Prevalence and subtypes of radiological cerebrovascular disease in late-onset isolated seizures and epilepsy

An Integrative Nomogram for Identifying Cognitive Impairment Using Seizure Type and Cerebral Small Vessel Disease Neuroimaging Markers in Patients with Late-Onset Epilepsy of Unknown Origin

INTRODUCTION

Cognitive impairment (CI) is a common comorbidity in patients with late-onset epilepsy of unknown origin (LOEU). However, limited data are available on effective screening methods for CI at an early stage. We aimed to develop and internally validate a nomogram for identifying patients with LOEU at risk of CI and investigate the potential moderating effect of education on the relationship between periventricular white matter hyperintensities (PVHs) and cognitive function.

METHODS

We retrospectively reviewed the clinical data of 61 patients aged ≥ 55 years diagnosed with LOEU. The main outcome was CI, reflected as an adjusted Montreal Cognition Assessment score of < 26 points. A nomogram based on a multivariable logistic regression model was constructed. Its discriminative ability, calibration, and clinical applicability were tested using calibration plots, the area under the curve (AUC), and decision curves. Internal model validation was conducted using the bootstrap method. The moderating effect of education on the relationship between PVH and cognitive function was examined using hierarchical linear regression.

RESULTS

Forty-four of 61 (72.1%) patients had CI. A nomogram incorporating seizure type, total cerebral small vessel disease burden score, and PVH score was built to identify the risk factors for CI. The AUC of the model was 0.881 (95% confidence interval: 0.771-0.994) and 0.78 (95% confidence interval: 0.75-0.8) after internal validation. Higher educational levels blunted the negative impact of PVH on cognitive function.

CONCLUSION

Our nomogram provides a convenient tool for identifying patients with LOEU who are at risk of CI. Moreover, our findings demonstrate the importance of education for these patients.

Frequency and predictors of poststroke epilepsy after mechanical thrombectomy for large vessel occlusion stroke: results from a multicenter cohort study

BACKGROUND

Poststroke epilepsy (PSE) represents an important complication of stroke. Data regarding the frequency and predictors of PSE in patients with large-vessel occlusion stroke receiving mechanical thrombectomy (MT) are scarce. Furthermore, information on acute and preexisting lesion characteristics on brain MRI has not yet been systematically considered in risk prediction of PSE. This study thus aims to assess PSE risk after acute ischemic stroke treated with MT, based on clinical and MRI features.

METHODS

In this multicenter study from two tertiary stroke centers, we included consecutive acute ischemic stroke patients who had received MT for acute intracranial large vessel occlusion (LVO) between 2011 and 2017, in whom post-interventional brain MRI and long term-follow-up data were available. Infarct size, affected cerebrovascular territory, hemorrhagic complications and chronic cerebrovascular disease features were assessed on MRI (blinded to clinical information). The primary outcome was the occurrence of PSE (> 7 days after stroke onset) assessed by systematic follow-up via phone interview or electronic records.

RESULTS

Our final study cohort comprised 348 thrombectomy patients (median age: 67 years, 45% women) with a median long-term follow-up of 78 months (range 0-125). 32 patients (9%) developed PSE after a median of 477 days (range 9-2577 days). In univariable analyses, larger postinterventional infarct size, infarct location in the parietal, frontal or temporal lobes and cerebral microbleeds were associated with PSE. Multivariable Cox regression analysis confirmed larger infarct size (HR 3.49; 95% CI 1.67-7.30) and presence of cerebral microbleeds (HR 2.56; 95% CI 1.18-5.56) as independent predictors of PSE.

CONCLUSION

In our study, patients with large vessel occlusion stroke receiving MT had a 9% prevalence of PSE over a median follow-up period of 6.5 years. Besides larger infarct size, presence of cerebral microbleeds on brain MRI predicted PSE occurrence.

Histopathological characterization of cerebral small vessel disease in epilepsy patients with temporal lobe epilepsy submitted to surgery: A case-control study

BACKGROUND

Cerebrovascular disease (CVD) is a major contributor to epilepsy; however, patients with epilepsy also have a significantly increased risk of stroke. The way in which epilepsy contributes to the increased risk of stroke is still uncertain and is ill-characterized in neuropathological studies. A neuropathological characterization of cerebral small vessel disease (cSVD) in patients with chronic epilepsy was performed.

METHODS

Thirty-three patients with refractory epilepsy and hippocampal sclerosis (HS) submitted to epilepsy surgery from a reference center were selected between 2010 and 2020 and compared with 19 autopsy controls. Five randomly selected arterioles from each patient were analyzed using a previously validated scale for cSVD. The presence of CVD disease imaging markers in pre-surgical brain magnetic resonance imaging (MRI) was studied.

RESULTS

There were no differences in age (43.8 vs. 41.6 years; p = 0.547) or gender distribution (female gender 60.6% vs. male gender 52.6%; p = 0.575) between groups. Most CVD findings in brain MRI were mild. Patients had a mean time between the epilepsy onset and surgery of 26 ± 14.7 years and were medicated with a median number of three antiseizure medication (ASMs) [IQR 2-3]. Patients had higher median scores in arteriolosclerosis (3 vs. 1; p < 0.0001), microhemorrhages (4 vs. 1; p < 0.0001) and total score value (12 vs. 8.9; p = 0.031) in comparison with controls. No correlation was found between age, number of years until surgery, number of ASMs or cumulative defined daily dosage of ASM.

CONCLUSION

The present study provides evidence supporting the increased burden of cSVD in the neuropathological samples of patients with chronic epilepsy.

Epileptogenicity of white matter lesions in cerebral small vessel disease: a systematic review and meta-analysis

BACKGROUND

The epileptogenic properties of white matter lesions (WML) in cerebral small vessel disease (CSVD) are not yet understood. The aim of our systematic review and meta-analysis was to estimate the association between the extent of WML in CSVD and epilepsy, analyze whether these WML are associated with an increased risk of seizure recurrence, and evaluate if treatment with anti-seizure medication (ASM) is justified in first-seizure patients with WML and no cortical lesions.

METHODS

Following a pre-registered study protocol (PROSPERO-ID CRD42023390665), we systematically searched Pubmed and Embase for relevant literature comparing WML load between patients with epilepsy and controls as well as studies on seizure recurrence risk and ASM therapy in the presence vs. absence of WML. We calculated pooled estimates using a random effects model.

RESULTS

Eleven studies comprising 2983 patients were included in our study. Presence of WML (OR 2.14, 95% CI 1.38-3.33) and presence of relevant WML as assessed by visual rating scales (OR 3.96, 95% CI 2.55-6.16) but not WML volume (OR 1.30, 95% CI 0.91-1.85) were significantly associated with seizures. These results stayed robust in sensitivity analyses restricted to studies on patients with late-onset seizures/epilepsy. Only two studies assessed the association between WML and risk of seizure recurrence with conflicting results. Currently, there are no studies on the efficacy of ASM therapy in the presence of WML in CSVD.

CONCLUSIONS

This meta-analysis suggests an association between presence of WML in CSVD and seizures. More research is needed addressing the association between WML and risk of seizure recurrence and ASM therapy focusing on a population of patients with a first unprovoked seizure.

In atrial fibrillation epilepsy risk differs between oral anticoagulants: active comparator, nested case-control study

AIMS

Atrial fibrillation (AF) is a risk factor for brain infarction, which can lead to epilepsy. We aimed to investigate whether treatment of AF with direct oral anticoagulants (DOACs) affects the risk of epilepsy in comparison to treatment with the vitamin K antagonist phenprocoumon (PPC).

METHODS AND RESULTS

We performed an active comparator, nested case-control study based on the German Pharmacoepidemiological Research Database that includes claims data from statutory health insurance providers of about 25 million persons since 2004. In 2011-17, 227 707 AF patients initiated treatment with a DOAC or PPC, of which 1828 cases developed epilepsy on current treatment with an oral anticoagulant. They were matched to 19 084 controls without epilepsy. Patients with DOAC treatment for AF had an overall higher risk of epilepsy with an odds ratio of 1.39, 95% CI (1.24; 1.55) compared to current PPC treatment. Cases had higher baseline CHA2DS2-VASc scores and more frequently a history of stroke than controls. After excluding patients with ischaemic stroke prior to the diagnosis of epilepsy, the risk of epilepsy was still higher on DOACs than on PPC. In contrast, within a cohort of patients with venous thromboembolism, the risk of epilepsy on treatment with DOACs was less elevated [adjusted odds ratio 1.15, 95% CI (0.98; 1.34)].

CONCLUSION

In patients with AF initiating oral anticoagulation, treatment with a DOAC was associated with an increased risk of epilepsy compared to the vitamin K antagonist PPC. Covert brain infarction may explain the observed elevated risk of epilepsy.

Epilepsy in Cerebrovascular Diseases: A Narrative Review

BACKGROUND

Epilepsy is a common comorbidity of cerebrovascular disease and an increasing socioeconomic burden.

OBJECTIVE

We aimed to provide an updated comprehensive review on the state of the art about seizures and epilepsy in stroke, cerebral haemorrhage, and leukoaraiosis.

METHODS

We selected English-written articles on epilepsy, stroke, and small vessel disease up until December 2021. We reported the most recent data about epidemiology, pathophysiology, prognosis, and management for each disease.

RESULTS

The main predictors for both ES and PSE are the severity and extent of stroke, the presence of cortical involvement and hemorrhagic transformation, while PSE is also predicted by younger age at stroke onset. Few data exist on physiopathology and seizure semiology, and no randomized controlled trial has been performed to standardize the therapeutic approach to post-stroke epilepsy.

CONCLUSION

Some aspects of ES and PSE have been well explored, particularly epidemiology and risk factors. On the contrary, few data exist on physiopathology, and existing evidence is mainly based on studies on animal models. Little is also known about seizure semiology, which may also be difficult to interpret by non-epileptologists. Moreover, the therapeutic approach needs standardization as regards indications and the choice of specific ASMs. Future research may help to better elucidate these aspects.

Diagnosis and Treatment of Poststroke Epilepsy: Where Do We Stand?

Purpose of Review

Stroke is the most common cause of seizures and epilepsy in older adults. This educational paper aims to give an update on current clinical aspects of diagnosis and treatment of poststroke epilepsy.

Recent Findings

Regarding epileptic seizures related to stroke, it is important to distinguish between acute symptomatic seizures and unprovoked seizures as they differ in their risk for seizure recurrence. In fact, after a single unprovoked poststroke seizure, a diagnosis of epilepsy can be made because there is a greater than 60% risk for further seizures. Clinical models that can predict the development of epilepsy after a stroke have been successfully established. However, treatment with anti-seizure medications is advised only after a first unprovoked poststroke seizure, as current treatments are not known to be effective for primary prevention. The management of poststroke epilepsy requires consideration of aspects such as age, drug-drug interactions and secondary vascular prophylaxis, yet evidence for the use of anti-seizure medications specifically in poststroke epilepsy is limited.

Summary

This text reviews the epidemiology and risk factors for poststroke epilepsy, explains the role of EEG and neuroimaging in patients with stroke and seizures and provides an overview on the clinical management of stroke-related acute symptomatic seizures and poststroke epilepsy.

Identification of factors associated with new-onset vascular disease in patients admitted for video-EEG monitoring: A longitudinal cohort study

OBJECTIVE

People with epilepsy are at a higher risk of developing vascular disease. Understanding the risk factors in observational studies is hampered by the challenge in separating epilepsy-related risk and treatment-related risk, and uncertainty in the epilepsy diagnosis. This study aimed to identify factors associated with risk of subsequent vascular disease in patients with video-EEG monitoring (VEM) confirmed epilepsy.

METHODS

We included patients with a diagnosis of epilepsy and nonepileptic disorders between January 1, 1995, and December 31, 2015. Incident cardiovascular, cerebrovascular, and peripheral vascular disease was determined by linkage to a state-wide hospital admissions database between 1st July 1994 and 28th February 2018. Incidence was compared with the general population.

RESULTS

1728 patients (59.7% female, median age 35 years) underwent VEM, and were followed up for a median of 9.2 years (range 2.2-22.9 years). Eight-hundred and thirty -two were diagnosed with epilepsy and 896 nonepileptic disorders. The incidence of cerebrovascular disease was higher in both patients with epilepsy (incidence rate ratio [IRR] 1.78, p = 0.001) and with nonepileptic disorders (IRR 1.61, p < 0.001) than in the general population. Patients who took valproic acid (VPA) were at a lower risk of vascular disease than those taking enzyme-inducing antiseizure medications (EIASM, subdistribution hazard ratio [SHR] 0.42, p = 0.013), and those taking neither VPA nor EIASM (SHR 0.47, p = 0.03). There was no difference in the incidence of vascular disease between patients with epilepsy and those without epilepsy (SHR 0.94, p = 0.766). Factors associated with increased risk included age (SHR 1.04, p < 0.001), male sex (SHR 1.50, p = 0.017), and smoking (SHR 1.68, p = 0.017).

SIGNIFICANCE

In this study, both patients with epilepsy and without epilepsy had increased vascular risk. This suggests that the increased risk may be in part due to factors not directly related to epilepsy, such as EIASM use and vascular risk factors.

Pathogenesis and research progress in leukoaraiosis

Leukoaraiosis is a common imaging marker of cerebral small vessel disease. In recent years, with the continuous advances in brain imaging technology, the detection rate of leukoaraiosis is higher and its clinical subtypes are gradually gaining attention. Although leukoaraiosis has long been considered an incidental finding with no therapeutic necessity, there is now growing evidence linking it to, among other things, cognitive impairment and a high risk of death after stroke. Due to different research methods, some of the findings are inconsistent and even contradictory. Therefore, a comprehensive and in-depth study of risk factors for leukoaraiosis is of great clinical significance. In this review, we summarize the literature on leukoaraiosis in recent years with the aim of elucidating the disease in terms of various aspects (including pathogenesis, imaging features, and clinical features, etc.).

Late-Onset Focal Epilepsy: Electroclinical Features and Prognostic Role of Leukoaraiosis

The aim of this study was to describe the electroclinical and prognostic characteristics, and to investigate the role of leukoaraiosis in outpatients with new-onset elderly focal epilepsy aged ≥60 years, referred to a tertiary epilepsy center between 2005 and December 31, 2020. Among the 720 patients who were referred to the center, we retrospectively selected 162 consecutive outpatients, with a first referral for recent-onset focal epilepsy of unknown cause (UC) or structural cause (SC), and collected a clinical and standard-Electroencephalogram (S-EEG), 24-h ambulatory EEG (A-EEG), and neuroimaging data. We also analyzed the seizure prognosis after titration of the first antiseizure medication (ASM). One hundred and four UC and 58 SC patients, followed up for 5.8 ± 5.3 years (mean ± SD), were included. Compared with the SC group, the patients with UC showed a predominance of focal seizures with impaired awareness (51.9% of cases) and focal to bilateral tonic-clonic seizures during sleep (25%); conversely, the SC group, more frequently, had focal to bilateral tonic-clonic seizures during wakefulness (39.6%) and focal aware seizures (25.8%) (p < 0.0001). Oral or gestural automatisms were prevalent in UC epilepsy (20.2 vs. 6.9% in the SC group, p = 0.04). In UC compared to patients with SC, interictal epileptiform discharges showed a preferential temporal lobe localization (p = 0.0007), low expression on S-EEG, and marked activation during deep Non-Rapid Eye Movement (NREM) sleep (p = 0.003). An overall good treatment response was found in the whole sample, with a probability of seizure freedom of 68.9% for 1 year. The cumulative probability of seizure freedom was significantly higher in the UC compared with the SC group (p < 0.0001). The prognosis was worsened by leukoaraiosis (p = 0.012). In the late-onset focal epilepsy of unknown cause, electroclinical findings suggest a temporal lobe origin of the seizures. This group showed a better prognosis compared with the patients with structural epilepsy. Leukoaraiosis, per se, negatively impacted on seizure prognosis.

Pearls and Oy-sters: De Novo Seizure and Stroke in the Elderly: The Issue of Chicken and Egg

Seizures immediately preceding the occurrence of an ischemic or hemorrhagic stroke are a rare but well documented phenomenon, for which the term "heraldic seizure" has been proposed. Cerebrovascular disease is the most common cause of epileptic seizures in elderly patients, thus screening and management of vascular risk factors should be done systematically in cases of late-onset epilepsy. MRI may help to distinguish heraldic seizure from stroke-elicited seizure by showing abnormalities confined to the cortex that spare vascular territories, increased MRA flow in the ipsilateral cerebral arteries and enhancement of the leptomeninges on postcontrast MRI. Here we present a case report that illustrates the difficulty of making the diagnosis of a heraldic seizure at onset.

Effect of late-onset epilepsy on cognitive functioning in patients with small vessel disease

RATIONALE

Late-onset epilepsy (LOE) often has underlying cerebrovascular cause and has been associated with neurocognitive deficits and dementia. Nevertheless, the interplay between these factors has not been studied thus far. Hence, we conducted a retrospective cross-sectional study aimed to explore how unprovoked epileptic seizures along with vascular-related factors contribute to neurocognitive impairments in patients with cerebral small vessel disease.

METHODS

Twenty-seven patients with LOE aged > 60 years with concomitant cerebral small vessel disease (cSVD) and a matched group of cSVD without epilepsy were cognitively assessed. Demographic, clinical, and vascular information were obtained and vascular burden score was calculated for each patient. Multiple linear regression models were used to explore the relationship between epilepsy and cognitive measures adjusting for demographic and vascular risk factors.

RESULTS

Compared with cSVD, cSVD-LOE group showed a poorer performance on verbal memory measures, visuomotor tracking and speed processing and phonetic fluency. In the multiple regression analysis, the presence of epilepsy was found to be the major predictor for verbal memory dysfunction, specifically in verbal short recall (p = 0.008) and verbal learning (p < 0.001). No interactions between vascular burden and epilepsy were found.

CONCLUSION

Patients who had cSVD with concurrent LOE showed poorer performance on memory function compared with patients with cSVD without epilepsy, and they showed a different cognitive profile from that typically manifested by patients with cSVD. The presence of epilepsy, but not seizure localization nor vascular burden, was the major contributor to the decrease in verbal memory.

Risk models to predict late-onset seizures after stroke: A systematic review

BACKGROUND AND PURPOSE

We performed a systematic review to evaluate available risk models to predict late seizure onset among stroke survivors.

METHODS

We searched major databases (PubMed, SCOPUS, and Cochrane Library) from inception to October 2020 for articles on the development and/or validation of risk models to predict late seizures after a stroke. The impact of models to predict late-onset seizures was also assessed. We included seven articles in the final analysis. For each of these studies, we evaluated the study design and scope of predictors analyzed to derive each model. We assessed the performance of the models during internal and external validation in terms of discrimination and calibration.

RESULTS

Three studies focused on ischemic stroke alone, with c-statistic values ranging from 0.73 to 0.77. The SeLECT model from Switzerland was externally validated in Italian, German, and Austrian cohorts where c-statistics ranged from 0.69 to 0.81. This model along with the PSEiCARe model, were internally validated and calibration performance was provided for both models. The CAVS and CAVE models reported on the risk of late-onset seizures in patients with hemorrhagic stroke. The CAVS model derivation cohort was racially diverse. The CAVS model's c-statistic was 0.76, while the CAVE model had a c-statistic of 0.81. Calibration and internal validation were not performed for either study. The CAVS model, created from a Finnish population, was externally validated in American and French cohorts, with c-statistics of 0.73 and 0.69, respectively. Finally, the two studies focusing on both types of stroke came from the PoSERS and INPOSE models. Neither model provided c-statistics, calibration metrics, internal or external validation information. We found no evidence of the presence of impact studies to assess the effect of adopting late-onset seizure risk models after stroke on clinical outcomes.

CONCLUSION

The SeLECT model was the only model developed in line with proposed guidelines for appropriate model development. The model, which was externally validated in a very similar and homogeneous population, may need to be tested in a more racially/ethnic diverse and younger population; testing the SeLECT model, accounting for overall brain health is likely to improve the identification of high-risk patients for late post stroke seizures.

Trends in prescribing patterns of antiepileptic drugs among older adult inpatients in a Brazilian tertiary center

BACKGROUND

Data on prescribing patterns of antiepileptic drugs (AEDs) to older adult inpatients are limited.

OBJECTIVE

To assess changes in prescribing patterns of AEDs to older adult inpatients with late-onset epilepsy between 2009-2010 and 2015-2019, and to interpret any unexpected patterns over the 2015-2019 period.

METHODS

Patients aged ≥60 years with late-onset epilepsy from a tertiary center were selected. Demographic data, seizure characteristics and etiology, comorbidities, and comedications were analyzed, in addition to prescription regimens of inpatients taking AEDs to treat epilepsy. AED regimens were categorized into two groups: group 1 included appropriate AEDs (carbamazepine, oxcarbazepine, valproic acid, gabapentin, clobazam, lamotrigine, levetiracetam, topiramate, and lacosamide); and group 2 comprised suboptimal AEDs (phenytoin and phenobarbital). Multivariate logistic regression analysis was performed to identify risk factors for prescription of suboptimal AEDs.

RESULTS

134 patients were included in the study (mean age: 77.2±9.6 years). A significant reduction in the prescription of suboptimal AEDs (from 73.3 to 51.5%; p<0.001) was found; however, phenytoin remained the most commonly prescribed AED to older adult inpatients. We also found an increase in the prescription of lamotrigine (from 5.5 to 33.6%) and levetiracetam (from 0 to 29.1%) over time. Convulsive status epilepticus (SE) and acute symptomatic seizures associated with remote and progressive etiologies were risk factors for the prescription of suboptimal AEDs.

CONCLUSIONS

Phenytoin was the main suboptimal AED prescribed in our population, and convulsive SE and acute symptomatic seizures associated with some etiologies were independent risk factors for phenytoin prescription. These results suggest ongoing commitment to reducing the prescription of suboptimal AEDs, particularly phenytoin in Brazilian emergence rooms.

Late-onset epilepsy predicts stroke: Systematic review and meta-analysis

OBJECTIVE

Late-onset epilepsy (LOE) is closely associated with cerebrovascular disease, acting as both a marker of cerebrovascular disease (CVD) and occurring as a direct consequence. Despite this, our understanding of LOE as a cerebrovascular phenomenon is in its infancy. LOE also appears to be a harbinger of dementia.

METHODS

A systematic review was performed to identify publications relating to LOE and identified observational studies, clinical studies, and radiological studies.

RESULTS

A meta-analysis of observational studies demonstrated that patients presenting with LOE experience an increased risk of subsequent stroke (weighted OR 3.88 (95% CI 2.76-5.46)). The additional studies demonstrated clinical and radiological evidence to support the premise that LOE is likely to reflect underlying cerebrovascular disease.

SIGNIFICANCE

Cerebrovascular disease risk factors convey increased risk of LOE and LOE can precede stroke and dementia, acting as an early marker for cerebrovascular risk. This may represent a potential point for intervention. There are a number of suggested mechanisms relating LOE to stroke; however, there is limited understanding of the natural history of LOE. Current data support the need for prospective research in order to understand the natural history of LOE and modify disease, in order to reduce the apparent sequelae of stroke and dementia.

Vascular risk factors as independent predictors of neurocognitive impairments in patients with late-onset epilepsy who have small-vessel disease

RATIONALE

Late-onset epilepsy is often accompanied by underlying cerebrovascular disease and has been associated with neurocognitive deficits even dementia, but the interrelation between them remains unknown. In this study, we aimed to explore the contribution of vascular-related and epilepsy-related factors on neurocognitive outcomes in a sample of late-onset epilepsy with history of cerebral small vessel disease.

METHODS

In this retrospective cross-sectional study, a comprehensive neurocognitive assessment was performed in 25 patients aged >60 years with one or more unprovoked seizures and history of small-vessel disease. Raw scores of cognitive tests were transformed in T-scores and were grouped in 6 cognitive domains. Regression models were performed to explore the contribution of vascular risk factors (diabetes mellitus, arterial hypertension, dyslipidemia, and smoking habit) and epilepsy-related factors (drug-resistance, number of antiepileptic drugs, age at epilepsy onset, and epileptic focus localization).

RESULTS

Diabetes (p = 0.03) and smoking habit (p = 0.05) were the best independent factors to predict attention performance; diabetes also predicted visual memory function (p = 0.02); gender was related to verbal memory performance (p = 0.04) and speed processing (p = 0.02). Age at onset predicted that executive function (p = 0.05); age (p = 0.01) and gender (p = 0.03) were the major contributors to language performance. Epilepsy-related variables did not predict any cognitive outcomes.

CONCLUSIONS

Vascular risk factors and sociodemographic characteristics were the best predictors of cognitive outcomes in a sample of late-onset epilepsy with cerebral small-vessel disease. Epilepsy did not show influence on cognitive function. Longitudinal studies are necessary to clarify the relationship between vascular risk factors and epilepsy on progression of cognitive deterioration in patients with late-onset epilepsy. This article is part of the Special Issue "Seizures & Stroke".

Seizures in the context of occult cerebrovascular disease

There is an important bidirectional relationship between seizures and cerebrovascular disease (CVD). Aside from poststroke epilepsy, Occult CVD is an important cause of late-onset seizures (LOS) and late-onset epilepsy (LOE). Late-onset seizures/LOE are associated with a threefold increased risk of subsequent clinical stroke. This relationship exists not only in later life, but with 'late-onset' seizures or epilepsy occurring from the fourth decade of life onwards. There is increasing evidence for the importance of hypertension and cerebral small vessel disease (SVD) in epileptogenesis, but there is a considerable need for further work to elucidate underlying mechanisms. There may be a disproportionately increased risk of intracerebral hemorrhage (ICH) after LOS/LOE; this too requires further study. There is also a bidirectional relationship between LOS/LOE and cognitive impairment/dementia: it is likely that there are important interactions between vascular and neurodegenerative pathological processes mediating LOE, stroke, and dementia. There is a pressing need for better epidemiological and natural history data as well as elucidation of epileptogenic mechanisms, in order to progress our understanding and to better inform clinical practice.

Synchrotron Radiation-Based Three-Dimensional Visualization of Angioarchitectural Remodeling in Hippocampus of Epileptic Rats

Characterizing the three-dimensional (3D) morphological alterations of microvessels under both normal and seizure conditions is crucial for a better understanding of epilepsy. However, conventional imaging techniques cannot detect microvessels on micron/sub-micron scales without angiography. In this study, synchrotron radiation (SR)-based X-ray in-line phase-contrast imaging (ILPCI) and quantitative 3D characterization were used to acquire high-resolution, high-contrast images of rat brain tissue under both normal and seizure conditions. The number of blood microvessels was markedly increased on days 1 and 14, but decreased on day 60 after seizures. The surface area, diameter distribution, mean tortuosity, and number of bifurcations and network segments also showed similar trends. These pathological changes were confirmed by histological tests. Thus, SR-based ILPCI provides systematic and detailed views of cerebrovascular anatomy at the micron level without using contrast-enhancing agents. This holds considerable promise for better diagnosis and understanding of the pathogenesis and development of epilepsy.

Late-onset unexplained epilepsy: What are we missing?

With the aging of the US population, the incidence of epilepsy will increase, with 25 to 50% of new cases with no identifiable etiology diagnosed as late-onset unexplained epilepsy (LOUE). In the current targeted review, we discuss the possible role of cerebral small vessel ischemic disease, accumulation of amyloidβ and hyperphosphorylated tau, and sleep apnea as potential pathophysiologic mechanisms explaining LOUE. We highlight the impact of these processes on cognition and avenues for diagnosis and treatment.

Predictors of early seizure recurrence among elderly inpatients admitted to a tertiary center: A prospective cohort study

PURPOSE

Early seizure recurrence is common among elderly inpatients and is related to increased morbidity and a longer length of hospital stay. There are few studies on the short-term outcomes of seizures in the elderly population. We aimed to identify the predictors of early seizure recurrence among elderly inpatients.

METHODS

We prospectively enrolled patients aged 60 years and older from a tertiary center who had seizures that either led to their hospital admission or occurred during hospitalization. We analyzed the demographic and hospitalization data, characteristics and etiology of seizures, and neurological and clinical comorbidities. Kaplan-Meier analysis was performed to determine the 30-day cumulative recurrence rates. The logrank test was used to analyze the risk of seizure recurrence within 30 days after the index seizure. Multivariable logistic regression analysis was used to identify risk factors for the recurrence of seizures within 30 days.

RESULTS

Overall, 109 patients (mean age: 75.9 ± 9.6 years) were enrolled. The mean age at the first-ever seizure was 74 ± 11.7 years. Unprovoked seizures occurred in 59.6% of the patients. Cerebrovascular disorders were the most prevalent etiology (52.3%). Early seizure recurrence, defined as within 30 days, occurred in 27.5% of patients. Multimorbidity was found in 95.4% of our inpatients (6.3 ± 2.3 [95% confidence interval, 5.4-7.2]), and the number of comorbidities was higher among those who had seizure recurrence than that among those who did not have seizure recurrence (p = 0.02). The probability of seizure recurrence was similar among the subgroups of patients who experienced acute seizures versus unprovoked seizures (both p = 0.03), and seizure recurrence was associated with a longer length of hospital stay (p = 0.005) compared to that of patients who did not experience seizure recurrence. After multivariate analysis, sepsis (p = 0.011), psychiatric disorders (p = 0.032), and cardiac arrhythmias (p = 0.037) were identified as risk factors for early seizure recurrence.

CONCLUSIONS

Higher multimorbidity and a longer length of stay were associated with early seizure recurrence; and sepsis, psychiatric disorders, and cardiac arrhythmias were independent risk factors for early seizure recurrence among elderly inpatients.

Hypertension, seizures, and epilepsy: a review on pathophysiology and management

BACKGROUND

Epilepsy and hypertension are common chronic conditions, both showing high prevalence in older age groups. This review outlines current experimental and clinical evidence on both direct and indirect role of hypertension in epileptogenesis and discusses the principles of drug treatment in patients with hypertension and epilepsy.

METHODS

We selected English-written articles on epilepsy, hypertension, stroke, and cerebrovascular disease until December, 2018.

RESULTS

Renin-angiotensin system might play a central role in the direct interaction between hypertension and epilepsy, but other mechanisms may be contemplated. Large-artery stroke, small vessel disease and posterior reversible leukoencephalopathy syndrome are hypertension-related brain lesions able to determine epilepsy by indirect mechanisms. The role of hypertension as an independent risk factor for post-stroke epilepsy has not been demonstrated. The role of hypertension-related small vessel disease in adult-onset epilepsy has been demonstrated. Posterior reversible encephalopathy syndrome is an acute condition, often caused by a hypertensive crisis, associated with the occurrence of acute symptomatic seizures. Chronic antiepileptic treatment should consider the risk of drug-drug interactions with antihypertensives.

CONCLUSIONS

Current evidence from preclinical and clinical studies supports the vision that hypertension may be a cause of seizures and epilepsy through direct or indirect mechanisms. In both post-stroke epilepsy and small vessel disease-associated epilepsy, chronic antiepileptic treatment is recommended. In posterior reversible encephalopathy syndrome blood pressure must be rapidly lowered and prompt antiepileptic treatment should be initiated.

Juxtacortical lesions are associated with seizures in cerebral small vessel disease

BACKGROUND AND OBJECTIVE

Small vessel cerebrovascular disease (SVCD) can manifest with epileptic seizures and transient ischemic attacks (TIA). This study was designed to test if the extent and spatial distribution of SVCD differs in patients with focal impaired awareness seizures (FIAS) from patients with TIA.

METHODS

This is a retrospective single-center case-control study of elderly patients at a high cardiovascular risk. 118 patients with FIAS (cases) were compared to a matched control group of 118 patients with TIA. The extent and spatial distribution of white matter hyperintensities (WMH) characteristic for SVCD and medial temporal lobe atrophy were analyzed on magnetic resonance imaging (MRI) obtained at admission. The Fazekas, Wahlund, and Scheltens scales were used for grading. Juxtacortical small lesions were analyzed separately.

RESULTS

FIAS patients were observed to have more extensive WMH (p < 0.001) and more pronounced medial temporal lobe atrophy (p < 0.001) than TIA patients. WMH in FIAS patients were predominantly localized in supratentorial white matter compared to TIA patients (p < 0.001). Juxtacortical hyperintensities were far more common in FIAS patients than in TIA patients (80.5% vs. 22.0%; p < 0.001). Multivariate analysis revealed juxtacortical small lesions as strong independent predictor (OR, 95% CI 12.8, 6.7-24.3) and medial temporal lobe atrophy as further independent predictor of FIAS (3.1, 1.3-7.1).

CONCLUSIONS

Juxtacortical small lesions and to a smaller extent medial temporal lobe atrophy are associated with epileptic seizures in elderly patients at a high cardiovascular risk. This observation may provide a structural explanation for epilepsy in SVCD. Juxtacortical small lesions in SVCD should be considered a structural cause for epilepsy and promote anticonvulsive therapy after a first seizure.

Association between white matter hyperintensities, cortical volumes, and late-onset epilepsy

OBJECTIVE

To identify the association between brain vascular changes and cortical volumes on MRI and late-onset epilepsy.

METHODS

In 1993-1995, 1,920 participants (median age 62.7, 59.9% female) in the community-based Atherosclerosis Risk in Communities (ARIC) Study underwent MRI, and white matter hyperintensities were measured. In addition, in 2011-2013, 1,964 ARIC participants (median age 72.4, 61.1% female) underwent MRI, and cortical volumes and white matter hyperintensities were measured. We identified cases of late-onset epilepsy (starting at age 60 or later) from ARIC hospitalization records and Medicare claims data. Using the 1993-1995 MRI, we evaluated the association between white matter hyperintensities and subsequent epilepsy using survival analysis. We used the 2011-2013 MRI to conduct cross-sectional logistic regression to examine the association of cortical volumes and white matter hyperintensities with late-onset epilepsy. All models were adjusted for demographics, hypertension, diabetes, smoking, and APOE ε4 allele status.

RESULTS

Ninety-seven ARIC participants developed epilepsy after having an MRI in 1993-1995 (incidence 3.34 per 1,000 person-years). The degree of white matter hyperintensities measured at ages 49-72 years was associated with the risk of late-onset epilepsy (hazard ratio 1.27 per age-adjusted SD, 95% confidence interval [CI] 1.06-1.54). Lower cortical volume scores were associated cross-sectionally with higher odds of late-onset epilepsy (odds ratio 1.87, 95% CI 1.16-3.02) per age-adjusted SD.

CONCLUSIONS

This study demonstrates associations between earlier-life white matter hyperintensities on MRI and later-life incident epilepsy, and between cortical volumes measured later in life and late-onset epilepsy. These findings may help illuminate the causes of late-onset epilepsy.

Frequency and Stratification of Epileptogenic Lesions in Elderly With New Onset Seizures

Objective: To evaluate prospectively the frequency of epileptogenic lesions in a consecutive cohort of elderly patients presenting with new onset unprovoked seizures, and who underwent a complete evaluation including dedicated epilepsy protocol MRI.

Methods and materials: We included all consecutive patients 60 years or older who participated in a prospective study on new onset epilepsy. The work-up included the acquisition of a dedicated epilepsy protocol MRI and a 3 h video/EEG recording. We evaluated the frequency and types of epileptogenic lesions in the whole cohort and stratified those variables by age, gender, types and number of seizures at presentation. We also correlated the EEG findings with the clinical characteristics and neuroimaging results.

Results: Of the 101 patients enrolled in the study and who underwent an epilepsy protocol MRI, an epileptogenic lesion was identified in 67% of cases. The most common etiologies were vascular events, followed by tumoral causes and traumatic brain injuries. Epileptogenic lesions were more likely to be identified in patients who presented with only focal aware and impaired awareness seizures. In addition, patients with tumoral epilepsy were significantly more likely to only experience those seizure types compared to patients with other pathological substrates. Interictal/ictal discharges were detected in the EEG of 21% of patients. Epileptiform discharges were significantly more frequent in patients with an epileptogenic lesion on brain MRI, especially in those with a brain tumor.

Conclusions: Our results stress the importance of obtaining a dedicated epilepsy protocol MRI in elderly patients with new onset seizures. An epileptogenic lesion will be identified in approximately two thirds of patients with important implications regarding initiation of treatment. In addition, the data underscore the value of distinguishing the types of seizures experienced at presentation as this will apprise the treating physician on the likelihood of identifying an epileptogenic lesion and on the probable etiologies.

Cerebral Small Vessel Disease: A Review Focusing on Pathophysiology, Biomarkers, and Machine Learning Strategies

Cerebral small vessel disease (cSVD) has a crucial role in lacunar stroke and brain hemorrhages and is a leading cause of cognitive decline and functional loss in elderly patients. Based on underlying pathophysiology, cSVD can be subdivided into amyloidal and non-amyloidal subtypes. Genetic factors of cSVD play a pivotal role in terms of unraveling molecular mechanism. An important pathophysiological mechanism of cSVD is blood-brain barrier leakage and endothelium dysfunction which gives a clue in identification of the disease through circulating biological markers. Detection of cSVD is routinely carried out by key neuroimaging markers including white matter hyperintensities, lacunes, small subcortical infarcts, perivascular spaces, cerebral microbleeds, and brain atrophy. Application of neural networking, machine learning and deep learning in image processing have increased significantly for correct severity of cSVD. A linkage between cSVD and other neurological disorder, such as Alzheimer's and Parkinson's disease and non-cerebral disease, has also been investigated recently. This review draws a broad picture of cSVD, aiming to inculcate new insights into its pathogenesis and biomarkers. It also focuses on the role of deep machine strategies and other dimensions of cSVD by linking it with several cerebral and non-cerebral diseases as well as recent advances in the field to achieve sensitive detection, effective prevention and disease management.

Cognition and dementia in older patients with epilepsy

With advances in healthcare and an ageing population, the number of older adults with epilepsy is set to rise substantially across the world. In developed countries the highest incidence of epilepsy is already in people over 65 and, as life expectancy increases, individuals who developed epilepsy at a young age are also living longer. Recent findings show that older persons with epilepsy are more likely to suffer from cognitive dysfunction and that there might be an important bidirectional relationship between epilepsy and dementia. Thus some people with epilepsy may be at a higher risk of developing dementia, while individuals with some forms of dementia, particularly Alzheimer's disease and vascular dementia, are at significantly higher risk of developing epilepsy. Consistent with this emerging view, epidemiological findings reveal that people with epilepsy and individuals with Alzheimer's disease share common risk factors. Recent studies in Alzheimer's disease and late-onset epilepsy also suggest common pathological links mediated by underlying vascular changes and/or tau pathology. Meanwhile electrophysiological and neuroimaging investigations in epilepsy, Alzheimer's disease, and vascular dementia have focused interest on network level dysfunction, which might be important in mediating cognitive dysfunction across all three of these conditions. In this review we consider whether seizures promote dementia, whether dementia causes seizures, or if common underlying pathophysiological mechanisms cause both. We examine the evidence that cognitive impairment is associated with epilepsy in older people (aged over 65) and the prognosis for patients with epilepsy developing dementia, with a specific emphasis on common mechanisms that might underlie the cognitive deficits observed in epilepsy and Alzheimer's disease. Our analyses suggest that there is considerable intersection between epilepsy, Alzheimer's disease and cerebrovascular disease raising the possibility that better understanding of shared mechanisms in these conditions might help to ameliorate not just seizures, but also epileptogenesis and cognitive dysfunction.

Cerebral small vessel disease predisposes to temporal lobe epilepsy in spontaneously hypertensive rats

The link between cerebral small vessel disease (CSVD) and epilepsy has been poorly investigated. Some reports suggest that CSVD may predispose to temporal lobe epilepsy (TLE). Aim of this study was to evaluate whether spontaneously hypertensive rats (SHRs), an established model of systemic hypertension and CSVD, have a propensity to develop TLE more than generalized seizures. To this aim, amygdala kindling, as a model of TLE, and pentylenetetrazole (PTZ)-induced kindling, as a model of generalized seizures, have been used to ascertain whether SHRs are more prone to TLE as compared to Wistar Kyoto control rats. While young SHRs (without CSVD) do not differ from their age-matched controls in both models, old SHRs (with CSVD) develop stage 5 seizures in the amygdala kindling model (TLE) faster than age-matched control rats without CSVD. At odds, no differences between old SHRs and age-matched controls was observed in the development of PTZ kindling. Enalapril pre-treatment prevented the development of CSVD and normalized kindling development to control levels in SHRs. No difference was observed in the response to pharmacological treatment with carbamazepine or losartan. Overall, our study suggests that uncontrolled hypertension leading to CSVD might represent a risk factor for TLE. Further experimental studies are needed to unravel other risk factors that, along with CSVD, may predispose to TLE.

Post-stroke epilepsy

Post-stroke epilepsy (PSE) is a common complication after stroke, yet treatment options remain limited. While many physicians prescribe antiepileptic drugs (AED) for secondary prevention of PSE, it is unclear which treatments are most effective in the prevention of recurrence of symptoms, or whether such therapy is needed for primary prevention. This review discusses the current understanding of epidemiology, diagnoses, mechanisms, risk factors, and treatments of PSE.

High incidence of obstructive sleep apnea syndrome in patients with late-onset epilepsy

OBJECTIVES

The objective of the present study was to evaluate the prevalence of obstructive sleep apnea (OSA) in patients with late-onset epilepsy (LOE) who were considered at higher risk of cardiovascular disease.

METHODS

Polysomnography was performed on 27 patients with LOE. Berlin questionnaires and Epworth sleepiness score were performed on all patients. We compared clinical, demographic and anthropometric characteristics, questionnaire scores on the patients with no or mild OSA (group 1) and the patients with moderate or severe OSA (group 2). Patients eligible for continuous positive airway pressure (CPAP) therapy were reviewed in consultation.

RESULTS

Twenty-four patients (88.9%) had OSA and 55.6% had moderate or severe OSA. Patients in group 2 (n=15) were older than patients in group 1 (n=12). The two groups were similar in terms of body mass index (BMI), neck circumference, nocturnal seizure frequency, vascular cardiovascular risk factors and excessive daytime sleepiness. Leukoaraiosis in MRI was highly prevalent in our patients (40.7%), especially in group 2 patients. Eighty percent of the patients who had begun CPAP therapy experienced decreased seizure frequency.

CONCLUSION

Patients with LOE should be screened for the presence of OSA and treated accordingly.

Delayed seizures after intracerebral haemorrhage

Late seizures after intracerebral haemorrhage occur after the initial acute haemorrhagic insult subsides, and represent one of its most feared long-term sequelae. Both susceptibility to late seizures and their functional impact remain poorly characterized. We sought to: (i) compare patients with new-onset late seizures (i.e. delayed seizures), with those who experienced a recurrent late seizure following an immediately post-haemorrhagic seizure; and (ii) investigate the effect of late seizures on long-term functional performance after intracerebral haemorrhage. We performed prospective longitudinal follow-up of consecutive intracerebral haemorrhage survivors presenting to a single tertiary care centre. We tested for association with seizures the following neuroimaging and genetic markers of cerebral small vessel disease: APOE variants ε2/ε4, computer tomography-defined white matter disease, magnetic resonance imaging-defined white matter hyperintensities volume and cerebral microbleeds. Cognitive performance was measured using the Modified Telephone Interview for Cognitive Status, and functional performance using structured questionnaires obtained every 6 months. We performed time-to-event analysis using separate Cox models for risk to develop delayed and recurrent seizures, as well as for functional decline risk (mortality, incident dementia, and loss of functional independence) after intracerebral haemorrhage. A total of 872 survivors of intracerebral haemorrhage were enrolled and followed for a median of 3.9 years. Early seizure developed in 86 patients, 42 of whom went on to experience recurrent seizures. Admission Glasgow Coma Scale, increasing haematoma volume and cortical involvement were associated with recurrent seizure risk (all P < 0.01). Recurrent seizures were not associated with long-term functional outcome (P = 0.67). Delayed seizures occurred in 37 patients, corresponding to an estimated incidence of 0.8% per year (95% confidence interval 0.5-1.2%). Factors associated with delayed seizures included cortical involvement on index haemorrhage (hazard ratio 1.63, P = 0.036), pre-haemorrhage dementia (hazard ratio 1.36, P = 0.044), history of multiple prior lobar haemorrhages (hazard ratio 2.50, P = 0.038), exclusively lobar microbleeds (hazard ratio 2.22, P = 0.008) and presence of ≥ 1 APOE ε4 copies (hazard ratio 1.95, P = 0.020). Delayed seizures were associated with worse long-term functional outcome (hazard ratio 1.83, P = 0.005), but the association was removed by adjusting for neuroimaging and genetic markers of cerebral small vessel disease. Delayed seizures after intracerebral haemorrhage are associated with different risk factors, when compared to recurrent seizures. They are also associated with worse functional outcome, but this finding appears to be related to underlying small vessel disease. Further investigations into the connections between small vessel disease and delayed seizures are warranted.

Epilepsy in cerebrovascular diseases: Review of experimental and clinical data with meta-analysis of risk factors

OBJECTIVE

Seizures may occur in close temporal association with a stroke or after a variable interval. Moreover, epilepsy is often encountered in patients with leukoaraiosis. Although early post-stroke seizures have been studied extensively, less attention has been paid to post-stroke epilepsy (PSE) and to epilepsy associated with leukoaraiosis (EAL). The aim of this paper is to review data concerning pathophysiology, prognosis, and treatment of PSE and EAL.

METHODS

We performed an extensive literature search to identify experimental and clinical articles on PSE and EAL. We also conducted a systematic review of risk factors for PSE and EAL among eligible studies.

RESULTS

PSE is caused by enhanced neuronal excitability within and near the scar. The role played by white matter changes in EAL remains to be elucidated. Meta-analysis showed that cortical involvement (odds ratio [OR] 3.71, 95% confidence interval [CI] 2.34-5.90, p < 0.001), cerebral hemorrhage (OR 2.41, 95% CI 1.57-3.70, p < 0.001), and early seizures (OR 4.43, 95% CI 2.36-8.32, p < 0.001) are associated with an increased risk of PSE. As regards EAL, no prospective, population-based studies evaluated the role of different variables on seizure risk. Studies about the management of PSE are limited. PSE is generally well controlled by drugs. Data about risk factors, prognosis, and treatment of EAL are lacking.

SIGNIFICANCE

Pathophysiology and risk factors are well defined for PSE but need to be elucidated for EAL. Management of PSE and EAL relies on the clinician's judgment and should be tailored on an individual basis.

Development of epilepsy after ischaemic stroke

For about 30% of patients with epilepsy the cause is unknown. Even in patients with a known risk factor for epilepsy, such as ischaemic stroke, only a subpopulation of patients develops epilepsy. Factors that contribute to the risk for epileptogenesis in a given individual generally remain unknown. Studies in the past decade on epilepsy in patients with ischaemic stroke suggest that, in addition to the primary ischaemic injury, existing difficult-to-detect microscale changes in blood vessels and white matter present as epileptogenic pathologies. Injury severity, location and type of pathological changes, genetic factors, and pre-injury and post-injury exposure to non-genetic factors (ie, the exposome) can divide patients with ischaemic stroke into different endophenotypes with a variable risk for epileptogenesis. These data provide guidance for animal modelling of post-stroke epilepsy, and for laboratory experiments to explore with increased specificity the molecular 'mechanisms, biomarkers, and treatment targets of post-stroke epilepsy in different circumstances, with the aim of modifying epileptogenesis after ischaemic stroke in individual patients without compromising recovery.

Structural and physiological MRI correlates of occult cerebrovascular disease in late-onset epilepsy

Late-onset epilepsy (LOE), with onset after 50 years of age, is often attributed to underlying occult cerebrovascular disease. LOE is associated with a three-fold increase in subsequent stroke risk, therefore it is important to improve our understanding of pathophysiology. In this exploratory study, we aimed to determine whether established structural magnetic resonance imaging markers and novel physiological imaging markers of occult cerebrovascular disease were more common in patients with LOE than age-matched controls.

Sixteen patients with LOE (mean age ± SD: 67.6 ± 6.5 years) and 15 age-matched control subjects (mean age: 65.1 ± 3.9 years) underwent a 3 T MRI scan protocol. T₁-weighted images and T₂-weighted fluid attenuated inversion recovery (FLAIR) images were used to determine cortical grey matter volume and white matter hyperintensity (WMH) volume respectively, whilst multiple delay time arterial spin labelling (ASL) images were collected at rest and during a hypercapnic challenge. Cerebral blood flow (CBF) and arterial arrival time (AAT) were calculated from ASL data under both normocapnic and hypercapnic conditions. Cerebrovascular reactivity was also calculated for both CBF and AAT relative to the change in end-tidal CO₂.

Patients with LOE were found to have significantly lower cortical volume than control subjects (33.8 ± 3.8% of intracranial volume vs. 38.0 ± 5.5%, p = 0.02) and significantly higher WMH volume (1339 ± 1408 mm³ vs. 514 ± 481 mm³, p = 0.047). Baseline whole brain AAT was found to be significantly prolonged in patients with LOE in comparison to control subjects (1539 ± 129 ms vs. 1363 ± 167 ms, p = 0.005). Voxel-based analysis showed the significant prolongation of AAT to be predominantly distributed in the frontal and temporal lobes. Voxel-based morphometry showed the lower cortical volume to be localised primarily to temporal lobes. No significant differences in CBF or cerebrovascular reactivity were found between the two groups. Baseline whole brain AAT and cortical volume differences persisted upon further analysis to take account of differences in smoking history between patients and control subjects.

These findings suggest that occult cerebrovascular disease is relevant to the pathophysiology of LOE.

•

LOE patients were found to have increased WMHs and reduced GM volume on MRI imaging in comparison to HC.

•

Baseline arterial arrival time was significantly longer in LOE patients than HC.

•

Baseline cerebral blood flow did not differ between LOE patients and HC.

•

Cerebrovascular reactivity did not differ between LOE patients and HC.

Etiological prevalence of epilepsy and epileptic seizures in hospitalized elderly in a Brazilian tertiary center - Salvador - Brazil

Epilepsy in the elderly has high incidence and prevalence and is often underecognized.

OBJECTIVE

To describe etiological prevalence of epilepsy and epileptic seizures in elderly inpatients.

METHODS

Retrospective analysis was performed on elderly patients who had epilepsy or epileptic seizures during hospitalization, from January 2009 to December 2010. One hundred and twenty patients were enrolled. They were divided into two age subgroups (median 75 years) with the purpose to compare etiologies.

RESULTS

The most common etiology was ischemic stroke (36.7%), followed by neoplasias (13.3%), hemorrhagic stroke (11.7%), dementias (11.4%) and metabolic disturbances (5.5%). The analysis of etiological association showed that ischemic stroke was predominant in the younger subgroup (45% vs 30%), and dementias in the older one (18.9% vs 3.8%), but with no statistical significance (p = 0.23).

CONCLUSION

This study suggests that epilepsy and epileptic seizures in the elderly inpatients have etiological association with stroke, neoplasias and dementias.

Stroke after adult-onset epilepsy: a population-based retrospective cohort study

BACKGROUND

Earlier studies indicate a higher risk of subsequent stroke in PWE aged ≥60. However, little is known of the incidence of subsequent stroke in people with epilepsy (PWE) aged 35 through 60. We determined the risk factors that increase the incidence of stroke following adult-onset epilepsy in a large statewide population over a 10-year period.

METHODS

South Carolina hospital discharge and emergency department (ED) data from 2000 to 2011 were used. The study was limited to persons aged ≥35years without prior stroke. Cases included patients diagnosed with epilepsy who were hospitalized or visited the ED. Controls were people with an isolated fracture of the lower extremity without any history of epilepsy or seizure disorders, presumed to approximate the health status of the general population. Epilepsy, fracture, stroke, and comorbid conditions were ascertained by diagnostic codes from health-care encounters. Only persons having stroke occurring ≥6months after the onset of epilepsy or after the first clinical encounter for controls were included. Cox proportional hazards modeling was performed to determine the risk of stroke.

RESULTS

There were 21,035 cases with epilepsy and 16,638 controls who met the inclusion criteria. Stroke incidence was 2.5 times higher following adult-onset epilepsy (6.3%) compared with controls (2.5%). After adjusting for comorbidities and other factors, cases with epilepsy showed a 60% higher risk of stroke (HR=1.6; 95% CI: 1.42-1.80) compared with controls. Nearly half of the strokes in cases with epilepsy occurred in those with first diagnosis between ages 35 and 55. Somatic comorbidities associated with increased risk of stroke were more prevalent in cases with epilepsy than controls yet similar in both groups with stroke. Risk of stroke increased with increasing age in both groups. However, the risk of stroke in cases with epilepsy increased faster and was similar to that in controls who were ≥10years older.

CONCLUSION

Adult-onset epilepsy at age 35 and older warrants consideration for occult cerebrovascular disease as an etiology of the epilepsy, which may also increase the risk of subsequent stroke. Somatic comorbidities frequently associated with epilepsy include comorbid conditions that share the same underlying pathology with stroke (i.e., hypertension, hyperlipidemia, myocardial infarction, diabetes, and arteriosclerosis). This increased risk of stroke in patients with adult-onset epilepsy should dictate the evaluation and management of stroke risk factors to prevent stroke.

Epileptic seizure as a precipitating factor of vascular progressive supranuclear palsy: a case report

BACKGROUND

Vascular progressive supranuclear palsy (vPSP) is an uncommon akinetic-rigid syndrome characterized by asymmetric lower body involvement, predominant corticospinal and pseudobulbar signs, urinary incontinence, cognitive impairment, and increased frequency of stroke risk factors, together with neuroimaging evidence of vascular disease.

CASE REPORT

We report a case of a patient with a PSP-like phenotype and marked cognitive impairment who significantly worsened after a generalized epileptic seizure that occurred a few months after its clinical onset.

RESULTS

Signs of widespread ischemic subcortical vascular disease, together with atrophy of the midbrain tectum, corpus callosum, and cerebral cortex, were evident on brain magnetic resonance imaging.

CONCLUSIONS

vPSP is a condition that should be considered when a patient presents with a gradually progressive clinical picture suggestive of idiopathic PSP associated with neuroimaging evidence of cerebrovascular disease. The occurrence of epileptic seizures has not been reported before in vPSP but they might trigger the onset or precipitate the course of the PSP-like disorders.

Late-onset epilepsy and occult cerebrovascular disease

The interface between cerebrovascular disease (CVD) and epilepsy is complex and multifaceted. Late-onset epilepsy (LOE) is increasingly common and is often attributed to CVD, and is indeed associated with an increased risk of stroke. This relationship is easily recognizable where there is a history of stroke, particularly involving the cerebral cortex. However, the relationship with otherwise occult, subcortical CVD is currently less well established yet causality is often invoked. In this review, we consider the diagnosis of LOE in clinical practice--including its behaviour as a potential mimic of acute ischemic stroke and transient ischemic attack; evidence for an association between occult CVD and LOE; and potential mechanisms of epileptogenesis in occult CVD, including potential interrelationships between disordered cerebral metabolism and perfusion, disrupted neurovascular unit integrity, blood-brain barrier dysfunction, and inflammation. We also discuss recently recognized issues concerning antiepileptic drug treatment and vascular risk and consider a variety of less common CVD entities associated with seizures.

Late-onset seizures and risk of subsequent stroke: a systematic review

Otherwise unexplained late-onset seizures, conventionally defined as epileptic seizures occurring in subjects older than 60years and in the absence of disorders known to increase the risk of developing epilepsy, have been assumed to be, in most cases, of cerebrovascular origin. We systematically searched the literature to identify the evidence supporting the association between otherwise unexplained late-onset seizures/epilepsy and the risk of subsequent stroke. Most data from the literature indicate that cerebrovascular disease often underlies otherwise unexplained late-onset seizures/epilepsy. Patients presenting with seizures occurring for the very first time in late life and without clinically overt cerebrovascular disease should be considered as at increased risk of stroke. Consequently, these patients should be screened for the presence of vascular risk factors and treated accordingly. Such measures may greatly contribute to prevent strokes in these patients.

Multifocal white matter lesions associated with the D313Y mutation of the α-galactosidase A gene

White matter lesions (WML) are clinically relevant since they are associated with strokes, cognitive decline, depression, or epilepsy, but the underlying etiology in young adults without classical risk factors still remains elusive. Our aim was to elucidate the possible clinical diagnosis and mechanisms leading to WML in patients carrying the D313Y mutation in the α-galactosidase A (GLA) gene, a mutation that was formerly described as nonpathogenic. Pathogenic GLA mutations cause Fabry disease, a vascular endothelial glycosphingolipid storage disease typically presenting with a symptom complex of renal, cardiac, and cerebrovascular manifestations. We performed in-depths clinical, biochemical and genetic examinations as well as advanced magnetic resonance imaging analyses in a pedigree with the genetically determined GLA mutation D313Y. We detected exclusive neurologic manifestations of the central nervous system of the “pseudo”-deficient D313Y mutation leading to manifest WML in 7 affected adult family members. Furthermore, two family members that do not carry the mutation showed no WML. The D313Y mutation resulted in a normal GLA enzyme activity in leukocytes and severely decreased activities in plasma. In conclusion, our results provide evidence that GLA D313Y is potentially involved in neural damage with significant WML, demonstrating the necessity of evaluating patients carrying D313Y more thoroughly. D313Y might broaden the spectrum of hereditary small artery diseases of the brain, which preferably occur in young adults without classical risk factors. In view of the existing causal therapy regime, D313Y should be more specifically taken into account in these patients.