Interictal interleukin-6 and tumor necrosis factor α levels are associated with seizure recurrence in adults with epilepsy

BACKGROUND

Although there are models predicting epilepsy recurrence under different clinical conditions, few studies have examined blood biomarkers. Inflammation plays a crucial role in the occurrence and development of epilepsy. We analyzed inflammatory mediators in a regional hospital-based epilepsy cohort and investigated their relationship with subsequent epilepsy recurrence.

METHODS

Interictal inflammatory mediators were measured in 128 patients diagnosed with epilepsy participating in a prospective study. Inflammatory mediators were compared during the follow-up period between patients who experienced epilepsy recurrence and those who did not. We also assessed the correlation between inflammatory mediators and the time interval until the next recurrence.

RESULTS

Over a median 4-month follow-up period, 41 patients experienced seizure recurrence. Differences in interleukin-6 (IL-6) and tumor necrosis factor α (TNF-α) levels were observed between seizure recurrence and non-recurrence groups. After adjusting for covariates through multivariate Cox regression analysis, the patients in the third IL-6 tertile (>2.31 pg/mL; HR: 2.49; 95 % CI: 1.00-6.16; P = 0.049) and in the third TNF-α tertile (>0.74 pg/mL; HR: 2.80; 95 % CI: 1.13-6.92; P = 0.026) had higher risk of seizure recurrence. The time until the next recurrence was negatively correlated with IL-6 level (ρ =  - 0.392, P = 0.011).

CONCLUSION

High levels of IL-6 and TNF-α are associated with a higher possibility of seizure recurrence. Future predictive models should also include inflammatory mediators in addition to clinical variables.

Acute Symptomatic Seizures and Risk of Seizure Recurrence in Patients with Anti-NMDAR, Anti-LGI1, and Anti-GABABR Encephalitis

AIMS

To analyze the clinical characteristics of acute symptomatic seizures and predict the risk factors for seizure recurrence in patients with anti-N-methyl-D-aspartate receptor (NMDAR), anti-leucine-rich glioma-inactivated 1 (LGI1), and anti-gamma-aminobutyric acid B receptor (GABABR) encephalitis.

METHODS

In this retrospective study, we included hospitalized patients who had been diagnosed with anti-NMDAR, anti-LGI1, and anti-GABABR encephalitis between November 2014 and April 2021. Binary logistic regression analysis was performed to identify the potential risk factors for seizure recurrence.

RESULTS

In total, 262 patients with anti-NMDAR, anti-LGI1, and anti-GABABR encephalitis were included, 197 (75.2%) of whom presented with acute symptomatic seizures. During follow-up, 42 patients exhibited seizure recurrence. In anti-NMDAR encephalitis, frontal lobe abnormality on brain magnetic resonance imaging, delayed immunotherapy, early seizures, and focal motor onset were associated with seizure recurrence.

CONCLUSIONS

Acute symptomatic seizure is a common clinical feature observed in patients with anti-NMDAR, anti-LGI1, and anti-GABABR encephalitis, with 50% of patients presenting with seizures as an initial symptom. The prognosis of patients with acute symptomatic seizures can be improved after receiving immunotherapy. Nevertheless, a minority of patients will experience seizure recurrence; therefore, restarting immunotherapy is recommended.

Early antiseizure medication withdrawal and risk of seizure recurrence in children after epilepsy surgery: A retrospective study

OBJECTIVE

The timing of antiseizure medication (ASM) withdrawal in children after epilepsy surgery remains controversial and lacks recognized standards. Given the various negative effects of ASM on development in children, this study aimed to evaluate the safety and feasibility of early ASM withdrawal after epileptic resection surgery.

METHODS

We retrospectively assessed the seizure outcomes and ASM profiles of children who had undergone epileptic resection surgery between August 2015 and August 2020 and attempted ASM reduction in the early postoperative phase. Tapering the dose of ASM was attempted when children were seizure-free with no interictal epileptiform discharges (IEDs) on electroencephalogram (EEG) for at least 6 months postoperatively.

RESULTS

This study included 145 children with a median follow-up duration of 40 months. Early ASM tapering was attempted postoperatively in 99 (68.3 %) children. Postoperative ASM discontinuation was attempted in 87 (60.0 %) children. Nine (9.1 %) children experienced seizure recurrence during the ASM reduction stage, and 10 (11.5 %) experienced recurrence after ASM discontinuation. Incomplete resection (P = 0.003) and postoperative seizures before ASM tapering (P = 0.003) were independent predictors of seizure recurrence during and after early ASM withdrawal.

SIGNIFICANCE

ASM withdrawal is viable and safe to be initiated in children who are seizure-free postoperatively and have no IEDs on the scalp EEG for at least 6 months. Children with incomplete resection and postoperative seizures before ASM withdrawal are at a higher risk of seizure recurrence and may need to continue ASM for a longer period.

Seizure recurrences in generalized convulsive status epilepticus under sedation: What are its predictors and its impact on outcome?

BACKGROUND

Management of status epilepticus (SE) is focused on the early seizure termination. Refractory SE is an indication for sedation in patients with SE, but up to 75% of patients may be ventilated due to a neurological or respiratory failure. In patients requiring sedation, the clinical assessment is not sufficient to assess seizure control. Identifying those at risk of recurrent seizures could be useful to adapt their management. On the other hand, patients with low risk could benefit from an early withdrawal of sedation to avoid the impact of inappropriate sedation on outcome.

OBJECTIVE

To determine the prevalence and the predictors of uncontrolled SE and its impact on outcome in patients with generalized convulsive SE (GCSE) requiring mechanical ventilation (MV).

METHODS

We retrospectively included patients admitted to the intensive care unit with GCSE requiring MV. Uncontrolled SE was defined as persistent or recurrent seizures during sedation or within 24hours following withdrawal. A multivariable logistic regression model was used to assess the associated factors.

RESULTS

Uncontrolled SE occurred in 37 out of 220 patients (17%). Persistent seizures at admission, higher SAPS II and central nervous system infection were associated with a higher risk of uncontrolled SE. Acute toxic or metabolic etiologies were associated with a decreased risk of uncontrolled SE. In a supplementary analysis, decrease of albumin blood levels was associated with uncontrolled SE. Uncontrolled SE was associated with a poor functional outcome and mortality at 90 days.

CONCLUSIONS

Seventeen percent of patients with a GCSE requiring MV suffered from uncontrolled SE. Etiology and persistent seizures at admission were the main predictors of uncontrolled SE. Patients with uncontrolled SE had a longer duration of sedation and MV, a poor functional outcome and a higher mortality. Further studies are required to determine the impact of continuous electroencephalogram monitoring on the clinical course.

Risk factors and outcome of epilepsy in adults with cerebral palsy or intellectual disability

INTRODUCTION

Epilepsy is found in 10-60% of individuals with cerebral palsy (CP) and 5.5-35% with intellectual disability (ID). However, little is known about the long-term evolution of epilepsy among adults. The aim of the study is to describe the factors associated with epilepsy and its outcome in a population of adults with CP or ID.

METHODS

This retrospective study reviewed the medical records of 306 individuals with CP/ID. All individuals underwent neurological, psychiatric, and neuropsychological follow-ups.

RESULTS

In the cohort, 72.5% of the individuals had a CP diagnosis, with a mean age of 36.4 years (IQR 24.0-46.0). Epilepsy was present in 55.6% of the individuals and was associated with CP (p < 0.01), spastic subtype (p < 0.01), a higher degree of ID (p < 0.01), hemorrhagic and congenital malformation etiologies (p 0.011), abnormal neuroimaging (p < 0.01), and worse scores on motor and communication scales (p < 0.01). Drug-resistant epilepsy (DRE) (22.4%) was associated with higher scores on motor scales (p < 0.01). Additionally, 42.3% of the individuals who attempted antiseizure medication (ASM) withdrawal experienced recurrence, which was associated with epileptic activity on the electroencephalogram (EEG) (p 0.004).

CONCLUSIONS

Epilepsy is a common comorbidity in adults with CP or ID and is associated with greater brain damage and a more severe phenotype. Seizure recurrence after ASM withdrawal occurred in half of the individuals and was associated with epileptic activity on the EEG.

Antiseizure medications (antiepileptic drugs) in adults: starting, monitoring and stopping

Up to 10% of people living to 80 years of age have one or more seizures; and many will not require anti-seizure medication (ASMs). In 85% of patients, the diagnosis comes from the history of the index event. One-third of patients with an apparent "first seizure" have previous events, changing their diagnosis to epilepsy. Targeted investigations are important for classification and risk prediction. Patients with a low risk of seizure recurrence are not usually offered ASM treatment. High-risk patients have multiple seizures, neurological deficits, intellectual disability and/or relevant abnormal investigations; and are offered ASMs. Individual factors modulate this decision-making. Future integrated technologies offer the game-changing potential for seizure monitoring and prediction, but are not yet robust, convenient or affordable. Therapeutic drug monitoring in patients taking ASMs may confirm ASM toxicity, or when non-adherence, malabsorption, or rapid metabolism are suspected causes of breakthrough seizures. They are less useful when these factors are intermittent or irregular. Current evidence does not favour routine monitoring of serum levels, as it neither reliably predicts control, relapse, or adverse effects. The decision to discontinue ASM should follow a full discussion with the patient of risks and benefits. Along with population risk factors for seizure recurrence, the patient's lifestyle and preferences must be considered. ASM are usually discontinued in a slow step-wise fashion, one at a time, after at least two years of remission. Seizure recurrence risk plateaus only after 2 years following ASM discontinuation, and patients need access to specialist follow-up over that period.

Individualised prediction of drug resistance and seizure recurrence after medication withdrawal in people with juvenile myoclonic epilepsy: A systematic review and individual participant data meta-analysis

BACKGROUND

A third of people with juvenile myoclonic epilepsy (JME) are drug-resistant. Three-quarters have a seizure relapse when attempting to withdraw anti-seizure medication (ASM) after achieving seizure-freedom. It is currently impossible to predict who is likely to become drug-resistant and safely withdraw treatment. We aimed to identify predictors of drug resistance and seizure recurrence to allow for individualised prediction of treatment outcomes in people with JME.

METHODS

We performed an individual participant data (IPD) meta-analysis based on a systematic search in EMBASE and PubMed - last updated on March 11, 2021 - including prospective and retrospective observational studies reporting on treatment outcomes of people diagnosed with JME and available seizure outcome data after a minimum one-year follow-up. We invited authors to share standardised IPD to identify predictors of drug resistance using multivariable logistic regression. We excluded pseudo-resistant individuals. A subset who attempted to withdraw ASM was included in a multivariable proportional hazards analysis on seizure recurrence after ASM withdrawal. The study was registered at the Open Science Framework (OSF; https://osf.io/b9zjc/).

FINDINGS

Our search yielded 1641 articles; 53 were eligible, of which the authors of 24 studies agreed to collaborate by sharing IPD. Using data from 2518 people with JME, we found nine independent predictors of drug resistance: three seizure types, psychiatric comorbidities, catamenial epilepsy, epileptiform focality, ethnicity, history of CAE, family history of epilepsy, status epilepticus, and febrile seizures. Internal-external cross-validation of our multivariable model showed an area under the receiver operating characteristic curve of 0·70 (95%CI 0·68-0·72). Recurrence of seizures after ASM withdrawal (n = 368) was predicted by an earlier age at the start of withdrawal, shorter seizure-free interval and more currently used ASMs, resulting in an average internal-external cross-validation concordance-statistic of 0·70 (95%CI 0·68-0·73).

INTERPRETATION

We were able to predict and validate clinically relevant personalised treatment outcomes for people with JME. Individualised predictions are accessible as nomograms and web-based tools.

FUNDING

MING fonds.

Seizures and risks for recurrence in critically ill patients: an observational cohort study

Background

To assess the frequency and clinical characteristics of seizures in adult critically ill patients, to identify predictors of recurrent seizures not transforming into status epilepticus and to characterize their effects on course and outcome.

Methods

ICU patients at a Swiss academic medical center with seizures not transforming into status epilepticus from 2015 to 2020 were included. Recurrent seizures and associated clinical characteristics were primary, death, and return to premorbid neurologic function were secondary outcomes.

Results

Two hundred of 26,370 patients (0.8%) with a median age of 65 years had seizures during ICU stay. Seizure semiology was described in 82% (49% generalized; 33% focal) with impaired consciousness during seizures in 80% and motor symptoms in 62%. Recurrent seizures were reported in 71% (36% on EEG) and associated with longer mechanical ventilation (p = 0.031), higher consultation rate by neurologists (p < 0.001), and increased use of EEG (p < 0.001) when compared to single seizures. The use of EEG was not associated with secondary outcomes. Acidosis at seizure onset and prior emergency operations were associated with decreased odds for seizure recurrence (OR 0.43; 95% CI 0.20–0.94 and OR 0.48; 95% CI 0.24–0.97). Epilepsy had increased odds for seizure recurrence (OR 3.56; 95% CI 1.14–11.16).

Conclusions

Seizures in ICU patients are infrequent, but mostly recurrent, and associated with higher resource utilization. Whenever seizures are observed, clinicians should be vigilant about the increased risk of seizures recurrence and the need for antiseizure treatment must be carefully discussed. While known epilepsy seems to promote recurrent seizures, our results suggest that both acidosis and previous emergency surgery seem to have protective/antiseizure effects.

Trial registration

Clinicaltrials.gov (No. NCT03860467).

Recurrence rate of the first nonfebrile seizure in children with autism spectrum disorder

OBJECTIVE

Epilepsy prevalence is higher in children with Autism Spectrum Disorder (ASD) and is a contributor to morbidity and mortality. Little is known about the recurrence rate after the first nonfebrile seizure in this population, specifically in regard to seizure type and electroencephalogram (EEG) findings.

METHODS

We reviewed pediatric medical records at our institution between 2006 and 2016 for subjects with ASD who had a first seizure. We then looked for risk of a recurrent non-provoked seizure within the next two years.

RESULTS

Overall, the recurrence rate in this study was 70.9%. This is much higher than the general population. The recurrence rate was higher in patients who had a generalized convulsion compared to those who had a behavioral arrest. When the first seizure was a generalized convulsion, there was an 84% chance of developing a second convulsion, whereas the recurrence rate was 59% for behavioral arrest type seizures (p = 0.002). The odds of having recurrence when the first seizure is a generalized convulsion was 5.36 higher than when it was a behavioral arrest (95% CI 2.14-13.42, p < 0.001). An abnormal EEG was a strong predictor of seizure recurrence in both seizure types. However, even with a normal EEG, generalized convulsions were more likely to recur within 2 years compared to behavioral arrest (OR 6.3, 95% CI 2.1-19).

SIGNIFICANCE

The recurrence rate for nonfebrile seizures in children with ASD is much higher than the general population, especially for generalized convulsions. An abnormal EEG has a strong predictive value for seizure recurrence. However, even when the EEG is normal, the recurrence rate for generalized convulsions is quite high. This is an important finding as epilepsy contributes to morbidity and mortality in this group and may impact clinical decisions about when to start anti-seizure medications.

Risk factors affecting seizure recurrence in childhood epilepsy during short-term follow-up

PURPOSE

The aim of this study is to examine the factors affecting seizure recurrence in pediatric patients diagnosed with epilepsy.

METHODS

Three hundred patients presenting to the pediatric neurology clinic between 2015 and 2018 and diagnosed with epilepsy and treated with single antiseizure drug were included in the study. Medical histories and clinical and laboratory findings were retrieved retrospectively from the hospital data system. The combined and adjusted effects of risk factors on seizure recurrence were evaluated using multivariate binary logistic regression analysis.

RESULTS

Boys had a higher rate of seizure recurrence than girls. Seizure recurrence was also higher in patients with abnormal neurological examinations at the time of diagnosis compared to those with normal neurological examinations. Seizure recurrence was significantly higher in patients with global growth retardation. Epilepsy patients with abnormal MRI findings also had a higher rate of seizure recurrence than patients with normal neuroimaging findings. In addition, seizure recurrence was significantly higher in epilepsy patients with comorbidities such as cerebral palsy and autism spectrum disorders compared to patients without comorbidities. No significant association was observed between seizure recurrence and the first drug, perinatal asphyxia history, localization of epileptiform discharges on EEG, family history of epilepsy, family history of febrile seizures, history of stay in the neonatal intensive care unit during the perinatal period, or preterm delivery.

CONCLUSION

Abnormal neurological examination, abnormal neuroimaging and accompanying comorbidities, and global growth retardation at the time of diagnosis are important factors affecting seizure recurrence in pediatric patients with epilepsy.

Toward individualized prediction of seizure recurrence: Hippocampal neuroimaging features in a cohort of patients from a first seizure clinic

PURPOSE

We performed an exploratory analysis of electroencephalography (EEG) and neuroimaging data from a cohort of 51 patients with first seizure (FS) and new-onset epilepsy (NOE) to identify variables, or combinations of variables, that might discriminate between clinical trajectories over a one-year period and yield potential biomarkers of epileptogenesis.

METHODS

Patients underwent EEG, hippocampal and whole brain structural magnetic resonance imaging (MRI), diffusion tensor imaging (DTI), and magnetic resonance spectroscopy (MRS) within six weeks of the index seizure, and repeat neuroimaging one year later. We classified patients with FS as having had a single seizure (FS-SS) or having converted to epilepsy (FS-CON) after one year and performed logistic regression to identify combinations of variables that might discriminate between FS-SS and FS-CON, and between FS-SS and the combined group FS-CON + NOE. We performed paired t-tests to assess changes in quantitative variables over time.

RESULTS

Several combinations of variables derived from hippocampal structural MRI, DTI, and MRS provided excellent discrimination between FS-SS and FS-CON in our sample, with areas under the receiver operating curve (AUROC) ranging from 0.924 to 1. They also provided excellent discrimination between FS-SS and the combined group FS-CON + NOE in our sample, with AUROC ranging from 0.902 to 1. After one year, hippocampal fractional anisotropy (FA) increased bilaterally, hippocampal radial diffusivity (RD) decreased on the side with the larger initial measurement, and whole brain axial diffusivity (AD) increased in patients with FS-SS; hippocampal volume decreased on the side with the larger initial measurement, hippocampal FA increased bilaterally, hippocampal RD decreased bilaterally and whole brain AD, FA and mean diffusivity increased in the combined group FS-CON + NOE (corrected threshold for significance, q = 0.017).

CONCLUSION

We propose a prospective, multicenter study to develop and test models for the prediction of seizure recurrence in patients after a first seizure, based on hippocampal neuroimaging. Further longitudinal neuroimaging studies in patients with a first seizure and new-onset epilepsy may provide clues to the microstructural changes occurring at the earliest stages of epilepsy and yield biomarkers of epileptogenesis.

Gender differences in seizure recurrence and antiepileptic drug polytherapy predicting health-related quality of life of persons 1 year after diagnosis of epilepsy

PURPOSE

The aim of this study was to determine whether gender influences the prediction of health-related quality of life (HRQoL) in persons with newly diagnosed epilepsy (NDE).

METHODS

This was a 1-year longitudinal study. Persons with NDE were assessed with the Quality of Life in Epilepsy Inventory-31 (QOLIE-31), the Hospital Anxiety Depression Scale (HADS), the Stigma Scale, and the Rosenberg Self-esteem Scale. An analysis of covariance (ANCOVA) with interaction terms was used.

RESULTS

Among 134 adults with NDE, there were no gender differences in the scores of the QOLIE-31 and its subscales. A multivariate linear regression analysis showed that the HADS-anxiety scores at diagnosis (p = 0.005) and seizure recurrence after diagnosis (p = 0.050) negatively predicted QOLIE-31 scores in persons with NDE. There were significant effects of the gender interaction with seizure recurrence (F = 8.745, p = 0.004, partial eta² = 0.066) and antiepileptic drug (AED) polytherapy (F = 6.320, p = 0.013, partial eta² = 0.049) in the adjusted model. Specifically, seizure recurrence negatively predicted the QOLIE-31 scores only in men. By contrast, AED polytherapy negatively predicted the QOLIE-31 scores only in women.

CONCLUSIONS

There are gender differences in certain epilepsy-related factors predicting HRQoL at 1 year in persons with NDE.

Reversible splenial lesions during febrile illness with or without white matter lesions

OBJECTIVE

Reversible splenium lesions during febrile illness (RESLEF) are found in a spectrum. There are two types of corpus callosum (CC) lesions: CC-only type, with limited lesions and the CC (+) type, with extensive white-matter lesions. This retrospective study aimed to describe the differences in clinical findings between CC-only and CC (+) lesions and the association between onset age and clinico-radiological features in RESLEF.

METHODS

Fifty-two episodes of CC-only or CC (+) lesions accompanied by neurological symptoms, e.g., seizures, delirious behavior (DB), and disturbance of consciousness (DC), from January 2008 to October 2019 were included. We analyzed the etiology (pathogen), clinical course, laboratory data, magnetic resonance imaging and electroencephalography findings, therapy, and prognosis.

RESULTS

The rate of DC in the CC (+) was significantly higher than that in the CC-only group (5/6 [83%] vs 7/46 [15%]; p = 0.0016). The median number of seizures in the CC (+) was also significantly higher than that in the CC-only group (4 [0-7] vs 0 [0-7]; p = 0.034). Further, in RESLEF, the median onset age (months) in the seizure was significantly lower than that in the no-seizure group (39 [12-74] vs 83 [28-174]; p = 0.0007). The median onset age (months) in the DB was significantly higher than that in the no-DB group (74.5 [26-174] vs 28 [12-139]; p = 0.003).

CONCLUSIONS

In RESLEF, CC (+) is a more severe neurological symptom than CC-only. Furthermore, the onset age is related to the type of neurological symptoms that appear.

Effect of early withdrawal of phenobarbitone on the recurrence of neonatal seizures: An open-label randomized controlled trial

BACKGROUND

The long-term administration of phenobarbitone in neonates may be associated with adverse neurological outcome. The timing of stopping phenobarbitone maintenance after acute seizure control in neonates is a matter of debate.

OBJECTIVES

To study the effect of early withdrawal of phenobarbitone on recurrence of neonatal seizures.

STUDY DESIGN

Open-label randomized controlled trial.

PARTICIPANTS

Outborn neonates (≥34 weeks of gestation to <28 days of postnatal period) with seizures (n = 221) admitted to Neonatal unit in Pediatric emergency of a tertiary care hospital in north India over 1 year.

INTERVENTION

After a loading dose of phenobarbitone (20 mg/kg), neonates who remained seizure free for at least 12 h were enrolled after written informed consent from parents, and randomized (computer generated block randomization) to 'phenobarbitone withdrawal group' (n = 112) where phenobarbitone maintenance was stopped and 'phenobarbitone continued group' (n = 109) where phenobarbitone maintenance was continued until discharge and further as per clinician's discretion.

OUTCOMES

The primary outcome was seizure recurrence until discharge and secondary outcomes were time to reach full enteral feeds, duration of hospital stay, abnormal neurological status at discharge, and mortality in two groups.

RESULTS

The baseline variables were comparable in 2 groups. The incidence of seizure recurrence was similar in the phenobarbitone withdrawal and phenobarbitone continued groups (50% vs. 37.6%, respectively, p = 0.078). Among secondary outcomes, the phenobarbitone withdrawal and continued groups had similar time to reach full enteral feeds (4.02 days vs. 4.2 days, p = 0.75), duration of hospital stay (6.3 days vs. 6.5 days, p = 0.23), abnormal neurological status at discharge (45.6% vs. 38%, p = 0.39), and mortality (11.6% vs. 8.3%, p = 0.50).

CONCLUSION

Early withdrawal of phenobarbitone in neonatal seizures does not lead to a significant increase in the rate of seizure recurrence.

Discontinuation of antiseizure medications in seizure-free patients with long-term follow-up: Patients' profile, seizure recurrence, and risk factors

OBJECTIVE

To compare withdrawal of antiseizure medications (ASM) to continued treatment in newly diagnosed individuals achieving seizure freedom, and assess the risk of relapse and factors associated with relapse.

METHODS

This is a multicenter retrospective cohort study with long-term follow-up. Patients with newly diagnosed epilepsy were identified from the medical records of 13 Italian epilepsy centers and followed up until the most recent visit or death. Seizure-free patients discontinuing treatment were compared to patients who maintained treatment for baseline characteristics. Treatment was stopped upon clinical judgment. The probability of relapse was calculated with the Kaplan-Meier method. Demographic, clinical, and instrumental variables associated with relapse were assessed with Cox proportional hazards models.

RESULTS

One thousand and six patients aged 1 month to 72 years at diagnosis were enrolled and followed up for 17,892 person-years (median follow-up, 9.9 years). Three hundred and twenty patients (31.8%) underwent one or more treatment discontinuations. Factors associated with ASM withdrawal were younger age at remission and normal psychiatric examination. The probability of relapse after the first withdrawal was 16% at six months, 24% at 12 months, and 36%, 45%, and 53% at three, five, and ten years, respectively. The probability of remission after the first relapse was 59% at one month, 67%, 72, and 76% at three, six, and 12 months, respectively. Variables associated with relapse were age 14+ years, structural etiology, abnormal neuroimaging, ASM initiation after a single seizure, and symptomatic/cryptogenic epilepsy.

CONCLUSIONS

About one half of seizure-free patients stopping ASM relapse in 10 years. However, the possibility of remission after relapse is high, particularly in children and patients with idiopathic/cryptogenic epilepsy. Treatment deprescription might be encouraged at least in these patients.

Spike wave characteristics and temporal spike evolution on serial EEG in childhood epilepsy with centrotemporal spikes

PURPOSE

To assess the spike characteristics and temporal spike evolution on serial EEG of children with childhood epilepsy with centrotemporal spikes (CECTS) treated with anti-seizure medication.

METHODS

The study cohort consisted of 127 children with CECTS divided into three groups based on anti-seizure medication responsiveness: group I: seizure-free with monotherapy (n: 61, 48%), group II: seizure-controlled with monotherapy (n: 52, 41%) and group III: seizure-controlled with dual therapy (n: 14, 11%). The clinical profiles and sequential four-year follow-up visual EEG recordings of the children were evaluated. Each EEG was reanalyzed with three spike characteristics on the epochs: (1) spike-wave rate, (2) spike topography, and (3) spike localization. We calculated the spike clearance velocity, which is defined as a decrease in the spike-wave rate over time in four-year sequential follow-up EEGs.

RESULTS

There was no statistical significance across the study groups with respect to initial EEG spike characteristics (spike-wave rate, spike localization, and spike topography). Seizure recurrence occurred in 15 patients (12.8%) who discontinued anti-seizure medication. There was no statistically significant difference between the spike characteristics on EEG just before the discontinuation of anti-seizure medication and seizure recurrence. However, the spike clearance velocity was significantly slower in group III than in group I in four-year sequential follow-up EEGs (p = 0.002). A statistically significant decrease in the mean spike-wave rate was observed in group I in the first year of anti-seizure medication (p<0.001). The spike clearance velocity was also more prominent during the second year of treatment in group II and the third year of treatment in group III. However, the spike clearance velocity was not different across the anti-seizure medication groups (oxcarbazepine, valproic acid, and levetiracetam).

CONCLUSION

Spike clearance velocity might be a valuable EEG marker to guide anti-seizure medication in children with CECTS.

"Neurological manifestations of COVID-19" - guideline of the German society of neurology

Infection with the new severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) leads to a previously unknown clinical picture, which is known as COVID-19 (COrona VIrus Disease-2019) and was first described in the Hubei region of China. The SARS-CoV-2 pandemic has implications for all areas of medicine. It directly and indirectly affects the care of neurological diseases. SARS-CoV-2 infection may be associated with an increased incidence of neurological manifestations such as encephalopathy and encephalomyelitis, ischemic stroke and intracerebral hemorrhage, anosmia and neuromuscular diseases. In October 2020, the German Society of Neurology (DGN, Deutsche Gesellschaft für Neurologie) published the first guideline on the neurological manifestations of the new infection. This S1 guideline provides guidance for the care of patients with SARS-CoV-2 infection regarding neurological manifestations, patients with neurological disease with and without SARS-CoV-2 infection, and for the protection of healthcare workers. This is an abbreviated version of the guideline issued by the German Neurological society and published in the Guideline repository of the AWMF (Working Group of Scientific Medical Societies; Arbeitsgemeinschaft wissenschaftlicher Medizinischer Fachgesellschaften).

The effect of COVID-19 pandemic on seizure control and self-reported stress on patient with epilepsy

OBJECTIVES

The objective of the study was to assess if patients with epilepsy (PWE) experienced an increase in seizure frequency and self-reported stress during the COVID-19 pandemic.

METHODS

This is a cross-sectional study conducted in Saudi Arabia in April 2020. An electronic self-administered questionnaire was distributed to PWE via their treating neurologist. The variables included were demographic and baseline clinical characteristics (age, gender, living situation, occupational status, type of epilepsy, duration of epilepsy, number of antiepileptic medications (AEDs), presence of known psychiatric illness, and use of psychiatric medications), their seizure control in the month prior to the pandemic, perceived stress during this period of time, sleep changes, compliance changes, and change in seizure control during the pandemic.

RESULTS

A total of 156 patients completed the questionnaire, with 29.5% reporting an increase in seizure frequency. Additionally, 59.4% reported an increase in self-reported stress and 71.2% experienced a significant change in their sleep during this period. Higher baseline seizure frequency, more AEDs, noncompliance, increase in self-reported stress, and sleep changes are the significant factors associated with increase in seizure frequency during the pandemic.

CONCLUSION

Identifying high-risk patients for seizure recurrence is important in order to provide them with adequate support to reduce such risk.

Predictors of early recurrent seizure after first seizure presentation to an emergency service: A retrospective cohort study

PURPOSE

To identify the predictors of seizure recurrence after a first seizure (FS) presentation to an emergency service.

METHODS

The clinical characteristics of FS patients presenting to the emergency department (ED) of our university hospital from January 2001 to December 2014 were retrospectively reviewed. Recurrence of seizures following the FS was classified as: early recurrence (0-1 month), intermediate recurrence (>1-3 months), and late recurrence (>3-12 months). The significant predictors of seizure recurrence in each period were identified by Cox proportional hazard ratios (p < 0.05).

RESULTS

648 FS patients of the 1248 overall seizures patients were initially enrolled. 414 FS patients were eligible for statistical analysis. Following the FS, 134 patients (32.4%) had recurrent seizures in which half of the first recurrences occurred within 3 months. The significant predictors of overall recurrence were remote symptomatic seizure (RSS) (adjusted hazard ratio [adj. HR] = 2.21 (1.38, 3.55), p = 0.003) and nocturnal onset seizure (NOS) (adj. HR = 1.53 (1.03, 2.26), p = 0.039). Those of early recurrence were NOS (adj. HR = 2.78 (1.44, 5.37), p = 0.002) and anti-epileptic drug (AED) prescription (adj. HR = 2.19 (1.00, 4.80), p = 0.038). Those of intermediate recurrence were RSS (adj. HR = 3.96 (1.63, 9.60), p = 0.006) and AED prescription (adj. HR = 4.90 (1.42, 16.95), p = 0.003). No predictor of late recurrence was identified.

CONCLUSION

The seizure recurrence rate was high in the first 3 months following the FS. The significant predictors were RSS, NOS and AED prescription.

Short-term risk of relapse after a first unprovoked seizure in an adult population

OBJECTIVE

To evaluate the incidence of short-term recurrence (<1 month) after a first unprovoked seizure (FUS) and the associated risk factors.

METHODS

This is a prospective monocentric one-year observational study on all consecutive adult patients admitted to the Emergency Department (ED) and diagnosed as FUS. Patients underwent neurological consultation at one and three months after the FUS. Demographic information, clinical examination and seizure features, seizure recurrence at 1 and 3 months, electroencephalogram (EEG), brain imaging, precipitating factors, seizure type, and prescribed antiepileptic drugs (AED) were prospectively collected.

RESULTS

Among 140 patients diagnosed as FUS, 109 patients attended the neurological consultation at 1 month. FUS diagnosis was confirmed in 80/109 cases. Nine patients (11.2%) had seizure recurrence before the consultation at 1 month. Identified specific risk factors of short-term recurrence were focal seizure (P=0.015) and abnormal EEG in the first 48hours (P=0.048). In the group of patients followed for three months (38 patients), the risk of seizure relapse was 15.7%.

CONCLUSION

Most patients with FUS diagnosed in the ED did not present seizure recurrence within the first month, especially if no specific risk factors were present (focal seizure, abnormal EEG within first 48hours). The systematic use of prophylactic AED (benzodiazepines) is not recommended in the ED in the clinical setting of FUS. A specialized consultation within a one-month period is safe and adequate for FUS follow-up.

Effects of a brief psychotherapeutic intervention on resilience and behavior in patients with drug-resistant mesial temporal lobe epilepsy and late seizure recurrence after surgery

Seizure recurrence (SR) after epilepsy surgery in patients with medically resistant temporal lobe epilepsy and mesial temporal sclerosis (TLE-MTS) can compromise medical treatment and quality of life (QOL). However, there is a scarcity of interventions specifically addressing this issue in the literature. We aimed to evaluate the impact of a four-week psychotherapeutic intervention on the levels of resilience, behavioral symptoms, and QOL of patients with drug-resistant TLE-MTS who underwent corticoamygdalohippocampectomy (CAH) and who presented with late SR. Fifty patients who had been diagnosed with TLE-TMS, undergone CAH, and presented with late SR were included. The study instruments included a clinical and sociodemographic questionnaire and the Brazilian versions of the Connor-Davidson Resilience Scale (CD-RISC-10), the Neurological Disorders Depression Inventory for Epilepsy (NDDI-E), the Interictal Dysphoric Disorder Inventory (IDDI), and the Quality of Life in Epilepsy Inventory (QOLIE-31). Significant reductions in the IDDI (p < 0.001) and NDDI-E (p < 0.001) scores, improvements in the CD-RISC-10 (p < 0.001) and QOLIE-31 (p < 0.001) scores, and positive correlations between resilience levels and QOL (p < 0.01), as well as a negative correlation between depressive symptoms and resilience (p < 0.01) and QOL (p < 0.01), were observed after the psychotherapeutic intervention. Improvements in the resilience levels and QOL, with concomitant reductions in depressive symptoms, were observed in patients with TLE-MTS and late SR after a brief psychotherapeutic intervention. Since there is a lack of studies that measured the impact of interventions in this patient subpopulation, these results may support the development of treatment strategies for this specific group.

Predictors of seizure recurrence in patients with surgery for focal cortical dysplasia: pairwise and network meta-analysis and trial sequential analysis

OBJECT

The aim of this study was to determine the predictors of seizure recurrence in surgery for focal cortical dysplasia (FCD) by conducting a meta-analysis.

METHODS

Publications that met the pre-stated inclusion criteria were selected from PubMed and CNKI databases. Two authors extracted data independently about prognostic factors, surgical outcome, and clinical characteristics of participants. A fixed-effects model was used to calculate the summary of odds ratio (OR) with 95% confidence interval (CI).

RESULTS

Forty-eight studies were included in our meta-analysis. Three predictors of seizure recurrence (Engel class III/IV)-histological FCD type I, incomplete resection, and extratemporal location were determined; combined OR with 95% CI were 1.94 (95%CI 1.53-2.46), 12.06 (95%CI 7.32-19.88), and 1.91 (95%CI 1.06-3.44), respectively. Trial sequential analysis revealed that the outcomes had a sufficient sample size to reach firm conclusions. Furthermore, seizure location was not substantially modified by geographic region, while histological FCD type I and incomplete resection showed a significant association with seizure recurrence in different continents except Asia for incomplete resection. Sensitivity analyses restricted to studies for each variable yielded robust results. Little evidence of publication bias was observed. Meanwhile, the difference in the standard for outcome failed to influence the results for prognosis. Network meta-analysis including 13 trials comparing subtypes of FCD found the FCD IIb had the lowest seizure recurrence rate.

CONCLUSIONS

This meta-analysis suggests that histological FCD type I, incomplete resection, and extratemporal location are recurrence factors in patients with epilepsy surgery for FCD. In addition, FCD IIb is associated with the highest rates of postoperative seizure control among the subtypes of FCD, type I and type II.

A Novel Protocol to Reduce Early Seizures After Cranioplasty: A Single-Center Experience

BACKGROUND

Cranioplasty is a relatively simple and straightforward intervention; however, it is associated with a high incidence of postoperative seizures. Postcranioplasty seizures, especially early seizures, are common and associated with poor outcomes and longer hospital stays. Protocols for preventing and managing early seizures have not been well established.

METHODS

The medical records of 595 patients who underwent cranioplasty were retrospectively reviewed. Of these patients, 259 had preexisting seizures and 336 had no seizures before cranioplasty. Prophylactic antiepileptic drugs (AEDs) were administered to patients who had no seizures before cranioplasty for 1 week, whereas an advanced AED regimen was administered to patients with preexisting seizures. Subsequently, clinical characteristics, occurrence of recurrent seizures, early seizures, and postoperative complications were analyzed.

RESULTS

Our previous study showed positive results for prophylaxis in new-onset early seizures. In the patients with preexisting seizures, 46.7% of the patients (121/259) experienced recurrent seizures after cranioplasty and 17.4% of the patients (45/259) experienced early recurrent seizures within 1 week of their operation. In the group who received the advanced AEDs, early recurrent seizures were significantly reduced to 8.7% compared with the regular group (20.5%; P = 0.027). Younger age and preoperative hydrocephalus engendered a higher risk of recurrent seizures. The number of previous craniotomies was observed to have a trend of increasing early recurrent seizures.

CONCLUSIONS

Cranioplasty is associated with a high incidence of postoperative seizures. Our management protocol for postcranioplasty seizures includes seizure prophylaxis and advanced use of AEDs, which can reduce the occurrence of early seizures.

Serial changes in the paroxysmal discharges in rolandic epilepsy may predict seizure recurrence: A retrospective 3-year follow-up study

OBJECTIVE

The aim of this study was to assess the electrographic criteria related to seizure recurrence and determine age-related seizure recurrence in children with rolandic epilepsy under long-term follow-up.

METHODS

We retrospectively analyzed the data belonging to 109 patients with rolandic epilepsy with sufficient information regarding disease course and follow-up duration longer than 3years. Patients were divided into two categories: Group A (n: 75), comprised of "patients having fewer than four seizures", and Group B (n: 34), the "recurrence group comprised of patients having more than four seizures in the first three months". The number of spikes per minute during both wakefulness and sleep, the localization of spikes other than centrotemporal region, and the duration of spike-wave activity were evaluated longitudinally, with repeated electroencephalogram (EEG) recordings every 6months.

RESULTS

The appearance of rolandic spikes in awake EEGs tended to be more prevalent in Group B than Group A. In Group B, spike rates significantly increased in the 12 and 18months after onset whereas spike rates increased significantly only 6months after onset in Group A. Seizure recurrence is mostly seen at 6-8years, and improvement becomes evident by age 12. The mean number of paroxysmal rolandic discharges during sleep was significantly higher in the younger age groups (3-5, 6-8), and the mean number of spikes per minute significantly decreased at ages 9-11 and over 12.

CONCLUSION

Our study demonstrates that extended periods of high frequency of paroxysmal discharges, initial frontal EEG focus, and persistence of awake interictal abnormalities are highly effective in predicting seizure recurrence in patients with rolandic epilepsy (RE).

Risk factors for post-stroke seizure recurrence after the first episode

PURPOSE

Seizure is a common complication after stroke. However, the clinical characteristics, treatment, and recurrence rates in patients with the first episode of post-stroke seizure remain unclarified. The aim of this study was to identify the predictors of seizure recurrence in those patients.

METHOD

We retrospectively identified patients admitted to our hospital between July 2010 and June 2014 and followed-up until June 2015 because of the first episode of post-stroke seizure. We classified post-stroke seizure as early (within one week after stroke) or late (in the second week or later). We compared the baseline clinical characteristics and treatment between the groups and investigated the factors that determined seizure recurrence by Cox proportional hazards model.

RESULTS

A total of 153 patients (84 men; mean age, 73.7±12.3years; 73 hemorrhagic and 80 ischemic strokes; 63 early and 90 late seizure) were included. Compared with the late seizure group, the early seizure group more frequently manifested with status epilepticus; tended to less often undergo stereotactic aspiration of hematoma; and less frequently used anti-epileptic drugs. During the observation period (median 364days, IQR 124-680days), 40 patients were lost to follow-up; subsequently, 113 patients were included in the analysis. The early seizure group had lower survival and seizure recurrence rates than the late seizure group. The factors significantly associated with seizure recurrence were presence of status epilepticus in the early group (HR 4.75, 95% CI 1.28-17.62) and younger age in the late seizure group (HR 0.95, 95% CI 0.93-0.99).

CONCLUSIONS

In patients with post-stroke seizure, status epilepticus and younger age were the predictors of recurrence after early and late seizure, respectively.

Clinical predictors of seizure recurrence after the first post-ischemic stroke seizure

Background

The number of patients suffering post-stroke seizure after ischemic stroke (PSSi) is quite considerable, especially because ischemic stroke is more prevalent than hemorrhage in the general population. This study aimed to determine the predicting factors for seizure recurrence in ischemic stroke survivors and develop a clinical scoring system for the prediction of risks for seizure recurrence after the first PSSi.

Methods

We reviewed 3792 ischemic stroke patients from the Ewha Stroke Registry. A total of 124 (3.3 %) patients who experienced PSSi were recruited (mean follow-up for 44.4 months). Medical records concerning the etiology, functional disability, seizure onset latency from stroke, type of seizure, electroencephalography (EEG), and neuroimaging findings were statistically analyzed to derive a seizure recurrence risk scoring system.

Results

Seizures recurred in 35.4 % (17/48) of early PSSi patients (≤1 week since stroke onset) and 48.7 % (37/76) of late PSSi (>1 week) patients. Atrial fibrillation, large sized, and cortical stroke lesion were more common in late onset PSSi compared to those in early onset PSSi (p < 0.05). Seizure recurrence tended to be more prevalent in early PSSi patients with male gender, atrial fibrillation or cortical stroke lesion, severe functional disability, and partial seizures. Seizure recurrence in late PSSi group was more common in patients of young age (≤65 years old), male gender, large lesion size, and partial seizure type. The validity of seizure recurrence risk score in the early PSSi group was better when evaluating based on gender, atrial fibrillation, cortical lesion, functional disability, and partial seizure type, with sensitivity of 70.6 % and specificity of 71.0 %.

Conclusions

Our study characterized the high risk group for seizure recurrence in patients with the first PSSi. PSSi patients with high risk score of seizure recurrence had a greater chance of developing epilepsy later. Therefore, they should be considered for further treatment such as antiepileptic drug medication in clinical practice.

Mozart's music in children with drug-refractory epileptic encephalopathies

Mozart's sonata for two pianos in D major, K448, has been shown to decrease interictal EEG discharges and recurrence of clinical seizures in both adults and young patients. In this prospective, open-label study, we evaluated the effect of listening to a set of Mozart's compositions, according to the Tomatis method, on sleep quality and behavioral disorders, including auto-/hetero-aggression, irritability, and hyperactivity, in a group of children and adolescents with drug-resistant epilepsy. The study group was composed of 11 outpatients (7 males and 4 females), between 1.5years and 21years of age (mean age: 11.9years), all suffering from drug-resistant epileptic encephalopathy (n=11). All of them had a severe/profound intellectual disability associated with cerebral palsy. During the study period, each patient had to listen to a set of Mozart's compositions 2h per day for fifteen days for a total of 30h, which could be distributed over the day depending on the habits and compliance of each patient. The music was filtered by a device preferably delivering higher sound frequencies (>3000Hz) according to the Tomatis principles. The antiepileptic drug therapy remained unchanged throughout the study period. During the 15-day music therapy, 2 out of 11 patients had a reduction of 50-75% in seizure recurrence, and 3 out of 12 patients had a reduction of 75-89%. Overall, 5 (45.4%) out of 11 patients had a ≥50% reduction in the total number of seizures, while the percentage decrease of the total seizure number (11/11) compared with baseline was -51.5% during the 15-day music therapy and -20.7% in the two weeks after the end of treatment. All responders also had an improvement in nighttime sleep and daytime behavior.

Can venous blood gas analysis be used for predicting seizure recurrence in emergency department?

BACKGROUND

Epileptic seizures account for 1%-2% of all admissions of patients to the emergency department (ED). The present study aimed to determine whether venous blood pH, bicarbonate, base excess, and lactate levels taken within 1 hour of the last seizure episode help to determine seizure recurrence in emergency departments.

METHODS

A cross-sectional study was conducted in the emergency department (ED) between January and July, 2012. Patients who were admitted to the emergency department consecutively were included in the study if they were 14 years or older and within 1 hour after last seizure. Demographics, seizure type, use of antiepileptic drugs, observation period at the emergency department, seizure recurrence, pH, bicarbonate, base excess, and lactate levels from venous blood gas analysis were determined.

RESULTS

A total of 94 patients aged 14 years or older were included in the study. Of these patients, 10.6% (n=10) experienced recurrent seizures in the observation period at the emergency department. To predict recurrent seizures in ED, threshold venous blood gas values were determined as follows: pH<7.245 [sensitivity 80% (95%CI: 44-96), negative predictive value 96.9% (95%CI: 88.3-99.4)], bicarbonate<17.1 mmol/L [sensitivity 80% (95%CI: 44-96), negative predictive value 97% (95%CI: 89-99.5)], base excess<-11.1 mEq/L [sensitivity 80% (95%CI: 44-96), negative predictive value 97% (95%CI: 89-99)], and lactate>7.65 mmol/L [sensitivity 80% (95%CI: 44-96), negative predictive value 96.6% (95%CI: 87-99)].

CONCLUSION

If venous blood gas analysis is made on pH, base excess, lactate and bicarbonate immediately one hour after the last epileptic seizure episode, it is possible to predict whether the patient will have seizure recurrence.

Sequential EEG characteristics may predict seizure recurrence in rolandic epilepsy

PURPOSE

The prognosis of rolandic epilepsy (RE) is considered favorable. Since a moderate proportion of cases presents with isolated seizures, continuous treatment should be considered only for frequent seizures. Clinical and electroencephalogram (EEG) markers to predict seizure recurrence need to be identified. The purpose of this study was to identify EEG criteria related to seizure recurrence in RE.

METHODS

There were 10 children (aged 3-10 years; 6 males, 4 females) in the recurrence group and 12 (aged 4-7 years; 6 males, 6 females) in the isolated group. Occurrences of the number of spikes were scored, and the presence of rolandic discharges (RD) in the awake record was evaluated. All patients were evaluated longitudinally, clinically and by EEG, with repeated EEG recordings every 3 months. Clinical and EEG follow-up was performed for ≥4 years.

RESULTS

Seizure recurrence and extended periods of high-frequency paroxysmal EEG abnormalities (>6 months after onset) were significantly correlated (p<0.001). Moreover, the appearance of RD in awake recordings tended to be more prevalent in the recurrence group than in the isolated group (odds ratio 4.714).

CONCLUSION

In addition to RD in the awake record, a combination of spike rate and extended periods of high-frequency paroxysmal EEG abnormalities may predict seizure recurrence in RE.

Clinical profile of Solitary Seizures

BACKGROUND

Solitary seizure is one of the controversies in neurology. This study was taken up to study the clinical profile of solitary seizure and the factors related to seizure recurrence with a view to evolve guidelines for management.

METHODS

We studied 150 cases of solitary seizure. All our patients were males. The age varied from 18-52 years. The diagnosis of seizure was confirmed with history. Apart from clinical neurological examination, blood counts, urinalysis and screening investigations to exclude possible underlying metabolic disorders were done. Inter-ictal EEG and contrast enhanced CT scan were done.

RESULTS

CT scan was abnormal in 28 cases. EEG was abnormal in 33; clinical abnormality was noted in 15 cases. Median follow up duration was 1.2 years. 18 patients had seizure recurrence. Type of seizure, EEG findings (normal or abnormal) and treatment with antiepileptic drugs did not have any effect on seizure recurrence. Seizure recurrence was less common in presence of CT scan abnormality though it was not significant statistically. Routine laboratory tests of blood count, blood sugar and urinalysis were normal in all cases.

CONCLUSION

In cases of solitary seizure, type of seizure, results of EEG and CT scan findings are not likely to predict seizure recurrence. Treatment with antiepileptic drugs does not prevent seizure recurrence. Laboratory investigations like blood counts, urinalysis and blood sugar estimation are unlikely to be of value in routine work-up of these cases.