Do et al present a patient with paroxysmal sympathetic storm, and include a sample of the patient's ictal EEG recording.1 It is stated that the absence of clear epileptiform activity serves as evidence against these episodes being epileptic in nature. However, if indeed the EEG recordings during an attack show significant slowing, as depicted in the EEG sample, this EEG change from a presumably normal EEG background rhythm at other times, would rather indicate that these events are, indeed, of seizure origin.

Deep seated epileptic foci very often do not project any sharply configured waveforms to the scalp surface; neither do they provide reliable localising information and can appear rather in a generalised fashion. In such cases, any reproducible and reliably observable EEG changes from the background rhythm that coincide …

Dr E Bromfield ebromfield{at}partners.org