Epilepsy, Immunity and Neuropsychiatric Disorders

Several studies have focused on the emerging role of immunity and inflammation in a wide range of neurological disorders. Autoimmune diseases involving central nervous system share well defined clinical features including epileptic seizures and additional neuropsychiatric symptoms, like cognitive and psychiatric disturbances. The growing evidence about the role of immunity in the pathophysiologic mechanisms underlying these conditions lead to the concept of autoimmune epilepsy. This relatively-new term has been introduced to highlight the etiological and prognostic implications of immunity in epileptogenesis. In this review, we aim to discuss the role of autoimmunity in epileptogenesis and its clinical, neurophysiological, neuroimaging and therapeutic implications. Moreover, we wish to address the close relationship between immunity and additional symptoms, particularly cognitive and psychiatric features, which deeply impact clinical outcomes in these patients. To assess these aspects, we first analyzed Rasmussen's encephalitis. Subsequently, we have covered autoimmune encephalitis, particularly those associated with autoantibodies against surface neuronal antigens, as these autoantibodies express a direct immune-mediated mechanism, different from those against intracellular antigens. Then, we discussed the connection between systemic immune disorders and neurological manifestations. This review aims to highlight the need to expand knowledge about the role of inflammation and autoimmunity in the pathophysiology of neurological disorders and the importance to early recognize these clinical entities. Indeed, early identification may result in faster recovery and a better prognosis.

Seizure triggers identified postictally using a smart watch reporting system

Persons with epilepsy (PWE) often report that seizure triggers can influence the occurrence and timing of seizures. Some previous studies of seizure triggers have relied on retrospective daily seizure diaries or surveys pertaining to all past seizures, recent and/or remote, in respondents. To assess the characteristics of seizure triggers at the granularity of individual seizures, we used a seizure-tracking app, called EpiWatch, on a smart watch system (Apple Watch and iPhone) in a national study of PWE. Participants tracked seizures during a 16-month study period using the EpiWatch app. Seizure tracking was initiated during a pre-ictal state or as the seizure was occurring and included collection of biosensor data, responsiveness testing, and completion of an immediate post-seizure survey. The survey evaluated seizure types, auras or warning symptoms, loss of awareness, use of rescue medication, and seizure triggers for each tracked seizure. Two hundred and thirty four participants tracked 2493 seizures. Ninety six participants reported triggers in 650 seizures: stress (65.8%), lack of sleep (30.5%), menstrual cycle (19.7%), and overexertion (18%) were the most common. Participants often reported having multiple combined triggers, frequent stress with lack of sleep, overexertion, or menses. Participants who reported triggers were more likely to be taking 3 or more anti-seizure medications compared to participants who did not report triggers. Participants were able to interact with the app and use mobile technology in this national study to record seizures and report common seizure triggers. These findings demonstrate the promise of longitudinal, self-reported data to improve our understanding of epilepsy and its related comorbidities.

Diagnostic Delay in Epilepsy: the Scope of the Problem

PURPOSE OF REVIEW

Diagnostic delay is an increasingly recognized issue in epilepsy. At the same time, there is a clear disparity between public awareness of epilepsy and that of other public health issues. A contributing factor for this seems to be a lack of studies testing interventions designed to improve seizure recognition. In this review, we summarize the main findings from recent studies investigating diagnostic delay in epilepsy, highlighting causes, consequences, and potential interventions in future research that may improve quality of care in this population.

RECENT FINDINGS

Building on prior evidence, diagnostic delay in patients with new-onset focal epilepsy has been identified as an important problem for patients with epilepsy. Such delay in diagnosis can lead to delayed treatment and potentially preventable morbidity and mortality including motor vehicle accidents. Nonmotor seizure semiology appears to be a major contributor for delay; such seizures are largely unrecognized when patients present to emergency departments for care. Improving recognition and diagnosis of recurrent nonmotor seizures in emergency departments represents a significant opportunity for improving time to diagnosis, particularly when patients present following a first lifetime motor seizure and meet diagnostic criteria for epilepsy. Diagnostic delay in epilepsy is a significant public health issue and recent studies have highlighted potential areas for intervention.

Readmission after epilepsy monitoring unit discharge in a nationally representative sample

OBJECTIVE

To determine the 30-day readmission rate after Epilepsy Monitoring Unit (EMU) discharge in a nationally representative sample, as well as patient, clinical, and hospital characteristics associated with readmission.

METHODS

This is a retrospective cohort study of adults discharged from an elective hospitalization with continuous video electroencephalography (vEEG) monitoring, sampled from the Healthcare Cost and Utilization Project's 2014 Nationwide Readmissions Database. Descriptive statistics were used to quantify and characterize readmission within 30 days and logistic regression models were built to examine factors associated with readmission.

RESULTS

6869 admissions met inclusion criteria, with 292 people (4.2 %) readmitted within 30 days. 79.5 % (n = 232/292) of all readmissions were non-elective. Patient characteristics associated with readmission included a higher Elixhauser comorbidity score [adjusted odds ratio (AOR) 1.03, 95 % confidence interval (CI) 1.02-1.04 per 1 point increase in Elixhauser score], a longer length of stay [AOR 1.05, 95 % CI 1.02-1.09 per one day increase in length], non-routine discharge [AOR 1.85, 95 %CI 102-3.38], and comorbid brain tumor diagnosis [AOR 2.55, 95 %CI 1.46-4.46]. Female sex was inversely associated with 30-day readmission [AOR 0.68, 95 % CI 0.54-0.85]. The most common reason for readmission was epilepsy or convulsion (27.6 %), followed by sepsis (5.8 %) and complications of surgical procedures or medical care (5.5 %).

CONCLUSIONS

Patients electively admitted for continuous vEEG monitoring are infrequently readmitted. These data provide a preliminary national readmission benchmark for patients with elective admissions for vEEG monitoring.

Seizures triggered by eating - A rare form of reflex epilepsy: A systematic review

Eating epilepsy is a rare disorder, characterised by reflex seizures induced by food intake. It is highly heterogenous, with clinical signs and EEG findings varying between patients. However, common features do emerge from the reported literature. The aim of this systematic review was to bring together this information to facilitate understanding and recognition. We therefore searched electronic databases (PubMed, Scopus, Medline) for relevant studies using keywords 'epilepsy', 'seizure' and 'eating' in March 2020. Human studies, written in English, that reported on cohorts of patients with eating epilepsy were included. Fifty-two unique papers were consequently identified, describing seizure characteristics and diagnostic features in 378 patients. Eating seizures began in the second decade of life, with a higher incidence in males. They were typically focal-onset, and most commonly of the focal impaired awareness type. Pharmacological therapy with one or multiple agents was noted in 80 % of cases, with poor control reported in approximately 25 % of patients. While this retrospective work highlights key features, it is important that future studies implicate video EEG to fully evaluate this highly unique and interesting disorder.

Prescription trends and psychiatric symptoms following first receipt of one of seven common antiepileptic drugs in general practice

We sought to examine the risk of psychiatric symptoms associated with a first prescription for specific antiepileptic drugs (AEDs) used in monotherapy in a general cohort of patients with epilepsy. We used The Health Improvement Network database (comprising the years 2000-2012) to identify incident patients with epilepsy. The index date was that on which they met the case definition for epilepsy, and analyses only included patients who remained on monotherapy or received no AED therapy following diagnosis to avoid confounding by polytherapy. Psychiatric symptoms were defined using mental health clinical or treatment (medical or therapeutic) code. We analyzed the AED of interest as a time-varying covariate in multivariate Cox proportional hazard regression models controlling for confounding factors. We identified 9595 patients with incident epilepsy, 7400 of whom (77%) received a first-recorded AED prescription. Prescriptions for newer generation AEDs (lamotrigine and levetiracetam) steadily increased (constituting over 30% of all AED prescriptions by 2012) while valproate use significantly declined in females (~40% in 2002 to just over 20% by 2012). A total of 2190 patients were first exposed to carbamazepine (29.3%) and 222 to lamotrigine (3%), both of which were associated with a lower hazard of any coded psychiatric symptom or disorder in multivariate analyses (hazard ratio [HR]: 0.84, 95% confidence interval [95% CI]: 0.73-0.97; p = 0.02 and HR: 0.83, 95% CI: 0.70-0.99; p = 0.03, respectively, for carbamazepine and lamotrigine). Carbamazepine was also associated with a lower hazard for depression (HR: 0.81; 95% CI: 0.69-0.96; p = 0.013) and anxiety (HR: 0.77; 95% CI: 0.63-0.95; p = 0.013) in secondary analyses. This study provides evidence that carbamazepine and lamotrigine are associated with lower hazards for psychiatric symptoms following a diagnosis of epilepsy. These estimates can be used in clinical settings, and the precision should improve with more contemporary data that include larger proportions of newer generation AEDs.

Women with epilepsy initiating a progestin IUD: A prospective pilot study of safety and acceptability

OBJECTIVE

Effective contraception enables women with epilepsy (WWE) to plan their pregnancies and improve outcomes for themselves and their children. Although popular among all women, complex drug interactions limit the efficacy and safety of oral contraceptives (OCs) for WWE. We sought to explore the safety, acceptability, and pharmacokinetic impact of a progestin-containing intrauterine device (IUD) in WWE.

METHODS

We enrolled 20 women with well-controlled epilepsy and a stable antiepileptic drug (AED) regimen and who were initiating a progestin-containing IUD (levonorgestrel 52 mg) in a prospective, observational study. For each AED, we compared the trough concentration before IUD insertion to the trough concentration 3 weeks, and 3 and 6 months later. Participants recorded seizures in a daily paper diary. We compared seizures that occurred during the month before IUD insertion to those occurring in the 6 months thereafter. Participants completed an acceptability questionnaire at 3 and 6 months.

RESULTS

Participants' average age was 28 years; 60% were nulligravid. They reported a history of multiple seizure types. During the baseline month, 75% were seizure-free and the remainder reported between one and three seizures. Fourteen received monotherapy and six received polytherapy. Lamotrigine use was most common (n = 12). AED trough concentrations remained stable during the 6 months after IUD insertion, without clinically meaningful deviations from baseline. Diary data showed that seizure frequency worsened in 3, and remained unchanged in 13 and improved in 4 after IUD insertion. Subjectively, no participant believed the IUD worsened her seizure control. All participants were either somewhat or very satisfied with the IUD throughout the study. All participants continued the IUD use at 6 months. No pregnancies occurred.

SIGNIFICANCE

This pilot study suggests that the progestin-containing IUD is a safe and acceptable long-acting contraceptive for WWE.

Qualitative analysis of double inversion recovery MRI in drug-resistant epilepsy

PURPOSE

To determine whether Double Inversion Recovery (DIR) on 3T MRI can enhance detection of epileptogenic lesions Methods: 29 adult patients with DRE were enrolled in a prospective pilot study. Brain MRIs were obtained using a specialized protocol that included: (1) Fast-Spin EchoT2, (2) T2 fluid attenuated inversion recovery (FLAIR), and (3) DIR sequences. Two neuroradiologists blinded to clinical information independently reviewed each sequence in the order listed above for T2-hyperintense lesions. Cortical lesions were determined to be concordant with the epileptic focus based upon available clinical and electrodiagnostic testing.

RESULTS

Of 29 studies, 21 had a lesion identified with 13/21 abnormalities being non-specific. Of 8 remaining studies, 3 revealed a lesion only with DIR sequencing. DIR-lesions were concordant with clinical data in 1 subject, non-discordant in 1 subject, and discordant in 1 subject.

SIGNIFICANCE

DIR has the potential to be more sensitive in detecting cortically based lesions relative to standard imaging. More data are needed to assess the sensitivity and specificity of DIR, particularly as it pertains to identification of epileptogenic lesions using electrodiagnostic testing and outcome after surgery.

Patient perceptions of physician-documented quality care in epilepsy

OBJECTIVE

The aim of this study was to compare physician encounter documentation with patient perceptions of quality of epilepsy care and examine the association between quality and patient assessment of provider communication.

METHODS

We identified 505 adult patients with epilepsy aged 18years or older over a 3-year period in two large academic medical centers. We abstracted individual, clinical, and care measures from 2723 electronic clinical notes written by physicians. We then randomly selected 245 patients for a phone interview. We compared patient perceptions of care with the documented care for several established epilepsy quality measures. We also explored the association of patient's perception of provider communication with provider documentation of key encounter interventions.

RESULTS

There were 88 patients (36%) who completed the interviews. Fifty-seven (24%) refused to participate, and 100 (40%) could not be contacted. Participants and nonparticipants were comparable in their demographic and clinical characteristics; however, participants were more often seen by epilepsy specialists than nonparticipants (75% vs. 61.9%, p<0.01). Quality scores based on patient perceptions differed from those determined by assessing the documentation in the medical record for several quality measures, e.g., documentation of side effects of antiseizure therapy (p=0.05), safety counseling (p<0.01), and counseling for women of childbearing potential with epilepsy (McNemar's p=0.03; intraclass correlation coefficient, ICC=0.07). There was a significant, positive association between patient-reported counseling during the encounter (e.g., personalized safety counseling) and patient-reported scores of provider communication (p=0.05).

CONCLUSIONS

The association between the patient's recollection of counseling during the visit and his/her positive perception of the provider's communication skills highlights the importance of spending time counseling patients about their epilepsy and not just determining if seizures are controlled.

High-dose versus low-dose valproate for the treatment of juvenile myoclonic epilepsy: Going from low to high

Juvenile myoclonic epilepsy (JME) is a genetic generalized epilepsy accounting for 3-12% of adult cases of epilepsy. Valproate has proven to be the first-choice drug in JME for controlling the most common seizure types: myoclonic, absence, and generalized tonic-clonic (GTC). In this retrospective study, we analyzed seizure outcome in patients with JME using valproate monotherapy for a minimum period of one year. Low valproate dose was considered to be 1000mg/day or lower, while serum levels were considered to be low if they were at or below 50mcg/dl. One hundred three patients met the inclusion criteria. Fifty-six patients (54.4%) were female. The current average age was 28.4±7.4years, while the age of epilepsy onset was 13.6±2.9years. Most patients corresponded to the subsyndrome of classic JME. Forty-six (44.7%) patients were free from all seizure types, and 76 (73.7%) patients were free from GTC seizures. No significant difference was found in seizure freedom among patients using a low dose of valproate versus a high dose (p=0.535) or among patients with low blood levels versus high blood levels (p=0.69). In patients with JME, it seems appropriate to use low doses of valproate (500mg to 1000mg) for initial treatment and then to determine if freedom from seizures was attained.

Antiepileptic drug prescribing patterns in Iraq and Afghanistan war veterans with epilepsy

OBJECTIVE

We examined patterns of antiepileptic drug (AED) use in a cohort of Iraq/Afghanistan war veterans (IAVs) who were previously identified as having epilepsy. We hypothesized that clinicians would be more likely to prescribe newer AEDs and would select specific AEDs to treat seizures based on patient characteristics including gender and comorbidities.

METHODS

From the cohort of IAVs previously identified with epilepsy between fiscal years 2009 and 2010, we selected those who received AEDs from the Veterans Health Administration in FY2010. Regimens were classified as monotherapy or polytherapy, and specific AED use was examine overall and by gender. Multivariable logistic regression examined associations of age; gender; race/ethnicity; medical, psychiatric, and neurological comorbidities; and receipt of neurology specialty care associated with the six most commonly used AEDs.

RESULTS

Among 256,284 IAVs, 2123 met inclusion criteria (mean age: 33years; 89% men). Seventy-two percent (n=1526) received monotherapy, most commonly valproate (N=425) and levetiracetam (n=347). Sixty-one percent of those on monotherapy received a newer AED (levetiracetam, topiramate, lamotrigine, zonisamide, oxcarbazepine). Although fewer women than men received valproate, nearly 90% (N=45) were of reproductive age (≤45years). Antiepileptic drug prescribing patterns were associated with posttraumatic stress disorder, bipolar disorder, cerebrovascular disease, dementia/cognitive impairment, headache, and receipt of neurological specialty care (all p<0.01).

SIGNIFICANCE

In this cohort of veterans with epilepsy, most received AED monotherapy and newer AEDs. Prescribing patterns were different for men and women. The patterns observed between AEDs and neurological/psychiatric comorbidities suggest that clinicians are practicing rational prescribing.

Depression screening in pediatric epilepsy: evidence for the benefit of a behavioral medicine service in early detection

Despite the increased risk and prevalence of depression in youth with epilepsy, only one-third receive mental health services. Untreated depression can contribute to negative outcomes and increased health-care utilization and medical cost. Proactive behavioral medicine screening may facilitate identification of depressive symptoms and necessary interventions in efforts to optimize behavioral health and health-related quality of life (HRQOL). Primary study aims included the examination of 1) rates of self-reported depression in youth with epilepsy, 2) differences in depression by demographic and medical variables, 3) the impact of depression on HRQOL, and 4) changes in depression and suicidal ideation following a behavioral medicine consultation. As part of routine clinic care over a 24-month period, youth with epilepsy of 7-17years of age completed the Children's Depression Inventory-Second Edition. Parents completed the PedsQL. A chart review was conducted to ascertain demographics, medical variables, and behavioral medicine visits and recommendations. A subsample with Time 1 and Time 2 depression data was examined. Time 1 participants included 311 youth with epilepsy (Mage=11.9years, 50% female, 84% Caucasian, 46.0% with localization-related epilepsy, 71.0% with seizure control in the past 3months). Elevated depression was identified in 23% of youth, with 14% endorsing suicidal ideation. Depression significantly varied by age, antiepileptic drug, and insurance. After controlling for seizure status, HRQOL worsened with elevated depression. Depression significantly decreased from Time 1 to Time 2 (n=159), particularly for those referred for behavioral medicine services at Time 1. Systematic assessment and early detection of depression and/or suicidal ideation in youth with epilepsy can improve HRQOL and decrease depression. Depression screening can be implemented through clinic-based behavioral medicine services.

Validation of the Patient Health Questionnaire-9 (PHQ-9) for depression screening in adults with epilepsy

OBJECTIVE

This study aimed to assess the accuracy and operating characteristics of the Patient Health Questionnaire-9 (PHQ-9) for depression screening in adults with epilepsy.

METHODS

Tertiary epilepsy center patients served as the study population, with 237 agreeing to structured interview using the Mini-International Neuropsychiatric Interview (MINI), a "gold standard" instrument developed for rapid diagnosis of neuropsychiatric disorders, including major depressive disorder (MDD); 172 also completed the PHQ-9, and 127 completed both the PHQ-9 and the Neurological Disorders Depression Inventory for Epilepsy (NDDI-E) within two days of the MINI. Sensitivity, specificity, positive and negative predictive values, and areas under the ROC curves for each instrument were determined. Cut-points of 10 for the PHQ-9 and 15 for the NDDI-E were used, and ratings at or above the cut-points were considered screen-positive. The PHQ-9 was divided into cognitive/affective (PHQ-9/CA) and somatic (PHQ-9/S) subscales to determine comparative depression screening accuracy.

RESULTS

The calculated areas under the ROC curves for the PHQ-9 (n=172) and the PHQ-9/CA and PHQ-9/S subscales were 0.914, 0.924, and 0.846, respectively, with the PHQ-9 more accurate than the PHQ-9/S (p=0.002) but not different from the PHQ-9/CA (p=0.378). At cut-points of 10 and 15, respectively, the PHQ-9 had higher sensitivity (0.92 vs 0.87) but lower specificity (0.74 vs 0.89) compared with the NDDI-E. The areas under the ROC curves of the PHQ-9 and the NDDI-E showed similar accuracy (n=127; 0.930 vs 0.934; p=0.864).

SIGNIFICANCE

The PHQ-9 is an efficient and nonproprietary depression screening instrument with excellent accuracy validated for use in adult patients with epilepsy as well as multiple other medical populations.