Use of perampanel oral suspension for the treatment of refractory and super-refractory status epilepticus

INTRODUCTION

Status epilepticus (SE) is a medical emergency associated with a significant risk of disability and death. The treatment of SE follows a step-wise approach, with limited data on ideal antiseizure medications (ASMs) for refractory and super refractory SE (RSE/SRSE). Perampanel (PER), an AMPA receptor antagonist, has shown promise in animal models but still has limited data in humans. This study tried to evaluate optimal dosage and safety of PER in RSE and SRSE patients.

MATERIALS AND METHODS

We retrospectively analysed 17 adult patients with RSE (1) or SRSE (16) treated with PER. Demographic and clinical data, including EEG patterns, ASMs administered, PER dosages, and PER plasma concentrations, were collected. For patients receiving a 24 mg PER loading dose (full dose group), the following treatment regimen was applied: 24 mg per day for 48 h following by 16 mg per day. The response to PER was assessed based on electroencephalographic (EEG) improvement from high to low epileptiform activity or from low to the absence of epileptiform activities. Safety was evaluated monitoring hepatic and renal function.

RESULTS

A response rate of 58.82 % was observed, with significantly higher responses in the full dose group (81.82 %) compared to those receiving PER doses below 24 mg (low dose group) (16.67 %) (p-value = 0.004; OR 0.044, 95 % CI 0.003 to 0.621, p = 0.021). No other clinical factors significantly influenced treatment response. Hepatic enzymes become elevated in most patients (70.59 %) but spontaneously decreased.

DISCUSSION

Our findings suggest that a 24 mg PER dose administered for 48 h may be more effective in managing RSE and SRSE compared to doses below 24 mg, potentially due to pharmacokinetic factors.

CONCLUSION

More robust data on PER in RSE and SRSE, including standardized dosing procedures and plasma level monitoring are needed. PER's potential benefits should be explored further, particularly in patients with RSE and SRSE.

First-line levetiracetam versus enzyme-inducing antiseizure medication in glioma patients with epilepsy

OBJECTIVE

This study aimed to directly compare the effectiveness of first-line monotherapy levetiracetam (LEV) versus enzyme-inducing antiseizure medications (EIASMs) in glioma patients.

METHODS

In this nationwide retrospective observational cohort study, Grade 2-4 glioma patients were included, with a maximum duration of follow-up of 36 months. Primary outcome was antiseizure medication (ASM) treatment failure for any reason, and secondary outcomes were treatment failure due to uncontrolled seizures and due to adverse effects. For estimation of the association between ASM treatment and ASM treatment failure, multivariate cause-specific cox proportional hazard models were estimated, adjusting for potential confounders.

RESULTS

In the original cohort, a total of 808 brain tumor patients with epilepsy were included, of whom 109 glioma patients were prescribed first-line LEV and 183 glioma patients first-line EIASMs. The EIASM group had a significantly higher risk of treatment failure for any reason compared to LEV (adjusted hazard ratio [aHR] = 1.82, 95% confidence interval [CI] = 1.20-2.75, p = .005). Treatment failure due to uncontrolled seizures did not differ significantly between EIASMs and LEV (aHR = 1.32, 95% CI = .78-2.25, p = .300), but treatment failure due to adverse effects differed significantly (aHR = 4.87, 95% CI = 1.89-12.55, p = .001).

SIGNIFICANCE

In this study, it was demonstrated that LEV had a significantly better effectiveness (i.e., less ASM treatment failure for any reason or due to adverse effects) compared to EIASMs, supporting the current neuro-oncology guideline recommendations to avoid EIASMs in glioma patients.

OS02.6.A Lacosamide in monotherapy in brain tumour-related epilepsy (BTRE): results from an Italian multicentre retrospective study

Background

Lacosamide (LCM) is a third-generation anti-seizure medication (ASM) approved for focal onset epilepsy in patients aged ≥4 years. Previous studies have reported an efficacy of LCM as add-on treatment in brain tumour-related epilepsy (BTRE). To date, there are no studies in the literature focusing on lacosamide used in monotherapy to treat BTRE. In our retrospective study we investigated efficacy and tolerability of LCM in monotherapy in a multicentre national cohort of primary brain tumour patients.

Patients and Methods

Adult patients who were treated with LCM in monotherapy were collected from 12 Italian Centres (either mainly involved in neuro-oncology or in epileptology). Main inclusion criteria were diagnosis of primary brain tumour; at least two focal-onset seizures in the disease course; LCM used either as primary or secondary monotherapy after withdrawal of previous ASMs. For each patient, we evaluated seizure freedom at 3 and 6 months (primary endpoints), side effects and drop-out rate (secondary endpoints).

Results

We collected 132 patients. The majority of patients had a diagnosis of diffuse gliomas, being those with lower-grade glioma 66 (50.0%) and those with glioblastoma 33 (25.0%). Overall, LCM led to seizure-freedom in 64.4% of patients at 3 months and 55% at 6 months. Patients who used two or more ASMs before LCM had a worse seizure control than patients in monotherapy with LCM as first choice.In 14 patients, we observed seizure control despite tumour progression on magnetic resonance (MRI). Multivariate analysis showed that gross-total resection at diagnosis and use of steroids were significantly associated with higher seizure freedom rate at 6 months. Side effects were mainly mild (grade 1-2 according to the CTCAE classification), and the drop-out rate was low (1.5%). The main side effects were dizziness and somnolence.

Conclusion

This is the first study on the role of LCM in monotherapy in BTRE. The study has shown a good efficacy and tolerability of LCM with more than a half of patients becoming seizure-free at 6 months and with a very low rate of drop-out. Further studies are needed to confirm these preliminary data in a prospective manner, adding quality of life and neurocognitive functions as endpoints.

Osmophobia in Migraine and Tension-Type Headache and Its Clinical Features in Patients With Migraine

Intolerance to smell is often reported by migraine patients. This study evaluates osmophobia in connection with the diagnosis of migraine and episodic tension-type headache (ETTH). The characteristics of this symptom are also investigated. We recruited from our Headache Centre 1005 patients (772 female, 233 male; age 37 ± 11 years), of whom 677 were migraine without aura (MoA), 130 migraine with aura (MA) and 198 TTH. Patients with two or more forms of primary headache were excluded. Among migraine patients, 43.9% with MoA and 38.5% with MA reported osmophobia during the attacks; none of the 198 TTH patients suffered this symptom. Most frequently offending odours were scents (63.9%), food (55.2%) and cigarette smoke (54.8%). Osmophobia appears structurally integrated into the migraine history of the patient. It seems to be a peculiar symptom favouring the diagnosis of migraine (MoA and MA) in the differential diagnosis with ETTH.

Cluster-like headache. A comprehensive reappraisal

Among the primary headaches, cluster headache (CH) presents very particular features allowing a relatively easy diagnosis based on criteria listed in Chapter 3 of the International Classification of Headache Disorders (ICHD-II). However, as in all primary headaches, possible underlying causal conditions must be excluded to rule out a secondary cluster-like headache (CLH). The observation of some cases with clinical features mimicking primary CH, but of secondary origin, led us to perform an extended review of CLH reports in the literature. We identified 156 CLH cases published from 1975 to 2008. The more frequent pathologies in association with CLH were the vascular ones (38.5%, n = 57), followed by tumours (25.7%, n = 38) and inflammatory infectious diseases (13.5%, n = 20). Eighty were excluded from further analysis, because of inadequate information. The remaining 76 were divided into two groups: those that satisfied the ICHD-II diagnostic criteria for CH, 'fulfilling' group (F), n = 38; and those with a symptomatology in disagreement with one or more ICHD-II criteria, 'not fulfilling' group (NF), n = 38. Among the aims of this study was the possible identification of clinical features leading to the suspicion of a symptomatic origin. In the differential diagnosis with CH, red flags resulted both for F and NF, older age at onset; for NF, abnormal neurological/general examination (73.6%), duration (34.2%), frequency (15.8%) and localization (10.5%) of the attacks. We stress the fact that, on first observation, 50% of CLH presented as F cases, perfectly mimicking CH. Therefore, the importance of accurate, clinical evaluation and of neuroimaging cannot be overestimated.

Development of a ICHD-II based computerised system for the general practitioner

We present a computerised programme designed for use in the office of a general practitioner. The system provides an assisted diagnosis according to the ICHD–II criteria for the principal forms of primary headaches (migraine, tension–type headache, cluster headache) and highlights the red flags of a possible secondary headache. A relevant feature is that explanations for the selection of a particular diagnosis are given at the end of the process; furthermore, the characteristics of the patient’s headache, which were previously inserted in the programme by the physician, are summarised, allowing critical evaluation of the suggested diagnosis. The software can also be used as a clinical file, in that it is possible to create for each patient a clinical chart in which to record the selected diagnosis, the recommended therapy and any eventual comments. Our programme aims for educational growth, promoting the learning of the basic ICHD–II criteria.

Headache in the elderly: a clinical study

Although the prevalence of headache in the elderly is relevant, until now few studies have been conducted in patients over the age of 65 years. We analyzed the clinical charts of 4,417 consecutive patients referred to our Headache Centre from 1995 to 2002. There were 282 patients over 65 years of age at the first visit, corresponding to 6.4% of the study population. Primary headaches were diagnosed in 81.6% of the cases, while secondary headaches and non-classifiable headaches represented, respectively, 14.9% and 3.5% of the cases. Among primary headaches, the prevalence was almost the same for migraine without aura (27.8%), transformed migraine (26.1%) and chronic tension- type headache (25.7%). The most frequent secondary headaches were trigeminal neuralgia and headache associated with cervical spine disorder.

Spontaneous carotid artery dissection with cluster-like headache

A case of carotid artery dissection in a 41-year-old-woman is described whose main symptom was cluster-like pain. The case is interesting for its atypical presentation with only two other like cases in the literature, and the site of dissection, localized in the intrapetrous curvature of the carotid artery. The case highlights the need for active co-operation between clinician and neuroradiologist during neuroimaging assessment which must be focused on the clinical evaluation of the individual patient so as to avoid error, particularly in atypical cases.

[The ST/HR slope and coronary stenoses]

BACKGROUND

The heart rate adjustment of ST depression (ST/HR Slope) has been shown by some authors to markedly improve the accuracy of treadmill exercise electrocardiogram for identifying and quantifying coronary artery disease. However, other authors have obtained different results. In the present study the results of our exercise electrocardiography laboratory are compared with the data obtained from the literature.

METHODS

Fifty patients (46 males and 4 females, age range 60 +/- 7 years) with suspect or certain coronary artery disease were referred for a routine treadmill exercise electrocardiogram, and subsequently underwent cardiac catheterization and selective coronary cineangiography to assess the severity of coronary obstruction. All patients exercised according to a recently reported modification of the standard Bruce protocol, proposed by Kligfield et al, for a more accurate evaluation of the ST/HR Slope, which was calculated in real time by a computerized system. Patients with coexisting valvular heart disease, cardiomyopathy, left bundle-branch block on the resting ECG, myocardial infarction within 8 weeks, diabetes mellitus, hypertensive response during exercise testing (diastolic blood pressure > 95 mm Hg and/or systolic blood pressure > 190 mm Hg), abnormalities or variations of the coronary arteries, were excluded from this study.

RESULTS

This method correctly identified 13 of 14 patients with multivessel coronary artery disease and 35 of 36 with less severe disease: one patient was false negative and another one false positive. Thus, in our exercise electrocardiography laboratory this approach shows a sensitivity of 93%, a specificity of 97%, a positive predictive value of 93% and a negative predictive value of 97% for the detection of severe coronary disease.

CONCLUSIONS

These findings suggest that, in patients selected as in this study, the ST/HR slope is a good method which improves the clinical usefulness of the treadmill exercise electrocardiogram in coronary artery disease.

Possible role of a ventricular conduction disturbance in the electrogenesis of the ECG-VCG signs of myocardial infarction

The typical QRS patterns of myocardial infarction (MI-QRS) are commonly attributed to myocardial cellular death. However, observation of a transient appearance of MI-QRS during coronary insufficiency, the disappearance of MI-QRS after coronary by-pass surgery and the appearance of MI-QRS after intracranial hemorrhage suggest that a different electrophysiological mechanism may be at work. There is a single convincing explanation for all these observations. It seems possible, at least theoretically, that a localized conduction disturbance can generate or contribute to the generation of the MI-QRS. The results obtained in nine out of 194 cases studied by means of premature right atrial stimulation (PRAS) in our laboratory seem to confirm this hypothesis. In five of them we observed typical MI-QRS in the aberrant beats which were absent in the basal tracings. In the other four cases, MI-QRS which were present in basal tracings disappeared in the aberrant beats. In three of these a reduction in the duration of QRS was also observed, while in the fourth the duration of QRS did not change. In no case could the alterations of QRS (induction or disappearance of MI-QRS) be explained by a classical conduction disturbance, preexcitation or by a premature ventricular beat. While the induction of MI-QRS was clearly due to an aberrant conduction in the supraventricular beats, the disappearance of basal MI-QRS changes in premature supraventricular beats is more difficult to explain. One possible electrophysiological mechanism could be a supernormal phase conduction. If this is the case, the basal MI-QRS could be due to a ventricular conduction disturbance. In conclusion, our results suggest that MI-QRS can be generated, at least in our cases, by a localized conduction disturbance.

The role of left ventricular conduction in the electrogenesis of left ventricular hypertrophy. An electrophysiologic study in man

Various electrocardiographic and vectorcardiographic (ECG-VCG) patterns of ventricular conduction disturbances are inducible by premature right atrial stimulation (PRAS). These patterns are a consequence of different degrees of refractoriness in the specialized ventricular conduction system. We observed that the intermediate phase of left bundle branch block (LBBB) induced by PRAS in 20 subjects with normal basal QRS (complexes) were similar to those of left ventricular hypertrophy (LVH). In 18 patients with basal ECG-VCG signs of LVH, right bundle branch block (RBBB) induced by PRAS produced a progressive disappearance of these signs and the "normalization" of the tracings. The initial maximum QRS vector decreased, disappeared or remained absent in the patients with LBBB induced by PRAS, and appeared (when absent in the basal VCG) and remained unchanged (when present) in patients with RBBB induced by PRAS. In this paper we discuss the electrogenetic implications of these data. The ECG-VCG sings of LVH are probably dependent on a slowed conduction in the left bundle branch system, while anatomical hypertrophy per se probably plays a less important role.