Current Classification of Seizures and Epilepsies: Scope, Limitations and Recommendations for Future Action

Enhanced Non-EEG Multimodal Seizure Detection: A Real-World Model for Identifying Generalised Seizures Across the Ictal State

Non-electroencephalogram seizure detection holds promise for the early identification of generalised onset seizures. However, existing methods often suffer from high false alarm rates and difficulty distinguishing normal movements from seizure manifestations. To address this, we obtained exclusive access to the Open Seizure Database and selected a representative dataset of 94 events (42 generalised tonic-clonic seizures, 19 focal seizures, and 33 labelled as Other), totaling approximately 5 hours and 29 minutes. Each event contains acceleration and heart rate data, which were expertly annotated by a clinician in 5 second timesteps, with each timestep assigned a class label of Normal, Pre-Ictal, or Ictal. We introduce AMBER (Attention-guided Multi-Branching pipeline with Enhanced Residual Fusion), a multimodal seizure detection model designed for Ictal-Phase Detection. AMBER constructs multiple branches to form independent feature extraction pipelines for each sensing modality. The outputs of each branch are passed to a Residual Fusion layer, where the extracted features are combined into a fused representation and propagated through two densely connected blocks. The results of these experiments highlight the effectiveness of Ictal Phase Detection, with the model recording an accuracy and f1-score of 0.9027 and 0.9035, respectively, on unseen test data. Further experiments recorded True Positive Rate of 0.8342, 0.9485, and 0.9118 for the Normal, Pre-Ictal, and Ictal phases, respectively, with an average False Positive Rate of 0.0502. This study presents a novel Ictal Phase Detection technique that enhances seizure phase classification while showing reduced false alarms, laying the groundwork for further advancements in non-electroencephalogram-based seizure detection research.

Updated classification of epileptic seizures: Position paper of the International League Against Epilepsy

The International League Against Epilepsy (ILAE) has updated the operational classification of epileptic seizures, building upon the framework established in 2017. This revision, informed by the implementation experience, involved a working group appointed by the ILAE Executive Committee. Comprising 37 members from all ILAE regions, the group utilized a modified Delphi process, requiring a consensus threshold of more than two thirds for any proposal. Following public comments, the Executive Committee appointed seven additional experts to the revision task force to address and incorporate the issues raised, as appropriate. The updated classification maintains four main seizure classes: Focal, Generalized, Unknown (whether focal or generalized), and Unclassified. Taxonomic rules distinguish classifiers, which are considered to reflect biological classes and directly impact clinical management, from descriptors, which indicate other important seizure characteristics. Focal seizures and those of unknown origin are further classified by the patient's state of consciousness (impaired or preserved) during the seizure, defined operationally through clinical assessment of awareness and responsiveness. If the state of consciousness is undetermined, the seizure is classified under the parent term, that is, the main seizure class (focal seizure or seizure of unknown origin). Generalized seizures are grouped into absence seizures, generalized tonic-clonic seizures, and other generalized seizures, now including recognition of negative myoclonus as a seizure type. Seizures are described in the basic version as with or without observable manifestations, whereas an expanded version utilizes the chronological sequence of seizure semiology. This updated classification comprises four main classes and 21 seizure types. Special emphasis was placed on ensuring translatability into languages beyond English. Its aim is to establish a common language for all health care professionals involved in epilepsy care, from resource-limited areas to highly specialized centers, and to provide accessible terms for patients and caregivers.

Unveiling the role of Na⁺/K⁺-ATPase pump: neurodegenerative mechanisms and therapeutic horizons

Sodium and potassium-activated adenosine 5'-triphosphatase (Na+/K+-ATPase) is a pivotal plasma membrane enzyme involved in neuronal activity and cellular homeostasis. The dysregulation of these enzymes has been implicated in a spectrum of neurodegenerative disorders like Alzheimer's disease (AD), Parkinson's disease (PD), Huntington's disease (HD), and neurodevelopmental disorders including autism spectrum disorder (ASD), psychiatric disorders such as schizophrenia, and neurological problems like epilepsy. A hallmark of these disorders is the gradual loss of neuronal integrity and function, often exacerbated by protein accumulation within brain cells. This review delves into the multifaceted role of Na+/K+-ATPase dysfunction in driving oxidative stress, excitotoxicity, and neuroinflammation, contributing to synaptic and neuronal damage. Emerging therapeutic strategies, such as gene therapy and developing isoform-specific enzyme modulators, offer promising avenues for targeted interventions. Furthermore, this review highlights innovative research directions, including the role of Na⁺/K⁺-ATPase in synaptic plasticity, the identification of endogenous regulators, and its contribution to neuroinflammatory pathways. Personalized medicine and advanced gene-editing technologies are positioned as transformative tools for crafting safer and more precise therapies tailored to individual patients. This comprehensive exploration underscores the enzyme's therapeutic potential and sets the stage for developing novel targeted strategies to mitigate the burden of Na⁺/K⁺-ATPase-linked neurological disorders.

A Systematic Review of the Anti-seizure and Antiepileptic Effects and Mechanisms of Piperine

INTRODUCTION AND AIMS

Seizures due to epilepsy in any form cause a wide range of problems in a patient's physical, psychological, and social health. This study aimed to investigate piperine's anti-seizure and antiepileptic effects and mechanisms.

METHODS

In this systematic review study, which was conducted according to the principles of PRISMA 2020, the initial search was conducted on November 2, 2023, using EndNote software. Various databases such as PubMed, Cochrane Library, Web of Science, Embase, and Scopus were searched using specific keywords. After screening the articles, a form was designed according to the objectives of the study, and the information related to the included articles was entered in the form, and the studies were reviewed.

RESULTS

Piperine showed its antiepileptic activity by affecting the brain's antioxidant, anti-inflammatory, and anti-apoptotic activity. It also, by modulating brain-derived neurotrophic factor (BDNF) and gamma-aminobutyric acid (GABA)ergic activity, can control seizures. In addition, piperine can help treat seizures and epilepsy by elevating 5-HT levels in the brain, modulating astrocyte and microglia function, modulatory effects on Ca2+ and NA+ channels, increasing antiepileptic drugs bioavailability and influencing protein and gene expression.

CONCLUSION

In vivo and in vitro studies showed beneficial effects on treating epilepsy. Although clinical studies also showed similar results, these needed to be increased, and more clinical studies needed to be designed in this field.

Quality of care and associated factors among patients with epilepsy at public hospitals in Arba Minch Town: a facility-based cross-sectional study

BACKGROUND

Epilepsy is one of the most common neurologic disorders affecting approximately 51 million people globally and is associated with significant cases of age-standardized DALYs (182.6 per 100 000 people). The quality of health care services offered to people suffering from epilepsy often fails to meet standards in Ethiopia or internationally. This study was designed to assess the quality of care and associated factors among patients with epilepsy at public hospitals in Arba Minch Town, 2024.

METHOD

A facility-based cross-sectional study was conducted among 392 adult epileptic patients attending public hospitals in Arba Minch Town. Data entry was performed via Epi-data 3.1 software, and the data were analyzed via SPSS version 24 software. Binary logistic regression analysis was used to evaluate the associations between quality of care and sociodemographic, disease-related, and treatment-related factors. Multivariate logistic regression analysis was applied to identify factors independently associated with quality of care.

RESULTS

Three hundred ninety-two adults with epilepsy participated in this study, for a response rate of 92.7%. More than one-half of the 237 (60.5%) patients were males, with a median age of 31 ± 12 years (interquartile range). Fewer than one-half (44.1%) of the patients adhered to antiepileptic medicines. The overall proportion of patients receiving quality care was 213 (54.3%). The seizure control rate was also low, at 130 (33.2%). Patients aged 18-29 years [AOR = 30.8 (95% CI, 8.22-35.616, p < 0.000)] and aged 30-39 years [AOR = 18.4 (95% CI, 5.016-67.613, p < 0.000)], and a seizure frequency of less than three [AOR = 2.318 (95% CI, 1.028-5.225, p < 0.043)] were positively associated with quality of care. Whereas, having poor knowledge about epilepsy [AOR = 0.107 (95% CI, 0.0.057-0.202, p < 0.000)] was negatively associated with quality care.

CONCLUSION

The quality of care provided to adult epilepsy patients at Arba Minch was low. In addition, patient knowledge, medication adherence, and the seizure control rate were also suboptimal. Therefore, addressing identified factors by involving all relevant stakeholders (health professionals, hospitals, zonal health departments, regional health bureaus, and patients) is critical for improving the quality of care. In addition, researchers willing to study this topic should use strong designs that can determine causal determinants of quality care.

Current Role of Brivaracetam in the Management of Epilepsy in Adults and Children: A Systematic Review

Epilepsy, a neurological condition, has a devastating effect on the quality of life (QoL) of patients if left untreated. Brivaracetam (BRV), a third-generation antiepileptic drug (AED), acts by modulating synaptic vesicle proteins, making it a valuable addition to the arsenal of drugs for epilepsy management. This study aims to assess the efficacy, safety, and reasons for switching from prior AEDs to BRV in patients with epilepsy. A systematic electronic search was performed in PubMed and Google Scholar for English-language articles published from 1 June 2013 to 2 June 2023 on the safety, efficacy, and behavioral adverse effects (BAEs) of BRV when used as monotherapy, add-on therapy, and after switching from prior AEDs (switch therapy; along with reasons for switching to BRV from prior AEDs in adult and pediatric populations), irrespective of the route of administration. A qualitative assessment was conducted using the Joanna Briggs Institute (JBI) tool. A qualitative synthesis of the data was performed. Sixty-one articles involving a total of 15,186 patients with epilepsy were included for qualitative synthesis. In adults, seizure reduction was reported in 31.4%-72.0%, 4.4%-82.1%, and 6.8%-54.3% of patients; seizure freedom in 12.10%-25.6%, 2.0%-80%, and 6.5%-30.6% of patients; and a responder rate of ≥50% in 30.8%, 21.9%-83.8%, and 16.7%-69.1% of patients with monotherapy, add-on therapy, and after switch therapy, respectively. In the pediatric population, seizure reduction was reported in 39.1%‍-‍62.5% and 21%-59% of patients, seizure freedom in 4.4%-37.5% and 12% of patients, and a responder rate of ≥50% in 19.7%-65% and 21%-45.2% of patients with add-on therapy and after switch therapy, respectively. BAEs such as irritability, mood changes, emotional lability, aggression, and agitation were reported in adults for all types of therapies, while anger was reported with only monotherapy and add-on therapy, hyperactivity with add-on therapy, and agitation with monotherapy and add-on therapy with BRV. In the pediatric population, irritability and aggression were reported with add-on and switch therapies, while emotional lability was reported with only switch therapy with BRV. The reasons for switching to BRV from previous AEDs were lack of efficacy and treatment-related adverse effects (AEs). BRV has a favorable efficacy and safety profile. The drug reduces seizure frequency, provides seizure freedom, and achieves a ≥50% responder rate in adult and pediatric patients with add-on therapy and after switching to BRV from other AEDs. However, there is limited evidence supporting its use as monotherapy.

Provoked Seizure Triggered By Electrolyte Imbalance And Substance Use: A Case Report

This case report explores the diagnostic challenges in evaluating first-time seizures by highlighting the importance of differentiating between provoked and unprovoked seizures. The patient, a 65-year-old female, experienced her first seizure during a yoga retreat in Costa Rica, influenced by a perfect storm of overlapping factors such as traveler's diarrhea, alcohol consumption, and THC use. Comprehensive evaluation and laboratory assessments revealed an elevated hematocrit and borderline magnesium deficiency. Despite limitations in reporting accuracy and the lack of immediate medical transfer, these findings did not hinder the diagnostic process. This episode, classified as a provoked seizure, highlights the necessity of a detailed case history when evaluating a presumed first-time seizure, targeted electrolyte assessment, and hydration strategies to inform clinical decision-making.

Seizures and Epilepsy: An Overview for UK Medical Students

Epilepsy is a common neurological disorder impacting millions globally, marked by recurrent, unprovoked seizures. This review article, tailored for UK medical students, provides a broad clinical overview of epilepsy, focusing on its pathophysiology, classification, and management strategies. The article clarifies the distinction between epilepsy and seizures and delves into key areas, including risk factors, clinical features, and differential diagnosis. The discussion extends to diagnostic methods, underscoring the importance of conducting a thorough evaluation in diagnosing and managing epilepsy effectively. Data were drawn from the UK National Institute for Health and Care Excellence (NICE) guidelines, World Health Organization (WHO) reports, and key peer-reviewed studies. Particular attention was given to UK-specific data on epilepsy incidence, treatment gaps, and clinical outcomes. A review of relevant literature was conducted, covering epidemiology, pathophysiology, diagnostic protocols, and management strategies based on UK practices. Finally, the article addresses the acute management of seizures and the pharmacological and non-pharmacological management of epilepsy based on the NICE guidelines. The goal is to offer medical students a concise yet comprehensive understanding of epilepsy, preparing them for practical, evidence-based decision-making in clinical practice.

Hypocalcemia-induced seizures in a peritoneal dialysis (PD) patient: A case report

Key Clinical Message

A thorough evaluation is necessary for seizures caused by hypocalcemia, both during the patient's presentation and following their recovery from the postictal seizure episode. This is because the underlying cause of hypocalcemia must be ruled out in order to ensure the best possible clinical outcome from calcium and vitamin D therapy.

Abstract

Patients with multiple systemic issues, including neurological involvement and seizure development, are not uncommon among nephrologists. Both the central and peripheral neural systems can be impacted by kidney disease. The main symptoms are myopathy, cranial or peripheral neuropathy, cognitive impairment, and seizures. A 22-year-old female with an unusual medical history who had been known to have end-stage kidney disease (ESKD) for a year and regularly had CAPD (continuous ambulatory peritoneal dialysis) suffered from two episodes of tonic-colonic seizures 2 weeks apart. On physical examination, symptoms of tongue biting, decreased vision in the left eye, and mild bilateral pulmonary air entry were notable. Upon examination, there was evidence of severe hypocalcemia, hyponatremia, a high renal profile (urea and creatinine), anemia, and a severe vitamin D deficiency. Her peritoneal dialysis (PD) prescription was reviewed, her seizures ceased, and she was released from the hospital after the hypocalcemia was treated with intravenous calcium and high doses of vitamin D. The issue of hypocalcemic seizures should be carefully evaluated both at the presentation and after the patient recovers from the postictal stage. By following this, seizure episodes can be prevented with good success if patients strictly adhere to the medication for which they are responsible.

Propagation of transient explosive synchronization in a mesoscale mouse brain network model of epilepsy

Generalized epileptic attacks, which exhibit widespread disruption of brain activity, are characterized by recurrent, spontaneous, and synchronized bursts of neural activity that self-initiate and self-terminate through critical transitions. Here we utilize the general framework of explosive synchronization (ES) from complex systems science to study the role of network structure and resource dynamics in the generation and propagation of seizures. We show that a combination of resource constraint and adaptive coupling in a Kuramoto network oscillator model can reliably generate seizure-like synchronization activity across different network topologies, including a biologically derived mesoscale mouse brain network. The model, coupled with a novel algorithm for tracking seizure propagation, provides mechanistic insight into the dynamics of transition to the synchronized state and its dependence on resources; and identifies key brain areas that may be involved in the initiation and spatial propagation of the seizure. The model, though minimal, efficiently recapitulates several experimental and theoretical predictions from more complex models and makes novel experimentally testable predictions.

The National Institutes of Health COVID-19 Neuro Databank/Biobank: Creation and Evolution

INTRODUCTION

Diverse neurological conditions are reported associated with the SARS-CoV-2 virus; neurological symptoms are the most common conditions to persist after the resolution of acute infection, affecting 20% of patients 6 months after acute illness. The COVID-19 Neuro Databank (NeuroCOVID) was created to overcome the limitations of siloed small local cohorts to collect detailed, curated, and harmonized de-identified data from a large diverse cohort of adults with new or worsened neurological conditions associated with COVID-19 illness, as a scientific resource.

METHODS

A Steering Committee including US and international experts meets quarterly to provide guidance. Initial study sites were recruited to include a wide US geographic distribution; academic and non-academic sites; urban and non-urban locations; and patients of different ages, disease severity, and comorbidities seen by a variety of clinical specialists. The NeuroCOVID REDCap database was developed, incorporating input from professional guidelines, existing common data elements, and subject matter experts. A cohort of eligible adults is identified at each site; inclusion criteria are: a new or worsened neurological condition associated with a COVID-19 infection confirmed by testing. De-identified data are abstracted from patients' medical records, using standardized common data elements and five case report forms. The database was carefully enhanced in response to feedback from site investigators and evolving scientific interest in post-acute conditions and their timing. Additional US and international sites were added, focusing on diversity and populations not already described in published literature. By early 2024, NeuroCOVID included over 2,700 patient records, including data from 16 US and 5 international sites. Data are being shared with the scientific community in compliance with NIH requirements. The program has been invited to share case report forms with the National Library of Medicine as an ongoing resource for the scientific community.

CONCLUSION

The NeuroCOVID database is a unique and valuable source of comprehensive de-identified data on a wide variety of neurological conditions associated with COVID-19 illness, including a diverse patient population. Initiated early in the pandemic, data collection has been responsive to evolving scientific interests. NeuroCOVID will continue to contribute to scientific efforts to characterize and treat this challenging illness and its consequences.

Evaluating the Credibility and Reliability of Online Information on Cannabidiol (CBD) for Epilepsy Treatment in Poland

The interest in the potential therapeutic use of cannabis, especially cannabidiol (CBD), has increased significantly in recent years. On the Internet, users can find lots of articles devoted to its medical features such as reducing seizure activity in epilepsy. The aim of our work was to evaluate the information contained on the websites, including social media, in terms of the credibility and the reliability of current knowledge about the usage of products containing cannabidiol in epilepsy treatment. We used online available links found using the Newspointtool. The initial database included 38,367 texts, but after applying the inclusion and exclusion criteria, 314 texts were taken into consideration. Analysis was performed using the DISCERN scale and the set of questions created by the authors. In the final assessment, we observed that most of the texts (58.9%) were characterized by a very poor level of reliability and the average DISCERN score was 26.97 points. Additionally, considering the form of the text, the highest average score (35.73) came from entries on blog portals, whereas the lowest average score (18.33) came from comments and online discussion forums. Moreover, most of the texts do not contain key information regarding the indications, safety, desired effects, and side effects of CBD therapy. The study highlights the need for healthcare professionals to guide patients towards reliable sources of information and cautions against the use of unverified online materials, especially as the only FDA-approved CBD medication, Epidiolex, differs significantly from over-the-counter CBD products.

Advances in understanding the pathogenesis of epilepsy: Unraveling the molecular mechanisms: A cross-sectional study

Introduction

Epilepsy is characterized by having two or more unprovoked seizures. Understanding the pathogenesis of epilepsy, requires deep investigation into the molecular mechanisms. This helps develop diagnostic techniques, treatments, and pharmacotherapy. It also enhances precision medicine and individualized treatment processes. This article reviews all the molecular mechanisms predisposing to epileptogenesis, presents the current diagnostic techniques and drug therapy, and suggests future perspectives in treating Epilepsy in a more comprehensive and holistic approach.

Methodology

Four authors searched keywords concerning epilepsy at a molecular level, Epilepsy diagnostic techniques and technologies, and antiepileptic drug therapy and precision medicine. Separate search strategies were conducted for each concern and retrieved articles were reviewed for relevant results.

Results

The traditional diagnostic techniques for Epilepsy and its pathogenesis are insufficient in highlighting dynamic brain changes. For this, emerging technologies including genetic sequencing and profiling, and functional neuroimaging techniques are prevailing. Concerning treatment, the current approach focuses on managing symptoms and stopping seizures using antiseizure medications. However, their usage is limited by developing resistance to such drugs. Some therapies show promise, although most antiseizure drugs do not prevent epilepsy.

Discussion

Understanding epileptogenesis at a molecular and genetic level aids in developing new antiepileptic pharmacotherapy. The aim is to develop therapies that could prevent seizures or modify disease course, decreasing the severity and avoiding drug resistance. Gene therapy and precision medicine are promising but applications are limited due to the heterogeneity in studying the Epileptic brain, dynamically. The dynamic investigation of the epileptic brain with its comorbidities works hand-in-hand with precision medicine, in developing personalized treatment plans.

Anti-seizure Medications: Challenges and Opportunities

Epilepsy is a chronic neurological condition characterized by unprovoked, recurrent seizures. There are several types of epilepsy, and the cause of the condition can vary. Some cases of epilepsy have a genetic component, while others may be caused by brain injuries, infections, or other underlying conditions. Treatment for epilepsy typically involves anti-seizure medications (ASMs), although different approaches, such as surgery or a special diet, may be considered in specific cases. The treatment aims to effectively manage and potentially eliminate seizures while minimizing any accompanying side effects. Many different ASMs are available, and the choice of medication depends on several factors, including the type of seizures, the patient's age, general health, and potential drug interactions. For the treatment of epilepsy, there have been significant advancements in recent decades, which have led to the approval of many different ASMs. Newer ASMs offer a broader range of mechanisms of action, improved tolerability profiles, and reduced drug interactions compared to older drugs. This review aims to discuss the pharmacological characteristics, clinical applications, effectiveness, and safety of ASMs, with a particular emphasis on various age groups, especially children. Moreover, this review seeks to provide a comprehensive understanding of ASM therapy for epilepsy management, assisting physicians in selecting suitable ASMs for their patients.

Whole exome sequencing identified five novel variants in CNTN2, CARS2, ARSA, and CLCN4 leading to epilepsy in consanguineous families

Introduction: Epilepsy is a group of neurological disorders characterized by recurring seizures and fits. The Epilepsy genes can be classified into four distinct groups, based on involvement of these genes in different pathways leading to Epilepsy as a phenotype. Genetically the disease has been associated with various pathways, leading to pure epilepsy-related disorders caused by CNTN2 variations, or involving physical or systemic issues along with epilepsy caused by CARS2 and ARSA, or developed by genes that are putatively involved in epilepsy lead by CLCN4 variations. Methods: In this study, five families of Pakistani origin (EP-01, EP-02, EP-04, EP-09, and EP-11) were included for molecular diagnosis. Results: Clinical presentations of these patients included neurological symptoms such as delayed development, seizures, regression, myoclonic epilepsy, progressive spastic tetraparesis, vision and hearing impairment, speech problems, muscle fibrillation, tremors, and cognitive decline. Whole exome sequencing in index patients and Sanger sequencing in all available individuals in each family identified four novel homozygous variants in genes CARS2: c.655G>A p.Ala219Thr (EP-01), ARSA: c.338T>C: p.Leu113Pro (EP-02), c.938G>T p.Arg313Leu (EP-11), CNTN2: c.1699G>T p.Glu567Ter (EP-04), and one novel hemizygous variant in gene CLCN4: c.2167C>T p.Arg723Trp (EP-09). Conclusion: To the best of our knowledge these variants were novel and had not been reported in familial epilepsy. These variants were absent in 200 ethnically matched healthy control chromosomes. Three dimensional protein analyses revealed drastic changes in the normal functions of the variant proteins. Furthermore, these variants were designated as "pathogenic" as per guidelines of American College of Medical Genetics 2015. Due to overlapping phenotypes, among the patients, clinical subtyping was not possible. However, whole exome sequencing successfully pinpointed the molecular diagnosis which could be helpful for better management of these patients. Therefore, we recommend that exome sequencing be performed as a first-line molecular diagnostic test in familial cases.

Investigating the Impact of Epilepsy on Cognitive Function: A Narrative Review

It has been noted that people who have epilepsy have an increased propensity for cognitive dysfunction. We explored 25 relevant articles on PubMed and Cochrane Library after implementing inclusion criteria. Different factors have been postulated and studied that may cause cognitive dysfunction in these patients; structural brain abnormalities, polypharmacy of antiepileptic medication, and neuropsychiatric disorders are the most common causes. Cognitive assessments such as Montreal Cognitive Assessment (MOCA) and Mini-Mental State Exam (MMSE) are the mainstay tools used to diagnose the degree of cognitive decline, and alterations in EEG (electroencephalogram) parameters have also been noted in people with cognitive decline. The mechanisms and treatments for cognitive decline are still being studied, while attention has also been directed toward preventive and predictive methods. Early detection and treatment of cognitive impairment can help minimize its impact on the patient's quality of life. Regular cognitive assessments are essential for epileptic patients, particularly those on multiple antiepileptic drugs. While proper management of epilepsy and related comorbidities would reduce cognitive decline and improve the overall quality of life for people with epilepsy.

Identification of patients with epilepsy using automated electronic health records phenotyping

OBJECTIVE

Unstructured data present in electronic health records (EHR) are a rich source of medical information; however, their abstraction is labor intensive. Automated EHR phenotyping (AEP) can reduce the need for manual chart review. We present an AEP model that is designed to automatically identify patients diagnosed with epilepsy.

METHODS

The ground truth for model training and evaluation was captured from a combination of structured questionnaires filled out by physicians for a subset of patients and manual chart review using customized software. Modeling features included indicators of the presence of keywords and phrases in unstructured clinical notes, prescriptions for antiseizure medications (ASMs), International Classification of Diseases (ICD) codes for seizures and epilepsy, number of ASMs and epilepsy-related ICD codes, age, and sex. Data were randomly divided into training (70%) and hold-out testing (30%) sets, with distinct patients in each set. We trained regularized logistic regression and an extreme gradient boosting models. Model performance was measured using area under the receiver operating curve (AUROC) and area under the precision-recall curve (AUPRC), with 95% confidence intervals (CI) estimated via bootstrapping.

RESULTS

Our study cohort included 3903 adults drawn from outpatient departments of nine hospitals between February 2015 and June 2022 (mean age = 47 ± 18 years, 57% women, 82% White, 84% non-Hispanic, 70% with epilepsy). The final models included 285 features, including 246 keywords and phrases captured from 8415 encounters. Both models achieved AUROC and AUPRC of 1 (95% CI = .99-1.00) in the hold-out testing set.

SIGNIFICANCE

A machine learning-based AEP approach accurately identifies patients with epilepsy from notes, ICD codes, and ASMs. This model can enable large-scale epilepsy research using EHR databases.

Diagnostic and therapeutic value of P2Y12R in epilepsy

There lacks biomarkers in current epilepsy diagnosis, and epilepsy is thus exposed to inadequate treatment, making it necessarily important to conduct search on new biomarkers and drug targets. The P2Y12 receptor is primarily expressed on microglia in the central nervous system, and acts as intrinsic immune cells in the central nervous system mediating neuroinflammation. In previous studies, P2Y12R in epilepsy has been found capable of controlling neuroinflammation and regulating neurogenesis as well as immature neuronal projections, and its expression is altered. P2Y12R is involved in microglia inhibition of neuronal activity and timely termination of seizures in acute seizures. In status epilepticus, the failure of P2Y12R in the process of "brake buffering" may not terminate the neuronal hyperexcitability timely. In chronic epilepsy, neuroinflammation causes seizures, which can in turn induce neuroinflammation, while on the other hand, neuroinflammation leads to neurogenesis, thereby causing abnormal neuronal discharges that give rise to seizures. In this case, targeting P2Y12R may be a novel strategy for the treatment of epilepsy. The detection of P2Y12R and its expression changes can contribute to the diagnosis of epilepsy. Meanwhile, the P2Y12R single-nucleotide polymorphism is associated with epilepsy susceptibility and endowed with the potential to individualize epilepsy diagnosis. To this end, functions of P2Y12R in the central nervous system were hereby reviewed, the effects of P2Y12R in epilepsy were explored, and the potential of P2Y12R in the diagnosis and treatment of epilepsy was further demonstrated.

Awareness of Nigerian Mothers on the Risk Factors, Prevention and Management of Seizures in Newborns

OBJECTIVES

The study aimed to assess the awareness of mothers on the risk factors, prevention, and management of seizures in newborns.

MATERIALS & METHODS

This descriptive cross-sectional study was conducted on 359 mothers using simple random sampling. The data were collected using questionnaires that included general awareness, awareness of the causes, risk factors, prevention, and management. The data collected were analyzed using frequencies and percentages. Null hypotheses were tested using chi-square at 0.05 level of significance.

RESULTS

Two hundred seventy-four mothers (76.3%) had high awareness of seizures in newborns, thirty-four (9.5%) had average awareness, and fifty-one (14.2%) had low awareness. Two hundred seventy-three mothers (76%) had high awareness of the risk factors, and eighty-six (24%) had low awareness, meaning that although some respondents had misconceptions, awareness of the risk factors and causes was good. Two hundred twenty-three (62.1%) respondents had high awareness of preventing seizures in newborns, while 136 (37.9%) had low awareness. The awareness of respondents on managing seizures in newborns is positive, as 291 (81.1%) had high awareness of managing seizures in newborns, while sixty-eight (18.9%) had low awareness. There was a significant relationship between age (p =0.000), marital status (p=0.018), level of education (p =0.000), and awareness of risk factors of seizures in the newborn.

CONCLUSION

A high awareness of neonatal seizures was found among mothers because of their high educational level, although some still had some misconceptions. Improving maternal neonatal seizure awareness and appropriate educational interventions to correct misconceptions are needed.

Parent perceptions and decision making about treatments for epilepsy: a qualitative evidence synthesis

OBJECTIVES

Epilepsy treatment decision making is complex and understanding what informs caregiver decision making about treatment for childhood epilepsy is crucial to better support caregivers and their children. We synthesised evidence on caregivers' perspectives and experiences of treatments for childhood epilepsy.

DESIGN

Systematic review of qualitative studies using a best-fit framework and Grading of Recommendations Assessment, Development and Evaluation Confidence in the Evidence from Reviews of Qualitative Research (GRADE-CERQual) approach.

DATA SOURCES

Searched Embase, PubMed, CINAHL, PsycINFO, SocINDEX and Web of Science from 1 January 1999 to 19 August 2021.

ELIGIBILITY CRITERIA

We included qualitative studies examining caregiver's perspectives on antiseizure medication, diet or surgical treatments for childhood epilepsy. We excluded studies not reported in English.

DATA EXTRACTION AND SYNTHESIS

We extracted qualitative evidence into 1 of 14 domains defined by the Theoretical Domains Framework (TDF). One reviewer extracted study data and methodological characteristics, and two reviewers extracted qualitative findings. The team verified all extractions. We identified themes within TDF domains and synthesised summary statements of these themes. We assessed our confidence in our summary statements using GRADE-CERQual.

RESULTS

We identified five studies (in six reports) of good methodological quality focused on parent perceptions of neurosurgery; we found limited indirect evidence on parents' perceptions of medications or diet. We identified themes within 6 of the 14 TDF domains relevant to treatment decisions: knowledge, emotion; social/professional role and identity; social influence; beliefs about consequences; and environmental context and resources.

CONCLUSIONS

Parents of children with epilepsy navigate a complex process to decide whether to have their child undergo surgery. Educational resources, peer support and patient navigators may help support parents through this process. More qualitative studies are needed on non-surgical treatments for epilepsy and among caregivers from different cultural and socioeconomic backgrounds to fully understand the diversity of perspectives that informs treatment decision making.

Responsive Neurostimulation for Seizure Control: Current Status and Future Directions

Electrocorticography (ECoG) data are commonly obtained during drug-resistant epilepsy (DRE) workup, in which subdural grids and stereotaxic depth electrodes are placed on the cortex for weeks at a time, with the goal of elucidating seizure origination. ECoG data can also be recorded from neuromodulatory devices, such as responsive neurostimulation (RNS), which involves the placement of electrodes deep in the brain. Of the neuromodulatory devices, RNS is the first to use recorded ECoG data to direct the delivery of electrical stimulation in order to control seizures. In this review, we first introduced the clinical management for epilepsy, and discussed the steps from seizure onset to surgical intervention. We then reviewed studies discussing the emergence and therapeutic mechanism behind RNS, and discussed why RNS may be underperforming despite an improved seizure detection mechanism. We discussed the potential utility of incorporating machine learning techniques to improve seizure detection in RNS, and the necessity to change RNS targets for stimulation, in order to account for the network theory of epilepsy. We concluded by commenting on the current and future status of neuromodulation in managing epilepsy, and the role of predictive algorithms to improve outcomes.

Seizure after surgical treatment of chronic subdural hematoma—Associated factors and effect on outcome

Introduction

Chronic subdural hematoma (cSDH) is becoming more prevalent due to population aging and the increasing use of antithrombotic drugs. Postoperative seizure in cSDH have a negative effect on outcome, and there currently no consensus regarding prophylactic anti-epileptic drug (AED) treatment. The objective of this study was to evaluate predisposing and triggering factors associated with postoperative epileptic seizure in patients with cSDH.

Methods

All patients, who were surgically treated for cSDH in a single tertiary care center between 2015 and 2019, were considered for inclusion. Relevant patient- and hematoma-specific characteristics were retrospectively extracted from hospital records. Paroxysmal events categorized by the treating physician as suspected postoperative seizures were noted. The clinical outcome was extracted from the last available follow-up visit and classified according to the Glasgow outcome scale (GOS).

Results

Of the included 349 patients, 54 (15.5%) developed suspected postoperative epileptic complications in the form of early seizure (≤ 7 days) in 11 patients (3.2%) and late seizure (&gt;7 days) in 43 patients (12.3%). In the logistic regression analysis, solely depressed brain volume (supratentorial volume (ml) not filled with re-expanded brain) was independently associated with postoperative seizure (odds ratio [OR] 1.006, 95% CI: 1.001–1.011; p = 0.034). The occurrence of postoperative seizure (OR 6.210, 95% CI: 2.704–14.258; p &lt; 0.001) and preoperative Markwalder grading (OR 2.919, 95% CI: 1.538–5.543; p = 0.001) were independently associated with unfavorable (GOS1−3) outcome.

Conclusion

Larger postoperative depressed brain volume was the only factor independently associated with suspected postoperative seizure, and it could help identify a subgroup of patients with higher susceptibility to epileptic events. Based on our data, no formal recommendation can be made regarding the prophylactic use of anti-epileptic drugs. Nevertheless, the relative safety of new generation AEDs and the detrimental effect of postoperative seizure on outcome may justify its use in a selected patient population.

The Influence of Neurotrophic Factors BDNF and GDNF Overexpression on the Functional State of Mice and Their Adaptation to Audiogenic Seizures

The high prevalence of diagnosed cases of severe neurological disorders, a significant proportion of which are epilepsy, contributes to a high level of mortality and disability in the population. Neurotrophic factors BDNF and GNDF are considered promising agents aimed at increasing the central nervous system's adaptive potential for the development of the epileptiform activity. Despite the pronounced neuroprotective and anticonvulsant potential, an appropriate way to stimulate these endogenous signaling molecules with minimal risk of side effects remains an open question. Herein, we assessed the safety of gene therapy using original adeno-associated viral constructs carrying the genes of neurotrophic factors BDNF and GDNF in the early postnatal period of development of experimental animals. The intraventricular injection of AAV-Syn-BDNF-eGFP and AAV-Syn-GDNF-eGFP viral constructs into newborn mice was found to provide persistent overexpression of target genes in the hippocampus and cerebral cortex in vivo for four weeks after injection. The application of viral constructs has a multidirectional effect on the weight and body length characteristics of mice in the early postnatal period; however, it ensures the animals' resistance to the development of seizure activity under audiogenic stimulation in the late postnatal period and preserves basic behavioral reactions, emotional status, as well as the mnestic and cognitive abilities of mice after simulated stress. Our results demonstrated the safety of using the AAV-Syn-BDNF-eGFP and AAV-Syn-GDNF-eGFP viral constructs in vivo, which indicates the expediency of further testing the constructs as therapeutic anticonvulsants.

Antiepileptic Drugs and Their Dual Mechanism of Action on Carbonic Anhydrase

(1) Background: The benefit of using inhibitors of carbonic anhydrase (CA), such as acetazolamide, in the treatment of epilepsy has previously been described. (2) Methods: In this paper, the effect on CA of the most well-known antiepileptic drugs was studied in vitro and in vivo. The effects, after chronic treatment, of carbamazepine, phenytoin, valproate, primidone, clonazepam, and ethosuximide were studied in vitro on purified CA, isozyme I (CA I) and CA, and isozyme II (CA II) activity and in vivo on epileptic erythrocyte CA I and CA II activity. (3) Results: In vitro results showed that all antiepileptic drugs reduced purified CA II activity according to dose–response relationships and slightly inhibited CA I activity. In vivo results showed that the chronic administration of antiseizure drugs induced a progressive reduction in erythrocyte CA II activity in all the groups studied. This study shows that CA II inhibition can be induced both in vitro and in vivo by major antiepileptic agents as it might be one of the effective mechanisms of these anticonvulsant drugs. (4) Conclusions: The decrease in CA II activity in epileptic patients after antiseizure treatment suggests the involvement of CA II in the pathogenesis of epilepsy.

Accelerating the Availability of Medications to Pediatric Patients by Optimizing the Use of Extrapolation of Efficacy

Improving pediatric therapeutic development is a mission of universal importance among health authorities, pharmaceutical companies, academic institutions, and healthcare professionals. Following the passage of legislation in the United States and Europe, we witnessed the most significant advancement yet in pediatric data generation, resulting in added pediatric use information to almost 700 product labels. Tools to accelerate generation of data for the pediatric population are available for use today, and when utilized in accordance with current practices and laws, these tools could increase the amount and timeliness of pediatric information available for clinicians and patients. If we utilize the current laws that allow regulators to incentivize and require evidence generation, apply extrapolation, and utilize modeling and simulation, as well as including adolescents in the pivotal studies alongside adults as appropriate, two strategic goals could be achieved by 2030: (1) reduce the time to pediatric approval by 50%, and (2) renew pediatric labeling information for 15 priority pediatric drugs without patent and/or exclusivity.

Clinical Characteristics and Etiology of Epilepsy in Children Aged Below Two Years: Perspective From a Tertiary Childcare Hospital in South Punjab, Pakistan

Background Epilepsy is described as an enduring disposition toward recurrent unprovoked seizures and by the neurobiological, cognitive, psychological, and social consequences of this condition. This study aimed to find the clinical characteristics and etiology of epilepsy in children aged below two years. Methodology This cross-sectional study was conducted at the department of pediatric neurology, the Children's Hospital and Institute of Child Health, Multan, Pakistan, from February 2021 to July 2021. During the study period, a total of 226 children of both genders, aged below two years, presenting with epilepsy and who underwent electroencephalography (EEG) were included. Socio-demographic and clinical data along with clinical features and radiological/imaging findings were noted. Results In a total of 226 children, 121 (53.5%) were male and 105 (46.5%) female. Overall, the mean age was calculated to be 14.6±5.2 months while 107 (47.3%) children were aged between 13 to 24 months. Residential status was found to be rural in 142 (62.8%) children. Generalized seizures (both primary and secondary) were reported in 205 (90.7%) children while the remaining 21 (9.3%) children had focal seizures. The most common etiology of epilepsy was noted to be structural/metabolic in 122 (54.0%) children. Abnormal EEG findings were observed among 150 (66.4%) children. Developmental delay (p=0.0016), hypotonia (p<0.0001), microcephaly or macrocephaly (p<0.0001), abnormal brain CT or MRI (p<0.0001), and abnormal EEG findings (p=0.0161) were found to have a significant association with etiology of epilepsy. Conclusion Generalized seizures like tonic-clonic and clonic types were the most common findings among children below two years of age with epilepsy. Structural abnormalities were the most common etiology in children with epilepsy. Age between one to two years was the commonest age of onset of seizures among young children.

Determination of the Initial Abnormal Discharge Site in Temporal Lobe Epilepsy Through Combined EEG and Neuroimaging. What Is Next?

Objective: The objective of this study was to determine the relationship between atrophy of the hippocampus and severity of epilepsy in patients with temporal lobe epilepsy (TLE) as the first step to evaluate the possibility of surgery for epilepsy and analyze why patients cannot undergo epilepsy surgery.

Methods: Volumetric MRI of the hippocampus was performed in 51 consecutive patients (29 men; mean age 40) with TLE. TLE diagnosis, lateralization, and severity (mild, moderate, severe) of seizures were based on a comprehensive evaluation that included neurologic examination and EEG in all patients. Patients with evidence of a lesion other than hippocampal sclerosis were not included in the study. We assessed the relationship between hippocampal volumes and electrophysiological evidence of seizure severity.

Results: According to the affected side based on the EEG, a statistically significant difference (p < 0.001) in volume and a positive correlation between epilepsy and hippocampal atrophy were found.

Conclusion: Our results confirm that volume loss to the hippocampus in patients with TLE correlates with the severity of epilepsy based on the EEG. Therefore, surgical treatment is considered early when hippocampal atrophy is evident in patients with refractory TLE. However, in Latin American countries, it is a challenge to get a patient to undergo epilepsy surgery. Therefore, we try to analyze the sad situation in our hospital.

Thymoquinone Potentiates the Effect of Phenytoin against Electroshock-Induced Convulsions in Rats by Reducing the Hyperactivation of m-TOR Pathway and Neuroinflammation: Evidence from In Vivo, In Vitro and Computational Studies

Epilepsy is a chronic neurodegenerative disease characterized by multiple seizures, hereto 35% of patients remain poor responders. Phenytoin (PHT; 20 and 40 mg/kg) and thymoquinone (THQ; 40 and 80 mg/kg) were given alone and as a low dose combination for 14 days (p.o), prior to challenge with maximal electroshock (MES; 180 mA, 220 V, 0.2 s). Apart from observing convulsions, hippocampal mTOR, IL-1β, IL-6 and TNF-α levels were measured. Hippocampal histomorphological analysis was also conducted. In vitro cell line studies and molecular docking studies were run in parallel. The results revealed the synergistic potential of the novel duo-drug combination regimen: PHT (20 mg/kg) and THQ (40 mg/kg) against MES-induced convulsions. MES amplified signaling through mTOR, and inflated the levels of proinflammatory markers (IL-1β, IL-6 and TNF-α), which was significantly averted (p < 0.001) with the said drug combination. The computational studies revealed that PHT and THQ cooperatively bind the active site on Akt (upstream target of m-TOR) and establish a good network of intermolecular interactions, which indicates the sequential inhibition of PI3K/Akt/m-TOR signaling with the combination. The combination also increased cell viability by 242.81% compared to 85.66% viability from the the toxic control. The results suggest that the PHT and THQ in combination possesses excellent anticonvulsant and neuroprotective effects.

Carbonic Anhydrase Inhibitors and Epilepsy: State of the Art and Future Perspectives

Carbonic anhydrases (CAs) are a group of ubiquitously expressed metalloenzymes that catalyze the reversible hydration/dehydration of CO₂/HCO₃. Thus, they are involved in those physiological and pathological processes in which cellular pH buffering plays a relevant role. The inhibition of CAs has pharmacologic applications for several diseases. In addition to the well-known employment of CA inhibitors (CAIs) as diuretics and antiglaucoma drugs, it has recently been demonstrated that CAIs could be considered as valid therapeutic agents against obesity, cancer, kidney dysfunction, migraine, Alzheimer's disease and epilepsy. Epilepsy is a chronic brain disorder that dramatically affects people of all ages. It is characterized by spontaneous recurrent seizures that are related to a rapid change in ionic composition, including an increase in intracellular potassium concentration and pH shifts. It has been reported that CAs II, VII and XIV are implicated in epilepsy. In this context, selective CAIs towards the mentioned isoforms (CAs II, VII and XIV) have been proposed and actually exploited as anticonvulsants agents in the treatment of epilepsy. Here, we describe the research achievements published on CAIs, focusing on those clinically used as anticonvulsants. In particular, we examine the new CAIs currently under development that might represent novel therapeutic options for the treatment of epilepsy.

Automated Epileptic Seizure Detection in Pediatric Subjects of CHB-MIT EEG Database-A Survey

Epilepsy is a neurological disorder of the brain that causes frequent occurrence of seizures. Electroencephalography (EEG) is a tool that assists neurologists in detecting epileptic seizures caused by an unexpected flow of electrical activities in the brain. Automated detection of an epileptic seizure is a crucial task in diagnosing epilepsy which overcomes the drawback of a visual diagnosis. The dataset analyzed in this article, collected from Children's Hospital Boston (CHB) and the Massachusetts Institute of Technology (MIT), contains long-term EEG records from 24 pediatric patients. This review paper focuses on various patient-dependent and patient-independent personalized medicine approaches involved in the computer-aided diagnosis of epileptic seizures in pediatric subjects by analyzing EEG signals, thus summarizing the existing body of knowledge and opening up an enormous research area for biomedical engineers. This review paper focuses on the features of four domains, such as time, frequency, time-frequency, and nonlinear features, extracted from the EEG records, which were fed into several classifiers to classify between seizure and non-seizure EEG signals. Performance metrics such as classification accuracy, sensitivity, and specificity were examined, and challenges in automatic seizure detection using the CHB-MIT database were addressed.

Potential surgical therapies for drug-resistant focal epilepsy

Drug-resistant focal epilepsy (DRFE), defined by failure of two antiepileptic drugs, affects 30% of epileptic patients. Epilepsy surgeries are alternative options for this population. Preoperative evaluation is critical to include potential candidates, and to choose the most appropriate procedure to maximize efficacy and simultaneously minimize side effects. Traditional procedures involve open skull surgeries and epileptic focus resection. Alternatively, neuromodulation surgeries use peripheral nerve or deep brain stimulation to reduce the activities of epileptogenic focus. With the advanced improvement of laser-induced thermal therapy (LITT) technique and its utilization in neurosurgery, magnetic resonance-guided LITT (MRgLITT) emerges as a minimal invasive approach for drug-resistant focal epilepsy. In the present review, we first introduce drug-resistant focal epilepsy and summarize the indications, pros and cons of traditional surgical procedures and neuromodulation procedures. And then, focusing on MRgLITT, we thoroughly discuss its history, its technical details, its safety issues, and current evidence on its clinical applications. A case report on MRgLITT is also included to illustrate the preoperational evaluation. We believe that MRgLITT is a promising approach in selected patients with drug-resistant focal epilepsy, although large prospective studies are required to evaluate its efficacy and side effects, as well as to implement a standardized protocol for its application.

The Effects of Antiepileptic Medications on Lipid Profile, Thyroid Panel, and Vitamin Level

Background: Conventional antiepileptic drugs (AEDs) have been used for many years to treat epilepsy, and physicians are generally familiar with their side-effect profiles and potential drug interactions. However, AEDs affect patient vitamin and mineral levels in a manner that is not well understood. The goal of this study was to determine the relationship between AEDs and patient vitamins and mineral levels.

Materials and methods: We conducted a retrospective analysis of liver enzyme levels, thyroid hormone levels, lipid profiles, and vitamin values (e.g., B12 and folic acid) in patients treated with carbamazepine, valproic acid, or levetiracetam at our institution. Patients were included in the study if their medical data included total cholesterol, triglyceride levels, low-density lipoprotein (LDL), and high-density lipoprotein (HDL) levels obtained on follow-up at least three months after the start of antiepileptic treatment with carbamazepine, valproic acid, or levetiracetam. Patients were grouped according to the antiepileptic drug used. We analyzed liver thyroid function tests, lipid profiles, levels of B12, and folic acid levels using laboratory test results and compared the findings from each group.

Results: Carbamazepine, valproic acid, and levetiracetam did not change the levels of liver enzymes such as aspartate transaminase and alanine aminotransferase (p values respectively: .802, .094). Cholesterol and LDL levels were lower in patients using carbamazepine (p values respectively: .005, .005), and no significant difference was observed for HDL and triglyceride levels (p values respectively: .400, .091). While thyroid-stimulating hormone levels were significantly higher in patients on medication than the control group (p=.007), the levels were still within reference ranges. No significant difference was found between tri-iodothyronine and thyroxine levels (p values respectively: .065, .053). The levels of B12 and folic acid were observed to be high in the group using carbamazepine (p values respectively: .049, .004).

Conclusion: Valproic acid and carbamazepine do not induce a significant increase in liver enzymes compared to levetiracetam, a new-generation antiepileptic medication, and they had no impact on lipoproteins such as HDL that are protective against coronary artery disease. These medications do not affect the levels of thyroid hormones in comparison to levetiracetam and the control group. Although carbamazepine and valproic acid are metabolized in the liver, liver enzyme monitoring is required; they have only affected liver enzyme values as much as levetiracetam and the control group.