbital was not made available to U.S. authorities for use in capital punishments. Lundbeck (...) argued that complete halting of provision of pentobarbital would be detrimental to patients suffering from conditions of severe epilepsy for whom the substance was developed and intended for treatment for life-threatening epileptic seizures. Lundbeck’s Danish headquarters also argued that controlling the provision of pentobarbital was out of Danish Lundbeck’s hands because the substance is produced at Lundbeck’s plant in the United States. Eventually, after talks with Amnesty International and Reprieve, Lundbeck in July 2011 announced that it would seek to put a stop to using pentobarbital in capital punishment through the introduction of a “drop-ship” program. (shrink)

Recent reports of the discovery of a “God module” in the human brain derive from the fact that epileptic seizures in the left temporal lobe are associated with ecstatic feelings sometimes described as an experience of the presence of God. The brain area involved has been described as either (a) the seat of an innate human faculty for experiencing the divine or (b) the seat of religious delusions.In fact, religious experience is extremely various and involves many parts of the (...) brain, including some that are prehuman in their evolutionary history and some that are characteristically human. In the continuing integration of such experiences, spiritual formation takes place. Thus the entire human brain might be described as a “God module.”Such a process is only possible because of the brain's complexity. The human brain is the most complex entity for its size that we know of. As used here, complexity is a specialized term denoting the presence of a web of interlinked and significant connections—the more intricate the web, the more complex the entity. Complex systems develop only in a milieu that provides both lawfulness and freedom, and they tend to be self‐organizing, becoming more complex and more effective as a result of both inward and outward experience. The evidence suggests that both personal growth and spiritual growth are processes of complexification of character, and of the brain itself. This thesis is tested in light of the work of William James and James W. Fowler. (shrink)

Parvalbumins (PVs) are acidic, intracellular Ca2+‐binding proteins of low molecular weight. They are associated with several Ca2+‐mediated cellular activities and physiological processes. It has been suggested that PV might function as a “Ca2+ shuttle” transporting Ca2+ from troponin‐C (TnC) to the sarcoplasmic reticulum (SR) Ca2+ pump during muscle relaxation. Thus, PV may contribute to the performance of rapid, phasic movements by accelerating the contraction–relaxation cycle of fast‐twitch muscle fibers. Interestingly, PVs promote the generation of power stroke in fish by speeding (...) up the rate of relaxation and thus provide impetus to attain maximal sustainable speeds. However, immunological monitoring of diverse tissues demonstrated that PVs are also present in non‐muscle cells. The axoplasmic transport and various intracellular secretory mechanisms including the endocrine secretions seem to be controlled by the Ca2+ regulation machinery. Any defect in the Ca2+ handling apparatus may cause several clinical problems; for instance, PV deficiency alters the neuronal activity, a key mechanism leading to epileptic seizures. Moreover, atypical relaxation of the heart results in diastolic dysfunction, which is a major cause of heart failure predominantly among the aged people. PV may offer a unique potential to correct defective relaxation in energetically compromised failing hearts through PV gene transfer. Consequently, PV gene transfer may present a new therapeutic approach to correct cellular disturbances in Ca2+ signaling pathways of diseased organs. Hence, PVs appear to be amazingly useful candidate proteins regulating a variety of cellular functions through action on Ca2+ flux management. (shrink)

Recent reports of the discovery of a “God module” in the human brain derive from the fact that epileptic seizures in the left temporal lobe are associated with ecstatic feelings sometimes described as an experience of the presence of God. The brain area involved has been described as either (a) the seat of an innate human faculty for experiencing the divine or (b) the seat of religious delusions.In fact, religious experience is extremely various and involves many parts of the (...) brain, including some that are prehuman in their evolutionary history and some that are characteristically human. In the continuing integration of such experiences, spiritual formation takes place. Thus the entire human brain might be described as a “God module.”Such a process is only possible because of the brain's complexity. The human brain is the most complex entity for its size that we know of. As used here, complexity is a specialized term denoting the presence of a web of interlinked and significant connections—the more intricate the web, the more complex the entity. Complex systems develop only in a milieu that provides both lawfulness and freedom, and they tend to be self‐organizing, becoming more complex and more effective as a result of both inward and outward experience. The evidence suggests that both personal growth and spiritual growth are processes of complexification of character, and of the brain itself. This thesis is tested in light of the work of William James and James W. Fowler. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:It Is Going to Be a Long Clinic DaySalvador Cruz-FloresIt was a routine neurology clinic day. I entered the room where one of the residents was seeing a patient that we will call Patty, a 32-year-old long-standing epilepsy patient. Patty was sitting in the chair with her husband by her side. She started screaming at me, complaining that she was tired of feeling sick and unable to do anything. (...) She had been in and out of emergency rooms with a variety of complaints, from passing out to dizziness with nausea and vomiting. She was visibly angry and started cursing me with direct expletives and blaming me for all her ailments.Her husband was quiet and, at times, would cover his face as if he was embarrassed. I felt an initial burst of anger. I felt my face getting red. I made a great effort to stay quiet, leaned on the exam table facing them, lowered my voice, and braced to take the barrage of insults that were coming my way. I had to make a strong conscious effort to control my emotions and let her vent. I felt that if I responded in kind, I would inflame the situation. Moreover, a resident and a student working with me that day were also present in the room, and I felt it was my duty to behave professionally, so I sat and tried to do active listening with the idea of offering solutions to her complaints. I am not sure how long the event lasted, but it seemed like an eternity. As she slowed down, I apologized for making her feel not cared for, repeated some of her complaints, and tried to offer solutions to them, but she would not have it and did not accept anything I said. She wanted to get her prescriptions and leave the clinic. I offered to have one of my colleagues do the follow-up as she really did not want to see me anymore.Patty is one of those patients that when you see the name in the schedule, you cringe and tell yourself, it is going to be a long clinic day. She could be in the group of patients who are considered very difficult. Before me, she had been seen by several other neurologists. They likely also preferred not to see her on the schedule because she is one of the 20–30% of patients that have a type of functional psychogenic disorder that becomes more complicated because of the coexistence of epileptic seizures along with non-epileptic psychogenic events. The latter is a more problematic event because it does not respond to pharmacological treatment and causes a lot of disability. The best way to establish whether an event is a true epileptic event or a non-epileptic psychogenic event is to do continuous electroencephalographic monitoring to capture as many events as possible on video. I tried different combinations of medications to no avail and with significant side effects. I tried to set her up for electroencephalogram home monitoring to tease the epileptic and psychogenic events apart. In truth, her social circumstances, insurance coverage, and economic situation made it impossible to do so. Every time she came to the clinic, she had a multitude of complaints, and she would ask for a medication to treat the problem. Any mention of the potential psychogenic nature of her problems would result in a defensive attitude "so you are saying I am crazy." We discussed multiple times the need to be careful with the medications and the potential bad side effects. I wanted to help her, but with every visit, there seemed to be a barrier, and the visit would end on bad terms. At least, that is how I felt. I was left every time, with a feeling of frustration. I believe that she left the clinic feeling the same. That day, I left the clinic upset and depressed. I tried to convince myself I had done all I could to help her. I just could not understand why this was the result.Several years have passed since I have seen Patty in the clinic. She certainly has not... (shrink)

This article situates the movement for the legalisation of medicinal cannabis within the bigger picture of the impetus toward recreational cannabis legalisation. It describes the role played by children with epileptic syndromes in the medicinal cannabis law reform campaigns in the United Kingdom, and Queensland, New South Wales and Victoria in Australia. Noting the ‘rule of rescue’ and the prominence in media campaigns of children in Australian and English cases of parental disputation with clinicians about treatment for their children, it (...) reviews whether paediatric epilepsy is a suitable test case for the legalisation of medicinal cannabis. Taking into account the vested commercial interests of Big Cannabis, the current medico-scientific knowledge of the efficacy of medicinal cannabis in controlling paediatric epileptic seizures, and issues of dignity, health privacy, and the enduring digital footprints of media coverage, the article commences discussion about the ethics of the media, parents, politicians and entrepreneurial doctors utilising parents’ testimonials about the effects of medicinal cannabis as part of the cannabis law reform movement. (shrink)

Although an invasive medical intervention, Deep Brain Stimulation (DBS) has been regarded as an efficient and safe treatment of Parkinson’s disease for the last 20 years. In terms of clinical ethics, it is worth asking whether the use of DBS may have unanticipated negative effects similar to those associated with other types of psychosurgery. Clinical studies of epileptic patients who have undergone an anterior temporal lobectomy have identified a range of side effects and complications in a number of domains: psychological, (...) behavioural, affective and social. In many cases, patients express difficulty adjusting from being chronically ill to their new status as ‘treated’ or ‘seizure free’. This postoperative response adjustment has been described in the literature on epilepsy as the ‘Burden of Normality’ (BoN) syndrome. Most of the discussion about DBS postoperative changes to self is focused on abnormal side effects caused by the intervention (ie, hypersexuality, hypomania, etc). By contrast, relatively little attention is paid to the idea that successfully ‘treated’ individuals might experience difficulties in adjusting to becoming ‘normal’. The purpose of this paper is (1) to articulate the postoperative DBS psychosocial adjustment process in terms of the BoN syndrome, (2) to address whether the BoN syndrome illustrates that DBS treatment poses a threat to the patient’s identity, and (3) to examine whether the current framework for rehabilitation after DBS procedures should be updated and take into account the BoN syndrome as a postoperative self-change response. (shrink)

Dreams of chase or pursuit, falling, sex, flying, nudity, failing an examination, one's own and other's death, fire, teeth falling out and some other themes experienced, even if only rarely, by many people all over the world have been labelled 'typical dreams'. This essay argues that typical dreaming, rather a syndrome of themes than monothematic, reflects an extraordinary state of mind and brain. Odd and particularly memorable perceptions, as well as emerging awareness of sleep and dreaming -- i.e. parallels to (...) lucid dreaming, sleep paralysis, complex partial seizure, epileptic and migraine auras, and aspects of dreaming after trauma -- can be traced with some plausibility in all prominent variants of typical dreaming. When viewed from this perspective, for example, dream pursuers are much more a shadow of the bodily self than a metaphor for the psycho- biographical situation or evolutionarily implemented sparring partners who make dreamers fit for the struggle for survival during waking hours. (shrink)

Power density spectra and phase synchrony measurements were taken from intracranial electrode grids implanted in epileptic subjects. Comparisons were made between data from the waking state and from the period of unconsciousness immediately following a generalised tonic–clonic seizure. Power spectra in the waking state resembled coloured noise. Power spectra in the unconscious state resembled coloured noise from 1 to about 5 Hz, but at higher frequencies changed in two out of three subjects to resemble white noise. This boosted unconscious gamma (...) power to a higher level than conscious gamma power. For both gamma and beta passbands, synchrony measurements showed more widespread phase synchrony in the unconscious than the conscious state. We conclude that neither gamma activity per se nor phase synchrony per se are neural correlates of consciousness. (shrink)

There is a paucity of treatment options for cognitively normal individuals with drug resistant genetic generalized epilepsy. Centromedian nucleus of the thalamus deep brain stimulation may be a viable treatment for GGE. Here, we present the case of a 27-year-old cognitively normal woman with drug resistant GGE, with childhood onset. Seizure semiology are absence seizures and generalized onset tonic clonic seizures. At baseline she had 4–8 GTC seizures per month and weekly absence seizures despite three antiseizure (...) medications and vagus nerve stimulation. A multidisciplinary committee recommended off-label use of CM DBS in this patient. Over 12-months of CM DBS she had two GTC seizure days, which were in the setting of medication withdrawal and illness, and no GTC seizures in the last 6 months. There was no significant change in the burden of absence seizures. Presently, just two studies clearly document CM DBS in cognitively normal individuals with GGE or idiopathic generalized epilepsy [in contrast to studies of cognitively impaired individuals with developmental and epileptic encephalopathies ]. Our results suggest that CM DBS can be an effective treatment for cognitively normal individuals with GGE and underscore the need for prospective studies of CM DBS. (shrink)

A core feature of drug-resistant epilepsy is hyperexcitability in the motor cortex, and low-frequency repetitive transcranial magnetic stimulation is a suitable treatment for seizures. However, the antiepileptic effect causing network reorganization has rarely been studied. Here, we assessed the impact of rTMS on functional network connectivity in resting functional networks and their relation to treatment response. Fourteen patients with medically intractable epilepsy received inhibitive rTMS with a figure-of-eight coil over the vertex for 10 days spread across two weeks. We (...) designed a 6-week follow-up phase divided into four time points to investigate FNC and rTMS-induced timing-dependent plasticity, such as seizure frequency and abnormal interictal discharges on electroencephalography. For psychiatric comorbidities, the Hamilton Depression Scale and the Hamilton Anxiety Scale were applied to measure depression and anxiety before and after rTMS. FNC was also compared to that of a cohort of 17 healthy control subjects. The after-effects of rTMS included all subjects that achieved the significant decrease rate of more than 50% in interictal epileptiform discharges and seizure frequency, 12 patients with the reduction rate above 50% compared to the baseline, as well as emotional improvements in depression and anxiety. In the analysis of RSNs, we found a higher synchronization between the sensorimotor network and posterior default-mode network in epileptic patients than in healthy controls. In contrast to pre-rTMS, the results demonstrated a weaker FNC between the anterior DMN and SMN after rTMS, while the FNC between the aDMN and dorsal attention network was greater. Importantly, the depressive score was anticorrelated with the FNC of the aDMN-SMN, which was markedly different in the good and bad response groups treated with rTMS. Based on the vertex suppression by rTMS, it is possible to achieve temporary clinical efficacy by modulating network reorganization in the DMN and SMN for patients with refractory epilepsy. (shrink)

IntroductionCerebral visual impairment results from damage to cerebral visual processing structures. It is the most common cause of pediatric visual impairment in developed countries and rising in prevalence in developing nations. There is currently limited understanding on how neurologic, developmental, and ophthalmic factors predict outcome for pediatric CVI.MethodA retrospective manual chart review of pediatric CVI patients seen at the tertiary pediatric hospital neurology and neuro-ophthalmology service between 2010 and 2019 was conducted. Patients were stratified into severity groups, and followed over (...) time to identify outcome predictors. Collected baseline characteristics included perinatal, genetic, developmental, and neurologic history, along with neuroimaging and fundoscopic findings on examination. Longitudinal data collected included age, seizure control, and type of therapy received. Linear mixed-effect models were used for longitudinal CVI grade outcome analysis.ResultsA total of 249 individuals spanning 779 patient visits were identified. Mean age at diagnosis was 18.8 ± 16.8 months. About 64.3% were born at term age. Perinatal history revealed hypoxic ischemic encephalopathy in 16.5%, intraventricular hemorrhage in 11.6%, and seizures in 21.7%. At presentation, 60.3% had a diagnosis of cerebral palsy and 84.7% had developmental delay. Among all subjects, 78.6% had epilepsy; 33.8% had an epileptic encephalopathy, with spasms/hypsarrhythmia being most common. Abnormal neuroimaging was present in 93.8%. Genetic anomalies were present in 26.9%. Baseline visual examination revealed no blink-to-light in 24.5%; only BTL in 34.5%, fixation/tracking in 26.5%, and optokinetic drum follow in 14.4%. Longitudinal data analysis showed that perinatal history of HIE, a positive epilepsy history, using multiple epilepsy medications, cerebral palsy, and abnormal fundoscopic findings were all negatively associated with CVI grade change over time. After controlling for significant confounders, receiving any type of therapy [early childhood intervention, physical and occupational therapy, refractive error correction or glasses] was significantly associated with longitudinal improvement in CVI grade compared to patients who did not receive any therapy, with glasses yielding the largest benefit.ConclusionThis study offers extensive insights into neurologic, developmental and ophthalmologic features in patients with moderate to severe CVI. In concordance with previous findings, aspects of perinatal history and epilepsy/seizure control may help inform severity and prognosis in the general neurology or ophthalmology clinic. Conversely, these aspects, as well as genetic and specific epilepsy traits may alert vision health care providers in the clinic to pursue visual evaluation in at-risk individuals. Longitudinal follow-up of CVI patients showed that interventional therapies demonstrated vision function improvement greater than no therapy and maturational development. (shrink)

A paradigmatic aspect of a paradigmatic kind of right is that the rights holder is the only one who can alienate it. When individuals waive rights, the normative source of that waiving is normally taken to be the individual herself. This moral feature?immunity?is usually in the background of discussions about rights. We bring it into the foreground here, with specific attention to a recent U.S. Supreme Court decision, Kentucky v. King (2011), concerning search and seizure rights. An entailment of the (...) Court's decision is that, at least in some cases, a right can be removed by the intentional actions of the very party against whom the right supposedly protects the rights holder. We argue that the Court's decision is mistaken. The police officers in the case were not morally permitted, and should not be legally permitted, to intentionally create the very circumstances that result in the removal of an individual's right against forced, warrantless search and seizure. (shrink)

Objective: Electrical stimulation potentially delineates epileptogenic cortex through induction of typical seizures. Although frequently employed, its value for epilepsy surgery remains controversial. Similarly, ES is used to identify symptomatogenic zones, but with greater success and a long-standing evidence base. Recent work points to new seizure symptoms such as ictal central apnea that may enhance presurgical hypotheses. The aims of this review are 2-fold: to determine the value of ES-induced seizures in epilepsy surgery and to analyze current evidence on (...) ICA as a new surrogate of symptomatogenic cortex.Methods: Three databases were searched for ESIS. Investigators independently selected studies according to pre-specified criteria. Studies reporting postoperative outcome in patients with ESIS were included in a meta-analysis. For ES-induced apnea, a thorough search was performed and reference list searching was employed.Results: Of 6,314 articles identified for ESIS, 25 were considered eligible to be reviewed in full text. Fourteen studies were included in the qualitative synthesis ; six studies were included in the meta-analysis. The meta-analysis showed that favorable outcome is associated with ESIS prior to surgery. In addition, the overall estimation of the occurrence of favorable outcome among cases with ESIS is 68.13%. On the other hand, recent studies have shown that stimulation of exclusively mesial temporal lobe structures elicits central apnea and represents symptomatogenic anatomic substrates of ICA. This is in variance with traditional teaching that mesial temporal ES is non-symptomatogenic.Conclusions: ES is a tool highly likely to aid in the delineation of the epileptogenic zone, since ESIS is associated with favorable postoperative outcomes. There is an urgent need for prospective evaluation of this technique, including effective stimulation parameters and surgical outcomes, that will provide knowledge base for practice. In addition, ES-induced apnea studies suggest that ICA, especially when it is the first or only clinical sign, is an important semiological feature in localizing the symptomatogenic zone to mesial temporal lobe structures, which must be considered in SEEG explorations where this is planned, and in surgical resection strategies. (shrink)