Showing papers in "Seizure-european Journal of Epilepsy in 2014"

The relative effectiveness of five antiepileptic drugs in treatment of benzodiazepine-resistant convulsive status epilepticus: A meta-analysis of published studies

Abstract: Purpose Systematic evaluation of published evidence-base of the efficacy of five antiepileptic drugs – lacosamide, levetiracetam, valproate, phenytoin and phenobarbital – in convulsive benzodiazepine-resistant status epilepticus. Methods Data sources included electronic databases, personal communication, and back tracing of references in pertinent studies. These were prospective and retrospective human studies presenting original data for participants with convulsive benzodiazepine-resistant status epilepticus. Interventions were intravenous lacosamide, levetiracetam, phenobarbital, phenytoin and valproate. Outcome measured is clinically detectable cessation of seizure activity. Level-of-evidence was assessed according to Oxford Centre of Evidence-Based Medicine and The Cochrane Collaboration's Tool for Assessment of Risk. Twenty seven studies (798 cases of convulsive status epilepticus) were identified and 22 included in a meta-analysis. Random-effects analysis of dichotomous outcome of a single group estimate (proportion), with inverse variance weighting, was implemented. Several sources of clinical and methodological heterogeneity were identified. Results Efficacy of levetiracetam was 68.5% (95% CI: 56.2–78.7%), phenobarbital 73.6% (95% CI: 58.3–84.8%), phenytoin 50.2% (95% CI: 34.2–66.1%) and valproate 75.7% (95% CI: 63.7–84.8%). Lacosamide studies were excluded from the meta-analysis due to insufficient data. Conclusion Valproate, levetiracetam and phenobarbital can all be used as first line therapy in benzodiazepine-resistant status epilepticus. The evidence does not support the first-line use of phenytoin. There is not enough evidence to support the routine use of lacosamide. Randomized controlled trials are urgently needed.

Ictal tachycardia: the head-heart connection.

Abstract: Epileptic seizures can lead to changes in autonomic function affecting the sympathetic, parasympathetic, and enteric nervous systems. Changes in cardiac signals are potential biomarkers that may provide an extra-cerebral indicator of ictal onset in some patients. Heart rate can be measured easily when compared to other biomarkers that are commonly associated with seizures (e.g., long-term EEG), and therefore it has become an interesting parameter to explore for detecting seizures. Understanding the prevalence and magnitude of heart rate changes associated with seizures, as well as the timing of such changes relative to seizure onset, is fundamental to the development and use of cardiac based algorithms for seizure detection. We reviewed 34 articles that reported the prevalence of ictal tachycardia in patients with epilepsy. Scientific literature supports the occurrence of significant increases in heart rate associated with ictal events in a large proportion of patients with epilepsy (82%) using concurrent electroencephalogram (EEG) and electrocardiogram (ECG). The average percentage of seizures associated with significant heart rate changes was similar for generalized (64%) and partial onset seizures (71%). Intra-individual variability was noted in several articles, with the majority of studies reporting significant increase in heart rate during seizures originating from the temporal lobe. Accurate detection of seizures is likely to require an adjustable threshold given the variability in the magnitude of heart rate changes associated with seizures within and across patients.

Ketogenic diet in adolescents and adults with epilepsy.

Abstract: Purpose The ketogenic diet is an alternative treatment for patients with refractory epilepsy. Most studies to date report dietary response in children. There are limited data evaluating the efficacy of the ketogenic diet in adults. This is a report of the long-term outcome in a largely adult population of patients treated with the ketogenic diet for epilepsy. Method Twenty-nine adult and adolescent patients (mean age 32 years, range 11–51) were initiated on the ketogenic diet and followed until diet discontinuation. Clinical response and adverse effects were noted during the duration of the diet. Results Fifty-two percent of patients had a significant reduction in seizure frequency on the ketogenic diet, including 45% with ≥50% reduction in seizure frequency. Thirty-one percent had no improvement, seven percent were unable to successfully initiate the diet, and 10% had a >50% increase in seizure frequency. The diet was continued for a mean of 9 months (range 0.13–35 months), with five patients completing ≥23 months. There was a trend toward better response and better tolerability/longer duration in patients with symptomatic generalized epilepsy. The diet was generally well-tolerated, but undesired weight loss and constipation were the most frequent adverse effects. Conclusion The ketogenic diet can be used safely in the adult and adolescent population, with a response rate similar to those seen in children. Patient with symptomatic generalized epilepsy may be particularly good candidates for this type of dietary treatment.

Insular and insulo-opercular epilepsy in childhood: An SEEG study

Abstract: Purpose In recent years, there have been series analysing the electro-clinical correlations of insular epilepsy in adult populations. In contrast, the ictal semiology in children with insular epilepsy is poorly described. Considering that early and successful surgery may greatly improve the cognitive outcome and quality of life, it is worthwhile to deepen our knowledge of insular epilepsy in children. Methods We retrospectively evaluated ten children with drug-resistant focal insular epilepsy who had been consecutively explored with stereoelectroencephalography (SEEG), followed by individually tailored resective surgery that included part of the insula in all cases. A detailed anatomo-electro-clinical analysis of non-invasive EEG and SEEG data was performed. At least one of the electrodes explored the insular cortex. SEEG analysis confirmed that the insular cortex was included in the ictal onset zone. Results Epilepsy onset was mostly during the first year of life, characterized by subtle seizures as well as spasms and myoclonic seizures. Later on, neurovegetative signs and asymmetric tonic and hypermotor seizures (HMS) dominated the ictal semiology. The epileptogenic zone was frequently wider than insular with frontal and central predominance. In eight patients, the tailored resection included a lesion. In seven patients, an Engel class 1 outcome as well as neuropsychological and behavioural improvement was obtained. Conclusions SEEG is feasible and useful in children with drug-resistant insular epilepsy which is often characterized by autonomic symptoms as the initial symptoms and should be suspected in cases with HMS, asymmetric tonic seizures and even asymmetric spasms. Early propagation is mostly frontal and central. Analysis of a larger population is required to refine these findings.

Gaps and opportunities in refractory status epilepticus research in children: A multi-center approach by the Pediatric Status Epilepticus Research Group (pSERG)

Abstract: A B S T R A C T Purpose: Status epilepticus (SE) is a life-threatening condition that can be refractory to initial treatment. Randomized controlled studies to guide treatment choices, especially beyond first-line drugs, are not available. This report summarizes the evidence that guides the management of refractory convulsive SE (RCSE) in children, defines gaps in our clinical knowledge and describes the development and works of the ‘pediatric Status Epilepticus Research Group’ (pSERG). Methods: A literature review was performed to evaluate current gaps in the pediatric SE and RCSE literature. In person and online meetings helped to develop and expand the pSERG network. Results: The care of pediatric RCSE is largely based on extrapolations of limited evidence derived from adult literature and supplemented with case reports and case series in children. No comparative effectiveness trials have been performed in the pediatric population. Gaps in knowledge include risk factors for SE, biomarkers of SE and RCSE, second- and third-line treatment options, and long-term outcome. Conclusion: The care of children with RCSE is based on limited evidence. In order to address these knowledge gaps, the multicenter pSERG was established to facilitate prospective collection, analysis, and

Landau–Kleffner syndrome: A study of 29 patients

Abstract: Purpose The aim of the study was to retrospectively analyze the electroclinical features, etiology, treatment, and prognosis of 29 patients with Landau–Kleffner syndrome (LKS) with a long-term follow-up. Methods Inclusion criteria were a diagnosis of LKS with: (1) acquired aphasia or verbal auditory aphasia; (2) with or without focal seizures, secondarily generalized tonic-clonic seizures, absences, or atonic seizures. Results Mean follow-up was 12 years. All cases except six had seizures. Before the onset of aphasia, developmental language and behavioral disturbances were present in 19 and 14 patients, respectively. All patients had verbal auditory agnosia. Aphasia was severe in 24 patients and moderate in five. Nonlinguistic cognitive dysfunctions were moderate in 14 patients. Behavioral disturbances were found in 16 patients. During the continuous spike-and-wave discharges during slow sleep phase, the spike-wave index was >85% in 15, 50–85% in eight, and 30–50% in four. In two patients, the EEG recording showed occasional bilateral spikes, without continuous spike-and-wave discharges during slow sleep. In this phase, the awake EEG recording showed more frequent interictal abnormalities, predominantly in the temporal regions. Eight patients recovered language completely, but the remaining patients continue to have language deficits of different degrees. Conclusion Landau–Kleffner syndrome is an epileptic encephalopathy characterized by acquired verbal auditory aphasia and seizures in most of the patients associated with continuous or almost continuous spike-and-wave discharges during slow wave sleep. The most commonly used treatments were clobazam, ethosuximide, sulthiame. High-dose steroids were also administered. Adequate and early management may avoid language and cognitive deterioration.

Seizure outcome after hippocampal deep brain stimulation in a prospective cohort of patients with refractory temporal lobe epilepsy

Abstract: Purpose In this study, we present the results obtained from a series of patients with refractory temporal lobe epilepsy (r-TLE) who underwent hippocampal deep brain stimulation (Hip-DBS). Methods Nine consecutive adult patients were studied. Low-frequency and high-frequency stimulation was carried out immediately after the insertion of each electrode. Chronic continuous high-frequency stimulation was used during treatment. The mean follow-up time was 30.1 months. The mean age of the patients was 37.2 years. The MRI scan was normal in three patients; four patients had bilateral mesial temporal sclerosis (MTS), and two had unilateral MTS. Results The patients with unilateral MTS received unilateral implantation and experienced a 76% and an 80% reduction in seizure frequency after Hip-DBS. All patients with normal MRI scans were implanted bilaterally. Two of these patients received unilateral activation of the electrodes and experienced a 97% and an 80% reduction in seizure frequency; the third patient had bilateral activation of the device and was a non-responder. All patients with bilateral MTS were implanted bilaterally. Three of these patients received unilateral activation of the device and experienced a 66%, a 66% and a 100% reduction in seizure frequency after Hip-DBS; one patient had bilateral electrode activation, and was a non-responder. Whenever present, generalised tonic–clonic seizures disappeared completely after Hip-DBS. Conclusions Although performed on a relatively small number of patients, Hip-DBS was safe and effective in our patients with r-TLE. Seven of the nine patients were considered responders. Hip-DBS might represent a useful therapeutic option in patients with refractory temporal lobe epilepsy who were not candidates for resective surgery or have had previous failed procedures.

Psychogenic non-epileptic seizures in Iran

Abstract: Purpose We investigated the demographic and clinical characteristics of psychogenic non-epileptic seizures (PNES) in patients in Iran. Methods In this prospective study, all patients with a clinical diagnosis of PNES (based on ictal recordings) were recruited at the outpatient epilepsy clinic at Shiraz University of Medical Sciences, from 2008 through 2013. The epileptologist interviewed all the patients. We investigated the demographic and clinical characteristics of PNES. Results Two hundred and forty-nine patients were diagnosed as having PNES. Two hundred and eleven patients had video-EEG recordings available and included in the study. One hundred and forty-one (66.8%) were female and 70 (33.2%) were male. There were no significant differences between our patients and previous reports regarding the clinical and semiological characteristics of PNES. Conclusion Psychogenic non-epileptic seizures are relatively common at epilepsy clinics. It appears that an Islamic lifestyle (in Iran) has little influence on the clinical characteristics and manifestations of PNES, as we observed similar results as in most previous studies from other cultures.

Behavioral side-effects of levetiracetam in children with epilepsy: A systematic review

Abstract: Purpose Children with epilepsy are more likely to have behavioral problems compared to children without epilepsy. Literature suggests that levetiracetam leads to behavioral side-effects in children with epilepsy. The objective of this study is to provide a better overview of the frequency and variety of behavioral side-effects, which can be initiated by levetiracetam therapy in children with epilepsy. Method Electronic databases used in the search were PubMed, Medline, Cochrane and Embase. Studies were eligible for inclusion when they included children from one month to 18 years of age with a diagnosis of epilepsy, used levetiracetam, had other AEDs on a stable regimen for at least two months, reported about behavioral side-effects and had a follow-up of at least two weeks. Quality assessments and data collection were carried out for all eligible studies. Results Thirteen studies, including 727 patients using levetiracetam, were included in this systematic review. Three randomized controlled trials showed a total of 62 behavioral side-effects in 203 patients, effects which led to discontinuation of levetiracetam in only two of 102 patients (2.0%). Hostility, nervousness and aggression were reported mostly. Meta-analysis showed a statistically significant relative risk of 2.18 for the total number of behavioral side-effects for levetiracetam versus placebo. Observational studies showed mixed results with both behavioral deteriorations and improvements following levetiracetam. Conclusion Based on the findings in this systematic review, children using levetiracetam have a risk of developing several behavioral side-effects such as aggression, hostility and nervousness compared to children who do not use levetiracetam.

Patients with epilepsy are at an increased risk of subsequent stroke: A population-based cohort study

Abstract: Purpose Epilepsy is well known as a disorder in poststroke patients. However, studies that have investigated the association between epilepsy and the risk of subsequent stroke are limited. This population-based study investigated the incidence and risk of stroke in patients with epilepsy by using the Taiwan National Health Insurance claims data. Methods We identified 3812 patients newly diagnosed with epilepsy in 2000–2008 and 15,248 nonepilepsy comparisons frequency matched according to sex, age, and index year. We searched for subsequent stroke diagnoses in both cohorts until the end of 2009. The incidence rates and hazard ratios of stroke were estimated based on sex, age, the average defined daily doses (DDDs) of antiepilepsy drugs, and comorbidity. Results The stroke incidence of the epilepsy cohort was 3-fold higher than that of the comparison cohort. The age-specific results indicated that in the epilepsy cohort and the comparison cohort, the risk was the highest for the youngest group (20–39 years). Conclusion The patients with epilepsy exhibited a higher incidence of cerebral stroke than the general population did. In addition, younger patients with epilepsy and patients who took a high doses of antiepileptic drugs exhibited a high risk of stroke.

Pilomotor seizures: An autonomic semiology of limbic encephalitis?

Abstract: Purpose Ictal piloerection is an infrequent seizure semiology that is commonly overlooked as an ictal epileptic manifestation. Piloerection is considered to be principally caused by temporal lobe activity although frontal and hypothalamic seizure origins have been reported. The described etiology has shown a wide variety of structural causes such as mesial temporal sclerosis, tumors, posttraumatic, cavernomas and cryptogenic epilepsies. Methods We retrospectively reviewed the incidence of ictal piloerection in the clinical records of patients who underwent video-EEG monitoring (VEEGM) between 2007 and 2013 in a multicenter cooperative study. All patients presented refractory epilepsies and were evaluated with a protocol that included brain MRI, neuropsychology and VEEGM. Results A total of 766 patients were evaluated in four tertiary centers in Spain. Five patients showed piloerection as principal seizure semiology (prevalence 0.65%). The mean age at seizure onset was 39.6 years and the average epilepsy duration was 5.2 years (range 2–14) before diagnosis. Four patients were additionally examined with FDG-PET and/or SPECT-SISCOM. All presented temporal lobe epilepsy (TLE), three right-sided and two left-sided. A typical unilateral hippocampal sclerosis was described in 3 cases. The etiology detected in all cases was limbic encephalitis. Three had LGI1, one anti-Hu, and another Ma2 antibodies. Conclusion Our series describes a so far not well-recognized autoimmune association of pilomotor seizures to limbic encephalitis. This etiology should be ruled out through a comprehensive diagnostic work-up even in cases of long-lasting TLE with typical hippocampal atrophy on MRI.

The effects of antiepileptic drugs on vascular risk factors: a narrative review.

Abstract: Purpose Epilepsy is associated with increased cardiovascular disease (CVD) morbidity and mortality. The exact causes of this link are not clearly defined. The role of antiepileptic drugs (AEDs) in influencing CVD risk in patients with epilepsy remains controversial. A link between epilepsy, AEDs and cardiac arrhythmias has been proposed and may be responsible for sudden unexpected death in epilepsy (SUDEP). Methods We searched MEDLINE up to December 1, 2013 for relevant publications using combinations of keywords. We also examined the reference list of articles identified by this search and selected those we judged relevant. These were included in this narrative review. Results AEDs may exert both beneficial and adverse cardiovascular effects. This narrative review considers the influence of AEDs on some predictors of vascular risk [i.e. weight, insulin resistance, metabolic syndrome, lipids, lipoprotein (a), C-reactive protein, homocysteine, vitamins, coagulation factors, uric acid, carotid intima media thickness, markers of oxidative status and matrix metalloproteinase-9]. Certain AEDs can also have pro-arrhythmic properties. Conclusions AEDs may exert different effects on various established and emerging predictors of vascular risk. Furthermore, pharmacokinetic interactions between AEDs and drugs used to reduce vascular risk (e.g. statins) need to be better documented. Whether this knowledge, in terms of individualizing antiepileptic and CVD prevention treatment, will prove to be relevant in clinical practice remains to be established.

Side-effects of antiepileptic drugs: the economic burden.

Abstract: Purpose Antiepileptic drugs are a potentially effective treatment for epilepsy. Side-effects are, however, common and the negative consequences necessitate treatment ranging from minor interventions to very expensive hospitalization. This analysis has been conducted to provide insight into the costs of side-effects due to antiepileptic drugs in The Netherlands from a societal perspective. Method Resources allocated to care (grouped according to health, patient and family and other) for five different categories of side-effect were measured using a questionnaire. Standard cost prices were derived from the Dutch costing manual. Chronic epilepsy patients were invited to complete the questionnaire if they had experienced side-effects during the previous 12 months. Results Based on data from 203 patients, the total societal costs of common side-effects in 2012 are estimated to be €20,751 CI:15,049–27,196 (US$26,675 CI:19,345–34,960) per patient per year. These consist of: health care costs (mean €4458; US$5731), patient and family costs (i.e. informal care, mean €10,526; US$13,531) and other costs (i.e. productivity losses, mean €5761; US$7406). Examining the different categories of side-effects separately, ranging from the most to the least expensive category, the cost estimates per patient per year were as follows: other (mean €13,228; US$17,005), behavioral (mean €9689; US$12,455), general health (mean €7454; US$9582), cognitive (mean €7285; US$9365) and cosmetic side-effects (mean €2845; US$3657). Subgroup analyses showed significant differences in costs between patients using monotherapy and those using polytherapy when looking at cognitive and cosmetic side-effects. Conclusion These estimates should be considered in the overall assessment of the economic impact of a pharmacotherapy.

Generalized versus partial reflex seizures: A review

Abstract: In this review we assess our currently available knowledge about reflex seizures with special emphasis on the difference between "generalized" reflex seizures induced by visual stimuli, thinking, praxis and language tasks, and "focal" seizures induced by startle, eating, music, hot water, somatosensory stimuli and orgasm. We discuss in particular evidence from animal, clinical, neurophysiological and neuroimaging studies supporting the concept that "generalized" reflex seizures, usually occurring in the setting of IGE, should be considered as focal seizures with quick secondary generalization. We also review recent advances in genetic and therapeutic approach of reflex seizures.

Clinical correlates of graph theory findings in temporal lobe epilepsy

Abstract: Purpose Temporal lobe epilepsy (TLE) is considered a brain network disorder, additionally representing the most common form of pharmaco-resistant epilepsy in adults. There is increasing evidence that seizures in TLE arise from abnormal epileptogenic networks, which extend beyond the clinico-radiologically determined epileptogenic zone and may contribute to the failure rate of 30–50% following epilepsy surgery. Graph theory allows for a network-based representation of TLE brain networks using several neuroimaging and electrophysiologic modalities, and has potential to provide clinicians with clinically useful biomarkers for diagnostic and prognostic purposes.

Primary school teacher's knowledge and attitudes toward children with epilepsy.

Abstract: Purpose Primary school teacher's knowledge and attitudes toward epilepsy can have significant impact on the performance and psycho-social development of the child with epilepsy. Our objectives were to study teacher's knowledge and attitudes and identify areas in which further teacher training and education are required. Methods A stratified random sample survey involving a group of primary school teachers in Jeddah, Saudi Arabia included private/public schools designated for male and female students. A structured 37-item questionnaire was used to examine their demographics, knowledge, attitudes, and experience with epilepsy. Results Six hundred and twenty primary school teachers working in public (58%) or private (42%) schools were included with ages ranging between 21 and 59 years (mean 36). Most teachers (79%) were of Saudi Arabian nationality and 66% had a college or university degree. Their years of experience ranged from 1 to 35 (mean 13.5). Only 17% of the teachers felt very well informed about epilepsy. Teachers with higher education were more likely to have good knowledge ( p =0.009). Teachers of Saudi nationality were also more likely to report good knowledge, independent of their educational level ( p =0.013). Overall, teachers with good knowledge were less likely to have negative attitudes including minding to have an epileptic child in their class ( p =0.028) or thinking that they should be placed in a special classroom ( p =0.029). Conclusions Primary school teacher's knowledge about epilepsy needs improvements. Their attitudes correlated highly with their knowledge. Educational campaigns about epilepsy are needed to develop a well informed and tolerant community.

Patient and caregiver quality of life in psychogenic non-epileptic seizures compared to epileptic seizures.

Abstract: Purpose Little is known about the effect of psychogenic non epileptic seizures (PNES) to caregiver quality of life (QOL), particularly as it compares to epileptic seizures (ES). We sought to characterize this effect and identify its determinants. Methods The study population comprised of 126 ES and 33 PNES patients who underwent video EEG monitoring along with 48 and 18 caregivers respectively who accompanied them to their investigations. Patients completed questionnaires providing demographic, disease-related, cognitive, psychiatric, sleep and QOL information on admission, prior to their diagnosis being clarified. Their caregivers completed questionnaires providing demographic, disease burden and generic QOL information. Paraclinical data were also gathered. Regression analysis was used to identify patient and caregiver related determinants of patient and caregiver QOL. Results QOL scores were significantly worse for PNES than ES patients and were mainly linked to depression levels. PNES and ES caregivers had comparable demographic characteristics and QOL scores. ES caregiver QOL was better in employed caregivers with lower burden scores for the physical component summary (PCS) and worse in female caregivers of depressed patients with higher burden scores for the mental component summary (MCS). Caregiver burden score was the strongest correlate of PNES caregiver MCS QOL score. Conclusion Caregiver QOL in PNES does not differ from caregiver QOL in ES, while patient QOL is worse in PNES. Caregiver burden emerges as a consistent correlate of caregiver QOL both in ES and PNES. These findings advocate for consideration of caregiver burden and QOL in PNES in clinical practice and for future research paradigms.

The effect of antiepileptic drugs on thyroid function in children.

Abstract: Background Limited and conflicting data exist for the influence of antiepileptic drugs on thyroid function in children. Objective The aim of this study was to investigate the effects of phenobarbital, valproate, carbamazepine, oxcarbazepine, and levetiracetam monotherapy on thyroid function in daily clinical practice during a 12-month treatment period. Method A total of 223 children (103 females and 120 males) with new onset and controlled epilepsy treated with valproate ( n =129), phenobarbital ( n =33), carbamazepine ( n =36), oxcarbazepine ( n =14), levetiracetam ( n =11) were enrolled in the study. Serum free thyroxine (fT4) and thyroid-stimulating hormone (TSH) levels were measured before and at first, sixth and twelfth months of therapy. Results At baseline, average fT4 and TSH concentrations were not different between the drug groups. Valproate-treated patients had decreased fT4 and increased TSH levels at months 1, 6, and 12. Carbamazepine-treated patients had decreased fT4 levels at months 1, 6, and 12 and increased TSH levels at months 1, and 6. Phenobarbital-treated patients had decreased fT4 levels at months 1, and 6, and increased TSH levels at months 6 and 12. Oxcarbazepine-treated patients had decreased fT4 levels at month 1. Levetiracetam-treated patients showed no significant change of fT4 and TSH at any times. The frequency of subclinical hypothyroidism at month 12 was 28% in valproate, 21.4% in oxcarbazepine, 18.2% in phenobarbital, 13.9% in carbamazepine, and 0% in levetiracetam groups. Conclusion Our data suggest that all antiepileptic drugs studied except levetiracetam had varying degrees of deleterious effects on thyroid function.

Efficacy of verapamil as an adjunctive treatment in children with drug-resistant epilepsy: a pilot study.

Abstract: Purpose Verapamil, a voltage-gated calcium channel blocker, has been occasionally reported to have some effect on reducing seizure frequency in drug-resistant epilepsy or status epilepticus. We aimed to investigate the efficacy of verapamil as add-on treatment in children with drug-resistant epilepsy. Methods Seven children with drug-resistant structural-metabolic, unknown or genetic ( e.g. , Dravet syndrome [DS]) epilepsy received verapamil as an add-on drug to baseline antiepileptic therapy. Verapamil was slowly introduced at the dosage of 1mg/kg/day and titrated up to 1.5mg/kg/day. After completing the titration period, patients entered a 14-month maintenance period and were followed up at 3, 8, and 14 months. Heart monitoring was performed at baseline and at each follow-up. The primary outcome measure was the response of seizures to verapamil. Results Three subjects with genetically determined DS showed a partial (reduction of 50–99%) response for all types of seizures. A patient with DS without known mutation showed a partial control of all types of seizures in the first 13 months; then seizures worsened and verapamil was suspended. Two patients with structural epilepsy and one with Lennox–Gastaut syndrome showed no improvement. Any side effects were recorded. Conclusions Add-on treatment with verapamil seems to have some effect in controlling seizures in patients with genetically determined DS. Our observations justify further research on the relationship between calcium channels, calcium channel blockers, and channelopathies.

A community study in Cornwall UK of sudden unexpected death in epilepsy (SUDEP) in a 9-year population sample

Abstract: Purpose Epilepsy-related death, particularly sudden unexpected death in epilepsy (SUDEP), is underestimated by healthcare professionals. One argument that physicians use to justify the failure to discuss SUDEP with patients and their families is that there is a lack of evidence for any protective interventions. However, there is growing evidence of potentially modifiable risk factors for SUDEP; although large-scale trials of interventions are still lacking. We determined the main risk factors associated with SUDEP in a comprehensive community sample of epilepsy deaths in Cornwall UK from 2004 to 2012. Methods We systemically inspected 93 cases of all epilepsy and epilepsy associated deaths which occurred in Cornwall between 2004 and 2012 made available to us by the HM Cornwall coroner. These are the deaths where epilepsy was a primary or a secondary cause. Results 48 cases met the criteria for SUDEP and we elicited associated relevant risk factors. Many findings from our study are comparable to what has been reported previously. New points such as most of the population had increase in either or both seizure frequency/intensity within six months of death and majority did not have an epilepsy specialist review in the last one year to demise were noted. Conclusion This study is the first epidemiological study in England occurring in a whole population identifying systemically all deaths and the first large scale review in UK of SUDEP deaths since 2005. Being a community based study a key issue which was highlighted was that in the SUDEPs examined many might have been potentially preventable.

Medicinal plants used in Iranian traditional medicine to treat epilepsy

Abstract: Antiepileptic drugs used to treat epilepsy can cause severe, life threatening side effects. In Iranian traditional medicine, herbal remedies have been used for centuries to treat seizures. In this study, the five most important herbals in Iranian traditional medicine, namely Canon, al-Hawi, al-Abniah 'an Haqaeq al Adwia, Tuhfat al-Mu'minin, and Makhzan ul-Adwia, were searched for the term "sar-e", which means epilepsy, to identify the herbs used for treatment in ancient times. We also searched scientific literature for pharmacological evidence of their effectiveness. Twenty-five plants were identified as herbal remedies to treat epilepsy. Pharmacological data related to the antiepileptic activity of eleven of these plants exists. A large number of these plants which have not been investigated pharmacologically for antiepileptic activity would be good candidates for study in exploring new herbal anticonvulsant remedies.

Prevalence and treatment gap of active convulsive epilepsy: a large community-based survey in rural West China.

Abstract: Purpose Active convulsive epilepsy (ACE) impacts patients greatly, especially in low-income countries where patients do not receive appropriate treatment. In the present study, we measured the prevalence and treatment gap (TG) of ACE in rural West China. Methods Six rural areas in West China that have a total population of 3,541,319 were selected to conduct prevalence and TG estimates of ACE via a clue survey from 2007 to 2009. Clue survey here is a community-based screening strategy among defined population which requires employed well-trained local physicians//health workers to collect all clues available to discover/identify/recruit patients within a study period. Questionnaire-based interviews were used for the identification of ACE patients, and information was obtained during the survey. Prevalence and TG of ACE were calculated. Results A total of 6547 patients with ACE were identified. The estimated prevalence of ACE was 1.8 per 1000 in the general population, with the prevalences in males and females determined to be 2.0 and 1.7, respectively ( p p >0.05). The TG figures dropped with advancing age and increased above 30 years of age. Patients aged 60 years or older had the largest TG (77.8%); those with disease course less than 10 years showed a larger TG and those who experienced two to five seizures annually had a significantly larger TG (70.6%). Additionally, only 63.9% of the ACE patients included in the study were aware of the disease and had consulted a doctor. Conclusions There exists a large TG of ACE in West China rural areas. Majority of those ever consulted a doctor but failed to receive or adhere to an appropriate treatment program. Management including public education as well as training of local physicians were necessary to fill that gap.

The value of home video with ambulatory EEG: a prospective service review.

Abstract: Purpose The demand for long term EEG monitoring is increasing with the emphasis on recording patients' attacks. Outpatient ambulatory EEG is relatively inexpensive and widely available. The main disadvantage of the technique is the lack of video which can make interpretation of an ictus difficult. We investigated whether patients, if offered home video equipment, would take it, if this resulted in simultaneous EEG-video capture of an ictus and if interpretation of the recording was facilitated by the video. Method All ambulatory EEG patients, adults and children, were offered a camcorder to take home during a 17-month study period. Results 130 patients/carers were offered a camcorder (93 adults, 37 children), 45 patients (35%) accepted; the main reason for not accepting was that attacks were considered too brief to record. An ictal event occurred in 34 patients (76%) with a camcorder; in 17 (50%) of these an attack was captured successfully on video. The main reasons for failure to capture events were that attacks were too brief, or that the camcorder was not operated successfully. Attacks were captured with greater success in children (14/23, 61%) than adults (3/11, 27%). Of the 17 video recordings, 14 (82%) were helpful in aiding interpretation of the ambulatory EEG. Conclusion In our study, home video facilities aided interpretation of ambulatory EEG recordings in approximately one third of patients. Technological advances and familiarity with portable recording devices will improve this figure and patients and their carers should be encouraged to use such facilities when available.

Development, evaluation and implementation of video-EEG telemetry at home

Abstract: Purpose To describe the development and implementation of video EEG telemetry (VT) in the patient's home (home video telemetry, HVT) in a single centre. Methods HVT met the UK Medical Research Council definition of a complex intervention, and we used its guidance to evaluate the process of piloting, evaluating, developing and implementing this new clinical service. The first phase was a feasibility study, comparing inpatient VT (IVT) with HVT in a test–retest design ( n =5), to assess data quality and yield of clinically relevant events. The second phase was a pre-implementation study ( n =8), to examine acceptability and satisfaction as well as the costs of IVT and HVT. Subsequently, we implemented the service, and reviewed the outcomes of the first 34 patients. Results The feasibility study found no difference in the quality of recording or clinical yield between IVT and HVT. The pre-implementation study showed excellent patient satisfaction. We also discuss the findings of the main stakeholder survey (consultants and technicians). Our economic modelling demonstrates a clear financial superiority of HVT over IVT. Conclusion Our findings show that diagnostic HVT for seizure classification and polysomnographies can be carried out safely in the patients' home and poses no security risks for staff. HVT can be effectively integrated into an existing tertiary care service as a routine home or community-based procedure. We hope to encourage other clinical neurophysiology departments and epilepsy centres to take advantage of our experience and consider adopting and implementing HVT, with the aim of a nationwide coverage.

Validation of Chinese version of the Morisky Medication Adherence Scale in patients with epilepsy

Abstract: Purpose This study aimed to validate a Chinese version of the Morisky Medication Adherence Scale (MMAS-8) in patients with epilepsy. The relationships between adherence, seizure frequency, and adverse effects were assessed using this method. Methods Data from patients diagnosed with epilepsy at the Department of Neurology of Huashan Hospital were collected between January and June 2013. To validate the MMAS-8, internal consistency, test–retest reliability, and factor analysis were calculated. Relationships between adherence, seizure frequency, and adverse effects were assessed using Pearson's correlation. Results One hundred and eleven patients were recruited. The MMAS-8 had moderate internal consistency (Cronbach's α =0.556) and good test–retest reliability (intraclass correlation coefficient=0.729). The MMAS-8 adherence rate was 79.2%. MMAS-8 adherence was negatively correlated with seizure frequency and adverse effects ( r =–0.708, p r =–0.484, p Conclusion The MMAS-8 scale can be used as a tool to assess medication adherence in Chinese patients with epilepsy. Better seizure control and lower rates of adverse effects were significantly correlated with higher adherence scores.

Impact of planning of pregnancy in women with epilepsy on seizure control during pregnancy and on maternal and neonatal outcomes

Abstract: Purpose To investigate whether planning of pregnancy in women with epilepsy affects seizure control during pregnancy and to compare the maternal and neonatal outcomes in planned and unplanned pregnancies. Methods This was a retrospective cohort study of 153 pregnant women with epilepsy who were treated at the University of Tsukuba Hospital and Hokkaido University Hospital between 2003 and 2011. Twenty-one pregnancies were excluded due to insufficient data. Data of patients followed by neurologists during their planned pregnancies (planned-pregnancy group, n =51) were compared to those of patients referred to neurologists after conception for managing epilepsy during pregnancy (unplanned-pregnancy group, n =81). The treatment profile for epilepsy, seizure control, and maternal and neonatal outcomes in both groups were compared using Chi-square test or Fisher's exact test and Mann–Whitney U test. Results Compared to the unplanned-pregnancy group, the planned-pregnancy group showed a significantly greater proportion of patients receiving monotherapy with antiepileptic drugs (80% vs. 61%: planned vs. unplanned, P =0.049) and those not requiring valproic acid (77% vs. 56%, P =0.031). Furthermore, the frequency of epileptic seizures (16% vs. 35%, P =0.018) and changes in antiepileptic drugs (24% vs. 41%, P =0.042) were significantly lower in the planned-pregnancy group than in the unplanned-pregnancy group. No significant intergroup differences were noted in the obstetric complications and neonatal outcomes, including congenital malformations. Conclusion For women with epilepsy, planning of pregnancy is associated with good seizure control during pregnancy and less fetal exposure to antiepileptic drugs.

Survival analysis for valproic acid use in adult glioblastoma multiforme: A meta-analysis of individual patient data and a systematic review

Abstract: Purpose Glioblastoma multiforme (GBM) is the most lethal type of primary brain tumor, and patients that undergo the maximum tumor resection that is safely possible and standard radiochemotherapy only achieve a median survival time of 14.6 months. Several clinical studies have reported that valproic acid could prolong survival of GBM patients. However, the results of these studies are inconsistent. We examined relevant studies and conducted a meta-analysis to assess the effects of VPA on survival times and recurrence. Methods A bibliographic search was performed in the EMBASE, MEDLINE, ClinicalTrials.gov and Cochrane Central Register of the Controlled Trials databases to identify potentially relevant articles or conference abstracts that investigated the effects of VPA on the outcome of glioma patients. Five observational studies were included. Results Pooled estimates of the hazard ratio (HR) and 95% confidence intervals (CI) were calculated. Our meta-analysis confirmed the benefit of using VPA (HR, 0.56; 95% CI, 0.44–0.71). Sub-group analysis shows that patients treated with VPA had a hazard ratio of 0.74 with a 95% confidence interval of 0.59–0.94 vs. patients treated by other-AEDs and a hazard ratio of 0.66 with a 95% confidence interval of 0.52–0.84 vs. patients treated by administration of non-AEDs. No heterogeneity was observed in the subset analysis. Conclusion The results of our study suggest that glioblastoma patients may experience prolonged survival due to VPA administration. Sub-analysis confirmed the benefit of VPA use compared to a non-AEDs group and an other-AEDs group. Further RCTs of this subject should be performed.

Trends in the first antiepileptic drug prescribed for epilepsy between 2000 and 2010

Abstract: Purpose To investigate changes in the choice of first anti-epileptic drug (AED) and co-prescription of folic acid after a new diagnosis of epilepsy. Methods We searched anonymised electronic primary care records dating between 2000 and 2010 for patients with a new diagnosis of epilepsy and recorded the first AED prescribed and whether folic acid was co-prescribed. Results From 13.3 million patient years of primary care records, we identified 3714 patients with a new diagnosis of epilepsy (925 children and 649 women aged 14–45 years). Comparing first time AED prescriptions in 2000 and 2001 to those in 2009 and 2010 showed a significant decrease in the proportion of carbamazepine and phenytoin prescribed and a significant increase in the proportion of lamotrigine and levetiracetam prescribed. In women aged 14–45 years, and girls aged p -value Conclusion The changing trends in the first AED prescribed over the last decade, particularly in women of childbearing age, reflect published evidence in terms of AED efficacy, tolerability and safety.

Praxis induction. Definition, relation to epilepsy syndromes, nosological and prognostic significance. A focused review.

Abstract: Purpose There is increasing awareness that reflex epileptic mechanisms provide unique insight into ictogenesis in human epilepsies. Several of the described triggers have in common that they imply complex visuomotor coordination and decision-making; they are today regarded as variations of one principle, i.e. praxis induction (PI). This focused review considers PI from the aspects of history and delineation, clinical and electroencephalographic presentation, syndromatic relations, prevalence, mechanisms of ictogenesis and nosological implications, treatment and prognosis. Methods We reviewed a series of published articles and case reports on PI in order to clarify clinical and electroencephalographic findings, treatment and outcome. Results Findings of both induction and inhibition by the same stimuli suggest widening the reflex epilepsy concept into a broader one of epilepsies with exogenous modification of ictogenesis. PI is closely related to juvenile myoclonic epilepsy (JME) where hyperexcitability and hyperconnectivity of the entire network of visuomotor coordination seem to provide the precondition for eliciting reflex myocloni in the musculature active in the precipitating task. Conclusion The conclusions on ictogenesis derived from PI support the concept of JME as a system disorder of the brain.

The impact of the ketogenic diet on arterial morphology and endothelial function in children and young adults with epilepsy: A case–control study

Abstract: Purpose The present study aimed to assess the impact of the ketogenic diet on arterial morphology and endothelial function of the big vessels of the neck and on cardiac diastolic function, in a cohort of epileptic children and young adults treated with the ketogenic diet. Methods Patients were recruited based on the following inclusion criteria: (1) patients who were or had been on the ketogenic diet for a time period of at least six months. Each patient underwent measurement of carotid intima media thickness, carotid artery stiffness, echocardiography, and diastolic function assessment. Patients with drug resistant epilepsy, matched for number, age and sex and never treated with ketogenic diet, were recruited as controls. Results The population study was composed by 43 epilepsy patients (23 males), aged between 19 months and 31 years (mean 11 years). Twenty-three patients were or had been treated with ketogenic diet, and 20 had never been on it (control group). Subjects treated with the ketogenic diet had higher arterial stiffness parameters, including AIx and β-index and higher serum levels of cholesterol or triglycerides compared to those who had never been on the diet (control group) ( p Conclusions Arterial stiffness is increased in children and young adults treated with the ketogenic diet, before the increase of the intima media thickness. This supports that arterial stiffness is an early marker of vascular damage.