Circadian patterns of generalized tonic-clonic evolutions in pediatric epilepsy patients

ObjectiveTo investigate the sleep/wake, day/night, and 24-h periodicity of pediatric evolution to generalized tonic–clonic seizures (GTC).MethodsCharts of 407 consecutive patients aged 0–21 years undergoing continuous video-EEG monitoring for epilepsy were reviewed for the presence of GTC evolution. Seizures were characterized according to 2001 ILAE terminology. Charts were reviewed for EEG seizure localization, MRI lesion, and for seizure occurrence in 3-h time blocks, out of sleep or wakefulness, and during the day (6 AM–6 PM) or night. Analysis was done with binomial testing. Regression models were fitted using generalized estimating equations with patients as the cluster level variable.Results71 patients (32 girls, mean age 12.63 ± 5.3 years) had 223 seizures with GTC evolution. Sleep/wake seizure distribution predicted tonic–clonic evolution better than time of day, with more occurring during sleep (p < 0.001). Tonic–clonic evolution occurred most frequently between 12–3 AM and 6–9 AM (p < 0.05). Patients with generalized EEG onset had more tonic–clonic evolution between 9 AM and 12 PM (p < 0.05). Patients with extratemporal focal seizures were more likely to evolve during sleep (p < 0.001); this pattern was not found in patients with temporal or generalized seizure onset on EEG. Patients without MRI lesions were more likely to evolve between 12 AM and 3 AM (p < 0.05), in the sleeping state (p < 0.001), and at night (p < 0.05). Logistic regression revealed that sleep and older patient age were the most important predictors of GTC evolution.ConclusionGTC evolution occurs most frequently out of sleep and in older patients. Our results may assist in seizure prediction, individualized treatment patterns, and potentially complication and SUDEP prevention.     

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.     

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.     

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.     

Risk factors for valproic acid resistance in childhood absence epilepsy

AimsValproic acid (VPA) is reported to be effective for the control of absence seizures in 75% of children. The aim of this study was to determine the clinical and socio-demographic factors associated with VPA response in newly diagnosed childhood absence epilepsy (CAE) and to determine if these factors also influence the chances of achieving long-term seizure freedom.MethodsMedical charts of 180 children with CAE were retrospectively reviewed. Clinical, electroencephalographic and imaging findings were recorded to correlate with complete VPA response and long-term epilepsy outcome. Factors associated with non-responsiveness were identified individually and in a multivariable logistic regression analysis.ResultsTreatment was successful in 112 (58.3%) children. More children that were non-responsive to VPA experienced generalized tonic clonic seizures (GTCS) (33.8% vs. 13.4% for responders; p = 0.001) and 52.9% had a pre-treatment seizure frequency greater than 10/day (vs. 27.0% for responders; p < 0.001). Finally, responders were older at time of diagnosis versus non-responders (p = 0.001). Absence of long-term seizure freedom was linked to the presence of GTCS, the absence of initial response and the need for multiple AEDs to control seizures.InterpretationOur results suggest that clinical phenotypes are associated with reduced response rates to VPA. This should be taken into account when counselling families of children with newly diagnosed absence epilepsy.     

Acute postoperative seizures and long-term outcome following pediatric epilepsy surgery

PurposeAcute post-operative seizures (APOS) after epilepsy surgery, previously believed to be benign, are increasingly associated with poor long-term prognosis. Prior literature has focused primarily on adult temporal lobe epilepsy. This retrospective study aimed to identify the prevalence, prognostic significance and risk factors for APOS in pediatric epilepsy surgery at a single center.MethodRetrospective chart review of all children aged 0–21 years undergoing resective surgery for epilepsy between 2009 and 2012 at a single center. APOS were defined as seizures within 30 days of resection. Surgical outcome was determined, using a minimum of 12 months postoperative follow-up for inclusion.ResultsAPOS, defined as a seizure within 30 days of resection, were identified in 50/112 (44%) of patients. APOS were a significant predictor of poor postoperative seizure outcome (ILAE 4–6); only 26% of those with APOS had a good outcome (ILAE 1–3), compared to 76% without APOS. Timing of postoperative seizure was not correlated with outcome. Most (54%) with APOS and good outcome had continued seizures between 14-30 days postoperatively. Patients with APOS after temporal (p = 0.05) and extratemporal (p < 0.001) resections had a significantly worse prognosis. APOS after hemispherectomy were not associated with a worse prognosis (p = 0.22). Key risk factors for APOS include lack of ictal EEG lateralization to operated hemisphere/side of MRI abnormality.ConclusionThis study shows an association between APOS and poor outcome in both temporal and extratemporal pediatric epilepsy surgery. Findings support the expansion of APOS duration to 30 days.     

Parasympathetic alteration during sub-clinical seizures

IntroductionAutonomic instability is considered a contributing factor in sudden unexpected death in epilepsy (SUDEP). The aim of this pilot study was to measure parasympathetic activity in sub-clinical seizures to investigate autonomic instability.Materials and methodsA prospective study based on Video-electroencephalography (EEG)/electrocardiography (ECG)/oxygen saturation (SAO2) recordings was selected from patients having sub-clinical seizures during stage 3 or 4 sleep. We analysed R–R intervals in the ECG from 1-min prior to the electrographic onset to the end of sub-clinical seizures. Matched non-ictal R–R baseline measurements were selected from stages 3 or 4 sleep. R–R interval data were analysed using NeuroScope software providing a cardiac index of parasympathetic activity (CIPA). BioSignal short-term heart rate variability (HRV) software was used to analyse the same R–R interval data previously analysed using NeuroScope except that sub-clinical seizure data was embedded within 5-min epochs and compared to 5-min epochs of non-ictal measurements.ResultsA total of 33 sub-clinical seizures were recorded from 11 patients comprising 19 generalised sub-clinical seizures (2 patients), 9 right temporal lobe sub-clinical seizures (5 patients) and 5 left temporal lobe sub-clinical seizures (4 patients) were compared to matched non-ictal measurements. Parasympathetic activity was clearly altered during total sub-clinical seizures in terms of the CIPA (p < 0.001) and 5-min HRV high frequency (HF) % (p = 0.026) measures. Generalised sub-clinical seizures resulted in increased cardiac parasympathetic activity whereas temporal lobe seizures were associated with a decrease in parasympathetic activity.ConclusionThis pilot study indicates that parasympathetic changes occur during sub-clinical seizures. Generalised sub-clinical seizures may be associated with more autonomic instability compared to temporal lobe sub-clinical seizures.     

Epidemiology of uncontrolled epilepsy in the Al-Kharga District,New Valley,Egypt

BackgroundDespite advances in treating epilepsy, uncontrolled epilepsy continues to be a major clinical problem. Therefore, this work aimed to study the epidemiology of uncontrolled epilepsy in Al-Kharga District, New Valley.MethodsThis study was carried out in 3 stages via door-to-door screening of the total population (62,583 persons). All suspected cases of epilepsy were subjected to case ascertainment, conventional ElectroEncephaloGraphy (EEG), and the Stanford-Binet Intelligence Scale. Patients who had been receiving suitable anti-epileptic drugs (AEDs) over the previous 6 months and were having active seizures were considered uncontrolled, according to Ohtsuka et al.²³ The patients underwent serum AED level estimation, video EEG monitoring, and brain MRIs. Fifty age- and gender-matched patients with controlled epilepsy were chosen for statistical analysis and compared with true intractable patients.ResultsA total of 437 patients with epilepsy were identified, 30.7% of whom (n = 134/437) were uncontrolled, with a prevalence of 2.1/1000. A total of 52.2% of uncontrolled patients (n = 70/134) were inappropriately treated, while 47.8% (n = 64/134) were compliant with appropriate treatments. Video monitoring EEG of compliant uncontrolled patients demonstrated that 78.1% patients (n = 50/64) had definite epilepsy, while 21.9% (n = 14/64) had psychogenic non-epileptic seizures (PNES). A logistic regression analysis revealed that status epilepticus, focal seizures, and mixed seizure types were risk factors for intractability.     

Evaluating the use of prolonged video-EEG monitoring to assess future seizure risk and fitness to drive

ObjectiveThe use of prolonged video-electroencephalography monitoring (VEM), rather than routine electroencephalography (EEG), in predicting the risk of future seizures in patients with epilepsy is not well studied. A longer period of monitoring could be more likely to capture either ictal or interictal epileptiform activity. This information may better assist clinical decision making on driving fitness. The goal of this study was to evaluate the use of 6-hour prolonged VEM versus routine EEG in the assessment of future seizure risk and driving fitness for patients with epilepsy.MethodsData on consecutive patients referred for 6-hour prolonged VEM were retrospectively analyzed. Criteria were developed that combined EEG findings and clinical factors to determine each patient's fitness to drive. Seizure relapse outcomes were followed over 2 years.ResultsOf 34 patients, 27 were considered safe to drive following prolonged VEM. Five (19%) of these 27 patients had seizure relapses; all had an obvious precipitant(s) identified including sleep deprivation, excessive alcohol, and missed medication doses. Seven of the 34 patients were deemed unsafe to drive. All seven (100%) had seizure relapses, with unprovoked seizures in four patients. The relative risk of seizure in patients deemed unfit to drive was 5.4 (P = 0.00015). If only the routine EEG component of the recordings were used with the criteria, the relative risk would have been 3.4 (P = 0.037), with nearly double the number of active drivers having seizures. The majority of patients (76%) in this study had idiopathic generalized epilepsy, with a relative seizure risk of 4.0 (P = 0.002) for patients deemed unfit to drive in this subgroup. The focal epilepsy group was small (eight patients) and did not quite achieve statistical significance.ConclusionSix-hour VEM improves the evaluation of driving fitness by better predicting the risk of subsequent seizure relapse for idiopathic generalized epilepsy and possibly focal epilepsy. Prolonged monitoring is superior to routine EEG. Ongoing avoidance of seizure-provoking factors remains paramount to driving safety.     

Seizure severity in children with epilepsy is associated with their parents' perception of stigma

AimsTo develop and implement interventions to improve the quality of life (QOL) in children with epilepsy, it is important for clinicians and researchers to understand the effects of the children's parents' perception of stigma. The purpose of this study was to identify a relationship between patient clinical characteristics and perception of stigma in the parents of children with epilepsy.MethodsParents of children with epilepsy were recruited from our university hospital between April 1, 2005 and March 31, 2012. Items for the Parent Stigma Scale were developed from the literature and open-ended interviews with parents of children with epilepsy about their concerns and fears, including those related to stigma. Parents were asked to respond to five items, each on a 5-point scale from 1 (strongly disagree) to 5 (strongly agree). Assessments were performed for each clinical characteristic, such as child's sex, age at seizure onset, family history of epilepsy, seizure frequency, presence of status epilepticus (SE), presence of treatment-related adverse events, and the scores of each scale.ResultsA total of 52 parents of children with epilepsy and 10 parents of healthy children were enrolled in the study. Parents of children with epilepsy showed significantly higher scores on the questionnaire than parents of healthy children. In multiple regression analysis, greater perceptions of stigma were associated with a seizure frequency of more than one per month (p = 0.0036, B = 1.104, β = 0.402). In contrast, the presence of prior febrile seizures (p = 0.0034, B = − 1.297, β = − 0.308) and family history of epilepsy (p = 0.0066, B = − 1.613, β = − 0.277) were associated with lower perceptions of stigma. Greater parental perceptions of stigma were seen with the presence of monthly seizures.ConclusionsParents of children with epilepsy are at risk of significant perceptions of stigma. Seizure severity, indicated by the presence of monthly seizures, was associated with greater perceptions of stigma in parents. In addition, the presence of prior febrile seizures and family history of epilepsy were associated with fewer perceptions of stigma. The findings of this study emphasize the importance of acknowledging and addressing parental perceptions of stigma.     

Seizure prognosis of patients with low-grade tumors

PurposeSeizures frequently impact the quality of life of patients with low grade tumors. Management is often based on best clinical judgment. We examined factors that correlate with seizure outcome to optimize seizure management.MethodsPatients with supratentorial low-grade tumors evaluated at a single institution were retrospectively reviewed. Using multiple regression analysis the patient characteristics and treatments were correlated with seizure outcome using Engel's classification.ResultsOf the 73 patients with low grade tumors and median follow up of 3.8 years (range 1–20 years), 54 (74%) patients had a seizure ever and 46 (63%) had at least one seizure before tumor surgery. The only factor significantly associated with pre-surgical seizures was tumor histology. Of the 54 patients with seizures ever, 25 (46.3%) had a class I outcome at last follow up. There was no difference in seizure outcome between grade II gliomas (astrocytoma grade II, oligodendroglioma grade II, mixed oligo-astrocytoma grade II) and other pathologies (pilocytic astrocytoma, ependymomas, DNET, gangliocytoma and ganglioglioma). Once seizures were established seizure prognosis was similar between different pathologies. Chemotherapy (p = 0.03) and radiation therapy (p = 0.02) had a positive effect on seizure outcome. No other parameter including significant tumor growth during the follow up period predicted seizure outcome. Only three patients developed new-onset seizures after tumor surgery that were non-perioperative. Anticonvulsant medication was tapered in 14 patients with seizures and 10 had no further seizures. Five patients underwent additional epilepsy surgery with a class I outcome in four. Two patients received a vagal nerve stimulator with >50% seizure reduction.DiscussionSeizures at presentation are the most important factor associated with continued seizures after tumor surgery. Pathology does not influence seizure outcome. Use of long term prophylactic anticonvulsants is unwarranted. Chemotherapy and radiation therapy have a favorable impact on seizure outcome. Additional epilepsy surgery is effective.     

Cerebrospinal fluid tau as a marker of neuronal damage after epileptic seizure

PurposeWhether repeated brief seizures can cause neuronal damage is controversial. Cerebrospinal fluid (CSF) total tau (T-tau) and phosphorylated tau (P-tau) measurements have been suggested for the diagnosis of Alzheimer's disease, and T-tau may also be a marker of axonal damage and neuronal degeneration. We studied T-tau and P-tau levels and P-tau/T-tau ratio in CSF after epileptic seizures in order to determine whether they are increased after seizures.MethodsA total of 54 patients with tonic–clonic or partial secondarily generalized seizures due to various etiologies were studied and CSF obtained within 48 h after the seizure.ResultsThere were no statistical differences in the levels of T-tau (p = 0.09, ANOVA) or P-tau (p = 0.60) between different etiologic groups or controls. No patients with epilepsy of unknown origin had abnormal CSF T-tau whereas 11 patients with acute or remote symptomatic seizures had abnormal T-tau levels and the P-tau/T-tau ratio showed significant differences between the groups and controls (p = 0.003).ConclusionsEpileptic seizures with unknown etiology did not increase CSF tau levels. Abnormal tau levels were associated with either acute or remote symptomatic seizures with known etiology. The presence of elevated CSF tau increases the probability of symptomatic cause in a patient with a seizure.     

Detecting health disparities among Caucasians and African-Americans with epilepsy

ObjectiveThe aim of the study was to determine whether African-Americans and Caucasians who receive care at a tertiary epilepsy center can be distinguished on a variety of demographic, clinical, and psychosocial variables.MethodsWe surveyed 111 consecutive patients followed at a tertiary epilepsy center.ResultsOn univariate analysis, African-Americans had significantly more seizures (P = 0.03), lower scores on the Beliefs About Medicines Questionnaire—Specific (Necessity minus Concerns) (BMQ-S) (P = 0.01), and higher scores on the BMQ—General (BMQ-G) (P = 0.02). In binary logistic regression with race as the target variable, higher seizure frequency remained significantly associated with being African-American (P = 0.04). After ordinal regression with seizure frequency as the target variable, being African-American (P = 0.04) and higher BMQ-G scores (P = 0.02) remained significantly associated with increased seizure frequency.ConclusionCompared with Caucasians, African-Americans have higher seizure frequency and scores on the BMQ indicating a higher mistrust of medications. Aside from race, attitudes toward medications are also independently associated with seizure control.     

Physical injuries in patients with epilepsy and their associated risk factors

ObjectivesTo determine the frequency, nature, and risk factors associated with physical injuries in patients with epilepsy.MethodsIn this retrospective cohort study, patients 18 years of age and older with active epilepsy for at least 1 year were included. A questionnaire (including age, gender, education, type of epilepsy, seizure frequency, having aura, drug compliance, polypharmacy, comorbidity, type and place of injury) was completed from patients and healthy individuals. Statistical analyses were performed using multiple logistic regression and Chi-square tests.Results264 patients with epilepsy and 289 healthy participants were studied. Among patients, 8.7% reported severe injuries and 44.3% had mild injuries. Most patients reported soft tissue injuries, followed by dental injury, burn, and head injury. Severe injuries were 2.9 times more frequent among patients having generalized tonic–clonic seizures (GTCS) compared to healthy control; this was not statistically significant (P = 0.07). No patient reported having severe injuries due to SPS, myoclonic or absence seizures. Mild injuries were 10.3 times more frequent among those with GTCS compared to healthy control (P = 0.001). The relative risk for having injury in patients compared to control group was 3.42 (95% confidence interval: 2.50–4.69). Injury was significantly related to having GTCSs, illiteracy, having fall with seizures, comorbidity and having uncontrolled seizures.ConclusionPhysical injuries are common in patients with epilepsy; however most of these injuries are mild. Severe injuries rarely occur in patients with seizures other than GTCS.     

Predictors of seizure occurrence in children undergoing pre-surgical monitoring

PurposeLong-Term-Monitoring (LTM) is a valuable tool for seizure localization/lateralization among children with refractory-epilepsy undergoing pre-surgical-monitoring. The aim of this study was to examine the factors predicting occurrence of single/multiple seizures in children undergoing pre-surgical monitoring in the LTM unit.MethodsChart review was done on 95 consecutive admissions on 92 children (40 females) admitted to the LTM-unit for pre-surgical workup. Relationship between occurrence of multiple (≥3) seizures and factors such as home seizure-frequency, demographics, MRI-lesions/seizure-type and localization/AED usage/neurological-exam/epilepsy-duration was evaluated by logistic-regression and survival-analysis. Home seizure-frequency was further categorized into low (up-to 1/month), medium (up-to 1/week) and high (>1/week) and relationship of these categories to the occurrence of multiple seizures was evaluated. Mean length of stay was 5.24 days in all 3 groups.ResultsHome seizure frequency was the only factor predicting the occurrence of single/multiple seizures in children undergoing presurgical workup. Other factors (age/sex/MRI-lesions/seizure-type and localization/AED-usage/neurological-exam/epilepsy-duration) did not affect occurrence of single/multiple seizures or time-to-occurrence of first/second seizure.Analysis of the home-seizure frequency categories revealed that 98% admissions in high-frequency, 94% in the medium, and 77% in low-frequency group had at-least 1 seizure recorded during the monitoring. Odds of first-seizure increased in high vs. low-frequency group (p = 0.01). Eighty-nine percent admissions in high-frequency, 78% in medium frequency, versus 50% in low-frequency group had ≥3 seizures. The odds of having ≥3 seizures increased in high-frequency (p = 0.0005) and in medium-frequency (p = 0.007), compared to low-frequency group. Mean time-to-first-seizure was 2.7 days in low-frequency, 2.1 days in medium, and 2 days in high-frequency group. Time-to-first-seizure in high and medium-frequency was less than in low-frequency group (p < 0.0014 and p = 0.038).ConclusionMajority of the admissions (92%) admitted to the LTM-unit for pre-surgical workup had at-least one seizure during a mean length of stay of 5.24 days. Home seizure-frequency was the only predictor influencing occurrence of single/multiple seizures in the LTM unit. Patients with low seizure-frequency are at risk for completing the monitoring with less than the optimum number (<3) of seizures captured.     

A reduction of sleep spindles heralds seizures in focal epilepsy

ObjectivesSleep has profound effects on epilepsy. It may alter the occurrence of interictal discharges (IEDs) and seizures. Vice versa, an active epilepsy changes sleep. Sleep spindles are typically associated with an increase of IEDs. We examined whether seizures change the number and power of spindles preceding nightly seizures.MethodsWe retrospectively examined the nightly EEG recordings of presurgical epilepsy patients from our EEG-video-monitoring unit. We evaluated the 200 s before the EEG seizure onset for spindle density (spindles per minute) and spindle power and compared that to the interictal baseline sleep.ResultsThe spindle density and the spindle power decreased significantly before the first seizure. The reduction before secondarily generalized seizures (8.7 ± 2.5; p = 0.001) was more pronounced than before focal seizures (10.5 ± 2.5; p = 0.003) compared to baseline (12.2 ± 2.7). This finding was more pronounced in extratemporal lobe epilepsies than in temporal lobe epilepsies. The reduction of spindle power was also significant and was more pronounced in XTLE. These results were consistent for all other seizures during sleep, the mean spindle density decreased significantly in all focal (10.2 ± 1.9; p = 0.001) and generalized preictal period (8.8 ± 2.4; p = 0.001) compared to the mean interictal period (12.1 ± 2.1). These were also more significant in XTLE than TLE group.ConclusionsOur data demonstrate that the occurrence of seizures and propensity of seizure generalisation in focal epilepsy is modulated by specific characteristics of light sleep such as sleep spindles.SignificanceThis study supports the notion that changes in the epileptic network precede the seizure onset and have an influence on seizure generation and termination.     

Seizure recurrence in patients with solitary cystic granuloma or single parenchymal cerebral calcification: A comparative evaluation

BackgroundSolitary cysticercus granuloma and single parenchymal calcified lesion are two common neuroimaging abnormalities in Indian patients with epilepsy. In this study, we evaluated the frequency and predictors of seizure recurrence in patients presenting with new onset epilepsy or single epileptic seizures and these two different imaging findings.Materials and methodsWe enrolled 115 patients with newly diagnosed epilepsy. All patients were clinically evaluated and were treated with oxcarbazepine. No anti-helminthic treatment was prescribed. The patients were followed up for 6 months. In the solitary cystic granuloma group, repeat computed tomography was done after 6 months.ResultsThe study included 80 patients with solitary cysticercus granuloma and 35 patients with a single calcified lesion. Twenty (25%) patients with solitary cysticercus granuloma and 12 (34.3%) patients with parenchymal calcified lesion had a seizure recurrence during the study period (p = 0.307). After 6 months, 57 (71.3%) patients in the solitary cysticercus granuloma group demonstrated complete resolution of the granuloma and in 21 (26.2%) patients the granuloma transformed into a calcified lesion. In the solitary cysticercus granuloma group, a family history of seizure, serial seizures and calcification on follow-up neuroimaging (p < 0.05) were significantly associated with recurrence of seizures. In patients with a single parenchymal calcified lesions, electroencephalographic abnormalities and serial seizures (p = <0.05) were significant predictors of recurrence. Kaplan–Meier statistics revealed that the seizure recurrence rate was insignificantly higher in patients with calcified lesions than in patients with solitary cysticercosis granulomas.ConclusionIn conclusion, in patients with solitary cysticercus granuloma, a family history of seizures, serial seizures and calcification of the granuloma, and in patients with a calcified brain lesion, electroencephalographic abnormalities, family history of epilepsy and serial seizures were associated with an increased risk of seizure recurrence.     

Rufinamide for refractory focal seizures: An open-label,multicenter European study

PurposeThe present study aimed to assess the efficacy and tolerability of rufinamide as adjunctive drug for the treatment of a large series of children, adolescents and adults with refractory cryptogenic or symptomatic focal epilepsy.MethodsPatients were recruited in a prospective, add-on, open-label treatment study from six Italian and one German centers for pediatric and adolescent epilepsy care. Inclusion criteria were: (1) age 3 years or more; (2) diagnosis of cryptogenic or symptomatic focal epilepsy refractory to at least three previous antiepileptic drugs (AEDs), alone or in combination; (3) more than one seizure per month in the last 6 months; (4) use of at least one other AED, but no more than three, at baseline; (5) informed consent from parents and/or caregivers.ResultsSixty-eight patients (40 males, 28 females), aged between 3 and 63 years (mean 19.9 years, median 16.0) ± SD 12.58, with cryptogenic (28 pts, 41.2%) or symptomatic focal epilepsy (40 pts, 58.8%), were recruited in the study. After a mean follow-up period of 10.4 ± 10.29 months, twenty-two patients (32.3%) had a 50–99% seizure reduction, and none became seizure-free. Twelve patients (17.6%) had a 25–49% seizure decrease, while in 30 (44.1%) seizure frequency was unchanged. A seizure worsening was reported in 5 patients (7.3%). A better response to rufinamide occurred in frontal lobe seizures (51.6%) and secondary generalized tonic–clonic seizures (50%).ConclusionRufinamide was effective against focal-onset seizures, particularly in the treatment of secondary generalized frontal lobe seizures.     

Electroencephalographic features of benign adult familial myoclonic epilepsy

ObjectiveTo investigate electroencephalographic (EEG) features of benign adult familial myoclonic epilepsy (BAFME).MethodsWe reviewed interictal EEG features in patients with BAFME treated between April 2005 and November 2012 at a tertiary referral center. The diagnostic criteria for BAFME were the presence of infrequent generalized tonic–clonic seizures, myoclonus or myoclonic seizures, and autosomal dominant inheritance. Interictal EEG findings of epilepsy with generalized tonic–clonic seizure only (EGTCS) were reviewed for comparison. We randomly selected 10 generalized spike/polyspike and wave complexes (GSW) for each BAFME patient and measured the duration of them. Photic stimulation and hyperventilation were performed in all.ResultsNineteen (eight men, 11 women) patients with BAFME were included in this study. The mean frequency of GSW was 4.3 ± 1.0 Hz (mean ± SD, n = 14) in BAFME and 3.2 ± 0.8 Hz (n = 10) in EGTCS. There was a statistically significant difference (p = 0.008) between the two. Photoparoxysmal responses (PPR) were noted in 18 (95%) patients with BAFME but 1 (10%) with EGTCS.ConclusionFaster frequency of GSW, compared with that in EGTCS, accompanied by PPR may be characteristic EEG features of BAFME.SignificanceThese findings may lead the diagnosis of BAFME.     

Emergent EEG in the emergency department in patients with altered mental states

ObjectiveTo evaluate whether EEG performed within 30 min of referral by an ED physician helps establish diagnosis and/or changes management and in which clinical setting.MethodsSingle-center prospective cohort intervention study 1 day/week, of sequentially referred adult patients with clinical seizures or altered mental status (AMS). Standard EEGs were performed by an EEG technician using a commercially available cap, interpreted by an epileptologist, immediately reported to the ED physician and a utility survey completed. Quality and interpretation of 20 min EEGs was compared to pre-specified 5 min segments of each EEG using the kappa coefficient.ResultsOver 1 year, 82 patients underwent ED EEG. Tonic clonic seizure activity had occurred in 33%. Mean time for EEG setup was 13.1 ± 6.2 min. EEG assisted the diagnosis in 51%, changed ED management in 4% and would be ordered again if EEG was available in 46%. Positive utility of EEG was significantly associated with toxicologic, psychiatric and endocrine/metabolic causes of AMS vs. other causes (p < 0.001) and sudden onset AMS (p = 0.007). Independent predictors of whether ED EEG would be ordered if available were witnessed seizures (p = 0.01), no prior head trauma (p = 0.001) and survey respondent being a physician assistant (vs. MD) (p = 0.02). The 5 (vs. 20) min EEG presented good agreement on waveform shape/amplitude (kappa = 0.78), artifact (kappa = 0.75) and interpretation categories (all kappa levels ?0.70).ConclusionsRapid availability of standard full-montage EEG in the ED is feasible and helps establish a diagnosis in about half of AMS patients, but rarely changes management. An abbreviated 5 min full-montage EEG presents adequate reliability which may improve use in the ED.SignificanceSpecific presentations of AMS offer the best diagnostic benefit for EEG in the ED.