Refractory Epilepsy Patients Research Articles

Expression and Significance of microRNA-3686 in Peripheral Blood of Patients with Refractory Epilepsy

The study is to investigate the expression and significance of microRNA-3686 in peripheral blood of refractory epilepsy patients (RE). 83 patients with untreated epilepsy were selected as the experimental group. During the treatment, According to diagnostic criteria for refractory epilepsy, 15 patients were diagnosed with refractory epilepsy (RE group) and 68 cases in no refractory epilepsy group (NRE group). 50 patients in the normal group were selected as the control group. The results showed that the expression of microRNA-3686 in the peripheral blood of the experimental group was lower than that of the control group (P < 0.05). The levels of P-gp and MRP1 in peripheral blood of patients in RE group were higher than those in NRE group (P < 0.05). microRNA-3686 was negatively correlated with P-gp (r= – 0.799, P < 0.05), and had no correlation with MRP1 (r= 0.279, P= 0.314); ROC curve showed microRNA-3686 prediction RE of the area under the curve of epilepsy AUC was 0.733, 95% CI (0.603–0.863), (P < 0 05). In Conclusion the microRNA-3686 is low in peripheral blood of patients with refractory epilepsy and may be involved in the resistance of epilepsy by regulating P-gp, but not MRP1.

Effects of CBD-Enriched Cannabis sativa Extract on Autism Spectrum Disorder Symptoms: An Observational Study of 18 Participants Undergoing Compassionate Use.

Autism Spectrum Disorders comprise conditions that may affect cognitive development, motor skills, social interaction, communication, and behavior. This set of functional deficits often results in lack of independence for the diagnosed individuals, and severe distress for patients, families, and caregivers. There is a mounting body of evidence indicating the effectiveness of pure cannabidiol (CBD) and CBD-enriched Cannabis sativa extract (CE) for the treatment of autistic symptoms in refractory epilepsy patients. There is also increasing data support for the hypothesis that non-epileptic autism shares underlying etiological mechanisms with epilepsy. Here we report an observational study with a cohort of 18 autistic patients undergoing treatment with compassionate use of standardized CBD-enriched CE (with a CBD to THC ratio of 75/1). Among the 15 patients who adhered to the treatment (10 non-epileptic and five epileptic) only one patient showed lack of improvement in autistic symptoms. Due to adverse effects, three patients discontinued CE use before 1 month. After 6–9 months of treatment, most patients, including epileptic and non-epileptic, showed some level of improvement in more than one of the eight symptom categories evaluated: Attention Deficit/Hyperactivity Disorder; Behavioral Disorders; Motor Deficits; Autonomy Deficits; Communication and Social Interaction Deficits; Cognitive Deficits; Sleep Disorders and Seizures, with very infrequent and mild adverse effects. The strongest improvements were reported for Seizures, Attention Deficit/Hyperactivity Disorder, Sleep Disorders, and Communication and Social Interaction Deficits. This was especially true for the 10 non-epileptic patients, nine of which presented improvement equal to or above 30% in at least one of the eight categories, six presented improvement of 30% or more in at least two categories and four presented improvement equal to or above 30% in at least four symptom categories. Ten out of the 15 patients were using other medicines, and nine of these were able to keep the improvements even after reducing or withdrawing other medications. The results reported here are very promising and indicate that CBD-enriched CE may ameliorate multiple ASD symptoms even in non-epileptic patients, with substantial increase in life quality for both ASD patients and caretakers.

Application of robot-assisted stereoencephalography electrode implantation in epilepsy surgery

Objective To explore the precision, efficiency and safety of robot-assisted stereoencephalography (SEEG) electrode implantation applied in epilepsy surgery. Methods A retrospective analysis was conducted on 23 patients of refractory epilepsy who were admitted to Beijing Institute of Functional Neurosurgery, Xuanwu Hospital of Capital Medical University from February 2018 to June 2018 and underwent robot-assisted SEEG electrode implantation ('robot’ group). A total of 25 refractory epilepsy patients admitted from October 2017 to January 2018 underwent CRW stereotactic apparatus-guided SEEG implantation and served as control ('CRW’ group). Continuous thin-slice CT was conducted post operation in each case, based on which the distance between the actual and planned target of each electrode trajectory was measured and set as operational deviation.Operational duration for each electrode implantation and incidences of postoperative complications were documented. The parameters as above were compared between the 2 groups. Results In the 'robot’ group, a total of 179SEEG electrodes with 2 642 contacts were implanted in this series (23 cases), with the median of 8 (5-10) electrodes with 120 (76-136)contacts in each patient.In the 'CRW’ group, 25 patients underwent implantation of 172 electrodes with 2 520 contacts, with the median of 7 (6-9)electrodes with 100 (60-128) contacts in each patient.The operational deviation of each electrode was 1.4 (0.4-9.3) mm ('robot’ group) and 1.4 (0-4.6) mm ('CRW’ group), respectively, which had no statistical difference (P>0.05). Compared with 'CRW’ group, the 'robot’ group had significantly shorter operational duration[8(5.9-12.8) min vs. 14.7 (10.3-18.5) min, P<0.01] for each electrode implantation. In the 'robot’ group, there were 2 cases (8.7%) of asymptomatic intracranial hemorrhage. No cases of infection or other complications were observed. In the 'CRW’ group, there were 1 case (4.0%) of intracerebral hemorrhage causing contralateral paralysis, 1 case (4.0%) of asymptomatic hemorrhage and no cases of other complications. Conclusions Robot-assisted technique seems to be able to remarkedly increase the efficiency of SEEG electrode implantation with relatively good precision and safety, which could thus be recommended for clinical use and promotion. Key words: Epilepsy; Neurosurgical procedures; Robot; Stereotaxic techniques; Intracranial electrode

The Role of Anterior Thalamic Deep Brain Stimulation as an Alternative Therapy in Patients with Previously Failed Vagus Nerve Stimulation for Refractory Epilepsy

Deep brain stimulation (DBS) has provided new treatment options for refractory epilepsy; however, treatment outcomes of DBS in refractory epilepsy patients previously treated with vagus nerve stimulation (VNS) have not been clarified. Herein, treatment outcomes of DBS of the anterior nucleus of the thalamus (ANT-DBS) in patients who had previously experienced VNS failure are reported. Seven patients who had previously experienced VNS failure underwent ANT-DBS device implantation. VNS was turned off before DBS device implantation. Monthly seizure counts starting from baseline to 12–18 months after DBS were analyzed. Five (71.3%) of the 7 patients experienced a >50% reduction of seizure counts after DBS; 1 responder reached a seizure-free status after DBS therapy. Of the 2 nonresponders, 1 subject showed improvement in seizure strength and duration, which lessened the impact of the seizures on the patient’s quality of life. This is the first study in which favorable outcomes of ANT-DBS surgery were observed in individual patients with refractory epilepsy who had not responded to prior VNS. Further studies with a larger number of subjects and longer follow-up period are needed to confirm the feasibility of ANT-DBS in patients who have previously experienced VNS failure.

Evidence for the Role of Magnetic Source Imaging in the Presurgical Evaluation of Refractory Epilepsy Patients.

Magnetoencephalography (MEG) in the field of epilepsy has multiple advantages; just like electroencephalography (EEG), MEG is able to measure the epilepsy specific information (i.e., the brain activity reflecting seizures and/or interictal epileptiform discharges) directly, non-invasively and with a very high temporal resolution (millisecond-range). In addition MEG has a unique sensitivity for tangential sources, resulting in a full picture of the brain activity when combined with EEG. It accurately allows to perform source imaging of focal epileptic activity and functional cortex and shows a specific high sensitivity for a source in the neocortex. In this paper the current evidence and practice for using magnetic source imaging of focal interictal and ictal epileptic activity during the presurgical evaluation of drug resistant patients is being reviewed.

The Effectiveness of Medical and Surgical Treatment for Children With Refractory Epilepsy

Abstract INTRODUCTION Pediatric refractory epilepsy affects quality of life, clinical disability, and healthcare costs for patients and families. We aimed to show the impact of surgical treatment for pediatric epilepsy on healthcare utilization compared to medically treated pediatric epilepsy over 5 yr. METHODS The Pediatric Health Information System database was used to study hospitalized children with epilepsy using five published algorithms. Refractory epilepsy (RE) patients treated with either antiepileptic medications (AEDs) only or AEDs plus epilepsy surgery (ES) between 1/1/2008 and 12/31/2014 were included. Patients with a history of ES before 1/1/2008 or a vagus nerve stimulation implantation surgery were excluded. ICD-9-CM codes were used to identify ES. Healthcare utilization following the index date at 2- and 5-yr including inpatient, emergency department (ED), and all epilepsy-related visits were evaluated. The propensity scores (PS) method was used to match surgically and medically treated patients. Covariates associated with the probability of receiving surgical treatment were chosen in the logistic regression model for calculating PS. SAS 9.4 and Stata 14.0 were used for data management and statistical analysis. RESULTS A total of 2106 (17.1%) and 10186 (82.9%) were surgically and medically treated, respectively. A total of 4050 matched cases, 2025 per each treated group, were included. Overall survival rates of matched cases were 98.07% and 99.58% at 2-yr and 96.66% and 98.99% at 5-yr for medically and surgically treated patients, respectively. Within 5-yr follow-up, seizure-associated healthcare utilization was lower for the surgically treated group: number of inpatient visits were 3.9 vs 2.5 and ED visits were 3.2 vs 1.7 for medically and surgically treated patients, respectively. The number of AEDs at 1-yr follow-up was significantly lower for the surgically treated group (3.22 decreased to 2.59: surgical group, 3.24 decreased to 3.06: medical group). CONCLUSION We found a significant decrease in inpatient and ED visits and number of antiepileptic drug prescriptions, as well as higher survival rates, at 2- and 5-yr follow-up in the surgically treated group compared to the medically treated group for pediatric patients with refractory epilepsy. Pediatric epilepsy surgery can provide beneficial outcomes, favorable long-term effectiveness, and reduced healthcare utilization compared to medical management.

Increased gamma and decreased fast ripple connections of epileptic tissue: A high-frequency directed network approach.

ObjectiveNew insights into high‐frequency electroencephalographic activity and network analysis provide potential tools to improve delineation of epileptic tissue and increase the chance of postoperative seizure freedom. Based on our observation of high‐frequency oscillations “spreading outward” from the epileptic source, we hypothesize that measures of directed connectivity in the high‐frequency range distinguish epileptic from healthy brain tissue.MethodsWe retrospectively selected refractory epilepsy patients with a malformation of cortical development or tumor World Health Organization grade I/II who underwent epilepsy surgery with intraoperative electrocorticography for tailoring the resection based on spikes. We assessed directed functional connectivity in the theta (4‐8 Hz), gamma (30‐80 Hz), ripple (80‐250 Hz), and fast ripple (FR; 250‐500 Hz) bands using the short‐time direct directed transfer function, and calculated the total, incoming, and outgoing propagation strength for each electrode. We compared network measures of electrodes covering the resected and nonresected areas separately for patients with good and poor outcome, and of electrodes with and without spikes, ripples, and FRs (group level: paired t test; patient level: Mann‐Whitney U test). We selected the measure that could best identify the resected area and channels with epileptic events using the area under the receiver operating characteristic curve, and calculated the positive and negative predictive value, sensitivity, and specificity.ResultsWe found higher total and outstrength in the ripple and gamma bands in resected tissue in patients with good outcome (rippletotal: P = .01; rippleout: P = .04; gammatotal: P = .01; gammaout: P = .01). Channels with events showed lower total and instrength, and higher outstrength in the FR band, and higher total and outstrength in the ripple, gamma, and theta bands (FRtotal: P = .05; FRin: P < .01; FRout: P = .02; gammatotal: P < .01; gammain: P = .01; gammaout: P < .01; thetatotal: P = .01; thetaout: P = .01). The total strength in the gamma band was most distinctive at the channel level (positive predictive value [PPV]good = 74%, PPVpoor = 43%).SignificanceInterictally, epileptic tissue is isolated in the FR band and acts as a driver up to the (fast) ripple frequency range. The gamma band total strength seems promising to delineate epileptic tissue intraoperatively.

The intracranial correlate of the 14&6/sec positive spikes normal scalp EEG variant

ObjectiveTo investigate the intracranial correlate of the 14&6/sec positive spikes normal variant of scalp EEG. MethodsOut of 35 adult refractory focal epilepsy patients who underwent intracranial electrode implantation with simultaneous scalp EEG electrodes, the 14&6/sec positive spikes variant was found in 4. We used three methods to identify and quantify intracranial correlates to the variant: visual inspection, time-referenced waveform averaging and 3D brain volume spectrum-based statistical parametric mapping (SPM). ResultsWe discovered a novel and robust relationship between the scalp variant and an atypical hippocampal discharge. This intracranial correlate is an ipsilateral hippocampal burst of highly synchronized high-amplitude paroxysmal-like spikes of negative polarity, with a ramping up amplitude profile, which often ramps down and is accompanied by an underlying sequence of low-amplitude negative slow waves. The 14/sec positive spikes of the variant are time-locked to the negative peak of the hippocampal spikes, while the 6/sec positive spikes are time-locked to the negative spikes overlying the low-amplitude slow waves. ConclusionsThe 14&6/sec positive spikes variant correlates with bursts of negative polarity spikes in the ipsilateral hippocampus. SignificanceThe identification of the hippocampal correlate of the 14&6/sec positive spikes variant fills a gap in our knowledge of normal intracranial variants. In clinical practice, this knowledge should reduce the chance that this electrophysiological signature is misinterpreted as epileptiform activity, which could inappropriately influence the interpretation of the intracranial study and subsequent surgical recommendation.

Refractory epilepsy and obstructive sleep apnea: is there an association?

BackgroundA high prevalence of obstructive sleep apnea (OSA) has been reported in medically refractory epilepsy patients, and there is increasing evidence that treatment of OSA in refractory epilepsy patients would reduce seizure frequency.ObjectiveStudying the frequency of occurrence of OSA in a group of refractory epilepsy patients, compared to a matched group with medically controlled epilepsy.MethodsSixty patients with epilepsy, 30 patients with controlled epilepsy (group I), and 30 patients with refractory epilepsy (group II) were included. All patients underwent overnight polysomnogram and sleep EEG and completed Sleep Apnea Sleep Disorders Questionnaire (SASDQ). All patients had normal general and neurological examination.ResultsThe frequency of OSA was found to be 10% in patients with controlled epilepsy, while its frequency in patients with refractory epilepsy was found to be 16.7%, yet this was statistically insignificant. In addition, O2 desaturation nadir was higher in group II, compared to group I with no statistical significance. In the controlled epilepsy group, we found that older patients tend to have higher Apnea–Hypopnea Index (AHI). Moreover, it was found that older subjects, with early onset of epilepsy, and longer duration of the illness tend to have higher AHI in group II.ConclusionThere is an association between refractory epilepsy and OSA, especially regarding O2 desaturation during sleep. In addition, older age, early onset of epilepsy, and longer duration of illness are independent risk factors for the OSA in patients with refractory epilepsy.

PND28 A BUDGET IMPACT ANALYSIS OF CENOBAMATE FOR THE TREATMENT OF REFRACTORY PARTIAL-ONSET EPILEPSY

To estimate health outcomes and financial impact to a private healthcare payer of adoption of cenobamate into clinical practice for patients with refractory partial-onset epilepsy. We developed a 1-year budget impact model from the U.S. private payer perspective, which included a cohort of adult refractory partial epilepsy patients taking adjunctive lacosamide, perampanel, brivaracetam, eslicarbazepine acetate, or cenobamate as they experience clinical events and accrue health resource use and costs. The model explicitly incorporates costs of provider and emergency room visits along with inpatient hospitalizations as a function of estimates of seizure reduction garnered from the drugs’ Phase III trials. Costs were estimated from the 2018 Medicare Fee Schedule, which were inflated to represent private payer reimbursement. Base case model assumed a hypothetical private health plan with 1,000,000 covered lives, with 77% adults (18+ years). After applying prevalence estimates, the final population represented 0.2% of total covered lives. Base case results suggest that, after introduction of cenobamate, at 17% uptake, the plan is exposed to 281 fewer provider visits, 49 fewer ER visits, and 55 fewer hospitalizations. Use of cenobamate led to cost savings of over $827,000, representing a $0.07 per-member per-month reduction in total plan costs. We conducted a one-way sensitivity analyses series to test the impact of key assumptions on plan savings after introduction of cenobamate. While the magnitude of cost savings varied, particularly as the uptake assumption was varied, the results directionality remained consistent, indicating improved effectiveness and economic efficiency upon introduction of cenobamate. The results of this model demonstrate use of cenobamate in patients with refractory partial-onset epilepsy leads to reductions in healthcare resource use, driven by better clinical outcomes based on results published in the literature. Consequently, payers can expect moderate cost savings over a one-year time horizon.

PSU8 THE EFFECTIVENESS OF TREATMENT CHOICES FOR REFRACTORY EPILEPSY AMONG PEDIATRIC POPULATION

To compare healthcare utilization following surgical or medical treatment for children with refractory epilepsy We extracted hospitalized children with epilepsy from the Pediatric Health Information System database using five published algorithms. Refractory epilepsy (RE) patients treated with either antiepileptic medications (AEDs) only or AEDs plus epilepsy surgery (ES) between 1/1/2008 and 12/31/2014 were included. Patients with a history of ES before 1/1/2008 or a vagus nerve stimulation implantation surgery were excluded. ICD-9-CM codes were used to identify ES. Healthcare utilization following the index date at 2- and 5- years including inpatient, emergency department (ED), and all epilepsy-related visits were evaluated. The propensity scores (PS) method was used to match surgically and medically treated patients. Covariates associated with the probability of receiving surgical treatment were chosen in the logistic regression model for calculating PS. SAS® 9.4 and Stata 14.0 were used for data management and statistical analysis. 10089 (82.8%) and 2083 (17.2%) were surgically and medically treated, respectively. Significant variations of subgroup distribution in age, race, insurance, sources of admission, primary diagnosis, and pediatric complex chronic conditions (p<0.001 for all binary tests) were identified between two groups. 4050 matched cases, 2025 per each treated group, were included. Compared to medically treated patients, utilization was reduced in the surgical group: at 2- and 5- years post-index date, there was a reduction of 40% and 42% of inpatient visits and 46% and 49% of ED visits. The total number (inpatient, ED, ambulatory visits) of epilepsy-associated visits were also reduced by 42%-45% in the surgical group compared to medically-treated group. In those who had surgery, the average reduction in AEDs was 16% at 2- and 5- years after treatment. Patients with refractory epilepsy treated with surgery had significant reductions in healthcare utilization compared with matched patients treated with antiepileptic medications only.

Single-Cell Recordings to Target the Anterior Nucleus of the Thalamus in Deep Brain Stimulation for Patients with Refractory Epilepsy.

Deep brain stimulation (DBS) of the anterior nucleus of the thalamus (ANT) is a promising treatment for patients with refractory epilepsy. However, therapy response varies and precise positioning of the DBS lead is potentially essential for maximizing therapeutic efficacy. We investigate if single-cell recordings acquired by microelectrode recordings can aid targeting of the ANT during surgery and hypothesize that the neuronal firing properties of the target region relate to clinical outcome. We prospectively included 10 refractory epilepsy patients and performed microelectrode recordings under general anesthesia to identify the change in neuronal signals when approaching and transecting the ANT. The neuronal firing properties of the target region, anatomical locations of microelectrode recordings and active contact positions of the DBS lead along the recorded trajectory were compared between responders and nonresponders to DBS. We obtained 19 sets of recordings from 10 patients (five responders and five nonresponders). Amongst the 403 neurons detected, 365 (90.6%) were classified as bursty. Entry into the ANT was characterized by an increase in firing rate while exit of the ANT was characterized by a decrease in firing rate. Comparing the trajectories of responders to nonresponders, we found differences neither in the neuronal firing properties themselves nor in their locations relative to the position of the active contact. Single-cell firing rate acquired by microelectrode recordings under general anesthesia can thus aid targeting of the ANT during surgery, but is not related to clinical outcome in DBS for patients with refractory epilepsy.

Robot-Assisted Responsive Neurostimulator System Placement in Medically Intractable Epilepsy: Instrumentation and Technique.

The management of medically refractory epilepsy patients who are not surgical candidates has remained challenging. Closed loop-or responsive-neurostimulation (RNS) is now an established therapy for the treatment of epilepsy with specific indications. The RNS® system (NeuroPace Inc, Mountainview, California) has recently been shown to be effective in reducing the seizure frequency of partial onset seizures. The electrode design consists of either intracerebral depth electrodes or subdural strip electrodes, and stereotaxis is typically used to guide placement into the EZ. Details on the operative techniques used to place these electrodes have been lacking. To address the advantage of using a robotic-assisted technique to place depth electrodes for RNS® system placement compared to the typical frame-based or frameless stereotactic systems. We retrospectively reviewed our single center, technical operative experience with RNS® system placement using robotic assistance from 2014 to 2016 via chart review. Twelve patients underwent RNS® system placement using robotic assistance. Mean operative time was 121 min for a median of 2 depth electrodes with mean deviation from intended target of ∼3 mm in x, y, and z planes. Two patients developed wound infections, 1 of whom was reimplanted. Seizures were reduced by ∼40% at 2 yr, similar to the results seen in the open label portion of the pivotal RNS trial. Robotic-assisted stereotaxis can be used to provide a stable and accurate stereotactic platform for insertion of intracerebral RNS electrodes, representing a safe, efficient and accurate procedure.

Promoting faster pathways to surgery: a clinical audit of patients with refractory epilepsy

BackgroundIndividuals with epilepsy who cannot be adequately controlled with anti-epileptic drugs, refractory epilepsy, may be suitable for surgical treatment following detailed assessment. This is a complex process and there are concerns over delays in referring refractory epilepsy patients for surgery and subsequent treatment. The aim of this study was to explore the different patient pathways, referral and surgical timeframes, and surgical and medical treatment options for refractory epilepsy patients referred to two Tertiary Epilepsy Clinics in New South Wales, Australia.MethodsClinical records were reviewed for 50 patients attending the two clinics, in two large teaching hospitals (25 in Clinic 1; 25 in Clinic 2. A purpose-designed audit tool collected detailed aspects of outpatient consultations and treatment. Patients with refractory epilepsy with their first appointment in 2014 were reviewed for up to six visits until the end of 2016. Data collection included: patient demographics, type of epilepsy, drug management, and assessment for surgery. Outcomes included: decisions regarding surgical and/or medical management, and seizure status following surgery. Patient-reported outcome measures to assess anxiety and depression were collected in Clinic 1 only.ResultsPatient mean age was 38.3 years (SD 13.4), the mean years since diagnosis was 17.3 years (SD 9.8), and 88.0% of patients had a main diagnosis of focal epilepsy. Patients were taking an average of 2.3 (SD 0.9) anti-epileptic drugs at the first clinic visit. A total of 17 (34.0%) patients were referred to the surgical team and 11 (22.0%) underwent a neuro-surgical procedure. The average waiting time between visit 1 to surgical referral was 38.8 weeks (SD 25.1), and between visit 1 and the first post-operative visit was 55.8 weeks (SD 25.0).ConclusionThe findings confirm international data showing significant waiting times between diagnosis of epilepsy and referral to specialist clinics for surgical assessment and highlight different approaches in each clinic in terms of visit numbers and recorded activities. A standardised pathway and data collection, including patient-reported outcome measures, would provide better evidence for whether promoting earlier referral and assessment for surgery improves the lives of this disease group.

Relation between early-onset psychosis and formal thought disorder in schizophrenia

To investigate the intracranial correlate of the 14&6/sec positive spikes normal variant of scalp EEG.Out of 35 adult refractory focal epilepsy patients who underwent intracranial electrode implantation with simultaneous scalp EEG electrodes, the 14&6/sec positive spikes variant was found in 4. We used three methods to identify and quantify intracranial correlates to the variant: visual inspection, time-referenced waveform averaging and 3D brain volume spectrum-based statistical parametric mapping (SPM).We discovered a novel and robust relationship between the scalp variant and an atypical hippocampal discharge. This intracranial correlate is an ipsilateral hippocampal burst of highly synchronized high-amplitude paroxysmal-like spikes of negative polarity, with a ramping up amplitude profile, which often ramps down and is accompanied by an underlying sequence of low-amplitude negative slow waves. The 14/sec positive spikes of the variant are time-locked to the negative peak of the hippocampal spikes, while the 6/sec positive spikes are time-locked to the negative spikes overlying the low-amplitude slow waves.The 14&6/sec positive spikes variant correlates with bursts of negative polarity spikes in the ipsilateral hippocampus.The identification of the hippocampal correlate of the 14&6/sec positive spikes variant fills a gap in our knowledge of normal intracranial variants. In clinical practice, this knowledge should reduce the chance that this electrophysiological signature is misinterpreted as epileptiform activity, which could inappropriately influence the interpretation of the intracranial study and subsequent surgical recommendation.

Validity and reliability of the QOLIE-10 instrument for assessing health related quality of life in epilepsy of refractory epilepsy adult patients at a Colombian neurological center

To determine feasibility, reliability and validity of the shortened version of the Quality of Life in Epilepsy Inventory-10 (QOLIE-10) in a population of refractory epilepsy adult patients in the Colombian Caribbean. Data were collected from 63 adult refractory epilepsy patients. The ten items of QOLIE-10 were derived from the Spanish version of QOLIE-89. We assess feasibility, validity, factorial analysis with communalities, reliability through internal consistency and sensitivity to change. Clinical and demographic features were determined; quality of life was established through frequencies. Construct validity: through factor analysis communalities there were no items considered irrelevant and were grouped into one single dimension. Kaiser-Meyer-Olkin: 0.891. Bartlett's test of sphericity: p < 0.001. Average intraclass correlation coefficient 0.843. The internal consistency reliability coefficient (Cronbach's alpha) was 0.98. The QOLIE-10 questionnaire for the assessment of health-related quality of life was validated in Spanish for adult patients with refractory epilepsy with excellent validity, reliability parameters and easy, quick filling. The QOLIE-10 questionnaire is a valid and reliable tool for use in adult patients with refractory epilepsy in Colombia. Health professionals are encouraged to use this questionnaire to routinely examine the influences of the disease process in epilepsy patients.

Chapter 11 - Video-EEG

Indications for video-EEG monitoring (VEM) include differential diagnosis of paroxysmal events including epileptic seizures, organic nonepileptic seizures, and psychogenic nonepileptic seizures; classification of seizure types and electroclinical syndromes; quantification of seizures and of interictal and ictal epileptiform discharges; and presurgical evaluation in medically refractory epilepsy patients. Standardized questionnaires and examinations should be used on admission to the epilepsy monitoring unit (EMU). Patients should be provided with comprehensive information concerning purpose and procedures during VEM and need to sign informed consents. Staff working in the EMU needs to be properly trained in the management of seizures and periictal testing according to written protocols as well as in cardiopulmonary resuscitation. Minimum staffing ratios of dedicated healthcare professionals to patients have been recommended. Antiepileptic drug tapering/withdrawal needs to be individualized for each patient. EEG recordings have to be performed according to established guidelines. Cardiorespiratory monitoring including continuous ECG monitoring and continuous measurement of oxygen saturation is strongly recommended. Patient safety is of utmost importance during VEM. Indicators for reporting quality and safety have been developed. Standardized ictal testing protocols and standardized computer-based organized reporting should further improve standards of VEM and training of EMU staff, and facilitate data exchange and collaborations between EMUs.

Bilateral insular functional connectivity in epilepsy patients: A cortico-cortical evoked potential study

Objective To explore bilateral insular functional connectivity in refractory epilepsy patients using electrical cortical stimulation by stereoelectroencephalography (SEEG) electrodes. Methods We retrospectively analyzed the clinical data of 4 patients with insular or insular-related drug resistant epilepsy at Epilepsy Center of Yuquan Hospital of Tsinghua University from January 2014 to August 2016. Four patients were implanted with SEEG electrodes in bilateral insular lobes for cortical electrical stimulation. The evoked potential response of each contact was determined by visual analysis and nonparametric test. The evoked potential response was recorded at the contralateral insular lobe electrode on the stimulating side, and the response rate and anatomical distribution were determined. Results A total of 28 SEEG electrodes (98 contacts) were implanted into the insular lobe in 4 patients, of which 12 electrodes (47 contacts) were implanted into the left insular lobe. Cortical-cortical evoked potential (CCEP) responses were found between bilateral insular lobes in 4 patients, and homotopic bidirectional CCEP connections were found between bilateral insular lobes. The response rate of contralateral insular CCEP was 39.8%, and the peak latency was 15.5-196.0 ms. There were bi-directional CCEP connections between corresponding bilateral insular gyri. Conclusions There are bi-directional functional connections between bilateral insular lobes in patients with insular or insular-related epilepsy, particularly in patients with post-viral encephalitis epilepsy. However, more studies are needed to confirm this result. Key words: Epilepsy; Insular; Stereoelectroencephalography; Electrical cortical stimulation; Cortico-cortical evoked potential

Comprehensive analysis of presurgical factors predicting psychiatric disorders in patients with refractory temporal lobe epilepsy and mesial temporal sclerosis underwent cortico-amygdalohippocampectomy.

BackgroundThis study aimed to evaluate the predictive value of presurgical factors for psychiatric disorders (PD) in refractory temporal lobe epilepsy and mesial temporal sclerosis (TLE‐MTS) patients underwent cortico‐amygdalohippocampectomy (CAH).MethodsA total of 98 refractory TLE‐MTS patients underwent CAH were consecutively enrolled in this cohort study. Several presurgical factors were recorded, such as married status, employment status, highest education, disease duration, family history of epilepsy, and disorganized VEEG background activity.ResultsThere were 17 (17.3%) refractory TLE‐MTS patients occurring PD after CAH, including 8 (8.2%) mood disorders, 7 (7.1%) anxiety disorders, 8 (8.2%) psychoses, and 1 (1.0%) interictal dysphoric disorder. Employed status correlated with low PD occurrence, while disease duration and asymmetric VEEG background activity positively correlated with PD occurrence. Multivariate logistic analysis revealed employed status (P = 0.009) could independently predict lower PD occurrence, while highest education (P = 0.027), disease duration (P = 0.028), seizure frequencies (P = 0.015), and asymmetric VEEG background activity (P = 0.034) could independently predict higher PD occurrence. Receiver operating characteristic curve showed combination of these five factors (area under curve (AUC) = 0.871, 95%CI: 0.783‐0.960) disclosed a great predictive value of PD occurrence. The sensitivity and specificity were 70.6% and 92.6% at the best cutoff point. In addition, the percentage of PD was increased with higher Engel classification (P = 0.003).ConclusionEmployed status, highest education, disease duration, seizure frequencies, and asymmetric VEEG background activity correlate with PD occurrence independently in epileptic patients.

Stereoelectroencephalography-Guided Laser Ablations in Patients With Neocortical Pharmacoresistant Focal Epilepsy: Concept and Operative Technique.

Laser ablation surgery has had encouraging results in the treatment of multiple intracranial diseases including primary and metastatic brain tumors, radiation necrosis, and epilepsy. The use of the stereoelectroencephalography (SEEG) method in combination with laser thermocoagulation therapy with the goal of modulating epileptic networks in patients with neocortical nonlesional phamacoresistant epilepsy has not been previously described. To describe the novel methodological and conceptual aspects related to SEEG-guided laser ablations in patients with magnetic resonance imaging (MRI)-negative pharmacoresistant neocortical focal epilepsy. Guided by previous SEEG intracranial data, a laser ablation probe was inserted by using a robotic guidance device in a 17-yr-old medically refractory epilepsy patient with difficult to localize seizures and nonlesional MRI. The laser applicator position was confirmed by MRI, targeting the left mesial rostral superior frontal gyrus. The ablation was performed under multiplanar digital imaging views and real-time thermal imaging and treatment estimates in each plane. A postablation MRI (contrasted T1 sequence) confirmed the ablation's location and size. The entire procedure was achieved in approximately 100 min. The actual ablation was performed in less than 3 min. Approximately, additional 30 min preoperatively were used for positioning and robot registration. Precise placement of laser application (in comparison with preplanned trajectories) was achieved using the robotic guidance and confirmed by the intraoperative magnetic resonance images. No complications were reported. The patient has been seizure-free since surgery. The follow-up period is 20 mo. Two additional patients, treated with similar methodology, are also described. The preliminary experience with the described method shows the feasibility of a unique combination of the SEEG methodology with laser thermocoagulation in patients with neocortical MRI-negative pharmacoresistant focal epilepsy.