Seizures from Art Exhibit, Latest Example of Photosensitive Epilepsy


Outside Gallery ZEE in Pittsburgh

A Pittsburgh art exhibit that closed this week after three people were treated for reported seizures.

Shaunda Miles, spokeswoman for the Pittsburgh Cultural Trust, said the exhibit titled “Zee” by Austrian artist Kurt Hentschlager is closed indefinitely.


The installation, part of the Cultural Trust’s Pittsburgh International Festival of Firsts, was scheduled to run through Oct. 27.

It includes heavy fog and intense strobe effects, and attendees must sign a waiver before entering.

Click here to find out more about this story.

Photosensitive Epilepsy

Epileptic seizure types can be  induced in certain susceptible patents by photic (or visual) stimuli,  usually flashing lights or rapidly changing/alternating images . Some famous examples have included:


An animated segment of a film promoting the 2012 London Olympics:

Flickering fluorescent lighting:

Video Games:

Strobe lights in clubs:

Photosensitive seizure only occur in a small proportion of patients with generalized epilepsy, and those patients will usually know they are susceptible based on their routine diagnostic EEG, which will usually include intermittent photic stimulation as part of routine testing.
Click here to find out more about seizures and epilepsy

Blackout – was it a fit or a faint?

People generally experience a blackout (temporary loss of consciousness) from one of two common problems: (1) Insufficient blood flow to the brain (syncope)  or (2) Abnormal electrical activity within the brain (seizure).


Syncope (or a faint) is caused by insufficient blood flow to the brain because of low blood pressure.  There may be a prodrome of dizziness loss of vision and hearing weakness, flushing, nausea (sometimes referred to pre-syncope).  Then there will be overt loss of consciousness that leads to the faint.  The affected patient will typically fall by dropping forwards from loss of muscle tone. The affected patient might look pale and clammy, and will usually come around quickly of they are allowed to lay down on floor allowing blood flow to return to the brain.  Syncope can be caused by dehydration, irregular heart beat, or emotion (vasovagal or “neurocardiogenic” syncope).


A seizure (or a “fit”) is caused by abnormal electrical activity in the brain, usually accompanied by a clinical event that can vary from a brief loss of awareness (an absence seizure or “petit mal”) to loss of awareness with thrashing limb movements (a tonic-clonic or grand mal seizure).  A generalized tonic-clonic seizure will usually be associated with increased muscle tone, so the patient will stiffen up and fall backwards not forward and may bite their tongue.  The eyes will be open, and their may be loss of bladder and bowel control.  There may be flailing limb movements that lead to injury.  After the seizure stops, the patient will usually be confused or dazed, and not come around immediately like the syncope patient.


Here is a table that emphasizes the differences between fits (seizures) and faints (syncope):



If you have experienced a blackout, what should you do? A simple faint in an otherwise young healthy person may not need emergent medical care.  However, syncope in an older person with a cardiac history, or syncope associated with chest pain and breathlessness could indicate a heart problem and usually justify an emergency room visit.  Similarly a new onset seizure in somebody not previously know to have epilepsy should justify an emergency room visit.

Epilepsy surgery and functional MRI



Epilepsy surgery is an option for patients with intractable partial onset seizures that are not controlled by oral medications.  Epilepsy monitoring is used to localize the seizure focus, often a lesion or abnormal area of brain located in the temporal lobe.  That part of the brain is then carefully removed to prevent future seizures:

seizure surgery2

A patient with a brain abnormality in the R temporal lobe (top) undergoes brain surgery to remove that area of brain and prevent future seizures.

Epilepsy surgery is very effective and yet still underutilized for treating seizures.

Left temporal lobe resections are more risky that right-sided cases, because the left hemisphere controls language functions in most (even left handed) patients.  Surgeons have to be very careful planning seizure surgery on the left side to be sure that they do not damage brain critical for speech and language and leave the patient with aphasia.

That’s where functional magnetic resonance imaging (fMRI) comes in.  fMRI goes beyond the conventional imaging of brain structure, and can actually localize regional brain functions by detecting changes in regional blood flow in response actual or imagined activity.

fMRI is increasingly being used to evaluate candidates for epilepsy surgery by identifying important functional regions within the brain, including unpredictable patterns of functional reorganization, to prevent unexpected post-operative deficits.  Click here for a link to a paper with illustrative cases.

Monmouth Epilepsy Program Receives NAEC Certification

Monmouth Medical Center’s Epilepsy Program was awarded prestigious level 3 certification today by the National Association of Epilepsy Centers!

Monmouth certificateThe National Association of Epilepsy Centers (NAEC) is a non-profit  association with the primary objective of connecting people with epilepsy to specialized epilepsy care and epilepsy centers.

Founded in 1987 by physician leaders committed to setting a national agenda for quality epilepsy care, the NAEC educates public and private policymakers and regulators about appropriate patient care standards, reimbursement and medical services policies.

NAEC works in conjunction with existing scientific and charitable epilepsy organizations.

A third-level center must provide all the medical, neuropsychological, and psychosocial services needed to treat patients with refractory epilepsy to achieve certification.

Click here to find out more about Monmouth’s Epilepsy Program.

Click here to find out more about seizures and epilepsy.

Alice in Wonderland Syndrome

Caused by a disturbance of perception rather than an actual physiological change
Altered body image (Ex: big buildings look same size as person’s own body)
Distorted perception of size (micropsia, macropsia)
Distorted perception of the shape of objects
Loss of spatial perspective (sense of time and space)
Auditory or tactile hallucinations

AIWS generally affects a younger population and has several associated conditions. Migraine is the classic disease linked to AIWS, the distorted sensations can either begin before a migraine (aura or “warning”) or afterwards, and in younger patients can even occur without headache

Check out these first-hand accounts of people with this interesting phenomenon:
Size Matters: Living in a Lewis Carroll ‘Wonderland’ – ABC News

When the world looks like a real-life Wonderland

Experience: I have Alice In Wonderland syndrome 

A Not So Pleasant Fairy Tale: Investigating Alice in Wonderland Syndrome | Serendip Studio

Other causes of Alice in Wonderland Syndrome are:
psychoactive drugs
infectious mononucleosis
temporal lobe epilepsy

Certain tests & imaging studies help rule out secondary causes:
urine toxicology screen
monospot test   
(for mononucleosis)
MRI brain
with and without contrast (to look for malignancy)
(to detect seizures or seizure-like activity)

Sounds scary, right? Well, good news is it’s not as bad as it sounds. Most patients who experience AIWS as children will outgrow the condition as adults. Patients should be monitored for worsening of symptom severity and frequency. If all studies are negative and the patient continues to improve clinically, then further evaluation and/or treatment is not needed. Best management for future attacks is focused on migraine prophylaxis and lifestyle modifications (healthy diet, regular exercise, adequate sleep).

Posted By Sidra Ghafoor, Drexel University College of Medicine Class of 2013

Epilepsy and Seizures, What’s the difference?


What is a Seizure?

A seizure (or “fit”) is physical finding or change in behavior that occurs because of abnormal electrical activity in the brain.

When people think of a seizure, they usually imagine a generalized (or “Grand Mal”) tonic clonic seizure:

It is estimated that as many as 5% of all Americans will experience an epileptic seizure during their lifetime.


What is epilepsy?

Epilepsy results from a permanent change in brain tissue causing it to be too excitable, leading to repeated unpredictable seizures over time.

This can occur from a brain injury, such as head trauma, birth asphyxia or a stroke, brain tumor or can be genetic (something you were born with).

The prevalence of epilepsy is estimated to be 1-2% in the USA.


Not all seizures lead to epilepsy.

Why is the prevalence of epilepsy so much lower than the incidence of seizures?

The answer is that not all seizures will lead to epilepsy.

A seizure can be provoked by some extraneous factor such as high fever, medication, drugs and alcohol, or blood electrolyte disorder, which if addressed properly will not lead to further seizures.

However, a single seizure can also be the beginning of epilepsy, necessitating an anti-epileptic medication (or anticonvulsant) to prevent further episodes.


So, how do you tell if a first seizure is the beginnings of epilepsy?

All patients presenting with their first seizure should have a thorough evaluation, including a detailed history (from someone who observed the episode), physical examination, blood work, brain imaging study and electroencephalogram.

A seizure which begins with a focal onset, such as a warning (“aura”), unusual behavior (“automatism”), or focal movements just as turning the head to one side or jerking on one side of the body suggests the beginnings of epilepsy from an underlying brain injury or lesion.


Seizure with automatism (Partial Complex Seizure):

Note that the patient appears awake, but is not responding normally, and has lip smacking and pointing (the automatisms), indicating a focal (temporal lobe) seizure onset.  He seems confused and disoriented afterwards.


Seizure with focal motor activity:

Although the patient is unresponsive and jerking, note that the head is turned to the right and there are only right sided limb movements, indicating that the seizure is coming from the left side of the brain.


Some genetic seizure syndromes, like juvenile myoclonic epilepsy or absence epilepsy (“petit mal”) begin in childhood or adolescence, are associated with characteristic EEG findings, and indicate epilepsy which will be recurrent without treatment.

Absence seizure:

The child is talking, then suddenly stops and stares off into space, then suddenly resumes speech as if nothing happens. This is a typical absence seizure or “Petit Mal” from epilepsy and will recur without treatment.


There are physical signs which suggest an underlying neurocutaneous syndrome, and epilepsy:

Syndrome characterized by a facial port-wine stain, seizures, paralysis or weakness on one side, learning disabilities, and "calcifications" in the brain

Syndrome characterized by a facial port-wine stain, seizures, paralysis or weakness on one side, learning disabilities, and “calcification” in the brain

Genetically determined syndrome of epilepsy associated with     Areas of the skin that are white (due to decreased pigment) and have either an ash leaf or confetti appearance    Red patches on the face containing many blood vessels (adenoma sebaceum)    Raised patches of skin with an orange-peel texture (shagreen spots), often on the back

Genetically determined syndrome of epilepsy associated with: Red patches on the face containing many blood vessels (adenoma sebaceum) . Areas of the skin that are white (due to decreased pigment) and have either an ash leaf or confetti appearance . Raised patches of skin with an orange-peel texture (shagreen spots), often on the back . Small tumor like lesions at the nail folds (subunguual fibromas) .


Genetically determined epilepsy syndrome associated with fatty tumors, pigmented patches (including in the arm pits), and Lisch nodules in the iris.


The presence of an abnormal EEG in a patient presenting with a single seizure increases the chances of another seizure (epilepsy) and may warrant initiation of an anticonvulsant medication. This could be either a focal spike suggesting a partial onset seizure focus:
EEG spike
Or a burst of generalized spike wave activity, suggesting a genetic generalized epilepsy:


A patient with seizures and an abnormal brain imaging study is also more likely to suffer a recurrence and develop epilepsy:
Abnormal Brain MRIs in Epilepsy

However, if all the tests are normal, it can be hard to tell if a single unprovoked seizure is the beginning of epilepsy or not, only about 20-30% of these patients will have a recurrent event, so sometimes it is better to wait and see what is going to happen rather than rushing into starting an anticonvulsant medication here.


Where to get more help.

These are complicated issues and decisions which should only be made after consultation with a neurologist, preferably a neurologist with subspeciality training or certification in epilepsy at an epilepsy center.

Is it OK to take a generic medication?


A generic” is a drug that is broadly equivalent to a brand name medication, but marketed under its chemical name, without advertising, usually at a significantly lower cost.

In most cases, generic products are available once the patent protections afforded to the original developer have expired, and when this happens free market competition leads to substantially lower prices for both the original brand name product and the generic forms.

Insurance companies and pharmacies will try to contain their own costs by encouraging patients to switch to generic medications with lower co-pays or co-insurance.

A generic drug must contain the same active ingredients as the original formulation. According to the FDA, generic drugs are identical or within an 80-125%  bioequivalent range to the brand name counterpart.

Generic substitution is not usually a major problem for most medication prescribed for common medical conditions like high blood pressure or diabetes.

Generic substitution for epilepsy medications is more contentious.

The problem is that most pharmacies get generic medications from wholesalers, and a patient on generic medication could potentially get drug from a different manufacturer every month.

Think of going shopping for peanut butter at a wholesale store like Costcos.  One month they might have Smuckers brand, the next month Kirkland brand, and then the next month some other brand – they have whatever they could order cheapest that month.  While these products all contain peanut butter, they each have slightly different recipes and taste a little bit different.

peanut butter

If you are taking levitiracetam (the generic equivalent of Keppra) for epilepsy, and you switch drug manufacturers every  month, you could potentially go from a product that was 125% Keppra bioavailability to a product that was 80% Keppra bioavailability, i.e. a 45% drop in effective drug ingredient at the same “dose”, and this could provoke a breakthrough seizure, with all of the ramifications for safety and driving that would go along with that.

That’s the reason that most neurologists and the Epilepsy Foundation have suggested that well-controlled epilepsy patients stick with brand name medications, so that they know they are getting the same thing every month when they refill their prescriptions.

Thankfully, we are beginning to see new mail order pharmacies, like Nuro Pharma, that will guarantee that the patient receive their generic epilepsy medications from the same manufacturer every month – if you know you are going to get Kirkland every month, it’s probably OK to pass on the Smuckers!!