Auras and the risk of seizures with impaired consciousness following epilepsy surgery: implications for driving

Long-term outcome of treatment-naïve patients with mesial temporal lobe epilepsy with hippocampal sclerosis: A retrospective study in a single center

PURPOSE

This study aimed to describe long-term treatment outcomes of treatment-naïve patients with mesial temporal lobe epilepsy with hippocampal sclerosis (MTLE-HS).

METHODS

A retrospective review was conducted of treatment-naïve patients with MTLE-HS who visited the Yonsei Epilepsy Clinic from April 2000 to April 2022 and were followed up for at least 2 years. Seizure freedom (SF) was defined as no seizures or auras only for >1 year, and complete SF was defined as no seizures including auras for >1 year.

RESULTS

Eighty-four treatment-naïve patients with MTLE-HS with a median follow-up of 122 months were included. Except for one patient who underwent early surgical treatment, of the remaining 83 patients, 31 (37.3 %) achieved SF and remained in remission, 38 (45.8 %) had fluctuations in seizure control, and 14 (16.9 %) never achieved SF. Additionally, 18 (21.7 %) patients achieved complete SF and remained in remission, 42 (50.6 %) showed fluctuations, and 23 (27.7 %) never achieved complete SF. Fifty-three (63.9 %) patients achieved SF and 34 (41.0 %) achieved complete SF at their last visit. Older age at epilepsy onset, male sex, low pretreatment seizure density, history of central nervous system infection before age 5, absence of aura, and fewer antiseizure medications in the final regimen were associated with favorable outcome. Of the 84 patients, 11 (13.1 %) underwent temporal lobectomy.

CONCLUSIONS

Medical treatment outcomes in treatment-naïve MTLE-HS were relatively better than previously reported outcomes in MTLE-HS, although frequent fluctuations in seizure control were observed.

Structural Brain Network Abnormalities and the Probability of Seizure Recurrence After Epilepsy Surgery

OBJECTIVE

We assessed preoperative structural brain networks and clinical characteristics of patients with drug-resistant temporal lobe epilepsy (TLE) to identify correlates of postsurgical seizure recurrences.

METHODS

We examined data from 51 patients with TLE who underwent anterior temporal lobe resection (ATLR) and 29 healthy controls. For each patient, using the preoperative structural, diffusion, and postoperative structural MRI, we generated 2 networks: presurgery network and surgically spared network. Standardizing these networks with respect to controls, we determined the number of abnormal nodes before surgery and expected to be spared by surgery. We incorporated these 2 abnormality measures and 13 commonly acquired clinical data from each patient into a robust machine learning framework to estimate patient-specific chances of seizures persisting after surgery.

RESULTS

Patients with more abnormal nodes had a lower chance of complete seizure freedom at 1 year and, even if seizure-free at 1 year, were more likely to relapse within 5 years. The number of abnormal nodes was greater and their locations more widespread in the surgically spared networks of patients with poor outcome than in patients with good outcome. We achieved an area under the curve of 0.84 ± 0.06 and specificity of 0.89 ± 0.09 in predicting unsuccessful seizure outcomes (International League Against Epilepsy [ILAE] 3-5) as opposed to complete seizure freedom (ILAE 1) at 1 year. Moreover, the model-predicted likelihood of seizure relapse was significantly correlated with the grade of surgical outcome at year 1 and associated with relapses up to 5 years after surgery.

CONCLUSION

Node abnormality offers a personalized, noninvasive marker that can be combined with clinical data to better estimate the chances of seizure freedom at 1 year and subsequent relapse up to 5 years after ATLR.

CLASSIFICATION OF EVIDENCE

This study provides Class II evidence that node abnormality predicts postsurgical seizure recurrence.

Recent Medico-Legal Developments on the Issue of Epilepsy and Driver's License Requirements in the Italian and European Legislation

Epilepsy is a condition that comprises a group of neurological disorders characterized by seizures. Forms of epilepsy that produce abrupt bouts that cause lapses in consciousness may pose a major road safety problem for drivers who, while going through a seizure, could seriously harm themselves as well as others. A fundamental strategy for the purpose of reducing the risk of car accidents caused by epileptic drivers is constituted by prevention, in addition to adequate pharmacological therapies. In that respect, forensic medicine plays a pivotal role, since it deals with the set of requirements that must be met by those who have been diagnosed with epilepsy in order to get a driver's license, and with the obligation to signal such individuals to the national Driver and Vehicle Licensing Agency (in Italian: Motorizzazione Civile). In that regard, the Italian legislative framework is partly hazy in some respects, which the authors have set out to analyze herein, taking into account recently issued European norms. The aim of this paper was to better understand the current Italian legislation in the matter of epilepsy and driver's license requirements, especially regarding the medical criteria that must be met in order to obtain the driving license. The importance of those criteria is underlined by the fact that they directly influence (and are influenced by) the safety for the drivers and for the persons involved in car accidents. Thus, we can consider the issue not only strictly of medico-legal relevance but also from the standpoint of primary prevention. The analysis was conducted by reviewing the most recent documents of medico-legal relevance, in the light of European Union legislation. The authors have ultimately stressed the need for clearer and straightforward regulations, given that professional liability may arise whenever a driver's license is issued, in disregard of legal norms, to an individual who then causes a road accident.