Comprehensive Epilepsy Center Research Articles

Association of Normative and Non-Normative Brain Networks With Cognitive Function in Patients With Temporal Lobe Epilepsy.

Despite their temporal lobe pathology, a significant subgroup of patients with temporal lobe epilepsy (TLE) is able to maintain normative cognitive functioning. In this study, we identify patients with TLE with intact vs impaired neurocognitive profiles and interrogate for the presence of both normative and highly individual intrinsic connectivity networks (ICNs)-all toward understanding the transition from impaired to intact neurocognitive status. This retrospective cross-sectional study included patients with TLE and matched healthy controls (HCs) from the Thomas Jefferson Comprehensive Epilepsy Center. Functional MRI data were decomposed using independent component analysis to obtain individualized ICNs. In this article, we calculated the degree of match between individualized ICNs and canonical ICNs (e.g., 17 resting-state networks by Yeo et al.) and divided each participant's ICNs into normative or non-normative status based on the degree of match. 100 patients with TLE (mean age 42.0 [SD: 13.7] years, 47 women) and 92 HCs were included in this study. We found that the individualized networks matched to the canonical networks less well in the cognitively impaired (n = 24) compared with the cognitively intact (n = 63) patients with TLE by 2-way mixed-measures analysis of variance (impaired vs intact mean difference [MD] -0.165 [-0.317, -0.013], p = 0.028). The cognitively impaired patients showed significant abnormalities in the profiles of both normative (impaired vs intact MD -0.537 [-0.998, -0.076], p = 0.017, intact vs HC MD -0.221 [-0.536, 0.924], p = 0.220, and impaired vs HC MD -0.759 [-1.200, -0.319], p < 0.001) and non-normative networks (impaired vs intact MD 0.484 [0.030, 0.937], p = 0.033, intact vs HC MD 0.369 [0.059, 0.678], p = 0.014, and impaired vs HC MD 0.853 [0.419, 1.286], p < 0.001) while the intact patients showed abnormalities only in non-normative networks. At the same time, we found that normative networks held a strong, positive association with the neuropsychological measures, with this association negative in non-normative networks. Our data demonstrated that significant cognitive deficits are associated with the status of both canonical and highly individual ICNs, making clear that the transition from intact to impaired cognitive status is not simply the result of disruption to normative brain networks.

Association of baseline sleep duration and sleep quality with seizure recurrence in newly treated patients with epilepsy.

Although sleep duration and sleep quality are considered to be significant factors associated with epilepsy and seizure risk, findings are inconsistent, and their joint association remains uncertain. This study aimed to determine independent and joint associations of these two modifiable sleep features with seizure recurrence risk in newly treated patients with epilepsy (PWE). This is a prospective cohort study of newly treated PWE at a comprehensive epilepsy center in northeast China between June 2020 and December 2023. Self-reported sleep duration and sleep quality were collected at baseline. All patients were followed for 12 months for recurrent seizures. Cox proportional hazard regression models were used to estimate the hazard ratios (HRs) of seizure recurrence. Models fitted with restricted cubic spline were conducted to test for linear and nonlinear shapes of each association. A total of 209 patients were included, and 103 experienced seizure recurrence during follow-up. Baseline short sleep was significantly associated with greater risk of seizure recurrence (adjusted HR = 2.282, 95% confidence interval [CI] = 1.436-3.628, p < .001). Sleep duration (h/day) and recurrent seizure risk showed a significant nonlinear U-shaped association, with a nadir at 8 h/day. Baseline poor sleep quality was significantly associated with greater risk of seizure recurrence (adjusted HR = 1.985, 95% CI = 1.321-2.984, p < .001). Pittsburgh Sleep Quality Index score and seizure recurrence risk exhibited a positive linear association. Participants with a combination of poor quality-short sleep showed the highest risk of seizure recurrence (adjusted HR = 3.13, 95% CI = 1.779-5.507, p < .001) compared to the referent good quality-intermediate sleep group. Baseline sleep duration and sleep quality were independently and jointly associated with risk of seizure recurrence in newly treated PWE. Our results point to an important potential role of baseline sleep duration and sleep quality in shaping seizure risk.

AB076. Underutilization of epilepsy surgery in Pakistan: 10-year experience from the only comprehensive epilepsy center in the country.

Eighty percent of the global epilepsy burden is borne by developing countries, and 30% of these patients have drug-resistant epilepsy (DRE). Epilepsy surgery (ES) can significantly improve the cognition and quality of life in DRE. A comprehensive epilepsy center was established in Pakistan in 2010, the only facility for ES in a country of 231 million people. Hundreds of epilepsy patients are medically managed at the center each year. We aimed to study seizure control in all ES cases performed at the only comprehensive epilepsy center in the country during last 10 years. It was a retrospective cohort study. Medical records of all cases of ES performed at our center from 2012 to 2021 were retrieved, through the Hospital's Information Management System. Patients were also contacted via phone calls where needed, to collect information about their seizure control as per Engel Classification. Data was analyzed using SPSSv21. Thirty-three surgeries including 10 temporal lobectomies with amygdalohippocampectomy, 11 selective amygdalohippocampectomies, 9 corpus callosotomies, 1 callosotomy with lesionectomy, 1 lesionectomy and 1 temporal lobectomy were performed. The median age of patients was 23: [18-31] years. Complex partial seizures were most common (14; 42.4%), followed by generalized seizures (10; 30.3%). The median duration of AEDs before surgery was 6 (IQR: 3.25-13.75) years. Eighteen (54.5%) patients had complete freedom from disabling seizures (Engel Class IA) at a median follow-up of 3.25 (IQR: 1.12-6) years. All patients continued to receive antiepileptic drugs after surgery, and all procedures had nearly 50% optimum seizure control outcomes. The clinical outcomes of ES performed at our center are consistent with evidence. However, the small volume highlights the underutilization of this extremely important service. More studies are needed to identify the factors responsible for this disparity, so that all DRE patients have access to ES.

Patient Handoff Practices at the Epilepsy Centers in the United States: A Survey of the Medical Directors.

Communication failure is one of the most significant causes of medical errors. Providing care to patients with seizures at comprehensive epilepsy centers requires uninterrupted coverage and a multidisciplinary approach. However, handoff practices in these settings have not been comprehensively assessed, and recommendations for their standardization are currently lacking. The aim of this observational study was to define the scope of existing practices for patient handoffs across epilepsy centers in the United States and provide relevant recommendations. A 79-question survey was developed to establish the patterns of transition of care for patients undergoing continuous EEG recording, including the periodicity of handoffs and specifics of the relevant workflow. With permission from the National Association of Epilepsy Centers (NAEC), the survey was distributed to the medical directors of all Level 3 and 4 NAEC-accredited epilepsy centers in the United States. The responses were obtained from 70 institutions yielding a survey response rate of 26%. Of these, more than 77% had established weekly handoff processes for both the epilepsy monitoring unit and continuous EEG (cEEG) monitoring services. However, only 53% and 43% of centers had procedures for daily service transfers for the patients admitted to the epilepsy monitoring unit or the patients undergoing cEEG, respectively. The patterns of handoffs were complex and utilized group handoffs in < 50% of institutions. In most centers (>70%), patient data transmitted through handoffs included history, clinical information, and EEG findings. However, templates were not applied to standardize this information. All participants agreed or strongly agreed that a culture of patient safety was maintained in their place of practice; however, 12% of participants felt that insufficient time was allowed to discuss these patients or carry out the handoffs without interruptions. Existing handoff practices are not uniform or fully established across epilepsy centers in the United States. This study recommends that guidelines for formal handoff procedures be developed and introduced as a quality metric for all NAEC-accredited epilepsy centers.

A survey of ictal physical examination during VEEG monitoring in a tertiary epilepsy center

BackgroundIctal examination based on video-based electroencephalography (EEG) is crucial for locating and lateralizing seizures. In this study, we aimed to evaluate the quality of ictal examination in the Comprehensive Epilepsy Center of West China Hospital, Sichuan University, in order to provide information for quality improvement in daily clinical practice.MethodsVideo recordings of 100 patients with epilepsy were retrospectively reviewed. The performance of the ictal examination was independently reviewed by two epileptologists using an ictal examination protocol.ResultsIn this retrospective analysis, 589 seizure episodes from 100 patients with epilepsy were reviewed. The ages of the patients ranged from 3 to 77 years, with a mean age of 25.8 ± 12.8 years. Among the 589 seizure episodes, a majority (93.7%) were focal seizures. For 226 (38.4%) seizures, the medical staff arrived at the bedside. Among them, 153 (153/226, 64.7%) seizure episodes, the medical staff arrival at the bedside within 30 s of onset, and 120 (120/226, 53.1%) seizures were tested by the medical staff. The compliance rates for "safety” and "visibility" reached 80% or higher while “naming”, “retelling”, and “memory testing” only reach less than 3%.ConclusionsOur survey identified the main problems in ictal assessments. It is challenging to complete a standardized examination for new trainees at Epilepsy Monitoring Units. Regularly strengthening training in ictal examination and understanding of semiology may improve patients’ examination ability. However, further study of the implementation of training is necessary.

Impact of Direct Outcome to a Comprehensive Epilepsy Center in Patients with Status Epilepticus (P4-2.001)

Impact of Direct Outcome to a Comprehensive Epilepsy Center in Patients with Status Epilepticus (P4-2.001)

Surveying neurologist perspectives and knowledge of epilepsy surgery to identify barriers to surgery referral.

Epilepsy surgery is an effective means of treating medically refractory epilepsy (MRE), but it remains underused. We aimed to analyze the perspectives and knowledge of referring neurologists in the New York metropolitan area, who serve a large epilepsy population. We adapted a previous Canadian survey by Roberts etal. (2015), adding questions regarding demographic descriptors, insurance coverage, training and practice details, and perceived social barriers for patients. We surveyed neurologists directly affiliated with Montefiore Medical Center and those referring to Montefiore's Comprehensive Epilepsy Center. Participants had 10 weeks to fill out an online Qualtrics survey with weekly reminders. Of 117 neurologists contacted, 51 eligible neurologists completed the survey (63.8% Montefiore, 35.0% referring group). A high proportion of the results were from epilepsy-trained individuals (41.2%) and neurologists who graduated residency ≤19 years ago (80.4%). 80.4% of respondents felt that epilepsy surgery is safe, but only 56.9% would refer a patient for surgical workup after two failed trials of anti-seizure medications. Epileptologists and providers with a larger volume of epilepsy patients and electroencephalogram readings had better knowledge of the epilepsy surgery workup guidelines. When asked to rank social barriers to patients receiving surgery, participants were most concerned about lack of social support, financial insecurity, and a patient's dual role as a caregiver. Our study suggests continued reluctance of neurologists regarding epilepsy surgery, and deficiencies in the knowledge and adherence to the recommended guidelines. In the context of prior studies, these results showed improved understanding of the definition of MRE (80.4%) and an increased likelihood to refer eligible patients as early as possible (78.4%) in line with current consensus recommendations. The finding that epilepsy-trained and more epilepsy/electroencephalogram-facing neurologists showed better understanding of the guidelines suggests that increased education efforts should be targeted at non-epileptologists. Our study asked New York City doctors about their approach to epilepsy surgery. Many do not consider it as early as they could in treatment plans. The doctors with extra epilepsy training were better at knowing when to consider surgery.

Guidelines for Specialized Epilepsy Centers: Executive Summary of the Report of the National Association of Epilepsy Centers Guideline Panel.

The National Association of Epilepsy Centers first published the guidelines for epilepsy centers in 1990, which were last updated in 2010. Since that update, epilepsy care and the science of guideline development have advanced significantly, including the importance of incorporating a diversity of stakeholder perspectives such as those of patients and their caregivers. Currently, despite extensive published data examining the efficacy of treatments and diagnostic testing for epilepsy, there remain significant gaps in data identifying the essential services needed for a comprehensive epilepsy center and the optimal manner for their delivery. The trustworthy consensus-based statements (TCBS) process produces unbiased, scientifically valid guidelines through a transparent process that incorporates available evidence and expert opinion. A systematic literature search returned 5937 relevant studies from which 197 articles were retained for data extraction. A panel of 41 stakeholders with diverse expertise evaluated this evidence and drafted recommendations following the TCBS process. The panel reached consensus on 52 recommendations covering services provided by specialized epilepsy centers in both the inpatient and outpatient settings in major topic areas including epilepsy monitoring unit care, surgery, neuroimaging, neuropsychology, genetics, and outpatient care. Recommendations were informed by the evidence review and reflect the consensus of a broad panel of expert opinions.

Identifying epilepsy surgery referral candidates with natural language processing in an Australian context.

Epilepsy surgery is known to be underutilized. Machine learning-natural language processing (ML-NLP) may be able to assist with identifying patients suitable for referral for epilepsy surgery evaluation. Data were collected from two tertiary hospitals for patients seen in neurology outpatients for whom the diagnosis of "epilepsy" was mentioned. Individual case note review was undertaken to characterize the nature of the diagnoses discussed in these notes, and whether those with epilepsy fulfilled prespecified criteria for epilepsy surgery workup (namely focal drug refractory epilepsy without contraindications). ML-NLP algorithms were then developed using fivefold cross-validation on the first free-text clinic note for each patient to identify these criteria. There were 457 notes included in the study, of which 250 patients had epilepsy. There were 37 (14.8%) individuals who fulfilled the prespecified criteria for epilepsy surgery referral without described contraindications, 32 (12.8%) of whom were not referred for epilepsy surgical evaluation in the given clinic visit. In the prediction of suitability for epilepsy surgery workup using the prespecified criteria, the tested models performed similarly. For example, the random forest model returned an area under the receiver operator characteristic curve of 0.97 (95% confidence interval 0.93-1.0) for this task, sensitivity of 1.0, and specificity of 0.93. This study has shown that there are patients in tertiary hospitals in South Australia who fulfill prespecified criteria for epilepsy surgery evaluation who may not have been referred for such evaluation. ML-NLP may assist with the identification of patients suitable for such referral. Epilepsy surgery is a beneficial treatment for selected individuals with drug-resistant epilepsy. However, it is vastly underutilized. One reason for this underutilization is a lack of prompt referral of possible epilepsy surgery candidates to comprehensive epilepsy centers. Natural language processing, coupled with machine learning, may be able to identify possible epilepsy surgery candidates through the analysis of unstructured clinic notes. This study, conducted in two tertiary hospitals in South Australia, demonstrated that there are individuals who fulfill criteria for epilepsy surgery evaluation referral but have not yet been referred. Machine learning-natural language processing demonstrates promising results in assisting with the identification of such suitable candidates in Australia.

Surgical Management of Epilepsy and Outcomes in a Comprehensive Epilepsy Center in Pakistan: A 20-year Retrospective Analysis

Background: Epilеpsy is a prеvalеnt nеurological disordеr in Pakistan, with an еarly onsеt in a substantial portion of thе population. Surgical intеrvеntion for drug-rеsistant еpilеpsy is a viablе trеatmеnt option, yеt it rеmains undеrutilizеd duе to limitеd spеcializеd cеntеrs and sociеtal stigmas. Objectives: Our study evaluated thе outcomеs of еpilеpsy surgеriеs pеrformеd ovеr two dеcadеs in a major Pakistani hospital. Mеthodology: A 20-yеar rеtrospеctivе cohort study was conductеd from 2002 to 2022, involving 31 patiеnts with focal еpilеpsy who undеrwеnt surgical procеdurеs. Patient demographics, clinical history, electroencephalogram (EEG) and magnetic resonance imaging (MRI) findings, and surgical interventions were recorded. Data analysis was pеrformеd using SPSS vеrsion 23. Rеsults: Among thе 31 patiеnts, thе majority had intractablе sеizurеs, and 14 wеrе on thrее or morе anti-еpilеptic drugs prеopеrativеly. Surgical procеdurеs includеd sеlеctivе amygdalohippocampеctomy, tеmporal lobеctomy, corpus callosotomy, lеsionеctomy, craniotomy, and hеmisphеrеctomy. Postsurgical complications wеrе minimal. Around 32.3% of the patients achieved complete seizure freedom at 6 months, and 45.2% at 1 year. Conclusion: Surgical procеdurеs, including tеmporal lobеctomy and corpus callosotomy, havе shown promisе in achiеving sеizurе frееdom or significant improvеmеnt in sеlеct casеs. Thе findings еmphasizе thе critical nееd for timеly diagnosis and carеful patiеnt sеlеction. Rеcognizing еpilеpsy’s impact on both physical and psychosocial wеll-bеing emphasizes thе importancе of considеring surgical options whеn consеrvativе thеrapiеs provе inеffеctivе. Incrеasing awarеnеss and accеssibility to spеcializеd еpilеpsy cеntеrs arе еssеntial stеps toward improving thе managеmеnt of еpilеpsy in developing countries.

Education Research: Virtual Patient Management Conference for Epilepsy Surgery in the Post-COVID-19 Era: An Educational Perspective.

The primary objective of this study was to assess the potential educational value of a virtual patient management conference (PMC) with the introduction of inclusive anonymous polling at a comprehensive epilepsy center. The secondary objective was to evaluate differences between faculty and trainee polling results. Two online surveys were sent 1 year apart seeking opinions about a transition to virtual PMC and completed by virtual PMC faculty participants (including representatives from neurology, neurosurgery, and neuropsychology). One online survey was sent to trainees (medical students, residents, and fellows) to assess the educational value of the conference. Anonymous electronic polls surveying treatment options were completed by both faculty and trainees after each virtual PMC presentation but before discussing the case. The results were collected and analyzed over 16 months, including over the course of 1 academic year. The degree of consensus was determined by the maximum percentage of votes that a single choice received. Eleven faculty and 22 trainees responded to their respective surveys. The initial faculty survey revealed that 60.0% of faculty had an "excellent" or "very good" experience with virtual PMC; 1 year later, this proportion increased to 100.0% while trainees reported 90.9%. Each virtual PMC component, including perceived standard of care, was found to be "excellent" or "very good" by most faculty and trainees, and most (91% faculty, 63.7% trainees) were equally comfortable or more comfortable expressing opinions during the virtual discussion. During virtual PMC polls, faculty members were significantly more likely to vote for vagus nerve stimulation as a treatment option, while trainees were more likely to opt for responsive neurostimulation. Linear regression over the course of the academic year showed stable consensus over time for both faculty and trainees; however, the match between faculty and trainee consensus significantly increased over the academic year. Our results demonstrate that the virtual PMC constitutes an effective educational experience as an alternative to in-person conferences for the management of patients with drug-resistant epilepsy.

The clinical characteristics of childhood-onset and late-onset functional seizures: How do they differ?

BackgroundWe investigated childhood-onset functional seizures (FS) and late-onset FS and hypothesized that there are differences in their characteristics. MethodsIn this retrospective study, we investigated all patients with confirmed FS with an age at onset of 14 years or younger and those with an age at onset of 50 years or older, who were admitted to the epilepsy monitoring units at one center in Iran (Shiraz Comprehensive Epilepsy Center, from 2008 until 2022) and one center in the USA (Vanderbilt University Medical Center, from 2011 until 2022). ResultsOne-hundred and forty patients were included. They included 80 patients with childhood-onset FS and 60 with late-onset FS. Those with late-onset FS were more likely to have medical comorbidities compared with the patients with childhood-onset FS (OR = 13.9). Those with late-onset FS more likely had a history of head injury compared with the patients with childhood-onset FS (OR = 5.97). Duration of illness was significantly longer in patients with childhood-onset FS compared with the patients with late-onset FS (6 years vs. 2 years). ConclusionOur study identified several similarities and differences in the clinical characteristics and predisposing factors of patients with childhood-onset and late-onset FS. In addition, we found that childhood-onset FS is more likely to remain undiagnosed and thus untreated for many years. These findings provide additional evidence that FS is a heterogenous condition and we propose that a proportion of the differences between patients may be accounted for by age-associated factors.

Editorial introductions.

Current Opinion in Neurology was launched in 1988. It is one of a successful series of review journals whose unique format is designed to provide a systematic and critical assessment of the literature as presented in the many primary journals. The field of neurology is divided into 14 sections that are reviewed once a year. Each section is assigned a Section Editor, a leading authority in the area, who identifies the most important topics at that time. Here we are pleased to introduce the Journal's Section Editors for this issue. SECTION EDITORS Lawrence J. HirschLawrence J. HirschLawrence J. Hirsch, MD is Professor of Neurology, Chief of the Division of Epilepsy and EEG, and Co-Director of the Comprehensive Epilepsy Center, all at Yale University, USA. He has held leadership positions in the American Clinical Neurophysiology Society (ACNS), American Epilepsy Society, American Academy of Neurology, and the Epilepsy Foundation, and is lead author of the 2012 and 2021 ACNS guidelines on critical care EEG terminology. He is founder and former chair of the Critical Care EEG Monitoring Research Consortium, which now includes more than 50 centers, and co-chair of the medical advisory board of the NORSE Institute. He has been an active researcher throughout his career, having published more than 200 peer-reviewed manuscripts and more than 100 reviews, editorials or book chapters on topics including status epilepticus, all aspects of EEG including intracranial recordings and brain monitoring in the critically ill, brain stimulation, epilepsy surgery, seizure clusters, rescue medications, sudden death in epilepsy (SUDEP), and anti-seizure medication use. He has won multiple teaching awards and is co-author of the first-ever atlas on EEG in critical care, now in its 2nd edition. He continues to see patients in the inpatient and outpatient setting, direct fellowship programs, teach, mentor, and manage a large epilepsy division at a level IV Comprehensive Epilepsy Center. Michael F. WatersMichael F. WatersMichael F. Waters, MD, PhD, is a neurologist, director of both the Neurovascular Division and the Petznick Stroke Center, and a professor in the Department of Neurology at Barrow Neurological Institute, USA. He is board certified in neurology by the American Board of Psychiatry and Neurology with subspecialty board certification in vascular neurology. Dr Waters’ expertise is stroke and neurovascular disease, including signs, symptoms, diagnostics, and treatments. He is a fellow of both the American Academy of Neurology and American Heart Association and a member of the American Neurological Association, American Society of Human Genetics, and the Society of Vascular and Interventional Neurology. Dr Waters received his Masters in genetics from Penn State University in State College, Pennsylvania, USA, and his doctorate in biochemistry and molecular biology from The University of Florida College of Medicine in Gainesville, USA, where he also completed his MD. He completed his residency training at the University of California – Los Angeles Department of Neurology and completed his fellowship in clinical and molecular neurogenetics at Cedars Sinai Medical Center in Los Angeles, USA. Dr Waters’ research studies include genetic mechanisms of stroke, neuroprotection in stroke, stroke treatment, multiple clinical trials investigating stroke treatments, and neurogenetic mechanisms of neuroplasticity.

Association Between Characteristics of National Association of Epilepsy Centers and Reported Utilization of Specific Surgical Techniques.

Nearly one-third of persons with epilepsy will continue having seizures despite trialing multiple antiseizure medications. Epilepsy surgery may be beneficial in these cases, and evaluation at a comprehensive epilepsy center is recommended. Numerous palliative and potentially curative approaches exist, and types of surgery performed may be influenced by center characteristics. This article describes epilepsy center characteristics associated with epilepsy surgery access and volumes in the United States. We analyzed National Association of Epilepsy Centers 2019 annual report and supplemental survey data obtained with responses from 206 adult epilepsy center directors and 136 pediatric epilepsy center directors in the United States. Surgical treatment volumes were compiled with center characteristics, including US Census region. We used multivariable modeling with zero-inflated Poisson regression models to present ORs and incidence rate ratios of receiving a given surgery type based on center characteristics. The response rate was 100% with individual element missingness less than 4% across 352 observations undergoing univariate analysis. Multivariable models included 319 complete observations. Significant regional differences were present. The rates of laser interstitial thermal therapy (LITT) were lower at centers in the Midwest (incidence rate ratio [IRR] 0.74, 95% CI 0.59-0.92; p = 0.006) and Northeast (IRR 0.77, 95% CI 0.61-0.96; p = 0.022) compared with those in the South. Conversely, responsive neurostimulation implantation rates were higher in the Midwest (IRR 1.45, 95% CI 1.1-1.91; p = 0.008) and West (IRR 1.91, 95% CI 1.49-2.44; p < 0.001) compared with the South. Center accreditation level, institution type, demographics, and resources were also associated with variations in access and rates of potentially curative and palliative surgical interventions. Epilepsy surgery procedure volumes are influenced by US epilepsy center region and other characteristics. These variations may affect access to specific surgical treatments for persons with drug resistant epilepsy across the United States.

NeuroMeasures-Implementation of a Web-Based, Real-Time Quality Metric Tool to Improve Provider Practices in an Epilepsy Clinic.

The retrospective nature of most available epilepsy quality improvement (QI) tools focuses on changing health care provider (HCP) clinical habits and documentation practices rather than a focus on real-time patient interventions. Furthermore, patient-reported outcome data are often not available to determine the efficacy of these tools. Our primary objective was to demonstrate the improvement of HCPs' documentation and review of epilepsy quality measures (EQMs) during the patient visit with the implementation of a novel web application, NeuroMeasures. Our secondary objective was to improve the percentage of point-of-care counseling and interventions based on quality measures during the patient encounter based on the results of the NeuroMeasures tool. Our QI study focused on comparing a preintervention and postintervention cohort of patients with epilepsy (PWE) before the implementation of NeuroMeasures, a web-based application that takes a self-guided patient survey through self-scoring algorithms focused on the American Academy of Neurology (AAN)'s 2017 EQMs. This e-tool then provides the HCP a tool to directly review the EQMs highlighted and perform any necessary counseling or interventions at the point-of-care visit. After intervention, EQMs were gained from the review of the NeuroMeasures HCP quality measures tool and a chart review for physician documentation. Patients with language barriers and severe cognitive disabilities were excluded from the study. The preintervention cohort consisted of 150 unique PWE, and the postintervention cohort included 379 unique adult PWE and 515 total encounters. Overall percentages of review/adherence of EQMs were significantly improved between the preintervention and postintervention group for counseling for women of childbearing potential (91.7%), intractable epilepsy referral to a comprehensive epilepsy center (74%), quality of life assessment (80%), improvement of quality of life measurements (41.7%), and depression and anxiety screening (85.6%), demonstrating a significant increase when compared with the preintervention group (p < 0.00001). A web-based point-of-care EQM application demonstrated significant improvement of the HCP's ability to perform and review EQMs at the point-of-care patient visit. Furthermore, the application was successful in creating opportunities for direct intervention based on the EQMs and chances for better patient education and provider-patient communication. Further considerations would include automated survey requests and expansion into other AAN QMs.

The endoscopic anterior transmaxillary temporal pole approach for mesial temporal lobe epilepsies: a feasibility study.

In mesial temporal lobe epilepsy (MTLE), the ideal surgical approach to achieve seizure freedom and minimize morbidity is an unsolved question. Selective approaches to mesial temporal structures often result in suboptimal seizure outcomes. The authors report the results of a pilot study intended to evaluate the clinical feasibility of using an endoscopic anterior transmaxillary (eATM) approach for minimally invasive management of MTLEs. The study is a prospectively collected case series of four consecutive patients who underwent the eATM approach for the treatment of MTLE and were followed for a minimum of 12 months. All participants underwent an epilepsy workup and surgical care at a tertiary referral comprehensive epilepsy center and had medically refractory epilepsy. The noninvasive evaluations and intracranial recordings of these patients confirmed the presence of anatomically restricted epileptogenic zones located in the mesial temporal structures. Data on seizure freedom at 1 year, neuropsychological outcomes, diffusion tractography, and adverse events were collected and analyzed. By applying the eATM technique and approaching the far anterior temporal lobe regions, mesial-basal resections of the temporal polar areas and mesial temporal structures were successfully achieved in all patients (2 with left-sided approaches, 2 with right-sided approaches). No neurological complications or neuropsychological declines were observed. All 4 patients achieved Engel class Ia outcome up to the end of the follow-up period (19, 15, 14, and 12 months). One patient developed hypoesthesia in the left V2 distribution but there were no other adverse events. The low degree of white matter injury from the eATM approach was analyzed using high-definition fiber tractography in 1 patient as a putative mechanism for preserving neuropsychological function. The described series demonstrates the feasibility and potential safety profile of a novel approach for medically refractory MTLE. The study affirms the feasibility of performing efficacious mesial temporal lobe resections through an eATM approach.

Dorsal bed nucleus of stria terminalis in depressed and nondepressed temporal lobe epilepsy patients.

Temporal lobe epilepsy (TLE) and depression are common comorbid disorders whose underlying shared neural network has yet to be determined. Although animal studies demonstrate a role for the dorsal bed nucleus of the stria terminalis (dBNST) in both seizures and depression, and human clinical studies demonstrate a therapeutic effect of stimulating this region on treatment-resistant depression, the role of the dBNST in depressed and nondepressed TLE patients is still unclear. Here, we tested the hypothesis that this structure is morphologically abnormal in these epilepsy patients, with an increased abnormality in TLE patients with comorbid depression. In this case-controlled study, 3-T structural magnetic resonance imaging scans were obtained from TLE patients with no depression (TLEonly), TLE patients with depression (TLEdep), and healthy control (HC) subjects. TLE subjects were recruited from the Yale University Comprehensive Epilepsy Center, diagnosed with the International League Against Epilepsy 2014 Diagnostic Guidelines, and confirmed by video-electroencephalography. Diagnosis of major depressive disorder was confirmed by a trained neuropsychologist through a Mini International Neuropsychiatric Interview based on the Diagnostic and Statistical Manual of Mental Disorders, 4th edition. The dBNST was delineated manually by reliable raters using Bioimage Suite software. The number of patients and subjects included 35 TLEonly patients, 20 TLEdep patients, and 102 HC subjects. Both TLEonly and TLEdep patients had higher dBNST volumes compared to HC subjects, unilaterally in the left hemisphere in the TLEonly patients (p= .003) and bilaterally in the TLEdep patients (p< .0001). Furthermore, the TLEdep patients had a higher dBNST volume than the TLEonly patients in the right hemisphere (p= .02). Here, we demonstrate an abnormality of the dBNST in TLE patients, both without depression (left enlargement) and with depression (bilateral enlargement). Our results demonstrate this region to underlie TLE both with and without depression, implicating it as a target in treating the comorbidity between these two disorders.

Postsurgical seizure outcome in temporal lobe epilepsy patients with normal or subtle, nonspecific MRI findings.

The authors' objective was to report postsurgical seizure outcome of temporal lobe epilepsy (TLE) patients with normal or subtle, nonspecific MRI findings and to identify prognostic factors related to seizure control after surgery. This was a retrospective study of patients who underwent surgery from 1999 to 2014 at two comprehensive epilepsy centers. Patients with a clear MRI lesion according to team discussion and consensus were excluded. Presurgical information, surgery details, pathological data, and postsurgical outcomes were retrospectively collected from medical charts. Multiple logistic regression analysis was used to assess the effect of clinical, surgical, and neuroimaging factors on the probability of Engel class I (favorable) versus class II-IV (unfavorable) outcome at last follow-up. The authors included 73 patients (59% were female; median age at surgery 35.9 years) who underwent operations after a median duration of epilepsy of 13 years. The median follow-up after surgery was 30.6 months. At latest follow-up, 44% of patients had Engel class I outcome. Favorable prognostic factors were focal nonmotor aware seizures and unilateral or no spikes on interictal scalp EEG. Favorable outcome can be achieved in a good proportion of TLE patients with normal or subtle, nonspecific MRI findings, particularly when presurgical investigation suggests a rather circumscribed generator. Presurgical factors such as the presence of focal nonmotor aware seizures and unilateral or no spikes on interictal EEG may indicate a higher probability of seizure freedom.

P.097 After-discharges and presurgical cortical stimulation in stereo-encephalography in the study of drug-resistant epilepsy

Background: Background: Cortical stimulation (CS) as a part of presurgical investigations in patients undergoing implantation of depth electrodes (SEEG) is a growing practice in some Comprehensive Epilepsy Centers. After-discharges (AD) are useful to determine epileptogenic tissue within or outside the epileptogenic network. Classification of afterdischarges was proposed by Blume using subdural recordings(1); its utility in SEEG is unknown. Methods: Methods: Single center, retrospective study that included patients with SEEG that underwent CS in the Epilepsy Monitoring Unit. Demographic characteristics were explored and Blume’s proposed AD classification was used to determine whether or not the CS changed surgical outcomes. Results: Results: From January 2015 to June 2021, a total of 177 patients were implanted with SEEG and analyzed. 95 patients had CS and 91 had AD. Morphologies found were: Rhythmic waves in 4 (0.04%), Rhythmic waves evolving into spikes in18 (19%), Polyspike bursts in 14 (15%), Spike-waves in 28 (30%), and sequential spikes in 18 (19%). 12/14 (86%) patients with Spike-waves had Engel I outcome; Engel class IV patients were more likely to have an evolution of morphology and frequency of ADs in 3 patients(75%). Conclusions: Conclusions: The most frequent morphology of ADs seen was spike-waves. AD morphology and duration may predict post-operative seizure outcomes.

P.098 Usefulness of language mapping during cortical stimulation for presurgical planning in Stereo-encephalograph

Background: Background: Language determination is a pivotal part of presurgical investigations. Presurgical cortical stimulation (CS) with language mapping (LM) in patients with intracranial recordings (SEEG) is a growing practice in some Comprehensive Epilepsy Centers. Methods: Methods: This retrospective, single center study included patients implanted with SEEG that underwent CS for LM in our Epilepsy Monitoring Unit. We describe frequencies, demographic characteristics of these patients and whether or not CS with LM was useful. Results: Results: From January 2015 to June2021, a total of 177 patients were implanted with SEEG and analyzed. 95 patients had CS and 44 of these had CS with LM. The mean age was 33 (ranging from 15-70). During LM, anomia was induced in 26 (58%), speech arrest in 22 (49%), paraphasic errors in 13 (29%), and hesitation in 9 (20%). LM results were recorded as influencing surgical decision in 7 (16%) patients, 4 (9%) did not undergo surgery due to expected language deficits and 3 (7%) proceeded with surgery due to an acceptable risk of language deficit. Conclusions: Conclusions: Cortical stimulation language mapping is useful for decision-making in presurgical evaluation and should be encouraged whenever involvement of language is suspected when determining the epileptogenic zone.