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Hays MA, Daraie AH, Smith RJ, Sarma SV, Crone NE, Kang JY. Network excitability of stimulation-induced spectral responses helps localize the seizure onset zone. Clin Neurophysiol 2024; 166:43-55. [PMID: 39096821 PMCID: PMC11401764 DOI: 10.1016/j.clinph.2024.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 03/11/2024] [Accepted: 07/19/2024] [Indexed: 08/05/2024]
Abstract
OBJECTIVE While evoked potentials elicited by single pulse electrical stimulation (SPES) may assist seizure onset zone (SOZ) localization during intracranial EEG (iEEG) monitoring, induced high frequency activity has also shown promising utility. We aimed to predict SOZ sites using induced cortico-cortical spectral responses (CCSRs) as an index of excitability within epileptogenic networks. METHODS SPES was conducted in 27 epilepsy patients undergoing iEEG monitoring and CCSRs were quantified by significant early (10-200 ms) increases in power from 10 to 250 Hz. Using response power as CCSR network connection strengths, graph centrality measures (metrics quantifying each site's influence within the network) were used to predict whether sites were within the SOZ. RESULTS Across patients with successful surgical outcomes, greater CCSR centrality predicted SOZ sites and SOZ sites targeted for surgical treatment with median AUCs of 0.85 and 0.91, respectively. We found that the alignment between predicted and targeted SOZ sites predicted surgical outcome with an AUC of 0.79. CONCLUSIONS These findings indicate that network analysis of CCSRs can be used to identify increased excitability of SOZ sites and discriminate important surgical targets within the SOZ. SIGNIFICANCE CCSRs may supplement traditional passive iEEG monitoring in seizure localization, potentially reducing the need for recording numerous seizures.
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Affiliation(s)
- Mark A Hays
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA.
| | - Amir H Daraie
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Rachel J Smith
- Department of Electrical and Computer Engineering, University of Alabama at Birmingham, Birmingham, AL, USA; Department of Neuroengineering, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Sridevi V Sarma
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA; Institute for Computational Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Nathan E Crone
- Department of Neurology, Johns Hopkins University, Baltimore, MD, USA
| | - Joon Y Kang
- Department of Neurology, Johns Hopkins University, Baltimore, MD, USA
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Akamine IR, Garich JV, Gulick DW, Hara SA, Benscoter MA, Kuehn ST, Worrell GA, Raupp GB, Blain Christen JM. Development of a novel, concentric micro-ECoG array enabling simultaneous detection of a single location by multiple electrode sizes. Biomed Phys Eng Express 2024; 10:045040. [PMID: 38744259 DOI: 10.1088/2057-1976/ad4b1c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 05/14/2024] [Indexed: 05/16/2024]
Abstract
Objective.Detection of the epileptogenic zone is critical, especially for patients with drug-resistant epilepsy. Accurately mapping cortical regions exhibiting high activity during spontaneous seizure events while detecting neural activity up to 500 Hz can assist clinicians' surgical decisions and improve patient outcomes.Approach.We designed, fabricated, and tested a novel hybrid, multi-scale micro-electrocorticography (micro-ECoG) array with a unique embedded configuration. This array was compared to a commercially available microelectrode array (Neuronexus) for recording neural activity in rodent sensory cortex elicited by somatosensory evoked potentials and pilocarpine-induced seizures.Main results.Evoked potentials and spatial maps recorded by the multi-scale array ('micros', 'mesos', and 'macros' refering to the relative electrode sizes, 40 micron, 1 mm, and 4 mm respectively) were comparable to the Neuronexus array. The SSEPs recorded with the micros had higher peak amplitudes and greater signal power than those recorded by the larger mesos and macro. Seizure onset events and high-frequency oscillations (∼450 Hz) were detected on the multi-scale, similar to the commercially available array. The micros had greater SNR than the mesos and macro over the 5-1000 Hz frequency range during seizure monitoring. During cortical stimulation experimentation, the mesos successfully elicited motor effects.Significance.Previous studies have compared macro- and microelectrodes for localizing seizure activity in adjacent regions. The multi-scale design validated here is the first to simultaneously measure macro- and microelectrode signals from the same overlapping cortical area. This enables direct comparison of microelectrode recordings to the macroelectrode recordings used in standard neurosurgical practice. Previous studies have also shown that cortical regions generating high-frequency oscillations are at an increased risk for becoming epileptogenic zones. More accurate mapping of these micro seizures may improve surgical outcomes for epilepsy patients.
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Affiliation(s)
- Ian R Akamine
- Biomedical & Health Systems Engineering, Arizona State University, Tempe, AZ, United States of America
| | - Jonathan V Garich
- Biomedical & Health Systems Engineering, Arizona State University, Tempe, AZ, United States of America
- Division of Engineering, Mayo Clinic, Rochester, MN, United States of America
| | - Daniel W Gulick
- Electrical, Computer, & Energy Engineering, Arizona State University, Tempe, AZ, United States of America
| | - Seth A Hara
- Division of Engineering, Mayo Clinic, Rochester, MN, United States of America
| | - Mark A Benscoter
- Division of Engineering, Mayo Clinic, Rochester, MN, United States of America
| | - Stephen T Kuehn
- Division of Engineering, Mayo Clinic, Rochester, MN, United States of America
| | - Gregory A Worrell
- Department of Neurology, Mayo Clinic, Rochester, MN, United States of America
| | - Gregory B Raupp
- Engineering of Matter, Transport, & Energy, Arizona State University, Tempe, AZ, United States of America
| | - Jennifer M Blain Christen
- Electrical, Computer, & Energy Engineering, Arizona State University, Tempe, AZ, United States of America
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Cai Z, Jiang X, Bagić A, Worrell GA, Richardson M, He B. Spontaneous HFO Sequences Reveal Propagation Pathways for Precise Delineation of Epileptogenic Networks. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.05.02.592202. [PMID: 38746136 PMCID: PMC11092614 DOI: 10.1101/2024.05.02.592202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Abstract
Epilepsy, a neurological disorder affecting millions worldwide, poses great challenges in precisely delineating the epileptogenic zone - the brain region generating seizures - for effective treatment. High-frequency oscillations (HFOs) are emerging as promising biomarkers; however, the clinical utility is hindered by the difficulties in distinguishing pathological HFOs from non- epileptiform activities at single electrode and single patient resolution and understanding their dynamic role in epileptic networks. Here, we introduce an HFO-sequencing approach to analyze spontaneous HFOs traversing cortical regions in 40 drug-resistant epilepsy patients. This data- driven method automatically detected over 8.9 million HFOs, pinpointing pathological HFO- networks, and unveiled intricate millisecond-scale spatiotemporal dynamics, stability, and functional connectivity of HFOs in prolonged intracranial EEG recordings. These HFO sequences demonstrated a significant improvement in localization of epileptic tissue, with an 818.47% increase in concordance with seizure-onset zone (mean error: 2.92 mm), compared to conventional benchmarks. They also accurately predicted seizure outcomes for 90% AUC based on pre-surgical information using generalized linear models. Importantly, this mapping remained reliable even with short recordings (mean standard deviation: 3.23 mm for 30-minute segments). Furthermore, HFO sequences exhibited distinct yet highly repetitive spatiotemporal patterns, characterized by pronounced synchrony and predominant inward information flow from periphery towards areas involved in propagation, suggesting a crucial role for excitation-inhibition balance in HFO initiation and progression. Together, these findings shed light on the intricate organization of epileptic network and highlight the potential of HFO-sequencing as a translational tool for improved diagnosis, surgical targeting, and ultimately, better outcomes for vulnerable patients with drug-resistant epilepsy. One Sentence Summary Pathological fast brain oscillations travel like traffic along varied routes, outlining recurrently visited neural sites emerging as critical hotspots in epilepsy network.
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Sun T, Wu S, Liu X, Tao JX, Wang Q. Impact of intracranial subclinical seizures on seizure outcomes after SLAH in patients with mesial temporal lobe epilepsy. Clin Neurophysiol 2024; 160:121-129. [PMID: 38422970 DOI: 10.1016/j.clinph.2024.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 12/31/2023] [Accepted: 02/11/2024] [Indexed: 03/02/2024]
Abstract
OBJECTIVE To investigate the association between subclinical seizures detected on intracranial electroencephalographic (i-SCSs)recordings and mesial temporal sclerosis (MTS), as well as their impact on surgical outcomes of stereotactic laser amygdalohippocampotomy (SLAH). METHODS A retrospective review was conducted on 27 patients with drug-resistant mesial temporal lobe epilepsy (MTLE) who underwent SLAH. The number of seizures detected on scalp EEG and iEEG was assessed. Patients were followed for a minimum of 3 years after SLAH. RESULTS Of the 1715 seizures recorded from mesial temporal regions, 1640 were identified as i-SCSs. Patients with MTS were associated with favorable short- and long-term surgical outcomes. Patients with MTS had a higher number of i-SCSs compared to patients without MTS. The numbers of i-SCSs were higher in patients with Engel I-II outcomes, but no significant statistical difference was found. However, it was observed that patients with MTS who achieved Engel I-II classification had higher numbers of i-SCSs than patients without MTS (P < 0.05). CONCLUSION Patients with MTS exhibited favorable short-term and long-term surgical outcome after SLAH. A higher number of i-SCSs was significantly associated with MTS in patients with MTLE. The number of i-SCSs tended to be higher in patients with Engel Ⅰ-Ⅱ surgical outcomes. SIGNIFICANCE The association between i-SCSs, MTS, and surgical outcomes in MTLE patients undergoing SLAH has significant implications for understanding the underlying mechanisms and identifying potential therapeutic targets to enhance surgical outcomes.
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Affiliation(s)
- Taixin Sun
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China; Department of Neurology, Beijing Electric Power Hospital, Capital Medical University, Beijing, PR China
| | - Shasha Wu
- Department of Neurology, The University of Chicago, Chicago, IL 60637, USA
| | - Xi Liu
- Department of Neurology, Zhongnan Hospital, Wuhan University, Wuhan, Hubei Province, PR China
| | - James X Tao
- Department of Neurology, The University of Chicago, Chicago, IL 60637, USA
| | - Qun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China.
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Wissel BD, Greiner HM, Glauser TA, Pestian JP, Ficker DM, Cavitt JL, Estofan L, Holland-Bouley KD, Mangano FT, Szczesniak RD, Dexheimer JW. Early Identification of Candidates for Epilepsy Surgery: A Multicenter, Machine Learning, Prospective Validation Study. Neurology 2024; 102:e208048. [PMID: 38315952 PMCID: PMC10890832 DOI: 10.1212/wnl.0000000000208048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 10/13/2023] [Indexed: 02/07/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Epilepsy surgery is often delayed. We previously developed machine learning (ML) models to identify candidates for resective epilepsy surgery earlier in the disease course. In this study, we report the prospective validation. METHODS In this multicenter, prospective, longitudinal cohort study, random forest models were validated at a pediatric epilepsy center consisting of 2 hospitals and 14 outpatient neurology clinic sites and an adult epilepsy center with 2 hospitals and 27 outpatient neurology clinic sites. The models used neurology visit notes, EEG and MRI reports, visit patterns, hospitalizations, and medication, laboratory, and procedure orders to identify candidates for surgery. The models were trained on historical data up to May 10, 2019. Patients with an ICD-10 diagnosis of epilepsy who visited from May 11, 2019, to May 10, 2020, were screened by the algorithm and assigned surgical candidacy scores. The primary outcome was area under the curve (AUC), which was calculated by comparing scores from patients who underwent epilepsy surgery before November 10, 2020, against scores from nonsurgical patients. Nonsurgical patients' charts were reviewed to determine whether patients with high scores were more likely to be missed surgical candidates. Delay to surgery was defined as the time between the first visit that a surgical candidate was identified by the algorithm and the date of the surgery. RESULTS A total of 5,285 pediatric and 5,782 adult patients were included to train the ML algorithms. During the study period, 41 children and 23 adults underwent resective epilepsy surgery. In the pediatric cohort, AUC was 0.91 (95% CI 0.87-0.94), positive predictive value (PPV) was 0.08 (0.05-0.10), and negative predictive value (NPV) was 1.00 (0.99-1.00). In the adult cohort, AUC was 0.91 (0.86-0.97), PPV was 0.07 (0.04-0.11), and NPV was 1.00 (0.99-1.00). The models first identified patients at a median of 2.1 years (interquartile range [IQR]: 1.2-4.9 years, maximum: 11.1 years) before their surgery and 1.3 years (IQR: 0.3-4.0 years, maximum: 10.1 years) before their presurgical evaluations. DISCUSSION ML algorithms can identify surgical candidates earlier in the disease course. Even at specialized epilepsy centers, there is room to shorten the time to surgery. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that a machine learning algorithm can accurately distinguish patients with epilepsy who require resective surgery from those who do not.
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Affiliation(s)
- Benjamin D Wissel
- From the Division of Biomedical Informatics (B.D.W., J.P.P., J.W.D.), Cincinnati Children's Hospital Medical Center; Department of Pediatrics (H.M.G., T.A.G., J.P.P., K.D.H.-B., F.T.M., R.D.S., J.W.D.), University of Cincinnati College of Medicine; Division of Neurology (H.M.G., T.A.G., K.D.H.-B.), Cincinnati Children's Hospital Medical Center; Department of Neurology and Rehabilitation Medicine (D.M.F., J.L.C., L.E.), University of Cincinnati; Division of Neurosurgery (F.T.M.); Division of Biostatistics and Epidemiology (R.D.S.); and Division of Emergency Medicine (J.W.D.), Cincinnati Children's Hospital Medical Center, OH
| | - Hansel M Greiner
- From the Division of Biomedical Informatics (B.D.W., J.P.P., J.W.D.), Cincinnati Children's Hospital Medical Center; Department of Pediatrics (H.M.G., T.A.G., J.P.P., K.D.H.-B., F.T.M., R.D.S., J.W.D.), University of Cincinnati College of Medicine; Division of Neurology (H.M.G., T.A.G., K.D.H.-B.), Cincinnati Children's Hospital Medical Center; Department of Neurology and Rehabilitation Medicine (D.M.F., J.L.C., L.E.), University of Cincinnati; Division of Neurosurgery (F.T.M.); Division of Biostatistics and Epidemiology (R.D.S.); and Division of Emergency Medicine (J.W.D.), Cincinnati Children's Hospital Medical Center, OH
| | - Tracy A Glauser
- From the Division of Biomedical Informatics (B.D.W., J.P.P., J.W.D.), Cincinnati Children's Hospital Medical Center; Department of Pediatrics (H.M.G., T.A.G., J.P.P., K.D.H.-B., F.T.M., R.D.S., J.W.D.), University of Cincinnati College of Medicine; Division of Neurology (H.M.G., T.A.G., K.D.H.-B.), Cincinnati Children's Hospital Medical Center; Department of Neurology and Rehabilitation Medicine (D.M.F., J.L.C., L.E.), University of Cincinnati; Division of Neurosurgery (F.T.M.); Division of Biostatistics and Epidemiology (R.D.S.); and Division of Emergency Medicine (J.W.D.), Cincinnati Children's Hospital Medical Center, OH
| | - John P Pestian
- From the Division of Biomedical Informatics (B.D.W., J.P.P., J.W.D.), Cincinnati Children's Hospital Medical Center; Department of Pediatrics (H.M.G., T.A.G., J.P.P., K.D.H.-B., F.T.M., R.D.S., J.W.D.), University of Cincinnati College of Medicine; Division of Neurology (H.M.G., T.A.G., K.D.H.-B.), Cincinnati Children's Hospital Medical Center; Department of Neurology and Rehabilitation Medicine (D.M.F., J.L.C., L.E.), University of Cincinnati; Division of Neurosurgery (F.T.M.); Division of Biostatistics and Epidemiology (R.D.S.); and Division of Emergency Medicine (J.W.D.), Cincinnati Children's Hospital Medical Center, OH
| | - David M Ficker
- From the Division of Biomedical Informatics (B.D.W., J.P.P., J.W.D.), Cincinnati Children's Hospital Medical Center; Department of Pediatrics (H.M.G., T.A.G., J.P.P., K.D.H.-B., F.T.M., R.D.S., J.W.D.), University of Cincinnati College of Medicine; Division of Neurology (H.M.G., T.A.G., K.D.H.-B.), Cincinnati Children's Hospital Medical Center; Department of Neurology and Rehabilitation Medicine (D.M.F., J.L.C., L.E.), University of Cincinnati; Division of Neurosurgery (F.T.M.); Division of Biostatistics and Epidemiology (R.D.S.); and Division of Emergency Medicine (J.W.D.), Cincinnati Children's Hospital Medical Center, OH
| | - Jennifer L Cavitt
- From the Division of Biomedical Informatics (B.D.W., J.P.P., J.W.D.), Cincinnati Children's Hospital Medical Center; Department of Pediatrics (H.M.G., T.A.G., J.P.P., K.D.H.-B., F.T.M., R.D.S., J.W.D.), University of Cincinnati College of Medicine; Division of Neurology (H.M.G., T.A.G., K.D.H.-B.), Cincinnati Children's Hospital Medical Center; Department of Neurology and Rehabilitation Medicine (D.M.F., J.L.C., L.E.), University of Cincinnati; Division of Neurosurgery (F.T.M.); Division of Biostatistics and Epidemiology (R.D.S.); and Division of Emergency Medicine (J.W.D.), Cincinnati Children's Hospital Medical Center, OH
| | - Leonel Estofan
- From the Division of Biomedical Informatics (B.D.W., J.P.P., J.W.D.), Cincinnati Children's Hospital Medical Center; Department of Pediatrics (H.M.G., T.A.G., J.P.P., K.D.H.-B., F.T.M., R.D.S., J.W.D.), University of Cincinnati College of Medicine; Division of Neurology (H.M.G., T.A.G., K.D.H.-B.), Cincinnati Children's Hospital Medical Center; Department of Neurology and Rehabilitation Medicine (D.M.F., J.L.C., L.E.), University of Cincinnati; Division of Neurosurgery (F.T.M.); Division of Biostatistics and Epidemiology (R.D.S.); and Division of Emergency Medicine (J.W.D.), Cincinnati Children's Hospital Medical Center, OH
| | - Katherine D Holland-Bouley
- From the Division of Biomedical Informatics (B.D.W., J.P.P., J.W.D.), Cincinnati Children's Hospital Medical Center; Department of Pediatrics (H.M.G., T.A.G., J.P.P., K.D.H.-B., F.T.M., R.D.S., J.W.D.), University of Cincinnati College of Medicine; Division of Neurology (H.M.G., T.A.G., K.D.H.-B.), Cincinnati Children's Hospital Medical Center; Department of Neurology and Rehabilitation Medicine (D.M.F., J.L.C., L.E.), University of Cincinnati; Division of Neurosurgery (F.T.M.); Division of Biostatistics and Epidemiology (R.D.S.); and Division of Emergency Medicine (J.W.D.), Cincinnati Children's Hospital Medical Center, OH
| | - Francesco T Mangano
- From the Division of Biomedical Informatics (B.D.W., J.P.P., J.W.D.), Cincinnati Children's Hospital Medical Center; Department of Pediatrics (H.M.G., T.A.G., J.P.P., K.D.H.-B., F.T.M., R.D.S., J.W.D.), University of Cincinnati College of Medicine; Division of Neurology (H.M.G., T.A.G., K.D.H.-B.), Cincinnati Children's Hospital Medical Center; Department of Neurology and Rehabilitation Medicine (D.M.F., J.L.C., L.E.), University of Cincinnati; Division of Neurosurgery (F.T.M.); Division of Biostatistics and Epidemiology (R.D.S.); and Division of Emergency Medicine (J.W.D.), Cincinnati Children's Hospital Medical Center, OH
| | - Rhonda D Szczesniak
- From the Division of Biomedical Informatics (B.D.W., J.P.P., J.W.D.), Cincinnati Children's Hospital Medical Center; Department of Pediatrics (H.M.G., T.A.G., J.P.P., K.D.H.-B., F.T.M., R.D.S., J.W.D.), University of Cincinnati College of Medicine; Division of Neurology (H.M.G., T.A.G., K.D.H.-B.), Cincinnati Children's Hospital Medical Center; Department of Neurology and Rehabilitation Medicine (D.M.F., J.L.C., L.E.), University of Cincinnati; Division of Neurosurgery (F.T.M.); Division of Biostatistics and Epidemiology (R.D.S.); and Division of Emergency Medicine (J.W.D.), Cincinnati Children's Hospital Medical Center, OH
| | - Judith W Dexheimer
- From the Division of Biomedical Informatics (B.D.W., J.P.P., J.W.D.), Cincinnati Children's Hospital Medical Center; Department of Pediatrics (H.M.G., T.A.G., J.P.P., K.D.H.-B., F.T.M., R.D.S., J.W.D.), University of Cincinnati College of Medicine; Division of Neurology (H.M.G., T.A.G., K.D.H.-B.), Cincinnati Children's Hospital Medical Center; Department of Neurology and Rehabilitation Medicine (D.M.F., J.L.C., L.E.), University of Cincinnati; Division of Neurosurgery (F.T.M.); Division of Biostatistics and Epidemiology (R.D.S.); and Division of Emergency Medicine (J.W.D.), Cincinnati Children's Hospital Medical Center, OH
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Zhu R, Zhao R. The Tip of the Iceberg: Coagulopathy in Pediatric Patients Undergoing Surgery for Epilepsy. World Neurosurg 2024; 181:186-187. [PMID: 37833160 DOI: 10.1016/j.wneu.2023.09.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2023]
Affiliation(s)
- Renqing Zhu
- Department of Neurosurgery, Children's Hospital of Fudan University, Shanghai, China
| | - Rui Zhao
- Department of Neurosurgery, Children's Hospital of Shanghai, Shanghai, China; Department of Neurosurgery, Hainan Women and Children's Medical Center, Haikou, China
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Fawcett J, Davis S, Manford M. Further advances in epilepsy. J Neurol 2023; 270:5655-5670. [PMID: 37458794 DOI: 10.1007/s00415-023-11860-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 06/29/2023] [Accepted: 06/29/2023] [Indexed: 10/15/2023]
Abstract
In 2017, one of us reviewed advances in epilepsy (Manford in J Neurol 264:1811-1824, 2017). The current paper brings that review up to date and gives a slight change in emphasis. Once again, the story is of evolution rather than revolution. In recognition that most of our current medications act on neurotransmitters or ion channels, and not on the underlying changes in connectivity and pathways, they have been renamed as antiseizure (ASM) medications rather than antiepileptic drugs. Cenobamate is the one newly licensed medication for broader use in focal epilepsy but there have been a number of developments for specific disorders. We review new players and look forward to new developments in the light of evolving underlying science. We look at teratogenicity; old villains and new concerns in which clinicians play a vital role in explaining and balancing the risks. Medical treatment of status epilepticus, long without evidence, has benefitted from high-quality trials to inform practice; like buses, several arriving at once. Surgical treatment continues to be refined with improvements in the pre-surgical evaluation of patients, especially with new imaging techniques. Alternatives including stereotactic radiotherapy have received further focus and targets for palliative stimulation techniques have grown in number. Individuals' autonomy and quality of life continue to be the subject of research with refinement of what clinicians can do to help persons with epilepsy (PWE) achieve control. This includes seizure management but extends to broader considerations of human empowerment, needs and desires, which may be aided by emerging technologies such as seizure detection devices. The role of specialist nurses in improving that quality has been reinforced by specific endorsement from the International League against Epilepsy (ILAE).
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Affiliation(s)
- Joanna Fawcett
- Department of Neurology, Royal United Hospital, Bath, UK
| | - Sarah Davis
- Department of Neurology, Royal United Hospital, Bath, UK
| | - Mark Manford
- Department of Neurology, Royal United Hospital, Bath, UK.
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Kyte EB, Holth Skogan A, Bjøråsen Baklid Å, Malmgren K, Ozanne A, Alfstad KÅ. Patients' long-term perspectives on gains and losses after temporal lobe resection for epilepsy. Epilepsy Behav 2023; 147:109400. [PMID: 37703614 DOI: 10.1016/j.yebeh.2023.109400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 07/25/2023] [Accepted: 08/19/2023] [Indexed: 09/15/2023]
Abstract
OBJECTIVE To investigate long-term (>10 years) experiences and overall satisfaction with temporal lobe resections (TLB) for epilepsy. METHODS Eligible participants were identified through the administrative epilepsy surgery registry at Oslo University Hospital. Data were collected through individual, semi-structured interviews with fifty participants. Interview records were analyzed using reflexive thematic analysis. RESULTS Participants' answers were divided into two main themes: "looking back on surgery" and"considering gains and losses from surgery". Most participants expressed satisfaction with having undergone surgery. Nevertheless, postsurgical problems had been encountered, and presurgical hopes had only partly been fulfilled. They described memory and naming problems with a major impact on daily life. Further, they had thoughts about effects on employment, independence, and feelings of loneliness, and expressed a need for more and better preoperative information. CONCLUSIONS Presurgical hopes go beyond seizure freedom and memory and naming problems are experienced lasting many years after surgery in the temporal lobe. Better preoperative information, particularly about unwanted cognitive effects, is of prime importance. By exploring patientś presurgical hopes, a common ground for expectations on surgery may be found along with strategies on how to cope with cognitive difficulties and possible negative life changes.
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Affiliation(s)
- Eli B Kyte
- The National Centre for Epilepsy, Member of the ERN EpiCARE, Oslo University Hospital, Postboks 4950, Nydalen, 0424 Oslo, Norway.
| | - Annette Holth Skogan
- The National Centre for Epilepsy, Member of the ERN EpiCARE, Oslo University Hospital, Postboks 4950, Nydalen, 0424 Oslo, Norway.
| | - Åsne Bjøråsen Baklid
- The National Centre for Epilepsy, Oslo University Hospital, Postboks 4950, Nydalen, 0424 Oslo, Norway
| | - Kristina Malmgren
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Blå stråket 7, SE-413 45 Gothenburg, Sweden; Department of Neurology, Member of ERN EpiCare, Sahlgrenska University Hospital, Blå Stråket 7, 413 46 Gothenburg, Sweden.
| | - Anneli Ozanne
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Box 100, 405 30 Gothenburg, Sweden; Department of Neurology, Member of ERN EpiCare, Sahlgrenska University Hospital, Blå Stråket 7, 413 46 Gothenburg, Sweden.
| | - Kristin Å Alfstad
- The National Centre for Epilepsy, Member of the ERN EpiCARE, Oslo University Hospital, Postboks 4950, Nydalen, 0424 Oslo, Norway.
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Boileau C, Deforges S, Peret A, Scavarda D, Bartolomei F, Giles A, Partouche N, Gautron J, Viotti J, Janowitz H, Penchet G, Marchal C, Lagarde S, Trebuchon A, Villeneuve N, Rumi J, Marissal T, Khazipov R, Khalilov I, Martineau F, Maréchal M, Lepine A, Milh M, Figarella-Branger D, Dougy E, Tong S, Appay R, Baudouin S, Mercer A, Smith JB, Danos O, Porter R, Mulle C, Crépel V. GluK2 Is a Target for Gene Therapy in Drug-Resistant Temporal Lobe Epilepsy. Ann Neurol 2023; 94:745-761. [PMID: 37341588 DOI: 10.1002/ana.26723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 06/09/2023] [Accepted: 06/12/2023] [Indexed: 06/22/2023]
Abstract
OBJECTIVE Temporal lobe epilepsy (TLE) is characterized by recurrent seizures generated in the limbic system, particularly in the hippocampus. In TLE, recurrent mossy fiber sprouting from dentate gyrus granule cells (DGCs) crea an aberrant epileptogenic network between DGCs which operates via ectopically expressed GluK2/GluK5-containing kainate receptors (KARs). TLE patients are often resistant to anti-seizure medications and suffer significant comorbidities; hence, there is an urgent need for novel therapies. Previously, we have shown that GluK2 knockout mice are protected from seizures. This study aims at providing evidence that downregulating KARs in the hippocampus using gene therapy reduces chronic epileptic discharges in TLE. METHODS We combined molecular biology and electrophysiology in rodent models of TLE and in hippocampal slices surgically resected from patients with drug-resistant TLE. RESULTS Here, we confirmed the translational potential of KAR suppression using a non-selective KAR antagonist that markedly attenuated interictal-like epileptiform discharges (IEDs) in TLE patient-derived hippocampal slices. An adeno-associated virus (AAV) serotype-9 vector expressing anti-grik2 miRNA was engineered to specifically downregulate GluK2 expression. Direct delivery of AAV9-anti grik2 miRNA into the hippocampus of TLE mice led to a marked reduction in seizure activity. Transduction of TLE patient hippocampal slices reduced levels of GluK2 protein and, most importantly, significantly reduced IEDs. INTERPRETATION Our gene silencing strategy to knock down aberrant GluK2 expression demonstrates inhibition of chronic seizure in a mouse TLE model and IEDs in cultured slices derived from TLE patients. These results provide proof-of-concept for a gene therapy approach targeting GluK2 KARs for drug-resistant TLE patients. ANN NEUROL 2023;94:745-761.
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Affiliation(s)
| | - Severine Deforges
- Univ. Bordeaux, CNRS, Interdisciplinary Institute for Neuroscience IINS, UMR 5297, Bordeaux, France
| | | | - Didier Scavarda
- APHM, INSERM, Aix Marseille Univ, INS, Timone Hospital, Pediatric Neurosurgery, Marseille, France
| | - Fabrice Bartolomei
- APHM, INSERM, Aix Marseille Univ, INS, Timone Hospital, Epileptology Department, Marseille, France
| | | | - Nicolas Partouche
- Aix-Marseille Univ. INSERM, Marseille, France
- Corlieve Therapeutics SAS, uniQure NV, Paris, France
| | - Justine Gautron
- Univ. Bordeaux, CNRS, Interdisciplinary Institute for Neuroscience IINS, UMR 5297, Bordeaux, France
- Corlieve Therapeutics SAS, uniQure NV, Paris, France
| | - Julio Viotti
- Univ. Bordeaux, CNRS, Interdisciplinary Institute for Neuroscience IINS, UMR 5297, Bordeaux, France
| | | | | | - Cécile Marchal
- Pellegrin Hospital, Neurosurgery Department, Bordeaux, France
| | - Stanislas Lagarde
- APHM, INSERM, Aix Marseille Univ, INS, Timone Hospital, Epileptology Department, Marseille, France
| | - Agnès Trebuchon
- APHM, INSERM, Aix Marseille Univ, INS, Timone Hospital, Epileptology Department, Marseille, France
| | - Nathalie Villeneuve
- APHM, INSERM, Aix Marseille Univ, INS, Timone Hospital, Epileptology Department, Marseille, France
| | - Julie Rumi
- Univ. Bordeaux, CNRS, Interdisciplinary Institute for Neuroscience IINS, UMR 5297, Bordeaux, France
| | | | | | | | | | - Marine Maréchal
- Univ. Bordeaux, CNRS, Interdisciplinary Institute for Neuroscience IINS, UMR 5297, Bordeaux, France
| | - Anne Lepine
- APHM, INSERM, Aix Marseille Univ, INS, Timone Hospital, Epileptology Department, Marseille, France
| | - Mathieu Milh
- APHM, INSERM, Aix Marseille Univ, INS, Timone Hospital, Epileptology Department, Marseille, France
| | - Dominique Figarella-Branger
- APHM, CNRS, INP, Inst Neurophysiopathol, CHU Timone, Service d'Anatomie Pathologique et de Neuropathologie, Aix-Marseille Univ, Marseille, France
| | - Etienne Dougy
- APHM, CNRS, INP, Inst Neurophysiopathol, CHU Timone, Service d'Anatomie Pathologique et de Neuropathologie, Aix-Marseille Univ, Marseille, France
| | - Soutsakhone Tong
- APHM, CNRS, INP, Inst Neurophysiopathol, CHU Timone, Service d'Anatomie Pathologique et de Neuropathologie, Aix-Marseille Univ, Marseille, France
| | - Romain Appay
- APHM, CNRS, INP, Inst Neurophysiopathol, CHU Timone, Service d'Anatomie Pathologique et de Neuropathologie, Aix-Marseille Univ, Marseille, France
| | | | | | | | | | | | - Christophe Mulle
- Univ. Bordeaux, CNRS, Interdisciplinary Institute for Neuroscience IINS, UMR 5297, Bordeaux, France
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Shenoy N, Srinivasan S, Menon G, Kurupath R. Surgical treatment of epilepsy - Initial experience from a comprehensive epilepsy program in coastal South India. J Neurosci Rural Pract 2023; 14:488-494. [PMID: 37692803 PMCID: PMC10483204 DOI: 10.25259/jnrp_116_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 05/18/2023] [Indexed: 09/12/2023] Open
Abstract
Objectives The objectives of this study were to share our initial experience with epilepsy surgery and provide an overview on the surgical treatments of epilepsies. Materials and Methods This was a retrospective analysis of the demographics and clinical and investigative features of patients who underwent epilepsy surgery between January 2016 and August 2021. Postoperative seizure outcome was categorized according to modified Engel's classification, and the minimum period of follow-up was 1 year. Results The study group included 30 patients with an age ranging from 6 years to 45 years (mean: 22.28 years, median: 20 years) and a male: female ratio of 20:10. The epilepsy duration before surgery ranged from 3 years to 32 years (median: 7 years). Majority of our patients underwent resective surgeries (28/30 = 93.3%), and disconnection procedures were done in two patients. This included one functional hemispherotomy and one posterior quadrantic disconnection. Temporal lobe resective surgery was the most common procedure (16/30 = 53.3%), followed by eight frontal lobe and two parietal lobe surgeries. Among resective surgeries, majority were lesional surgeries and the pathologies included mesial temporal sclerosis (4), dysembryoplastic neuroepithelial tumor (8), ganglioglioma (6), cavernoma (4), focal cortical dysplasia (2), gliosis (1), and one case of hypothalamic hamartoma. Intraoperative electrocorticography was used in all cases for optimizing surgical resection/disconnection. Nearly two-thirds of our patients (66.6%) had an Engel's Class I outcome, five patients had Engel's Class II outcome, three patients had Class III outcome, and one patient did not have any worthwhile improvement. Temporal lobe surgery patients had a better seizure outcome compared to extratemporal surgeries (84% vs. 74%). Overall, complications were minimal and short lasting, and comprised meningitis in three patients (5.6%) and transient worsening of hemiparesis following hemispherotomy in two patients. There was no mortality or long-lasting major morbidity in our patients. Conclusion In carefully selected patients with drug-resistant epilepsy, surgery offers an excellent chance of becoming seizure-free with significant improvement in overall quality of life. Majority of the common epilepsy surgery procedures can be performed through a multidisciplinary approach even in centers with limited resources.
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Affiliation(s)
- Nisha Shenoy
- Department of Neurology, Kasturba Medical College, Manipal Academy of Higher Education, Udupi, Karnataka, India
| | - Siddharth Srinivasan
- Department of Neurosurgery, Kasturba Medical College, Manipal Academy of Higher Education, Udupi, Karnataka, India
| | - Girish Menon
- Department of Neurosurgery, Kasturba Medical College, Manipal Academy of Higher Education, Udupi, Karnataka, India
| | - Radhakrishnan Kurupath
- Department of Neurology, Kasturba Medical College, Manipal Academy of Higher Education, Udupi, Karnataka, India
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Gagliano L, Chang A, Shokooh LA, Toffa DH, Lesage F, Sawan M, Nguyen DK, Assi EB. Cross-bispectrum connectivity of intracranial EEG: A novel approach to seizure onset zone localization. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2023; 2023:1-4. [PMID: 38082787 DOI: 10.1109/embc40787.2023.10340885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Connectivity analyses of intracranial electroencephalography (iEEG) could guide surgical planning for epilepsy surgery by improving the delineation of the seizure onset zone. Traditional approaches fail to quantify important interactions between frequency components. To assess if effective connectivity based on cross-bispectrum -a measure of nonlinear multivariate cross-frequency coupling- can quantitatively identify generators of seizure activity, cross-bispectrum connectivity between channels was computed from iEEG recordings of 5 patients (34 seizures) with good postsurgical outcome. Personalized thresholds of 50% and 80% of the maximum coupling values were used to identify generating electrode channels. In all patients, outflow coupling between α (8-15 Hz) and β (16-31 Hz) frequencies identified at least one electrode inside the resected seizure onset zone. With the 50% and 80% thresholds respectively, an average of 5 (44.7%; specificity = 82.6%) and 2 (22.5%; specificity = 99.0%) resected electrodes were correctly identified. Results show promise for the automatic identification of the seizure onset zone based on cross-bispectrum connectivity analysis.
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12
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Goldenholz DM. Can machine learning solve this one? Clinical pitfalls in surgical outcome prediction. Epilepsia 2023; 64:1190-1194. [PMID: 36825988 PMCID: PMC10175174 DOI: 10.1111/epi.17559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 02/20/2023] [Accepted: 02/22/2023] [Indexed: 02/25/2023]
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Fearns N, Birk D, Bartkiewicz J, Rémi J, Noachtar S, Vollmar C. Quantitative analysis of the morphometric analysis program MAP in patients with truly MRI-negative focal epilepsy. Epilepsy Res 2023; 192:107133. [PMID: 37001290 DOI: 10.1016/j.eplepsyres.2023.107133] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 03/21/2023] [Accepted: 03/27/2023] [Indexed: 03/31/2023]
Abstract
OBJECTIVE In the presurgical evaluation of epilepsy, identifying the epileptogenic zone is challenging if magnetic resonance imaging (MRI) is negative. Several studies have shown the benefit of using a morphometric analysis program (MAP) on T1-weighted MRI scans to detect subtle lesions. MAP can guide a focused re-evaluation of MRI to ultimately identify structural lesions that were previously overlooked. Data on patients where this additional review after MAP analysis did not reveal any lesions is limited. Here we evaluate the diagnostic yield of MAP in a large group of truly MRI-negative patients. METHODS We identified 68 patients with MRI-negative focal epilepsy and clear localization of the epileptogenic zone by intracranial EEG or postoperative seizure freedom. High resolution 3D T1 data of patients and 73 healthy controls were acquired on a 3 T scanner. Morphometric analysis was performed with MAP software, creating five z-score maps, reflecting different structural properties of the brain and a patient's deviation from the control population, and a neural network-based focal cortical dysplasia probability map. Ten brain regions were specified to quantify whether MAP findings were located in the correct region. Receiver operating characteristic (ROC) analyses were performed to identify the optimal thresholds for each map. RESULTS MAP-guided visual re-evaluation of the original MRI revealed overlooked lesions in three patients. The remaining 65 truly MRI-negative patients were included in the statistical analysis. At the optimal thresholds, maximum sensitivity was 84 %, with 35 % specificity. Balanced accuracy (arithmetic mean of sensitivity and specificity) of the respective maps ranged from 51 % to 60 %, creating three to six times more false positive than true positive findings. CONCLUSION This study confirms that MAP is useful in detecting previously overlooked subtle structural lesions. However, in truly MRI-negative patients, the additional diagnostic yield is very limited.
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Vasilica AM, Litvak V, Cao C, Walker M, Vivekananda U. Detection of pathological high-frequency oscillations in refractory epilepsy patients undergoing simultaneous stereo-electroencephalography and magnetoencephalography. Seizure 2023; 107:81-90. [PMID: 36996757 DOI: 10.1016/j.seizure.2023.03.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 03/22/2023] [Indexed: 03/29/2023] Open
Abstract
BACKGROUND Stereo-electroencephalography (SEEG) and magnetoencephalography (MEG) have generally been used independently as part of the pre-surgical evaluation of drug-resistant epilepsy (DRE) patients. However, the possibility of simultaneously employing these recording techniques to determine whether MEG has the potential of offering the same information as SEEG less invasively, or whether it could offer a greater spatial indication of the epileptogenic zone (EZ) to aid surgical planning, has not been previously evaluated. METHODS Data from 24 paediatric and adult DRE patients, undergoing simultaneous SEEG and MEG as part of their pre-surgical evaluation, was analysed employing manual and automated high-frequency oscillations (HFOs) detection, and spectral and source localisation analyses. RESULTS Twelve patients (50%) were included in the analysis (4 males; mean age=25.08 years) and showed interictal SEEG and MEG HFOs. HFOs detection was concordant between the two recording modalities, but SEEG displayed higher ability of differentiating between deep and superficial epileptogenic sources. Automated HFO detector in MEG recordings was validated against the manual MEG detection method. Spectral analysis revealed that SEEG and MEG detect distinct epileptic events. The EZ was well correlated with the simultaneously recorded data in 50% patients, while 25% patients displayed poor correlation or discordance. CONCLUSION MEG recordings can detect HFOs, and simultaneous use of SEEG and MEG HFO identification facilitates EZ localisation during the presurgical planning stage for DRE patients. Further studies are necessary to validate these findings and support the translation of automated HFO detectors into routine clinical practice.
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Affiliation(s)
| | - Vladimir Litvak
- Wellcome Centre for Human Neuroimaging, UCL, Queen Square, London, WC1N 3AR, United Kingdom
| | - Chunyan Cao
- Department of Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai 200025, China
| | - Matthew Walker
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, United Kingdom
| | - Umesh Vivekananda
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, United Kingdom
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15
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Darwish A, Ahmed OEF, Ebrahim KS, Shata MO, Abouelmaaty EH, Hamada SM. Re-appraisal of callosotomy: rates and predictors of short-term seizure outcome in pediatric epileptic encephalopathy. THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2023. [DOI: 10.1186/s41983-023-00620-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023] Open
Abstract
Abstract
Background
Epilepsy is a chronic debilitating disease especially in pediatric population. Most of reported studies for corpus callosotomy as a palliative surgery in drug-resistant cases are on limited number of cases and there is scarcity in literature for outcomes reported from developing countries. Here, we present our study on a large series of cases with analysis of potential predicators outcomes in the era of more expensive devices like vagal nerve stimulation to give a litany on a universal epilepsy surgery procedure which had been missed in the literature through the last decade.
Results
An observational retrospective study was done reviewing 129 patients with PEE underwent open microscopic corpus callosotomy. Total and drop attack seizure outcomes were studied after surgery. Potential outcomes predictors studied are: preoperative EEG and MRI. Preoperative IQ impairment epilepsy duration, age at diagnosis, MRI finding, IQ score, EEG findings, history of infantile spasm and extent of callosotomy done. All the recorded outcomes were substantially improved after callosotomy in our study population of 129 pediatric patients. The median (IQR) preoperative drop attack frequency was 70 (21–140) which decreased to 3 (0–14) postoperatively. Similarly, the number of anti-epileptics used by patients had a median of 3 (2–4) which decreased to 2 (2–3) after the surgery. All patients were experiencing status epilepticus which disappeared in 72% of the patients after callosotomy. Preoperative normal MRI was a predictor for drop attack favorable outcome and mild preoperative impairment of IQ was a predictor of favorable total seizure and drop attack outcome.
Conclusions
Corpus callosotomy is a well-tolerated palliative procedure for drug-resistant generalized epilepsy notably, drop attacks which had its notorious effect on quality of life of pediatric patients and their families, no appreciable prognostic factors for favorable outcome were clearly observed except for normal preoperative MRI, mild preoperative IQ affection, and complete callosotomy.
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Mulligan BP, Carniello TN. A procedure for predicting, illustrating, communicating, and optimizing patient-centered outcomes of epilepsy surgery using nomograms and Bayes' theorem. Epilepsy Behav 2023; 140:109088. [PMID: 36702057 DOI: 10.1016/j.yebeh.2023.109088] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 12/30/2022] [Accepted: 01/05/2023] [Indexed: 01/26/2023]
Abstract
Clinicians have an ethical obligation to obtain and convey relevant information about possible treatment outcomes in a manner that can be comprehended by patients. This contributes to the processes of informed consent and shared prospective decision-making. In epilepsy neurosurgery, there has historically been an emphasis on studying clinician-centered (e.g., seizure- and cognition-related) outcomes and using these data to inform recommendations and, by extension, to frame pre-surgical counseling with respect to patients' decisions about elective neurosurgery. In contrast, there is a relative dearth of available data related to patient-centered outcomes of epilepsy neurosurgery, such as functional (e.g., employment) status, and there is also a lack of methods to communicate these data to patients. Here, illustrated using a hypothetical case scenario, we present a potential solution to the latter of these problems using principles of evidence-based neuropsychology; published data on patient employment status before and after epilepsy neurosurgery; and Bayes' theorem. First, we reviewed existing literature on employment outcomes following epilepsy neurosurgery to identify and extract data relevant to our hypothetical patient, clinical question, and setting. Then, we used the base rate (prior probability) of post-surgical unemployment, contingency tables (to derive likelihood ratios), and Bayes' theorem to compute the conditional (posterior) probability of post-surgical employment status for our hypothetical patient scenario. Finally, we translated this information to an intuitive visual format (Bayesian nomogram) that can support evidence-based pre-surgical counseling. We propose that the application of our patient-centered decision-support process and visual aid will improve clinician-patient communication about prospective risks and benefits of epilepsy neurosurgery and will empower clinicians and patients to make informed decisions about whether or not to pursue elective neurosurgery with a greater degree of confidence and with more realistic and concrete expectations about possible outcomes. We further propose that clinicians and patients would benefit from incorporating this evidence-based framework into a broader sequence of function-focused epilepsy treatment that includes pre-surgical assessments and interventions ("prehabilitation"), neurosurgery, and post-surgical cognitive/vocational rehabilitation.
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Affiliation(s)
- Bryce P Mulligan
- Epilepsy Program, The Ottawa Hospital, Ottawa, ON, Canada; Department of Psychology, The Ottawa Hospital, Ottawa, ON, Canada; School of Psychology, University of Ottawa, Ottawa, ON, Canada.
| | - Trevor N Carniello
- Behavioural Neuroscience Program, Laurentian University, Sudbury, ON, Canada; Department of Psychology, Laurentian University, Sudbury, ON, Canada
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Banerjee A, Kamboj P, Wyckoff SN, Sussman BL, Gupta SKS, Boerwinkle VL. Automated seizure onset zone locator from resting-state functional MRI in drug-resistant epilepsy. FRONTIERS IN NEUROIMAGING 2023; 1:1007668. [PMID: 37555141 PMCID: PMC10406253 DOI: 10.3389/fnimg.2022.1007668] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Accepted: 10/24/2022] [Indexed: 08/10/2023]
Abstract
OBJECTIVE Accurate localization of a seizure onset zone (SOZ) from independent components (IC) of resting-state functional magnetic resonance imaging (rs-fMRI) improves surgical outcomes in children with drug-resistant epilepsy (DRE). Automated IC sorting has limited success in identifying SOZ localizing ICs in adult normal rs-fMRI or uncategorized epilepsy. Children face unique challenges due to the developing brain and its associated surgical risks. This study proposes a novel SOZ localization algorithm (EPIK) for children with DRE. METHODS EPIK is developed in a phased approach, where fMRI noise-related biomarkers are used through high-fidelity image processing techniques to eliminate noise ICs. Then, the SOZ markers are used through a maximum likelihood-based classifier to determine SOZ localizing ICs. The performance of EPIK was evaluated on a unique pediatric DRE dataset (n = 52). A total of 24 children underwent surgical resection or ablation of an rs-fMRI identified SOZ, concurrently evaluated with an EEG and anatomical MRI. Two state-of-art techniques were used for comparison: (a) least squares support-vector machine and (b) convolutional neural networks. The performance was benchmarked against expert IC sorting and Engel outcomes for surgical SOZ resection or ablation. The analysis was stratified across age and sex. RESULTS EPIK outperformed state-of-art techniques for SOZ localizing IC identification with a mean accuracy of 84.7% (4% higher), a precision of 74.1% (22% higher), a specificity of 81.9% (3.2% higher), and a sensitivity of 88.6% (16.5% higher). EPIK showed consistent performance across age and sex with the best performance in those < 5 years of age. It helped achieve a ~5-fold reduction in the number of ICs to be potentially analyzed during pre-surgical screening. SIGNIFICANCE Automated SOZ localization from rs-fMRI, validated against surgical outcomes, indicates the potential for clinical feasibility. It eliminates the need for expert sorting, outperforms prior automated methods, and is consistent across age and sex.
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Affiliation(s)
- Ayan Banerjee
- School of Computing and Augmented Intelligence, Arizona State University, Tempe, AZ, United States
| | - Payal Kamboj
- School of Computing and Augmented Intelligence, Arizona State University, Tempe, AZ, United States
| | - Sarah N. Wyckoff
- Division of Neuroscience, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ, United States
| | - Bethany L. Sussman
- Division of Neuroscience, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ, United States
| | - Sandeep K. S. Gupta
- School of Computing and Augmented Intelligence, Arizona State University, Tempe, AZ, United States
| | - Varina L. Boerwinkle
- Division of Child Neurology, University of North Carolina Department of Neurology, Chapel Hill, NC, United States
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Hays MA, Smith RJ, Wang Y, Coogan C, Sarma SV, Crone NE, Kang JY. Cortico-cortical evoked potentials in response to varying stimulation intensity improves seizure localization. Clin Neurophysiol 2023; 145:119-128. [PMID: 36127246 PMCID: PMC9771930 DOI: 10.1016/j.clinph.2022.08.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 08/05/2022] [Accepted: 08/27/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVE As single pulse electrical stimulation (SPES) is increasingly utilized to help localize the seizure onset zone (SOZ), it is important to understand how stimulation intensity can affect the ability to use cortico-cortical evoked potentials (CCEPs) to delineate epileptogenic regions. METHODS We studied 15 drug-resistant epilepsy patients undergoing intracranial EEG monitoring and SPES with titrations of stimulation intensity. The N1 amplitude and distribution of CCEPs elicited in the SOZ and non-seizure onset zone (nSOZ) were quantified at each intensity. The separability of the SOZ and nSOZ using N1 amplitudes was compared between models using responses to titrations, responses to one maximal intensity, or both. RESULTS At 2 mA and above, the increase in N1 amplitude with current intensity was greater for responses within the SOZ, and SOZ response distribution was maximized by 4-6 mA. Models incorporating titrations achieved better separability of SOZ and nSOZ compared to those using one maximal intensity. CONCLUSIONS We demonstrated that differences in CCEP amplitude over a range of current intensities can improve discriminability of SOZ regions. SIGNIFICANCE This study provides insight into the underlying excitability of the SOZ and how differences in current-dependent amplitudes of CCEPs may be used to help localize epileptogenic sites.
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Affiliation(s)
- Mark A Hays
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Rachel J Smith
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Institute for Computational Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Yujing Wang
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Christopher Coogan
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sridevi V Sarma
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Institute for Computational Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Nathan E Crone
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Joon Y Kang
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Niesvizky-Kogan I, Bass M, Goldenholz SR, Goldenholz DM. Focal Cooling for Drug-Resistant Epilepsy: A Review. JAMA Neurol 2022; 79:937-944. [PMID: 35877102 PMCID: PMC10101767 DOI: 10.1001/jamaneurol.2022.1936] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Epilepsy affects at least 1.2% of the population, with one-third of cases considered to be drug-resistant epilepsy (DRE). For these cases, focal cooling therapy may be a potential avenue for treatment, offering hope to people with DRE for freedom from seizure. The therapy leverages neuroscience and engineering principles to deliver a reversible treatment unhindered by pharmacology. Observations Analogous to (but safer than) the use of global cooling in postcardiac arrest and neonatal ischemic injury, extensive research supports the premise that focal cooling as a long-term treatment for epilepsy could be effective. The potential advantages of focal cooling are trifold: stopping epileptiform discharges, seizures, and status epilepticus safely across species (including humans). Conclusions and Relevance This Review presents the most current evidence supporting focal cooling in epilepsy. Cooling has been demonstrated as a potentially safe and effective treatment modality for DRE, although it is not yet ready for use in humans outside of randomized clinical trials. The Review will also offer a brief overview of the technical challenges related to focal cooling in humans, including the optimal device design and cooling parameters.
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Affiliation(s)
- Itamar Niesvizky-Kogan
- Harvard Medical School, Boston, Massachusetts.,Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | | | - Daniel M Goldenholz
- Harvard Medical School, Boston, Massachusetts.,Beth Israel Deaconess Medical Center, Boston, Massachusetts
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Khoo A, de Tisi J, Foong J, Bindman D, O'Keeffe AG, Sander JW, Miserocchi A, McEvoy AW, Duncan JS. Long-term seizure, psychiatric and socioeconomic outcomes after frontal lobe epilepsy surgery. Epilepsy Res 2022; 186:106998. [PMID: 35985250 DOI: 10.1016/j.eplepsyres.2022.106998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 07/17/2022] [Accepted: 08/09/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Resective surgery for selected individuals with frontal lobe epilepsy can be effective, although multimodal outcomes are less established than in temporal lobe epilepsy. We describe long-term seizure remission and relapse patterns, psychiatric comorbidity, and socioeconomic outcomes following frontal lobe epilepsy surgery. METHODS We reviewed individual data on frontal lobe epilepsy procedures at our center between 1990 and 2020. This included the presurgical evaluation, operative details and annual postoperative seizure and psychiatric outcomes, prospectively recorded in an epilepsy surgery database. Outcome predictors were subjected to multivariable analysis, and rates of seizure freedom were analyzed using Kaplan-Meier methods. We used longitudinal assessment of the Index of Multiple Deprivation to assess change in socioeconomic status over time. RESULTS A total of 122 individuals with a median follow-up of seven years were included. Of these, 33 (27 %) had complete seizure freedom following surgery, with a further 13 (11 %) having only auras. Focal MRI abnormality, histopathology (focal cortical dysplasia, cavernoma or dysembryoplastic neuronal epithelial tumor) and fewer anti-seizure medications at the time of surgery were predictive of a favorable outcome; 67 % of those seizure-free for the first 12 months after surgery never experienced a seizure relapse. Thirty-one of 50 who had preoperative psychiatric pathology noticed improved psychiatric symptomatology by two years postoperatively. New psychiatric comorbidity was diagnosed in 15 (13 %). Persistent motor complications occurred in 5 % and dysphasia in 2 %. No significant change in socioeconomic deciles of deprivation was observed after surgery. SIGNIFICANCE Favorable long-term seizure, psychiatric and socioeconomic outcomes can be seen following frontal lobe epilepsy surgery. This is a safe and effective treatment that should be offered to suitable individuals early.
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Affiliation(s)
- Anthony Khoo
- Department of Neurology, National Hospital for Neurology and Neurosurgery, Queen Square, London WC1N 3BG, UK; Department of Clinical & Experimental Epilepsy, UCL Queen Square Institute of Neurology, London WC1N 3BG, UK; College of Medicine and Public Health, Flinders University, Bedford Park SA 5042, Australia.
| | - Jane de Tisi
- Department of Neurology, National Hospital for Neurology and Neurosurgery, Queen Square, London WC1N 3BG, UK; Department of Clinical & Experimental Epilepsy, UCL Queen Square Institute of Neurology, London WC1N 3BG, UK
| | - Jacqueline Foong
- Department of Neuropsychiatry, National Hospital for Neurology and Neurosurgery, Queen Square, London WC1N 3BG, UK
| | - Dorothea Bindman
- Department of Neuropsychiatry, National Hospital for Neurology and Neurosurgery, Queen Square, London WC1N 3BG, UK
| | - Aidan G O'Keeffe
- School of Mathematical Sciences, University of Nottingham, Nottingham NG7 2RD, UK
| | - Josemir W Sander
- Department of Clinical & Experimental Epilepsy, UCL Queen Square Institute of Neurology, London WC1N 3BG, UK; Chalfont Centre for Epilepsy, Chalfont St Peter SL9 0RJ, UK; Stichting Epilepsie Instellingen Nederland (SEIN), Achterweg 5, Heemstede 2103SW, Netherlands; Department of Neurology, West China Hospital, & Institute of Brain Science & Brain-inspired Technology, Sichuan University, Chengdu 610041, China
| | - Anna Miserocchi
- Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, London WC1N 3BG, UK
| | - Andrew W McEvoy
- Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, London WC1N 3BG, UK
| | - John S Duncan
- Department of Neurology, National Hospital for Neurology and Neurosurgery, Queen Square, London WC1N 3BG, UK; Department of Clinical & Experimental Epilepsy, UCL Queen Square Institute of Neurology, London WC1N 3BG, UK; Chalfont Centre for Epilepsy, Chalfont St Peter SL9 0RJ, UK
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21
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Efficacy of cenobamate for uncontrolled focal seizures in patients with previous epilepsy-related surgery: Post hoc analysis of a phase 3, multicenter, open-label study. Epilepsy Res 2022; 184:106952. [DOI: 10.1016/j.eplepsyres.2022.106952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 05/06/2022] [Accepted: 05/25/2022] [Indexed: 11/23/2022]
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22
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McLeod GA, Abbasian P, Toutant D, Ghassemi A, Duke T, Rycyk C, Serletis D, Moussavi Z, Ng MC. Sleep-wake states change the interictal localization of candidate epileptic source generators. Sleep 2022; 45:6547903. [PMID: 35279715 PMCID: PMC9189983 DOI: 10.1093/sleep/zsac062] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Revised: 02/28/2022] [Indexed: 11/12/2022] Open
Abstract
STUDY OBJECTIVES To compare estimated epileptic source localizations from 5 sleep-wake states (SWS): wakefulness (W), rapid eye movement sleep (REM), and non-REM 1-3. METHODS Electrical source localization (sLORETA) of interictal spikes from different SWS on surface EEG from the epilepsy monitoring unit at spike peak and take-off, with results mapped to individual brain models for 75% of patients. Concordance was defined as source localization voxels shared between 2 and 5 SWS, and discordance as those unique to 1 SWS against 1-4 other SWS. RESULTS 563 spikes from 16 prospectively recruited focal epilepsy patients across 161 day-nights. SWS exerted significant differences at spike peak but not take-off. Source localization size did not vary between SWS. REM localizations were smaller in multifocal than unifocal patients (28.8% vs. 54.4%, p = .0091). All five SWS contributed about 45% of their localizations to converge onto 17.0 ± 15.5% voxels. Against any one other SWS, REM was least concordant (54.4% vs. 66.9%, p = .0006) and most discordant (39.3% vs. 29.6%, p = .0008). REM also yielded the most unique localizations (20.0% vs. 8.6%, p = .0059). CONCLUSIONS REM was best suited to identify candidate epileptic sources. sLORETA proposes a model in which an "omni-concordant core" of source localizations shared by all five SWS is surrounded by a "penumbra" of source localizations shared by some but not all SWS. Uniquely, REM spares this core to "move" source voxels from the penumbra to unique cortex not localized by other SWS. This may reflect differential intra-spike propagation in REM, which may account for its reported superior localizing abilities.
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Affiliation(s)
- Graham A McLeod
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Parandoush Abbasian
- Medical Physics, Department of Physics and Astronomy, University of Manitoba, Winnipeg, MB, Canada.,CancerCare Manitoba Research Institute, Winnipeg, MB, Canada
| | - Darion Toutant
- Biomedical Engineering, University of Manitoba, Winnipeg, MB, Canada
| | | | - Tyler Duke
- Biomedical Engineering, University of Manitoba, Winnipeg, MB, Canada
| | - Conrad Rycyk
- Biomedical Engineering, University of Manitoba, Winnipeg, MB, Canada
| | - Demitre Serletis
- Charles Shor Epilepsy Center, Cleveland Clinic, Cleveland, OH, USA.,Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Zahra Moussavi
- Biomedical Engineering, University of Manitoba, Winnipeg, MB, Canada
| | - Marcus C Ng
- Biomedical Engineering, University of Manitoba, Winnipeg, MB, Canada.,Section of Neurology, University of Manitoba, Winnipeg, MB, Canada
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23
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Associations between cognition and employment outcomes after epilepsy surgery. Epilepsy Behav 2022; 131:108709. [PMID: 35526464 DOI: 10.1016/j.yebeh.2022.108709] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 03/31/2022] [Accepted: 04/15/2022] [Indexed: 11/21/2022]
Abstract
OBJECTIVES Previous studies have shown that younger age, higher education, and seizure freedom after epilepsy surgery are associated with employment. However, very few studies have investigated associations with cognition and employment status in epilepsy surgery patients. METHODS This retrospective study consists of 46 adult patients, who underwent resective epilepsy surgery in the Helsinki University Hospital between 2010 and 2018 and who had been assessed by a neuropsychologist prior to surgery and 6 months after surgery using a systematic test battery. In addition to neuropsychological evaluation, neurologists assessed the patients prior to surgery and followed up the patients up to 24 months after the surgery and evaluated work status of the patients. Logistic regression models were used to assess the effects of cognition on changes in employment status, while controlling for age and education. RESULTS Out of the 46 patients 38 (82.6%) were seizure free and 7 (15.2%) had their seizures reduced 2 years postsurgically. From prior to surgery to 2 years postsurgery, use of antiseizure medication was reduced in most of the patients, mean reduction of the dosage being 26.9%. Employment status improved in 10 (21.7%) patients, remained unchanged in 27 (58.7%) and worsened in 3 (6.5%). An additional 6 patients were already not working prior to surgery. Subsequent analyses are based on the subsample of 37 patients whose employment status improved or remained unchanged. Mistakes in executive function tasks (p = 0.048) and working memory performance (p = 0.020) differentiated between the group whose employment status remained similar and those who were able to improve their employment status. Epilepsy surgery outcome or changes in antiseizure medication (ASM) use were not associated with changes in employment status. CONCLUSIONS In the subsample of 37 patients, errors in executive function tasks and poorer working memory differentiated patients whose employment status did not change from those patients who could improve their employment status. Problems in executive function and working memory tasks might hinder performance in a complex work environment. When assessing the risks and opportunities in returning to work after surgery, difficulties in working memory and executive function performance should be taken into consideration as they may predispose the patient to challenges at work.
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24
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Sun J, Barth K, Qiao S, Chiang CH, Wang C, Rahimpour S, Trumpis M, Duraivel S, Dubey A, Wingel KE, Rachinskiy I, Voinas AE, Ferrentino B, Southwell DG, Haglund MM, Friedman AH, Lad SP, Doyle WK, Solzbacher F, Cogan G, Sinha SR, Devore S, Devinsky O, Friedman D, Pesaran B, Viventi J. Intraoperative microseizure detection using a high-density micro-electrocorticography electrode array. Brain Commun 2022; 4:fcac122. [PMID: 35663384 PMCID: PMC9155612 DOI: 10.1093/braincomms/fcac122] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 02/10/2022] [Accepted: 05/24/2022] [Indexed: 11/14/2022] Open
Abstract
One-third of epilepsy patients suffer from medication-resistant seizures. While surgery to remove epileptogenic tissue helps some patients, 30-70% of patients continue to experience seizures following resection. Surgical outcomes may be improved with more accurate localization of epileptogenic tissue. We have previously developed novel thin-film, subdural electrode arrays with hundreds of microelectrodes over a 100-1000 mm2 area to enable high-resolution mapping of neural activity. Here, we used these high-density arrays to study microscale properties of human epileptiform activity. We performed intraoperative micro-electrocorticographic recordings in nine patients with epilepsy. In addition, we recorded from four patients with movement disorders undergoing deep brain stimulator implantation as non-epileptic controls. A board-certified epileptologist identified microseizures, which resembled electrographic seizures normally observed with clinical macroelectrodes. Recordings in epileptic patients had a significantly higher microseizure rate (2.01 events/min) than recordings in non-epileptic subjects (0.01 events/min; permutation test, P = 0.0068). Using spatial averaging to simulate recordings from larger electrode contacts, we found that the number of detected microseizures decreased rapidly with increasing contact diameter and decreasing contact density. In cases in which microseizures were spatially distributed across multiple channels, the approximate onset region was identified. Our results suggest that micro-electrocorticographic electrode arrays with a high density of contacts and large coverage are essential for capturing microseizures in epilepsy patients and may be beneficial for localizing epileptogenic tissue to plan surgery or target brain stimulation.
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Affiliation(s)
- James Sun
- Center for Neural Science, New York University, New York, NY, USA
| | - Katrina Barth
- Department of Biomedical Engineering, Duke University, Durham, NC, USA
| | - Shaoyu Qiao
- Center for Neural Science, New York University, New York, NY, USA
| | - Chia-Han Chiang
- Department of Biomedical Engineering, Duke University, Durham, NC, USA
| | - Charles Wang
- Department of Biomedical Engineering, Duke University, Durham, NC, USA
| | - Shervin Rahimpour
- Department of Neurosurgery, Duke University School of Medicine, Durham, NC, USA
- Department of Neurosurgery, Clinical Neuroscience Center, University of Utah, Salt Lake City, UT, USA
| | - Michael Trumpis
- Department of Biomedical Engineering, Duke University, Durham, NC, USA
| | | | - Agrita Dubey
- Center for Neural Science, New York University, New York, NY, USA
| | - Katie E. Wingel
- Center for Neural Science, New York University, New York, NY, USA
| | - Iakov Rachinskiy
- Department of Biomedical Engineering, Duke University, Durham, NC, USA
| | - Alex E. Voinas
- Center for Neural Science, New York University, New York, NY, USA
| | | | - Derek G. Southwell
- Department of Neurosurgery, Duke University School of Medicine, Durham, NC, USA
- Department of Neurobiology, Duke University School of Medicine, Durham, NC, USA
| | - Michael M. Haglund
- Department of Neurosurgery, Duke University School of Medicine, Durham, NC, USA
| | - Allan H. Friedman
- Department of Neurosurgery, Duke University School of Medicine, Durham, NC, USA
| | - Shivanand P. Lad
- Department of Neurosurgery, Duke University School of Medicine, Durham, NC, USA
| | - Werner K. Doyle
- Department of Neurosurgery, NYU Grossman School of Medicine, New York, NY, USA
| | - Florian Solzbacher
- Department of Electrical and Computer Engineering, University of Utah, Salt Lake City, UT, USA
- Department of Biomedical Engineering, University of Utah, Salt Lake City, UT, USA
- Department of Materials Science & Engineering, University of Utah, Salt Lake City, UT, USA
| | - Gregory Cogan
- Department of Neurosurgery, Duke University School of Medicine, Durham, NC, USA
- Department of Psychology and Neuroscience, Duke University, Durham, NC, USA
- Center for Cognitive Neuroscience, Duke University, Durham, NC, USA
- Duke Comprehensive Epilepsy Center, Duke University School of Medicine, Durham, NC, USA
- Department of Neurology, Duke University School of Medicine, Durham, NC, USA
| | - Saurabh R. Sinha
- Duke Comprehensive Epilepsy Center, Duke University School of Medicine, Durham, NC, USA
- Department of Neurology, Duke University School of Medicine, Durham, NC, USA
| | - Sasha Devore
- Department of Neurology, NYU Grossman School of Medicine, New York, NY, USA
| | - Orrin Devinsky
- Department of Neurosurgery, NYU Grossman School of Medicine, New York, NY, USA
- Department of Neurology, NYU Grossman School of Medicine, New York, NY, USA
- Department of Psychiatry, NYU Grossman School of Medicine, New York, NY, USA
| | - Daniel Friedman
- Department of Neurology, NYU Grossman School of Medicine, New York, NY, USA
| | - Bijan Pesaran
- Center for Neural Science, New York University, New York, NY, USA
- Department of Neurology, NYU Grossman School of Medicine, New York, NY, USA
| | - Jonathan Viventi
- Department of Biomedical Engineering, Duke University, Durham, NC, USA
- Department of Neurosurgery, Duke University School of Medicine, Durham, NC, USA
- Department of Neurobiology, Duke University School of Medicine, Durham, NC, USA
- Duke Comprehensive Epilepsy Center, Duke University School of Medicine, Durham, NC, USA
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25
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Khoo A, Martin L, Tisi JD, O’Keeffe AG, Sander JW, Duncan JS. Cost of pre-surgical evaluation for epilepsy surgery: A single-center experience. Epilepsy Res 2022; 182:106910. [DOI: 10.1016/j.eplepsyres.2022.106910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 02/24/2022] [Accepted: 03/13/2022] [Indexed: 11/03/2022]
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26
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Siriratnam P, Foster E, Shakhatreh L, Neal A, Carney PW, Jackson GD, O'Brien TJ, Kwan P, Chen Z, Ademi Z. The effect of epilepsy surgery on productivity: A systematic review and meta-analysis. Epilepsia 2022; 63:789-811. [PMID: 35088411 DOI: 10.1111/epi.17172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 01/12/2022] [Accepted: 01/12/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVES An important but understudied benefit of resective epilepsy surgery is improvement in productivity; that is, people's ability to contribute to society through participation in the workforce and in unpaid roles such as carer duties. Here, we aimed to evaluate productivity in adults with drug-resistant epilepsy (DRE) pre- and post-resective epilepsy surgery, and to explore the factors that positively influence productivity outcomes. METHODS We conducted a systematic review and meta-analysis using four electronic databases: Medline (Ovid), EMBASE (Ovid), EBM Reviews - Cochrane Central Register of Controlled Trials (CENTRAL), and Cochrane Library. All studies over the past 30 years reporting on pre- and post-resective epilepsy surgical outcomes in adults with DRE were eligible for inclusion. Meta-analysis was performed to assess the post-surgery change in employment outcomes. RESULTS A total of 1005 titles and abstracts were reviewed. Seventeen studies, comprising 2056 unique patients, were suitable for the final quantitative synthesis and meta-analysis. Resective epilepsy surgery resulted in a 22% improvement in overall productivity (95% confidence interval [CI]: 1.07-1.40). The factors associated with increased post-surgery employment risk ratios were lower pre-surgical employment in the workforce (relative risk ratio [RRR] =0.34; 95% CI: 0.15-0.74), shorter follow-up duration (RRR = 0.95; 95% CI: 0.90-0.99), and lower mean age at time of surgery (RRR= 0.97; 95% CI: 0.94-0.99). The risk of bias of the included studies was assessed using Risk Of Bias In Non-randomised Studies - of Interventions and was low for most variables except "measurement of exposure." SIGNIFICANCE There is clear evidence that resective surgery in eligible surgical DRE patients results in improved productivity. Future work may include implementing a standardized method for collecting and reporting productivity in epilepsy cohorts and focusing on ways to reprioritize health care resource allocation to allow suitable candidates to access surgery earlier. This will ultimately benefit individuals with DRE, their families, our communities, and the wider health care system.
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Affiliation(s)
- Pakeeran Siriratnam
- Neurology Department, Alfred Health, Melbourne, Victoria, Australia.,Neurology Department, Eastern Health, Box Hill, Victoria, Australia
| | - Emma Foster
- Neurology Department, Alfred Health, Melbourne, Victoria, Australia.,Department of Neuroscience, The Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Lubna Shakhatreh
- Neurology Department, Alfred Health, Melbourne, Victoria, Australia.,Department of Neuroscience, The Central Clinical School, Monash University, Melbourne, Victoria, Australia.,Neurology Department, The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Andrew Neal
- Neurology Department, Alfred Health, Melbourne, Victoria, Australia.,Department of Neuroscience, The Central Clinical School, Monash University, Melbourne, Victoria, Australia.,Neurology Department, The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Patrick W Carney
- Florey Institute of Neuroscience and Mental Health, Parkville, Victoria, Australia.,Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Box Hill Hospital, Box Hill, Victoria, Australia
| | - Graeme D Jackson
- Florey Institute of Neuroscience and Mental Health, Parkville, Victoria, Australia
| | - Terence J O'Brien
- Neurology Department, Alfred Health, Melbourne, Victoria, Australia.,Department of Neuroscience, The Central Clinical School, Monash University, Melbourne, Victoria, Australia.,Neurology Department, The Royal Melbourne Hospital, Parkville, Victoria, Australia.,Department of Medicine (The Royal Melbourne Hospital), The University of Melbourne, Parkville, Victoria, Australia
| | - Patrick Kwan
- Neurology Department, Alfred Health, Melbourne, Victoria, Australia.,Department of Neuroscience, The Central Clinical School, Monash University, Melbourne, Victoria, Australia.,Neurology Department, The Royal Melbourne Hospital, Parkville, Victoria, Australia.,Department of Medicine (The Royal Melbourne Hospital), The University of Melbourne, Parkville, Victoria, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Zhibin Chen
- Department of Neuroscience, The Central Clinical School, Monash University, Melbourne, Victoria, Australia.,Department of Medicine (The Royal Melbourne Hospital), The University of Melbourne, Parkville, Victoria, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Zanfina Ademi
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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27
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Krylov VV, Gekht AB, Trifonov IS, Lebedeva AV, Rider FK, Kaimovsky IL, Sinkin MV, Kordonskaya OO, Magomedsultanov AI, Navruzov RA, Yakovlev AA, Grigorieva EV, Mamulashvili GV. [Long-term postoperative outcomes in patients with drug-resistant epilepsy]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2021; 85:6-13. [PMID: 34713998 DOI: 10.17116/neiro2021850516] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Epilepsy surgery is effective in 30-82% of patients with drug-resistant epilepsy. However, risk factors of unfavorable outcomes after epilepsy surgery require further study. OBJECTIVE To evaluate risk factors of favorable and unfavorable long-term postoperative outcomes in patients with drug-resistant epilepsy. MATERIAL AND METHODS Postoperative outcomes in a large cohort of patients with epilepsy are reported for the first time in the Russian Federation. There were 271 patients with drug-resistant scheduled for surgery. Preoperative examination and surgical treatment were carried out between January 1, 2014 and December 12, 2019 at the Evdokimov Moscow State University of Medicine and Dentistry and Sklifosovsky Research Institute for Emergency Care. We used Engel grading system to assess postoperative outcomes after 12, 24, 48 and 60 months. We distinguished favorable (Engel I-II) and unfavorable (Engel III-IV) outcomes and analyzed the factors influencing postoperative results in these patients. RESULTS There were 319 surgical procedures in 271 patients (217 primary resections, implantation of vagus nerve stimulator in 31 patients, 9 redo resections and 8 radiosurgical procedures). Focal cortical dysplasia (FCD) was found in 162 (60%) patients, «dual pathology» - in 118 (44%) cases. In 12 months after surgery, favorable outcomes (Engel l-II) were observed in 69% of patients (n=148), after 24 months - in 71% (n=127) of patients. Postoperative complications occurred in 6 (1.9%) patients. There was no mortality. The earlier onset of epilepsy (p=0.01), multifocal (p=0.002) and bilateral lesions (p=0.0038) were the most significant risk factors of unfavorable postoperative outcomes. CONCLUSION Surgical resection is effective approach for drug-resistant epilepsy.
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Affiliation(s)
- V V Krylov
- Evdokimov Moscow State University of Medicine and Dentistry, Moscow, Russia.,Sklifosovsky Research Institute for Emergency Care, Moscow, Russia
| | - A B Gekht
- Solovyov Scientific and Practical Psychoneurological Center, Moscow, Russia.,Pirogov Russian National Research Medical University, Moscow, Russia
| | - I S Trifonov
- Evdokimov Moscow State University of Medicine and Dentistry, Moscow, Russia
| | - A V Lebedeva
- Solovyov Scientific and Practical Psychoneurological Center, Moscow, Russia.,Pirogov Russian National Research Medical University, Moscow, Russia
| | - F K Rider
- Solovyov Scientific and Practical Psychoneurological Center, Moscow, Russia
| | - I L Kaimovsky
- Evdokimov Moscow State University of Medicine and Dentistry, Moscow, Russia.,Solovyov Scientific and Practical Psychoneurological Center, Moscow, Russia.,Buyanov Moscow City Clinical Hospital, Moscow, Russia
| | - M V Sinkin
- Sklifosovsky Research Institute for Emergency Care, Moscow, Russia
| | - O O Kordonskaya
- Sklifosovsky Research Institute for Emergency Care, Moscow, Russia.,Federal Center for Brain and Neurotechnologies, Moscow, Russia
| | | | - R A Navruzov
- Evdokimov Moscow State University of Medicine and Dentistry, Moscow, Russia
| | - A A Yakovlev
- Solovyov Scientific and Practical Psychoneurological Center, Moscow, Russia.,Institute of Higher Nervous Activity and Neurophysiology, Moscow, Russia
| | - E V Grigorieva
- Evdokimov Moscow State University of Medicine and Dentistry, Moscow, Russia
| | - G V Mamulashvili
- Evdokimov Moscow State University of Medicine and Dentistry, Moscow, Russia
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28
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Samanta D, Beal JC, Grinspan ZM. Automated Identification of Surgical Candidates and Estimation of Postoperative Seizure Freedom in Children - A Focused Review. Semin Pediatr Neurol 2021; 39:100914. [PMID: 34620464 PMCID: PMC9082396 DOI: 10.1016/j.spen.2021.100914] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 08/09/2021] [Accepted: 08/11/2021] [Indexed: 11/15/2022]
Abstract
Surgery is an effective but underused treatment for drug-resistant epilepsy in children. Algorithms to identify surgical candidates and estimate the likelihood of postoperative clinical improvement may be valuable to improve access to epilepsy surgery. We provide a focused review of these approaches. For adults with epilepsy, tools to identify surgical candidates and predict seizure and cognitive outcomes (Ie, Cases for Epilepsy (toolsforepilepsy.com) and Epilepsy Surgery Grading Scale) have been validated and are in use. Analogous tools for children need development. A promising approach is to apply statistical learning tools to clinical datasets, such as electroencephalogram tracings, imaging studies, and the text of clinician notes. Demonstration projects suggest these techniques have the potential to be highly accurate, and await further validation and clinical application.
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Affiliation(s)
- Debopam Samanta
- Neurology Division, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Jules C. Beal
- Department of Pediatrics, Weill Cornell Medicine, New York, NY
| | - Zachary M. Grinspan
- Department of Pediatrics, Weill Cornell Medicine, New York, NY.,Department of Population Health Sciences, Weill Cornell Medicine, New York, NY
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29
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Khoo A, de Tisi J, Mannan S, O'Keeffe AG, Sander JW, Duncan JS. Reasons for not having epilepsy surgery. Epilepsia 2021; 62:2909-2919. [PMID: 34558079 DOI: 10.1111/epi.17083] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 09/12/2021] [Accepted: 09/13/2021] [Indexed: 02/05/2023]
Abstract
OBJECTIVE This study was undertaken to determine reasons for adults with drug-resistant focal epilepsy who undergo presurgical evaluation not proceeding with surgery, and to identify predictors of this course. METHODS We retrospectively analyzed data on 617 consecutive individuals evaluated for epilepsy surgery at a tertiary referral center between January 2015 and December 2019. We compared the characteristics of those in whom a decision not to proceed with surgical treatment was made with those who underwent definitive surgery in the same period. Multivariate logistic regression was performed to identify predictors of not proceeding with surgery. RESULTS A decision not to proceed with surgery was reached in 315 (51%) of 617 individuals evaluated. Common reasons for this were an inability to localize the epileptogenic zone (n = 104) and the presence of multifocal epilepsy (n = 74). An individual choice not to proceed with intracranial electroencephalography (icEEG; n = 50) or surgery (n = 39), risk of significant deficit (n = 33), declining noninvasive investigation (n = 12), and coexisting neurological comorbidity (n = 3) accounted for the remainder. Compared to 166 surgically treated patients, those who did not proceed to surgery were more likely to have a learning disability (odds ratio [OR] = 2.35, 95% confidence interval [CI] = 1.07-5.16), normal magnetic resonance imaging (OR = 4.48, 95% CI = 1.68-11.94), extratemporal epilepsy (OR = 2.93, 95% CI = 1.82-4.71), bilateral seizure onset zones (OR = 3.05, 95% CI = 1.41-6.61) and to live in more deprived socioeconomic areas (median deprivation decile = 40%-50% vs. 50%-60%, p < .05). SIGNIFICANCE Approximately half of those evaluated for surgical treatment of drug-resistant focal epilepsy do not proceed to surgery. Early consideration and discussion of the likelihood of surgical suitability or need for icEEG may help direct referral for presurgical evaluation.
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Affiliation(s)
- Anthony Khoo
- Department of Neurology, National Hospital for Neurology and Neurosurgery, London, UK.,Department of Clinical and Experimental Epilepsy, University College London Queen Square Institute of Neurology, London, UK
| | - Jane de Tisi
- Department of Clinical and Experimental Epilepsy, University College London Queen Square Institute of Neurology, London, UK
| | - Shahidul Mannan
- Department of Clinical and Experimental Epilepsy, University College London Queen Square Institute of Neurology, London, UK
| | | | - Josemir W Sander
- Department of Clinical and Experimental Epilepsy, University College London Queen Square Institute of Neurology, London, UK.,Chalfont Centre for Epilepsy, Chalfont St Peter, UK.,Stichting Epilepsie Instellingen Nederland, Heemstede, Netherlands.,Department of Neurology, West China Hospital, and Institute of Brain Science and Brain-Inspired Technology, Sichuan University, Chengdu, China
| | - John S Duncan
- Department of Clinical and Experimental Epilepsy, University College London Queen Square Institute of Neurology, London, UK.,Chalfont Centre for Epilepsy, Chalfont St Peter, UK
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Xu N, Shan W, Qi J, Wu J, Wang Q. Presurgical Evaluation of Epilepsy Using Resting-State MEG Functional Connectivity. Front Hum Neurosci 2021; 15:649074. [PMID: 34276321 PMCID: PMC8283278 DOI: 10.3389/fnhum.2021.649074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 06/07/2021] [Indexed: 11/21/2022] Open
Abstract
Epilepsy is caused by abnormal electrical discharges (clinically identified by electrophysiological recording) in a specific part of the brain [originating in only one part of the brain, namely, the epileptogenic zone (EZ)]. Epilepsy is now defined as an archetypical hyperexcited neural network disorder. It can be investigated through the network analysis of interictal discharges, ictal discharges, and resting-state functional connectivity. Currently, there is an increasing interest in embedding resting-state connectivity analysis into the preoperative evaluation of epilepsy. Among the various neuroimaging technologies employed to achieve brain functional networks, magnetoencephalography (MEG) with the excellent temporal resolution is an ideal tool for estimating the resting-state connectivity between brain regions, which can reveal network abnormalities in epilepsy. What value does MEG resting-state functional connectivity offer for epileptic presurgical evaluation? Regarding this topic, this paper introduced the origin of MEG and the workflow of constructing source-space functional connectivity based on MEG signals. Resting-state functional connectivity abnormalities correlate with epileptogenic networks, which are defined by the brain regions involved in the production and propagation of epileptic activities. This paper reviewed the evidence of altered epileptic connectivity based on low- or high-frequency oscillations (HFOs) and the evidence of the advantage of using simultaneous MEG and intracranial electroencephalography (iEEG) recordings. More importantly, this review highlighted that MEG-based resting-state functional connectivity has the potential to predict postsurgical outcomes. In conclusion, resting-state MEG functional connectivity has made a substantial progress toward serving as a candidate biomarker included in epileptic presurgical evaluations.
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Affiliation(s)
- Na Xu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Wei Shan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jing Qi
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jianping Wu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- National Clinical Research Center for Neurological Diseases, Beijing, China
- Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China
| | - Qun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- National Clinical Research Center for Neurological Diseases, Beijing, China
- Beijing Institute of Brain Disorders, Collaborative Innovation Center for Brain Disorders, Capital Medical University, Beijing, China
- Beijing Key Laboratory of Neuromodulation, Beijing, China
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Ictal gamma-band interactions localize ictogenic nodes of the epileptic network in focal cortical dysplasia. Clin Neurophysiol 2021; 132:1927-1936. [PMID: 34157635 DOI: 10.1016/j.clinph.2021.04.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 03/18/2021] [Accepted: 04/05/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Epilepsy surgery fails in > 30% of patients with focal cortical dysplasia (FCD). The seizure persistence after surgery can be attributed to the inability to precisely localize the tissue with an endogenous potential to generate seizures. In this study, we aimed to identify the critical components of the epileptic network that were actively involved in seizure genesis. METHODS The directed transfer function was applied to intracranial EEG recordings and the effective connectivity was determined with a high temporal and frequency resolution. Pre-ictal network properties were compared with ictal epochs to identify regions actively generating ictal activity and discriminate them from the areas of propagation. RESULTS Analysis of 276 seizures from 30 patients revealed the existence of a seizure-related network reconfiguration in the gamma-band (25-170 Hz; p < 0.005) - ictogenic nodes. Unlike seizure onset zone, resecting the majority of ictogenic nodes correlated with favorable outcomes (p < 0.012). CONCLUSION The prerequisite to successful epilepsy surgery is the accurate identification of brain areas from which seizures arise. We show that in FCD-related epilepsy, gamma-band network markers can reliably identify and distinguish ictogenic areas in macroelectrode recordings, improve intracranial EEG interpretation and better delineate the epileptogenic zone. SIGNIFICANCE Ictogenic nodes localize the critical parts of the epileptogenic tissue and increase the diagnostic yield of intracranial evaluation.
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Noninvasive high-frequency oscillations riding spikes delineates epileptogenic sources. Proc Natl Acad Sci U S A 2021; 118:2011130118. [PMID: 33875582 PMCID: PMC8092606 DOI: 10.1073/pnas.2011130118] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Millions of people affected by epilepsy may undergo surgical resection of the epileptic tissues to stop seizures if such epileptic foci can be accurately delineated. High-frequency oscillations (HFOs), existing in electroencephalography, are highly correlated with epileptic brain, which is promising for guiding successful neurosurgery. However, it is unclear whether and how pathological HFOs can be differentiated to localize the epileptogenic tissues given the presence of various nonepileptic high-frequency activities. Here, we show morphological and source imaging evidence that pathological HFOs can be identified by the concurrence of epileptiform spikes. We describe a framework to delineate the underlying epileptogenicity using this biomarker. Our work may offer translational tools to improve treatments by noninvasively demarking pathological activities and hence epileptic foci. High-frequency oscillations (HFOs) are a promising biomarker for localizing epileptogenic brain and guiding successful neurosurgery. However, the utility and translation of noninvasive HFOs, although highly desirable, is impeded by the difficulty in differentiating pathological HFOs from nonepileptiform high-frequency activities and localizing the epileptic tissue using noninvasive scalp recordings, which are typically contaminated with high noise levels. Here, we show that the consistent concurrence of HFOs with epileptiform spikes (pHFOs) provides a tractable means to identify pathological HFOs automatically, and this in turn demarks an epileptiform spike subgroup with higher epileptic relevance than the other spikes in a cohort of 25 temporal epilepsy patients (including a total of 2,967 interictal spikes and 1,477 HFO events). We found significant morphological distinctions of HFOs and spikes in the presence/absence of this concurrent status. We also demonstrated that the proposed pHFO source imaging enhanced localization of epileptogenic tissue by 162% (∼5.36 mm) for concordance with surgical resection and by 186% (∼12.48 mm) with seizure-onset zone determined by invasive studies, compared to conventional spike imaging, and demonstrated superior congruence with the surgical outcomes. Strikingly, the performance of spike imaging was selectively boosted by the presence of spikes with pHFOs, especially in patients with multitype spikes. Our findings suggest that concurrent HFOs and spikes reciprocally discriminate pathological activities, providing a translational tool for noninvasive presurgical diagnosis and postsurgical evaluation in vulnerable patients.
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González-Ortiz S, Medrano S, Capellades J, Vilas M, Mestre A, Serrano L, Conesa G, Pérez-Enríquez C, Arumi M, Bargalló N, Delgado-Martinez I, Rocamora R. Voxel-based morphometry for the evaluation of patients with pharmacoresistant epilepsy with apparently normal MRI. J Neuroimaging 2021; 31:560-568. [PMID: 33817887 DOI: 10.1111/jon.12849] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Revised: 02/15/2021] [Accepted: 02/18/2021] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND AND PURPOSE Magnetic resonance imaging (MRI) is essential in the diagnosis of pharmacoresistant epilepsy (PRE), because patients with lesions detected by MRI have a better prognosis after surgery. Focal cortical dysplasia (FCD) is one of the most frequent etiologies of PRE but can be difficult to identify by MRI. Voxel-based morphometric analysis programs, like the Morphometric Analysis Program (MAP), have been developed to help improve MRI detection. Our objective was to evaluate the clinical usefulness of MAP in patients with PRE and an apparently normal MRI. METHODS We studied 70 patients with focal PRE and a nonlesional MRI. The 3DT1 sequence was processed with MAP, obtaining three z-score maps. Patients were classified as MAP+ if one or more z-score maps showed a suspicious area of brightness, and MAP- if the z-score maps did not show any suspicious areas. For MAP+ cases, a second-look MRI was performed with a dedicated inspection based on the MAP findings. The MAP results were correlated with the epileptogenic zone. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated. RESULTS Thirty-one percent of patients were classified as MAP+ and 69% were MAP-. Results showed a sensitivity of 0.57, specificity of 0.8, PPV of 0.91, and NPV of 0.35. In 19% of patients, an FCD was found in the second-look MRI after MAP. CONCLUSIONS MAP was helpful in the detection of lesions in PRE patients with a nonlesional MRI, which could have important repercussions for the clinical management and postoperative prognosis of these patients.
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Affiliation(s)
- Sofía González-Ortiz
- Radiology Department, Hospital del Mar, Barcelona, Spain.,Epilpsy Reserach Group, Institut Hospital del Mar d'Investigacions Mèdiques, Barcelona, Spain
| | | | | | - Marta Vilas
- Radiology Department, Hospital del Mar, Barcelona, Spain
| | - Antoni Mestre
- Nuclear Medicine Department, Hospital Trueta, Girona, Spain
| | - Laura Serrano
- Neurosurgery Department, Hospital del Mar, Barcelona, Spain
| | - Gerardo Conesa
- Neurosurgery Department, Hospital del Mar, Barcelona, Spain.,Epilpsy Reserach Group, Institut Hospital del Mar d'Investigacions Mèdiques, Barcelona, Spain
| | - Carmen Pérez-Enríquez
- Neurology Department, Hospital del Mar, Barcelona, Spain.,Epilpsy Reserach Group, Institut Hospital del Mar d'Investigacions Mèdiques, Barcelona, Spain
| | - Montserrat Arumi
- Anatomic Pathology Department, Hospital del Mar, Barcelona, Spain
| | - Nuria Bargalló
- Centre de Diagnosi per la Imatge, Hospital Clínic, Barcelona, Spain
| | - Ignacio Delgado-Martinez
- Neurosurgery Department, Hospital del Mar, Barcelona, Spain.,Epilpsy Reserach Group, Institut Hospital del Mar d'Investigacions Mèdiques, Barcelona, Spain
| | - Rodrigo Rocamora
- Neurology Department, Hospital del Mar, Barcelona, Spain.,Epilpsy Reserach Group, Institut Hospital del Mar d'Investigacions Mèdiques, Barcelona, Spain
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Berger A, Cohen N, Fahoum F, Medvedovsky M, Meller A, Ekstein D, Benifla M, Aizenstein O, Fried I, Gazit T, Strauss I. Preoperative localization of seizure onset zones by magnetic source imaging, EEG-correlated functional MRI, and their combination. J Neurosurg 2021; 134:1037-1043. [PMID: 32413858 DOI: 10.3171/2020.3.jns192794] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Accepted: 03/06/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Preoperative localization of seizure onset zones (SOZs) is an evolving field in the treatment of refractory epilepsy. Both magnetic source imaging (MSI), and the more recent EEG-correlated functional MRI (EEG-fMRI), have shown applicability in assisting surgical planning. The purpose of this study was to evaluate the capability of each method and their combination in localizing the seizure onset lobe (SL). METHODS The study included 14 patients who underwent both MSI and EEG-fMRI before undergoing implantation of intracranial EEG (icEEG) as part of the presurgical planning of the resection of an epileptogenic zone (EZ) during the years 2012-2018. The estimated location of the SL by each method was compared with the location determined by icEEG. Identification rates of the SL were compared between the different methods. RESULTS MSI and EEG-fMRI showed similar identification rates of SL locations in relation to icEEG results (88% ± 31% and 73% ± 42%, respectively; p = 0.281). The additive use of the coverage lobes of both methods correctly identified 100% of the SL, significantly higher than EEG-fMRI alone (p = 0.039) and nonsignificantly higher than MSI (p = 0.180). False-identification rates of the additive coverage lobes were significantly higher than MSI (p = 0.026) and EEG-fMRI (p = 0.027). The intersecting lobes of both methods showed the lowest false identification rate (13% ± 6%, p = 0.01). CONCLUSIONS Both MSI and EEG-fMRI can assist in the presurgical evaluation of patients with refractory epilepsy. The additive use of both tests confers a high identification rate in finding the SL. This combination can help in focusing implantation of icEEG electrodes targeting the SOZ.
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Affiliation(s)
- Assaf Berger
- 1Department of Neurosurgery
- 7Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv
| | - Noa Cohen
- 2Sagol Brain Institute
- 7Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv
| | - Firas Fahoum
- 3Department of Neurology, and
- 7Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv
| | - Mordekhay Medvedovsky
- 4Department of Neurology, Hadassah Medical Center, Jerusalem
- 8Hebrew University Hadassah Medical School, Jerusalem; and
| | - Aaron Meller
- 2Sagol Brain Institute
- 7Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv
| | - Dana Ekstein
- 4Department of Neurology, Hadassah Medical Center, Jerusalem
- 8Hebrew University Hadassah Medical School, Jerusalem; and
| | - Mony Benifla
- 5Department of Neurosurgery, Rambam Health Care Campus, Haifa
- 9Rappaport Faculty of Medicine-Technion, Haifa, Israel
| | - Orna Aizenstein
- 6Department of Radiology, Tel Aviv Medical Center, Tel Aviv
- 7Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv
| | - Itzhak Fried
- 1Department of Neurosurgery
- 7Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv
| | - Tomer Gazit
- 2Sagol Brain Institute
- 7Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv
| | - Ido Strauss
- 1Department of Neurosurgery
- 7Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv
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Brændholt M, Jensen M. Evidence From Meta-Analysis Supports Ictal Magnetoencephalographic Source Imaging as an Accurate Method in Presurgery Evaluation of Patients With Drug-Resistant Epilepsy. Clin EEG Neurosci 2020; 51:403-411. [PMID: 32437218 DOI: 10.1177/1550059420921534] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND. Successful epilepsy surgery relies on localization and removal of the brain area responsible for initializing the seizures called the epileptogenic zone (EZ). Intracranial EEG (icEEG) is gold standard of this localization but has several limitations like invasiveness and limited covered area. A noninvasive method with accurate localization precision is therefore desirable. The aim of this article is to investigate the following hypotheses: (1) Ictal onset zone as localized by magnetic source imaging (iMSI) can reliably localize the EZ in focal epilepsy and (2) this localization is as good as that of icEEG. METHODS. Six original studies and a total of 59 unique patients were included in a meta-analysis. RESULTS. Sensitivity and specificity of iMSI based on surgery outcome were 77% (95% CI 60%-90%) and 75% (95% CI 53%-90%), respectively. Specificity of iMSI was statistically higher than that of icEEG. There was no significant difference between sensitivity of iMSI and icEEG. CONCLUSION. The meta-analysis supports that iMSI is an accurate method, achieving similar sensitivity and higher specificity than icEEG. However, at present the use of the method is limited by short recording times. A limitation that might be overcome in the future using technical advances.
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Affiliation(s)
- Malthe Brændholt
- Department of Clinical Neurophysiology, Aarhus University Hospital, Aarhus, Denmark.,Embodied Computation Group, Center of Functionally Integrative Neuroscience, Aarhus University, Aarhus, Denmark
| | - Mads Jensen
- NedComm Lab-Laboratory of NeuroDynamics of Human Communication and Center of Functionally Integrative Neuroscience, Aarhus University, Aarhus, Denmark
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Lesko R, Benova B, Jezdik P, Liby P, Jahodova A, Kudr M, Tichy M, Zamecnik J, Krsek P. The clinical utility of intraoperative electrocorticography in pediatric epilepsy surgical strategy and planning. J Neurosurg Pediatr 2020; 26:533-542. [PMID: 32736347 DOI: 10.3171/2020.4.peds20198] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 04/29/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE In this study, the authors aimed to determine 1) whether the use of intraoperative electrocorticography (ECoG) affects outcomes and complication rates of children undergoing resective epilepsy surgery; 2) which patient- and epilepsy-related variables might influence ECoG-based surgical strategy; and 3) what the predictors of epilepsy surgery outcomes are. METHODS Over a period of 12 years, data were collected on pediatric patients who underwent tailored brain resections in the Motol Epilepsy Center. In patients in whom an abnormal ECoG pattern (e.g., spiking, suppression burst, or recruiting rhythm) was not observed beyond presurgically planned resection margins, the authors did not modify the surgical plan (group A). In those with significant abnormal ECoG findings beyond resection margins, the authors either did (group B) or did not (group C) modify the surgical plan, depending on the proximity of the eloquent cortex or potential extent of resection. Using Fisher's exact test and the chi-square test, the 3 groups were compared in relation to epilepsy surgery outcomes and complication rate. Next, multivariate models were constructed to identify variables associated with each of the groups and with epilepsy surgery outcomes. RESULTS Patients in group C achieved significantly lower rates of seizure freedom compared to groups A (OR 30.3, p < 0.001) and B (OR 35.2, p < 0.001); groups A and B did not significantly differ (p = 0.78). Patients in whom the surgical plan was modified suffered from more frequent complications (B vs A+C, OR 3.8, p = 0.01), but these were mostly minor (duration < 3 months; B vs A+C, p = 0.008). In all cases, tissue samples from extended resections were positive for the presence of the original pathology. Patients with intended modification of the surgical plan (groups B+C) suffered more often from daily seizures, had a higher age at first seizure, had intellectual disability, and were regarded as MR-negative (p < 0.001). Unfavorable surgical outcome (Engel class II-IV) was associated with focal cortical dysplasia, incomplete resection based on MRI and/or ECoG findings, negative MRI finding, and inability to modify the surgical plan when indicated. CONCLUSIONS Intraoperative ECoG serves as a reliable tool to guide resection and may inform the prognosis for seizure freedom in pediatric patients undergoing epilepsy surgery. ECoG-based modification of the surgical plan is associated with a higher rate of minor complications. Children in whom ECoG-based modification of the surgical plan is indicated but not feasible achieve significantly worse surgical outcomes.
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Affiliation(s)
| | | | - Petr Jezdik
- 3Department of Circuit Theory, Faculty of Electrical Engineering, Czech Technical University of Prague, Czech Republic
| | | | | | | | | | - Josef Zamecnik
- 4Pathology and Molecular Medicine, Second Faculty of Medicine, Charles University and Motol University Hospital; and
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Impact of predictive, preventive and precision medicine strategies in epilepsy. Nat Rev Neurol 2020; 16:674-688. [PMID: 33077944 DOI: 10.1038/s41582-020-0409-4] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/01/2020] [Indexed: 12/15/2022]
Abstract
Over the last decade, advances in genetics, neuroimaging and EEG have enabled the aetiology of epilepsy to be identified earlier in the disease course than ever before. At the same time, progress in the study of experimental models of epilepsy has provided a better understanding of the mechanisms underlying the condition and has enabled the identification of therapies that target specific aetiologies. We are now witnessing the impact of these advances in our daily clinical practice. Thus, now is the time for a paradigm shift in epilepsy treatment from a reactive attitude, treating patients after the onset of epilepsy and the initiation of seizures, to a proactive attitude that is more broadly integrated into a 'P4 medicine' approach. This P4 approach, which is personalized, predictive, preventive and participatory, puts patients at the centre of their own care and, ultimately, aims to prevent the onset of epilepsy. This aim will be achieved by adapting epilepsy treatments not only to a given syndrome but also to a given patient and moving from the usual anti-seizure treatments to personalized treatments designed to target specific aetiologies. In this Review, we present the current state of this ongoing revolution, emphasizing the impact on clinical practice.
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White M, Mackay M, Whittaker R. Taking Optogenetics into the Human Brain: Opportunities and Challenges in Clinical Trial Design. OPEN ACCESS JOURNAL OF CLINICAL TRIALS 2020; 2020:33-41. [PMID: 34471390 DOI: 10.2147/oajct.s259702] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Optogenetics, the use of light to control the activity of suitably sensitized cells, has led to major advances in the field of basic neuroscience since it first emerged in 2005. Already, the technique has entered clinical trials for conditions such as Retinitis Pigmentosa. A major focus of interest is the use of optogenetics within the brain, where the ability to precisely control the activity of specific subsets of neurons could lead to novel treatments for a wide range of disorders from epilepsy to schizophrenia. However, since any therapy would require both the use of gene therapy techniques to introduce non-human proteins, and implantable electronic devices to provide optical stimulation, applying this technique in the brain presents a unique set of obstacles and challenges. This review looks at the reasons why researchers are exploring the use of optogenetics within the brain. It then explores the challenges facing scientists, engineers and clinicians wanting to take this technology from the lab into the first human brain, discussing different possibilities for a first-in-human clinical trial from a sponsor, patient and regulatory perspective.
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Affiliation(s)
- Michael White
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, NE2 4HH, United Kingdom
| | - Michael Mackay
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, NE2 4HH, United Kingdom
| | - Roger Whittaker
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, NE2 4HH, United Kingdom.,Department of Clinical Neurophysiology, Royal Victoria Hospital, Queen Victoria Road, Newcastle upon Tyne, NE1 4LP, United Kingdom
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Effects of resective epilepsy surgery on the social determinants of health. Epilepsy Res 2020; 163:106338. [DOI: 10.1016/j.eplepsyres.2020.106338] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 03/24/2020] [Accepted: 04/07/2020] [Indexed: 01/24/2023]
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An S, Kang C, Lee HW. Artificial Intelligence and Computational Approaches for Epilepsy. J Epilepsy Res 2020; 10:8-17. [PMID: 32983950 PMCID: PMC7494883 DOI: 10.14581/jer.20003] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 06/18/2020] [Accepted: 07/14/2020] [Indexed: 12/30/2022] Open
Abstract
Studies on treatment of epilepsy have been actively conducted in multiple avenues, but there are limitations in improving its efficacy due to between-subject variability in which treatment outcomes vary from patient to patient. Accordingly, there is a growing interest in precision medicine that provides accurate diagnosis for seizure types and optimal treatment for an individual epilepsy patient. Among these approaches, computational studies making this feasible are rapidly progressing in particular and have been widely applied in epilepsy. These computational studies are being conducted in two main streams: 1) artificial intelligence-based studies implementing computational machines with specific functions, such as automatic diagnosis and prognosis prediction for an individual patient, using machine learning techniques based on large amounts of data obtained from multiple patients and 2) patient-specific modeling-based studies implementing biophysical in-silico platforms to understand pathological mechanisms and derive the optimal treatment for each patient by reproducing the brain network dynamics of the particular patient per se based on individual patient's data. These computational approaches are important as it can integrate multiple types of data acquired from patients and analysis results into a single platform. If these kinds of methods are efficiently operated, it would suggest a novel paradigm for precision medicine.
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Affiliation(s)
- Sora An
- Department of Neurology, Ewha Womans University School of Medicine and Ewha Medical Research Institute, Seoul, Korea.,Department of Medical Science, Ewha Womans University School of Medicine and Ewha Medical Research Institute, Seoul, Korea
| | - Chaewon Kang
- Department of Neurology, Ewha Womans University School of Medicine and Ewha Medical Research Institute, Seoul, Korea.,Department of Computational Medicine, Ewha Womans University School of Medicine and Ewha Medical Research Institute, Seoul, Korea
| | - Hyang Woon Lee
- Department of Neurology, Ewha Womans University School of Medicine and Ewha Medical Research Institute, Seoul, Korea.,Department of Medical Science, Ewha Womans University School of Medicine and Ewha Medical Research Institute, Seoul, Korea.,Department of Computational Medicine, Ewha Womans University School of Medicine and Ewha Medical Research Institute, Seoul, Korea
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Abstract
Placebos impact epilepsy in a number of ways. Through randomized clinical trials, explicit clinical use, and also through implicit clinical use, placebos play a role in epilepsy. This chapter will discuss the reasons placebo is used, the determinants of placebo response in epilepsy, observations about placebo specific to epilepsy, and ways in which clinical trial design is impacted by placebo.
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Coleman H, McIntosh A, Wilson SJ. A patient-centered approach to understanding long-term psychosocial adjustment and meaning-making, 15 to 20 years after epilepsy surgery. Epilepsy Behav 2020; 102:106656. [PMID: 31778879 DOI: 10.1016/j.yebeh.2019.106656] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Revised: 10/03/2019] [Accepted: 10/09/2019] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Different psychosocial trajectories have been identified following treatment with epilepsy surgery, as patients adjust to possible changes in seizure frequency and the subsequent impact on their psychosocial functioning. Qualitative research has been key to understanding this adjustment process, particularly in the short-term (2-5 years). Currently, however, there is a lack of qualitative research examining longer-term (>15 years) outcomes, precluding the same rich, detailed understanding of longer-term psychosocial outcomes. Using a grounded theory approach, we explored how patients reflected on and made sense of their adjustment trajectories, 15 to 20 years after surgery. This included the impact of surgery on their sense of self and broader psychosocial functioning. METHODS We recruited 40 adult patients who had undergone anterior temporal lobectomy (ATL) 15 to 20 years ago (24 females; 26 left-sided). Median age at habitual seizure onset was 9.7 years (Interquartile range; IQR = 13.8), and at surgery was 31 years (IQR = 12). Median length of follow-up was 18.4 years (IQR = 4.3). Comprehensive one-on-one interviews (median time = 86 min, IQR = 28) were used to elicit patient experiences of their surgery and subsequent psychosocial outcomes. Data were analyzed using a grounded theory inductive-deductive process. RESULTS Patient narratives revealed a common process of psychosocial change and meaning-making triggered by surgery, which was often perceived as a major turning point in life. Patients reflected on moving through an early postsurgical period (<5 years) of upheaval and psychological disequilibrium. While this period was often remembered as stressful, difficulties were softened and/or reframed in hindsight. Through this process of reframing and meaning-making, patients were able to reestablish equilibrium and a sense of normality. Differences were evident in how patients navigated the process of meaning-making, and the extent to which they felt surgery had changed their self-identity. DISCUSSION We propose a model of postsurgical meaning-making, evident in the narratives of patients who have undergone ATL, providing a new perspective on long-term psychosocial outcomes. This model contributes to our understanding of patient well-being and quality of life, by acknowledging the active role that patients play in seeking to create their own sense of normality after epilepsy surgery.
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Affiliation(s)
- Honor Coleman
- Melbourne School of Psychological Sciences, The University of Melbourne, Melbourne, Victoria, Australia; Epilepsy Research Centre, Department of Medicine (Austin Health), University of Melbourne, Australia.
| | - Anne McIntosh
- Epilepsy Research Centre, Department of Medicine (Austin Health), University of Melbourne, Australia; Department of Neurosciences, Medicine, Nursing and Health Sciences, Monash University, Australia; Melbourne Brain Centre, The Royal Melbourne Hospital, Department of Medicine, University of Melbourne, Australia
| | - Sarah J Wilson
- Melbourne School of Psychological Sciences, The University of Melbourne, Melbourne, Victoria, Australia; Epilepsy Research Centre, Department of Medicine (Austin Health), University of Melbourne, Australia
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Auer T, Schreppel P, Erker T, Schwarzer C. Functional characterization of novel bumetanide derivatives for epilepsy treatment. Neuropharmacology 2020; 162:107754. [PMID: 31476353 DOI: 10.1016/j.neuropharm.2019.107754] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 08/23/2019] [Accepted: 08/29/2019] [Indexed: 12/12/2022]
Abstract
Temporal lobe epilepsy (TLE) is the most common type of focal epilepsies, affecting approximately 35 million people worldwide. Despite the introduction of numerous novel antiepileptic drugs during the last decades, the proportion of patients with therapy-resistant TLE is still high. As an impaired cellular chloride homeostasis appears involved in disease pathophysiology, bumetanide, an antagonist to Na-K-Cl cotransporters, gained interest as potential therapeutic option. However, bumetanide induces a strong diuretic effect and displays poor penetration across the blood-brain barrier (BBB). To reduce these unwanted effects, we modified the already described BUM690 by exchanging the allyl-into a trifluoro-ethyl group to yield BUM532. Furthermore, we exchanged the nitrogen for oxygen in the trifluoro-ethyl group to yield BUM97. In the intrahippocampal kainic acid mouse model of TLE BUM532 ± phenobarbital (PB), bumetanide ± PB and PB alone significantly reduced hippocampal paroxysmal discharges (HPDs) but not spike trains. By contrast, treatment with BUM97 suppressed HPDs as well as spike trains dose-dependently, more pronounced compared to the other tested compounds and exerted a synergistic anticonvulsant effect with PB. Moreover, at higher doses BUM97 achieved long-lasting reduction of spike trains. In pentylenetetrazole-induced acute seizures only BUM532 combined with a sub-effective dose of PB increased the seizure threshold. No diuretic effects were observed at any dose of the three derivatives. Our data demonstrate the successful optimization of the pharmacological profile of bumetanide and the potential of the improved derivative BUM97 for the treatment of therapy-resistant TLE, in particular in combinatorial drug regimens with a GABA mimetic.
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Affiliation(s)
- Theresa Auer
- Department of Pharmacology, Medical University of Innsbruck, Peter-Mayr-Str. 1a, 6020, Innsbruck, Austria.
| | - Philipp Schreppel
- Department of Pharmaceutical Chemistry, University of Vienna, Althanstrasse 14, 1090, Vienna, Austria.
| | - Thomas Erker
- Department of Pharmaceutical Chemistry, University of Vienna, Althanstrasse 14, 1090, Vienna, Austria.
| | - Christoph Schwarzer
- Department of Pharmacology, Medical University of Innsbruck, Peter-Mayr-Str. 1a, 6020, Innsbruck, Austria.
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Klimes P, Cimbalnik J, Brazdil M, Hall J, Dubeau F, Gotman J, Frauscher B. NREM sleep is the state of vigilance that best identifies the epileptogenic zone in the interictal electroencephalogram. Epilepsia 2019; 60:2404-2415. [PMID: 31705527 DOI: 10.1111/epi.16377] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 10/09/2019] [Accepted: 10/09/2019] [Indexed: 01/26/2023]
Abstract
OBJECTIVE Interictal epileptiform anomalies such as epileptiform discharges or high-frequency oscillations show marked variations across the sleep-wake cycle. This study investigates which state of vigilance is the best to localize the epileptogenic zone (EZ) in interictal intracranial electroencephalography (EEG). METHODS Thirty patients with drug-resistant epilepsy undergoing stereo-EEG (SEEG)/sleep recording and subsequent open surgery were included; 13 patients (43.3%) had good surgical outcome (Engel class I). Sleep was scored following standard criteria. Multiple features based on the interictal EEG (interictal epileptiform discharges, high-frequency oscillations, univariate and bivariate features) were used to train a support vector machine (SVM) model to classify SEEG contacts placed in the EZ. The performance of the algorithm was evaluated by the mean area under the receiver-operating characteristic (ROC) curves (AUCs) and positive predictive values (PPVs) across 10-minute sections of wake, non-rapid eye movement sleep (NREM) stages N2 and N3, REM sleep, and their combination. RESULTS Highest AUCs were achieved in NREM sleep stages N2 and N3 compared to wakefulness and REM (P < .01). There was no improvement when using a combination of all four states (P > .05); the best performing features in the combined state were selected from NREM sleep. There were differences between good (Engel I) and poor (Engel II-IV) outcomes in PPV (P < .05) and AUC (P < .01) across all states. The SVM multifeature approach outperformed spikes and high-frequency oscillations (P < .01) and resulted in results similar to those of the seizure-onset zone (SOZ; P > .05). SIGNIFICANCE Sleep improves the localization of the EZ with best identification obtained in NREM sleep stages N2 and N3. Results based on the multifeature classification in 10 minutes of NREM sleep were not different from the results achieved by the SOZ based on 12.7 days of seizure monitoring. This finding might ultimately result in a more time-efficient intracranial presurgical investigation of focal epilepsy.
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Affiliation(s)
- Petr Klimes
- Montreal Neurological Institute and Hospital, McGill University, Montréal, Quebec, Canada.,Institute of Scientific Instruments, The Czech Academy of Sciences, Brno, Czech Republic
| | - Jan Cimbalnik
- International Clinical Research Center, St. Anne's University Hospital, Brno, Czech Republic
| | - Milan Brazdil
- Brno Epilepsy Center, Department of Neurology, St. Anne's University Hospital, Faculty of Medicine, Masaryk University, Brno, Czech Republic.,Behavioral and Social Neuroscience Research Group, CEITEC Central European Institute of Technology, Masaryk University, Brno, Czech Republic
| | - Jeffery Hall
- Montreal Neurological Institute and Hospital, McGill University, Montréal, Quebec, Canada
| | - François Dubeau
- Montreal Neurological Institute and Hospital, McGill University, Montréal, Quebec, Canada
| | - Jean Gotman
- Montreal Neurological Institute and Hospital, McGill University, Montréal, Quebec, Canada
| | - Birgit Frauscher
- Montreal Neurological Institute and Hospital, McGill University, Montréal, Quebec, Canada
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Goldenholz D, Sun H, Westover B. Commentary on "Predicting seizure freedom after epilepsy surgery, a challenge in clinical practice". Epilepsy Behav 2019; 99:106408. [PMID: 31375412 DOI: 10.1016/j.yebeh.2019.07.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 07/03/2019] [Indexed: 11/18/2022]
Affiliation(s)
- Daniel Goldenholz
- Harvard Beth Israel Deaconess Medical Center, Department of Neurology, United States of America.
| | - Haoqi Sun
- Harvard Massachusetts General Hospital, Department of Neurology, United States of America.
| | - Brandon Westover
- Harvard Massachusetts General Hospital, Department of Neurology, United States of America.
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Thomschewski A, Hincapié AS, Frauscher B. Localization of the Epileptogenic Zone Using High Frequency Oscillations. Front Neurol 2019; 10:94. [PMID: 30804887 PMCID: PMC6378911 DOI: 10.3389/fneur.2019.00094] [Citation(s) in RCA: 83] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 01/23/2019] [Indexed: 01/22/2023] Open
Abstract
For patients with drug-resistant focal epilepsy, surgery is the therapy of choice in order to achieve seizure freedom. Epilepsy surgery foremost requires the identification of the epileptogenic zone (EZ), defined as the brain area indispensable for seizure generation. The current gold standard for identification of the EZ is the seizure-onset zone (SOZ). The fact, however that surgical outcomes are unfavorable in 40-50% of well-selected patients, suggests that the SOZ is a suboptimal biomarker of the EZ, and that new biomarkers resulting in better postsurgical outcomes are needed. Research of recent years suggested that high-frequency oscillations (HFOs) are a promising biomarker of the EZ, with a potential to improve surgical success in patients with drug-resistant epilepsy without the need to record seizures. Nonetheless, in order to establish HFOs as a clinical biomarker, the following issues need to be addressed. First, evidence on HFOs as a clinically relevant biomarker stems predominantly from retrospective assessments with visual marking, leading to problems of reproducibility and reliability. Prospective assessments of the use of HFOs for surgery planning using automatic detection of HFOs are needed in order to determine their clinical value. Second, disentangling physiologic from pathologic HFOs is still an unsolved issue. Considering the appearance and the topographic location of presumed physiologic HFOs could be immanent for the interpretation of HFO findings in a clinical context. Third, recording HFOs non-invasively via scalp electroencephalography (EEG) and magnetoencephalography (MEG) is highly desirable, as it would provide us with the possibility to translate the use of HFOs to the scalp in a large number of patients. This article reviews the literature regarding these three issues. The first part of the article focuses on the clinical value of invasively recorded HFOs in localizing the EZ, the detection of HFOs, as well as their separation from physiologic HFOs. The second part of the article focuses on the current state of the literature regarding non-invasively recorded HFOs with emphasis on findings and technical considerations regarding their localization.
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Affiliation(s)
- Aljoscha Thomschewski
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, Salzburg, Austria
- Department of Psychology, Paris-Lodron University of Salzburg, Salzburg, Austria
| | - Ana-Sofía Hincapié
- Montreal Neurological Institute and Hospital, McGill University, Montreal, QC, Canada
| | - Birgit Frauscher
- Montreal Neurological Institute and Hospital, McGill University, Montreal, QC, Canada
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Zhang C, Yang H, Liu C, Zhang G, Chen N, Li K. Brain network alterations of mesial temporal lobe epilepsy with cognitive dysfunction following anterior temporal lobectomy. Epilepsy Behav 2018; 87:123-130. [PMID: 30115603 DOI: 10.1016/j.yebeh.2018.07.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 07/01/2018] [Accepted: 07/21/2018] [Indexed: 11/17/2022]
Abstract
The aims of this study were to investigate the brain network connectivity alterations of intractable unilateral mesial temporal lobe epilepsy (MTLE) with cognitive dysfunction before and after anterior temporal lobectomy (ATL) using resting-state functional magnetic resonance imaging (rs-fMRI) study and to further observe the correlation between the brain network connectivity with cognitive performance. Fourteen patients with unilateral left MTLE before and after ATL were compared with thirty healthy controls (HCs) on functional connectivity (FC) between resting-state networks (RSNs). The correlation between the neuropsychological tests of patients and abnormal FC was further investigated. When compared with the HCs, patients before surgery showed significantly changed FC between special RSNs. No difference of FC was found between each RSN when patients were compared with the HCs after surgery. Compared with patients before surgery, patients after surgery showed significantly decreased FC between RSNs. Abnormal FC between RSNs significantly correlated with Montreal Cognitive Assessment (MoCA) scores. Our study suggested that dynamic alterations of RSN after ATL in unilateral MTLE may be closely related with seizure generating. However, unchanged FC between RSN before and after ATL may be closely related with cognitive performance. The present findings may help us understand the feature of brain network alterations in patients with left MTLE who became seizure-free following ATL.
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Affiliation(s)
- Chao Zhang
- Department of Radiology, Xuanwu Hospital, Capital Medical University, Beijing, PR China; Beijing Key Laboratory of Magnetic Resonance Imaging and Brain Informatics, Beijing, PR China
| | - Hongyu Yang
- Department of Radiology, Xuanwu Hospital, Capital Medical University, Beijing, PR China; Beijing Key Laboratory of Magnetic Resonance Imaging and Brain Informatics, Beijing, PR China
| | - Chang Liu
- Department of Functional Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, PR China
| | - Guojun Zhang
- Department of Functional Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, PR China
| | - Nan Chen
- Department of Radiology, Xuanwu Hospital, Capital Medical University, Beijing, PR China; Beijing Key Laboratory of Magnetic Resonance Imaging and Brain Informatics, Beijing, PR China.
| | - Kuncheng Li
- Department of Radiology, Xuanwu Hospital, Capital Medical University, Beijing, PR China; Beijing Key Laboratory of Magnetic Resonance Imaging and Brain Informatics, Beijing, PR China.
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Bautista RED, Persaud AS. Epilepsy wellness: The standard of care for the 21st century. Epilepsy Behav 2018; 87:241-242. [PMID: 30170896 DOI: 10.1016/j.yebeh.2018.07.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Accepted: 07/30/2018] [Indexed: 10/28/2022]
Affiliation(s)
- Ramon Edmundo D Bautista
- Comprehensive Epilepsy Program, Department of Neurology, University of Florida Health Sciences Center/Jacksonville, United States of America.
| | - Amanda S Persaud
- Comprehensive Epilepsy Program, Department of Neurology, University of Florida Health Sciences Center/Jacksonville, United States of America
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Mohan M, Keller S, Nicolson A, Biswas S, Smith D, Osman Farah J, Eldridge P, Wieshmann U. The long-term outcomes of epilepsy surgery. PLoS One 2018; 13:e0196274. [PMID: 29768433 PMCID: PMC5955551 DOI: 10.1371/journal.pone.0196274] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Accepted: 04/10/2018] [Indexed: 02/07/2023] Open
Abstract
Objective Despite modern anti-epileptic drug treatment, approximately 30% of epilepsies remain medically refractory and for these patients, epilepsy surgery may be a treatment option. There have been numerous studies demonstrating good outcome of epilepsy surgery in the short to median term however, there are a limited number of studies looking at the long-term outcomes. The aim of this study was to ascertain the long-term outcome of resective epilepsy surgery in a large neurosurgery hospital in the U.K. Methods This a retrospective analysis of prospectively collected data. We used the 2001 International League Against Epilepsy (ILAE) classification system to classify seizure freedom and Kaplan-Meier survival analysis to estimate the probability of seizure freedom. Results We included 284 patients who underwent epilepsy surgery (178 anterior temporal lobe resections, 37 selective amygdalohippocampectomies, 33 temporal lesionectomies, 36 extratemporal lesionectomies), and had a prospective median follow-up of 5 years (range 1–27). Kaplan-Meier estimates showed that 47% (95% CI 40–58) remained seizure free (apart from simple partial seizures) at 5 years and 38% (95% CI 31–45) at 10 years after surgery. 74% (95% CI 69–80) had a greater than 50% seizure reduction at 5 years and 70% (95% CI 64–77) at 10 years. Patients who had an amygdalohippocampectomy were more likely to have seizure recurrence than patients who had an anterior temporal lobe resection (p = 0.006) and temporal lesionectomy (p = 0.029). There was no significant difference between extra temporal and temporal lesionectomies. Hippocampal sclerosis was associated with a good outcome but declined in relative frequency over the years. Conclusion The vast majority of patients who were not seizure free experienced at least a substantial and long-lasting reduction in seizure frequency. A positive long-term outcome after epilepsy surgery is possible for many patients and especially those with hippocampal sclerosis or those who had anterior temporal lobe resections.
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Affiliation(s)
- Midhun Mohan
- The Walton Centre, NHS Foundation Trust, Liverpool, Merseyside, United Kingdom
| | - Simon Keller
- The Walton Centre, NHS Foundation Trust, Liverpool, Merseyside, United Kingdom
- Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, Merseyside, United Kingdom
| | - Andrew Nicolson
- The Walton Centre, NHS Foundation Trust, Liverpool, Merseyside, United Kingdom
| | - Shubhabrata Biswas
- The Walton Centre, NHS Foundation Trust, Liverpool, Merseyside, United Kingdom
| | - David Smith
- The Walton Centre, NHS Foundation Trust, Liverpool, Merseyside, United Kingdom
| | - Jibril Osman Farah
- The Walton Centre, NHS Foundation Trust, Liverpool, Merseyside, United Kingdom
| | - Paul Eldridge
- The Walton Centre, NHS Foundation Trust, Liverpool, Merseyside, United Kingdom
| | - Udo Wieshmann
- The Walton Centre, NHS Foundation Trust, Liverpool, Merseyside, United Kingdom
- * E-mail:
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Vakharia VN, Duncan JS, Witt JA, Elger CE, Staba R, Engel J. Getting the best outcomes from epilepsy surgery. Ann Neurol 2018. [PMID: 29534299 PMCID: PMC5947666 DOI: 10.1002/ana.25205] [Citation(s) in RCA: 144] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Neurosurgery is an underutilized treatment that can potentially cure drug‐refractory epilepsy. Careful, multidisciplinary presurgical evaluation is vital for selecting patients and to ensure optimal outcomes. Advances in neuroimaging have improved diagnosis and guided surgical intervention. Invasive electroencephalography allows the evaluation of complex patients who would otherwise not be candidates for neurosurgery. We review the current state of the assessment and selection of patients and consider established and novel surgical procedures and associated outcome data. We aim to dispel myths that may inhibit physicians from referring and patients from considering neurosurgical intervention for drug‐refractory focal epilepsies. Ann Neurol 2018;83:676–690
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Affiliation(s)
- Vejay N Vakharia
- Department of Clinical and Experimental Epilepsy, UCL Institute of Neurology, London, United Kingdom, and Chalfont Centre for Epilepsy
| | - John S Duncan
- Department of Clinical and Experimental Epilepsy, UCL Institute of Neurology, London, United Kingdom, and Chalfont Centre for Epilepsy
| | - Juri-Alexander Witt
- Department of Epileptology, University of Bonn Medical Center, Bonn, Germany
| | - Christian E Elger
- Department of Epileptology, University of Bonn Medical Center, Bonn, Germany
| | - Richard Staba
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Jerome Engel
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
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