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Rubboli G, Beier CP, Selmer KK, Syvertsen M, Shakeshaft A, Collingwood A, Hall A, Andrade DM, Fong CY, Gesche J, Greenberg DA, Hamandi K, Lim KS, Ng CC, Orsini A, Striano P, Thomas RH, Zarubova J, Richardson MP, Strug LJ, Pal DK. Variation in prognosis and treatment outcome in juvenile myoclonic epilepsy: a Biology of Juvenile Myoclonic Epilepsy Consortium proposal for a practical definition and stratified medicine classifications. Brain Commun 2023; 5:fcad182. [PMID: 37361715 PMCID: PMC10288558 DOI: 10.1093/braincomms/fcad182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Revised: 03/21/2023] [Accepted: 06/08/2023] [Indexed: 06/28/2023] Open
Abstract
Reliable definitions, classifications and prognostic models are the cornerstones of stratified medicine, but none of the current classifications systems in epilepsy address prognostic or outcome issues. Although heterogeneity is widely acknowledged within epilepsy syndromes, the significance of variation in electroclinical features, comorbidities and treatment response, as they relate to diagnostic and prognostic purposes, has not been explored. In this paper, we aim to provide an evidence-based definition of juvenile myoclonic epilepsy showing that with a predefined and limited set of mandatory features, variation in juvenile myoclonic epilepsy phenotype can be exploited for prognostic purposes. Our study is based on clinical data collected by the Biology of Juvenile Myoclonic Epilepsy Consortium augmented by literature data. We review prognosis research on mortality and seizure remission, predictors of antiseizure medication resistance and selected adverse drug events to valproate, levetiracetam and lamotrigine. Based on our analysis, a simplified set of diagnostic criteria for juvenile myoclonic epilepsy includes the following: (i) myoclonic jerks as mandatory seizure type; (ii) a circadian timing for myoclonia not mandatory for the diagnosis of juvenile myoclonic epilepsy; (iii) age of onset ranging from 6 to 40 years; (iv) generalized EEG abnormalities; and (v) intelligence conforming to population distribution. We find sufficient evidence to propose a predictive model of antiseizure medication resistance that emphasises (i) absence seizures as the strongest stratifying factor with regard to antiseizure medication resistance or seizure freedom for both sexes and (ii) sex as a major stratifying factor, revealing elevated odds of antiseizure medication resistance that correlates to self-report of catamenial and stress-related factors including sleep deprivation. In women, there are reduced odds of antiseizure medication resistance associated with EEG-measured or self-reported photosensitivity. In conclusion, by applying a simplified set of criteria to define phenotypic variations of juvenile myoclonic epilepsy, our paper proposes an evidence-based definition and prognostic stratification of juvenile myoclonic epilepsy. Further studies in existing data sets of individual patient data would be helpful to replicate our findings, and prospective studies in inception cohorts will contribute to validate them in real-world practice for juvenile myoclonic epilepsy management.
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Affiliation(s)
- Guido Rubboli
- Correspondence may also be addressed to: Guido Rubboli Danish Epilepsy Center, Filadelfia/University of Copenhagen Kolonivej 2A, Dianalund 4293, Denmark E-mail:
| | - Christoph P Beier
- Department of Neurology, Odense University Hospital, Odense 5000, Denmark
| | - Kaja K Selmer
- Department of Research and Innovation, Division of Clinical Neuroscience, Oslo University Hospital, Oslo 0372, Norway
- National Centre for Epilepsy, Oslo University Hospital, Oslo 1337, Norway
| | - Marte Syvertsen
- Department of Neurology, Drammen Hospital, Vestre Viken Health Trust, Oslo 3004, Norway
| | - Amy Shakeshaft
- Department of Basic and Clinical Neurosciences, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London SE5 8AF, UK
- MRC Centre for Neurodevelopmental Disorders, King’s College London, London SW1H 9NA, UK
| | - Amber Collingwood
- Department of Basic and Clinical Neurosciences, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London SE5 8AF, UK
| | - Anna Hall
- Department of Basic and Clinical Neurosciences, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London SE5 8AF, UK
| | - Danielle M Andrade
- Adult Epilepsy Genetics Program, Krembil Research Institute, University of Toronto, Toronto M5T 0S8, Canada
| | - Choong Yi Fong
- Division of Paediatric Neurology, Department of Pediatrics, Faculty of Medicine, University of Malaya, Kuala Lumpur 50603, Malaysia
| | - Joanna Gesche
- Department of Neurology, Odense University Hospital, Odense 5000, Denmark
| | - David A Greenberg
- Abigail Wexner Research Institute, Nationwide Children’s Hospital, Columbus 43215, USA
| | - Khalid Hamandi
- Department of Neurology, Cardiff & Vale University Health Board, Cardiff CF14 4XW, UK
| | - Kheng Seang Lim
- Division of Neurology, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur 50603, Malaysia
| | - Ching Ching Ng
- Institute of Biological Sciences, Faculty of Science, University of Malaya, Kuala Lumpur 50603, Malaysia
| | - Alessandro Orsini
- Department of Clinical and Experimental Medicine, Pisa University Hospital, Pisa 56126, Italy
| | | | - Pasquale Striano
- Pediatric Neurology and Muscular Disease Unit, IRCCS Istituto ‘G. Gaslini’, Genova 16147, Italy
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Genova 16132, Italy
| | - Rhys H Thomas
- Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne NE7 7DN, UK
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne NE1 7RU, UK
| | - Jana Zarubova
- Department of Neurology, Second Faculty of Medicine, Charles University, Prague 150 06, Czech Republic
- Motol University Hospital, Prague 150 06, Czech Republic
| | - Mark P Richardson
- Department of Basic and Clinical Neurosciences, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London SE5 8AF, UK
- MRC Centre for Neurodevelopmental Disorders, King’s College London, London SW1H 9NA, UK
- School of Neuroscience, Institute of Psychiatry, Psychology and Neuroscience, King’s College, London SE5 8AF, UK
| | - Lisa J Strug
- Program in Genetics and Genome Biology, The Hospital for Sick Children, Toronto M5G 1X8, Canada
- Departments of Statistical Sciences and Computer Science and Division of Biostatistics, The University of Toronto, Toronto M5G 1Z5, Canada
| | - Deb K Pal
- Correspondence to: Deb K. Pal Maurice Wohl Clinical Neurosciences Institute Institute of Psychiatry, Psychology and Neuroscience, King’s College London 5 Cutcombe Road, London SE5 9RX, UK E-mail:
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Alzahrany M, Punia V. Extreme late onset of genetic generalized epilepsy in older adults and the elderly: A cohort study and literature review. Epilepsia Open 2023; 8:193-199. [PMID: 36366877 PMCID: PMC9977743 DOI: 10.1002/epi4.12671] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 11/09/2022] [Indexed: 11/13/2022] Open
Abstract
Rare case reports describe genetic generalized epilepsy (GGE) starting de novo in people ≥50 years of age (older adults and the elderly). We aimed to provide comprehensive detail of electro-clinical findings of this extremely late-onset GGE using a retrospective, single-center cohort design and a systematic review of the literature. People with de novo seizure onset ≥50 years of age with EEG and clinical history consistent with GGE were included. These 12 individuals (9; 75% females) with a median age of 56 years at seizure onset accounted for 7.9% of 152 older adults and the elderly with generalized epilepsy. Three patients only had absence seizures. A family history of epilepsy was present in 5 individuals. They had tried a median of 2 anti-seizure medications. More than 90% (11 of 12) were seizure-free for >1 year at the last follow-up, including four requiring monotherapy. Valproate was used in only two patients and levetiracetam in 75% of them. A systematic literature review revealed six papers with 10 extreme late-onset GGE cases. They similarly had good seizure outcomes but a majority were on valproate. Our study shows that rarely, late-onset epilepsy can be GGE, which mostly has a good prognosis.
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Affiliation(s)
- Majed Alzahrany
- Epilepsy Center, Department of Neurology, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA.,Department of Medicine, Division of Neurology, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Vineet Punia
- Epilepsy Center, Department of Neurology, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Huang L, Fu C, Li J, Peng S. Late-onset epilepsy and the risk of dementia: a systematic review and meta-analysis. Aging Clin Exp Res 2022; 34:1771-1779. [PMID: 35428922 DOI: 10.1007/s40520-022-02118-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 03/13/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Patients with dementia have higher risk of epilepsy. However, it remains not comprehensively evaluated if late-onset epilepsy (LOE) is associated with higher risk of dementia. We, therefore, performed a meta-analysis to systematically evaluate the association. METHODS Relevant cohort studies were identified by search of electronic databases including PubMed, Embase, and Web of Science. A randomized-effect model incorporating the possible between-study heterogeneity was used to pool the results. RESULTS Overall, seven cohort studies including 873,438 adults were included, and 16,036 (1.8%) of them had LOE. With a mean follow-up duration of 8.7 years, 33,727 of them were diagnosed as dementia. Pooled results showed that LOE was associated with a higher risk of dementia (risk ratio [RR] 2.39, 95% confidence interval [CI] 2.04-2.81, p < 0.001, I2 = 67%). Results of subgroup analysis showed that the association between LOE and the risk of dementia was stronger in hospital-derived participants (RR 4.23, 95% CI 2.67-6.70, p < 0.001) than that in community-derived population (RR 2.25, 95% CI 1.93-2.63, p < 0.001; p for subgroup difference = 0.01). Pooled results of three studies showed that LOE was associated with a higher risk of Alzheimer's disease (RR 2.35, 95% CI 1.08-5.08, p = 0.03, I2 = 85%). One study suggested a significant association between LOE and risk of vascular dementia (RR 2.0, 95% CI 1.77-2.26, p < 0.001). CONCLUSIONS Evidence from cohort studies suggests that LOE may be a risk factor of dementia.
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Affiliation(s)
- Lei Huang
- Department of Neurology, The First People's Hospital of Yibin, No. 65 Wenxing Street, Cuiping District, Yibin City, 644000, Sichuan, China.
| | - Chi Fu
- Department of Neurology, The First People's Hospital of Yibin, No. 65 Wenxing Street, Cuiping District, Yibin City, 644000, Sichuan, China
| | - Jie Li
- Department of Neurology, The First People's Hospital of Yibin, No. 65 Wenxing Street, Cuiping District, Yibin City, 644000, Sichuan, China
| | - Shijun Peng
- Department of Neurology, The First People's Hospital of Yibin, No. 65 Wenxing Street, Cuiping District, Yibin City, 644000, Sichuan, China
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Epilepsy and aging. HANDBOOK OF CLINICAL NEUROLOGY 2020. [PMID: 31753149 DOI: 10.1016/b978-0-12-804766-8.00025-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2023]
Abstract
The intersection of epilepsy and aging has broad, significant implications. Substantial increases in seizures occur both in the elderly population, who are at a higher risk of developing new-onset epilepsy, and in those with chronic epilepsy who become aged. There are notable gaps in our understanding of aging and epilepsy at the basic and practical levels, which have important consequences. We are in the early stages of understanding the complex relationships between epilepsy and other age-related brain diseases such as stroke, dementia, traumatic brain injury (TBI), and cancer. Furthermore, the clinician must recognize that the presentation and treatment of epilepsy in the elderly are different from those of younger populations. Given the developing awareness of the problem and the capabilities of contemporary, multidisciplinary approaches to advance understanding about the biology of aging and epilepsy, it is reasonable to expect that we will unravel some of the intricacies of epilepsy in the elderly; it is also reasonable to expect that these gains will lead to further improvements in our understanding and treatment of epilepsy for all age groups.
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Ketzef M, Gitler D. Epileptic synapsin triple knockout mice exhibit progressive long-term aberrant plasticity in the entorhinal cortex. ACTA ACUST UNITED AC 2012; 24:996-1008. [PMID: 23236212 DOI: 10.1093/cercor/bhs384] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Studying epileptogenesis in a genetic model can facilitate the identification of factors that promote the conversion of a normal brain into one chronically prone to seizures. Synapsin triple-knockout (TKO) mice exhibit adult-onset epilepsy, thus allowing the characterization of events as preceding or following seizure onset. Although it has been proposed that a congenital reduction in inhibitory transmission is the underlying cause for epilepsy in these mice, young TKO mice are asymptomatic. We report that the genetic lesion exerts long-term progressive effects that extend well into adulthood. Although inhibitory transmission is initially reduced, it is subsequently strengthened relative to its magnitude in control mice, so that the excitation to inhibition balance in adult TKOs is inverted in favor of inhibition. In parallel, we observed long-term alterations in synaptic depression kinetics of excitatory transmission and in the extent of tonic inhibition, illustrating adaptations in synaptic properties. Moreover, age-dependent acceleration of the action potential did not occur in TKO cortical pyramidal neurons, suggesting wide-ranging secondary changes in brain excitability. In conclusion, although congenital impairments in inhibitory transmission may initiate epileptogenesis in the synapsin TKO mice, we suggest that secondary adaptations are crucial for the establishment of this epileptic network.
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Affiliation(s)
- Maya Ketzef
- Department of Physiology and Cell Biology, Faculty of Health Sciences and Zlotowski Center for Neuroscience, Ben-Gurion University of the Negev, Beer-Sheva 84105, Israel
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Jiang J, Chen X, Liu W, Zhao Y, Guan Y, Han Y, Wang F, Lu J, Yu Z, Du Z, Zhang X. Correlation between human seizure-related gene 6 variants and idiopathic generalized epilepsy in a Southern Chinese Han population. Neural Regen Res 2012; 7:96-100. [PMID: 25767482 PMCID: PMC4354136 DOI: 10.3969/j.issn.1673-5374.2012.02.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2011] [Accepted: 12/12/2011] [Indexed: 11/18/2022] Open
Abstract
This study sought to analyze the genotype and gene mutations of human seizure-related gene 6 in 98 patients with idiopathic generalized epilepsy (non-febrile seizures), who were selected from three generations of the Chinese Han population living in Shanghai, Zhejiang Province, Wuxi of Jiangsu Province, and Jiangxi Province of Southern China. Twenty-six patients’ parents were available as a first-degree relatives group and 100 biologically unrelated healthy controls were collected as the control group. Based on the age of onset and seizure type, the patients were divided into six subgroups. Polymerase chain reaction and DNA direct sequencing analysis showed that the most frequent mutations c.1249dupC (p.Gly418Argfx31) and c.1636A > G (p.Thr546Ala) were detected in some idiopathic generalized epilepsy patients and their asymptomatic first-degree relatives (30.6% vs. 19.2% and 11.2% vs. 26.9%). A novel mutation c.1807G > A (p.Val603Met) was found in a patient with late-onset idiopathic generalized epilepsy. There was no significant difference in the incidence of these three mutations among the different subgroups of idiopathic generalized epilepsy and controls. Thus, further analysis of a larger population is needed to confirm the assumption that human seizure-related gene 6 is a susceptibility gene for idiopathic generalized epilepsy with various sub-syndromes.
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Affiliation(s)
- Jianming Jiang
- Department of Neurology, Changhai Hospital, Second Military Medical University of Chinese PLA, Shanghai 200433, China
| | - Xiaoling Chen
- Department of Biochemistry & Genetics, the National Education Base for Basic Medical Sciences, Institute of Cell Biology, Zhejiang University School of Medicine, Hangzhou 310058, Zhejiang Province, China
| | - Wenting Liu
- Department of Biochemistry & Genetics, the National Education Base for Basic Medical Sciences, Institute of Cell Biology, Zhejiang University School of Medicine, Hangzhou 310058, Zhejiang Province, China
| | - Yan Zhao
- Department of Biochemistry & Genetics, the National Education Base for Basic Medical Sciences, Institute of Cell Biology, Zhejiang University School of Medicine, Hangzhou 310058, Zhejiang Province, China
| | - Yangtai Guan
- Department of Neurology, Changhai Hospital, Second Military Medical University of Chinese PLA, Shanghai 200433, China
| | - Yan Han
- Department of Neurology, Changhai Hospital, Second Military Medical University of Chinese PLA, Shanghai 200433, China
| | - Feng Wang
- Department of Neurology, Changhai Hospital, Second Military Medical University of Chinese PLA, Shanghai 200433, China
| | - Jiajun Lu
- Department of Biochemistry & Genetics, the National Education Base for Basic Medical Sciences, Institute of Cell Biology, Zhejiang University School of Medicine, Hangzhou 310058, Zhejiang Province, China
| | - Zhiliang Yu
- Department of Neurology, Changhai Hospital, Second Military Medical University of Chinese PLA, Shanghai 200433, China
| | - Zhenfang Du
- Department of Biochemistry & Genetics, the National Education Base for Basic Medical Sciences, Institute of Cell Biology, Zhejiang University School of Medicine, Hangzhou 310058, Zhejiang Province, China
| | - Xianning Zhang
- Department of Biochemistry & Genetics, the National Education Base for Basic Medical Sciences, Institute of Cell Biology, Zhejiang University School of Medicine, Hangzhou 310058, Zhejiang Province, China
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Electroclinical features of idiopathic generalized epilepsies in the elderly: A geriatric hospital-based study. Seizure 2011; 20:292-8. [DOI: 10.1016/j.seizure.2010.12.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2010] [Revised: 12/19/2010] [Accepted: 12/27/2010] [Indexed: 11/18/2022] Open
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Massengo S, Ondze B, Bastard J, Guiziou C, Velmans N, Rajabally Y. Elderly patients with epileptic seizures: In-patient observational study of two French community hospitals. Seizure 2011; 20:231-9. [DOI: 10.1016/j.seizure.2010.11.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2010] [Revised: 10/04/2010] [Accepted: 11/22/2010] [Indexed: 10/18/2022] Open
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Nguyen-Michel V, Ourabah Z, Sebban C, Lavallard-Rousseau MC, Adam C. Épilepsies généralisées idiopathiques chez le sujet âgé : le point de vue du gériatre. Rev Neurol (Paris) 2009; 165:924-32. [DOI: 10.1016/j.neurol.2009.01.042] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2008] [Revised: 10/24/2008] [Accepted: 01/16/2009] [Indexed: 11/17/2022]
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Tebartz van Elst L, Baker G, Kerr M. The psychosocial impact of epilepsy in older people. Epilepsy Behav 2009; 15 Suppl 1:S17-9. [PMID: 19303941 DOI: 10.1016/j.yebeh.2009.03.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2009] [Accepted: 03/05/2009] [Indexed: 11/30/2022]
Abstract
Given a prevalence of 0.5-1%, the epilepsies belong to the most common of neuropsychiatric diseases. Many clinicians think of the epilepsies as an entity beginning in early in life. However, the peak incidence of epilepsy in the developed world is now in the age group beyond 60 years. This population has thus an increasing importance; and in this paper we review and summarize the specific aspects of the clinical presentation, etiology, diagnosis, and treatment of older-age patients with epilepsy. In particular, we focus on the specific psychosocial impact that epilepsy has on the life of older people and their carers.
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Affiliation(s)
- Ludger Tebartz van Elst
- Section for Experimental Neuropsychiatry, Department of Psychiatry and Psychotherapy, University of Freiburg, Hauptstr. 5, 79104 Freiburg, Germany.
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Lee SA, Choi EJ, Kang JK. Reflex epilepsy induced by playing oriental card or board games. J Clin Neurol 2006; 2:262-7. [PMID: 20396530 PMCID: PMC2854977 DOI: 10.3988/jcn.2006.2.4.262] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2006] [Accepted: 10/16/2006] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND AND PURPOSE There are currently few studies on clinical profiles of reflex epilepsy induced by thinking and spatial tasks. We studied the clinical characteristics of reflex epilepsy induced by playing oriental card and board games. METHODS This study included 17 patients who presented with seizures that occur predominantly while playing games. We collected clinical data via protocol-based interviews. EEGs and brain MRI were performed. RESULTS All of the subjects were men, and all of them were older than 30 years at the onset of seizure. Thirteen patients (76%) experienced their seizures while playing the oriental card game "Go-stop" and the remaining four patients (24%) experienced them while playing the oriental board game "Baduk". Generalized tonic-clonic seizures were frequently preceded by prodromal symptoms, but myoclonus was not evident. Most patients had no spontaneous seizures and generalized epileptiform discharges on EEGs, and infrequent seizures that were well controlled. CONCLUSIONS Our patients exhibited some features that differ from those described previously in the literature, suggesting that the clinical spectrum of reflex epilepsy induced by thinking and spatial tasks is wide.
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Affiliation(s)
- Sang Ahm Lee
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Betting LE, Mory SB, Lopes-Cendes I, Li LM, Guerreiro MM, Guerreiro CAM, Cendes F. EEG Features in Idiopathic Generalized Epilepsy: Clues to Diagnosis. Epilepsia 2006; 47:523-8. [PMID: 16529616 DOI: 10.1111/j.1528-1167.2006.00462.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
PURPOSE To investigate the EEG profile and its contribution for diagnosis and management in a group of patients with a clinical diagnosis of idiopathic generalized epilepsy (IGE) who were referred to a tertiary hospital. METHODS We retrospectively studied clinical and EEG features of 180 consecutive patients with IGE. Eighty patients were diagnosed with juvenile myoclonic epilepsy (JME), 35 had absence epilepsy (AE), 13 had generalized tonic-clonic seizures on awakening (GTCS-A), 28 had generalized tonic-clonic seizures only (TCS), and 24 had adult-onset idiopathic generalized epilepsy (AIGE). The EEGs were classified in typical (synchronous generalized spike or polyspikes-and-wave discharges with normal background), atypical (with clear focalities or asymmetries), and normal. RESULTS The 493 EEG exams were analyzed. The first EEG was normal in 45% of the 180 patients, and only 33% had typical abnormalities. AE had a higher proportion of typical examinations and needed fewer sequential examinations to register a typical abnormality compared with the other groups. By contrast, the serial EEG profile of TCS and AIGE showed a higher proportion of normal and atypical EEG findings. CONCLUSIONS These findings support previous recommendations that IGE patients should be treated with appropriate therapy based on clinical history. Waiting for a typical abnormal EEG pattern can generate an unacceptable delay in the correct diagnosis and treatment of these patients. In patients with long-term epilepsy, the diagnosis may be difficult. Furthermore, serial EEGs can help to elucidate the syndromic diagnosis, especially in patients with TCS and AIGE.
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Abstract
Juvenile myoclonic epilepsy constitutes 5-10% of idiopathic generalised epileptic syndromes. The clinical triad of absence seizures, myoclonic jerks and generalised tonic clonic seizures (GTCS) rarely begin after the second decade of life. We present the case of a 74-year-old lady presenting for the first time with myoclonic jerks and absences. The electro encephalogram revealed generalised polyspike and wave epileptiform activity with photosensitivity. On close questioning, she appeared to have had a single episode of GTCS at the age of 10. She remained asymptomatic for 64 years before the diagnosis was made. Although rare, idiopathic myoclonic epilepsy could remain asymptomatic for decades and can present in the elderly. Proper classification of this epileptic syndrome, even in the elderly, is essential in view of the response to appropriate antiepileptic therapy.
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Affiliation(s)
- Saiju Jacob
- Department of Neurology, Leicester General Hospital, University Hospitals of Leicester, Leicester LE5 4PW, UK
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Abstract
From a phenomenological point of view, absence seizures refer to any type of epileptic event characterized by loss of awareness and responsiveness. However, a phenomenological definition of absence seizures is hampered by difficulties in conceptualizing consciousness and needs to take into account the electroclinical features and anatomical basis of seizures. Sensu stricto, absence seizures are defined as an electroclinical pattern of generalized 3/s spike-wave activity accompanied by loss of awareness and responsiveness. Although there is general belief that absences are most often encountered in childhood or early adolescence, a considerable number of patients suffer from absences late into adulthood, which are often refractory to antiepileptic drugs. These patients generally fall into one of two groups. The first group consists of those who have more or less typical absences in childhood or adolescence which continue into adulthood, and may be accompanied by other generalized seizures or neurological impairment. Few data are available addressing whether the seizure semiology of the absences in these patients changes over time or not. The second class of patients corresponds to those in whom absences emerge for the first time in adulthood or even in the senium. These need to be carefully distinguished from later aggravation or semiological transformation of undiagnosed childhood epilepsies and from certain complex focal seizures originating from the frontal or temporal lobe. A wide range of aetiologically and anatomically diverse processes may lead to the appearance of epileptic absences. It is important to note that absences also vary in their intensity, their impact on the ability of the subject to respond and react, and in particular in their natural history and their response to antiepileptic medication.
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Affiliation(s)
- E Trinka
- Universitätsklinik für Neurologie, Medizinische Universität Innsbruck, Innsbruck, Austria.
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Kanner AM. Idiopathic Generalized Epilepsy is Not Restricted To Young Patients. Epilepsy Curr 2004; 3:127-128. [PMID: 15309054 PMCID: PMC321197 DOI: 10.1046/j.1535-7597.2003.03406.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Yenjun S, Harvey AS, Marini C, Newton MR, King MA, Berkovic SF. EEG in adult-onset idiopathic generalized epilepsy. Epilepsia 2003; 44:252-6. [PMID: 12558583 DOI: 10.1046/j.1528-1157.2003.26402.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE It remains controversial whether adult-onset idiopathic generalized epilepsy (IGE) is a distinct syndrome or a continuum among IGE syndromes. EEG is the only known biologic marker of IGE and helps differentiate many of its classic subsyndromes. In this study, we looked for the differences in the EEG findings of IGE of classic adolescent onset versus adult onset that may suggest syndromic heterogeneity. METHODS Seventy-six patients (47 adolescent-onset IGE, 29 adult-onset IGE) with a clinical and EEG diagnosis of IGE were included. We defined IGE with age at onset of 11-20 years as adolescent-onset IGE and age at onset of 20 years or after as adult-onset IGE. Patients with first-decade onset of seizures, delayed EEGs, and no EEG available for review were excluded. The first EEG was performed within 24 h of the seizure, and if negative, a sleep-deprived EEG was done. All EEGs were reviewed in detail with respect to the background activity and the generalized spike-wave (GSW) characteristic. RESULTS EEGs (87; 56 adolescent-onset IGE, 31 adult-onset IGE) were systematically reviewed. Background was normal in all patients. The morphology, amplitude, duration, frequency, occurrence, or activation of the GSW pattern did not differ between these two groups. CONCLUSIONS No differences of EEG features were found between the classic adolescent-onset and the adult-onset IGE. This supports the hypothesis that they share common biologic determinants and exist along a life-long age spectrum of classic IGE.
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Affiliation(s)
- Suthida Yenjun
- Epilepsy Research Institute and Department of Medicine (Neurology), University of Melbourne, Austin and Repatriation Medical Centre, Melbourne, Australia
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Marini C, King MA, Archer JS, Newton MR, Berkovic SF. Idiopathic generalised epilepsy of adult onset: clinical syndromes and genetics. J Neurol Neurosurg Psychiatry 2003; 74:192-6. [PMID: 12531947 PMCID: PMC1738270 DOI: 10.1136/jnnp.74.2.192] [Citation(s) in RCA: 80] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To study the clinical features and genetics of idiopathic generalised epilepsy (IGE) beginning in adult life. METHODS Consecutive patients with IGE, defined as generalised seizures with spike or polyspike and wave on EEG, were studied in the setting of a first seizure clinic where an early postictal EEG record is part of the protocol. Patients were divided into two groups: "classical IGE" with onset before 20 years and inclusive of all the IGE subsyndromes recognised by the international classification; and "adult onset IGE", when seizure onset was at age 20 years or later. Seizure patterns, clinical features, and genetics of the adult onset group were examined. RESULTS Of 121 patients with an electro-clinical diagnosis of IGE, 34 (28%) were diagnosed as adult onset IGE. The seizure patterns in these 34 cases were tonic-clonic seizures + absences (3), tonic-clonic seizures + myoclonus (6), and tonic-clonic seizures alone (25). Tonic-clonic seizures were often precipitated by alcohol or sleep deprivation. The proportion of affected first and second degree relatives did not differ between the classical and adult onset IGE groups. Twenty adult onset cases were treated with sodium valproate, four with other antiepileptic drugs, and 10 were untreated. Follow up of 32 of the 34 cases (for 31 (22) months (mean (SD)) showed that tonic-clonic seizures recurred in eight patients: five with identified provocative factors and three without. CONCLUSIONS Adult onset IGE is a relatively frequent and benign disorder. Seizures are usually provoked and are easy to control. Patients in this age group may often be misdiagnosed as having non-lesional partial epilepsy. Early postictal EEG and sleep deprivation studies may improve the detection of these patients. Pedigree analysis suggests that adult onset IGE, like classical IGE, has a genetic aetiology.
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MESH Headings
- Adolescent
- Age Factors
- Aged
- Anticonvulsants/therapeutic use
- Child
- Child, Preschool
- Diagnosis, Differential
- Drug Therapy, Combination
- Electroencephalography/drug effects
- Epilepsies, Myoclonic/diagnosis
- Epilepsies, Myoclonic/drug therapy
- Epilepsies, Myoclonic/genetics
- Epilepsy, Absence/diagnosis
- Epilepsy, Absence/drug therapy
- Epilepsy, Absence/genetics
- Epilepsy, Generalized/diagnosis
- Epilepsy, Generalized/drug therapy
- Epilepsy, Generalized/genetics
- Epilepsy, Tonic-Clonic/diagnosis
- Epilepsy, Tonic-Clonic/drug therapy
- Epilepsy, Tonic-Clonic/genetics
- Female
- Follow-Up Studies
- Genetic Predisposition to Disease/genetics
- Humans
- Male
- Middle Aged
- Pedigree
- Syndrome
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Affiliation(s)
- C Marini
- Epilepsy Research Institute, Austin and Repatriation Medical Centre, University of Melbourne, Melbourne, Victoria 3081, Australia
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Abstract
The incidence of epilepsy increases with advancing age. Epilepsy in the elderly has different aetiologies from that in younger populations, cerebrovascular disease being the most common condition associated with seizures. Partial seizures are the predominant seizure type in older patients. A diagnosis of epilepsy in the elderly is based mainly on the history and is frequently delayed. In addition, seizure imitators are especially frequent. In many cases ancillary tests for diagnosis may show normal age-related variants, sometimes making results difficult to interpret. Treating epilepsy in the elderly is problematic due to a number of issues that relate to age and comorbidity. The physical changes associated with increasing age frequently lead to changes in the pharmacokinetics of many anticonvulsants. The treatment of epilepsy in the elderly is also complicated by the existence of other diseases that might affect the metabolism or excretion of anticonvulsants and the presence of concomitant medications that might interact with them. Moreover, specific trials of anticonvulsants in the aged population are scarce. General guidelines for treatment include starting at lower doses, slowing the titration schedule, individualising the choice of anticonvulsant to the characteristics of the patient, avoiding anticonvulsants with important cognitive or sedative adverse effects, and where possible, treating with monotherapy.
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Affiliation(s)
- S Arroyo
- Epilepsy Unit, Hospital Clínico de Barcelona, Barcelona, Spain
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Cutting S, Lauchheimer A, Barr W, Devinsky O. Adult-onset idiopathic generalized epilepsy: clinical and behavioral features. Epilepsia 2001; 42:1395-8. [PMID: 11879340 DOI: 10.1046/j.1528-1157.2001.14901.x] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE To identify and define clinical and behavioral features of patients with adult-onset idiopathic generalized epilepsy (IGE). METHODS We reviewed the charts of 313 IGE patients at the NYU Comprehensive Epilepsy Center over the past 5 years to identify patients with adult onset (18 years old or older). We excluded patients with childhood or adolescent symptoms that suggested absence, myoclonic, or tonic-clonic seizures, as well as those with a history of significant head injury or other known causes of localization-related epilepsy. RESULTS Forty-two (13.4%) patients had a clear onset of IGE in adulthood; average age of onset was early 20s (mean, 23.8 years; range, 18-55 years). Twenty-one patients had adult myoclonic epilepsy (AME, 50%), and three had generalized tonic-clonic seizures on awakening (GTCS-A, 7%). More than two thirds (n=30) are well controlled with current antiepileptic drugs (AEDs), and almost 90% are currently employed (n=37). One third were diagnosed and treated for mental disorders, including depression (n=12), anxiety (n=7), obsessive-compulsive personality disorder (n=2), and postictal psychosis (n=1). CONCLUSIONS Adult-onset IGE is associated with a good prognosis. An association may exist between psychological disorders, psychotropic medication, and level of seizure control in adults with IGE.
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Affiliation(s)
- S Cutting
- Department of Neurology, New York University School of Medicine, New York, New York, USA
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