The use of deception in medical care is highly suspect in this country. Yet there is one condition for which deception is often used as a diagnostic tool. Nonepileptic seizures, a psychiatric condition in which emotional or psychological conflicts manifest themselves unconsciously through bodily symptoms, are currently diagnosed by a procedure called “provocative saline infusion.” The test is fundamentally deceptive, requiring the physician to intentionally and directly lie to the patient, causing the patient to believe that the administered (...) solution caused his seizures. Without such deception, the test might be useless. (shrink)

The American Journal of Bioethics, Volume 12, Issue 5, Page 11-12, May 2012.

The authors present a case study involving truth telling responsibilities in the setting of nonepileptic seizures. Specifically, over the course of several suspected nonepileptic seizures, a patient’s seizures stopped after he received a saline flush meant to precede the administration of anti-seizure medication. The patient and his surrogate believed he had received the medication each time, and the team wondered whether they should disclose the truth. Some worried that disclosure would reinforce the suspected psychogenic behavior, (...) exacerbating the patient’s condition. In this way, the case study presents a twist on the traditional truth telling archetype. While most truth telling cases center on navigating cultural differences or worries about emotional harm, this case presented concerns about medical harm in the form of exacerbating the patient’s condition. The authors describe the complex patient-family-team dynamic that preceded this ethical dilemma, describe the case, analyze the ethical issue, and describe the outcome. (shrink)

Most work addressing clinical workers' professional responsibilities concerns the norms of conduct within established professional–patient relationships, but such responsibilities may extend beyond the clinical context. We explore health workers' professional responsibilities in such “informal” encounters through the example of a doctor witnessing the misdiagnosis and mistreatment of a serious long-term condition in a television documentary, arguing that neither internalist approaches to professional responsibility nor externalist ones provide sufficiently clear guidance in such situations. We propose that a mix of both approaches, (...) emphasizing the noncomplacency and practical wisdom of virtue ethics, but grounding the normative authority of virtue in an external source, is able to engage with the health worker's responsibilities in such situations to the individual, the health care system, and the population at large. (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)

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)

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)

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)

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)

BackgroundResponsive neurostimulation has been utilized as a treatment for intractable epilepsy. The RNS System delivers stimulation in response to detected abnormal activity, via leads covering the seizure foci, in response to detections of predefined epileptiform activity with the goal of decreasing seizure frequency and severity. While thalamic leads are often implanted in combination with cortical strip leads, implantation and stimulation with bilateral thalamic leads alone is less common, and the ability to detect electrographic seizures using RNS System thalamic leads (...) is uncertain.ObjectiveThe present study retrospectively evaluated fourteen patients with RNS System depth leads implanted in the thalamus, with or without concomitant implantation of cortical strip leads, to determine the ability to detect electrographic seizures in the thalamus. Detailed patient presentations and lead trajectories were reviewed alongside electroencephalographic analyses.ResultsAnterior nucleus thalamic leads, whether bilateral or unilateral and combined with a cortical strip lead, successfully detected and terminated epileptiform activity, as demonstrated by Cases 2 and 3. Similarly, bilateral centromedian thalamic leads or a combination of one centromedian thalamic alongside a cortical strip lead also demonstrated the ability to detect electrographic seizures as seen in Cases 6 and 9. Bilateral pulvinar leads likewise produced reliable seizure detection in Patient 14. Detections of electrographic seizures in thalamic nuclei did not appear to be affected by whether the patient was pediatric or adult at the time of RNS System implantation. Sole thalamic leads paralleled the combination of thalamic and cortical strip leads in terms of preventing the propagation of electrographic seizures.ConclusionThalamic nuclei present a promising target for detection and stimulation via the RNS System for seizures with multifocal or generalized onsets. These areas provide a modifiable, reversible therapeutic option for patients who are not candidates for surgical resection or ablation. (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;}.

This article introduces the concept of 'cognitive comorbidity,' which lays emphasis on common cognitive deficits that cut across different disorders. The concept is illustrated with the help of two commonly reported overlapping conditions (autism and epilepsy). It is further explained by concentrating on two important cognitive processes of facial emotional recognition and emotional memory, shown to be compromised in both conditions; and their underlying neural substrates. Cognitive comorbidity is then contrasted with 'comorbidity,' a term which is more commonly used for (...) describing cognitive disorders. The paper closes by providing directions for rehabilitative and theoretical efforts that could be inspired by the newly introduced concept. (shrink)

Epilepsy surgery is the most effective therapeutic approach for children with drug resistant epilepsy. Recent advances in neurosurgery, such as the Laser Interstitial Thermal Therapy, improved the safety and non-invasiveness of this method. Electric and magnetic source imaging plays critical role in the delineation of the epileptogenic focus during the presurgical evaluation of children with DRE. Yet, they are currently underutilized even in tertiary epilepsy centers. Here, we present a case of an adolescent who suffered from DRE for 16 years (...) and underwent surgery at Cook Children's Medical Center. The patient was previously evaluated in a level 4 epilepsy center and treated with multiple antiseizure medications for several years. Presurgical evaluation at CCMC included long-term video electroencephalography, magnetoencephalography with simultaneous conventional EEG and high-density EEG in two consecutive sessions, MRI, and fluorodeoxyglucose - positron emission tomography. Video long-term EEG captured nine focal-onset clinical seizures with a maximal evolution over the right frontal/frontal midline areas. MRI was initially interpreted as non-lesional. FDG-PET revealed a small region of hypometabolism at the anterior right superior temporal gyrus. ESI and MSI performed with dipole clustering showed a tight cluster of dipoles in the right anterior insula. The patient underwent intracranial EEG which indicated the right anterior insular as seizure onset zone. Eventually LITT rendered the patient seizure free. Retrospective analysis of ESI and MSI clustered dipoles found a mean distance of dipoles from the ablated volume ranging from 10 to 25 mm. Our findings highlight the importance of recent technological advances in the presurgical evaluation and surgical treatment of children with DRE, and the underutilization of epilepsy surgery in children with DRE. (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)

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)

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)

It is proposed to reappraise the nature of Sappho's seizure , to demonstrate that it constitutes proof positive of her lesbianism and to delimit, on the basis of psycho-physiological considerations, the sense any emendation of must have, if it is to match the clinical precision and to fit the rest of the seizure she describes.

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)