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Convulsive seizures and electroencephalogram changes in three patients during levodopa therapy

WHEN we started the Georgetown levodopa study, we reviewed the EEGs of patients in the study before and during treatment with levodopa and found very little significant difference. Personal communications to Dr. O’Malley from a number of other investigators contained similarly negative findings. For these reasons we decided to discontinue routine pretreatment EEGs. In the past few weeks, however, three interesting cases have been observed at Georgetown, and my discussion is addressed to these cases. Dr. John Hughes presented, at the 1963 symposium on Parkinson’s disease, an excellent review of the medical literature on EEGs-the types of abnormalities found and other aspects. The earliest papers reviewed by Hughes uniformly showed minimal, and some showed no, abnormalities. But as the years passed, the reports tended to show a gradually increasing incidence of EEG abnormality. Hughes found that, overall, 40% of the entire series of reports showed abnormal EEGs. In a more recent series of studies done during the late 1950s and early 1960s, some authors reported 80 to 100% incidence of EEG abnormality. Our experience runs more toward this high percentage of abnormal recordings in the pretreatment EEGs; approximately 60 to 75% of our tracings taken before levodopa therapy began were abnormal. Reported abnormalities have usually been either mild generalized slowing, with some generalized disorganization of the background tracing, or a mild increase in slow activity in theta frequency ranges. Some investigators described diffuse abnormalities in the slower ranges down into the delta frequencies. Hughes noted that in all of the reviewed cases, there were few reports of seizure activity in parkinsonian patients: only 2 of 633 reviewed patients were described as having clinical seizures associated with Parkinson’s disease. Mathematical analysis showed that this incidence was statistically significantly different from the incidence of epilepsy in the general population. Hughes, confronted with an apparent inverse relationship between parkinsonism and epilepsy frequencies, postulated that the two neurological syndromes tended to be mutually exclusive. It had been noted also that parkinsonian patients appeared to have supranormal resistance to convulsant drugs such as pentylenetetrazole (MetrazolB) . In the Georgetown series, 3 patients exhibited generalized convulsions during levodopa therapy. Dr. O’Malley was particularly interested in these 3 patients and asked me to comment on them. Before doing so, let me acknowledge that the number is small and that the statistical significance of our observations may rightly be questioned. The 3 cases were part of a total study group of 220.