Resistant Epilepsy Research Articles

Centromedian thalamic nucleus with or without anterior thalamic nucleus deep brain stimulation for epilepsy in children and adults: A retrospective case series

The centromedian (CM) and anterior nucleus of the thalamus (ANT) are deep brain stimulation (DBS) targets for management of generalized, and focal drug resistant epilepsy (DRE), respectively. We report on a single center retrospective case series of 16 children and adults with DRE who underwent CM with simultaneous ANT (69 %) or CM without simultaneous ANT DBS (31 %). Seizure frequency, epilepsy severity, life satisfaction, and quality of sleep before and after DBS were compared. Baseline median seizure frequency was 323 seizures per month (IQR, 71–563 sz/mo). Median follow up time was 80 months (IQR 37–97 mo). Median seizure frequency reduction was 58 % (IQR 13–87 %, p = 0.002). Ten patients (63 %) reported ≥50 % seizure frequency reduction. Median seizure frequency reduction and responder rate were not significantly different for CM + ANT versus CM only. Seizure severity and life satisfaction were significantly improved. Three patients (19 %) developed device-related side effects, 2 of them (12.5 %) required surgical intervention. In a heterogenous population of children and adults with generalized, multifocal, posterior onset, and poorly localized DRE, CM with or without ANT DBS is feasible, relatively safe and is associated with reduced seizure frequency and severity, as well as improved life satisfaction.

Cognitive and behavioral effects of cannabidiol in patients with treatment-resistant epilepsy

PurposeTherapeutic use of cannabidiol (CBD) in intractable epilepsies has increased considerably over the last ten years. As more evidence for the potentially beneficial effects of CBD on different epilepsy types is emerging, it is important to monitor potential cognitive and behavioral side effects. So far, studies including standardized neuropsychological data in the context of treatment with CBD in epilepsy patients are sparse. The present open-label study examines cognitive and behavioral effects of CBD in children and adults with treatment resistant epilepsy. MethodThirty-nine patients with treatment-resistant epilepsy completed the study protocol, i.e. they were tested at baseline (T0) and after three months of CBD treatment (T1). Patients completed standardized neuropsychological tests on memory, executive functions and attention if they were capable. For cognitively impaired patients who could not complete cognitive tests, caregiver interviews were conducted and caregiver questionnaires completed. ResultsSignificant cognitive decline from T0 to T1 was observed on none of the included measures. There was a significant improvement on a measure of selective attention and on a caregiver-rated behavioral measure. More than 89% of all individual test results remained stable or showed reliable improvement from T0 to T1. Cognitive and behavioral changes from T0 to T1 were not significantly correlated with CBD dose. Improvements in short-term/working memory were significantly related to better therapy response. ConclusionNo adverse group-level effects of CBD treatment were detected. On an individual level, most test results remained stable or were improved. Cognitive change was not related to CBD dose. The present results show that, from a cognitive and behavioral point of view, CBD seems to have an encouraging side-effect profile. The results need to be replicated with larger samples.

Efficacy and Tolerability of Rufinamide in Epileptic Children Younger Than 4 Years.

Rufinamide, a triazole derivative, is a new-generation antiseizure medication with a novel mechanism of action. We evaluated the efficacy and safety of rufinamide treatment in children with epilepsy younger than 4 years at our center. In this retrospective study, we included children younger than 4 years who had pharmacologically resistant epilepsy and were treated with rufinamide at Boston Children's Hospital between June 2010 and June 2018. Safety and efficacy of rufinamide treatment were assessed immediately prior to initiation of rufinamide and at the last follow-up visit. Responders were defined as patients who had greater than 50% reduction in seizure frequency on follow-up as compared to baseline. We reviewed records of 128 children and included 103 with complete information. Patients consisted of 60 boys (58%), with a median age of 20 months (interquartile range 13-28, range 2-36). Median treatment duration was 15 months, and median rufinamide dosage at the last follow-up was 42 mg/kg/d (interquartile range 34-56). At the last follow-up, seizure frequency decreased (450 vs 90, P<.001) and overall seizure reduction was 54%. Fifty-one patients (49.5%) were responders with 94% seizure reduction, including 20 (19.4%) who achieved seizure freedom. Treatment retention rate at 12 months was 63%. Thirty patients (29%) developed adverse events and 41 patients (39.8%) discontinued rufinamide because of adverse events (15; 14.5%) and lack of efficacy (26; 25%). Rufinamide is effective in reducing seizure frequency in pediatric epilepsy patients younger than 4 years, and overall well tolerated.

Impact of ictal subtraction SPECT and PET in presurgical evaluation.

To assess the relative contribution of ictal subtraction single-photon emission computed tomography (ISSPECT) and 18 F-fluorodeoxyglucose positron emission tomography computed tomography (PET) in epilepsy surgery decision making. A retrospective 3-year study of consecutive patients with resistant focal epilepsy who underwent ISSPECT and PET to evaluate to what extent these modalities influence decisions in epilepsy surgery and outcomes. ISSPECT imaging was performed in 106 patients and 58 (55%) had PET also. The clinical consensus (ClinC) was the final arbiter for decisions. Post-surgical outcomes were collected from follow-up clinics. Non-parametric statistics were used to assess association and logistic regression to evaluate prediction of outcomes. Of 106 patients, 60 were males (57%). MRI was non-lesional in 46 (43%). Concordance with ClinC was seen in 80 patients (76%) for ISSPECT, in 46 patients (79%) for PET, and in 37 patients (64%) for ISSPECT + PET. Fifty-six patients (53%) were planned for intracranial video-electroencephalography monitoring (IVEM). Those with ClinC-PET concordance were likely to proceed to IVEM (p=0.02). ClinC-PET concordance and ClinC-ISSPECT concordance did not predict decision to proceed to surgery, but VEM-MRI concordance did in lesional cases (p=0.018). Forty-five (42%) underwent surgery of which 29 had minimum follow-up for 1year (mean, 20months; SD, 8) and 22 (76%) had Engel class I outcomes. ClinC-ISSPECT concordance (p=0.024) and VEM-MRI concordance (p=0.016) predicted Engel class I outcomes. Those with ClinC-PET concordance were more likely to proceed with IVEM. ClinC-ISSPECT concordance and VEM-MRI concordance predicted good surgical outcomes.

Resistant Temporal Lobe Epilepsy: Initial Steps into a Bigger Epilepsy Surgery Program.

Background Among the patients of drug-resistant epilepsy, a subset which has focal impaired seizures localizes to the temporal lobe region (TLE). A majority of these cases are surgically amenable with anterior-medial temporal lobe resection or “lesionectomy.” Objective In India, there is scarcity of “specialized centers” providing “comprehensive epilepsy care” and this dearth is further worse in populous states. In this article, we share our single center, observational, and retrospective experience of TLE in background of limited resources and utmost requirement. Methodology Our study is a retrospective analysis medically refractory epilepsy patients (2016–2019). Patients with medically refractory epilepsy were selected based upon our noninvasive protocol (clinical semiology, interictal scalp electroencephalography (EEG), long-term video EEG monitoring data, and magnetic resonance injury [MRI]). The follow-up was noted from the last out-patient visit record or through telephonic conversation (International League Against Epilepsy score). Results Of 23 cases of TLE ( n = 7, mesial temporal sclerosis; n = 16 temporal lobe like cavernomas, tumors, or arterio-venous malformations). Single photon emission computed tomography/positron emission tomography (SPECT/PET) was performed in five cases (three cases of ictal/interictal SPECT and two cases of PET scan) where there was discordance between EEG/clinical and MRI. The median follow-up was of 19 months with 18 cases being seizure free. Five cases were fully off the antiepileptic drug (AEDs) while in 15 cases, the AEDs dosages or the number were reduced. Average number of AEDs reduced from 2.9 in preoperative period to 1.2 postoperatively. Two cases had quadrantanopia and one case of cerebrospinal fluid leak. Conclusion A multidisciplinary and holistic approach is required for best patient care. The results of our initial surgical experience are encouraging.

Cannabis: are there any benefits?

Cannabis has been used as a medicine for millennia. Prohibition in the mid-20th century precluded early scientific investigation. 'Cannabis' describes three separate forms - herbal cannabis, 'hemp' products, pharmaceutical-grade regulated cannabinoid-based medical products (CBMP). In Australia, CBMP became available for prescription in November 2016. Herbal cannabis with Δ9-tetrahydrocannabinol (THC), which is illegal, and cannabidiol (CBD) in herbal extracts, are both unregulated and unreliable sources of cannabinoids. The endocannabinoid system (ECS), delineated in the late 1990s, has increased the understanding and interest in research for appropriate clinical indications. The ubiquitous ECS has homeostatic and anti-inflammatory effects and comprises cannabinoid receptors, endocannabinoids and degrading enzymes. Phytocannabinoids are partial agonists of the ECS. In pre-clinical studies, THC and CBD produce beneficial effects in chronic pain, anxiety, sleep and inflammation. Systematic reviews often conflate herbal cannabis and CBMP, confusing the evidence. Currently large randomised controlled trials are unlikely to be achieved. Other methodologies with quality end-points are required. Rich, valuable high-quality real-world evidence for the safe and effective use of CBMP provides an opportunity to examine benefits and potential harms. Evidence demonstrates benefit of CBMP in multiple sclerosis, chronic neuropathic pain, chemotherapy induced nausea and vomiting, resistant paediatric epilepsy, anxiety and insomnia. CBMP are well tolerated with few serious adverse events. Additional clinical benefits are promising in many other resistant chronic conditions. Pharmaceutical grade prescribed CBMP has proven clinical benefits and provides another clinical option in the physician's pharmacopeia.

Electrographic pattern recognition: A simple tool to predict clinical outcome in children with lissencephaly

PurposeTo describe and correlate the clinical, radiological and EEG findings in children with lissencephaly. MethodRetrospective record analysis of children with lissencephaly presenting to tertiary health centre in Northern India was performed. Radiological classification and severity scoring were done. EEG findings were categorized into three patterns and its association with clinical severity was studied. ResultsTwenty-eight children (males = 17) with lissencephaly were enrolled. Median age at diagnosis was 6.5months (range 3days-3years). Global developmental delay (median social quotient (SQ) = 25 (range15−68) was seen in all; motor deficits in 23 (82 %); epilepsy in 21 (75 %); behavioural problems in 18 (64 %); ophthalmic problems in 17 (61 %); microcephaly in 13 (46 %); feeding difficulty in 12 (43 %). Radiologically, classical Type I lissencephaly was seen in 18(64 %), cobblestone variant (Type II) in 5 (18 %) and microlissencephaly in 5 (18 %). Grade 4 (diffuse pachygyria) radiologic severity was most common (severity grade 1–6); no cases with severity score 5 or 6 were seen. The clinical profile did not correspond with radiological severity grading. EEG pattern recognition revealed pattern I in 14 (50 %); pattern II in 6 (21 %); pattern III in 8 (29 %). Children with pattern III EEG had drug resistant epilepsy and severe developmental delay. No relationship between EEG patterns and radiological severity grading was evident. ConclusionEEG is better predictor of clinical status and outcome rather than radiological severity grading. EEG pattern III is associated with severe developmental delay and drug resistant epilepsy.

Ketogenic diet experience at Ondokuz Mayıs University.

The ketogenic diet(KD) is a special diet that is rich in fat, and poor in protein and carbohydrates. KD is the first-line treatment for some metabolic disorders, and is also used in resistant epilepsy, autism, cancer, Parkinson, Alzheimer's diseases, and stroke. The KD team consists of a doctor (child neurologist), nurse, and dietician. After diet adjustment, family training, metabolic tests, consultations, material supply, the initial and follow-up stages are performed by this team. Retrospective data analyses of patients followed at ketogenic diet outpatient clinic were made. Fourteen patients (6F, 8M) continued their KD treatment, and nine (4F, 5M) of them stopped the treatment. KD treatment duration for those who continued KD was between 1 and 24 months (mean 7.1, median 4), and KD duration of those who left was between 0.5 and 12 months (mean 5, median 5). Three patients became seizure-free, seven patients had ≥ 50% reduction in their seizures, and four patients had no change in seizure. Anti-epileptic drugs could be reduced in five patients. Improvement in perception and social behaviour of the children was expressed by the families. Although one of the patients was seizure-free and the others had 75% decrease in seizures, they left KD due to frequent infection and family desire. The other seven patients who left KD had no changes in their seizures, but four of them continued KD in less than 2 months, and two of them only for 15 days. Weight loss, family problems, infection, and financial concerns were the reasons for them leaving. Today, although the approach is changing, KD still comes to mind for the most resistant, troubled patients. Stopping the patients' seizures, opening their perceptions, and reducing the medications are satisfactory results. We wanted to share our small group of patients and their results in the hope of expanding the ketogenic diet.

Radiosurgical Lesionectomy For Cavernomas Associated With Drug Resistant Epilepsy

Radiosurgical Lesionectomy For Cavernomas Associated With Drug Resistant Epilepsy

Teleneuropsychology in the time of COVID-19: The experience of The Australian Epilepsy Project

PurposeTraditional neuropsychological testing carries elevated COVID-19 risk for both examinee and examiner. Here we describe how the pilot study of the Australian Epilepsy Project (AEP) has transitioned to tele-neuropsychology (teleNP), enabling continued safe operations during the pandemic. MethodsThe AEP includes adults (age 18–60) with a first unprovoked seizure, new diagnosis of epilepsy or drug resistant focal epilepsy. Shortly after launching the study, COVID-related restrictions necessitated adaptation to teleNP, including delivery of verbal tasks via videoconference; visual stimulus delivery via document camera; use of web-hosted, computerised assessment; substitution of oral versions for written tests; online delivery of questionnaires; and discontinuation of telehealth incompatible tasks. ResultsTo date, we have completed 24 teleNP assessments: 18 remotely (participant in own home) and six on-site (participant using equipment at research facility). Five face-to-face assessments were conducted prior to the transition to teleNP. Eight of 408 tests administered via teleNP (1.9 %) have been invalidated, for a variety of reasons (technical, procedural, environmental). Data confirm typical patterns of epilepsy-related deficits (p < .05) affecting processing speed, executive function, language and memory. Questionnaire responses indicate elevated rates of patients at high risk of mood (34 %) and anxiety disorder (38 %). ConclusionResearch teleNP assessments reveal a typical pattern of impairments in epilepsy. A range of issues must be considered when introducing teleNP, such as technical and administrative set up, test selection and delivery, and cohort suitability. TeleNP enables large-scale neuropsychological research during periods of social distancing (and beyond), and offers an opportunity to expand the reach and breadth of neuropsychological services.

Performance analysis of EEG seizure detection features

Automatic detection of epileptic seizures can serve as a valuable clinical tool which involves a more objective and computationally efficient method for the analysis of EEG data in order to generate increasingly accurate and reliable results. Automatic seizure detection is also an important component of closed-loop responsive cortical stimulation systems. The goal of this study is to evaluate EEG-based features recently proposed for seizure detection to discover the optimum ones for a reliable seizure detection system. We extracted seizure detection features from intracranial EEG signals that were recorded during invasive pre-surgical epilepsy monitoring of people with drug resistant focal epilepsy at the Epilepsy Center of the University Hospital of Freiburg. Features from time, frequency and phase space domains as well as similarity/dissimilarity features were considered. The performance of each feature was investigated using the statistical test ANOVA. Performance analysis was conducted separately on the recordings from the channels within the seizure-onset zone (SOZ-in) and the recordings from the channels outside the seizure-onset zone (SOZ-out). Similarity/dissimilarity features that measure dynamic properties of the EEG signal and the evolving phenomena of the seizures could significantly separate ictal (during seizure) states from pre-ictal (before seizure) states (p < 0.01). Among them, our proposed feature, Bhattacharyya-based dissimilarity index (BBDI), successfully passed Tukey's post-hoc test as well suggesting that it can distinguish both pre-ictal and post-ictal (after seizure) periods from ictal period. BBDI was further applied to detect epileptic seizures and achieved area under the curve of the receiver-operator characteristic (ROC) equal to 0.96 and 0.94 for SOZ-in and SOZ-out channels, respectively. No significant difference (p = 0.59) was observed in the performance of features between SOZ-in recordings and SOZ-out recordings. The discriminative value of EEG seizure detection features was determined by statistical tests. As a result, the best features to be selected for a reliable seizure detection system designed for people with drug-resistant focal epilepsy were suggested, which include similarity/dissimilarity indices.

Polygonogram with isobolographic synergy for three-drug combinations of phenobarbital with second-generation antiepileptic drugs in the tonic\u2013clonic seizure model in mice

BackgroundCombination therapy consisting of two or more antiepileptic drugs (AEDs) is usually prescribed for patients with refractory epilepsy. The drug–drug interactions, which may occur among currently available AEDs, are the principal criterion taken by physicians when prescribing the AED combination to the patients. Unfortunately, the number of possible three-drug combinations tremendously increases along with the clinical approval of novel AEDs.AimTo isobolographically characterize three-drug interactions of phenobarbital (PB) with lamotrigine (LTG), oxcarbazepine (OXC), pregabalin (PGB) and topiramate (TPM), the maximal electroshock-induced (MES) seizure model was used in male albino Swiss mice.Materials and methodThe MES-induced seizures in mice were generated by alternating current delivered via auricular electrodes. To classify interactions for 6 various three-drug combinations of AEDs (i.e., PB + TPM + PGB, PB + OXC + TPM, PB + LTG + TPM, PB + OXC + PGB, PB + LTG + PGB and PB + LTG + OXC), the type I isobolographic analysis was used. Total brain concentrations of PB were measured by fluorescent polarization immunoassay technique.ResultsThe three-drug mixtures of PB + TPM + PGB, PB + OXC + TPM, PB + LTG + TPM, PB + OXC + PGB, PB + LTG + PGB and PB + LTG + OXC protected the male albino Swiss mice from MES-induced seizures. All the observed interactions in this seizure model were supra-additive (synergistic) (p < 0.001), except for the combination of PB + LTG + OXC, which was additive. It was unable to show the impact of the studied second-generation AEDs on total brain content of PB in mice.ConclusionsThe synergistic interactions among PB and LTG, OXC, PGB and TPM in the mouse MES model are worthy of being transferred to clinical trials, especially for the patients with drug resistant epilepsy, who would benefit these treatment options.

Chronic Oxytocin treatment has long lasting therapeutic potential in a rat model of neonatal hypercapnic-hypoxia injury, through enhanced GABAergic signaling and by reducing hippocampal gliosis with its anti-inflammatory feature

Previous studies have shown that, oxytocin has anticonvulsant and neuroprotective effects. One of the most important complications of Hypercapnic-hypoxia is drug resistance epilepsy. Effects of chronic intraperitoneal oxytocin treatment on gliosis, neuroinflammation and seizure activity was investigated in a model in which rats were exposed to hypoxia on postnatal day 1 and later challenged to the seizure-inducing pentylenetetrazolForty pups were included in the study on their first day of birth. 16 pups were exposed to 100% CO2 for 5 minutes and other 16 pups for 10 minutes. The remaining 8 pups comprised the control group. Groups were classified according to oxytocin administration within the first 4 weeks. Pentylenetetrazol was administered 6 months after the oxytocin treatment. The Racine’s Convulsion Scale and onset times of first myoclonic jerk (FMJ) were evaluated. To determine the mechanisms by which oxytocin exerted its effects on hypercapnic-anoxia exposed rats, we performed CA1 total neuron count & CA1 GFAP immunostaining, and measured brain levels of TNF-α and GAD-67.The Racine scale and TNF-α values were significantly lower in both groups that received oxytocin, while time-to-FMJ and GAD-67 level were significantly higher. The histopathological evaluations showed that oxytocin had significant ameliorative effects (especially regarding gliosis) on the hippocampus of hypoxic rats.Regarding the results of present study, it can be speculated that after acute hypercapnic-anoxia exposure, chronic Oxytocin treatment has long lasting therapeutic potential on rats, possibly by reducing the gliosis with its anti-inflammatory feature and by activating the GABA pathway.

MRI-negative PET-negative epilepsy long-term surgical outcomes: A single-institution retrospective review

PurposeSurgical planning for people with drug resistant non-lesional focal epilepsy can be challenging. Prior studies focus on cases that are only MRI-negative or MRI-negative with PET-positive imaging, but little is known about outcomes in patients with non-lesional findings on both MRI and PET imaging. In this study, we investigate 5-year surgical outcomes in patients who underwent epilepsy surgery for drug resistant MRI/PET-negative focal epilepsy. MethodsWe collected clinical and testing data on 131 consecutive patients with drug resistant non-lesional epilepsy who were presented at a multidisciplinary epilepsy surgery conference at the New York University Comprehensive Epilepsy Center between 2010 and 2014, and identified those who underwent epilepsy surgery in order to review 5-year surgical outcomes. ResultsThere were 103 with non-lesional MRI studies, and of these, 22 had corresponding non-lesional PET imaging. 14 MRI/PET-negative patients pursued a surgical treatment option and 9 underwent resections after intracranial EEG. At 5 years, 77.8 % of patients had favorable (ILAE class 1 and 2) outcomes. Most (77.8 %) had focal cortical dysplasia type Ia (FCDIa) on pathology. ConclusionThese findings suggest that with careful planning and patient selection, surgery for patients with drug resistant MRI/PET-negative focal epilepsy can be successful.

Dual/double pathology in neurocysticercosis causing drug resistant epilepsy – Chance association or causal?

IntroductionNeurocysticercosis (NCC) as cause of drug resistant epilepsy (DRE) is commonly reported from India. We reviewed the neuropathological findings in patients undergoing resective surgery for DRE due to NCC, to determine the pathomechanism of epileptogenesis. MethodsClinical, demographic and neuropathological findings of histologically confirmed cases of NCC causing DRE between 2005–2019 were reviewed. NeuN, GFAP, phosphorylated neurofilament, vimentin, CD34 for glial/ neuronal alterations, and Masson trichrome, Luxol Fast blue for evidence of fibrosis/ demyelination was used to determine cause of epileptogenesis. ResultsThere were 12 cases of NCC associated with dual/ double pathology, which constituted 3.02 % (12/398) of all the operated DRE. [Age range: 17–37y, Male:Female = 1.4:1]. Seizure duration ranged from 3–32y, with seizure onset between 4–27y. On MRI, lesions were of variable signal intensity on T1 and isointense on T2 with blooming on GRE/ SWI, and CT revealed calcification.Majority (11/12) had associated hippocampal sclerosis (HS) type 1 (dual pathology), localised to the same side as cysticercal cyst, suggesting it may be involved in the pathogenesis of HS. Ten had single cysticercal lesion involving ipsilateral hippocampus in 6, parahippocampal gyrus in 2, amygdala and temporal lobe in 1 case each. One had multiple NCC located in bilateral frontal, parietal and ipsilateral hippocampus. Adjacent cortex around the NCC evaluated in 6 cases, revealed inflammation, gliosis, axonal disruption/ beading, and variable synaptic/ neuronal dystrophic changes. There was a single case of NCC with Focal cortical dysplasia (FCD) type IIb (double pathology). In 11/12 cases Engel’s post-surgery outcome was available with all having class I outcome. ConclusionHS was most common pathology associated with cysticercosis (Dual pathology), localised ipsilateral to the cysticercal cyst, suggesting that HS is a secondary/ epiphenomenon. Perilesional changes such as inflammation, gliosis, dystrophic synaptic and axonal pathology play a role in inducing or perpetuating the epileptiform activity. The association of FCD IIb with NCC in one case is likely to be a chance occurrence.

A prospective multicenter study of laser ablation for drug resistant epilepsy – One year outcomes

ObjectiveTo report one-year seizure outcomes, procedural data, and quality of life scores following laser interstitial thermal therapy (LITT) of epileptogenic foci. MethodsData from an ongoing prospective, multi-center registry were assessed. Procedural information, Engel seizure outcomes, and quality of life (QoL) scores were analyzed. A responder analysis was performed to better understand potential clinical characteristics that could influence seizure outcome. ResultsSixty patients have been enrolled into LAANTERN (Laser Ablation of Abnormal Neurological Tissue Using Robotic NeuroBlate System) specifically for epilepsy treatment, of which 42 reached one year follow up. Engel I outcome was achieved in 64.3 % at one year follow up. Patients with mesial temporal lobe epilepsy (MTLE) comprised 56.7 % of this cohort of multiple epilepsy types. Other significant etiologies included focal cortical dysplasia, hypothalamic hamartoma, cavernoma, heterotopias, and tuberous sclerosis. Median length of stay was 32.7 h. At discharge, head pain score averaged 1.4 ± 2.1 on a scale from 1 to 10. Five adverse events were reported, one categorized as serious. Seizure worry and social functioning scores improved significantly in quality of life measures. SignificanceSurgical treatment with LITT for epileptic foci is a safe and effective treatment option for people with drug resistant epilepsy. Our multicenter prospective seizure outcomes continue to expand published LITT experience in MTLE as well as non-MTLE epilepsies. The minimally invasive nature allows for short hospitalizations with minimal reported pain and discomfort.

Transition of Care for Adolescent and Young Adult Patients on Dietary Therapy for Epilepsy

AbstractKetogenic diets are high-fat, low-carbohydrate diets designed to alter metabolism, induce nutritional ketosis, and reduce seizures in patients with epilepsy. In the past 15 to 20 years, the diets have been refined, gaining momentum in the treatment of resistant epilepsy. As ketogenic diets have gained popularity for treatment of pediatric epilepsies, an increasing number of adolescents treated with dietary therapy are approaching the age of transitioning their care to adult providers. Transition of care for this vulnerable population brings unique challenges posed by a paucity of adult providers who prescribe ketogenic diets, a lack of adult nutritionists trained in dietary therapy for epilepsy, and reluctance of pediatric patients to transition care. In this article, we will discuss the rationale for establishing transition protocols for young adult patients with epilepsy and present guidelines for transition of care for patients treated with dietary therapy for epilepsy.

A prospective controlled study about sleep disorders in drug resistant epilepsy

ObjectiveTo evaluate sleep disorders and chronotype in patients with drug resistant focal and generalised epilepsy compared to healthy controls. MethodsSixty four patients with focal and six with generalised, drug resistant epilepsy were included and compared to 70 age- and gender-matched healthy controls. Patients with any relevant comorbidity were excluded. Sleep disorders and chronotype were investigated by validated questionnaires. The impact of epilepsy on quality of life was also documented in patients. ResultsThe median Pittsburgh Sleep Quality Index (PSQI) was 4 in patients and 3 in controls (median [range], IQR; patients: 4 [1–17], 3–6; controls: 3 [0–11], 2–4; p = 0.024). Self-reported confusional arousals and probable REM sleep behaviour disorder (RBD) were more frequent in patients (30.4% vs. 8.6%, p = 0.036 and 10.6% vs. 1.4%, p = 0.030, respectively). A higher risk for possible sleep apnea was identified in patients (22.9% vs. 5.7%, p = 0.042), whereas Epworth Sleepiness Score was normal in both groups (p = 1). Chronotype, assessed by the midsleep on free days, did not differ between groups (p = 0.540). Quality of life was worse in patients with PSQI scores >5 (p = 0.016). ConclusionSelf-reported confusional arousals, probable RBD and a high risk for sleep apnea occurred significantly more often in patients with drug resistant epilepsy. Sleep quality differed significantly between both groups. Whether these results are due to motor activity during nocturnal epileptic seizures, parasomnia episodes, or sleep-related breathing disorder, needs further evaluation via video-polysomnography. We could confirm, at least in some cases, the previously reported mutual relationship between sleep disorders and epilepsy.

Advanced intraoperative ultrasound (ioUS) techniques in focal cortical dysplasia (FCD) surgery: A preliminary experience on a case series

Introduction: Focal Cortical Dysplasia (FCD) represents a broad spectrum of histopathological entities that cause drug-resistant epilepsy. Surgery has been shown to be the treatment of choice, but incomplete resection represents the leading cause of seizure persistence. Preliminary experiences with intraoperative ultrasound (ioUS) have proven its potential in defining and characterizing the lesion. In this study we analyzed the feasibility of advanced ultrasound techniques such as sono-elastography (SE) and contrast enhancement ultrasound (CEUS) in a small cohort of patients with FCD. Material and methods: We retrospectively reviewed all clinical records and images of patients with drug resistant epilepsy who underwent at least one advanced sonographic technique (SE and/or CEUS) during ioUS guided surgery between November 2014 and October 2017. We excluded from our analysis all patients with lesions other than FCD or those who had FCD associated with other pathological entities. Results: Four patients with type IIb FCD in the right frontal lobe were evaluated. All of them underwent SE, which highlighted heterogeneous stiffness in the dysplastic foci, also multiple areas of higher consistency were detected in all patients. Three patients evaluated with CEUS had visible enhancement in the FCD. Neither SE nor CEUS were better than ioUS in the identification of lesion boundaries. In the three patients who underwent both SE and CEUS we found no correspondence between stiffer areas and enhancement in the dysplastic areas. Conclusion: Ourpreliminary report confirms the feasibility of SE and CEUS in FCD surgery and describes the imaging findings in this category of patients. Studies on larger cohorts of patients are warranted to better clarify the role of these advanced intraoperative ultrasound techniques in patients with FCD.

Posttraumatic epilepsy may be a state in which underlying epileptogenicity involves focal cortical dysplasia

IntroductionThe occurrence rate of posttrauma epilepsy ranges widely from 1% to 30%. Little is known about the underlying epileptogenesis of traumatic brain injury (TBI)-related epilepsy (TRE), because no comparison between TRE and TBI without epilepsy has been performed in terms of neuropathology. Therefore, we postulated that different neuropathological factors may be present between TRE and TBI without epilepsy. The purpose of this study was to clarify differences between TRE and TBI without epilepsy. MethodsWe studied patients who experienced severe head trauma and underwent brain surgery. The age range of the patients was 9–71 years old. Patients with medically resistant epilepsy were included in the Epilepsy group, and patients without epilepsy were included in the nonepilepsy group. Pathological findings, age, sex, and cause of head trauma were statistically compared between these two groups. ResultsThis study involved 10 patients, nine of whom met the inclusion criteria. Pathological findings for all patients in the Epilepsy group included focal cortical dysplasia (FCD) (p = 0.012). ConclusionThe difference between TRE and TBI without epilepsy was underlying FCD in patients with TRE.