To improve patient care and facilitate clinical research, the International League Against Epilepsy (ILAE) appointed a Task Force to formulate a consensus definition of drug resistant epilepsy. The overall framework of the definition has two "hierarchical" levels: Level 1 provides a general scheme to categorize response to each therapeutic intervention, including a minimum dataset of knowledge about the intervention that would be needed; Level 2 provides a core definition of drug resistant epilepsy using a set of essential criteria based on the categorization of response (from Level 1) to trials of antiepileptic drugs. It is proposed as a testable hypothesis that drug resistant epilepsy is defined as failure of adequate trials of two tolerated, appropriately chosen and used antiepileptic drug schedules (whether as monotherapies or in combination) to achieve sustained seizure freedom. This definition can be further refined when new evidence emerges. The rationale behind the definition and the principles governing its proper use are discussed, and examples to illustrate its application in clinical practice are provided.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1528-1167.2009.02397.x

Definition of drug resistant epilepsy: consensus proposal by the ad hoc Task Force of the ILAE Commission on Therapeutic Strategies.

Background Randomized trials of surgery for epilepsy have not been conducted, because of the difficulties involved in designing and implementing feasible studies. The lack of data supporting the therapeutic usefulness of surgery precludes making strong recommendations for patients with epilepsy. We conducted a randomized, controlled trial to assess the efficacy and safety of surgery for temporal-lobe epilepsy. Methods Eighty patients with temporal-lobe epilepsy were randomly assigned to surgery (40 patients) or treatment with antiepileptic drugs for one year (40 patients). Optimal medical therapy and primary outcomes were assessed by epileptologists who were unaware of the patients' treatment assignments. The primary outcome was freedom from seizures that impair awareness of self and surroundings. Secondary outcomes were the frequency and severity of seizures, the quality of life, disability, and death. Results At one year, the cumulative proportion of patients who were free of seizures impairing awarenes...

A randomized, controlled trial of surgery for temporal-lobe epilepsy.

*Division of Neurology, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China; yInstitute for Children and Adolescents with Epilepsy-IDEE, University Hospital of Lyon (HCL) and Inserm U821, Lyon, France; zDepartment of Biology, Northern Illinois University, DeKalb, Illinois, U.S.A.; xEpilepsy Unit, Western Infirmary, Glasgow, United Kingdom;{GH Sergievsky Center, Columbia University, New York, New York, U.S.A.; #Department of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, California, U.S.A.; **The Saul R. Korey Department of Neurology, Dominick P. Purpura Department of Neuroscience and Department of Pediatrics, Albert Einstein College of Medicine, Bronx, New York, U.S.A.; yyClinical Trial Center, Institute of Neurology IRCCS C. Mondino Foundation, and Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy; zzDepartment of Clinical Neurosciences, University of Calgary, and Hotchkiss Brain Institute, Calgary, Alberta, Canada; and xxNYU Comprehensive Epilepsy Center, New York, New York, U.S.A.

Definition of drug resistant epilepsy: Consensus proposal by the ad hoc Task Force of the ILAE Commission on Therapeutic Strategies

An overview of the following six cortical zones that have been defined in the presurgical evaluation of candidates for epilepsy surgery is given: the symptomatogenic zone; the irritative zone; the seizure onset zone; the epileptogenic lesion; the epileptogenic zone; and the eloquent cortex. The stepwise historical evolution of these different zones is described. The current diagnostic techniques used in the definition of these cortical zones, such as video-EEG monitoring, MRI and ictal single photon emission computed tomography, are discussed. Established diagnostic tests are set apart from procedures that should still be regarded as experimental, such as magnetoencephalography, dipole source localization and spike-triggered functional MRI. Possible future developments that might lead to a more direct definition of the epileptogenic zone are presented.

/pdf/presurgical-evaluation-of-epilepsy-216chlpgp2.pdf

Presurgical evaluation of epilepsy.

Evoked potentials in clinical medicine , Evoked potentials in clinical medicine , کتابخانه مرکزی دانشگاه علوم پزشکی ایران

Evoked Potentials in Clinical Medicine

Objective The goal of this study was to determine current and lifetime rates of DSM-III-R disorders in patients with pseudoseizures and to ascertain whether trauma is associated with the occurrence of pseudoseizures. Methods Adult pseudoseizure patients (N = 45) were interviewed regarding seizure course and life events, and they were given the Structured Clinical Interview for DSM-III-R--Patient Version, the Structured Clinical Interview for DSM-III-R Dissociative Disorders, the Dissociative Experiences Scale, and the Personality Diagnostic Questionnaire--Revised. The pseudoseizures were diagnosed in a tertiary-care video-EEG facility. Most of the subjects (78%) were female, and the mean age of the overall patient group was 37.5 years (SD = 9.7). Results The mean duration of the subjects' seizure history was 8.3 years (SD = 8.0). Common current psychiatric diagnoses included somatoform disorders (89%), dissociative disorders (91%), affective disorders (64%), personality disorders (62%), posttraumatic stress disorder (PTSD) (49%), and other anxiety disorders (47%). The lifetime occurrence of nonseizure conversion disorders was 82%. The mean Dissociative Experiences Scale score was 20.2 (SD = 18.2). Trauma was reported by 84% of the subjects: sexual abuse by 67%, physical abuse by 67%, and other traumas by 73%. Conclusions Pseudoseizure subjects have high rates of the psychiatric disorders found in traumatized groups; they closely resemble patients with dissociative disorders. Reclassification of conversion seizures with the dissociative disorders should be considered. Pseudoseizures often appear to express distress related to abuse reports. Clinicians should screen pseudoseizure patients for adult and childhood trauma, dissociative disorders, depression, and PTSD.

Psychodynamics and psychiatric diagnoses of pseudoseizure subjects

Simultaneous video-EEG monitoring has allowed pseudoseizures to be effectively diagnosed. Discussing the results of the monitoring with the patient is the 1st step in treatment. We outline a protocol for presenting the diagnosis of pseudoseizure with the goal of conveying to the patient the importance of knowing the nonepileptic nature of the spells and the need for psychiatric follow-up. The protocol also allows elicitation of a sexual abuse history and the use of suggestion to aid in controlling the pseudoseizures.

Presenting the diagnosis of pseudoseizure

Summary:  Purpose: We studied the surgical outcome, complications, and the late mortality rate in a large group of patients with medically refractory temporal lobe epilepsy (TLE).

Methods: Two-hundred fifteen patients with TLE were treated surgically between 1984 and 1999 after a comprehensive presurgical evaluation. Patients were followed up at 6 weeks, 3–6 months, and yearly thereafter. In addition, questionnaires were sent on the anniversary of their surgery. Surgical outcome (Engel's classification), complication rate, and factors contributing to late mortality were analyzed. Standardized mortality ratios (SMRs) were calculated.

Results: There was no surgical mortality. Two (0.9%) had mild hemiparesis, one (0.4%) had a hemianopia, seven (3.2%) had transient cranial nerve palsies, and eight (3.7%) had transient postoperative language difficulties. One hundred forty-eight (69%) became seizure free, 43 (20%) had rare seizures, 14 (6.5%) had worthwhile seizure reduction, and 10 (4.6%) had no improvement (follow-up, 1–15 years). Three (2%) of 148 seizure-free patients died during follow-up, compared with eight (11.9%) of 67 not seizure-free patients. The mean duration of epilepsy before surgery for the surviving patients was 17.8 years, and for those patients who died, 25.9 years (p < 0.05). Six (5.7%) of 104 patients with right-sided resections died during follow-up, compared with five (4.5%) of 111 with left-sided resections.

Conclusions: Eighty-nine percent of patients became seizure free or had rare seizures, with low morbidity, and no surgical mortality. The late mortality occurred predominantly in patients with persistent seizures (SMR, 7.4). Those patients who died had a longer duration of epilepsy before surgery. In contrast, among those patients who became seizure free, the mortality rate was much lower, and similar to the general population of Indiana (SMR, 1.7).

https://onlinelibrary.wiley.com/doi/pdf/10.1046/j.1528-1157.2002.33800.x

Temporal lobe epilepsy surgery: outcome, complications, and late mortality rate in 215 patients.

Summary: Purpose: A prospective study to investigate health-related quality of life (HRQOL) outcome in patients with temporal lobe epilepsy treated with anterior temporal lobectomy (ATL).



Methods: The majority of the patients with medically refractory focal epilepsy had Quality of Life in Epilepsy-89 (QOLIE-89) assessment at the time of prolonged video/EEG monitoring as part of their presurgical evaluation. Thirty-seven patients who were not treated surgically constituted the control group, and 53 patients who underwent ATL made up the surgery group. Both control and surgery groups had HRQOL assessment repeated at ∼1- and 2-year intervals. Repeated measures analysis of variance (ANOVA) was used to test for differences between the two groups.



Results: For the overall score and almost every scale, the surgery group had a higher baseline mean than the control group. Because of this baseline difference, change scores were used in further analysis. The overall score and 10 of 17 scales in QOLIE-89 showed significant HRQOL improvement after ATL, and the improvement was significant relative to score changes of the nonsurgical comparison group. Scores improved in overall QOL, emotional well-being, attention/concentration, language, social isolation, health perception, role limitations-physical, work/drive/social, health discouragement, and seizure worry. For the first five scales, there was group-time interaction; the improvement was significantly more on the 2-year than on the 1-year follow-up. When the surgery patients were divided into four categories (class IA-, completely seizure free; class IA+, seizure free with aura; class II, rare seizures; class III, worthwhile improvement in seizure control; and class IV, no improvement), the improved HRQOL in the surgery group was almost entirely contributed by the class IA- outcome patients who were totally seizure free. The class IA+ patients with continuing aurae and class II/III/IV patients had no significant improvement in their overall HRQOL scores at 1- or 2-year follow-up.



Conclusions: Overall score and 10 of the 17 scales of QOLIE-89 significantly improved in patients with medically refractory temporal lobe epilepsy after ATL. For some scales, there was delay in the improvement to manifest. The HRQOL improvement was related to achieving an entirely seizure-free status (i.e., no seizures or aurae postoperatively).

Health‐Related Quality of Life Outcome in Medically Refractory Epilepsy Treated with Anterior Temporal Lobectomy

Clinical features were studied in 83 patients with slow spike-wave activity in the EEG. Epileptic seizures, usually intractable, occurred in 82 patients. The majority had the onset of seizures during the first 2 years of life. Minor motor seizures alone or in combination with other types of seizures occurred in 80 percent, and most had more than one type of seizure. The combination of tonic-clonic, minor motor, and absence seizures was the commonest, occurring in 37 percent. Sixty-six patients were definitely retarded and 49 showed definite motor impairment. Etiologic factors responsible for cerebral insult were identified in 53 patients. Serial EEG studies showed a close relationship between the EEG patterns of hypsarrhythmia, independent multifocal spike discharges, and slow spike-wave activity. The eponym "Lennox-Gastaut" syndrome is appropriate for a patient who has slow spike-wave activity in the EEG, exhibits mental retardation, and has intractable seizures of various types. However, the syndrome does not imply a pathologic entity because many diverse processes, both static and progressive, can produce this syndrome.

Omkar N. Markand

Papers

Psychodynamics and psychiatric diagnoses of pseudoseizure subjects

Presenting the diagnosis of pseudoseizure

Temporal lobe epilepsy surgery: outcome, complications, and late mortality rate in 215 patients.

Health‐Related Quality of Life Outcome in Medically Refractory Epilepsy Treated with Anterior Temporal Lobectomy

Slow spike-wave activity in EEG and associated clinical features: often called 'Lennox' or "Lennox-Gastaut' syndrome.