1
|
Carton RJ, Doyle MG, Kearney H, Steward CA, Lench NJ, Rogers A, Heinzen EL, McDonald S, Fay J, Lacey A, Beausang A, Cryan J, Brett F, El-Naggar H, Widdess-Walsh P, Costello D, Kilbride R, Doherty CP, Sweeney KJ, O'Brien DF, Henshall DC, Delanty N, Cavalleri GL, Benson KA. Somatic variants as a cause of drug-resistant epilepsy including mesial temporal lobe epilepsy with hippocampal sclerosis. Epilepsia 2024; 65:1451-1461. [PMID: 38491957 DOI: 10.1111/epi.17943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 02/14/2024] [Accepted: 02/26/2024] [Indexed: 03/18/2024]
Abstract
OBJECTIVE The contribution of somatic variants to epilepsy has recently been demonstrated, particularly in the etiology of malformations of cortical development. The aim of this study was to determine the diagnostic yield of somatic variants in genes that have been previously associated with a somatic or germline epilepsy model, ascertained from resected brain tissue from patients with multidrug-resistant focal epilepsy. METHODS Forty-two patients were recruited across three categories: (1) malformations of cortical development, (2) mesial temporal lobe epilepsy with hippocampal sclerosis, and (3) nonlesional focal epilepsy. Participants were subdivided based on histopathology of the resected brain. Paired blood- and brain-derived DNA samples were sequenced using high-coverage targeted next generation sequencing to high depth (585× and 1360×, respectively). Variants were identified using Genome Analysis ToolKit (GATK4) MuTect-2 and confirmed using high-coverage Amplicon-EZ sequencing. RESULTS Sequence data on 41 patients passed quality control. Four somatic variants were validated following amplicon sequencing: within CBL, ALG13, MTOR, and FLNA. The diagnostic yield across 41 patients was 10%, 9% in mesial temporal lobe epilepsy with hippocampal sclerosis and 20% in malformations of cortical development. SIGNIFICANCE This study provides novel insights into the etiology of mesial temporal lobe epilepsy with hippocampal sclerosis, highlighting a potential pathogenic role of somatic variants in CBL and ALG13. We also report candidate diagnostic somatic variants in FLNA in focal cortical dysplasia, while providing further insight into the importance of MTOR and related genes in focal cortical dysplasia. This work demonstrates the potential molecular diagnostic value of variants in both germline and somatic epilepsy genes.
Collapse
Affiliation(s)
- Robert J Carton
- FutureNeuro Science Foundation Ireland Research Centre, Royal College of Surgeons in Ireland, Dublin, Ireland
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Michael G Doyle
- FutureNeuro Science Foundation Ireland Research Centre, Royal College of Surgeons in Ireland, Dublin, Ireland
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
- Epilepsy Programme, Department of Neurology, Beaumont Hospital, Dublin, Ireland
- Strategic Academic Recruitment Doctor of Medicine Programme, Royal College of Surgeons in Ireland in collaboration with Blackrock Clinic, Dublin, Ireland
| | - Hugh Kearney
- FutureNeuro Science Foundation Ireland Research Centre, Royal College of Surgeons in Ireland, Dublin, Ireland
- Epilepsy Programme, Department of Neurology, Beaumont Hospital, Dublin, Ireland
| | | | | | - Anthony Rogers
- Congenica Limited, BioData Innovation Centre, Cambridge, UK
| | - Erin L Heinzen
- Department of Genetics, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Seamus McDonald
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Joanna Fay
- Royal College of Surgeons in Ireland Biobanking Service, Dublin, Ireland
| | - Austin Lacey
- FutureNeuro Science Foundation Ireland Research Centre, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Alan Beausang
- Department of Neuropathology, Beaumont Hospital, Dublin, Ireland
| | - Jane Cryan
- Department of Neuropathology, Beaumont Hospital, Dublin, Ireland
| | - Francesca Brett
- Department of Neuropathology, Beaumont Hospital, Dublin, Ireland
| | - Hany El-Naggar
- FutureNeuro Science Foundation Ireland Research Centre, Royal College of Surgeons in Ireland, Dublin, Ireland
- Epilepsy Programme, Department of Neurology, Beaumont Hospital, Dublin, Ireland
| | - Peter Widdess-Walsh
- FutureNeuro Science Foundation Ireland Research Centre, Royal College of Surgeons in Ireland, Dublin, Ireland
- Epilepsy Programme, Department of Neurology, Beaumont Hospital, Dublin, Ireland
| | - Daniel Costello
- FutureNeuro Science Foundation Ireland Research Centre, Royal College of Surgeons in Ireland, Dublin, Ireland
- Department of Neurology, Cork University Hospital, Cork, Ireland
| | - Ronan Kilbride
- FutureNeuro Science Foundation Ireland Research Centre, Royal College of Surgeons in Ireland, Dublin, Ireland
- Epilepsy Programme, Department of Neurology, Beaumont Hospital, Dublin, Ireland
| | - Colin P Doherty
- FutureNeuro Science Foundation Ireland Research Centre, Royal College of Surgeons in Ireland, Dublin, Ireland
- Department of Neurology, St. James's Hospital, Dublin, Ireland
| | - Kieron J Sweeney
- FutureNeuro Science Foundation Ireland Research Centre, Royal College of Surgeons in Ireland, Dublin, Ireland
- Epilepsy Programme, Department of Neurology, Beaumont Hospital, Dublin, Ireland
| | - Donncha F O'Brien
- FutureNeuro Science Foundation Ireland Research Centre, Royal College of Surgeons in Ireland, Dublin, Ireland
- Epilepsy Programme, Department of Neurology, Beaumont Hospital, Dublin, Ireland
| | - David C Henshall
- FutureNeuro Science Foundation Ireland Research Centre, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Norman Delanty
- FutureNeuro Science Foundation Ireland Research Centre, Royal College of Surgeons in Ireland, Dublin, Ireland
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
- Epilepsy Programme, Department of Neurology, Beaumont Hospital, Dublin, Ireland
| | - Gianpiero L Cavalleri
- FutureNeuro Science Foundation Ireland Research Centre, Royal College of Surgeons in Ireland, Dublin, Ireland
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Katherine A Benson
- FutureNeuro Science Foundation Ireland Research Centre, Royal College of Surgeons in Ireland, Dublin, Ireland
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| |
Collapse
|
2
|
Behan C, Hynes S, Ennis P, Khalil MI, Hogan J, Brett F, Sweeney K, Kilbride R, Doherty CP. Neurosurgery for intractable epilepsy in pregnancy: A case report. Epilepsy Behav Rep 2023; 23:100607. [PMID: 37283698 PMCID: PMC10239692 DOI: 10.1016/j.ebr.2023.100607] [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: 03/28/2023] [Revised: 05/18/2023] [Accepted: 05/22/2023] [Indexed: 06/08/2023] Open
Abstract
We describe the management of a 39-year-old woman with intractable focal epilepsy whose condition deteriorated during pregnancy and who required emergency neurosurgery. A literature search did not identify any previous reports of epilepsy surgery in pregnancy. To our knowledge, this is the first time surgery was planned and executed in rapid order with a successful outcome, without obstetrical or surgical complications and seizure freedom achieved. The value of rapid communication between established women's health advanced nurse practitioner clinics, the multidisciplinary Epilepsy Surgery Group and specialist Obstetrical Epilepsy service is highlighted. A care cycle for pregnant women with refractory epilepsy is proposed.
Collapse
Affiliation(s)
- Claire Behan
- Neurology Dept., St. James's Hospital, Ireland
- School of Medicine, Trinity College Dublin, Ireland
- FutureNeuro SFI Research Centre, RSCI, Ireland
| | | | | | | | - Jennifer Hogan
- The Coombe, Women and Infants University Hospital, Ireland
| | | | | | - Ronan Kilbride
- Neurology Dept., Beaumont Hospital, Ireland
- FutureNeuro SFI Research Centre, RSCI, Ireland
| | - Colin P Doherty
- Neurology Dept., St. James's Hospital, Ireland
- School of Medicine, Trinity College Dublin, Ireland
- FutureNeuro SFI Research Centre, RSCI, Ireland
| |
Collapse
|
3
|
Adenan MH, Khalil M, Loh KS, Kelly L, Shukralla A, Klaus S, Kilbride R, Mullins G, Widdess-Walsh P, Kinney M, Delanty N, El-Naggar H. A retrospective study of the correlation between duration of monitoring in the epilepsy monitoring unit and diagnostic yield. Epilepsy Behav 2022; 136:108919. [PMID: 36166879 DOI: 10.1016/j.yebeh.2022.108919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 09/11/2022] [Accepted: 09/11/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Long-term video-electroencephalographic (LTVEM) monitoring is a valuable tool in the evaluation of paroxysmal clinical events. However, vEEG itself is costly. Hence, we aimed to establish if longer duration of monitoring (DOM) is associated with higher diagnostic yield. METHOD A retrospective review of patients admitted into the epilepsy monitoring unit (EMU) for the diagnostic evaluation of paroxysmal events was performed. Patients' demographic, clinical characteristics, and vEEG data were analyzed. In the cohort of patients with DOM > 7 days, the reasons for prolonged DOM were identified and the differences in clinical characteristics and vEEG data between conclusive and inconclusive studies were analyzed. RESULT A total of 501 patients were included. Four hundred and thirty-six (87 %) patients had conclusive studies. Of these patients, 67.9 % patients with conclusive studies received diagnosis within the first 7 days of monitoring with the highest on day 7. The likelihood of conclusive studies decreased beyond 7 days. A total of 175 had DOM > 7 days, of which 140 (80 %) had conclusive studies. In the cohort with DOM > 7 days, patients with previous abnormal routine EEG, previous vEEG monitoring, first event recorded before day 5 of admission and ≥1 events recorded during vEEG monitoring were more likely to have conclusive studies. The most common reason for prolonging DOM beyond 7 days was to adequately record multiple semiologically distinctive events (76 %). CONCLUSION Our study supports that longer DOM is associated with an increase in diagnostic yield. More than one-third of our cohort were monitored beyond 7 days with majority (80 %) being conclusive. Our findings may guide clinicians in planning the DOM and predicting the likelihood of conclusive vEEG studies in patients with prolonged DOM based on the clinical characteristics and vEEG data.
Collapse
Affiliation(s)
- Mohammad Hijaz Adenan
- National Epilepsy Programme, Beaumont Hospital, Dublin, Ireland; Royal College of Surgeons, Ireland.
| | - Mohamed Khalil
- National Epilepsy Programme, Beaumont Hospital, Dublin, Ireland
| | - Kai Sheng Loh
- National Epilepsy Programme, Beaumont Hospital, Dublin, Ireland
| | - Luke Kelly
- National Epilepsy Programme, Beaumont Hospital, Dublin, Ireland
| | - Arif Shukralla
- National Epilepsy Programme, Beaumont Hospital, Dublin, Ireland
| | - Stephen Klaus
- National Epilepsy Programme, Beaumont Hospital, Dublin, Ireland
| | - Ronan Kilbride
- National Epilepsy Programme, Beaumont Hospital, Dublin, Ireland
| | - Gerard Mullins
- National Epilepsy Programme, Beaumont Hospital, Dublin, Ireland
| | - Peter Widdess-Walsh
- National Epilepsy Programme, Beaumont Hospital, Dublin, Ireland; Royal College of Surgeons, Ireland
| | - Michael Kinney
- Department of Neurology, Royal Victoria Hospital, Belfast, UK; Queen's University, Belfast, UK
| | - Norman Delanty
- National Epilepsy Programme, Beaumont Hospital, Dublin, Ireland; Royal College of Surgeons, Ireland; FutureNeuro, Science Foundation Ireland Research Centre, Ireland
| | - Hany El-Naggar
- National Epilepsy Programme, Beaumont Hospital, Dublin, Ireland; Royal College of Surgeons, Ireland; FutureNeuro, Science Foundation Ireland Research Centre, Ireland
| |
Collapse
|
4
|
Behan J, Murphy E, McMahon P, Kilbride R, El Naggar H, Delanty N, Mullins G, Molloy F. TH-211. Not so sweet: The spectrum of seizures and EEG abnormalities in diabetic patients with poor glycemic control. Clin Neurophysiol 2022. [DOI: 10.1016/j.clinph.2022.07.397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
|
5
|
Adenan MH, Khalil M, Loh KS, Shukralla A, Kilbride R, Mullins G, Widdess-Walsh P, Kinney M, Delanty N, El-Naggar H. 058 Does prolonging duration of monitoring in epilepsy monitoring unit improve diagnostic yield? J Neurol Psychiatry 2022. [DOI: 10.1136/jnnp-2022-abn2.102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Long-term video electroencephalographic (vEEG) monitoring is a valuable tool in the evaluation of par- oxysmal clinical events. However, vEEG itself is costly. We aimed to establish whether longer duration of monitoring (DOM) is associated with higher diagnostic yield. We performed a retrospective study of 501 patients admitted to the epilepsy monitoring unit for diagnostic evaluation. Overall, 436 (87%) patients had diagnostic studies. Of these, 67.9% patients received diagnosis within the first 7 days of monitoring with the highest during day 7. A total of 175 had DOM >7 days of which 80.1% were diagnostic. In cohort with DOM >7 days, patients with previous abnormal routine EEG, previous vEEG monitoring, earlier first event recorded and more number of events were more likely to have diagnostic studies. The most common reason for DOM >7 days was to capture more events (76%). Our study supports that longer DOM was associated with an increase in diagnostic yield. More than one third of our cohort were monitored beyond 7 days with majority of these (80.1%) were diagnostic. Our findings may guide clinicians in planning DOM and predicting likelihood of diagnostic studies in patients with prolonged DOM based on clinical char- acteristics and vEEG data.
Collapse
|
6
|
Sweeney KJ, Amoo M, Kilbride R, Jallo GI, Javadpour M. Exoscope aided trans-sulcal minimally invasive parafascicular resection of a paediatric brainstem pilocytic astrocytoma using a tubular retractor system. Br J Neurosurg 2021:1-6. [PMID: 34397316 DOI: 10.1080/02688697.2021.1967880] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Revised: 06/15/2021] [Accepted: 08/09/2021] [Indexed: 10/20/2022]
Abstract
The surgical management of brainstem glioma is challenging and has significant morbidity. Advances in surgical armamentarium has presented the opportunity to tackle these lesions. We present the case of a paediatric patient with a 2.3cm midbrain pilocytic astrocytoma. With the aid of tractography, neuro-navigation, 3-dimensional exoscope and a tubular retractor, near total resection of the tumour was achieved through a trans-sulcal para-fascicular approach without permanent injury to the corticospinal tract. To our knowledge this is the first report of a brainstem tumour resected using this approach and demonstrates what can be achieved with synergistic utility of evolving technologies in neurosurgery.
Collapse
Affiliation(s)
- Kieron J Sweeney
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland
- Department of Neurology, Royal College of Surgeons in Ireland, Dublin, Ireland
- Children's Health Ireland, Temple Street Children's University Hospital, Dublin, Ireland
| | - Michael Amoo
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland
- Department of Neurology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Ronan Kilbride
- Department of Neurology and Clinical Neurophysiology, Beaumont Hospital, Dublin, Ireland
| | - George I Jallo
- Department of Pediatric Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mohsen Javadpour
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland
- Department of Neurology, Royal College of Surgeons in Ireland, Dublin, Ireland
- Department of Academic Neurology, Trinity College Dublin, Dublin, Ireland
| |
Collapse
|
7
|
Khalil M, Shukralla AA, Kilbride R, Mullins G, Widdess-Walsh P, Delanty N, El-Naggar H. Ictal asystole during long-term video-EEG; semiology, localization, and intervention. Epilepsy Behav Rep 2021; 15:100416. [PMID: 33437961 PMCID: PMC7786025 DOI: 10.1016/j.ebr.2020.100416] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Revised: 11/17/2020] [Accepted: 11/19/2020] [Indexed: 11/23/2022] Open
Abstract
Ictal arrhythmias are disturbances of cardiac conduction that occur during clinical or electrographic seizures. Ictal asystole (IA) is rare, and its incidence can range from 0.3–0.4% in patients with epilepsy who were monitored by video-EEG (van der Lende et al., 2015). We report on ten patients (six males and four females) with an age ranging from 31 to 70 years old) who were monitored in our video-EEG (VEEG) unit over the last eight years. These patients were selected based on the history of documented ictal asystole during inpatient VEEG monitoring). In our series the mean latency from the seizure onset to the onset of ictal asystole was 22 seconds and the mean duration of the IA was 15.8 seconds. During the asystolic phase the seizures may clinically continue or syncopal signs may supervene. In our case series all the patients had either left or right temporal lobe epilepsy, six of which were lesional. We found two patterns of ictal semiology in our series. The first group of patients included five patients who experienced a rapid onset of IA in their seizure and the second group where the latency of ictal asystole was relatively late. All our cohort had a permanent pacemaker following the diagnosis, six of these patients have been event free since placement.
Collapse
|
8
|
Amoo M, Sweeney KJ, Kilbride R, Javadpour M. How I do it: parietal trans-sulcal para-fascicular approach to lateral thalamic/internal capsule cavernous malformation. Acta Neurochir (Wien) 2021; 163:2497-2501. [PMID: 34164736 PMCID: PMC8357681 DOI: 10.1007/s00701-021-04884-2] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 05/13/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND The surgical management of deep brain lesions is challenging, with significant morbidity. Advances in surgical technology have presented the opportunity to tackle these lesions. METHODS We performed a complete resection of a thalamic/internal capsule CM using a tubular retractor system via a parietal trans-sulcal para-fascicular (PTPF) approach without collateral injury to the nearby white matter tracts. CONCLUSION PTPF approach to lateral thalamic/internal capsule lesions can be safely performed without injury to eloquent white matter fibres. The paucity of major vessels along this trajectory and the preservation of lateral ventricle integrity make this approach a feasible alternative to traditional approaches.
Collapse
Affiliation(s)
- Michael Amoo
- Department of Neurosurgery, Beacon Hospital, Sandyford, Dublin 18, Ireland.
- National Neurosurgical Centre, Beaumont Hospital, Dublin 9, Ireland.
- Royal College of Surgeons in Ireland, Dublin, Ireland.
| | - Kieron J Sweeney
- National Neurosurgical Centre, Beaumont Hospital, Dublin 9, Ireland
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Ronan Kilbride
- Department of Neurology and Clinical Neurophysiology, Beaumont Hospital, Dublin 9, Ireland
| | - Mohsen Javadpour
- Department of Neurosurgery, Beacon Hospital, Sandyford, Dublin 18, Ireland
- National Neurosurgical Centre, Beaumont Hospital, Dublin 9, Ireland
- Royal College of Surgeons in Ireland, Dublin, Ireland
- Department of Academic Neurology, Trinity College Dublin, Dublin, Ireland
| |
Collapse
|
9
|
Haughton G, Crimmins D, O’Rourke D, Kilbride R. S115. Multimodal intraoperative neurophysiology monitoring during the resection of a 4th ventricular mass in a 2 year-old boy with hemifacial spasm and seizure. Clin Neurophysiol 2018. [DOI: 10.1016/j.clinph.2018.04.475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
|
10
|
Whelehan A, Mullins G, Kilbride R, Delanty N, Walsh PW. BS10. Asystole in the video-telemetry unit-two cases. Clin Neurophysiol 2018. [DOI: 10.1016/j.clinph.2018.04.558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
|
11
|
El-Naggar H, Moloney P, Widdess-Walsh P, Kilbride R, Delanty N, Mullins G. Simultaneous occurrence of nonepileptic and epileptic seizures during a single period of in-patient video-electroencephalographic monitoring. Epilepsia Open 2017; 2:467-471. [PMID: 29588977 PMCID: PMC5862101 DOI: 10.1002/epi4.12071] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/06/2017] [Indexed: 11/17/2022] Open
Abstract
Epilepsy and psychogenic nonepileptic seizures (PNES) can coexist and may present in two forms: sequential and simultaneous. In sequential presentations, epileptic seizures (ES) are treated and PNES emerge later. Simultaneous recording of ES and PNES by video‐electroencephalogram (vEEG) is less well described. We retrospectively reviewed all patients diagnosed with PNES by vEEG following standard seizure induction practices over a 21‐month period. Within this cohort, we established the prevalence of coexisting epilepsy using clinical and electrographic data acquired from our epilepsy‐specific patient record. We identified patients with simultaneous PNES and ES recorded during a single vEEG admission, establishing the frequency and emergent timing of each type. Of our 262 monitored patients, 59 were diagnosed with PNES. Nineteen of the patients with PNES had coexisting epilepsy (prevalence rate of 7.3% or 32% of those with PNES). Sixteen patients had PNES and ES recorded during the same admission, and the remaining three patients had sequential PNES following successful treatment of ES. PNES occurred earlier (mean, within 1.21 days), with ES occurring later (mean, within 4.86 days). The simultaneous occurrence of PNES and ES recorded during a single admission is more common than previously reported. Identifying this group of patients may require a significantly longer period of vEEG monitoring and a detailed analysis of each individual's historical seizure events.
Collapse
Affiliation(s)
- Hany El-Naggar
- Epilepsy Programme Beaumont Hospital Dublin Ireland.,Royal College of Surgeons Dublin Ireland
| | | | | | | | - Norman Delanty
- Epilepsy Programme Beaumont Hospital Dublin Ireland.,Royal College of Surgeons Dublin Ireland
| | | |
Collapse
|
12
|
Hernandez-Lain A, Hedley-Whyte ET, Hariri LP, Molyneaux B, Nagle KJ, Cole AJ, Kilbride R. Pathology of bilateral pulvinar degeneration following long duration status epilepticus. Seizure 2013; 22:901-4. [PMID: 23962521 DOI: 10.1016/j.seizure.2013.07.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [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: 03/07/2013] [Revised: 07/16/2013] [Accepted: 07/17/2013] [Indexed: 10/26/2022] Open
Abstract
PURPOSE To define the neuropathological findings of pulvinar degeneration seen in long duration status epilepticus. METHODS We review the clinical, radiologic, neurophysiologic, investigational and neuropathological findings on a 27 year old woman who died after 162 days of prolonged refractory status epilepticus. RESULTS Continuous EEG monitoring confirmed recurrent uncontrolled seizure activity bilaterally and independently, most frequent in the right fronto-temporal region. Initial MRI of the brain was normal. Repeat study until on day 127 of admission showed advanced changes, with bilateral pulvinar T2/FLAIR hyperintensities. The autopsy revealed sharply defined, grey, soft, granular nodules in each medial pulvinar nucleus. Microscopically these consisted of sharply defined paucicellular areas with loss of neurons and myelin and with numerous macrophages in their centers, surrounded by reactive astrocytes with relatively spared of axons. The spinal cord at cervical and thoracic levels showed symmetric spongy vacuolation in the central part of the dorsal columns and lateral corticospinal tracts, with mild myelin loss, relatively preserved axons. The pathological lesions found in this case in thepulvinar are somewhat similar to the pathologic lesions described in Wernicke's encephalopathy. Those found in the spinal cord of our patient resemble characteristic features of B12 related subacute combined degeneration. CONCLUSION Characteristic pulvinar degeneration may be found as an acquired phenomenon in prolonged refractory status epilepticus. We hypothesize that the neuropathological findings result from an excessive focal metabolic demand, secondary to neuronal network over activation in the setting of prolonged, frequent bi-temporal seizures.
Collapse
Affiliation(s)
- Aurelio Hernandez-Lain
- Charles S Kubik Laboratory for Neuropathology, Department of Pathology, Boston, MA, USA; Servicio de Anatomía Patológica (Neuropatología) and Instituto de Investigación i+12, Hospital Universitario 12 de Octubre, Madrid, Spain.
| | | | | | | | | | | | | |
Collapse
|
13
|
Gaspard N, Foreman B, Judd LM, Brenton JN, Nathan BR, McCoy BM, Al-Otaibi A, Kilbride R, Fernández IS, Mendoza L, Samuel S, Zakaria A, Kalamangalam GP, Legros B, Szaflarski JP, Loddenkemper T, Hahn CD, Goodkin HP, Claassen J, Hirsch LJ, Laroche SM. Intravenous ketamine for the treatment of refractory status epilepticus: a retrospective multicenter study. Epilepsia 2013; 54:1498-503. [PMID: 23758557 PMCID: PMC3731413 DOI: 10.1111/epi.12247] [Citation(s) in RCA: 157] [Impact Index Per Article: 14.3] [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] [Accepted: 05/09/2013] [Indexed: 11/29/2022]
Abstract
PURPOSE To examine patterns of use, efficacy, and safety of intravenous ketamine for the treatment of refractory status epilepticus (RSE). METHODS Multicenter retrospective review of medical records and electroencephalography (EEG) reports in 10 academic medical centers in North America and Europe, including 58 subjects, representing 60 episodes of RSE that were identified between 1999 and 2012. Seven episodes occurred after anoxic brain injury. KEY FINDINGS Permanent control of RSE was achieved in 57% (34 of 60) of episodes. Ketamine was felt to have contributed to permanent control ("possible" or "likely" responses) in 32% (19 of 60) including seven (12%) in which ketamine was the last drug added (likely responses). Four of the seven likely responses, but none of the 12 possible ones, occurred in patients with postanoxic brain injury. No likely responses were observed when infusion rates were lower than 0.9 mg/kg/h, when ketamine was introduced at least 8 days after SE onset, or after failure of seven or more drugs. Ketamine was discontinued due to possible adverse events in five patients. Complications were mostly attributed to concurrent drugs, especially other anesthetics. Mortality rate was 43% (26 of 60), but was lower when SE was controlled within 24 h of ketamine initiation (16% vs. 56%, p = 0.0047). SIGNIFICANCE Ketamine appears to be a relatively effective and safe drug for the treatment of RSE. This retrospective series provides preliminary data on effective dose and appropriate time of intervention to aid in the design of a prospective trial to further define the role of ketamine in the treatment of RSE.
Collapse
Affiliation(s)
- Nicolas Gaspard
- Comprehensive Epilepsy Center, Department of Neurology, School of Medicine, Yale-New Haven Hospital, Yale University, New Haven, Connecticut 06520, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
14
|
Abstract
PURPOSE How long after starting a new medication must a patient go without seizures before they can be regarded as seizure-free? A recent International League Against Epilepsy (ILAE) task force proposed using a "Rule of Three" as an operational definition of seizure freedom, according to which a patient should be considered seizure-free following an intervention after a period without seizures has elapsed equal to three times the longest preintervention interseizure interval over the previous year. This rule was motivated in large part by statistical considerations advanced in a classic 1983 paper by Hanley and Lippman-Hand. However, strict adherence to the statistical logic of this rule generally requires waiting much longer than recommended by the ILAE task force. Therefore, we set out to determine whether an alternative approach to the Rule of Three might be possible, and under what conditions the rule may be expected to hold or would need to be extended. METHODS Probabilistic modeling and application of Bayes' rule. KEY FINDINGS We find that an alternative approach to the problem of inferring seizure freedom supports using the Rule of Three in the way proposed by the ILAE in many cases, particularly in evaluating responses to a first trial of antiseizure medication, and to favorably-selected epilepsy surgical candidates. In cases where the a priori odds of success are less favorable, our analysis requires longer seizure-free observation periods before declaring seizure freedom, up to six times the average preintervention interseizure interval. The key to our approach is to take into account not only the time elapsed without seizures but also empirical data regarding the a priori probability of achieving seizure freedom conferred by a particular intervention. SIGNIFICANCE In many cases it may be reasonable to consider a patient seizure-free after they have gone without seizures for a period equal to three times the preintervention interseizure interval, as proposed on pragmatic grounds in a recent ILAE position paper, although in other commonly encountered cases a waiting time up to six times this interval is required. In this work we have provided a coherent theoretical basis for modified criterion for seizure freedom, which we call the "Rule of Three-To-Six."
Collapse
Affiliation(s)
- M Brandon Westover
- Neurology Department, Epilepsy Service, Massachusetts General Hospital, Boston, Massachusetts 02114, USA.
| | | | | | | | | | | | | |
Collapse
|
15
|
Hutchinson S, Courtney R, Mulcahy F, O'Connor M, Mullaney S, Kilbride R. Monitoring cytomegalovirus retinitis prevalence in an HIV-seropositive cohort: the assessment of improvements observed following the introduction of highly active antiretroviral triple therapy. Int J STD AIDS 1999; 10:652-6. [PMID: 10582631 DOI: 10.1258/0956462991913213] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [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: 11/18/2022]
Abstract
This paper concerns the ophthalmic assessment of patients with acquired immunodeficiency syndrome (AIDS) for a number of eye conditions and in particular cytomegalovirus (CMV) retinitis. CMV has been the most common opportunistic infection associated with AIDS and the leading cause of blindness among AIDS patients. There have been early indications of a widespread fall in CMV prevalence internationally following the introduction of a new highly active antiretroviral triple (HAART) therapy. Our study sought to assess the position for Ireland. Our cohort was the entire population of stage IV AIDS patients attending the country's leading referral centre. The total number of patients examined was 167 and the period of examination was 1 May 1995 to 30 April 1997. HAART was introduced in March 1996, so the data permitted a 'before and after' comparison of various clinical findings. The incidence of new CMV cases was found to be 4 among the 102 patients examined in the first 12-month period and one among 107 patients examined in the second 12-month period. There were accompanying declines in HIV-related noninfectious retinal vasculopathy (HIVR), keratitis and other conditions. The findings are promising, but we argue that caution is needed in assessing long-term trends. In the paper we discuss a number of methodological issues in the collection and analysis of the clinical data and in the interpretation of results.
Collapse
Affiliation(s)
- S Hutchinson
- Department of Ophthalmology, St James's Hospital, Dublin, Ireland
| | | | | | | | | | | |
Collapse
|