Sleep before and after temporal lobe epilepsy surgery

PurposePatients with epilepsy often complain of non-restorative sleep. This is the consequence of the acute effect of seizures and the chronic effect of epilepsy responsible for disrupting sleep architecture. Other factors such as antiepileptic drugs (AEDs), also play a role in the alteration of sleep organization. The aim of this study was to evaluate the specific effect of seizures and interictal epileptiform abnormalities (IEAs) on sleep, in particular to see whether reducing seizure frequency by epilepsy surgery might improve sleep organization in these patients.MethodsEleven patients with refractory mesial temporal lobe epilepsy, who underwent surgical treatment and who were seizure free at the follow-up, were included in the study. Treatment with AEDs was not significantly modified before the second year of follow-up. Patients were evaluated before surgery, at 1-year and 2-year follow-up visits with a videoEEG monitoring (24 h/24). At each follow-up visit, interictal epileptiform abnormalities and sleep macrostructure parameters were assessed.ResultsAll patients showed a reduction of their IEAs. At 1-year follow-up, total sleep time and REM sleep increased significantly (p = 0.032 and p = 0.006, respectively). At 2-year follow-up, an important increase of REM sleep was observed (p = 0.028). Most significant variations were noted 1 year after surgery. No significant variations were observed between the first and the second year after surgery.ConclusionsSurgical treatment of temporal lobe epilepsy may improve sleep macrostructure by reducing the number of seizures and of IEAs. These results indirectly confirm the role of epilepsy in disrupting sleep organization chronically.     

Extended retention intervals can help to bridge the gap between subjective and objective memory impairment

PurposeDespite their excellent clinical validity, objective measures of memory often do not reflect self-perceived memory impairment. This discordance has mostly been attributed to depressed mood. Alternatively, a lack of ecological validity due to the rather short standard retention intervals of 20–60 min may be responsible for this discordance. Therefore, we explored the value of extended retention intervals in regard to subjective memory deficits.MethodsOur prospective study was based on 73 patients with epilepsy. In addition to the standard 30-min retention interval of a verbal learning and memory test (VLMT) patients were randomized to either a free delayed recall after 1 week or after 4 weeks. Mood was assessed by the Beck Depression Inventory (BDI).ResultsForty-four patients (60%) reported self-perceived memory deficits, whereas objective verbal memory impairment was present in 26 patients (36%). Concordance between subjective and objective memory performance was observed in 53% of the patients. Multivariate analyses identified memory performance after 4 weeks and self-rated mood as determinants of subjective memory impairment. Self-perceived memory impairment correlated with the number of remembered words after 4 weeks (r = ?0.361, p = 0.030) and the BDI total score (r = 0.332, p = 0.004) but neither with recall performance after 30 min nor after 1 week.ConclusionSubjective memory appears to follow a different time scale than routine memory testing. Thus, the introduction of longer retention intervals may enhance the ecological validity of standard memory tests. Furthermore, the findings again underscore that controlling for mood is mandatory when dealing with subjective memory complaints.     

Healthcare utilization and costs in children with stable and uncontrolled epilepsy

ObjectiveEpilepsy adversely affects childhood development, possibly leading to increased economic burden in pediatric populations. We compared annual healthcare utilization and costs between children (< 12 years old) with stable and uncontrolled epilepsy treated with antiepileptic drugs (AEDs).MethodsChildren (< 12 years old) with epilepsy (ICD-9-CM 345.xx or 780.39) in 2008 were identified in the MarketScan claims database from 2007 to 2009. Patients with “stable” epilepsy used the same AED for ≥ 12 months, and patients with “uncontrolled” epilepsy were prescribed additional AED(s) during that period. For patients with uncontrolled epilepsy, the study index date was the start of additional AED(s); for patients with stable epilepsy, the study index date was a random AED fill date. Epilepsy-related utilization included medical services with 345.xx or 780.39 in any diagnosis field and AED fills. Epilepsy-related costs included AEDs, medical claims with epilepsy in any diagnosis field, and certain tests. We adjusted for baseline cohort differences (demographics, region, usual-care physician specialty, and comorbidities) using logistic regression and analysis of covariance.ResultsTwo thousand one hundred seventy patients were identified (mean: 7.5 years; 45.3% were female; Charlson comorbidity index: 0.3; 422 (19.4%) patients with uncontrolled epilepsy). Patients with uncontrolled epilepsy faced more hospitalizations (30.1% vs. 12.0%) and greater overall ($30,343 vs. $18,206) and epilepsy-related costs ($16,894 vs. $7979) (all p < .001). Adjusting for baseline measures, patients with uncontrolled epilepsy had greater odds of hospitalization (OR: 2.5; 95% CI: 1.9–3.3) and costs (overall: $3908, p = .087; epilepsy-related: $5744, p < .001).ConclusionsChildren with uncontrolled epilepsy use significantly more healthcare resources and have a greater economic burden than children with stable epilepsy. However, epilepsy accounted for only half of overall costs, indicating that comorbid conditions may add substantially to the disease burden.     

Self reported adverse effects of mono and polytherapy for epilepsy

PurposeAdverse effects of anti epileptic drugs (AEDs) can significantly affect the life of people with epilepsy. We used a register to determine if polytherapy with AED has more adverse effects than monotherapy.MethodsWe established a register for people with epilepsy (www.UKAED.info). Participants were requested to complete the Liverpool Adverse Event Profile (LAEP) to quantify adverse effects. We also recorded type of epilepsy, seizure control and AED including drug doses. Five hundred and seventy six complete data sets were available, monotherapy (n = 186), polytherapy (n = 325) and control subjects not taking AED (n = 65).ResultsThe mean LAEP scores in polytherapy (45.56, confidence interval (CI) = 44.36–46.76) were significantly higher than the mean LAEP scores in monotherapy (42.29, CI = 40.65–44.02) and the mean LAEP scores in controls (33.25, CI = 31.05–35.44). Tiredness, memory problems and difficulty concentrating were the most common symptoms in patients taking AED and were consistently higher in polytherapy than in monotherapy. Tiredness was reported as always or sometimes being a problem in (polytherapy/monotherapy/controls) 82.5%/75.6%/64.6%, memory problems in 76%/63.2%/29.2% and difficulty concentrating in 68%/63.9%/30.8%. The proportion of seizure-free patients was significantly lower in the polytherapy group (17%) than in the monotherapy group (55%). Depression rates between the monotherapy and polytherapy groups were similar. Drug dosages were higher in polytherapy, however this did not reach statistical significance.ConclusionPatients on polytherapy had significantly higher LAEP scores than patients on monotherapy. This should be carefully discussed with the patient before a second AED is added.     

Symptoms of heart disease or its treatment may increase Beck Depression Inventory Scores in hospitalized post-myocardial infarction patients

ObjectiveThe Beck Depression Inventory (BDI) is one of the most commonly used self-report depression symptom questionnaires in medical settings. The revised BDI-II was developed in 1996, partially due to concerns about the influence of somatic symptoms from medical illness on BDI scores. The BDI, however, continues to be frequently used in medical settings. The objective of this study was to examine the degree to which somatic symptom items influence BDI scores among hospitalized post-myocardial infarction (MI) patients with major depressive disorder (MDD) compared to psychiatry outpatients with MDD matched on cognitive/affective scores, sex, and age.MethodsSomatic scores of post-MI patients with MDD and matched psychiatry outpatients with MDD were compared using independent samples t-tests.ResultsA total of 579 post-MI patients with MDD (mean age = 54.4 years, SD = 9.9) and 579 psychiatry outpatients with MDD (mean age = 51.2 years, SD = 9.7) were matched on cognitive/affective scores, sex, and age. Somatic symptoms accounted for 47% of BDI total scores among post-MI patients (mean total = 22.6, SD = 8.8) versus 37% among psychiatry outpatients (mean total = 19.2, SD = 9.7). Somatic scores of post-MI patients were 3.4 points higher than for matched psychiatry outpatients (95% confidence interval 3.0 to 3.9; p < .001), a difference that is equivalent to 15% of total post-MI patient scores.ConclusionBDI scores of hospitalized post-MI patients with MDD may, in part, reflect symptoms of the acute medical condition or its treatment, rather than depression. The BDI-II was designed to reduce the influence of somatic symptoms on total scores and may be preferable to the 'BDI among heart disease patients.     

Seizure frequency in children with epilepsy: Factors influencing accuracy and parental awareness

RationaleThe objective of this study was to ascertain the accuracy of clinical reports to determine the seizure frequency in children diagnosed with epilepsy.MethodsWe reviewed the clinical record of 78 children (January–May of 2006) admitted to the EEG–video monitoring with epilepsy diagnosis. Clinical reports of parents and the files of EEG–video monitoring were reviewed to determine parents’ awareness for seizures.ResultsDuring video–EEG monitoring, 1244 were recorded on 78 children. Seizures were confirmed in 1095 of which 472 were correctly reported (38%) by parents whereas 623 remained under-reported (50%). Parents’ report thus had a sensitivity of 43%, positive predictive value of 76% to identify seizures. Based on the EEG–video monitoring, seizures were reported accurately in 22 (28%) and under-reported in 38 (49%) children. In the under-reported group, none of the seizures were recognized in 10 (13%), only a portion identified in 28 children. The parents’ report describing seizure frequency has limited value for young children (p = 0.01) and children with absence seizures (p = 0.03). However, clinical reports were accurate for the children with developmental delay (p < 0.06) or not being on any anticonvulsant drug (AED) therapy (p = 0.02).ConclusionOur results indicate that a significant number of seizures remain under-reported by parents of children with epilepsy. The current study underscores that the seizure frequency should be interpreted with caution for young children and children with absence seizures. Video–EEG recording has a complimentary role to the clinical observation for the accurate assessment of seizure frequency in children.     

To what extent does depression influence quality of life of people with pharmacoresistant epilepsy in Argentina?

IntroductionDepression is the most frequent psychiatric co-morbidity in patients with epilepsy. Lifetime prevalence of depression is reported more frequently in temporal lobe epilepsy and is estimated at 35%. This co-morbidity appears to be related with various mechanisms. The aim of this study was to determine the quality of life (QoL) of patients with pharmacoresistant epilepsy with and without co-morbid depression in an Argentinean population.MethodsPatients admitted to the video-EEG monitoring unit during the period 2010–2013 went through a standardized psychiatric assessment using SCID-I (Structured Clinical Interview for Axis I diagnoses of DSM-IV), BDI II (Beck Depression Inventory) GAF (Global assessment of functioning), and Q LES Q-SF (for quality of life). Patients were divided in two groups: with and without depression (according to DSM-IV). Sociodemographic data, BDI II scores, GAF, and quality of life (QoL) were compared between the two groups. Comparisons were made using Student's t-test and Mann–Whitney U test. Frequency distributions were compared by Chi-square test. Spearman correlation coefficients were determined.ResultsSeventy-seven patients with pharmacoresistant epilepsy were eligible for this study, 41 patients were included in the group with depression (mean BDI II 15.93), and 36 in the group without depression (mean BDI II 3.36) (p = 0.001). The overall QoL was significantly lower in the group with depression compared to the group without depression (p < 0.01). The most affected areas were: physical health (p = 0.013), mood (p = 0.006), course activities (referring to school as well as to hobbies or classes outside of school) (p = 0.003), leisure time activities (p = 0.011), social activities (p = 0.047), general activities (p = 0.042), and medication (p = 0.022). Severity of depression according to BDI II had a negative correlation with overall QoL (r - 0.339, p < 0.01). No correlations were found between seizure frequency, QoL and BDI II.ConclusionPatients with pharmacoresistant epilepsy and co-morbid depression reported worst QoL. Depression disrupts daily functioning (leisure, social functioning) and is a negative influence for subjective perception of health and medication. Interdisciplinary treatment should be considered (neurology–psychiatry–psychotherapy).     

Health-related quality of life in Portuguese patients with narcolepsy

ObjectiveTo evaluate the perception of health-related quality of life (HRQoL) in Portuguese patients with narcolepsy, and to compare the results to normative data.MethodsFifty-one narcoleptic adults (26M, 25F), aged between 18 and 80 years (mean = 43.35, SD = 15.32), were included in the final analysis of a multicentric cross-sectional study. The Medical Outcome Study – 36 Item Short-Form Survey (SF-36) was used to assess quality of life, and the Beck Depression Inventory (BDI) was used for self-assessment of depression.ResultsSeveral HRQoL domains were significantly lower than National surveys, except physical function and bodily pain (p between 0.000 and 0.006). SF-36 presented the lowest score in vitality (39.93). Deterioration was significantly higher in role physical (p = 0.006), vitality (p = 0.011), and mental health (p = 0.008) in women, and in physical function (p = 0.003) and bodily pain (p = 0.045) in elderly subjects. Those with higher literacy had better physical function (p = 0.046).ConclusionHRQoL is significantly deteriorated in narcoleptics, affecting all dimensions (except physical function and bodily pain) when compared with the general Portuguese population. The results are consistent with studies of narcolepsy in other countries in demonstrating the profound impact of this disorder on quality of life.     

Cognitive improvement after long-term electrical stimulation of bilateral anterior thalamic nucleus in refractory epilepsy patients

IntroductionThe cognitive and behavioral effect of deep brain stimulation (DBS) administered to the deep cerebral nuclei for epilepsy treatment is unknown. We investigated the cognitive outcomes at least 12 months after DBS to the bilateral anterior thalamic nucleus (ATN) for controlling intractable epilepsy.MethodsNine patients with intractable epilepsy who were not candidates for resective surgery, but who were treated by bilateral ATN DBS underwent cognitive and behavioral assessments before implantation and more than 1 year after DBS surgery. Postoperative cognitive assessments were carried out under a continuous stimulation mode.ResultsThe mean seizure-reduction rate of these patients after ATN DBS was 57.9% (35.6–90.4%). Cognitive testing showed favorable results for verbal fluency tasks (letter and category, p < 0.05), and a significant improvement in delayed verbal memory was observed (p = 0.017). However, we did not observe any significant changes in general abilities (IQ, MMSE), information processing (digit forward and backward, Trail A, and Digit Symbol), or executive function (Trail B and WCST). Interestingly, we did not observe any significant cognitive decline approximately 1 year (mean, 15.9 months) after ATN DBS surgery.ConclusionsWe showed that ATN DBS not only resulted in promising clinical effects but was also associated with improvements in both verbal recall and oral information processing, which may be related to the bilateral activation of the fronto-limbic circuit following DBS surgery. Further controlled, long-term studies with larger populations are warranted for elucidating the clinical effects of ATN DBS.     

A retrospective study comparing preoperative evaluations and postoperative outcomes in paediatric and adult patients undergoing surgical resection for refractory epilepsy

PurposeTo review and compare the preoperative characteristics and postsurgical outcomes in paediatric and adult patients who underwent surgical resections from 2001 to 2009.MethodsCombined data from noninvasive measures such as ictal semiology, interictal/ictal scalp EEGs, MRI and SPECT were utilised to identify the epileptogenic zones (EZ). When noninvasive investigations produced inconclusive or inconsistent findings, patients underwent intracranial EEG monitoring. Resective micro-surgical procedures were conducted according to the results of the anatomo-electro-clinical investigations and were carried out to remove the EZ. We then followed up 222 paediatric (≤18 years old) and 100 adult patients (≥19 years old) for 1–9 years postoperatively.ResultsThe mean age of seizure onset in paediatric group was significantly lower than that in adult group. 95 (43%) of the paediatric and 42 (42%) of the adult patients required long-term intracranial EEG recording. 54 (24.3%) of the paediatric and 62 (62%) of the adult patients were found to have temporal lobe epilepsy (TLE), while 149 (67.1%) of the paediatric and 37 (37.0%) of the adult patients had extra-temporal lobe epilepsy (ETLE) (p = 0.000). 19 (8.6%) of the paediatric patients and 1 (1%) adult patient had hemispheric lesions (p = 0.009). 148 (66.7%) of the paediatric and 61 (61.0%) of the adult patients were seizure-free during the follow-up period. 17 of 19 (89.5%) children who underwent hemispherectomy were seizure-free. In both paediatric and adult groups, the surgical outcome for patients with TLE was significantly better than that of patients with ETLE (p = 0.018 in children, p = 0.029 in adults). Both the location of EZs and seizure-free ratio were significantly different (p < 0.001) between the preadolescent (≤12 years old) and adolescent (13–18 years old) group. Hippocampal sclerosis was the most common pathologic finding in patients with TLE in both groups, and was followed by focal cortical dysplasia. In patients with TLE, the proportion of tumour was significantly higher in the paediatric than the adult group (25.9% vs. 10%, p = 0.021).ConclusionPaediatric patients with refractory seizures had more extratemporal or hemispheric resectable epileptogenic foci and fewer temporal foci than adults. Our study demonstrates that resective surgery is an effective and safe early intervention in strictly selected paediatric patients with refractory epilepsy.     

Effect of obstructive sleep apnea on response to cognitive behavior therapy for depression after an acute myocardial infarction

ObjectiveTo determine whether obstructive sleep apnea (OSA) interferes with cognitive behavior therapy (CBT) for depression in patients with coronary heart disease.MethodsPatients who were depressed within 28 days after an acute myocardial infarction (MI) were enrolled in the Enhancing Recovery in Coronary Heart Disease (ENRICHD) trial; 289 (12%) of the 2481 participants in ENRICHD met the criteria for inclusion in this ancillary study.ResultsA validated ambulatory ECG algorithm was used to detect OSA. Of the 289 participants, 64 (22%) met the criteria for OSA. CBT was efficacious relative to usual care (UC) for depression (p = .004). OSA had no effect on 6-month Beck Depression Inventory (BDI) scores (p = .11), and there was no interaction between OSA and treatment (p = .42). However, the adjusted mean (s.e.) 6-month BDI scores among patients without OSA were 12.2 (0.8) vs. 9.0 (0.8) in the UC and CBT groups (Cohen's d = .40); among those with OSA, they were 9.5 (1.4) and 8.1 (1.5) in the UC and CBT groups (d = .17). There were no significant OSA × Treatment interactions in the major depression (n = 131) or minor depression (n = 158) subgroups, but in those with major depression, there was a larger treatment effect in those without (d = .44) than with (d = .09) OSA. In those with minor depression, the treatment effects were d = .37 and d = .25 for the non-OSA and OSA subgroups.ConclusionCBT is efficacious for depression after an acute myocardial infarction in patients without obstructive sleep apnea, but it may be less efficacious for post-MI patients with OSA.     

Efficacy of vagus nerve stimulation over time: review of 65 consecutive patients with treatment-resistant epilepsy treated with VNS > 10 years

ObjectiveStudies have reported improved seizure control with increased duration of vagus nerve stimulation (VNS) but are prone to methodological biases. We analyzed the efficacy of VNS over time in patients with treatment-resistant epilepsy (TRE) who underwent VNS therapy 10 or more years.MethodsWe retrospectively reviewed 65 consecutive patients (29 females) who underwent VNS therapy ≥ 10 years. The mean age at VNS insertion was 30.0 years. Forty-four adults (≥ 18 years; 67.7%) and 21 children (32.3%) were included. Seizure frequency and antiepileptic drug (AED) regimens were recorded prior to VNS and, following VNS insertion, at 6 months, 1 year, 2 years, and every 2 years thereafter.ResultsThe mean duration of VNS therapy for this group was 10.4 years, and the mean decrease in seizure frequency at last follow-up was 76.3%. The mean reduction in seizures at 6 months and years 1, 2, 4, 6, 8, and 10 years was 35.7, 52.1, 58.3, 60.4, 65.7, 75.5, and 75.5%, respectively. Seizure frequency was significantly reduced from baseline at each of the recorded intervals (P < 0.001). There was a trend toward increased AED burden in the latter years of the follow-up period.ConclusionFollowing a “ramp-up” and accommodation period throughout the initial 24 months after VNS implantation, seizure control improved slightly over the subsequent years of therapy and eventually stabilized. Variation in seizure frequency, however, was common, and frequent changes in AED regimens or stimulation parameters were likely an important and possibly synergistic component of seizure control.     

Fracture risk with use of liver enzyme inducing antiepileptic drugs in people with active epilepsy: Cohort study using the General Practice Research Database

PurposeLiver enzyme inducing antiepileptic drugs (LEI AEDs) have adverse effects on bone metabolism but it is unclear whether this translates into increased fracture risk. This population based cohort study aimed to evaluate whether treatment with LEI AEDs is associated with increased risk of fracture in people with active epilepsy.MethodsThe cohort included patients diagnosed with epilepsy and prescribed AEDs while registered at a GPRD general practice during 1993–2008. The hazard ratio with current use of LEI AEDs for fracture at any site and hip fracture was estimated using Cox proportional hazards models.ResultsThere were 7356 fractures (788 hip fractures) in 63 259 participants. In women, the adjusted hazard ratio with use of LEI AEDs was 1.22 for fracture (95% CI 1.12–1.34; p < 0.001) and 1.49 for hip fracture (1.15–1.94; p = 0.002). In men, the hazard ratio for fracture was 1.09 (0.98–1.20; p = 0.123) and for hip fracture 1.53 (1.10–2.12; p = 0.011). For every 10 000 women treated with LEI AEDs for one year, there could be 48 additional fractures, including 10 additional hip fractures. For every 10 000 men treated with LEI AEDs for one year, there could be 4 additional hip fractures.ConclusionsLEI AEDs may increase the risk of fracture in people with epilepsy. In patients at high risk of osteoporotic fracture alternative AED therapy may be appropriate. Further information is urgently needed on the safety of valproate and newer AEDs and on strategies to maintain bone health in people who need to be treated with LEI.     

Factors influencing the costs of epilepsy in adults with an intellectual disability

PurposeDespite the common occurrence of intellectual disability (ID) in people with epilepsy, most studies of the cost of epilepsy have focussed primarily or exclusively on people without ID. This paper estimates the costs of supporting people with epilepsy and ID.MethodsProspective resource use and outcome data were collected on 91 participants from the east of England for seven months. Multivariate analysis was used to investigate the relationship between costs and patient and healthcare provider characteristics.ResultsMean health care costs relating to epilepsy or ID were £2800 (3500 Euros, 5200 USD) p.a. Modelling suggests costs are lower for patients with more severe ID (p = 0.014); and higher for patients managed by a consultant neurologist (p = 0.037).DiscussionOur findings support limited evidence from the literature of increased epilepsy costs in people with ID. Patterns of expenditure suggest clinical variation in the treatment of epilepsy according to the severity of ID, particularly in the absence of management by a consultant neurologist.     

Preoperative depressive symptoms predict postoperative seizure outcome in temporal and frontal lobe epilepsy

ObjectiveRecent research has pointed to the possibility of a bidirectional relationship between seizure frequency in epilepsy and depressive symptoms. The study described here investigated the relationship between preoperative depressive symptomatology and postoperative seizure outcome in a sample of patients with temporal (TLE) and frontal (FLE) lobe epilepsy.MethodsA retrospective analysis was conducted on the data from 115 eligible patients with TLE (N = 97) and FLE (N = 18) and resections limited to one cortical lobe who were evaluated preoperatively and 1 year after epilepsy surgery with respect to depressive symptoms (Beck Depression Inventory, BDI) and seizure outcome. The latter was assessed in terms of actual total seizure frequency as well as a dichotomous variable (seizure free vs. not seizure free) for the 1-year outcome. Repeated-measures analyses of variance and regression analyses were applied.ResultsSeizure-free patients had significantly lower BDI scores preoperatively as well as postoperatively than patients who were not seizure free. In the regression analyses, the preoperative BDI score was a significant predictor of postoperative seizure frequency as well as seizure freedom. When only patients with TLE were analyzed, the results for the association between preoperative BDI and postoperative seizure frequency and seizure freedom remained consistent.ConclusionThe present results provide evidence for a statistical bidirectionality of the relationship between depressive symptoms and postoperative seizure status in a mixed sample of patients with TLE and FLE. Possible reasons for this bidirectional association include an underlying common pathology in both depression and epilepsy, for example, structural changes or functional alterations in neurotransmitter systems.     

Co-morbidity and clinically significant interactions between antiepileptic drugs and other drugs in elderly patients with newly diagnosed epilepsy

PurposeA study was conducted to investigate the frequency of potential pharmacokinetic drug-to-drug interactions in elderly patients with newly diagnosed epilepsy. We also investigated co-morbid conditions associated with epilepsy.MethodFrom the register of Kuopio University Hospital (KUH) we identified community-dwelling patients aged 65 or above with newly diagnosed epilepsy and in whom use of the first individual antiepileptic drug (AED) began in 2000–2013 (n = 529). Furthermore, register data of the Social Insurance Institution of Finland were used for assessing potential interactions in a nationwide cohort of elderly subjects with newly diagnosed epilepsy. We extracted all patients aged 65 or above who had received special reimbursement for the cost of AEDs prescribed on account of epilepsy in 2012 where their first AED was recorded in 2011–2012 as monotherapy (n = 1081). Clinically relevant drug interactions (of class C or D) at the time of starting of the first AED, as assessed via the SFINX–PHARAO database, were analysed.ResultsHypertension (67%), dyslipidemia (45%), and ischaemic stroke (32%) were the most common co-morbid conditions in the hospital cohort of patients. In these patients, excessive polypharmacy (more than 10 concomitant drugs) was identified in 27% of cases. Of the patients started on carbamazepine, 52 subjects (32%) had one class-C or class-D drug interaction and 51 (31%) had two or more C- or D-class interactions. Only 2% of the subjects started on valproate exhibited a class-C interaction. None of the subjects using oxcarbazepine displayed class-C or class-D interactions. Patients with 3–5 (OR 4.22; p = 0.05) or over six (OR 8.86; p = 0.003) other drugs were more likely to have C- or D-class interaction. The most common drugs with potential interactions with carbamazepine were dihydropyridine calcium-blockers, statins, warfarin, and psychotropic drugs.ConclusionsElderly patients with newly diagnosed epilepsy are at high risk of clinically relevant pharmacokinetic interactions with other drugs, especially if exposed to carbamazepine, but these interactions can be controlled via rational drug choices and with prediction of the possible drug-to-drug interactions. Patients on dihydropyridine calcium-channel blockers, statins, warfarin, and risperidone face the highest risk of interactions.     

Metabolic syndrome among Chinese obese patients with epilepsy on sodium valproate

BackgroundMany publications have addressed the problem of weight gain and endocrine abnormalities in patients treated with sodium valproate (VPA). However, the presence of metabolic syndrome (MetS) among obese patients with epilepsy on VPA has received little attention.MethodsThirty-six patients receiving VPA monotherapy were included in this study to evaluate the presence of MetS. All patients were interviewed and clinically examined. Blood samples were obtained after an overnight fast, and an oral glucose-tolerance test was performed. Twenty-eight subjects who were obese but had no epilepsy and were otherwise well were collected as controls (“simple obesity” group).ResultsThe two study groups were well matched in terms of age, gender and body mass index. Insulin resistance measured via homeostasis model assessment (HOMA) index was more severe among the VPA-treated group (4.91 ± 2.91 vs. 2.00 ± 1.72, P = 0.007). The frequency of the MetS was slightly higher in the patients with epilepsy compared to controls (47.2% vs. 32.1%, respectively), but this difference was not statistically significant (P = 0.223). Multivariate analysis with stepwise logistic regression revealed low positive correlations between MetS development, HOMA index (P = 0.029; r = 0.361) and valproic acid dose (P = 0.049; r = 0.323). These correlations were independent of other clinical parameters.ConclusionsOur preliminary study suggests that obese patients with epilepsy treated with VPA are at higher risk of MetS than individuals who are “simply obese” but otherwise well. Therefore, the HOMA index should be monitored in obese patients who receive VPA therapy, rather than monitoring body weight alone.     

Major depressive disorder as a predictor of a worse seizure outcome one year after surgery in patients with temporal lobe epilepsy and mesial temporal sclerosis

PurposeThe association between pre-surgical psychiatric disorders (PDs) and worse seizure outcome in patients with refractory epilepsy submitted to surgery has been increasingly recognized in the literature. The present study aimed to verify the impact of pre- and post-surgical PD on seizure outcome in a series of patients with refractory temporal lobe epilepsy and mesial temporal sclerosis (TLE–MTS).MethodData from 115 TLE–MTS patients (65 females; 56.5%) who underwent cortico-amygdalohippocampectomy (CAH) were analyzed. Pre- and post-surgical psychiatric evaluations were performed using DSM-IV and ILAE criteria. The outcome subcategory Engel IA was considered as corresponding to a favorable prognosis. A multivariate logistic regression model was applied to identify possible risk factors associated with a worse seizure outcome.ResultsPre-surgical PDs, particularly major depressive disorder (MDD), anxiety and psychotic disorders, were common, being found in 47 patients (40.8%). Fifty-six patients (48.7%) were classified as having achieved an Engel IA one year after CAH. According to the logistic regression model, the presence of pre-surgical MDD (OR = 5.23; p = 0.003) appeared as the most important risk factor associated with a non-favorable seizure outcome.ConclusionAlthough epilepsy surgery may be the best treatment option for patients with refractory TLE–MTS, our findings emphasize the importance of performing a detailed psychiatric examination as part of the pre-surgical evaluation protocol.     

Safety of video-EEG monitoring and surgical outcome in patients with mesial temporal sclerosis and psychosis of epilepsy

PurposeCortico-amygdalohippocampectomy (CAH) has become an important treatment option for patients with refractory temporal lobe epilepsy and mesial temporal sclerosis (TLE-MTS); it has resulted in a 60–70% seizure remission rate and significant quality of life (QOL) improvements. Video-electroencephalography (VEEG) monitoring has been widely used in epilepsy centers for pre-surgical evaluation. A major concern in epilepsy surgery is whether to consider CAH treatment in patients with psychosis of epilepsy (POE). This study analyzed the safety and adverse events (AEs) of VEEG monitoring and the post-surgical outcomes of patients with refractory TLE-MTS and POE who underwent CAH.MethodClinical, sociodemographic and VEEG data from 18 patients with TLE-MTS and POE were analyzed. Psychiatric evaluations were performed using DSM-IV and ILAE criteria. The seizure outcome was evaluated using Engel's criteria.ResultsTwo patients (11.2%) presented AEs that did not result in increased lengths of hospitalization. Of the 10 patients (55.5%) who underwent CAH, 6 (60%) became free of disabling seizures (Engel I). The psychiatric and QOL evaluations revealed improvements of psychotic symptoms (p = 0.01) and in Physical Health (p = 0.01) following surgery.ConclusionThese data reinforce that VEEG monitoring is a safe method to evaluate patients with refractory TLE-MTS and POE in epilepsy centers.