[The impact of antiepileptic therapy on sleep disorders in women with epilepsy]

OBJECTIVE

To analyze the frequency of various sleep disorders in patients with epilepsy receiving antiepileptic therapy.

MATERIAL AND METHODS

Sixty-four women were selected from the register of patients with epilepsy and other paroxysmal conditions. The group consisted of young and middle-aged women (36.9±13.5 years), all patients received antiepileptic therapy. To diagnose sleep disorders, we used a sequential algorithm for clinical examination supplemented by instrumental methods according to indications (polysomnography, respiratory monitoring).

RESULTS

The duration of epilepsy was 15.7±7.6 years, the disease was represented by three forms: structural (n=15, 23.4%), genetic (n=32, 50%) and unspecified (n=17, 26.6%). Sleep disorders were common among female patients with epilepsy (43.7%), they are most frequently combined with genetic epilepsy (18.7%), and represented by: insomnia (43%) mild to moderately severe breathing disorders (32%) and sleep movement disorders (25%). Sleep disorders were combined with symptoms of depression in the majority of patients (71%). A 6-month follow-up evaluation of nighttime sleep parameters after treatment showed a decrease in the frequency of sleep disorders to 25%; scores on the Epworth Sleepiness Scale significantly decreased to 6.7±3.6. A change in antiepileptic therapy in patients with sleep breathing disorders resulted in a marked regression of the Apnea-Hypopnea Index (9.2±2.5 points; p=0.003). However, there were no significant changes in the severity of sleep movement disorders.

CONCLUSION

Sleep disorders are common in patients with epilepsy, in most cases they are associated with mood disorders, and may regress after optimization of antiepileptic therapy.

[Epileptic syndromes associated with focal clonic seizures]

OBJECTIVE

To study clinical, electroencephalographic and neuroimaging features in children with epileptic syndromes associated with focal clonic seizures (FCS).

MATERIAL AND METHODS

We examined 1258 patients with various forms of epilepsy with the onset of seizures from the first day of life to 18 years.

RESULTS

FCS was identified in 263 patients (20.9%). FCS were included in the structure of 13 different epileptic syndromes: Rolandic epilepsy (28.1%), structural focal epilepsy (27.5%), structural focal epilepsy associated with benign epileptiform discharges of childhood (SFE-BEDC) (20.6%), focal epilepsy of unknown etiology (7.5%), epilepsia partialis continua (4.6%), pseudo-Lennox syndrome (3.4%), ESES syndrome (2.7%), Landau-Kleffner syndrome (1.5%), Dravet syndrome (1.1%), benign occipital epilepsy (1.1%), benign focal epilepsy in infancy (0.8%), MISF syndrome (0.8%), cognitive epileptiform disintegration (0.8%). In 50% of cases, epilepsy associated with FCS debuts before the age of 5 years (from 1 month to 18 years, average age 4.26±3.9).

CONCLUSION

The groups of syndromes associated with FCS have different prognosis for remission of seizures. Prognostic predictors of seizure remission are: epileptic syndromes associated with BEDC, the presence of periventricular leukomalacia. A severe prognosis for the course of epilepsy is associated with local structural changes in the neocortex. Despite a favorable prognosis for seizures, continued diffuse interictal epileptiform activity with BEDC on the electroencephalogram is a predictor of the onset of cognitive impairment in children.

Design and evaluation of pharmacological properties of a new 1,3,4-thiadiazolylamide derivative of 2-propylpentanoic acid

Introduction: The use of the pharmacophoric approach is a promising direction for modifying the chemical structure of 2-propylpentanoic (valproic) acid in order to obtain new drugs.

Materials and methods: In the experiments on mice, acute toxicity, neurotoxicity, antiepileptic activity and analgesic effect of N-(5-ethyl-1,3,4-thiadiazol-2-yl)-2-propylpentanamide (valprazolamide) were evaluated. LD50 was determined by probit analysis. Neurotoxicity was determined in a rotarod test and a bar test in mice. The effects of valprazolamide on the exploratory behavior of mice in open field test and in a light/dark transition test were evaluated. Its antiepileptic activity was tested in mice against seizures induced by maximal electroshock, pentylenetetrazole (scPTZ); isoniazid, thiosemicarbazide, pilocarpine, and camphor. The analgesic effect was studied in a hot plate test.

Results and discussion: N-(5-ethyl-1,3,4-thiadiazol-2-yl)-2-propylpentanamide was obtained by introducing pharmacophores into the structure of 2-propylpentanoic acid: a substituted amide group and an electron-donor domain of 1,3,4-thiadiazole. The LD50 value for intraperitoneal administration of a new 2-propylpentanoic acid: derivative to mice was 924.8 mg/kg, and the TD50 value in the rotarod test and the bar test were 456.7 mg/kg and 546.7 mg/kg, respectively. The suppression of orienting responses in the animals was noted when it was administered in neurotoxic doses. Valprazolamide showed the most antiepileptic activity on models of MES, scPTZ and isoniazid antagonism tests. The ED50 values were 138.4 mg/kg, 74.5 mg/kg, and 126.8 mg/kg, respectively. The therapeutic indices for these models of epilepsy were 6.7; 12.4; 7.3, and protective index – 3.3; 6.1 and 3.6, respectively. In the hot plate test, valprazolamide increased the latency period before a defensive response to a thermal stimulus (ED50 165 mg/kg).

Conclusion: N-(5-ethyl-1,3,4-thiadiazol-2-yl)-2-propylpentanamide is a new 1,3,4-thiadiazolylamide derivative of 2-propylpentanoic acid with antiepileptic and analgesic activities, which belongs to the group of low-toxic agents.

Graphic abstract

N-(5-ethyl-1,3,4-thiadiazol-2-yl)-2-propylpentanamide (3D)

LD50=924.8 mg/kg (mice, intraperitoneally)

TD50=456.7 mg/kg (rotarod, mice, intraperitoneally)

ED50=138.4 mg/kg (MES, mice, intraperitoneally)

ED50=74.5 mg/kg (scPTZ, mice, intraperitoneally)

[Clinical results and prospects for the use of phenosanic acid in patients with focal epilepsy]

OBJECTIVE

To study the efficacy and safety of using a new original synthetic antioxidant - phenosanic acid as an adjunct therapy in patients with focal epilepsy.

MATERIAL AND METHODS

A randomized, double-blind, placebo-controlled, parallel-group study evaluated the efficacy and safety of phenosanic acid as an adjunct therapy to basic antiepileptic drugs in 120 patients with focal epilepsy. Primary purpose: to study the dynamic of seizure frequency. Secondary purposes: to study the dynamic of seizure-free days, the dynamics of bilateral tonic-clonic seizures, the results of questionnaires and scales (General Dynamics Assessment, Visual Analogue Scale (VAS), Quality of Life in Epilepsy (QOLIE-31-P), European Quality of Life Questionnaire (EQ-5D), Hospital Anxiety and Depression Scale (HADS), Frontal Asstssment Battery (FAB), Mini-Mental State Examination (MMSE)).

RESULTS

Phenosanic acid (Dibufelon) showed statistically significant benefit over placebo in the primary indicator of efficacy (reduction in the frequency of epileptic seizures by at least 50%) and in the secondary indicators. The drug was safe and well tolerated by the patients.

CONCLUSION

The addition of phenosanic acid (Dibufelon) to base antiepileptic drugs seems to be perspective because of its positive effect on reducing the number of epileptic seizures, as well as on comorbid disorders in the emotional and cognitive spheres.

[Healthcare of Russia today. Epileptological service]

OBJECTIVE

To examine the state of the epileptological service in Russia by conducting a survey of epileptologists working in different regions of the Russian Federation.

MATERIAL AND METHODS

To assess the structure and mechanisms of the antiepileptic service in the Russian Federation, the Russian League Against Epilepsy (RLAE) offered a questionnaire to 63 epileptologists, which has been answered by 37 epileptologists from 28 regions of the country.

RESULTS AND CONCLUSION

Among the respondents, 43% are focused on the care of outpatients, 35% work both in outpatient and inpatient appointments, 22% work only in hospitals. 24% of doctors are employees of neurological departments. 84% of epileptologists noted the neurological profile of their medical institution. The most common patient routing options were: «therapist-neurologist-epileptologist» (59%), «Neurologist-epileptologist» (81%), self-referral to an epileptologist (22%), «Psychiatrist-epileptologist» (16%). 59.5% of epileptologists work with adults and with children. 27% of respondents noted that they work with psychiatric patients. Interaction between the departments of neurology and practical health care is carried out in the form of consultations and training events, as noted by 68% of epileptologists. 73% of the epileptologist reported the willingness to actively interact with the RLAE. 54% of the respondents conduct socially oriented schools for patients and their relatives. In the context of the planned reorganization of the health care system, the epileptologists gave the outlook on the work of the epileptological service.

CONCLUSION

The main initiatives mentioned by the respondents were the following increasing the availability of medicines and examination methods, increase of continuity in the work of the epileptological service, creation of unified databases, creation of specialized epileptological centers and/or offices of epileptologists.

Transcutaneous Vagus Nerve Stimulation (t-VNS) and epilepsy: A systematic review of the literature

INTRODUCTION

Transcutaneous auricular vagus nerve stimulation (t-VNS) has been proposed as an alternative method for the treatment of various neurological and psychiatric disorders. Contrary to the classic invasive vagus nerve stimulation (i-VNS), t-VNS does not require surgical intervention. The application of t-VNS for the treatment of epilepsy has been poorly studied. Hence, we performed a systematic review of the literature to elucidate efficacy, adverse effects and technical features of t-VNS in patients with epilepsy.

MATERIAL AND METHODS

We systematically searched MEDLINE and SCOPUS databases using the following keywords: [TRANSCUTANEOUS VAGUS NERVE STIMULATION OR TRANSCUTANEOUS VAGAL NERVE STIMULATION] AND [EPILEPSY OR SEIZURES]. We searched for observational studies in English concerning the application of t-VNS for the treatment of epilepsy in humans. The full-text version of relevant studies was obtained and reviewed. Technical parameters of the stimulation, percentage of seizure frequency reduction, QOLIE-31(Quality of Life In Epilepsy-31) and LSSS (Liverpool Seizure Severity Scale) questionnaires and adverse effects were recorded and analyzed.

RESULTS

A total of 10 studies with 350 patients were included. Both bilateral and unilateral placement of the electrode were applied. Stimulation frequency varied from 10-30Hz, while treatment intensity was usually adjusted according to patients' preferences and tolerance (around 1mA) and below the pain threshold. In the clinical trials included in our review, the mean seizure frequency reduction varied from 30 to 65%. Eight and four studies provided information about QOLIE-31 and LSSS questionnaires respectively. Three studies reported a statistically significant (p<0,05) improvement in patients' quality of life and two studies reported statistically significant (p<0,05) seizure severity reduction. The most common side effect was headache (8,9%), followed by skin irritation at the placement site (7,1%) and nasopharyngitis (5,1%). No serious or life-threatening side effects were reported.

CONCLUSION

Due to the heterogeneity of the included studies, no safe conclusions could be extracted concerning the efficacy of t-VNS. However, the results of this review suggest that patients with epilepsy could possibly benefit from the use of t-VNS. The present study also emphasizes the limitations of previous clinical trials concerning the applications of t-VNS in people with epilepsy and thus could be a guidance for the conduction of future trials.

Mechanisms of Drug Resistance in the Pathogenesis of Epilepsy: Role of Neuroinflammation. A Literature Review

Epilepsy is a chronic neurological disorder characterized by recurring spontaneous seizures. Drug resistance appears in 30% of patients and it can lead to premature death, brain damage or a reduced quality of life. The purpose of the study was to analyze the drug resistance mechanisms, especially neuroinflammation, in the epileptogenesis. The information bases of biomedical literature Scopus, PubMed, Google Scholar and SciVerse were used. To obtain full-text documents, electronic resources of PubMed Central and Research Gate were used. The article examines the recent research of the mechanisms of drug resistance in epilepsy and discusses the hypotheses of drug resistance development (genetic, epigenetic, target hypothesis, etc.). Drug-resistant epilepsy is associated with neuroinflammatory, autoimmune and neurodegenerative processes. Neuroinflammation causes immune, pathophysiological, biochemical and psychological consequences. Focal or systemic unregulated inflammatory processes lead to the formation of aberrant neural connections and hyperexcitable neural networks. Inflammatory mediators affect the endothelium of cerebral vessels, destroy contacts between endothelial cells and induce abnormal angiogenesis (the formation of “leaky” vessels), thereby affecting the blood–brain barrier permeability. Thus, the analysis of pro-inflammatory and other components of epileptogenesis can contribute to the further development of the therapeutic treatment of drug-resistant epilepsy.

Recommendations of the Russian League Against Epilepsy (RLAE) on the use of magnetic resonance imaging in the diagnosis of epilepsy

Introduction. The MRI method has revolutionized the diagnosis of epilepsy. However, the widespread adoption of MRI in clinical practice is slowed by an insufficient number of high-field MRI scanners, a shortage of trained specialists, and the lack of standard examination protocols. The aim of this article is to present the Recommendations of the Russian League Against Epilepsy (RLAE) on the use of magnetic resonance imaging in the diagnosis of epilepsy.

Materials and methods. As a structural element of the International League Against Epilepsy (ILAE), the RLAE considers it important to adapt the Protocol developed by ILAE for specialists in Russia and EAEU countries. The working group analyzed and generalized the clinical practice existing in the Russian Federation, the Republic of Kazakhstan, the Republic of Belarus and the Republic of Uzbekistan. These recommendations are intended for doctors in specialized centers of epilepsy surgery, and for doctors in general medical centers. The recommendations are applicable primarily to adult patients, but the general principles are relevant to children as well.

Results. In all patients with convulsive seizures shortly after the first seizure, or patients diagnosed with epilepsy who have an unexplained increase in the frequency of seizures, rapid decrease in cognitive functions or the appearance / worsening of neuropsychiatric symptoms, the RLAE recommends using a unified MR protocol for the neuroimaging of structural sequences in epilepsy with three-dimensional pulse sequences T1 and T2 FLAIR with isotropic voxel 1 × 1 × 1 mm3 and two-dimensional T2- weighted pulse sequences with a pixel size of 1 × 1 mm2 or less. The MRI examination should be combined with EEG or EEG-video monitoring. Using this protocol allows one to set a unified standard for examining patients with epilepsy in order to detect (with high sensitivity) brain lesions playing a key role in the occurrence of seizures. Here, all 13 recommendations are presented.

Conclusion. Implementation of these recommendations in clinical practice will improve the access to high-tech medical care and optimize health care costs. 

[Lacosamide in treatment of patients with focal epilepsy and comorbid mental disorders]

In this article, the results of personal prospective observation of lacosamide (LCM) administration in 91 adults with epilepsy and comorbid mental disorders are presented. LCM was administered as a part of polytherapy for 80 patients at a dose of up to 400 mg/day and of monotherapy for 11 patients at a dose of up to 600 mg/day for up to 12 months. Clinical-psychopathological and experimental-psychological monitoring of patients' condition over time was carried out using the Mental Health Comprehensive Assessment Scale (MHCAS), the Global Clinical Impression scale (GCI). As a result, the majority of patients (58 people (63.7%)) achieved remission with good tolerability and positive changes in cognitive functions and emotional-volitional characteristics, confirming their stability after 1 year of LCM administration.

[Speech and language neurodevelopmental disorders in epilepsy: pathophysiologic mechanisms and therapeutic approaches]

Speech and language development may be impaired in all forms of epilepsy involving specialized functional areas in the dominant cerebral hemisphere and their connections. The concept of epilepsy-aphasia clinical spectrum was recently proposed, but the notion of aphasia is quite conditional here as many of these patients demonstrate disorders of speech and language development from their infancy. Those forms of epilepsy are considered as continuum from the most severe Landau-Kleffner syndrome (LKS) and epilepsy with continuous spike-and-wave during sleep (CSWS) (also indicating as electrical status epilepticus during sleep - ESES) to intermediate epilepsy-aphasia disorders (with incomplete correspondence to diagnostic criteria of LKS and epilepsy with CSWS). The mild end of the spectrum is represented by benign childhood epilepsy with centrotemporal spikes (rolandic), which is often associated with speech and language disorders. The importance of genetic factors is discussed, including mutations in SRPX2, GRIN2A and other genes. The perspectives of individualized pharmacotherapy in epilepsy, co-morbid with neurodevelopmental disorders or impairments of speech and language development, are depending on the progress in genetic studies. In the new generation of antiepileptic drugs the positive influence on neuroplasticity mechanisms and higher cerebral functions are supposed for levetiracetam.