Epilepsy Center Research Articles

1 Network Efficiency as Structural Reserve: Pre- And Post-Operative Associations Between Network Organization and Memory in Temporal Lobe Epilepsy

Objective:Memory impairment is a common comorbidity in individuals with temporal lobe epilepsy (TLE). Further, in medication-resistant epilepsy the frontline option, neurosurgical epileptogenic zone destruction, places memory at significant risk. Research has highlighted that TLE causes whole-brain network efficiency disruption, but it is not established how this may explain pre- and post-surgical cognition. Here we examine whether white matter structural network organization predicts pre-operative memory function and/or risk for post-operative memory decline.Participants and Methods:Patients with drug-resistant TLE were recruited from two epilepsy centers in a prospective longitudinal study. The pre-operative sample included 51 individuals with left TLE (L-TLE), 52 with right TLE (R-TLE), and 57 healthy controls who underwent T1- and diffusion-weighted MRI (dMRI), and neuropsychological tests of verbal and visual memory. Forty-four patients (n=21 L-TLE) subsequently underwent temporal lobe surgery (36 anterior temporal lobectomy; 7 stereotactic laser amygdalohippocampectomy; 1 amygdalohippocampectomy) and completed post-operative memory testing. Whole-brain connectomes were generated via diffusion tractography and analyzed using graph theory, focusing on network integration (path length) and specialization (transitivity). In the preoperative dataset, first we compared TLE versus controls with analysis of covariance (ANCOVAs) controlling for age. Next, linear regressions examined the association between memory scores and network efficiency between L-TLE, R-TLE and controls. In the post-operative sample, bivariate correlations examined the association between pre- to post-operative memory change and 1) global network efficiency and 2) asymmetry of mesial temporal efficiency (i.e., local efficiency of the hippocampal, parahippocampal, and entorhinal nodes). Finally, efficiency metrics were entered into stepwise regressions along with established predictors of memory decline.Results:Compared to controls, TLE showed longer path length (p < .05; ηp2 = .03) and lower transitivity (p = .01; ηp2 = .04). Pre-operatively, better verbal learning and memory were associated with both shorter path length (β = -0.23 to -0.32; psadjusted < .05) and increased transitivity (β = 0.20 to 0.31; psadjusted < .05). These associations were greater in L-TLE than R-TLE (i.e., a significant interaction; β = -0.29 to 0.25; psadjusted <.05). Post-operatively, global metrics predicted decline on list learning for LTLEs (rs = -.57 to .58; ps < .01), and were marginal on list recall (rs = -.42 to .40; ps < .10). Leftward asymmetry of mesial temporal local efficiency predicted greater decline across most verbal memory measures for L-TLE (rs -.47 to -59; psadjusted <.05), but not R-TLE. Asymmetry of mesial network efficiency uniquely explained at least 20 to 43% of the variance in list learning, recall, and story learning for L-TLE, outperforming hippocampal asymmetry and preoperative score (psadjusted <.05).Conclusions:Our findings suggest that global white matter network abnormalities contribute to verbal memory impairment pre-operatively and vulnerability to decline post-operatively in L-TLE. Asymmetry of a predefined mesial temporal sub-network may help predict post-operative memory function following left temporal lobe surgery, such that greater efficiency in the to-beresected mesial temporal network may be an important risk factor for decline. Our findings extend the importance of network approaches in TLE to include the relationships between neurobiological networks and memory function.

34 Executive Function as a Protective Factor for Post-Surgical Quality of Life in Unilateral Epilepsy Surgery

Objective:Many epilepsy syndromes are medically refractory, leading patients to be referred for surgical work-up to control their seizures and improve their quality of life (QOL). Although surgical treatments may reduce or stop seizures, many patients continue to present with declines in mood and/or cognition post-operatively. In addition, pre-operative QOL of patients with medically refractory epilepsy is impacted by executive function (EF). The present study aims to investigate the relationship between post-operative mood/QOL and pre-operative EF in adults with epilepsy. It was hypothesized that mood would remain stable or decline post-operatively; pre-operative EF would be a protective factor for mood decline and QOL.Participants and Methods:The sample consisted of 47 adult patients (57.4% female; Age, M= 34.02(11.59)) with medically refractory epilepsy at the UCSF Epilepsy Center. Participants were included if they received surgical treatment for their epilepsy (42.6% right anterior temporal lobectomy [ATL], 46.8% left ATL, 2.1% laser ablation, 6.4% responsive neurostimulation, 2.1% multiple surgical interventions) and received both a pre- and post-surgical neuropsychological evaluation. Most patients were right-handed (95.7% right). Mood and QOL were assessed from pre- and post-operative evaluations using the Beck Depression Inventory- Second Edition (BDI-II), Beck Anxiety Inventory (BAI), and Quality of Life in Epilepsy- 31 (QOLIE-31). Executive function was assessed using the Trail Making Test, and the Delis-Kaplan Executive Function Scale (D-KEFS) subtests Color-Word Interference (CW-I) and Verbal Fluency. Descriptive statistics were obtained for each of the measures listed. A paired sample t-test was conducted between time A and B to determine whether mood and QOL were significantly different. Two multiple regressions were conducted. One analysis for post-operative depression and QOL respectively with pre-operative EF.Results:At time A, both anxiety and depression were minimal (BDI M= 17.8, SD= 10.34; BAI M= 13; SD= 8.94). QOL was borderline clinically significant (QOLIE M= 37.46, SD= 9.74). Depression at time B was positively correlated with depression at time A (r[45]= 0.316, p=0.035). A paired sample t-test indicated that depression and QOL were significantly different at time A and time B (t[44]= 2.04, p= 0.047; t[31]= -3.34, p= 0.002), with improved scores post-operatively. Anxiety was not significantly different across time points (t[39]= 1.20, p=0.238). Multiple regression analyses indicated that pre-operative depression and EF did not predict post-operative depression (F(5,27)= 1.62, p= 0.189). Pre-operative EF (CW-I Inhibition-Switching), but not pre-operative depression, predicted post-operative QOL (F(4(24)= 3.13, p=.03, R2= .343).Conclusions:Results were somewhat discrepant from prior research in that depression and QOL improved post-surgically. Notably, while the observed change in depression was statistically significant it was not clinically significant according to literature (Doherty et al., 2021). Pre-surgical inhibitory control predicted QOL, illustrating that EF may serve as a protective factor post-surgically. The present study did not include a measure of seizure freedom classification post-operatively, therefore, future studies should investigate how seizure freedom classification impacts the relationship between mood, QOL, and cognitive outcomes.

Trajectories of parent well-being in children with drug-resistant epilepsy.

This longitudinal cohort study aimed to identify trajectories of parent well-being over the first 2 years after their child's evaluation for candidacy for epilepsy surgery, and to identify the baseline clinical and demographic characteristics associated with these trajectories. Parent well-being was based on parent depressive and anxiety symptoms and family resources (i.e., family mastery and social support). Parents of 259 children with drug-resistant epilepsy (105 of whom eventually had surgery) were recruited from eight epilepsy centers across Canada at the time of their evaluation for epilepsy surgery candidacy. Participants were assessed at baseline and 6-month, 1-year, and 2-year follow-up. The trajectories of parents' depressive symptoms, anxiety symptoms, and family resources were jointly estimated using multigroup latent class growth models. The analyses identified three trajectories: an optimal-stable group with no/minimal depressive or anxiety symptoms, and high family resources that remained stable over time; a mild-decreasing-plateau group with mild depressive and anxiety symptoms that decreased over time then plateaued, and intermediate family resources that remained stable; and a moderate-decreasing group with moderate depressive and anxiety symptoms that decreased slightly, and low family resources that remained stable over time. Parents of children with higher health-related quality of life, fathers, and parents who had higher household income were more likely to have better trajectories of well-being. Treatment type was not associated with the trajectory groups, but parents whose children were seizure-free at the time of the last follow-up were more likely to have better trajectories (optimal-stable or mild-decreasing-plateau trajectories). This study documented distinct trajectories of parent well-being, from the time of the child's evaluation for epilepsy surgery. Parents who present with anxiety and depressive symptoms and low family resources do not do well over time. They should be identified and offered supportive services early in their child's epilepsy treatment history.

Poor midterm clinical outcomes and a high percentage of unsatisfying results are reported after seizure-related shoulder injuries, especially after posterior proximal humerus fracture-dislocations

Treating seizure-related shoulder injuries is challenging, and an evidence-based consensus to guide clinicians is lacking. The aim of this prospective single-center observational clinical trial was to evaluate the clinical results of a cohort of patients undergoing treatment of seizure-related shoulder injuries, to categorize them according to the lesion's characteristics, with special focus on patients with proximal humerus fracture-dislocations (PHFDs), and to define groups at risk of obtaining unsatisfactory results. We hypothesized that patients with a PHFD, considered the worst-case scenario among these injuries, would report worse clinical results in terms of the quick Disabilities of the Arm, Shoulder, and Hand questionnaire (qDASH) as compared to the other patients. Patients referred to a tertiary epilepsy center who have seizure-related shoulder injuries and with a minimum follow-up of 1 year were included. A quality-of-life assessment instrument (EQ-5D-5L), a district-specific patient-reported outcome measure (qDASH), and a pain assessment tool (visual analog scale [VAS]) were used for the clinical outcome evaluation. Subjective satisfaction and fear of new shoulder injuries was also documented. Categorization and subgroup analysis according to the presence and features of selected specific lesions were performed. A total of 111 patients were deemed eligible and 83 were available for follow-up (median age 38 years, 30% females), accounting for a total of 107 injured shoulders. After a median follow-up of 3.9 (1.6-8.2) years, overall moderate clinical results were reported. In addition, 34.1% of the patients reported a VAS score ≥35 mm, indicating moderate to severe pain, and 34.1% a qDASH score ≥40 points, indicating severe disability of an upper limb. These percentages rose to, respectively, 45.5% and 48.5% in the subgroup of patients with PHFDs and to 68.8% and 68.8% in patients experiencing posterior PHFD. Overall, 46.9% of the patients considered themselves unsatisfied with the treatment and 62.5% reported a persistent fear of a new shoulder injury. Patients with seizure-related shoulder injuries reported only moderate clinical results at their midterm follow-up. Older age, male sex, and absence or discontinuation of antiepileptic drug (AED) treatment were identified as characterizing features of patients with posterior dislocation episodes. In patients with PHFD, a tendency to worse clinical results was observed, with posterior PHFD patients emerging as a definite subgroup at risk of reporting unsatisfying results after treatment.

Prevalence of dementia in a level 4 university epilepsy center: how big is the problem?

The relationship between epilepsy and dementia is currently a topic of great interest. Our study aimed to determine the prevalence of dementia diagnoses among patients of a large level 4 university epilepsy center. In this retrospective monocentric study conducted at the Department of Epileptology of the University Hospital Bonn, we searched for dementia-related terms in a total of 145,501 medical letters from 40,360 adult patients who were seen between 2003 and 2021. Files with at least one hit were selected and analyzed with regard to diagnoses, age, age at epilepsy onset, and the question as to whether epilepsy preceded or followed the dementia diagnosis. Among the medical letters of 513 patients, dementia-related terms were found. The letters of 12.7% of these patients stated a dementia diagnosis, 6.6% were suspected of having dementia, 4.9% had mild cognitive impairment, and 6.6% had other neurodegenerative diseases without dementia. Taking all 40,360 patients into account, the prevalence of diagnosed or suspected dementia was 0.25%. An older age (≥60 years) and late-onset epilepsy (≥60 years), but not a longer epilepsy duration, increased the odds of dementia by 6.1 (CI 3.5-10.7) and 2.9 (CI 1.7-4.7), respectively. Additionally, vascular, metabolic, inflammatory, and behavioral mood-related comorbidities were commonly observed. Epilepsy tended to precede (23.2%) rather than follow (8.1%) the dementia diagnosis. Despite the clear limitations of a selection bias and the potential underdiagnosis of dementia and underestimation of its prevalence when relying on the medical letters from a specialized center which rather focuses on epilepsy-related issues, the findings of this study offer valuable insights from the perspective of an epilepsy center. In this setting, the prevalence of dementia in epilepsy is rather low. However, physicians should be aware that the risk of dementia is higher in the elderly, in late-onset epilepsies, and when comorbid risk factors exist. Seizures can also be an early sign of a neurodegenerative disease. Future research should explicitly screen for dementia in patients with epilepsy and stratify them according to their underlying pathologies and comorbidities.

Application of the International Classification of Cognitive Disorders in Epilepsy (IC-CoDE) to frontal lobe epilepsy using multicenter data

RationaleThe International Classification of Cognitive Disorders in Epilepsy (IC-CoDE) was recently introduced as a consensus-based, empirically-driven taxonomy of cognitive disorders in epilepsy and has been effectively applied to patients with temporal lobe epilepsy (TLE). The purpose of this study was to apply the IC-CoDE to patients with frontal lobe epilepsy (FLE) using national multicenter data. MethodsNeuropsychological data of 455 patients with FLE aged 16 years or older were available across four US-based sites. First, we examined test-specific impairment rates across sites using two impairment thresholds (1.0 and 1.5 standard deviations below the normative mean). Following the proposed IC-CoDE guidelines, patterns of domain impairment were determined based on commonly used tests within five cognitive domains (language, memory, executive functioning, attention/processing speed, and visuospatial ability) to construct phenotypes. Impairment rates and distributions across phenotypes were then compared with those found in patients with TLE for which the IC-CoDE classification was initially validated. ResultsThe highest rates of impairment were found among tests of naming, verbal fluency, speeded sequencing and set-shifting, and complex figure copy. The following IC-CoDE phenotype distributions were observed using the two different threshold cutoffs: 23–40% cognitively intact, 24–29% single domain impairment, 13–20% bi-domain impairment, and 18–33% generalized impairment. Language was the most common single domain impairment (68% for both thresholds) followed by attention and processing speed (15–18%). Overall, patients with FLE reported higher rates of cognitive impairment compared with patients with TLE. ConclusionsThese results demonstrate the applicability of the IC-CoDE to epilepsy syndromes outside of TLE. Findings indicated generally stable and reproducible phenotypes across multiple epilepsy centers in the U.S. with diverse sample characteristics and varied neuropsychological test batteries. Findings also highlight opportunities for further refinement of the IC-CoDE guidelines as the application expands.

Readability and content gaps in online epilepsy surgery materials as potential health literacy and shared-decision-making barriers.

Epilepsy surgery is an effective albeit underused treatment for refractory epilepsy, and online materials are vital to patient understanding of the complex process. Our goal is to analyze the readability and content inclusion of online patient health education materials designed for epilepsy surgery. A private browser setting was used on Google and Bing to identify the top 100 search results for the terms "epilepsy+surgery". Scientific papers, insurance pages, pay-wall access sites, and non-text content were excluded. The website text was reformatted to exclude graphics, contact information, links, and headers. Readability metrics were calculated using an online tool. Text content was analyzed for inclusion of important concepts (pre-surgical evaluation, complications, risks of continued seizures, types of surgery, complimentary diagrams/audiovisual material). Comparison of readability and content inclusion was performed as a function of organization types (epilepsy center, community health organization, pediatric-specific) and location (region, country). Browser search yielded 82 distinct websites with information regarding epilepsy surgery, with 98.7% of websites exceeding the recommended 6th-grade reading level for health information. Epilepsy centers had significantly worse readability (Flesch-Kincaid Grade Level (FKGL) P < 0.01 and Flesch Reading Ease (FRE) P < 0.05). Content analysis showed that only 37% of websites discuss surgical side effects and only 23% mention the risks of continued seizures. Epilepsy centers were less likely to report information on surgical side effects (P < 0.001). UK-based websites had better readability (FKGL P < 0.01 and FRE P < 0.01) and were more likely to discuss side effects (P = 0.01) compared to US-based websites. The majority of online health content is overly complex and relatively incomplete in multiple key areas important to health literacy and understanding of surgical candidacy. Our findings suggest academic organizations, including level 4 epilepsy centers, need to simplify and broaden online education resources. More comprehensive, publicly accessible, and readable information may lead to better-shared decision-making.

Effects of attachment styles, childhood traumas, and alexithymia in Turkish patients with epilepsy and functional seizures

IntroductionIn this cross-sectional study, we used self-report scales to compare childhood traumas, attachment styles, and alexithymia among patients with functional seizures (FS) to patients with epilepsy and healthy controls. We also investigated risk factors associated with FS. Material and methodsA total of 44 patients with epilepsy, 14 patients with FS, and 25 healthy controls were included. All participants were over the age of 18 and were referred to the Baskent University Adana Epilepsy and Video-EEG Center. The patients underwent neurological examinations, brain MRIs, and video-EEG evaluations. Epileptic seizures were classified based on video EEG. The control group consisted of healthy individuals without neurological or psychiatric illness and a history of epileptic seizures or syncope. Beck Depression Inventory (BDI), Childhood Trauma Questionnaire (CTQ), Adult Attachment Scale (AAS), and Toronto Alexithymia Scale-20 (TAS-20) were applied to all participants. ResultsPatients with FS had lower educational levels, higher rates of unemployment and single-marital status. The FS group had higher depression, childhood trauma, and alexithymia scores than the other groups. Furthermore, FS patients had a higher prevalence of avoidant attachment. The alexithymia and childhood trauma scores were both correlated with depression. Through the logistic regression analysis, childhood trauma scores and alexithymia were significant risk factors for FS. ConclusionThe use of video-EEG for diagnosing FS can reduce the risk of misdiagnosis and inappropriate antiepileptic treatment. Psychiatric comorbidities, childhood traumas, and alexithymia are prevalent in patients with FS. Therefore, implementing a multidisciplinary treatment approach that addresses the psychological, medical, and social aspects of FS can significantly improve outcomes.

Efficacy and tolerability of oxcarbazepine in the treatment of focal epilepsy in neonates and infants under 3 months of age: A single-center retrospective analysis

ObjectiveThe neonatal and infantile period is the age group with the highest incidence of epilepsy, in which gene variants in sodium and potassium channels are an important etiology, so the sodium channel blocker class of antiseizure medications may be effective in the treatment of early onset epilepsy. This study aimed to summarize the efficacy and tolerability of oxcarbazepine (OXC) in the treatment of focal epilepsy in neonates and infants under 3 months of age. MethodsA retrospective analysis of children with focal epilepsy onset within 3 months of age and treated with OXC in a tertiary pediatric epilepsy center in China was conducted. The efficacy, tolerability and influencing factors of OXC were evaluated. ResultsA total of 50 patients were enrolled, with a median age of epilepsy onset of 11.5 (2, 42) days. There were 32 cases of early infantile developmental and epileptic encephalopathy, 10 cases of self-limited neonatal or neonatal-infantile epilepsy, and 8 cases of focal epilepsy that could not be classified as epileptic syndrome. The median age of application of OXC was 47 (31, 66) days. The median follow-up time was 16.5 (10, 25) months, with 7 deaths. Thirty-eight cases (76.0 %) were effective with OXC treatment, including 28 cases (56.0 %) achieved seizure freedom. Of the 34 cases whose pathogenesis involved genetic factors, 19 cases with sodium/ potassium channel gene variants had higher effective and seizure-free rates than those with other gene variants. The most common adverse event was transient hyponatremia. 2 cases had rash and 2 cases had abnormal electrocardiogram, 3 of which discontinued OXC. SignificanceThis single-center retrospective study suggests that OXC is effective and tolerable for the treatment of focal epilepsy in neonates and infants under 3 months of age. The efficacy of OXC is better in patients with sodium/ potassium channel gene variants.

H - 47 Bilingual Auditory Naming Test Performance in an Epilepsy Sample.

The growing multilingual population in the United States calls for culturally adapted norms for neuropsychological tools. Language testing, for example, is paramount in pre-surgical assessment in patients with dominant temporal lobe epilepsy. The Boston Naming Test (BNT) and the Auditory Naming Test (ANT) are frequently used in pre-surgical epilepsy evaluations; yet, while bilingual norms exist for the BNT, these are lacking for the ANT. To parse out how much of a bilingual patient's language performance is accounted for by bilingualism versus language deficits, we studied whether there is a significant difference in ANT performance between bilingual and monolingual English-speaking epilepsy patients. Our sample of patients with localized epilepsy from the UCSF Epilepsy Center included 22 bilingual (English-dominant; non-dominant languages included Spanish, Arabic, Dutch, Taiwanese, and Japanese) and 61 monolingual English-speakers (39% female, M age = 36.3). All patients took anti-seizure medication and completed the ANT and BNT as part of a pre-surgical neuropsychological assessment. Compared to monolingual English-speaking patients, bilingual patients had significantly lower scores on the ANT (Bilingual M = -4.03 [SD = 5.6], Monolingual M = -0.7 [SD = 1.9]; t(81) = 3.89, p < 0.001) and BNT (t(77) = 2.76, p = 0.007). This performance difference was significantly greater for the ANT than BNT (F(1,77) = 7.71, p = 0.007). These results highlight the importance of considering multilingualism in neuropsychological assessments. This is especially needed for pre-surgical language mapping in epilepsy surgical candidates. Future research should establish bilingual normative standards for neuropsychological language-based tests such as the ANT.

A scoping review of the functional magnetic resonance imaging-based functional connectivity of focal cortical dysplasia-related epilepsy.

Focal cortical dysplasia (FCD) is the most frequent etiology of operable pharmacoresistant epilepsy in children. There is burgeoning evidence that FCD-related epilepsy is a disorder that involves distributed brain networks. Functional magnetic resonance imaging (fMRI) is a tool that allows one to infer neuronal activity and to noninvasively map whole-brain functional networks. Despite its relatively widespread availability at most epilepsy centers, the clinical application of fMRI remains mostly task-based in epilepsy. Another approach is to map and characterize cortical functional networks of individuals using resting state fMRI (rsfMRI). The focus of this scoping review is to summarize the evidence to date of investigations of the network basis of FCD-related epilepsy, and to highlight numerous potential future applications of rsfMRI in the exploration of diagnostic and therapeutic strategies for FCD-related epilepsy. There are numerous studies demonstrating a global disruption of cortical functional networks in FCD-related epilepsy. The underlying pathological subtypes of FCD influence overall functional network patterns. There is evidence that cortical functional network mapping may help to predict postsurgical seizure outcomes, highlighting the translational potential of these findings. Additionally, several studies emphasize the important effect of FCD interaction with cortical networks and the expression of epilepsy and its comorbidities.

High-purified cannabidiol efficacy and safety in a cohort of adult patients with various types of drug-resistant epilepsies

About 30% of patients with epilepsy are drug resistant. Lennox-Gastaut syndrome (LGS), Dravet syndrome (DS) and tuberous sclerosis complex (TSC) are diseases for which high-purified-cannabidiol (CBD) known as Epidiolex® (GW pharma) can be prescribed in add-on of other medications in case of drug-resistance. Currently, there are only a few recent data in the literature about the efficacy and safety of CBD in other forms of refractory epilepsies especially focal epilepsies in adults. We report retrospectively the experience of high-purified-CBD use in two French reference medical centers for epilepsy in various forms of drug-resistant epilepsy. We distinguished two groups of patients: group A with epileptic encephalopathies and group B with focal or multifocal epilepsy. Safety and efficacy (% of responder patients) were evaluated. Finally, 73 patients (51 in group A and 22 in group B) used high-purified CBD as an add-on treatment for their drug-resistant epilepsy. Patients in group A were significantly younger (P=0.0155), with a longer exposition of treatment (P=0.0497) than group B and with higher doses (P=0.0300). Respectively, 15 patients (29.4%) and five patients (22.7%) were responders during the follow-up period (P=0.552). The association with clobazam was more frequent in responders than in non-responder patients (16 patients [80%] versus four [20%]). The most frequent side effect was somnolence. At the end of follow-up, 15 patients in group A (29.4%) and nine patients in group B (40.1%) had stopped the high-purified-CBD treatment due to aggravation of seizure, absence of positive effects, or adverse events. This study showed no significant difference regarding the type of drug-resistant epilepsy and suggests that this treatment may be of interest for all types of drug-resistant epilepsy.

Adverse life events in patients with functional seizures: Assessment in clinical practice and association with long-term outcome

BackgroundA history of adverse life events (ALE) is a risk factor for functional seizures (FS). Their influence on long-term outcome remains unclear. International guidelines recommend assessing ALE in patients presenting with associated disorders. It is not clear to what extent patients evaluated for FS are regularly asked about ALE. ObjectivesWe hypothesised that the presence of ALE would relate to worse outcome at follow-up and, that the rate of detection of ALE in clinical work-up would be inferior to that based on self-report questionnaires. Methods53 patients with FS from the National Centre for Epilepsy in Norway, aged 16–62 years were included. Symptom severity, health-related quality of life (HRQoL), and antecedent ALE were assessed at baseline. Medical records were examined for disclosure of ALE. At a mean of 70.45 (SD 29.0, range 22–130) months after inclusion, participants were inquired about FS status, FS-related health care utilization and HRQoL.Findings: A history of emotional abuse documented in the medical record was an independent risk factor for worse HRQoL at follow-up. Prevalence of ALE documented in medical records was lower compared with rates measured by a self-report questionnaire. ConclusionsThese findings indicate an association between antecedent ALE and HRQoL years after diagnosis. A substantial proportion of the adverse life events by a self-report questionnaire had not been documented in the clinical records. Clinical implicationsThe supplemental use of a self-report questionnaire in the diagnostic work-up of patients with FS may be valuable for detecting ALE.

Long-term seizure and developmental outcomes of epilepsy surgery in children under 3 years old: A single-center study of 113 patients.

To investigate the clinical characteristics, surgical strategy, developmental and seizure outcomes, and predictors of surgical outcome in children with drug-resistant epilepsy (DRE) under 3 years old. One hundred thirteen consecutive children younger than 3 years of age with DRE underwent curative surgical treatment after multidisciplinary preoperative evaluation using the strategy developed in the pediatric epilepsy center of Peking University First Hospital (PKFHPEC) between 2014 and 2018. These patients were selected for retrospective study. The relevant clinical data were collected and analyzed. The surgical prognoses were classified using the Engel classification, and the developmental assessment results were collected. Statistical analysis of the clinical data was performed to analyze the predictors of seizure outcomes and their correlation with developmental outcomes. All the patients were followed up for more than 3 years, and 98 (86.7%) patients had no seizure recurrence. One year after surgery, the seizure-free rate was 86.7%, which was as high as that at the last follow-up. Cortical dysplasia was the most frequent etiology of DRE in this cohort, accounting for 77.0%. According to the Engel classification, acute postoperative seizure (APOS; p < 0.001) was a predictor of seizure recurrence. No deaths occurred. No unpredicted long-term severe complications occurred except for one ventricular peritoneal shunt. The patients' neurodevelopmental statuses were improved after successful surgery, while the scores of the pre- and postoperative developmental assessments were closely correlated. For children who are younger than 3 years old and have DRE and structural abnormalities, early curative treatment can lead to long-term good seizure outcomes and a low complication rate. The development of appropriate strategies for both presurgical evaluation and resection is crucial for the success of surgery.

Role of optically pumped magnetometers in presurgical epilepsy evaluation: Commentary of the American Clinical Magnetoencephalography Society.

One of the major challenges of modern epileptology is the underutilization of epilepsy surgery for treatment of patients with focal, medication resistant epilepsy (MRE). Aggravating this distressing failure to deliver optimum care to these patients is the underuse of proven localizing tools, such as magnetoencephalography (MEG), a clinically validated, non-invasive, neurophysiological method used to directly measure and localize brain activity. A sizable mass of published evidence indicates that MEG can improve identification of surgical candidates and guide pre-surgical planning, increasing the yield of SEEG and improving operative outcomes. However, despite at least 10 common, evidence supported, clinical scenarios in MRE patients where MEG can offer non-redundant information and improve the pre-surgical evaluation, it is regularly used by only a minority of USA epilepsy centers. The current state of the art in MEG sensors employs SQUIDs, which require cooling with liquid helium to achieve superconductivity. This sensor technology has undergone significant generational improvement since whole head MEG scanners were introduced around in 1990s, but still has limitations. Further advances in sensor technology which may make ME G more easily accessible and affordable have been eagerly awaited, and development of new techniques should be encouraged. Of late, optically pumped magnetometers (OPMs) have received considerable attention, even prompting some potential acquisitions of new MEG systems to be put on hold, based on a hope that OPMs will usher in a new generation of MEG equipment and procedures. The development of any new clinical test used to guide intracranial EEG monitoring and/or surgical planning must address several specific issues. The goal of this commentary is to recognize the current state of OPM technology and to suggest a framework for it to advance in the clinical realm where it can eventually be deemed clinically valuable to physicians and patients. The American Clinical MEG Society (ACMEGS) strongly supports more advanced and less expensive technology and looks forward to continuing work with researchers to develop new sensors and clinical devices which will improve the experience and outcome for patients, and perhaps extend the role of MEG. However, currently, there are no OPM devices ready for practical clinical use. Based on the engineering obstacles and the clinical tradeoffs to be resolved, the assessment of experts suggests that there will most likely be another decade relying solely on "frozen SQUIDs" in the clinical MEG field.

Levetiracetam vs Lamotrigine as First-Line Antiseizure Medication in Female Patients With Idiopathic Generalized Epilepsy

After the recent limitations to prescribing valproate, many studies have highlighted the challenging management of female patients of reproductive age with idiopathic generalized epilepsy (IGE). However, no study, to the authors' knowledge, has addressed the comparative effectiveness of alternative antiseizure medications (ASMs) in these patients. To compare the effectiveness and safety of levetiracetam and lamotrigine as initial monotherapy in female patients of childbearing age with IGE. This was a multicenter, retrospective, comparative effectiveness cohort study analyzing data from patients followed up from 1994 to 2022. Patients were recruited from 22 primary, secondary, and tertiary adult and child epilepsy centers from 4 countries. Eligible patients were female individuals of childbearing age, diagnosed with IGE according to International League Against Epilepsy (2022) criteria and who initiated levetiracetam or lamotrigine as initial monotherapy. Patients were excluded due to insufficient follow-up after ASM prescription. Levetiracetam or lamotrigine as initial monotherapy. Inverse probability of treatment weighting (IPTW)-adjusted Cox proportional hazards regression was performed to compare treatment failure (TF) among patients who received levetiracetam or lamotrigine as initial monotherapy. A total of 543 patients were included in the study, with a median (IQR) age at ASM prescription of 17 (15-21) years and a median (IQR) follow-up of 60 (24-108) months. Of the study population, 312 patients (57.5%) were prescribed levetiracetam, and 231 (42.5%) were prescribed lamotrigine. An IPTW-adjusted Cox model showed that levetiracetam was associated with a reduced risk of treatment failure after adjustment for all baseline variables (IPTW-adjusted hazard ratio [HR], 0.77; 95% CI, 0.59-0.99; P = .04). However, after stratification according to different IGE syndromes, the higher effectiveness of levetiracetam was confirmed only in patients with juvenile myoclonic epilepsy (JME; IPTW-adjusted HR, 0.47; 95% CI, 0.32-0.68; P < .001), whereas no significant differences were found in other syndromes. Patients treated with levetiracetam experienced adverse effects more frequently compared with those treated with lamotrigine (88 of 312 [28.2%] vs 42 of 231 [18.1%]), whereas the 2 ASMs had similar retention rates during follow-up (IPTW-adjusted HR, 0.91; 95% CI, 0.65-1.23; P = .60). Results of this comparative effectiveness research study suggest the use of levetiracetam as initial alternative monotherapy in female patients with JME. Further studies are needed to identify the most effective ASM alternative in other IGE syndromes.

The impact of a newly established specialized pediatric epilepsy center in Tanzania: An observational study

PurposeThis study evaluated the impact of a newly established clinic for the diagnosis of pediatric epilepsy in a resource-limited center (Ifakara, Tanzania). MethodsPatients aged 0–18 years referred to the Pediatric Epilepsy Unit of Saint Francis Referral Hospital were recruited. Demographic and clinical data were collected through Kobo Toolbox and analyzed through a descriptive analysis.. Results143 patients were evaluated, and for 48 of them an EEG was recorded (abnormalities were detected in 80.85% of the cases). The diagnosis of epilepsy was confirmed in 87 patients. Focal epilepsy was diagnosed in 57 patients, generalized epilepsy in 24 patients, and forms of unknown onset in 6 patients. Epilepsy was excluded for 9 children. Etiologies included hypoxic-ischemic encephalopathy (39%), central nervous system infections (3.4%), and genetic diseases (3.4%). A specific epilepsy syndrome was diagnosed in 16 patients. 74 patients were under treatment; the most used antiseizure medication (ASM) was phenobarbital (43.36%), followed by carbamazepine (16.08%), sodium valproate (11.19%), phenytoin (2.8%), and lamotrigine (0.7%). Therapeutic changes were proposed to 95 patients, more frequently consisting of withdrawing phenobarbital (39.16%), switching to sodium valproate (27.97%), switching to or adjusting carbamazepine dosage (27.27%), and starting prednisone (2.8%). 76% of the patients with confirmed epilepsy achieved complete seizure freedom at the fourth follow-up consultation. ConclusionsOur data depicted the epilepsy spectrum and highlighted the prognostic implications of improving the availability of ASMs such as sodium valproate and second- and third-generation ones in resource-limited countries.

Diagnostic Value of Intermittent Photic Stimulation Among Adult Patients in a Tertiary Referral Epilepsy Center: A Retrospective Study.

Photosensitivity is a phenomenon that may be elicited by standardized intermittent photic stimulation during EEG recording and is detected more frequently in children and adolescents. Nevertheless, at our Epilepsy Center, we routinely assess photosensitivity in all newly referred adult patients. In this investigation, we sought to address the diagnostic yield under the prerequisites described. We reanalyzed all routine EEG recordings among referrals to the department of adults during the first six months of 2019, including a simultaneous video that is always coregistered in our center. The prevalence of abnormal findings during photic stimulation was assessed. Intermittent photic stimulation was performed on 344 patients. Photoparoxysmal response were detected in five subjects (1.5%). All patients were female. Four patients were diagnosed with idiopathic generalized epilepsy, and one with Doose syndrome. Photomyogenic responses were recorded in 1.1% and only in patients with psychogenic nonepileptic seizures. In two subjects with psychogenic nonepileptic seizures, the typical seizure was provoked by intermittent photic stimulation (8.7% of all subjects with psychogenic nonepileptic seizures in this cohort). Photoparoxysmal response was not detected in any subject with focal epilepsy, syncope, or other nonepileptic paroxysmal events. In every case of photoparoxysmal responses, increased photosensitivity had already been reported before recording. In our study, photoparoxysmal responses was a rare phenomenon among adults with a preponderance of females and idiopathic generalized epilepsies. Intermittent photic stimulation may be helpful in provoking typical psychogenic nonepileptic seizures and thus abbreviate the diagnostic process. Provided a careful history, routine intermittent photic stimulation in adults with epilepsy does not appear to be mandatory.

Frequency of SCN2A-related disorder in the regional epilepsy centre of brescia between 2002 and 2021

ObjectiveSCN2A gene pathogenic variants are associated with a wide phenotypic spectrum, encompassing epilepsy, developmental delay, and autism spectrum disorder. Researches conducted in Denmark have revealed a disease frequency of approximately 1/78,608 (0.0012%) live births in this population. We estimated the frequency of SCN2A-related disorder in the birth cohort of Brescia and its province between 2002 and 2021. MethodsFrequency was calculated by ratio between patients with SCN2A pathogenic variant and the total number of live births at the Regional Epilepsy Center of Brescia, between 2002 and 2021. The number of births in Brescia and province was obtained from the Italian National Institute of Statistics (ISTAT). ResultsA frequency of 11/23,2678 births (0.0047%) was found. In comparison with Danish data, we noticed a higher frequency of the pathogenic variant in our population, even considering the same time frame (0.0035% of subjects born between 2006 and 2014). ConclusionThe frequency of SCN2A pathogenic variant among live births in Brescia and its Province between 2006 and 2014 was about three times that of Danish population; this difference was about four times if we consider the period from 2002 to 2021. More studies are needed to further delineate the frequency of SCN2A pathogenic variant in Italian population.

Effect of vagus nerve stimulation against generalized seizure and status epilepticus recurrence.

Vagus nerve stimulation (VNS) is a palliative surgery for drug-resistant epilepsy. The two objectives of this study were to (1) determine the seizure type most responsive to VNS and (2) investigate the preventive effect on status epilepticus (SE) recurrence. We retrospectively reviewed 136 patients with drug-resistant epilepsy who underwent VNS implantation. We examined seizure outcomes at 6, 12, and 24 months following implantation of VNS as well as at the last visit to the Juntendo Epilepsy Center. Univariate analysis and multivariate logistic regression models were used to estimate the prognostic factors. 125 patients were followed up for at least 1 year after VNS implantation. The percentage of patients with at least a 50% reduction in seizure frequency compared with prior to VNS implantation increased over time at 6, 12, and 24 months after VNS implantation: 28, 41, and 52%, respectively. Regarding overall seizure outcomes, 70 (56%) patients responded to VNS. Of the 40 patients with a history of SE prior to VNS implantation, 27 (67%) showed no recurrence of SE. The duration of epilepsy, history of SE prior to VNS implantation and seizure type were correlated with seizure outcomes after VNS implantation in univariate analysis (p = 0.05, p < 0.01, and p = 0.03, respectively). In multivariate logistic regression analysis, generalized seizure was associated with VNS response [odds ratio (OR): 4.18, 95% CI: 1.13-15.5, p = 0.03]. A history of SE prior to VNS implantation was associated with VNS non-responders [(OR): 0.221, 95% CI: 0.097-0.503, p < 0.01]. The duration of epilepsy, focal to bilateral tonic-clonic seizure and epileptic spasms were not significantly associated with VNS responders (p = 0.07, p = 0.71, and p = 0.11, respectively). Following 125 patients with drug-resistant epilepsy for an average of 69 months, 56% showed at least 50% reduction in seizure frequency after VNS implantation. This study suggests that generalized seizure is the most responsive to VNS, and that VNS may reduce the risk of recurrence of SE. VNS was shown to be effective against generalized seizure and also may potentially influence the risk of further events of SE, two marker of disease treatment that can lead to improved quality of life.