Psychiatric Care in Epilepsy Surgery: Who Needs It?

At present there is considerable variability in the psychiatric evaluation and follow-up of patients in epilepsy surgery programs globally. There is a large body of research now demonstrating heightened risk for psychological disturbance in surgically remedial patients before and after surgery. This evidence provides a compelling case for the routine provision of psychiatric and psychological treatment to optimize the benefits of epilepsy surgery and patient outcomes. In a comprehensive model of care, presurgical psychiatric and psychosocial evaluation plays an integral role in shaping the team''s understanding of surgical candidacy and the patient''s capacity for informed consent. After surgery, efficacious treatment of psychiatric comorbidity increases the likelihood of seizure freedom as well as optimizes psychosocial functioning and quality of life. By contrast, failure to treat can allow psychiatric comorbidity to persist or psychological difficulties to develop as the patient adjusts to life after surgery.     

Posttraumatic Epilepsy: What's Contusion Got to Do With It?

Text of Abstract Liability to develop posttraumatic epilepsy (PTE) correlates in a general way with trauma dose. While contusion of the brain produces an admixture of extravasated blood, edema fluid and necrotic tissue at the site of skull trauma and in regions remote from the direct force, an unpredictable cascade of shearing injury, torsion and rotation and a myriad of physiological changes occur in structures subject to the mechanical pressure wave. Animal models mimic components of injury, some more thoroughly than others. Designing a treatment that is a prophylaxis for the development of PTE awaits understanding the mechanisms of epileptogenesis initiated by trauma.Traumatic brain injury from blunt force impact propagates a pressure wave through the skull causing cavitation within the neuropil and rotational forces that result in structural damage with cortical laceration and contusion. Whether trauma is civilian or military, the severity of the injury correlates with the likelihood for a person to develop epilepsy. However, specific mechanisms and risk factors for development of posttraumatic epilepsy (PTE) remain unknown. Head trauma and the complication of PTE are major public health problems. Prophylaxis has failed because trials were not based upon the fundamental mechanisms that initiate epileptogenesis. Animal models suggest mechanisms of epileptogenesis and even rational interventions. However, the critical challenge is to design screening of interventions, establish efficacy in a broad range of animal models, and then determine whether a severely injured patient can withstand the burden of the side effects of agents that have utility in animals.     

Who Likes to be With Whom in an Integrated Nursery?

This small scale study took place in an integrated nursery class in an SLD school containing eleven children with severe learning difficulties (SLD) and six children without disabilties — referred to as ‘playgroup’ children. In order to assess the potential for social interaction between all the children, they were asked to select whom they would like to ‘play with’ and ‘sit next to’. The results indicate that, overall, children with SLD choose equally between the two groups whereas the playgroup children tended to choose children from their own group.     

Colchicine Treatment in Children With Familial Mediterranean Fever: Is it a Risk Factor for Neuromyopathy?

BackgroundWe cared for a 17-year-old adolescent with familial Mediterranean fever under colchicine treatment. Because of the increased creatinine kinase level (3937 U/L) observed in this individual, we planned to assess all pediatric patients with familial Mediterranean fever under colchicine treatment to detect any resultant neuromyopathy.MethodsThe study included 88 children with familial Mediterranean fever who were receiving colchicine. The patient with myopathy was not included in the study. Serum creatinine kinase levels were measured and nerve conduction studies were carried out in all patients.ResultsThe study included 88 patients (47 female, 53.4%) with an average age of 10.1 ± 3.35 years. The average period of colchicine use was 28.25 ± 17.66 months. Side effects of colchicine were detected in 10 patients (11%)—as diarrhea in eight patients, leukopenia in one patient, and hair loss in one patient. Nerve conduction studies determined incidental carpal tunnel syndrome in only one patient.ConclusionsOur study did not suggest an elevated risk of neuromyopathy associated with the use of colchicine for familial Mediterranean fever.     

Explaining the Unexplained; Expecting the Unexpected: Where Are We With Sudden Unexpected Death in Epilepsy?

Sudden death is over 20 times more frequent in people with epilepsy than the general population. The literature on clinical risk factors is now able to define individuals at the highest risk. Despite these advances in our understanding of risk, the mechanism of sudden unexpected death in epilepsy remains elusive. While it is unlikely that a single mechanism will be found to explain all deaths, there have been recent advances that identify factors that play a critical role. This review provides an update on new advances in the understanding of sudden unexpected death in epilepsy.Death is the most devastating outcome of epilepsy. People with epilepsy have a two to three times increased risk of death compared with the general population (1–3). Mortality in children with epilepsy may be as much as 90 times more frequent than in children without epilepsy (4). Active epilepsy, reflected by the failure to obtain 5-year seizure remission, was found to be the strongest risk factor for death of any cause in a study of long-term mortality in childhood onset epilepsy (3). Mortality risk is strongly related to underlying condition, with most of the increased risk attributable to those with secondary or symptomatic epilepsy (1, 3, 5). Other factors include nonadherance to antiepileptic drug therapy, which was shown to be associated with an over three times increased risk of mortality in patients with epilepsy (6).While mortality in epilepsy may be explained by the underlying condition, a proportion of deaths in people with epilepsy remains unexplained by circumstances and autopsy. Sudden death is nearly 24 times more likely in people with epilepsy (7). The entity known as Sudden Unexplained or Unexpected Death in Epilepsy (SUDEP) is defined as a sudden, unexpected, witnessed or unwitnessed, nontraumatic and non-drowning death in a patient with epilepsy, with or without evidence of a seizure and excluding documented status epilepticus. Postmortem examination does not reveal a toxicologic or anatomic cause of death in SUDEP (Table 1) (8–10). The term Probable SUDEP is used for cases that meet all criteria, but no postmortem examination is available (8). This review highlights some of the new advances in the understanding of SUDEP.     

Is Intraoperative Electrocorticography Reliable in Children with Intractable Neocortical Epilepsy?

PURPOSE: To study the relation between the spike frequency during intraoperative electrocorticography (ECoG) under general anesthesia with isoflurane and that during extraoperative ECoG monitoring in children with intractable neocortical epilepsy. METHODS: Twenty-one children (age, 1-16 years; 15 boys and six girls) who underwent intraoperative and extraoperative ECoG monitoring with subdural electrode arrays were studied. The spike frequency and the spatial pattern of spike frequency were compared between intraoperative and extraoperative ECoGs for each patient (by using Wilcoxon signed-ranks and Spearman's rank correlation, respectively). RESULTS: In 15 of 21 patients, the spike frequency was significantly lower during intraoperative than during extraoperative ECoG (mean z = -6.3; p < 0.001). In four of 21 patients, no significant difference was found in the spike frequency between intraoperative and extraoperative recordings. In two of 21 patients, spike frequency reached one spike/min neither during intraoperative nor extraoperative recording; therefore appropriate comparison of spike frequency was not possible. A significant positive correlation in the spike-frequency pattern was seen between intraoperative and extraoperative recordings in nine of nine cases who had > or = 10 spikes/min during intraoperative ECoG (mean rho = 0.62; p < 0.01), in five of six cases with one to nine spikes/min (mean rho = 0.50; p < 0.01), and in none of five cases with less than one spike/min (mean rho = 0.13). CONCLUSIONS: General anesthesia often decreases the spike frequency in children with neocortical epilepsy, yet intraoperative ECoG can reliably reflect the awake interictal spiking pattern when spike frequency exceeds one spike/min during intraoperative ECoG recording.     

The Children’s Psychosocial Rehabilitation Treatment Adherence Measure: Development and Initial Validation

This paper reports on two studies designed to develop and validate a treatment adherence measure for Children’s Psychosocial Rehabilitation (CPSR)—a home- and community-based treatment for youth with serious emotional disturbance. In Study 1, we derived CPSR treatment adherence and differentiation criteria from a treatment manual and evaluated their content validity via structured feedback from practitioners. In study 2 we assessed the reliability and validity of the resultant CPSR Treatment Adherence Measure (CTAM) in a clinical sample of youth receiving CPSR (n = 11) or outpatient psychotherapy (n = 20). Results from Study 1 revealed strong agreement among practitioners regarding the validity of the proposed adherence criteria (ICC = .82). Results from Study 2 indicated the CTAM had good internal consistency (parent- and supervisor report α’s = .86 & .91) and high inter-rater reliability (r = .87, P = .001) in this pilot sample. CTAM scores reliably distinguished between children receiving CPSR versus psychotherapy (z = −3.16, P = .002) and between CPSR interventionists with reputations for high- (n = 4) or low- (n = 7) adherence to the model (z = −2.47, P = .014). Findings indicate the CTAM is worthy of further development as a practice and research instrument.     

Does the Cause of Localisation‐Related Epilepsy Influence the Response to Antiepileptic Drug Treatment?

PURPOSE: We investigated the response to antiepileptic drug (AED) therapy in patients with localisation-related epilepsy associated with different underlying causes. METHODS: Five hundred and fifty adolescent and adult patients who had partial epilepsy treated with AEDs and who had undergone magnetic resonance imaging of brain were followed up prospectively from 1984 at a single centre. More than 70% were newly diagnosed. None had had epilepsy surgery. RESULTS: Three hundred and twelve (57%) patients had been seizure free at their last clinic visit for at least a year. Patients with mesial temporal sclerosis (MTS; n = 73, 42% seizure free) were less likely to be controlled (p < 0.01) than were those with arteriovenous malformation (AVM; n = 14, 78%), cerebral infarction (n = 46, 67%), primary tumour (n = 35, 63%), cortical gliosis (n = 81, 57%), cerebral atrophy (n = 49, 55%), and cortical dysplasia (CD; n = 63, 54%). Among the seizure-free patients, those with MTS were more likely to require more than one AED compared with those with other aetiologies (48 vs. 35%; p < 0.05). There was no difference in outcome between patients with symptomatic and cryptogenic epilepsy (n = 361, 58% vs. n = 189, 56% seizure free, respectively). Patients with MTS, CD, and cryptogenic epilepsy were more likely (p = 0.02) to have a family history of epilepsy than were the other groups. MTS patients also had a higher incidence of febrile convulsions (p < 0.001). CONCLUSIONS: The majority of patients with focal-onset epilepsy became seizure free on AED treatment. MTS-related seizures had the worst prognosis. Although many patients with this pathology may benefit from epilepsy surgery, a considerable number will be controlled with AED therapy.     

Changes in Quality of Life in Epilepsy: How Large Must They Be to Be Real?

PURPOSE: The study goal was to assess the magnitude of change in generic and epilepsy-specific health-related quality-of-life (HRQOL) instruments needed to exclude chance or error at various levels of certainty in patients with medically refractory epilepsy. METHODS: Forty patients with temporal lobe epilepsy and clearly defined criteria of clinical stability received HRQOL measurements twice, 3 months apart, using the Quality of Life in Epilepsy Inventory-89 and -31 (QOLIE-89 and QOLIE-31), Liverpool Impact of Epilepsy, adverse drug events, seizure severity scales, and the Generic Health Utilities Index (HUI-III). Standard error of measurement and test-retest reliability were obtained for all scales and for QOLIE-89 subscales. Using the Reliable Change Index described by Jacobson and Truax, we assessed the magnitude of change required by HRQOL instruments to be 90 and 95% certain that real change has occurred, as opposed to change due to chance or measurement error. RESULTS: Clinical features, point estimates and distribution of HRQOL measures, and test-retest reliability (all > 0.70) were similar to those previously reported. Score changes of +/-13 points in QOLIE-89, +/-15 in QOLIE-31, +/-6.3 in Liverpool seizure severity-ictal, +/-11 in Liverpool adverse drug events, +/-0.25 in HUI-III, and +/-9.5 in impact of epilepsy exclude chance or measurement error with 90% certainty. These correspond, respectively, to 13, 15, 17, 18, 25, and 32% of the potential range of change of each instrument. CONCLUSIONS: Threshold values for real change varied considerably among HRQOL tools but were relatively small for QOLIE-89, QOLIE-31, Liverpool Seizure Severity, and adverse drug events. In some instruments, even relatively large changes cannot rule out chance or measurement error. The relation between the Reliable Change Index and other measures of change and its distinction from measures of minimum clinically important change are discussed.