Good Seizure Control Research Articles

Treatment-Related Costs of Childhood Epilepsy in Mainland China: A Preliminary Study in a Tertiary Pediatric Epilepsy Center.

This study aimed to investigate the treatment-related annual cost of childhood epilepsy and its related factors in mainland China. A total of 244 cases were collected at the outpatient clinics of Peking University First Hospital Pediatrics from April 2010 to August 2013. The median annual epilepsy treatment-related costs per patient were estimated to be RMB7822 (US$1160), accounting for 43.72% (median) of urban residents' disposable income in China. Those who lived far away or with uncontrolled seizures yielded much higher costs. This study concluded that the treatment of children with epilepsy produces a heavy burden on both families and society in mainland China. The constitution ratio of antiepileptic drugs and travel expenses are much higher than those of other countries. Adjusting medical insurance coverage, balancing medical resource distribution, and taking good control of seizures might be effective in reducing the economic burden of childhood epilepsy in China.

Health-related quality of life of children with seizure disorder in Uyo, Nigeria

Background: Seizure disorder is a common chronic neurologic condition in children. Children with seizure disorder have been reported to have a more compromised health-related quality of life compared with healthy children. No known study has been undertaken in our environment. Objectives: To assess the health-related quality of life of children with epilepsy and to compare it with that of apparently healthy children in Uyo, Nigeria. Methods: Child self-report and parent-proxy report questionnaires (Pediatrics Quality of Life inventory version 4.0) were administered to 60 children and their mothers. Thirty of the children had seizure disorders and 30 were apparently healthy children who were age, gender and social class matched with the subjects. Parental education and occupation were used to allot a social class to the children. Results: Of the 30 subjects/controls, 10 (33.3%) were males while 20 (66.7%) were females giving a male to female ratio of 1:2. Thirteen belonged to 8-12 years age group, 12 were 13-18 years old while 5 were 5-7 years of age. Majority (27) belonged to the upper and middle social classes and 3 belonged to the lower social class. Twenty children had good seizure control while 10 had one or more seizure episodes per month. Children with seizure disorder had mean total score and mean score in the subscales that was significantly lower than that of the controls. Good quality of life was associated with good seizure control. Conclusion: Children with seizure disorder had lower health related quality of life than apparently healthy children. There is therefore need to maintain good seizure control in children with seizure disorder as it has a positive impact on health-related quality of life of these children.

F02. Tachycardia-triggered vagus nerve autostimulation using the AspireSR 106 model in patients with refractory epilepsy: Treatment outcome between de novo implantation and replacement of old models

Vagus nerve stimulation (VNS) therapy with open-loop stimulation has been shown to effectively reduce the frequency or severity of seizures. Manual application of the magnet to trigger extrastimulation at the time of the perceived seizure onset may not be feasible in some patients. The automatic stimulation mode (AutoStim, closed-loop) feature of AspireSR 106 model, triggered by ictal tachycardia (IT), aims to terminate a seizure or to reduce severity. We presented a novel series to further refine the benefit of AutoStim. We retrospectively analyzed seizure frequency, severity, and clinical outcome in 24 adult patients with AspireSR 106 implanted between 8/2015 and 7/2017; 13 were replacements of old models, and 11 de novo implantation. Pre-implantation: all patients failed more than 2 antiepileptics, with more than 3 seizures each month. No severe post-implantation adverse events were reported. 13 patients (5 M/8F, median age 32, mean followup 13.6 months) underwent replacement of old models. Malfunctional VNS were found in 6 patients, only two patients reported less frequent seizures. Near end of service or low battery was reported in 7 patients, none reported changes in seizure frequency, but one patient noted reduced severity. 11 patients (4 M/7F, median age 40, mean followup 8.7 months) were de novo implantation. Prior to implantation, 9 patients were monitored in EMU, of whom 4 were found with IT (identified as 50% HR increases from pre-ictal baseline). IT detected by AspireSR 106 at seizure onset was confirmed by EEG monitoring in one patient post-implantation. While followup, time-stamp data were retrieved in 3 patients and showed 60–70% match rate between IT detection and the reported seizures. Average seizure reduction was 37 ± 11% in all 11 patients. Within this group, 8 patients (4 with IT) reported good seizure control, of whom 5 patients had over 50% reduction in frequency and notable decreases of severity, 3 patients reported dramatic decreases of severity with 13.9% reduction in frequency. One patient elected to turn off AutoStim for 2 months, increased aura frequency was noted during the AutoStim OFF period. The frequency was dramatically decreased after AutoStim was resumed. One patient elected not to turn on the AutoStim feature for 6 months after the implantation. The seizure frequency was reduced ∼40% during the open loop stimulation period. It produced a further 70% reduction in frequency and significantly decreased severity with AutoStim turned on. Our data have suggested that, with pre-implantation monitoring and identification of IT, the combined open- and closed-loop stimulation delivered by AspireSR 106 may exhibit greater efficacy in seizure control. The AutoStim has an acceptable specificity of triggering VNS at seizure onset. The discrepancy between the replacement and de novo group raises the question about best utilization, which should prompt larger studies to confirm the clinical efficacy of AutoStim in different groups.

Elevated Ictal Brain Network Ictogenicity Enables Prediction of Optimal Seizure Control.

Recent studies have shown that mathematical models can be used to analyze brain networks by quantifying how likely they are to generate seizures. In particular, we have introduced the quantity termed brain network ictogenicity (BNI), which was demonstrated to have the capability of differentiating between functional connectivity (FC) of healthy individuals and those with epilepsy. Furthermore, BNI has also been used to quantify and predict the outcome of epilepsy surgery based on FC extracted from pre-operative ictal intracranial electroencephalography (iEEG). This modeling framework is based on the assumption that the inferred FC provides an appropriate representation of an ictogenic network, i.e., a brain network responsible for the generation of seizures. However, FC networks have been shown to change their topology depending on the state of the brain. For example, topologies during seizure are different to those pre- and post-seizure. We therefore sought to understand how these changes affect BNI. We studied peri-ictal iEEG recordings from a cohort of 16 epilepsy patients who underwent surgery and found that, on average, ictal FC yield higher BNI relative to pre- and post-ictal FC. However, elevated ictal BNI was not observed in every individual, rather it was typically observed in those who had good post-operative seizure control. We therefore hypothesize that elevated ictal BNI is indicative of an ictogenic network being appropriately represented in the FC. We evidence this by demonstrating superior model predictions for post-operative seizure control in patients with elevated ictal BNI.

Knowledge of sudden unexpected death in epilepsy (SUDEP) among 372 patients attending a German tertiary epilepsy center

BackgroundThere is evidence that the sudden unexpected death in epilepsy (SUDEP) risk can be reduced by good seizure control, nocturnal supervision, and by early cardiopulmonary resuscitation if cardiorespiratory arrest occurs in the aftermaths of generalized tonic–clonic seizures (GTCS). These measures, however, may critically depend on the knowledge of patients and relatives on SUDEP. Here, we assessed the basic knowledge on SUDEP of people with epilepsy at a tertiary epilepsy center in Germany. MethodsAdult patients with epilepsy and relatives or caregivers of patients with epilepsy aged 16years or older attending our outpatient clinic from January to March 2014 were given the opportunity to participate in a (assisted or unassisted) written survey. In the anonymized questionnaire, people were asked if they had already heard about SUDEP, by what means and if they wish to learn (more) about SUDEP. Furthermore, age, sex, epilepsy duration, highest degree of education, number of GTCS during the last year, and estimation of subjective impairment by their disease were assessed. Statistics were done using mixed linear or logistic regression models. ResultsA total of 372 patients' questionnaires were included in this survey. More than 87% of the participants had never heard of SUDEP before. Whereas about 50% of the participants wanted to learn more about SUDEP, about 40% did not. Only the age at survey was significantly associated with both being informed and the desire of learning more about SUDEP: Younger patients had more often heard (p=0.022) and wanted to know more about SUDEP (p=0.020). Thirty-nine patients were considered at high risk for SUDEP. Of these, only 6 patients (15%) knew about SUDEP prior to this survey, but 18 patients (46%) wanted to learn more about this fatal complication. ConclusionOur data suggest that the level of information on SUDEP among people with epilepsy is poor in Germany regardless of sex, school education, or epilepsy severity. Additionally, a considerable proportion of people with epilepsy seems to prefer not getting detailed information on SUDEP. More efforts are required to understand the potential barriers of the education of patients and relatives on sudden death with the ultimate goal of decreasing the risk of SUDEP.

Levetiracetam use during pregnancy in women with epilepsy: Preliminary observations from a tertiary care center in Northern India.

INTRODUCTION:Data on efficacy and safety of levetiracetam (LEV) during pregnancy is still limited. We analyzed efficacy and safety of LEV during pregnancy in North Indian women with epilepsy (WWE) which is being presented here.PATIENTS AND METHODS:This retrospective study included 99 WWE (on treatment with a single antiepileptic drug [AED]) who were evaluated in medical-surgical disorder antenatal clinic of the department of obstetrics and gynecology at a tertiary care teaching hospital and referral center in North India. All the obstetric and fetal data as well as data pertaining to epilepsy were noted meticulously.RESULTS:In this study (n = 99), 35 women received carbamazepine, 28 received LEV, 15 received valproate (VPA), 13 received phenytoin (PHT), three each received oxcarbazepine and lamotrigine, respectively, and two received clobazam. Although the use of VPA was associated with significantly better control of seizures compared to LEV, its use was associated with higher risk of major congenital malformations (13.3%). The incidence of gestational hypertension was lower while incidence of fetal distress was significantly higher in WWE receiving PHT during pregnancy. None of the child born to pregnant women receiving LEV had any congenital malformation.CONCLUSION:LEV is a first-line AED during pregnancy. Future prospective studies using therapeutic drug monitoring during pregnancy may further help in establishing its role during pregnancy.

Interactive effects of seizure frequency and lateralization on intratemporal effective connectivity in temporal lobe epilepsy.

Patients with temporal lobe epilepsy (TLE) show brain connectivity changes in association with cognitive impairment. Seizure frequency and lateralization are 2 important clinical factors that characterize epileptic seizures. In this study, we sought to examine an interactive effect of the 2 seizure factors on intratemporal effective connectivity based on resting-state functional magnetic resonance imaging (rsfMRI) in patients with TLE. For rsfMRI data acquired from 48 TLE patients and 45 healthy controls, we applied stochastic dynamical causal modeling to infer effective connectivity between 3 medial temporal lobe (MTL) regions, including the hippocampus (Hipp), parahippocampal gyrus (PHG), and amygdala (Amyg), ipsilateral to the seizure focus. We searched for the effect of the 2 seizure factors, seizure frequency (good vs poor seizure control) and lateralization (left vs right TLE), on connection strengths and their relationship with the level of verbal memory and language impairment. Impairment of verbal memory and language function was mainly affected by seizure lateralization, consistent with preferential involvement of the left MTL in verbal mnemonic processing. For the fully connected model, which was selected as the effective connectivity structure that best explained the observed rsfMRI time series, alterations in connection strengths were primarily influenced by seizure frequency; there was an increase in the strength of the Hipp to PHG connection in TLE patients with poor seizure control, whereas the strength of the Amyg to PHG connection increased in those with good seizure control. Furthermore, the association between connection strength alterations and cognitive impairment was interactively affected by both seizure frequency and lateralization. These findings suggest an interactive effect as well as an individual effect of seizure frequency and lateralization on neuroimaging features and cognitive function. This potential interaction needs to be evaluated in the consideration of multiple seizure factors.

Pediatric Neurocysticercosis

Neurocysticercosis is the most common helminth infection of nervous system in humans caused by the encysted larvae of Taenia solium. It is a major cause of epilepsy in tropical areas and the most common cause of focal-onset seizures in North Indian children. Children with neurocysticercosis have pleomorphic manifestations depending on the location, number and viability of the cysts and host response. In endemic areas, neurocysticercosis should be clinically suspected in any child with recent-onset seizures, headache or focal motor deficits where there is no other suggestion of an underlying neurological disorder. Diagnosis of neurocysticercosis is essentially based on neuroimaging; visualization of a scolex is diagnostic. Management includes use of cysticidal drugs usually albendazole, which seems to be effective for lesion resolution and seizure remission, use of steroids and anti-epileptic drugs. Single lesions portend good prognosis with resolution of lesions in >60% of the cases within 6 mo and good seizure control. Prognosis is guarded in cysticercus encephalitis, racemose and extraparenchymal neurocysticercosis.

23 Long-term follow-up in transient epileptic amnesia: prognosis over 10–20 years

Objective Transient Epileptic Amnesia (TEA) is a form of adult onset temporal lobe epilepsy characterised by ictal amnesia, which is often accompanied by interictally memory disturbances of autobiographical amnesia and accelerated long-term forgetting. Short-term follow-up studies conducted 1–2 years after commencing anticonvulsant therapy, suggest good seizure control, together with a relatively stable cognitive profile. Recent case reports, however, have raised concerns regarding a risk of developing Alzheimer’s Disease (AD). This paper reports on the clinical and cognitive outcome of TEA patients over a 10 to 20 year period. Method Two cohorts of TEA participants were studied at 10 year intervals: an initial cohort of 10 patients (C1), followed up at 10 and 20 years; and an additional 42 patients (C2), followed up at 10 years only. Information regarding clinical outcomes (mortality, seizure history and subjective reports of memory functioning) was gained via GP records and clinical interview. Objective memory function was determined at each time point via a comprehensive neuropsychological assessment, where possible. Results were compared with age-matched healthy control participants. Results Information was available for 9 patients from C1 (90%), and 37 (88%) from C2. In C1, 4 participants (40%) had died over the 20 year period, with no indication of dementia prior to death (mean age at death =82 years). One participant was diagnosed with Vascular Dementia. In C2, 15 participants (40%) had died, including one patient with AD (mean age of death =81 years). Dementia was diagnosed in a further 5 patients (3 with AD). Seizures were generally well controlled in both cohorts. Subjective memory complaints were significantly greater in TEA patients than matched controls, although reports varied in both C1 and C2, ranging from no concerns through to either stable memory difficulties, or worsening memory. Neuropsychological assessment showed no evidence of a general cognitive decline at either the 10- or the20-year follow up, with TEA participants performed similarly to healthy controls on the majority of standard neuropsychological tests. Within the memory domain, both TEA cohorts included patients with stable memory performance over time relative to healthy controls, as well as those showing impairments on one or more memory measures. Additional impairments in other cognitive domains (typically executive function) were observed in some patients. Conclusion Despite concerns raised regarding dementia, the prognosis of TEA appears relatively benign. While persistent memory difficulties are a common outcome, the prevalence of dementia in TEA does not exceed population prevalence data.

Breastfeeding initiation, duration and exclusivity in mothers with epilepsy from South West China

Purposes1) To study the breastfeeding initiation, duration and exclusivity rates, and common reasons for early weaning in Chinese mothers with epilepsy (MWE); 2) To identify potential perinatal breastfeeding correlations with selected sociodemographic and clinical factors. MethodsA semi-structured questionnaire was administered to 281 MWE attending hospitals in South-west China from February 2014 to July 2015. Data about breastfeeding behaviors, sociodemographic, obstetric, and epileptic variables were collected. Descriptive analyses, followed by univariate and multivariate logistic regression analyses, were utilized to examine associations with breastfeeding, its duration and exclusivity. ResultsBreastfeeding initiation rate in MWE was 59.4%. At 3 months post partum total breastfeeding rate was 49.5% and exclusive breastfeeding rate was 36.3%. At 6 months, about one third (33.1%) of MWE had continued breastfeeding their babies and 12.8% of enrolled infants were exclusively breastfed. During lactation, fear of exposure of the babies to antiepileptic drugs (AEDs) via breast milk, frequent seizures, and insufficient breast milk supply were the commonest reasons for early cessation of breastfeeding. Mothers with epilepsy who had babies delivered at full term were more inclined to breastfeed their babies. Mothers who had gestational non-active epilepsy were more likely to engage in long-term breastfeeding. AED polytherapy was associated with poor breastfeeding behaviors in all aspects. ConclusionMWE in our study had a lower prevalence of breastfeeding than what would be expected in the general population, where approximately 95% breastfeed. Good seizure control and optimal antiepileptic therapy during gestation and lactation were associated with a higher rate of breastfeeding. Targeted intervention programs enhancing antenatal care services and breastfeeding consultation are needed.

Younger age at surgery and lesser seizure frequency as prognostic factors for favorable seizure-related outcome after glioma resection in adults.

The identification of variables predictive of good seizure control following surgical tumor resection in adult glioma patients with tumor-related epilepsy would greatly benefit treatment decisions. Therefore, we analyzed the clinical data of adult patients with tumor-related epilepsy who underwent tumor resection at our institute between November 2011 and August 2013. Patients were divided into seizure-free (Engel Ia) and unfavorable outcome groups (Engel Ib–IV), and potential prognostic factors were analyzed. Of 90 patients, 61 (68%) had a favorable outcome at an average of 3 years after surgery. Our analyses indicated that younger age at surgery (P=0.048) and rare seizure frequency (P=0.006) were associated with significantly more favorable postoperative seizure-related outcomes. In conclusion, younger age at surgery and lesser seizure frequency were independent predictors of favorable epileptic seizure control after glioma resection in adults. Thus, early surgical resection is necessary for achieving favorable seizure outcome.

Perisylvian, including insular, childhood epilepsy: Presurgical workup and surgical outcome.

To report the presurgical workup, surgical procedures, and outcomes in a series of pediatric patients with drug-resistant epilepsy involving the perisylvian/insular regions. We retrospectively assessed 16 pediatric patients affected by drug-resistant focal epilepsy involving perisylvian/insular regions, who consecutively underwent tailored resective surgery. All patients underwent a detailed presurgical workup, which included the analysis of the anatomoelectroclinical correlations with scalp electroencephalography (EEG) and/or with stereo-electroencephalography (SEEG), brain magnetic resonance imaging (MRI), and comprehensive cognitive and neuropsychological evaluations. After surgery, all patients underwent serial clinical and laboratory evaluations. Focal motor seizures restricted to perioral area, associated with symptoms related to the surrounding areas (as auditory hallucinations, unpleasant paresthesia, fear, and epigastric sensation), characterized the ictal semiology in 75% of patients. In 50%, autonomic manifestations were present and in 56% subjective manifestations were reported. The 50% of the patients underwent SEEG with insular sampling to better define the epileptogenic zone. In all patients, the insular cortex was always part of the epileptogenic zone, and tailored resections also involved, with variable degree, the frontal, parietal, and temporal opercula. Preoperatively, the neuropsychological assessment revealed impairments in specific cognitive functions and mild or moderate cognitive compromise in 88% of the patients. Postoperatively, one patient had permanent slight hemiparesis. At the most recent follow-up (median 39 months), seizure outcome was satisfactory in 69% of patients: seven patients were completely seizure-free (Engel class Ia), two were free of disabling seizure (class Ic), and two had rare disabling seizures (class II). The cognitive functioning remained unchanged in 62%, and improved in 38%. The assessment of perisylvian/insular epilepsy in children is particularly challenging. However, tailored resections based on a careful presurgical evaluation, including SEEG recording, may lead to a good seizure control and to a better overall outcome.

Cavernous malformations of central nervous system in pediatric patients: our single-centered experience in 50 patients and review of literature.

Cavernous malformations (CMs) are rare developmental cerebrovascular malformations of the central nervous system with a childhood prevalence of 0.3 to 0.53%. Our purpose was to assess the clinical features and microsurgical outcome in pediatric central nervous system (CNS) CMs. We retrospectively enrolled all the CM patients admitted to our institute from 1 January 2001 to 31 December 2014. Data was analyzed for their clinical features and surgical outcome. A total of 50 patients with CMs (30 supratentorial, 14 infratentorial, and 6 spinal) with a mean age of 14years (3-18years, SD ±4.64) were enrolled into the study. Most of these patients (78%) were male. Size varied from 1.2 to 6cm. Three patients had multiple CMs. Symptoms of CMs were site specific. Seizure was the most common symptom (63.3%) of CMs at supratentorial location followed by headache (46%) and neurodeficiency (26%), while all brainstem and spinal CMs presented with neurodeficiencies. History of clinically significant acute hemorrhage was present in 19.2% of supratentorial (ST) superficial CMs, 50% of ST deep CMs, 25% of cerebellar CMs, 44.4% of brainstem CMs, and 50% of spinal CMs. Forty-five CMs in 44 patients were surgically excised. Their follow-up ranged from 6 to 162months (mean 47.2months, SD ±53). All supratentorial CM patients showed improvement in their symptoms. Patients with preoperative seizure showed good seizure control with Engel scale I in 16 (94.1%) and Engel scale II in 1 (5.9%). In infratentorial (IT) and spinal CM patients, 92.3 and 66.7% had improvement in their neurodeficiencies, respectively. There was no mortality in our series. Microsurgical excision of CNS CM results in excellent neurological outcome in pediatric patients. Early intervention is necessary in spinal CMs for better outcome.

Precuneal epilepsy: Clinical features and surgical outcome.

The precuneus is a complex and highly connected structure located in the medial portion of the superior parietal lobule. The clinical presentation of precuneal epilepsy is poorly characterized, mostly because these patients have seldom been distinguished from those with other types of parietal lobe epilepsy. The present study aims to improve the understanding of precuneal epilepsy by detailing its clinical features and surgical outcomes. Six previously unreported cases of drug-resistant precuneal epilepsy investigated between 2002 and 2014 were retrospectively studied. Seizure focus was confirmed by presence of a lesion, intracranial monitoring, or post-operative seizure control when applicable. Seizures arising from the precuneus have heterogeneous presentations, including body movement sensation, visual auras, eye movements, vestibular manifestations, and complex motor behaviors. Two patients with an anterior precuneus lesion described body movement sensations whereas two others with a posterior precuneus lesion experienced visual symptoms. Two of the five patients who underwent epilepsy surgery achieved good seizure control (Engel IA). One patient underwent gamma knife surgery with an Engel IV outcome. Surgical complications included contralateral visual field impairment, limb hypoesthesia and hemispatial neglect. One patient developed late-onset epilepsia partialis continua from a Rolandic subdural grid-related contusion. In absence of a clear precuneal epileptogenic lesion, recognition of a precuneal focus is challenging. Magnetoencephalography may sometimes localize the generator but invasive EEG remains in well-selected cases necessary to identify the seizure focus. Surgical failures may be explained by the widespread connectivity of the precuneus with distant and adjacent structures. Different ictal manifestations of precuneal epilepsy in this series provide a clinical correlate to the described functional subdivisions of the precuneus.

MELAS presenting as occipital lobe epilepsy: Not all occipital epilepsies are benign

We report an 11-year-old boy with normal development who initially presented with visual disturbances (perceiving flashes of light), photosensitivity and eye flickering. An electroencephalogram (EEG) showed occipital spike wave discharges and was treated with levetiracetam. He further developed myoclonic twitches and was investigated. Metabolic screen was negative including a normal brain MRI and normal serum lactate. The patient gained good seizure control with levetiracetam. He later presented with a gradual-onset occipital headache and further visual disturbances. He was found to have a right quadrantinopia and magnetic resonance imaging (MRI) of the brain showed a subacute ischaemia in the left occipital region. Childhood stroke screen was done and no particular cause was found. Serum lactate was again within the normal limits. At 15 years, he presented with an increasing seizure frequency. He developed a visual loss, with headaches, unsteadiness of his gait, slurred speech and fluctuating confusion. Computed tomography of the head showed a combination of anterior and posterior circulation stroke, with involvement of both the right and left posterior cerebral artery. MRI and magnetic resonance angiography showed similar findings. A lumbar puncture revealed high lactate levels in the cerebrospinal fluid. Mutation studies confirmed a diagnosis of MELAS with the A3243G mutation. Many consider occipital epilepsy in the paediatric patient as benign. Upon review of the literature, patients with MELAS have presented with adult-onset occipital seizures. We have identified only two patients, in America and Japan respectively, with MELAS presenting in childhood with occipital lobe epilepsy. However, these patients both presented with status epilepticus, with secondary generalisation. This is the first case to our knowledge of MELAS presenting with recurrent occipital seizures in a paediatric patient without the progression to status epilepticus. This highlights the need to consider MELAS early in childhood occipital epilepsy.

Analysis of Sturge–Weber syndrome: A retrospective study of multiple associated variables

IntroductionSturge–Weber syndrome is a congenital vascular disorder characterised by facial capillary malformation (port-wine stain) associated with venous and capillary malformations in the brain and eye. Neurological symptoms and alterations in other locations may also be observed. ObjectivesThis study describes the clinical and epidemiological characteristics and different treatments in a cohort of patients diagnosed with Sturge–Weber syndrome in a tertiary hospital. Material and methodsThis comparative, retrospective and cross-sectional study was conducted by reviewing the medical records of patients diagnosed with Sturge–Weber syndrome between 1998 and 2013. ResultsThe study included 13 patients (54% male, 46% female) diagnosed with Sturge–Weber syndrome. The mean age at diagnosis was 15 months. Leptomeningeal angiomatosis was present in 100% of cases: right hemisphere (46%), left hemisphere (38%), and bilateral (15%). Facial angioma was present in 61% of the cases: right (23%), left (38%) and bilateral (7%). Other skin disorders were found in 23% of the cases, including 2 with hemilateral involvement on the side where facial and leptomeningeal angiomatosis was present and one case of generalised cutis marmorata. Ocular disease was found in 77% of patients; the most common conditions were glaucoma (46%), strabismus (23%) and choroidal angioma (23%). Epilepsy was present in 100% of the cases, with partial seizures (simple or complex) being the most frequent (62%). Seizure control was highly variable; 31% of the patients had needed to try more than 3 drugs, 15% 3 drugs, and 31% 2 drugs, while 23% experienced good seizure control with monotherapy. One patient required surgery for epilepsy (left hemispherectomy) and has been seizure-free since then. The most frequent observations in electroencephalograms were spikes, polyspikes, and wave spikes in the lobes affected by leptomeningeal angiomatosis (46%). Other neurological symptoms were hemiparesis (39%), recurrent headaches (39%), stroke-like episodes (23%), psychomotor retardation (46%), and mental retardation (46%). Leptomeningeal calcifications could be seen in 85% of patient MRIs, as well as increased calcification in 70%; 54% of the patients had been treated with aspirin. ConclusionsThere are multiple clinical manifestations of Sturge–Weber syndrome. Being familiar with all of them is vitally important for diagnosing and for monitoring and treating the condition correctly, which will improve the quality of life of these patients.

Risk Factors for Preoperative Seizures and Loss of Seizure Control in Patients Undergoing Surgery for Metastatic Brain Tumors.

Metastatic brain tumors are the most common brain tumors in adults. Patients with metastatic brain tumors have poor prognoses with median survival of 6-12 months. Seizures are a major presenting symptom and cause of morbidity and mortality. In this article, risk factors for the onset of preoperative seizures and postoperative seizure control are examined. Adult patients who underwent resection of one or more brain metastases at a single institution between 1998 and 2011 were reviewed retrospectively. Of 565 patients, 114 (20.2%) patients presented with seizures. Factors independently associated with preoperative seizures were preoperative headaches (P=0.044), cognitive deficits (P= 0.031), more than 2 intracranial metastatic tumors (P= 0.013), temporal lobe location (P= 0.031), occipital lobe location (P= 0.010), and bone involvement by tumor (P= 0.029). Factors independently associated with loss of seizure control after surgical resection were preoperative seizures (P= 0.001), temporal lobe location (P= 0.037), lack of postoperative chemotherapy (P= 0.010), subtotal resection of tumor (P= 0.022), and local recurrence (P= 0.027). At last follow-up, the majority of patients (93.8%) were seizure-free. Thirty patients (5.30%) in total had loss of seizure control, and only 8 patients (1.41%) who did not have preoperative seizures presented with new-onset seizures after surgical resection of their metastases. The brain is a common site for metastases from numerous primary cancers, such as breast and lung. The identification of factors associated with onset of preoperative seizures as well as seizure control postoperatively could aid management strategies for patients with metastatic brain tumors. Patients with preoperative seizures who underwent resection tended to have good seizure control after surgery.

Mapping seizure foci and tumor genetic factors in glioma associated seizure patients.

Epilepsy, which is the most common symptom accompanying gliomas, was reported as an independent favorable prognosis factor for glioma patients. However, the correlation between glioma location and epilepsy prognosis, genesis and genetic phenotypes of the glioma associated seizure (GAS) patients is far from clear, the purpose of the current study was to provide probabilistic radiographic atlases reflecting seizure susceptible regions, relationship between tumor associated biomarkers and seizure initiation and poor epilepsy prognosis areas. Preoperative MRIs were collected from 119 newly diagnosed patients with histologically confirmed gliomas. These samples were analyzed for seizure status and tumor genetic makers (TP53 mutations, MMP-9.PTEN, MGMT, EGFR and IDH1) using a statistical voxel-based lesion-symptom mapping (VLSM) method. We found bilaterally that the frontal lobe containing regions were associated with GAS for low grades gliomas, moreover lesions with the PTEN mutation and IDH1 mutation and seizure susceptible regions were located close together and partially overlapped, Patients with preoperative tumor involving the right frontal lobe may have good seizure control; however, for the glioma-infiltrated regions in front of the precentral regions in the left hemisphere, the epilepsy prognosis is poor. The current results of seizure associated molecules and specific regions on structural MRI could be used in preoperative surgical planning, seizure prognosis predictions and anti-epilepsy drug usage.

Seizure Control and Memory Impairment Are Related to Disrupted Brain Functional Integration in Temporal Lobe Epilepsy.

Brain functional integration can be disrupted in patients with temporal lobe epilepsy (TLE), but the clinical relevance of this disruption is not completely understood. The authors hypothesized that disrupted functional integration over brain regions remote from, as well as adjacent to, the seizure focus could be related to clinical severity in terms of seizure control and memory impairment. Using resting-state functional MRI data acquired from 48 TLE patients and 45 healthy controls, the authors mapped functional brain networks and assessed changes in a network parameter of brain functional integration, efficiency, to examine the distribution of disrupted functional integration within and between brain regions. The authors assessed whether the extent of altered efficiency was influenced by seizure control status and whether the degree of altered efficiency was associated with the severity of memory impairment. Alterations in the efficiency were observed primarily near the subcortical region ipsilateral to the seizure focus in TLE patients. The extent of regional involvement was greater in patients with poor seizure control: it reached the frontal, temporal, occipital, and insular cortices in TLE patients with poor seizure control, whereas it was limited to the limbic and parietal cortices in TLE patients with good seizure control. Furthermore, TLE patients with poor seizure control experienced more severe memory impairment, and this was associated with lower efficiency in the brain regions with altered efficiency. These findings indicate that the distribution of disrupted brain functional integration is clinically relevant, as it is associated with seizure control status and comorbid memory impairment.

Health service provision for people with epilepsy in sub-Saharan Africa: A situational review.

Epilepsy is a public health issue in sub-Saharan Africa (SSA) where many people with the condition receive no treatment. Health-care services for epilepsy in this region have not been comprehensively assessed. We examined key features of epilepsy health services provided in SSA. This was a scoping review conducted using pre-specified protocols. We implemented an electronic search strategy to identify relevant citations using PUBMED, EMBASE, Web of Science, Scopus, Cumulative Index to Nursing and Allied Health Literature (CINAHL), African Index Medicus (AIM), Open Grey, Cochrane database, and Google Scholar. Articles eligible for full-text review were screened and data of interest were reported. The search identified 81 eligible articles, forty-nine from East Africa, 19 from West Africa, 8 from South Africa, and 5 from Central Africa. A variety of care services were identified, with reporting of rural epilepsy care in 75% of retrieved articles mainly from East and South African countries. The majority of the rural epilepsy clinics were health worker- or nurse-led, reporting good seizure control in about two-thirds of patients using phenobarbital as the most commonly prescribed antiepileptic drug. Funding for rural epilepsy care came mainly from external donor agencies. We attempted to provide a 'snapshot' of epilepsy care services in SSA. The successes achieved in some of the centers are due to the use of existing primary health-care systems and employing non-physician health-care personnel. The true picture of epilepsy care coverage is not apparent due to the lack of data and proper health system structure in most parts of SSA. As more individuals begin to receive care, the long-term funding for epilepsy care in African countries will depend on the commitment of their respective governments.