Remote Symptomatic Etiology Research Articles

Etiology, Clinical Profile, and Outcome of Unprovoked Seizure in Children: A Prospective Observational Study from Eastern India

Abstract Background: Unprovoked seizures in children refer to seizures that occur without an immediate precipitating factor, such as fever, infection, or head injury. These seizures are often a manifestation of an underlying neurological condition and can be indicative of epilepsy if recurrent. Understanding the causes, diagnosis, and treatment options for unprovoked seizures in children is crucial for proper management and care. Materials and Methods: This prospective observational study was carried out in the pediatrics department of a tertiary care teaching hospital over a period of 2 years. A total of 85 children aged <14 years were included in this study. All the data related to demography, clinical and laboratory parameters, and treatment outcomes were recorded. Descriptive statistics were used to analyze and report the data. Results: In the present study, 5-10 year age group constituted the majority with male dominance. Generalized seizure was the most common type. The complex partial seizure was common in the remote symptomatic group than in the idiopathic seizure (IS) group. History of febrile seizure was present in <10% of cases. Around 16.5% of cases had developmental delay or mental retardation. Status epilepticus at presentation was seen in 36.37% of cases, and 37.65% were newly diagnosed epilepsy. Neurocysticercosis alone accounted for 14.12% of all cases and euro-tuberculosis alone accounted for 12.94% of all cases of unprovoked seizure. Seizure recurrence was common in the idiopathic group, complex partial seizure type, and those not taking an antiseizure medication (ASM). Conclusions: Unprovoked seizure is a common problem in children. IS/cryptogenic seizure is more common than remote symptomatic etiologies. Electroencephalogram and neuroimaging should be done in all cases. Seizure recurrence was common in the idiopathic group, complex partial seizure type, and those not taking an ASM.

First seizure from sleep: Clinical features and prognosis.

Patients with a first-ever unprovoked seizure commonly have subsequent seizures and identifying predictors of recurrence has important management implications. Both prior brain insult and epileptiform abnormalities on electroencephalography (EEG) are established predictors of seizure recurrence. Some studies suggest that a first-ever seizure from sleep has a higher likelihood of recurrence. However, with relatively small numbers and inconsistent definitions, more data are required. Prospective cohort study of adults with first-ever unprovoked seizure seen by a hospital-based first seizure service between 2000 and 2015. Clinical features and outcomes of first-ever seizure from sleep and while awake were compared. First-ever unprovoked seizure occurred during sleep in 298 of 1312 patients (23%), in whom the 1-year cumulative risk of recurrence was 56.9% (95% confidence interval [CI] 51.3-62.6) compared to 44.2% (95% CI 41.1-47.3, p < .0001) for patients with first-ever seizure while awake. First-ever seizure from sleep was an independent predictor of seizure recurrence, with a hazard ratio [HR] of 1.44 (95% CI 1.23-1.69), similar to epileptiform abnormalities on EEG (HR 1.48, 95% CI 1.24-1.76) and remote symptomatic etiology (HR 1.47, 95% CI 1.27-1.71). HR for recurrence in patients without either epileptiform abnormalities or remote symptomatic etiology was 1.97 (95% CI 1.60-2.44) for a sleep seizure compared to an awake seizure. For first seizure from sleep, 76% of second seizures also arose from sleep (p < .0001), with 65% of third seizures (p < .0001) also from sleep. Seizures from sleep were less likely to be associated with injury other than orolingual trauma, both with the presenting seizure (9.4% vs 30.6%, p < .0001) and first recurrence (7.5% vs 16.3%, p = .001). First-ever unprovoked seizures from sleep are more likely to recur, independent of other risk factors, with recurrences also usually from sleep, and with a lower risk of seizure-related injury. These findings may inform treatment decisions and counseling after first-ever seizure.

Clinical, etiological profile and outcomes of convulsive refractory and non-refractory status epilepticus at a tertiary care centre

Introduction: Epidemiological data on childhood status epilepticus (SE) limited in India. This study depicts clinical profiles, etiology, and outcomes of convulsive refractory SE (RSE) and compares the results with cases of nonrefractory SE (NRSE). Subjects and Methods: This observational, cross-sectional study enrolled 300 children aged 1 month to 18 years, presenting with convulsive SE at a tertiary care hospital. Details of children who progressed to RSE were compared to those without RSE. Results: In the acute symptomatic etiology group, common causes for RSE were central nervous system infections (33.8%), cryptogenic etiology (13.8%), and remote symptomatic etiology (7%). RSE iwas associated with a higher rate of complications (58% Vs 24%) as compared to NRSE. Thirty percent of cases that progressed to RSE needed ventilator support as compared to only 8% of cases in the NRSE group. RSE was also associated with higher rates of shock (25%), AKI (16%), transaminitis (25%), acute liver failure (5.69%), multiple organ dysfunction score (12.6%), and acidosis (53%) as compared to NRSE. RSE was associated with higher mortality (28%) and morbidity (32%) as compared to NRSE cases. Cryptogenic etiology led to the highest mortality (33.3%) in cases of RSE while acute symptomology was associated with the highest morbidity (62%). Conclusions: RSE is a serious pediatric emergency that requires prompt recognition and management. Clinical knowledge and early administration of appropriate antiepileptic drugs at health-care facilities is the key to reduce morbidity and mortality.

TOPOGRAPHIC RELATIONSHIPS OF MORPHOLOGICALLY HETEROGENEOUS ORGANS IN REACTIONS TO DEPLETED URANIUM

Annotation: Researches of the effect of radionuclides on the human body remain relevant up to date. Their effect of penetrating the body is characterized by involvement of numerous systems of human body. The causal significance of the effects of depleted uranium exposure has not been specifically defined, however, people who live in zones of armed conflict, as well as armed forces personnel, had health problems of "unknown origin", and with remote symptomatic etiology. The risk of possible exposure is also may appear when manufacture of nose spikes for armor piercers and atomic energetics products. In view of these perspectives, depleted uranium, which used in various types of weapons, has been considered as the cause of complaints. Acute uranium intoxication is appeared in polytropic effect that is apparently depended on the resistance of the body. Getting into the internal milieu, depleted uranium exhibits radiation effect of exposure followed by alpha particles radiation. Long-term consequences after oral incorporation of depleted uranium with drinking water are matters of particular interest. The study purpose is defined by assessing of morphofunctional state of the trachea and thyroid gland, united by topographic proximity and different by morphological heterogeneity, upon one month after a single oral incorporation of an aqueous solution of depleted uranium oxides. General histological and histochemical staining methods on thin paraffin slices have been performed for studying on morphological and functional state of the trachea and thyroid gland The results of the morphological and statistical analysis of the trachea wall upon staining with hematoxylin and eosin revealed changes in the structural components that determined deformation of its functionality a month after oral incorporation of an aqueous solution of depleted uranium oxides. Morphological diagnosis was characterized by a change thickness of the epithelial layer, its multi-rowed structure, the cellular composition of the epithelium, and the loss of special organelles. Modifying effect of depleted uranium is also extended to the glandular epithelium with exposure of secretory segments hypertrophy and excretory ducts. There was revealed the diffuse lymphocyte infiltration of the tracheal membranes and formation of lymph nodules. Histochemical analysis of hormone formation in the thyroid gland has demonstrated a change in the ratio of follicles according to the degree of iodization of colloid amino acids with accurate predomination of non-iodized amino acids of irregular shape with accurate smaller diameter against target parameters, with flat or low cubic epithelium, indicating a decrease of gland functionality. The bioeffect of depleted uranium, independently from organ implementation and tissue organization, was prolonged indicating a functional inability.

Recurrent status epilepticus: Clinical features and recurrence risk in an adult population.

Knowledge regarding consequences among status epilepticus (SE) survivors is still scarce. We assessed the risk of recurrence in a cohort of first-ever adult SE survivors, comparing the clinical features of patients with recurrent and incident events. We reviewed our prospective register of consecutive SE patients, from September 1st 2013 to September 1st 2020. We excluded post-anoxic events and those patients with a SE prior the study period. We examined the effect of clinical predictors on the risk of subsequent SE through Cox proportional hazard regression, while the risk of recurrence was estimated through a survival analysis. 430 patients were considered (mean follow-up: 23.3 months). 44 patients experienced SE recurrence, whereas 386 patients presented an isolated event. The highest risk of recurrence was observed within 6 months from the index event (7.9%), whereas the cumulative recurrence rate was 9.5%, 13%, and 20.5% at 6 months, 1 year, and 4-years respectively. SE recurrence was independently associated to remote (HR 2.8 - 95% CI 1.4 to 6.0) or progressive symptomatic etiologies (HR 3.9 - 95% CI 1.8 to 8.7) and it was higher for Super-Refractory SE (SRSE) cases (HR 3.3 - 95% CI 1.4 to 7.8). High STESS values (p=0.01) and SE refractoriness (p=0.01) were associated with early relapses (within 6 months from the index event). SE recurrence involved a significantly proportion of our cohort. Etiology other than acute symptomatic and SRSE were independently associated with a higher risk of recurrence, in particular within 6 months from the index event.

Role of cerebrospinal fluid tau protein levels as a biomarker of brain injury in pediatric status epilepticus

Background Various biomarkers have been studied for predicting etiology and outcome in status epilepticus (SE); cerebrospinal fluid (CSF) total tau (t-tau) protein levels is foremost among them. Only handful of studies are available regarding role of t-tau in childhood SE. Methodology This prospective study was conducted in a tertiary care center of Northern India in children 6 months −12 years of age. The Cases were patients with convulsive status epilepticus (CSE) whereas Controls were patients without SE and normal CSF. The t-tau levels were done in CSF of both the groups. The outcome was assessed by GOS-E Peds score. Results A total of 50 (62% males) cases and 15 (67% males) controls were enrolled in the study. SE was generalized in 78% cases whereas 14% had refractory SE. Most common etiology of CSE was acute symptomatic (52%), followed by prolonged febrile seizure (24%), remote symptomatic group (14%), unknown etiology (8%) and progressive disorder (2%). Case fatality rate was 10%. Poor outcome was seen in 30% cases. Median (IQR) CSF t-tau levels was significantly lower 2.6 × 103 (0.5–9.4 × 103) pg/ml in cases vs 10.6 × 103 (6.0–14.2 × 103) pg/ml in controls (p = 0.004). There was no significant correlation seen between type, duration, etiology and response to antiepileptic drugs of SE with CSF t-tau levels. Also, no significant correlation of poor sensorium, outcome of SE and critical care needs with CSF t-tau levels was noted. Conclusion CSF t-tau is not a useful diagnostic or prognostic biomarker in pediatric SE.

Clinical phenotypes within nonconvulsive status epilepticus.

The study aimed to identify distinct phenotypes within nonconvulsive status epilepticus (NCSE). Consecutive episodes of NCSE in patients at least 14 years old were included. The level of consciousness was assessed through the Glasgow Coma Scale (GCS). Etiology of NCSE was defined as symptomatic (acute, remote, progressive) or unknown. Electroencephalographic (EEG) recordings were searched for lateralized periodic discharges (LPDs), generalized sharply and/or triphasic periodic potentials (GPDs), and spontaneous burst suppression (BS). According to treatment response, NCSE was classified as responsive, refractory, or superrefractory. Average linkage hierarchical cluster analysis was performed with Pearson correlation as similarity measure. Two hundred twenty‐nine episodes of NCSE were included. Three clusters were identified. The first cluster linked GCS score 3–8, presence of spontaneous BS on EEG, acute symptomatic etiology, and treatment superrefractoriness. The second cluster gathered GCS score 9–12, presence of LPDs or GPDs on EEG, unknown etiology, and treatment refractoriness. The third cluster associated GCS score 13–15, absence of LPDs, GPDs, and spontaneous BS on EEG, and progressive and remote symptomatic etiology with treatment responsiveness. Phenotyping the heterogeneity of NCSE into electroclinical clusters can contribute to understanding correlations between pathologic and clinical domains, assessing the intrinsic severity of NCSE episodes, and estimating the likelihood of treatment responsiveness.

ETIOLOGY, CLINICAL PROFILE AND OUTCOME OF FIRST EPISODE OF SEIZURE IN CHILDREN

Background: Seizure is a commonly encountered problem in pediatric practice. Convulsive disorder constitutes a heterogeneous group with a varied etiology. Arriving at the cause of seizure is important as it plays a vital role in managing the child. Chances of recurrence to be analyzed, after the rst episode of seizure for management. The aim was to study the etiology and the causes of recurrence after a rst episode seizure. A Methods: prospective observational study was done on 135 children for a period of six months admitted in tertiary care center. Proper history, complete neurological and other systemic examinations was done. Blood investigations and imaging with EEG was done when indicated. All children were classied according to International League against epilepsy and followed up for recurrence rate and history leading to recurrence. Co- relation between recurrence and risk factors was analyzed. Electroencephalogram tracing Results: was abnormal in 62 out of 105 children. 19 out of 62 had recurrence while only 2 among 43 normal EEG had recurrence. This was statistically signicant (P value 0.001). Children with remote symptomatic etiology constitutes the majority in those with abnormal EEG tracings. In children with remote symptomatic etiology, only one child had normal EEG. Remote symptomatic had higher number of abnormal EEG when compared to others and was found to have more recurrence. Conclusions: Children with EEG abnormalities after the rst episode of afebrile seizure have more chance of recurrence. Children with seizure secondary to remote symptomatic etiology had more recurrences

Etiology, Risk Factors, Mortality and Morbidity of Status Epilepticus in Children: A Retrospective Cross-Sectional Study in Tehran, Iran

Background:Risk factors identification associated with status epilepticus is valuable in order to prevent morbidity and mortality in children. This study aimed to consider the etiology, risk factors, morbidity and mortality in children with status epilepticus.Methods:This retrospective cross-sectional study was performed on 119 patients aged from one month old to 15 years old. Patients’ data were recorded, including basic demographic, etiology and clinical information. The different risk factors correlated to morbidity and mortality were evaluated in this study.Results:The most common etiologies were acute symptomatic and febrile status epilepticus by 32.8% and 22.7%, respectively. Abnormal brain imaging results were reported far more frequently in patients with a history of neurodevelopmental delay and previous status epilepticus (p&lt;0.001). The overall morbidity and mortality rates were 18.9% and 10.9%, respectively; while these rates in patients with delayed development (45.16% and 18.42%, respectively) were significantly higher than patients with normal development (8% and 7.4%, respectively). The morbidity rates in patients with previous seizures and previous status epilepticus were remarkably higher than those without previous history of seizure (26.41% vs 11.32%; p=0.047) and without previous status epilepticus (36.36%versus14.28%; p=0.018). The length of hospital stay in patients with mortality was considerably longer than patients without mortality (12.30 ± 16.1 days vs 7.29 ± 6.24 days; p=0.033). The mortality rate in patients with normal Lumbar Puncture result was notably lower than those with abnormal LP result (2.9% vs 50%). The morbidity rate in patients with abnormal brain imaging results (p&lt;0.001) was significantly greater than those in patients with normal results. The mortality rate was relatively higher in patients with abnormal imaging results compared to those normal results. Etiology was an important predictor of mortality and morbidity rates; acute symptomatic (32.8%), febrile status epilepticus (22.7%) and remote symptomatic (16.8%) etiologies were the most common underlying causes of S.E. While in children less than 3 years old, the acute symptomatic etiology and febrile status epilepticus etiologies were estimated as the most common, in most patients older than 3 years old the most common etiology of status epilepticus was unknown. Congenital brain defects etiology had the highest mortality (36.36%) and morbidity (42.85%) rate. The lowest morbidity (3.84%) and mortality (0%) rates were for patients with febrile status epilepticus etiology.Conclusion:Age, developmental delay, history of previous status epilepticus, the length of hospital stay, abnormal brain imaging results and the underlying etiology of status epilepticus were associated with increased morbidity and mortality among children with status epilepticus.

Electroencephalography in neonatal epilepsies.

Neonatal epilepsies - neonatal seizures caused by remote symptomatic etiologies - are infrequent compared with those caused by acute symptomatic etiologies. The etiologies of neonatal epilepsies are classified into structural, genetic, and metabolic. Electroencephalography (EEG) and amplitude-integrated EEG (aEEG) are essential for the diagnosis and monitoring of neonatal epilepsies. Electroencephalography / aEEG findings may differ substantially among infants, even within infants with variants in a single gene. Unusual EEG/aEEG findings, such as downward seizure patterns on aEEG, can be found. Neonatal seizures are exclusively of focal onset. An International League Against Epilepsy task force proposed that the seizure type is typically determined by the predominant clinical feature and is classified into motor or non-motor presentations. Ictal EEG usually demonstrates a sudden, repetitive, evolving, and stereotyped activities with a minimum duration of 10s. In epileptic spasms and myoclonic seizures, the cut-off point of 10s cannot be applied. One must always be aware of electro-clinical dissociation in neonates suspected to have seizures. Amplitude-integrated EEG is also useful for the diagnosis and monitoring of neonatal epilepsies but aEEG cannot be recommended as the mainstay because of its relatively low sensitivity and specificity. At present, EEG findings are not pathognomonic, although some characteristic ictal or interictal EEG findings have been reported in several neonatal epilepsies. Deep learning will be expected to be introduced into EEG interpretation in near future. Objective EEG classification derived from deep learning may help to clarify EEG characteristics in some specific cases of neonatal epilepsy.

The relationship between epileptic seizure and melatonin in children

ObjectiveStudies about the relationship between epileptic seizures (ESs) and melatonin are limited in children and have been performed in heterogeneous patient groups and with different methods. In this study, it was planned to investigate this relationship according to seizure and epilepsy characteristics. Material and methodsIn 91 children with ES, serum melatonin levels were measured within half an hour following the seizure and on a seizure-free day. Seizures were categorized according to the diagnosis, semiology, etiology, duration, electroencephalography (EEG) findings, and response to treatment. Melatonin levels were compared between each group and control group. In addition, basal melatonin levels of 21 patients with electrical status epilepticus in sleep (ESES) were compared with a control group. ResultsBasal melatonin levels were found to be lower in children with ESs and ESES group compared with the control group (p < 0.001, p < 0.001). Likewise, similar results were obtained in subgroups except for remote symptomatic etiology, severe EEG findings, and refractory epilepsy. No significant difference was observed between basal and postseizure levels of melatonin. ConclusionThis is the first study to reveal the relationship between ESs and basal melatonin levels according to all the characteristics of seizure and epilepsy in the largest patient group. It also demonstrates the need for more detailed studies on the role of melatonin in the pathogenesis of both ESs and ESES, which may provide a basis for a future treatment.

Neonatal seizures: When semiology points to etiology

ObjectiveThe aim of our study was to evaluate the relationship between seizure semiology and etiological factors in our population of neonates, in pointing out that specific kinds of clinical presentation are strictly related to specific etiologies. MethodsWe selected neonates which presented clinical seizures during video-EEG monitoring performed in Neonatal and Neurological Units between 2010 and 2017. We excluded patients with electrographic seizures only or video-EEGs of poor quality.Seizures were divided into the main subgroups “motor” (focal clonic, focal tonic and myoclonic) and “non motor”. For each patient we evaluated etiology, considering two major categories: acute and remote symptomatic. ResultsThe study included 65 patients, including 44 with an acute symptomatic cause and 21 with remote symptomatic etiology. Focal motor clonic seizures were almost exclusively associated to acute symptomatic etiology (p < 0.05), mainly to stroke and infective causes. Focal motor tonic seizures were the prevalent type of seizures in remote symptomatic etiologies (p < 0.05). They were observed mainly in patients with Developmental Epileptic Encephalopathy. Focal non motor seizures were more represented in acute symptomatic causes (p = 0.01) and were the main type of seizure in HIE. ConclusionsSeizure semiology in neonates may help physicians in the early recognition of specific etiologies. In particular, focal clonic seizures are strongly suggestive of acute symptomatic causes, allowing an early diagnosis and treatment.

A study of clinical profile of intractable epilepsy in children

Background: This study was undertaken to find out the prevalence and clinical features of intractable epilepsy (IE) in a tertiary referral center.Methods: Study was conducted in a tertiary care hospital on 60 children with intractable epilepsy. Cases includes intractable epilepsy is when seizures continue to occur despite maximally tolerated doses of more than two antiepileptics, occurrence of an average of one seizure per month for 18 months with no more than a 3 month seizure free period during these 18 months. Controls: epileptic children who had good control of seizures for the previous 18 months.Results: The prevalence of intractable seizures was 10% with maximum number of children 25 (41.6%) belonged to the 5-12 years. 15 (50%) children had daily seizures. Myoclonic seizures proved to be an important predictor of intractability. 4 children among the cases had history of family seizures, 6 children in cases had history febrile seizure, whereas, 6 children among the controls had history of family seizures, 8 children in controls had history febrile seizure. 23.3% of children presented with Status epilepticus in the cases and 16.6% of the children in the controls. Remote symptomatic etiology 12(40%) is the commonest cause of seizure. 13 (43.3%) children in cases and 3 (10%) children among the controls had a history suggestive of birth asphyxia. EEG was abnormal in 17 (56.6%) cases when compared to 11 (36.6%) children in the controls. CT scan was abnormal in 14 (46.6%) cases and 10 (33.3%) controls. MRI was abnormal in 16 (53.3%) children of the cases and 8 (26.6%) children of the controls.Conclusions: The commonest cause of intractable epilepsy was perinatal asphyxia. Perinatal asphyxia can be prevented by good nutrition during pregnancy, regular antenatal check ups with detection of high risk pregnancy, promoting hospital deliveries and prompt resuscitation of newborn when required.

The effect of early midazolam infusion on the duration of pediatric status epilepticus patients

PurposeStatus epilepticus is one of the most common neurological emergencies in pediatric emergency departments. Although there are different approaches to treatment in the literature, early control of seizure activity is the most important factor determining prognosis. The purpose of this study was to evaluate the effect of early midazolam infusion on seizure duration. MethodThis retrospective study included 150 episodes of 135 patients aged one month to 18 years old with status epilepticus. All patients were treated according to the local hospital protocol for SE, which included early midazolam infusion. Demographic data, medical history, applied treatments during SE, and seizure durations were recorded. ResultsThe median age of the patients (58.7% male) was 2.7 years (1.0–6.0 years). The most common identified etiologies were remote symptomatic etiologies, and generalized tonic-clonic seizure was the most common seizure type. The pediatricians had selected intravenous midazolam for 130 patients (86.7%) as the first-line therapy in emergency services. In 55 patients given continuous midazolam infusion, the cumulative bolus of midazolam was 0.5 mg/kg (0.4–0.7 mg/kg), and the median peak rate of midazolam infusion was 0.2 mg/kg/h (0.2–0.4 mg/kg/h). The median duration between the start of midazolam infusion and the complete cessation of SE was 15.0 min (9.0–25.0 min). The early-midazolam infusion group had shorter seizure duration after initiation of midazolam infusion (p = 0.020). ConclusionThe current study shows that aggressive management of SE with early initiation of midazolam infusion was associated with a shorter seizure duration in SE patients.

Etiology, clinical profile and outcome of first episode of seizure in children

Background: Seizure is a commonly encountered problem in pediatric practice. Convulsive disorder constitutes a heterogeneous group with a varied etiology. Arriving at the cause of seizure is important as it plays a vital role in managing the child. Chances of recurrence to be analyzed, after the first episode of seizure for management. The aim was to study the etiology and the causes of recurrence after a first episode seizure.Methods: A prospective observational study was done on 135 children for a period of two months admitted in tertiary care center. Proper history, complete neurological and other systemic examinations was done. Blood investigations and imaging with EEG was done when indicated. All children were classified according to International League against epilepsy and followed up for recurrence rate and history leading to recurrence. Co- relation between recurrence and risk factors was analyzed.Results: Electroencephalogram tracing was abnormal in 62 out of 105 children. 19 out of 62 had recurrence while only 2 among 43 normal EEG had recurrence. This was statistically significant (P value 0.001). Children with remote symptomatic etiology constitutes the majority in those with abnormal EEG tracings. In children with remote symptomatic etiology, only one child had normal EEG. Remote symptomatic had higher number of abnormal EEG when compared to others and was found to have more recurrence.Conclusions: Children with EEG abnormalities after the first episode of afebrile seizure have more chance of recurrence. Children with seizure secondary to remote symptomatic etiology had more recurrences.

Status epilepticus in the elderly: Comparison with younger adults in a comprehensive community hospital

PurposePrevious studies on status epilepticus (SE) in the elderly were conducted in tertiary centers. We aimed to delineate the features and outcomes of elderly SE patients by comparing them to those of younger patients in a comprehensive community hospital providing primary to tertiary care. MethodsWe retrospectively investigated 197 consecutive adult SE patients admitted to our hospital. The clinical, electroencephalography, and diffusion-weighted imaging (DWI) findings of 112 elderly patients (aged ≥65 years) were compared to those of 85 younger patients (aged <65 years). ResultsCompared to that in younger patients, SE in elderly patients more frequently presented de novo (68.8% vs. 52.9%, p = 0.02); was less likely to be tonic-clonic (55.4% vs. 83.5%, p < 0.001) but more likely to be focal motor (36.6% vs. 12.9%, p < 0.001); and was more frequently refractory (30.4% vs. 14.1%, p = 0.008), particularly refractory nonconvulsive SE (13.4% vs. 4.7%, p = 0.04). Lateralized periodic discharges on electroencephalography (20.9% vs. 4.8%, p = 0.001) and SE-associated hyperintensities on DWI (27.8% vs. 13.6%, p = 0.03) were more common in the elderly than in the younger SE patients. The mortality rates did not significantly differ between the groups (6.3% vs. 3.5%, p = 0.52). The percentage of poor functional outcomes did not significantly differ between the groups in cases with acute symptomatic etiology (52.0% vs. 45.7%, p = 0.63), but was higher in elderly patients with remote symptomatic and cryptogenic etiologies (33.3% vs. 12.0%, p = 0.006). ConclusionsSE in the elderly differed from that in younger adults in the semiology, refractoriness, electroencephalography and DWI findings, and functional outcome. Outcomes were better than previously reported.

Risk of recurrence after a first unprovoked seizure in children

ObjectivesThis study aimed to evaluate the first episode of unprovoked epileptic seizure in children and assess recurrence risk factors. MethodsThis was a retrospective observational study, based on the analysis of medical records of patients admitted between 2003 and 2014, with first epileptic seizure, at the pediatric service of a secondary hospital. The data were analyzed using the SPSS 20.0 program. ResultsOf the 103 patients, 52.4% were boys. The median age at the first seizure was 59 (1‐211) months. About 93% of children were submitted to an electroencephalogram (EEG) at the first episode and 47% underwent neuroimaging assessment. Treatment with an antiepileptic drug was started in 46% of patients. The recurrence rate was 38% and of these, 80% had the second seizure within six months after the first event. Of the assessed risk factors, there was a statistically significant association between seizure during sleep and recurrence (p=0.004), and between remote symptomatic etiology seizure and occurrence of new seizure (p=0.02). The presence of EEG abnormalities was also associated with the occurrence of new seizures (p=0.021). No association was found between age, duration of the seizure, and family history of epilepsy with increased risk of recurrence. ConclusionsMost children with a first unprovoked epileptic seizure had no recurrences. The risk of recurrence was higher in patients with seizure occurring during sleep or remote symptomatic ones and those with abnormal EEG results.

Risk of recurrence after a first unprovoked seizure in children

ObjectivesThis study aimed to evaluate the first episode of unprovoked epileptic seizure in children and assess recurrence risk factors. MethodsThis was a retrospective observational study, based on the analysis of medical records of patients admitted between 2003 and 2014, with first epileptic seizure, at the pediatric service of a secondary hospital. The data were analyzed using the SPSS 20.0 program. ResultsOf the 103 patients, 52.4% were boys. The median age at the first seizure was 59 (1–211) months. About 93% of children were submitted to an electroencephalogram at the first episode and 47% underwent neuroimaging assessment. Treatment with an antiepileptic drug was started in 46% of patients. The recurrence rate was 38% and of these, 80% had the second seizure within six months after the first event. Of the assessed risk factors, there was a statistically significant association between seizure during sleep and recurrence (p=0.004), and between remote symptomatic etiology seizure and occurrence of new seizure (p=0.02). The presence of electroencephalogram abnormalities was also associated with the occurrence of new seizures (p=0.021). No association was found between age, duration of the seizure, and family history of epilepsy with increased risk of recurrence. ConclusionsMost children with a first unprovoked epileptic seizure had no recurrences. The risk of recurrence was higher in patients with seizure occurring during sleep or remote symptomatic ones and those with abnormal electroencephalogram results.

Predictors of Poor Seizure Control in Children Managed at a Tertiary Care Hospital of Eastern Nepal.

Various factors have been claimed to predict outcome of afebrile seizures in children. This study was aimed to find out the predictors of poor seizure control in children at a resource limited setting. This prospective study was done from July 1st, 2009 to January 31st, 2012 at B.P. Koirala Institute of Health Sciences, Nepal. Children (1 month-20 yr of age) with afebrile seizures presenting to pediatric neurology clinic were studied. Significant predictors on bivariate analysis were further analyzed with binary logistic model to find out the true predictors. Positive predictive values (PPVs) and negative predictive values (NPVs) for the true predictors were calculated. Out of 256 patients (male: female ratio 3:2) with afebrile seizures followed up for median duration of 27 (IQR 12-50) months, seizure was poorly controlled in 20% patients. Three factors predicted poor seizure control. They were frequent (≥1 per month) seizures at onset (OR 12.76, 95% CI 1.44-112.73, PPV 25%, NPV 98%); remote symptomatic etiology (OR 3.56, 95% CI 1.04-12.17, PPV 36%, NPV 92%); and need of more than one anticonvulsant drug (polytherapy) (OR 12.83, 95% CI 5.50-29.9, PPV 56%, NPV 96%). The strongest predictor was need of polytherapy. When all three factors were present, PPV and NPV for prediction of poor seizure control were 70% and 90% respectively. Frequent seizures at onset, remote symptomatic etiology of seizure and need of polytherapy were associated with poor seizure control in children with afebrile seizures.

An audit of the predictors of outcome in status epilepticus from a resource-poor country: a comparison with developed countries.

Status epilepticus is a neurological emergency with significant morbidity and mortality. This study describes the clinical profile, treatment, and predictors of outcome of status epilepticus in a tertiary referral centre in a developing country and aims to highlight the similarities and differences from data available from the western world. A retrospective analysis of data of patients treated for status epilepticus was conducted from prospectively maintained records, between January2000 and September2010. The demographic data, clinical profile and investigations (including neuroimaging and EEG), aetiology, treatment, and outcomes were studied and compared with data available from the western world. The analysis included 108 events in 84 patients. A single episode of status epilepticus was treated in 72 patients (86%) and multiple status epilepticus events, ranging from two to six per patient, were managed in 12 patients (14%). Mean age was 24.1±20.3 years and 63% were males. The types of status epilepticus included convulsive status in 98 (90.7%), non-convulsive status in seven (6.5%), and myoclonic status in three (2.8%). The majority of events (60%) were remote symptomatic, 16% were acute symptomatic, 16% were of unexplained aetiology, and 8% were progressive symptomatic. In 85 events (79%), status epilepticus could be aborted with first and second-line drugs. The remaining 23 events (21%) progressed to refractory status epilepticus, among which, 13 (56%) were controlled with continuous intravenous midazolam infusion. Case fatality rate was 11%, neurological sequelae were reported in 22%, and 67% returned to baseline. Acute symptomatic status, older age, altered sensorium at the time of admission, and delayed hospitalisation were predictors of poor outcome. Aetiology was the most important determinant of outcome of status epilepticus, as in reports from the western world, with remote symptomatic aetiology secondary to gliosis being the most common. Treatment delay was frequent and adversely affected the outcome.