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Deng DZ, Husari KS. Approach to Patients with Seizures and Epilepsy: A Guide for Primary Care Physicians. Prim Care 2024; 51:211-232. [PMID: 38692771 DOI: 10.1016/j.pop.2024.02.008] [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] [Indexed: 05/03/2024]
Abstract
Seizures and epilepsy are common neurologic conditions that are frequently encountered in the outpatient primary care setting. An accurate diagnosis relies on a thorough clinical history and evaluation. Understanding seizure semiology and classification is crucial in conducting the initial assessment. Knowledge of common seizure triggers and provoking factors can further guide diagnostic testing and initial management. The pharmacodynamic characteristics and side effect profiles of anti-seizure medications are important considerations when deciding treatment and counseling patients, particularly those with comorbidities and in special populations such as patient of childbearing potential.
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Affiliation(s)
- Doris Z Deng
- Department of Neurology, Comprehensive Epilepsy Center, Johns Hopkins University, 600 N. Wolfe Street, Meyer 2-147, Baltimore, MD 21287, USA
| | - Khalil S Husari
- Department of Neurology, Comprehensive Epilepsy Center, Johns Hopkins University, 600 N. Wolfe Street, Meyer 2-147, Baltimore, MD 21287, USA.
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Hlauschek G, Nicolo J, Sinclair B, Law M, Yasuda CL, Cendes F, Lossius MI, Kwan P, Vivash L. Role of the glymphatic system and perivascular spaces as a potential biomarker for post-stroke epilepsy. Epilepsia Open 2024; 9:60-76. [PMID: 38041607 PMCID: PMC10839409 DOI: 10.1002/epi4.12877] [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: 04/03/2023] [Accepted: 11/29/2023] [Indexed: 12/03/2023] Open
Abstract
Stroke is one of the most common causes of acquired epilepsy, which can also result in disability and increased mortality rates particularly in elderly patients. No preventive treatment for post-stroke epilepsy is currently available. Development of such treatments has been greatly limited by the lack of biomarkers to reliably identify high-risk patients. The glymphatic system, including perivascular spaces (PVS), is the brain's waste clearance system, and enlargement or asymmetry of PVS (ePVS) is hypothesized to play a significant role in the pathogenesis of several neurological conditions. In this article, we discuss potential mechanisms for the role of perivascular spaces in the development of post-stroke epilepsy. Using advanced MR-imaging techniques, it has been shown that there is asymmetry and impairment of glymphatic function in the setting of ischemic stroke. Furthermore, studies have described a dysfunction of PVS in patients with different focal and generalized epilepsy syndromes. It is thought that inflammatory processes involving PVS and the blood-brain barrier, impairment of waste clearance, and sustained hypertension affecting the glymphatic system during a seizure may play a crucial role in epileptogenesis post-stroke. We hypothesize that impairment of the glymphatic system and asymmetry and dynamics of ePVS in the course of a stroke contribute to the development of PSE. Automated ePVS detection in stroke patients might thus assist in the identification of high-risk patients for post-stroke epilepsy trials. PLAIN LANGUAGE SUMMARY: Stroke often leads to epilepsy and is one of the main causes of epilepsy in elderly patients, with no preventative treatment available. The brain's waste removal system, called the glymphatic system which consists of perivascular spaces, may be involved. Enlargement or asymmetry of perivascular spaces could play a role in this and can be visualised with advanced brain imaging after a stroke. Detecting enlarged perivascular spaces in stroke patients could help identify those at risk for post-stroke epilepsy.
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Affiliation(s)
- Gernot Hlauschek
- Division of Clinical Neuroscience, National Centre for Epilepsy, member of ERN EpicareOslo University HospitalNorway
- The University of OsloOsloNorway
- Department of Neurosciences, Central Clinical SchoolMonash UniversityMelbourneVictoriaAustralia
| | - John‐Paul Nicolo
- Department of Neurosciences, Central Clinical SchoolMonash UniversityMelbourneVictoriaAustralia
- Department of NeurologyThe AlfredMelbourneVictoriaAustralia
- Departments of Medicine and NeurologyThe University of Melbourne, Royal Melbourne HospitalParkvilleVictoriaAustralia
| | - Benjamin Sinclair
- Department of Neurosciences, Central Clinical SchoolMonash UniversityMelbourneVictoriaAustralia
- Department of NeurologyThe AlfredMelbourneVictoriaAustralia
| | - Meng Law
- Department of Neurosciences, Central Clinical SchoolMonash UniversityMelbourneVictoriaAustralia
- Department of RadiologyThe AlfredMelbourneVictoriaAustralia
| | | | | | - Morten Ingvar Lossius
- Division of Clinical Neuroscience, National Centre for Epilepsy, member of ERN EpicareOslo University HospitalNorway
- The University of OsloOsloNorway
| | - Patrick Kwan
- Department of Neurosciences, Central Clinical SchoolMonash UniversityMelbourneVictoriaAustralia
- Department of NeurologyThe AlfredMelbourneVictoriaAustralia
- Departments of Medicine and NeurologyThe University of Melbourne, Royal Melbourne HospitalParkvilleVictoriaAustralia
| | - Lucy Vivash
- Department of Neurosciences, Central Clinical SchoolMonash UniversityMelbourneVictoriaAustralia
- Department of NeurologyThe AlfredMelbourneVictoriaAustralia
- Departments of Medicine and NeurologyThe University of Melbourne, Royal Melbourne HospitalParkvilleVictoriaAustralia
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Lee SH, Gillespie C, Bandyopadhyay S, Nazari A, Ooi SZY, Park JJ, Champ C, Taylor C, Kinney M, Mackay G, Myint PK, Marson A. National audit of pathways in epileptic seizure referrals (NAPIER): A national, multicentre audit of first seizure clinics throughout the UK and Ireland. Seizure 2023; 111:165-171. [PMID: 37639958 DOI: 10.1016/j.seizure.2023.08.010] [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: 06/08/2023] [Revised: 07/28/2023] [Accepted: 08/18/2023] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND Current guidelines set clinical standards for the management of suspected first seizures and epilepsy. We aimed to assess if these standards are being met across first seizure clinics nationally, to describe variations in care and identify opportunities for service delivery improvement. METHODS Multicentre audit assessing the care of adults (≥16 years) referred to first seizure clinics from 31st December 2019 going backwards (30 consecutive patients per centre). Patients with pre-existing diagnosis of epilepsy were excluded. Anonymised referral, clinic, and follow-up data are reported with descriptive statistics. RESULTS Data provided for 727 patients from 25 hospitals in the UK and Ireland (median age 41 years [IQR 26-59], 52% males). Median time to review was 48 days (IQR 26-86), with 13.8% (IQR 3.3%-24.0%) of patients assessed within 2 weeks. Seizure recurrence was seen in 12.7% (IQR 6.6%-17.4%) of patients awaiting first appointment. Documentation for witness accounts and driving advice was evident in 85.0% (IQR 74.0%-100%) and 79.7% (IQR 71.2%-96.4%) of first seizure/epilepsy patients, respectively. At first appointment, discussion of sudden unexpected death in epilepsy was documented in 30.1% (IQR 0%-42.5%) of patients diagnosed with epilepsy. In epilepsy patients, median time to MRI neuroimaging was 37 days [IQR 22-56] and EEG was 30 days [IQR 19-47]. 30.4% ([IQR 0%-59.5%]) of epilepsy patients were referred to epilepsy nurse specialists. CONCLUSIONS There is variability nationally in the documented care of patients referred to first seizure clinics. Many patients are facing delays to assessment with epilepsy specialists with likely subsequent impact on further management.
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Affiliation(s)
- Seong Hoon Lee
- Department of Neurology, Aberdeen Royal Infirmary, NHS Grampian, UK; Institute of Applied Health Sciences, School of Medicine, University of Aberdeen, UK.
| | - Conor Gillespie
- Institute of Systems, Molecular and Integrative Biology, University of Liverpool, UK; Department of Neurology, The Walton Centre NHS Foundation Trust, UK
| | - Soham Bandyopadhyay
- Oxford University Global Surgery Group, Nuffield Department of Surgical Sciences, University of Oxford, UK
| | - Armin Nazari
- University of Dundee Medical School, University of Dundee, UK
| | | | - Jay J Park
- University of Edinburgh Division of Clinical and Surgical Sciences, University of Edinburgh, UK
| | | | - Claire Taylor
- Liverpool Clinical Trials Centre, University of Liverpool, Faculty of Health and Life Sciences, UK
| | - Michael Kinney
- Department of Neurology, Royal Victoria Hospital, Belfast Health & Social Care Trust, UK
| | - Graham Mackay
- Department of Neurology, Aberdeen Royal Infirmary, NHS Grampian, UK
| | - Phyo Kyaw Myint
- Ageing Clinical & Experimental Research (ACER) Team, Institute of Applied Health Sciences, University of Aberdeen, UK
| | - Anthony Marson
- Department of Neurology, The Walton Centre NHS Foundation Trust, UK; Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, UK
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Yeap TB, Ab Mukmin L, Ang SY, Ghani AR. Perianaesthetic challenges in patients undergoing vagus nerve stimulation (VNS) placement. BMJ Case Rep 2023; 16:e252692. [PMID: 36750294 PMCID: PMC9906277 DOI: 10.1136/bcr-2022-252692] [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] [Indexed: 02/09/2023] Open
Abstract
Patients with medically refractory epilepsy (MRE) are indicated for vagus nerve stimulation (VNS) placement. Anaesthesia for VNS placement is extremely challenging and requires several considerations. We present a man in his 20s with MRE who successfully underwent VNS placement. We review the mechanism of action of VNS, anaesthetic challenges and measures to prevent seizures.
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Affiliation(s)
- Tat Boon Yeap
- Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah, Kota Kinabalu, Malaysia
| | - Laila Ab Mukmin
- Department of Anaesthesia and Intensive Care Unit, Hospital Universiti Sains Malaysia, Kota Bahru, Malaysia
| | - Song Yee Ang
- Department of Neurosciences, School of Medical Sciences, Hospital Universiti Sains Malaysia, Kota Bahru, Malaysia
| | - Ab Rahman Ghani
- Department of Neurosciences, School of Medical Sciences, Hospital Universiti Sains Malaysia, Kota Bahru, Malaysia
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Tabaee Damavandi P, Storti B, Fabin N, Bianchi E, Ferrarese C, DiFrancesco JC. Epilepsy in cerebral amyloid angiopathy: an observational retrospective study of a large population. Epilepsia 2023; 64:500-510. [PMID: 36515439 DOI: 10.1111/epi.17489] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 12/02/2022] [Accepted: 12/12/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Cerebral amyloid angiopathy (CAA) is a major cause of spontaneous intracranial hemorrhage in older adults. Epilepsy represents a possible sequela of the disease. To date, studies on epilepsy in CAA are lacking, and the few data available mainly focus on CAA-related inflammation (CAA-ri), the inflammatory form of the disease. METHODS In this retrospective observational study, we consecutively recruited CAA patients observed over a time span of 10 years, collecting demographic, clinical, and instrumental data. Significant baseline characteristics were evaluated as potential risk factors for the development of epilepsy in the CAA population, and in the subgroups of CAA-ri and CAA without inflammatory reaction (CAA-nri). The effect of potential risk factors for epilepsy was measured as odds ratio with 95% confidence interval. RESULTS Within 96 recruited CAA cases, 33 (34.4%) developed epilepsy during follow-up (median = 13.5 months). The prevalent type of seizure was focal (81.3%); 12.1% of the epileptic patients presented status epilepticus, and 6.1% developed drug-resistant epilepsy. Electroencephalographic traces revealed slow and epileptic discharge activity in the majority of epileptic patients, but also in those without epilepsy. The presence of focal or disseminated cortical superficial siderosis (cSS) was associated with an increased risk of epilepsy in the CAA-nri group, and the association with CAA-ri and epilepsy was present in the overall population. SIGNIFICANCE Epilepsy is a common manifestation during the course of CAA, where CAA-ri and cSS represent predisposing factors for the development of seizures. These data suggest the importance of a deep characterization of CAA patients, to better select those more prone to develop epilepsy.
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Affiliation(s)
- Payam Tabaee Damavandi
- Department of Neurology, ASST San Gerardo Hospital, School of Medicine and Surgery and Milan Center for Neuroscience, University of Milan-Bicocca, Monza, Italy
| | - Benedetta Storti
- Department of Neurology, ASST San Gerardo Hospital, School of Medicine and Surgery and Milan Center for Neuroscience, University of Milan-Bicocca, Monza, Italy
| | - Natalia Fabin
- Laboratory of Epidemiological and Clinical Cardiology, Department of Experimental, Diagnostic, and Specialty Medicine, University of Bologna, Bologna, Italy
| | - Elisa Bianchi
- Neurological Disorders, Mario Negri Institute of Pharmacological Research, Scientific Institute for Research and Health Care, Milan, Italy
| | - Carlo Ferrarese
- Department of Neurology, ASST San Gerardo Hospital, School of Medicine and Surgery and Milan Center for Neuroscience, University of Milan-Bicocca, Monza, Italy
| | - Jacopo C DiFrancesco
- Department of Neurology, ASST San Gerardo Hospital, School of Medicine and Surgery and Milan Center for Neuroscience, University of Milan-Bicocca, Monza, Italy
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Neligan A, Adan G, Nevitt SJ, Pullen A, Sander JW, Bonnett L, Marson AG. Prognosis of adults and children following a first unprovoked seizure. Cochrane Database Syst Rev 2023; 1:CD013847. [PMID: 36688481 PMCID: PMC9869434 DOI: 10.1002/14651858.cd013847.pub2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Epilepsy is clinically defined as two or more unprovoked epileptic seizures more than 24 hours apart. Given that, a diagnosis of epilepsy can be associated with significant morbidity and mortality, it is imperative that clinicians (and people with seizures and their relatives) have access to accurate and reliable prognostic estimates, to guide clinical practice on the risks of developing further unprovoked seizures (and by definition, a diagnosis of epilepsy) following single unprovoked epileptic seizure. OBJECTIVES 1. To provide an accurate estimate of the proportion of individuals going on to have further unprovoked seizures at subsequent time points following a single unprovoked epileptic seizure (or cluster of epileptic seizures within a 24-hour period, or a first episode of status epilepticus), of any seizure type (overall prognosis). 2. To evaluate the mortality rate following a first unprovoked epileptic seizure. SEARCH METHODS We searched the following databases on 19 September 2019 and again on 30 March 2021, with no language restrictions. The Cochrane Register of Studies (CRS Web), MEDLINE Ovid (1946 to March 29, 2021), SCOPUS (1823 onwards), ClinicalTrials.gov, the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP). CRS Web includes randomized or quasi-randomized, controlled trials from PubMed, Embase, ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry Platform (ICTRP), the Cochrane Central Register of Controlled Trials (CENTRAL), and the Specialized Registers of Cochrane Review Groups including Epilepsy. In MEDLINE (Ovid) the coverage end date always lags a few days behind the search date. SELECTION CRITERIA We included studies, both retrospective and prospective, of all age groups (except those in the neonatal period (< 1 month of age)), of people with a single unprovoked seizure, followed up for a minimum of six months, with no upper limit of follow-up, with the study end point being seizure recurrence, death, or loss to follow-up. To be included, studies must have included at least 30 participants. We excluded studies that involved people with seizures that occur as a result of an acute precipitant or provoking factor, or in close temporal proximity to an acute neurological insult, since these are not considered epileptic in aetiology (acute symptomatic seizures). We also excluded people with situational seizures, such as febrile convulsions. DATA COLLECTION AND ANALYSIS Two review authors conducted the initial screening of titles and abstracts identified through the electronic searches, and removed non-relevant articles. We obtained the full-text articles of all remaining potentially relevant studies, or those whose relevance could not be determined from the abstract alone and two authors independently assessed for eligibility. All disagreements were resolved through discussion with no need to defer to a third review author. We extracted data from included studies using a data extraction form based on the checklist for critical appraisal and data extraction for systematicreviews of prediction modelling studies (CHARMS). Two review authors then appraised the included studies, using a standardised approach based on the quality in prognostic studies (QUIPS) tool, which was adapted for overall prognosis (seizure recurrence). We conducted a meta-analysis using Review Manager 2014, with a random-effects generic inverse variance meta-analysis model, which accounted for any between-study heterogeneity in the prognostic effect. We then summarised the meta-analysis by the pooled estimate (the average prognostic factor effect), its 95% confidence interval (CI), the estimates of I² and Tau² (heterogeneity), and a 95% prediction interval for the prognostic effect in a single population at three various time points, 6 months, 12 months and 24 months. Subgroup analysis was performed according to the ages of the cohorts included; studies involving all ages, studies that recruited adult only and those that were purely paediatric. MAIN RESULTS Fifty-eight studies (involving 54 cohorts), with a total of 12,160 participants (median 147, range 31 to 1443), met the inclusion criteria for the review. Of the 58 studies, 26 studies were paediatric studies, 16 were adult and the remaining 16 studies were a combination of paediatric and adult populations. Most included studies had a cohort study design with two case-control studies and one nested case-control study. Thirty-two studies (29 cohorts) reported a prospective longitudinal design whilst 15 studies had a retrospective design whilst the remaining studies were randomised controlled trials. Nine of the studies included presented mortality data following a first unprovoked seizure. For a mortality study to be included, a proportional mortality ratio (PMR) or a standardised mortality ratio (SMR) had to be given at a specific time point following a first unprovoked seizure. To be included in the meta-analysis a study had to present clear seizure recurrence data at 6 months, 12 months or 24 months. Forty-six studies were included in the meta-analysis, of which 23 were paediatric, 13 were adult, and 10 were a combination of paediatric and adult populations. A meta-analysis was performed at three time points; six months, one year and two years for all ages combined, paediatric and adult studies, respectively. We found an estimated overall seizure recurrence of all included studies at six months of 27% (95% CI 24% to 31%), 36% (95% CI 33% to 40%) at one year and 43% (95% CI 37% to 44%) at two years, with slightly lower estimates for adult subgroup analysis and slightly higher estimates for paediatric subgroup analysis. It was not possible to provide a summary estimate of the risk of seizure recurrence beyond these time points as most of the included studies were of short follow-up and too few studies presented recurrence rates at a single time point beyond two years. The evidence presented was found to be of moderate certainty. AUTHORS' CONCLUSIONS Despite the limitations of the data (moderate-certainty of evidence), mainly relating to clinical and methodological heterogeneity we have provided summary estimates for the likely risk of seizure recurrence at six months, one year and two years for both children and adults. This provides information that is likely to be useful for the clinician counselling patients (or their parents) on the probable risk of further seizures in the short-term whilst acknowledging the paucity of long-term recurrence data, particularly beyond 10 years.
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Affiliation(s)
- Aidan Neligan
- Homerton University Hospital, NHS Foundation Trust, London, UK
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, UK
| | - Guleed Adan
- Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
- The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Sarah J Nevitt
- Department of Health Data Science, University of Liverpool, Liverpool, UK
| | | | - Josemir W Sander
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, UK
- National Hospital for Neurology and Neurosurgery, London, UK
| | - Laura Bonnett
- Department of Health Data Science, University of Liverpool, Liverpool, UK
| | - Anthony G Marson
- Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
- The Walton Centre NHS Foundation Trust, Liverpool, UK
- Liverpool Health Partners, Liverpool, UK
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Pease M, Gonzalez-Martinez J, Puccio A, Nwachuku E, Castellano JF, Okonkwo DO, Elmer J. Risk Factors and Incidence of Epilepsy after Severe Traumatic Brain Injury. Ann Neurol 2022; 92:663-669. [PMID: 35713346 PMCID: PMC9489614 DOI: 10.1002/ana.26443] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Revised: 06/09/2022] [Accepted: 06/13/2022] [Indexed: 11/12/2022]
Abstract
We determined the incidence of post-traumatic epilepsy after severe traumatic brain injury. Of 392 patients surviving to discharge, cumulative incidence of post-traumatic epilepsy was 25% at 5 years and 32% at 15 years, an increase compared with historical reports. Among patients with one late seizure (>7 days post-trauma), the risk of seizure recurrence was 62% after 1 year and 82% at 10 years. Competing hazards regression identified age, decompressive hemicraniectomy, and intracranial infection as independent predictors of post-traumatic epilepsy. Patients with severe traumatic brain injury and a single late post-traumatic seizure will likely require long-term antiseizure medicines. ANN NEUROL 2022;92:663-669.
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Affiliation(s)
- Matthew Pease
- University of Pittsburgh Medical Center, Department of Neurosurgery
| | | | - Ava Puccio
- University of Pittsburgh Medical Center, Department of Neurosurgery
| | - Enyinna Nwachuku
- University of Pittsburgh Medical Center, Department of Neurosurgery
| | | | - David O. Okonkwo
- University of Pittsburgh Medical Center, Department of Neurosurgery
| | - Jonathan Elmer
- University of Pittsburgh Medical Center, Department of Neurology
- University of Pittsburgh Medical Center, Department of Critical Care
- University of Pittsburgh Medical Center, Department of Emergency Medicine
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Molecular Mechanism and Regulation of Autophagy and Its Potential Role in Epilepsy. Cells 2022; 11:cells11172621. [PMID: 36078029 PMCID: PMC9455075 DOI: 10.3390/cells11172621] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 08/14/2022] [Accepted: 08/22/2022] [Indexed: 01/18/2023] Open
Abstract
Autophagy is an evolutionally conserved degradation mechanism for maintaining cell homeostasis whereby cytoplasmic components are wrapped in autophagosomes and subsequently delivered to lysosomes for degradation. This process requires the concerted actions of multiple autophagy-related proteins and accessory regulators. In neurons, autophagy is dynamically regulated in different compartments including soma, axons, and dendrites. It determines the turnover of selected materials in a spatiotemporal control manner, which facilitates the formation of specialized neuronal functions. It is not surprising, therefore, that dysfunctional autophagy occurs in epilepsy, mainly caused by an imbalance between excitation and inhibition in the brain. In recent years, much attention has been focused on how autophagy may cause the development of epilepsy. In this article, we overview the historical landmarks and distinct types of autophagy, recent progress in the core machinery and regulation of autophagy, and biological roles of autophagy in homeostatic maintenance of neuronal structures and functions, with a particular focus on synaptic plasticity. We also discuss the relevance of autophagy mechanisms to the pathophysiology of epileptogenesis.
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Profiles of indigenous patients with epilepsy in a Brazilian village. Epilepsy Behav 2022; 131:108703. [PMID: 35526465 DOI: 10.1016/j.yebeh.2022.108703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 04/06/2022] [Accepted: 04/07/2022] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Identifying epilepsy in local indigenous populations and describing its epidemiological, etiological, electroencephalographic, and therapeutic aspects can assist public health policies planning toward epilepsy in indigenous communities. METHODS This descriptive, cross-sectional study investigated epilepsy among indigenous people residing in Jaguapirú Village, Dourados, Mato Grosso do Sul, Brazil. Participants had their clinical histories reviewed and physical examination performed, as well as one or more electroencephalograms (EEG) registered. Other laboratory tests and neuroimaging data available were analyzed and patients with nonepileptic paroxysmal events were additionally identified. RESULTS Out of 2,994 respondents, 49 had a confirmed diagnosis of epilepsy (2.37%) and 22 had self-limited epileptic syndromes, a rate that exceeds the global prevalence but is close to other data reported in the Brazilian population. Focal epilepsy, predominantly from temporal lobe origin, was the most prevalent epileptic syndrome (71.4%). Febrile seizures occurred in only 0.4% of respondents, much lower rate than reported in the general population, which can be attributed to the cross-sectional study design. The etiology of epilepsy was undetermined in 82.6% of cases, with the remaining cases attributed to head trauma, hypoxic-ischemic encephalopathy, and brain malformations. A history of delayed neuropsychomotor development was significantly associated with epilepsy. Monotherapy with first-generation antiseizure medications was greatly effective in most epilepsy cases (87.7%). Electroencephalogram helped to define focal epilepsies and diagnose seizures of nonepileptic origin; the latter mostly included cases of psychogenic seizures and, less frequently, syncope. CONCLUSION Diagnosing epilepsy, its clinical presentation, and therapeutical response profile in traditional communities is essential for the establishment of public health policies in developing countries and may help community involvement for successful treatment.
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Pellino G, Faggioli R, Madrassi L, Falsaperla R, Suppiej A. Operational diagnosis of epilepsy in children at undetermined risk: A meta-analysis of prognostic factors for seizure recurrence. Epilepsy Behav 2022; 127:108498. [PMID: 34954509 DOI: 10.1016/j.yebeh.2021.108498] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 11/23/2021] [Accepted: 12/04/2021] [Indexed: 11/15/2022]
Abstract
PURPOSE According to the operational epilepsy definition adopted by the International League Against Epilepsy (ILAE) in 2014, in patients with one unprovoked seizure, clinicians must stratify the recurrence risk to determine if the criteria for diagnosis of epilepsy have been met and if antiseizure medications (ASM) are required. A remote symptomatic etiology was considered to be one of the best predictors for seizure recurrence, also according to the available prediction tools, but in children with a previously negative history and a normal neurological examination, estimating the probability of seizure relapse remains less obvious. This meta-analysis aimed to fill this gap of knowledge. METHODS The PubMed, Embase, and Scopus databases were searched from January 2000 to December 2020. We selected studies reporting children (1 month-18 years old) presenting a first unprovoked seizure. The absence of a known remote neurological pathology had to be clearly stated in the paper or the idiopathic/cryptogenic group data were used; the finding of epileptogenic structural brain MRI abnormalities during the diagnostic workup at the moment of the first unprovoked seizure was not an exclusion criterion. Factors analyzed, as possible predictors of recurrence, included: age at onset, sex, family history of epilepsy, type of seizure (focal or generalized), epileptiform abnormalities on EEG, and epileptogenic structural brain MRI abnormalities. RESULTS Four studies met the inclusion criteria and the sample size consisted of 741 children. The estimated recurrence rate within 3 years was 50% (95%CI:33.9%-66.0%). Among the predictors of recurrence, focal seizure (OR = 1.52; 95%CI = 1.05-2.19), epileptiform abnormalities on EEG (OR = 1.97; 95%CI = 1.31-2.96), and positive family history for epilepsy (OR = 2.37; 95%CI = 1.56-3.59) were associated with a statistically significant increased risk. CONCLUSION The analysis of data available until now cannot adequately assess the risk of recurrence after a first unprovoked seizure in neurotypical children. Prospective and multicenter cohort studies are expected.
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Affiliation(s)
- Giuditta Pellino
- Pediatric Unit, Azienda USL Ferrara - University Hospital of Ferrara, Ferrara, Italy; Department of Neuroscience and Rehabilitation, University of Ferrara, Ferrara, Italy.
| | - Raffaella Faggioli
- Department of Medical Sciences, Section of Pediatrics, University of Ferrara, Ferrara, Italy
| | - Laura Madrassi
- Department of Medical Sciences, Section of Pediatrics, University of Ferrara, Ferrara, Italy
| | - Raffaele Falsaperla
- Neonatal Intensive Care Unit, AOU San Marco-Policlinico, University of Catania, Via Carlo Azeglio Ciampi, 95121 Catania, Italy
| | - Agnese Suppiej
- Department of Medical Sciences, Section of Pediatrics, University of Ferrara, Ferrara, Italy
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Esmael A, Elsherbeny S, Abbas M. Association of epileptiform brain activity and specific language impairment (SLI) in preschool children. THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2021. [DOI: 10.1186/s41983-021-00269-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Epileptiform activities can cause transient or permanent deficits that affect the children during development and may be accompanied by neurodevelopmental disorders like specific language impairment.
Objectives
The objective of this study was to find if there is a possible association and the impact of epilepsy and epileptiform activity in children with specific language impairment.
Patients and methods
The study was conducted on 80 children suffering from specific language impairment and 80 age and sex match healthy control children. Computed tomography brain was performed and electroencephalography was recorded for children. Intelligence quotient level, cognitive age, social, and phoniatric assessment were done for all patients.
Results
Eighty children with specific language impairment (51 males and 29 females) with a mean age of 4.11 ± 1.93. Patients with specific language impairment showed significantly higher rates of abnormal electroencephalography (P = 0.006) and epilepsy (P < 0.001) compared to the control group. Spearman correlation demonstrated a highly negative significant relationship linking the language, intelligence quotient with abnormal electroencephalography and epilepsy (r = − 0.91, P < 0.01 and r = − 0.91, P < 0.01 respectively). Also, there was a moderately inverse significant relationship linking the cognitive age, social with abnormal electroencephalography, and epilepsy (r = − 0.70, P < 0.05 and r = − 0.65, P < 0.05 respectively).
Conclusion
Epileptiform activities even without epilepsy in preschool children may alter normal language function. Specific language impairment was associated with lower intelligence quotient levels, social, and cognitive age.
Trial registration
ClinicalTrials.gov ID: NCT04141332
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Schmidt MH, Crocker CE, Abdolell M, Ghuman MS, Pohlmann-Eden B. Toward individualized prediction of seizure recurrence: Hippocampal neuroimaging features in a cohort of patients from a first seizure clinic. Epilepsy Behav 2021; 122:108118. [PMID: 34144462 DOI: 10.1016/j.yebeh.2021.108118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 05/25/2021] [Accepted: 05/25/2021] [Indexed: 11/15/2022]
Abstract
PURPOSE We performed an exploratory analysis of electroencephalography (EEG) and neuroimaging data from a cohort of 51 patients with first seizure (FS) and new-onset epilepsy (NOE) to identify variables, or combinations of variables, that might discriminate between clinical trajectories over a one-year period and yield potential biomarkers of epileptogenesis. METHODS Patients underwent EEG, hippocampal and whole brain structural magnetic resonance imaging (MRI), diffusion tensor imaging (DTI), and magnetic resonance spectroscopy (MRS) within six weeks of the index seizure, and repeat neuroimaging one year later. We classified patients with FS as having had a single seizure (FS-SS) or having converted to epilepsy (FS-CON) after one year and performed logistic regression to identify combinations of variables that might discriminate between FS-SS and FS-CON, and between FS-SS and the combined group FS-CON + NOE. We performed paired t-tests to assess changes in quantitative variables over time. RESULTS Several combinations of variables derived from hippocampal structural MRI, DTI, and MRS provided excellent discrimination between FS-SS and FS-CON in our sample, with areas under the receiver operating curve (AUROC) ranging from 0.924 to 1. They also provided excellent discrimination between FS-SS and the combined group FS-CON + NOE in our sample, with AUROC ranging from 0.902 to 1. After one year, hippocampal fractional anisotropy (FA) increased bilaterally, hippocampal radial diffusivity (RD) decreased on the side with the larger initial measurement, and whole brain axial diffusivity (AD) increased in patients with FS-SS; hippocampal volume decreased on the side with the larger initial measurement, hippocampal FA increased bilaterally, hippocampal RD decreased bilaterally and whole brain AD, FA and mean diffusivity increased in the combined group FS-CON + NOE (corrected threshold for significance, q = 0.017). CONCLUSION We propose a prospective, multicenter study to develop and test models for the prediction of seizure recurrence in patients after a first seizure, based on hippocampal neuroimaging. Further longitudinal neuroimaging studies in patients with a first seizure and new-onset epilepsy may provide clues to the microstructural changes occurring at the earliest stages of epilepsy and yield biomarkers of epileptogenesis.
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Affiliation(s)
- Matthias H Schmidt
- Department of Diagnostic Radiology, Dalhousie University, Halifax, Canada; Division of Neurosurgery, Dalhousie University, Halifax, Canada; Department of Medical Neuroscience, Dalhousie University, Halifax, Canada; Brain Repair Centre, Dalhousie University, Halifax, Canada.
| | - Candice E Crocker
- Department of Diagnostic Radiology, Dalhousie University, Halifax, Canada; Department of Psychiatry, Dalhousie University, Halifax, Canada
| | - Mohamed Abdolell
- Department of Diagnostic Radiology, Dalhousie University, Halifax, Canada; Department of Community Health and Epidemiology, Dalhousie University, Halifax, Canada
| | - Mandeep S Ghuman
- Department of Diagnostic Radiology, Dalhousie University, Halifax, Canada
| | - Bernd Pohlmann-Eden
- Brain Repair Centre, Dalhousie University, Halifax, Canada; Division of Neurology, Dalhousie University, Halifax, Canada
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13
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Vergonjeanne M, Auditeau E, Erazo D, Luna J, Gelle T, Gbessemehlan A, Boumediene F, Preux PM. Epidemiology of Epilepsy in Low- and Middle-Income Countries: Experience of a Standardized Questionnaire over the Past Two Decades. Neuroepidemiology 2021; 55:369-380. [PMID: 34315167 DOI: 10.1159/000517065] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 05/04/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Epilepsy affects >50 million people worldwide, with 80% of them living in low- and middle-income countries (LMICs). Studies with a standardized methodology are required to obtain comparable data on epilepsy and implement health policies in order to reduce the treatment gap and improve the diagnosis and management of epilepsy. In 2000, following the guidelines of the International League Against Epilepsy (ILAE), the "questionnaire for investigation of epilepsy in tropical countries" (IENT questionnaire) was developed to promote epidemiological surveys on epilepsy using a standard methodology. This study aims to describe how, when, where, and why the IENT questionnaire has been used through epidemiological studies on epilepsy over the last 2 decades and to acquire users' opinions about the tool. METHODS Studies that used the IENT questionnaire were searched through international and local bibliographic databases, including the gray literature. An online survey was carried out, including a snowball effect. Original research studies were included. Characteristics of the studies and populations and general information on the instrument and its use were collected. RESULTS Eighty-two documents were selected referring to 61 studies that were mostly carried out on the African continent (n = 54). Most of them aimed to determine the prevalence (n = 31) and associated factors (n = 28) of epilepsy in LMICs. Among the 61 studies, 35 were population-based, and 30 included both adults and children. A methodological heterogeneity was found between studies, and in cases where the IENT questionnaire alone did not ensure complete data collection, other tools were used concomitantly (n = 40). DISCUSSION/CONCLUSION Over the last 2 decades, the IENT questionnaire has been continuously used in different LMICs. This result favors its promotion and updating, with the inclusion of new topics related to epilepsy (e.g., comorbidities, quality of life, and stigma), current ILAE guidelines, and digital versions.
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Affiliation(s)
- Marion Vergonjeanne
- INSERM, Univ. Limoges, CHU Limoges, IRD, U1094, Tropical Neuroepidemiology, Institute of Epidemiology and Tropical Neurology, GEIST, Limoges, France,
| | - Emilie Auditeau
- INSERM, Univ. Limoges, CHU Limoges, IRD, U1094, Tropical Neuroepidemiology, Institute of Epidemiology and Tropical Neurology, GEIST, Limoges, France
| | - Daniells Erazo
- INSERM, Univ. Limoges, CHU Limoges, IRD, U1094, Tropical Neuroepidemiology, Institute of Epidemiology and Tropical Neurology, GEIST, Limoges, France
| | - Jaime Luna
- INSERM, Univ. Limoges, CHU Limoges, IRD, U1094, Tropical Neuroepidemiology, Institute of Epidemiology and Tropical Neurology, GEIST, Limoges, France
| | - Thibaut Gelle
- INSERM, Univ. Limoges, CHU Limoges, IRD, U1094, Tropical Neuroepidemiology, Institute of Epidemiology and Tropical Neurology, GEIST, Limoges, France
| | - Antoine Gbessemehlan
- INSERM, Univ. Limoges, CHU Limoges, IRD, U1094, Tropical Neuroepidemiology, Institute of Epidemiology and Tropical Neurology, GEIST, Limoges, France
| | - Farid Boumediene
- INSERM, Univ. Limoges, CHU Limoges, IRD, U1094, Tropical Neuroepidemiology, Institute of Epidemiology and Tropical Neurology, GEIST, Limoges, France
| | - Pierre-Marie Preux
- INSERM, Univ. Limoges, CHU Limoges, IRD, U1094, Tropical Neuroepidemiology, Institute of Epidemiology and Tropical Neurology, GEIST, Limoges, France
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14
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Giussani G, Bianchi E, Beretta S, Carone D, DiFrancesco JC, Stabile A, Zanchi C, Pirovano M, Trentini C, Padovano G, Colombo M, Cereda D, Tinti L, Scanziani S, Gasparini S, Bogliun G, Ferrarese C, Beghi E. Comorbidities in patients with epilepsy: Frequency, mechanisms and effects on long-term outcome. Epilepsia 2021; 62:2395-2404. [PMID: 34309011 DOI: 10.1111/epi.17022] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 06/22/2021] [Accepted: 07/15/2021] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To assess frequency, types, and mechanisms of comorbidities in people with epilepsy and verify their association with disease features and outcome. METHODS This cohort study was performed in 13 Italian epilepsy centers with nationwide distribution and accurate records. Eligible patients were children and adults diagnosed before December 31, 2005, and followed for a minimum of 10 years. Two pairs of raters independently reviewed patients' records and classified each comorbidity. In case of disagreement, a third reviewer made the final decision. Comorbidities were classified according to type (organ/system) and underlying mechanism (causal, shared risk factors, chance association). Comorbidity types and mechanisms were described in the entire sample and according to epilepsy prognostic patterns (sustained remission, relapsing-remitting course, no remission). RESULTS Of 1006 included patients, 266 (26.4%) had at least one comorbidity. The most common were developmental/perinatal (7.5% of cases), psychiatric (6.2%), cardiovascular (5.3%), and endocrine/metabolic (3.8%). Among 408 reported comorbidities, the underlying mechanisms were, in decreasing order, chance association (42.2%), shared risk factors (31.1%), and causal (26.7%). Psychiatric diseases were present in 13.3% of patients with no remission, 5.9% of patients with relapsing-remitting course, and 4.8% of patients with sustained remission (p = .016). The corresponding numbers for endocrine/metabolic diseases were respectively, 9.6%, 3.4%, and 2.9% (p = .013); for respiratory diseases were 3.6%, .3%, and .3% (p = .001), and for urogenital diseases were 3.6%, .7%, and 1.6% (p = .048). The association of endocrine/metabolic, psychiatric, and respiratory comorbidities with epilepsy prognosis was confirmed by multivariable analysis adjusted for the main demographic and clinical variables, with patients with these comorbidities showing a lower probability of achieving remission. SIGNIFICANCE Comorbidities in epilepsy are not uncommon and reflect differing underlying mechanisms. Psychiatric, endocrine/metabolic, and respiratory disorders are associated with a worse long-term epileptological outcome.
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Affiliation(s)
- Giorgia Giussani
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milano, Italy
| | - Elisa Bianchi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milano, Italy
| | - Simone Beretta
- Epilepsy Center, Department of Neurology, San Gerardo Hospital ASST Monza, University of Milano Bicocca, Monza, Italy
| | - Davide Carone
- Epilepsy Center, Department of Neurology, San Gerardo Hospital ASST Monza, University of Milano Bicocca, Monza, Italy
| | - Jacopo C DiFrancesco
- Epilepsy Center, Department of Neurology, San Gerardo Hospital ASST Monza, University of Milano Bicocca, Monza, Italy
| | - Andrea Stabile
- Epilepsy Center, Department of Neurology, San Gerardo Hospital ASST Monza, University of Milano Bicocca, Monza, Italy
| | - Clara Zanchi
- Epilepsy Center, Department of Neurology, San Gerardo Hospital ASST Monza, University of Milano Bicocca, Monza, Italy
| | - Marta Pirovano
- Epilepsy Center, Department of Neurology, San Gerardo Hospital ASST Monza, University of Milano Bicocca, Monza, Italy
| | - Claudia Trentini
- Epilepsy Center, Department of Neurology, San Gerardo Hospital ASST Monza, University of Milano Bicocca, Monza, Italy
| | - Giada Padovano
- Epilepsy Center, Department of Neurology, San Gerardo Hospital ASST Monza, University of Milano Bicocca, Monza, Italy
| | - Matteo Colombo
- Epilepsy Center, Department of Neurology, San Gerardo Hospital ASST Monza, University of Milano Bicocca, Monza, Italy
| | - Diletta Cereda
- Epilepsy Center, Department of Neurology, San Gerardo Hospital ASST Monza, University of Milano Bicocca, Monza, Italy
| | - Lorenzo Tinti
- Epilepsy Center, Department of Neurology, San Gerardo Hospital ASST Monza, University of Milano Bicocca, Monza, Italy
| | - Sofia Scanziani
- Epilepsy Center, Department of Neurology, San Gerardo Hospital ASST Monza, University of Milano Bicocca, Monza, Italy
| | - Sara Gasparini
- Medical and Surgical Sciences Department, School of Medicine, Magna Graecia University of Catanzaro, Catanzaro, Italy.,Regional Epilepsy Centre, Great Metropolitan Hospital, Reggio Calabria, Italy
| | - Graziella Bogliun
- Epilepsy Center, Department of Neurology, San Gerardo Hospital ASST Monza, University of Milano Bicocca, Monza, Italy
| | - Carlo Ferrarese
- Epilepsy Center, Department of Neurology, San Gerardo Hospital ASST Monza, University of Milano Bicocca, Monza, Italy
| | - Ettore Beghi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milano, Italy
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Sharma S, Chen Z, Rychkova M, Dunne J, Lee J, Lawn N, Kwan P. Short- and long-term outcomes of immediate and delayed treatment in epilepsy diagnosed after one or multiple seizures. Epilepsy Behav 2021; 117:107880. [PMID: 33711683 DOI: 10.1016/j.yebeh.2021.107880] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 02/06/2021] [Accepted: 02/17/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVES To compare the outcomes between immediate and deferred treatments in patients diagnosed after one or multiple (two or more) seizures. METHODS Our observational study investigated seizure recurrence and 12-month seizure remission in patients with newly diagnosed epilepsy, comparing immediate to deferred treatment in patients diagnosed after one seizure or after two or more seizures. RESULTS Of 598 patients (62% male, median age 39 years), 347 (58%) were treated at diagnosis and 251 (42%) received deferred or no treatment. Seizure recurrence was higher with deferred treatment both in patients diagnosed after two or more seizures (n = 363; adjusted hazard ratio [aHR] = 2.38, 95% confidence interval [CI]: 1.79-3.14, p < 0.001) and after one seizure (n = 235; aHR = 1.41, 95% CI: 0.995-1.99, p = 0.05). Cumulative seizure recurrence rates at two years in patients diagnosed after two or more seizures were 73% with deferred treatment and 49% with immediate treatment (risk-factor-corrected number-needed-to-treat [NNT] = 4), and in those diagnosed after one seizure the rates were 60% and 51% (NNT = 8). Of 380 patients with eligible follow-up (median 4.3 years), 287 (76%) had been in seizure remission for at least one year and 211 (56%) remained in remission at last follow-up. Long-term remission rates were similar between immediate and deferred treatments, and between patients diagnosed after one seizure and those with two or more seizures. SIGNIFICANCE Immediate rather than deferred treatment was less likely to influence seizure recurrence in patients diagnosed with epilepsy after a single seizure than in those diagnosed after two or more seizures, and showed no differences in long-term seizure freedom.
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Affiliation(s)
- Sameer Sharma
- Department of Neurosciences, Central Clinical School, Monash University, Alfred Hospital, The Alfred Centre, 99 Commercial Road, Melbourne, VIC 3004, Australia.
| | - Zhibin Chen
- Department of Neurosciences, Central Clinical School, Monash University, Alfred Hospital, The Alfred Centre, 99 Commercial Road, Melbourne, VIC 3004, Australia; Department of Medicine, The University of Melbourne, Royal Melbourne Hospital, 300 Grattan Street, Parkville, VIC 3050, Australia; School of Public Health and Preventive Medicine, Monash University, 533 St Kilda Road, Melbourne, VIC 3004, Australia.
| | - Maria Rychkova
- Department of Medicine, The University of Melbourne, Royal Melbourne Hospital, 300 Grattan Street, Parkville, VIC 3050, Australia.
| | - John Dunne
- School of Medicine, Royal Perth Hospital Unit, University of Western Australia, Victoria Square, Perth, WA 6000, Australia; WA Adult Epilepsy Service, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands, WA 6009, Australia.
| | - Judy Lee
- WA Adult Epilepsy Service, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands, WA 6009, Australia.
| | - Nicholas Lawn
- WA Adult Epilepsy Service, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands, WA 6009, Australia.
| | - Patrick Kwan
- Department of Neurosciences, Central Clinical School, Monash University, Alfred Hospital, The Alfred Centre, 99 Commercial Road, Melbourne, VIC 3004, Australia; Department of Medicine, The University of Melbourne, Royal Melbourne Hospital, 300 Grattan Street, Parkville, VIC 3050, Australia; School of Public Health and Preventive Medicine, Monash University, 533 St Kilda Road, Melbourne, VIC 3004, Australia.
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16
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Beghi E, Beretta S, Colombo M, Bianchi E, Carone D, Zanchi C, Tinti L, Pirovano M, Trentini C, Padovano G, Cereda D, Scanziani S, Giussani G, Gasparini S, Bogliun G, Ferrarese C. Discontinuation of antiseizure medications in seizure-free patients with long-term follow-up: Patients' profile, seizure recurrence, and risk factors. Epilepsy Behav 2021; 117:107871. [PMID: 33690066 DOI: 10.1016/j.yebeh.2021.107871] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 02/09/2021] [Accepted: 02/21/2021] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To compare withdrawal of antiseizure medications (ASM) to continued treatment in newly diagnosed individuals achieving seizure freedom, and assess the risk of relapse and factors associated with relapse. METHODS This is a multicenter retrospective cohort study with long-term follow-up. Patients with newly diagnosed epilepsy were identified from the medical records of 13 Italian epilepsy centers and followed up until the most recent visit or death. Seizure-free patients discontinuing treatment were compared to patients who maintained treatment for baseline characteristics. Treatment was stopped upon clinical judgment. The probability of relapse was calculated with the Kaplan-Meier method. Demographic, clinical, and instrumental variables associated with relapse were assessed with Cox proportional hazards models. RESULTS One thousand and six patients aged 1 month to 72 years at diagnosis were enrolled and followed up for 17,892 person-years (median follow-up, 9.9 years). Three hundred and twenty patients (31.8%) underwent one or more treatment discontinuations. Factors associated with ASM withdrawal were younger age at remission and normal psychiatric examination. The probability of relapse after the first withdrawal was 16% at six months, 24% at 12 months, and 36%, 45%, and 53% at three, five, and ten years, respectively. The probability of remission after the first relapse was 59% at one month, 67%, 72, and 76% at three, six, and 12 months, respectively. Variables associated with relapse were age 14+ years, structural etiology, abnormal neuroimaging, ASM initiation after a single seizure, and symptomatic/cryptogenic epilepsy. CONCLUSIONS About one half of seizure-free patients stopping ASM relapse in 10 years. However, the possibility of remission after relapse is high, particularly in children and patients with idiopathic/cryptogenic epilepsy. Treatment deprescription might be encouraged at least in these patients.
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Affiliation(s)
- Ettore Beghi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milano, Italy.
| | - Simone Beretta
- Epilepsy Center, Department of Neurology, San Gerardo Hospital ASST Monza, University of Milano Bicocca, Monza, Italy
| | - Matteo Colombo
- Epilepsy Center, Department of Neurology, San Gerardo Hospital ASST Monza, University of Milano Bicocca, Monza, Italy
| | - Elisa Bianchi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milano, Italy
| | - Davide Carone
- Epilepsy Center, Department of Neurology, San Gerardo Hospital ASST Monza, University of Milano Bicocca, Monza, Italy
| | - Clara Zanchi
- Epilepsy Center, Department of Neurology, San Gerardo Hospital ASST Monza, University of Milano Bicocca, Monza, Italy
| | - Lorenzo Tinti
- Epilepsy Center, Department of Neurology, San Gerardo Hospital ASST Monza, University of Milano Bicocca, Monza, Italy
| | - Marta Pirovano
- Epilepsy Center, Department of Neurology, San Gerardo Hospital ASST Monza, University of Milano Bicocca, Monza, Italy
| | - Claudia Trentini
- Epilepsy Center, Department of Neurology, San Gerardo Hospital ASST Monza, University of Milano Bicocca, Monza, Italy
| | - Giada Padovano
- Epilepsy Center, Department of Neurology, San Gerardo Hospital ASST Monza, University of Milano Bicocca, Monza, Italy
| | - Diletta Cereda
- Epilepsy Center, Department of Neurology, San Gerardo Hospital ASST Monza, University of Milano Bicocca, Monza, Italy
| | - Sofia Scanziani
- Epilepsy Center, Department of Neurology, San Gerardo Hospital ASST Monza, University of Milano Bicocca, Monza, Italy
| | - Giorgia Giussani
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milano, Italy
| | - Sara Gasparini
- Medical and Surgical Sciences Department, School of Medicine, Magna Græcia University of Catanzaro, Catanzaro, Italy; Regional Epilepsy Centre, Great Metropolitan Hospital, Reggio Calabria, Italy
| | - Graziella Bogliun
- Epilepsy Center, Department of Neurology, San Gerardo Hospital ASST Monza, University of Milano Bicocca, Monza, Italy
| | - Carlo Ferrarese
- Epilepsy Center, Department of Neurology, San Gerardo Hospital ASST Monza, University of Milano Bicocca, Monza, Italy
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Falco-Walter J. Epilepsy-Definition, Classification, Pathophysiology, and Epidemiology. Semin Neurol 2020; 40:617-623. [PMID: 33155183 DOI: 10.1055/s-0040-1718719] [Citation(s) in RCA: 87] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Seizures affect the lives of 10% of the global population and result in epilepsy in 1 to 2% of people around the world. Current knowledge about etiology, diagnosis, and treatments for epilepsy is constantly evolving. As more is learned, appropriate and updated definitions and classification systems for seizures and epilepsy are of the utmost importance. Without proper definitions and classification, many individuals will be improperly diagnosed and incorrectly treated. It is also essential for research purposes to have proper definitions, so that appropriate populations can be identified and studied. Imprecise definitions, failure to use accepted terminology, or inappropriate use of terminology hamper our ability to study and advance the field of epilepsy. This article begins by discussing the pathophysiology and epidemiology of epilepsy, and then covers the accepted contemporary definitions and classifications of seizures and epilepsies.
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Affiliation(s)
- Jessica Falco-Walter
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Palo Alto, California
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18
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Capal JK, Macklin EA, Lu F, Barnes G. Factors Associated With Seizure Onset in Children With Autism Spectrum Disorder. Pediatrics 2020; 145:S117-S125. [PMID: 32238538 DOI: 10.1542/peds.2019-1895o] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/27/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Children with autism spectrum disorder (ASD) have a higher prevalence of epilepsy compared with general populations. In this pilot study, we prospectively identified baseline risk factors for the development of seizures in individuals with ASD and also identified characteristics sensitive to seizure onset up to 6 years after enrollment in the Autism Speaks Autism Treatment Network. METHODS Children with ASD and no history of seizures at baseline who either experienced onset of seizures after enrollment in the Autism Treatment Network or remained seizure free were included in the analysis. RESULTS Among 472 qualifying children, 22 (4.7%) experienced onset of seizures after enrollment. Individuals who developed seizures after enrollment exhibited lower scores at baseline on all domains of the Vineland Adaptive Behavior Scales, greater hyperactivity on the Aberrant Behavior Checklist (25.4 ± 11.8 vs 19.2 ± 11.1; P = .018), and lower physical quality of life scores on the Pediatric Quality of Life Inventory (60.1 ± 24.2 vs 76.0 ± 18.2; P < .001). Comparing change in scores from entry to call-back, adjusting for age, sex, length of follow-up, and baseline Vineland II composite score, individuals who developed seizures experienced declines in daily living skills (-8.38; 95% confidence interval -14.50 to -2.50; P = .005). Adjusting for baseline age, sex, and length of follow-up, baseline Vineland II composite score was predictive of seizure development (risk ratio = 0.95 per unit Vineland II composite score, 95% confidence interval 0.92 to 0.99; P = .007). CONCLUSIONS Individuals with ASD at risk for seizures exhibited changes in adaptive functioning and behavior.
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Affiliation(s)
- Jamie K Capal
- Department of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; .,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Eric A Macklin
- Biostatistics Center, Massachusetts General Hospital, Boston, Massachusetts.,Department of Medicine, Harvard Medical School, Harvard University, Boston, Massachusetts; and
| | - Frances Lu
- Biostatistics Center, Massachusetts General Hospital, Boston, Massachusetts
| | - Gregory Barnes
- Departments of Neurology and Pediatrics, University of Louisville Autism Center, Louisville, Kentucky
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Abstract
PURPOSE OF REVIEW Seizures and status epilepticus are very common diagnoses in the critically ill patient and are associated with significant morbidity and mortality. There is an abundance of research on the utility of antiseizure medications in this setting, but limited randomized-controlled trials to guide the selection of medications in these patients. This review examines the current guidelines and treatment strategies for status epilepticus and provides an update on newer antiseizure medications in the critical care settings. RECENT FINDINGS Time is brain applies to status epilepticus, with delays in treatment corresponding with worsened outcomes. Establishing standardized treatment protocols within a health system, including prehospital treatment, may lead to improved outcomes. Once refractory status epilepticus is established, continuous deep sedation with intravenous anesthetic agents should be effective. In cases, which prove highly refractory, novel approaches should be considered, with recent data suggesting multiple recently approved antiseizure medications, appropriate therapeutic options, as well as novel approaches to upregulate extrasynaptic γ-aminobutyric acid channels with brexanolone. SUMMARY Although there are many new treatments to consider for seizures and status epilepticus in the critically ill patient, the most important predictor of outcome may be rapid diagnosis and treatment. There are multiple new and established medications that can be considered in the treatment of these patients once status epilepticus has become refractory, and a multidrug regimen will often be necessary.
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20
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Sharma S, Chen Z, Rychkova M, Dunne J, Lee J, Kalilani L, Lawn N, Kwan P. Treatment initiation decisions in newly diagnosed epilepsy–A longitudinal cohort study. Epilepsia 2020; 61:445-454. [DOI: 10.1111/epi.16439] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 01/08/2020] [Accepted: 01/08/2020] [Indexed: 02/07/2023]
Affiliation(s)
- Sameer Sharma
- Department of Neurosciences Central Clinical School Alfred Hospital Monash University Melbourne Victoria Australia
| | - Zhibin Chen
- Department of Neurosciences Central Clinical School Alfred Hospital Monash University Melbourne Victoria Australia
- Department of Medicine Royal Melbourne Hospital The University of Melbourne Parkville Victoria Australia
- School of Public Health and Preventive Medicine Monash University Melbourne Victoria Australia
| | - Maria Rychkova
- Department of Medicine Royal Melbourne Hospital The University of Melbourne Parkville Victoria Australia
| | - John Dunne
- School of Medicine Royal Perth Hospital Unit University of Western Australia Perth Western Australia Australia
- WA Adult Epilepsy Service Perth Western Australia Australia
| | - Judy Lee
- WA Adult Epilepsy Service Perth Western Australia Australia
| | | | - Nicholas Lawn
- WA Adult Epilepsy Service Perth Western Australia Australia
| | - Patrick Kwan
- Department of Neurosciences Central Clinical School Alfred Hospital Monash University Melbourne Victoria Australia
- Department of Medicine Royal Melbourne Hospital The University of Melbourne Parkville Victoria Australia
- School of Public Health and Preventive Medicine Monash University Melbourne Victoria Australia
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21
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Abstract
PURPOSE OF REVIEW The classification of seizures, epilepsies, and epilepsy syndromes creates a framework for clinicians, researchers, and patients and their families. This classification has evolved over the years, and in 2017 the International League Against Epilepsy (ILAE) published an operational classification of seizures and epilepsies. Understanding this classification is important in the diagnosis, treatment, and understanding of seizures and epilepsies, including epilepsy incidence. RECENT FINDINGS The 2017 ILAE classification system builds on newly formulated definitions of seizures and epilepsy. Seizure classification begins by determining whether the initial manifestations of the seizure are focal or generalized. If the onset of the seizure is missed or unclear, the seizure is of unknown onset. Focal seizures are classified according to the individual's level of awareness, the most prominent motor or nonmotor features of the seizure, and whether the focal seizure evolves to a bilateral tonic-clonic seizure. Similarly, generalized seizures are classified according to motor or nonmotor manifestations. Motor seizures are either tonic-clonic or other motor seizures. Nonmotor generalized seizures primarily refer to absence seizures. Similar to seizure classification, the epilepsies can be classified as focal or generalized. In addition, the new classification system recognizes two new categories: combined generalized and focal epilepsy and unknown epilepsy. The concept of an epilepsy syndrome has been introduced under the new classification system and refers to a cluster of features incorporating seizure types, EEG, imaging, and other features including genetics. The new classification system emphasizes the etiology of seizures and epilepsies. SUMMARY The recent ILAE seizure and epilepsy classification system aims to create a framework to better classify seizures and the epilepsies. Universal adoption and implementation of this system will enable patients, their families, clinicians, and researchers to better define and treat the epilepsies. Incidence studies have not generally classified seizures and the epilepsies, and use of this classification system, which emphasizes etiology, will lead to a better understanding of epilepsy incidence.
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Beghi E, Beretta S, Carone D, Zanchi C, Bianchi E, Pirovano M, Trentini C, Padovano G, Colombo M, Cereda D, Scanziani S, Giussani G, Gasparini S, Bogliun G, Ferrarese C. Prognostic patterns and predictors in epilepsy: a multicentre study (PRO-LONG). J Neurol Neurosurg Psychiatry 2019; 90:1276-1285. [PMID: 31248935 DOI: 10.1136/jnnp-2019-320883] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 05/24/2019] [Accepted: 06/03/2019] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To describe the long-term prognosis of epilepsy and prognostic patterns in a large cohort of newly diagnosed patients and identify prognostic factors. METHODS Study participants were 13 Italian epilepsy centres with accessible records dating back to 2005 or earlier, complete data on seizure outcome and treatments, precise epilepsy diagnosis, and follow-up of at least 10 years. Records were examined by trained neurology residents for demographics, seizure characteristics, neurological signs, psychiatric comorbidity, first electroencephalogram (EEG) and MRI/CT, epilepsy type and aetiology, antiepileptic drugs (AEDs), and 1-year, 2-year, 5-year and 10-year seizure remissions. Five predefined prognostic patterns were identified: early remission, late remission, relapsing-remitting course, worsening course and no remission. Prognostic factors were assessed using multinomial logistic regression models. RESULTS 1006 children and adults were followed for 17 892 person-years (median 16 years; range 10-57). During follow-up, 923 patients (91.7%) experienced 1-year remission. 2-year, 5-year and 10-year remissions were present in 89.5%, 77.1% and 44.4% of cases. 5-year remission was associated with one to two seizures at diagnosis, generalised epilepsy, no psychiatric comorbidity, and treatment with one or two AEDs during follow-up. 10-year remission was associated with one or two AEDs. The most common prognostic pattern was relapsing-remitting (52.2%), followed by early remission (24.5%). 8.3% of cases experienced no remission. Predictors of a relapsing-remitting course were <6 seizures at diagnosis, (presumed) genetic aetiology and no psychiatric comorbidity. CONCLUSIONS Few seizures at diagnosis, generalised epilepsy and no psychiatric comorbidity predict early or late seizure freedom in epilepsy. Achieving remission at any time after the diagnosis does not exclude further relapses.
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Affiliation(s)
- Ettore Beghi
- Laboratory of Neurological Disorders, Department of Neuroscience, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milano, Italy
| | - Simone Beretta
- Epilepsy Center, Department of Neurology, San Gerardo Hospital ASST Monza, University of Milano Bicocca, Monza, Italy
| | - Davide Carone
- Epilepsy Center, Department of Neurology, San Gerardo Hospital ASST Monza, University of Milano Bicocca, Monza, Italy
| | - Clara Zanchi
- Epilepsy Center, Department of Neurology, San Gerardo Hospital ASST Monza, University of Milano Bicocca, Monza, Italy
| | - Elisa Bianchi
- Laboratory of Neurological Disorders, Department of Neuroscience, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milano, Italy
| | - Marta Pirovano
- Epilepsy Center, Department of Neurology, San Gerardo Hospital ASST Monza, University of Milano Bicocca, Monza, Italy
| | - Claudia Trentini
- Epilepsy Center, Department of Neurology, San Gerardo Hospital ASST Monza, University of Milano Bicocca, Monza, Italy
| | - Giada Padovano
- Epilepsy Center, Department of Neurology, San Gerardo Hospital ASST Monza, University of Milano Bicocca, Monza, Italy
| | - Matteo Colombo
- Epilepsy Center, Department of Neurology, San Gerardo Hospital ASST Monza, University of Milano Bicocca, Monza, Italy
| | - Diletta Cereda
- Epilepsy Center, Department of Neurology, San Gerardo Hospital ASST Monza, University of Milano Bicocca, Monza, Italy
| | - Sofia Scanziani
- Epilepsy Center, Department of Neurology, San Gerardo Hospital ASST Monza, University of Milano Bicocca, Monza, Italy
| | - Giorgia Giussani
- Laboratory of Neurological Disorders, Department of Neuroscience, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milano, Italy
| | - Sara Gasparini
- Medical and Surgical Sciences Department, School of Medicine, Magna Græcia University of Catanzaro, Viale Europa, Catanzaro, Italy.,Regional Epilepsy Centre, Great Metropolitan Hospital, Reggio Calabria, Italy
| | - Graziella Bogliun
- Epilepsy Center, Department of Neurology, San Gerardo Hospital ASST Monza, University of Milano Bicocca, Monza, Italy
| | - Carlo Ferrarese
- Epilepsy Center, Department of Neurology, San Gerardo Hospital ASST Monza, University of Milano Bicocca, Monza, Italy
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A Systems Biology Approach for Personalized Medicine in Refractory Epilepsy. Int J Mol Sci 2019; 20:ijms20153717. [PMID: 31366017 PMCID: PMC6695675 DOI: 10.3390/ijms20153717] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 07/22/2019] [Accepted: 07/28/2019] [Indexed: 02/01/2023] Open
Abstract
Epilepsy refers to a common chronic neurological disorder that affects all age groups. Unfortunately, antiepileptic drugs are ineffective in about one-third of patients. The complex interindividual variability influences the response to drug treatment rendering the therapeutic failure one of the most relevant problems in clinical practice also for increased hospitalizations and healthcare costs. Recent advances in the genetics and neurobiology of epilepsies are laying the groundwork for a new personalized medicine, focused on the reversal or avoidance of the pathophysiological effects of specific gene mutations. This could lead to a significant improvement in the efficacy and safety of treatments for epilepsy, targeting the biological mechanisms responsible for epilepsy in each individual. In this review article, we focus on the mechanism of the epilepsy pharmacoresistance and highlight the use of a systems biology approach for personalized medicine in refractory epilepsy.
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Cho YW, Kim KT. The Latest Classification of Epilepsy and Clinical Significance of Electroencephalography. ACTA ACUST UNITED AC 2019. [DOI: 10.32587/jnic.2019.00094] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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Falco-Walter JJ, Scheffer IE, Fisher RS. The new definition and classification of seizures and epilepsy. Epilepsy Res 2018; 139:73-79. [DOI: 10.1016/j.eplepsyres.2017.11.015] [Citation(s) in RCA: 123] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Revised: 11/16/2017] [Accepted: 11/27/2017] [Indexed: 10/18/2022]
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