Definition Of Epilepsy Research Articles

Risk of epilepsy diagnosis after a first unprovoked seizure in dementia

PurposeTo estimate the risk of an epilepsy diagnosis after a first unprovoked seizure in dementia, in relation to the 60 % cut-off specified in the ILAE definition of epilepsy. MethodsThe study was register-based. Individuals with diagnostic codes of a first unprovoked seizure were identified in the Swedish Dementia Register (SveDem) or a three times larger age- and sex- matched pool of controls (n = 1039 in SveDem and 743 controls). The risk of a diagnostic code for epilepsy was estimated by Kaplan Meier analysis. ResultsThe 5-year risk of a subsequent epilepsy diagnosis after a first unprovoked seizure was 32 % (95 % CI 27–37) in patients with dementia and 31 % (95 % CI 25–38) in controls. The 5-year risk of epilepsy was 48 % (95 % CI 37–59) for individuals age 70 years or below. The dementia subtype with the highest risk of epilepsy was early onset Alzheimer. ConclusionThe risk of an epilepsy diagnosis after a first unprovoked seizure is similar in patients with dementia and in controls. Our results indicate that epilepsy cannot be diagnosed after a first seizure simply on the basis of the patient having dementia. Instead, more studies are needed for individualized prediction of recurrence risk in dementia. Such studies should focus on particular dementia subtypes, younger patients, and identifying biomarkers.

Lack of Evidence Complicates Care for Nursing Home Residents With Epilepsy

There’s mixed news for the diagnosis and management of epilepsy in nursing homes, where the prevalence of the disorder is estimated to be more than seven times higher than among seniors in the community. Generally speaking, for instance, the main evidence-based guideline on management of an unprovoked first seizure in adults — published by the American Academy of Neurology and American Epilepsy Society (Neurology 2015;84:1705–1713) — is applicable to the nursing home population. That’s good news, as is the development of a broader and “practical” definition of epilepsy by the International League Against Epilepsy (ILAE), two epilepsy specialists said at the Annual Conference of AMDA – The Society for Post-Acute and Long-Term Care Medicine. What is vexing — and what represents a “huge hole” for clinicians caring for nursing home residents with epilepsy — is the lack of evidence to guide the appropriate use of antiseizure medications in this population, the speakers said. “I don’t necessarily have evidence that any of [newer] drugs are actually really better than others,” said Ilo Leppik, MD, during a question-and-answer session that focused largely on drug choice and questions about therapeutic monitoring. “Levetiracetam and lamotrigine appear to be better for the elderly, especially in nursing homes, but we just don’t have the data.” The 2015 guideline on management of an unprovoked first seizure does not discuss drug choice but rather decision-making about whether to initiate therapy immediately. Level A evidence supports that recurrence risk is greatest early within the first two years (21% to 45%), the guideline states. Clinical variables associated with increased risk include a previous brain insult, including stroke (level A); an electroencephalogram with epileptiform abnormalities (level A); a significant brain-imaging abnormality (level B); and a nocturnal seizure (level B). “Immediate antiseizure therapy compared with a delay pending a second seizure is likely to reduce the recurrence risk for the first two years but may not improve the quality of life due to medication side effects,” said Dr. Leppik, professor of neurology and pharmacy at the University of Minnesota, in reviewing the guideline. He said that, interestingly enough, immediate treatment is unlikely to improve the longer-term (>3 years) prognosis for seizure remission. The guideline is not as applicable to the nursing home population when it comes to adverse event risks. The guideline reports a risk of drug-related adverse events of 7% to 31% and advises that the effects are predominantly mild; however, Dr. Leppik said, “in the nursing home the side effects may be more than mild because of preexisting issues with cognition.” Levetiracetam is probably the “most widely used antiseizure medication for the elderly, including in my practice,” Dr. Leppik said during the question-and-answer session. The drug has “definite advantages ... but it causes the most issues with behavior. For that reason alone, I’m not convinced it’s the best drug to use in the nursing home setting.” Rebecca O’Dwyer, MD, assistant professor in the Department of Neurological Sciences at Rush Medical College in Chicago, agreed that levetiracetam’s side effect profile is concerning — particularly, based on her experience, in patients with frontal lobe epilepsy. “It’s helpful to know where the seizures are coming from,” she said, noting that she also often uses lamotrigine. “It’s anecdotal, but I sometimes feel that people with temporal lobe epilepsy are less susceptible to those negative side effects [of levetiracetam].” When asked about newer agents such as eslicarbazepine acetate (Aptiom) and lacosamide (Vimpat), Dr. Leppik cautioned that “industry is really pushing Aptiom for the elderly, but it’s in the family of carbamazepine and oxcarbazepine, and all three of these drugs have a propensity for lowering sodium levels.” Therapeutic drug monitoring in the elderly requires a high level of individualization, Drs. Leppik and O’Dwyer emphasized. Asked about the importance of titrating antiseizure agents based on blood levels versus on seizure control, Dr. Leppik cautioned that “therapeutic range is a lab range value and can be very misleading” in the elderly population. “It needs to be individualized,” he said. “We know from experience that the elderly generally need lower blood levels because, for one, their seizures seem to better controlled [with lower levels], and secondly they seem to get side effects at lower levels than other adults.” Dr. Leppik said he was securing funding for a national survey of medical directors to learn more about how new-onset epilepsy is managed in the nursing home. His prior research has helped define the epidemiology of epilepsy in the nursing home population. In 2017, Dr. Leppik and his coauthors reported in an analysis of all residents in all Medicare/Medicaid-certified nursing homes that the point prevalence of epilepsy/seizures was 7.7%, and that prevalence is 7 to 30 times higher in individuals with certain comorbid neurologic conditions. (Neurology 2017;88:750–757). Christine Kilgore is a freelance writer based in Falls Church, VA.

Accuracy of ICD-10-CM claims-based definitions for epilepsy and seizure type

ObjectiveTo evaluate the accuracy of ICD-10-CM claims-based definitions for epilepsy and classifying seizure types in the outpatient setting. MethodsWe reviewed electronic health records (EHR) for a cohort of adults aged 18+ years seen by six neurologists who had an outpatient visit at a level 4 epilepsy center between 01/2019−09/2019. The neurologists used a standardized documentation template to capture the diagnosis of epilepsy (yes/no/unsure), seizure type (focal/generalized/unknown), and seizure frequency in the EHR. Using linked ICD-10-CM codes assigned by the provider, we assessed the accuracy of claims-based definitions for epilepsy, focal seizure type, and generalized seizure type against the reference-standard EHR documentation by estimating sensitivity (Sn), specificity (Sp), positive predictive value (PPV), and negative predictive value (NPV). ResultsThere were 673 eligible outpatient encounters. After review of EHRs for standardized documentation, an analytic sample consisted of 520 encounters representing 402 unique patients. In the EHR documentation, 93.5 % (n = 486/520) of encounters were with patients with a diagnosis of epilepsy. Of those, 66.0 % (n = 321/486) had ≥1 focal seizure, 41.6 % (n = 202/486) had ≥1 generalized seizure, and 7% (n = 34/486) had ≥1 unknown seizure. An ICD-10-CM definition for epilepsy (i.e., ICD-10 G40.X) achieved Sn = 84.4 % (95 % CI 80.8−87.5%), Sp = 79.4 % (95 % CI 62.1−91.3%), PPV = 98.3 % (95 % CI 96.6−99.3%), and NPV = 26.2 % (95 % CI 18.0−35.8%). The classification of focal vs generalized/unknown seizures achieved Sn = 69.8 % (95 % CI 64.4−74.8%), Sp = 79.4 % (95 % CI 72.4−85.3%), PPV = 86.8 % (95 % CI 82.1−90.7%), and NPV = 57.5 % (95 % CI 50.8−64.0%). ConclusionsClaims-based definitions using groups of ICD-10-CM codes assigned by neurologists in routine outpatient clinic visits at a level 4 epilepsy center performed well in discriminating between patients with and without a diagnosis of epilepsy and between seizure types.

Socioeconomic consequences of drug-resistant epilepsy in an adult cohort from southern India

ObjectiveThe objective of this study was to describe the socioeconomic consequences of drug-resistant epilepsy (DRE). MethodsThis study comprised 132 (equal males and females) consecutive patients aged ≥18 years, who fulfilled the International League Against Epilepsy (ILAE) definition for DRE, prospectively seen in a tertiary care center in South India. We used a structured questionnaire to gather relevant information. ResultsThe mean age was 31 (range 18–70) years. Mean age of onset of epilepsy was 17 years and mean duration of epilepsy 14 years. The most common epilepsy type and etiology were focal epilepsy and gliotic lesions secondary to perinatal insults, respectively. The average out of the pocket expenditure on antiseizure drugs annually amounted to 19% of the gross national product (GNP)/capita, which was borne by family members in more than two-thirds of the subjects. Almost 60% reported epilepsy having affected their education, 40% their employment, and 90% their marital prospects. Female patients were less often employed outside their homes and had more marital problems compared with males. ConclusionsIn addition to high seizure burden, DRE adversely affects the pursuit of higher education, employment, and marriage. Besides the direct cost of epilepsy, these issues augment both the patient and the caregiver's liability. Socioeconomic consequences of DRE are widely prevalent in developing countries, and this study highlights the need to address them.

Memory efficiency in patients with drug-resistant epilepsy

ABSTRACT Objective To evaluate memory in patients with drug-resistant epilepsy. Methods Following an examination, 50 patients were diagnosed in accordance with the 2005 proposal of the International League Against Epilepsy and the definition of drug-resistant epilepsy from 2010. The neuropsychological examination used the Wechsler Memory Scale. It assessed seven structural types of memory: general knowledge, orientation, mental control, logical memory, number memory, associative memory, and visual reproduction. The values were compared with 50 subjects without epilepsy. Results Patients with epilepsy had statistically significantly lower values in five of seven structural units of memory. The average value of overall memory efficacy in subjects with epilepsy was 96.5 ± 19.6, while in subjects without epilepsy it was 118 ± 15.6 (p = 0.0002). Memory impairments are greater in those taking polytherapy (p = 0.0429). The overall memory efficiency correlated significantly negatively with seizure frequency (p = 0.0015) and insignificantly negative with the duration of epilepsy (p = 0.1935). Conclusion Patients with drug-resistant epilepsy have lower memory efficiency. Memory impairments are greater in those taking polytherapy, as with those with more frequent seizures. The duration of epilepsy has no significant effect on overall memory performance.

Incidence of first seizures, epilepsy, and seizure mimics in a geographically defined area.

To determine the incidence of first seizures, epilepsy, and seizure mimics in a geographically defined area using the updated 2014 International League Against Epilepsy (ILAE) definition, which allows an epilepsy diagnosis after a single seizure when the risk of further seizures over the next 10 years is ≈60% or greater. This replaced the 1993 definition by which epilepsy was diagnosed when a person had ≥2 seizures separated by 24 hours. Using multiple overlapping methods of case ascertainment followed by individual case classification by an epileptologist, we identified all first seizures, new diagnosis of epilepsy, and seizure mimics occurring in a defined geographic area (population 542,868) from January 1, 2017, to December 31, 2017. Incidence was age standardized to the Standard European Population. We compared incidence rates using the 2014 and 1993 ILAE definitions. When the 2014 ILAE definition of epilepsy was applied, the incidence of new diagnosis of epilepsy was 62 per 100,000 (age standardized 74) compared to 41 per 100,000 (age standardized 48) when the 1993 definition was applied, and the difference was more pronounced at older ages. The incidence of all first seizures and of seizure mimics was 102 per 100,000 (age standardized 123) and 94 per 100,000 (age standardized 111), respectively. The most frequently encountered seizure mimic was syncope. Application of the 2014 ILAE definition of epilepsy resulted in a higher incidence of new diagnosis of epilepsy compared to the 1993 definition. The incidence of seizure mimics almost equals that of all first seizures. Seizures, epilepsy, and seizure mimics represent a significant burden to health care systems.

Pediatric EEG and the COVID-19 Pandemic: Can We Develop a Safe Transition Pathway to Reopen Our Laboratories?

Although epilepsy is a clinical diagnosis, routine electroencephalography (EEG) data can aid in the determination of seizure/epilepsy type. According to the current International League Against Epilepsy definition, epileptiform abnormalities can contribute importantly to the diagnosis of epilepsy even following a single unprovoked seizure.[1] The COVID-19 pandemic and the mandated community mitigation strategies (e.g., physical distancing) used to protect vulnerable populations and to slow disease transmission[2] have profoundly impacted our ability to perform EEG. Given the close contact and prolonged exposure to patients with unknown COVID-19 status, the safety of EEG technicians is of paramount importance. Within this editorial, we review our strategy to reopen our EEG laboratory as we concentrate on technician, patient, and community safety.

Epilepsy treatment gap in Sub-Saharan Africa: Meta-analysis of community-based studies.

To evaluate the prevalence, highlight the variation and determine the trend over time, of epilepsy treatment gap (ETG) in Sub-Saharan Africa (SSA). We systematically searched PubMed, MEDLINE, Embase, ISI databases, and African Journal Online (AJOL). We determined the pooled prevalence estimate of ETG and the degree of heterogeneity in the region. Further subgroup analysis by sub-region, settlement setting, and cutoff adopted for active epilepsy in the studies was carried out. Meta-regression technique was also used to determine the trend of the ETG magnitude over time. Twenty-three studies from SSA met the inclusion criteria. We found a high level of discordance among the studies that were included. Collectively, the estimated ETG was 68.5% (95% CI: 59.5%-77.5%). On subgroup analysis, the prevalence of the ETG was 67% (95% CI: 52%, 83%) in the Western, 68% (95% CI: 56%, 80%) in the Eastern, and 63% (95% CI: 53%, 73%) in the Southern Africa sub-regions. On stratified analysis based on 1-year, 5-year, and 2-year cutoffs for definition of active epilepsy, the prevalence figures for the ETG were 71% (95% CI: 56%, 85%), 55% (95% CI: 33%, 77%), and 57% (95% CI: 43%, 71%), respectively. Meta-regression result suggested that the prevalence of the ETG decreases by approximatelyby 0.006 per year. The study showed a high prevalence of ETG, higher than the average for resource poor countries, and twice in rural compared with urban settlements in SSA.

The risk of epilepsy in children with celiac disease: a population-based cohort study.

The purpose was to estimate the risk of epilepsy in a cohort of young individuals with celiac disease (CD) compared to that of matched references. The cohort consisted of 213635 individuals born during 1989-2011 and residing in Friuli-Venezia Giulia (Italy). 1215 individuals affected by CD and 6075 reference individuals matched by sex and age were identified. Epilepsy was defined by means of hospital diagnosis or drug prescriptions. Conditional logistic regression was used to estimate the odds ratios (ORs) of having epilepsy amongst individuals with CD, before CD diagnosis and in the entire period, compared with those of their matched references. Cox regression was used to calculate the hazard ratios for epilepsy diagnosed after CD diagnosis. Different definitions of epilepsy were used for sensitivity analyses. Thirty-one (2.6%) individuals with CD and 78 (1.3%) reference individuals had epilepsy [adjusted OR 2.03; 95% confidence interval (CI) 1.33-3.10]. The risk of epilepsy was increased prior to CD (adjusted OR 2.29; 95% CI 1.33-3.94), with similar estimates after CD diagnosis (adjusted hazard ratio 1.96; 95% CI 0.95-4.02). The increased risk of epilepsy was not explained by a peak in epilepsy diagnosis just around CD diagnosis. Sex stratification found a significantly higher risk of epilepsy amongst female individuals with CD. Sensitivity analyses confirmed the positive association between CD and epilepsy. Children and youths with CD were at increased risk of epilepsy. Patients with epilepsy without a clear etiology should be screened for CD since an early diagnosis and treatment might improve the response to antiepileptic therapies.

Investigatory pathway and principles of patient selection for epilepsy surgery candidates: a systematic review

BackgroundThe predominant treatment for epilepsy is pharmacotherapy, yet 20–40% do not respond to anti-epileptic drugs. After becoming pharmacoresistant, some patients are worked-up to determine candidacy for epilepsy surgery. Despite the 2009 American Epilepsy Society guidelines, there is no broadly accepted criteria for the investigatory pathway and principles of patient selection for epilepsy surgery candidates. The objective of this systematic review is to elucidate what diagnostic pathways clinicians globally utilize.MethodsUtilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) and the Cochrane Handbook of Systemic Reviews of Interventions, we conducted a systematic review through MEDLINE, Embase, and CENTRAL.ResultsFrom 2092 screened articles, 14 met inclusion criteria for qualitative synthesis. Structural MRI was required in all investigatory pathways. All but two articles required neuropsychological assessment. Six required neuropsychiatric assessment. Two protocols mentioned assessing the patient’s support network. Three other protocols mentioned discussing expectations with patients. One also motioned conducing an occupational evaluation and making all surgery decisions in a multidisciplinary management conference. fMRI and the Wada test were required assessments in seven of the protocols. [18F]FDG-PET and SPECT were ancillary for all but three articles (where they were required). MEG and intracranial EEG were only mentioned as ancillary. Magnetic resonance (MR) spectroscopy was required at two institutes. With regards to the actual indication for selecting patients to begin the investigatory pathway, seven of the articles used a variation of the International League Against Epilepsy definition of refectory epilepsy, while one incorporated patient social history.ConclusionsDespite attempts to standardize patient selection and investigatory pathways, no two protocols were identical. Scalp video/EEG telemetry, structural MRI, and neuropsychological assessment were the only assessments utilized in nearly all protocols. Socioeconomic restrictions appear to play a role in determining which tests are utilized in the investigatory pathway—not just for developing countries. However, cost-effective assessments, such as assessing patient support network and providing realistic expectation of outcomes, were only utilized in few protocols. In addition, no advanced imaging technologies (i.e., qMRI, 3D-MMI) were utilized. Overall, even amongst expert examiners there is significant variation throughout epilepsy centers globally, in selecting candidates and working up patients.

How to interpret images in epileptic seizures: correlation between clinical and functional MRI findings

Neuroimaging studies are essential in patients with epilepsy, both for diagnosis and surgical management. This article focuses on adult epileptic patients, reviewing the updated clinical criteria published by the International League Against Epilepsy for the definitions of seizures, epilepsy, and status epilepticus. It also describes the different types of epilepsy, the different presentations, the signs, the radiologic approach to managing seizures, and the differences between generalized and focal seizures. Finally, it discusses the relations between possible functional cerebral deficits secondary to potentially epileptogenic lesions and epilepsy surgery, underlining the importance of functional magnetic resonance imaging studies.

Painting epilepsy – The essence of disease by participants of the Latin American Summer School on Epilepsy (LASSE XIII)

PurposeThe purpose of this study was to present and analyze the way epilepsy researchers and specialists present epilepsy through visual art forms. MethodsStudents and epilepsy specialists, including clinicians and scientists, participating in the Latin American Summer School on Epilepsy (LASSE XIII) 2019 were asked to voluntarily portray epilepsy artistically by painting or drawing what they perceive that represents the feeling or challenges of persons with epilepsy. Resulting artwork was categorized according to several themes. The latter was analyzed in the clinical and social context of the disease. ResultsTwenty-six paintings available for analysis have been reviewed. The three main interpretations of epilepsy were outlined as follows: epilepsy as an identity schism, epilepsy as a loss of control, and epilepsy as a complex condition. Five artworks best suited the first category as they presented people with faces split into healthy and diseased sides, representing the emotional and social burden of seizures. Three drawings defined epilepsy as a loss of control, visualizing that all the phases of seizure activity (ictal, postictal, and interictal) are able to imprison the patient by disrupting mental processes. The last theme included four artworks that defined epilepsy as being a multicomponent enigma: the intertwining of unresolved pathophysiologic processes and psychosocial burden accompanying the disease was emphasized. In addition, the challenges to care for the patients in order to improve not only seizures but also their quality of life were noticed as an idea complementing the visual definition of epilepsy. ConclusionParticipants of LASSE XIII demonstrated an ability to empathize with their patients in retrospect by portraying the inner feelings of division and imprisonment of those having seizures. Epilepsy specialists visualize the disease as a composite phenomenon both in terms of its neural origin and of multidisciplinary requirements to implement its care.

The evolution of the concepts of seizures and epilepsy: What's in a name?

This review aims to highlight the historical hallmarks in the development of the concepts of seizures and epilepsy. It begins with a discussion of seizure semiology and terminology, followed by the pathophysiology of seizures. We then discuss the definition of epilepsy, its etiologies, and ultimately classification schemes. Each section starts with our current views and subsequently transports the reader back in time to understand how these views evolved and came to be what they are today. People living as early as in the prehistoric times may have been aware of the existence of seizures, and descriptions and terminology have been provided as early as 2500 BC. While names have been revised and updated through time, the meanings are seemingly unchanged. However, it is clearly evident that we have come a long way in understanding the pathophysiology and etiology of seizures and epilepsy, thus leading to our current classification schemes. No classification scheme will be perfect yet, until our understanding is advanced enough to create one based predominantly on scientific grounds. The goal is that it is relevant to clinical practice, leading to a more precise diagnosis to guide targeted treatments.

Mitochondrial epilepsy: a cross-sectional nationwide Italian survey

Many aspects of epilepsy in mitochondrial disorders (MDs) need to be further clarified. To this aim, we explored retrospectively a cohort of individuals with MDs querying the "Nationwide Italian Collaborative Network of Mitochondrial Diseases" (NICNMD) database (1467 patients included since 2010 to December 2016). We collected information on age at epilepsy onset, seizure type and frequency, genetic findings, and antiepileptic drugs (AEDs). At the time of our survey, 147/1467 (10%) patients in the NICNMD database had epilepsy. Complete information was available only for 98 patients, 52 males and 46 females, aged 5-92years (mean age 40.4 ± 18.4; 14/98 children/teenagers and 84 adults). Epilepsy was the presenting feature of MD in 46/98 (47%) individuals, with onset at a median age of 19years (range, 0.2-68; < 3years in 14/97 (14%), 3-19years in 36/97 (37%), > 19years in 47/97 (49%)). Moreover, 91/98 patients (93%) displayed multiple seizures, with daily or weekly frequency in 25/91 (28%). Interictal EEG was abnormal in 70/78 (90%) patients, displaying abnormal background (47/70; 67%) and/or interictal paroxysms (53/70; 76%). Eighty of 90 patients (89%) displayed a 50-100% reduction of seizures on AEDs; levetiracetam was the most commonly used. Forty-one patients (42%) carried the m.3243A>G mutation, 16 (16%) the m.8344A>G, and 9 (9%) nuclear DNA (nDNA) mutations. Individuals with early-onset seizures mainly carried nDNA mutations and had a more severe epilepsy phenotype, higher seizure frequency, and disorganized background EEG activity. A better definition of epilepsy in MDs may foster the diagnostic workup, management, and treatment of affected patients, and allow more homogeneous patient stratification.

Decisional collisions between evidence and experience based medicine in care of people with epilepsy

Background - Based on the literature and his long-term clinical practice the author stresses the main collisions of evidence and experience based medicine in the care of people with epilepsy. Purpose - To see, what are the professional decisions of high responsibility in the epilepsy-care, in whose the relevant clinical research is still lacking or does not give a satisfactory basis. Methods - Following the structure of the Hungarian Guideline the author points the critical situations and decisions. He explains also the causes of the dilemmas: the lack or uncertainty of evidences or the difficulty of scientific investigation of the situation. Results - There are some priorities of experience based medicine in the following areas: definition of epilepsy, classification of seizures, etiology - including genetic background -, role of precipitating and provoking factors. These are able to influence the complex diagnosis. In the pharmacotherapy the choice of the first drug and the optimal algorithm as well as the tasks during the care are also depends on personal experiences sometimes contradictory to the official recommendations. Same can occur in the choice of the non-pharmacological treatments and rehabilitation. Discussion and conclusion - Personal professional experiences (and interests of patients) must be obligatory accessories of evidence based attitude, but for achieving the optimal results, in some situations they replace the official recommendations. Therefore it is very important that the problematic patients do meet experts having necessary experiences and also professional responsibility to help in these decisions.

Incidence Study of Epilepsy using the ILAE 2017 Classification of Epilepsies in a Cohort of School Children Accessing Education in Government Primary Schools in South India.

Recently, the International League Against Epilepsy (ILAE) has proposed new classification schemes for seizures and epilepsy. The applicability of these classification schemes has not been studied in resource-poor countries. To determine the incidences of epilepsies in a cohort of school children using the ILAE 2017 classification of epilepsies. The study cohort included 7,408 school going children [age range 5-15 years]. They were followed for new-onset unprovoked seizure and seizure recurrence through first grade to fifth grade. The data collected during the first visit included clinical details including details of seizure semiology. All children had EEG and contrast CT scan. All these data were used to classify seizure type and epilepsy using ILAE classification schemes. The ILAE 2014 epilepsy definition was used to diagnose epilepsy. The average annual incidence rates (AAIR) and 95% confidence intervals (CI) were calculated for epilepsies by onset and by etiology. The AAIR of epilepsy was 57.85 (95% CI 39.0-82.6) per 100,000 population. The AAIRs per 100,000 for different epilepsies by mode of onset were focal epilepsies 25.07 (95% CI 13.35-42.87); generalized epilepsies 13.5 (95% CI 5.43-27.8); and unknown onset epilepsies 19.28 (95% CI 9.25-35.46). The AAIRs per 100,000 of epilepsies by etiology were focal genetic epilepsies 7.71 (95% CI 2.1-19.75); genetic generalized epilepsies 13.5 (95% CI 5.43-27.8); and epilepsies due to structural cause 17.36 (95% CI 9.25-35.46). The lesional epilepsies seen in this cohort were geographically specific to resource-poor countries. The AAIR of epilepsy due to calcific neurocysticercosis (cNCC) was 9.64 (95% CI 3.1-22.5) per 100,000. This study demonstrates that the ILAE 2017 classification of epilepsies can be applied in resource-poor countries with limited workup. Lesional epilepsies seen in this study is geographically specific to resource-poor countries.

Mortality in Epilepsy: Referral to a Specialty Center Makes a Difference.

Association of Levels of Specialized Care With Risk of Premature Mortality in Patients With Epilepsy Lowerison MW, Josephson CB, Jetté N, et al. JAMA Neurol. 2019;76:1352-1358.Importance:Patients with epilepsy are at an elevated risk of premature mortality. Interventions to reduce this risk are crucial.Objective:To determine if the level of care (non-neurologist, neurologist, or comprehensive epilepsy program) is negatively associated with the risk of premature mortality.Design, Setting, and Participants:In this retrospective open cohort study, all adult patients 18 years or older who met the administrative case definition for incident epilepsy in linked databases (Alberta Health Services administrative health data and the Comprehensive Calgary Epilepsy Programme Registry [CEP]) inclusive of the years 2002 to 2016 were followed up until death or loss to follow-up. The final analyses were performed on May 1, 2019.Exposures:Evaluation by a non-neurologist, neurologist, or epileptologist.Main Outcomes and Measures:The outcome was all-cause mortality. We used extended Cox models treating exposure to a neurologist or the CEP as time-varying covariates. Age, sex, socioeconomic deprivation, disease severity, and comorbid burden at index date were modeled as fixed-time coefficients.Results:A total 23 653 incident cases were identified (annual incidence of 89 per 100 000); the mean age (SD) at index date was 50.8 (19.1) years and 12 158 (50.3%) were women. A total of 14 099 (60%) were not exposed to specialist neurological care, 9554 (40%) received care by a neurologist, and 2054 (9%) received care in the CEP. In total, 4098 deaths (71%) occurred in the nonspecialist setting, 1481 (26%) for those seen by a neurologist, and 176 (3%) for those receiving CEP care. The standardized mortality rate was 7.2% for the entire cohort, 9.4% for those receiving nonspecialist care, 5.6% for those seen by a neurologist, and 2.8% for those seen in the CEP. The hazard ratio (HR) of mortality was lower in those receiving neurologist (HR, 0.85; 95% CI, 0.77-0.93) and CEP (HR, 0.49; 95% CI, 0.38-0.62) care. In multivariable modeling, specialist care, the age at index, and disease severity were retained in the final model of the association between specialist care and mortality.Conclusions and Relevance:Exposure to specialist care is associated with incremental reductions in the hazard of premature mortality. Those referred to a comprehensive epilepsy program received the greatest benefit.

Prolonged EEGs in adult patients with a first unprovoked seizure: a prospective pilot study.

Definitions of epilepsy have changed to include a first unprovoked seizure with a high (>60%) risk of recurrence in the next 10 years. A single seizure and an epileptiform discharge on an EEG would suffice for this diagnosis. We hypothesized that an extended six-hour EEG in adult patients presenting with a first unprovoked seizure would demonstrate an increased yield of epileptiform discharges in comparison to a standard 30-minute EEG, and therefore higher rates of epilepsy diagnosis. Thirty-eight patients were recruited at Hamilton Health Sciences over six years and 36 underwent extended six-hour EEGs. Two of seven patients demonstrated epileptiform discharges on their EEG after only the first 30 minutes of recording, observed during sleep for both patients. This correlated to an overall increase of 5.56%, or a yield of 29%. A third more patients could benefit from early diagnosis with extended EEGs. The rate of epilepsy diagnosis based on EEG overall was superior to that of brain imaging (19% versus 6%). Given the limitations due to sample size in this study, a larger trial would be beneficial to confirm these findings.

Crisis epiléptica: ¿cómo interpretar la imagen? Correlación clínica-funcional

Neuroimaging studies are essential in patients with epilepsy, both for diagnosis and surgical management. This article focuses on adult epileptic patients, reviewing the updated clinical criteria published by the International League Against Epilepsy for the definitions of seizures, epilepsy, and status epilepticus. It also describes the different types of epilepsy, the different presentations, the signs, the radiologic approach to managing seizures, and the differences between generalized and focal seizures. Finally, it discusses the relations between possible functional cerebral deficits secondary to potentially epileptogenic lesions and epilepsy surgery, underlining the importance of functional magnetic resonance imaging studies.

Post-stroke epilepsy in an ischemic stroke cohort-Incidence and diagnosis.

Stroke is a common cause of adult-onset epilepsy (post-stroke epilepsy, PSE). Despite an increasing awareness, there is a concern for underdiagnosis of the condition. We aimed to study the adherence to the latest updated epilepsy definition, as well as the incidence and diagnosis of PSE in an ischemic stroke cohort admitted to a tertiary University Hospital. We retrospectively investigated the occurrence and diagnosis of unprovoked seizures and PSE in all ischemic stroke patients admitted to Karolinska University Hospital in Stockholm during 2015 and registered in the Swedish Stroke Register. Patient records were scrutinized for the presence of post-stroke seizures/epilepsy. A total of 240 patients fulfilling the inclusion criteria were surveyed. Median follow-up time was 1062days (IQR 589-1195days). Thirteen patients were diagnosed with PSE according to the study criteria, the incidence of PSE 23/1000 person-years (95% CI 13-38/1000 person-years). Median time to PSE from stroke-onset was 237days (IQR 33-688). Eleven of 13 PSE patients received an epilepsy diagnosis, eight patients after one unprovoked seizure, and three patients after two. The majority of PSE patients were given a correct epilepsy diagnosis and treated with antiepileptic drugs. However, this study suggests that there still is potential for improvement in the adherence to the latest updated epilepsy definition. The incidence of PSE in a Swedish ischemic stroke cohort using updated epilepsy definitions is similar to previous studies. Larger studies are needed to confirm our findings on the incidence of PSE.