Predictors of intractable childhood epilepsy

Predictors of medical intractability in children with epilepsy onset during the first two years of life, excluding infantile epileptic spasm syndrome

PURPOSE

Early childhood epilepsy presents a significant challenge, with approximately 30 % of individuals experiencing treatment failure. This study aimed to identify predictors of medical intractability in children with epilepsy onset during the first two years of life, excluding infantile epileptic spasm syndrome.

METHODS

A total of 323 children were retrospectively evaluated. The analyses included a review of medical records for demographic, laboratory, radiological, and electroencephalographic (EEG) findings. Children were diagnosed with drug-resistant epilepsy (DRE) according to the ILAE diagnostic criteria. Twenty-one potential prognostic predictors were examined in relation to medical intractability.

RESULTS

Among the 323 children (56.7 % male), 119 (36.8 %) had unknown epilepsy, 131 (40.6 %) had structural epilepsy, 53 (16.4 %) had genetic epilepsy, and 20 (6.2 %) had metabolic epilepsy. Over a median follow-up of 68 months, 55.4 % of the children achieved ≥6 months of seizure freedom, 33.1 % developed DRE, and the remaining 11.5 % had rare ongoing seizures but did not meet the criteria for DRE because they were only treated with one antiseizure medication at the last follow-up. Univariate logistic regression analyses identified ten risk factors significantly associated with DRE. Multivariate logistic regression analyses revealed that the presence of developmental delay at epilepsy onset (p = 0.000; OR 7.890; 95 %CI 2.713 to 22.945), history of status epilepticus (p = 0.000; OR 8.247; 95 %CI 3.619 to 18.793), number of antiseizure medications (ASMs) at the sixth month of diagnosis (p = 0.000; OR 20.585; 95 %CI 8.993 to 47.117), and initial EEG findings (p = 0.046; OR 2.366; 95 %CI 1.015 to 5.518) were predictors of medical intractability. Nineteen (5.9 %) children died during follow-up for various reasons, including progressive neurogenetic or neurodegenerative disorders.

CONCLUSION

Developmental delay at epilepsy onset, a history of status epilepticus, the use of two or more ASMs in the sixth month of diagnosis, and abnormal initial EEG findings were associated with medical intractability.

Drug resistant epilepsy and associated factors among children with epilepsies in tanzania: a cross-sectional study

BACKGROUND

Epilepsy contributes to high morbidity among children and adolescents in developing countries. A quarter of all children with epilepsy will be resistant to anti-seizure medications (ASMs), with associated neurocognitive impairments and risk of higher mortality. This study aimed to estimate and characterize drug-resistant epilepsy (DRE) (defined as failure to achieve sustained remission after adequate trials of two tolerated and appropriately chosen ASMs) and its associated factors among children and adolescents with epilepsies attending the pediatric neurology clinic at Muhimbili National Hospital (MNH), Dar es Salaam Tanzania.

METHODS

This cross-sectional study was conducted from June 2020 to June 2021. Children with epilepsies and who had been treated with ASMs for at least 3 months were eligible for inclusion. Exclusion criteria included children whose caregivers denied consent and those who exhibited acute medical conditions necessitating admission on the scheduled visit day. Data on demographic characteristics, perinatal history, detailed history of the seizures semiology, drug history, magnetic resonance imaging (MRI), and electroencephalography (EEG) results were obtained from caregivers and medical records available during recruitment. Seizures and epilepsies were classified using the 2017 International League Against Epilepsy (ILAE) classification. Logistic regression was used to determine factors associated with DRE.

RESULTS

A total of 236 children and adolescents aged between 4 months and 15 years (Median age 72 months (IQR = 42-78)) were enrolled in this study. We found the proportion of DRE to be 14.8% in this cohort. Of the thirty-five patients with DRE, 60% had generalized epilepsy and almost 25% had a diagnosis of an epilepsy syndrome, the most common being Lennox-Gastaut syndrome (LGS). Structural abnormalities on brain MRI were seen in almost 80% of all patients with DRE, the most prevalent being cystic encephalomalacia, which was observed in 34% of patients. Patients using both ASMs and alternative therapies accounted for 9% of this cohort. The onset of seizures during the first month of life (aOR = 1.99; 95%CI 1.7-4.6; p = 0.031) and high initial seizure frequency (aOR = 3.6; 95%CI 1.6-8;p = 0.002) were found to be independently associated with DRE.

CONCLUSION

The proportion of DRE in Tanzania is high. Patients with neonatal onset seizures and high initial seizure frequency should be followed up closely to ensure early diagnosis of DRE.

Identification of drug resistance in a validated cohort of incident epilepsy patients in the Danish National Patient Register

OBJECTIVE

The main purposes of this study were to validate the epilepsy diagnosis in incident epilepsy cases in the Danish National Patient Registry (DNPR), which contains information on nearly 9 000 000 individuals, and to identify persons in the validated cohort who fulfilled the International League Against Epilepsy (ILAE) criteria for drug-resistant epilepsy (DRE).

METHODS

We reviewed a random sample of medical records from all individuals registered with a first diagnosis of epilepsy (International Classification of Diseases, 10th Revision [ICD-10]: G40) or seizures (ICD-10: G41, R56, or F445) in the Central Denmark Region from 2010 to 2019. In persons with a validated incident epilepsy diagnosis, we determined the proportion with DRE at the latest contact. We performed logistic regression analyses to identify clinical factors that correlated with risk of DRE.

RESULTS

Of 20 723 persons with a first diagnosis of epilepsy (n = 11 812) or seizures (n = 8911), we reviewed the medical records of n = 1067 with incident epilepsy and n = 610 with incident seizures. Among those with a register diagnosis of epilepsy, the diagnosis was confirmed in 838 cases (45% females, mean age at onset = 42.4 years), providing a positive predictive value (PPV) of 79% (95% confidence interval [CI] = 76%-81%). The PPV of focal epilepsy was 86% (95% CI = 82%-89%), and the PPV of generalized epilepsy was 71% (95% CI = 61%-80%). Of 740 patients with confirmed incident epilepsy and ≥1 year of follow-up, 103 (14%) fulfilled the definition of DRE, 476 (64%) were drug responsive, and 161 (22%) had undefined responsiveness. In multivariable logistic regression analysis, early age at epilepsy onset, cognitive impairment, and a history of status epilepticus were associated with DRE.

SIGNIFICANCE

In the DNPR, we found a PPV of the epilepsy diagnosis of 79%. Among persons with confirmed epilepsy, 14% fulfilled ILAE criteria for DRE. Early age at epilepsy onset, cognitive impairment, and a history of status epilepticus were independently associated with drug resistance.

The Frequency and Precipitating Factors for Breakthrough Seizures in Children with Epilepsy

Background and Purpose

To determine the common precipitating factors for breakthrough seizures in children with epilepsy.

Methods

This retrospective study reviewed the charts of children with epilepsy who were followed up in the pediatric neurology clinic of King Fahad Hospital in Al-Baha region, Saudi Arabia, between January 2015 and August 2022. Children between 1 to 14 years of age who had epilepsy, as per the International League Against Epilepsy definition and received anti-seizure medication with a seizure-free period of at least 2 months before breakthrough seizure episode, were included in the study.

Results

Of the 108 children included in the study, the mean age was 6.8±1.6 years, and among them (55.5%) were male. Most parents (69.5%) were unaware of the triggering factors of seizure. The majority of patients (88%) reported at least one precipitating factor for breakthrough seizures and the most common one was systemic infection associated with fever (52.8%), and then non-compliance to medications in (34.3%) of the patients. In terms of the electroencephalogram, around 84 patients (77.8%) had abnormal electroencephalogram. Finally, monotherapy was maintained in 63.9% of patients.

Conclusions

We conclude that the most common trigger for breakthrough seizure is a systemic infection associated with fever and non-compliance to anti-seizure medications. Increasing the level of awareness by different methods may help limit or even prevent seizures from occurring. Randomized controlled trials could shed light on the adjustment of anti-seizure medications temporarily by increasing the dosage or giving extra doses during the infection to avoid breakthrough seizures.

Medical treatment in infants and young children with epilepsy: Off-label use of antiseizure medications. Survey Report of ILAE Task Force Medical Therapies in Children

OBJECTIVE

Antiseizure medications (ASMs) remain the mainstay of epilepsy treatment. These ASMs have mainly been tested in trials in adults with epilepsy, which subsequently led to market authorization (MA). For treatment of - especially young - children with epilepsy, several ASMs do not have a MA and guidelines are lacking, subsequently leading to "off-label" use of ASMs. Even though "off-label" ASM prescriptions for children could lead to more adverse events, it can be clinically appropriate and rational if the benefits outweigh the risks. This could be the case if "on-label" ASM, in mono- or polytherapy, fails to achieve adequate seizure control.

METHODS

The Medical Therapies Task Force of the International League Against Epilepsy (ILAE) Commission for Pediatrics performed a survey to study the current treatment practices in six classic, early life epilepsy scenarios. Our aim was not only to study first- and second-line treatment preferences but also to illustrate the use of "off-label" drugs in childhood epilepsies.

RESULTS

Our results reveal that several ASMs (e.g. topiramate, oxcarbazepine, benzodiazepines) are prescribed "off-label" in distinct scenarios of young children with epilepsy. In addition, recent scientific guidelines were not always adopted by several survey respondents, suggesting a potential knowledge gap.

SIGNIFICANCE

We report the relatively common use of "off-label" prescriptions that underlines the need for targeted and appropriately designed clinical trials, including younger patients, which will also result in the ability to generate evidence-based guidelines.

Clinical, radiological and electrophysiological predictors for drug-resistant epilepsy

Background

Epilepsy is the third chronic brain illness worldwide. About a third of the epileptic patients will be drug resistant. Early identification of these patients is critical for appropriate treatment selection and prevention of the devastating consequences of recurrent seizures. The objective of this study aims to detect clinical, electrophysiological, and radiological predictors for drug-resistant epilepsy patients.

Results

One hundred fifty-five patients were included in this study, divided into a well-controlled epilepsy group (103 patients) and a drug-resistant group (52 patients). Both groups were compared regarding clinical, electrophysiological, and neuro-radiological data. Younger age at onset, history of delayed milestones, history of perinatal insult (especially hypoxia), mental retardation, neurological deficits, depression, status epilepticus (SE), complex febrile seizures, focal seizure to bilateral tonic–clonic convulsion as well as multiple seizures and high seizure frequency (daily) at onset, poor response to first anti-seizure drug (ASD), structural and metabolic etiology, abnormal brain imaging, and slow background and multifocal epileptiform discharges in EEG were significant risk factors for the development of drug-resistant epilepsy.

Conclusion

MRI abnormalities are the most significant predictor for drug-resistant epilepsy. Drug-resistant epilepsy is associated with clinical, electrophysiological, and radiological risk factors that can be used to diagnose drug-resistant patients early and choose the best treatment option and time.

Poor Seizure Control Among Children Attending a Tertiary Hospital in South Western Uganda - A Retrospective Study

Background

Seizure control among children with epilepsy (CWE) receiving anti-seizure medications (ASMs) remains a challenge in low-resource settings. Uncontrolled seizures are significantly associated with increased morbidity and mortality among CWE. This negatively impacts their quality of life and increases stigma.

Aim

This study determined seizure control status and described the factors associated among CWE receiving ASMs at Mbarara Regional Referral Hospital (MRRH).

Methods

In a retrospective chart review study, socio-demographic and clinical data were obtained from 112 medical records. CWE receiving ASMs for at least six months and regularly attending the clinic were included in the study. Physical or telephone interviews were conducted with the immediate caregivers of the CWE to establish the current seizure control status of the participants.

Results

A total of 112 participants were enrolled. Of these, three-quarters had generalized onset seizures, 23% had focal onset seizures, while 2% had unknown onset motor seizures. About 60.4% of the study participants had poor seizure control. Having a comorbidity (p-value 0.048, AOR 3.2 (95% CI 1.0-9.9)), history suggestive of birth asphyxia (p-value 0.014, AOR 17.8 (95% CI 1.8-176.8)), and being an adolescent (p-value 0.006, AOR 6.8 (95% CI 1.8-26.6)) were significantly associated with poor seizure control.

Conclusion

Seizure control among CWE receiving ASMs at MRRH remains poor. Efforts geared to addressing seizure control and optimizing drugs are needed, especially among children with comorbidities, those with history of birth asphyxia, and adolescents.

Potential clinical and biochemical markers for the prediction of drug-resistant epilepsy: A literature review

Drug resistance is a major challenge in the treatment of epilepsy. Drug-resistant epilepsy (DRE) accounts for 30% of all cases of epilepsy and is a matter of great concern because of its uncontrollability and the high burden, mortality rate, and degree of damage. At present, considerable research has focused on the development of predictors to aid in the early identification of DRE in an effort to promote prompt initiation of individualized treatment. While multiple predictors and risk factors have been identified, there are currently no standard predictors that can be used to guide the clinical management of DRE. In this review, we discuss several potential predictors of DRE and related factors that may become predictors in the future and perform evidence rating analysis to identify reliable potential predictors.

Drug-resistant epilepsy at the age extremes: Disentangling the underlying etiology

The incidence of epilepsy is highest at the extreme age ranges: childhood and elderly age. The most common syndromes in these demographics - self-limited epilepsies of childhood and idiopathic generalized epilepsies in pediatric age, focal epilepsy with structural etiology in older people - are expected to be drug responsive. In this work, we focus on such epilepsy types, overviewing the complex clinical background of unexpected drug-resistance. For self-limited epilepsies of childhood and idiopathic generalized epilepsies, we illustrate drug-resistance resulting from syndrome misinterpretation, reason on possible unexpected courses of epilepsy, and explicate the influence of inappropriate treatments. For elderly-onset epilepsy, we show the challenges in differential diagnosis possibly leading to pseudoresistance and analyze how drug-resistant epilepsy can arise in stroke, neurocognitive disorders, brain tumors, and autoimmune encephalitis. In children and senior people, drug-resistance can be regarded as a hint to review the diagnosis or explore alternative therapeutic strategies. Refractory seizures are not only a therapeutic challenge, but also a cardinal sign not to be overlooked in syndromes commonly deemed to be drug-responsive.

Development and validation of a nomogram for the early prediction of drug resistance in children with epilepsy

BACKGROUND AND PURPOSE

This study aimed to effectively identify children with drug-resistant epilepsy (DRE) in the early stage of epilepsy, and take personalized interventions, to improve patients' prognosis, reduce serious comorbidity, and save social resources. Herein, we developed and validated a nomogram prediction model for children with DRE.

METHODS

The training set was patients with epilepsy who visited the Children's Hospital of Soochow University (Suzhou Industrial Park, Jiangsu Province, China) between January 2015 and December 2017. The independent risk factors for DRE were screened by univariate and multivariate logistic regression analyses using SPSS21 software. The nomogram was designed according to the regression coefficient. The nomogram was validated in the training and validation sets. Internal validation was conducted using bootstrapping analyses. We also externally validated this instrument in patients with epilepsy from the Children's Hospital of Soochow University (Gusu District, Jiangsu Province, China) and Yancheng Maternal and Child Health Hospital between January 2018 and December 2018. The nomogram's performance was assessed by concordance (C-index), calibration curves, as well as GiViTI calibration belts.

RESULTS

Multivariate logistic regression analysis of 679 children with epilepsy from the Children's Hospital of Soochow University (Suzhou Industrial Park, Jiangsu Province, China) showed that onset age<1, status epilepticus (SE), focal seizure, > 20 pre-treatment seizures, clear etiology (caused by genetic, structural, metabolic, or infectious), development and epileptic encephalopathy (DEE), and neurological abnormalities were all independent risk factors for DRE. The AUC of 0.92 for the training set compared to that of 0.91 for the validation set suggested a good discrimination ability of the prediction model. The C-index was 0.92 and 0.91 in the training and validation sets. Additionally, both good calibration curves and GiViTI calibration belts (P-value: 0.849 and 0.291, respectively) demonstrated that the predicted risks had strong consistency with the observed outcomes, suggesting that the prediction model in both groups was perfectly calibrated.

CONCLUSION

A nomogram prediction model for DRE was developed, with good discrimination and calibration in the training set and the validation set. Furthermore, the model demonstrated great accuracy, consistency, and prediction ability. Therefore, the nomogram prediction model can aid in the timely identification of DRE in children.

Celiac Disease in Children: An Association With Drug-Resistant Epilepsy

BACKGROUND

Neurological manifestations are commonly reported in patients with celiac disease (CD). We aimed to characterize epilepsy features in a pediatric population with CD and the effect of a gluten-free diet (GFD) on seizure burden.

METHODS

A retrospective chart review was performed on pediatric patients treated at the University of Utah and Primary Children's Hospital in Salt Lake City, Utah, with both epilepsy and CD and compared with a control group with epilepsy only.

RESULTS

We identified 56 patients with epilepsy and biopsy-confirmed CD (n = 36, 64%) or elevated tissue transglutaminase antibodies (tTG-Ab) without biopsy-confirmed CD (n = 20, 36%). Age- and gender-matched controls were selected from patients with epilepsy only (n = 168). Patients with biopsy-proven CD or positive tTG-Ab had high percentage of drug-resistant epilepsy (DRE) compared with the control group (P < 0.05). Age at seizure onset preceded the diagnosis of CD on average by 5.9 years for patients with DRE (P < 0.01) compared with 2.2 years for those with drug-responsive epilepsy. Adhering to a GFD reduced seizure frequency or resulted in weaning dosage or weaning off of one or more antiseizure medications in a majority of patients with DRE.

CONCLUSIONS

DRE was more prevalent in pediatric patients with biopsy-confirmed CD and positive tTG-Ab compared with the control group (which included childhood epilepsy syndromes), but comparable with the prevalence of DRE in the general population. Adherence to a GFD in combination with antiseizure medications appears to reduce seizure burden for those with CD and DRE.

Clinical predictors of drug-resistant epilepsy in children

Background/aim

In up to 20% of epilepsy patients, seizures may not be controlled despite the use of antiepileptic drugs, either alone or in combination. These individuals are considered to have drug-resistant epilepsy. Drug-resistant epilepsy is usually associated with intellectual disability, psychiatric comorbidity, physical injury, sudden unexpected death, and low quality of life. Early detection and prediction of drug-resistant epilepsy are essential in determining the patient’s most appropriate treatment option. This retrospective study aimed to determine the clinical, electroencephalographic, and radiological factors associated with medically intractable childhood seizures.

Materials and methods

Data regarding 177 patients diagnosed with drug-resistant epilepsy were compared with 281 patients with drug-responsive epilepsy.

Results

Univariate analysis showed that age at seizure onset, having mixed seizure types, history of status epilepticus, history of neonatal seizures, history of both having febrile and afebrile seizures, daily seizures at the onset, abnormality on the first electroencephalogram, generalized epileptic abnormality on electroencephalogram, abnormal neurodevelopmental status, abnormal neuroimaging, and having symptomatic etiology were significant risk factors for the development of drug-resistant epilepsy (p < 0.05). In multivariable analysis, having mixed seizure types, history of status epilepticus, having multiple seizures in a day, intellectual disability, symptomatic etiology, and neuroimaging abnormality remained significant predictors for developing drug-resistant epilepsy.

Conclusions

In the course of childhood epilepsy, some clinical features may predict the outcome. Early identification of patients with high risk for drug-resistant epilepsy will help plan the appropriate treatment option. Further prospective studies should confirm these findings.

Assessment of the response to antiepileptic drugs in epileptic patients with structural lesion(s) on neuroimaging

Background

Focal epilepsy is the most common form of epilepsy in adults. Advances in brain imaging allowed better identification of different structural lesions underlying focal epilepsy. However, the response to antiepileptic drugs in lesional epilepsy is heterogeneous and difficult to anticipate. This study aimed to evaluate the response to antiepileptic drugs (AED) in patients with lesional epilepsy and to identify the predictors for poor seizure control.

Methods

One hundred and sixty-five patients with lesional epilepsy were included; the clinical diagnosis of epilepsy and seizure classification was based on the revised criteria of the International League Against Epilepsy (ILAE). Patients were subjected to full clinical assessment, MRI brain imaging epilepsy protocol, and EEG monitoring. All subjects were followed in the epilepsy clinic for at least 6 months.

Results

75.8% of patients with lesional epilepsy showed poor response to antiepileptic medications. Cerebromalatic lesions related to brain trauma was the most frequently encountered (21.8%). Malformations of cortical development were significantly associated with poor response to AED (p = 0.040). Polytherapy and the combined use of 1st- and 2nd-generation AED were higher in the poor response group. Logistic regression analysis revealed that younger age at seizure onset and abnormal EEG findings was 0.965 times and 2.5 times more associated with poor seizure control, respectively.

Conclusion

This study revealed that patients with lesional epilepsy who develop seizures in their early life, who suffer from malformations of cortical development, or who show abnormal EEG findings are more suspected to show poor response to AED.

Pregabalin adjunctive therapy for focal onset seizures in children 1 month to <4 years of age: A double-blind, placebo-controlled, video-electroencephalographic trial

OBJECTIVE

To evaluate the efficacy and safety of pregabalin as adjunctive treatment for children (aged 1 month-<4 years) with focal onset seizures (FOS) using video-electroencephalography (V-EEG).

METHODS

This randomized, placebo-controlled, international study included V-EEG seizure monitoring (48-72 hours) at baseline and over the last 3 days of 14-day (5-day dose escalation; 9-day fixed dose) double-blind pregabalin treatment (7 or 14 mg/kg/d in three divided doses). This was followed by a double-blind 1-week taper. The primary efficacy endpoint was log-transformed seizure rate (log_e [24-hour seizure rate + 1]) for all FOS recorded during the double-blind V-EEG monitoring, evaluated in subjects who took ≥1 dose of study medication, experienced ≥1 baseline seizure(s), and had a treatment phase V-EEG. Safety and tolerability were assessed by adverse events (AEs), clinical laboratory data, physical/neurological examinations, vital signs, and electrocardiograms.

RESULTS

Overall, 175 patients were randomized (mean age = 28.2 months; 59% male, 69% white, 30% Asian) in a 2:1:2 ratio to pregabalin 7 or 14 mg/kg/d (n = 71 or n = 34, respectively), or placebo (n = 70). Pregabalin 14 mg/kg/d (n = 28) resulted in a statistically significant 35% reduction of log_e (24-hour seizure rate + 1) versus placebo (n = 53; P = .022), an effect that was not observed with pregabalin 7 mg/kg/d (n = 59; P = .461). The most frequently reported treatment-emergent AEs for pregabalin 7 mg/kg/d, 14 mg/kg/d, and placebo, respectively, were somnolence (11.3%, 17.6%, and 5.7%) and upper respiratory tract infection (7.0%, 11.8%, and 11.4%). All AEs were mild to moderate in severity.

SIGNIFICANCE

Pregabalin 14 mg/kg/d (but not 7 mg/kg/d) significantly reduced seizure rate in children with FOS, when assessed using V-EEG, compared with placebo. Both pregabalin dosages were generally safe and well tolerated in children 1 month to <4 years of age with FOS. Safety and tolerability were consistent with the known profile of pregabalin in older children with epilepsy.

Factors Associated with Good Seizure Control in Patients on Valproic Acid

Objective

This study aims to generate a reference range for valproic acid (VPA) in this cohort and determine the factors associated with good seizure control in patients taking this drug.

Materials and Methods

We conducted a prospective, cohort, observational study among patients with epilepsy who received VPA treatment at Hospital Kuala Lumpur. The patients were considered to have good control if they had a 50% or higher seizure reduction in the one-year study period compared with the previous year. The VPA reference range was generated from those patients who had good control and whose drug concentration values were available. Multiple logistic regression analysis with a backward likelihood ratio method was applied to assess the predicting factors for good seizure control.

Results

A total of 242 patients were recruited and followed up for one year. The VPA reference range was determined to be 40-85 mg/L. After multivariate analysis, significant predictive variables for good control were monotherapy [adjusted OR 4.74, 95% CI: 2.258, 9.947, p<0.001], non-smoking [adjusted OR 3.23, 95% CI: 1.099, 9.473, p=0.033], normal brain imaging results [adjusted OR 5.83, 95% CI: 2.507, 13.552, p<0.001], and the absence of stress [adjusted OR 19.98, 95% CI: 9.255, 42.764, p<0.001].

Conclusion

Monotherapy, non-smoking, normal brain imaging results, and the absence of stress are predictive of good seizure control in patients on VPA. However, a serum concentration of VPA in the reference range failed to predict good seizure control.

Safety and Efficacy of Brivaracetam in Pediatric Refractory Epilepsy: A Single-Center Clinical Experience

Brivaracetam is a new antiepileptic drug with limited data in children. The objective of this study was to assess the efficacy/tolerability of brivaracetam. This is a retrospective chart review of children/adolescents with refractory epilepsy treated with brivaracetam from 2016 to 2018. The primary outcome was seizure reduction (decrease in seizure frequency >50%). Twenty-three patients were identified. Mean age at initiation was 12.5 years. Fourteen were females. Epilepsy was focal in 11, generalized in 6, and mixed in 3. Average dose was 3.9 mg/kg/d. The mean duration of treatment was 8.2 months. Eight had greater than 50% decrease in seizure frequency, of which 7 had focal epilepsy, and 1 had Lennox-Gastaut/mixed epilepsy. Two had drowsiness and 3 behavioral complaints. One experienced tingling and dizziness. Our retrospective review suggests that brivaracetam is an effective therapy for refractory focal epilepsy in children older than 4 years of age.

Seizure and cognitive outcomes of posterior quadrantic disconnection: a series of 12 pediatric patients

Purpose: To evaluate surgical outcomes and cognitive improvements after posterior quadrantic disconnection (PQD) in children who had medically intractable epilepsy and to compare the various characteristics between the acquired group and the developmental group.Method: Between 2015 and 2017, we retrospectively enrolled all pediatric patients who underwent PQD. We used image post-processing techniques for preoperative evaluation. Seizure outcomes and postoperative cognitive improvements were analysed. The patients were divided into the acquired group and the developmental group depending on the pathology; we then compared groups regarding age at onset, surgery, history, and seizure and cognitive outcomes.Results: A total of 12 pediatric patients were enrolled, including 7 acquired patients and 5 developmental patients. After a median 28.9-month follow-up, 11 (91.7%) of 12 patients were seizure free. The image post-processing facilitated a better visualization on preoperative evaluation and helped with detection of the epileptogenic zone. There were significant linear relationships between improvements in IQ and operative age (R²=0.527, p = 0.007) and IQ and epileptic history (R²=0.696, p = 0.001). The median age at seizure onset was 4.86 ± 2.12 years in the acquired group and 2.40 ± 1.14 years in the developmental group (t = 2.344, p = 0.028). Epileptic histories, seizure outcomes and cognitive outcomes were not significantly different between groups.Conclusion: Posterior quadrantic disconnection is an effective epilepsy surgery in selected patients. The use of image post-processing is important for preoperative evaluation. The age at seizure onset and surgery in malformation of cortical development (MCD) patients was earlier; however, the seizure outcome was no better than in acquired pathology patients. Early surgery did not change seizure outcomes but improved cognition.

Risk factors for drug-resistant epilepsy: A systematic review and meta-analysis

BACKGROUND

Drug resistant epilepsy (DRE) is very common among children and adults and studies had found some related risk factors for DRE, while the results were not consistent. The aim of this study was to identify risk factors for drug-resistant epilepsy.

METHODS

Three electronic databases (Medline, Embase and Cochrane library) were searched to identify studies with a cohort design reporting on epidemiologic evidence regarding risk factors for DRE.

RESULTS

The pooled prevalence of DRE in newly diagnosed epilepsy patients was 25% (95% CI 17-32%). Abnormal electroencephalography (EEG) (both slow wave and epileptiform discharges) (RR 2.80; 95% CI 1.95-4.0), status epilepticus (SE) (RR 11.60; 95% CI 7.39-18.22), symptomatic etiology (RR 3.36; 95% CI 2.53-4.46), multiple seizure types (RR 3.66; 95% CI 2.37-5.64) and febrile seizures (RR 3.43; 95% CI 1.95-6.02) were identified as strong risk factors for DRE. In addition, firm conclusions cannot be drawn for poor short-term outcomes of therapy, neurodevelopment delay and high initial seizure frequency for the heterogeneity of study results. The predictive effect of focus onset seizure was not stable after removing one study and switching the effect model. Age of onset was not risk factors for DRE.

CONCLUSIONS

The current meta-analysis identified potential risk factors for DRE. The results may contribute to better prevention strategies and treatments for DRE.

Etiology, clinical course and outcome of infant epilepsy: Experience of a tertiary center in Thailand

PURPOSE

Explore etiology, clinical course and outcome of infant epilepsy in Bhumibol Adulyadej Hospital.

METHOD

Retrospective and prospective descriptive analysis of infants 1 month to 1 year diagnosed with epilepsy between January 1, 2012, and April 30, 2018.

RESULTS

Total 57 infants. Average age of seizure onset was 4.7 months. Follow-up period averaged 34.2 months. Prenatal risk factors were found in 28.1 percent (16/57). Of these, 50 percent (8/16) had seizure in neonatal period. An additional 6 infants without any prenatal risk factor had seizure in the neonatal period, bringing the total newborn with seizure to 24.6 percent (14/57). Family history of seizure was positive in only 15.8 percent (9/57). Neuroimaging was done 68.4 percent (39/57) and electroencephalogram 50.9 percent (29/57). The etiology was mostly structural 38.6 percent (22/57), followed by unknown 35.1 percent (20/57), genetics 14 percent (8/57), infection 10.5 percent (6/57) and metabolic 1.8 percent (1/57). Status epilepticus was found 21.1 percent of the times (12/57). Antiepileptic drugs were discontinued 19.3 percent (11/57). Intractable seizure was found 29.8 percent (17/57) and developmental delay 56.1 percent (32/57). By multivariate logistic regression analysis, status epilepticus and developmental delay predicted intractable seizure, whereas, abnormal neurological examination and abnormal neuroimaging predicted developmental delay. Mortality rate was 3.5 percent.

CONCLUSION

The study shows that early onset of epilepsy in children under a year is similar to that found in children less than 2-3 years as found in prior studies. High percentages of intractable seizure and developmental delay were found.

Off-label use and manipulations of antiepileptic drugs in children: Analysis of the outpatient prescriptions in a tertiary center

OBJECTIVES

Little is known about off-label use and manipulations to achieve the prescribed dose of antiepileptic drugs (AEDs) in outpatient prescriptions. This study aimed to evaluate this practice in a tertiary center for child epilepsy.

METHODS

We reviewed off-label use and manipulations of AEDs delivered to the outpatient's epilepsy clinic. Multivariate logistic regressions were used to determine the factors associated with off-label and manipulated uses.

RESULTS

Five hundred eleven consultations generated 897 AED deliveries (1.75/consultation). Off-label use involved 182 (20.3%) of prescribed AEDs. Factors associated with off-label use were polytherapy and new AEDs while increase of age and nondevelopmental and structural-metabolic etiologies have a protective effect. Among the 1725 doses of AEDs prescribed per day, 33.5% generated manipulations (n=582): 40% inadequate (n=237) and 60% adequate (203 syrups, 112 scored tablets, 30 drops medicine). Polytherapy (p<10^-4) and the absence of market authorization significantly favored manipulations whereas the increase in age restricted them.

CONCLUSION

Off-label use and manipulations of AEDs remain an important problem in home care of children with epilepsy. This is mainly a concern for the most vulnerable groups, i.e., young patients, patients undergoing polytherapy, and patients with developmental and epileptic encephalopathy (DEE). International initiatives have been launched to improve the availability of labeled and adapted drugs in this population.

Predictive factors of drug-resistant epilepsy in children presenting under 2 years of age: experience of a tertiary center in Turkey

Population-based studies report that children with epilepsy have relatively better prognosis than those with an onset at infancy, though studies about this period are limited. We aimed to evaluate the etiology in infant epilepsy less than 2 years of age and foreseeable risk factors for anti-epileptic drug resistance. We evaluated the patients who were presented to the division of pediatric neurology in our university hospital with seizures when they were between 1 and 24 months of age and diagnosed as epilepsy. Two hundred and twenty-nine patients (110 male and 119 female) who were diagnosed between the ages of 1-24 months were included in the study. The etiologies were structural (n = 55;24%), genetic (n = 29;12.7%), metabolic (n = 27;11.7%), and infectious (n = 8;3.5%), and it was unknown in 110 patients (48%). One-hundred and forty (61%) patients met the criteria for drug-resistant epilepsy (DRE). Multivariate logistic regression analysis showed that developmental delay at onset (OR 3.9, 95% CI 1.22, 12.47, p = 0.021), multifocal epileptiform discharges (OR 2.8, 95% CI 1.1, 7.44, p = 0.031), and history of status epilepticus (OR 32.9, 95% CI 3.8, 285.35, p = 0.001) were strong predictive factors for DRE. The epilepsy in children under 2 years of age is highly resistant to the anti-epileptic drugs, which could be related to the history of status epilepticus, developmental delay at onset, and multifocal epileptiform discharges.

Drug-resistant epilepsy development following stem cell transplant and cyclosporine neurotoxicity induced seizures: Case report in an adult and analysis of reported cases in the literature

Introduction

Drug-resistant epilepsy (DRE) occurs in 20–30% of all patients who develop epilepsy and can occur from diverse causes. Cyclosporine-A (CSA) is an immunosuppressive drug utilized to prevent graft-versus-host disease (GvHD) in transplant patients and is known to cause neurotoxicity, including seizures. In some cases, however, patients can develop DRE. Only a limited number of cases have been reported in which DRE has developed after CSA exposure — all in children. Here we present a rare case of an adult developing DRE after post-transplant CSA neurotoxicity. In addition, we provide a comprehensive review and analysis of all reported cases in the literature.

Case report

A 29-year-old man with Non-Hodgkin's Lymphoma underwent an allogenic hematopoietic stem cell transplant and experienced a CSA-induced seizure at 7.5 months' post-transplant. The patient was discontinued on CSA and began a low dose tacrolimus regimen. At 33 months' post-transplant, he had seizure recurrence and developed DRE. Imaging revealed right mesial temporal sclerosis (MTS) and video EEG localized ictal activity to the right anterior temporal lobe. He was successfully treated with a right anterior temporal lobectomy and amygdalohippocampectomy.

Literature review

Seven peer-reviewed studies described 15 patients who underwent transplantation with post-transplant CSA administration and subsequently developed DRE following an initial CSA-induced seizure. All 15 patients were children suggesting that young age is a risk factor for DRE after CSA-induced seizures. Initial CSA-induced seizures occurred at an average of 1.6 ± 1.1 months after transplant and seizure recurrence 9.2 ± 8.0 months after transplant. All reported CSA routes of administration (n = 6) were intravenous and 7 of 9 (78%) reported CSA blood levels above the therapeutic range. The incidence of MTS (40%) in these 15 patients was significantly higher than the incidence in the general DRE population (24%) and was most effectively treated via epilepsy surgery.

Conclusions

The use of cyclosporine for GvHD prophylaxis and treatment following transplantation may cause seizures and be associated with DRE. Although discontinuation and dose decrease of CSA often reverse adverse neurological events, initial CSA-induced seizures may be associated with MTS that and subsequent greater risk of DRE development.

Intravenous immunoglobulin G as adjuvant treatment in drug-resistant childhood epilepsy

BACKGROUND

Epilepsy is the most common neurological disease in childhood; depending on the definition of drug-resistant epilepsy, incidence varies from 10% to 23% in the paediatric population. The objective of this study was to account for the decrease in the frequency and/or monthly duration of epileptic seizures in paediatric patients with drug-resistant epilepsy treated with antiepileptic drugs, before and after adding intravenous immunoglobulin G (iIV IgG).

METHODS

This is an analytic, observational, retrospective case-control study. We studied paediatric patients with drug-resistant epilepsy who were treated with IV IgG at the Centro Médico Nacional 20 de Noviembre, in Mexico City, from 2003 to 2013.

RESULTS

One hundred and sixty seven patients (19.5%) had drug-resistant epilepsy and 44 (5.1%) started adjuvant treatment with IV IgG. The mean age of patients at the beginning of treatment was 6.12 years±5.14); aetiology was structural acquired in 28 patients (73.6%), genetic in 5 (13.1%), immune in 1 (2.6%), and unknown in 4 (10.5%). At 2 months from starting IV IgG, seizure duration had reduced to 66.66%; the frequency of seizures was reduced by 64% at 4 months after starting treatment (P<.001).

CONCLUSIONS

According to the results of this study, intravenous immunoglobulin may be an effective therapy for reducing the frequency and duration of seizures in paediatric patients with drug-resistant epilepsy.

Predicting drug resistance in adult patients with generalized epilepsy: A case-control study

OBJECTIVES

Using an adult cohort of patients with generalized epilepsy, we aimed to identify risk factors for development of drug-resistant epilepsy (DRE), which if identifiable would allow patients to receive earlier treatment and more specifically individualized treatment plans.

METHODS

For the case-control study, 118 patients with generalized epilepsy (GE) between the ages of 18 and 75 were included after selection from a database of 800 patients referred from throughout the Saskatchewan Epilepsy Program. Definitions were used in accordance with ILAE criteria. The odds ratio and its confidence interval were calculated. We performed a logistic regression analysis.

RESULTS

Forty-four (37%) patients fulfilled the definition of DRE (cases), and seizures in 74 (63%) patients were not intractable (controls). Patients with DRE were significantly younger than the controls at the onset of epilepsy (6.6 vs. 18.8 years, p=<0.001). Significant variables on univariate analysis were the following: epilepsy diagnosed prior to 12 years (OR: 12.1, CI: 4.8-29.9, p<0.001), previous history of status epilepticus (OR: 15.1, CI: 3.2-70.9, p<0.001), developmental delay (OR: 12.6, CI: 4.9-32, p<0.001), and cryptogenic epilepsy (OR: 10.5, CI: 3.9-27.8, p<0.001). Our study showed some protective factors for DRE such as a good response to first AED, idiopathic etiology, and history of febrile seizures. In the logistic regression analysis, two variables remained statistically significant: developmental delay and more than one seizure type.

CONCLUSION

Our study has identified a set of variables that predict DRE in patients with generalized epilepsy. Risk factors identified in our study are similar to those previously identified in pediatric studies, however, our study is specifically tailored to adult patients with generalized epilepsy.

Refractory epilepsy in children

Refractory epilepsy, estimated to affect 10-20% children with epilepsy, can have profound effect on the education, social and cognitive functioning and recreational activities of the child. The definitions are still evolving. A detailed clinical evaluation may reveal an accurate syndromic and etiological diagnosis. The recent advances in neuroimaging and electrophysiology have revolutionized the management of children with refractory epilepsy and supplement the clinical evaluation. Genetic and metabolic evaluation may be indicated in selected cases. The rational use of anti-epileptic drugs, epilepsy surgery and dietary therapies are the mainstay in the management. Various experimental treatment options and pharmacogenetics offer hope for future.

Early prediction of medication refractoriness in children with idiopathic epilepsy based on scalp EEG analysis

Refractory epilepsy often has deleterious effects on an individual's health and quality of life. Early identification of patients whose seizures are refractory to antiepileptic drugs is important in considering the use of alternative treatments. Although idiopathic epilepsy is regarded as having a significantly lower risk factor of developing refractory epilepsy, still a subset of patients with idiopathic epilepsy might be refractory to medical treatment. In this study, we developed an effective method to predict the refractoriness of idiopathic epilepsy. Sixteen EEG segments from 12 well-controlled patients and 14 EEG segments from 11 refractory patients were analyzed at the time of first EEG recordings before antiepileptic drug treatment. Ten crucial EEG feature descriptors were selected for classification. Three of 10 were related to decorrelation time, and four of 10 were related to relative power of delta/gamma. There were significantly higher values in these seven feature descriptors in the well-controlled group as compared to the refractory group. On the contrary, the remaining three feature descriptors related to spectral edge frequency, kurtosis, and energy of wavelet coefficients demonstrated significantly lower values in the well-controlled group as compared to the refractory group. The analyses yielded a weighted precision rate of 94.2%, and a 93.3% recall rate. Therefore, the developed method is a useful tool in identifying the possibility of developing refractory epilepsy in patients with idiopathic epilepsy.

Developing the Pediatric Refractory Epilepsy Questionnaire: a pilot study

PURPOSE

Up to 14% of children with epilepsy continue to experience seizures despite having appropriate medical therapy and develop medically refractory epilepsy (MRE). Assessing clinical outcomes and therapeutic efficacy in children with MRE undergoing palliative epilepsy surgery has been challenging because of the lack of a quantitative instrument capable of estimating the clinical status of these patients. The ideal instrument would at once consider seizure control, neurodevelopment, caregiver burden, and quality of life. The purpose of this study was to develop and pilot the Pediatric Refractory Epilepsy Questionnaire (PREQ), a quantitative instrument to assess the severity and individual burden of epilepsy in children with MRE undergoing palliative epilepsy treatments.

METHODS

The caregivers of 25 patients with MRE completed the PREQ and the Quality of Life in Childhood Epilepsy (QOLCE) measure and participated in a semistructured interview. Medical records of the patients were reviewed, an Early Childhood Epilepsy Severity Scale (E-CHESS) score was calculated, and a Global Assessment of Severity of Epilepsy (GASE) score was obtained for each patient.

KEY FINDINGS

The initial PREQ was modified based on the analysis of responses, association with previously validated scales, comments from caregivers, and expertise of the PREQ panelists. Pediatric Refractory Epilepsy Questionnaire subscale scores were calculated based on clinical paradigm and compared with independent measures of seizure severity and quality of life. Significant correlations were observed between the seizure severity subscale and the GASE score (r=0.55) and between the mood subscale and the well-being score (r=0.61) on the QOLCE. Significant correlations were also observed between the caregiver rating of seizure severity and the GASE score (r=0.53), the social activity score (r=0.57), and the behavior score (r=0.43) on the QOLCE. Correlations between the caregiver rating of quality of life and the quality of life score (r=0.58) and the number of AEDs used (r=0.45) were also significant.

SIGNIFICANCE

This pilot study is an initial, critical step in the development of the PREQ. The significant correlations between the PREQ subscales and the external epilepsy severity and quality of life measures lend preliminary support to our hypothesis that the PREQ is assessing the severity of epilepsy along with other important domains, such as mood, neurodevelopment, and quality of life. A larger prospective study of this modified PREQ is currently underway to further develop the PREQ.