Factors associated with lack of response to valproic acid monotherapy in juvenile myoclonic epilepsy

PurposeTo determine factors associated with lack of response to valproic acid (VPA) in juvenile myoclonic epilepsy (JME).MethodRetrospective analysis of clinical and EEG data of 201 patients with JME who had at least 3 years follow up was performed. Psychiatric evaluation was performed using ICD-10 by structured clinical interview. Patients were divided into two groups: VPA responders (seizure free for 2 or more years) and those with lack of response to VPA. Effect size for non-response and correlations for variables significantly different between the groups was performed, the findings were confirmed by ROC curves.ResultsThe mean duration of follow up was 7.75 (range 3–12) years; 55.2% were males. Focal semiologic features were noted is 16%. EEG was abnormal in 67%; focal EEG abnormalities were noted in 32.8%. Coexisting psychiatric disorders (PDs) were found in 33.3%. Lack of response to VPA was noted in 19%. Diagnosis of PDs and focal EEG abnormalities significantly increased the risk of VPA non-responsiveness by 5.54 (95% CI of 2.60–11.80; p < 0.0001) and 3.01 times respectively (95% CI of 1.40–6.47; p < 0.008). Diagnosis of PDs showed significant correlation (r = 0.332; p < 0.0001) and association (AUC 0.700; p < 0.0001) with lack of response to VPA. Though focal EEG abnormalities increased the chances, it did not correlate with lack of response to VPA.ConclusionLack of response to VPA was noted 19% of patients with JME. Coexisting PDs showed significant correlation and association with lack of response to VPA.     

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.     

Prevalence of personality disorders in patients with chronic migraine

BackgroundThe present study aimed to investigate the prevalence of personality disorders (PDs) in patients with chronic migraine (CM).MethodsThis study included 105 CM patients who were diagnosed according to the criteria of the International Headache Society (IHS) and 100 healthy volunteers. PDs were diagnosed with the Structured Clinical Interview for DSM, Revised Third Edition Personality Disorders, and pain severity and level of disability were assessed with the Migraine Disability Assessment (MIDAS) test.ResultsOf the 105 CM patients, 85 (81%) had at least one PD. PDs were more prevalent in the patient group than in the healthy control group, and the most common PDs were obsessive–compulsive (n = 53, 50.5%), dependent (n = 20, 19%), avoidant (n = 20, 19%), and passive–aggressive (n = 14, 13.3%) PDs. The MIDAS scores of the CM patients with PDs were higher than those of the CM patients without PDs.ConclusionPDs, particularly obsessive–compulsive, dependent, avoidant, and passive–aggressive PDs, were frequently observed in CM patients in the present study.     

Temporal lobe surgery in medically refractory epilepsy: A comparison between populations based on MRI findings

IntroductionHigh resolution MRI findings suggestive of mesial temporal sclerosis (MRI-MTS) correlate with good outcome after surgery. However, a large group of patients present with normal brain MRI (N-MRI) and temporal lobe epilepsy (TLE). We aim to compare pre-operative ictal EEG patterns in predicting surgical outcomes in the population with MRI-MTS vs. N-MRI after selective anterior-mesial temporal lobe (AMTL) resection.Methods241 patients with unilateral anterior ictal EEG findings underwent selective AMTL resection. 143 MRI-MTS and 98 N-MRI patients were identified. Outcome was based on the modified Engel classification, ictal EEG pattern at seizure onset, demographics and MRI findings.ResultsSeizure-free outcome was seen in the MRI-MTS in 79% of patients, compared to 59.1% (p < .005) of the N-MRI group. No significant difference was identified in ictal EEG patterns at presentation between groups. Class I outcome was achieved in 78.9% of patients that had theta rhythm and MRI-MTS compared to 57.9% of patients that had theta rhythm and N-MRI (p < 0.05).Discussion and conclusionSurgical treatment for mesial TLE is effective. Positive MRI suggestive of mesial temporal sclerosis (MTS) predicts better seizure control after surgery. Theta rhythm is the most common ictal pattern and seems to carry the best prognosis for TLE. However, a well-selected group of patients with N-MRI will benefit from surgical intervention, and similar outcome to MRI-MTS patients can be achieved if delta ictal EEG pattern is presented at initial onset. Early referral to an epilepsy center cannot be emphasized enough, even in situations when high-resolution brain MRI is normal.     

Should we treat patients with impaired consciousness and periodic patterns on EEG?

PurposeThe significance of periodic EEG patterns in patients with impaired consciousness is controversial. We aimed to determine if treating these patterns influences clinical outcome.MethodWe studied all patients who had periodic discharges on their EEG recordings from January 2007 to December 2009. Patients with clinical seizures within the preceding 24 h, or with unequivocal electrographical seizure activity were excluded. Logistic regression was performed to analyze for factors associated with (a) mortality (b) functional status (c) resolution of EEG pattern.ResultsOf the 4246 patients who had EEG, 111 (2.6%) had periodic EEG patterns. 64 met inclusion criteria. In adjusted analysis, higher mortality was associated with acute symptomatic etiology (OR 17.74, 95% CI 1.61–196.07, p = 0.019), and presence of clinical seizures (OR 4.73, 95% CI 1.10–20.34, p = 0.037). For each unit decrement of GCS, the odds of inpatient mortality and a poorer functional state on discharge increased by 23% (95% CI 7–37%, p = 0.009) and 33% (95% CI 9–51%, p = 0.011) respectively. Administration of abortive therapy was an independent risk factor for poorer functional status on discharge (adjusted OR 41.39, 95% CI 2.88–594.42, p = 0.006), while patients with history of pre-existing cerebral disease appeared more likely to return to baseline functional status on discharge (unadjusted OR 5.00, 95% CI 1.40–17.86, p = 0.013).ConclusionTreatment of periodic EEG patterns does not independently improve clinical outcome of patients with impaired conscious levels. Occurrence of seizures remote to the time of EEG and lower GCS scores independently predict poor prognoses.     

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.     

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.     

Duration of electroencephalographic recordings in patients with epilepsy

PurposePrevious studies have demonstrated different diagnostic yields with electroencephalography (EEG). Due to the small sample sizes or different patient populations (outpatients or inpatients only) in these previous studies, the clinical use of routine EEG and outpatient/inpatient video-EEG monitoring (VEM) needs further clarification. In this study, we investigated EEGs obtained from patients referred by epileptologists; by comparing the results of different EEG methods, we sought to determine the optimal durations and specific types of EEG recordings for different clinical situations.MethodsThe data from 335 routine EEGs, 281 3 h outpatient VEMs, and 247 inpatient VEMs (>48 h) were reviewed. We analyzed the latency to the first epileptiform discharge or clinical event.ResultsIn patients undergoing outpatient VEMs, 48% of the first epileptiform discharges appeared within 20 min, and 64% appeared within 30 min. In patients undergoing inpatient VEMs, 21.2% had their first attack within 3 h. The second peak of event occurrence was during the 33rd–36th h. Only 3.5% of the seizures were recorded after 57 h. The detection rate of epileptiform discharges was higher for 3 h outpatient VEM than for routine EEG (54.1% versus 16.4%, p < 0.01). Epileptic and/or nonepileptic events were recorded in 45.8% of the inpatient VEMs, the diagnostic yield of which was higher than for outpatient VEMs (p < 0.01). Since the patients in this study had been selected to limit the bias between each group, the diagnostic yield of EEGs in this study are likely to have been higher than those found in routine practice. Patients with generalized epilepsy had a shorter latency to the first epileptiform discharge compared to patients with localization-related epilepsy (mean, 22.1 min versus 33.9 min, p < 0.05).ConclusionsTwo-thirds of epileptiform discharges were detected within 30 min of VEM. A 30-min recording is recommended for routine EEG examinations that aim to detect epileptiform discharges. A 3 h outpatient VEM is a reasonable option when a routine EEG fails to detect epileptiform discharges. The latency to the first epileptiform discharge was shorter in patients with generalized epilepsy than in patients with localization-related epilepsy. 48 h of inpatient VEM might be adequate for detecting the target events.     

The duration of temporal lobe epilepsy and seizure outcome after epilepsy surgery

To assess the effect of the duration of epilepsy on the outcome of epilepsy surgery in non-lesional medically refractory temporal lobe epilepsy we reviewed the outcome of 76 patients.MethodsAll patients had anterior temporal resections for “non-lesional” temporal epilepsy (excluding any patient with tumours or vascular malformations but including patients with hippocampal sclerosis). Outcome at one year was assessed using Engel's scale.Results67% had a good outcome (Engel I or II). The mean duration of epilepsy was 23.0 years (range 2.9–46.9 years). Overall, there was no significant difference between patients with good outcome (mean duration 22.4 years) and poor outcome (mean duration 24.2 years) (p = 0.49). The proportion of patients with good outcome was slightly higher in the shorter duration groups. (Duration less than 10 years 75%, 10–19 years 71%, 20–29 years 65%, 30–39 years 62%, and 40–49 years 60% good outcome, p = 0.95).ConclusionWe found no significant associations between outcome and duration of epilepsy.     

EEG features and epilepsy in MECP2-mutated patients with the Zappella variant of Rett syndrome

ObjectiveTo assess the presence/absence of peculiar EEG features and epilepsy in MECP2-mutated Rett patients with the Zappella–Rett variant (Z-RTT) also known as preserved speech variant.MethodsRetrospective analysis of 16 (age 19.4 ± 8.4 years; range 8–38 years) MECP2 mutated Z-RTT cases, including 11 high or intermediate performance (HIP), and five low-performance (LP) patients was performed. Peculiar EEG features were analyzed as a function of the HIP or LP Z-RTT categories: (1) centro-temporal spikes, (2) multifocal EEG activity, (3) EEG encephalopathy (i.e. multifocal EEG activity associated with the presence of background slowing and diffuse slow activity), (4) spindles and K-complex. Furthermore, we assessed the occurrence of epilepsy.Correlations between electroclinical features and category of Z-RTT genotype (missense or truncation mutation) were also tested.ResultsThe Z-RTT HIP group showed a very abnormal EEG (presence of centro-temporal spikes: p = 0.004808), although the cases studied were not epileptogenic and did not develop encephalopathy. The LP group showed multifocal EEG activity (p = 0.000229), EEG encephalopathy (p = 0.000229) and epilepsy (p = 0.299451). No significant differences between the prevalence of centro-temporal spikes, multifocal EEG activity, EEG encephalopathy, and epilepsy between the patients with the truncation or missense mutation were observed.ConclusionsEEG electrophysiological patterns and epileptogenic susceptibility differ in Z-RTT according to the level of performance (i.e. HIP or LP).SignificanceThese results indicate that HIP and LP Z-RTT should be considered as distinct entities, not only on a clinical basis, but also as it concerns EEG features and epileptogenic susceptibility.These results could offer support in the practical management of patients and family counseling.     

Impact of a family history of epilepsy on the diagnosis of epilepsy in southern Saudi Arabia

PurposeEpilepsy can develop at any age for reasons that remain poorly understood. The aim of this study was to determine the impact of a family history of epilepsy (FHE) on the incidence and recurrence of seizures.MethodsThis retrospective study was conducted in Aseer central hospital, Abha, Saudi Arabia between January and June 2012. The medical records of 420 patients were analyzed to test the impact of FHE on the risk factors, etiology and diagnosis of epilepsy determined by magnetic resonance imaging (MRI) and electroencephalography (EEG).Results420 patients were studied. Idiopathic epilepsy was seen in 140 patients (33%), symptomatic in 152 (36%), and cryptogenic in 128 patients (30%). FHE was seen in 113 patients (27%), which was associated with younger at the disease onset (15 years vs 20 years, p < 0.05). Idiopathic epilepsy was seen more in patients with FHE (43% vs 30%, p value <0.05), and generalized seizures (primary or secondary) were also seen more in patients with FHE (51% vs 36%, p value <0.05). Abnormal EEG was also seen more in patients with FHE (79% vs 66%, p < 0.05). Multivariate regression analysis showed that temporal epileptic discharges were the best predictor for the presence of FHE (p < 0.05, OR = 3.1, 95% CI 1.7–5.8), more than idiopathic epilepsy or younger age at epilepsy onset.ConclusionsFHE has a significant impact on epilepsy, its classifications, and the EEG findings, and may underlie the presence of a genetic etiology, which could be related to a high incidence of consanguinity seen in our population. Temporal epileptic discharges were the best predictor for FHE, which may suggest the presence of familial TLE.     

Long-term outcome and predictors of resective surgery prognosis in patients with refractory extratemporal epilepsy

PurposeWe analyzed the long-term postoperative outcome and possible predictive factors of the outcome in surgically treated patients with refractory extratemporal epilepsy.MethodsWe retrospectively analyzed 73 patients who had undergone resective surgery at the Epilepsy Center Brno between 1995 and 2010 and who had reached at least 1 year outcome after the surgery. The average age at surgery was 28.3 ± 11.4 years. Magnetic resonance imaging (MRI) did not reveal any lesion in 24 patients (32.9%). Surgical outcome was assessed annually using Engel's modified classification until 5 years after surgery and at the latest follow-up visit.ResultsFollowing the surgery, Engel Class I outcome was found in 52.1% of patients after 1 year, in 55.0% after 5 years, and in 50.7% at the last follow-up visit (average 6.15 ± 3.84 years). Of the patients who reached the 5-year follow-up visit (average of the last follow-up 9.23 years), 37.5% were classified as Engel IA at each follow-up visit. Tumorous etiology and lesions seen in preoperative MRI were associated with significantly better outcome (p = 0.035; p < 0.01). Postoperatively, 9.6% patients had permanent neurological deficits.ConclusionSurgical treatment of refractory extratemporal epilepsy is an effective procedure. The presence of a visible MRI-detected lesion and tumorous etiology is associated with significantly better outcome than the absence of MRI-detected lesion or other etiology.     

Is reoperation an option for patients with temporal lobe epilepsy after failure of surgery?

PurposeEpilepsy surgery is the most efficacious therapeutic modality for patients with medically refractory focal epilepsies, but surgical failures remain a challenge to the epilepsy treatment team. The aim of present study was to evaluate the postoperative outcome of patients who underwent reoperation after a failed epilepsy surgery on the temporal lobe.MethodsWe systematically analyzed the results of comprehensive preoperative evaluations before the first surgery, and before and after reoperation in 17 patients with drug resistant temporal lobe epilepsies.ResultsOverall, 13 of 17 patients (76.5%) improved after reoperation: five patients (29.4%) were completely seizure free after reoperation (median duration 60 months, range 12–72); six patients (35.3%) were seizure free at least 12 month before observation points (median duration 120.5 months, range 35–155) and two patients (11.8%) had a decrease in seizure frequency. Four patients (23.5%) remained unchanged with respect to seizure frequency and severity. There was no correlation between the improvement in seizure outcome after reoperation and other clinical data except of the history of traumatic brain injury (TBI). The patients who had no history of TBI improved after reoperation, compared to patients with TBI (p = 0.044). The postoperative seizure outcome of patients with incongruent Video-EEG results before the first surgery (p = 0.116) and before reoperation (p = 0.622) was not poorer compared to patients with congruent Video-EEG results.ConclusionsReoperation can considerably improve the operative outcome of the first failed epilepsy surgery in patients with drug resistant temporal lobe epilepsies. Epilepsy centres should be encouraged to report the results of failed epilepsy surgeries.     

Clinical characteristics and treatment responses in new-onset epilepsy in the elderly

PurposeEpidemiologic studies have shown that the incidence of epilepsy is the highest in the elderly population. Because the elderly constitutes the most rapidly growing population, epilepsy in this group is an important health issue worldwide. To identify the characteristics of epilepsy in the elderly, we reviewed our experience at a tertiary referral center in Japan.MethodsWe searched all electronic medical records of the past 6 years at the epilepsy clinic of the hospital affiliated to our University-affiliated hospital. We defined an elderly person as an individual aged 65 years and above. All patients underwent history and physical examinations, 3 T magnetic resonance imaging and/or computer tomography, and electroencephalogram (EEG). The diagnosis of epilepsy, age of onset, etiology, and antiepileptic medication were recorded.ResultsWe identified 70 patients who developed epilepsy after the age of 65 years. The mean age of seizure onset was 73.1 years and 52.9% patients were males. Complex partial seizures (CPS) without secondarily generalization (n = 33, 47.1%) were most frequent. The most frequent diagnosis was temporal lobe epilepsy (n = 50, 71.4%). Etiological diagnosis was possible in nearly 50% patients, including those with cerebrovascular disease. A clear cause of epilepsy was not found (i.e., non-lesional epilepsy) in 52.8% patients. Interictal EEG revealed focal epileptiform discharges in 72.9% (n = 51) patients. Of the 54 patients who were followed more than 1 year, 42 patients (77.8%) were on antiepileptic monotherapy and 52 patients (96.3%) had been seizure-free for more than 1 year.ConclusionThe most frequent diagnosis in our cohort of elderly persons with new-onset epilepsy was temporal lobe epilepsy. Non-lesional temporal lobe epilepsy was not uncommon. Epileptogenecity was relatively low in elderly patients and they responded well to antiepileptic medication.     

Effect of successful epilepsy surgery on subjective and objective sleep parameters – a prospective study

ObjectiveTo evaluate the effect of surgery on subjective and objective measures of sleep quality among patients with medically refractory focal epilepsy.MethodsIn a prospective cohort study, patients with medically refractory epilepsy undergoing epilepsy surgery were recruited. All patients were assessed seven days pre- and three months post-surgery in terms of history pertaining to epilepsy and sleep, Epworth sleepiness score (ESS), one week sleep log and over night polysomnography (PSG).ResultsAmong 17 patients (mean age 18, 11 males), seizure frequency had reduced (p = 0.04) and self reported sleep parameters had significantly improved (reduced total duration of night time sleep, regularity on one week sleep log and ESS (p < 0.05)) three months following epilepsy surgery. Patients with good surgical outcome (n = 12) showed reduced seizure frequency (p = 0.01) and reduced ESS with corresponding reduction in arousal index (AI) (p = 0.02) and increase in total sleep time (p = 0.03), postoperatively. Three patients in the good surgical outcome group showed reduction in apnea–hypopnea index (AHI) from more than five to less than five. There was no significant change either in seizure frequency, self reported clinical parameters or PSG parameters among patients with poor surgical outcome.ConclusionEpilepsy surgery improves subjective sleep parameters in patients with medically refractory epilepsy during the early post operative period. Successful epilepsy surgery may improve objective (PSG documented) sleep quality, sleep architecture and obstructive sleep apnea with resultant reduction in excessive daytime sleepiness.     

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.     

Prediction of rhythmic and periodic EEG patterns and seizures on continuous EEG with early epileptiform discharges

BackgroundContinuous EEG (cEEG) is necessary to document nonconvulsive seizures (NCS), nonconvulsive status epilepticus (NCSE), as well as rhythmic and periodic EEG patterns of ‘ictal–interictal uncertainty’ (RPPIIU) including periodic discharges, rhythmic delta activity, and spike-and-wave complexes in neurological intensive care patients. However, cEEG is associated with significant recording and analysis efforts. Therefore, predictors from short-term routine EEG with a reasonably high yield are urgently needed in order to select patients for evaluation with cEEG.ObjectiveThe aim of this study was to assess the prognostic significance of early epileptiform discharges (i.e., within the first 30 min of EEG recording) on the following: (1) incidence of ictal EEG patterns and RPPIIU on subsequent cEEG, (2) occurrence of acute convulsive seizures during the ICU stay, and (3) functional outcome after 6 months of follow-up.MethodsWe conducted a separate analysis of the first 30 min and the remaining segments of prospective cEEG recordings according to the ACNS Standardized Critical Care EEG Terminology as well as NCS criteria and review of clinical data of 32 neurological critical care patients.ResultsIn 17 patients with epileptiform discharges within the first 30 min of EEG (group 1), electrographic seizures were observed in 23.5% (n = 4), rhythmic or periodic EEG patterns of ‘ictal–interictal uncertainty’ in 64.7% (n = 11), and neither electrographic seizures nor RPPIIU in 11.8% (n = 2). In 15 patients with no epileptiform discharges in the first 30 min of EEG (group 2), no electrographic seizures were recorded on subsequent cEEG, RPPIIU were seen in 26.7% (n = 4), and neither electrographic seizures nor RPPIIU in 73.3% (n = 11). The incidence of EEG patterns on cEEG was significantly different between the two groups (p = 0.008). Patients with early epileptiform discharges developed acute seizures more frequently than patients without early epileptiform discharges (p = 0.009). Finally, functional outcome six months after discharge was significantly worse in patients with early epileptiform discharges (p = 0.01).ConclusionsEpileptiform discharges within the first 30 min of EEG recording are predictive for the occurrence of ictal EEG patterns and for RPPIIU on subsequent cEEG, for acute convulsive seizures during the ICU stay, and for a worse functional outcome after 6 months of follow-up.This article is part of a Special Issue entitled Status Epilepticus.     

Predictive factors of postoperative outcome in the elderly after resective epilepsy surgery

ObjectiveTo evaluate the efficiency of resective epilepsy surgery (RES) in patients over 50 years and determine prognostic factors.ResultsOver the 147 patients over 50 years (54.9 ± 3.8 years [50–69]) coming from 8 specialized French centres for epilepsy surgery, 72.1%, patients were seizure-free and 91.2% had a good outcome 12 months after RES. Seizure freedom was not associated with the age at surgery or duration of epilepsy. In multivariate analysis, seizure freedom was associated with MRI and neuropathological hippocampal sclerosis (HS) (P = 0.009 and P = 0.028 respectively), PET hypometabolism (P = 0.013), temporal epilepsy (P = 0.01). On the contrary, the need for intracranial exploration was associated with a poorer prognosis (P = 0.001). Postoperative number of antiepileptic drugs was significantly lower in the seizure-free group (P = 0.001). Neurological adverse event rate after surgery was 21.1% and 11.7% of patients had neuropsychological adverse effects overall transient.ConclusionsRES is effective procedure in the elderly. Even safe it remains at higher risk of complication and population should be carefully selected. Nevertheless, age should not be considered as a limiting factor, especially when good prognostic factors are identified.     

Incidence of recurrent seizures following hospital discharge in patients with LPDs (PLEDs) and nonconvulsive seizures recorded on continuous EEG in the critical care setting

PurposeContinuous EEG (cEEG) has helped to identify nonconvulsive seizures (NCS) and nonconvulsive status epilepticus (NCSE) along with lateralized periodic patterns (LPDs or PLEDs) in ICU patients with much higher frequency than previously appreciated, but understanding their implications may be more complex. The aim of this study was to investigate the incidence of recurrent seizures after hospital discharge and their associated factors in patients with PLEDs and NCS in the critical care setting.MethodsAfter IRB approval, we used our EEG reporting database to find 200 consecutive patients who had PLEDs and/or NCSs on cEEG. Patients with less than 3 months of follow-up were excluded. Remaining patients were divided into three groups: PLEDs + Seizure (NCS/NCSE), PLEDs only, and Seizures (NCS/NCSE) only. Medical records were reviewed to gather demographical and clinical details. Univariate data analysis was done using JMP 9.0 (Marlow, Buckinghamshire, UK).ResultsThere were 51 patients in ‘PLEDs + Seizure’ group, 45 in ‘PLEDs only’ group, and 22 in ‘Seizure only’ group. Ischemic stroke, hemorrhage, and tumors were the top three etiologies. Nearly 47% of our study population had postdischarge seizures during a mean follow-up period of 11.9 (+/− 6) months. We found that 24.4% of patients in the PLEDs only group had seizures after discharge, which increased to 60.7% if they had seizures as well during their ICU stay. Slightly more than 52% of patients had a postdischarge EEG, of which, 59% was in the form of inpatient cEEG during a rehospitalization, accounting for 30.5% of the total study population. It was an indicator of high readmission rates in this population.ConclusionAlmost every other patient with PLEDs and/or NCS on cEEG had seizures after ICU discharge. A quarter of patients on cEEG in the ICU with PLEDs alone had seizures after discharge, and after excluding prior epilepsy, 17% of patients with PLEDs had seizures on follow-up. This was dramatically increased with the recording of PLEDs with NCS, with 60% of patients having seizures after discharge from the ICU and 48% of patients after excluding prior epilepsy. Patients with NCS on cEEG alone had 63% chance of seizure recurrence that dropped to 38% with exclusion of prior epilepsy. Future studies are needed to define the postdischarge outcomes including seizure recurrence in this patient population.This article is part of a Special Issue entitled “Status Epilepticus”.     

Long-term outcome and tolerability of the ketogenic diet in drug-resistant childhood epilepsy—The Austrian experience

PurposeTo evaluate the long-term efficacy/tolerability of the ketogenic diet (KD) in paediatric drug-resistant epilepsies.MethodsData from children who were treated between 1999 and 2008 and had continuous follow-up of at least 6 months after initiation of the KD were analysed retrospectively. Response was defined as ≥50% seizure reduction. Treatment effects on EEG, developmental outcome and the “outcome-predictive” value of various clinical factors were also assessed.Results50 children (22 boys; mean age 4.5 years ± 3.55) were included. Mean follow-up was 3.93 ± 2.95. 50% of the patients were responders, 48% of them became seizure free. 50% were non-responders, 20% of them deteriorated. In responders, EEG background activity improved significantly (p = 0.014) and a significantly lower rate of epileptic discharges (p = 0.009) was seen after 6 months. In addition, neurological examination findings demonstrated significant developmental progress (p = 0.038).Favourable treatment outcome was associated with a shorter disease duration (p = 0.025) and generalised tonic clonic seizures (p = 0.059). No further significant outcome predictors were detected. However, response was 44% in patients with infantile spasms, 62.5% in those with Dravet syndrome and 50% in Lennox-Gastaut-syndrome.Side effects occurred in 28%, but discontinuation of the KD was not required in any case. They most often observed with concomitant topiramate (p = 0.001) and valproate (p = 0.046).ConclusionDespite the retrospective nature of the study and the inhomogeneous patient sample, we found good long-term effects of the KD on seizure frequency, EEG and neurological development.