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Weiss SA, Sperling MR, Engel J, Liu A, Fried I, Wu C, Doyle W, Mikell C, Mofakham S, Salamon N, Sim MS, Bragin A, Staba R. Simulated resections and RNS placement can optimize post-operative seizure outcomes when guided by fast ripple networks. medRxiv 2024:2024.03.26.24304802. [PMID: 38585730 PMCID: PMC10996761 DOI: 10.1101/2024.03.26.24304802] [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: 04/09/2024]
Abstract
Resecting cortical tissue generating high-frequency oscillations (HFOs) has been investigated as a more efficacious alternative to resecting the clinically defined seizure onset zone (SOZ). In this study, we asked if seizure freedom would be achieved using virtual resections of fast ripple (FR) networks. We compared these virtual resections to the individual patient's actual resection and clinical outcome. We conclude that the SOZ is the minimum territory of cortex that must be resected to achieve seizure freedom. By utilizing support vector machines (SVMs) with an accuracy of 0.78 for labeling seizure freedom using factors from FR networks we could predict whether resection of the SOZ corresponded with a seizure free outcome. Furthermore, this approach could identify regions that generate FR autonomously and at high rates outside the SOZ. In the patients who experienced seizures after resection of the SOZ, virtual resections that included the SOZ and other FR generating regions rendered the patient virtually seizure free. We examined responsive neurostimulator system (RNS) patients and virtually targeted the RNS stimulation contacts proximal to sites generating FR. We used the simulations to investigate if the likelihood of a RNS super responder (>90% seizure reduction) outcome would be increased.
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Affiliation(s)
- Shennan Aibel Weiss
- Dept. of Neurology, State University of New York Downstate, Brooklyn, New York 11203, USA
- Dept. of Physiology and Pharmacology, State University of New York Downstate, Brooklyn, New York 11203, USA
- Dept. of Neurology, New York City Health + Hospitals/Kings County, Brooklyn, NY, 11203 USA
| | - Michael R. Sperling
- Dept. of Neurology, Thomas Jefferson University, Philadelphia, PA 19107, USA
| | - Jerome Engel
- Dept. of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, California 90095, USA
- Dept. of Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles, California 90095, USA
- Dept. of Neurobiology, David Geffen School of Medicine at UCLA, Los Angeles, California 90095, USA
- Dept. of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at UCLA, Los Angeles, California 90095, USA
- Brain Research Institute, David Geffen School of Medicine at UCLA, Los Angeles, California 90095, USA
| | - Anli Liu
- Department of Neurology, NYU Grossman School of Medicine, New York, NY, 10016 USA
- Neuroscience Institute, NYU Langone Medical Center, New York, NY, 10016 USA
| | - Itzhak Fried
- Dept. of Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles, California 90095, USA
| | - Chengyuan Wu
- Dept. of Neuroradiology, Thomas Jefferson University, Philadelphia, PA, 19107, USA
- Dept. of Neurosurgery, Thomas Jefferson University, Philadelphia, PA 19107, USA
| | - Werner Doyle
- Department of Neurosurgery, NYU Grossman School of Medicine, New York, NY, 10016 USA
| | - Charles Mikell
- Department of Neurosurgery, State University of New York Stony Brook, Stony Brook, New York 11790, USA
| | - Sima Mofakham
- Department of Neurosurgery, State University of New York Stony Brook, Stony Brook, New York 11790, USA
| | - Noriko Salamon
- Dept. of Neuroradiology, David Geffen School of Medicine at UCLA, Los Angeles, California 90095, USA
| | - Myung Shin Sim
- Dept. of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California 90095, USA
| | - Anatol Bragin
- Dept. of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, California 90095, USA
| | - Richard Staba
- Dept. of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, California 90095, USA
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Javidi SS, He X, Ankeeta A, Zhang Q, Citro S, Sperling MR, Tracy JI. Edge-wise analysis reveals white matter connectivity associated with focal to bilateral tonic-clonic seizures. Epilepsia 2024. [PMID: 38517477 DOI: 10.1111/epi.17960] [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: 12/06/2023] [Revised: 03/09/2024] [Accepted: 03/11/2024] [Indexed: 03/23/2024]
Abstract
OBJECTIVE Focal to bilateral tonic-clonic seizures (FBTCS) represent a challenging subtype of focal temporal lobe epilepsy (TLE) in terms of both severity and treatment response. Most studies have focused on regional brain analysis that is agnostic to the distribution of white matter (WM) pathways associated with a node. We implemented a more selective, edge-wise approach that allowed for identification of the individual connections unique to FBTCS. METHODS T1-weighted and diffusion-weighted images were obtained from 22 patients with solely focal seizures (FS), 43 FBTCS patients, and 65 age/sex-matched healthy participants (HPs), yielding streamline (STR) connectome matrices. We used diffusion tensor-derived STRs in an edge-wise approach to determine specific structural connectivity changes associated with seizure generalization in FBTCS compared to matched FS and HPs. Graph theory metrics were computed on both node- and edge-based connectivity matrices. RESULTS Edge-wise analyses demonstrated that all significantly abnormal cross-hemispheric connections belonged to the FBTCS group. Abnormal connections associated with FBTCS were mostly housed in the contralateral hemisphere, with graph metric values generally decreased compared to HPs. In FBTCS, the contralateral amygdala showed selective decreases in the structural connection pathways to the contralateral frontal lobe. Abnormal connections in TLE involved the amygdala, with the ipsilateral side showing increases and the contralateral decreases. All the FS findings indicated higher graph metrics for connections involving the ipsilateral amygdala. Data also showed that some FBTCS connectivity effects are moderated by aging, recent seizure frequency, and longer illness duration. SIGNIFICANCE Data showed that not all STR pathways are equally affected by the seizure propagation of FBTCS. We demonstrated two key biases, one indicating a large role for the amygdala in the propagation of seizures, the other pointing to the prominent role of cross-hemispheric and contralateral hemisphere connections in FBTCS. We demonstrated topographic reorganization in FBTCS, pointing to the specific WM tracts involved.
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Affiliation(s)
- Sam S Javidi
- Department of Neurology, Farber Institute for Neuroscience, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Xiaosong He
- Department of Psychology, University of Science and Technology of China, Hefei, Anhui, China
| | - Ankeeta Ankeeta
- Department of Neurology, Farber Institute for Neuroscience, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Qirui Zhang
- Department of Neurology, Farber Institute for Neuroscience, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | | | - Michael R Sperling
- Department of Neurology, Farber Institute for Neuroscience, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Joseph I Tracy
- Department of Neurology, Farber Institute for Neuroscience, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Perucca E, French JA, Aljandeel G, Balestrini S, Braga P, Burneo JG, Felli AC, Cross JH, Galanopoulou AS, Jain S, Jiang Y, Kälviäinen R, Lim SH, Meador KJ, Mogal Z, Nabbout R, Sofia F, Somerville E, Sperling MR, Triki C, Trinka E, Walker MC, Wiebe S, Wilmshurst JM, Wirrell E, Yacubian EM, Kapur J. Which terms should be used to describe medications used in the treatment of seizure disorders? An ILAE position paper. Epilepsia 2024; 65:533-541. [PMID: 38279786 PMCID: PMC10948296 DOI: 10.1111/epi.17877] [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: 08/22/2022] [Revised: 12/16/2023] [Accepted: 01/02/2024] [Indexed: 01/28/2024]
Abstract
A variety of terms, such as "antiepileptic," "anticonvulsant," and "antiseizure" have been historically applied to medications for the treatment of seizure disorders. Terminology is important because using terms that do not accurately reflect the action of specific treatments may result in a misunderstanding of their effects and inappropriate use. The present International League Against Epilepsy (ILAE) position paper used a Delphi approach to develop recommendations on English-language terminology applicable to pharmacological agents currently approved for treating seizure disorders. There was consensus that these medications should be collectively named "antiseizure medications". This term accurately reflects their primarily symptomatic effect against seizures and reduces the possibility of health care practitioners, patients, or caregivers having undue expectations or an incorrect understanding of the real action of these medications. The term "antiseizure" to describe these agents does not exclude the possibility of beneficial effects on the course of the disease and comorbidities that result from the downstream effects of seizures, whenever these beneficial effects can be explained solely by the suppression of seizure activity. It is acknowledged that other treatments, mostly under development, can exert direct favorable actions on the underlying disease or its progression, by having "antiepileptogenic" or "disease-modifying" effects. A more-refined terminology to describe precisely these actions needs to be developed.
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Affiliation(s)
- Emilio Perucca
- Department of Medicine, University of Melbourne (Austin Health), Heidelberg, Victoria, Australia
- Department of Neuroscience, Monash University, Melbourne, Victoria, Australia
| | | | - Ghaieb Aljandeel
- Iraqi Council for Medical Specializations, Faculty of Epileptology, Medical City, Baghdad, Iraq
| | - Simona Balestrini
- Neuroscience Department, Meyer Children’s Hospital, member of EPICARE, Florence, Italy
- University of Florence, Florence, Italy
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, UK
| | - Patricia Braga
- Institute of Neurology, Facultad de Medicina, Universidad de la República, Uruguay
| | - Jorge G. Burneo
- Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
- Department of Epidemiology & Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
- Neuroepidemiology Unit, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | | | - J. Helen Cross
- Developmental Neurosciences Research and Teaching Department, UCL NIHR BRC Great Ormond Street Institute of Child Health, London, UK
- Department of Neurology, Great Ormond Street Hospital, London, UK
- Young Epilepsy, Lingfield, UK
| | - Aristea S. Galanopoulou
- Saul R. Korey Department of Neurology, Isabelle Rapin Division of Child Neurology, Dominick P Purpura Department of Neuroscience, Albert Einstein College of Medicine, New York, NY, USA
| | | | - Yuwu Jiang
- Department of Pediatrics and Pediatric Epilepsy Center, Peking University First Hospital, Beijing, Department of Pediatrics, Peking University First Hospital, Beijing, China
- Pediatric Epilepsy Center, Peking University First Hospital, Beijing, China
- Beijing Key Laboratory of Molecular Diagnosis and Study on Pediatric Genetic Diseases, Beijing, China
- Key Laboratory for Neuroscience, Ministry of Education/National Health and Family Planning Commission, Peking University, Beijing, China
- Center of Epilepsy, Beijing Institute for Brain Disorders, Beijing, China
| | - Reetta Kälviäinen
- Kuopio Epilepsy Center, Kuopio University Hospital, Member of ERN EpiCARE, Kuopio, Finland
- Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Shih Hui Lim
- National Neuroscience Institute, Singapore
- Duke-National University of Singapore Medical School, Singapore
| | - Kimford J. Meador
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Zarine Mogal
- National Epilepsy Center, Jinnah Postgraduate Medical Center, Karachi, Pakistan
| | - Rima Nabbout
- Reference Centre for Rare Epilepsies, Department of Pediatric Neurology, Necker–Enfants Malades Hospital, Paris, France; Assistance Publique – Hôpitaux de Paris, Paris, France; European Reference Network EpiCARE
- Institut Imagine - INSERM UMR 1163, Paris, France; Université Paris cité, Paris, France
| | | | - Ernest Somerville
- Prince of Wales Hospital, Sydney, Australia and University of New South Wales, Sydney, Australia
| | - Michael R. Sperling
- Department of Neurology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Chahnez Triki
- Child Neurology Department, Hedi Chaker University Hospital, LR19ES15, Sfax Medical School, University of Sfax, Sfax, Tunisia
| | - Eugen Trinka
- Department of Neurology, Neurocritical Care, and Neurorehabilitation, Christian Doppler University Hospital, Paracelsus Medical University, Centre for Cognitive Neuroscience, Member of EpiCARE, Salzburg, Austria
- Department of Public Health, Health Services Research and Health Technology Assessment, UMIT – University for Health Sciences, Medical Informatics and Technology, Hall in Tirol, Austria
| | - Matthew C. Walker
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, UK
| | - Samuel Wiebe
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Jo M. Wilmshurst
- Department of Pediatric Neurology, Red Cross War Memorial Children’s Hospital, Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Elaine Wirrell
- Divisions of Child and Adolescent Neurology and Epilepsy, Department of Neurology, Mayo Clinic, Rochester MN, USA
| | - Elza Márcia Yacubian
- Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Jaideep Kapur
- Department of Neurology, University of Virginia, Charlottesville, VA, USA
- UVA Brain Institute, University of Virginia, Charlottesville, VA, USA
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Rehman M, Higdon LM, Sperling MR. Long-Term Home EEG Recording: Wearable and Implantable Devices. J Clin Neurophysiol 2024; 41:200-206. [PMID: 38436387 DOI: 10.1097/wnp.0000000000001014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2024] Open
Abstract
SUMMARY Electroencephalography (EEG) monitoring has served as a cornerstone in the diagnostic and therapeutic evaluation of epilepsy since its development. This has been accomplished with short-term inpatient video-EEG hospitalization enabling observation of both the semiological and the electrographic features of seizures or with short-term home ambulatory EEG or video-EEG. The advantages of inpatient video-EEG monitoring are limited by high cost, inconvenience, and inability to monitor patients for long periods (weeks or months) as might be done in the outpatient setting. This limitation has impelled the development of wearable EEG devices, which aim to capture high-quality long-term EEG data in a user-friendly and unobtrusive manner. This review article aims to summarize three broad categories of wearable EEG devices, including scalp, subcutaneous, and intracranial EEG. In this review, we will discuss the features of each type of device and the implications for the management of epilepsy. This review does not aim to describe every wearable EEG device on the market but instead seeks to provide a broad overview of the various categories of device that are available, giving examples of each and those in development (with no intention to recommend or advocate for any particular product).
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Affiliation(s)
- Mahnoor Rehman
- Department of Neurology, Jefferson Comprehensive Epilepsy Center, Thomas Jefferson University, Philadelphia, Pennsylvania
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Hadady L, Sperling MR, Alcala-Zermeno JL, French JA, Dugan P, Jehi L, Fabó D, Klivényi P, Rubboli G, Beniczky S. Prediction tools and risk stratification in epilepsy surgery. Epilepsia 2024; 65:414-421. [PMID: 38060351 DOI: 10.1111/epi.17851] [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: 08/08/2023] [Revised: 12/03/2023] [Accepted: 12/05/2023] [Indexed: 12/17/2023]
Abstract
OBJECTIVE This study was undertaken to conduct external validation of previously published epilepsy surgery prediction tools using a large independent multicenter dataset and to assess whether these tools can stratify patients for being operated on and for becoming free of disabling seizures (International League Against Epilepsy stage 1 and 2). METHODS We analyzed a dataset of 1562 patients, not used for tool development. We applied two scales: Epilepsy Surgery Grading Scale (ESGS) and Seizure Freedom Score (SFS); and two versions of Epilepsy Surgery Nomogram (ESN): the original version and the modified version, which included electroencephalographic data. For the ESNs, we used calibration curves and concordance indexes. We stratified the patients into three tiers for assessing the chances of attaining freedom from disabling seizures after surgery: high (ESGS = 1, SFS = 3-4, ESNs > 70%), moderate (ESGS = 2, SFS = 2, ESNs = 40%-70%), and low (ESGS = 2, SFS = 0-1, ESNs < 40%). We compared the three tiers as stratified by these tools, concerning the proportion of patients who were operated on, and for the proportion of patients who became free of disabling seizures. RESULTS The concordance indexes for the various versions of the nomograms were between .56 and .69. Both scales (ESGS, SFS) and nomograms accurately stratified the patients for becoming free of disabling seizures, with significant differences among the three tiers (p < .05). In addition, ESGS and the modified ESN accurately stratified the patients for having been offered surgery, with significant difference among the three tiers (p < .05). SIGNIFICANCE ESGS and the modified ESN (at thresholds of 40% and 70%) stratify patients undergoing presurgical evaluation into three tiers, with high, moderate, and low chance for favorable outcome, with significant differences between the groups concerning having surgery and becoming free of disabling seizures. Stratifying patients for epilepsy surgery has the potential to help select the optimal candidates in underprivileged areas and better allocate resources in developed countries.
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Affiliation(s)
- Levente Hadady
- Department of Neurology, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
| | - Michael R Sperling
- Department of Neurology, Jefferson Comprehensive Epilepsy Center, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Juan Luis Alcala-Zermeno
- Department of Neurology, Jefferson Comprehensive Epilepsy Center, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Jacqueline A French
- Department of Neurology, New York University Grossman School of Medicine, New York, New York, USA
| | - Patricia Dugan
- Department of Neurology, New York University Grossman School of Medicine, New York, New York, USA
| | - Lara Jehi
- Epilepsy Center, Cleveland Clinic, Cleveland, Ohio, USA
- Center for Computational Life Sciences, Cleveland, Ohio, USA
| | - Dániel Fabó
- Department of Neurology, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
- Department of Neurology, National Institute of Clinical Neurosciences, Budapest, Hungary
| | - Péter Klivényi
- Department of Neurology, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
| | - Guido Rubboli
- Department of Neurology, Danish Epilepsy Center, Dianalund, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Sándor Beniczky
- Department of Neurology, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
- Department of Neurophysiology, Danish Epilepsy Center, Dianalund, Denmark
- Department of Clinical Medicine, Aarhus University and Department of Clinical Neurophysiology, Aarhus University Hospital, Aarhus, Denmark
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Weiss SA, Fried I, Engel J, Bragin A, Wang S, Sperling MR, Wong RK, Nir Y, Staba RJ. Pathological neurons generate ripples at the UP-DOWN transition disrupting information transfer. Epilepsia 2024; 65:362-377. [PMID: 38041560 PMCID: PMC10922301 DOI: 10.1111/epi.17845] [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: 08/03/2023] [Revised: 11/29/2023] [Accepted: 11/30/2023] [Indexed: 12/03/2023]
Abstract
OBJECTIVE To confirm and investigate why pathological high-frequency oscillations (pHFOs), including ripples (80-200 Hz) and fast ripples (200-600 Hz), are generated during the UP-DOWN transition of the slow wave and if information transmission mediated by ripple temporal coupling is disrupted in the seizure-onset zone (SOZ). METHODS We isolated 217 total units from 175.95 intracranial electroencephalography (iEEG) contact-hours of synchronized macro- and microelectrode recordings from 6 patients. Sleep slow oscillation (.1-2 Hz) epochs were identified in the iEEG recording. iEEG HFOs that occurred superimposed on the slow wave were transformed to phasors and adjusted by the phase of maximum firing in nearby units (i.e., maximum UP). We tested whether, in the SOZ, HFOs and associated action potentials (APs) occur more often at the UP-DOWN transition. We also examined ripple temporal correlations using cross-correlograms. RESULTS At the group level in the SOZ, HFO and HFO-associated AP probability was highest during the UP-DOWN transition of slow wave excitability (p < < .001). In the non-SOZ, HFO and HFO-associated AP was highest during the DOWN-UP transition (p < < .001). At the unit level in the SOZ, 15.6% and 20% of units exhibited more robust firing during ripples (Cohen's d = .11-.83) and fast ripples (d = .36-.90) at the UP-DOWN transition (p < .05 f.d.r. corrected), respectively. By comparison, also in the SOZ, 6.6% (d = .14-.30) and 8.5% (d = .33-.41) of units had significantly less firing during ripples and fast ripples at the UP-DOWN transition, respectively. Additional data shows that ripple and fast ripple temporal correlations, involving global slow waves, between the hippocampus, entorhinal cortex, and parahippocampal gyrus were reduced by >50% in the SOZ compared to the non-SOZ (N = 3). SIGNIFICANCE The UP-DOWN transition of slow wave excitability facilitates the activation of pathological neurons to generate pHFOs. Ripple temporal correlations across brain regions may be important in memory consolidation and are disrupted in the SOZ, perhaps by pHFO generation.
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Affiliation(s)
- Shennan A Weiss
- Dept. of Neurology, State University of New York Downstate, Brooklyn, New York, 11203 USA
- Dept. of Physiology and Pharmacology, State University of New York Downstate, Brooklyn, New York, 11203 USA
- Dept. of Neurology, New York City Health + Hospitals/Kings County, Brooklyn, NY, USA
| | - Itzhak Fried
- Dept. of Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles, California, 90095, USA
| | - Jerome Engel
- Dept. of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, California, 90095, USA
- Dept. of Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles, California, 90095, USA
- Dept. of Neurobiology, David Geffen School of Medicine at UCLA, Los Angeles, California, 90095, USA
- Dept. of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at UCLA, Los Angeles, California, 90095, USA
- Brain Research Institute, David Geffen School of Medicine at UCLA, Los Angeles, California, 90095, USA
| | - Anatol Bragin
- Dept. of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, California, 90095, USA
| | - Shuang Wang
- Depts of Neurology, Epilepsy Center, Second Affiliated Hospital of Medical College, Zhejiang University, Zhejiang, China
| | - Michael R. Sperling
- Depts. of Neurology and Neuroscience, Thomas Jefferson University, Philadelphia, Pennsylvania, 19107, USA
| | - Robert K.S. Wong
- Dept. of Physiology and Pharmacology, State University of New York Downstate, Brooklyn, New York, 11203 USA
| | - Yuval Nir
- Department of Physiology and Pharmacology, Sackler School of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
- Sagol School of Neuroscience, Tel Aviv University, Tel Aviv 6997801, Israel
- Department of Biomedical Engineering, Faculty of Engineering, Tel Aviv University, Tel Aviv 6997801, Israel
- The Sieratzki-Sagol Center for Sleep Medicine, Tel Aviv Sourasky Medical Center, Tel Aviv 6423906, Israel
| | - Richard J Staba
- Dept. of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, California, 90095, USA
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Ezzyat Y, Kragel JE, Solomon EA, Lega BC, Aronson JP, Jobst BC, Gross RE, Sperling MR, Worrell GA, Sheth SA, Wanda PA, Rizzuto DS, Kahana MJ. Functional and anatomical connectivity predict brain stimulation's mnemonic effects. Cereb Cortex 2024; 34:bhad427. [PMID: 38041253 PMCID: PMC10793570 DOI: 10.1093/cercor/bhad427] [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: 08/27/2023] [Revised: 10/05/2023] [Accepted: 10/06/2023] [Indexed: 12/03/2023] Open
Abstract
Closed-loop direct brain stimulation is a promising tool for modulating neural activity and behavior. However, it remains unclear how to optimally target stimulation to modulate brain activity in particular brain networks that underlie particular cognitive functions. Here, we test the hypothesis that stimulation's behavioral and physiological effects depend on the stimulation target's anatomical and functional network properties. We delivered closed-loop stimulation as 47 neurosurgical patients studied and recalled word lists. Multivariate classifiers, trained to predict momentary lapses in memory function, triggered the stimulation of the lateral temporal cortex (LTC) during the study phase of the task. We found that LTC stimulation specifically improved memory when delivered to targets near white matter pathways. Memory improvement was largest for targets near white matter that also showed high functional connectivity to the brain's memory network. These targets also reduced low-frequency activity in this network, an established marker of successful memory encoding. These data reveal how anatomical and functional networks mediate stimulation's behavioral and physiological effects, provide further evidence that closed-loop LTC stimulation can improve episodic memory, and suggest a method for optimizing neuromodulation through improved stimulation targeting.
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Affiliation(s)
- Youssef Ezzyat
- Dept. of Psychology, Wesleyan University, Middletown, CT 06459, USA
| | - James E Kragel
- Dept. of Neurology, University of Chicago, Chicago, IL 60637, USA
| | - Ethan A Solomon
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Bradley C Lega
- Dept. of Neurosurgery, University of Texas Southwestern, Dallas, TX 75390, USA
| | - Joshua P Aronson
- Dept. of Neurosurgery, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
| | - Barbara C Jobst
- Dept. of Neurology, Dartmouth-Hitchcock Medical Center, Lebanon, NH 03756, USA
| | - Robert E Gross
- Dept. of Neurosurgery, Emory University Hospital, Atlanta, GA 30322, USA
| | - Michael R Sperling
- Dept. of Neurology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA 19107, USA
| | | | - Sameer A Sheth
- Dept. of Neurosurgery, Baylor College of Medicine, Houston, TX 77030, USA
| | - Paul A Wanda
- Dept. of Psychology, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Daniel S Rizzuto
- Dept. of Psychology, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Michael J Kahana
- Dept. of Psychology, University of Pennsylvania, Philadelphia, PA 19104, USA
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Misra SN, Sperling MR, Rao VR, Peters JM, Penovich P, Wheless J, Hogan RE, Davis CS, Carrazana E, Rabinowicz AL. Analyses of patients who self-administered diazepam nasal spray for acute treatment of seizure clusters. Epilepsy Behav Rep 2024; 25:100644. [PMID: 38274142 PMCID: PMC10808926 DOI: 10.1016/j.ebr.2024.100644] [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: 10/18/2023] [Revised: 12/15/2023] [Accepted: 01/01/2024] [Indexed: 01/27/2024] Open
Abstract
For acute treatment of seizure clusters in patients with epilepsy, intranasal administration of acute seizure therapies has been shown to provide accessibility and ease of use to care partners as well as the potential for self-administration by patients. Diazepam nasal spray (Valtoco®) was approved by the US Food and Drug Administration for acute treatment of intermittent, stereotypic episodes of frequent seizure activity (ie, seizure clusters, acute repetitive seizures) in patients with epilepsy aged ≥6 years. Self-administration consistent with the prescribing information is feasible and was reported by a subgroup of patients (n = 27 of 163) in a long-term phase 3 safety study. Data regarding self-administration among these patients with seizure clusters are examined here to explore the safety profiles and measures of effectiveness, as well as the quality of life of those who self-treated. In addition, this focused look at patients who self-administered diazepam nasal spray may offer some insights into the characteristics of patients who may be appropriate for self-administration.
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Affiliation(s)
- Sunita N Misra
- Formerly of Neurelis, Inc., 3430 Carmel Mountain Rd, Ste 300, San Diego, CA 92121, USA
| | | | - Vikram R. Rao
- University of California, San Francisco, 400 Parnassus Ave Fl 8, San Francisco, CA 94143, USA
| | - Jurriaan M. Peters
- Boston Children’s Hospital, Harvard Medical School, 300 Longwood Ave, Boston, MA 20115, USA
| | | | - James Wheless
- Le Bonheur Children’s Hospital, University of Tennessee Health Science Center, 49 N Dunlap St, FOB Room 393, Memphis, TN 38105, USA
| | - R. Edward Hogan
- Washington University in St. Louis, 4921 Parkview Pl, St. Louis, MO 63110, USA
| | - Charles S. Davis
- CSD Biostatistics, Inc., 1005 W Soft Wind Pl, Oro Valley, AZ 85737, USA
| | - Enrique Carrazana
- John A. Burns School of Medicine, University of Hawaii, 651 Ilalo St., Honolulu, HI 96813, USA
- Neurelis, Inc., 3430 Carmel Mountain Rd, Ste 300, San Diego, CA, 92121, USA
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9
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Sperling MR, Wu C, Kang J, Makhalova J, Bartolomei F, Southwell D. The Temporal Lobe Club: Newer Approaches to Treat Temporal Lobe Epilepsy. Epilepsy Curr 2024; 24:10-15. [PMID: 38327532 PMCID: PMC10846515 DOI: 10.1177/15357597231213161] [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] [Indexed: 02/09/2024] Open
Abstract
This brief review summarizes presentations at the Temporal Lobe Club Special Interest Group session held in December 2022 at the American Epilepsy Society meeting. The session addressed newer methods to treat temporal epilepsy, including methods currently in clinical use and techniques under investigation. Brief summaries are provided for each of 4 lectures. Dr Chengyuan Wu discussed ablative techniques such as laser interstitial thermal ablation, radiofrequency ablation, focused ultrasound; Dr Joon Kang reviewed neuromodulation techniques including electrical stimulation and focused ultrasound; Dr Julia Makhalova discussed network effects of the aforementioned techniques; and Dr Derek Southwell reviewed inhibitory interneuron transplantation. These summaries are intended to provide a brief overview and references are provided for the reader to learn more about each topic.
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Affiliation(s)
| | - Chengyuan Wu
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Joon Kang
- Department of Neurology, Johns Hopkins University, Baltimore, MD, USA
| | - Julia Makhalova
- APHM, Timone Hospital, Epileptology and Cerebral Rhythmology, Marseille, France
- Aix Marseille Univ, INSERM, INS, Inst Neurosci Syst, Marseille, France
- APHM, Timone Hospital, CEMEREM, Marseille, France
| | - Fabrice Bartolomei
- APHM, Timone Hospital, Epileptology and Cerebral Rhythmology, Marseille, France
- Aix Marseille Univ, INSERM, INS, Inst Neurosci Syst, Marseille, France
| | - Derek Southwell
- Department of Neurosurgery, Duke University, Durham, NC, USA
- Department of Neurobiology, Duke University, Durham, NC, USA
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Youngerman BE, Banu MA, Khan F, McKhann GM, Schevon CA, Jagid JR, Cajigas I, Theodotou CB, Ko A, Buckley R, Ojemann JG, Miller JW, Laxton AW, Couture DE, Popli GS, Buch VP, Halpern CH, Le S, Sharan AD, Sperling MR, Mehta AD, Englot DJ, Neimat JS, Konrad PE, Sheth SA, Neal EG, Vale FL, Holloway KL, Air EL, Schwalb JM, D'Haese PF, Wu C. Long-term outcomes of mesial temporal laser interstitial thermal therapy for drug-resistant epilepsy and subsequent surgery for seizure recurrence: a multi-centre cohort study. J Neurol Neurosurg Psychiatry 2023; 94:879-886. [PMID: 37336643 PMCID: PMC10776034 DOI: 10.1136/jnnp-2022-330979] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 05/30/2023] [Indexed: 06/21/2023]
Abstract
BACKGROUND Magnetic resonance-guided laser interstitial thermal therapy (MRgLITT) is a minimally invasive alternative to surgical resection for drug-resistant mesial temporal lobe epilepsy (mTLE). Reported rates of seizure freedom are variable and long-term durability is largely unproven. Anterior temporal lobectomy (ATL) remains an option for patients with MRgLITT treatment failure. However, the safety and efficacy of this staged strategy is unknown. METHODS This multicentre, retrospective cohort study included 268 patients consecutively treated with mesial temporal MRgLITT at 11 centres between 2012 and 2018. Seizure outcomes and complications of MRgLITT and any subsequent surgery are reported. Predictive value of preoperative variables for seizure outcome was assessed. RESULTS Engel I seizure freedom was achieved in 55.8% (149/267) at 1 year, 52.5% (126/240) at 2 years and 49.3% (132/268) at the last follow-up ≥1 year (median 47 months). Engel I or II outcomes were achieved in 74.2% (198/267) at 1 year, 75.0% (180/240) at 2 years and 66.0% (177/268) at the last follow-up. Preoperative focal to bilateral tonic-clonic seizures were independently associated with seizure recurrence. Among patients with seizure recurrence, 14/21 (66.7%) became seizure-free after subsequent ATL and 5/10 (50%) after repeat MRgLITT at last follow-up≥1 year. CONCLUSIONS MRgLITT is a viable treatment with durable outcomes for patients with drug-resistant mTLE evaluated at a comprehensive epilepsy centre. Although seizure freedom rates were lower than reported with ATL, this series represents the early experience of each centre and a heterogeneous cohort. ATL remains a safe and effective treatment for well-selected patients who fail MRgLITT.
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Affiliation(s)
- Brett E Youngerman
- Department of Neurological Surgery, Columbia University, New York, New York, USA
| | - Matei A Banu
- Department of Neurological Surgery, Columbia University, New York, New York, USA
| | - Farhan Khan
- Department of Neurological Surgery, Columbia University, New York, New York, USA
| | - Guy M McKhann
- Department of Neurological Surgery, Columbia University, New York, New York, USA
| | | | - Jonathan R Jagid
- Department of Neurological Surgery, Jackson Memorial Hospital, University of Miami, Miami, Florida, USA
| | - Iahn Cajigas
- Department of Neurological Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Christian B Theodotou
- Department of Neurological Surgery, Jackson Memorial Hospital, University of Miami, Miami, Florida, USA
| | - Andrew Ko
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Robert Buckley
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Jeffrey G Ojemann
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - John W Miller
- Department of Neurology, University of Washington, Seattle, Washington, USA
| | - Adrian W Laxton
- Department of Neurological Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Daniel E Couture
- Department of Neurological Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Gautam S Popli
- Department of Neurology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Vivek P Buch
- Department of Neurological Surgery, Stanford Neuroscience Health Center, Stanford, California, USA
| | - Casey H Halpern
- Department of Neurological Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Scheherazade Le
- Department of Neurology, Stanford Comprehensive Epilepsy Center, Stanford, California, USA
| | - Ashwini D Sharan
- Department of Neurological Surgery, Vickie and Jack Farber Institute for Neuroscience, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Michael R Sperling
- Department of Neurology, Vickie and Jack Farber Institute for Neuroscience, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Ashesh D Mehta
- Department of Neurological Surgery, Zucker School of Medicine at Hofstra Northwell, Hempstead, New York, USA
| | - Dario J Englot
- Department of Neurological Surgery, Vanderbilt University, Nashville, Nashville, Tennessee, USA
| | - Joseph S Neimat
- Department of Neurological Surgery, University of Louisville, Louisville, Kentucky, USA
| | - Peter E Konrad
- Department of Neurological Surgery, Vanderbilt University, Nashville, Nashville, Tennessee, USA
| | - Sameer A Sheth
- Department of Neurological Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Elliot G Neal
- Department of Neurological Surgery, University of South Florida Health South Tampa Center, Tampa, Florida, USA
| | - Fernando L Vale
- Department of Neurological Surgery, Medical College of Georgia-Augusta University, Augusta, Georgia, USA
| | - Kathryn L Holloway
- Department of Neurological Surgery, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Ellen L Air
- Department of Neurological Surgery, Henry Ford Health, Detroit, Michigan, USA
| | - Jason M Schwalb
- Department of Neurological Surgery, Henry Ford Health, Detroit, Michigan, USA
| | - Pierre-François D'Haese
- Rockefeller Neuroscience Institute, West Virginia University, Morgantown, West Virginia, USA
| | - Chengyuan Wu
- Department of Neurological Surgery, Vickie and Jack Farber Institute for Neuroscience, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Weiss SA, Fried I, Engel J, Sperling MR, Wong RKS, Nir Y, Staba RJ. Fast ripples reflect increased excitability that primes epileptiform spikes. Brain Commun 2023; 5:fcad242. [PMID: 37869578 PMCID: PMC10587774 DOI: 10.1093/braincomms/fcad242] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 07/08/2023] [Accepted: 09/07/2023] [Indexed: 10/24/2023] Open
Abstract
The neuronal circuit disturbances that drive inter-ictal and ictal epileptiform discharges remain elusive. Using a combination of extra-operative macro-electrode and micro-electrode inter-ictal recordings in six pre-surgical patients during non-rapid eye movement sleep, we found that, exclusively in the seizure onset zone, fast ripples (200-600 Hz), but not ripples (80-200 Hz), frequently occur <300 ms before an inter-ictal intra-cranial EEG spike with a probability exceeding chance (bootstrapping, P < 1e-5). Such fast ripple events are associated with higher spectral power (P < 1e-10) and correlated with more vigorous neuronal firing than solitary fast ripple (generalized linear mixed-effects model, P < 1e-9). During the intra-cranial EEG spike that follows a fast ripple, action potential firing is lower than during an intra-cranial EEG spike alone (generalized linear mixed-effects model, P < 0.05), reflecting an inhibitory restraint of intra-cranial EEG spike initiation. In contrast, ripples do not appear to prime epileptiform spikes. We next investigated the clinical significance of pre-spike fast ripple in a separate cohort of 23 patients implanted with stereo EEG electrodes, who underwent resections. In non-rapid eye movement sleep recordings, sites containing a high proportion of fast ripple preceding intra-cranial EEG spikes correlate with brain areas where seizures begin more than solitary fast ripple (P < 1e-5). Despite this correlation, removal of these sites does not guarantee seizure freedom. These results are consistent with the hypothesis that fast ripple preceding EEG spikes reflect an increase in local excitability that primes EEG spike discharges preferentially in the seizure onset zone and that epileptogenic brain regions are necessary, but not sufficient, for initiating inter-ictal epileptiform discharges.
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Affiliation(s)
- Shennan A Weiss
- Department of Neurology, State University of New York Downstate, Brooklyn, NY 11203, USA
- Department of Physiology and Pharmacology, State University of New York Downstate, Brooklyn, NY 11203, USA
- Department of Neurology, New York City Health + Hospitals/Kings County, Brooklyn, NY 11203, USA
| | - Itzhak Fried
- Department of Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
| | - Jerome Engel
- Department of Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
- Department of Neurobiology, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
- Brain Research Institute, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
| | - Michael R Sperling
- Departments of Neurology and Neuroscience, Thomas Jefferson University, Philadelphia, PA 19107, USA
| | - Robert K S Wong
- Department of Physiology and Pharmacology, State University of New York Downstate, Brooklyn, NY 11203, USA
| | - Yuval Nir
- Department of Physiology and Pharmacology, Sackler School of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
- Sagol School of Neuroscience, Tel Aviv University, Tel Aviv 6997801, Israel
- Department of Biomedical Engineering, Faculty of Engineering, Tel Aviv University, Tel Aviv 6997801, Israel
- The Sieratzki-Sagol Center for Sleep Medicine, Tel Aviv Sourasky Medical Center, Tel Aviv 6423906, Israel
| | - Richard J Staba
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
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Stevelink R, Campbell C, Chen S, Abou-Khalil B, Adesoji OM, Afawi Z, Amadori E, Anderson A, Anderson J, Andrade DM, Annesi G, Auce P, Avbersek A, Bahlo M, Baker MD, Balagura G, Balestrini S, Barba C, Barboza K, Bartolomei F, Bast T, Baum L, Baumgartner T, Baykan B, Bebek N, Becker AJ, Becker F, Bennett CA, Berghuis B, Berkovic SF, Beydoun A, Bianchini C, Bisulli F, Blatt I, Bobbili DR, Borggraefe I, Bosselmann C, Braatz V, Bradfield JP, Brockmann K, Brody LC, Buono RJ, Busch RM, Caglayan H, Campbell E, Canafoglia L, Canavati C, Cascino GD, Castellotti B, Catarino CB, Cavalleri GL, Cerrato F, Chassoux F, Cherny SS, Cheung CL, Chinthapalli K, Chou IJ, Chung SK, Churchhouse C, Clark PO, Cole AJ, Compston A, Coppola A, Cosico M, Cossette P, Craig JJ, Cusick C, Daly MJ, Davis LK, de Haan GJ, Delanty N, Depondt C, Derambure P, Devinsky O, Di Vito L, Dlugos DJ, Doccini V, Doherty CP, El-Naggar H, Elger CE, Ellis CA, Eriksson JG, Faucon A, Feng YCA, Ferguson L, Ferraro TN, Ferri L, Feucht M, Fitzgerald M, Fonferko-Shadrach B, Fortunato F, Franceschetti S, Franke A, French JA, Freri E, Gagliardi M, Gambardella A, Geller EB, Giangregorio T, Gjerstad L, Glauser T, Goldberg E, Goldman A, Granata T, Greenberg DA, Guerrini R, Gupta N, Haas KF, Hakonarson H, Hallmann K, Hassanin E, Hegde M, Heinzen EL, Helbig I, Hengsbach C, Heyne HO, Hirose S, Hirsch E, Hjalgrim H, Howrigan DP, Hucks D, Hung PC, Iacomino M, Imbach LL, Inoue Y, Ishii A, Jamnadas-Khoda J, Jehi L, Johnson MR, Kälviäinen R, Kamatani Y, Kanaan M, Kanai M, Kantanen AM, Kara B, Kariuki SM, Kasperavičiūte D, Kasteleijn-Nolst Trenite D, Kato M, Kegele J, Kesim Y, Khoueiry-Zgheib N, King C, Kirsch HE, Klein KM, Kluger G, Knake S, Knowlton RC, Koeleman BPC, Korczyn AD, Koupparis A, Kousiappa I, Krause R, Krenn M, Krestel H, Krey I, Kunz WS, Kurki MI, Kurlemann G, Kuzniecky R, Kwan P, Labate A, Lacey A, Lal D, Landoulsi Z, Lau YL, Lauxmann S, Leech SL, Lehesjoki AE, Lemke JR, Lerche H, Lesca G, Leu C, Lewin N, Lewis-Smith D, Li GHY, Li QS, Licchetta L, Lin KL, Lindhout D, Linnankivi T, Lopes-Cendes I, Lowenstein DH, Lui CHT, Madia F, Magnusson S, Marson AG, May P, McGraw CM, Mei D, Mills JL, Minardi R, Mirza N, Møller RS, Molloy AM, Montomoli M, Mostacci B, Muccioli L, Muhle H, Müller-Schlüter K, Najm IM, Nasreddine W, Neale BM, Neubauer B, Newton CRJC, Nöthen MM, Nothnagel M, Nürnberg P, O’Brien TJ, Okada Y, Ólafsson E, Oliver KL, Özkara C, Palotie A, Pangilinan F, Papacostas SS, Parrini E, Pato CN, Pato MT, Pendziwiat M, Petrovski S, Pickrell WO, Pinsky R, Pippucci T, Poduri A, Pondrelli F, Powell RHW, Privitera M, Rademacher A, Radtke R, Ragona F, Rau S, Rees MI, Regan BM, Reif PS, Rhelms S, Riva A, Rosenow F, Ryvlin P, Saarela A, Sadleir LG, Sander JW, Sander T, Scala M, Scattergood T, Schachter SC, Schankin CJ, Scheffer IE, Schmitz B, Schoch S, Schubert-Bast S, Schulze-Bonhage A, Scudieri P, Sham P, Sheidley BR, Shih JJ, Sills GJ, Sisodiya SM, Smith MC, Smith PE, Sonsma ACM, Speed D, Sperling MR, Stefansson H, Stefansson K, Steinhoff BJ, Stephani U, Stewart WC, Stipa C, Striano P, Stroink H, Strzelczyk A, Surges R, Suzuki T, Tan KM, Taneja RS, Tanteles GA, Taubøll E, Thio LL, Thomas GN, Thomas RH, Timonen O, Tinuper P, Todaro M, Topaloğlu P, Tozzi R, Tsai MH, Tumiene B, Turkdogan D, Unnsteinsdóttir U, Utkus A, Vaidiswaran P, Valton L, van Baalen A, Vetro A, Vining EPG, Visscher F, von Brauchitsch S, von Wrede R, Wagner RG, Weber YG, Weckhuysen S, Weisenberg J, Weller M, Widdess-Walsh P, Wolff M, Wolking S, Wu D, Yamakawa K, Yang W, Yapıcı Z, Yücesan E, Zagaglia S, Zahnert F, Zara F, Zhou W, Zimprich F, Zsurka G, Zulfiqar Ali Q. GWAS meta-analysis of over 29,000 people with epilepsy identifies 26 risk loci and subtype-specific genetic architecture. Nat Genet 2023; 55:1471-1482. [PMID: 37653029 PMCID: PMC10484785 DOI: 10.1038/s41588-023-01485-w] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 07/21/2023] [Indexed: 09/02/2023]
Abstract
Epilepsy is a highly heritable disorder affecting over 50 million people worldwide, of which about one-third are resistant to current treatments. Here we report a multi-ancestry genome-wide association study including 29,944 cases, stratified into three broad categories and seven subtypes of epilepsy, and 52,538 controls. We identify 26 genome-wide significant loci, 19 of which are specific to genetic generalized epilepsy (GGE). We implicate 29 likely causal genes underlying these 26 loci. SNP-based heritability analyses show that common variants explain between 39.6% and 90% of genetic risk for GGE and its subtypes. Subtype analysis revealed markedly different genetic architectures between focal and generalized epilepsies. Gene-set analyses of GGE signals implicate synaptic processes in both excitatory and inhibitory neurons in the brain. Prioritized candidate genes overlap with monogenic epilepsy genes and with targets of current antiseizure medications. Finally, we leverage our results to identify alternate drugs with predicted efficacy if repurposed for epilepsy treatment.
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Ezzyat Y, Kragel JE, Solomon EA, Lega BC, Aronson JP, Jobst BC, Gross RE, Sperling MR, Worrell GA, Sheth SA, Wanda PA, Rizzuto DS, Kahana MJ. Functional and anatomical connectivity predict brain stimulation's mnemonic effects. bioRxiv 2023:2023.07.27.550851. [PMID: 37609181 PMCID: PMC10441352 DOI: 10.1101/2023.07.27.550851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/24/2023]
Abstract
Closed-loop direct brain stimulation is a promising tool for modulating neural activity and behavior. However, it remains unclear how to optimally target stimulation to modulate brain activity in particular brain networks that underlie particular cognitive functions. Here, we test the hypothesis that stimulation's behavioral and physiological effects depend on the stimulation target's anatomical and functional network properties. We delivered closed-loop stimulation as 47 neurosurgical patients studied and recalled word lists. Multivariate classifiers, trained to predict momentary lapses in memory function, triggered stimulation of the lateral temporal cortex (LTC) during the study phase of the task. We found that LTC stimulation specifically improved memory when delivered to targets near white matter pathways. Memory improvement was largest for targets near white matter that also showed high functional connectivity to the brain's memory network. These targets also reduced low-frequency activity in this network, an established marker of successful memory encoding. These data reveal how anatomical and functional networks mediate stimulation's behavioral and physiological effects, provide further evidence that closed-loop LTC stimulation can improve episodic memory, and suggest a method for optimizing neuromodulation through improved stimulation targeting.
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Affiliation(s)
- Youssef Ezzyat
- Dept. of Psychology, Wesleyan University, Middletown CT 06459
| | | | - Ethan A. Solomon
- Perelman School of Medicine, University of Pennsylvania, Philadelphia PA 19104
| | - Bradley C. Lega
- Dept. of Neurosurgery, University of Texas Southwestern, Dallas TX 75390
| | - Joshua P. Aronson
- Dept. of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon NH 03756
| | - Barbara C. Jobst
- Dept. of Neurology, Dartmouth-Hitchcock Medical Center, Lebanon NH 03756
| | - Robert E. Gross
- Dept. of Neurosurgery, Emory University Hospital, Atlanta GA 30322
| | - Michael R. Sperling
- Dept. of Neurology, Thomas Jefferson University Hospital, Philadelphia PA 19107
| | | | - Sameer A. Sheth
- Dept. of Neurosurgery, Columbia University Medical Center, New York, NY 10032
| | - Paul A. Wanda
- Dept. of Psychology, University of Pennsylvania, Philadelphia PA 19104
| | - Daniel S. Rizzuto
- Dept. of Psychology, University of Pennsylvania, Philadelphia PA 19104
| | - Michael J. Kahana
- Dept. of Psychology, University of Pennsylvania, Philadelphia PA 19104
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Weiss SA, Fried I, Engel J, Bragin A, Wang S, Sperling MR, Wong RK, Nir Y, Staba RJ. Pathological neurons generate ripples at the UP-DOWN transition disrupting information transfer. medRxiv 2023:2023.08.01.23293365. [PMID: 37609251 PMCID: PMC10441494 DOI: 10.1101/2023.08.01.23293365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/24/2023]
Abstract
Objective To confirm and investigate why pathological HFOs (pHFOs), including Ripples [80-200 Hz] and fast ripples [200-600 Hz], are generated during the UP-DOWN transition of the slow wave and if pHFOs interfere with information transmission. Methods We isolated 217 total units from 175.95 iEEG contact-hours of synchronized macro- and microelectrode recordings from 6 patients. Sleep slow oscillation (0.1-2 Hz) epochs were identified in the iEEG recording. iEEG HFOs that occurred superimposed on the slow wave were transformed to phasors and adjusted by the phase of maximum firing in nearby units (i.e., maximum UP). We tested whether, in the seizure onset zone (SOZ), HFOs and associated action potentials (AP) occur more often at the UP-DOWN transition. We also examined ripple temporal correlations using cross correlograms. Results At the group level in the SOZ, HFO and HFO-associated AP probability was highest during the UP-DOWN transition of slow wave excitability (p<<0.001). In the non-SOZ, HFO and HFO-associated AP was highest during the DOWN-UP transition (p<<0.001). At the unit level in the SOZ, 15.6% and 20% of units exhibited more robust firing during ripples (Cohen's d=0.11-0.83) and fast ripples (d=0.36-0.90) at the UP-DOWN transition (p<0.05 f.d.r corrected), respectively. By comparison, also in the SOZ, 6.6% (d=0.14-0.30) and 8.5% (d=0.33-0.41) of units had significantly less firing during ripples and fast ripples at the UP-DOWN transition, respectively. Additional data shows ripple temporal correlations, involving global slow waves, between the hippocampus, entorhinal cortex, and parahippocampal gyrus were reduced by ~50-80% in the SOZ compared to the non-SOZ (N=3). Significance The UP-DOWN transition of slow wave excitability facilitates the activation of pathological neurons to generate pHFOs. The pathological neurons and pHFOs disrupt ripple temporal correlations across brain regions that transfer information and may be important in memory consolidation.
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Affiliation(s)
- Shennan A Weiss
- Dept. of Neurology
- Dept. of Physiology and Pharmacology, State University of New York Downstate, Brooklyn, New York, 11203 USA
- Dept. of Neurology, New York City Health + Hospitals/Kings County, Brooklyn, NY, USA
| | | | - Jerome Engel
- Dept. of Neurology
- Dept. of Neurosurgery
- Dept. of Neurobiology
- Dept. of Psychiatry and Biobehavioral Sciences
- Brain Research Institute, David Geffen School of Medicine at UCLA, Los Angeles, California, 90095, USA
| | | | - Shuang Wang
- Depts of Neurology, Epilepsy Center, Second Affiliated Hospital of Medical College, Zhejiang University, Zhejiang, China
| | - Michael R. Sperling
- Depts. of Neurology and Neuroscience, Thomas Jefferson University, Philadelphia, Pennsylvania, 19107, USA
| | - Robert K.S. Wong
- Dept. of Physiology and Pharmacology, State University of New York Downstate, Brooklyn, New York, 11203 USA
| | - Yuval Nir
- Department of Physiology and Pharmacology, Sackler School of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
- Sagol School of Neuroscience, Tel Aviv University, Tel Aviv 6997801, Israel
- Department of Biomedical Engineering, Faculty of Engineering, Tel Aviv University, Tel Aviv 6997801, Israel
- The Sieratzki-Sagol Center for Sleep Medicine, Tel Aviv Sourasky Medical Center, Tel Aviv 6423906, Israel
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Wilmshurst JM, Sperling MR. Equity in access to antiseizure medications: Who has the right to decide and what are the consequences of crisis decisions? Epilepsia 2023; 64:2011-2013. [PMID: 37326490 DOI: 10.1111/epi.17685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 06/14/2023] [Indexed: 06/17/2023]
Affiliation(s)
- Jo M Wilmshurst
- Department of Paediatric Neurology, Red Cross War Memorial Children's Hospital, Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Michael R Sperling
- Department of Neurology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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16
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Sperling MR. An interview with Riccardo De Feo, 2023 Epilepsia Prize winner for Basic Science Research. Epilepsia 2023; 64:2214-2215. [PMID: 37195247 DOI: 10.1111/epi.17652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 05/15/2023] [Indexed: 05/18/2023]
Affiliation(s)
- Michael R Sperling
- Department of Neurology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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17
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Sperling MR. An interview with Brad Kamitaki, 2023 Epilepsia Prize Winner for Clinical Research. Epilepsia 2023; 64:2212-2213. [PMID: 37195246 DOI: 10.1111/epi.17653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 05/12/2023] [Indexed: 05/18/2023]
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Rosenfeld WE, Ferrari L, Kerr WT, Sperling MR. Sudden unexpected death in epilepsy during cenobamate clinical development. Epilepsia 2023; 64:2108-2115. [PMID: 37219391 DOI: 10.1111/epi.17662] [Citation(s) in RCA: 3] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 05/18/2023] [Accepted: 05/22/2023] [Indexed: 05/24/2023]
Abstract
OBJECTIVE We assessed mortality, sudden unexpected death in epilepsy (SUDEP), and standardized mortality ratio (SMR) among adults treated with cenobamate during the cenobamate clinical development program. METHODS We retrospectively analyzed deaths among all adults with uncontrolled focal (focal to bilateral tonic-clonic [FBTC], focal impaired awareness, focal aware) or primary generalized tonic-clonic (PGTC) seizures who received ≥1 dose of adjunctive cenobamate in completed and ongoing phase 2 and 3 clinical studies. In patients with focal seizures from completed studies, median baseline seizure frequencies ranged from 2.8 to 11 seizures per 28 days and median epilepsy duration ranged from 20 to 24 years. Total person-years included all days that a patient received cenobamate during completed studies or up to June 1, 2022, for ongoing studies. All deaths were evaluated by two epileptologists. All-cause mortality and SUDEP rates were expressed per 1000 person-years. RESULTS A total of 2132 patients (n = 2018 focal epilepsy; n = 114 idiopathic generalized epilepsy) were exposed to cenobamate for 5693 person-years. Approximately 60% of patients with focal seizures and all patients in the PGTC study had tonic-clonic seizures. A total of 23 deaths occurred (all in patients with focal epilepsy), for an all-cause mortality rate of 4.0 per 1000 person-years. Five cases of definite or probable SUDEP were identified, for a rate of .88 per 1000 person-years. Of the 23 overall deaths, 22 patients (96%) had FBTC seizures, and all 5 of the SUDEP patients had a history of FBTC seizures. The duration of exposure to cenobamate for patients with SUDEP ranged from 130 to 620 days. The SMR among cenobamate-treated patients in completed studies (5515 person-years of follow-up) was 1.32 (95% confidence interval [CI] .84-2.0), which was not significantly different from the general population. SIGNIFICANCE These data suggest that effective long-term medical treatment with cenobamate may reduce excess mortality associated with epilepsy.
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Affiliation(s)
- William E Rosenfeld
- Comprehensive Epilepsy Care Center for Children and Adults, St. Louis, Missouri, USA
| | | | - Wesley T Kerr
- Department of Neurology, University of Michigan, Ann Arbor, Michigan, USA
| | - Michael R Sperling
- Department of Neurology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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19
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Klein P, Krauss GL, Steinhoff BJ, Devinsky O, Sperling MR. Failure to use new breakthrough treatments for epilepsy. Epilepsia 2023; 64:1458-1465. [PMID: 36855241 DOI: 10.1111/epi.17564] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [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: 12/08/2022] [Revised: 01/29/2023] [Accepted: 02/27/2023] [Indexed: 03/02/2023]
Abstract
Despite the approval of ~20 additional antiseizure medications (ASMs) since the 1980s, one-third of epilepsy patients experience seizures despite therapy. Drug-resistant epilepsy (DRE) is associated with cognitive and psychiatric comorbidities, socioeconomic impairment, injuries, and a 9.3-13.4 times higher mortality rate than in seizure-free patients. Improved seizure control can reduce morbidity and mortality. Two new ASMs were launched in the United States in 2020: cenobamate for focal epilepsy in adults and fenfluramine for Dravet syndrome (DS). They offer markedly improved efficacy. Cenobamate achieved 21% seizure freedom with the highest dose and decreased tonic-clonic seizures by 93% during maintenance treatment in a randomized clinical trial (RCT). In long-term, open-label studies, 10%-36% of patients were seizure-free for a median duration of ~30-45 months. Fenfluramine treatment in DS reduced convulsive seizure frequency by 56% over placebo at the highest dose, with 8% of patients free of convulsive seizures, and 25% with only one convulsive seizure over 14 weeks. These results were sustained for up to 3 years in open-label extension studies. Mortality was reduced 5-fold. These results are superior to all other approved ASMs, placing these two drugs among the most effective antiseizure therapies. The adverse event profiles resemble those of other ASMs. Despite greater efficacy and similar toxicity, these medications are infrequently used. Two years after US market entry, < 5% of either adults with focal DRE or patients with DS were treated with either cenobamate or fenfluramine. We believe this is a failure of our medical system, resulting from limited knowledge about these drugs stemming partly from the separation of academia from industry; restrictions to access created by health care payors, hospitals, and regulatory agencies; and insufficient post-launch information about the efficacy and safety of these ASMs.
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Affiliation(s)
- Pavel Klein
- Mid-Atlantic Epilepsy and Sleep Center, Bethesda, Maryland, USA
| | - Gregory L Krauss
- Johns Hopkins University School of Medicine, Department of Neurology, Baltimore, Maryland, USA
| | - Bernhard J Steinhoff
- Epilepsiezentrum Kork, Kehl-Kork, Germany and Medical Faculty, Albert-Ludwigs University, Freiburg, Germany
| | - Orrin Devinsky
- NYU Langone School of Medicine, Department of Neurology, New York, New York, USA
| | - Michael R Sperling
- Thomas Jefferson University, Department of Neurology, Philadelphia, Pennsylvania, USA
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20
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Rubinstein DY, Weidemann CT, Sperling MR, Kahana MJ. Direct brain recordings suggest a causal subsequent-memory effect. Cereb Cortex 2023; 33:6891-6901. [PMID: 36702495 PMCID: PMC10233277 DOI: 10.1093/cercor/bhad008] [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: 10/14/2022] [Revised: 01/04/2023] [Accepted: 01/05/2023] [Indexed: 01/28/2023] Open
Abstract
Endogenous variation in brain state and stimulus-specific evoked activity can both contribute to successful encoding. Previous studies, however, have not clearly distinguished among these components. We address this question by analysing intracranial EEG recorded from epilepsy patients as they studied and subsequently recalled lists of words. We first trained classifiers to predict recall of either single items or entire lists and found that both classifiers exhibited similar performance. We found that list-level classifier output-a biomarker of successful encoding-tracked item presentation and recall events, despite having no information about the trial structure. Across widespread brain regions, decreased low- and increased high-frequency activity (HFA) marked successful encoding of both items and lists. We found regional differences in the hippocampus and prefrontal cortex, where in the hippocampus HFA correlated more strongly with item recall, whereas, in the prefrontal cortex, HFA correlated more strongly with list performance. Despite subtle differences in item- and list-level features, the similarity in overall classification performance, spectral signatures of successful recall and fluctuations of spectral activity across the encoding period argue for a shared endogenous process that causally impacts the brain's ability to learn new information.
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Affiliation(s)
- Daniel Y Rubinstein
- Department of Neurology, Thomas Jefferson University, Philadelphia, PA 19107, USA
| | - Christoph T Weidemann
- Department of Psychology, Swansea University, Swansea SA2 8PP, UK
- Department of Bioengineering, Columbia University, New York, NY 10027, USA
| | - Michael R Sperling
- Department of Neurology, Thomas Jefferson University, Philadelphia, PA 19107, USA
| | - Michael J Kahana
- Department of Psychology, University of Pennsylvania, Philadelphia, PA 19104, USA
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21
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Herweg NA, Kunz L, Schonhaut D, Brandt A, Wanda PA, Sharan AD, Sperling MR, Schulze-Bonhage A, Kahana MJ. A Learned Map for Places and Concepts in the Human Medial Temporal Lobe. J Neurosci 2023; 43:3538-3547. [PMID: 37001991 PMCID: PMC10184731 DOI: 10.1523/jneurosci.0181-22.2023] [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: 01/24/2022] [Revised: 03/10/2023] [Accepted: 03/15/2023] [Indexed: 04/03/2023] Open
Abstract
Distinct lines of research in both humans and animals point to a specific role of the hippocampus in both spatial and episodic memory function. The discovery of concept cells in the hippocampus and surrounding medial temporal lobe (MTL) regions suggests that the MTL maps physical and semantic spaces with a similar neural architecture. Here, we studied the emergence of such maps using MTL microwire recordings from 20 patients (9 female, 11 male) navigating a virtual environment featuring salient landmarks with established semantic meaning. We present several key findings. The array of local field potentials in the MTL contains sufficient information for above-chance decoding of subjects' instantaneous location in the environment. Closer examination revealed that as subjects gain experience with the environment the field potentials come to represent both the subjects' locations in virtual space and in high-dimensional semantic space. Similarly, we observe a learning effect on temporal sequence coding. Over time, field potentials come to represent future locations, even after controlling for spatial proximity. This predictive coding of future states, more so than the strength of spatial representations per se, is linked to variability in subjects' navigation performance. Our results thus support the conceptualization of the MTL as a memory space, representing both spatial- and nonspatial information to plan future actions and predict their outcomes.SIGNIFICANCE STATEMENT Using rare microwire recordings, we studied the representation of spatial, semantic, and temporal information in the human MTL. Our findings demonstrate that subjects acquire a cognitive map that simultaneously represents the spatial and semantic relations between landmarks. We further show that the same learned representation is used to predict future states, implicating MTL cell assemblies as the building blocks of prospective memory functions.
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Affiliation(s)
- Nora A Herweg
- Computational Memory Lab, Department of Psychology, University of Pennsylvania, Philadelphia, Pennsylvania, 19104
- Department of Neuropsychology, Institute of Cognitive Neuroscience, Faculty of Psychology, Ruhr University Bochum, 44801 Bochum, Germany
| | - Lukas Kunz
- Department of Biomedical Engineering, Columbia University, New York, New York 10027
- Epilepsy Center, Medical Center, University of Freiburg, Faculty of Medicine, 79106 Freiburg, Germany
| | - Daniel Schonhaut
- Computational Memory Lab, Department of Psychology, University of Pennsylvania, Philadelphia, Pennsylvania, 19104
| | - Armin Brandt
- Epilepsy Center, Medical Center, University of Freiburg, Faculty of Medicine, 79106 Freiburg, Germany
| | - Paul A Wanda
- Computational Memory Lab, Department of Psychology, University of Pennsylvania, Philadelphia, Pennsylvania, 19104
| | | | - Michael R Sperling
- Neurology, Thomas Jefferson University, Philadelphia, Pennsylvania 19107
| | - Andreas Schulze-Bonhage
- Epilepsy Center, Medical Center, University of Freiburg, Faculty of Medicine, 79106 Freiburg, Germany
| | - Michael J Kahana
- Computational Memory Lab, Department of Psychology, University of Pennsylvania, Philadelphia, Pennsylvania, 19104
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22
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Weiss SA, Fried I, Engel J, Sperling MR, Wong RK, Nir Y, Staba RJ. Fast ripples reflect increased excitability that primes epileptiform spikes. medRxiv 2023:2023.03.26.23287702. [PMID: 37034609 PMCID: PMC10081394 DOI: 10.1101/2023.03.26.23287702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
The neuronal circuit disturbances that drive interictal and ictal epileptiform discharges remains elusive. Using a combination of extraoperative macro- and micro-electrode interictal recordings in six presurgical patients during non-rapid eye movement (REM) sleep we found that, exclusively in the seizure onset zone, fast ripples (FR; 200-600Hz), but not ripples (80-200 Hz), frequently occur <300 msec before an interictal intracranial EEG (iEEG) spike with a probability exceeding chance (bootstrapping, p<1e-5). Such FR events are associated with higher spectral power (p<1e-10) and correlated with more vigorous neuronal firing than solitary FR (generalized linear mixed-effects model, GLMM, p<1e-3) irrespective of FR power. During the iEEG spike that follows a FR, action potential firing is lower than during a iEEG spike alone (GLMM, p<1e-10), reflecting an inhibitory restraint of iEEG spike initiation. In contrast, ripples do not appear to prime epileptiform spikes. We next investigated the clinical significance of pre-spike FR in a separate cohort of 23 patients implanted with stereo EEG electrodes who underwent resections. In non-REM sleep recordings, sites containing a high proportion of FR preceding iEEG spikes correlate with brain areas where seizures begin more than solitary FR (p<1e-5). Despite this correlation, removal of these sites does not guarantee seizure freedom. These results are consistent with the hypothesis that FR preceding EEG spikes reflect an increase in local excitability that primes EEG spike discharges preferentially in the seizure onset zone and that epileptogenic brain regions are necessary, but not sufficient, for initiating interictal epileptiform discharges.
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Affiliation(s)
- Shennan A Weiss
- Dept. of Neurology, State University of New York Downstate, Brooklyn, New York, 11203 USA
- Dept. of Physiology and Pharmacology, State University of New York Downstate, Brooklyn, New York, 11203 USA
- Dept. of Neurology, New York City Health + Hospitals/Kings County, Brooklyn, NY, USA
| | - Itzhak Fried
- Dept. of Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles, California, 90095, USA
| | - Jerome Engel
- Dept. of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, California, 90095, USA
- Dept. of Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles, California, 90095, USA
- Dept. of Neurobiology, David Geffen School of Medicine at UCLA, Los Angeles, California, 90095, USA
- Dept. of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at UCLA, Los Angeles, California, 90095, USA
- Brain Research Institute, David Geffen School of Medicine at UCLA, Los Angeles, California, 90095, USA
| | - Michael R. Sperling
- Depts. of Neurology and Neuroscience, Thomas Jefferson University, Philadelphia, Pennsylvania, 19107, USA
| | - Robert K.S. Wong
- Dept. of Physiology and Pharmacology, State University of New York Downstate, Brooklyn, New York, 11203 USA
| | - Yuval Nir
- Department of Physiology and Pharmacology, Sackler School of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
- Sagol School of Neuroscience, Tel Aviv University, Tel Aviv 6997801, Israel
- Department of Biomedical Engineering, Faculty of Engineering, Tel Aviv University, Tel Aviv 6997801, Israel
- The Sieratzki-Sagol Center for Sleep Medicine, Tel Aviv Sourasky Medical Center, Tel Aviv 6423906, Israel
| | - Richard J Staba
- Dept. of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, California, 90095, USA
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23
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Hinds W, Modi S, Ankeeta A, Sperling MR, Pustina D, Tracy JI. Pre-surgical features of intrinsic brain networks predict single and joint epilepsy surgery outcomes. Neuroimage Clin 2023; 38:103387. [PMID: 37023491 PMCID: PMC10122017 DOI: 10.1016/j.nicl.2023.103387] [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: 12/15/2022] [Revised: 03/02/2023] [Accepted: 03/24/2023] [Indexed: 03/31/2023]
Abstract
Despite the effectiveness of surgical interventions for the treatment of intractable focal temporal lobe epilepsy (TLE), the substrates that support good outcomes are poorly understood. While algorithms have been developed for the prediction of either seizure or cognitive/psychiatric outcomes alone, no study has reported on the functional and structural architecture that supports joint outcomes. We measured key aspects of pre-surgical whole brain functional/structural network architecture and evaluated their ability to predict post-operative seizure control in combination with cognitive/psychiatric outcomes. Pre-surgically, we identified the intrinsic connectivity networks (ICNs) unique to each person through independent component analysis (ICA), and computed: (1) the spatial-temporal match between each person's ICA components and established, canonical ICNs, (2) the connectivity strength within each identified person-specific ICN, (3) the gray matter (GM) volume underlying the person-specific ICNs, and (4) the amount of variance not explained by the canonical ICNs for each person. Post-surgical seizure control and reliable change indices of change (for language [naming, phonemic fluency], verbal episodic memory, and depression) served as binary outcome responses in random forest (RF) models. The above functional and structural measures served as input predictors. Our empirically derived ICN-based measures customized to the individual showed that good joint seizure and cognitive/psychiatric outcomes depended upon higher levels of brain reserve (GM volume) in specific networks. In contrast, singular outcomes relied on systematic, idiosyncratic variance in the case of seizure control, and the weakened pre-surgical presence of functional ICNs that encompassed the ictal temporal lobe in the case of cognitive/psychiatric outcomes. Our data made clear that the ICNs differed in their propensity to provide reserve for adaptive outcomes, with some providing structural (brain), and others functional (cognitive) reserve. Our customized methodology demonstrated that when substantial unique, patient-specific ICNs are present prior to surgery there is a reliable association with poor post-surgical seizure control. These ICNs are idiosyncratic in that they did not match the canonical, normative ICNs and, therefore, could not be defined functionally, with their location likely varying by patient. This important finding suggested the level of highly individualized ICN's in the epileptic brain may signal the emergence of epileptogenic activity after surgery.
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Affiliation(s)
- Walter Hinds
- Thomas Jefferson University, Department of Neurology, and Vicky and Jack Farber Institute for Neuroscience, USA
| | - Shilpi Modi
- Thomas Jefferson University, Department of Neurology, and Vicky and Jack Farber Institute for Neuroscience, USA
| | - Ankeeta Ankeeta
- Thomas Jefferson University, Department of Neurology, and Vicky and Jack Farber Institute for Neuroscience, USA
| | - Michael R Sperling
- Thomas Jefferson University, Department of Neurology, and Vicky and Jack Farber Institute for Neuroscience, USA
| | | | - Joseph I Tracy
- Thomas Jefferson University, Department of Neurology, and Vicky and Jack Farber Institute for Neuroscience, USA.
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24
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Weiss SA, Eliashiv D, Stern J, Rubinstein D, Fried I, Wu C, Sharan A, Engel J, Staba R, Sperling MR. Stimulation better targets fast-ripple generating networks in super responders to the responsive neurostimulator system. Epilepsia 2023; 64:e48-e55. [PMID: 36906958 DOI: 10.1111/epi.17582] [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: 12/10/2022] [Revised: 03/08/2023] [Accepted: 03/09/2023] [Indexed: 03/14/2023]
Abstract
How responsive neurostimulation (RNS) decreases seizure frequency is unclear. Stimulation may alter epileptic networks during inter-ictal epochs. Definitions of the epileptic network vary but fast ripples (FRs) may be an important substrate. We, therefore, examined whether stimulation of FR-generating networks differed in RNS super responders and intermediate responders. In 10 patients, with subsequent RNS placement, we detected FRs from stereo-electroencephalography (SEEG) contacts during pre-surgical evaluation. The normalized coordinates of the SEEG contacts were compared with those of the eight RNS contacts, and RNS-stimulated SEEG contacts were defined as those within 1.5 cm3 of the RNS contacts. We compared the post-RNS placement seizure outcome to (1) the ratio of stimulated SEEG contacts in the seizure-onset zone (SOZ stimulation ratio [SR]); (2) the ratio of FR events on stimulated contacts (FR SR); and (3) the global efficiency of the FR temporal correlational network on stimulated contacts (FR SGe). We found that the SOZ SR (p = .18) and FR SR (p = .06) did not differ in the RNS super responders and intermediate responders, but the FR SGe did (p = .02). In super responders, highly active desynchronous sites of the FR network were stimulated. RNS that better targets FR networks, as compared to the SOZ, may reduce epileptogenicity more.
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Affiliation(s)
- Shennan Aibel Weiss
- Department Of Neurology, State University of New York Downstate, Brooklyn, New York, 11203, USA.,Department of Physiology and Pharmacology, State University of New York Downstate, Brooklyn, New York, 11203, USA.,Department of Neurology, New York City Health + Hospitals/Kings County, Brooklyn, New York, USA
| | - Dawn Eliashiv
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, California, 90095, USA
| | - John Stern
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, California, 90095, USA
| | - Daniel Rubinstein
- Department of Neurology, Thomas Jefferson University, Philadelphia, Pennsylvania, 19107, USA
| | - Itzhak Fried
- Department of Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles, California, 90095, USA
| | - Chengyuan Wu
- Department of Neuroradiology, Thomas Jefferson University, Philadelphia, Pennsylvania, 19107, USA.,Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, 19107, USA
| | - Ashwini Sharan
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, 19107, USA
| | - Jerome Engel
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, California, 90095, USA.,Department of Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles, California, 90095, USA.,Department of Neurobiology, David Geffen School of Medicine at UCLA, Los Angeles, California, 90095, USA.,Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at UCLA, Los Angeles, California, 90095, USA.,Brain Research Institute, David Geffen School of Medicine at UCLA, Los Angeles, California, 90095, USA
| | - Richard Staba
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, California, 90095, USA
| | - Michael R Sperling
- Department of Neurology, Thomas Jefferson University, Philadelphia, Pennsylvania, 19107, USA
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25
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Weiss SA, Fried I, Wu C, Sharan A, Rubinstein D, Engel J, Sperling MR, Staba RJ. Graph theoretical measures of fast ripple networks improve the accuracy of post-operative seizure outcome prediction. Sci Rep 2023; 13:367. [PMID: 36611059 PMCID: PMC9825369 DOI: 10.1038/s41598-022-27248-x] [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: 09/10/2022] [Accepted: 12/28/2022] [Indexed: 01/09/2023] Open
Abstract
Fast ripples (FR) are a biomarker of epileptogenic brain, but when larger portions of FR generating regions are resected seizure freedom is not always achieved. To evaluate and improve the diagnostic accuracy of FR resection for predicting seizure freedom we compared the FR resection ratio (RR) with FR network graph theoretical measures. In 23 patients FR were semi-automatically detected and quantified in stereo EEG recordings during sleep. MRI normalization and co-registration localized contacts and relation to resection margins. The number of FR, and graph theoretical measures, which were spatial (i.e., FR rate-distance radius) or temporal correlational (i.e., FR mutual information), were compared with the resection margins and with seizure outcome We found that the FR RR did not correlate with seizure-outcome (p > 0.05). In contrast, the FR rate-distance radius resected difference and the FR MI mean characteristic path length RR did correlate with seizure-outcome (p < 0.05). Retesting of positive FR RR patients using either FR rate-distance radius resected difference or the FR MI mean characteristic path length RR reduced seizure-free misclassifications from 44 to 22% and 17%, respectively. These results indicate that graph theoretical measures of FR networks can improve the diagnostic accuracy of the resection of FR events for predicting seizure freedom.
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Affiliation(s)
- Shennan A. Weiss
- grid.262863.b0000 0001 0693 2202Department of Neurology, State University of New York Downstate, Brooklyn, USA ,grid.262863.b0000 0001 0693 2202Department of Physiology and Pharmacology, State University of New York Downstate, 450 Clarkson Avenue, MSC 1213, Brooklyn, NY 11203 USA ,grid.422616.50000 0004 0443 7226Department of Neurology, New York City Health + Hospitals/Kings County, Brooklyn, NY USA
| | - Itzhak Fried
- grid.19006.3e0000 0000 9632 6718Department of Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles, USA
| | - Chengyuan Wu
- grid.265008.90000 0001 2166 5843Department of Neuroradiology, Thomas Jefferson University, Philadelphia, USA ,grid.265008.90000 0001 2166 5843Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA 19107 USA
| | - Ashwini Sharan
- grid.265008.90000 0001 2166 5843Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA 19107 USA
| | - Daniel Rubinstein
- grid.265008.90000 0001 2166 5843Department of Neurology and Neuroscience, Thomas Jefferson University, Philadelphia, USA
| | - Jerome Engel
- grid.19006.3e0000 0000 9632 6718Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, USA ,grid.19006.3e0000 0000 9632 6718Department of Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles, USA ,grid.19006.3e0000 0000 9632 6718Department of Neurobiology, David Geffen School of Medicine at UCLA, Los Angeles, USA ,grid.19006.3e0000 0000 9632 6718Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at UCLA, Los Angeles, USA ,grid.19006.3e0000 0000 9632 6718David Geffen School of Medicine at UCLA, Brain Research Institute, Los Angeles, CA 90095 USA
| | - Michael R. Sperling
- grid.265008.90000 0001 2166 5843Department of Neurology and Neuroscience, Thomas Jefferson University, Philadelphia, USA
| | - Richard J. Staba
- grid.19006.3e0000 0000 9632 6718Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, USA
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26
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Perucca P, Stanley K, Harris N, McIntosh AM, Asadi-Pooya AA, Mikati MA, Andrade DM, Dugan P, Depondt C, Choi H, Heinzen EL, Cavalleri GL, Buono RJ, Devinsky O, Sperling MR, Berkovic SF, Delanty N, Goldstein DB, O'Brien TJ. Rare Genetic Variation and Outcome of Surgery for Mesial Temporal Lobe Epilepsy. Ann Neurol 2022; 93:752-761. [PMID: 36534060 DOI: 10.1002/ana.26581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Revised: 12/03/2022] [Accepted: 12/13/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Genetic factors have long been debated as a cause of failure of surgery for mesial temporal lobe epilepsy (MTLE). We investigated whether rare genetic variation influences seizure outcomes of MTLE surgery. METHODS We performed an international, multicenter, whole exome sequencing study of patients who underwent surgery for drug-resistant, unilateral MTLE with normal magnetic resonance imaging (MRI) or MRI evidence of hippocampal sclerosis and ≥2-year postsurgical follow-up. Patients with either sustained seizure freedom (favorable outcome) or ongoing uncontrolled seizures since surgery (unfavorable outcome) were included. Exomes of controls without epilepsy were also included. Gene set burden analyses were carried out to identify genes with significant enrichment of rare deleterious variants in patients compared to controls. RESULTS Nine centers from 3 continents contributed 206 patients operated for drug-resistant unilateral MTLE, of whom 196 (149 with favorable outcome and 47 with unfavorable outcome) were included after stringent quality control. Compared to 8,718 controls, MTLE cases carried a higher burden of ultrarare missense variants in constrained genes that are intolerant to loss-of-function (LoF) variants (odds ratio [OR] = 2.6, 95% confidence interval [CI] = 1.9-3.5, p = 1.3E-09) and in genes encoding voltage-gated cation channels (OR = 2.4, 95% CI = 1.4-3.8, p = 2.7E-04). Proportions of subjects with such variants were comparable between patients with favorable outcome and those with unfavorable outcome, with no significant between-group differences. INTERPRETATION Rare variation contributes to the genetic architecture of MTLE, but does not appear to have a major role in failure of MTLE surgery. These findings can be incorporated into presurgical decision-making and counseling. ANN NEUROL 2022.
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Affiliation(s)
- Piero Perucca
- Epilepsy Research Centre, Department of Medicine, Austin Health, University of Melbourne, Melbourne, Victoria, Australia
- Bladin-Berkovic Comprehensive Epilepsy Program, Department of Neurology, Austin Health, Melbourne, Victoria, Australia
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Department of Neurology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Neurology, Alfred Health, Melbourne, Victoria, Australia
| | - Kate Stanley
- Institute for Genomic Medicine, Columbia University, New York, New York, USA
| | - Natasha Harris
- Institute for Genomic Medicine, Columbia University, New York, New York, USA
| | - Anne M McIntosh
- Epilepsy Research Centre, Department of Medicine, Austin Health, University of Melbourne, Melbourne, Victoria, Australia
- Bladin-Berkovic Comprehensive Epilepsy Program, Department of Neurology, Austin Health, Melbourne, Victoria, Australia
- Department of Neurology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Ali A Asadi-Pooya
- Jefferson Comprehensive Epilepsy Center, Department of Neurology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
- Epilepsy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mohamad A Mikati
- Division of Pediatric Neurology and Developmental Medicine, Department of Pediatrics, Duke University, Durham, North Carolina, USA
| | | | - Patricia Dugan
- Department of Neurology, New York University Langone Medical Center, New York, New York, USA
| | - Chantal Depondt
- Department of Neurology, Hôpital Universitaire de Bruxelles, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Hyunmi Choi
- Department of Neurology, Columbia University, New York, New York, USA
| | - Erin L Heinzen
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Gianpiero L Cavalleri
- FutureNeuro Research Centre, Royal College of Surgeons in Ireland, Dublin, Ireland
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Russell J Buono
- Department of Biomedical Science, Cooper Medical School of Rowan University, Camden, New Jersey, USA
| | - Orrin Devinsky
- Department of Neurology, New York University Langone Medical Center, New York, New York, USA
| | - Michael R Sperling
- Jefferson Comprehensive Epilepsy Center, Department of Neurology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Samuel F Berkovic
- Epilepsy Research Centre, Department of Medicine, Austin Health, University of Melbourne, Melbourne, Victoria, Australia
- Bladin-Berkovic Comprehensive Epilepsy Program, Department of Neurology, Austin Health, Melbourne, Victoria, Australia
| | - Norman Delanty
- FutureNeuro Research Centre, Royal College of Surgeons in Ireland, Dublin, Ireland
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
- Department of Neurology, Beaumont Hospital, Dublin, Ireland
| | - David B Goldstein
- Institute for Genomic Medicine, Columbia University, New York, New York, USA
| | - Terence J O'Brien
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Department of Neurology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Neurology, Alfred Health, Melbourne, Victoria, Australia
- Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
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Sperling MR. Thank you to our Reviewers in 2022. Epilepsia 2022. [PMID: 36510853 DOI: 10.1111/epi.17487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 12/09/2022] [Indexed: 12/15/2022]
Affiliation(s)
- Michael R Sperling
- Thomas Jefferson University, Neurology, 901 Walnut St, Suite 400, Philadelphia¸ Pennsylvania, United States
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He X, Caciagli L, Parkes L, Stiso J, Karrer TM, Kim JZ, Lu Z, Menara T, Pasqualetti F, Sperling MR, Tracy JI, Bassett DS. Uncovering the biological basis of control energy: Structural and metabolic correlates of energy inefficiency in temporal lobe epilepsy. Sci Adv 2022; 8:eabn2293. [PMID: 36351015 PMCID: PMC9645718 DOI: 10.1126/sciadv.abn2293] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
Network control theory is increasingly used to profile the brain's energy landscape via simulations of neural dynamics. This approach estimates the control energy required to simulate the activation of brain circuits based on structural connectome measured using diffusion magnetic resonance imaging, thereby quantifying those circuits' energetic efficiency. The biological basis of control energy, however, remains unknown, hampering its further application. To fill this gap, investigating temporal lobe epilepsy as a lesion model, we show that patients require higher control energy to activate the limbic network than healthy volunteers, especially ipsilateral to the seizure focus. The energetic imbalance between ipsilateral and contralateral temporolimbic regions is tracked by asymmetric patterns of glucose metabolism measured using positron emission tomography, which, in turn, may be selectively explained by asymmetric gray matter loss as evidenced in the hippocampus. Our investigation provides the first theoretical framework unifying gray matter integrity, metabolism, and energetic generation of neural dynamics.
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Affiliation(s)
- Xiaosong He
- Department of Psychology, School of Humanities and Social Sciences, University of Science and Technology of China, Hefei, Anhui, China
- Department of Bioengineering, University of Pennsylvania, Philadelphia, PA, USA
- Corresponding author. (X.H.); (D.S.B.)
| | - Lorenzo Caciagli
- Department of Bioengineering, University of Pennsylvania, Philadelphia, PA, USA
- UCL Queen Square Institute of Neurology, Queen Square, London, UK
- MRI Unit, Epilepsy Society, Chesham Lane, Chalfont St Peter, Buckinghamshire, UK
| | - Linden Parkes
- Department of Bioengineering, University of Pennsylvania, Philadelphia, PA, USA
| | - Jennifer Stiso
- Department of Bioengineering, University of Pennsylvania, Philadelphia, PA, USA
| | - Teresa M. Karrer
- Personalized Health Care, Product Development, F. Hoffmann-La Roche Ltd., Basel, Switzerland
| | - Jason Z. Kim
- Department of Bioengineering, University of Pennsylvania, Philadelphia, PA, USA
| | - Zhixin Lu
- Department of Bioengineering, University of Pennsylvania, Philadelphia, PA, USA
| | - Tommaso Menara
- Department of Mechanical and Aerospace Engineering, University of California, San Diego, San Diego, CA, USA
| | - Fabio Pasqualetti
- Department of Mechanical Engineering, University of California, Riverside, Riverside, CA, USA
| | | | - Joseph I. Tracy
- Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Dani S. Bassett
- Department of Bioengineering, University of Pennsylvania, Philadelphia, PA, USA
- Departments of Electrical and Systems Engineering, Physics and Astronomy, Psychiatry, and Neurology, University of Pennsylvania, Philadelphia, PA, USA
- Santa Fe Institute, Santa Fe, NM, USA
- Corresponding author. (X.H.); (D.S.B.)
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29
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Weiss SA, Sheybani L, Seenarine N, Fried I, Wu C, Sharan A, Engel J, Sperling MR, Nir Y, Staba RJ. Delta oscillation coupled propagating fast ripples precede epileptiform discharges in patients with focal epilepsy. Neurobiol Dis 2022; 175:105928. [DOI: 10.1016/j.nbd.2022.105928] [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: 09/20/2022] [Revised: 11/13/2022] [Accepted: 11/15/2022] [Indexed: 11/18/2022] Open
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30
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Jehi L, Jette N, Kwon CS, Josephson CB, Burneo JG, Cendes F, Sperling MR, Baxendale S, Busch RM, Triki CC, Cross JH, Ekstein D, Englot DJ, Luan G, Palmini A, Rios L, Wang X, Roessler K, Rydenhag B, Ramantani G, Schuele S, Wilmshurst JM, Wilson S, Wiebe S. Timing of referral to evaluate for epilepsy surgery: Expert Consensus Recommendations from the Surgical Therapies Commission of the International League Against Epilepsy. Epilepsia 2022; 63:2491-2506. [PMID: 35842919 PMCID: PMC9562030 DOI: 10.1111/epi.17350] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [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: 03/01/2022] [Revised: 06/25/2022] [Accepted: 06/27/2022] [Indexed: 11/26/2022]
Abstract
Epilepsy surgery is the treatment of choice for patients with drug-resistant seizures. A timely evaluation for surgical candidacy can be life-saving for patients who are identified as appropriate surgical candidates, and may also enhance the care of nonsurgical candidates through improvement in diagnosis, optimization of therapy, and treatment of comorbidities. Yet, referral for surgical evaluations is often delayed while palliative options are pursued, with significant adverse consequences due to increased morbidity and mortality associated with intractable epilepsy. The Surgical Therapies Commission of the International League Against Epilepsy (ILAE) sought to address these clinical gaps and clarify when to initiate a surgical evaluation. We conducted a Delphi consensus process with 61 epileptologists, epilepsy neurosurgeons, neurologists, neuropsychiatrists, and neuropsychologists with a median of 22 years in practice, from 28 countries in all six ILAE world regions. After three rounds of Delphi surveys, evaluating 51 unique scenarios, we reached the following Expert Consensus Recommendations: (1) Referral for a surgical evaluation should be offered to every patient with drug-resistant epilepsy (up to 70 years of age), as soon as drug resistance is ascertained, regardless of epilepsy duration, sex, socioeconomic status, seizure type, epilepsy type (including epileptic encephalopathies), localization, and comorbidities (including severe psychiatric comorbidity like psychogenic nonepileptic seizures [PNES] or substance abuse) if patients are cooperative with management; (2) A surgical referral should be considered for older patients with drug-resistant epilepsy who have no surgical contraindication, and for patients (adults and children) who are seizure-free on 1-2 antiseizure medications (ASMs) but have a brain lesion in noneloquent cortex; and (3) referral for surgery should not be offered to patients with active substance abuse who are noncooperative with management. We present the Delphi consensus results leading up to these Expert Consensus Recommendations and discuss the data supporting our conclusions. High level evidence will be required to permit creation of clinical practice guidelines.
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Affiliation(s)
- Lara Jehi
- Epilepsy Center, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Nathalie Jette
- Department of Neurology and Department of Population Health, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Churl-Su Kwon
- Department of Neurology, Epidemiology, Neurosurgery and the Gertrude H. Sergievsky Center, Columbia University, New York, USA
| | - Colin B Josephson
- Department of Clinical Neurosciences and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Jorge G. Burneo
- Department of Clinical Neurological Sciences and NeuroEpidemiology Unit, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Fernando Cendes
- Department of Neurology, University of Campinas, Campinas, Brazil
| | | | - Sallie Baxendale
- Department of Clinical and Experimental Epilepsy, University College London Queen Square Institute of Neurology, London, UK
| | - Robyn M. Busch
- Epilepsy Center, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Chahnez Charfi Triki
- Department of Child Neurology, Hedi Chaker Hospital, LR19ES15 Sfax University, Sfax, Tunisia
| | - J Helen Cross
- UCL Great Ormond Street Institute of Child Health, London, UK
| | - Dana Ekstein
- Department of Neurology, Agnes Ginges Center for Human Neurogenetics, Hadassah Medical Organization, Jerusalem, Israel
| | - Dario J Englot
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Guoming Luan
- Department of Neurosurgery, Comprehensive Epilepsy Center, Sanbo Brain Hospital, Capital Medical University; Beijing Key Laboratory of Epilepsy; Epilepsy Institution, Beijing Institute for Brain Disorders, Beijing, China
| | - Andre Palmini
- Neurosciences and Surgical Departments, School of Medicine, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Brazil
| | - Loreto Rios
- Clínica Integral de Epilepsia, Campus Clínico Facultad de Medicina Universidad Finis Terrae, Santiago, Chile
| | - Xiongfei Wang
- Department of Neurosurgery, Comprehensive Epilepsy Center, Sanbo Brain Hospital, Capital Medical University; Beijing Key Laboratory of Epilepsy; Epilepsy Institution, Beijing Institute for Brain Disorders, Beijing, China
| | - Karl Roessler
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Bertil Rydenhag
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Georgia Ramantani
- Department of Neuropediatrics, and University Children’s Hospital Zurich, Switzerland, University of Zurich, Switzerland
| | - Stephan Schuele
- Department of Neurology, Northwestern University, Chicago, Illinois, USA
| | - Jo M Wilmshurst
- Department of Pediatric Neurology, Red Cross War Memorial Children’s Hospital, Cape Town, South Africa; Institute of Neurosciences, University of Cape Town, South Africa
| | - Sarah Wilson
- Melbourne School of Psychological Sciences, University of Melbourne, Melbourne, Vic., Australia
| | - Samuel Wiebe
- Department of Clinical Neurosciences and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
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31
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Misra SN, Sperling MR, Rao VR, Peters JM, Davis C, Carrazana E, Rabinowicz AL. Significant improvements in SEIzure interVAL (time between seizure clusters) across time in patients treated with diazepam nasal spray as intermittent rescue therapy for seizure clusters. Epilepsia 2022; 63:2684-2693. [PMID: 35975599 DOI: 10.1111/epi.17385] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [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: 06/10/2022] [Revised: 08/01/2022] [Accepted: 08/03/2022] [Indexed: 01/07/2023]
Abstract
OBJECTIVE Intermittent rescue therapy may be used for seizure clusters, which are clinical emergencies that may persist ≥24 h and increase risk of status epilepticus, emergency room visits, and reduced quality of life for patients with epilepsy. Beyond effectiveness for aborting seizure clusters, no data exist on how intermittent rescue therapy may impact the long-term natural course of seizure clusters. This novel analysis explores SEIzure interVAL (SEIVAL; time between seizure clusters) in patients from a long-term safety study of diazepam nasal spray (Valtoco) to assess SEIVAL changes with intermittent rescue therapy across time. METHODS Patients were aged 6-65 years. Age- and weight-based doses of diazepam nasal spray were administered during a 12-month treatment period with an optional follow-up period. SEIVAL was evaluated in patients receiving two or more doses of diazepam nasal spray using 90-day periods. RESULTS Of 163 treated patients, 151 had one or more SEIVALs. One hundred twenty had SEIVALs in Period 1 and one or more other periods. An increase in SEIVAL was noted from Period 1 compared with all subsequent periods (p ≤ .001). A consistent cohort (n = 76) had one or more SEIVALs in each of Periods 1-4 (360 days); mean SEIVALs increased significantly (p < .01) from 12.2 days (Period 1) to 25.7 days (Period 4). Similar SEIVAL patterns occurred when repeat doses within a seizure cluster were eliminated and irrespective of age group, treatment duration, and change to concomitant medications. In adults, Quality of Life in Epilepsy scores were maintained with increased SEIVALs. SIGNIFICANCE Across 12 months, increases in SEIVAL were demonstrated in patients using diazepam nasal spray for seizure cluster treatment in a phase 3 safety study. Increased time between seizure clusters may reflect a previously unrecognized beneficial effect of intermittent rescue therapy. These results generate a range of biological and behavioral hypotheses and warrant exploration of the impact of intermittent rescue therapy.
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Affiliation(s)
| | | | - Vikram R Rao
- University of California, San Francisco, San Francisco, California, USA
| | | | | | - Enrique Carrazana
- Neurelis, Inc., San Diego, California, USA.,John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii, USA
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Simpson HD, Schulze-Bonhage A, Cascino GD, Fisher RS, Jobst BC, Sperling MR, Lundstrom BN. Practical considerations in epilepsy neurostimulation. Epilepsia 2022; 63:2445-2460. [PMID: 35700144 PMCID: PMC9888395 DOI: 10.1111/epi.17329] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [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: 03/30/2022] [Revised: 06/10/2022] [Accepted: 06/13/2022] [Indexed: 02/02/2023]
Abstract
Neuromodulation is a key therapeutic tool for clinicians managing patients with drug-resistant epilepsy. Multiple devices are available with long-term follow-up and real-world experience. The aim of this review is to give a practical summary of available neuromodulation techniques to guide the selection of modalities, focusing on patient selection for devices, common approaches and techniques for initiation of programming, and outpatient management issues. Vagus nerve stimulation (VNS), deep brain stimulation of the anterior nucleus of the thalamus (DBS-ANT), and responsive neurostimulation (RNS) are all supported by randomized controlled trials that show safety and a significant impact on seizure reduction, as well as a suggestion of reduction in the risk of sudden unexplained death in epilepsy (SUDEP). Significant seizure reductions are observed after 3 months for DBS, RNS, and VNS in randomized controlled trials, and efficacy appears to improve with time out to 7 to 10 years of follow-up for all modalities, albeit in uncontrolled follow-up or retrospective studies. A significant number of patients experience seizure-free intervals of 6 months or more with all three modalities. Number and location of epileptogenic foci are important factors affecting efficacy, and together with comorbidities such as severe mood or sleep disorders, may influence the choice of modality. Programming has evolved-DBS is typically initiated at lower current/voltage than used in the pivotal trial, whereas target charge density is lower with RNS, however generalizable optimal parameters are yet to be defined. Noninvasive brain stimulation is an emerging stimulation modality, although it is currently not used widely. In summary, clinical practice has evolved from those established in pivotal trials. Guidance is now available for clinicians who wish to expand their approach, and choice of neuromodulation technique may be tailored to individual patients based on their epilepsy characteristics, risk tolerance, and preferences.
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Affiliation(s)
- Hugh D. Simpson
- Division of Epilepsy, Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | | | - Gregory D. Cascino
- Division of Epilepsy, Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Robert S. Fisher
- Department of Neurology, Stanford Neuroscience Health Center, Palo Alto, CA, USA
| | - Barbara C. Jobst
- Geisel School of Medicine at Dartmouth, Department of Neurology, Dartmouth-Hitchcock Medical Center, NH, USA
| | - Michael R. Sperling
- Division of Epilepsy, Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Brian N. Lundstrom
- Division of Epilepsy, Department of Neurology, Mayo Clinic, Rochester, MN, USA
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Sperling MR. From the Editor-in-Chief. Epilepsia 2022; 63:2171. [PMID: 35979604 DOI: 10.1111/epi.17392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 08/15/2022] [Indexed: 11/28/2022]
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34
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Wheless JW, Friedman D, Krauss GL, Rao VR, Sperling MR, Carrazana E, Rabinowicz AL. Future Opportunities for Research in Rescue Treatments. Epilepsia 2022; 63 Suppl 1:S55-S68. [PMID: 35822912 PMCID: PMC9541657 DOI: 10.1111/epi.17363] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 02/28/2022] [Revised: 06/16/2022] [Accepted: 07/11/2022] [Indexed: 11/30/2022]
Abstract
Clinical studies of rescue medications for seizure clusters are limited and are designed to satisfy regulatory requirements, which may not fully consider the needs of the diverse patient population that experiences seizure clusters or utilize rescue medication. The purpose of this narrative review is to examine the factors that contribute to, or may influence the quality of, seizure cluster research with a goal of improving clinical practice. We address five areas of unmet needs and provide advice for how they could enhance future trials of seizure cluster treatments. The topics addressed in this article are: (1) unaddressed end points to pursue in future studies, (2) roles for devices to enhance rescue medication clinical development programs, (3) tools to study seizure cluster prediction and prevention, (4) the value of other designs for seizure cluster studies, and (5) unique challenges of future trial paradigms for seizure clusters. By focusing on novel end points and technologies with value to patients, caregivers, and clinicians, data obtained from future studies can benefit the diverse patient population that experiences seizure clusters, providing more effective, appropriate care as well as alleviating demands on health care resources.
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Affiliation(s)
- James W Wheless
- Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Daniel Friedman
- New York University Grossman School of Medicine, New York, New York, USA
| | - Gregory L Krauss
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Vikram R Rao
- University of California, San Francisco, California, USA
| | | | - Enrique Carrazana
- Neurelis, San Diego, California, USA.,John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii, USA
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Camarillo-Rodriguez L, Leenen I, Waldman Z, Serruya M, Wanda PA, Herweg NA, Kahana MJ, Rubinstein D, Orosz I, Lega B, Podkorytova I, Gross RE, Worrell G, Davis KA, Jobst BC, Sheth SA, Weiss SA, Sperling MR. Temporal lobe interictal spikes disrupt encoding and retrieval of verbal memory: A subregion analysis. Epilepsia 2022; 63:2325-2337. [PMID: 35708911 DOI: 10.1111/epi.17334] [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: 01/28/2022] [Revised: 06/14/2022] [Accepted: 06/14/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The medial temporal lobe (MTL) encodes and recalls memories and can be a predominant site for interictal spikes (IS) in patients with focal epilepsy. It is unclear whether memory deficits are due to IS in the MTL producing a transient decline. Here, we investigated whether IS in the MTL subregions and lateral temporal cortex impact episodic memory encoding and recall. METHODS Seventy-eight participants undergoing presurgical evaluation for medically refractory focal epilepsy with depth electrodes placed in the temporal lobe participated in a verbal free recall task. IS were manually annotated during the pre-encoding, encoding, and recall epochs. We examined the effect of IS on word recall using mixed-effects logistic regression. RESULTS IS in the left hippocampus (odds ratio [OR] = .73, 95% confidence interval [CI] = .63-.84, p < .001) and left middle temporal gyrus (OR = .46, 95% CI = .27-.78, p < .05) during word encoding decreased subsequent recall performance. Within the left hippocampus, this effect was specific for area CA1 (OR = .76, 95% CI = .66-.88, p < .01) and dentate gyrus (OR = .74, 95% CI = .62-.89, p < .05). IS in other MTL subregions or inferior and superior temporal gyrus and IS occurring during the prestimulus window did not affect word encoding (p > .05). IS during retrieval in right hippocampal (OR = .22, 95% CI = .08-.63, p = .01) and parahippocampal regions (OR = .24, 95% CI = .07-.8, p < .05) reduced the probability of recalling a word. SIGNIFICANCE IS in medial and lateral temporal cortex contribute to transient memory decline during verbal episodic memory.
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Affiliation(s)
| | - Iwin Leenen
- Faculty of Psychology, National Autonomous University of Mexico, Mexico City, Mexico
| | - Zachary Waldman
- Department of Neurology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Mijail Serruya
- Department of Neurology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Paul A Wanda
- Department of Psychology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nora A Herweg
- Department of Psychology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michael J Kahana
- Department of Psychology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Daniel Rubinstein
- Department of Neurology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Iren Orosz
- Department of Neurology, University of California, Los Angeles, Los Angeles, California, USA
| | | | | | - Robert E Gross
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| | | | - Kathryn A Davis
- Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Barbara C Jobst
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Sameer A Sheth
- Department of Neurological Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Shennan A Weiss
- Department of Neurology, State University of New York Downstate Medical Center, Brooklyn, New York, USA.,Department of Physiology and Pharmacology, State University of New York Downstate Medical Center, Brooklyn, New York, USA.,Departments of Neurology, New York City Health + Hospitals/Kings County, Brooklyn, New York, USA
| | - Michael R Sperling
- Department of Neurology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Dimakopoulos V, Gotman J, Stacey W, von Ellenrieder N, Jacobs J, Papadelis C, Cimbalnik J, Worrell G, Sperling MR, Zijlmans M, Imbach L, Frauscher B, Sarnthein J. Protocol for multicentre comparison of interictal high-frequency oscillations as a predictor of seizure freedom. Brain Commun 2022; 4:fcac151. [PMID: 35770134 PMCID: PMC9234061 DOI: 10.1093/braincomms/fcac151] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 04/29/2022] [Accepted: 06/07/2022] [Indexed: 11/17/2022] Open
Abstract
In drug-resistant focal epilepsy, interictal high-frequency oscillations (HFOs) recorded from intracranial EEG (iEEG) may provide clinical information for delineating epileptogenic brain tissue. The iEEG electrode contacts that contain HFO are hypothesized to delineate the epileptogenic zone; their resection should then lead to postsurgical seizure freedom. We test whether our prospective definition of clinically relevant HFO is in agreement with postsurgical seizure outcome. The algorithm is fully automated and is equally applied to all data sets. The aim is to assess the reliability of the proposed detector and analysis approach. We use an automated data-independent prospective definition of clinically relevant HFO that has been validated in data from two independent epilepsy centres. In this study, we combine retrospectively collected data sets from nine independent epilepsy centres. The analysis is blinded to clinical outcome. We use iEEG recordings during NREM sleep with a minimum of 12 epochs of 5 min of NREM sleep. We automatically detect HFO in the ripple (80-250 Hz) and in the fast ripple (250-500 Hz) band. There is no manual rejection of events in this fully automated algorithm. The type of HFO that we consider clinically relevant is defined as the simultaneous occurrence of a fast ripple and a ripple. We calculate the temporal consistency of each patient's HFO rates over several data epochs within and between nights. Patients with temporal consistency <50% are excluded from further analysis. We determine whether all electrode contacts with high HFO rate are included in the resection volume and whether seizure freedom (ILAE 1) was achieved at ≥2 years follow-up. Applying a previously validated algorithm to a large cohort from several independent epilepsy centres may advance the clinical relevance and the generalizability of HFO analysis as essential next step for use of HFO in clinical practice.
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Affiliation(s)
- Vasileios Dimakopoulos
- Klinik für Neurochirurgie, UniversitätsSpital Zürich, Universität Zürich, Zürich, Switzerland
| | - Jean Gotman
- Montreal Neurological Institute & Hospital, McGill University, Montreal, Quebec, Canada
| | - William Stacey
- Department of Neurology and Department of Biomedical Engineering, University of Michigan, Ann Arbor, Michigan, MI, USA
| | | | - Julia Jacobs
- Alberta Children’s Hospital, University of Calgary, Calgary, Canada
| | | | - Jan Cimbalnik
- St. Anne’s University Hospital, Brno, Czech Republic
| | | | - Michael R Sperling
- Department of Neurology, Jefferson University Hospitals, Philadelphia, PA, USA
| | - Maike Zijlmans
- University Medical Center, Utrecht, and Stichting Epilepsie Instellingen Nederland (SEIN), Utrecht, The Netherlands
| | - Lucas Imbach
- Schweizerisches Epilepsie Zentrum, Zurich, Switzerland
| | - Birgit Frauscher
- Montreal Neurological Institute & Hospital, McGill University, Montreal, Quebec, Canada
| | - Johannes Sarnthein
- Klinik für Neurochirurgie, UniversitätsSpital Zürich, Universität Zürich, Zürich, Switzerland
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37
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Nehlig A, Sperling MR. The debate on the treatment of neonatal seizures introductory remarks. Epilepsia 2022; 63:1862. [PMID: 35524449 DOI: 10.1111/epi.17275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 04/26/2022] [Indexed: 11/28/2022]
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Hirsch E, French J, Scheffer IE, Bogacz A, Alsaadi T, Sperling MR, Abdulla F, Zuberi SM, Trinka E, Specchio N, Somerville E, Samia P, Riney K, Nabbout R, Jain S, Wilmshurst JM, Auvin S, Wiebe S, Perucca E, Moshé SL, Tinuper P, Wirrell EC. ILAE definition of the Idiopathic Generalized Epilepsy Syndromes: Position statement by the ILAE Task Force on Nosology and Definitions. Epilepsia 2022; 63:1475-1499. [PMID: 35503716 DOI: 10.1111/epi.17236] [Citation(s) in RCA: 114] [Impact Index Per Article: 57.0] [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: 04/23/2021] [Revised: 03/18/2022] [Accepted: 03/21/2022] [Indexed: 12/13/2022]
Abstract
In 2017, the International League Against Epilepsy (ILAE) Classification of Epilepsies described the "genetic generalized epilepsies" (GGEs), which contained the "idiopathic generalized epilepsies" (IGEs). The goal of this paper is to delineate the four syndromes comprising the IGEs, namely childhood absence epilepsy, juvenile absence epilepsy, juvenile myoclonic epilepsy, and epilepsy with generalized tonic-clonic seizures alone. We provide updated diagnostic criteria for these IGE syndromes determined by the expert consensus opinion of the ILAE's Task Force on Nosology and Definitions (2017-2021) and international external experts outside our Task Force. We incorporate current knowledge from recent advances in genetic, imaging, and electroencephalographic studies, together with current terminology and classification of seizures and epilepsies. Patients that do not fulfill criteria for one of these syndromes, but that have one, or a combination, of the following generalized seizure types: absence, myoclonic, tonic-clonic and myoclonic-tonic-clonic seizures, with 2.5-5.5 Hz generalized spike-wave should be classified as having GGE. Recognizing these four IGE syndromes as a special grouping among the GGEs is helpful, as they carry prognostic and therapeutic implications.
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Affiliation(s)
- Edouard Hirsch
- Francis Rohmer Neurology Epilepsy Units, National Institute of Health and Medical Research 1258, Federation of Translational Medicine of Strasbourg, Strasbourg University, Strasbourg, France
| | - Jacqueline French
- New York University Grossman School of Medicine and NYU Langone Health, New York, New York, USA
| | - Ingrid E Scheffer
- Austin Health and Royal Children's Hospital, Florey Institute, Murdoch Children's Research Institute, University of Melbourne, Melbourne, Victoria, Australia
| | - Alicia Bogacz
- Institute of Neurology, Clinical Hospital, Faculty of Medicine, University of the Republic, Montevideo, Uruguay
| | - Taoufik Alsaadi
- Department of Neurology, American Center for Psychiatry and Neurology, Abu Dhabi, United Arab Emirates
| | - Michael R Sperling
- Department of Neurology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Fatema Abdulla
- Salmaniya Medical Complex-Government Hospital, Manama, Bahrain
| | - Sameer M Zuberi
- Paediatric Neurosciences Research Group, Royal Hospital for Children and Institute of Health & Wellbeing, University of Glasgow, member of EpiCARE, Glasgow, UK
| | - Eugen Trinka
- Department of Neurology and Neuroscience Institute, Christian Doppler University Hospital, Paracelsus Medical University, Center for Cognitive Neuroscience, member of EpiCARE, Salzburg, Austria.,Department of Public Health, Health Services Research, and Health Technology Assessment, University for Health Sciences, Medical Informatics, and Technology, Hall in Tirol, Austria
| | - Nicola Specchio
- Rare and Complex Epilepsy Unit, Department of Neuroscience, Bambino Gesù Children's Hospital, Scientific Institute for Research and Health Care, member of EpiCARE, Rome, Italy
| | - Ernest Somerville
- Prince of Wales Hospital, University of New South Wales, Sydney, New South Wales, Australia
| | - Pauline Samia
- Department of Pediatrics and Child Health, Aga Khan University, East Africa, Nairobi, Kenya
| | - Kate Riney
- Neurosciences Unit, Queensland Children's Hospital, South Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Rima Nabbout
- Reference Center for Rare Epilepsies, Department of Pediatric Neurology, Necker-Enfants Malades Hospital, Public Hospital Network of Paris, member of EpiCARE, Imagine Institute, National Institute of Health and Medical Research, Mixed Unit of Research 1163, University of Paris, Paris, France
| | | | - Jo M Wilmshurst
- Department of Paediatric Neurology, Red Cross War Memorial Children's Hospital, Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Stephane Auvin
- Pediatric Neurology, Public Hospital Network of Paris, Robert Debré Hospital, NeuroDiderot, National Institute of Health and Medical Research, Department Medico-Universitaire, Innovation Robert-Debré, University of Paris, Paris, France.,University Institute of France, Paris, France
| | - Samuel Wiebe
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Emilio Perucca
- Department of Neuroscience, Monash University, Melbourne, Victoria, Australia.,Department of Medicine, Austin Health, University of Melbourne, Heidelberg, Victoria, Australia
| | - Solomon L Moshé
- Isabelle Rapin Division of Child Neurology, Saul R. Korey Department of Neurology, and Departments of Neuroscience and Pediatrics, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York, USA
| | - Paolo Tinuper
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy.,Institute of Neurological Sciences, Scientific Institute for Research and Health Care, member of EpiCARE, Bologna, Italy
| | - Elaine C Wirrell
- Divisions of Child and Adolescent Neurology and Epilepsy, Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
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Weiss SA, Pastore T, Orosz I, Rubinstein D, Gorniak R, Waldman Z, Fried I, Wu C, Sharan A, Slezak D, Worrell G, Engel J, Sperling MR, Staba RJ. Graph theoretical measures of fast ripples support the epileptic network hypothesis. Brain Commun 2022; 4:fcac101. [PMID: 35620169 PMCID: PMC9128387 DOI: 10.1093/braincomms/fcac101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Revised: 02/10/2022] [Accepted: 04/12/2022] [Indexed: 11/16/2022] Open
Abstract
The epileptic network hypothesis and epileptogenic zone hypothesis are two
theories of ictogenesis. The network hypothesis posits that coordinated activity
among interconnected nodes produces seizures. The epileptogenic zone hypothesis
posits that distinct regions are necessary and sufficient for seizure
generation. High-frequency oscillations, and particularly fast ripples, are
thought to be biomarkers of the epileptogenic zone. We sought to test these
theories by comparing high-frequency oscillation rates and networks in surgical
responders and non-responders, with no appreciable change in seizure frequency
or severity, within a retrospective cohort of 48 patients implanted with
stereo-EEG electrodes. We recorded inter-ictal activity during non-rapid eye
movement sleep and semi-automatically detected and quantified high-frequency
oscillations. Each electrode contact was localized in normalized coordinates. We
found that the accuracy of seizure onset zone electrode contact classification
using high-frequency oscillation rates was not significantly different in
surgical responders and non-responders, suggesting that in non-responders the
epileptogenic zone partially encompassed the seizure onset zone(s)
(P > 0.05). We also found that in the
responders, fast ripple on oscillations exhibited a higher spectral content in
the seizure onset zone compared with the non-seizure onset zone
(P < 1 × 10−5).
By contrast, in the non-responders, fast ripple had a lower spectral content in
the seizure onset zone
(P < 1 × 10−5).
We constructed two different networks of fast ripple with a spectral content
>350 Hz. The first was a rate–distance network that
multiplied the Euclidian distance between fast ripple-generating contacts by the
average rate of fast ripple in the two contacts. The radius of the
rate–distance network, which excluded seizure onset zone nodes,
discriminated non-responders, including patients not offered resection or
responsive neurostimulation due to diffuse multifocal onsets, with an accuracy
of 0.77 [95% confidence interval (CI) 0.56–0.98]. The second fast
ripple network was constructed using the mutual information between the timing
of the events to measure functional connectivity. For most non-responders, this
network had a longer characteristic path length, lower mean local efficiency in
the non-seizure onset zone, and a higher nodal strength among non-seizure onset
zone nodes relative to seizure onset zone nodes. The graphical theoretical
measures from the rate–distance and mutual information networks of 22
non- responsive neurostimulation treated patients was used to train a support
vector machine, which when tested on 13 distinct patients classified
non-responders with an accuracy of 0.92 (95% CI 0.75–1). These
results indicate patients who do not respond to surgery or those not selected
for resection or responsive neurostimulation can be explained by the epileptic
network hypothesis that is a decentralized network consisting of widely
distributed, hyperexcitable fast ripple-generating nodes.
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Affiliation(s)
- Shennan A Weiss
- Dept. of Neurology, State University of New York Downstate, Brooklyn, New York, 11203 USA
- Dept. of Physiology and Pharmacology, State University of New York Downstate, Brooklyn, New York, 11203 USA
- Dept. of Neurology, New York City Health + Hospitals/Kings County, Brooklyn, NY, USA
| | - Tomas Pastore
- Dept. of Computer Science, University of Buenos Aires, Buenos Aires, Argentina
| | - Iren Orosz
- Dept. of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, California, 90095, USA
| | - Daniel Rubinstein
- Depts. of Neurology and Neuroscience, Thomas Jefferson University, Philadelphia, Pennsylvania, 19107, USA
| | - Richard Gorniak
- Dept. of Neuroradiology, Thomas Jefferson University, Philadelphia, Pennsylvania, 19107, USA
| | - Zachary Waldman
- Depts. of Neurology and Neuroscience, Thomas Jefferson University, Philadelphia, Pennsylvania, 19107, USA
| | - Itzhak Fried
- Dept. of Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles, California, 90095, USA
| | - Chengyuan Wu
- Dept. of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, 19107, USA
| | - Ashwini Sharan
- Dept. of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, 19107, USA
| | - Diego Slezak
- Dept. of Computer Science, University of Buenos Aires, Buenos Aires, Argentina
| | - Gregory Worrell
- Dept. of Neurology, Mayo Systems Electrophysiology Laboratory (MSEL), USA
- Dept. of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN 55905, USA
| | - Jerome Engel
- Dept. of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, California, 90095, USA
- Dept. of Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles, California, 90095, USA
- Dept. of Neurobiology, David Geffen School of Medicine at UCLA, Los Angeles, California, 90095, USA
- Dept. of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at UCLA, Los Angeles, California, 90095, USA
- Brain Research Institute, David Geffen School of Medicine at UCLA, Los Angeles, California, 90095, USA
| | - Michael R. Sperling
- Depts. of Neurology and Neuroscience, Thomas Jefferson University, Philadelphia, Pennsylvania, 19107, USA
| | - Richard J Staba
- Dept. of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, California, 90095, USA
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Cascino GD, Tarquinio D, Wheless JW, Hogan RE, Sperling MR, Desai J, Vazquez B, Samara E, Misra SN, Carrazana E, Rabinowicz AL. Lack of Clinically Relevant Differences in Safety and Pharmacokinetics After Second-Dose Administration of Intranasal Diazepam Within 4 Hours for Acute Treatment of Seizure Clusters: A Population Analysis. Epilepsia 2022; 63:1714-1723. [PMID: 35377464 PMCID: PMC9543781 DOI: 10.1111/epi.17249] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 02/15/2022] [Revised: 04/01/2022] [Accepted: 04/01/2022] [Indexed: 11/30/2022]
Abstract
Objective Current diazepam nasal spray labeling requires waiting 4 h before administering a second dose. The objective of the current analyses was to examine safety and pharmacokinetic profiles of second doses of diazepam nasal spray given 0−4 h after the first dose. Methods Two datasets were analyzed. The first, a long‐term, repeat‐dose safety study of diazepam nasal spray, compared rates of treatment‐emergent adverse events (TEAEs), serious TEAEs, and treatment‐related TEAEs for patients receiving ≥1 second dose ≤4 h versus all second doses >4 h after the first. The second was a population pharmacokinetic analysis using data from three phase 1 studies to model drug exposure when a second dose of diazepam nasal spray was administered across multiple time points (1 min−4 h) following the first dose. Results In the repeat‐dose safety study, a second dose of diazepam nasal spray was administered ≤24 h after the first to treat 485 seizure clusters in 79 patients. Rates of TEAEs were similar between patients receiving ≥1 second dose in ≤4 h (89.5%, n = 38) compared with >4–24 h only (80.5%, n = 41). The most common treatment‐related TEAEs were associated with nasal discomfort, which was mild or moderate and transient. There were no reports of respiratory or cardiac depression. The pharmacokinetic simulations of second doses predicted comparable elevations of plasma diazepam concentrations with administrations across a range of intervals after the first dose (1 min−4 h). Significance These data indicate that the safety and pharmacokinetic profiles of a second dose of diazepam nasal spray administered within 4 h of the first dose are consistent with those associated with current labeling. This is potentially important for patients with seizure clusters who have a recurrent seizure within 4 h of first treatment and might benefit from immediate retreatment to reduce the risk of progression to status epilepticus.
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Affiliation(s)
| | | | - James W Wheless
- Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN, USA
| | | | | | - Jay Desai
- Children's Hospital of Los Angeles, CA, USA
| | - Blanca Vazquez
- New York University, Comprehensive Epilepsy Center, New York, NY, USA
| | - Emil Samara
- PharmaPolaris International, Inc, Washington, DC, USA
| | | | - Enrique Carrazana
- Neurelis, Inc., San Diego, CA, USA.,John A. Burns School of Medicine, University of Hawaii, Honolulu, HI, USA
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41
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Nehlig A, Sperling MR. An interview with Carmen De Caro, 2022 Epilepsia Prize Winner for Basic Science. Epilepsia 2022; 63:1023-1024. [PMID: 35315134 DOI: 10.1111/epi.17221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 03/09/2022] [Indexed: 11/29/2022]
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42
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Nehlig A, Sperling MR. An interview with Margherita Contento, 2022 Epilepsia Prize winner for clinical research. Epilepsia 2022; 63:1021-1022. [PMID: 35315063 DOI: 10.1111/epi.17222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 03/09/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Astrid Nehlig
- National Institute of Health and Medical Research, Paris, France
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43
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Klodowski DA, George BJ, Sperling MR. Seizure Latency and Epilepsy Localization as Predictors of Recurrence Following Epilepsy Surgery. Epilepsia 2022; 63:1074-1080. [PMID: 35286721 DOI: 10.1111/epi.17224] [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: 11/15/2021] [Revised: 03/08/2022] [Accepted: 03/09/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The primary purpose is to determine if the time between epilepsy surgery and first seizure recurrence can estimate the timing of the next seizure event for temporal and extratemporal epilepsy. A secondary endpoint aimed to compare temporal and extratemporal epilepsy surgery and examine which subgroup has a higher hazard of subsequent seizure recurrence. METHODS Data was used from a retrospective database at Thomas Jefferson University Hospital. Records were stratified into temporal (N = 943) and extratemporal (N = 125) surgeries. Analyses were done using SAS and utilized Cox-Proportional hazards models while controlling for demographics and clinical factors. The primary predictor of time between surgery and first recurrence was treated as a nominal variable binned into six segments, while secondary endpoints used a categorical predictor of epilepsy location while controlling for seizure latency. RESULTS Generally, as seizure latency following surgery increased, the time between first seizure and second seizure increased. These results were statistical meaningful in the temporal set (Wald Chi Square: 40.4715, df = 5, p<0.0001). Outcomes could also be interpreted based on predictor group, for instance, if seizure one occurred between one to two months following surgery in the temporal set, the median number of days until the next seizure was 35.5 days (95% CIs: 21 - 89 days). Secondary analysis showed that temporal lobe epilepsy had a lower hazard of a second seizure than extratemporal lobe epilepsy (89.2% reduction in hazard; 95% CIs: 0.015 - 0.795). SIGNIFICANCE This analysis provides a framework to use initial seizure latency to predict the median number of days until the next seizure event, while stratifying based on epilepsy location and controlling for multiple variables. It also suggests that the hazard of seizure recurrence in temporal lobe epilepsy is lower than extratemporal lobe epilepsy.
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Affiliation(s)
- David A Klodowski
- Sidney Kimmel Medical College, Thomas Jefferson University.,Jefferson College of Population Health
| | - Brandon J George
- Jefferson College of Population Health.,Division of Biostatistics, Department of Pharmacology and Experimental Therapeutics, Thomas Jefferson University
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44
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Isaac E, Ney D, Serruya M, Keith S, Lippa C, Sperling MR. Tolerability of memantine monotherapy versus adding memantine as combination therapy. J Natl Med Assoc 2022; 114:308-313. [PMID: 35272847 DOI: 10.1016/j.jnma.2022.02.006] [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: 06/01/2021] [Revised: 01/16/2022] [Accepted: 02/14/2022] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Prior studies have focused on the clinical efficacy of combination therapy, donepezil and memantine, for patient's diagnosed with Alzheimer's disease. As a result, it has become increasingly routine for providers to prescribe both medications for all-cause neurodegenerative disorders in variable stages of disease. However, the potential adverse drug reactions while described as mild can have serious sequelae in older adults who are already managing the side effects of polypharmacy. This study looks to explore the tolerability of switching cholinesterase inhibitors to memantine monotherapy versus adding memantine as combination therapy for all-cause neurodegenerative disorders. MATERIALS & METHODS The study is an IRB approved retrospective chart review that includes 175 patients diagnosed with neurocognitive disorders (ICD 10 F00-F03.91 and ICD10 G30-G31.84). Only side effects reported to and recorded by a neurocognitive subspecialist at Jefferson's Memory Disorder Center from 2016 to 2019 were included. RESULTS & DISCUSSION The odds of a patient reporting side effects on combination therapy in comparison with those patients on memantine monotherapy reporting side effects were significantly greater (OR = 4.33, CI 95% (1.62, 11.52), p = 0.003). In our patient sample, more than 80% of the patients reporting side effects qualified as polypharmacy or excessive polypharmacy (Table 2). As a result, variable polypharmacy (p = 0.047) was statistically significant in the in a binary logistic regression model for predicting outcomes for patients on combination therapy (Table 3). Therefore, as a patient progresses to moderate-severe stages of disease, we recommend switching CI monotherapy to memantine monotherapy as opposed to adding memantine as combination therapy for those patients on more than 10 other medications to increase tolerability. Given the limitations of a smaller sample size, variables such as severity of disease, renal and liver impairment as well as medication dosing were not significant predictors (Table 3) for those reporting side effects on combination therapy.
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Affiliation(s)
- Estevana Isaac
- Department of Neurology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States of America.
| | - David Ney
- Department of Neurology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States of America
| | - Mijail Serruya
- Department of Neurology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States of America
| | - Scott Keith
- Department of Neurology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States of America
| | - Carol Lippa
- Department of Neurology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States of America
| | - Michael R Sperling
- Department of Neurology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States of America
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45
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Sperling MR, Wheless JW, Hogan RE, Dlugos D, Cascino GD, Liow K, Rabinowicz AL, Carrazana E. Use of second doses of Valtoco® (diazepam nasal spray) across 24 hours after the initial dose for out-of-hospital seizure clusters: Results from a phase 3, open-label, repeat-dose safety study. Epilepsia 2022; 63:836-843. [PMID: 35112342 PMCID: PMC9305147 DOI: 10.1111/epi.17177] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [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: 10/26/2021] [Revised: 01/14/2022] [Accepted: 01/14/2022] [Indexed: 11/29/2022]
Abstract
Objective An exploratory analysis from a long‐term, phase 3, open‐label, repeat‐dose safety study of diazepam nasal spray for acute treatment of seizure clusters assessed the use of a second dose up to 24 hours after the initial dose and effectiveness in potentially reducing the number of seizures. Methods Seizures and doses were recorded in diaries. Results Of 175 patients enrolled, 163 received ≥1 dose of diazepam nasal spray and were included in the safety population; those patients received a total of 4390 doses for a total of 3853 seizure clusters. Less than half of these patients used a second dose a least once during the study (79 patients [48.5%]), with a total of 485 second doses for seizure clusters (12.6% of all seizure clusters). Among these 79 patients, 33 (41.8%) used only one second dose during the study (range: 1–82). The proportion of seizure clusters treated with a second dose over time was consistently low across 24 h: 0–4 h, 152 (3.9%); 4–6 h, 72 (1.9%); 6–8 h, 39 (1.0%); 8–12 h, 55 (1.4%); 12–16 h, 42 (1.1%); 16–20 h, 42 (1.1%); 20–24 h, 83 (2.2%). Rates of treatment‐emergent adverse events (TEAEs) and treatment‐related TEAEs occurring within 1 day of a second dose were low (15.2% and 5.1%, respectively). Significance Patients with epilepsy may experience seizure clusters lasting up to 24 hours, and little is known about the effectiveness of rescue therapies for that duration. The current labeling of the US Food and Drug Administration (FDA)–approved outpatient treatments for seizure clusters (rectal diazepam, intranasal midazolam, and diazepam nasal spray) allows for a second dose, if needed, for control. These findings support the safety profile of second doses, and the low use supports the effectiveness of diazepam nasal spray across 24 hours.
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Affiliation(s)
| | - James W Wheless
- Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - R Edward Hogan
- Washington University in St. Louis, St. Louis, Missouri, USA
| | - Dennis Dlugos
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | | | - Kore Liow
- Hawaii Pacific Neuroscience, Honolulu, Hawaii, USA
| | | | - Enrique Carrazana
- Neurelis, Inc., San Diego, California, USA.,John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii, USA
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46
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Klein P, McCarter R, Sperling MR. Comments on the Evaluation of Suicidality Risk of Newer Antiseizure Medications-Reply. JAMA Neurol 2022; 79:310-311. [PMID: 35099505 DOI: 10.1001/jamaneurol.2021.5141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Pavel Klein
- Mid-Atlantic Epilepsy and Sleep Center, Bethesda, Maryland
| | - Robert McCarter
- Retired, Children's National Medical Center, Bioinformatics, Washington, DC
| | - Michael R Sperling
- Department of Neurology, Thomas Jefferson University, Philadelphia, Pennsylvania
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47
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Steriade C, Sperling MR, DiVentura B, Lozano M, Shellhaas RA, Kessler SK, Dlugos D, French J. Proposal for an updated seizure classification framework in clinical trials. Epilepsia 2022; 63:565-572. [PMID: 34997581 PMCID: PMC9302660 DOI: 10.1111/epi.17120] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 10/13/2021] [Accepted: 10/25/2021] [Indexed: 11/29/2022]
Abstract
The International League Against Epilepsy (ILAE) seizure classification scheme has been periodically updated to improve its reliability and applicability to clinicians and researchers alike. Here, members of the Epilepsy Study Consortium propose a pragmatic seizure classification, based on the ILAE scheme, designed for use in clinical trials with a focus on outcome measures that have high reliability, broad interpretability across stakeholders, and clinical relevance in the context of the development of novel antiseizure medications. Controversies around the current ILAE classification scheme are discussed in the context of clinical trials, and pragmatic simplifications to the existing scheme are proposed, for intended use by investigators, industry sponsors, and regulatory agencies.
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Affiliation(s)
- Claude Steriade
- New York University Comprehensive Epilepsy Center, New York, New York, USA.,Epilepsy Study Consortium, Reston, Virginia, USA
| | - Michael R Sperling
- Epilepsy Study Consortium, Reston, Virginia, USA.,Department of Neurology, Jefferson Comprehensive Epilepsy Center, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | | | - Meryl Lozano
- Epilepsy Study Consortium, Reston, Virginia, USA
| | - Renée A Shellhaas
- Epilepsy Study Consortium, Reston, Virginia, USA.,Department of Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
| | - Sudha Kilaru Kessler
- Epilepsy Study Consortium, Reston, Virginia, USA.,Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Dennis Dlugos
- Epilepsy Study Consortium, Reston, Virginia, USA.,Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jacqueline French
- New York University Comprehensive Epilepsy Center, New York, New York, USA.,Epilepsy Study Consortium, Reston, Virginia, USA
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48
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Asadi-Pooya AA, Beniczky S, Rubboli G, Sperling MR, Rampp S, Perucca E. The EpiPick algorithm to select appropriate antiseizure medications in patients with epilepsy: Validation studies and updates. Epilepsia 2021; 63:254-255. [PMID: 34797915 DOI: 10.1111/epi.17129] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 11/08/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Ali A Asadi-Pooya
- Epilepsy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.,Jefferson Comprehensive Epilepsy Center, Department of Neurology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Sándor Beniczky
- Department of Clinical Neurophysiology, Danish Epilepsy Centre (member of the ERN EpiCARE), Dianalund, Denmark.,Department of Clinical Medicine, Aarhus University and Department of Clinical Neurophysiology, Aarhus University Hospital, Aarhus, Denmark
| | - Guido Rubboli
- Department of Neurology, Danish Epilepsy Centre (member of the ERN EpiCARE), Dianalund, Denmark.,University of Copenhagen, Copenhagen, Denmark
| | - Michael R Sperling
- Jefferson Comprehensive Epilepsy Center, Department of Neurology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Stefan Rampp
- Department of Neurosurgery, University Hospital Erlangen, Erlangen, Germany.,Department of Neurosurgery, University Hospital Halle, Halle, Germany
| | - Emilio Perucca
- Department of Neuroscience, Monash University, Melbourne, Victoria, Australia
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Hadady L, Klivényi P, Perucca E, Rampp S, Fabó D, Bereczki C, Rubboli G, Asadi-Pooya AA, Sperling MR, Beniczky S. Web-based decision support system for patient-tailored selection of antiseizure medication in adolescents and adults: An external validation study. Eur J Neurol 2021; 29:382-389. [PMID: 34741372 DOI: 10.1111/ene.15168] [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: 10/11/2021] [Accepted: 11/02/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND AND PURPOSE Antiseizure medications (ASMs) should be tailored to individual characteristics, including seizure type, age, sex, comorbidities, comedications, drug allergies, and childbearing potential. We previously developed a web-based algorithm for patient-tailored ASM selection to assist health care professionals in prescribing medication using a decision support application (https://epipick.org). In this validation study, we used an independent dataset to assess whether ASMs recommended by the algorithm are associated with better outcomes than ASMs considered less desirable by the algorithm. METHODS Four hundred twenty-five consecutive patients with newly diagnosed epilepsy were followed for at least 1 year after starting an ASM chosen by their physician. Patient characteristics were fed into the algorithm, blinded to the physician's ASM choices and outcome. The algorithm recommended ASMs, ranked in hierarchical groups, with Group 1 ASMs labeled as the best option for that patient. We evaluated retention rates, seizure freedom rates, and adverse effects leading to treatment discontinuation. Survival analysis contrasted outcomes between patients who received favored drugs and those who received lower ranked drugs. Propensity score matching corrected for possible imbalances between the groups. RESULTS Antiseizure medications classified by the algorithm as best options had a higher retention rate (79.4% vs. 67.2%, p = 0.005), higher seizure freedom rate (76.0% vs. 61.6%, p = 0.002), and lower rate of discontinuation due to adverse effects (12.0% vs. 29.2%, p < 0.001) than ASMs ranked as less desirable by the algorithm. CONCLUSIONS Use of the freely available decision support system is associated with improved outcomes. This drug selection application can provide valuable assistance to health care professionals prescribing medication for individuals with epilepsy.
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Affiliation(s)
- Levente Hadady
- Department of Neurology, Interdisciplinary Excellence Center, Faculty of Medicine, Albert Szent-Györgyi Clinical Center, University of Szeged, Szeged, Hungary
| | - Péter Klivényi
- Department of Neurology, Interdisciplinary Excellence Center, Faculty of Medicine, Albert Szent-Györgyi Clinical Center, University of Szeged, Szeged, Hungary
| | - Emilio Perucca
- Division of Clinical and Experimental Pharmacology, Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
| | - Stefan Rampp
- Department of Neurosurgery, University Hospital Erlangen, Erlangen, Germany.,Department of Neurosurgery, University Hospital Halle (Saale), Halle (Saale), Germany
| | - Dániel Fabó
- Department of Neurology, Interdisciplinary Excellence Center, Faculty of Medicine, Albert Szent-Györgyi Clinical Center, University of Szeged, Szeged, Hungary.,Department of Neurology, National Institute of Clinical Neurosciences, Budapest, Hungary
| | - Csaba Bereczki
- Department of Pediatrics, Interdisciplinary Excellence Center, Faculty of Medicine, Albert Szent-Györgyi Clinical Center, University of Szeged, Szeged, Hungary
| | - Guido Rubboli
- Department of Neurology, Danish Epilepsy Center (Member of the European Reference Network EpiCARE), Dianalund, University of Copenhagen, Copenhagen, Denmark
| | - Ali A Asadi-Pooya
- Epilepsy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.,Department of Neurology, Jefferson Comprehensive Epilepsy Center, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Michael R Sperling
- Department of Neurology, Jefferson Comprehensive Epilepsy Center, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Sándor Beniczky
- Department of Clinical Neurophysiology, Danish Epilepsy Center (Member of the European Reference Network EpiCARE), Aarhus University Hospital, Dianalund, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Weiss SA, Staba RJ, Sharan A, Wu C, Rubinstein D, Das S, Waldman Z, Orosz I, Worrell G, Engel J, Sperling MR. Accuracy of high-frequency oscillations recorded intraoperatively for classification of epileptogenic regions. Sci Rep 2021; 11:21388. [PMID: 34725412 PMCID: PMC8560764 DOI: 10.1038/s41598-021-00894-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 10/19/2021] [Indexed: 11/10/2022] Open
Abstract
To see whether acute intraoperative recordings using stereo EEG (SEEG) electrodes can replace prolonged interictal intracranial EEG (iEEG) recording, making the process more efficient and safer, 10 min of iEEG were recorded following electrode implantation in 16 anesthetized patients, and 1-2 days later during non-rapid eye movement (REM) sleep. Ripples on oscillations (RonO, 80-250 Hz), ripples on spikes (RonS), sharp-spikes, fast RonO (fRonO, 250-600 Hz), and fast RonS (fRonS) were semi-automatically detected. HFO power and frequency were compared between the conditions using a generalized linear mixed-effects model. HFO rates were compared using a two-way repeated measures ANOVA with anesthesia type and SOZ as factors. A receiver-operating characteristic (ROC) curve analysis quantified seizure onset zone (SOZ) classification accuracy, and the scalar product was used to assess spatial reliability. Resection of contacts with the highest rate of events was compared with outcome. During sleep, all HFOs, except fRonO, were larger in amplitude compared to intraoperatively (p < 0.01). HFO frequency was also affected (p < 0.01). Anesthesia selection affected HFO and sharp-spike rates. In both conditions combined, sharp-spikes and all HFO subtypes were increased in the SOZ (p < 0.01). However, the increases were larger during the sleep recordings (p < 0.05). The area under the ROC curves for SOZ classification were significantly smaller for intraoperative sharp-spikes, fRonO, and fRonS rates (p < 0.05). HFOs and spikes were only significantly spatially reliable for a subset of the patients (p < 0.05). A failure to resect fRonO areas in the sleep recordings trended the most sensitive and accurate for predicting failure. In summary, HFO morphology is altered by anesthesia. Intraoperative SEEG recordings exhibit increased rates of HFOs in the SOZ, but their spatial distribution can differ from sleep recordings. Recording these biomarkers during non-REM sleep offers a more accurate delineation of the SOZ and possibly the epileptogenic zone.
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Affiliation(s)
- Shennan A Weiss
- Department of Neurology, State University of New York Downstate, Brooklyn, NY, 11203, USA.,Department of Physiology and Pharmacology, State University of New York Downstate, Brooklyn, NY, 11203, USA.,Department of Neurology, New York City Health + Hospitals/Kings County, Brooklyn, NY, USA
| | - Richard J Staba
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, 90095, USA
| | - Ashwini Sharan
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, 19107, USA
| | - Chengyuan Wu
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, 19107, USA
| | - Daniel Rubinstein
- Department of Neurology and Neuroscience, Thomas Jefferson University, 901 Walnut St. Suite 400, Philadelphia, PA, 19107, USA
| | - Sandhitsu Das
- Penn Image Computing & Science Lab, University of Pennsylvania, Philadelphia, PA, 19143, USA
| | - Zachary Waldman
- Department of Neurology and Neuroscience, Thomas Jefferson University, 901 Walnut St. Suite 400, Philadelphia, PA, 19107, USA
| | - Iren Orosz
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, 90095, USA
| | - Gregory Worrell
- Department of Neurology, Mayo Systems Electrophysiology Laboratory (MSEL), Rochester, USA.,Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN, 55905, USA
| | - Jerome Engel
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, 90095, USA.,Department of Neurobiology, David Geffen School of Medicine at UCLA, Los Angeles, CA, 90095, USA.,Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at UCLA, Los Angeles, CA, 90095, USA.,Brain Research Institute, David Geffen School of Medicine at UCLA, Los Angeles, CA, 90095, USA
| | - Michael R Sperling
- Department of Neurology and Neuroscience, Thomas Jefferson University, 901 Walnut St. Suite 400, Philadelphia, PA, 19107, USA.
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