video game induced seizures - journal of neurology ... · video game. an eeg examination showed...

J7ournal ofNeurology, Neurosurgety, and Psychiatry 1994;57:925-931

Video game induced seizures

C D Ferrie, P De Marco, R A Gruanewald, S Giannakodimos, C P Panayiotopoulos

AbstractFifteen patients who experienced epilep-tic seizures while playing video games aredescribed together with a review of 20cases in the English literature. Nine ofthe 15 cases and all but two of thereported cases experienced their firstseizure while playing video games. Twothirds of patients had idiopathic gener-alised epilepsy and mainly reported gen-eralised tonic clonic seizures, but somehad typical absence seizures andmyoclonic jerks while playing videogames. In this series, 30% with idiopathicgeneralised epilepsy had juvenile myo-clonic epilepsy. Overall, 70% of patientswith idiopathic generalised epilepsy werephotosensitive to intermittent photicstimulation and the mechanism ofseizure provocation was probably similarto that of television induced seizures,although sensitivity to specific patternswas sometimes important. Two childrenhad self induced video game seizures.Non-photic factors such as excitement,fatigue, sleep deprivation, cognitive pro-cessing, and diurnal variation in suscep-tibility seemed to be important seizureprecipitants, particularly in non-photo-sensitive patients. Twenty nine per centof patients had partial (mainly occipital)video game associated seizures. Occipitalspikes were common in the EEG of thesepatients. Photosensitivity to intermittentphotic stimulation may have been impor-tant in two patients but in the others, whoall played arcade video games, othermechanisms need to be considered.Video game associated seizures are a fea-ture of several epileptic syndromes anddiffer in precipitants and appropriatemanagement.

(i Neurol Neurosurg Psychiatry 1994;57:925-93 1)

Since the first description of "space invaderepilepsy" in 19811 more than 20 cases ofvideo game induced seizures have beenreported in the English literature.2-'4 Recentmedia reports have highlighted the risk ofseizures precipitated by playing videogames.'5-'7 Manufacturers now warn of thedanger and the British Department of Tradeand Industry has sponsored research into thesubject.

It has been supposed that similar mecha-nisms that lead to television induced seizurescause video game induced seizures.'819 Mostpatients with television induced seizures haveidiopathic generalised epilepsy and easilydemonstrable photosensitivity on intermittent

photic stimulation. Studies of televisioninduced seizures, however, have concentratedmainly on patients known to be photosensi-tive,20 21 and patients in whom seizure precipi-tants are non-photic are important may beunder-represented.We report 15 patients who had seizures

while playing video games. We also reviewsubstantive cases reported in the English liter-ature together with further information onsome of them. The study aimed to ascertainwhether video game induced seizures are anhomogeneous seizure disorder, and whethervideo game induced seizures are analogous totelevision induced seizures, and to describethe important mechanisms of seizure precipi-tation.

MethodWe reviewed all patients known to us over aperiod of seven years who had seizures whileplaying video games. Information on themwas collected retrospectively from their med-ical notes, supplemented by interviews withpatients and witnesses. Photosensitivity dur-ing EEG examinations was assessed withintermittent photic stimulation with a lineargrid over the photic stimulator. A photocon-vulsive response was defined as a generaliseddischarge of spike/multiple spike and wavecomplexes. A syndrome diagnosis based onthe proposals of The International LeagueAgainst Epilepsy was attempted in all cases.22

Substantive cases of video game inducedseizures in the English literature werereviewed. Further information was requestedfrom the authors of cases published before themajor series of Maeda et al,9 especially con-cerning the subsequent clinical course andwhether it had been possible to give asyndrome diagnosis.

ResultsFifteen patients with video game inducedseizures are reported. Two were mentioned ina previous report."3 Unless otherwise stated,medical and family histories were not contrib-utory and neurodevelopmental examinationwas normal. Identification of the particularvideo game associated with the seizures wasimpossible in many patients.

CASE 1This female patient had a simple febrile con-vulsion at 3 years of age. Since the age of 14she had typical absence seizures, myoclonicjerks, and infrequent generalised tonic clonicseizures (GTCSs) and was diagnosed as hav-ing juvenile myoclonic epilepsy. Her firstGTCS occurred while playing monopoly, the

Department ofClinicalNeurophysiology andEpilepsy, St Thomas'sHospital, London SEI7EH, UKC D FerrieS GiannakodimosC P PanayiotopoulosDepartnent ofPediatric Neurology,Istituti OspedalieriRiuniti, 38100 Trento,ItalyP De MarcoDepartment ofNeurology, NationalHospital forNeurology andNeurosurgery, QueenSquare, LondonWC1N 3BG, UKR A GruinewaldCorrespondence to:Dr C D Ferrie.Received 18 October 1993and in final form20 December 1993.Accepted 6 January 1994

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second while playing a simulated game oftennis on a home video game, and the thirdwhile watching television. Subsequent GTCSsoccurred after sleep deprivation without clearphotic precipitants.EEG examinations showed generalised

spike/multiple spike and wave discharges,spontaneously, on hyperventilation, and onintermittent photic stimulation at 15 Hz. Herlast EEG (at 22 years) no longer showedphotosensitivity. Control was achieved withsodium valproate combined with carba-

23mazepine.

CASE 2At the age of 12 years, this boy had a GTCS.Myoclonic jerks were recognised a year laterand juvenile myoclonic epilepsy was diag-nosed. The GTCSs occurred mainly whileplaying a variety of home video games. Noother precipitating factors were elicited.An EEG showed generalised spike/multiple

spike, and wave discharges spontaneously, onoverbreathing, and on intermittent photicstimulation. Treatment with sodium valproatewas successful.

CASE 3This male patient developed typical absenceseizures at the age of 14 years and myoclonicjerks and infrequent GTCSs two years later.Absences and particularly GTCSs occurredmainly while watching television and whileplaying various "Atari" home video games.Seizures were more likely after sleep depriva-tion. Excitement and frustration were power-ful precipitating factors and television inducedseizures only occurred while watching footballand specifically when his team missed a scoringopportunity.On EEG generalised spike/multiple spike

and wave discharges were seen spontaneouslyand on overbreathing but not on intermittentphotic stimulation. He was successfullytreated with sodium valproate and clon-azepam.

CASE 4This 22 year old man had a single GTCSwhile playing a home video game. He hadbeen deprived of sleep the previous night andhad been playing the game for some hours.Questioning failed to show any history of pre-vious absences or jerks but the GTCS hadbeen preceded by a few jerks of his upperlimbs.An EEG, including overbreathing and

intermittent photic stimulation, was normal.He has avoided video games and hasremained seizure free without drug treatment.

CASE 5This 21 year old man had a strong family his-tory of epilepsy. His mother and sister hadphotosensitive epilepsy with typical absencesand GTCSs. A maternal uncle died during aGTCS. Between the ages of 12 and 14 yearshe had three GTCSs. All occurred whileplaying home video games in the morning,although he usually played in the afternoon or

evening. He was not treated with anticonvul-sants but stopped playing video games. Hehad one further GTCS walking to college on asunny morning while under considerableemotional stress.An EEG showed generalised spike/multiple

spike and wave discharges on intermittentphotic stimulation at flash frequencies of12-25 and 50 Hz.

CASE 6This 38 year old man had had typical absenceseizures since age 10 years and GTCSs sinceage 20 years. Juvenile absence epilepsy wasdiagnosed. His GTCSs were precipitated bysleep deprivation and alcohol. He particularlynoticed absences during tasks requiring con-centration for example, when playing ahome video game that involved racing a cararound a circuit. Absences often occurred atthe most testing parts of the game causinghim to crash.

Six EEGs showed generalised 3 Hz spikeand wave discharges without photosensitivity.A combination of lamotrigine and sodium val-proate controlled the seizures.

CASE 7This 11 year old boy often played home videogames without incident. While playing "SuperMario Bros" in an arcade he felt "dizzy" with asensation of his head falling backwards. Oneto two minutes later he had a short GTCS.No other precipitating factors were identified.

His EEG was normal apart from a fewbursts of generalised sharp theta waves consis-tent with idiopathic generalised epilepsy.There was no photoconvulsive response tointermittent photic stimulation. No treatmentwas started.

CASE 8This 11 year old girl had a GTCS thatoccurred while changing television channels.Over the previous year she had had typicalabsences and myoclonic jerks that she foundpleasurable and induced by rapidly changingtelevision channels, particularly when emo-tionally upset. When this behaviour was frus-trated by a new television set she inducedabsences, jerks, and occasional GTCSs byrapidly switching between games on a homevideo game.An EEG examination showed generalised

spike/multiple spike and wave dischargesspontaneously with the eyes closed (but noton eye closure) and on intermittent photicstimulation. Sodium valproate suppressed herseizures.

CASE 9This 12 year old boy has a sister with tele-vision induced absences and photosensitivityto intermittent photic stimulation. Absencesstarted at the age of 2-5 years and GTCS atage 5 years. Seizures were precipitated bylight or television and were so numerous as torequire special schooling. Many were selfinduced by changing television channels.Recently his teachers reported that he had



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Figure 1 EEGfrom case Eyes open10. Paroxysms ofoccipitalspikes seen spontaneously Fp2-F4~only when the eyes areclosed (top and bottom F4-C4 Nleft). Paroxysms are C4-P4induced by intermittentphotic stimulation when P4-02the eyes are open (topright). A single generalised Fpl-F3discharge, associated withmild impairment ofconsciousness, was seen on F3-C3 _one occasion only (bottomright). C3-P3

P3-02

140 jV I1 s

Eyes closed

Fp2-F4 - -. d

F4-C4 _

C4-P4'

P4-02 - A_A 1

Fp1-F3

F3-C3_

C3-P3

P3-02

absences, often self induced, when playinghome video games. Scenes involving flashes oroscillating images were particularly provoca-tive.EEG examinations showed spontaneous

generalised discharges and pronounced pho-tosensitivity with generalised spike/multiplespike and wave discharges over a wide rangeof flash frequencies as low as 1-5 Hz.Treatment with sodium valproate and carba-mazepine was unsuccessful.

CASE 10This 11 year old girl had had a number offebrile convulsions in early childhood thenremained well until aged 5 years.Subsequently she had infrequent partialseizures during which consciousness was usu-ally retained. She described obscuration ofvision and elementary visual hallucinations ofcoloured light during the seizures, whichlasted a few minutes and often occurredimmediately after watching television. Oneattack occurred while toasting a bun in frontof a fire and others occurred spontaneously.At 9 years of age she had had a seizure whileplaying a home video game. Additionally,occasional brief "absences" accompanied byeyelid fluttering were reported.

Five standard and two video EEGexaminations (fig 1) showed bilateral parox-ysms of occipital spikes and multiple spikeswhen the eyes were closed. Intermittentphotic stimulation induced multiple spikes inthe same regions (occipital photoconvulsiveresponse) and was often associated with eyelidfluttering. There was no fixation off sensi-tivity. One record showed a generaliseddischarge of 3 Hz spike and slow waves with

Eyes openFp2-F4

F4-C4 -v-

C4-P4

P4-02

Fpl-F3-,

F3-C3100 pM L 1..

C3-P3

P3-02IPS -1H

15 Hz

Fp2-F8

F8-T4

T4-T6

T6-02

Fpl-F7

F7-T3

T3-T5

T5-01

mild impairment of consciousness. CT wasnormal. Treatment with sodium valproatewas successful.

CASE I 1This 19 year old man had three short GTCSsall while playing the arcade video game"Captain Battle". No other precipitating fac-tors were identified. An EEG showed photo-sensitivity on intermittent photic stimulationat 7-27 Hz. Subsequently he avoided videogames and had no more seizures. Medicationwas not started.

CASE 12This 10 year old boy had had two seizures onemonth apart at the age of 9 years. Bothoccurred while playing the video game"Michael Jackson" in an arcade. On bothoccasions initial ictal symptoms consisted ofelementary visual hallucinations, lasting about20 seconds, followed by a short GTCS.An EEG showed occipital spikes (fig 2).

There was no photoconvulsive response tointermittent photic stimulation. He avoidedvideo games and had no more seizures.Medication was not started.

CASE 13This 14 year old boy experienced a singleseizure after playing a video game in an arcadefor 10 minutes. Initial visual symptoms (sco-tomata and elementary visual hallucinations)lasting for about 60 seconds were followed by aGTCS. An EEG showed a right occipitalspike focus. There was no photoconvulsiveresponse to intermittent photic stimulation.No medication was started but he avoidedvideo games and had no more seizures.



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50 LsV2 s

3 4 N

25 5

6

8 IVFigure 2 EEG from case 12.

CASE 14This 14 year old boy had a seizure whilst play-ing "Asterix against the Romans" in an

arcade. Initial visual symptoms (elementaryvisual hallucinations followed by scotomata)were followed by a GTCS. An EEG showed a

right temporo-occipital spike focus. Therewas no photoconvulsive response to intermit-tent photic stimulation. Medication was notstarted but he avoided video games and hadno further seizures.

CASE 15This 15 year old boy with no history or familyhistory of note had a single seizure while play-ing an arcade video game. Initial visual symp-

toms (foggy vision and restriction of both

visual fields) were followed after about 40 sec-

onds by a GTCS. An EEG showed a righttemporo-occipital spike focus. There was no

photoconvulsive response to intermittentphotic stimulation. No medication was startedbut he avoided video games and had no more

seizures.

There were 20 patients with video game

induced seizures in 12 substantive case

reports in the English literature. These, sup-

plemented with further information (seeacknowledgements), are summarised in thetable. We excluded reports which were insuffi-ciently detailed.12 13 14

Combining the data from our 15 cases withthe 20 described in the literature, the medianage at which video game induced seizureswere first experienced was 13 (range 4-35)years with a male:female ratio of almost 4:1.In 15 patients seizures occurred while playinghome video games (in one a hand held ver-

sion) and in 12 patients whilst playing arcadevideo games. In eight patients this informa-tion was not known. No patient with mixedhome and arcade video game induced seizureswas found. In only one family was more thanone sibling affected by video game inducedseizures.'0 In 19 patients all seizures were pro-

voked by video games (in 11 cases only a singleseizure had occurred). Nine patients had alsoexperienced other light induced seizures. Incontrast to our patients, none of the previouscases had television induced seizures. Twelveout of the 35 patients had also experiencedspontaneous seizures.

Fourteen patients (70%) in the literatureand 10 of our cases (67%) had forms of idio-

Summary of substantive reports of video game induced seizures in the literature

Video game Television Otherinduced induced photic Spontaneous

Author Sex Age (y) seizures seizures seizures seizures

Rushton' M 17 + (GTCS preceded by - -"temporal lobe type aura")+ + (2 "auras")

Jeavons et a!2 M 14 + + (3 GTCSs) - -

Daneshmend F 17 + (GTCSs) -

and Campbell3Dalquist et al4 M 15 + (absence status ?) - + (GTCS) + *

+ (GTCS)Helfgott and M 8 + ("unobserved fall") - - + (GTCS)Meister'Glista et al! M 14 + + (2 GTCSs) - - + (GTCS)

M 15 + (GTCS with preceding visual - - -

symptoms)De Marco and M 8 + (2 GTCSs) - -

Ghersini7M 13 + + (3 GTCSs with preceding - -

visual symptoms)Hart8 F 13 + ("felt strange" followed by - + (GTCS) -

GTCS)Maeda et al' M 6 + (scotomata followed by LOC) - - + (GTCS)

+ + (headachest) + (headachestF 10 + (headache, pallor, and jaw - + (GTCS) + + (headachest)

tremble)F 12 + (GTCS) - -M 4 + (adversive seizure) - -M 11 + +(GTCS) - -

M 13 + (GTCS) - - + (GTCS)M 9 +(GTCS) - - + (GTCS)

Cook and M 11 + (GTCS) and - - + ("funny tingling")Hoskins'° + (funny tingling) - -

M 17 + (GTCS) - -Thompson" M 15 + (lightheaded followed by - -

GTCS)

*Nature of this seizure unclear. tConsidered ictal. The designation of idiopathic generalised epilepsy or partial seizure disorder is our interpretation of the availabledata; age refers to first video game induced seizure; + = one seizure of this type experienced; ++ = more than one seizure of this type experienced; -= this type ofseizure not experienced; GTCS = generalised tonic clonic seizure; SSW = spike/multiple spike and slow wave discharge.



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pathic generalised epilepsy or single GTCSswith no clinical or EEG evidence of focalonset. Thirteen of the previously reportedcases had video game induced GTCS. Onepatient reported "feeling strange" before theGTCS8 and another felt "light headed.""These may have been absence seizures.Another patient experienced symptoms sug-gestive of absence status after playing a videogame.4 Four of our patients had video gameinduced absences and one had video gameinduced myoclonic jerks. Ten patients (76%)with idiopathic generalised epilepsy reportedin the literature and six of our cases (60%)were photosensitive on intermittent photicstimulation.

Five patients (25%) in the literature andfive of our cases (33%) had video gameinduced partial seizures. Three of the reportedcases6 79 and all of ours had elementary visualsymptoms usually preceding GTCSs.Interictal EEG recordings in six of these casesshowed occipital or temporo-occipitalspikes/multiple spikes. One patient in the lit-erature was photosensitive on intermittentphotic stimulation9 and one of our cases (case10) had an occipital photoconvulsive response.

DiscussionThe median age at first video game inducedseizure is similar to that seen in photosensitiveepilepsies in general and television inducedseizures in particular.'8 '9 There is a 4:1 malepredominance in video game inducedseizures, despite two thirds of photosensitivepatients being female.'9 This has been attrib-uted to a greater number of boys playing

video games than girls,9 but a survey of videogame playing in American schoolchildrenfound that 66% of girls and 90% of boysplayed home video games for at least one totwo hours a week.24 Factors other thanphotosensitivity may therefore contribute tothe male excess.

Patients with video game induced epilepticseizures fall into at least three main groups:(a) Those with idiopathic generalised epilepsyand photosensitivity; (b) those with idiopathicgeneralised epilepsy without photo-sensitivity; (c) those with partial (occipital)seizures.

IDIOPATHIC GENERALISED EPILEPSIESMost patients with video game inducedseizures had forms of idiopathic generalisedepilepsy. Syndromic diagnosis of the idio-pathic generalised epilepsy was not providedfor any of the cases in the literature. Onereport was consistent with juvenile myoclonicepilepsy4 and this was the diagnosis in three ofour cases (30%), compatible with the highprevalence of photosensitivity in this syn-drome.25 Another patient had juvenile absenceepilepsy.

In the reported cases GTCSs predominate.Our series is the first clearly to describe videogame induced absences and myoclonic jerks,although they have been described in patientswith television induced seizures20 21 26 27 and arecommonly precipitated in photosensitive sub-jects by intermittent photic stimulation.

PHOTOSENSITIVITYMost patients with idiopathic generalisedepilepsy and video game induced seizures are

Classification

Partial seizure disorder

Irregular SSW with inconstant focal features. Photoconvulsive response onintermittent photic stimulation (15-18 Hz) and on playing video gamesPhotoconvulsive response on intermittent photic stimulation (15-21 Hz)

Photoconvulsive response on intermittent photic stimulation (15 and 20 Hz)

Spontaneous left focal SSW

Spontaneous SSW. Intermittent photic stimulation negativeNormal

Photoconvulsive response on intermittent photic stimulation (20-22 Hz)

Left occipital spike focus. Intermittent photic stimulation negative

Photoconvulsive response on intermittent photic stimulation >8 Hz

Occipital slow wave. Photoconvulsive response on intermittent photic stimulation(3-30 Hz), pattern and video game testingOccipital slow wave. Photoconvulsive response on intermittent photic stimulation(12-30 Hz), pattern and video game testingPhotoconvulsive response on video game testing onlyPhotoconvulsive response on video game testing onlyPhotoconvulsive response on intermittent photic stimulation (15-30 Hz).Occipital spike on pattern testingPhotoconvulsive response on intermittent photic stimulation (12-30 Hz)Photoconvulsive response on intermittent photic stimulation (3-30 Hz)Photoconvulsive response on intermittent photic stimulation (wide range offrequencies)Photoconvulsive response on idiopathic generalised epilepsy (11-20 Hz)Normal

Idiopathic generalised epilepsy


Idiopathic generalised epilepsy,probably juvenile myoclonic epilepsyProbably idiopathic generalised epilepsy

Idiopathic generalised epilepsyPartial seizure disorder





Classification uncertain

Single GTCSPartial seizure disorder?Probable idiopathic generalised epilepsy

Idiopathic generalised epilepsyIdiopathic generalised epilepsyIdiopathic generalised epilepsy

Idiopathic generalised epilepsySingle GTCS

EEGfindings

Normal



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photosensitive to intermittent photic stimula-tion and may also experience televisioninduced seizures. Television induced seizuresare provoked by the 50 Hz flicker from themains or by the 25 Hz raster pattern of thepicture.1819 Similar mechanisms are likely tobe involved in provoking video game inducedseizures in photosensitive patients who playhome video games on television screens. Selfinduction of seizures-for example, by rapidlychanging television channels-has beendescribed in photosensitive patients,'9 2' butcases 7 and 8 are the first reports of similarbehaviour with video games.Some patients who are photosensitive to

intermittent photic stimulation are also sensi-tive to patterns, particularly oscillating blackand white stripes,28 29 and seizure provocationby patterns may be clinically dominant.303'Maeda et al provoked a photoconvulsiveresponse in patients more easily by showingcertain scenes in video games than by inter-mittent photic stimulation.9 Such provocativepatterns may be more frequent and persistentin video games than in television pictures.

NON-PHOTIC FACTORSA significant minority of patients with idio-pathic generalised epilepsy and video gameinduced seizures were not photosensitive tointermittent photic stimulation, in contrast tomost reports of television induced seizures.202'Our methods of testing maximise detection ofphotosensitivity32 and it is therefore unlikelythat deficiencies in methodology explain this.

Several non-photic factors may have a rolein precipitating video game induced seizures.Playing video games evokes a metabolicresponse equivalent to light exercise,33 probablyreflecting emotional excitement. Excitementwas an important mechanism in provokingseizures in at least one patient (case 3). Sleepdeprivation and fatigue caused by prolongedplaying were important in case 4 and werealso mentioned in other reports.5 810 Theincreased susceptibility to seizures for the fewhours after wakening seemed relevant in case5 (who was also photosensitive). In patient 6cognitive functions were responsible for pro-voking video game induced absences. Suchmechanisms may be responsible for othercases of game playing seizures.34

PARTIAL EPILEPSIESThere was a high proportion of video gameinduced seizures of partial, usually occipital,onset. The mechanisms provoking occipitalvideo game induced seizures are not clear.Photosensitive mechanisms may sometimesbe involved, as in case 10. In this case the lackof fixation off sensitivity, the occurrence of anoccipital photoconvulsive response, and themorphology of the spikes distinguish the con-dition from benign childhood epilepsy withoccipital paroxysms.35 Most patients withvideo game induced occipital seizures werenot photosensitive. Partial video gameinduced seizures were characteristically pro-voked by playing arcade video games. Thecontrast in illumination between the screenand surroundings may be an important

provocative factor. Fixation off sensitivity,which is sometimes enhanced by previousprolonged fixation,36 may be involved in somepatients. At the time this was not routinelytested for and, therefore, we cannot commenton its prevalence in cases 12-15.

Television-induced partial seizures maypreviously have been under-recognised andpossibly constitute up to one third of televi-sion induced seizures,'4 37 similar to the preva-lence of partial epilepsy in this series of videogame induced seizures. Patients with occipitaltelevision induced seizures and video gameinduced seizures may have a form of benignpartial epilepsy. 4

OTHER SEIZURESThe series by Maeda et al is unusual for thefrequency at which headaches are described.9It is not clear if these were associated withgeneralised or partial seizures. The differen-tiation between migrainous headaches andoccipital seizures has been recentlyreviewed.38

Relation between playing video games andinduction of seizuresA problem in all studies of reflex epilepsies isestablishing a causal relation between seizuresand their supposed precipitant. Whererepeated seizures occur that are all or mainlyassociated with the precipitant then the rela-tion is clear (cases 2, 3, 5, 8, 9, 11, and 12).Additionally in patients who are photosensi-tive the occurrence of a seizure while playingvideo games is likely to be causally linked(cases 1 and 10). Where patients have fre-quent spontaneous seizures, their occurrencewhile playing video games is likely to arise bychance. None of our patients clearly comeinto this category, although it is possible thatplaying video games merely brought theoccurrence of absences to the attention ofpatient 6. This is unlikely, however, as it wasonly during "difficult" parts of the game thathe was liable to crash. It may be argued that inpatients who had single seizures and were notphotosensitive on intermittent partial seizures(cases 4 and 7), the association with playingvideo games is likely to be fortuitous andother factors such as sleep deprivation werethe sole precipitates. We consider that a morelikely explanation is that the accumulation ofa number of factors, some unrelated to videogames (for example, sleep deprivation) andothers that are related (for example, fatigue,excitement, frustration), is probably impor-tant.

MANAGEMENTIn patients who had a single GTCS the associ-ation with playing a video game may havebeen fortuitous, and the possibility of non-epileptic events should always be considered.Advice depends on the type of video gameinduced seizures. In highly photosensitivepatients, that which is given to patients withtelevision induced seizures is probably appro-priate'8 and may allow some to continue play-ing. In others avoidance of video gamesaltogether or at least specific games may be



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necessary. The importance of non-photic fac-tors should be stressed to both groups. At pre-sent it is not clear how those with occipitalvideo game induced seizures should beadvised but arcade video games may need tobe avoided. Play should be stopped if minorevents suggestive of absences, jerks, or visualphenomena occur, as this may prevent pro-gression to GTCS.Drug treatment may not always be neces-

sary. Sodium valproate is the drug of choice inthose with idiopathic generalised epilepsy. Inthose with occipital seizures the treatment ofchoice is not clear.

In conclusion, the term "video gameseizures" encompasses a diverse group ofreflex epilepsies, and may occur in several dis-tinct idiopathic generalised epilepsy syn-dromes. An important finding of this study isthe precipitation by video games of partialseizures arising from the occipital lobe. Videogame induced seizures are not synonymouswith television induced seizures, and the firstoften have non-photic seizure precipitants.Further studies of the mechanisms provokingvideo game induced seizures should increaseour understanding of the mechanisms under-lying seizure precipitation in general.

AddendumSince submitting this paper, we have seen afurther three patients with video gameinduced seizures. None had generalisedphotoconvulsive responses on intermittentphotic stimulation. One 22 year old man had aGTCS while playing a video game on adomestic television, and a further GTCS pre-ceded by a prolonged absence while playing avideo game on a laptop computer. Hunger,thirst, fatigue, and mild photosensitivity (tran-sient sharp activity following intermittentphotic stimulation) may have been com-pounding precipitating factors. Another boy,aged 13, had recurrent episodes of obscura-tion of vision and visual hallucinations ofcoloured lights and a single GTCS, precededby these symptoms, while playing a handheldvideo game. EEG showed an occipital spikefocus. The final patient had recurrent noctur-nal GTCS with postictal headache and vomit-ing. At age 14, he had a single diurnal GTCS,preceded by visual hallucinations of colouredballs of light, while playing a video game on adomestic television in a well lit room. EEGhas been consistently normal and he has beenfree of seizures for four years and is now offtreatment.

We thank the following authors of reports on this subject forkindly supplying further information on their cases: DNRushton, PM Jeavons, DW Klass, PC Helfgott, and EJ Hart.This work was supported by the British Telecom CharitableOrganisation and the Special Trustees of St Thomas'sHospital. One author (CDF) is funded by a fellowship fromMarion Merrell Dow and Co.

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