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Journal of Peking University(Health Sciences) ›› 2019, Vol. 51 ›› Issue (3): 422-429. doi: 10.19723/j.issn.1671-167X.2019.03.008

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Photosensitive tonic-clonic seizures:a continuum between focal and generalized seizures

Jiao-yang LU,Jiao XUE,Pan GONG,Hai-po YANG,Zhi-xian YANG△()   

  1. Department of Pediatrics,Peking University First Hospital,Beijing 100034, China
  • Received:2019-03-18 Online:2019-05-10 Published:2019-06-26
  • Supported by:
    Supported by the National Natural Science Foundation of China(81771393), the Fundamental Research Funds for the Central Universities: Peking University Medicine Seed Fund for Medicine-Information Interdisciplinary Research (BMU20160586), the Beijing Municipal Science and Technology Commission (Z171100001017125)

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Abstract:

Objective: To investigate whether the tonic-clonic seizure(TCS) induced by intermittent photic stimulation(IPS)was generalized tonic-clonic seizure (GTCS)or partial secondarily tonic-clonic seizure(PGTCS),and to analyze the relationship between them. Methods: Video-electroencephalogram(VEEG)database of Peking University First Hospital from March 2010 to October 2018 were reviewed. Fifteen cases with idiopathic epilepsy who had TCS induced by IPS were included in this study, and their clinical and electroencephalogram(EEG)characteristics were retrospectively analyzed. Results: In this study, 4 of the 15 cases were boys and 11 were girls. The age of seizure onset ranged from 1 to 13 years. According to the medical records: 12 cases were considered as GTCS,while the remaining 3 cases were considered as PGTCS. The age at VEEG monitoring ranged from 2.5 to 16.0 years. All backgrounds of the VEEG were normal. Interictal discharges:generalized discharges in 11 cases,of which 4 cases coexisted with posterior discharges, 2 cases coexisted with Rolandic discharges, the other 5 cases merely had generalized discharges;merely focal discharges in two cases,one in the Rolandic area and the other in the posterior area;no interictal discharge in the remaining 2 cases. IPS induced photoparoxysmal response(PPR)results: 2 cases without PPR,the remaining 13 cases with PPR of generalized discharges,and 6 of the 13 cases coexisted with posterior discharges. IPS induced photoconvulsive response(PCR)results:GTCS in one case (contradictory to medical history),PGTCS in 11 cases (consistent with medical history),and GTCS and PGTCS hardly to distinguish in the remaining 3 cases. Of the three conditions above, there were generalized myoclonic seizures induced by IPS before TCS in 7 cases. Conclusion: The medical history was unreliable in determining whether TCS was generalized or focal. Myoclonic seizures can coexist with PGTCS, and sometimes GTCS was indistinguishable from PGTCS, indicating that the dicho-tomy of seizure types need to be improved. Photosensitive TCS should be regarded as a continuum between focal and generalized seizures.

Key words: Idiopathic epilepsy, Intermittent photic stimulation, Photosensitivity, Tonic-clonic seizure

CLC Number: 

  • R742.8

Table 1

General characteristics of 15 patients in our study"

No. Gender Age of onset Age at EEG
monitoring		 AEDs used before
EEG monitoring		 AEDs at EEG
monitoring		 History of FS Family history of
epilepsy or FS
1 F 12 y 12 y - - - -
2 F 2 y 6 m 6 y LEV, VPA, NZP, LTG VPA, LTG - -
3 M 13 y 14 y - - - EP
4 M 12 y 14 y VPA VPA - -
5 M 6 y 11 y VPA, PB, CBZ VPA, PB, CBZ - -
6 F 10 y 11 y - - - FS
7 F 12 y 14 y LEV LEV - -
8 F 6 y 16 y VPA, LTG LTG - EP
9 F 1 y 2 y 6 m LEV, CZP, VPA, LTG, TPM LTG, CZP + EP
10 F 5 y 10 y - - + -
11 F 8 y 8 y - - - -
12 M 6 y 7 y VPA VPA - FS
13 F 5 y 9 y VPA, LEV VPA, LEV - -
14 F 7 y 9 y VPA, CBZ VPA, CBZ - EP
15 F 10 y 16 y VPA VPA - -

Table 2

Clinical characteristics by history and electroclinical characteristics on electroencephalogram of seizures of 15 patients"

Figure 1

Case 1, GTCS was evoked by eye closed IPS at 16 Hz, which was preceded by a series of myoclonic seizures. The patient presented as several rapid limbs dithering followed by limbs rigidity and then rhythmic clonus. The ictal EEG showed generalized spike and slow waves discharging for several seconds, and then generalized voltage attenuation, followed by generalized spike waves rhythm combined with a large number of muscle artifacts and then slow waves intrusion gradually (average montage)"

Figure 2

Case 9, seizures evoked by eye opened IPS at 6 Hz. The patient presented as binocular gaze→eyelids rhythmic twitching followed by limbs rigidity and rhythmic twitching. The ictal EEG started from rhythmic fast activities in bilateral posterior, without significant difference between the two sides, and then gradually evolved to adjacent areas and rapidly generalized (average montage)"

Figure 3

Case 11, PGTCS onset from left occipital evoked by eye opened IPS at 12 Hz. The ictal EEG showed rhythmic fast activities started from left occipital, and amplitude increased gradually, frequency slowed down, slow waves inserted gradually, and then gradually evolved to adjacent areas. The patient presented as diminished response, eyes wide open and staring→tilting the head to the left and tip back→lower limbs straight and upper limbs flexed with slightly strength→limbs rhythmic twitching (bipolar montage,blue on the left and red on the right)"

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