Hemispherectomy Outcome Prediction Scale: a validity study

OBJECTIVE

Hemispherectomy is highly effective for patients with medically refractory epilepsy (MRE) arising from a single hemisphere. Recently, the Hemispherectomy Outcome Prediction Scale (HOPS) was developed as a prediction tool for seizure freedom after hemispherectomy. The authors' goal was to perform a validation study to determine the generalizability of the HOPS score.

METHODS

The authors present an observational, retrospective, 20-year, single-institution, two-surgeon experience using the lateral peri-insular hemispherectomy approach to validate the HOPS score. Variables used to derive the HOPS score included seizure onset age, semiology, PET hypometabolism, seizure substrate, and history of prior epilepsy resection. Multivariable logistic regression, multiple imputation, and Bayesian analyses were used to determine validity.

RESULTS

The authors' cohort comprised 60 patients; 55% of patients were male and 78% were Caucasian. The median age at first hemispherectomy surgery was 72 months. At 1 year postoperatively, 80% of patients had Engel class I outcomes, analogous to most contemporary series. All patients who experienced seizure recurrence after hemispherectomy did so within the first 2 years postoperatively. Sixteen (27%) and 10 (17%) patients had contralateral MRI findings and hypometabolism on PET, respectively. Both a multivariable logistic regression model using HOPS score variables (model p = 0.2588) and a revised model that included contralateral MRI findings (model p = 0.4715) were not statistically significant in this cohort. Bayesian analysis also did not validate the HOPS score.

CONCLUSIONS

While seizure outcome prediction tools may be helpful for counseling patients about postoperative outcomes, rigorous validity and reliability testing are required. Prospective, standardized, and longitudinal evaluation of patients undergoing hemispherectomy are needed.

Longitudinal impact of cannabidiol on EEG measures in subjects with treatment-resistant epilepsy

OBJECTIVE

To assess the longitudinal impact of highly purified cannabidiol (CBD) on the electroencephalogram (EEG) of children and adults.

METHODS

Participants received an EEG prior to starting CBD, after approximately 12 weeks of CBD (FU1) and after approximately one year of CBD therapy (FU2). Longitudinal changes in five EEG measures (background frequency, focal slowing, reactivity, frequency of interictal, and ictal discharges) were examined following CBD exposure. Data were compared between pediatric and adult groups at two follow-up time points and within groups over time. Population-averaged models with generalized estimation equations or linear mixed effects models were used to analyze data where appropriate. Correlation analysis was used to assess any association between changes in seizure frequency and changes in EEG interictal discharge (IED) frequency. An alpha level of 5% was used to assess statistical significance.

RESULTS

At FU1, the adult group showed significant decrease in IED/minute (IDR 0.07, 95% CI [0.04, 0.14], P < 0.001); a nonsignificant decrease was observed among children (IDR 0.87, 95% CI [0.47, 0.64], P = 0.67). The difference in changes over time between participant groups was significant after adjusting for last CBD dose (IDR 11.8, 95% CI [4.86, 28.65], P < 0.0001). At FU2 both groups showed significant reduction from baseline after controlling for last CBD dose. This decrease was more pronounced in children (IDR 15.38, 95% CI [4.93, 47.99], P < 0.001). There was no significant correlation between changes in seizure frequency and EEG IED frequency at each timepoint (P = 0.542, 0.917 and 0.989 from baseline to FU1, FU1 to FU2 and baseline to FU2, respectively).

SIGNIFICANCE

This longitudinal EEG study shows that highly-purified plant-derived CBD has positive effects on interictal epileptiform discharge frequency but no effects on other EEG measures. The effect of CBD does not appear to be dose or treatment-duration dependent.

Relative contribution of individual versus combined functional imaging studies in predicting seizure freedom in pediatric epilepsy surgery: an area under the curve analysis

OBJECTIVE

The goal of this study was to evaluate the predictive value and relative contribution of noninvasive presurgical functional imaging modalities based on the authors' institutional experience in pursuing seizure-free surgical outcomes in children with medically refractory epilepsy.

METHODS

This was a retrospective, single-institution, observational cohort study of pediatric patients who underwent evaluation and surgical treatment for medically refractory partial epilepsy between December 2003 and June 2016. During this interval, 108 children with medically refractory partial epilepsy underwent evaluation for localization and resective epilepsy surgery. Different noninvasive functional imaging modalities, including ictal SPECT, FDG-PET, and magnetoencephalography-magnetic source imaging, were utilized to augment a standardized paradigm (electroencephalography/semiology, MRI, and neuropsychology findings) for localization. Outcomes were evaluated at a minimum of 2 years (mean 7.5 years) utilizing area under the receiver operating characteristic curve analysis. Localizing modalities and other clinical covariates were examined in relation to long-term surgical outcomes.

RESULTS

There was variation in the contribution of each test, and no single presurgical workup modality could singularly and reliably predict a seizure-free outcome. However, concordance of presurgical modalities yielded a high predictive value. No difference in long-term outcomes between inconclusive (normal or diffusely abnormal) and abnormal focal MRI results were found. Long-term survival analyses revealed a statistically significant association between seizure freedom and patients with focal ictal EEG, early surgical intervention, and no history of generalized convulsions.

CONCLUSIONS

Comprehensive preoperative evaluation utilizing multiple noninvasive functional imaging modalities is not redundant and can improve pediatric epilepsy surgical outcomes.

Surgical treatment of epilepsy in Vietnam: program development and international collaboration

OBJECTIVE

The purpose of this report was to describe an international collaboration model to facilitate the surgical treatment of children with epilepsy in Vietnam.

METHODS

This model uses three complementary methods to achieve a meaningful expansion in epilepsy surgery capacity: US-based providers visiting Hanoi, Vietnam; Vietnamese providers visiting the US; and ongoing telecollaboration, including case review and real-time mentorship using internet-based communication platforms.

RESULTS

Introductions took place during a US neurosurgeon’s visit to Vietnam in 2014. Given the Vietnamese surgeon’s expertise in intraventricular tumor surgery, the focus of the initial visit was corpus callosotomy. After two operations performed jointly, the Vietnamese surgeon went on to perform 10 more callosotomy procedures in the ensuing 6 months with excellent results. The collaborative work grew and matured in 2016–2017, with 40 pediatric epilepsy surgeries performed from 2015 through 2017. Because pediatric epilepsy care requires far more than neurosurgery, teams traveling to Vietnam included a pediatric neurologist and an electroencephalography (EEG) technologist. Also, in 2016–2017, a neurosurgeon, two neurologists, and an EEG nurse from Vietnam completed 2- to 3-month fellowships at Children’s of Alabama (COA) in the US. These experiences improved EEG capabilities and facilitated the development of intraoperative electrocorticography (ECoG), making nonlesional epilepsy treatment more feasible. The final component has been ongoing, i.e., regular communication. The Vietnamese team regularly sends case summaries for discussion to the COA epilepsy conference. Three patients in Vietnam have undergone resection guided by ECoG without the US team present, although there was communication via internet-based telecollaboration tools between Vietnamese and US EEG technologists. To date, two of these three patients remain seizure free. The Vietnamese team has presented the results of their epilepsy experience at two international functional and epilepsy surgery scientific meetings.

CONCLUSIONS

Ongoing international collaboration has improved the surgical care of epilepsy in Vietnam. Experience suggests that the combination of in-country and US-based training, augmented by long-distance telecollaboration, is an effective paradigm for increasing the capacity for highly subspecialized, multidisciplinary neurosurgical care.

Cannabidiol improves frequency and severity of seizures and reduces adverse events in an open-label add-on prospective study

The objective of this study was to characterize the changes in adverse events, seizure severity, and frequency in response to a pharmaceutical formulation of highly purified cannabidiol (CBD; Epidiolex®) in a large, prospective, single-center, open-label study. We initiated CBD in 72 children and 60 adults with treatment-resistant epilepsy (TRE) at 5 mg/kg/day and titrated it up to a maximum dosage of 50 mg/kg/day. At each visit, we monitored treatment adverse events with the adverse events profile (AEP), seizure severity using the Chalfont Seizure Severity Scale (CSSS), and seizure frequency (SF) using seizure calendars. We analyzed data for the enrollment and visits at 12, 24, and 48 weeks. We recorded AEP, CSSS, and SF at each follow-up visit for the weeks preceding the visit (seizures were averaged over 2-week periods). Of the 139 study participants in this ongoing study, at the time of analysis, 132 had 12-week, 88 had 24-week, and 61 had 48-week data. Study retention was 77% at one year. There were no significant differences between participants who contributed all 4 data points and those who contributed 2 or 3 data points in baseline demographic and AEP/SF/CSSS measures. For all participants, AEP decreased between CBD initiation and the 12-week visit (40.8 vs. 33.2; p < 0.0001) with stable AEP scores thereafter (all p ≥ 0.14). Chalfont Seizure Severity Scale scores were 80.7 at baseline, decreasing to 39.2 at 12 weeks (p < 0.0001) and stable CSSS thereafter (all p ≥ 0.19). Bi-weekly SF decreased from a mean of 144.4 at entry to 52.2 at 12 weeks (p = 0.01) and remained stable thereafter (all p ≥ 0.65). Analyses of the pediatric and adult subgroups revealed similar patterns. Most patients were treated with dosages of CBD between 20 and 30 mg/kg/day. For the first time, this prospective, open-label safety study of CBD in TRE provides evidence for significant improvements in AEP, CSSS, and SF at 12 weeks that are sustained over the 48-week duration of treatment.

Effect of EEG electrode number on epileptic source localization in pediatric patients

OBJECTIVE

To investigate the relationship between EEG source localization and the number of scalp EEG recording channels.

METHODS

128 EEG channel recordings of 5 pediatric patients with medically intractable partial epilepsy were used to perform source localization of interictal spikes. The results were compared with surgical resection and intracranial recordings. Various electrode configurations were tested and a series of computer simulations based on a realistic head boundary element model were also performed in order to further validate the clinical findings.

RESULTS

The improvement seen in source localization substantially decreases as the number of electrodes increases. This finding was evaluated using the surgical resection, intracranial recordings and computer simulation. It was also shown in the simulation that increasing the electrode numbers could remedy the localization error of deep sources. A plateauing effect was seen in deep and superficial sources with further increasing the electrode number.

CONCLUSION

The source localization is improved when electrode numbers increase, but the absolute improvement in accuracy decreases with increasing electrode number.

SIGNIFICANCE

Increasing the electrode number helps decrease localization error and thus can more ably assist the physician to better plan for surgical procedures.

Effect of epilepsy magnetic source imaging on intracranial electrode placement

OBJECTIVE

Intracranial electroencephalography (ICEEG) with chronically implanted electrodes is a costly invasive diagnostic procedure that remains necessary for a large proportion of patients who undergo evaluation for epilepsy surgery. This study was designed to evaluate whether magnetic source imaging (MSI), a noninvasive test based on magnetoencephalography source localization, can supplement ICEEG by affecting electrode placement to improve sampling of the seizure onset zone(s).

METHODS

Of 298 consecutive epilepsy surgery candidates (between 2001 and 2006), 160 patients were prospectively enrolled by insufficient localization from seizure monitoring and magnetic resonance imaging results. Before presenting MSI results, decisions were made whether to proceed with ICEEG, and if so, where to place electrodes such that the hypothetical seizure-onset zone would be sampled. MSI results were then provided with allowance of changes to the original plan.

RESULTS

MSI indicated additional electrode coverage in 18 of 77 (23%) ICEEG cases. In 39% (95% confidence interval, 16.4-61.4), seizure-onset ICEEG patterns involved the additional electrodes indicated by MSI. Sixty-two patients underwent surgical resection based on ICEEG recording of seizures. Highly localized MSI was significantly associated with seizure-free outcome (mean, 3.4 years; minimum, >1 year) for the entire surgical population (n = 62).

INTERPRETATION

MSI spike localization increases the chance that the seizure-onset zone is sampled when patients undergo ICEEG for presurgical epilepsy evaluations. The clinical impact of this effect, improving diagnostic yield of ICEEG, should be considered in surgery candidates who do not have satisfactory indication of epilepsy localization from seizure semiology, electroencephalogram, and magnetic resonance imaging.

Advances in intracranial monitoring

Intracranial monitoring using electroencephalography (IC-EEG) continues to play a critical role in the assessment of patients with medically intractable localization-related epilepsy. There has been minimal change in grid or electrode design in the last 15–20 years, and the surgical approaches for implantation are unchanged. Intracranial monitoring using EEG allows detailed definition of the region of ictal onset and defines the epileptogenic zone, particularly with regard to adjacent potentially eloquent tissue. Recent developments of IC-EEG include the coregistration of functional imaging data such as magnetoencephalography to the frameless navigation systems. Despite significant inherent limitations that are often overlooked, IC-EEG remains the gold standard for localization of the epileptogenic cortex. Intracranial electrodes take a variety of different forms and may be placed either in the subdural (subdural strips and grids, depth electrodes) or extradural spaces (sphenoidal, peg, and epidural electrodes). Each form has its own advantages and shortcomings but extensive subdural implantation of electrodes is most common and is most comprehensively discussed. The indications for intracranial electrodes are reviewed.

Vagus nerve stimulation in children less than 5 years old

INTRODUCTION

Vagus nerve stimulation (VNS) has been used in both adults and older children with varying success.

MATERIALS AND METHODS

We retrospectively reviewed our experience with VNS in very young children (below 5 years old). The mean age at stimulator implantation was 20.5 months. Two patients were below 2 years old at implantation and two patients were below 1 year old at their initial surgery. The average follow up time for this group was 22 months.

RESULTS

Of the six patients (three males and three females) with long-term follow up, 83% had a significant decrease in the frequency of their seizure. Of these, two are seizure-free (33%), three are improved (50%), and one (17%) has had no change in seizure status at their most recent clinical examination. Age at implantation of the vagus nerve stimulator did not seem to correlate with patient success. In this group, atonic seizures were found to best respond to VNS with cessation of this type of seizure in two patients. No patients were made worse by the procedure and no morbidity was observed related to VNS.

CONCLUSIONS

Based on our small patient cohort, it appears that VNS in very young children with life-threatening epilepsy can be efficacious. Larger groups and other institutional experiences are now needed to verify our findings.

Early progressive encephalopathy in boys and MECP2 mutations

MECP2 mutations mainly occur in females with Rett syndrome. Mutations have been described in 11 boys with progressive encephalopathy: seven of nine with affected sisters and two de novo. The authors report four de novo occurrences: three pathogenic and one potentially pathogenic. Common features include failure to thrive, respiratory insufficiency, microcephaly, and abnormal motor control. MECP2 mutations should be assessed in boys with progressive encephalopathy and one or more of respiratory insufficiency, abnormal movements or tone, and intractable seizures.

Magnetic source imaging versus intracranial electroencephalogram in epilepsy surgery: A prospective study

OBJECTIVE

Noninvasive brain imaging tests can potentially supplement or even replace the use of intracranial electroencephalogram (ICEEG), an invasive, costly procedure used in presurgical epilepsy evaluation. This study prospectively examined the agreement between magnetic source imaging (MSI) and ICEEG localization in epilepsy surgery candidates.

METHODS

Patients completing video monitoring with scalp EEG who had intractable partial epilepsy based on ictal electro-clinico-anatomical features were screened. Forty-nine enrolled patients (mean age, 27 years; range, 1-61 years) completed MSI and ICEEG studies. Decisions about ICEEG and surgery were made at a consensus conference where MSI could only influence ICEEG coverage by indicating supplemental coverage to that already planned by an original hypothesis.

RESULTS

The positive predictive value of MSI for seizure localization was 82 to 90%, depending on whether computed against ICEEG alone or in combination with surgical outcome. The kappa score of agreement for MSI with ICEEG was 0.2744 (p < 0.01)

INTERPRETATION

MSI yields localizing information with a high positive predictive value in epilepsy surgery candidates who typically require ICEEG. This finding suggests that enough clinical validity exists for MSI to potentially replace ICEEG for seizure localization.

Chorea as manifestation of epilepsia partialis continua in a child

The authors present a case of a child with epilepsy who developed choreoathetotic movements coinciding with the development of epilepsia partialis continua. His abnormal movements and seizures resolved after successful management of his epilepsia partialis continua with intravenous immunoglobulin and steroid therapy. The authors propose that the chorea was an unusual manifestation of epilepsia partialis continua.

High plasma branched-chain amino acids:aromatic amino acids ratio in children on the ketogenic diet: a mechanism in controlling epilepsy

BACKGROUND

The authors proposed that ketogenic diets will produce an increase in the ratio of branched chain amino acids (BCAAs) and aromatic amino acids (BCAAs) in plasma of children who are on the diets.

SUBJECTS AND METHOD

A sample of plasma amino acids sample before initiation of fasting and on day 10 of the dietary treatment was obtained in patients with refractory epilepsy who were newly admitted for initiation of ketogenic diet. Plasma amino acids were determined by high performance liquid chromatography equipment.

RESULTS

There are 20 patients with refractory epilepsy participating in this study. Outcomes of ketogenic diet therapy were satisfactory. Nineteen cases out of 20 cases had a significantly higher ratio of plasma BCAAs:ARAAs during ketogenic diets than before the diet (P < 0.001).

CONCLUSION

The ketogenic diets produced an increased ratio of plasma BCAAs:ARAAs. Whether the increased ratio of plasma BCAAs:ARAAs plays an important role in controlling epilepsy is yet to be elucidated.

Vigabatrin therapy in infantile spasms

RATIONALE

To determine the clinical outcome and side effects of vigabatrin (VGB) in the treatment of infantile spasms (IS) and its long-term outcome.

METHOD

All children with IS treated with vigabatrin were studied. Clinical data regarding age of onset, duration of IS before therapy started, recurrence of IS, types of seizures that relapse, clinical outcome and side effects were monitored.

RESULTS

36 children (17 girls, 19 boys) with IS participated in the study. The mean age of onset of IS was 115.55 +/- 67.3 days old (range, 15 to 300 days). Six were cryptogenic IS and 30 were symptomatic IS. The etiologies of symptomatic IS in this study were tuberous sclerosis, hypoxic ischemic encephalopathy (HIE)/periventricular leukomalacia, porencephaly, partial agenesis of corpus callosum, hemimegalencephaly, cortical dysplasia, and microcephaly. 66.67 per cent (24 of 36) of patients responded to VGB within a mean 2.95 +/- 2.25 days (range, 1 to 7 days). In those who responded to VGB, 3 patients developed recurrent IS within 69.3 +/- 46.7 days (range, 30 to 121 days). Five patients developed epilepsy with different types of seizure during long-term follow-up. The mean duration of subsequent epilepsy after cessation of IS was 16.4 months (range, 5 months to 3 years 10 months). The mean duration of follow-up was 2.74 years (range, 1.09 years to 5.76 years). 10 patients were successfully weaned off VGB after a mean IS free period of 22.5 +/- 5.5 months (range, 12 to 27 months). Transient drowsiness was seen in 4 patients. Three patients had transient abnormal sleep patterns and irritability. Visual field abnormalities were not found but difficult to assess fully in this study.

CONCLUSION

VGB therapy has a high response rate for the control of IS and is well tolerated in most children. All patients who responded to VGB and were spasm free for more than one year were successfully weaned off VGB therapy. Because serious side effects such as visual field abnormalities are difficult to monitor, the authors propose that VGB could be withdrawn or switched to another AED after a spasm-free period of more than one year.

Childhood onset myasthenia gravis

The authors share experiences in taking care of 27 cases of childhood onset myasthenia gravis (MGS). In all cases, the diagnosis was confirmed by a combination of clinical examination and Neostigmine test. The majority (92%) had localized ocular myasthenia with median onset of symptoms at 33 months of age. About 24 per cent of them progressed to generalized MGS. A few (8%) presented with respiratory failure that required ventilatory support with onset of symptoms at about 22 months. Thymectomy was performed in 10 cases. Complete and partial remissions were achieved in about 70 per cent and 26 per cent of cases respectively with the combination of an immunosuppressant (azathioprine) and a Cholinesterase inhibitor (pyridostigmine). None experienced a myasthenic crisis with proper management and good follow-up using the above combinations.

Ketogenic diet: an alternative treatment for refractory epilepsy in children

RATIONALE

The aim of this study was to establish the first ketogenic diet treatment program for refractory epilepsy in Thailand and to assess its feasibility as well as its efficacy.

METHOD

Children with refractory epilepsy were enrolled in the study. This was a prospective open trial study with 35 children (16 boys and 19 girls). Not all patients started on the diet at the same time. Each patient was cumulatively enrolled in this study over the period of 4 years. The mean age on diet was 5.37 +/- 3.57 years (2 months-13 years), mean age of onset of seizures was 19.2 +/- 27.47 months (1 days-8 years), and an average duration on ketogenic diet was 7.67 months (6 days to 29 months). The classic "4:1" formula ketogenic diet was used with some modification. The patient's parents were allowed to improvise and use any fatty diets available in the market such as coconut milk if needed. Parents were closely supervised and instructed on how to prepare the patient's own meals while in the hospital and continued to attend neurology and nutrition clinics. The seizure outcome and side effects were monitored as well as a daily test for urine ketone.

RESULTS

At 1 month, 3 months, 6 months, and 12 months duration on the diet, 90 per cent seizure reductions were achieved in 62.5 per cent, 68.18 per cent, 75 per cent, and 66.67 per cent of patients remaining on the diet, respectively. The number of antiepileptic drugs (AEDs) used by each patient also decreased as a result of better seizure control.

CONCLUSION

Ketogenic diet can be tried as a management option for refractory epilepsy. It is not difficult to implement even in a developing country like Thailand where resources are limited. It may also help reduce the cost of treatment especially in view of the high prices of the new AEDs.

Viral etiologies of encephalitis in Thai children

A prospective study of childhood encephalitis was performed in Bangkok from 1996 through 1998. The viral agents identifiable in 26 (65%) of 40 children were dengue virus (8), Japanese encephalitis (6), herpes simplex virus (4), human herpes virus type 6 (3), mumps (2), enterovirus (1), varicella-zoster virus (VZV) (1) and rabies (1).

Dengue infection presenting with central nervous system manifestation

The objective of this study was to investigate the possibility of dengue virus infection causing an abnormal neurologic presentation. Between 1996 and 1998, all pediatric patients with clinical manifestations of encephalitis-like illness who were admitted to the Department of Pediatrics, Siriraj Hospital were prospectively studied for any evidence of dengue virus infection. The diagnosis of dengue virus infection was based on mosquito viral isolation and serologic and polymerase chain reaction (PCR) evidence. Of 44 patients with the preliminary diagnosis of acute viral encephalitis, 8 were diagnosed with dengue infection. All of these 8 patients were diagnosed by serology. In addition to the serologic diagnosis, four also had positive PCR, one had positive viral isolation, and one had both positive PCR and viral isolation. Only two patients were diagnosed by serologic evidence alone. All except one had clinical courses and laboratory findings compatible with typical dengue infection. All had obvious encephalitic clinical manifestations with normal cerebrospinal fluid findings except one patient, who had mildly increased cerebrospinal fluid protein. All of these patients recovered completely and had benign clinical courses except one patient, who developed leakage symptoms. None had liver failure. Dengue virus can cause acute encephalopathy with fever. It can masquerade as other types of acute viral encephalitis. However, its clinical course and prognosis are usually favorable.

Lateralizing value of asymmetric tonic limb posturing observed in secondarily generalized tonic-clonic seizures

PURPOSE

A striking asymmetry of limb posture occurs during secondarily generalized tonic-clonic (GTC) seizures wherein one elbow is extended while the other is flexed during the tonic phase of the GTC seizure. We have named this phenomenon asymmetric tonic limb posturing (ATLP) or the "Figure 4 Sign."

METHODS

Fifty-nine secondarily GTC seizures from 31 patients with partial epilepsy who underwent successful epilepsy surgery were analyzed, in addition to another group of 64 GTC and generalized clonic seizures from 26 patients collected prospectively over a 7-month period. Three observers reviewed these seizures blinded to the side of ictal EEG onset and other clinical data.

RESULTS

The extended elbow was contralateral to the side of ictal onset in 35 of 39 patients who had ATLP during their seizures. The kappa index, a measure of interobserver agreement, was calculated, and ATLP was found to have very good agreement between observers.

CONCLUSIONS

In secondarily generalized tonic-clonic seizures, ATLP (Figure 4 Sign) may sometimes be only available lateralizing sign.

Epilepsy awareness among school teachers in Thailand

PURPOSE

Epilepsy is one of the most common neurologic disorders of childhood. However, in Thailand, as well as in most of other developing countries, little attention has been paid to improve the public knowledge regarding epilepsy. Currently public attitude toward epilepsy is rather negative, full of prejudices and bias. Children with epilepsy in Thailand still find themselves confronted with social barriers that prevent them from academic achievements, in addition to the limitation that the disease itself has already placed on them. To delineate the magnitude and scope of this problem, we performed a small pilot study to assess the knowledge, attitude, and practice of epilepsy in the school teachers in Thailand whose major impact on the children is manifested by attitudes and learning.

METHODS

The study was conducted by sending simple self-administered questionnaires to 360 schools all over Thailand. The questionnaires contained 14 questions relating to epilepsy awareness, attitudes, and first-aid management of seizures.

RESULTS

We found that 38% of respondents had not heard of or read about epilepsy, and 46.6% believed that epilepsy is a chronic incurable disease. Fifteen percent of the respondents preferred to place all children with epilepsy in a special classroom. Furthermore, half of the respondents who had experience with first-aid management of seizures used improper and potentially harmful measures.

CONCLUSIONS

Besides the proper management of epilepsy, a general public education campaign for epilepsy and the need to address and correct the existing biases are necessary to improve the quality of life of children with epilepsy in Thailand.

Salivary antiepileptic drug levels in Thai children

A total of 123 patients were enrolled in this study. 88 patients were enrolled in the first stage of the study, which was to evaluate the commercial salivary collecting devices: Orasure and Omnisol. 35 patients were enrolled in the second stage of the study and were asked to spit whole saliva samples for further analysis of AED levels. Serum AED levels and corresponding saliva AED levels were paired and analyzed for the correlation coefficients with the linear regression model. None of the commercial salivary collecting devices can provide the linear regression correlation between the serum AED level and saliva AED level in all three AEDs studied. The correlation coefficients of serum and whole saliva AED levels of phenobarbital, phenytoin, and carbamazepine were highly correlated (r-squared were 0.981, 0.976, and 0.888, respectively). Saliva samples can be used clinically to monitor the AEDs level in phenobarbital, phenytoin and carbamazepine. This would be another alternative method of therapeutic drug monitoring that can be done painlessly and is easier in children than the blood sampling method.

Lateralizing value and semiology of ictal limb posturing and version in temporal lobe and extratemporal epilepsy

PURPOSE

Unilateral dystonic limb posturing in partial seizures has been shown to be an accurate lateralizing sign indicating seizure onset in the contralateral hemisphere. However, its clinical utility may be reduced by confusion with other lateralized ictal motor phenomena. In this study, the ictal phenomena of dystonic limb posturing, tonic limb posturing, unilateral immobile limb, and version were distinguished and examined in patients with temporal and extratemporal seizures.

METHODS

Partial seizures in 54 patients, successfully treated by surgery (34 temporal, 20 extratemporal; 14 frontal, 3 parietal, and 3 occipital), were analyzed blindly by 3 reviewers. Interobserver agreement was tested with kappa indexes and positive predictive value (PPV) was determined for each sign.

RESULTS

In patients with temporal lobe epilepsy (TLE), dystonic posturing occurred in 35.3% (kappa 0.78, positive predictive value (PPV) for the sign being contralateral to seizure onset 92%); tonic limb posturing occurred in 17.7% (kappa 0.36, PPV 40%); unilateral immobile limb occurred in 11.8% (kappa 0.23, PPV 100%); and version occurred in 35.3% (kappa 0.77, PPV 100%). In patients with extratemporal epilepsy, dystonic posturing occurred in 20.0% (kappa 0.31, PPV 100%); tonic limb posturing occurred in 15.0% (kappa 0.08, PPV 67%); and version occurred in 40.0% (kappa 0.54, PPV 100%). The higher kappa indexes were significant for dystonic posturing (p < 0.001) and tonic limb posturing (p = 0.032) in TLE. Dystonic posturing (p = 0.034), tonic posturing (p = 0.07), and version (p = 0.0038) occurred earlier in extratemporal seizures than in temporal seizures.

CONCLUSIONS

Of the limb ictal motor phenomena, only dystonic posturing was accurate and had good interobserver agreement.

Möbius syndrome in infant exposed to cocaine in utero

The pathophysiology of Möbius syndrome has been debated for decades. A vascular etiology is currently favored because it explains the wide clinical spectrum of this syndrome. An infant is reported who was born with Möbius syndrome after a pregnancy complicated by heavy maternal use of cocaine and alcohol. We speculate that cocaine-induced vasoconstriction at a critical time of cerebrovascular development produced a vascular disruption sequence leading to the Möbius syndrome.