Early Seizures Research Articles

Overview of systematic reviews: Management of common Traumatic Brain Injury-related complications.

Many clinical interventions are trialled to manage medical complications following Traumatic Brain Injury (TBI). However, published evidence for the effects of those clinical interventions is limited. This article is an overview of common complications and their management from published systematic reviews in TBI. A health science electronic database search for published systematic reviews for management of common complications in TBI was conducted in the last decade till 31st January 2021. Methodological quality and evidence were critically appraised using the Grading of Recommendations, Assessment, Development and Evaluations and Revised-Assessment of Multiple Systematic review tools. Overall, only six systematic reviews complied with search criteria, these evaluated fatigue, spasticity and post traumatic seizures (29 RCTs, 13 cohort studies, n = 5639 participants). No systematic reviews for other common TBI-related complications met criteria for this review. The included reviews varied from 'moderate to high' in methodological quality. The findings suggest beneficial treatment effect of anti-epileptic drugs (phenytoin/levetiracetam) compared with placebo in reducing early seizure incidence, but no significant benefit of phenytoin over levetiracetam, valproate, or neuroprotective agent for early or late posttraumatic seizures. There was 'limited' evidence for spasticity-related interventions, and 'insufficient' evidence of cardiorespiratory training on fatigue levels. Despite the high prevalence and associated functional impact of TBI-related complications, there is limited evidence to guide treating clinicians for management of common TBI complications. More robust studies are needed to build evidence in this population.

頭部外傷後早期痙攣発作に対するレベチラセタム予防投与の効果：後ろ向きコホート研究(A retrospective cohort study of the effect of prophylaxis with levetiracetam on early posttraumatic seizures)

要旨【目的】頭部外傷後1週間以内に生じる早期痙攣発作（early PTS）に対するレベチラセタム（LEV）予防投与の有用性は確立されていない。本研究の目的は，レベチラセタム予防投与の効果や副作用に関して評価を行うことである。【対象】2016年4月～2021年3月の間に大阪大学医学部附属病院高度救命救急センターへ入院となった16歳以上の頭部外傷症例で，来院時Glasgow coma scale < 9もしくは穿頭/開頭術を行った症例を対象とした。脳震盪症例，受傷後1週間以内の死亡症例，LEV以外の抗てんかん薬が予防投与された症例は除外した。レベチラセタム予防投与群（LEV群）と非投与群（non LEV群）について，背景や臨床経過，血液・画像検査所見，early PTS合併の有無，予防投与に起因する副作用の有無を後方視的に比較検討した。【結果】対象症例は計86例であった（LEV群45例，non LEV群41例）。Early PTSの合併はnon LEV群24.4%に対してLEV群6.7%であり，LEV群が有意に低かった（p=0.0195）。LEV群に重篤な副作用はなく，early PTS合併症例の半数は入院初日に痙攣発作を生じていた。【結語】レベチラセタムの予防投与はearly PTSの合併を軽減させる可能性が示され，重篤な副作用も認めなかった。

P12-53 A combined in vitro approach for early seizure prediction utilising human derived induced pluripotent stem cells and human ion channel assays

P12-53 A combined in vitro approach for early seizure prediction utilising human derived induced pluripotent stem cells and human ion channel assays

Prioritizing Hormone Therapy Over Vigabatrin as the First Treatment for Infantile Spasms: A Quality Improvement Initiative.

Infantile spasms (IS) are early childhood seizures with potentially devastating consequences. Standard therapies (adrenocorticotropic hormone [ACTH], high-dose prednisolone, and vigabatrin) are strongly recommended as the first treatment for IS. Although this recommendation comes without preference for one standard therapy over another, early remission rates are higher with hormone therapy (ACTH and high-dose prednisolone) when compared with vigabatrin. Using quality improvement (QI) methodology that included hormone therapy as the first treatment, we sought to increase the percentage of children with new-onset nontuberous sclerosis complex (TSC)-associated IS achieving 3-month electroclinical remission from a mean of 53.8% to ≥70%. This was an observational consecutive sample cohort study at a single academic tertiary care hospital that compared a prospective intervention cohort (May 2019-January 2022, N = 57) with a retrospective baseline cohort (November 2015-April 2019, N = 67). Our initiative addressed key drivers such as the routine use of vigabatrin over hormone therapy as first treatment and the common initiation of a second treatment after 14 days for initial nonresponders. We included consecutive children without TSC presenting with new-onset IS diagnosed and treated between ages 2 and 24 months. We displayed our primary outcome and process measures as control charts in which the centerline is the quarterly (previous 3 months) mean based on statistical process control methodology. QI interventions that included the standardization of hormone therapy as the first treatment resulted in higher rates of 3-month remission, rising from 53.8% (baseline cohort) to 75.9% (intervention cohort). Process measure results included an increased rate of children receiving hormone therapy as first treatment (mean, 44.6%-100%) and a decreased number of days to both clinical follow-up after first treatment (mean, of 16.3-12.6 days) and starting a second treatment within 14 days for initial nonresponders (mean, 36.3-17.2 days). For children with IS, improved rates of 3-month electroclinical remission can be achieved with QI methodology. Implementation of similar QI initiatives at other centers may likewise improve local remission rates.

Association of Cerebral and Systemic Physiology With Quantitative Electroencephalographic Characteristics of Early Posttraumatic Seizures.

Early posttraumatic seizures (EPTS) occur after pediatric traumatic brain injury and have been associated with unfavorable outcomes. We aimed to characterize the relationship among quantitative EEG characteristics of early posttraumatic seizures, cerebral and somatic physiologic measures. Differences in baseline physiologic, neuroimaging, and demographic characteristics between those with and without early posttraumatic seizures were investigated using Mann-Whitney U test or Fisher exact test. Multivariable dynamic structural equations modeling was used to investigate time series associations between ictal quantitative EEG characteristics with intracranial pressure, arterial blood pressure, heart rate (HR), and cerebral regional oximetry. Quantitative EEG characteristics included amplitude, total power, spectral edge frequency, peak value frequency, complexity, and periodicity. Among 72 children, 146 seizures were identified from 19 patients. Early posttraumatic seizures were associated with younger age ( P = 0.0034), increased HR ( P = 0.0018), and increased Glasgow Outcome Scale-Extended scores ( P = 0.0377). Group dynamic structural equations modeling analysis of the first seizure for patients demonstrated that intracranial pressure is negatively associated with spectral edge frequency (standardized regression coefficient -0.12, 99% credible interval [-0.21 to -0.04]), and HR is positively associated with peak value frequency (standardized regression coefficient 0.16, [0.00-0.31]). Among nine patients with seizures arising over the frontal lobe regions, HR was positively associated with peak value frequency (standardized regression coefficient 0.26 [0.02-0.50]) and complexity (standardized regression coefficient 0.14 [0.03-0.26]). Variation in strength and direction of associations was observed between subjects for relationships that were significant during group analysis. Quantitative EEG characteristics of pediatric early posttraumatic seizures are associated with variable changes in cerebral and systemic physiology, with spectral edge frequency negatively associated with intracranial pressure and peak value frequency positively associated with HR.

KBG syndrome: videoconferencing and use of artificial intelligence driven facial phenotyping in 25 new patients

Genetic variants in Ankyrin Repeat Domain 11 (ANKRD11) and deletions in 16q24.3 are known to cause KBG syndrome, a rare syndrome associated with craniofacial, intellectual, and neurobehavioral anomalies. We report 25 unpublished individuals from 22 families with molecularly confirmed diagnoses. Twelve individuals have de novo variants, three have inherited variants, and one is inherited from a parent with low-level mosaicism. The mode of inheritance was unknown for nine individuals. Twenty are truncating variants, and the remaining five are missense (three of which are found in one family). We present a protocol emphasizing the use of videoconference and artificial intelligence (AI) in collecting and analyzing data for this rare syndrome. A single clinician interviewed 25 individuals throughout eight countries. Participants’ medical records were reviewed, and data was uploaded to the Human Disease Gene website using Human Phenotype Ontology (HPO) terms. Photos of the participants were analyzed by the GestaltMatcher and DeepGestalt, Face2Gene platform (FDNA Inc, USA) algorithms. Within our cohort, common traits included short stature, macrodontia, anteverted nares, wide nasal bridge, wide nasal base, thick eyebrows, synophrys and hypertelorism. Behavioral issues and global developmental delays were widely present. Neurologic abnormalities including seizures and/or EEG abnormalities were common (44%), suggesting that early detection and seizure prophylaxis could be an important point of intervention. Almost a quarter (24%) were diagnosed with attention deficit hyperactivity disorder and 28% were diagnosed with autism spectrum disorder. Based on the data, we provide a set of recommendations regarding diagnostic and treatment approaches for KBG syndrome.

Early seizure detection in childhood focal epilepsy with electroencephalogram feature fusion on deep autoencoder learning and channel correlations

Early seizure detection in childhood focal epilepsy with electroencephalogram feature fusion on deep autoencoder learning and channel correlations

Amelioration of Leigh syndrome induced by mouse blastocyst complementation with a mutant human mitochondrial ATP synthase 6

AbstractBackgroundMutation of the m. 8993 T > G ATP6 subunit of ATP synthase causes a maternally inherited Leigh Syndrome (LS), a rapidly fatal encephalomyelopathy in childhood called and related Neuropathy, Ataxia and Retinitis Pigmentosa (NARP) in adults. There is no cure, and relevant animal models are few. Here we describe a novel ATP6 mouse model of LS and preclinical efficacy of a gene therapy approach to neutralize the ATP6 mutation by competition with a mitochondrial targeted adeno‐associated virus serotype 9 (AAV9) vector containing wild‐type ATP6.MethodsLS transgenic mice with an ATP6 mutation were developed by microinjecting AAV2 modified by a COX8 mitochondrial targeting sequence (MTS) into mouse blastocysts to deliver the human ATP6 gene with a T > G mutation at position 8993 of the mitochondrial genome, responsible for clinical LS DNA, protein, and metabolic assays confirmed functional gene delivery and in depth physiological/clinical assessments supported germline transmission of an LS phenotype. Rescue of LS in this model was evaluated after intravenous injection of mito‐targeted AAV9 containing wild‐type ATP6 followed by reevaluation of phenotypes.ResultsLS transgenic mice expressed mutant ATP6 protein in multiple relevant tissues including brain, eye, liver. Mutant ATP6 incorporated into Complex V and conferred decreased ATP synthase efficiency. Mice exhibited hallmarks of the human disease with one or multiple systemic symptoms including early death, paralysis, hunching, vision loss and seizures over six generations. Necropsy revealed spongiform encephalopathy, retinal degeneration, and cardiomegaly. Rescue by mitochondrially directed AAV9 containing wild type ATP6 after disease onset conferred prolonged survival and reduced paralysis. When administered prior to disease onset all treated ATP6 mice survived with evidence of globally improved function.ConclusionsThe results are consistent with efficient delivery and expression of foreign genes in mitochondria by AAV vectors directed by MTS and support further development of such strategies via intravenous injection of mitochondrial targeted AAV9 to deliver corrective genes.

Safety and efficacy of prophylactic levetiracetam for prevention of epileptic seizures in the acute phase of intracerebral haemorrhage (PEACH): a randomised, double-blind, placebo-controlled, phase 3 trial

The incidence of early seizures (occurring within 7 days of stroke onset) after intracerebral haemorrhage reaches 30% when subclinical seizures are diagnosed by continuous EEG. Early seizures might be associated with haematoma expansion and worse neurological outcomes. Current guidelines do not recommend prophylactic antiseizure treatment in this setting. We aimed to assess whether prophylactic levetiracetam would reduce the risk of acute seizures in patients with intracerebral haemorrhage. The double-blind, randomised, placebo-controlled, phase 3 PEACH trial was conducted at three stroke units in France. Patients (aged 18 years or older) who presented with a non-traumatic intracerebral haemorrhage within 24 h after onset were randomly assigned (1:1) to levetiracetam (intravenous 500 mg every 12 h) or matching placebo. Randomisation was done with a web-based system and stratified by centre and National Institutes of Health Stroke Scale (NIHSS) score at baseline. Treatment was continued for 6 weeks. Continuous EEG was started within 24 h after inclusion and recorded over 48 h. The primary endpoint was the occurrence of at least one clinical seizure within 72 h of inclusion or at least one electrographic seizure recorded on continuous EEG, analysed in the modified intention-to-treat population, which comprised all patients who were randomly assigned to treatment and who had a continuous EEG performed. This trial was registered at ClinicalTrials.gov, NCT02631759, and is now closed. Recruitment was prematurely stopped after 48% of the recruitment target was reached due to a low recruitment rate and cessation of funding. Between June 1, 2017, and April 14, 2020, 50 patients with mild-to-moderate severity intracerebral haemorrhage were included: 24 were assigned to levetiracetam and 26 to placebo. During the first 72 h, a clinical or electrographic seizure was observed in three (16%) of 19 patients in the levetiracetam group versus ten (43%) of 23 patients in the placebo group (odds ratio 0·16, 95% CI 0·03-0·94, p=0·043). All seizures in the first 72 h were electrographic seizures only. No difference in depression or anxiety reporting was observed between the groups at 1 month or 3 months. Depression was recorded in three (13%) patients who received levetiracetam versus four (15%) patients who received placebo, and anxiety was reported for two (8%) patients versus one (4%) patient. The most common treatment-emergent adverse events in the levetiracetam group versus the placebo group were headache (nine [39%] vs six [24%]), pain (three [13%] vs ten [40%]), and falls (seven [30%] vs four [16%]). The most frequent serious adverse events were neurological deterioration due to the intracerebral haemorrhage (one [4%] vs four [16%]) and severe pneumonia (two [9%] vs two [8%]). No treatment-related death was reported in either group. Levetiracetam might be effective in preventing acute seizures in intracerebral haemorrhage. Larger studies are needed to determine whether seizure prophylaxis improves functional outcome in patients with intracerebral haemorrhage. French Ministry of Health.

Shoulder arthroplasty in patients with a history of epilepsy is safe and effective

BackgroundThe safety of shoulder arthroplasty for patients with a history of convulsive seizures is unknown. Concerns include the possibility of a postoperative seizure resulting in dislocation, cuff disruption, or implant failure. We sought to compare outcomes and complications following shoulder arthroplasty in patients with and without a history of convulsive seizures. MethodsOur institutional Total Joint Registry Database was queried to identify all patients with a history of convulsive seizures who had undergone a primary shoulder arthroplasty between 2000 and 2018. The query identified 56 shoulders (49 patients) with an average age of 61.8 years. 51.8% of patients were female. This cohort was matched 2:1 to a group of patients with similar surgical and demographic characteristics who did not have a seizure history. Kaplan–Meier estimates and univariate Cox regression models were utilized to compare implant survival and reoperation rates. Patient-reported outcomes, including the American Shoulder and Elbow Surgeons score were also extracted. ResultsAt most recent follow-up, cumulative reoperation rates were equivalent between the groups (P = .9) with 3 reoperations out of 56 shoulders (5.4%) in the seizure group, and 7 reoperations out of 112 shoulders (6.3%) in the nonseizure group. Rates of implant revision were also similar. Five-year Kaplan–Meier survival estimates free of reoperation were 97.8% (95% confidence interval, 91.1-100.0) in the seizure group and 93.1% (95% confidence interval, 87.4-98.9) in the nonseizure group. Postoperatively, 23 of 56 patients in the seizure group had at least 1 known seizure after their index arthroplasty, at an average of 4.4 years after surgery. None of the patients with postoperative seizures sustained a dislocation. Altogether only 3 episodes of prosthetic dislocation were observed, all in the nonseizure group. The only complication attributable to a seizure was an early postoperative seizure resulting in subscapularis failure, although this patient never underwent reoperation. Patient-reported outcomes and range of motion were similar between groups, with average American Shoulder and Elbow Surgeons scores of 77.2 and 74.9 in the seizure and nonseizure groups, respectively (P = .6). DiscussionReoperation rates and implant survival following shoulder arthroplasty were similar when comparing patients with and without a history of convulsive seizures. Postarthroplasty seizures occurred in a notable number of patients but did not result in any major complications. While it remains prudent to ensure that patients’ seizures are well controlled prior to arthroplasty, our data suggest that individuals with a convulsive seizure disorder can undergo shoulder arthroplasty safely.

Weak self-supervised learning for seizure forecasting: a feasibility study.

This paper proposes an artificial intelligence system that continuously improves over time at event prediction using initially unlabelled data by using self-supervised learning. Time-series data are inherently autocorrelated. By using a detection model to generate weak labels on the fly, which are concurrently used as targets to train a prediction model on a time-shifted input data stream, this autocorrelation can effectively be harnessed to reduce the burden of manual labelling. This is critical in medical patient monitoring, as it enables the development of personalized forecasting models without demanding the annotation of long sequences of physiological signal recordings. We perform a feasibility study on seizure prediction, which is identified as an ideal test case, as pre-ictal brainwaves are patient-specific, and tailoring models to individual patients is known to improve forecasting performance significantly. Our self-supervised approach is used to train individualized forecasting models for 10 patients, showing an average relative improvement in sensitivity by 14.30% and a reduction in false alarms by 19.61% in early seizure forecasting. This proof-of-concept on the feasibility of using a continuous stream of time-series neurophysiological data paves the way towards a low-power neuromorphic neuromodulation system.

EIF2B2 gene mutation causing early onset vanishing white matter disease: a case report

BackgroundLeukoencephalopathy with vanishing white matter (VWM) is an autosomal recessive neurological disease. The physiopathology of disease is still little understood, but it seems to involve impairment in maturation of astrocytes; as a consequence white matter is more prone to cellular stress. Disease is caused by mutations in five genes encoding subunits of the translation initiation factor eIF2B. We know five different types of VWM syndrome classified based different ages of onset (prenatal, infantile, childhood, juvenile and adult onset).Case presentationWe report the case of a 4-month-old boy with early seizure onset, recurrent hypoglycemia and post mortem diagnosis of vanishing white matter disease (VMD). At the admission he presented suspected critical episodes, resolved after intravenous administration of benzodiazepines. The brain MRI showed total absence of myelination that suggested hypomyelination leukoencephalopathy. The whole exome sequencing (WES) revealed a variant of EIF2B2 gene (p. Val308Met) present in homozygosity. In this case report we also describe the clinical evolution of seizures, in fact the epileptic seizures had a polymorphic aspect, from several complex partial seizures secondarily generalized to status epilepticus.ConclusionInfantile and early childhood onset forms are associated with chronic progressive neurological signs, with episodes of rapid neurological worsening, and poor prognosis, with death in few months or years. Clinical presentation of epilepsy is poorly documented and do not include detailed information about the type, time of onset and severity of seizures. No therapeutic strategies for VWM disease have been reported.

Early post-traumatic seizures in hospitalized patients with traumatic brain injury.

Early post-traumatic seizures (EPTS) are a well-known complication of traumatic brain injury (TBI). EPTS increase the risk of secondary brain injury and may cause significant challenges during the period of critical care. Routine use of prophylactic anti-seizure medication is controversial due to conflicting reports on efficacy and risk of adverse effects. The purpose of this study was to expand the understanding of EPTS by examining incidence and risk factors in hospitalized patients with TBI. Adult patients with TBI and evidence of intracranial injury admitted to Oslo University Hospital between 2015 and 2019 were identified from the Oslo TBI Registry - Neurosurgery. Demographic and clinical data including occurrence of seizures were retrieved from the registry. The patients did not receive routine seizure prophylaxis. Univariate and multivariable logistic regression analyses were used to investigate risk factors associated with EPTS. 103 of 1827 patients (5.6%) had new-onset seizures within the first week after TBI. The following factors were in multivariable analyses associated with EPTS; alcohol abuse (odds ratio [OR] 3.6, 95% CI 2.3-5.7, p < .001), moderate and severe brain injury (OR 2.2, 95% CI 1.3-3.8, p=.004 and OR 2.1, 95% CI 1.2-3.6, p=.012), brain contusion (OR 1.6, 95% CI 1.0-2.4, p=.046) and subdural hematoma (OR 1.6, 95% CI 1.0-2.6, p=.052). In our material, EPTS occurred in 5.6% of hospital-admitted TBI-patients. Alcohol abuse was the most significant risk factor, followed by moderate and severe brain injury. The results of this study contribute to the discussion about preventive treatment of EPTS in certain risk groups.

Factors associated with acute symptomatic seizure occurrence among patients with posterior reversible encephalopathy syndrome

ObjectivesWe aimed to define the factors associated with acute symptomatic seizure occurrence in posterior reversible encephalopathy syndrome (PRES) in the Thai-Asian population. Materials and methodsWe conducted a retrospective cohort study enrolling patients with PRES admitted to the hospital between 2006 and 2019. In addition to seizure characteristics, baseline characteristics, clinical presentations, precipitating factors, neuroimaging characteristics, hospital complications, and hospital outcomes were compared between the seizure and non-seizure groups. Factors with p-value <0.05 in the univariate analysis were entered into the first model of multivariate logistic regression analysis to determine the factors associated with seizure occurrence if the p-value <0.05. The interaction of associated factors was also analyzed in the final multiple logistic regression analysis model. ResultsAcute symptomatic seizure, which is mainly based on the clinical documentation without electroencephalography, occurred in 50.0% of 136 patients with PRES. Of these, early seizures within 14 days of PRES occurred in 98.5% which mostly developed at presentation (82.4%) with a single seizure attack (55.9%). Convulsive seizures (77.9%) were the most common seizure semiology. The seizure group was significantly younger (median [interquartile range: IQR] 36.00 years old (21.75–48.50) vs 46.50 years old (31.25–61.00), p = 0.003). In univariate analysis, the seizure group had a higher prevalence of consciousness impairment (61.76% vs 26.47%, p < 0.001), Glasgow coma scale (GCS) score of 0–13 (42.46% vs 13.23%, p < 0.001), preeclampsia (20.58% vs 4.41%, p = 0.004), autoimmune disease (17.65% vs 5.88%, p = 0.033), and frontal lesions (25.00% vs 11.76%, p = 0.046) than those in the non-seizure group. In contrast, the seizure group had a lower prevalence of headache (27.94% vs 61.76%, p < 0.001). In the final multivariate logistic regression analysis which included the interaction terms, the acute symptomatic seizure occurrence directly associated with preeclampsia (adjusted odds ratio (aOR) 6.426, 95% confidence interval (CI) 1.450–27.031, p = 0.016) and autoimmune disease (aOR 4.962, 95% CI 1.283–18.642, p = 0.025), while headache showed a reverse association (aOR 0.310, 95% CI = 0.158–0.721, p = 0.008). ConclusionsAcute symptomatic seizure occurred in a half of patients with PRES in this cohort. Preeclampsia and autoimmune disease were directly associated with seizure occurrence, while headache showed a reverse association.

Pregabalin Add-On vs. Dose Increase in Levetiracetam Add-On Treatment: A Real-Life Trial in Dogs With Drug-Resistant Epilepsy.

Epilepsy is a common neurological disorder affecting 0.6–0.75% of dogs in veterinary practice. Treatment is frequently complicated by the occurrence of drug-resistant epilepsy and cluster seizures in dogs with idiopathic epilepsy. Only few studies are available to guide treatment choices beyond licensed veterinary drugs. The aim of the study was to compare antiseizure efficacy and tolerability of two add-on treatment strategies in dogs with drug-resistant idiopathic epilepsy. The study design was a prospective, open-label, non-blinded, comparative treatment trial. Treatment success was defined as a 3-fold extension of the longest baseline interseizure interval and to a minimum of 3 months. To avoid prolonged adherence to a presumably ineffective treatment strategy, dog owners could leave the study after the third day with generalized seizures if the interseizure interval failed to show a relevant increase. Twenty-six dogs (mean age 5.5 years, mean seizure frequency 4/month) with drug-resistant idiopathic epilepsy and a history of cluster seizures were included. Dogs received either add-on treatment with pregabalin (PGB) 4 mg/kg twice daily (14 dogs) or a dose increase in levetiracetam (LEV) add-on treatment (12 dogs). Thirteen dogs in the PGB group had drug levels within the therapeutic range for humans. Two dogs in the PGB group (14.3%; 2/14) and one dog in the LEV group (8.3%; 1/12) achieved treatment success with long seizure-free intervals from 122 to 219 days but then relapsed to their early seizure frequency 10 months after the study inclusion. The overall low success rates with both treatment strategies likely reflect a real-life situation in canine drug-resistant idiopathic epilepsy in everyday veterinary practice. These results delineate the need for research on better pharmacologic and non-pharmacologic treatment strategies in dogs with drug-resistant epilepsy.

Technical challenges to anterior temporal lobectomy after laser interstitial thermal therapy for mesial temporal lobe epilepsy: technical note.

Mesial temporal sclerosis (MTS) is a frequent cause of medically refractory epilepsy, for which laser interstitial thermal therapy (LITT) is an effective treatment. However, experience with the technical considerations posed by additional surgery after an initial LITT procedure is lacking. The authors present the case of a 12-year-old female with medically refractory temporal lobe epilepsy and left MTS who underwent LITT at a separate institution prior to referral. This patient had no change in early postoperative seizure control (Engel class IVB) and then her seizures worsened despite ongoing medical treatment (Engel class IVC). Post-LITT MRI revealed sparing of the mesial hippocampus head, a poor prognostic factor. The authors describe the technical details illustrated by this case of secondary, stereotactic electroencephalography-guided mesial temporal resection following LITT. The case was managed with anterior temporal lobectomy including the resection of residual hippocampus and amygdala.

ES-RED (Early Seizure Recurrence in the Emergency Department) Calculator: A Triage Tool for Seizure Patients.

Seizure is a common neurological presentation in patients visiting the emergency department (ED) that requires time for evaluation and observation. Timely decision and disposition standards for seizure patients need to be established to prevent overcrowding in the ED and achieve patients’ safety. Here, we conducted a retrospective cohort study to predict early seizure recurrence in the ED (ES-RED). We randomly assigned 688 patients to the derivation and validation cohorts (2:1 ratio). Prediction equations extracted routine clinical and laboratory information from EDs using logistic regression (Model 1) and machine learning (Model 2) methods. The prediction equations showed good predictive performance, the area under the receiver operating characteristics curve showing 0.808 in Model 1 [95% confidential interval (CI): 0.761–0.853] and 0.805 in Model 2 [95% CI: 0.747–0.857] in the derivation cohort. In the external validation, the models showed strong prediction performance of 0.739 [95% CI: 0.640–0.824] in Model 1 and 0.738 [95% CI: 0.645–0.819] in Model 2. Intriguingly, the lowest quartile group showed no ES-RED after 6 h. The ES-RED calculator, our proposed prediction equation, would provide strong evidence for safe and appropriate disposition of adult resolved seizure patients from EDs, reducing overcrowding and delays and improving patient safety.

Risk factors for acute encephalitis and early seizure recurrence in complex febrile seizures.

The purpose of this study is to elucidate risk factors for central nervous system infection and early seizure recurrence in children with febrile seizures (FSs) and thus facilitate outpatient management of complex FS. This single-center, retrospective cohort study investigated 688 children (6-60months old) with FSs in Japan during 2011-2021. We investigated the incidence and clinical manifestations of children with acute encephalitis or bacterial meningitis. Logistic regression modeling was used to examine risk factors for seizure recurrence within 24h. Among children with recurrent FSs, the distribution of intervals between first and second FS was assessed. Among 145 children with complex FSs, 2 patients (1.4%) had acute viral encephalitis and none had bacterial meningitis. Acute encephalitis was found in 2 of 8 patients (25%) with FSs prolonged ≥30min and 2 of 3 patients (67%) requiring ≥2 intravenous anticonvulsants to stop seizures. Seizure recurrence within 24h was observed in 16% of participants and was independently associated with preceding use of diazepam and family history of FS. In 82% of patients with FS recurrence within 24h, early recurrences occurred within 8h of the first seizure. Conclusion: Patients with prolonged or refractory FSs are still indicated for hospital admission due to the risk of acute encephalitis. FS patients with a family history of FS may be managed safely by 8-h observation or single-dose rectal diazepam as prophylaxis against early recurrent seizure. What is Known: •Hospitalization has been recommended for children with complex febrile seizures due to the increased risk of central nervous infections. •Recent studies showed low incidences of bacterial meningitis (<1%) in children with complex febrile seizures in the presence of routine immunization. What is New: •Acute encephalitis was identified in 1.4% of children with complex febrile seizures, characterized by prolonged seizures ≥30 min and refractory seizures. •Early recurrent seizures may be safely managed by prophylactic diazepam or 8-h expectant observation.

Early EEG hyperexcitability is associated with decreased survival in newly diagnosed IDH-wildtype glioma.

The relationship between peritumoral neuronal activity, early onset clinical seizures, and glioma survival outcomes remains poorly understood. Hyperexcitability on continuous EEG in the peri-operative period was studied as a prognostic biomarker in patients with newly diagnosed IDH-wildtype diffuse glioma. A retrospective observational cohort study was performed including adults with newly diagnosed diffuse glioma, absence of IDH1/2 mutations, and continuous EEG monitoring prior to chemoradiation and within 1month of initial resection. EEG hyperexcitability was defined by the presence of lateralized periodic discharges and/or electrographic seizures. The primary outcome of overall survival was estimated using the Kaplan-Meier method and compared between groups using multivariate Cox proportional hazards model. There were 424 patients without continuous EEG and 32 with continuous EEG, of whom lateralized periodic discharges and/or electrographic seizures were seen in 17 (53%). Peri-operative EEG hyperexcitability was associated with decreased overall survival in multivariate analysis (median 12.5 [95% CI 6.2-25.6] months with hyperexcitability versus median 19.9 [95% CI 8.9-53.5] months without hyperexcitability, p = 0.043). Compared to patients without continuous EEG, overall survival was decreased in patients with hyperexcitability (p < 0.0001) and similar in patients without hyperexcitability (p = 0.193). Patients with and without hyperexcitability had similar rates of exposure to anti-seizure medication at baseline, and in long-term follow-up had no difference in number of medications required for seizure control. These findings indicate the potential prognostic value of a clinical EEG biomarker of glioma aggressiveness prior to the initiation of chemoradiation.

Analysis of risk factors related to early post-traumatic seizures and post-traumatic epilepsy

Objective: We investigated factors associated with early post-traumatic seizures (EPTSs) and post-traumatic epilepsy (PTE) to determine factors associated with PTE in comparison with previous reports. Methods: We enrolled 78 patients with acute head trauma from January 2008 to December 2011 (range of follow-up duration, 5–12.9 years). We conducted a comparative analysis of various factors in both groups.Results: Nine of the 78 patients experienced EPTSs during admission, and 18 patients developed PTE. All nine patients with EPTSs progressed to PTE. Treatment type, academic background, marital status, hemoglobin at hospital day 1 (HD#1), Glasgow coma scale (GCS) at admission, GCS at discharge, and the modified Rankin score (mRS) at the final visit were significantly different between the nine patients with EPTSs and the 69 patients who did not have EPTSs via the Mann-Whitney U-test. Statistically significant differences were identified in the type of brain trauma, treatment type, marital status, glucose level at HD#1, GCS at admission, GCS at discharge, and mRS at the final visit by the Mann-Whitney U-test between the 18 patients who developed PTE and the 60 patients who did not develop PTE. Conclusion: The patients with PTSs and PTE were relatively younger and were more likely to be unmarried. It is premature to draw a firm conclusion, but more active administration and long-term meticulous follow-up may be needed for young, highly educated, unmarried male patients. In addition, the analysis of more patients over a longer period of time will be needed.