Cingulate Epilepsy Manifesting as Panic Disorder:
Multimodal Approach to Diagnosis
Michelle Tall,
1Functional
1
RN ;
Milena Korostenskaja,
1,2,4
PhD ;
3,4
PsyD ;
3,4
PhD, ABPP-CN ;
Tanya R. Grace,
Michael Westerveld,
Joo-Hee Seo,
3,4
4
Christine M. Salinas, PsyD ; Ki Hyeong Lee, MD
4
MD ;
Jane C. Cook,
5
DO ;
Po-Ching Chen,
1,2,4
PhD ;
Brain Mapping and Brain-Computer Interface Lab, Florida Hospital for Children, Orlando, Florida; 2MEG Lab, Florida Hospital for Children, Orlando, Florida; 2Dirivion of Neuropsychology, Florida Hospital for Children, Orlando, Florida; 4Comprehensive Pediatric Epilepsy Center, Florida Hospital for
Children, Orlando, Florida; 5Department of Radiology, Florida Hospital, Orlando, Florida
INTRODUCTION
Background & Significance
Anterior Cingulate Epilepsy (ACE) is a diagnostic and therapeutic
challenge with a wide range of nonspecific symptoms that can
negatively impact an individual’s cognition, behavior, and emotions.
Scalp EEG and brain MRI may not be helpful because of the deep
midline location of Anterior Cingulate Gyrus (ACG).
Study Aims
Primary objective: To demonstrate the utility of a multimodal
approach to diagnose ACE.
Secondary objective: To raise awareness to the medical
community about the complexity of this disorder and associated
treatment delay.
Patient #2
Baseline: Previous EEG and brain MRI was reported as normal.
Patient’s typical episode was associated with diffuse bilateral
rhythmic spikes (Fig. 3A). Ictal SPECT and SISCOM demonstrated
focal hyperperfusion in the left ACG and medial frontal region
(Figure 3B). Neuropsychological evaluation revealed cognitive
impairments associated with frontal lobe dysfunction.
RESULTS
Patient #1
Evaluation: Previous EEG and 1.5T-MRI was reported as normal.
Patient’s typical episode was captured during long-term video-EEG
that showed diffuse ictal onset (Fig 1). 3T-MRI revealed high T2
signal in the right anterior cingulate gyrus (Fig. 2.A). SISCOM
demonstrated a significant focal hyperperfusion in the right medial
parafalcine frontal lobe and cingulate gyrus (Fig. 2.B).
Neuropsychological test scores were normal.
Follow up: Patient is seizure-free with topiramate monotherapy.
Follow up: Patient became seizure-free with oxcarbazepine
monotherapy.
METHOD
Setting & Design
A retrospective chart review was conducted on two pediatric
patients at the Comprehensive Epilepsy Center at Florida Hospital
for Children. This study was approved by IRB at Florida Hospital.
Subjects
Patient 1: 3 year old, previously healthy female was diagnosed
with panic attacks by her pediatrician. She presented with daily
episodes of intense fear coupled with screaming and inconsolable
crying that developed 5 weeks prior to admission.
Fig. 3. Patient #2. A: Ictal EEG pattern arising from left frontal and
midline vertex areas on long-term video-EEG monitoring; B: Ictal
SPECT and SISCOM demonstrated focal hyperperfusion in the left
medial parafalcine frontal lobe and ACG.
CONCLUSIONS
Fig. 1: Ictal EEG showed diffuse bilateral rhythmic spikes with frontal
dominance.
•
Patient 2: 13 year old male was initially diagnosed with panic
disorder by his primary neurologist. In addition, at age 7, he was
diagnosed with recurrent seizures characterized by sudden
frightened facial grimaces, followed by episodes of hyperventilation,
repetitive wrist slapping, and walking in circles.
•
•
Comprehensive Epilepsy Evaluation:
•
Long-term video-EEG monitoring
•
3T-MRI with epilepsy protocol
•
FDG-PET, subtraction ictal SPECT co-registered to MRI
(SISCOM)
•
Neuropsychological testing
•
Fig. 2. Patient #1. A: 3T-MRI revealed high T2 signal in the right
medial frontal lobe cingulated gyrus; B: SISCOM demonstrated a
significant focal hyperperfusion in the right medial parafalcine frontal
lobe and cingulate gyrus.
ACE can be misdiagnosed as generalized anxiety, behavioral
problems, or other psychiatric conditions because of diverse
clinical manifestation of ACE.
Early identification of ACE can improve outcomes in cognition,
behavior, and quality of life.
MRI and EEG alone may not be sufficiently sensitive for diagnosis
and localization of ACE in some cases.
Our findings indicate that a combined multimodal diagnostic
approach is useful for the diagnosis of ACE.