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Xu J, Wei W, Liu Y, Ye H, Liu X. Efficacy and safety of adjunctive cenobamate based on patient etiology: Post-hoc analysis of YKP3089C017 randomized clinical trial. Seizure 2024; 118:95-102. [PMID: 38652999 DOI: 10.1016/j.seizure.2024.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2023] [Revised: 04/17/2024] [Accepted: 04/17/2024] [Indexed: 04/25/2024] Open
Abstract
INTRODUCTION Adjunctive cenobamate was effective and safe for the treatment of uncontrolled focal onset seizures in a randomized, double-blind, placebo-controlled, phase 2 study (YKP3089C017; NCT01866111). This post-hoc analysis assessed the efficacy of adjunctive cenobamate in the treatment of patients with different epileptic etiologies during the study. METHODS Adult patients with uncontrolled focal seizures who previously received 1 to 3 antiseizure medications (ASMs) were randomly assigned in a ratio of 1:1:1:1 to receive placebo or cenobamate 100, 200 or 400 mg/day. Patients were further stratified based on their etiologic causes as genetic/presumed genetic, unknown cause, structural cause, and not reported (NR) groups. The frequency per 28 days for an 18-week double-blind treatment period, responder rates (≥50 %, ≥75 %, ≥90 %, and 100 %) during the maintenance phase (12 weeks), and safety were assessed. RESULTS A total of 394 patients were categorized into the genetic/presumed genetic (n = 9; 2.28 %), unknown cause (n = 199; 50.51 %), structural cause (n = 177; 44.92 %), and NR (n = 13; 3.30 %) groups, with 4 patients were classified into either of the two etiological causes each. The baseline characteristics were comparable. The percentage of reduction in seizure frequency per 28 days was significantly higher in the cenobamate-treated structural (p = 0.01) and unknown cause (p = 0.0003) groups compared with the placebo group. Responder rates of ≥50 %, ≥75 %, ≥90 %, and 100 % were also higher with cenobamate therapy. Notably, no serious treatment-emergent adverse events (TEAEs) were observed in the genetic/presumed genetic group treated with cenobamate. The most common TEAEs (≥10 %) occurring in patients treated with cenobamate were nervous system disorders by system organ class, and somnolence was the most commonly reported TEAE. CONCLUSION Cenobamate reduces seizures in adult patients previously treated with ASMs, with high responder rates and acceptable safety, regardless of underlying causes.
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Affiliation(s)
- Jie Xu
- Department of Neurology, Institute of Neuroscience, Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and the Ministry of Education of China, The Second Affiliated Hospital, Guangzhou Medical University, Guangzhou 510260, China
| | - Wei Wei
- Department of Neurology, Institute of Neuroscience, Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and the Ministry of Education of China, The Second Affiliated Hospital, Guangzhou Medical University, Guangzhou 510260, China
| | - Yutong Liu
- Ignis Therapeutics (Shanghai) Limited, Shanghai 200000, China
| | - Hui Ye
- Ignis Therapeutics (Shanghai) Limited, Shanghai 200000, China
| | - Xiaorong Liu
- Department of Neurology, Institute of Neuroscience, Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and the Ministry of Education of China, The Second Affiliated Hospital, Guangzhou Medical University, Guangzhou 510260, China.
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Mason JA, Juarez-Colunga E, Knupp KG. Electrographic screening for infantile epileptic spasms syndrome in a single sleep-wake cycle. Epilepsia 2024. [PMID: 38572956 DOI: 10.1111/epi.17967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 02/21/2024] [Accepted: 03/13/2024] [Indexed: 04/05/2024]
Abstract
OBJECTIVE Infantile epileptic spasms syndrome (IESS) is a common and urgent diagnosis with seizure and nonseizure mimics. Evaluation with prolonged video-electroencephalography (EEG) can be time-consuming and costly. This study investigated the use of EEG review of a single sleep-wake cycle to exclude IESS. METHODS We retrospectively reviewed video-EEG studies to rule out IESS in children between the ages of 2 months and 2 years in the period from January 2019 through June 2020. EEG studies were reviewed from the start of the recording through the first sleep-wake cycle and scored as "normal," "consistent with IESS," or "abnormal but not diagnostic of IESS." Scores were compared to the clinical report created by analysis of the entire video-EEG. RESULTS Inclusion criteria were met in 238 EEG studies. The mean patient age was 7.6 months. The median duration of the full study was 908 min, compared to 107.5 min for the first sleep-wake cycle only. The median difference in recording time was 801 min, p-value < .01. Scored outcomes were similar. Sixty-eight percent of EEG studies were scored as "normal" on first sleep-wake cycle review as compared to 63% on full study review, 13% scored as "consistent with IESS" compared to 16% and 19% scored as "abnormal but not diagnostic of IESS" compared to 21%. Sensitivity and specificity of the first sleep-wake cycle review for studies "consistent with IESS" was 84% and 100%, respectively. No cases of IESS were scored as normal on first sleep-wake cycle review. SIGNIFICANCE A single sleep-wake cycle captured on EEG can triage studies when IESS is suspected. A normal first sleep-wake cycle did not miss cases of IESS and could result in reduced EEG recording time. Because most of these cases presented to an emergency department, a normal first sleep-wake cycle may help providers determine the acuity, or necessity, of further testing.
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Affiliation(s)
- John A Mason
- Department of Neurology, University of new Mexico, Albuquerque, New Mexico, USA
| | - Elizabeth Juarez-Colunga
- Department of Biostatistics and Informatics, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Kelly G Knupp
- Department of Pediatrics and Neurology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
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Kovačević M, Sokić D, Ristić A, Berisavac I, Ercegovac M, Milićević O, Vojvodić N. Familial occurrence of seizure disorders across MRI defined structural focal epilepsy etiology. J Clin Neurosci 2024; 123:15-22. [PMID: 38508018 DOI: 10.1016/j.jocn.2024.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Revised: 03/10/2024] [Accepted: 03/13/2024] [Indexed: 03/22/2024]
Abstract
BACKGROUND Previous studies have established familial occurrence of epilepsy and seizure disorders and early age of epilepsy onset as predictors of genetic epilepsy, but have not evaluated the rate of their occurrence in patients with different epilepsy etiology. Our study determines the distribution of familial occurrence and age of epilepsy onset across structural focal epilepsy (FE) etiology in a large FE cohort. METHODS Records of 1354 consecutive patients evaluated for epilepsy and seizure disorders in The Neurology Clinic, University Clinical Center of Serbia from 2008 to 2019 were screened for FE. Structural etiology, lobar diagnosis, familial occurrence, and age at epilepsy onset were determined. Patients with a. nonlesional focal epilepsy (NLFE), b. hippocampal sclerosis (HS) and c. congenital or perinatal etiology (CPE) were classified as NAFE, while patients with an identified acquired focal epilepsy (AFE) constituted the control group. RESULTS We identified 965 patients with FE, 329 (34.1 %) with NLFE, 213 (22.1 %) with HS, 174 (18.0 %) with CPE and 249 (25.8 %) with AFE. Familial occurrence was identified in 160 (16.6 %), 19.1 % of patients with NAFE and 9.2 % of AFE (p = 0.003). Patients with NAFE had a younger age of epilepsy onset (13 vs. 18 years, p < 0.001). The highest proportion of familial occurrence was found in patients with NLFE (23.7 %), while the youngest median age of epilepsy onset was identified in patients with HS (12 years) and CPE (11 years). CONCLUSION Patients with NAFE frequently have familial occurrence of epilepsy and have an earlier age of epilepsy onset than patients with AFE.
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Affiliation(s)
- Maša Kovačević
- Neurology Clinic, University Clinical Center of Serbia, University of Belgrade Faculty of Medicine, Serbia; Faculty of Medicine, University of Belgrade, Serbia.
| | - Dragoslav Sokić
- Neurology Clinic, University Clinical Center of Serbia, University of Belgrade Faculty of Medicine, Serbia; Faculty of Medicine, University of Belgrade, Serbia
| | - Aleksandar Ristić
- Neurology Clinic, University Clinical Center of Serbia, University of Belgrade Faculty of Medicine, Serbia; Faculty of Medicine, University of Belgrade, Serbia
| | - Ivana Berisavac
- Neurology Clinic, University Clinical Center of Serbia, University of Belgrade Faculty of Medicine, Serbia; Faculty of Medicine, University of Belgrade, Serbia
| | - Marko Ercegovac
- Neurology Clinic, University Clinical Center of Serbia, University of Belgrade Faculty of Medicine, Serbia; Faculty of Medicine, University of Belgrade, Serbia
| | | | - Nikola Vojvodić
- Neurology Clinic, University Clinical Center of Serbia, University of Belgrade Faculty of Medicine, Serbia; Faculty of Medicine, University of Belgrade, Serbia
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Tahir S, Flynn K, Babiker MOE. Efficacy of Melatonin as a Sleep Inducer in EEG Procedures in the Pediatric Population: A Cross-Sectional Study. Cureus 2024; 16:e54196. [PMID: 38496117 PMCID: PMC10942123 DOI: 10.7759/cureus.54196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/10/2024] [Indexed: 03/19/2024] Open
Abstract
Introduction Melatonin has been used as an alternative to sleep deprivation for EEG sleep induction in the pediatric population. Our study aims to describe the efficacy of the currently used doses of melatonin for sleep induction among the pediatric age group. Methods A retrospective cross-sectional study included all patients who underwent an EEG after receiving melatonin over the period of one year. A total of 126 patients have been included in the study. Patients aged one year to three years received oral melatonin in doses between 2 mg and 6 mg. Patients in the age of three years and above received 10 mg of melatonin. Patients' success rate in achieving sleep and the exact time required for the patients to fall asleep were obtained using the readings of their EEG. The percentage of patients who have achieved sleep and the time required for those patients to sleep were calculated and correlated with the patient's gender, the presence of any associated neurobehavioral disorders, and their use of antiepileptic drugs (AED). Results Successful sleep was achieved in 84.9% (n:107) of the patients, with a mean time of 24 minutes to fall asleep (SD = 14.36). Patients with neurobehavioral disorders were 20% less likely to fall asleep when compared to other patients without neurobehavioral disorders (p: 0.003). However, there was not a statistically significant difference among different genders and among patients who received AED. Conclusion Melatonin is an effective sleep inducer for patients undergoing EEG procedures. It should be considered in the majority of patients. However, in patients with neurobehavioral disorders, a lower success rate is expected.
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Affiliation(s)
- Saja Tahir
- Department of Pediatrics, Al Jalila Children's Speciality Hospital, Dubai, ARE
| | - Kate Flynn
- Department of Neurology, Al Jalila Children's Speciality Hospital, Dubai, ARE
| | - Mohamed O E Babiker
- Department of Pediatrics, Al Jalila Children's Speciality Hospital, Dubai, ARE
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Tsur A, Spierer R, Cohen R, Blatch D, Eyal S, Honig A, Ekstein D. First unprovoked seizures among soldiers recruited to the Israeli Defense Forces during 10 consecutive years: A population-based study. Epilepsia 2024; 65:127-137. [PMID: 37597251 DOI: 10.1111/epi.17750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 08/16/2023] [Accepted: 08/16/2023] [Indexed: 08/21/2023]
Abstract
OBJECTIVE The management of patients after a first unprovoked seizure (FUS) can benefit from stratification of the average 50% risk for further seizures. We characterized subjects with FUSs, out of a large generally healthy homogenous population of soldiers recruited by law to the Israeli Defense Forces, to investigate the role of the type of service, as a trigger burden surrogate, in the risk for additional seizures. METHODS Soldiers recruited between 2005 and 2014, who experienced an FUS during their service, were identified from military records. Subjects with a history of epilepsy or lack of documentation of FUS characteristics were excluded from the study. Data on demographics and military service and medical details were extracted for the eligible soldiers. RESULTS Of 816 252 newly recruited soldiers, representing 2 138 000 person-years, 346 had an FUS, indicating an incidence rate of 16.2 per 100 000 person-years. The FUS incidence rate was higher in combat versus noncombat male and female soldiers (p < .0001). Most subjects (75.7%) were prescribed antiseizure medications (ASMs), and 29.2% had additional seizures after the FUS. Service in combat units, abnormal magnetic resonance imaging, and being prescribed ASMs were correlated with a lower risk of having multiple seizures (95% confidence interval [CI] = .48-.97, .09-.86, .15-.28, respectively). On multivariate analysis, service in combat units (odds ratio [OR] = .48 for seizure recurrence, 95% CI = .26-.88) and taking medications (OR = .46, 95% CI = .24-.9) independently predicted not having additional seizures. SIGNIFICANCE FUS incidence rate was higher in combat soldiers, but they had a twofold lower risk of additional seizures than noncombat soldiers, emphasizing the value of strenuous triggers as negative predictors for developing epilepsy. This suggests a shift in the perception of epilepsy from a "yes or no" condition to a continuous trend of predisposition to seizures, warranting changes in the ways etiologies of epilepsy are weighted and treatments are delivered.
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Affiliation(s)
- Adili Tsur
- Israeli Defense Forces Medical Corps, Tel Aviv, Israel
- Department of Neurology, Sheba Medical Center, Ramat Gan, Israel
| | - Ronen Spierer
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Renana Cohen
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Dana Blatch
- International Center for Multimorbidity and Complexity, University of Zurich, Zurich, Switzerland
- Department of Psychosomatic Medicine, University Hospital Basel and Merian Iselin Klinik Basel, Basel, Switzerland
| | - Sara Eyal
- Institute for Drug Research, School of Pharmacy, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Asaf Honig
- Department of Neurology, Soroka Medical Center, Beer Sheva, Israel
| | - Dana Ekstein
- Department of Neurology, Agnes Ginges Center for Human Neurogenetics, Hadassah Medical Organization, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
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Rigoni I, Padmasola GP, Sheybani L, Schaller K, Quairiaux C, Vulliemoz S. Reproducible network changes occur in a mouse model of temporal lobe epilepsy but do not correlate with disease severity. Neurobiol Dis 2024; 190:106382. [PMID: 38114050 DOI: 10.1016/j.nbd.2023.106382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 11/27/2023] [Accepted: 12/13/2023] [Indexed: 12/21/2023] Open
Abstract
Studying the development of brain network disruptions in epilepsy is challenged by the paucity of data before epilepsy onset. Here, we used the unilateral, kainate mouse model of hippocampal epilepsy to investigate brain network changes before and after epilepsy onset and their stability across time. Using 32 epicranial electrodes distributed over the mouse hemispheres, we analyzed EEG epochs free from epileptic activity in 15 animals before and 28 days after hippocampal injection (group 1) and in 20 animals on two consecutive days (d28 and d29, group 2). Statistical dependencies between electrodes were characterized with the debiased-weighted phase lag index. We analyzed: a) graph metric changes from baseline to chronic stage (d28) in group 1; b) their reliability across d28 and d29, in group 2; c) their correlation with epileptic activity (EA: seizure, spike and fast-ripple rates), averaged over d28 and d29, in group 2. During the chronic stage, intra-hemispheric connections of the non-injected hemisphere strengthened, yielding an asymmetrical network in low (4-8 Hz) and high theta (8-12 Hz) bands. The contralateral hemisphere also became more integrated and segregated within the high theta band. Both network topology and EEG markers of EA were stable over consecutive days but not correlated with each other. Altogether, we show reproducible large-scale network modifications after the development of focal epilepsy. These modifications are mostly specific to the non-injected hemisphere. The absence of correlation with epileptic activity does not allow to specifically ascribe these network changes to mechanisms supporting EA or rather compensatory inhibition but supports the notion that epilepsy extends beyond the sole repetition of EA and impacts network that might not be involved in EA generation.
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Affiliation(s)
- Isotta Rigoni
- EEG and Epilepsy unit, Department of Neuroscience, University Hospital and Faculty of Medicine of Geneva, University of Geneva, Geneva, Switzerland.
| | - Guru Prasad Padmasola
- Department of Basic Neuroscience, Faculty of Medicine, University of Geneva, Geneva, Switzerland; Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, UK
| | - Laurent Sheybani
- EEG and Epilepsy unit, Department of Neuroscience, University Hospital and Faculty of Medicine of Geneva, University of Geneva, Geneva, Switzerland; Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, UK
| | - Karl Schaller
- Department of Neurosurgery, University Hospital and Faculty of Medicine of Geneva, Geneva, Switzerland
| | - Charles Quairiaux
- Department of Basic Neuroscience, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Serge Vulliemoz
- EEG and Epilepsy unit, Department of Neuroscience, University Hospital and Faculty of Medicine of Geneva, University of Geneva, Geneva, Switzerland
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Kariuki SM, Wagner RG, Gunny R, D'Arco F, Kombe M, Ngugi AK, White S, Odhiambo R, Cross JH, Sander JW, Newton CRJC. Magnetic resonance imaging findings in Kenyans and South Africans with active convulsive epilepsy: An observational study. Epilepsia 2024; 65:165-176. [PMID: 37964464 DOI: 10.1111/epi.17829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Revised: 11/10/2023] [Accepted: 11/10/2023] [Indexed: 11/16/2023]
Abstract
OBJECTIVE Focal epilepsy is common in low- and middle-income countries. The frequency and nature of possible underlying structural brain abnormalities have, however, not been fully assessed. METHODS We evaluated the possible structural causes of epilepsy in 331 people with epilepsy (240 from Kenya and 91 from South Africa) identified from community surveys of active convulsive epilepsy. Magnetic resonance imaging (MRI) scans were acquired on 1.5-Tesla scanners to determine the frequency and nature of any underlying lesions. We estimated the prevalence of these abnormalities using Bayesian priors (from an earlier pilot study) and observed data (from this study). We used a mixed-effect modified Poisson regression approach with the site as a random effect to determine the clinical features associated with neuropathology. RESULTS MRI abnormalities were found in 140 of 240 (modeled prevalence = 59%, 95% confidence interval [CI]: 53%-64%) of people with epilepsy in Kenya, and in 62 of 91 (modeled prevalence = 65%, 95% CI: 57%-73%) in South Africa, with a pooled modeled prevalence of 61% (95% CI: 56%-66%). Abnormalities were common in those with a history of adverse perinatal events (15/23 [65%, 95% CI: 43%-84%]), exposure to parasitic infections (83/120 [69%, 95% CI: 60%-77%]) and focal electroencephalographic features (97/142 [68%, 95% CI: 60%-76%]), but less frequent in individuals with generalized electroencephalographic features (44/99 [44%, 95% CI: 34%-55%]). Most abnormalities were potentially epileptogenic (167/202, 82%), of which mesial temporal sclerosis (43%) and gliosis (34%) were the most frequent. Abnormalities were associated with co-occurrence of generalized non-convulsive seizures (relative risk [RR] = 1.12, 95% CI: 1.04-1.25), lack of family history of seizures (RR = 0.91, 0.86-0.96), convulsive status epilepticus (RR = 1.14, 1.08-1.21), frequent seizures (RR = 1.12, 1.04-1.20), and reported use of anti-seizure medication (RR = 1.22, 1.18-1.26). SIGNIFICANCE MRI identified pathologies are common in people with epilepsy in Kenya and South Africa. Mesial temporal sclerosis, the most common abnormality, may be amenable to surgical correction. MRI may have a diagnostic value in rural Africa, but future longitudinal studies should examine the prognostic role.
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Affiliation(s)
- Symon M Kariuki
- Neurosciences Unit, KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - Ryan G Wagner
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Roxana Gunny
- Department of Neuroradiology, Great Ormond Street Hospital, London, UK
| | - Felice D'Arco
- Department of Neuroradiology, Great Ormond Street Hospital, London, UK
| | - Martha Kombe
- Neurosciences Unit, KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Anthony K Ngugi
- Department of Population Health, Medical College, Aga Khan University of East Africa, Nairobi, Kenya
| | | | - Rachael Odhiambo
- Department of Population Health, Medical College, Aga Khan University of East Africa, Nairobi, Kenya
| | - J Helen Cross
- Developmental Neurosciences, UCL, NIHR BRC Great Ormond Street Institute of Child Health, London, UK
| | - Josemir W Sander
- Department of Clinical & Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, UK
- Chalfont Centre for Epilepsy, Chalfont St Peter, UK
- Stichting Epilepsie Instellingen Nederland (SEIN), Heemstede, The Netherlands
- Department of Neurology, West China Hospital, Chengdu, China
- Institute of Brain Science & Brain-Inspired Technology, Sichuan University, Chengdu, China
| | - Charles R J C Newton
- Neurosciences Unit, KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Department of Psychiatry, University of Oxford, Oxford, UK
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De Stefano P, Ménétré E, Stancu P, Mégevand P, Vargas MI, Kleinschmidt A, Vulliémoz S, Wiest R, Beniczky S, Picard F, Seeck M. Added value of advanced workup after the first seizure: A 7-year cohort study. Epilepsia 2023; 64:3246-3256. [PMID: 37699424 DOI: 10.1111/epi.17771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 09/02/2023] [Accepted: 09/08/2023] [Indexed: 09/14/2023]
Abstract
OBJECTIVE This study was undertaken to establish whether advanced workup including long-term electroencephalography (LT-EEG) and brain magnetic resonance imaging (MRI) provides an additional yield for the diagnosis of new onset epilepsy (NOE) in patients presenting with a first seizure event (FSE). METHODS In this population-based study, all adult (≥16 years) patients presenting with FSE in the emergency department (ED) between March 1, 2010 and March 1, 2017 were assessed. Patients with obvious nonepileptic or acute symptomatic seizures were excluded. Routine EEG, LT-EEG, brain computed tomography (CT), and brain MRI were performed as part of the initial workup. These examinations' sensitivity and specificity were calculated on the basis of the final diagnosis after 2 years, along with the added value of advanced workup (MRI and LT-EEG) over routine workup (routine EEG and CT). RESULTS Of the 1010 patients presenting with FSE in the ED, a definite diagnosis of NOE was obtained for 501 patients (49.6%). Sensitivity of LT-EEG was higher than that of routine EEG (54.39% vs. 25.5%, p < .001). Similarly, sensitivity of MRI was higher than that of CT (67.98% vs. 54.72%, p = .009). Brain MRI showed epileptogenic lesions in an additional 32% compared to brain CT. If only MRI and LT-EEG were considered, five would have been incorrectly diagnosed as nonepileptic (5/100, 5%) compared to patients with routine EEG and MRI (25/100, 25%, p = .0001). In patients with all four examinations, advanced workup provided an overall additional yield of 50% compared to routine workup. SIGNIFICANCE Our results demonstrate the remarkable added value of the advanced workup launched already in the ED for the diagnosis of NOE versus nonepileptic causes of seizure mimickers. Our findings suggest the benefit of first-seizure tracks or even units with overnight EEG, similar to stroke units, activated upon admission in the ED.
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Affiliation(s)
- Pia De Stefano
- EEG & Epilepsy Unit, Department of Clinical Neurosciences, University Hospitals of Geneva, Geneva, Switzerland
- Neuro-Intensive Care Unit, Department of Intensive Care, University Hospitals of Geneva, Geneva, Switzerland
| | - Eric Ménétré
- EEG & Epilepsy Unit, Department of Clinical Neurosciences, University Hospitals of Geneva, Geneva, Switzerland
| | - Patrick Stancu
- EEG & Epilepsy Unit, Department of Clinical Neurosciences, University Hospitals of Geneva, Geneva, Switzerland
| | - Pierre Mégevand
- EEG & Epilepsy Unit, Department of Clinical Neurosciences, University Hospitals of Geneva, Geneva, Switzerland
| | | | - Andreas Kleinschmidt
- EEG & Epilepsy Unit, Department of Clinical Neurosciences, University Hospitals of Geneva, Geneva, Switzerland
| | - Serge Vulliémoz
- EEG & Epilepsy Unit, Department of Clinical Neurosciences, University Hospitals of Geneva, Geneva, Switzerland
| | - Roland Wiest
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, University of Berne, Bern, Switzerland
| | - Sandor Beniczky
- Department of Clinical Neurophysiology, Aarhus University Hospital, Aarhus and Danish Epilepsy Center, Dianalund, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Fabienne Picard
- EEG & Epilepsy Unit, Department of Clinical Neurosciences, University Hospitals of Geneva, Geneva, Switzerland
| | - Margitta Seeck
- EEG & Epilepsy Unit, Department of Clinical Neurosciences, University Hospitals of Geneva, Geneva, Switzerland
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Abstract
ABSTRACT BACKGROUND: Nonconvulsive seizures are a major source of in-hospital morbidity and a cause of unexplained encephalopathy in critically ill patients. Electroencephalography (EEG) is essential to confirm nonconvulsive seizures and can guide patient-specific workup, treatment, and prognostication. In a 208-bed community hospital, EEG services were limited to 1 part-time EEG technician and 1 EEG machine shared between inpatient and outpatient settings. Its use was restricted to typical business hours. A nursing-led quality improvement (QI) project endeavored to enhance access to EEG by introducing a point-of-care rapid-response EEG program. METHODS: For this project, a multidisciplinary protocol was developed to deploy a Food and Drug Administration-cleared, point-of-care rapid-response EEG platform (Ceribell Inc) in a community hospital's emergency department and inpatient units to streamline neurodiagnostic workups. This QI project compared EEG volume, study location, time-to-EEG, number of cases with seizures captured on EEG, and hospital-level financial metrics of diagnosis-related group reimbursements and length of stay for the 6 months before (pre-QI, using conventional EEG) and 6 months after implementing the rapid-response protocol (post-QI). RESULTS: Electroencephalography volume increased from 35 studies pre-QI to 115 post-QI (3.29-fold increase), whereas the median time from EEG order to EEG start decreased 7.6-fold (74 [34-187] minutes post-QI vs 562 [321-1034] minutes pre-QI). Point-of-care EEG was also associated with more confirmed seizure diagnoses compared with conventional EEG (27/115 post-QI vs 0/35 pre-QI). This resulted in additional diagnosis-related group reimbursements and hospital revenue. Availability of point-of-care EEG was also associated with a shorter median length of stay. CONCLUSION: A nurse-led, rapid-response EEG protocol at a community hospital resulted in significant improvements in EEG accessibility and seizure diagnosis with hospital-level financial benefits. By expanding access to EEG, confirming nonconvulsive seizures, and increasing care efficiency, rapid-response EEG protocols can enhance patient care.
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Affiliation(s)
- Eleanor Eberhard
- Eleanor Eberhard, DNP MBA RN, is VP, CNO, and COO, Dignity Health Sequoia Hospital
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Gibbs-Shelton S, Benderoth J, Gaykema RP, Straub J, Okojie KA, Uweru JO, Lentferink DH, Rajbanshi B, Cowan MN, Patel B, Campos-Salazar AB, Perez-Reyes E, Eyo UB. Microglia play beneficial roles in multiple experimental seizure models. Glia 2023; 71:1699-1714. [PMID: 36951238 DOI: 10.1002/glia.24364] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 03/09/2023] [Accepted: 03/10/2023] [Indexed: 03/24/2023]
Abstract
Seizure disorders are common, affecting both the young and the old. Currently available antiseizure drugs are ineffective in a third of patients and have been developed with a focus on known neurocentric mechanisms, raising the need for investigations into alternative and complementary mechanisms that contribute to seizure generation or its containment. Neuroinflammation, broadly defined as the activation of immune cells and molecules in the central nervous system (CNS), has been proposed to facilitate seizure generation, although the specific cells involved in these processes remain inadequately understood. The role of microglia, the primary inflammation-competent cells of the brain, is debated since previous studies were conducted using approaches that were less specific to microglia or had inherent confounds. Using a selective approach to target microglia without such side effects, we show a broadly beneficial role for microglia in limiting chemoconvulsive, electrical, and hyperthermic seizures and argue for a further understanding of microglial contributions to contain seizures.
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Affiliation(s)
- Synphane Gibbs-Shelton
- Brain Immunology and Glia Center, University of Virginia, Charlottesville, Virginia, USA
- Department of Pharmacology, University of Virginia, Charlottesville, Virginia, USA
| | - Jordan Benderoth
- Brain Immunology and Glia Center, University of Virginia, Charlottesville, Virginia, USA
- Department of Neuroscience, University of Virginia, Charlottesville, Virginia, USA
| | - Ronald P Gaykema
- Department of Pharmacology, University of Virginia, Charlottesville, Virginia, USA
| | - Justyna Straub
- Department of Pharmacology, University of Virginia, Charlottesville, Virginia, USA
| | - Kenneth A Okojie
- Brain Immunology and Glia Center, University of Virginia, Charlottesville, Virginia, USA
- Department of Neuroscience, University of Virginia, Charlottesville, Virginia, USA
| | - Joseph O Uweru
- Brain Immunology and Glia Center, University of Virginia, Charlottesville, Virginia, USA
- Department of Neuroscience, University of Virginia, Charlottesville, Virginia, USA
- Neuroscience Graduate Program, University of Virginia, Charlottesville, Virginia, USA
| | - Dennis H Lentferink
- Brain Immunology and Glia Center, University of Virginia, Charlottesville, Virginia, USA
- Department of Neuroscience, University of Virginia, Charlottesville, Virginia, USA
| | - Binita Rajbanshi
- Department of Pharmacology, University of Virginia, Charlottesville, Virginia, USA
| | - Maureen N Cowan
- Brain Immunology and Glia Center, University of Virginia, Charlottesville, Virginia, USA
- Department of Neuroscience, University of Virginia, Charlottesville, Virginia, USA
- Neuroscience Graduate Program, University of Virginia, Charlottesville, Virginia, USA
| | - Brij Patel
- Brain Immunology and Glia Center, University of Virginia, Charlottesville, Virginia, USA
- Neuroscience Graduate Program, University of Virginia, Charlottesville, Virginia, USA
| | - Anthony Brayan Campos-Salazar
- Brain Immunology and Glia Center, University of Virginia, Charlottesville, Virginia, USA
- Neuroscience Graduate Program, University of Virginia, Charlottesville, Virginia, USA
| | - Edward Perez-Reyes
- Department of Pharmacology, University of Virginia, Charlottesville, Virginia, USA
| | - Ukpong B Eyo
- Brain Immunology and Glia Center, University of Virginia, Charlottesville, Virginia, USA
- Department of Neuroscience, University of Virginia, Charlottesville, Virginia, USA
- Neuroscience Graduate Program, University of Virginia, Charlottesville, Virginia, USA
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11
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Hernandez-Ronquillo L, Thorpe L, Feng C, Hunter G, Dash D, Hussein T, Dolinsky C, Waterhouse K, Roy PL, Jette N. Diagnostic Accuracy of Ambulatory EEG vs Routine EEG in Patients With First Single Unprovoked Seizure. Neurol Clin Pract 2023; 13:e200160. [PMID: 37197370 PMCID: PMC10184557 DOI: 10.1212/cpj.0000000000200160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 02/27/2023] [Indexed: 05/19/2023]
Abstract
Background and Objective To evaluate the diagnostic accuracy of the ambulatory EEG (aEEG) at detecting interictal epileptiform discharges (IEDs)/seizures compared with routine EEG (rEEG) and repetitive/second rEEG in patients with a first single unprovoked seizure (FSUS). We also evaluated the association between IED/seizures on aEEG and seizure recurrence within 1 year of follow-up. Methods We prospectively evaluated 100 consecutive patients with FSUS at the provincial Single Seizure Clinic. They underwent 3 sequential EEG modalities: first rEEG, second rEEG, and aEEG. Clinical epilepsy diagnosis was ascertained based on the 2014 International League Against Epilepsy definition by a neurologist/epileptologist at the clinic. An EEG-certified epileptologist/neurologist interpreted all 3 EEGs. All patients were followed up for 52 weeks until they had either second unprovoked seizure or maintained single seizure status. Accuracy measures (sensitivity, specificity, negative and positive predictive values, and likelihood ratios), receiver operating characteristic (ROC) analysis, and area under the curve (AUC) were used to evaluate the diagnostic accuracy of each EEG modality. Life tables and the Cox proportional hazard model were used to estimate the probability and association of seizure recurrence. Results Ambulatory EEG captured IED/seizures with a sensitivity of 72%, compared with 11% for the first rEEG and 22% for the second rEEG. The diagnostic performance of the aEEG was statistically better (AUC: 0.85) compared with the first rEEG (AUC: 0.56) and second rEEG (AUC: 0.60). There were no statistically significant differences between the 3 EEG modalities regarding specificity and positive predictive value. Finally, IED/seizure on the aEEG was associated with more than 3 times the hazard of seizure recurrence. Discussion The overall diagnostic accuracy of aEEG at capturing IED/seizures in people presenting with FSUS was higher than the first and second rEEGs. We also found that IED/seizures on the aEEG were associated with an increased risk of seizure recurrence. Classification of Evidence This study provides Class I evidence supporting that, in adults with First Single Unprovoked Seizure (FSUS), 24-h ambulatory EEG has increased sensitivity when compared with routine and repeated EEG.
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Affiliation(s)
- Lizbeth Hernandez-Ronquillo
- Community Health and Epidemiology (LH-R, LT), Saskatoon, SK; Division of Neurology, Department of Medicine (LH-R, GH.), Saskatoon, SK; Department of Community Health and Epidemiology (CF), Halifax, NS; Neurophysiology Laboratory (DD, CD), Royal University Hospital, Saskatoon, SK; Neurophysiology Laboratory (TH), BC Children's Hospital, Vancouver, BC; Neuromodulation/Epilepsy Programs (KW), Royal University Hospital, Saskatoon, SK; Division of Neurology, Department of Medicine (PLR), Lakeridge Health Oshawa, Oshawa, ON; Department of Neurology and Population Health Science & Policy (NJ), NY
| | - Lilian Thorpe
- Community Health and Epidemiology (LH-R, LT), Saskatoon, SK; Division of Neurology, Department of Medicine (LH-R, GH.), Saskatoon, SK; Department of Community Health and Epidemiology (CF), Halifax, NS; Neurophysiology Laboratory (DD, CD), Royal University Hospital, Saskatoon, SK; Neurophysiology Laboratory (TH), BC Children's Hospital, Vancouver, BC; Neuromodulation/Epilepsy Programs (KW), Royal University Hospital, Saskatoon, SK; Division of Neurology, Department of Medicine (PLR), Lakeridge Health Oshawa, Oshawa, ON; Department of Neurology and Population Health Science & Policy (NJ), NY
| | - Cindy Feng
- Community Health and Epidemiology (LH-R, LT), Saskatoon, SK; Division of Neurology, Department of Medicine (LH-R, GH.), Saskatoon, SK; Department of Community Health and Epidemiology (CF), Halifax, NS; Neurophysiology Laboratory (DD, CD), Royal University Hospital, Saskatoon, SK; Neurophysiology Laboratory (TH), BC Children's Hospital, Vancouver, BC; Neuromodulation/Epilepsy Programs (KW), Royal University Hospital, Saskatoon, SK; Division of Neurology, Department of Medicine (PLR), Lakeridge Health Oshawa, Oshawa, ON; Department of Neurology and Population Health Science & Policy (NJ), NY
| | - Gary Hunter
- Community Health and Epidemiology (LH-R, LT), Saskatoon, SK; Division of Neurology, Department of Medicine (LH-R, GH.), Saskatoon, SK; Department of Community Health and Epidemiology (CF), Halifax, NS; Neurophysiology Laboratory (DD, CD), Royal University Hospital, Saskatoon, SK; Neurophysiology Laboratory (TH), BC Children's Hospital, Vancouver, BC; Neuromodulation/Epilepsy Programs (KW), Royal University Hospital, Saskatoon, SK; Division of Neurology, Department of Medicine (PLR), Lakeridge Health Oshawa, Oshawa, ON; Department of Neurology and Population Health Science & Policy (NJ), NY
| | - Dianne Dash
- Community Health and Epidemiology (LH-R, LT), Saskatoon, SK; Division of Neurology, Department of Medicine (LH-R, GH.), Saskatoon, SK; Department of Community Health and Epidemiology (CF), Halifax, NS; Neurophysiology Laboratory (DD, CD), Royal University Hospital, Saskatoon, SK; Neurophysiology Laboratory (TH), BC Children's Hospital, Vancouver, BC; Neuromodulation/Epilepsy Programs (KW), Royal University Hospital, Saskatoon, SK; Division of Neurology, Department of Medicine (PLR), Lakeridge Health Oshawa, Oshawa, ON; Department of Neurology and Population Health Science & Policy (NJ), NY
| | - Tabrez Hussein
- Community Health and Epidemiology (LH-R, LT), Saskatoon, SK; Division of Neurology, Department of Medicine (LH-R, GH.), Saskatoon, SK; Department of Community Health and Epidemiology (CF), Halifax, NS; Neurophysiology Laboratory (DD, CD), Royal University Hospital, Saskatoon, SK; Neurophysiology Laboratory (TH), BC Children's Hospital, Vancouver, BC; Neuromodulation/Epilepsy Programs (KW), Royal University Hospital, Saskatoon, SK; Division of Neurology, Department of Medicine (PLR), Lakeridge Health Oshawa, Oshawa, ON; Department of Neurology and Population Health Science & Policy (NJ), NY
| | - Chelsea Dolinsky
- Community Health and Epidemiology (LH-R, LT), Saskatoon, SK; Division of Neurology, Department of Medicine (LH-R, GH.), Saskatoon, SK; Department of Community Health and Epidemiology (CF), Halifax, NS; Neurophysiology Laboratory (DD, CD), Royal University Hospital, Saskatoon, SK; Neurophysiology Laboratory (TH), BC Children's Hospital, Vancouver, BC; Neuromodulation/Epilepsy Programs (KW), Royal University Hospital, Saskatoon, SK; Division of Neurology, Department of Medicine (PLR), Lakeridge Health Oshawa, Oshawa, ON; Department of Neurology and Population Health Science & Policy (NJ), NY
| | - Karen Waterhouse
- Community Health and Epidemiology (LH-R, LT), Saskatoon, SK; Division of Neurology, Department of Medicine (LH-R, GH.), Saskatoon, SK; Department of Community Health and Epidemiology (CF), Halifax, NS; Neurophysiology Laboratory (DD, CD), Royal University Hospital, Saskatoon, SK; Neurophysiology Laboratory (TH), BC Children's Hospital, Vancouver, BC; Neuromodulation/Epilepsy Programs (KW), Royal University Hospital, Saskatoon, SK; Division of Neurology, Department of Medicine (PLR), Lakeridge Health Oshawa, Oshawa, ON; Department of Neurology and Population Health Science & Policy (NJ), NY
| | - Pragma Laboni Roy
- Community Health and Epidemiology (LH-R, LT), Saskatoon, SK; Division of Neurology, Department of Medicine (LH-R, GH.), Saskatoon, SK; Department of Community Health and Epidemiology (CF), Halifax, NS; Neurophysiology Laboratory (DD, CD), Royal University Hospital, Saskatoon, SK; Neurophysiology Laboratory (TH), BC Children's Hospital, Vancouver, BC; Neuromodulation/Epilepsy Programs (KW), Royal University Hospital, Saskatoon, SK; Division of Neurology, Department of Medicine (PLR), Lakeridge Health Oshawa, Oshawa, ON; Department of Neurology and Population Health Science & Policy (NJ), NY
| | - Nathalie Jette
- Community Health and Epidemiology (LH-R, LT), Saskatoon, SK; Division of Neurology, Department of Medicine (LH-R, GH.), Saskatoon, SK; Department of Community Health and Epidemiology (CF), Halifax, NS; Neurophysiology Laboratory (DD, CD), Royal University Hospital, Saskatoon, SK; Neurophysiology Laboratory (TH), BC Children's Hospital, Vancouver, BC; Neuromodulation/Epilepsy Programs (KW), Royal University Hospital, Saskatoon, SK; Division of Neurology, Department of Medicine (PLR), Lakeridge Health Oshawa, Oshawa, ON; Department of Neurology and Population Health Science & Policy (NJ), NY
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12
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Chawner E, Ukai M, Sears W, James F. Frequency of non-generalized tonic clonic seizures in a referral population of dogs. Vet J 2023; 295:105986. [PMID: 37141933 DOI: 10.1016/j.tvjl.2023.105986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 03/22/2023] [Accepted: 04/30/2023] [Indexed: 05/06/2023]
Abstract
Absence seizures are a type of generalized onset seizure associated in humans with brief activity interruptions, unresponsiveness and staring. Absence seizures are infrequently reported in veterinary patients, visually indistinguishable from focal seizures, and so may be grouped as non-generalized tonic clonic seizures (non-GTCS). The objective of this retrospective study was to provide a preliminary understanding of the frequency of non-GTCS in dogs and estimate its prevalence by evaluating the distribution of seizure types presented to a referral hospital over 4 years (May 2017-April 2021), as determined from the medical record history and electroencephalography (EEG) diagnostic testing where available. A total of 528 cases were included via a medical record search for dogs with epilepsy and/or seizures presented to the neurology or emergency services. Cases were categorized into seizure types based on reported clinical signs. Each year, 53-63 % of seizure cases were described as generalized tonic clonic seizures (GTCS), 9-15 % GTCS with additional events and 29-35 % suspected non-GTCS. EEG confirmed absence seizures in 12 of 44 EEGs, 5 cases having a history of GTCS and seven without prior GTCS. This preliminary study suggests that non-GTCS may be relatively common as one third of seizure cases in the referral population presented with non-GTCS clinical signs. Prospective studies using EEG are merited to definitively determine the prevalence of these different seizure types in dogs. Acknowledging the impact of these seizures will improve awareness, aiding veterinarians in their recognition, diagnosis and potential treatment options.
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Affiliation(s)
- E Chawner
- Department of Clinical Studies, Ontario Veterinary College at the University of Guelph, N1G 2W1 Canada
| | - M Ukai
- Department of Clinical Studies, Ontario Veterinary College at the University of Guelph, N1G 2W1 Canada
| | - W Sears
- Department of Population Medicine, Ontario Veterinary College at the University of Guelph, N1G 2W1 Canada
| | - F James
- Department of Clinical Studies, Ontario Veterinary College at the University of Guelph, N1G 2W1 Canada.
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13
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Shelton-Gibbs S, Benderoth J, Gaykema RP, Straub J, Okojie KA, Uweru JO, Lentferink DH, Rajbanshi B, Cowan MN, Patel B, Campos-Salazar AB, Perez-Reyes E, Eyo UB. Microglia play beneficial roles in multiple experimental seizure models. bioRxiv 2023:2023.03.04.531090. [PMID: 36945556 PMCID: PMC10028974 DOI: 10.1101/2023.03.04.531090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/10/2023]
Abstract
Seizure disorders are common, affecting both the young and the old. Currently available antiseizure drugs are ineffective in a third of patients and have been developed with a focus on known neurocentric mechanisms, raising the need for investigations into alternative and complementary mechanisms that contribute to seizure generation or its containment. Neuroinflammation, broadly defined as the activation of immune cells and molecules in the central nervous system (CNS), has been proposed to facilitate seizure generation, although the specific cells involved in these processes remain inadequately understood. The role of microglia, the primary inflammation-competent cells of the brain, is debated since previous studies were conducted using approaches that were less specific to microglia or had inherent confounds. Using a selective approach to target microglia without such side effects, we show a broadly beneficial role for microglia in limiting chemoconvulsive, electrical, and hyperthermic seizures and argue for a further understanding of microglial contributions to contain seizures.
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Affiliation(s)
- Synphane Shelton-Gibbs
- Brain Immunology and Glia Center, University of Virginia, Charlottesville, VA, USA
- Department of Pharmacology, University of Virginia, Charlottesville, Virginia, USA
| | - Jordan Benderoth
- Brain Immunology and Glia Center, University of Virginia, Charlottesville, VA, USA
- Department of Neuroscience, University of Virginia, Charlottesville, VA, USA
| | - Ronald P. Gaykema
- Department of Pharmacology, University of Virginia, Charlottesville, Virginia, USA
| | - Justyna Straub
- Department of Pharmacology, University of Virginia, Charlottesville, Virginia, USA
| | - Kenneth A. Okojie
- Brain Immunology and Glia Center, University of Virginia, Charlottesville, VA, USA
- Department of Neuroscience, University of Virginia, Charlottesville, VA, USA
| | - Joseph O. Uweru
- Brain Immunology and Glia Center, University of Virginia, Charlottesville, VA, USA
- Department of Neuroscience, University of Virginia, Charlottesville, VA, USA
- Neuroscience Graduate Program, University of Virginia, Charlottesville, Virginia, USA
| | - Dennis H. Lentferink
- Brain Immunology and Glia Center, University of Virginia, Charlottesville, VA, USA
- Department of Neuroscience, University of Virginia, Charlottesville, VA, USA
| | - Binita Rajbanshi
- Department of Pharmacology, University of Virginia, Charlottesville, Virginia, USA
| | - Maureen N. Cowan
- Brain Immunology and Glia Center, University of Virginia, Charlottesville, VA, USA
- Department of Neuroscience, University of Virginia, Charlottesville, VA, USA
- Neuroscience Graduate Program, University of Virginia, Charlottesville, Virginia, USA
| | - Brij Patel
- Brain Immunology and Glia Center, University of Virginia, Charlottesville, VA, USA
- Department of Neuroscience, University of Virginia, Charlottesville, VA, USA
| | - Anthony Brayan Campos-Salazar
- Brain Immunology and Glia Center, University of Virginia, Charlottesville, VA, USA
- Department of Neuroscience, University of Virginia, Charlottesville, VA, USA
| | - Edward Perez-Reyes
- Department of Pharmacology, University of Virginia, Charlottesville, Virginia, USA
| | - Ukpong B. Eyo
- Brain Immunology and Glia Center, University of Virginia, Charlottesville, VA, USA
- Department of Neuroscience, University of Virginia, Charlottesville, VA, USA
- Neuroscience Graduate Program, University of Virginia, Charlottesville, Virginia, USA
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14
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Özdemir FMA, Öztoprak Ü, Atasoy E, Aksoy E, Çelik H, Ceylan N, Tuygun N, Yüksel D. Characteristics and clinical value of early electroencephalography (EEG) after a first unprovoked seizure in children. Neurophysiol Clin 2023; 53:102848. [PMID: 36827816 DOI: 10.1016/j.neucli.2023.102848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 01/27/2023] [Accepted: 01/28/2023] [Indexed: 02/24/2023] Open
Abstract
OBJECTIVE This study aimed to examine the timing and features of electroencephalography (EEG) as a predictor of seizure recurrence in children with a first unprovoked seizure. METHODS We retrospectively evaluated the medical records and EEG recordings of pediatric patients who presented within 24 h of a first unprovoked seizure between January 2018-December 2019 and had at least 1 year of pediatric neurology clinical follow-up. RESULTS The study included 108 patients (53.7% males) with a mean age of 98.75±57.75 months. Sixty-eight patients (63%) had an abnormal initial EEG, of which 55 (80.9%) were focal. The semiology of the first unprovoked seizure was focal in 50% of the patients and correlated with initial EEG findings (p<0.001). Forty-three patients had seizure recurrence during the follow-up period of mean 26.86±7.39 months. Recurrence was observed in the first 6 months in 30 patients and occurred twice in 4 patients. An abnormal EEG after the first unprovoked seizure was found to be an independent risk factor for recurrence, with a 2.42-fold higher recurrence risk in patients with focal EEG abnormalities compared to those with a normal EEG (p = 0.044). Analysis of 7 different timing patterns up to 96 h after the first unprovoked seizure showed that EEG timing was not associated with abnormality detection. DISCUSSION Our study showed that EEG abnormalities, especially focal abnormalities, after a first unprovoked seizure are a predictor of seizure recurrence. But the rate of detection of EEG abnormalities was not related to the timing of EEG recording, relative to seizure occurrence.
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15
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Koo GE, Jeong HT, Youn YC, Han SH. Is Functional Connectivity after a First Unprovoked Seizure Different Based on Subsequent Seizures and Future Diagnosis of Epilepsy? J Epilepsy Res 2022; 12:62-67. [PMID: 36685746 PMCID: PMC9830024 DOI: 10.14581/jer.22011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 12/06/2022] [Accepted: 12/14/2022] [Indexed: 01/09/2023] Open
Abstract
Background and Purpose There are no highly sensitive biomarkers for epilepsy to date. Recently, promising results regarding functional connectivity analysis have been obtained, which may improve epilepsy diagnosis even in the absence of visible abnormality in electroencephalography. We aimed to investigate the differences in functional connectivity after a first unprovoked seizure between patients diagnosed with epilepsy within 1 year due to subsequent seizures and those who were not. Methods We compared quantitative electroencephalography power spectra and functional connectivity between 12 patients who were diagnosed with epilepsy (two or more unprovoked seizures) within 1 year and 17 controls (those not diagnosed within 1 year) using iSyncBrain® (iMediSync Inc., Suwon, Korea; https://isyncbrain.com/). In the source-level analysis, the current distribution across the brain was assessed using the standardized low-resolution brain electromagnetic tomography technique, to compare relative power values in 68 regions of interest and connectivity (the imaginary part of coherency) between regions of interest. Results In the epilepsy group, quantitative electroencephalography showed lower alpha2 band power in left frontal, central, superior temporal, and parietal regions and higher beta2 power in both frontal, central, temporal, occipital, and left parietal regions compared with the control group. Additionally, epilepsy patients had significantly lower connectivity in alpha2 and beta2 bands than the controls. Conclusions Patients experiencing their first unprovoked seizure presented different brain function according to whether they have subsequent seizures and future epilepsy. Our results propose the potential clinical ability to diagnose epilepsy after the first unprovoked seizure in the absence of interictal epileptiform discharges.
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Affiliation(s)
- Ga Eun Koo
- Department of Neurology, Chung-Ang University College of Medicine, Seoul, Korea
| | - Ho Tae Jeong
- Department of Neurology, Chung-Ang University College of Medicine, Seoul, Korea
| | - Young Chul Youn
- Department of Neurology, Chung-Ang University College of Medicine, Seoul, Korea
| | - Su-Hyun Han
- Department of Neurology, Chung-Ang University College of Medicine, Seoul, Korea
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Bonuccelli A, Santangelo A, Castelli F, Magherini G, Volpi E, Costa E, Alesci E, Massimetti G, Operto FF, Peroni DG, Orsini A. Efficacy of Liposomal Melatonin in sleep EEG in Childhood: A Double Blind Case Control Study. Int J Environ Res Public Health 2022; 20:552. [PMID: 36612875 PMCID: PMC9819026 DOI: 10.3390/ijerph20010552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 12/15/2022] [Accepted: 12/21/2022] [Indexed: 06/17/2023]
Abstract
Electroencephalography (EEG) is pivotal in the clinical assessment of epilepsy, and sleep is known to improve the diagnostic yield of its recording. Sleep-EEG recording is generally reached by either partial deprivation or by administration of sleep-inducing agents, although it is still not achieved in a considerable percentage of patients. We conducted a double-blind placebo-controlled study, involving a hundred patients between 1 and 6 years old, randomized into two groups: Group 1 received liposomal melatonin (melatosome) whereas Group 2 received a placebo. Sleep latency (SL), defined as the time span between the onset of a well-established posterior dominant rhythm, considered as a frequency of 3 to 4 Hz, increasing to 4-5 Hz by the age of 6 months, to 5-7 Hz by 12 months, and finally to 8 Hz by 3 years, and the first EEG sleep figures detected, were measured for each patient. A significant difference in SL was observed (10.8 ± 5 vs. 18.1 ± 13.4 min, p-value = 0.002). Within each group, no differences in sleep latency were detected between genders. Furthermore, no difference in EEG abnormality detection was observed between the two groups. Our study confirmed the efficacy and safety of melatonin administration in sleep induction. Nonetheless, liposomal melatonin presents a greater bioavailability, ensuring a faster effect and allowing lower dosages. Such results, never before reported in the literature, suggest that the routine employment of melatonin might improve clinical practice in neurophysiology, reducing unsuccessful recordings.
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Affiliation(s)
- Alice Bonuccelli
- Pediatric Neurology, University Hospital of Pisa, Azienda Ospedaliero Universitaria Pisana, 56126 Pisa, Italy
| | - Andrea Santangelo
- Pediatric Clinic, University Hospital of Pisa, Azienda Ospedaliero Universitaria Pisana, 56126 Pisa, Italy
| | - Francesca Castelli
- Pediatric Neurology, University Hospital of Pisa, Azienda Ospedaliero Universitaria Pisana, 56126 Pisa, Italy
| | - Giulia Magherini
- Pediatric Neurology, University Hospital of Pisa, Azienda Ospedaliero Universitaria Pisana, 56126 Pisa, Italy
| | - Elena Volpi
- Pediatric Neurology, University Hospital of Pisa, Azienda Ospedaliero Universitaria Pisana, 56126 Pisa, Italy
| | - Elisa Costa
- Pediatric Clinic, University Hospital of Pisa, Azienda Ospedaliero Universitaria Pisana, 56126 Pisa, Italy
| | - Elena Alesci
- Pediatric Clinic, University Hospital of Pisa, Azienda Ospedaliero Universitaria Pisana, 56126 Pisa, Italy
| | - Gabriele Massimetti
- Department of Clinical and Experimental Medicine, University of Pisa, Azienda Ospedaliero Universitaria Pisana, 56126 Pisa, Italy
| | - Francesca Felicia Operto
- Child and Adolescent Neuropsychiatry Unit, Department of Medicine, Surgery and Dentistry, University of Salerno, 84081 Baronissi, Italy
| | - Diego Giampiero Peroni
- Pediatric Clinic, University Hospital of Pisa, Azienda Ospedaliero Universitaria Pisana, 56126 Pisa, Italy
| | - Alessandro Orsini
- Pediatric Neurology, University Hospital of Pisa, Azienda Ospedaliero Universitaria Pisana, 56126 Pisa, Italy
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Maldjian JA, Lee R, Jordan J, Davenport EM, Proskovec AL, Wintermark M, Stufflebeam S, Anderson J, Mukherjee P, Nagarajan SS, Ferrari P, Gaetz W, Schwartz E, Roberts TPL. ACR White Paper on Magnetoencephalography and Magnetic Source Imaging: A Report from the ACR Commission on Neuroradiology. AJNR Am J Neuroradiol 2022; 43:E46-E53. [PMID: 36456085 DOI: 10.3174/ajnr.a7714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 10/04/2022] [Indexed: 12/04/2022]
Abstract
Magnetoencephalography, the extracranial detection of tiny magnetic fields emanating from intracranial electrical activity of neurons, and its source modeling relation, magnetic source imaging, represent a powerful functional neuroimaging technique, able to detect and localize both spontaneous and evoked activity of the brain in health and disease. Recent years have seen an increased utilization of this technique for both clinical practice and research, in the United States and worldwide. This report summarizes current thinking, presents recommendations for clinical implementation, and offers an outlook for emerging new clinical indications.
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Affiliation(s)
- J A Maldjian
- From the Advanced Neuroscience Imaging Research Laboratory (J.A.M., E.M.D., A.L.P.) .,MEG Center of Excellence (J.A.M., E.M.D., A.L.P.).,Department of Radiology (J.A.M., E.M.D., A.L.P.), University of Texas Southwestern Medical Center, Dallas, Texas
| | - R Lee
- Department of Neuroradiology (R.L.), University of California San Diego, San Diego, California
| | - J Jordan
- ACR Commission on Neuroradiology (J.J.), American College of Radiology, Reston, Virginia.,Stanford University School of Medicine (J.J.), Stanford, California
| | - E M Davenport
- From the Advanced Neuroscience Imaging Research Laboratory (J.A.M., E.M.D., A.L.P.).,MEG Center of Excellence (J.A.M., E.M.D., A.L.P.).,Department of Radiology (J.A.M., E.M.D., A.L.P.), University of Texas Southwestern Medical Center, Dallas, Texas
| | - A L Proskovec
- From the Advanced Neuroscience Imaging Research Laboratory (J.A.M., E.M.D., A.L.P.).,MEG Center of Excellence (J.A.M., E.M.D., A.L.P.).,Department of Radiology (J.A.M., E.M.D., A.L.P.), University of Texas Southwestern Medical Center, Dallas, Texas
| | - M Wintermark
- Department of Neuroradiology (M.W.), University of Texas MD Anderson Center, Houston, Texas
| | - S Stufflebeam
- Athinoula A. Martinos Center for Biomedical Imaging (S.S.), Department of Radiology, Massachusetts General Hospital, Charlestown, Massachusetts
| | - J Anderson
- Department of Radiology and Imaging Sciences (J.A.), University of Utah School of Medicine, Salt Lake City, Utah
| | - P Mukherjee
- Department of Radiology and Biomedical Imaging (P.M., S.S.N.), University of California, San Francisco, San Francisco, California
| | - S S Nagarajan
- Department of Radiology and Biomedical Imaging (P.M., S.S.N.), University of California, San Francisco, San Francisco, California
| | - P Ferrari
- Pediatric Neurosciences (P.F.), Helen DeVos Children's Hospital, Grand Rapids, Michigan.,Department of Pediatrics and Human Development (P.F.), College of Human Medicine, Michigan State University, Grand Rapids, Michigan
| | - W Gaetz
- Department of Radiology (W.G., E.S., T.P.L.R.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - E Schwartz
- Department of Radiology (W.G., E.S., T.P.L.R.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - T P L Roberts
- Department of Radiology (W.G., E.S., T.P.L.R.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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Falcicchio G, Negri F, Trojano M, La Neve A. On epilepsy perception: Unravelling gaps and issues. Epilepsy Behav 2022; 137:108952. [PMID: 36306590 DOI: 10.1016/j.yebeh.2022.108952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 10/09/2022] [Accepted: 10/10/2022] [Indexed: 01/05/2023]
Abstract
Epilepsy is one of the most common neurological diseases, but it can sometimes be under-reported or have a time delay in diagnosis. This data is not surprising if we consider that a person often seeks medical attention only after presenting a generalized tonic-clonic seizure. Epilepsy diagnostic delay is caused by several factors: under-reporting by patients, under-diagnosed epileptic manifestations by inexperienced clinicians, and lack of time in the emergency setting. The consequences of this delay are increased accidents, a high rate of premature mortality, and economic expanses for the healthcare system. Moreover, people with epilepsy have a higher probability of comorbidities than the general population, such as mood disorders or cognitive problems. Along with recurrent seizures, these comorbid diseases promote isolation and stigmatization of people with epilepsy, who suffer from discrimination at school, in the workplace, and even in social relationships. Public awareness of epilepsy and its comorbidities is necessary to prevent diagnostic delays and overcome social and professional iniquities for people with epilepsy.
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Taylor R, Lochner A, Grahf D, John R, Vohra T, Krupp S. Evaluation and Management of New Onset and Breakthrough Seizures in Adults in the Emergency Department. Curr Emerg Hosp Med Rep 2022. [DOI: 10.1007/s40138-022-00253-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Moellmann HL, Mehr VN, Karnatz N, Wilkat M, Riedel E, Rana M. Evaluation of the Fitting Accuracy of CAD/CAM-Manufactured Patient-Specific Implants for the Reconstruction of Cranial Defects-A Retrospective Study. J Clin Med 2022; 11:2045. [PMID: 35407653 DOI: 10.3390/jcm11072045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Revised: 04/02/2022] [Accepted: 04/04/2022] [Indexed: 02/04/2023] Open
Abstract
Cranioplasties show overall high complication rates of up to 45.3%. Risk factors potentially associated with the occurrence of postoperative complications are frequently discussed in existing research. The present study examines the positioning of 39 patient-specific implants (PSI) made from polyetheretherketone (PEEK) and retrospectively investigates the relationship between the fitting accuracy and incidence of postoperative complications. To analyze the fitting accuracy of the implants pre- and post-operatively, STL files were created and superimposed in a 3D coordinate system, and the deviations were graphically displayed and evaluated along with the postoperative complications. On average, 95.17% (SD = 9.42) of the measurements between planned and surgically achieved implant position were within the defined tolerance range. In cases with lower accordance, an increased occurrence of complications could not be demonstrated. The overall postoperative complication rate was 64.1%. The fitting of the PEEK-PSI was highly satisfactory. There were predominantly minor deviations of the achieved compared to the planned implant positions; however, estimations were within the defined tolerance range. Despite the overall high accuracy of fitting, a considerable complication rate was found. To optimize the surgical outcome, the focus should instead be directed towards the investigation of other risk factors.
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Abstract
PURPOSE OF REVIEW This article focuses on the evaluation of children and adults who present with new-onset seizures, with an emphasis on differential diagnosis, classification, evaluation, and management. RECENT FINDINGS New-onset seizures are a common presentation in neurologic practice, affecting approximately 8% to 10% of the population. Accurate diagnosis relies on a careful history to exclude nonepileptic paroxysmal events. A new classification system was accepted in 2017 by the International League Against Epilepsy, which evaluates seizure type(s), epilepsy type, epilepsy syndrome, etiology, and comorbidities. Accurate classification informs the choice of investigations, treatment, and prognosis. Guidelines for neuroimaging and laboratory and genetic testing are summarized. SUMMARY Accurate diagnosis and classification of first seizures and new-onset epilepsy are key to choosing optimal therapy to maximize seizure control and minimize comorbidities.
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22
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Yang M, Tan KM, Carney P, Kwan P, O'Brien TJ, Berkovic SF, Perucca P, McIntosh AM. Diagnostic delay in focal epilepsy: association with brain pathology and age. Seizure 2022; 96:121-127. [DOI: 10.1016/j.seizure.2022.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 02/07/2022] [Accepted: 02/09/2022] [Indexed: 10/19/2022] Open
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Vorderwülbecke BJ, Wandschneider B, Weber Y, Holtkamp M. Genetic generalized epilepsies in adults - challenging assumptions and dogmas. Nat Rev Neurol 2022; 18:71-83. [PMID: 34837042 DOI: 10.1038/s41582-021-00583-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/19/2021] [Indexed: 01/16/2023]
Abstract
Genetic generalized epilepsy (GGE) syndromes start during childhood or adolescence, and four commonly persist into adulthood, making up 15-20% of all cases of epilepsy in adults. These four GGE syndromes are childhood absence epilepsy, juvenile absence epilepsy, juvenile myoclonic epilepsy and epilepsy with generalized tonic-clonic seizures alone. However, in ~20% of patients with GGE, characteristics of more than one syndrome are present. Novel insights into the genetic aetiology, comorbidities and prognosis of the GGE syndromes have emerged and challenge traditional concepts about these conditions. Evidence has shown that the mode of inheritance in GGE is mostly polygenic. Neuropsychological and imaging studies indicate similar abnormalities in unaffected relatives of patients with GGE, supporting the concept that underlying alterations in bilateral frontothalamocortical networks are genetically determined. Contrary to popular belief, first-line anti-seizure medication often fails to provide seizure freedom in combination with good tolerability. Nevertheless, long-term follow-up studies have shown that with advancing age, many patients can discontinue their anti-seizure medication without seizure relapses. Several outcome predictors have been identified, but prognosis across the syndromes is more homogeneous than previously assumed. Overall, overlap in pathophysiology, seizure types, treatment responses and outcomes support the idea that GGEs are not separate nosological entities but represent a neurobiological continuum.
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Gunawardena S, Chikkannaiah M, Stolfi A, Kumar G. Utility of electroencephalogram in the pediatric emergency department. Am J Emerg Med 2022. [DOI: 10.1016/j.ajem.2022.01.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Revised: 01/07/2022] [Accepted: 01/18/2022] [Indexed: 11/22/2022] Open
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Rodríguez Quintana JH, Bueno SJ, Zuleta-Motta JL, Ramos MF, Vélez-van-Meerbeke A. Utility of Routine EEG in Emergency Department and Inpatient Service. Neurol Clin Pract 2021; 11:e677-e681. [PMID: 34840882 DOI: 10.1212/cpj.0000000000000961] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 07/31/2020] [Indexed: 11/15/2022]
Abstract
Objective The most important indication for EEGs is the investigation of epileptic and nonepileptic seizures. However, it is unclear whether EEG in the emergency depatment (ED) can be useful in managing other conditions. Our objective was to investigate the usefulness of EEGs in the ED. Methods We performed an observational, descriptive, retrospective study based on clinical records between 2018 and 2019. We evaluated patients admitted to our ED or hospital wards who underwent an EEG. We defined the EEG results as useful when they prompted changes in antiepileptic drug (AED) treatment or clinical management. Results We gathered information from 236 patients with a mean age of 59.23 years (SD ±22.6), of whom 47.9% were women. In patients with seizures, 18.2% were generalized, 27.1% were focal, and 18.6% were unknown. Overall, 25.8% of the EEGs were abnormal. However, in patients with a history of predisposing conditions for epileptic seizures or encephalopathies, the tracing was abnormal in 47.5%. The most frequent alteration on the abnormal EEGs was generalized slowing (18.2%). The EEG was useful in 76.7% of patients: AEDs changed in 8.4% and clinical management changed in 76.2% of patients. The usefulness of EEGs associated with acute ischemic lesions on CT (p = 0.023) and with the diagnosis of vasovagal syncope (p = 0.022). Conclusions Routine EEG is useful in the ED, even in patients with a normal CT or MR brain image, because it helps determine clinical management or AED changes.
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Affiliation(s)
- Jesús H Rodríguez Quintana
- Hospital Universitario Mayor Méderi (JHRQ), Fundación Cardioinfantil (JHRQ, SJB, JLZ-M) and Neuroscience Research Group (NeURos) (JHRQ, MFR, AV-v-M), Escuela de Medicina y Ciencias de la Salud-Universidad del Rosario (MFR), Bogotá, Colombia
| | - Silvia Juliana Bueno
- Hospital Universitario Mayor Méderi (JHRQ), Fundación Cardioinfantil (JHRQ, SJB, JLZ-M) and Neuroscience Research Group (NeURos) (JHRQ, MFR, AV-v-M), Escuela de Medicina y Ciencias de la Salud-Universidad del Rosario (MFR), Bogotá, Colombia
| | - Jessica L Zuleta-Motta
- Hospital Universitario Mayor Méderi (JHRQ), Fundación Cardioinfantil (JHRQ, SJB, JLZ-M) and Neuroscience Research Group (NeURos) (JHRQ, MFR, AV-v-M), Escuela de Medicina y Ciencias de la Salud-Universidad del Rosario (MFR), Bogotá, Colombia
| | - Mario Federico Ramos
- Hospital Universitario Mayor Méderi (JHRQ), Fundación Cardioinfantil (JHRQ, SJB, JLZ-M) and Neuroscience Research Group (NeURos) (JHRQ, MFR, AV-v-M), Escuela de Medicina y Ciencias de la Salud-Universidad del Rosario (MFR), Bogotá, Colombia
| | - Alberto Vélez-van-Meerbeke
- Hospital Universitario Mayor Méderi (JHRQ), Fundación Cardioinfantil (JHRQ, SJB, JLZ-M) and Neuroscience Research Group (NeURos) (JHRQ, MFR, AV-v-M), Escuela de Medicina y Ciencias de la Salud-Universidad del Rosario (MFR), Bogotá, Colombia
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Affiliation(s)
- Andrew J Cole
- From the Departments of Neurology (A.J.C.), Emergency Medicine (J.E.S.), Medicine (E.T.R.), Radiology (M.H.L.), and Pathology (G.E.), Massachusetts General Hospital, and the Departments of Neurology (A.J.C.), Emergency Medicine (J.E.S.), Medicine (E.T.R.), Radiology (M.H.L.), and Pathology (G.E.), Harvard Medical School - both in Boston
| | - Jonathan E Slutzman
- From the Departments of Neurology (A.J.C.), Emergency Medicine (J.E.S.), Medicine (E.T.R.), Radiology (M.H.L.), and Pathology (G.E.), Massachusetts General Hospital, and the Departments of Neurology (A.J.C.), Emergency Medicine (J.E.S.), Medicine (E.T.R.), Radiology (M.H.L.), and Pathology (G.E.), Harvard Medical School - both in Boston
| | - Edward T Ryan
- From the Departments of Neurology (A.J.C.), Emergency Medicine (J.E.S.), Medicine (E.T.R.), Radiology (M.H.L.), and Pathology (G.E.), Massachusetts General Hospital, and the Departments of Neurology (A.J.C.), Emergency Medicine (J.E.S.), Medicine (E.T.R.), Radiology (M.H.L.), and Pathology (G.E.), Harvard Medical School - both in Boston
| | - Michael H Lev
- From the Departments of Neurology (A.J.C.), Emergency Medicine (J.E.S.), Medicine (E.T.R.), Radiology (M.H.L.), and Pathology (G.E.), Massachusetts General Hospital, and the Departments of Neurology (A.J.C.), Emergency Medicine (J.E.S.), Medicine (E.T.R.), Radiology (M.H.L.), and Pathology (G.E.), Harvard Medical School - both in Boston
| | - George Eng
- From the Departments of Neurology (A.J.C.), Emergency Medicine (J.E.S.), Medicine (E.T.R.), Radiology (M.H.L.), and Pathology (G.E.), Massachusetts General Hospital, and the Departments of Neurology (A.J.C.), Emergency Medicine (J.E.S.), Medicine (E.T.R.), Radiology (M.H.L.), and Pathology (G.E.), Harvard Medical School - both in Boston
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Abdennadher M, Saxena A, Pavlova MK. Evaluation and Management of First-Time Seizure in Adults. Semin Neurol 2021; 41:477-482. [PMID: 34619775 DOI: 10.1055/s-0041-1735143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
First seizures are often perceived as devastating events by patients and their families due to the fear of having a life-long disease. One in 10 people experiences one or more seizures during their lifetime, while 1 in 26 people develops epilepsy. Acute symptomatic seizures are often related to a provoking factor or an acute brain insult and typically do not recur. Careful history and clinical examination should guide clinicians' management plans. Electroencephalography and brain imaging, preferably with epilepsy-specific magnetic resonance imaging, may help characterize both etiology and risk of seizure recurrence. Antiepileptic drugs should be initiated in patients with newly diagnosed epilepsy. In patients without an epilepsy diagnosis, the decision to prescribe drugs depends on individual risk factors for seizure recurrence and possible complications from seizures, which should be discussed with the patient. Counseling about driving and lifestyle modifications should be provided early, often at the first seizure encounter.
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Affiliation(s)
- Myriam Abdennadher
- Department of Neurology, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
| | - Aneeta Saxena
- Department of Neurology, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
| | - Milena K Pavlova
- Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts
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Ye Z, Bennett MF, Bahlo M, Scheffer IE, Berkovic SF, Perucca P, Hildebrand MS. Cutting edge approaches to detecting brain mosaicism associated with common focal epilepsies: implications for diagnosis and potential therapies. Expert Rev Neurother 2021; 21:1309-1316. [PMID: 34519595 DOI: 10.1080/14737175.2021.1981288] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Mosaic variants arising in brain tissue are increasingly being recognized as a hidden cause of focal epilepsy. This knowledge gain has been driven by new, highly sensitive genetic technologies and genome-wide analysis of brain tissue from surgical resection or autopsy in a small proportion of patients with focal epilepsy. Recently reported novel strategies to detect mosaic variants limited to brain have exploited trace brain DNA obtained from cerebrospinal fluid liquid biopsies or stereo-electroencephalography electrodes. AREAS COVERED The authors review the data on these innovative approaches published in PubMed before 12 June 2021, discuss the challenges associated with their application, and describe how they are likely to improve detection of mosaic variants to provide new molecular diagnoses and therapeutic targets for focal epilepsy, with potential utility in other nonmalignant neurological disorders. EXPERT OPINION These cutting-edge approaches may reveal the hidden genetic etiology of focal epilepsies and provide guidance for precision medicine.
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Affiliation(s)
- Zimeng Ye
- Department of Medicine (Austin Health), Epilepsy Research Centre, University of Melbourne, Heidelberg, Australia
| | - Mark F Bennett
- Department of Medicine (Austin Health), Epilepsy Research Centre, University of Melbourne, Heidelberg, Australia.,Population Health and Immunity Division, The Walter and Eliza Hall Institute of Medical Research, Parkville, Australia.,Department of Medical Biology, The University of Melbourne, Parkville, Australia
| | - Melanie Bahlo
- Population Health and Immunity Division, The Walter and Eliza Hall Institute of Medical Research, Parkville, Australia.,Department of Medical Biology, The University of Melbourne, Parkville, Australia
| | - Ingrid E Scheffer
- Department of Medicine (Austin Health), Epilepsy Research Centre, University of Melbourne, Heidelberg, Australia.,Neuroscience Research Group, Murdoch Children's Research Institute, Parkville, Australia.,Department of Paediatrics, University of Melbourne, Royal Children's Hospital, Parkville, Australia.,Department of Neurology, Comprehensive Epilepsy Program, Austin Health, Heidelberg, Australia
| | - Samuel F Berkovic
- Department of Medicine (Austin Health), Epilepsy Research Centre, University of Melbourne, Heidelberg, Australia.,Department of Neurology, Comprehensive Epilepsy Program, Austin Health, Heidelberg, Australia
| | - Piero Perucca
- Department of Medicine (Austin Health), Epilepsy Research Centre, University of Melbourne, Heidelberg, Australia.,Department of Neurology, Comprehensive Epilepsy Program, Austin Health, Heidelberg, Australia.,Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Australia.,Department of Neurology, Alfred Health, Melbourne, Australia.,Department of Neurology, The Royal Melbourne Hospital, Parkville, Australia
| | - Michael S Hildebrand
- Department of Medicine (Austin Health), Epilepsy Research Centre, University of Melbourne, Heidelberg, Australia.,Neuroscience Research Group, Murdoch Children's Research Institute, Parkville, Australia
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Hakami T, Hakami M. Sudden unexpected death in epilepsy: Experience of neurologists in Saudi Arabia. Epilepsy Behav 2021; 121:108025. [PMID: 34022620 DOI: 10.1016/j.yebeh.2021.108025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 04/17/2021] [Accepted: 04/27/2021] [Indexed: 10/21/2022]
Abstract
IMPORTANCE Sudden unexpected death in epilepsy (SUDEP) may account for up to 17% of all deaths in epilepsy. However, it is unknown if neurologists discuss this risk with patients. OBJECTIVE This study aimed to examine the understanding and practices of SUDEP by neurologists in Saudi Arabia. METHODS An electronic web-based survey was sent to 125 neurologists using the mailing list of the Saudi Neurology Society. The survey questions included respondents' demographics, frequency of SUDEP discussion, reasons for discussing/not discussing SUDEP, and perceived patient reactions. Respondents' knowledge of the SUDEP risk factors was examined using 12 items from the currently available literature. Logistic regression analyses were applied to examine the factors that influence the frequency of SUDEP discussions and perceived patient reactions. PARTICIPANTS The participants were neurologists who had completed postgraduate training, devoted >5% of their time to clinical care, and had at least one patient with epilepsy in their independent neurology clinic. RESULTS A total of 60 respondents met the eligibility criteria and completed the surveys. Of them, 25% discussed SUDEP most of the time, 65% sometimes or rarely, and 10% never discussed it. Of those who discussed SUDEP with their patients, 63.3% did it if the patient was at high risk. Poor compliance with antiepileptic drugs (AEDs) was the most common patient factor highlighted (81.7%). The perceived patients' reactions were variable, with positive reactions (motivation to comply and appreciation) being the most frequent. The majority of respondents (78.3%) had incomplete understanding of the published SUDEP risk factors, with SUDEP knowledge scores ≤2.5 (≤50% of the possible total score). The most identified risk factors were frequent generalized tonic-clonic seizures (83.3%), long duration of epilepsy (53.3%), lack of use or sub-therapeutic levels of AEDs (50%), and AED polytherapy (50%). No association was found between how often SUDEP was discussed and other factors, including training in epilepsy, ≥10 years in practice, seeing ≥100 patients, and having SUDEP cases in the past two years. It was found that patients positively reacted to discussion on SUDEP if neurologists had a good understanding of the SUDEP risk factors (χ2 = 5.773, p = 0.016). CONCLUSIONS Neurologists in Saudi Arabia do not often discuss SUDEP with patients that have epilepsy. Moreover, when they do, they stress a more individualized approach despite having only a limited understanding of the SUDEP risk factors. Our findings suggest that more guidance should be provided to practitioners on how best to counsel their patients about SUDEP.
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Affiliation(s)
- Tahir Hakami
- The Faculty of Medicine, Jazan University, Jazan, Saudi Arabia.
| | - Mohammed Hakami
- Division of Neurology, King Fahd Central Hospital, Jazan, Saudi Arabia
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30
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Affiliation(s)
- Phil E M Smith
- From the Department of Neurology, University Hospital of Wales, Cardiff, United Kingdom
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Abstract
Epilepsy is the third most frequent neurological disorder in aged patients after stroke and dementia. The incidence of epilepsy increases with age with the highest rates in patients ≥ 65 years old. Due to demographic changes the number of aged patients with epilepsy is expected to increase further in the coming years. The leading cause of new onset epilepsy in aged patients is cerebrovascular disease followed by dementia. The recognition of seizures in aged patients is often delayed. Status epilepticus occurs more frequently in aged patients and is associated with a high mortality and morbidity. Antiepileptic drug (AED) treatment of aged patients is complicated by comorbidities and polypharmacy and AEDs with a low interaction profile and high tolerability should be selected. Levetiracetam and lamotrigine are the AEDs of choice due to low interactions and good tolerability.
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Affiliation(s)
- Alexandra Rohracher
- Paracelsus Medizinische Privatuniversität Salzburg, Universitätsklinik für Neurologie, Ignaz-Harrer-Str. 79, 5020, Salzburg, Österreich
| | - Eugen Trinka
- Paracelsus Medizinische Privatuniversität Salzburg, Universitätsklinik für Neurologie, Ignaz-Harrer-Str. 79, 5020, Salzburg, Österreich.
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Hudson ER, Lesko A, Lucas L, Baraban E, Fertig EJ. Healthcare utilization and cost outcomes for a multicenter first seizure and new onset epilepsy clinic. Epilepsy Behav 2021; 120:107972. [PMID: 33971392 DOI: 10.1016/j.yebeh.2021.107972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 03/15/2021] [Accepted: 04/01/2021] [Indexed: 11/26/2022]
Abstract
RATIONALE A First Seizure/New Onset Epilepsy (FS/NOE) protocol was implemented to ensure proper evaluation by an epileptologist and improve overall care for patients. We compared healthcare utilization and cost incurred by patients pre and post protocol implementation. METHODS Clinical data were retrospectively collected from the EMR and cost data from the financial database. Patients were identified by FS event and grouped into either the pre-implementation (pre-FSC) or post-implementation cohort (post-FSC). Pre-FSC patients were seen between January 2014-December 2015 and post-FSC between March 2016-January 2018. Utilization outcomes include time from FS to neurology appointment, MRI, and electroencephalogram (EEG). Cost outcomes included the annualized median difference in pre versus post costs for ER, inpatient, outpatient or ambulatory, and total hospital services. Cost and utilization outcomes were collected within 90 days or 6 months post first-seizure event. Pre and post cohorts were compared using Kaplan-Meier analysis and Cox proportional hazard models for time-to-event outcomes, multivariable median regression models for cost differences and negative binomial regression models for utilization analyses. Models were adjusted for age, sex, health insurance, and comorbidities. RESULTS One-hundred and fifty six patients were included with 84 (53.8%) pre- and 72 (46.2%) post-FSC patients. Kaplan-Meier and Cox regression results indicated post-FSC patients had significantly faster time-to-first neurology appointment (5.0 vs. 20.9 days, p < .001; Adjusted Hazard Ratio (HR) = 5.98, p < .001), time-to-MRI (9.0 vs. 27.0 days; p = 0.005; HR = 1.88, p = .021) and EEG (3.6 vs. 48.6 days, p < .001; HR = 9.01, p < .001). A total of 138 patients had at least one cost in the financial database. For 6-month follow-up period, post-FSC patients had higher adjusted all-cause total median costs (+$830, p = 0.009) and outpatient costs (+$1203, p < .001) but lower ED costs (-245, p = 0.073), not significant. Results were similar for seizure-related costs. Similarly, Post-FSC patients had a significantly higher likelihood of all-cause (Adjusted Rate Ratio (ARR) = 1.41, p = .029) and outpatient utilization (ARR = 1.72, p = .008) but lower ED utilization (ARR = 0.54, p < .001). CONCLUSIONS Implementation of the FSC decreased time to evaluation by a neurologist and time to diagnostic workup. Ultimately, total healthcare costs and ambulatory costs increased but ED costs and utilization were reduced. It is our hypothesis that faster access to initial care and diagnosis would result in better control of seizures and reduce long-term costs and utilization. Further research over a longer duration of time across a broader population is needed to evaluate the full implications of an epilepsy specialist-populated FSC.
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Affiliation(s)
- Emily R Hudson
- Western University of Health Sciences College of Osteopathic Medicine of the Pacific, Northwest, 200 Mullins Dr, Lebanon, OR 97355, United States; Providence Brain and Spine Institute, 9135 SW Barnes Rd., Suite 363, Portland, OR 97225, United States
| | - Alexandra Lesko
- Western University of Health Sciences College of Osteopathic Medicine of the Pacific, Northwest, 200 Mullins Dr, Lebanon, OR 97355, United States; Providence Brain and Spine Institute, 9135 SW Barnes Rd., Suite 363, Portland, OR 97225, United States.
| | - Lindsay Lucas
- Western University of Health Sciences College of Osteopathic Medicine of the Pacific, Northwest, 200 Mullins Dr, Lebanon, OR 97355, United States; Providence Brain and Spine Institute, 9135 SW Barnes Rd., Suite 363, Portland, OR 97225, United States
| | - Elizabeth Baraban
- Western University of Health Sciences College of Osteopathic Medicine of the Pacific, Northwest, 200 Mullins Dr, Lebanon, OR 97355, United States; Providence Brain and Spine Institute, 9135 SW Barnes Rd., Suite 363, Portland, OR 97225, United States
| | - Evan J Fertig
- Western University of Health Sciences College of Osteopathic Medicine of the Pacific, Northwest, 200 Mullins Dr, Lebanon, OR 97355, United States; Providence Brain and Spine Institute, 9135 SW Barnes Rd., Suite 363, Portland, OR 97225, United States
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Khalily MA, Akhtar M, Ali S, Rafique S, Sultan T, Wasim A. Spectrum of Electroencephalography Findings in Newly Diagnosed Epilepsy. Cureus 2021; 13:e15938. [PMID: 34336438 PMCID: PMC8312348 DOI: 10.7759/cureus.15938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/26/2021] [Indexed: 11/05/2022] Open
Abstract
Background Epilepsy is a neurological disorder that presents with recurrent seizures associated with erratic brain activity which can be measured through EEG in addition to other neurological investigations. However, EEG may show abnormal patterns and waveforms while the patient is having a seizure which is crucial for making an accurate diagnosis. Objective This study aims to evaluate the spectrum of EEG findings in newly diagnosed epileptic patients as part of a neurological investigation. Material and methods This cross-sectional study was carried out at the Department of Paediatric Neurology, the Children's Hospital, and the Institute of Child Health, Lahore for six months. A sample of 122 patients was enrolled in this study with an age range of >1 month and <18 years, with a diagnosis of epilepsy based upon ≥2 unprovoked seizures that occurred ≥ 24 hours apart. After obtaining informed consent from the patients, a one-time EEG was carried out and details were noted such as type and frequency of the discharge, site of maximum amplitude, paroxysm morphology, and onset and offset (focal/generalized) of the discharges. The data was analyzed using SPSS v.25 (IBM SPSS Statistics for Windows, Armonk, NY). Results The mean age of children enrolled in this study was 5.58 ± 3.46 years. There were 70 (57.4%) males and 52 (42.6%) females. The mean age at the onset of seizures was 4.85 ± 3.16 years. Out of 122 children, focal onset aware epilepsy type was noted in 8 cases, focal onset impaired awareness was noted in 19 cases and generalized onset motor type of epilepsy was noted in 95 cases. Furthermore, EEG findings were normal in 41 (33.61%) patients; however, 81 (66.39%) EEG findings of the patients place them in the abnormal range. On EEG, paroxysm morphology was typical in 78 (96.3%) patients while atypical in 3 (3.7%) patients. Discharge spectrum was generalized in 46 (56.8%) patients, localized in 19 (23.5%) patients, bilateral independent in 1 (1.2%) patient and multifocal in 15 (18.5%) patients. Discharge pattern was periodic in seven (8.6%) cases, rhythmic delta activity was noted in 4 (4.9%) cases, spike and wave pattern was noted in 68 (84.0%) cases and sharp and wave pattern was observed in 36 (44.4%) patients. Conclusion Our study concluded that EEG findings were abnormal in 81 (66.39%) patients. Thus to make the recommendations locally and nationally, we observed that EEG can highlight the abnormal pattern and discharges in newly diagnosed individuals with epilepsy. Our findings could be instrumental to identify the type of EEG discharges in a timely fashion while making diagnoses and treatment plan protocols accordingly. This study finding recommends the early application of EEG after the presentation of epileptic symptoms by the patient. We further recommend that further similar studies be conducted in multiple tertiary care settings to reach a firm and valuable conclusion.
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Affiliation(s)
- Muhammad A Khalily
- Department of Pediatric Neurology, The Children's Hospital and The Institute Of Child Health, Lahore, PAK
| | - Muhammad Akhtar
- Department of Pediatric Neurology, The Children's Hospital and The Institute Of Child Health, Lahore, PAK
| | - Shaila Ali
- Department of Pediatric Neurology, The Children's Hospital and The Institute Of Child Health, Lahore, PAK
| | - Shumaila Rafique
- Department of Pediatric Neurology, The Children's Hospital and The Institute Of Child Health, Lahore, PAK
| | - Tipu Sultan
- Department of Pediatric Neurology, The Children's Hospital and The Institute Of Child Health, Lahore, PAK
| | - Areeba Wasim
- Department of Pediatric Neurology, The Children's Hospital and The Institute Of Child Health, Lahore, PAK
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Aloraidi A, Alkhaibary A, Alharbi A, Alnefaie N, Alaglan A, AlQarni A, Elarjani T, Arab A, Abdullah JM, Almubarak AO, Abbas M, Khairy I, Almadani WH, Alowhaibi M, Alarifi A, Khairy S, Alkhani A. Effect of cranioplasty timing on the functional neurological outcome and postoperative complications. Surg Neurol Int 2021; 12:264. [PMID: 34221595 PMCID: PMC8247689 DOI: 10.25259/sni_802_2020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 04/28/2021] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND The optimal timing for performing cranioplasty and its effect on functional outcome remains debatable. Multiple confounding factors may come into role; including the material used, surgical technique, cognitive assessment tools, and the overall complications. The aim of this study is to assess the neurological outcome and postoperative complications in patients who underwent early versus late cranioplasty. METHODS A retrospective cohort study was conducted to investigate the neurological outcome and postoperative complications in patients who underwent cranioplasty between 2005 and 2018 at a Level l trauma center. Early and late cranioplasties were defined as surgeries performed within and more than 90 days of decompressive craniectomy, respectively. The Glasgow Outcome Score (GOS) and modified Rankin scale (mRS), recorded within 1 week of cranioplasty, were used to assess the neurological outcome. RESULTS A total of 101 cases of cranioplasty were included in the study. The mean age of the patients was 31.4 ± 13.9 years. Most patients (n = 86; 85.1%) were male. The mean GOS for all patients was 4.0 ± 1.0. The mean mRS was 2.2 ± 1.78. Hydrocephalus was noted in 18 patients (early, n = 6; late, n = 12; P = 0.48). Seizures developed in 28 patients (early, n = 12; late, n = 16; P = 0.77). CONCLUSION The neurological outcome in patients who underwent early versus late cranioplasty is almost identical. The differences in the rates of overall postoperative complications between early versus late cranioplasty were statistically insignificant. The optimal timing for performing cranioplasty is mainly dependent on the resolution of cerebral swelling.
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Affiliation(s)
- Ahmed Aloraidi
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Division of Neurosurgery, Department of Surgery, Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia
| | - Ali Alkhaibary
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Division of Neurosurgery, Department of Surgery, Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia
| | - Ahoud Alharbi
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Division of Neurosurgery, Department of Surgery, Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia
| | - Nada Alnefaie
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Abeer Alaglan
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Division of Neurosurgery, Department of Surgery, Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia
| | - Abdulaziz AlQarni
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Division of Neurosurgery, Department of Surgery, Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia
| | - Turki Elarjani
- University of Miami, Department of Neurological Surgery, Miami, FL. USA
| | - Ala Arab
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Division of Neurosurgery, Department of Surgery, Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia
| | - Jamal M. Abdullah
- Department of Neurosurgery, Prince Sultan Military Medical City, Riyadh, Arabia
| | | | - Munzir Abbas
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Division of Neurosurgery, Department of Surgery, Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia
| | - Ibtesam Khairy
- Faculty of Applied Medical Sciences, Jazan University, Jazan, Saudi Arabia
| | - Wedad H. Almadani
- National Center for Evidence Based Healthcare, Saudi Health Council, Riyadh, Saudi Arabia
| | - Mohammed Alowhaibi
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Division of Neurosurgery, Department of Surgery, Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia
| | - Abdulaziz Alarifi
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Division of Neurosurgery, Department of Surgery, Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia
| | - Sami Khairy
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Division of Neurosurgery, Department of Surgery, Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia
| | - Ahmed Alkhani
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Division of Neurosurgery, Department of Surgery, Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia
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Bagla J, Kaur H, Singhal A, Mishra D, Kumari S, Dubey AP, Soneja S. Electroencephalogram versus Magnetic Resonance Imaging Brain as the Initial Investigation of Choice in Neurologically Normal Children with First Afebrile Seizure in India. J Epilepsy Res 2021; 11:56-62. [PMID: 34395224 PMCID: PMC8357547 DOI: 10.14581/jer.21008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 05/05/2021] [Accepted: 05/09/2021] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND AND PURPOSE To compare the rates of clinically relevant information provided by electroencephalogram (EEG) and magnetic resonance imaging (MRI) brain in first afebrile seizure (FAS) in children. METHODS In this prospective randomized controlled trial, neurologically normal children between the age of 2 and 14 years, presenting with first episode of unprovoked, afebrile generalized or partial seizures, were included. Enrolled patients were randomized into two groups. After stabilization, initial workup and management, group I-patients underwent an EEG followed by MRI, whereas group II-patients underwent an initial MRI brain followed by an EEG. The patients were followed up after results of both the investigations and then every 3 months for seizure recurrence. The primary outcome was the proportion of investigations, providing clinically relevant information. The secondary outcomes were to determine the etiological diagnosis of FAS and record adverse events associated with EEG and MRI. RESULTS Out of 170 enrolled patients, 52 patients (61.2%) in initial EEG group and 53 patients (70.6%) in initial MRI group had abnormal results on first investigation. An etiological diagnosis could not be made in any patient in initial EEG group. Neuroimaging revealed an etiological diagnosis in 53 patients (70.6%) in initial MRI group. Inflammatory granuloma was found to be the most common cause of FAS, followed by idiopathic epilepsy. CONCLUSIONS The results of our study done in neurologically normal children with FAS showed a high diagnostic yield with an initial MRI. We recommend MRI brain to be considered as the initial investigation for evaluation of FAS in children.
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Affiliation(s)
- Jyoti Bagla
- Department of Pediatrics, ESI PGIMSR, New Delhi, India
| | - Harpreet Kaur
- Department of Pediatrics, ESI PGIMSR, New Delhi, India
| | - Anu Singhal
- Department of Radiodiagnosis, ESI PGIMSR, New Delhi, India
| | - Devendra Mishra
- Department of Pediatrics, Maulana Azad Medical College, New Delhi, India
| | - Sweta Kumari
- Department of Pediatrics, ESI PGIMSR, New Delhi, India
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Alessi N, Perucca P, McIntosh AM. Missed, mistaken, stalled: Identifying components of delay to diagnosis in epilepsy. Epilepsia 2021; 62:1494-1504. [PMID: 34013535 DOI: 10.1111/epi.16929] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 04/16/2021] [Accepted: 04/30/2021] [Indexed: 11/27/2022]
Abstract
A substantial proportion of individuals with newly diagnosed epilepsy report prior seizures, suggesting a missed opportunity for early epilepsy care and management. Consideration of the causes and outcomes of diagnostic delay is needed to address this issue. We aimed to review the literature pertaining to delay to diagnosis of epilepsy, describing the components, characteristics, and risk factors for delay. We undertook a systematic search of the literature for full-length original research papers with a focus on diagnostic delay or seizures before diagnosis, published 1998-2020. Findings were collated, and a narrative review was undertaken. Seventeen papers met the inclusion criteria. Studies utilized two measures of diagnostic delay: seizures before diagnosis and/or a study-defined time between first seizure and presentation/diagnosis. The proportion of patients with diagnostic delay ranged from 16% to 77%; 75% of studies reported 38% or more to be affected. Delays of 1 year or more were reported in 13%-16% of patients. Seizures prior to diagnosis were predominantly nonconvulsive, and usually more than one seizure was reported. Prior seizures were often missed or mistaken for symptoms of other conditions. Key delays in the progression to specialist review and diagnosis were (1) "decision delay" (the patient's decision to seek/not seek medical review), (2) "referral delay" (delay by primary care/emergency physician referring to specialist), and (3) "attendance delay" (delay in attending specialist review). There were few data available relevant to risk factors and virtually none relevant to outcomes of diagnostic delay. This review found that diagnostic delay consists of several components, and progression to diagnosis can stall at several points. There is limited information relating to most aspects of delay apart from prevalence and seizure types. Risk factors and outcomes may differ according to delay characteristics and for each of the key delays, and recommendations for future research include examining each before consideration of interventions is made.
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Affiliation(s)
- Natasha Alessi
- Department of Medicine (Austin Health), Epilepsy Research Centre, University of Melbourne, Melbourne, Victoria, Australia.,Department of Medicine, Melbourne Brain Centre, University of Melbourne, Melbourne, Victoria, Australia.,Department of Neurology, Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Melbourne School of Psychological Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Piero Perucca
- Department of Medicine (Austin Health), Epilepsy Research Centre, University of Melbourne, Melbourne, Victoria, Australia.,Department of Medicine, Melbourne Brain Centre, University of Melbourne, Melbourne, Victoria, Australia.,Department of Neurology, Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Neurology, Comprehensive Epilepsy Program, Austin Health, Melbourne, Victoria, Australia.,Department of Neurology, Alfred Health, Melbourne, Victoria, Australia.,Central Clinical School, Department of Neuroscience, Monash University, Melbourne, Victoria, Australia
| | - Anne M McIntosh
- Department of Medicine (Austin Health), Epilepsy Research Centre, University of Melbourne, Melbourne, Victoria, Australia.,Department of Medicine, Melbourne Brain Centre, University of Melbourne, Melbourne, Victoria, Australia.,Department of Neurology, Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Neurology, Comprehensive Epilepsy Program, Austin Health, Melbourne, Victoria, Australia
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Abstract
SUMMARY Recording of interictal epileptiform discharges to classify the epilepsy syndrome is one of the most common indications for ambulatory EEG. Ambulatory EEG has superior sampling compared with standard EEG recordings and advantages in terms of cost-effectiveness and convenience compared with a prolonged inpatient EEG study. Ambulatory EEG allows for EEG recording in all sleep stages and transitional states, which can be very helpful in capturing interictal epileptiform discharges. In the absence of interictal epileptiform discharges or in patients with atypical events, the characterization of an epilepsy syndrome may require recording of the habitual events. Diagnostic ambulatory EEG can be a useful alternative to inpatient video-EEG monitoring in a selected number of patients with frequent events who do not require medication taper or seizure testing for surgical localization.
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Hasan TF, Tatum WO. When should we obtain a routine EEG while managing people with epilepsy? Epilepsy Behav Rep 2021; 16:100454. [PMID: 34041475 PMCID: PMC8141667 DOI: 10.1016/j.ebr.2021.100454] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 03/24/2021] [Accepted: 04/22/2021] [Indexed: 11/30/2022] Open
Abstract
More than eight decades after its discovery, routine electroencephalogram (EEG) remains a safe, noninvasive, inexpensive, bedside test of neurological function. Knowing when a routine EEG should be obtained while managing people with epilepsy is a critical aspect of optimal care. Despite advances in neuroimaging techniques that aid diagnosis of structural lesions in the central nervous system, EEG continues to provide critical diagnostic evidence with implications on treatment. A routine EEG performed after a first unprovoked seizure can support a clinical diagnosis of epilepsy and differentiate those without epilepsy, classify an epilepsy syndrome to impart prognosis, and characterize seizures for antiseizure management. Despite a current viral pandemic, EEG services continue, and the value of routine EEG is unchanged.
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Affiliation(s)
- Tasneem F. Hasan
- Department of Neurology, Ochsner Louisiana State University Health Sciences Center, Shreveport, LA, United States
| | - William O. Tatum
- Department of Neurology, Mayo Clinic, Jacksonville, FL, United States
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Haddad N, Melikyan G, Alarcon G, Shaheen Y, Siddiqi M, Ali E, Mesraoua B, AlHail H, Al-Abdulghani A, Alrabi A, Syamala A, Kazi F, Mahfoud Z. 24-Hour video EEG in the evaluation of the first unprovoked seizure. Clin Neurophysiol Pract 2021; 6:123-128. [PMID: 33997530 PMCID: PMC8089767 DOI: 10.1016/j.cnp.2021.02.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 02/05/2021] [Accepted: 02/24/2021] [Indexed: 11/06/2022] Open
Abstract
In the evaluation of a first seizure, the capture of epileptiform discharges is increased with 24-hour EEG recordings. This likely stems from a combination of increased sampling and robust sleep recording. Subtle seizures were also recorded by prolonging the EEG in a minority of first seizure presentations.
Objective To assess the gain in detection of epileptiform abnormalities in 24-hour EEG recordings following the first seizure. Methods We identified patients who underwent 24-hour video EEG (VEEG) with “first seizure” as an indication. We noted the presence or absence of epileptiform discharges (EDs) in the VEEG study and the latency for the appearance of such discharges. We compared the rate of EDs during the initial 60 min with those occurring only later during the recording. Results Data from 25 patients, aged 15 to 59, were included. Of the 11 patients with EDs, eight (73%) appeared only after 60 min of recording. This equates to a 32% absolute increase in the detection of EDs across all patients. The latency to first EDs varied from one to 1080 min with a median of 170 min. In four cases, actual subtle seizures were recorded. Conclusion This study suggests an increase in the detection of EDs with the 24-hour studies compared to the traditional shorter recordings, in the context of a first seizure. Significance A standard EEG can be performed close to the seizure, followed by a longer up to 24-hour recording if the initial shorter study is unrevealing.
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Affiliation(s)
- Naim Haddad
- Hamad Medical Corporation, PO Box 3050, Doha, Qatar.,Weill Cornell Medicine-Qatar, PO Box 24144, Education City, Doha, Qatar
| | - Gayane Melikyan
- Hamad Medical Corporation, PO Box 3050, Doha, Qatar.,Weill Cornell Medicine-Qatar, PO Box 24144, Education City, Doha, Qatar
| | - Gonzalo Alarcon
- Hamad Medical Corporation, PO Box 3050, Doha, Qatar.,Weill Cornell Medicine-Qatar, PO Box 24144, Education City, Doha, Qatar
| | - Yanal Shaheen
- Weill Cornell Medicine-Qatar, PO Box 24144, Education City, Doha, Qatar
| | | | - Elfateh Ali
- Hamad Medical Corporation, PO Box 3050, Doha, Qatar
| | - Boulenouar Mesraoua
- Hamad Medical Corporation, PO Box 3050, Doha, Qatar.,Weill Cornell Medicine-Qatar, PO Box 24144, Education City, Doha, Qatar
| | - Hassan AlHail
- Hamad Medical Corporation, PO Box 3050, Doha, Qatar.,Weill Cornell Medicine-Qatar, PO Box 24144, Education City, Doha, Qatar
| | | | | | | | - Farhana Kazi
- Hamad Medical Corporation, PO Box 3050, Doha, Qatar
| | - Ziyad Mahfoud
- Weill Cornell Medicine-Qatar, PO Box 24144, Education City, Doha, Qatar
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Nezami A, Tarhani F, Shoshtari NK. Organic Lesions in the Brain MRI of Children with Febrile Seizure. Curr Med Imaging 2021; 17:148-154. [PMID: 32101131 DOI: 10.2174/1573405616666200226103615] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Revised: 01/28/2020] [Accepted: 02/10/2020] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Seizure is the most common neurological disorders in children, where 4-10% of the cases experience at least one seizure before the age of 16. The most frequent causes of seizures in children are fever, epilepsy, infection and brain damage. The aim of this study was to investigate the frequency of organic lesions in MRI of children with seizures unrelated to fever. MATERIALS AND METHODS This cross-sectional study included children presented with fever-unrelated seizures. The MRI was examined by a radiologist to identify abnormal findings in each patient. A researcher-made questionnaire including general information, history of head trauma, obstructed labor and the history of seizure was completed for the patients. RESULTS Of 287 children with fever-related seizure, 127 (45.7%) were male and 151 (54.3%) were female. History of seizure, history of obstructed labor, abnormal MRI, complete delay, use of antiepileptic drug and history of trauma were 22(9.9%), 1 (0.4%), 11(4%), 5(1.8%), 259(93.2%) and 12 (4.3%), respectively. Of 11 patients with abnormal MRI, 4 had MTS lesions, 2 had tumor lesions, 2 had scarring trauma, 1 had an epidural abscess and 1 had meningitis. The frequency of organic lesions had no significant differences based on gender, use of antiepileptic drug and traumatic history, but it had a significant relation with obstructed labor andthehistory of seizure. CONCLUSION The results showed that organic brain lesions in children with fever-unrelated seizure had a significant relationship with the history of seizure and obstructed maternal labor.
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Affiliation(s)
- Alireza Nezami
- Department of Cardiology, School of Medicine, Lorestan University of Medical Sciences, Khorramabad, Iran
| | - Fariba Tarhani
- Department of Cardiology, School of Medicine, Lorestan University of Medical Sciences, Khorramabad, Iran
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McIntosh AM, Tan KM, Hakami TM, Newton MR, Carney PW, Yang M, Saya S, Marco DJT, Perucca P, Kwan P, O’Brien TJ, Berkovic SF. Newly diagnosed seizures assessed at two established first seizure clinics: Clinic characteristics, investigations, and findings over 11 years. Epilepsia Open 2021; 6:171-180. [PMID: 33681660 PMCID: PMC7918310 DOI: 10.1002/epi4.12460] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 11/12/2020] [Accepted: 12/14/2020] [Indexed: 11/11/2022] Open
Abstract
Objective 'First seizure' clinics (FSCs) aim to achieve early expert assessment for individuals with possible new-onset epilepsy. These clinics also have substantial potential for research into epilepsy evolution, outcomes, and costs. However, a paucity of FSCs details has implications for interpretation and utilization of this research. Methods We reviewed investigation findings over 11 years (2000-2010) from two established independent FSCs at Austin Health (AH) and Royal Melbourne Hospital (RMH), Australia. These adult clinics are in major public hospitals and operate with similar levels of expertise. Organizational differences include screening and dedicated administration at AH. Included were N = 1555 patients diagnosed with new-onset unprovoked seizures/epilepsy (AH n = 901, RMH n = 654). Protocol-driven interviews and investigations had been recorded prospectively and were extracted from medical records for study. Results Median patient age was 37 (IQR 26-52, range 18-94) years (AH 34 vs RMH 42 years; P < .001). Eighty-six percent of patients attended FSC within three weeks postindex seizure (median AH 12 vs RMH 25 days; P < .01). By their first appointment, 42% had experienced ≥2 seizures. An EEG was obtained within three weeks postindex seizure in 73% of patients, demonstrating epileptiform discharges in 25% (AH 33% vs RMH 15%). Seventy-six percent of patients had an MRI within 6 weeks. Of those with imaging (n = 1500), 19% had potentially epileptogenic abnormalities (RMH 28% vs AH 12%; P < .01). At both sites, changes due to previous stroke/hemorrhage were the commonest lesions, followed by traumatic brain injury. ≥WHO level 1 brain tumors diagnosed at presentation comprised a very small proportion (<1%) at each clinic. At both sites, epilepsy type could be determined in 60% of patients; RMH had more focal and AH more generalized epilepsy diagnoses. Significance Differences between the clinics' administrative and screening practices may contribute to differences in investigation findings. Insight into these differences will facilitate interpretation and utilization, and planning of future research.
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Affiliation(s)
- Anne M. McIntosh
- The Melbourne Brain CentreThe Department of MedicineThe University of MelbourneMelbourneAustralia
- The Department of NeurologyThe Royal Melbourne HospitalMelbourneAustralia
- Epilepsy Research CentreDepartment of Medicine (Austin Health)University of MelbourneMelbourneAustralia
- Department of NeuroscienceCentral Clinical SchoolMonash UniversityMelbourneAustralia
| | - K. Meng Tan
- The Melbourne Brain CentreThe Department of MedicineThe University of MelbourneMelbourneAustralia
- The Department of NeurologyThe Royal Melbourne HospitalMelbourneAustralia
- Gold Coast University Medical CentreSouthportAustralia
| | - Tahir M. Hakami
- The Melbourne Brain CentreThe Department of MedicineThe University of MelbourneMelbourneAustralia
- The Faculty of MedicineUniversity of JazanJazanSaudi Arabia
| | - Mark R. Newton
- Epilepsy Research CentreDepartment of Medicine (Austin Health)University of MelbourneMelbourneAustralia
- Department of NeurologyAustin HealthHeidelbergAustralia
| | - Patrick W. Carney
- Department of NeurologyAustin HealthHeidelbergAustralia
- Florey Institute of Neuroscience and Mental HealthParkvilleAustralia
- Department of MedicineMonash UniversityMelbourneAustralia
- Eastern HealthBox HillAustralia
| | - Mengjiazhi Yang
- The Melbourne Brain CentreThe Department of MedicineThe University of MelbourneMelbourneAustralia
- The Department of NeurologyThe Royal Melbourne HospitalMelbourneAustralia
| | - Sibel Saya
- Epilepsy Research CentreDepartment of Medicine (Austin Health)University of MelbourneMelbourneAustralia
- Centre for Cancer ResearchThe University of MelbourneMelbourneAustralia
- Department of General PracticeThe University of MelbourneMelbourneAustralia
| | - David J. T. Marco
- Epilepsy Research CentreDepartment of Medicine (Austin Health)University of MelbourneMelbourneAustralia
- Centre for Palliative CareSt Vincent’s HospitalMelbourneAustralia
| | - Piero Perucca
- The Melbourne Brain CentreThe Department of MedicineThe University of MelbourneMelbourneAustralia
- The Department of NeurologyThe Royal Melbourne HospitalMelbourneAustralia
- Department of NeuroscienceCentral Clinical SchoolMonash UniversityMelbourneAustralia
- Department of NeurologyAlfred HealthMelbourneAustralia
| | - Patrick Kwan
- The Melbourne Brain CentreThe Department of MedicineThe University of MelbourneMelbourneAustralia
- The Department of NeurologyThe Royal Melbourne HospitalMelbourneAustralia
- Department of NeuroscienceCentral Clinical SchoolMonash UniversityMelbourneAustralia
- Department of MedicineMonash UniversityMelbourneAustralia
- Department of NeurologyAlfred HealthMelbourneAustralia
| | - Terence J. O’Brien
- The Melbourne Brain CentreThe Department of MedicineThe University of MelbourneMelbourneAustralia
- The Department of NeurologyThe Royal Melbourne HospitalMelbourneAustralia
- Department of NeuroscienceCentral Clinical SchoolMonash UniversityMelbourneAustralia
- Department of NeurologyAlfred HealthMelbourneAustralia
| | - Samuel F. Berkovic
- Epilepsy Research CentreDepartment of Medicine (Austin Health)University of MelbourneMelbourneAustralia
- Department of NeurologyAustin HealthHeidelbergAustralia
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Mc Manus E, Gilbertson L, Timmings P, Lynch C, Asztely F. Long-term outcome of 200 patients referred to a first seizure clinic. Acta Neurol Scand 2021; 143:140-145. [PMID: 32885416 DOI: 10.1111/ane.13340] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 08/10/2020] [Accepted: 08/21/2020] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To determine what proportion of our First Seizure referrals reflected true unprovoked first seizures or epilepsy, and to assess the long-term diagnostic accuracy of our First Seizure Clinic (FSC) by quantifying the risk of subsequent seizures in our FSC cohort. METHODS We prospectively collected data of 200 adult patients referred to the FSC between May 2014 and December 2015. We reviewed clinical notes, electroencephalography (EEG) data and performed telephone follow-up at 28-month post-diagnosis. RESULTS Of the 200 patients referred to the FSC, 181 attended. At the initial assessment, 39 of these patients were diagnosed with epilepsy, with most of these patients (59%) found to have a history of previous seizures. Fifty patients were diagnosed with a first seizure, of which 28% were labelled as provoked seizures. Sixty nine of the patients received another diagnosis and 23 were labelled as indeterminable. At 28 months follow-up, 11 (22%) of patients who received a diagnosis of first seizure subsequently received a diagnosis of epilepsy. In the remaining groups, only 5 (5%) patients were diagnosed with epilepsy (of these three were in the indeterminable group). CONCLUSIONS Our study shows that 50% of the patients referred to a FSC had not experienced a seizure but were given an alternative diagnosis. Secondly, our study indicates that the risk of seizure recurrence following a first seizure is quite low (22%). This is because a substantial proportion of the patients were diagnosed with epilepsy already at the first assessment. The high proportion of patients being diagnosed with epilepsy was mainly due to a history of previous seizures. Thirdly, patients who were given an alternative diagnosis at the first assessment had a low probability (5%) for seizure recurrence.
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Affiliation(s)
- Eileen Mc Manus
- Department of Neurology Waikato Hospital Hamilton New Zealand
| | | | - Paul Timmings
- Department of Neurology Waikato Hospital Hamilton New Zealand
| | | | - Fredrik Asztely
- Department of Neurology Waikato Hospital Hamilton New Zealand
- Institute of Neuroscience and Physiology University of Gothenburg Gothenburg Sweden
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El-Hallal M, Shah Y, Nath M, Eksambe P, Theroux L, Amlicke M, Steele F, Krief W, Kothare S. Length of stay linked to neurodiagnostic workup for seizures presenting to the pediatric emergency department. Epilepsy Behav 2021; 115:107639. [PMID: 33378722 DOI: 10.1016/j.yebeh.2020.107639] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 11/08/2020] [Accepted: 11/16/2020] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Patients presenting to the pediatric emergency department (ED) often undergo unnecessary testing that leads to prolonged ED visits. Lower ED length of stay has been linked to improved patient experience and may reduce ED overcrowding, a costly burden on a health system. METHODS This is a retrospective cohort study involving patient records over the period of 6 months at an urban tertiary children's hospital who presented with seizures. Febrile seizures, seizures associated with trauma, and charts of patients who did not present initially through our ED were excluded. RESULTS 328 charts were obtained through this search criteria. Head imaging was performed in 52 (16%) patients and consisted of 81% CT (n = 42) and 19% (n = 10) magnetic resonance imaging (MRI). Obtaining an MRI was associated with a 3.5 h longer ED visit (p = 0.07); obtaining a CT was associated with a 1.5 h longer ED visit (p = 0.005). An Electroencephalogram (EEG) was obtained for 67 (20%) visits and was associated with a 3.0 h longer ED length of stay (p < 0.001). Ten % of the CT scans showed new or progressive findings and 40% of the MRIs done provided useful information for management. Thirty-seven % of EEGs performed in new onset seizure patients revealed epileptiform findings and 5% of EEGs in established seizure patients provided meaningful findings important to management. CONCLUSION Obtaining neurodiagnostic studies significantly prolongs duration of stay in the ED. Electroencephalograms appear to have the greatest yield in new onset seizure patients and can help make a diagnosis of an epilepsy syndrome in children.
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Affiliation(s)
- Maria El-Hallal
- Division of Child Neurology, Department of Pediatrics, Cohen Children's Medical Center, 2001 Marcus Avenue Suite W290, Lake Success, NY 11042, USA
| | - Yash Shah
- Division of Child Neurology, Department of Pediatrics, Cohen Children's Medical Center, 2001 Marcus Avenue Suite W290, Lake Success, NY 11042, USA
| | - Manan Nath
- Division of Child Neurology, Department of Pediatrics, Cohen Children's Medical Center, 2001 Marcus Avenue Suite W290, Lake Success, NY 11042, USA
| | - Padmavati Eksambe
- Division of Child Neurology, Department of Pediatrics, Cohen Children's Medical Center, 2001 Marcus Avenue Suite W290, Lake Success, NY 11042, USA
| | - Liana Theroux
- Divison of Epilepsy, Department of Neurology, Northwell Health, 300 Community Dr, 9 Tower, Manhasset, NY 11030, USA
| | - Maire Amlicke
- Division of Emergency Medicine, Department of Pediatrics, Cohen Children's Medical Center, 269-01 76th Ave, Queens, NY 11040, USA
| | - Frances Steele
- Division of Emergency Medicine, Department of Pediatrics, Cohen Children's Medical Center, 269-01 76th Ave, Queens, NY 11040, USA
| | - William Krief
- Division of Emergency Medicine, Department of Pediatrics, Cohen Children's Medical Center, 269-01 76th Ave, Queens, NY 11040, USA
| | - Sanjeev Kothare
- Division of Child Neurology, Department of Pediatrics, Cohen Children's Medical Center, 2001 Marcus Avenue Suite W290, Lake Success, NY 11042, USA.
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McHugh JC, Daly N, Colfer A. Measuring the effects of pre-test probability on out-patient first EEG investigation in children - A guide to evidence-based EEG triage in a pandemic. Seizure 2021; 86:8-15. [PMID: 33515907 DOI: 10.1016/j.seizure.2021.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 12/18/2020] [Accepted: 01/06/2021] [Indexed: 10/22/2022] Open
Abstract
INTRODUCTION The yield of epileptiform EEG abnormalities is lower in unselected Paediatric populations than in prospective studies of incident seizures or prevalent epilepsy studies. At a time of limited capacity, it is important to match available EEG resources to children who are most likely to benefit. In this study we evaluated a prospective triage tool for estimating the likelihood of epileptiform abnormality in children's first out-patient EEG. METHODS We prospectively triaged 1865 out-patient referrals to the largest Paediatric EEG laboratory in Ireland. Based on a structured algorithm, we dichotomized first EEG referrals into priority and non-priority groups and assigned one of 5 sub-levels based on anticipated EEG yield. EEGs were reported by a single Consultant in Clinical Neurophysiology. RESULTS Triage designated 757 (41 %) EEG referrals as non-priority. Priority exceeded non-priority referrals for all age groups except children between 18 months and 3.5 years. EEGs showed a two-fold higher incidence of interictal epileptiform abnormalities for priority referrals (36 % vs 18 %, p < 0.001). Rates of interictal epileptiform abnormality correlated with the 5 sub-levels of triage (p < 0.01). Epileptiform yield was highest (39 %) for children over 5 years vs 17 % for those under 5 years (p < 0.00001); these rates increased to 49 % and 20 % respectively for priority referrals. CONCLUSION Structured pre-test triage of EEG referrals can identify children who have the greatest likelihood of epileptiform abnormality. In a mixed population of Paediatric referrals, the epileptiform yield of first time EEG is 49 % for children over 5 years who are referred with an appropriate EEG indication. This is subject to much variability with epileptiform yields as low as 13 % in younger children with non-priority referrals. The use of a structured triage algorithm can help to optimise utility of EEG in situations of limited laboratory capacity.
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Affiliation(s)
- John C McHugh
- Department of Clinical Neurophysiology, Children's Health Ireland (CHI)-Crumlin, Crumlin, Dublin 12, Ireland.
| | - Nicole Daly
- Department of Clinical Neurophysiology, Children's Health Ireland (CHI)-Crumlin, Crumlin, Dublin 12, Ireland
| | - Ailish Colfer
- Department of Clinical Neurophysiology, Children's Health Ireland (CHI)-Crumlin, Crumlin, Dublin 12, Ireland
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Dozières-Puyravel B, Dufour L, Hachon Le Camus C, Abi Warde MT, Cances C, Chemaly N, Gibaud M, Lefranc J, Milh M, Perivier M, Toulouse J, Trauffler A, Vermelle M, Maurey H, Auvin S. Real-life use of videos in pediatric epilepsy consultations. Epilepsy Behav 2021; 114:107636. [PMID: 33309428 DOI: 10.1016/j.yebeh.2020.107636] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 11/15/2020] [Accepted: 11/16/2020] [Indexed: 11/15/2022]
Abstract
Paroxysmal events are usually not directly observed by physicians. The diagnosis remains challenging and relies mostly on the description of witnesses. The effectiveness of videos for seizure diagnosis has been validated by several studies, but their place in clinical practice is not yet clear. The aim of our study was to evaluate the real-life use of videos by child neurologists. We conducted a three-month prospective study in which child neurologists were asked to use a short questionnaire to evaluate all videos that were watched in their clinical practice for an initial diagnosis or during follow-up. A click-off meeting during the French pediatric neurology meeting allowed to recruit participants. A total of 165 questionnaires were completed by 15 physicians over the study period. The physicians were child neurologists working in secondary and tertiary/university hospitals, consulting children with epilepsy. Based on the evaluation of child neurologists, 51% of the videos consisted of epileptic seizures; 40%, nonepileptic paroxysmal events; and 9%, psychogenic nonepileptic seizures. Most of the videos were made on parental initiative. The use of video has modified the first diagnosis hypothesis in 35% of cases. The physicians' feelings regarding the interest of the video used during the diagnostic phase were similar to those of the video used during follow-up. It appears that videos have become a part of the epilepsy clinic and are helpful for diagnosis as well as during follow-up. Unfortunately, one of the limitations of this study is the absence of private practitioner.
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Affiliation(s)
| | - Louis Dufour
- APHP, Pediatric Neurology Department, Rare Epilepsy Center, CHU Robert Debré, Paris, France
| | | | | | - Claude Cances
- Pediatric Neurology Department, CHU Toulouse, France
| | - Nicole Chemaly
- APHP, Pediatric Neurology Department, Rare Epilepsy Center, CHU Necker Enfants Malades Hospital, Paris, France
| | - Marc Gibaud
- Pediatric Neurology, CH Saint Nazaire, France
| | | | - Mathieu Milh
- Pediatric Neurology Department, Assistance Publique des Hôpitaux de Marseille, CHU La Timone , Marseille, France
| | | | - Joseph Toulouse
- Paediatric Clinical Epileptology, Sleep Disorders and Functional Neurology, Coordinator of the ERN on Rare and Complex Epilepsy EpiCARE, University Hospital of Lyon (HCL), France
| | - Adeline Trauffler
- Pediatric Neurology Department, CHU Jeanne de Flandres, Lille, France
| | - Marie Vermelle
- Pediatric Neurology Department, CHU Jeanne de Flandres, Lille, France; Pediatric Department, CH Dunkerque, France
| | - Hélène Maurey
- APHP, Pediatric Neurology Department, CHU Kremlin Bicêtre, Paris, France
| | - Stéphane Auvin
- APHP, Pediatric Neurology Department, Rare Epilepsy Center, CHU Robert Debré, Paris, France
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Hassankhani A, Stein JM, Haboosheh AG, Vossough A, Loevner LA, Nabavizadeh SA. Anatomical Variations, Mimics, and Pitfalls in Imaging of Patients with Epilepsy. J Neuroimaging 2020; 31:20-34. [PMID: 33314527 DOI: 10.1111/jon.12809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 10/22/2020] [Accepted: 10/26/2020] [Indexed: 11/27/2022] Open
Abstract
Epilepsy is among one of the most common neurologic disorders. The role of magnetic resonance imaging (MRI) in the diagnosis and management of patients with epilepsy is well established, and most patients with epilepsy are likely to undergo at least one or more MRI examinations in the course of their disease. Recent advances in high-field MRI have enabled high resolution in vivo visualization of small and intricate anatomic structures that are of great importance in the assessment of seizure disorders. Familiarity with normal anatomic variations is essential in the accurate diagnosis and image interpretation, as these variations may be mistaken for epileptogenic foci, leading to unnecessary follow-up imaging, or worse, unnecessary treatment. After a brief overview of normal imaging anatomy of the mesial temporal lobe, this article will review a few important common and uncommon anatomic variations, mimics, and pitfalls that may be encountered in the imaging evaluation of patients with epilepsy.
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Affiliation(s)
- Alvand Hassankhani
- Division of Neuroradiology, Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Joel M Stein
- Division of Neuroradiology, Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Amit G Haboosheh
- Department of Radiology, Hadassah Ein Karem Hospital, Jerusalem, Israel
| | - Arastoo Vossough
- Division of Neuroradiology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Laurie A Loevner
- Division of Neuroradiology, Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Seyed Ali Nabavizadeh
- Division of Neuroradiology, Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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Lewis AK, Harding KE, Taylor NF, O'Brien TJ, Carney PW. The feasibility of delivering first suspected seizure care using telehealth: A mixed methods controlled study. Epilepsy Res 2020; 169:106520. [PMID: 33302224 DOI: 10.1016/j.eplepsyres.2020.106520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 11/16/2020] [Accepted: 11/29/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE Prompt access to specialist assessment is critical after a first suspected seizure. We aimed to test the feasibility of providing this service via telehealth, compared with usual care (face-to-face appointment) in patients referred to a first seizure clinic. METHOD This feasibility study was a prospective mixed-methods non-randomised controlled design in a single centre. Patients referred to the first seizure clinic chose to receive their consultation by telehealth (intervention group) or face-to-face (usual care). Demand, practicality, acceptability and limited-efficacy testing were assessed using recruitment and routinely collected clinic data, participant surveys and a clinician focus group. RESULTS Telehealth in the first seizure clinic was feasible; however, internet connection, computer hardware and software, patient confidence and organisational support impacted on practicality. Of patients who were eligible for telehealth, 25 % chose to use telehealth for their appointment, with more women taking up the opportunity. Geography and age were not factors in likelihood of uptake. There was no significant between-group difference found in acceptability and limited efficacy measures conducted. CONCLUSION Telehealth is a responsive and convenient way to reach some patients who face barriers in access to specialist neurology assessment following a first suspected seizure.
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Affiliation(s)
- Annie K Lewis
- Allied Health Clinical Research Office, Eastern Health, 5 Arnold Street, Box Hill, VIC 3128, Australia; College of Science Health and Engineering, La Trobe University, Kingsbury Drive, Bundoora, VIC 3086, Australia.
| | - Katherine E Harding
- Allied Health Clinical Research Office, Eastern Health, 5 Arnold Street, Box Hill, VIC 3128, Australia; College of Science Health and Engineering, La Trobe University, Kingsbury Drive, Bundoora, VIC 3086, Australia.
| | - Nicholas F Taylor
- Allied Health Clinical Research Office, Eastern Health, 5 Arnold Street, Box Hill, VIC 3128, Australia; College of Science Health and Engineering, La Trobe University, Kingsbury Drive, Bundoora, VIC 3086, Australia.
| | - Terence J O'Brien
- Neurology, Alfred Hospital, 55 Commercial Rd, Melbourne, VIC 3004, Australia; Department of Neuroscience, The Central Clinical School, Monash University, 99 Commercial Road, Melbourne, Victoria, 3004, Australia.
| | - Patrick W Carney
- Department of Neurosciences, Eastern Health, 5 Arnold St, Box Hill, VIC 3128, Australia; The Florey Institute for Neuroscience and Mental Health, Melbourne Brain Centre, Burgundy Street, Heidelberg, VIC 3084, Australia; Neurosciences, Monash University, 21 Chancellors Walk, Clayton, VIC 3800, Australia.
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Mascola M, Karmali R, Mathews J, Obligado S. Hypertensive emergency and seizures in a 30-year-old man with anti-glomerular basement membrane disease. Clin Case Rep 2020; 8:3322-3327. [PMID: 33363926 PMCID: PMC7752327 DOI: 10.1002/ccr3.3361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 08/14/2020] [Accepted: 08/24/2020] [Indexed: 11/07/2022] Open
Abstract
Anti-glomerular basement membrane disease can rapidly lead to renal failure and blood pressure dysregulation. A rare complication is hypertensive encephalopathy in the form of seizures. Patients who have a negative initial seizure workup should have an MRI. These patients need tight blood pressure control and monitoring to prevent future seizures.
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Affiliation(s)
- Michael Mascola
- Touro College of Osteopathic MedicineMiddletownNYUSA
- Garnet Health Medical CenterMiddletownNYUSA
| | - Rehan Karmali
- Touro College of Osteopathic MedicineMiddletownNYUSA
- Garnet Health Medical CenterMiddletownNYUSA
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Parviainen L, Kälviäinen R, Jutila L. Impact of diagnostic delay on seizure outcome in newly diagnosed focal epilepsy. Epilepsia Open 2020; 5:605-610. [PMID: 33336131 PMCID: PMC7733655 DOI: 10.1002/epi4.12443] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 10/25/2020] [Accepted: 10/26/2020] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE In the current study, we aimed to assess the diagnostic delay and the impact of diagnostic delay on seizure outcome in a cohort of newly diagnosed patients with focal epilepsy. METHODS The study material was compiled from eight clinical antiseizure medication monotherapy trials conducted at Kuopio Epilepsy Center during 1995-2016. We analyzed the time from first seizure to diagnosis, the number of seizures before diagnosis, and the response to treatment at five years. RESULTS Of the 176 patients (age range 15-75 years) in the cohort, 135 (77%) had had more than two seizures before treatment. The majority of these (79 patients, 45%) had had three to ten seizures. Median number of all seizures before diagnosis was 5 (range 2-2000). Focal aware seizures and focal impaired awareness seizures were more frequent than focal to bilateral tonic-clonic seizures; median number 45 (range 2-2000), 11 (range 2-220), and 3 (range 2-30), respectively (P < .001). Median delay was 12 months (range 0-362). Diagnostic delay alone did not correlate with the treatment response at five years. However, an increasing number of seizures before diagnosis indicated a worse seizure outcome (P < .001). SIGNIFICANCE This study shows that patients with focal epilepsy experience significant delays in diagnosis even in developed countries, especially with seizure types other than tonic-clonic seizures. In these cases, a long delay in diagnosis alone might not affect the long-term outcome. However, when accompanied with recurrent seizures misinterpreted by the patient or healthcare providers, the effect of such delay on prognosis can be considerable.
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Affiliation(s)
- Laura Parviainen
- Epilepsy Center, Neuro CenterKuopio University Hospital, Member of the European Reference Network EpiCAREKuopioFinland
| | - Reetta Kälviäinen
- Epilepsy Center, Neuro CenterKuopio University Hospital, Member of the European Reference Network EpiCAREKuopioFinland
- Faculty of Health Sciences, School of Medicine, Institute of Clinical MedicineUniversity of Eastern FinlandKuopioFinland
| | - Leena Jutila
- Epilepsy Center, Neuro CenterKuopio University Hospital, Member of the European Reference Network EpiCAREKuopioFinland
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Kim S, DeGrauw T, Berg AT, Hass KB, Koh S. Evaluation of pediatric patients in new-onset seizure clinic (NOSc). Epilepsy Behav 2020; 112:107428. [PMID: 32920376 DOI: 10.1016/j.yebeh.2020.107428] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 08/06/2020] [Accepted: 08/12/2020] [Indexed: 12/01/2022]
Abstract
AIM We evaluated the clinical and demographic features of children presenting with unprovoked seizures at a regional new-onset seizure clinic (NOSc). METHODS We retrospectively reviewed charts of 492 consecutive patients evaluated in the NOSc at the Childrne's Healthcare of Atlanta RESULTS: Nonepileptic events (NEE) were diagnosed in 102 (24%) and epileptic seizures in the remaining 326 (76%). Patients with NEE were younger than patients with epileptic seizure (5.0 vs. 7.4 years). Except for headache which occurred more frequently in NEE (14% vs. 6%), frequencies of comorbidities were similar in groups with NEE and epileptic seizure. Electroencephalogram (EEG) was performed in 98%, and finding was abnormal in 51%. Brain magnetic resonance imaging (MRI) was performed in 55%, and finding was abnormal in 15%. An electroclinical epilepsy syndrome was diagnosed in 42%. Antiseizure medication was started in 25% with first seizure and in 77% with recurrent seizures. INTERPRETATION For children with newly-presenting seizures, a regional NOSc provided efficient, timely diagnosis and appropriate evaluations and treatment. Timely recognition of NEE resulted in fewer unnecessary evaluations and treatment for a quarter of referred patients whereas identification of the specific types of seizures and epilepsy allowed appropriate use, including deferral, of neuroimaging and guided treatment selection.
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Affiliation(s)
- Seunghyo Kim
- Department of Pediatrics, Jeju National University School of Medicine, Jeju-si, Jeju, South Korea; Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Ton DeGrauw
- Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Anne T Berg
- Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University, Chicago, IL, United States of America
| | - Kristen B Hass
- Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Sookyong Koh
- Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, United States of America.
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