Showing papers in "Seizure-european Journal of Epilepsy in 2002"
TL;DR: It is hypothesized that 'refractory epilepsy' may be prevented by interrupting this self-perpetuating progression to intractable 'refractoriness' and a downward spiraling quality of life, and AEDs should be combined with the aim of achieving 'synergism'.
Abstract: Intractable seizures are just one manifestation of 'refractory epilepsy', which can be recognized as a distinct condition with multifaceted dimensions, including neurobiochemical plastic changes, cognitive decline and psychosocial dysfunction, leading to dependent behaviour and a restricted lifestyle. The biological basis of 'refractoriness' is likely to be multifactorial, and may include the severity of the syndrome and/or underlying neuropathology, abnormal reorganization of neuronal circuitry, alteration in neurotransmitter receptors, ion channelopathies, reactive autoimmunity, and impaired antiepileptic drug (AED) penetration to the seizure focus. Some of these deleterious changes may be a consequence of recurrent seizures. We hypothesize that 'refractory epilepsy' may be prevented by interrupting this self-perpetuating progression. There is increasing evidence that these patients can be identified early in the clinical course and, thus, be targeted early for effective therapeutic intervention. Failure of two first-line AEDs due to lack of efficacy or poor tolerability should prompt consideration of epilepsy surgery in a patient with a resectable brain abnormality. For the majority not suitable for 'curative' surgery, AEDs should be combined with the aim of achieving 'synergism'. This strategy has the potential to improve outcome by preventing the insidious progression to intractable 'refractoriness' and a downward spiraling quality of life.
154 citations
TL;DR: Treatment with two or three but not four AEDs may be a useful therapeutic option for patients not responding to monotherapy, and further explorations of the best regimens for individual seizure types and epilepsy syndromes is required.
Abstract: Many people with epilepsy take antiepileptic drug (AED) polytherapy, although supportive evidence for the success of this strategy is sparse. Of 2881 treated patients registered in our database, 1617 (56%) have been seizure-free for at least the previous year, with 21% taking more than one AED (287 on two, 86%; 42 on three, 13%; 3 on four, 1%). There were 40 effective duotherapies and 28 triple therapies. Treatment with two or three but not four AEDs may be a useful therapeutic option for patients not responding to monotherapy. Further explorations of the best regimens for individual seizure types and epilepsy syndromes is required.
108 citations
TL;DR: It is concluded that EEG or clinical abnormalities suggestive of epileptic seizures are common in undiagnosed NES patients and considerably delay appropriate treatment implementation.
Abstract: The clinical differentiation between epileptic seizures (ES) and non-epileptic seizures (NES) is often difficult and mostly based on the presence or absence of widely recognized features of ES such as tongue biting, falling, incontinence or concomitant epileptic abnormalities in the electroencephalogram (EEG). We retrospectively analysed the records of all patients referred to our Epilepsy Centre for refractory epilepsy and finally diagnosed with NES between 1980 and 1999 ( n= 103), half of them also exhibiting ES. The mean time-lapse between first attack and NES diagnosis was 8.7 +/- 1.3 years and 16.5 +/- 1.4 years for the NES and NES + ES groups respectively. At least one of the usual signs associated with generalized tonic-clonic seizures (tongue biting, falling or incontinence) was reported by 66% and 60% of patients with NES or NES + ES respectively. Interictal EEG abnormalities were recorded in 16% of NES patients vs. 80% of NES + ES patients. In the NES group, delay before establishing the correct diagnosis was significantly longer when the patients exhibited > or =1 symptom(s) of generalized seizures, or when patients exhibited interictal EEG abnormalities. Upon admission, 72% of NES patients and all NES + ES patients were being treated with antiepileptic drugs (AEDs).We conclude that EEG or clinical abnormalities suggestive of epileptic seizures are common in undiagnosed NES patients. Such diagnostic pitfalls, besides considerably delaying NES diagnosis, also considerably delay appropriate treatment implementation.
101 citations
TL;DR: Levetiracetam appears to be well tolerated in patients with severe epilepsy and shows efficacy in a long-term follow-up, consistent with the findings of clinical trials.
Abstract: Problem: Levetiracetam (LEV) is a new antiepileptic drug shown to be effective for the treatment of partial seizures in pivotal clinical trials We investigated the long-term efficacy and tolerability of LEV as add-on therapy, regardless of seizure type, especially in persons who would not be eligible for clinical trials due to factors such as mental retardation and concomitant psychiatric disorders Methods: Ninety-eight patients participated and were followed for 1 year Demographic data, seizure frequency, and side effects were recorded at baseline and during the 1-year follow-up The first 35 patients were given LEV at a starting dose of 500mg bid with weekly increments of 1000mg (fast titration) The other patients were given LEV with a starting dose of 250mg bid with weekly increments of 250mg (slow titration) Results: Fourteen patients were completely seizure free after titration to effective dose and 57 were responders with >50% seizure reduction for the first year In the group with generalized seizures, 1 out of 19 became seizure free, but 8 patients had >50% decrease Average dose at 1 year was 1900mg (±900) Seventeen of 38 discontinuations were due to adverse effects and 21 were due to lack of efficacy With fast titration, 15 out of 35 (43%) experienced tiredness during the first 12 weeks, and with slower titration 20 of 63 (32%) experienced tiredness The difference was not statistically significant Four out of the five patients who discontinued due to behavioral adverse events (mainly irritability) previously had behavioral problems and/or mental retardation One patient discontinued due to psychosis Conclusions: Levetiracetam appears to be well tolerated in patients with severe epilepsy and shows efficacy in a long-term follow-up Behavioral adverse events were noted in a small number of patients and occurred mainly in patients who had a history of behavioral disturbance or were mentally retarded These data from an open population are consistent with the findings of clinical trials
98 citations
TL;DR: The outcome of pregnancy was monitored to identify antiepileptic drug treatment associated with a poor outcome in a mainly prospective study of women attending an outpatient clinic and a positive association between adverse outcome and dose was found for sodium valproate but not for carbamazepine.
Abstract: The risk of an adverse outcome to pregnancy is increased in women with epilepsy. This is partly attributable to antiepileptic drugs. Guidelines for the management of pregnancy in women with epilepsy generally advise against polytherapy but make no distinction between the risks of different drugs. Several recent studies have however shown greater risk of adverse outcome in offspring exposed to sodium valproate in utero, particularly at higher doses. The outcome of pregnancy was monitored to identify antiepileptic drug treatment associated with a poor outcome in a mainly prospective study of women attending an outpatient clinic. From January 1990 to December 1999 all 69 pregnancies in women referred to the clinic were monitored. Drug treatments and other risk factors were recorded. In each child dysmorphic features, developmental delay and structural anomalies were assessed and graded. Data were analysed for drug- and dosage-dependent differences in outcome. In each assessment area a positive association between adverse outcome and dose was found for sodium valproate but not for carbamazepine. Severe adverse outcomes were found only in children exposed to sodium valproate at maternal doses above 1000 mg per day.
98 citations
TL;DR: It was concluded that paucity of good knowledge of epilepsy probably resulted in negative attitude and beliefs despite the teachers' high level of education.
Abstract: The social problems encountered by schoolchildren with epilepsy as a result of negative attitudes and beliefs are enormous. Varying reports on teachers' perception of epilepsy abound. Furthermore previous research has shown that urbanization and differences in socio-cultural environments could also influence teachers' perception of epilepsy. A few studies have explored the knowledge, attitude and beliefs of schoolteachers towards epilepsy in urban schools in Nigeria. This study was undertaken to examine teachers' perception of epilepsy in the rural communities with regards to knowledge, attitude and beliefs. A cross-sectional survey, using a self-administered questionnaire, was carried out among rural community primary and secondary schoolteachers in schools randomly selected from three local government areas in Enugu. One hundred and twenty five teachers correctly completed their questionnaires. Despite a fairly high level of education of the teachers, the mean overall score for correct response for knowledge was 59.2%. A majority of the teachers had negative attitudes and beliefs. None had received any form of health education on epilepsy. The level of education significantly affected various aspects of knowledge, attitudes and beliefs. This study concluded that paucity of good knowledge of epilepsy probably resulted in negative attitude and beliefs despite the teachers' high level of education.
91 citations
TL;DR: Ictal scalp EEG was the most useful diagnostic tool in the localization of epileptogenic foci and interictal FDG-PET and ictal SPECT were found to be useful as complementary and, sometimes, independent modalities.
Abstract: Pre-surgical evaluation and the surgical treatment of non-lesional neocortical epilepsy is one of the most challenging areas in epilepsy surgery. The aim of this study was to evaluate the surgical outcome and the diagnostic role of ictal scalp electroencephalography (EEG), interictal (18)F-fluorodeoxyglucose-positron emission tomography (FDG-PET), and ictal technetium-99m hexamethylpropyleneamine oxime single photon emission tomography ( (99m)Tc-HMPAO SPECT). In 41 non-lesional neocortical epilepsy patients (16 frontal lobe epilepsy, 11 neocortical temporal lobe epilepsy, seven occipital lobe epilepsy, four parietal lobe epilepsy, and three with multifocal onset) who underwent surgical treatment between December 1994 and July 1998, we evaluated the surgical outcome with a follow-up of at least 1 year. The localizing and lateralizing values of ictal scalp EEG, interictal FDG-PET, and ictal SPECT were evaluated in those patients with good surgical outcome. Ictal scalp EEG had the highest diagnostic sensitivity in the localization of epileptogenic foci (69.7% vs. 42.9% for FDG-PET and 33.3% for ictal SPECT; P= 0.027). However, no significant difference was found in the lateralization of the epileptogenic hemisphere among the three modalities (78.8% for ictal scalp EEG, 57.2% for FDG-PET, and 55.5% for ictal SPECT; P= 0.102). During a mean follow-up of 2.77 +/- 1.12 years, 33 (80.5%) showed good surgical outcome (seizure free or seizure reduction >90%), including 16 (39.0%) seizure free patients. Ictal scalp EEG was the most useful diagnostic tool in the localization of epileptogenic foci. Interictal FDG-PET and ictal SPECT were found to be useful as complementary and, sometimes, independent modalities. Many patients with non-lesional neocortical epilepsy would benefit from surgical treatment.
89 citations
TL;DR: It is found that subjects with frontal lobe damage were significantly impaired relative to controls on a wide range of cognitive functions independent of neurological cause, demonstrating the devastating effect that frontal lobe epilepsy can have on cognitive functioning.
Abstract: The search for a special neuropsychological profile of frontal lobe epilepsy subjects (FLE) has so far led to inconclusive results. In this paper we compared the preoperative neuropsychological performance of FLE and temporal lobe epilepsy (TLE) subjects. We further investigated whether frontal lobe lesions of epileptogenic cause produce the same type of cognitive dysfunction as do tumours of the frontal lobe. Sixteen FLE subjects were compared to 16 TLE subjects as well as to a group of 10 subjects after the removal of frontal lobe tumors (TUM) and a healthy control group. A set of neuropsychological test measures routinely used for presurgical evaluation, an emotional conceptualization task and two associative learning tasks were administered. We found that subjects with frontal lobe damage were significantly impaired relative to controls on a wide range of cognitive functions independent of neurological cause. FLE subjects could hardly be discriminated from TLE subjects as both groups showed a similarly reduced level of neuropsychological performance. Our results demonstrate the devastating effect that frontal lobe epilepsy can have on cognitive functioning. Routinely used neuropsychological test measures lack the specificity to distinguish between frontal and temporal lobe epilepsy. Highly specialized measures are necessary to reveal differences.
86 citations
TL;DR: CSF pleocytosis and increase in some indicators of inflammation should not automatically be attributed to systemic or central nervous system infections in patients with acute seizures.
Abstract: Cerebrospinal fluid (CSF) and peripheral blood pleocytosis have been observed after epileptic seizures without any evidence of infections, but no systematic studies on the acute phase reaction in such patients have been performed. We have previously reported increased levels of interleukin-6 (IL-6) in patients with recent tonic‐clonic seizures. Because IL-6 is a major inducer of the systemic acute phase reaction, we decided to study various indicators of inflammation in the blood as well as their correlation with plasma and CSF IL-6 levels. CSF and blood samples were studied from 37 patients with previously undiagnosed and untreated tonic‐clonic seizures without any clinical evidence of systemic or central nervous system infections as well as from 40 controls. The mean peripheral blood and CSF-leukocyte counts were significantly higher in patients compared with controls (7.9 ◊ 10 9 vs. 6.1 ◊ 10 9 , P = 0.002 and 1.9 ◊ 10 6 vs. 1.1 ◊ 10 6 , P = 0.032, respectively). There was some indication of increased concentration of C-reactive protein (CRP) and no difference in haptoglobin levels. There was a significant correlation between plasma but not CSF IL-6 concentration and those of both B-leukocyte count (r = 0.051, P = 0.009) and CRP (r = 0.42, P = 0.009). Epileptic seizures provoke a production of cytokines such as IL-6 that may in turn cause an activation of the acute phase reaction. Thus, CSF pleocytosis and increase in some indicators of inflammation should not automatically be attributed to systemic or CNS infections in patients with acute seizures. c 2001 BEA Trading Ltd
83 citations
TL;DR: Prophylactic anti-epileptic drug treatment is worth considering for Sturge-Weber disease, but a randomized prospective study is necessary to determine this.
Abstract: Purpose : In Sturge–Weber disease, motor and cognitive defects are supposed to result mostly from severe epilepsy. They might, therefore be partly prevented by prophylactic antiepileptic drug treatment. This condition constitutes a possible model for the study of prophylactic drug treatment in severe epilepsy. In the present study, we compared the outcome of patients treated prospectively with phenobarbitone before the first seizure, with those referred following the first seizure, in order to identify the issues related to the evaluation of prophylactic treatment of severe epilepsy. Methods : Motor and cognitive outcome were compared in patients treated prophylactically with phenobarbitone (16 cases) and in those treated following the first seizures (21 cases). Results : Whereas the incidence of motor deficit was similar in both groups (44 vs. 52%), that of mental retardation was lower in the group treated prophylactically (76.2 vs. 43.7%, P Conclusion : Prophylactic anti-epileptic drug treatment is worth considering for Sturge–Weber disease, but a randomized prospective study is necessary to determine this. It should be multicentric, take in account the size of the angioma, and decide what the most appropriate medication should be.
81 citations
TL;DR: There might be a causal relationship between chronic toxoplasmosis and the aetiology of cryptogenic epilepsy.
Abstract: Purpose: Cryptogenic epilepsy, defines a group of epilepsy syndromes for which an aetiology is unknown but an underlying brain disease is suspected. We selected patients in this subgroup of epilepsy and investigated the sero-positivity rate for anti- Toxoplasma IgG antibodies by Enzyme Linked Immunosorbent Assay (ELISA). We investigated the probable relationship between Toxoplasma gondii and cryptogenic epilepsy. Methods: We selected 50 patients with cryptogenic epilepsy, 50 patients with known cause epilepsy and 50 healthy volunteers and investigated the sero-positivity rate for anti- Toxoplasma IgG antibodies by ELISA. Results: The sero-positivity rate for anti- Toxoplasma IgG antibodies among cryptogenic epilepsy patients (52%) was found to be higher than healthy volunteers (18%) and known cause epilepsy patients (22%) with statistical significance, ( X 2 =18.095, P Conclusion: There might be a causal relationship between chronic toxoplasmosis and the aetiology of cryptogenic epilepsy.
TL;DR: The results suggest that topiramate may be effective in childhood absence epilepsy, and controlled studies are now required to identify the clinically optimal dose.
Abstract: This open-label, single-site, pilot study evaluated the therapeutic usefulness of topiramate in five children with typical absence seizures defined as loss of awareness associated with 3 Hz spike-wave activity on 24 hour ambulatory electroencephalogram (EEG). The children were previously untreated or treated unsuccessfully using other antiepileptic medication. Topiramate was initiated at a dose of 1 mg x kg (-1)day (-1), titrated twice weekly in 1 mg x kg (-1)day (-1)increments to 12 mg x kg (-1)day (-1)or individual maximally tolerated dose. Response was assessed after 6 weeks with ambulatory EEG monitoring and patient/parent record of seizure counts. All children completed the study. One previously untreated child became seizure-free on 5 mg x kg (-1)day(-1) topiramate, with no residual spike-wave activity at the final visit. In two patients, the frequency of seizures decreased in the early phases of titration, but rose to baseline levels as the topiramate dose was increased. With a reduction in dose to 6 mg x kg (-1)day (-1), seizure control improved, with substantial reductions in spike-wave activity. Seizure counts were not improved in the two remaining patients. Transient mood changes were noted in two patients. No child was withdrawn secondary to adverse effects. The results suggest that topiramate may be effective in childhood absence epilepsy. Controlled studies are now required to identify the clinically optimal dose.
TL;DR: Patients with intractable epilepsy suffer significant neuropsychological difficulties in terms of their intellect, memory and language, which can be improved by the application of various psychological therapies and interventions.
Abstract: Purpose : To investigate and document the neuropsychological and emotional effects of epilepsy in people with intractable temporal lobe epilepsy (TLE). Methods : 273 patients with a diagnosis of TLE underwent a complete neuropsychological and psychological examination as a routine part of their investigation for epilepsy surgery. Neuropsychological assessment included measures of intellect, memory, language functioning, higher executive functioning, emotional well-being and the psychosocial impact of epilepsy and its treatment. Results : The sample comprised 135 females and 138 males with a clearly lateralised epileptogenic focus. Patients were mildly anxious but not depressed, although many reported that epilepsy and its treatment had a marked effect on their daily lives. Current reading ability was in the average range; the mean obtained full scale IQ was 88 (low average range). Verbal memory functioning was within the borderline impaired range with visual memory functioning within the average range. Mean language performance was between the 5–10th percentile. Higher executive functioning results were in the normal range. Multiple univariate analyses were performed according to onset laterality. There were no significant differences between the groups on measures of psychological or emotional functioning. Participants with left TLE scored significantly lower than those in the right temporal group on measures of verbal intelligence, general intelligence, attention span and expressive language functioning. Conclusions : Patients with intractable epilepsy suffer significant neuropsychological difficulties in terms of their intellect, memory and language. Higher executive functioning appears unaffected. In addition, there is also evidence of emotional distress. These all impact upon their day-to-day functioning, which can be improved by the application of various psychological therapies and interventions.
TL;DR: A good seizure outcome was associated with early age of seizure onset, low number of previously used antiepileptic drugs (AEDs) and surgical treatment, and there is a better long-term outcome in patients with MTS receiving surgical therapy in comparison with medical therapy.
Abstract: The long-term prognosis of pharmacological therapy in patients with mesial temporal sclerosis (MTS) is generally considered poor. On the contrary, successful surgical therapy is frequently reported. We performed a retrospective case record survey of patients with MTS in a comprehensive epilepsy center between 1993 and 1999 in order to develop treatment strategies. The time period allowed access to high-resolution qualitative magnetic resonance imaging (MRI) and a minimum of 1-year outcome assessment. Eighty-three patients with intractable partial epilepsy with MRI and electroencephalograph (EEG) abnormalities and seizure semiology consistent with temporal lobe epilepsy were identified. Thirty-six patients were treated pharmacologically and surgically and 47 patients received only pharmacotherapy. The number of patients who became seizure free was in total 37 (45%); in the surgical group 26 and in the non-surgical group 11. The proportions of seizure-free patients in each group were 72% (surgical) and 23% (non-surgical). Clinical factors such as age, gender, lesion side, previous medical history, duration of illness, seizure frequency and IQ did not correlate to prognosis. A good seizure outcome was associated with early age of seizure onset, low number of previously used antiepileptic drugs (AEDs) and surgical treatment. There is a better long-term outcome in patients with MTS receiving surgical therapy in comparison with medical therapy.
TL;DR: PriH and PoiH were more frequently encountered before and after secondary generalized tonic-clonic seizures (GTCS) compared to other seizure groups and the type of pain was 'throbbing' in complex partial seizures and 'steady' in GTCS.
Abstract: We investigated the type and frequency of interictal primary headache and peri-ictal headache in 109 patients with partial-onset and 26 patients with generalized onset seizures in this study. Interictal headaches were present in 50 (40.7%) of 135 patients. Comparing the interictal headache on the basis of seizure type, we couldn't find any significant difference between the seizure groups. Seventy-nine (58.51%) patients had peri-ictal headache. Eleven of these patients had pre-ictal headache (PriH), three of all had ictal headache and, 56 of these had post-ictal headache (PoiH). PriH and PoiH were more frequently encountered before and after secondary generalized tonic-clonic seizures (GTCS) compared to other seizure groups. The type of pain in PoiH was 'throbbing' in complex partial seizures and 'steady' in GTCS.
TL;DR: A prospective study of 10 consecutive referrals to the Seizure Alert Dogs service of people with tonic-clonic seizures finds a significant drop in seizure frequency was seen during the first 4 weeks of training and this final improvement was maintained for the whole 24 week follow up.
Abstract: We have previously reported that dogs can be trained to recognize specific changes preceding an epileptic seizure in humans. Such dogs can provide an overt signal that acts as a useful warning to the human. Early observations suggested that seizure frequency might also be reduced. We report a prospective study of 10 consecutive referrals to our Seizure Alert Dogs service of people with tonic-clonic seizures. Seizure frequency was monitored over a 48 week period including 12 weeks baseline after entry, a 12 week training period, and 24 weeks follow up. Comparing baseline seizure frequency to the last 12 weeks of follow up, there was a 43% mean reduction in seizure frequency ( P= 0.002). Nine out of /10 subjects showed a 34% or greater reduction, 4 /10 showed a 50% or greater reduction, and only one showed no improvement. Although a significant drop in seizure frequency was seen during the first 4 weeks of training ( P= 0.0078) a further drop occurred between the first and last 4 week period of training (P = 0.038) and this final improvement was maintained for the whole 24 week follow up.
TL;DR: The study in four patients shows fMRI can be performed safely in patients with an implanted vagal nerve stimulator and offers potential advantages over PET imaging by allowing rapid image acquisition and the ability to repeatedly study patients over time.
Abstract: Objective : To demonstrate the feasibility and safety of using functional magnetic resonance imaging (fMRI) to determine the blood oxygen level dependent changes (BOLD) in patients undergoing vagal nerve stimulation (VNS) for the treatment of epilepsy. Methods : Four patients with an implanted vagus nerve stimulator had fMRI images acquired during several cycles of intermittent VNS. Blood oxygen level dependent changes were detected. These regions were then superimposed upon the patients' structural MR images. Results : Patients undergoing VNS tolerated fMRI without difficulty. No complications with the implanted stimulators were encountered. Areas of activation were noted in several cortical regions, including frontal, temporal, parietal, and occipital cortices. Conclusion : Our study in four patients shows fMRI can be performed safely in patients with an implanted vagal nerve stimulator. The successful use of fMRI during VNS offers potential advantages over PET imaging by allowing rapid image acquisition and the ability to repeatedly study patients over time. Our preliminary results differ from previous PET or SPECT studies in failing to detect changes in subcortical areas. This finding could be due to the smaller n in this study compared with the other studies.
TL;DR: Repeated magnetic resonance imaging (MRI) volumetric analysis of the hippocampi in a 23-month-old boy after a prolonged focal febrile seizure demonstrates a shorter interval for the radiologic development of hippocampal sclerosis compared to other reports.
Abstract: Mesial temporal sclerosis (MTS) has been linked to prolonged febrile seizures. The sequence of changes in the temporal lobe/hippocampus following prolonged febrile seizures and status epilepticus is beginning to be elucidated. We obtained repeated magnetic resonance imaging (MRI) volumetric analysis of the hippocampi in a 23-month-old boy after a prolonged focal febrile seizure. Three days after a prolonged left focal febrile seizure, brain MRI showed increased T2 weighted signal and increased volume (swelling) of the right hippocampus. Repeat MRI 2 months later demonstrated sclerosis of the right hippocampus. Review of the literature shows four other children with prolonged focal seizures associated with the MRI sequence of temporal lobe swelling followed by sclerosis. All had left focal seizures followed by right MTS. Our patient demonstrates a shorter interval for the radiologic development of hippocampal sclerosis compared to other reports.
TL;DR: Children with prior unrecognized seizures were already at increased risk of teacher-rated behaviour problems before starting medication and before any possible stigma effects related to seizures, which suggests underlying neurological problems causing both behavioural problems and seizures.
Abstract: Rationale : Recent data suggest that children with new-onset seizures may be at increased risk for behaviour problems. Teachers are an excellent source of data about such problems. They do not have the potential bias that a parent worried about a new onset of seizures might have and, furthermore, they are accustomed to comparing performance of children and work in an environment in which the behavioural problems associated with epilepsy may be quite evident. We obtained teachers' reports of behaviour problems in children in the 2 months prior to their first recognized seizure. We also obtained similar data on children with new-onset, moderate severity asthma. In addition to comparing behavioural scores between children with seizures and children with asthma, we compared teachers' assessments of behaviour in children with no prior seizures to those of children with previously unrecognized seizures. Methods : We evaluated 192 children with new-onset seizures, including 129 children with no prior episodes and 63 children with recognized prior seizure-like episodes. The comparison group consisted of 78 children with new-onset, moderate severity asthma. Behaviour was assessed by the teacher's report form (TRF) of the child behaviour checklist (CBCL) or the caregiver-teacher report form for ages 2–5 (C-TRF). Mean scores were compared by two-sample t -tests and analysis of variance (ANOVA). Results : The children with new-onset seizures had more thought problems than children with asthma. In comparison to children with no prior seizures, the children with prior unrecognized seizures had higher scores in total behaviour problems, internalizing problems, somatic complaints, anxious/depressed, thought problems, and attention problems. Conclusions : In this sample, children with prior unrecognized seizures were already at increased risk of teacher-rated behaviour problems before starting medication and before any possible stigma effects related to seizures. This sequence suggests underlying neurological problems causing both behavioural problems and seizures.
TL;DR: Cognitive decline, motor deficits and pharmacoresistance to drugs were significantly seen among children with Type 2 EPC, and patients with Type 1 EPC had mild impairment of functional status with good response to treatment.
Abstract: Epilepsia partialis continua (EPC) is a rare type of localization-related motor epilepsy. Clinical spectrum, electroencephalography (EEG) characteristics and various prognostic factors in EPC were studied in 20 patients. Patients who fulfilled the criteria for EPC between the years 1985 and 1999 were included in this retrospective and prospective study. The mean age was 18 years (range 5 months-70 years). Eleven patients (55%) had Type 1 EPC and in the remaining nine (45%) patients there were features of Type 2 EPC. Among children Rasmussen's encephalitis and viral encephalitis were the commonest cause for EPC. Encephalitis and vascular aetiology were frequently observed in adults. Tuberculous meningitis and tuberculomas occurred evenly in both the groups. The cause was unknown in two cases. Focal EEG abnormalities commonly consisted of discrete spikes, sharp waves (or) slow wave activity and periodic lateralized epileptiform discharges. The mean duration of follow up was 9.6 months with a range between 1 month and 4 years. Cognitive decline, motor deficits and pharmacoresistance to drugs were significantly seen among children with Type 2 EPC. Patients with Type 1 EPC had mild impairment of functional status with good response to treatment. The long-term prognosis depends upon the underlying cause.
TL;DR: The study shows that the majority of recurrent ASE cases do not fit into the International syndrome classification, and IV Clonazepam lead to a dramatic improvement.
Abstract: In order to outline the clinical and EEG characteristics of recurrent absence status epilepticus (ASE), eight cases with more than two attacks of ASE were studied. Their current ages were between 13 and 84 years, and five of the patients were women. There was a history of epilepsy in five of the patients before the first ASE episode. A varying degree of confusion was the main clinical symptom with associated mild motor signs like perioral, eyelid and generalised myoclonus, seen in one, two and four patients respectively. Two of the patients had juvenile myoclonic epilepsy. One patient had an atypical form of childhood absence epilepsy characterised by recurrent ASE attacks on awakening. There were two patients with phantom absences and late onset generalised convulsions, one patient with perioral myoclonia and absences, and finally two patients with eyelid myoclonia with absences, which are proposed syndromes. On the EEGs that revealed the diagnosis of ASE, there was a marked variability of the generalised multispike and wave discharges. The EEG findings appeared to be syndrome-related with some exceptions. IV Clonazepam lead to a dramatic improvement. Our study shows that the majority of recurrent ASE cases do not fit into the International syndrome classification.
TL;DR: Interictal tests may predict which patients are most likely to benefit from comprehensive pre-surgical evaluation and the combination of SDEEG and MRI may be more cost-effective as outpatient screening tools.
Abstract: Our aim was to determine if less expensive interictal indices can predict which epilepsy patients may benefit from the more expensive comprehensive pre-surgical evaluation. Surgical treatment was determined based on the results of a comprehensive inpatient continuous video-EEG monitoring. This evaluation included three interictal tests, which were reviewed retrospectively-2 hour-sleep-deprived electroencephalogram (SDEEG), magnetic resonance imaging (MRI), and positron emission tomography (PET). Sixty-nine patients were evaluated with 35 patients having focal resection (33 temporal, two frontal). When two or more interictal tests were positive, 77% (27 /35) went to surgery, but when one test was positive 23% (8 /34) had surgery. When all tests were negative, only a single patient (1 /13 or 7.7%) had surgery, a frontal resection. The positive predictive value for any single interictal test was 68%, while it was higher for any combination of two positive tests (77-83%). PET was the most sensitive (0.86) single interictal test, compared to SDEEG (0.66) and MRI (0.66). The odds ratio for predicting surgical treatment for a positive PET, SDEEG, or MRI was 8.57, 4.01, and 4.01, respectively. MRI was three and PET was six times the cost of a SDEEG. The combination of SDEEG and MRI had the best cost/PPV ratio. Seventy-nine percent (11 /14) of the patients with three positive tests were seizure free following focal resection compared to 43% (9 /21) when less than three tests were positive ( P
TL;DR: A seizure-related death in a patient with juvenile myoclonic epilepsy 3 months following a previous generalised tonic-clonic seizure complicated by pulmonary oedema is reported to indicate an increased susceptibility to epilepsy related death.
Abstract: We report a seizure-related death in a patient with juvenile myoclonic epilepsy 3 months following a previous generalised tonic-clonic seizure complicated by pulmonary oedema. Seizure-related pulmonary oedema is rare but may indicate an increased susceptibility to epilepsy related death. We consider possible preventative measures for patients presenting with seizure-related pulmonary oedema.
TL;DR: This work reports three cases where elevation of tiagabine dosage was followed by electroclinical features, or electroencephalographic features without clinical signs, of non-convulsive status epilepticus, and discusses the different pathophysiological hypotheses about the association in the light of new experimental data.
Abstract: There have been several recent reports of non-convulsive status epilepticus during tiagabine therapy in patients with partial epilepsy. We report three cases where elevation of tiagabine dosage was followed by electroclinical features, or electroencephalographic features without clinical signs, of non-convulsive status epilepticus. Administration of clonazepam and/or discontinuation to tiagabine lead to complete remission. In one case after re-exhibition of tiagabine the EEG again showed rhythmic delta waves. We review the other cases reported so far and discuss the different pathophysiological hypotheses about the association in the light of new experimental data.
TL;DR: Propranolol and its two enantiomers have anticonvulsant effects in models for generalized tonic-clonic and complex partial seizures which may be accounted for by the sodium channel blocking and not by the ss-adrenoceptor blocking activity.
Abstract: The anticonvulsant properties of the s-adrenoceptor antagonist propranolol and its two enantiomers were examined in various screening tests in order to characterize the anticonvulsant profile as well as the possible molecular mechanism of action. These compounds dose-dependently raised the threshold for tonic electroshock seizures in mice and were effective in the traditional maximal electroshock test (ED 50 s 15– 20 mg kg −1 i.p.). In combination with clinically used antiepileptics, the anticonvulsant effectiveness of the latter was significantly increased. In the pentylenetetrazol (85 mg kg −1 s.c.) seizure threshold test, ( ±)- and ( +)-propranolol were not effective in preventing clonic seizures. In unrestrained rats with chronically implanted electrodes in the dorsal hippocampus, propranolol and its ( +)-enantiomer equieffectively reduced the duration of electrically-evoked hippocampal afterdischarges (10 and 20 mg kg −1 i.p.) and raised the focal stimulation threshold (20 mg kg −1 i.p.). In amygdala-kindled rats, both drugs ( ≥ 10 mg kg −1 i.p.) reduced the seizure severity from stage 5 (generalized clonic–tonic) to stage 3 (unilateral forelimb) seizures. Furthermore, whole-cell patch-clamp experiments showed that ( +)- as well as ( −)-propranolol ( 10 −6 to 10 −4 M) depressed the fast inward sodium current in a concentration- and use-dependent manner in cultured rat cardiomyocytes and inhibited picrotoxin-induced burst firing activity of mouse spinal cord neurones in culture. In conclusion, propranolol and its two enantiomers have anticonvulsant effects in models for generalized tonic–clonic and complex partial seizures which may be accounted for by the sodium channel blocking and not by the s-adrenoceptor blocking activity.
TL;DR: The results have drawn attention to the fact that individuals should be informed about epilepsy and the risk factors for epilepsy in the control group from the same region and those with epilepsy were investigated by means of logistic regression analyses.
Abstract: ISTANBUL'DA BIR KIRSAL ALANDA EPILEPSI PREVALANSI**** OZET Bu calisma Istanbul-Kucukcekmece Bolgesi'nde Haziran 1999 – Subat 2000 tarihlerinde gerceklestirilmis kesitsel ve vaka kontrollu bir alan calismasidir. Bolgede basit rastlantisal ornekleme yontemi ile secilen evler ( n = 493) tek tek gezilerek anket yontemi ile bireylerden ( n = 2187) % 2.65 inin epilepsi supheli oldugu ( n = 58) saptandi. Oyku alma, norolojik muayene ve EEG den yararlanilarak epilepsi tanisi alanlar ( n = 17) belirlendi. Yasamboyu Epilepsi Prevalansi % 0.8 idi. 17 epilepsili olgudan % 41.2 ( n = 7) si parsiyel, % 47.0 ( n = 8) si jeneralize, % 11.8 ( n = 2) i fokal ya da jeneralize oldugu belirlenemeyen epilepsi idi. Epilepsili bireyler ile ayni bolgeden olusturulan kontrol grubunda ( n = 125) epilepsi ile ilgili risk faktorleri Lojistik Regresyon Analizi ile arastirildi. Ogrenim durumu (Odds Ratio = 1.82 , % 95 Guven Araligi = 1.13–2.94, P = 0.01), meslek (OR = 0.76 , % 95 GA = 0.60 –0.97, P = 0.03), ailede epilepsili birey olmasi (OR = 0.67 , % 95 GA = 0.47 –0.94, P = 0.02) ile epilepsi arasinda istatistik anlamlilik verecek derecede iliski oldugu saptandi. Sonuclar bireylerin epilepsi konusunda bilgilendirilmesi gerekliligine dikkat cekmektedir. Anahtar Kelimeler : Noroepidemiyoloji, epilepsi, tarama. ****Bu calisma Istanbul Tip Fakultesi Arastirma Fonu tarafindan T – 693 / 280699 nolu proje olarak desteklenmistir. This study is a field study with cross-section and case control conducted in the Kucukcekmece Region of Istanbul between June 1999 and February 2000. Four hundred and ninety three dwellings selected by a simple random sampling method were visited. From a population of 2187, 58 people, after filling in a questionnaire were suspected to have epilepsy. Following an interview, neurological examination and an electroencephalogram (EEG) 17 were diagnosed as having epilepsy. Lifetime epilepsy prevalence was 0.8%. 41.2% of the 17 epilepsy cases had partial epilepsy ( n = 7), 47.0% had generalized ( n = 8) and in 11.8% seizures could not be classified ( n = 2). The risk factors for epilepsy in the control group ( n = 125) from the same region and those with epilepsy were investigated by means of logistic regression analyses. Educational status (odds ratio : 1.82, 95% confidence interval : 1.13–2.94; P = 0.01), profession (OR : 0.76, 95% CI : 0.60–0.97; P = 0.03), history of epilepsy in the family (OR : 0.67, 95% CI : 0.47–0.94; P = 0.02) were determined to be correlated with epilepsy. The results have drawn attention to the fact that individuals should be informed about epilepsy.
TL;DR: The literature on functional MRI (fMRI) investigation of EEG activity, fMRI evaluation of cognitive and motor functions, magnetic resonance spectroscopy (MRS), single photon emission computed tomography (SPECT) and positron emission tomography in epilepsy are reviewed.
Abstract: Functional imaging plays a growing role in the clinical assessment and research investigation of patients with epilepsy. This article reviews the literature on functional MRI (fMRI) investigation of EEG activity, fMRI evaluation of cognitive and motor functions, magnetic resonance spectroscopy (MRS), single photon emission computed tomography (SPECT) and positron emission tomography (PET) in epilepsy. The place of these techniques in clinical evaluation and their contribution to a better neurobiological understanding of epilepsy are discussed.
TL;DR: Psychological adjustment was found to be associated with coping response in the patient but not the control group, and exhibited significantly more non-productive coping than the patient group.
Abstract: Chronic illnesses, such as epilepsy, have been shown to have detrimental effects on both psychological adjustment and coping behaviour. Using the process model of coping, these effects were investigated in a patient group of 36, 16–21 year olds with epilepsy and a control group of 31 of their peers. Participants completed a postal questionnaire containing measures of psychological adjustment (self-esteem, affect, self-efficacy) and an adolescent coping questionnaire. Comparison of the two groups showed that the patient group exhibited significantly more non-productive coping than the control group. The control group exhibited significantly more problem solving coping and displayed significantly more problem solving bias than the patient group. No significant differences were found between the patient and control group on measures of psychological adjustment. However, psychological adjustment was found to be associated with coping response in the patient but not the control group.
TL;DR: The clinical features and EEG data of JME probands were comparable to reports from other parts of the world except for the fact that the incidence of FC was higher in the authors' JME patients.
Abstract: We aimed to characterize the clinical profile, EEG features and response to treatment of juvenile myoclonic epilepsy (JME) patients. We studied 103 JME probands with a standard protocol recording age of onset, type, frequency of seizures, EEG data, detailed family history and response to treatment in a superspeciality university hospital in New Delhi. The mean age of onset of disease was 14.01 ±3.14 years with a male to female ratio of 1.19 : 1. The myoclonic jerks were present in all the probands, generalized tonic–clonic seizures (GTCS) were present in 75.72% and 11.65% probands had absence seizures. The incidence of febrile convulsion (FC) was higher (9.7%) in our JME probands reflecting some ethnic variation or ascertainment bias. There was a considerable delay (of approximately 5.26 ±4.61 years) in the diagnosis of JME in our probands because most of the patients were referred from private physicians who were possibly not familiar with this epileptic syndrome in this part of the world or thought it was a milder variety of GTCS. The family history was positive in 25.24% JME probands among first- and second-degree relatives. An interictal EEG was found to be abnormal in 81 (78.64%) patients with the predominant abnormality being generalized polyspike and wave (PSW) discharges (39.80% probands). The majority of patients (80.58%) showed a good response to treatment with valproate alone. There was a subset of patients (11.65%) who required the addition of other antiepileptic drugs (AEDs) for control of GTCS: 7.76% of JME patients were diagnosed as cases of GTCS by private practitioners before they were registered in our study and their seizures were well controlled on other AEDs (without valproate) prescribed by the referring physicians (carbamazepine-4, phenytoin-2, clobazam-2). It is concluded that the clinical features and EEG data of JME probands were comparable to reports from other parts of the world except for the fact that the incidence of FC was higher in our JME patients. There was a delay in the diagnosis of JME due to unfamiliarity with the epileptic syndrome among private practitioners in this part of the world. There was a subset of JME patients who had complete seizure control on other AEDs besides valproate.
TL;DR: The purpose of this study was to estimate the prevalence of MTS by MRI in the general population and reviewed the charts of patients undergoing MRI scans over an 18-month period, finding 204 patients met the inclusion criteria.
Abstract: The identification of mesial temporal sclerosis (MTS) on magnetic resonance imaging (MRI) is critical in the evaluation for temporal lobectomy. The purpose of this study was to estimate the prevalence of MTS by MRI in the general population. We reviewed the charts of patients undergoing MRI scans over an 18-month period. In order to be included, patients had to have no history of seizures, and the MRIs had to read as 'normal'. Patients were excluded if there was a history of seizures, mental illness, or alcohol abuse, and if they had a family history of seizures. Ages had to be from 5 to 50 years. All patients had MRI scans performed in three planes on 1.5 T systems. MRI diagnosis of MTS was based on standard visual diagnostic criteria analyzing: (1) hippocampal atrophy and (2) increased hippocampal T2 signal. Out of 375 charts reviewed, 204 met the inclusion criteria. Of the 204, 29 (14%) had abnormal and asymmetric mesial temporal structures consistent with a diagnosis of unilateral MTS. Nineteen (9.3%) had hippocampal atrophy only, two (1%) had T2 signal abnormalities, and eight (4%) met both criteria. There are some 'false positives' and MRI evidence for MTS is only meaningful in the proper clinical context.