Definition of drug resistant epilepsy: consensus proposal by the ad hoc Task Force of the ILAE Commission on Therapeutic Strategies

Epilepsy care pathway: The Finnish model

OBJECTIVE

Integrated care pathways are essential for consistent, effective epilepsy care, offering equal access and quality regardless of socioeconomic status. They must align with the WHO Global Action Plan on Epilepsy, ensuring best practices and cost-effective management. We describe the Finnish national epilepsy care pathway, which includes multiple levels of care, from initial diagnosis to long-term care for all types of epilepsy, with a specific focus on rare and complex cases integrated with the European Reference Network (ERN) for Rare and Complex Epilepsies EpiCARE.

METHODS

In 2017, the Finnish government nominated Kuopio University Hospital to coordinate diagnostics and care for severe epilepsy in Finland. A national multidisciplinary consensus panel, including specialists from both adult and pediatric neurology departments across all five Finnish university hospitals and from the patient organization, was established. The resulting pathway was adopted into the current Finnish evidence-based current care guidelines for epilepsy.

RESULTS

The Finnish epilepsy care pathway focuses on timely referrals, continuity of care and enhanced communication between healthcare providers at different levels of care. Patient involvement is assured with an individualized digital application offering secure online messaging, a seizure calendar, and remote visits. The pathway enhances virtual consultations and includes regular national diagnostic multidisciplinary meetings for severe epilepsies before selected cases are consulted in ERN EpiCARE meetings.

SIGNIFICANCE

This Finnish model for epilepsy care provides a streamlined, multidisciplinary approach to diagnosis and treatment and combines modern digital tools, data sharing, and peer support. This pathway can serve to model how integrated healthcare systems can effectively manage complex conditions.

PLAIN LANGUAGE SUMMARY

We describe the Finnish national epilepsy care pathway, which includes multiple levels of care, from initial diagnosis to long-term care for all types of epilepsy, with a specific focus on rare and complex cases integrated with the European Reference Network (ERN) for Rare and Complex Epilepsies EpiCARE. Finnish model for epilepsy care provides a streamlined, multidisciplinary approach to diagnosis and long-term treatment of epilepsy. The pathway enhances virtual consultations and includes national and European-level diagnostic multidisciplinary meetings for severe epilepsies. To improve outcomes, we emphasize the use of modern digital tools, data sharing, and peer support.

How accurate are machine learning models in predicting anti-seizure medication responses: A systematic review

IMPORTANCE

Current epilepsy management protocols often depend on anti-seizure medication (ASM) trials and assessment of clinical response. This may delay the initiation of the ASM regimen that might optimally balance efficacy and tolerability for individual patients. Machine learning (ML) can offer a promising tool for efficiently predicting ASM response.

OBJECTIVE

The objective of this review is to synthesize the available information about the effectiveness and limitations of ML models in predicting and classifying the response of patients with epilepsy to ASMs, and to assess the impact of various data inputs on prediction performance.

EVIDENCE REVIEW

We conducted a comprehensive search of studies utilizing ML models for ASM response prediction using PubMed and Scopus up until November 2024.

FINDINGS

The review included 37 studies. Various data types, including clinical information, brain MRI, EEG, and genetic data, are useful in predicting responses to ASMs. Tree-based ML algorithms and Support Vector Machines are the most used models. Reported results vary widely, with certain models achieving near-perfect accuracy and others performing similar to random classifiers. The review also highlights the limitations of this research field, especially concerning the quality and quantity of data.

CONCLUSIONS AND RELEVANCE

The findings indicate that while ML models show great promise in predicting ASM responses in epilepsy, further research is required to refine these models for practical clinical application. The review underscores both the potential of ML in advancing precision medicine in epilepsy management and the need for continued research to improve prediction accuracy.

Investigating the frequency of neural autoantibodies in refractory focal epilepsy

OBJECTIVES

There have been conflicting reports about the frequency of neural autoantibodies in epilepsy cohorts, which is confounded by the lack of clear distinction of epilepsy from acute symptomatic seizures due to encephalitis. The aim of this study was to determine the frequency of neural autoantibodies in a well characterised population of refractory focal epilepsy of known and unknown cause.

METHODS

Cases were recruited from epilepsy outpatient clinics at the Princess Alexandra, Mater, Royal Brisbane and Women's and Cairns Base Hospitals from 2021 - 2023. Included cases were refractory to medical therapy, met the ILAE definition of focal epilepsy and were characterised using anatomo-electro-clinical correlation. Cases with prior encephalitis, inflammatory neurological disease or prior parenchymal brain insults were excluded.

RESULTS

A total of 100 patients were recruited. No cases with clinically significant neural autoantibodies were discovered. One was positive for serum anti-NMDAR antibodies, however autoantibodies were absent from CSF. Cases were also screened using a predictive score (McGinty et al.). From this, 2 cases were identified as seronegative autoimmune associated epilepsy and demonstrated significant reduction in seizure frequency with administration of immunotherapy. These cases had common features including temporo-perisylvian semiology especially ictal piloerection and high seizure frequency.

CONCLUSION

Clinically relevant neural autoantibodies are uncommon in well characterised chronic focal epilepsy populations. Despite this there are isolated cases that still demonstrate improved seizure control with the use of immunotherapy. Such cases highlight the need for further studies to understand the role of immunity in novel pathophysiological mechanisms in epilepsy.

Efficacy, safety, and tolerability of adjunctive perampanel in the treatment of pediatric patients aged 4-18 years with epilepsy: A single-center, retrospective, observational real-world study

PURPOSE

To observe the efficacy, safety, and tolerability of perampanel (PER) as add-on therapy in children aged 4-18 years with epilepsy in a real-world environment.

METHODS

A single-center, retrospective, observational study was conducted at the First Affiliated Hospital of Fujian Medical University enrolling children with epilepsy aged 4-18 years who received PER as add-on therapy from January 2021 to November 2022 with 12 months of follow-up. Outcomes included 3-, 6- and 12-month retention, seizure freedom, responder rates, and adverse events (AEs) throughout follow-up.

RESULTS

Seventy-eight children were included, of whom three were lost to follow-up. The responder rate at follow-up of 12 months was 54.7 %, the seizure-free rate was 32.0 % and the retention rate was 81.3 %. The number of seizures at baseline was a factor influencing the efficacy of the PER. Nine children reported AEs, with dizziness, drowsiness, and irritability being common.

CONCLUSIONS

PER is safe, effective, and well tolerated for the treatment of children aged 4-18 years with epilepsy in clinical practice and is a potential option for refractory epilepsy. Patients with lower baseline seizure frequencies are more likely to exhibit a favorable response to PER.

Comparing the Risk of Epilepsy in Patients With Simple Congenital Heart Diseases: A Prospective Cohort Study

AIMS

Simple congenital heart diseases (CHD) are associated with various central nervous system diseases, including epilepsy. This study aimed to compare the risk of epilepsy in patients with different types of simple CHD.

METHODS

In this prospective cohort study, from January 2008 to June 2022, patients with atrial septal defect (ASD), patent foramen ovale (PFO), ventricular septal defect (VSD), and patent ductus arteriosus (PDA) were recruited at the Registration Center of CHD in West China Hospital. Follow-up was conducted yearly until the diagnosis of epilepsy, loss to follow-up, or end of study. The outcomes included a comparison of epilepsy incidence according to different simple CHD types and a risk assessment of developing epilepsy. Multivariable Poisson regression was performed to adjusted factors of demographics and disease history.

RESULTS

Of 10,914 patients who met the inclusion criteria, 108 were diagnosed with epilepsy at an average follow-up of 2.19 years. Epilepsy incidence in patients with PFO, VSD, PDA, and ASD was 8.58/1000, 4.85/1000, 3.98/1000, and 2.63/1000 person-years, respectively. Compared with ASD patients (reference group), the risk ratios (95% confidence intervals) in patients with PFO, VSD, and PDA were 3.28 (2.00-5.43), 1.47 (0.79-2.68), and 1.46 (0.70-2.82), respectively. Subgroup analyses determined that patients with simple CHD who underwent CHD surgery demonstrated a lower risk of epilepsy than those who did not.

CONCLUSION

Among the major types of simple CHD, PFO was associated with a significantly higher risk of epilepsy, while the risk was reduced in those who underwent PFO closure procedures.

Clinical and biochemical assessments of circulating High Mobility Group Box Protein1 in children with epilepsy: relation to cognitive function and drug responsiveness

BACKGROUND

Childhood epilepsy is a major health concern posing a significant burden and having disastrous consequences for cognitive function. High Mobility Group Box1 (HMGB1) is an activator of neuroinflammation, and it is possibly involved in the initiation and progression of epilepsy. We aimed to investigate circulating HMGB1 in children with epilepsy and its connection to cognitive function and drug responsiveness.

METHODS

Case-control research included 100 epileptic youngsters and 100 healthy matched controls. Serum HMGB1 was measured using a commercially available ELISA assay. Cognitive functions were evaluated by the Stanford-Binet test 5th edition.

RESULTS

Drug-resistant epilepsy (DRE) was found in 37% of the investigated patients. Epileptic children have lower cognitive function parameter levels versus the control group and lower cognitive function in the DRE group compared to the drug-responsive group (P-value < 0.0001). HMGB1 levels were significantly higher in the patients' group (6.279 µg/L) compared to the control group (2.093 µg/L) and in the drug-resistant group (14.26 µg/L) versus the drug-responsive group (4.88 µg/L). A significant negative correlation was detected between HMGB1 with Full-scale IQ (r = - 0.547, P = 0.000), Visual-spatial reasoning (r = - 0.501, P = 0.000), fluid reasoning (r = - 0.510, P = 0.000), and working memory (r = - 0.555, P = 0.000). Serum HMGB1 cut-off levels > 6.85 µg/L differentiate drug-responsive from resistant patients.

CONCLUSION

Elevated HMGB1 levels, especially in patients with drug-resistant epilepsy, correlate negatively with cognitive performance, emphasizing its importance as a potential marker for early prediction of drug resistance and impairment of cognitive function.

Neuroimaging in Epilepsy

OBJECTIVE

The goal of this article is to review the use of neuroimaging in the treatment of new-onset seizures and epilepsy. The article will focus predominantly on MRI because this is the most common modality, but it will also review others that are often used in individuals being considered for epilepsy surgery. The article also reviews common causes of epilepsy and their appearance on imaging and various imaging tools that can be combined to assist in the care of people with epilepsy.

LATEST DEVELOPMENTS

MRI has revolutionized the ability to diagnose the cause of many forms of epilepsy. However, to maximize the diagnostic power of MRI, it is essential to order the correct imaging sequences. In this article, the harmonized neuroimaging of epilepsy structural sequences (HARNESS) MRI protocol proposed by the International League Against Epilepsy is discussed.

ESSENTIAL POINTS

MRI is the preferred imaging modality to identify lesions associated with epilepsy. Protocols should include thin-cut, no-gap sequences to permit the identification of small epileptogenic lesions, and studies should be reviewed with an understanding of all the clinical information to help guide the identification of potential lesions.

Peak width of skeletonized mean diffusivity as a marker of small vessel disease in patients with temporal lobe epilepsy with hippocampal sclerosis

OBJECTIVE

White matter abnormalities in patients with temporal lobe epilepsy (TLE) and hippocampal sclerosis (HS) are well known. Peak width of skeletonized mean diffusivity (PSMD) is a novel marker for quantifying white matter integrity that may reflect small vessel disease. In this study, we aimed to quantify the extent of white matter damage in patients with TLE and HS by using PSMD.

METHODS

We enrolled 52 patients with TLE with HS and 54 age- and sex-matched healthy controls. Diffusion tensor imaging (DTI) was performed using a 3-T magnetic resonance imaging scanner. We measured PSMD using DTI findings and compared PSMD between patients with TLE with HS and healthy controls. We also evaluated the correlation between PSMD and clinical factors in patients with TLE and HS.

RESULTS

PSMD differed significantly between healthy controls and patients with TLE and HS, and it was higher in the patients (2.375 × 10-4 mm2/s vs. 2.108 × 10-4 mm2/s, p < .001). Furthermore, PSMD in the ipsilateral hemisphere of the HS was higher than in the contralateral hemisphere of the HS (2.472 × 10-4 mm2/s vs. 2.258 × 10-4 mm2/s, p = .040). PSMD was positively correlated with age (r = .512, p < .001) and age at seizure onset (r = .423, p = .002) in patients with TLE and HS.

SIGNIFICANCE

Patients with TLE and HS had higher PSMD values than healthy controls, and PSMD was positively correlated with age. These findings provide evidence of white matter damage probably due to small vessel disease in patients with TLE and HS and support the feasibility of PSMD as a promising imaging marker for epileptic disorders.

Effects of immune modulatory treatment on language and psychiatric profile in patients with electrical status epilepticus in sleep (ESES)

Electrical status epilepticus in sleep (ESES) is an electrographic pattern associated with cognitive impairment. Our study aimed to prospectively evaluate the psychiatric findings and language skills in patients diagnosed with ESES and to determine the immune modulatory treatment-responsive subgroups. We assessed the patients for psychiatric features and language skills at the baseline and 12 months after. Psychiatric disorders were screened according to DSM-V criteria. We implemented standardized tests including Clinical Global Impressions-Severity Scale (CGI-S), Revised-Children Anxiety and Depression Scale, Children's Sleep Habits Questionnaire-Abbreviated, Aberrant Behavior Checklist (ABC), and Childhood Autism Rating Scale. We used tests adapted/developed for Turkish language including Test of Language Development-Primary-Fourth Edition: Turkish (TOLDP-4:T), Turkish Non-word Repetition Test (TNRT), Turkish Multilingual Sentence Repetition Test (MultiSIT-TR) and Turkish Communication Development Inventory (TCDI). Disability was evaluated by Pediatric Evaluation of Disability Inventory (PEDI). Thirty-nine patients were included. Psychiatric evaluation revealed attention deficit hyperactivity disorder-like symptoms in 25 patients, intellectual disability in 12, and specific learning disability in 8. Patients were treated with corticosteroids or IVIg in addition to anti-seizure medication. The spike wave indexes improved significantly at the end of follow-up period (80 % (65-91) vs. 37 % (24-65), p < 0.001). After 12 months, statistically significant improvement was found in ABC, CGI-S, TOLDP-4:T, TNRT, MultiSIT-TR, TCDI, and PEDI scores (p < 0.05). Patients with improvement in psychiatric symptoms had earlier age. Phonologic working memory performance was significantly preserved and improved compared to other language domains. Immune modulatory treatments may contribute to improvement of psychiatric symptoms and language skills. Preservation of phonologic working memory and grammar performance might be a valuable feature to differentiate ESES-related language impairment.

Mild Malformation of Cortical Development With Oligodendroglial Hyperplasia and Epilepsy: A Systematic Review

Background and Objectives

Mild malformation of cortical development with oligodendroglial hyperplasia and epilepsy (MOGHE) is a newly described rare entity of drug-resistant epilepsy, with a wide spectrum of presentations. We aim to describe the diagnostic features and prognosis of MOGHE in a large cohort.

Methods

We performed a systematic review preregistered on PROSPERO (CRD42023472978), in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. We searched PubMed, Embase, Scopus, and ScienceDirect between database inception and November 30, 2023, for all published studies on MOGHE. Inclusion criteria were a histopathologic diagnosis of MOGHE. The risk of bias was analyzed with a standardized tool specifically for case reports and case series. The demographic, clinical, EEG, neuroimaging, genetic, and neuropathologic features; treatments; and prognosis were extracted and analyzed. Subgroup analysis was performed with the age at onset and SLC35A2 variant status.

Results

A total of 163 patients with MOGHE from 18 studies were included in the analysis. The median age at seizure onset was 1.2 years, and 103 were male. Ninety-five patients presented with unilobed lesions. Ninety-nine had lesions in the frontal lobe. A total of 101 patients achieved a favorable surgical outcome. Patients with an onset before 10 years were more likely to present with epileptic spasms, the West syndrome, a circumscribed pattern of interictal EEG, intellectual disabilities, and a better seizure outcome, compared with those with an onset age 10 years and older. Forty-five patients (72.6%) were SLC35A2-positive. Patients harboring the SLC35A2 variants were more likely to present as Lennox-Gastaut syndrome, when compared with those who were SLC35A2-negative.

Discussion

MOGHE is a distinct entity of drug-resistant epilepsy associated with SLC35A2 variants, characterized by age-dependent phenotypes. The study emphasizes the clinical pearls indicative of the rare disease, which may facilitate early recognition and appropriate selection of treatments. The included studies were case reports or series, which were mainly limited by selection and reporting biases.

Prevalence and correlates of alexithymia in drug-resistant epilepsies

INTRODUCTION

Alexithymia, characterized by difficulty identifying and expressing emotions, is commonly observed in individuals with psychiatric and neurological disorders. However, its prevalence in patients with epilepsy (PWE), particularly in those with drug-resistant epilepsy (DRE), remains under-researched. This study investigates the prevalence of alexithymia in patients with DRE and explores its associated factors.

METHODS

We conducted a retrospective observational study of 118 adult patients with focal DRE undergoing presurgical evaluation at Bordeaux University Hospital. Alexithymia was assessed using the Toronto Alexithymia Scale-20 (TAS-20), while psychiatric symptoms were evaluated with validated scales. Data on demographic characteristics, epilepsy duration, seizure frequency, antiepileptic drug use, and localization of the epileptogenic zone (EZ) were collected and analyzed using logistic regression models.

RESULTS

Alexithymia was identified in 40.7 % of patients. Depression and anxiety were significantly associated with alexithymia (p < 0.01), whereas no correlation was observed between alexithymia and the localization or lateralization of the EZ.

DISCUSSION

These findings suggest that alexithymia is prevalent among patients with DRE, with significant associations to depression and anxiety. The high prevalence of affective symptoms underscores the importance of early identification and intervention for alexithymia to improve outcomes in patients with DRE.

Dreaming in patients with epilepsy: a cross-sectional cohort study

Epilepsy impacts cognition during wakefulness. As epileptic activity is present and even augmented during sleep, epilepsy could also influence sleep-related cognitive processes. However, whether epilepsy modulates sleep-related experiences like dreaming remains poorly known. Here, we prospectively investigated the characteristics and determinants of dreaming in patients with epilepsy. Consecutive adult patients with epilepsy and no major cognitive deficit were recruited in an epilepsy outpatient clinic. They completed a questionnaire about their dreams, sleep and epilepsy over the past year. Medical data on epilepsy characteristics were gathered from the medical file. A generalised linear model was used to explore the determinants of dream recall frequency (DRF). We included 300 patients, with a mean (standard deviation [SD]) age of 40.4 (13.4) years and 51.3% female; 28.6% had more than one seizure/month, and 34.7% already had seizures during sleep. Patients recalled dreams on an average of 1.6 (1.5) days/week and 11% had one or more nightmare/week. Younger age, higher number of nocturnal awakenings, and lower seizures frequency predicted a higher DRF. In patients with focal epilepsy (65.3%), the localisation of the epileptic focus in the parieto-occipital area was negatively associated with DRF. Regarding dream content, 34.0% of patients reported having already dreamt about epilepsy. Dreams of seizures were associated with sleep-related seizures (p = 0.034) and dreams of epilepsy were associated with nightmare frequency (p = 0.004). Our results show that patients with epilepsy share several determinants of DRF (age, awakenings, role of the parieto-occipital area) with healthy subjects. In addition, epilepsy-related factors (seizure frequency, focus localisation) also impact DRF. Investigating dreams in patients with epilepsy can provide information on their epilepsy and their sleep.

Late-onset unexplained seizures are associated with cognitive impairment and lower amygdala volumes

Late-onset epilepsy has been linked with accelerated cognitive decline and a higher risk of dementia. In this study, we sought to characterize the cognitive profile of participants with late-onset unexplained epilepsy and compare their MRI findings to healthy controls, to better understand underlying disease mechanisms. We recruited participants with at least one new-onset unexplained seizure at age 55 or later, without cortical lesions on MRI, within 5 years of the first seizure. We administered a neuropsychological battery to generate Preclinical Alzheimer Cognitive Composite and composite scores for delayed verbal recall, processing speed and executive function. We held a consensus meeting to determine whether the participants fulfilled criteria for mild cognitive impairment. An MRI volumetric analysis of hippocampal, amygdalae, and white matter hyperintensity volume was performed and compared to 353 healthy controls from the Harvard Aging Brain Study. On late-onset unexplained epilepsy participants, we also obtained 24-h EEG recording. Seventy participants were recruited, mean age 71.0 ± 7.0 years, 49% female, 15.6 ± 3.0 years of education. Impaired cognition (z-score ≤ -1.5) for late-onset unexplained epilepsy included the following: 15.9% for Preclinical Alzheimer Cognitive Composite -5, 23.2% for delayed verbal recall, 15.6% for processing speed and 7.5% for executive function. Seventeen percent were found to have mild cognitive impairment. Late-onset unexplained epilepsy participants who were drug resistant were more likely to have cognitive impairment (50% vs. 9%). When controlling for age, sex and race, late-onset unexplained epilepsy group had lower left AV (%; β = -0.003, P = 0.0016), right AV (%) (β = -0.003, P = 0.01), and log-transformed WMV (mm3; β = -0.21, P = 0.03) compared with Harvard Aging Brain Study (HABS); there were no differences in left or right HV between groups. EEG captured epileptiform abnormalities in 49% late-onset unexplained epilepsy participants, with a left temporal predominance (54%). In this single-site study of prospectively enrolled participants with late-onset unexplained epilepsy, we show that individuals with late-onset unexplained epilepsy exhibit cognitive impairments, mostly in verbal memory, and temporal dysfunction with left-sided predominance. Neuroimaging, when compared with healthy controls, shows lower amygdalae and white matter hyperintensity but not hippocampal volumes suggesting that the amygdalae is one of the earliest sites involved in the disease. The results also highlight the importance of seizure control given the association between mild cognitive impairment and drug-resistant epilepsy. Future studies extending these findings to Alzheimer's disease biomarkers and longitudinal follow-up will inform predictors of cognitive decline.

The use of cannabidiol as adjunctive therapy in adult patients with drug-resistant epilepsy: a systematic review and meta-analysis

Background

Highly purified cannabidiol (CBD), recently approved for various neurological disorders, is explored as a potential therapeutic avenue for drug-resistant epilepsy (DRE) among adult people with epilepsy (PWE) in this systematic review and meta-analysis.

Objectives

To conduct an extensive literature review and meta-analysis of CBD use for DRE in adult PWE.

Design

Systematic review and meta-analysis.

Data sources and methods

We conducted a systematic review of the literature according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and two electronic resources; we searched Ovid MEDLINE and Scopus using appropriate keywords until August 2023. Data were presented as standardized mean difference (SMD) and odds ratio with confidence interval (CI) via random effect. We appraised the risk of bias of the included studies using the Joanna Briggs Institute critical appraisal tool while their strength of evidence with the Oxford Centre for Evidence-Based Medicine (OCEBM) and Grading of Recommendations Assessment Development and Education (GRADE) Levels of Evidence.

Results

We identified 16 studies, 3 of which were randomized controlled trials and 3 prospective cohort studies, while the rest were expanded access programs, deriving a total of 668 participants receiving CBD for seizure control. CBD was used concomitantly with antiseizure medications in all studies. There was a statistically significant seizure reduction in the group receiving CBD therapy compared to the placebo group (SMD: -1.50, 95% CI (-3.47, 0.47), p < 0.01).

Conclusion

The evidence on CBD use in adult patients with DRE demonstrates a moderate level of certainty according to GRADE level and OCEBM level 2. Further prospective studies involving multiple centers are encouraged to study both the efficacy and safety of CBD in adult patients with DRE.

Trial registration

International Prospective Register of Systematic Reviews (PROSPERO) 2023 CRD42023449955.

Seizure Detection Devices

Goals of automated detection of epileptic seizures using wearable devices include objective documentation of seizures, prevention of sudden unexpected death in epilepsy (SUDEP) and seizure-related injuries, obviating both the unpredictability of seizures and potential social embarrassment, and finally to develop seizure-triggered on-demand therapies. Automated seizure detection devices are based on the analysis of EEG signals (scalp-EEG, subcutaneous EEG and intracranial EEG), of motor manifestations of seizures (surface EMG, accelerometry), and of physiologic autonomic changes caused by seizures (heart and respiration rate, oxygen saturation, sweat secretion, body temperature). While the detection of generalized tonic-clonic and of focal to bilateral tonic-clonic seizures can be achieved with high sensitivity and low false alarm rates, the detection of focal seizures is still suboptimal, especially in the everyday ambulatory setting. Multimodal seizure detection devices in general provide better performance than devices based on single measurement parameters. Long-term use of seizure detection devices in home environments helps to improve the accuracy of seizure diaries and to reduce seizure-related injuries, while evidence for prevention of SUDEP is still lacking. Automated seizure detection devices are generally well accepted by patients and caregivers.

Effect of Lamotrigine on Refractory Epilepsy: Clinical Outcomes and EEG Changes

Background

Refractory epilepsy poses significant challenges in clinical management due to its resistance to standard antiepileptic therapies, necessitating the exploration of more effective treatment regimens. Lamotrigine, with its proven efficacy and tolerability, offers potential benefits when combined with traditional medications like valproate, though its comprehensive impact on clinical outcomes and neurological markers requires further study.

Objective

To analyze the improvement effect of combined application of lamotrigine on refractory epilepsy patients and its impact on patients' EEG and neurological function.

Methods

This retrospective cohort study analyzed the clinical data of 93 patients with refractory epilepsy who were admitted to our hospital between January 2023 and June 2024. Based on the treatment interventions received, patients were divided into a control group (n=46, treated with valproate) and an observation group (n=47, treated with lamotrigine in addition to valproate). The clinical treatment effects, EEG (δ, θ, α, β) power levels, neurological function indicators [brain-derived neurotrophic factor (BDNF), nerve growth factor (NGF), pro-apoptotic protein Bcl-2, Bax], inflammatory response indicators [interleukin-1β (IL-1β), interleukin-6 (IL-6), prostaglandin E2 (PGE2)], and the incidence of adverse reactions were compared between the two groups.

Results

The clinical treatment effect in the observation group was significantly better than that in the control group, with a higher total effective rate (93.62% vs 76.09%, P<0.05). The monthly seizure frequency was significantly reduced in both groups after treatment (P < 0.05). The observation group demonstrated a significantly greater reduction in seizure frequency compared to the control group (P = 0.014). Regarding EEG power levels, both groups showed decreases in δ and θ power levels and increases in α and β power levels after treatment, with the observation group exhibiting more pronounced changes (P<0.05). Neurological function indicators revealed that Bcl-2 levels decreased, while BDNF, NGF, and Bax levels increased in both groups after treatment, with the observation group showing more significant improvements (P<0.05). Similarly, inflammatory response indicators, including IL-1β, IL-6, and PGE2, decreased in both groups, with the observation group demonstrating greater reductions (P<0.05). The incidence of adverse reactions was comparable between the two groups, with no significant difference observed (23.40% vs 17.39%, P>0.05).

Conclusion

Compared to valproate treatment alone, the combined application of lamotrigine can further enhance the efficacy in refractory epilepsy patients, Lower the seizure frequency, improve EEG power levels and neurological function, reduce inflammatory responses, and does not increase the risk of related adverse reactions.

Adult phenotypes of genetic developmental and epileptic encephalopathies

Developmental and epileptic encephalopathies constitute a group of severe epilepsies, with seizure onset typically occurring in infancy or childhood, and diverse clinical manifestations, including neurodevelopmental deficits and multimorbidities. Many have genetic aetiologies, identified in up to 50% of individuals. Whilst classically considered paediatric disorders, most are compatible with survival into adulthood, but their adult phenotypes remain inadequately understood. This cross-sectional study presents detailed phenotypes of 129 adults (age range 17-71 years), with genetic developmental and epileptic encephalopathies involving causal variants in 42 genes. We describe diverse disease aspects, and we sought genetic insights from the age-related trends of expression of the genes involved. Most developmental and epileptic encephalopathies (69.7%) are epileptic encephalopathies in adulthood, with the presence of epileptic encephalopathy correlating with worse cognitive phenotypes (P = 0.0007). However, phenotypic variability was observed, ranging from those with epileptic encephalopathy to seizure-free individuals with normal EEG or intermediate clinical and EEG phenotypes. This variability was found across individual genes and age-related gene expression trends, suggesting that other influential factors are likely at play. Mobility, feeding and communication impairments were common, with significant dependence on others for activities of daily living. Neurological and psychiatric comorbidities were most prevalent, along with additional systemic comorbidities observed, particularly musculoskeletal, cardiac and gastrointestinal conditions, highlighting the need for comprehensive and multisystemic monitoring. Despite an average diagnostic delay of 25.2 years, aetiology-based therapeutic interventions were feasible for 54.8% of the cohort, underscoring the critical need for genome-wide genetic testing for adults with these phenotypes. Optimizing seizure control remains necessary, but it may not be sufficient to ensure good outcomes, which may differ significantly from childhood metrics, like cognitive function and independence in daily living. Therapies addressing additional aspects beyond seizures are necessary for improving overall outcomes. Understanding the intricate relationship between molecular pathways and the age-related trends of gene expression is crucial for development of appropriate gene-specific therapies and timely intervention. Whilst prospective data are also needed to define these complexities, such studies of necessity take years to acquire: insights from adults can inform care strategies for both paediatric and adult populations now.

Somatic DNA Variants in Epilepsy Surgery Brain Samples from Patients with Lesional Epilepsy

Epilepsy affects 50 million people worldwide and is drug-resistant in approximately one-third of cases. Even when a structural lesion is identified as the epileptogenic focus, understanding the underlying genetic causes is crucial to guide both counseling and treatment decisions. Both somatic and germline DNA variants may contribute to the lesion itself and/or influence the severity of symptoms. We therefore used whole exome sequencing (WES) to search for potentially pathogenic somatic DNA variants in brain samples from children with lesional epilepsy who underwent epilepsy surgery. WES was performed on 20 paired DNA samples extracted from both lesional brain tissue and reference tissue from the same patient, such as leukocytes or fibroblasts. The paired WES data were jointly analyzed using GATK Mutect2 to identify somatic single nucleotide variants (SNVs) or insertions/deletions (InDels), which were subsequently evaluated in silico for their disease-causing potential using MutationTaster2021. We identified known pathogenic somatic variants in five patients (25%) with variant allele frequencies (VAF) ranging from 3-35% in the genes MTOR, TSC2, PIK3CA, FGFR1, and PIK3R1 as potential causes of cortical malformations or central nervous system (CNS) tumors. Depending on the VAF, we used different methods such as Sanger sequencing, allele-specific qPCR, or targeted ultra-deep sequencing (amplicon sequencing) to confirm the variant. In contrast to the usually straightforward confirmation of germline variants, the validation of somatic variants is more challenging because current methods have limitations in sensitivity, specificity, and cost-effectiveness. In our study, WES identified additional somatic variant candidates in additional genes with VAFs ranging from 0.7-7.0% that could not be validated by an orthogonal method. This highlights the importance of variant validation, especially for those with very low allele frequencies.

Autoimmune encephalitis: recovery, residual symptoms and predictors of long-term sequelae

BACKGROUND

Data regarding long-term recovery from autoimmune encephalitis (AE) remain limited.

METHODS

This retrospective observational study investigated outcomes in 182 patients who met the 2016 criteria for definite AE. Recovery data were available in 172 patients. Follow-up data at ≥24 months post-attack were available for 119. Recovery trajectory, residual symptoms, outcome predictors and causes of post-AE death were assessed.

RESULTS

Of 172 patients, 138 (80%) achieved good recovery (modified Rankin Scale (mRS) ≤2) with a median recovery time of 4 months (95% CI: 2 to 6 months). Recovery varied by associated neural antibody, with the best recovery observed in leucine-rich glioma-inactivated 1 (97% good recovery, median recovery time 0 (0 to 2) months). Paraneoplastic AE (p=0.007), severe attacks (eg, mRS ≥4 at attack, p=0.007) and cerebrospinal fluid pleocytosis (p=0.005) were associated with a lower likelihood of good recovery, while seizure presentation (p=0.026) was associated with better recovery. Despite good recovery, several residual symptoms persisted ≥24 months post-AE, including cognitive deficits (53%), seizures (26%), depression (23%), sleep disorders (25%), brainstem/cerebellar symptoms (13%), other movement disorders (14%) and autonomic symptoms (12%). Predictors of long-term sequelae included disabling cognitive deficit at onset and delayed immunotherapy for post AE-dementia, and medial temporal atrophy as well as escalation to cyclophosphamide therapy for both drug-resistant epilepsy and chronic depression. Of 182 patients, 20 (11%) died; the most common cause of death was progression of AE (6/20 (30%)).

CONCLUSION

While the majority of patients achieved functional independence after AE, several residual symptoms persisted. Several clinical and paraclinical features were associated with long-term sequelae.

The natural history of CDKL5 deficiency disorder into adulthood

Knowledge of the natural history of CDKL5 deficiency disorder (CDD) is limited to the results of cross-sectional analysis of largely pediatric cohorts. Assessment of outcomes in adulthood is critical for clinical decision-making and future precision medicine approaches but is challenging because of the diagnostic gap and duration of follow-up that would be required for prospective studies. We aimed to delineate the natural history retrospectively from adulthood. We analyzed clinical data about an international cohort of 67 adults with CDD. We analyzed demographic, phenotypic, CDKL5 Developmental Score (CDS), and treatment data, and tested associations with genetic factors, sex, and a positive or negative history of neonatal seizures, as an early predictor of prognosis. All but one of 67 adults (55 females, median age of 24 years at last follow-up) had epilepsy, typically beginning with epileptic spasms or tonic seizures before 4 months of age. Focal-onset and non-motor seizures emerged later. Fewer than a third had been documented as having bilateral tonic-clonic seizures or status epilepticus. Seizures often improved with age, but 73% had never experienced more than 6 months of seizure-freedom. Clobazam, sodium valproate, and lamotrigine were the most frequently prescribed antiseizure medications, but no specific treatment demonstrated superiority. Common comorbidities included movement disorders, visual impairment, sleep disorders, constipation, and scoliosis. All participants had intellectual disability, 75% had not acquired speech and 45% had regressed developmentally. 16% never achieved any CDS skill, but most attained at least three, and 28% attained six or all seven. By adulthood, half of those who had achieved any CDS skill retained all their CDS skills. The skills most frequently lost were independent walking and standing. Those with a history of neonatal seizures tended to attain fewer CDS skills and were more likely to have abnormal muscle tone in adulthood, atrioventricular conduction delay, and potential complications of their illness and treatment. Individuals carrying missense variants attained more CDS skills than those with other variants and were more likely to lose skills in adulthood and develop anxiety, possibly reflecting the limited neurodevelopment of those with non-missense variants, who manifested a more multisystemic disorder. In summary, retrospective data from adulthood elucidates the evolution of symptoms, variation in developmental outcomes, and the treatment landscape in CDKL5 deficiency disorder. Presence a non-missense variants or a history of neonatal seizures indicates a more complex disorder and lower developmental trajectory. Our findings will inform management decisions, prognostication, and the design of clinical trials in CDKL5 Deficiency Disorder.

Late-onset temporal lobe epilepsy: insights from brain atrophy and Alzheimer's disease biomarkers

Considering the growing age of the world population, the incidence of epilepsy in older adults is expected to increase significantly. It has been suggested that late-onset temporal lobe epilepsy (LO-TLE) may be neurodegenerative in origin and overlap with Alzheimer's disease (AD). Herein, we aimed to characterize the pattern of cortical atrophy and CSF biomarkers of AD (total and phosphorylated tau and amyloid-β) in a selected population of LO-TLE of unknown origin. We prospectively enrolled individuals with temporal lobe epilepsy onset after the age of 50 and no cognitive impairment. They underwent a structural MRI scan and CSF biomarkers measurement. Imaging and biomarkers data were compared to three retrospectively collected groups: (i) age-sex-matched healthy controls; (ii) patients with mild cognitive impairment (MCI) and abnormal CSF AD biomarkers (MCI-AD); and (iii) patients with MCI and normal CSF AD biomarkers (MCI-noAD). From a pool of 52 patients, 20 consecutive eligible LO-TLE patients with a mean disease duration of 1.8 years were recruited. As control populations, 25 patients with MCI-AD, 25 patients with MCI-noAD and 25 healthy controls were enrolled. CSF biomarkers returned normal values in LO-TLE, significantly different from patients with MCI due to AD. There were no differences in cortico-subcortical atrophy between epilepsy patients and healthy controls, while patients with MCI demonstrated widespread injuries of cortico-subcortical structures. Individuals with LO-TLE, characterized by short disease duration and normal CSF amyloid-β and tau protein levels, showed patterns of cortical thickness and subcortical volumes not significantly different from healthy controls, but highly different from patients with MCI, either due to AD or not.

Diffusion tensor imaging for detecting biomarkers of idiopathic epilepsy in dogs

Idiopathic epilepsy (IE) is the most common neurological disease in dogs. Approximately 1/3 of dogs with IE are resistant to anti-seizure medications (ASMs). Because the diagnosis of IE is largely based on the exclusion of other diseases, it would be beneficial to indicate an IE biomarker to better understand, diagnose, and treat this disease. Diffusion tensor imaging (DTI), a magnetic resonance imaging (MRI) sequence, is used in human medicine to detect microstructural biomarkers of epilepsy. Based on the translational model between people and dogs, the use of DTI should be investigated in a veterinary context to determine if it is a viable resource for detecting microstructural white matter abnormalities in the brains of dogs with IE. As well, to determine if there are differences in white matter microstructure between dogs who are responsive to ASMs and dogs who are resistant to ASMs. Using DTI to better understand neurostructural abnormalities associated with IE and ASM resistance might help refine diagnostic approaches and treatment processes in veterinary medicine.

Exploring the role of epileptic focus lateralization on facial emotion recognition in the spectrum of mesial temporal lobe epilepsy

Introduction

Evidence increasingly shows that facial emotion recognition (FER) is impaired in refractory mesial temporal lobe epilepsy (rMTLE), especially in patients with a right focus. This study explores FER in both mild (mMTLE) and refractory forms, examining the influence of epileptic focus lateralization on FER.

Methods

50 MTLE patients, categorized by epilepsy severity and focus lateralization, were compared with healthy controls. FER was assessed using the Ekman Faces Test (EFT), which evaluates recognition of six basic emotions, alongside a battery of cognitive and mood tests.

Results

mMTLE patients showed selective deficits in recognizing fear and anger, while rMTLE patients displayed broader deficits, affecting all emotions except surprise. Patients with a right focus underperformed across all negative emotions, whereas those with a left focus showed deficits mainly in fear and anger. Analysis indicated that early epilepsy onset was associated with poorer FER in right-focused patients; febrile seizures and mesial temporal sclerosis significantly impacted FER in left-focused patients.

Conclusion

MTLE affects circuits of FER even in mild subjects, although to a lesser extent than in refractory ones. Earlier onset of MTLE could disrupt the development of FER, possibly interfering during a critical phase of maturation of its circuits, when the focus is right. Conversely, left MTLE may cause less damage to FER circuits, requiring additional factors such as a history of febrile seizures and/or mesial temporal sclerosis for significant impact. Clinically, refractory and right-sided MTLE might be viewed as risk factors of FER deficits.

Nanocarriers-based therapeutic strategy for drug-resistant epilepsy: A systematic review

BACKGROUND

Nanocarriers have been proposed as a solution for drug-resistant epilepsy.

METHODS

A systematic review of animal and in vitro studies was conducted to evaluate the efficacy, toxicity, and biological properties of nanocarriers. Searches were performed in PubMed/Medline and Scopus from March 2023 to March 2024.

RESULTS

Eighteen studies were identified: 2 in vitro, 9 in vivo, and 7 combined. While epilepsy models and seizure control assessments were consistent, there was variability in evaluating the potential toxicity of nanocarriers. Only one study did not show a reduction in brain inflammation, seizures, and cell loss. Nanocarrier toxicity was evaluated just in six studies, all of which indicated low toxicity both in vitro and in vivo.

CONCLUSIONS

Nanocarriers with antiseizure drugs manage seizures, inflammation, oxidative stress, and behavior impairment in drug-resistant epilepsy. Furthermore, nanocarriers are a safe option for delivering antiseizure drugs, though more research is needed to confirm these findings.

Novel Phenotypes and Genotype-Phenotype Correlations in a Large Clinical Cohort of Patients With Kleefstra Syndrome

Kleefstra syndrome (KLEFS) is a genetic neurodevelopmental disorder caused by haploinsufficiency of EHMT1. The full spectrum of clinical features and genotype-phenotype correlations is currently not fully understood. We performed a retrospective chart review of patients with KLEFS evaluated at the Boston Children's Hospital Kleefstra Clinic. There were 65 individuals (40 females, 25 males, mean age 9.3 years). 17% had large 9q34 deletions (≥ 1 Mb), 29% had small 9q34 deletions (< 1 Mb), and 54% had sequence variants. Global developmental delay (GDD) or intellectual disability (ID) was present in 77%. Behavioral disorders, such as autism spectrum disorder (38%), were common. Epilepsy affected 15%. Systemic health issues included structural cardiac defects (40%), hearing loss (32%), and constipation (31%). Novel features including subgroups with significant motor impairment (24%) and refractory epilepsy (9%), as well as small numbers with opsoclonus-like eye movements (n = 2), thrombocytopenia (n = 2), progressive cerebral atrophy (n = 1), and adrenal carcinoma (n = 1). 9q34 deletion subgroups had higher rates of GDD/ID (p = 0.037), significant motor impairment (p = 0.01), epilepsy (p = 0.004), and cortical visual impairment (p = 0.003) compared to the subgroup with sequence variants. This information may be used to improve clinical care as well as inform research and future therapeutic initiatives.

Effectiveness and tolerability of cenobamate: A single center experience

INTRODUCTION

Medication-resistant epilepsy (MRE) is characterized by the failure of adequate trials of two antiseizure medications (ASMs). Numerous studies have shown that once two ASMs fail to control seizures, the likelihood of subsequent ASM regimens providing seizure control diminishes significantly. Recent clinical data on cenobamate (CNB) suggest it may offer higher rates of seizure freedom in MRE patients. This study aims to report real-world, single-center findings on the effectiveness and tolerability of CNB in treating MRE.

METHODS

This retrospective study includes adult patients diagnosed with MRE and treated with CNB between 2020 and 2023 at The George Washington University (GWU). Data were collected from electronic medical records. Statistical analyses were conducted to evaluate CNB's impact on seizure control and patient outcomes.

RESULTS

121 patients with medication-resistant epilepsy (MRE) were prescribed cenobamate (CNB). After exclusions, 104 patients were included in the effectiveness analysis and 111 in the tolerability analysis. Results showed that 34.6 % of patients achieved seizure freedom for at least three months, with a mean duration of seizure freedom of 11 ( ± 7.9) months.

SIGNIFICANCE

CNB use in a large population of more than 100 patients demonstrated impressive anti-seizure activity with a good proportion of patients with MRE achieving seizure freedom despite having failed multiple prior ASMs.

Long-term trends in total administered radiation dose from brain [18F]FDG-PET in children with drug-resistant epilepsy

PURPOSE

To assess the trends in administered 2-[18F]fluoro-2-deoxy-D-glucose ([18F]FDG) doses, computed tomography (CT) radiation doses, and image quality over the last 15 years in children with drug-resistant epilepsy (DRE) undergoing hybrid positron emission tomography (PET) brain scans.

METHODS

We retrospectively analyzed data from children with DRE who had [18F]FDG-PET/CT or magnetic resonance scans for presurgical evaluation between 2005 and 2021. We evaluated changes in injected [18F]FDG doses, administered activity per body weight, CT dose index volume (CTDIvol), and dose length product (DLP). PET image quality was assessed visually by four trained raters. Conversely, CT image quality was measured using region-of-interest analysis, normalized by signal-to-noise (SNR) and contrast-to-noise ratio (CNR).

RESULTS

We included 55 children (30 male, mean age: 9 ± 6 years) who underwent 61 [18F]FDG-PET scans (71% as PET/CT). Annually, the injected [18F]FDG dose decreased by ~ 1% (95% CI: 0.92%-0.98%, p < 0.001), with no significant changes in administered activity per body weight (p = 0.51). CTDIvol and DLP decreased annually by 16% (95% CI: 9%-23%) and 15% (95% CI: 8%-21%, both p < 0.001), respectively. PET image quality improved by 9% year-over-year (95% CI: 6%-13%, p < 0.001), while CT-associated SNR and CNR decreased annually by 7% (95% CI: 3%-11%, p = 0.001) and 6% (95% CI: 2%-10%, p = 0.008), respectively.

CONCLUSION

Our findings indicate stability in [18F]FDG administered activity per body weight alongside improvements in PET image quality. Conversely, CT-associated radiation doses reduced. These results reaffirm [18F]FDG-PET as an increasingly safer and higher-resolution auxiliary imaging modality for children with DRE. These improvements, driven by technological advancements, may enhance the diagnostic precision and patient outcomes in pediatric epilepsy surgery.

Advances in Therapy for Refractory Epilepsy

Drug-resistant epilepsy (DRE) is defined as failure to achieve sustained seizure control with adequate trials of two appropriate antiseizure medications (ASMs). DRE affects one-third of patients with epilepsy and is associated with significant morbidity and mortality. Newer ASMs provide pharmacological therapy that is better tolerated but not necessarily more effective than older ASMs. Resective brain surgery is the gold standard to treat DRE and achieve seizure freedom, with laser ablation offering an alternative with less morbidity but lower effectiveness. For patients who are not candidates for resection or ablation, multiple neuromodulation options can reduce seizure burden. These neuromodulation devices have shown comparable effectiveness in randomized clinical trials, but the results vary in open-label follow-up cohorts, as do the risks of complications and associated costs. Dietary therapies can help, particularly in pediatric genetic epilepsies. Innovative genetic therapy approaches are being pursued, offering the promise of precision medicine.

Combining MRI radiomics and clinical features for early identification of drug-resistant epilepsy in people with newly diagnosed epilepsy

OBJECTIVE

To identify newly diagnosed patients with drug-resistant epilepsy (DRE) based on radiomics and clinical features.

METHODS

A radiomics approach was used to combine clinical features with magnetic resonance imaging (MRI) features extracted by the ResNet-18 deep learning model to predict DRE. Three machine learning classifiers were built, and k-fold cross-validation was used to assess the classifier outcomes, and other evaluation metrics of accuracy, sensitivity, specificity, F1 score, and area under the curve (AUC) were used to evaluate the performance of these models.

RESULTS

One hundred and thirty-four newly diagnosed epilepsy patients with 13 available clinical features and 1394 MRI features extracted by the ResNet-18 model were included in our study. Then three machine learning classifiers were built based on5 clinical features and 8 MRI features, including Support Vector Machine (SVM), Gradient-Boosted Decision Tree (GBDT) and Random Forest. After internally validation, the GBDT model performed the best, with an average accuracy of 0.85 [95% confidence interval (CI) 0.77-0.91], sensitivity of 0.97 [95% CI 0.85-1.00], specificity of 0.96 [95% CI 0.83-1.00], F1 score of 0.81 [95% CI 0.77-0.89], AUC of 0.95 [95% CI 0.82-0.99], and ten-fold cross validation avg score of 0.96 [95% CI 0.89-0.99] in test set.

SIGNIFICANCE

This study offers a novel approach for early diagnosis of DRE. Radiomics can provide potential diagnostic and predictive information to support personalized treatment decisions.

Cerebellar transcranial magnetic stimulation to treat drug-resistant epilepsy: A randomized, controlled, crossover clinical trial

OBJECTIVE

Epilepsy is one of the most prevalent brain diseases. Approximately one third of patients consistently experience drug-resistant epilepsy (DRE), a condition where seizures persist despite the use of antiseizure medications. Exploration of new therapies for DRE is urgently needed. In this single-center, randomized, sham-controlled, crossover clinical trial (NCT05042726), we aimed to investigate the effectiveness and safety of transcranial magnetic continuous theta burst stimulation (cTBS) targeting the cerebellum to treat DRE.

METHODS

Patients with DRE for ≥2 years and a seizure frequency of ≥2 seizures per month were enrolled and randomized 1:1 to receive active stimulation followed by sham stimulation or vice versa. The bilateral cerebellum was targeted by navigated cTBS focusing on the cerebellar dentate nucleus, once daily on workdays for 2 weeks. The primary outcomes were the percentage of seizure reduction and 50% responder rate in the per-protocol population within 2 months after treatment.

RESULTS

Forty-four patients were enrolled and randomized; 18 patients in the active stimulation-first group and 20 in the sham stimulation-first group were included in the final analysis. Active cTBS significantly reduced seizures compared to sham stimulation (difference in percentage of seizure reduction between treatments = 25%, 95% confidence interval [CI] = 5%-46%, p = .018). The 50% responder rate after active stimulation was significantly higher than that after sham stimulation (difference in 50% responder rate between treatments = 24%, 95% CI = 11%-40%, p = .029). Adverse events occasionally occurred during active stimulation (moderate headache in 5% of patients, tinnitus in 3% of patients, dizziness in 3% of patients) but resolved spontaneously within days after treatment completion.

SIGNIFICANCE

This trial suggested that cTBS targeting the cerebellum was effective and well tolerated in the treatment of DRE. Further studies are warranted to confirm its effectiveness and mechanism.

Dual-responsive two-photon probe for specific lipid droplets near-infrared fluorescence imaging in the brain of epileptic mice

Abnormal lipid metabolism in glial cells is a key pathological feature of epilepsy. The identification of lipid droplets (LDs) is essential for investigating lipid metabolism, disease progression, and potential therapeutic interventions. Two-photon imaging technology enables real-time visualization of the spatial distribution and temporal dynamics of LDs in epilepsy models. In this study, we developed a novel two-photon excited dual-responsive near-infrared fluorescent probe, CabA, based on viscosity and polarity, to monitor dynamic changes in LDs. The fluorescence of CabA at 670 nm exhibits a significant increase in response to low polarity and high viscosity due to the twisted intramolecular charge transfer and intramolecular charge transfer mechanisms. The LDs-targeting capability of CabA at the cellular level and the process of LDs generation between neurons and astrocytes during the pathological advancement of epilepsy have been validated. In situ synchronous imaging experiments in epileptic and normal mice using CabA revealed abnormal LDs accumulation in the brain during seizures. Two-photon fluorescence imaging further demonstrated LDs accumulation in the brains of epileptic mice at a penetration depth of 100 μm. This study offers a valuable tool for enhancing the understanding of LDs in physiological and pathological processes, potentially aiding in the early diagnosis of epilepsy.

Cerebrospinal fluid-specific oligoclonal bands in dogs with idiopathic epilepsy

BACKGROUND

In dogs with idiopathic epilepsy (IE), 33% develop resistance to conventional anti-seizure medication (ASM) despite adequate treatment. In human medicine, an immune-mediated etiology is suspected in a subset of ASM-resistant patients with epilepsy and cerebrospinal fluid (CSF)-specific immunoglobulin G (IgG)-type oligoclonal bands (OCBs) have been detected. In dogs, cases of autoimmune encephalitis recently were reported. Neuroinflammation may provide an additional explanation for the lack of response of certain dogs with IE to ASM.

HYPOTHESIS

Cerebrospinal fluid-specific OCBs are found in a subgroup of dogs with ASM-resistant IE.

ANIMALS

Eighty-four dogs with IE were recruited from 3 referral centers and classified based on their response to ASM treatment (responsive, n = 56; resistant, n = 28).

METHODS

Detection of OCBs was performed using isoelectric focusing (IEF) followed by immunoblotting. Associations of CSF-specific OCBs with seizure type, severity, and response to ASM were calculated using logistic regression models.

RESULTS

The overall frequency of CSF-specific OCBs in dogs with IE was 15.5% (95% confidence interval [CI], 8.5%-25%). In dogs with ASM-resistant IE, 21.4% (6/28) had CSF-specific OCBs compared with only 12.5% (7/56) in those responsive to ASM, but no evidence of an association was detected (odds ratio, 1.9; 95% CI, 0.57-6.35; P = .29).

CONCLUSIONS AND CLINICAL IMPORTANCE

Cerebrospinal fluid-specific OCBs were detected in a subgroup of dogs with IE. This finding could indicate that intrathecal IgG synthesis as a sign of neuroinflammation may play a role in disease pathogenesis.

Long-Term Outcome of Vagus Nerve Stimulation for Drug-Resistant Epilepsy

BACKGROUND AND OBJECTIVES

In this study, we aimed to assess the long-term outcome of vagus nerve stimulation (VNS) in patients with drug-resistant epilepsy (DRE).

METHODS

A retrospective analysis of outcome data of 24 patients with DRE, who had been implanted with VNS and had at least 5 years of post-surgery follow-up was performed. The seizure outcome at the latest follow-up was classified as class I-V as proposed by John C. McHugh. The cognitive, psychiatric, and behavioral outcomes were recorded using standardized tests.

RESULTS

Mean age at the time of VNS implantation was 18.7 (6-38) years; nine (37.5%) of the patients were females. Mean duration of epilepsy was 13.6 years (range: 2.5-35 years); 18 (75%) patients had multiple (≥2) seizure types and 15 (62.5%) had daily seizures. The most common etiology was perinatal hypoxic injury (15, 62.5%). More than 50% seizure reduction (class 1 and 2) was noted in 54.2% of patients at 1 year, which increased to 75% at ≥5 years follow-up. A significantly higher number of patients with other etiologies had >50% reduction in seizures at the latest follow-up, when compared to those with hypoxic-ischemic encephalopathy (53.3% vs. 100%, P = 0.0024). The average intelligence quotient (IQ; 71.17 ± 28.92 vs. 64.65 ± 29.61, P = 0.014) and quality of life (66.64 ± 14.63 vs. 64.65 ± 29.61, P < 0.001) scores were significantly higher in patients post-VNS implantation, when compared to their baseline scores. Furthermore, significant number of patients had improvement in psychiatric diagnosis (29.2% vs. 4.2%, P = 0.047) and behavioral problems (50% vs. 4.2%, P < 0.001) post-VNS implantation.

CONCLUSIONS

The present study shows >50% seizure reduction in 75% of patients after VNS implantation at long-term follow-up, with improvement in IQ, quality of life, psychiatric and behavioral problems.

SCN1A Genetic Alterations and Oxidative Stress in Idiopathic Generalized Epilepsy Patients: A Causative Analysis in Refractory Cases

Single Nucleotide Polymorphisms (SNPs) have found it be associated with drug resistance in epilepsy. The purpose of this study was to determine the role of SCN1A gene polymorphism in developing drug resistance in idiopathic generalized epilepsy (IGE) patients, along with increased oxidative stress. The study was conducted at a tertiary care hospital in Delhi, India. We recruited 100 patients diagnosed with IGE patients, grouped as drug-resistant and drug-responsive, and then further compared the SCN1A SNP rs10167228 A*/T analysis between the two groups. We utilized the PCR-RFLP technique to investigate the association between polymorphisms and refractory epilepsy. Serum HMGB1 levels were estimated using the ELISA technique to analyze oxidative stress in both groups. rs10167228 A*/T polymorphism genotypes AT and AA genotypes are significantly associated with an increased risk of developing drug resistance. Serum HMGB1, IL-1β, and IL-6 levels were significantly higher in drug-resistant cases, compared to the drug-responsive group. The association of SCN1A gene polymorphisms, in conjunction with raised oxidative stress, may be predictive of the development of drug-resistant epilepsy. The AT and AA genotypes of rs10167228 may pose a risk factor for developing drug-resistant epilepsy.

Detection challenges of temporal encephaloceles in epilepsy: A retrospective analysis

Temporal encephaloceles (TEs) are herniations of cerebral parenchyma through structural defects in the floor of the middle cranial fossa. They are a relatively common, but only relatively recently identified potential cause of drug-resistant epilepsy. Uncontrolled epilepsy is associated with many negative long term health consequences including a heightened risk of death. The most effective treatment for drug-resistant epilepsy is surgery. One of the most predictive factors associated with successful surgery is identification of an abnormality on imaging. However, TEs can be difficult to detect and are often overlooked on neuroimaging studies. Improving our ability to accurately detect TEs by MRI is an important step in improving surgical outcomes in patients with drug-resistant epilepsy. We performed a review on existing imaging modalities for detecting TEs and report on our attempt to use a voxel-based morphometry (VBM) algorithm to detect TEs in T1-weighted MRIs of 81 patients from a database comprised of 25 patients with confirmed encephaloceles and 56 controls. Our program's sensitivity and specificity were compared to those of two neuroradiologists and two epileptologists using visualization during surgery as the gold standard. On average, the neuroradiologists and epileptologists had sensitivities of 41 % and 58 % and specificities of 81 % and 60 % while our VBM-based approach had sensitivities and specificities ranging from 11 % to 50 % and 0.2 % to 17 %, respectively. This work provides an overview of the different imaging modalities utilized in the detection of TEs and highlights the difficulties associated with their detection for both experienced physicians and cutting-edge computational methods. Our findings suggest that VBM-based methods could potentially be used to enhance clinicians' ability to detect TEs thereby facilitating surgical planning, improving surgical outcomes by allowing for more specific targeting, and bettering the long-term health and well-being of patients with drug-resistant epilepsy secondary to TEs.

Do We Practice What We Preach? Examining Barriers to Timely Epilepsy Surgery Referrals

Surveying neurologist perspectives and knowledge of epilepsy surgery to identify barriers to surgery referral Namal U. Seneviratne Objective: Epilepsy surgery is an effective means of treating medically refractory epilepsy (MRE), but it remains underused. We aimed to analyze the perspectives and knowledge of referring neurologists in the New York metropolitan area, who serve a large epilepsy population. Methods: We adapted a previous Canadian survey by Roberts et al, adding questions regarding demographic descriptors, insurance coverage, training and practice details, and perceived social barriers for patients. We surveyed neurologists directly affiliated with Montefiore Medical Center and those referring to Montefiore's Comprehensive Epilepsy Center. Participants had 10 weeks to fill out an online Qualtrics survey with weekly reminders. Results: Of 117 neurologists contacted, 51 eligible neurologists completed the survey (63.8% Montefiore, 35.0% referring group). A high proportion of the results were from epilepsy-trained individuals (41.2%) and neurologists who graduated residency ≤19 years ago (80.4%). About 80.4% of respondents felt that epilepsy surgery is safe, but only 56.9% would refer a patient for surgical workup after two failed trials of antiseizure medications. Epileptologists and providers with a larger volume of epilepsy patients and electroencephalogram readings had better knowledge of the epilepsy surgery workup guidelines. When asked to rank social barriers to patients receiving surgery, participants were most concerned about lack of social support, financial insecurity, and a patient's dual role as a caregiver. Significance: Our study suggests continued reluctance of neurologists regarding epilepsy surgery and deficiencies in the knowledge and adherence to the recommended guidelines. In the context of prior studies, these results showed and improved understanding of the definition of MRE (80.4%) and an increased likelihood to refer eligible patients as early as possible (78.4%) in line with current consensus recommendations. The finding that epilepsy-trained and more epilepsy/electroencephalogram-facing neurologists showed a better understanding of the guidelines suggests that the increased education efforts should be targeted at nonepileptologists.

Central expression and peripheral levels of MMP-9 and TIMP-1 in patients with temporal lobe epilepsy

PURPOSE

Thirty percent of epilepsy patients are drug-resistant (DR) and, in adults, temporal lobe epilepsy (TLE) is the most common form of DR- epilepsy. Patients with TLE exhibit a neuroinflammatory response associated with blood-brain barrier dysfunction. In this context, the main aim of our study was to evaluate peripheral levels and central expression of MMP-9 and TIMP-1 in TLE patients and assess their association with drug resistance and inflammatory markers.

METHODS

Three groups of patients were included, 41 DR-TLE patients, 10 non-DR-TLE patients, and 20 healthy controls (HC). MMP-9 and TIMP-1 were assessed by ELISA in sera in all patients, and by immunohistochemistry and immunofluorescence in the cerebral cortex and hippocampus in a subgroup of DR-TLE patients and 3 controls. Peripheral and central cells phenotypes were determined by flow cytometry and immunohistochemistry, respectively, while cytokines were determined in the two compartments by ELISA.

RESULTS

Central expression of MMP-9 and TIMP-1, and peripheral expression of TIMP-1, were higher in DR-TLE patients than in controls, while peripheral levels of MMP-9 and TIMP-1 were higher in DR-TLE patients compared with non-DRE-TLE patients. MMP-9 levels in serum increased with seizure severity and decreased after successful epilepsy surgery. MMP-9 levels in the serum of DR-TLE patients were positively correlated with several markers of peripheral inflammation, which was not the case in the groups of non-DR-TLE patients and healthy controls. MMP-9 and TIMP-1 expression in the hippocampus of DR-TLE patients correlated positively with various markers of central inflammation. Negative correlations between their peripheral levels and central expression were observed.

CONCLUSION

MMP-9 and TIMP-1 are markers that seem to be associated to the central and peripheral inflammatory reaction occurring in DR-TLE patients. The significant negative correlations between central and peripheral markers are interesting to note, and further studies need to be carried out to fully understand the complex regulation of these proteins during DR epilepsy.

Effects of anti-seizure medications on resting-state functional networks in juvenile myoclonic epilepsy: An EEG microstate analysis

OBJECTIVE

Juvenile myoclonic epilepsy (JME) is associated with large-scale brain network dysfunction. This study aims to investigate how anti-seizure medication (ASM) treatment alters resting-state functional networks in JME patients through resting-state EEG microstate analysis.

METHODS

Ninety-six subjects participated in this study: 24 healthy controls (HC), 29 newly diagnosed JME patients who had not started ASMs therapy (JME-NM), and 43 JME patients on ASMs treatment with effective seizure control (JME-M). EEG data were collected for 10 min while participants were awake and resting with their eyes closed, using a standard 19-channel recording system. EEG topographies were categorized into four microstate classes (A, B, C, D), and parameters such as mean duration, occurrence rate, time coverage, and transition probabilities between microstates were computed and compared among the three groups. Advanced statistical methods were employed to ensure the robustness and validity of the findings.

RESULTS

Significant alterations in EEG microstate characteristics were observed in untreated JME patients (JME-NM) compared to both healthy controls and treated patients. Microstate B had a markedly reduced mean duration in the JME-NM group, while microstate A displayed an increased occurrence rate and greater time coverage. Transition probabilities between specific microstates, such as from A to C, A to D, and B to C, were also significantly different in the JME-NM group. The normalization of these parameters in the JME-M group suggests that ASMs effectively stabilize altered brain networks, potentially mitigating the pathophysiological disruptions associated with JME.

CONCLUSION

This study demonstrates that ASMs effectively normalize disruptions in sensory-motor and visual networks in JME patients. EEG microstate analysis provides a dynamic view of brain network alterations and offers potential as a biomarker for the diagnosis and monitoring of JME, as well as for evaluating treatment response. These findings advance our understanding of the neurophysiological mechanisms underlying JME.

Evidence of small vessel disease in patients with juvenile myoclonic epilepsy based on the peak width of skeletonized mean diffusivity

OBJECTIVES

Peak width of skeletonized mean diffusivity (PSMD) is a novel marker of white matter changes probably due to small vessel disease. This study aimed to investigate the presence of white matter changes in juvenile myoclonic epilepsy (JME) using PSMD.

METHODS

We enrolled patients with JME and age- and sex-matched healthy controls. We performed diffusion tensor imaging (DTI) using a three tesla magnetic resonance imaging scanner. We measured the PSMD based on DTI in several steps, including preprocessing, skeletonization, application of a custom mask, and histogram analysis, using the FSL program. We compared the PSMD between patients with JME and healthy controls and the PSMD according to the antiseizure medication (ASM) response among the patients with JME. We also performed a correlation analysis between the PSMD and clinical factors in patients with JME.

RESULTS

We enrolled the 42 patients with newly diagnosed JME and 42 healthy controls. There was a significant difference in the PSMD between patients with JME and healthy controls. PSMD was higher in patients with JME than in healthy controls (2.234 vs. 2.085 × 10-4 mm2/s, p = 0.013). In addition, the PSMD was higher in patients with JME who were ASM poor responders than in those who were ASM good responders (2.586 vs. 2.176 × 10-4 mm2/s, p = 0.007). The PSMD was positively correlated with age (r = 0.364, p = 0.017).

CONCLUSION

Patients with JME have a higher PSMD than healthy controls, indicating evidence of white matter changes in patients with JME. In addition, white matter changes are related to the ASM response in patients with JME. This finding also highlights the potential of PSMD as a marker for detecting white matter changes probably due to small vessel disease in patients with epilepsy, which would require further studies.

[18F]FDG PET for mapping the cerebral glucose metabolic characteristics of drug-sensitive and drug-resistant epilepsy in pediatric patients

OBJECTIVE

This study aimed to investigate [18F]fluorodeoxyglucose positron emission tomography ([18F]FDG PET) mapping for cerebral glucose metabolism in drug-sensitive and drug-resistant pediatric epilepsy patients.

METHODS

This retrospective study enrolled 40 patients and 25 controls. Patients were categorized into drug-sensitive epilepsy (n = 22) and drug-resistant epilepsy (n = 18) according to the seizure frequency at follow-up. All patients underwent two [18F]FDG PET scans separated by a minimum of one year. Absolute asymmetry index (|AI|) was calculated for assessing metabolic differences and changes in epileptic foci. Statistical Parametric Mapping (SPM) was utilized to reveal voxel-wise metabolic characteristics and alterations throughout the brain. Network analysis based on graph theory was used to investigate network-level differences between the two patient groups.

RESULTS

The drug-sensitive group showed a lower |AI| at both baseline (P = 0.038) and follow-up (P = 0.003) PET scans than the drug-resistant group. |AI| decreased in the drug-sensitive group and increased in the drug-resistant group across scans, but these trends were not statistically significant (P = 0.240 and P = 0.450, respectively). Both groups exhibited hypometabolism at baseline. The drug-sensitive group showed less hypometabolic brain regions than the drug-resistant group. The drug-sensitive maintained stable level of hypometabolism between the two scans, whereas the drug-resistant group showed an increasing hypometabolism. Network analysis demonstrated that the drug-sensitive group had a higher global efficiency, average degree, and clustering, along with a shorter characteristic path length compared to the drug-resistant group.

CONCLUSIONS

For the first time, this study revealed in vivo cerebral glucose metabolic pattern of nonsurgical pediatric epilepsy patients treated by antiepileptic drugs. Especially, drug-resistant epilepsy patients represented significantly extensive and progressive hypometabolism with inefficient brain network connectivity compared with drug-sensitive epilepsy. [18F]FDG PET imaging may be a potential visual approach for theranostics of epilepsy patients.

Clinical profiles and prognostic factors in reflex epilepsy: Insights from a Taiwanese cohort

PURPOSE

To investigate the clinical characteristics, treatment, and prognosis of patients with reflex epilepsies in Taiwan.

METHODS

Patients with reflex epilepsies (RE) induced by specific trigger factors from July 2000 to May 2024, were recruited at Chang Gung Memorial Hospital, Linkou, Taiwan. All patients had at least 12 months of follow-up. Demographic data, antiseizure medication (ASM) treatment, stimulus avoidance, and seizure outcome were analyzed. We further divided the patients into extrinsic and intrinsic RE groups based on the nature of stimuli. We also categorized them into ongoing seizure and seizure-free groups based on their seizure control. Fisher's exact test and Independent-Samples Mann-Whitney U Test were used to evaluate associations between clinical factors and prognosis. Multivariate logistic regression analysis was further carried out to determine the predictors of seizure outcomes.

RESULTS

In this study, 81 patients with reflex epilepsies (RE) were analyzed, focusing on those with extrinsic (photosensitive) and intrinsic (Mah-Jong-related) seizure triggers. Patients with extrinsic RE were significantly younger (mean age 40.4 years) than those with intrinsic RE (mean age 64.4 years, p < 0.001) and had a notably earlier onset of reflex seizures (21.9 years vs. 49.7 years, p < 0.001). A higher proportion of extrinsic RE patients experienced spontaneous seizures (98 %) compared to intrinsic RE (40 %). Abnormal EEG findings were more prevalent in the extrinsic group (94.1 %) than in the intrinsic group (66.7 %). Ninety-eight percent of patients with extrinsic RE were treated with antiseizure medications (ASMs), with an average of 2.2 ASMs per patient, compared to 73.3 % and 1.2 ASMs in patients with intrinsic RE. Furthermore, the rate of stimulus avoidance was significantly higher among those with intrinsic RE, at 43.3 % compared to 3.9 % in the extrinsic group (p < 0.001). Both groups achieved similar seizure-free outcomes (68.6 % in extrinsic vs. 63.3 % in intrinsic RE), but stimulus avoidance is independently associated with a reduced likelihood of ongoing seizures (p = 0.038), with an odds ratio (OR) of 0.110.

CONCLUSION

Intrinsic RE exhibited a later onset of spontaneous and reflex seizures than extrinsic RE. Avoidance of seizure triggers was more frequent in intrinsic RE and among seizure-free patients, suggesting that stimulus avoidance is crucial for better seizure control and prognosis. On the other hand, patients with extrinsic RE had a lower rate of trigger avoidance but were more likely to receive ASM treatment, suggesting ASM is crucial for managing seizures due to challenges in avoiding environmental triggers. Despite these differences, both groups achieved similar seizure-free outcomes, underscoring the necessity for tailored management strategies based on the type of reflex seizures.

Impact of post-traumatic stress disorder on epileptogenic networks: a functional connectivity study

Post-traumatic stress disorder (PTSD) is more common in patients with drug-resistant epilepsy. Some of these patients experience PTSD due to early psychotraumatic events. This study aims to assess the influence of PTSD on interictal functional connectivity using stereoelectroencephalography (SEEG) recordings in patients with temporal lobe DRE (TDRE). Two groups were considered: TDRE patients with PTSD (PTSD+, N = 11) and TDRE patients without PTSD (PTSD-, N = 12). All subjects had questionnaires measuring anxiety, depression, PTSD symptoms related to seizures, a diagnostic PTSD questionnaire, and a childhood trauma questionnaire. Resting state functional connectivity (FC) was evaluated on SEEG signals to analyze network characteristics. We mainly focused on brain regions involved in PTSD (amygdala, orbitofrontal cortex, hippocampus, insula, rhinal cortex, anterior cingulate cortex). Results revealed increased FC in PTSD + subjects in the brain regions involved in PTSD, but only in the hemisphere ipsilateral to the epileptogenic zone. In contrast, a decreased FC in the contralateral hemisphere was observed in the hippocampus. These findings support the existence of a PTSD-epilepsy-reinforced network, leading to FC alterations dependent on the epilepsy side and the region. Our study is the first to offer insights into the intricate dynamic linking PTSD and epilepsy and highlights the need for accounting for the influence of comorbidities on epileptogenic networks.

ESR Essentials: Image evaluation of patients with seizures and epilepsy-practice recommendations by the European Society of Neuroradiology

Epilepsy, a neurological disorder characterised by recurrent seizures, poses significant challenges in diagnosis, treatment, and management. Understanding the underlying causes and identifying precise anatomical locations of epileptogenic foci are critical for effective management strategies, particularly in drug-resistant patients. Neuroimaging techniques, particularly magnetic resonance (MR), play a pivotal role in the evaluation of epilepsy patients, offering insights into structural abnormalities, epileptogenic lesions, and functional alterations within the brain. Diverse clinical scenarios that warrant neuroimaging in epilepsy patients, ranging from first-onset seizures to drug-resistant epilepsy, will be presented, elucidating the considerations and recommendations for imaging modalities. The dedicated MR protocol for epilepsy patients will be discussed, justifying the rationale behind sequence selection and optimisation strategies and providing clues about how to read these magnetic resonance imaging (MRI) exams. Finally, MR findings associated with common epileptogenic lesions, such as hippocampal sclerosis, focal cortical dysplasia, and long-term epilepsy-associated tumours, will be described. This article reviews essential concepts, including definitions, classification, imaging indications, protocols, and neuroradiological findings, aiming to understand how neuroimaging contributes to diagnosing and managing epilepsy comprehensively. KEY POINTS: MR should be performed in adults and children with a recent diagnosis of epilepsy of unknown aetiology, a first seizure, and a negative CT. Performing a dedicated MR protocol in focal epilepsy is essential for increasing the detection of potentially epileptogenic lesions. For presurgical evaluations, MR abnormalities should correlate with the electric pattern, semiology data, or other neuroimaging examination to be considered the epileptogenic lesion.

Quality of care and associated factors among patients with epilepsy at public hospitals in Arba Minch Town: a facility-based cross-sectional study

BACKGROUND

Epilepsy is one of the most common neurologic disorders affecting approximately 51 million people globally and is associated with significant cases of age-standardized DALYs (182.6 per 100 000 people). The quality of health care services offered to people suffering from epilepsy often fails to meet standards in Ethiopia or internationally. This study was designed to assess the quality of care and associated factors among patients with epilepsy at public hospitals in Arba Minch Town, 2024.

METHOD

A facility-based cross-sectional study was conducted among 392 adult epileptic patients attending public hospitals in Arba Minch Town. Data entry was performed via Epi-data 3.1 software, and the data were analyzed via SPSS version 24 software. Binary logistic regression analysis was used to evaluate the associations between quality of care and sociodemographic, disease-related, and treatment-related factors. Multivariate logistic regression analysis was applied to identify factors independently associated with quality of care.

RESULTS

Three hundred ninety-two adults with epilepsy participated in this study, for a response rate of 92.7%. More than one-half of the 237 (60.5%) patients were males, with a median age of 31 ± 12 years (interquartile range). Fewer than one-half (44.1%) of the patients adhered to antiepileptic medicines. The overall proportion of patients receiving quality care was 213 (54.3%). The seizure control rate was also low, at 130 (33.2%). Patients aged 18-29 years [AOR = 30.8 (95% CI, 8.22-35.616, p < 0.000)] and aged 30-39 years [AOR = 18.4 (95% CI, 5.016-67.613, p < 0.000)], and a seizure frequency of less than three [AOR = 2.318 (95% CI, 1.028-5.225, p < 0.043)] were positively associated with quality of care. Whereas, having poor knowledge about epilepsy [AOR = 0.107 (95% CI, 0.0.057-0.202, p < 0.000)] was negatively associated with quality care.

CONCLUSION

The quality of care provided to adult epilepsy patients at Arba Minch was low. In addition, patient knowledge, medication adherence, and the seizure control rate were also suboptimal. Therefore, addressing identified factors by involving all relevant stakeholders (health professionals, hospitals, zonal health departments, regional health bureaus, and patients) is critical for improving the quality of care. In addition, researchers willing to study this topic should use strong designs that can determine causal determinants of quality care.

Immediate postoperative course in the pediatric intensive care unit following epilepsy surgery

PURPOSE

To describe the immediate postoperative PICU course and short-term outcomes of children undergoing various epilepsy surgeries.

METHODS

Single-center, retrospective observational study. All patients younger than 20 years of age who had been admitted to the PICU between 2018 and 2022 following epilepsy surgery were eligible for study entry.

RESULTS

Fifty-two children (median age 7.9 years) underwent epilepsy surgery during the study period (25 focal lesionectomies and lobectomies [FL], 10 corpus callosotomy [CC], and 17 hemispheric surgeries [HS]). The average number of preoperative antiseizure medications (ASM) was 3, and the average number of failed ASM was 6. Cortical dysplasia was the most frequent etiology (25%). Preoperative cognitive delay and motor deficits were reported in 38 (74%) and 26 (50%) patients, respectively. The median length of stay in the PICU was 1 day (5 for the HS group). No seizures occurred among 44 (85%) children during the first postoperative day nor during the entire hospital stay in 40 (77%) patients (20/25 [82%] in the FL group, 4/10 [40%] in the CC group, and 14/17 [82%] in the HS group). There were no status epilepticus events during the PICU stay. None of patients required hemodynamic support, and only 3(6%) needed respiratory support. Twenty-six patients (50%) had electrolyte abnormalities. Pain was mostly perceived as mild. Fever was present in 28 (54%) patients, most notably in the HS group (94%).

CONCLUSION

Epilepsy surgery in children is associated with very limited immediate postoperative morbidity and low seizure burden, especially in the FL and HS groups.

Pharmacogenetic insights into ABCB1, ABCC2, CYP1A2, and CYP2B6 variants with epilepsy susceptibility among Egyptian Children: A retrospective case-control study

BACKGROUND

Pediatric epilepsy is a complicated neuropsychiatric disorder that is characterized by recurrent seizures and unusual synchronized electrical activities within brain tissues. It has a substantial effect on the quality of life of children, thus understanding of the hereditary considerations influencing epilepsy susceptibility and the response to antiepileptic medications is crucial. This study focuses on assessing the correlation of the ABCB1, ABCC2, CYP1A2, and CYP2B6 genetic polymorphisms with the susceptibility to epileptic seizures and their contributions to antiepileptic medication throughout the course of the disease.

METHODS

This study included 134 Egyptian epileptic children, comprising 67 drug-responsive and 67 drug-resistant patients, along with 124 healthy controls matching for age, gender, and geographical district. Genotyping of the rs2032582, rs717620, rs2273697, rs762551, and rs3745274 variants was performed using the PCR technique. Statistical analyses, including haplotype, multivariate, logistic regression, and bioinformatics approaches, were conducted to evaluate the associations within the disease.

RESULTS

The ABCC2*rs717620 (T allele) revealed an increased risk of epilepsy compared to healthy controls (OR = 2.12, p-value < 0.001), with the rs717620 (C/T + T/T genotypes) showing significant differences between drug-responsive and drug-resistant patients (p-value < 0.05). Moreover, the ABCC2*rs2273697 (A allele) indicated a decreased risk of epileptic seizures compared to healthy controls (OR = 0.51, p-value = 0.033), with the rs2273697 (G/A + A/A genotypes) indicating a significant association with drug-resistant patients (OR = 0.21, p-value = 0.002). The rs717620*T/rs2273697*G haplotype was significantly correlated with an elevated risk of epileptic seizures within drug-responsive patients (OR = 2.26, p-value = 0.019). Additionally, the CYP1A2*rs762551 (A allele) represented a protective effect against epilepsy susceptibility (OR = 0.50, p-value < 0.001), with the rs762551 (G/A + A/A genotypes) disclosing a substantial association with a decreased risk of epileptic seizures among drug-resistant patients compared to drug-responsive patients (OR = 0.07, p-value < 0.001). Conversely, the ABCB1*rs2032582 (G allele) and the CYP2B6*rs3745274 (T allele) did not attain a significant difference with the epilepsy risk compared to healthy controls (p-value > 0.05).

CONCLUSIONS

The findings of our study emphasize the importance of pharmacogenetic screening in epilepsy research, particularly regarding to drug-resistant patients. The ABCC2*rs717620 variant conferred a significant correlation with elevated risk of epileptic seizures, while the ABCC2*rs2273697 and CYP1A2*rs762551 variants confirmed their contributions as protective markers against epilepsy development. Conversely, the ABCB1*rs2032582 and CYP2B6*rs3745274 alleles were not considered as independent risk factors with the course of epilepsy disease.

Cenobamate, a New Promising Antiseizure Medication: Experimental and Clinical Aspects

About 40-50% of patients with drug-resistant epilepsy do not properly respond to pharmacological therapy with antiseizure medications (ASMs). Recently approved by the US Food and Drug Administration and European Medicines Agency as an add-on drug for focal seizures, cenobamate is an ASM sharing two basic mechanisms of action and exhibiting a promising profile of clinical efficacy. The drug preferably inhibits persistent sodium current and activates GABA-mediated events via extrasynaptic, non-benzodiazepine receptors. Thus, its antiseizure potential is dependent on both reducing excitation and enhancing inhibition in the central nervous system. In experimental seizure models, cenobamate exhibited a clear-cut activity in many of them with promising protective indexes, with only bicuculline-induced seizures being unaffected. Randomized clinical trials indicate that combinations of cenobamate, with already prescribed ASMs, resulted in significant percentages of seizure-free patients and patients with a significant reduction in seizure frequency, compared to other ASMs in the form of an add-on therapy. Its greater antiseizure efficacy was accompanied by adverse events comparable to other ASMs. Cenobamate has also been shown to possess neuroprotective activity, which may be of importance in affecting the process of epileptogenesis and, thus, modifying the course of epilepsy.

Perampanel reduces seizure frequency in patients with developmental and epileptic encephalopathy for a long term

Seizures in patients with developmental and epileptic encephalopathies (DEEs) are often highly resistant to various antiseizure medications. Perampanel (PER) is a novel antiseizure medication that non-competitively inhibits the α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor and is expected to reduce seizure frequency not only for focal seizures and generalized tonic-clonic seizures (GTCS) but also for other seizure types. This study aimed to clarify the long-term therapeutic efficacy and tolerability of PER in patients with DEEs. We analyzed data regarding patients' background characteristics, medication retention, trends in seizure frequency, and adverse events obtained from 24 patients with DEEs who had been on PER treatment for 60 months. The retention rates were 62.5% and 46.9% at 12 and 60 months, respectively. At 60 months after PER initiation, the rate of patients with > 50% seizure reduction was 33.3%, 33.3%, 38.5%, 54.5%, 54.5%, and 36.4% among patients with atypical absence seizures, tonic seizures, focal seizures, GTCS, myoclonic seizures, and atonic seizures, respectively. The frequency of adverse events was 70.8%. PER showed long-term efficacy in various seizure types. PER is a promising treatment option for patients with DEEs.

Recent Advances in Pharmacologic Treatments of Drug-Resistant Epilepsy: Breakthrough in Sight

Epilepsy affects approximately 1% of the world population. Patients have recurrent seizures, increased physical and psychiatric comorbidities, and higher mortality rate than the general population. Over the last 40 years, research has resulted in 20 new antiseizure medications (ASMs) approved between 1990 and 2018. In spite of this, up to one-third of patients (~ 1 million patients in the USA) have drug-resistant epilepsy (DRE), with little change between 1982 and 2018, a period of intense new ASM development. A minority of patients with DRE may benefit from surgical treatment, but this specialized care remains challenging to scale. Therefore, the greatest hope for breakthroughs for patients with DRE is in pharmacologic therapies. Recently, several advances promise to change the outcomes for patients with DRE. Cenobamate, a drug with dual mechanisms of modulating sodium channel currents and GABA-A receptors, achieves 90-100% seizure reduction in 25-33% of patients with focal DRE, a response not observed with other ASMs. Fenfluramine, a serotonin-acting drug, dramatically reduces the frequency of convulsive seizures in Dravet syndrome, a devastating developmental epileptic encephalopathy with severe DRE. Both drugs reduce mortality. In addition, the possibility of DRE prevention was recently raised in patients with tuberous sclerosis complex, a relatively common genetic form of epilepsy. A paradigm shift is emerging in the treatment of epilepsy. Seizure freedom has become attainable in a significant proportion of patients with focal DRE, and dramatic seizure reduction has been achieved in a developmental encephalopathy. Coupled with a rich pipeline of new compounds under clinical development, the long sought-after breakthrough in the treatment of epilepsy may finally be in sight.