Improvement In Seizure Frequency Research Articles

Epilepsy in patients with pineal gland cyst

ObjectiveThe aim of the study is to describe types of epileptic seizures in patients with pineal gland cyst (PGC) and their outcome during follow up period (6–10 years). We wanted to determine whether patients with epilepsy differ in PGC volume and compression of the PGC on surrounding brain structures compared to patients with PGC, without epilepsy. Patients and methodsWe analyzed prospectivelly 92 patients with PGC detected on magnetic resonance (MR) of the brain due to various neurological symptoms during the period 2006–2010. Data on described compression of the PGC on surrounding brain structures and size of the PGC were collected. Results29 patients (16 women, 13 men), mean age 21.17 years had epilepsy and PGC (epilepsy group). 63 patients (44 women, 19 men), mean age 26.97 years had PGC without epilepsy (control group). Complex partial seizures were present in 8 patients, complex partial seizures with secondary generalization in 8 patients, generalized tonic clonic seizures (GTCS) in 10 and absance seizures in 3 patients. Mean PGC volume in epilepsy group was 855.93 mm3, in control group 651.59 mm3. There was no statistically significant difference between epilepsy and control group in PGC volume. Compression of PGC on surrounding brain structures was found in 3/29 patients (10.34%) in epilepsy group and in 11/63 patients (17.46%) in control group with no statistically significant difference between epilepsy and control group. All patients with epilepsy were put on antiepileptic therapy (AET). During the follow up period, 23 patients (79.31%) were seizure free, 3 patients (13.04%) had reduction in seizure frequency, whereas 3 patients had no improvement in seizure frequency. Two patients from epilepsy group and 3 patients from control group were operated with histologically confirmed diagnosis of PGC in 4, and pinealocytoma in 1 patient. ConclusionsIn patients with PGC, epileptic seizures were classified as: complex partial seizures (with or without secondary generalization), GTCS and absance seizures. All patients were put on AET. During follow up period 79.31% patients were seizure free. There was no difference in PGC volume, nor in described compression of the PGC on surrounding brain structures between epilepsy and control group. Based on our findings, pathomechanism of epileptic seizures in patients with PGC cannot be attributable solely to PGC volume or described compression on surrounding brain structures based on MRI findings.

Refractory Epilepsy: The Role of Positron Emission Tomography.

Presurgical localization of the epileptogenic focus is critical to successful surgery. Traditionally, localization of the epileptogenic focus depends on seizure semiology, scalp video-electroencephalography (vEEG), magnetic resonance imaging (MRI), neuropsychological assessment, and, when needed, intracranial EEG (iEEG). We aimed to explore the role of positron emission tomography (PET) in the presurgical evaluation of patients with refractory epilepsy. A retrospective review was conducted on patients from London Health Sciences Centre (London, Ontario) with refractory epilepsy who underwent PET from September of 2011 to April of 2016. The accuracy of epileptogenic focus localization was compared between different investigative modalities (MRI, vEEG, iEEG, PET), and the outcomes were documented, including seizure freedom after surgical resection, improvement of seizure frequency, guidance for further investigations, and exclusion of patients from further evaluation. Patients who underwent surgery were followed up at 3 months and onward. We identified 62 patients with refractory epilepsy who underwent PET. The mean age was 34 years (range=20-68). A total of 36 had concordant PET and vEEG findings: 6 had surgical resection and either became seizure-free (29.4%) or had improvement in seizure frequency (5.9%) at 3 months; 11 had surgical resection and either became seizure-free (29.4%) or had improvement in seizure frequency (35.3%) at 3 months, but required iEEG for final verification. PET has an important role in presurgical evaluation of patients with refractory epilepsy. It may allow resection of the epileptogenic focus without the need for iEEG, guiding intracranial electrode placement for further localization of the epileptogenic focus, or exclusion of patients from further evaluation.

The use of cannabidiol for seizure management in patients with brain tumor-related epilepsy

ABSTRACTEpilepsy, commonly encountered by patients with brain tumors, is often refractory to standard therapies. Our aim was to examine the safety and efficacy of pharmaceutical grade cannabidiol (CBD; Epidiolex; Greenwich Biosciences) in those patients with epilepsy with concomitant tumors enrolled in The University of Alabama at Birmingham CBD Program (NCT02700412 and NCT02695537). Of the three patients with refractory seizures and a history of a primary brain tumor, two had improvement in seizure frequency and all three had improvement in seizure severity. These pilot results suggest that CBD should be further studied for the treatment of brain tumor-related epilepsy.

A review of people who did not attend an epilepsy clinic and their clinical outcomes

PurposeTo review the clinical outcomes of people who failed to attend or failed subsequent follow up in a Primary Care based specialist epilepsy service. MethodThe case notes of 200 people who had failed to initially attend the service or subsequent follow up from 2005 to 2013 were reviewed. ResultsClinical outcomes were determined for 152 people, with the remaining 48 having left the area. For those not attending at all, 64% had no further recorded events, a further 22% came under alternative specialist care and were managed appropriately, 6% were already in remission at the time of referral or at follow up and stayed seizure free. For people attending, but were subsequently lost to follow up, 78% were in remission, had improved seizure frequency, and normal pregnancies. In total 6% of those with poor control came under subsequent Neurological care. ConclusionThis study suggests that for the majority of people who fail to attend or are lost to follow up in a primary care specialist epilepsy clinic, the primary reasons appear to be that they had no further events, improved seizure control or that seizure remission has been achieved. The majority with persistent poor control came under Neurological care.

Cognition in epilepsy patients with hypothalamic hamartomas

Many patients with epilepsy caused by hypothalamic hamartomas (HHs) have cognitive impairments during the course of the disease or following neurosurgical treatment. The purpose of this study was to assess cognitive function in these patients, as well as factors influencing preoperative cognitive performance and cognitive outcome after neurosurgical treatment. Using the two largest and most detailed neuropsychology datasets on HH and epilepsy from two centers, we retrospectively report on cognitive functions in 48 patients with structural epilepsy due to HH (mean age ± standard deviation [SD] 20±12 years, range 5-53 years, median 16years; disease duration mean 17±11years). Intelligence, verbal learning and recall, and speed and executive functions (processing speed and cognitive flexibility) were assessed before and on average 19 (±11) months after surgery (interstitial radiosurgery: N=22; neurosurgical resection/disconnection: N=26). Prior to neurosurgical treatment, 52% of patients showed impaired executive and 62% showed reduced verbal memory functions. A trend for a detrimental effect of higher drug load on cognitive functioning was found. After neurosurgical treatment, intellectual functions for the entire cohort tended to increase. This correlated with improved seizure frequency and decreased number of antiepileptic drugs (AEDs). However, postoperative outcomes for individual patients were highly variable, with significant deteriorations in 17% (processing speed) to 34% (cognitive flexibility and verbal learning), and performance increases in 17% (intellectual functioning) up to 39% (processing speed) of the patients. Higher levels of presurgical performance were significant predictors of cognitive decline after surgery. These results are highly relevant for patient consultation and may help with therapeutic decisions.

Role of P-glycoprotein inhibitors in children with drug-resistant epilepsy

The role of P-glycoprotein (Pgp), one of the known multidrug transporters, has been suggested in drug-resistant epilepsy (DRE). The following study aimed to measure the serum level of Pgp as a possible indicator of tissue Pgp overexpression in patients with DRE and to assess the efficacy of verapamil (as a Pgp inhibitor agent) in these patients. A group of 24 patients with DRE were recruited and subdivided into two groups, one receiving verapamil and the other receiving a placebo in a double-blind randomized study. Pgp serum levels were measured at enrollment and 12 months later. Twenty medically controlled epileptic patients served as a control group. A significant statistical increase was found in the Pgp level of patients when compared the control group. Patients on both verapamil and the placebo showed improvement in seizure frequency and severity where statistical analysis showed no significant differences. Pgp serum levels in patients with DRE were significantly elevated compared to patients with medically controlled epilepsy. The effect of verapamil as Pgp inhibitor on DRE requires further evaluation and research.

Epilepsy in patients with GRIN2A alterations: Genetics, neurodevelopment, epileptic phenotype and response to anticonvulsive drugs.

To delineate the genetic, neurodevelopmental and epileptic spectrum associated with GRIN2A alterations with emphasis on epilepsy treatment. Retrospective study of 19 patients (7 females; age: 1-38 years; mean 10.1 years) with epilepsy and GRIN2A alteration. Genetic variants were classified according to the guidelines and recommendations of the American College of Medical Genetics (ACMG). Clinical findings including epilepsy classification, treatment, EEG findings, early childhood development and neurodevelopmental outcome were collected with an electronic questionnaire. 7 out of 19 patients fulfilled the ACMG-criteria of carrying "pathogenic" or "likely pathogenic variants", in twelve patients the alterations were classified as variants of unknown significance. The spectrum of pathogenic/likely pathogenic mutations was as follows: nonsense n=3, missense n=2, duplications/deletions n=1 and splice site n=1. First seizures occurred at a mean age of 2.4 years with heterogeneous seizure types. Patients were treated with a mean of 5.6 AED. 4/5 patients with VPA had an improved seizure frequency (n=3 with a truncation: n=1 missense). 3/5 patients with STM reported an improvement of seizures (n=2 truncation, n=1 splicing). 3/5 CLB patients showed an improvement (n=2: truncation; n=1 splicing). Steroids were reported to have a positive effect on seizure frequency in 3/5 patients (n=1 each truncation, splicing or deletion). Our data indicate that children with epilepsy due to pathogenic GRIN2A mutations present with different clinical phenotypes and a spectrum of seizure types in the context of a pharmacoresistant epilepsy providing information for clinicians treating children with this form of genetically determined epileptic syndrome.

Phenobarbital administration every eight hours: improvement of seizure management in idiopathic epileptic dogs with decreased phenobarbital elimination half-life

Estimated prevalence of canine idiopathic epilepsy is 0.6 per cent in the first-opinion canine population in the UK. Phenobarbital monotherapy has been reported to reduce/eradicate seizure activity in 60–93 per...

Biofeedback as complementary treatment in patients with epilepsy – an underestimated therapeutic option? Review, results, discussion

SummaryBackground.Biofeedback methods represent side effect free complementary options in the treatment of epilepsy. In this paper we review the current status of these methods in terms of clinical study results and their evaluation by systematic review papers. Possible mechanisms of action in biofeedback methods are discussed.Aim.To present the current status of biofeedback methods applied to patients with epilepsy.Material and Methods.With a literature search up to 10/2016 we screened publications containing the search terms “biofeedback”, “neurofeedback” or “neurotherapy” and “epilepsy” or “seizure” for intervention and population search terms respectively.Results.Four different techniques of biofeedback were used to improve seizure frequency in patients with epilepsy. Three of these techniques, measuring EEG (slow cortical potentials and sensory motor rhythm) or electrodermal activity (galvanic skin response, GSR) seem to be promising methods for successful seizure control. Nevertheless, methodological standards in the conducted trials were too low for assured empirical evidence in their efficacy.Conclusions.Biofeedback methods could be applied to patients to a greater extent. Probably due to the missing empirical evidence of efficacy and the high demand on patients’ and therapists’ time and commitment and therefore low cost effectiveness, these methods are hardly offered. Especially the relatively new approach of GSR biofeedback represents a promising option here.

Intracranial stimulation for children with epilepsy.

To evaluate the efficacy of intracranial stimulation to treat refractory epilepsy in children. This is a retrospective analysis of a pilot study on all 8 children who had intracranial electrical stimulation for the investigation and treatment of refractory epilepsy at King's College Hospital between 2014 and 2015. Five children (one with temporal lobe epilepsy and four with frontal lobe epilepsy) had subacute cortical stimulation (SCS) for a period of 20-161h during intracranial video-telemetry. Efficacy of stimulation was evaluated by counting interictal discharges and seizures. Two children had thalamic deep brain stimulation (DBS) of the centromedian nucleus (one with idiopathic generalized epilepsy, one with presumed symptomatic generalized epilepsy), and one child on the anterior nucleus (right fronto-temporal epilepsy). The incidence of interictal discharges was evaluated visually and quantified automatically. Among the three children with DBS, two had >60% improvement in seizure frequency and severity and one had no improvement. Among the five children with SCS, four showed improvement in seizure frequency (>50%) and one chid did not show improvement. Procedures were well tolerated by children. Cortical and thalamic stimulation appear to be effective and well tolerated in children with refractory epilepsy. SCS can be used to identify the focus and predict the effects of resective surgery or chronic cortical stimulation. Further larger studies are necessary.

Efficacy of Epileptological Consultation After Initially Unsuccessful Antiepileptic Medication

At least 25 % of patients with epilepsy do not achieve seizure freedom with their first antiepileptic medication. The aim of this study is to make a contribution to discussions on the efficacy of further antiepileptic medications in achieving seizure freedom for at least one year or reduction of seizure frequency of more than 50 % for more than one year. All patients who presented between January 1, 2009 and July 1, 2013 to the epileptological outpatient consulting service of the University of Rostock with at least one seizure in the previous year despite taking at least one antiepileptic medication were evaluated. Outcome was assessed according to the data available on July 1, 2014. 70 patients (35 f/35 m) aged 43.6 years on average (SD 16.7) with active epilepsy, who had taken 3.7 antiepileptic drugs on average (SD 2.8) before the first presentation to our service, were counseled on further antiepileptic treatment options. On average, 1.96 (SD 1.8) antiepileptic drugs were introduced in the therapy. At the last visit to our service, 15.7 % of the patients were seizure free for more than one year and 45,6 % of the patients had a reduction of seizure frequency of at least more than 50 %. With specialized epileptological counseling, substantial improvement in seizure frequency can be achieved in about 60 % of patients with epilepsy after failure of the initial antiepileptic drug.

Clinical Outcome of Patients with Deep Brain Stimulation of the Centromedian Thalamic Nucleus for Refractory Epilepsy and Location of the Active Contacts

Objectives: To investigate the clinical outcome of patients treated with chronic deep brain stimulation (DBS) of the centromedian nucleus (CM) for refractory epilepsy and to determine the location of active contacts. Methods: The outcome of CM stimulation was evaluated as percent seizure reduction compared to the baseline 3 months. To establish the location of active contacts, 27 leads were studied in 14 patients with refractory epilepsy. An analysis was conducted to reveal whether any coordinates of the center of the active contacts predicted percent seizure reduction. Results: With an average follow-up of 18.2 ± 5.6 months, the mean percent seizure reduction (n = 14) was 68 ± 22.4% (25-100%). Eleven of the 14 patients (78.6%) achieved >50% improvement in seizure frequency. Specifically, all 4 patients (100%) with generalized epilepsy (Lennox-Gastaut syndrome) and 7 of 10 patients (70%) with multilobar epilepsy showed >50% reduction in seizure frequency. The mean coordinates of the center of the active contact were located in the superior part of the anterior ventrolateral CM. The calculated coordinates of laterality from midline (x), anterior-posterior (y) and height (z) from the posterior commissure did not correlate with seizure outcome measured by percent seizure reduction. However, the locations of active contacts used during chronic CM stimulation in multilobar epilepsy were identified more dorsal to those used in generalized epilepsy. Conclusions: Chronic CM stimulation is a safe and effective means in the treatment of refractory epilepsy.

Sleep-Related Epilepsy

Sleep has a strong influence on interictal epileptiform discharges and on epileptic seizures. Interictal epileptiform discharges are activated by sleep deprivation and sleep, and some epilepsies occur almost exclusively during sleep. Treatment of sleep-related epilepsy should take in account the type of epileptic syndrome, the type of seizures, the patient characteristics, and also the pharmacokinetics of the drug. Proper characterization of the epilepsy is essential to choose appropriate antiepileptic drugs. Drugs effective in focal epilepsy may be used to treat benign genetic focal epilepsies such as rolandic epilepsy and other focal (frontal or not) sleep epilepsies. These include both classical (such as carbamazepine) and new (such as levetiracetam and lacosamide) antiepileptic drugs. Drug-resistant cases should be evaluated for epilepsy surgery, which may be efficacious in this setting. Valproate, lamotrigine, topiramate, levetiracetam, and perampanel are effective against generalized tonic-clonic seizures in genetic generalized epilepsies, which frequently happen on awakening. Risks of valproate should be considered before prescribing it to women of childbearing age. Specific syndromes such as ESES require specific treatment such as a combination of high dose steroids, benzodiazepines, levetiracetam, and even surgery when an epileptogenic lesion is present. Sleep disorders that may worsen epilepsy such as obstructive sleep apnea or insomnia should be adequately treated to improve seizure frequency. Adequate control of seizures during sleep (especially generalized tonic-clonic seizures) decreases risk of sudden unexpected death in epilepsy (SUDEP).

Resultados de la estimulación del nervio vago en pacientes con epilepsia farmacorresistente en un centro de referencia nacional de epilepsia

To describe clinical results and complications derived from vagal nerve stimulation therapy in drug resistant epileptic patients unsuitable for other surgical treatments, since the first implant in an epilepsy national referral centre. A retrospective analysis of the patients implanted in our centre was held. Data related to baseline characteristics of their epilepsy and therapy complications was collected. 32 new implants in 31 patients are included, mean age of 34 years, 29.3 years of disease evolution, three anti-epileptic drugs at surgery and a postoperative follow-up of 4.03 years. Complex partial seizures types (71.9%) and cryptogenic aetiology (59.4%) were the most frequent. 75% of patients hadn't history of previous epilepsy surgery. 43.8% of patients had a seizure frequency improvement above 50%, with a better response in patients with complex partial seizures (p = 0.22) and cryptogenic aetiology. None statistical significance was found between antiepileptic drugs and seizure frequency. Dysphonia, hoarseness and dysphagia, mostly transient, were the side effects registered. There was an asystole during surgery, completely recovered. One device was replaced due to hardware rupture after a seizure related trauma, one had to be adjusted due to a previous vocal cord paresis, and one dysfunctioning device was removed. In 84.4% the tolerance was excellent. Vagal nerve stimulation is an effective treatment for significant seizure frequency improvement of resistant patients untreatable with other medical or surgical treatments. Further studies are needed to predict the individual response of each patient to therapy and optimizing indications, therefore contributing to cost/benefit optimization.

Surgical outcomes with non-invasive presurgical evaluation in MRI determined bilateral mesial temporal sclerosis: A retrospective cohort study

Background & objectiveEpilepsy surgery for bilateral hippocampal sclerosis continues to pose a challenge and outcomes even with invasive evaluations have not been very promising. Very few studies have analyzed surgery outcomes for patients with MRI determined, bilateral mesial temporal sclerosis (MTS) after non-invasive pre-surgical evaluation. Material and methodsWe studied 35 patients with bilateral MTS who underwent anterior temporal lobectomy (ATL) after non-invasive pre-surgical evaluation. Clinical history, EEG, neuropsychology profile and symmetry of MTS on MRI were reviewed in the groups of ‘seizure free’ and ‘not seizure free’ patients. ResultsAt an average follow up of 44 months (range 12–110 months), 26 out of 35 patients (74%) were seizure free. Unilateral interictal discharges were seen in 57% patients. 94% patients had unilateral ictal EEG onset. Bilateral interictal discharges were significantly associated with ‘not seizure free’ outcome (p = 0.02). Pre-operatively, 24 (71%) patients had bilateral (verbal and visual) memory impairment while 10 (28%) patients had unilateral (verbal or visual) memory impairment and 1 patient had a normal memory profile. Overall, no significant decline in memory was seen in left or right surgery groups post-operatively. There was significant improvement in Quality of Life scores in all patients (p = <0.0005). ConclusionPatients with bilateral MTS on MRI can be unilateral on electro physiology and neuropsychology, and can have a very good surgical outcome. In a setting of limited resources, a noninvasive pre-surgical protocol can be used. With proper patient selection, the outcomes may be comparable to those reported with invasive pre-surgical protocols. Patients with unilateral interictal and ictal EEG have the best outcome. Up to 50% patients with bilateral interictal discharges can have a seizure free outcome. Patients with bilateral independent seizure onset have a less favourable prognosis. Patients who are not seizure free can still attain worthwhile improvement in seizure frequency without significant decline in memory and some improvement in quality of life.

Use of zonisamide in twelve patients with intractable seizures refractory to common anti-epileptic regimens

This non-randomized, uncontrolled, single-center study was conducted to evaluate the effects of zonisamide on intractable epilepsy in a primarily pediatric population. Twelve patients ranging in age from 18 months to 23 years were included in the study. All patients were diagnosed with intractable seizures. Adjunctive therapy with zonisamide was initiated at 100 mg once a day and increased, if needed, by 50-100 mg after one week to reach the maximal or therapeutic dosage depending on patient age and weight. Follow-up occurred in person or by phone at two weeks, one month, and every three months. All 12 patients responded favorably to adjunctive zonisamide. Five patients had subclinical status interrupted and stopped as evidenced by clinical examinations and electroencephalographic (EEG) findings. These patients also became awake, alert, more attentive, and more interactive. An additional six patients experienced clinical and EEG improvement in their seizure frequency, duration, and severity. One patient with autonomic seizures showed EEG improvement in seizure frequency, duration, and severity; however, seizure prodrome control was not obtained. Adjunctive therapy with zonisamide benefited all patients in this study, despite the variation in symptoms and etiology. Zonisamide is thought to have multiple mechanisms of action, which may benefit more patient types than antiepileptic drugs with a single mechanism of action. Zonisamide was well tolerated by all patients.

Temporal lobe epilepsy in patients with nonlesional MRI and normal memory: an SEEG study.

Temporal lobe epilepsy (TLE) in the absence of MRI abnormalities and memory deficits is often presumed to have an extramesial or even extratemporal source. In this paper the authors report the results of a comprehensive stereoelectroencephalography (SEEG) analysis in patients with TLE with normal MRI images and memory scores. Eighteen patients with medically refractory epilepsy who also had unremarkable MR images and normal verbal and visual memory scores on neuropsychological testing were included in the study. All patients had seizure semiology and video electroencephalography (EEG) findings suggestive of TLE. A standardized SEEG investigation was performed for each patient with electrodes implanted into the mesial and lateral temporal lobe, temporal tip, posterior temporal neocortex, orbitomesiobasal frontal lobe, posterior cingulate gyrus, and insula. This information was used to plan subsequent surgical management. Interictal SEEG abnormalities were observed in the mesial temporal structures in 17 patients (94%) and in the temporal tip in 6 (33%). Seizure onset was exclusively from mesial structures in 13 (72%), exclusively from lateral temporal cortex and/or temporal tip structures in 2 (11%), and independently from mesial and neocortical foci in 3 (17%). No seizure activity was observed arising from any extratemporal location. All patients underwent surgical intervention targeting the temporal lobe and tailored to the SEEG findings, and all experienced significant improvement in seizure frequency with a postoperative follow-up observation period of at least 1 year. This study demonstrates 3 important findings: 1) normal memory does not preclude mesial temporal seizure onset; 2) onset of seizures exclusively from mesial temporal structures without early neocortical involvement is common, even in the absence of memory deficits; and 3) extratemporal seizure onset is rare when video EEG and semiology are consistent with focal TLE.

Vagus nerve stimulation in children less than 3 years with medically intractable epilepsy

ObjectiveTo describe the characteristics of children less than three years of age with medically intractable epilepsy, who underwent Vagus Nerve Stimulator (VNS) therapy at Children's Hospital of Pittsburgh between 2004 and 2011. Methods: Retrospective chart review. Results: Seventeen patients were identified; adequate follow-up was available for 15. Median follow up duration was 4.3 years (1.4–10.2 years). 12/15 (80%) had a known etiology for their epilepsy. All patients had more than 1 seizure per week prior to VNS and a history of status epilepticus was frequent (40%, 6/15). Five patients (33%) reported improved seizure frequency at one year after VNS. A normal MRI was associated with seizure improvement (p=0.007). No patient had status epilepticus after VNS at one-year follow-up. At three years after VNS, four patients had experienced status epilepticus with only one patient experiencing multiple episodes. Complications were seen in 2/15 (13%) patients and in 2/21 (9.5%) procedures. Significance: A normal MRI was associated with seizure improvement at one year in children less than three years of age at the time of VNS implant. The degree of overall seizure reduction was modest, but the frequency of status epilepticus was decreased after VNS implant. VNS was tolerated well in this age group.

LORETA Z-score Neurofeedback in Patients with Medically Refractory Epilepsy

Rationale: Published studies suggest that augmentation of the sensorimotor rhythm (SMR), a commonly-used neurofeedback protocol for patients with epilepsy, can be an effective means of reducing seizure frequency, even in patients with medically-refractory seizures. However, SMR protocols are limited to training a few frequency bands over sensorimotor cortex. Newer neurofeedback technology allows for the selection of multiple frequency bands in multiple head regions for training purposes and thus allows for training of neural networks.Functional MRI studies have shown abnormal connectivity within the default mode network (DMN) in patients with both focal-onset and primary generalized epilepsy syndromes. The DMN has also been shown to have altered activity concurrent with interictalepileptiform discharges. The effectiveness of newer neurofeedback techniques in reducing seizure frequency for patients with medically-refractory seizures has not yet been established. This case series explores the potential effectiveness of using LORETA z-score training within the DMN in reducing seizure frequency in patients with medically-refractory seizures. Methods: The records for all consecutive patients seen in the Neurofeedback Clinic at a single academic medical center over a one year period (n=6) were retrospectively reviewed. All patients had medically-refractory epilepsy and were either not candidates for epilepsy surgery (based on consensus decision of the center’s faculty) or had refused to consider surgery for personal reasons. Data on patient demographics, duration of epilepsy prior to training, seizure types and frequencies, antiepileptic drugs (AEDs), psychiatric and medical comorbidities, imaging results, neurophysiological results, and the duration of neurofeedback training were abstracted and analyzed. Patient-reported seizure frequency was also analyzed. Results: 125 total training sessions were reviewed. Mean patient age was 33 +/- 6.1 years with mean duration of epilepsy prior to training of 17.2 +/- 3.2 years. Five out of six patients had focal onset epilepsy. None of the patients had a structural lesion on MRI that correlated with their seizure focus. Five out of 6 patients had a history of comorbid mood disorder. No patient had ever been seizure free for more than 1 year. Patients had been trained using LORETA z-score training within the DMN for an average of 20.8 +/- 5.2weeks (1-2 sessions per weekfor 20-30 minutes per session) at the time of analysis. Five out of 6 patients trained had a subjective reduction in reported weekly seizure frequency after LORETA z-score neurofeedback training began. Conclusions: In this small case series, DMN training using LORETA z-score neurofeedback techniques resulted in subjective improvement in seizure frequency from reported baseline for five out of the six patients in this series.Larger studies are needed to more definitively assess the effectiveness of these techniques for reducing seizure frequency in patients with medically-refractory seizures who are not, for either medical or personal reasons, candidates for surgical intervention.

Long-term outcome of psychogenic nonepileptic seizures: The role of induction by suggestion

PurposeThe aims of our retrospective observational study were to evaluate the long-term outcome of PNESs after communication of the diagnosis and to define predictors of good outcome. MethodTwenty-seven consecutive patients with a certain diagnosis of psychogenic nonepileptic seizures (PNESs) were included in the study. Follow-up information was obtained from each participant through a questionnaire designed for the study. Regarding seizure frequency, the patients were asked to report how many seizures they had experienced on average every month before the communication of the diagnosis and after it. ResultsAfter the communication of the diagnosis, the median seizure frequency had dropped to 4 every month (p<0.001). Seventeen participants (63%) were seizure-free at follow-up, and a further five (18.5%) showed a greater than 50% improvement in seizure frequency. Regarding the predictive value of clinical and sociodemographic variables for PNES global outcome, the factors gender, education, economic status, interval of time from onset, comorbidity with epilepsy, psychiatric history, mental retardation, psychological therapy, psychiatric therapy, and the presence of stressful and traumatic events were not related to prognosis; the only factor associated with a better outcome was the diagnosis made after the induction of PNESs by suggestion (p=0.000, χ2=4.654). ConclusionA substantial majority of our patients became seizure-free with communication of the diagnosis as the only intervention. The use of the induction by suggestion test was an important predictor of good outcome.