New-onset Epileptic Seizures Research Articles

Validation of different predictive scoring scales in patients with new-onset epileptic seizures or epilepsy related to neuronal surface antibody-mediated autoimmune encephalitis

ObjectiveTo validate the different predictive scoring scales in the Chinese population with new-onset epileptic seizures or epilepsy of unknown etiology related to neuronal surface antibody (Ab)-mediated autoimmune encephalitis (AE). MethodsWe retrospectively reviewed the charts of 174 consecutive patients from October 2018 to December 2022, whose serum and cerebrospinal fluid samples were tested for neuronal surface Abs. The antibody prevalence in epilepsy and encephalopathy (APE2), antibodies contributing to focal epilepsy signs and symptoms (ACES), “obvious” indications for neural antibody testing in epilepsy or seizures (ONES) checklist, and the combinations were used to validate the predictive models of neuronal surface Ab-mediated AE. ResultsA total of 139 patients with new-onset epileptic seizures or epilepsy of unknown etiology were enrolled. Abs were detected in 37 patients (26.6%). The APE2/ONES reflex score had the highest sensitivity (89.2%) and lowest specificity (41.7%). The ACES score had the lowest sensitivity (67.5%) and highest specificity (64.7%). Variations in the performance were observed in the different types of AE.100% of patients with anti-γ-aminobutyric acid B-B receptor encephalitis were predicted by ONES, APE2/ONES reflex, and ACES/ONES reflex scores. Only 75% of patients with anti-N-methyl-D-aspartate receptor encephalitis were predicted by the APE2/ONES and ACES/ONES reflex scores. ConclusionOur study was the first to validate various predictive scoring scales in the Chinese cohort of patients with new-onset epileptic seizures or epilepsy of unknown etiology related to neuronal surface Ab-mediated AE. Based upon clinical suspicion, more than one scoring scale should be performed to predict the chance of AE in those patients.

Early Epileptic Seizures after Ischemic Stroke: Their Association with Stroke Risk Factors and Stroke Characteristics.

Background and Objectives: A growing number of stroke survivors face various stroke complications, including new-onset epileptic seizures (ESs). Post-stroke ESs are divided into early and late ESs based on the time of onset after stroke. Early ESs are associated with worse stroke outcomes, longer hospitalization and an increased risk of late ESs. A variety of risk factors for early ESs are being studied in order to prevent their occurrence. Therefore, we aim to determine the association of early ESs with ischemic stroke risk factors and characteristics. Materials and Methods: A total of 166 patients, treated for ischemic stroke in the Hospital of Lithuanian University of Health Sciences Kaunas Clinics, were enrolled in a prospective cohort study. Initially, data about stroke risk factors, localization, severity and treatment were collected, followed by an observation period of 14 days for early ESs. Results: Early ESs occurred in 11 (6.6%) participants. The probability of early ESs after ischemic stroke among males and females (LogRank = 1.281; p > 0.05), younger (≤65 y) and older (>65 y) participants (LogRank = 0.129; p > 0.05) was the same. The presence of ischemic stroke risk factors, such as atrial fibrillation (LogRank = 0.004; p > 0.05), diabetes mellitus (LogRank = 1.168; p > 0.05) and dyslipidemia (LogRank = 0.092; p > 0.05), did not increase the probability of early ESs. However, participants without a prior history of arterial hypertension (LogRank = 4.453; p < 0.05) were more likely to develop early ESs. Stroke localization (anterior versus posterior) (LogRank = 0.011; p > 0.05), stroke severity (LogRank = 0.395; p > 0.05) and type of treatment (specific versus non-specific) (LogRank = 1.783; p > 0.05) did not affect the probability of early ESs.

Convolutional Neural Network Classification of Rest EEG Signals among People with Epilepsy, Psychogenic Non Epileptic Seizures and Control Subjects.

Identifying subjects with epileptic seizures or psychogenic non-epileptic seizures from healthy subjects via interictal EEG analysis can be a very challenging issue. Indeed, at visual inspection, EEG can be normal in both cases. This paper proposes an automatic diagnosis approach based on deep learning to differentiate three classes: subjects with epileptic seizures (ES), subjects with non-epileptic psychogenic seizures (PNES) and control subjects (CS), analyzed by non-invasive low-density interictal scalp EEG recordings. The EEGs of 42 patients with new-onset ES, 42 patients with PNES video recorded and 19 patients with CS all with normal interictal EEG on visual inspection, were analyzed in the study; none of them was taking psychotropic drugs before registration. The processing pipeline applies empirical mode decomposition (EMD) to 5s EEG segments of 19 channels in order to extract enhanced features learned automatically from the customized convolutional neural network (CNN). The resulting CNN has been shown to perform well during classification, with an accuracy of 85.7%; these results encourage the use of deep processing systems to assist clinicians in difficult clinical settings.

Permutation Entropy-Based Interpretability of Convolutional Neural Network Models for Interictal EEG Discrimination of Subjects with Epileptic Seizures vs. Psychogenic Non-Epileptic Seizures.

The differential diagnosis of epileptic seizures (ES) and psychogenic non-epileptic seizures (PNES) may be difficult, due to the lack of distinctive clinical features. The interictal electroencephalographic (EEG) signal may also be normal in patients with ES. Innovative diagnostic tools that exploit non-linear EEG analysis and deep learning (DL) could provide important support to physicians for clinical diagnosis. In this work, 18 patients with new-onset ES (12 males, 6 females) and 18 patients with video-recorded PNES (2 males, 16 females) with normal interictal EEG at visual inspection were enrolled. None of them was taking psychotropic drugs. A convolutional neural network (CNN) scheme using DL classification was designed to classify the two categories of subjects (ES vs. PNES). The proposed architecture performs an EEG time-frequency transformation and a classification step with a CNN. The CNN was able to classify the EEG recordings of subjects with ES vs. subjects with PNES with 94.4% accuracy. CNN provided high performance in the assigned binary classification when compared to standard learning algorithms (multi-layer perceptron, support vector machine, linear discriminant analysis and quadratic discriminant analysis). In order to interpret how the CNN achieved this performance, information theoretical analysis was carried out. Specifically, the permutation entropy (PE) of the feature maps was evaluated and compared in the two classes. The achieved results, although preliminary, encourage the use of these innovative techniques to support neurologists in early diagnoses.

INCIDENCE OF ACUTE SYMPTOMATIC SEIZURES IN PATIENTS WITH COVID-19: A SINGLE-CENTER STUDY.

The most common neurological symptoms in patients with SARS-CoV-2 infection are headache, myalgia, encephalopathy, dizziness, dysgeusia and anosmia, making more than 90 percent of neurological manifestations of COVID-19. Other neurological manifestations such as stroke, movement disorder symptoms or epileptic seizures are rare but rather devastating, with possible lethal outcome. The primary aim of this study was to estimate the prevalence of acute symptomatic seizures among COVID-19 patients, while secondary aim was to determine their possible etiology. Out of 5382 patients with COVID-19 admitted to Dubrava University Hospital from November 1, 2020 until June 1, 2021, 38 (seizure rate 0.7%) of them had acute symptomatic seizures. Of these 38 patients, 29 (76.3%) had new-onset epileptic seizures and nine (23.7%) patients with previous epilepsy history had breakthrough seizures during COVID-19. Although acute symptomatic seizures are an infrequent complication of COVID-19, seizure risk must be considered in these patients, particularly in the group of patients with a severe course of the disease. Accumulation of proinflammatory cytokines may contribute to the occurrence of seizures in patients with COVID-19, but seizures may also be secondary to primary brain pathology related to COVID-19, such as stroke or encephalitis.

Clinical characteristics of 30 COVID-19 patients with epilepsy: A retrospective study in Wuhan

ObjectiveThis study aims to present the clinical characteristics of 30 hospitalized cases with epileptic seizures and coronavirus disease 2019(COVID-19). MethodsThis is a retrospective observational research study. Clinical data were extracted from electronic medical records in 1550 patients with a laboratory-confirmed diagnosis of COVID-19, who were hospitalized in Wuhan Central Hospital, China, from 1 January to 31 April 2020. 30 COVID-19 patients with the diagnosis of epilepsy were enrolled. The clinical characteristics, complications, treatments, and clinical outcomes of 30 cases were collected and analyzed. ResultOf 30 patients with a diagnosis of epilepsy and COVID-19, 13 patients (43.4%) had new-onset epileptic seizures without an epilepsy history(new-onset seizure group, NS group), ten patients(33.3%) had an epilepsy history with a recurrent epileptic seizure (recurrent seizure group, RS group) and seven patients(23.3%) had an epilepsy history but no seizure during the course of COVID-19 (epilepsy history group, EH group). Patients in the RS group had a larger number of other-neurological-disease histories than those in the NS and EH groups (7/10[70%] VS 1/13 [7.7%] VS 1/7[14.3%]); the difference between the RS group and NS group is significant (P < 0.05). Patients in the NE and RS groups suffered more severe/critical COVID-19 infection than patients in the EH group (10/13[76.9%] VS 6/10[60%] VS 1/7[14.3%]); the difference between the NS group and EH group is significant (P < 0.05). 36.7% of patients had one to five neurological complications, and 46.4% of patients had 6–10 neurological complications. The complications in patients with seizures (in the RS and NS groups) seem to be more than those without seizures (in the EH group), but it did not reach statistical significance. The proportion of antiepileptic drugs (AEDs) treatment before admission was higher in the EH group than in the RE group(7/7 [100%] VS 2/10 [20%], P < 0.05). The mortality of 30 patients with epilepsy and COVID-19 was 36.67%. The mortality of the NS group(38.5%) and the RS group(50%) were a little higher than in the EH group(14.3%). None of the convalescent patients had a recurrent seizure, and there were no more deaths in the 3-month follow-up after discharge. ConclusionsCOVID-19 patients with recurrent epileptic seizures had more underlying neurological diseases than patients who had an epilepsy history but without a seizure. Patients with new-onset and recurrent epileptic seizures suffered more severe/critical COVID-19, which may lead to a worse prognosis. If patients with epilepsy history continue using AEDs during COVID-19 pandemics, the risk of recurrent seizure may be reduced, and a good prognosis for patients with epilepsy history could be expected.

Chapter 7 - Clinical neurophysiology of stroke

Stroke constitutes the third most common cause of death and the leading cause of acquired neurologic handicap. During ischemic stroke, very early after the onset of the focal perfusion deficit, excitotoxicity triggers a number of events that can further contribute to tissue death. Such events include peri-infarct depolarizations and spreading depolarizations (SDs) within the ischemic penumbra. SDs spread slowly through continuous gray matter at a typical velocity of 2-5mm/min. SDs exacerbate neuronal injury through prolonged ionic breakdown and SD-related hypoperfusion (spreading ischemia). Scalp EEG alone is not yet sufficient to reliably diagnose SDs. Hyperexcitability occurs in parallel, both in the acute and chronic phases of stroke. Stroke is a common cause of new-onset epileptic seizures after middle age and is the leading cause of symptomatic epilepsy in adults. The last part of this chapter is dedicated to noninvasive neurophysiologic techniques that can be used to promote stroke rehabilitation. These techniques mainly include repetitive transcranial magnetic stimulation and tDCS. These approaches are based on the concept of interhemispheric rivalry and aim at modulating the imbalance of cortical activities between both hemispheres resulting from stroke.

Reliability of the early syndromic diagnosis in adults with new-onset epileptic seizures: A retrospective study of 116 patients attended in the emergency room

PurposeNew-onset seizures (NOS) are a common reason for emergency department (ED) consultations. Decisions regarding treatment and further examinations are made based on the initial evaluation. We aimed to evaluate the reliability of the early syndromic diagnosis in NOS and find predictive factors to establish a consistent early diagnosis based on the semiology and prompt supplementary examinations. MethodsWe recruited patients attended in our ED for NOS over 2 years (2014–2015), excluding patients with a loss of consciousness of suspected non-epileptic origin. All patients were assessed by a neurologist. A baseline diagnosis was established according to clinical findings and neuroimaging/EEG data.Over 1 year of follow-up in our Epilepsy Unit, a definite diagnosis was made based on clinical progress and further examinations. Results116 patients were recruited (mean age 56.5 ± 22.1 years; 50% women). 47% were seizures of unknown cause. The concordance index between the baseline and definite diagnosis was κ = 0.662 (the diagnosis changed during follow-up in 25% of patients). Focal epilepsy of unknown cause was the baseline diagnosis that most often changed at follow-up (diagnostic change, 41.2%; p < 0.001). Lesions detected on CT-scanning and EEG abnormalities predicted the final diagnosis with the greatest accuracy (p = 0.009 and p = 0.026, respectively). Pathological findings in the MRI studies performed and seizure recurrence were not key factors for diagnostic changes. ConclusionDespite prompt examinations, the baseline epilepsy diagnosis changes within a short time period in 25% of patients. The presence of neuroimaging lesions and EEG abnormalities was associated with the greatest diagnostic accuracy in these cases.

Mind the gap: Multiple events and lengthy delays before presentation with a "first seizure".

Up to half of patients assessed for suspected new-onset epileptic seizures report previous undiagnosed events. This suggests that delay to timely and expert assessment is a major issue. Very little is known about the degree of delay or nature of the undiagnosed events, impacting on our understanding of new-onset epilepsy. In this study we aimed to examine events that occur before presentation, as well as the extent and risk factors for delay to assessment. Included in this retrospective study were 220 patients diagnosed at the First Seizure Clinic (Austin Health, Australia) between 2003 and 2006 with an epileptic index seizure. Patients with a prior diagnosis of epileptic seizures were excluded. Chartreview was undertaken, including detailed interviews conducted by an epileptologist at first assessment. Logistic regression assessed risk factors for delay from first event to presentation, including event characteristics, socioeconomic disadvantage, employment, and distance to medical facility. Forty-one percent (n=90) of patients had one or more event before their index seizure. Of these, 50% had multiple or more than five prior events and 28% experienced one or more convulsive event before the index seizure. Of the total 220 patients, 36% had delayed presentation >4weeks, 21% delayed >6months, and 14% delayed >2years. First events without convulsions or features likely to disrupt behaviour were strongly associated with delay (p=<0.001). Relative socioeconomic disadvantage was also associated with delay to presentation (p=0.04). Our findings suggest a gap in early diagnosis and care in a sizable proportion of new-onset cases, despite a "first world" urban environment and the availability of free basic medical care. Delay appears particularly likely when events are nonconvulsive or low-impact, suggesting that these seizure types may be underrepresented in studies of new-onset epilepsy. This has implications for our understanding of the incidence, evolution, impact, and treatment response of new-onset epilepsy.

Crises épileptiques révélant des anomalies du métabolisme phosphocalcique

Hypocalcemia due to hypoparathyroidism produces a broad spectrum of clinical manifestations, but overt symptoms may be sparse. One unusual presentation is onset or aggravation of epilepsy in adolescence revealing hypoparathyroidism. This situation can lead to delayed diagnosis, with inefficacity of the antiepileptic drugs. We report five cases of adolescence-onset epilepsy with unsuccessful antiepileptic therapy, even with gradually increasing dose. Physical examination revealed signs of hypocalcemia, confirmed biologically. Full testing disclosed the origin of the seizures: hypoparathyroidism in three patients and pseudohypoparathyroidism in the other two. In four of five patients, computed tomography showed calcification of the basal ganglia, defining Fahr's syndrome. The patients were treated with oral calcium and active vitamin D (1-alphahydroxy vitamin D3). Seizure frequency progressively decreased and serum calcium levels returned to normal. These cases illustrate the importance of the physical examination and of routine serum calcium assay in patients with new-onset epileptic seizures in order to detect hypocalcemia secondary to hypoparathyroidism.

Lacosamide as add-on treatment of focal symptomatic epilepsy in a patient with alcoholic liver cirrhosis.

The occurrence of epileptic seizures in the presence of hepatic disease is not uncommon in clinical practice. Selecting an appropriate AED for patients affected by liver failure who have new-onset epileptic seizures can be challenging. We describe a 64-year-old man affected by liver cirrhosis. The patient developed partial epilepsy with secondary generalization because of an intracerebral hemorrhage in the left parieto-occipital regions. After the neurosurgery procedure, seizures reappeared and were initially managed with levetiracetam. After one month, the patient experienced clusters of seizures while on stable treatment with levetiracetam. Pregabalin as add-on was not tolerated; therefore, he received a low dose of phenobarbital as add-on treatment. The patient developed hepatic encephalopathy. Phenobarbital was immediately stopped, and oral lacosamide was added. A rapid recovery of encephalopathy with a 6-month seizure freedom was obtained. The patient died 6 months later because of progressive impairment of liver function. Lacosamide may represent an alternative to other AEDs in patients with liver failure; however, further prospective evaluation of its efficacy and safety in this clinical setting is needed.

Epileptic seizure as the first sign of hypoparathyroidism

Hypoparathyroidism refers to a group of disorders in which extracellular calcium levels cannot be maintained within the normal range due to relative or absolute deficiency of parathyroid hormone (PTH). The clinical features of hypoparathyroidism are consistent with hypocalcaemia and, predominantly, neuromuscular dysfunction. Although hypocalcaemia-induced seizures are well documented hypoparathyroidism-induced epilepsy is often misdiagnosed as idiopathic epilepsy. We reported a 57-year-old woman with new-onset seizure due to hypoparathyroidism. At first, diagnosis of epilepsy was established and the antiepileptic therapy was initiated with gradual increase of the dose. Computerized tomography scan of the head revealed bilateral basal ganglia and cerebellar calcification and many punctiform calcifications between cortical and subcortical parts. During hospitalization, laboratory tests showed hypocalcemia, hyperphosphatemia and low PTH level. Once the diagnosis of hypoparathyroidism was established, a proper treatment with calcium and vitamin D was started, and the patient was discharged from hospital with full seizure control. Standard evaluation of serum calcium levels in patients with new-onset epileptic seizures should be obligatory part of a diagnostic algoritam to avoid misdiagnosis of idiopathic epilepsy.

Early presentation of de novo high grade glioma with epileptic seizures: electroclinical and neuroimaging findings

We report the clinical, EEG and neuroradiologic findings from three adult patients who developed new-onset seizure disorders as early clinical manifestations of de novo high grade glioma. The malignancies could not be recognised at the time of the first epileptic seizure because of minimal non-specific brain abnormalities, which showed no signs of necrosis or significant contrast enhancement on computed tomography and magnetic resonance imaging. Focal EEG abnormalities were recorded in all cases and appeared consistent with the neuroradiologic findings. The patients regained normal neurological status after the first seizure but rapidly developed space-occupying necrotic lesions. Two patients underwent surgery and received histological diagnoses of the tumours. Another patient was finally diagnosed with a malignant glioma based on the neuroradiologic picture and rapid progression of the cerebral lesion. It should be noted that in adult patients, new-onset epileptic seizures might reveal the presence of malignant gliomas at a very early stage in the tumour formation process. This report indicates that typical anatomoradiologic features of de novo high grade glioma, such as necrosis and rim-contrast enhancement, could be absent at the time of the first epileptic seizure but become clear within a short period after clinical presentation.

Levetiracetam monotherapy in Alzheimer patients with late‐onset seizures: a prospective observational study

Levetiracetam (LEV) monotherapy was investigated in 25 patients with advanced Alzheimer's disease (AD) and new-onset epileptic seizures in a prospective open-label study. At a daily dose of 1000-1500 mg, 72% were seizure-free for at least one year; 16% discontinued for untolerability; 8% were unresponsive; 4% were lost to follow-up. These results suggest the need for controlled studies to confirm if LEV can be a first-choice drug in AD.

Carbamazepine may trigger new-onset epileptic seizures in an individual with autism spectrum disorders: a case report

We herein report a case of new-onset epileptic seizures induced by carbamazepine in an individual with autism spectrum disorders (ASD). We clinicians should bear in mind the possibility that epileptic seizures may possibly be either precipitated or exacerbated by carbamazepine especially in individuals with ASD.

Levetiracetam monotherapy for liver transplant patients with seizures

Selecting an appropriate anticonvulsant for treatment of recipients of orthostatic liver transplants who have new-onset epileptic seizures can be challenging because first-line agents may contribute to worsening encephalopathy, alter the plasma concentration of immunosuppressive agents, and result in hepatotoxicity. We describe the case of a 55-year-old man who underwent orthotopic liver transplantation because of end-stage liver disease due to alcoholic cirrhosis and hepatitis C. He required two repeat transplantation procedures. After the last procedure, epileptic seizures developed, which were initially managed with phenytoin. However, the patient remained stuporous and mental status fluctuated. Breakthrough seizures later developed in the setting of rejection. Levetiracetam (500 mg orally, twice a day) was chosen for its favorable pharmacokinetic properties as an alternative to phenytoin. By the third day of levetiracetam therapy, the patient became more responsive. At most recent follow-up, 3 months after the start of levetiracetam therapy, the patient was still treated with levetiracetam monotherapy, and seizure control was judged to be excellent.