Patterns of treatment response in newly diagnosed epilepsy

Drug-resistant epilepsy: Definition, pathophysiology, and management

There are currently >51 million people with epilepsy (PWE) in the world and every year >4.9 million people develop new-onset epilepsy. The cornerstone of treatment in PWE is drug therapy with antiseizure medications (ASMs). However, about one-third of PWE do not achieve seizure control and do not respond well to drug therapy despite the use of appropriate ASMs [drug-resistant epilepsy (DRE)]. The aims of the current narrative review are to discuss the definition of DRE, explain the biological underpinnings and clinical biomarkers of this condition, and finally to suggest practical management strategies to tackle this issue appropriately, in a concise manner.

Twenty-five years of epilepsy surgery at a Central European comprehensive epilepsy center-Trends in intervention delay and outcomes

OBJECTIVE

We analyzed trends in patients' characteristics, outcomes, and waiting times over the last 25 years at our epilepsy surgery center situated in Central Europe to highlight possible areas of improvement in our care for patients with drug-resistant epilepsy.

METHODS

A total of 704 patients who underwent surgery at the Brno Epilepsy Center were included in the study, 71 of those were children. Patients were separated into three time periods, 1996-2000 (n = 95), 2001-2010 (n = 295) and 2011-2022 (n = 314) based on first evaluation at the center.

RESULTS

The average duration of epilepsy before surgery in adults remained high over the last 25 years (20.1 years from 1996 to 2000, 21.3 from 2001 to 2010, and 21.3 from 2011 to 2020, P = 0.718). There has been a decrease in rate of surgeries for temporal lobe epilepsy in the most recent time period (67%-70%-52%, P < 0.001). Correspondingly, extratemporal resections have become more frequent with a significant increase in surgeries for focal cortical dysplasia (2%-8%-19%, P < 0.001). For resections, better outcomes (ILAE scores 1a-2) have been achieved in extratemporal lesional (0%-21%-61%, P = 0.01, at least 2-year follow-up) patients. In temporal lesional patients, outcomes remained unchanged (at least 77% success rate). A longer duration of epilepsy predicted a less favorable outcome for resective procedures (P = 0.024) in patients with disease duration of less than 25 years.

SIGNIFICANCE

The spectrum of epilepsy surgery is shifting toward nonlesional and extratemporal cases. While success rates of extratemporal resections at our center are getting better, the average duration of epilepsy before surgical intervention is still very long and is not improving. This underscores the need for stronger collaboration between epileptologists and outpatient neurologists to ensure prompt and effective treatment for patients with drug-resistant epilepsy.

Efficacy and safety of perampanel as early add-on therapy in Chinese patients with focal-onset seizures: a multicenter, open-label, single-arm study

Background

No interventional study has been conducted in China to assess efficacy and safety of perampanel in treating Chinese patients with epilepsy, nor has there been any study on perampanel early add-on therapy in China. This interventional study aimed to assess efficacy and safety of perampanel as an early add-on treatment of focal-onset seizures (FOS) with or without focal-to-bilateral tonic-clonic seizures (FBTCS) in Chinese patients.

Methods

In this multicenter, open-label, single-arm, phase 4 interventional study, Chinese patients ≥ 12 years old with FOS with or without FBTCS who failed anti-seizure medication (ASM) monotherapy from 15 hospitals in China were enrolled and treated with perampanel add-on therapy (8-week titration followed by 24-week maintenance). The primary endpoint was 50% responder rate. Secondary endpoints included seizure-freedom rate and changes in seizure frequency from baseline. Treatment-emergent adverse events (TEAEs) and drug-related TEAEs were recorded.

Results

The full analysis set included 150 patients. The mean maintenance perampanel dose was 5.9 ± 1.5 mg/day and the 8-month retention rate was 72%. The 50% responder rate and seizure-freedom rate for all patients during maintenance were 67.9 and 30.5%, respectively. Patients with FBTCS had higher 50% responder rate (96.0%) and seizure-freedom rate (76.0%) during maintenance. Patients on concomitant sodium valproate had a significantly higher seizure-freedom rate than those on concomitant oxcarbazepine. Eight-six (55.1%) patients experienced treatment-related TEAEs, and the most common TEAEs were dizziness (36.5%), hypersomnia (11.5%), headache (3.9%), somnolence (3.2%), and irritability (3.2%). Withdrawal due to TEAEs occurred to 14.7% of the patients.

Conclusion

Perampanel early add-on was effective and safe in treating Chinese patients≥12 years old with FOS with or without FBTCS.Clinical trial registrationwww.chictr.org.cn, Identifier ChiCTR2000039510.

The challenges to control epilepsy in an isolated indigenous tribe in Brazil's Amazon: 15 years of follow-up

BACKGROUND

Epilepsy is a common neurological disease that affects people all over the world, but it is rarely described in indigenous peoples.

OBJECTIVE

To study the epilepsy characteristics and risk factors for seizure control in people from an isolated indigenous population.

METHODS

This is a retrospective and historical cohort study conducted from 2003 to 2018 (15 years), at a neurology outpatient clinic, of 25 Waiwai tribes' indigenous individuals with epilepsy, inhabitants of an isolated forest reserve in the Amazon. Clinical aspects, background, comorbidities, exams, treatment, and response were studied. Factors that impacted seizure control over 24 months were identified using Kaplan-Meier curves and Cox and Weibull regression models.

RESULTS

The majority of cases started in childhood, with no difference regarding gender. Focal epilepsies were predominant. Most patients had tonic-clonic seizures. A quarter of them had a family history, and 20% had referred febrile seizures. There was intellectual disability in 20% of patients. Neurological examination and psychomotor development were altered in one third of the participants. The treatment controlled 72% of the patients (monotherapy in 64%). Phenobarbital was the most prescribed anti-seizure medication, followed by carbamazepine and valproate. The most relevant factors that impacted seizure control over time were abnormal neurological exam and family history.

CONCLUSION

Family history and abnormal neurological exam were predicted risk factors for refractory epilepsy. Even in an isolated indigenous tribe, the partnership between the indigenous people and the multidisciplinary team ensured treatment adherence. The public healthcare system must guarantee modern anti-seizure medications, mainly for this vulnerable population, which has no other source of treatment.

Predictive factors for successful vagus nerve stimulation in patients with refractory epilepsy: real-life insights from a multicenter study

Introduction

Vagus nerve stimulation (VNS) therapy is an established treatment for patients with drug-resistant epilepsy that reduces seizure frequency by at least 50% in approximately half of patients; however, the characteristics of the patients with the best response have not yet been identified. Thus, it is important to identify the profile of patients who would have the best response to guide early indications and better patient selection.

Methods

This retrospective study evaluated vagus nerve stimulation (VNS) as an adjuvant therapy for patients with drug-resistant epilepsy from six epilepsy centers in Brazil. Data from 192 patients aged 2-66 years were analyzed, and all patients received at least 6 months of therapy to be included.

Results

Included patients were aged 2-66 years (25.6 ± 14.3), 105 (54.7%) males and 87 (45.8%) females. Median follow-up interval was 5 years (range, 2005-2018). Overall, the response rate (≥50% seizure reduction) after VNS implantation was 65.6% (126/192 patients). Most patients had 50-90% seizure reduction (60.9%) and nine patients became seizure-free. There were no serious complications associated with VNS implantation. The rate of a ≥ 50% seizure reduction response was significantly higher in patients with no history of neurosurgery. The presence of focal without generalized seizures and focal discharges on interictal EEG was associated with better response. Overall, etiological predictors of a better VNS response profile were tumors while a worse response to VNS was related to the presence of vascular malformations and Lennox-Gastaut Syndrome.

Discussion

We observed an association between a better response to VNS therapy no history of neurosurgery, focal interictal epileptiform activity, and focal seizure pattern. Additionally, it is important to highlight that age was not a determinant factor of the response, as children and adults had similar response rates. Thus, VNS therapy should be considered in both adults and children with DRE.

Resective Epilepsy Surgery, QUality of life and Economic evaluation (RESQUE): the change in quality of life after resective epilepsy surgery-protocol for a multicentre, prospective cohort study

INTRODUCTION

Resective epilepsy surgery is often seen as a last resort when treating drug-resistant epilepsy. Positive results on quality of life (QoL) and economic benefits after surgery argue for a less restrictive attitude towards epilepsy surgery for drug-resistant epilepsy. QoL and economic benefits are country-dependent. The objective of the Resective Epilepsy Surgery, QUality of life and Economic evaluation (RESQUE) trial is to evaluate the change in QoL before and after epilepsy surgery in Dutch people with drug-resistant epilepsy. The results will form part of an economic evaluation of epilepsy surgery in people with epilepsy (PWE) in The Netherlands.

METHODS AND ANALYSIS

A longitudinal prospective multicentre cohort study involving 100 PWE undergoing epilepsy surgery between 2019 and 2025 is being performed in three Dutch academic hospitals. Excluded are PWE who have a lower level of intelligence (TIQ<70) or who do not master the Dutch language. Before surgery and 3, 6, 12 and 24 months after surgery, PWE receive validated online questionnaires (QOLIE-31, EQ-5D, iMCQ and iPCQ) on QoL, cost of care, expectations and satisfaction. Primary outcome is the change in QoL. Secondary outcomes are change in generic QoL, seizure reduction (International League Against Epilepsy Outcome Classification), medical consumption, productivity, the correlation between QoL and seizure reduction and expectation of and satisfaction with the surgery.

ETHICS AND DISSEMINATION

The study design has been approved by the Medical Ethics Review Committee (METC) of Maastricht UMC+ (2019-1134) and the Amsterdam UMC (vu). At the time of writing, UMC Utrecht is in the process of considering approval. The study will be conducted according to the Dutch Medical Research Involving Human Subjects Act and the Declaration of Helsinki. The results will be publicly disclosed and submitted for publication in international peer-reviewed scientific journals. There is no veto on publication by the involved parties.

TRIAL REGISTRATION

NL8278; Pre-results.

Controlling neocortical epileptic seizures using forced temporal spike-time stimulation: an in silico computational study

Epileptic seizure is typically characterized by highly synchronized episodes of neural activity. Existing stimulation therapies focus purely on suppressing the pathologically synchronized neuronal firing patterns during the ictal (seizure) period. While these strategies are effective in suppressing seizures when they occur, they fail to prevent the re-emergence of seizures once the stimulation is turned off. Previously, we developed a novel neurostimulation motif, which we refer to as "Forced Temporal Spike-Time Stimulation" (FTSTS) that has shown remarkable promise in long-lasting desynchronization of excessively synchronized neuronal firing patterns by harnessing synaptic plasticity. In this paper, we build upon this prior work by optimizing the parameters of the FTSTS protocol in order to efficiently desynchronize the pathologically synchronous neuronal firing patterns that occur during epileptic seizures using a recently published computational model of neocortical-onset seizures. We show that the FTSTS protocol applied during the ictal period can modify the excitatory-to-inhibitory synaptic weight in order to effectively desynchronize the pathological neuronal firing patterns even after the ictal period. Our investigation opens the door to a possible new neurostimulation therapy for epilepsy.

Drug resistance in epilepsy

Drug resistance is estimated to affect about a third of individuals with epilepsy, but its prevalence differs in relation to the epilepsy syndrome, the cause of epilepsy, and other factors such as age of seizure onset and presence of associated neurological deficits. Although drug-resistant epilepsy is not synonymous with unresponsiveness to any drug treatment, the probability of achieving seizure freedom on a newly tried medication decreases with increasing number of previously failed treatments. After two appropriately used antiseizure medications have failed to control seizures, individuals should be referred whenever possible to a comprehensive epilepsy centre for diagnostic re-evaluation and targeted management. The feasibility of epilepsy surgery and other treatments, including those targeting the cause of epilepsy, should be considered early after diagnosis. Substantial evidence indicates that a delay in identifying an effective treatment can adversely affect ultimate outcome and carry an increased risk of cognitive disability, other comorbidities, and premature mortality. Research on mechanisms of drug resistance and novel therapeutics is progressing rapidly, and potentially improved treatments, including those targeting disease modification, are on the horizon.

Pathophysiology of drug-resistant canine epilepsy

Drug resistance continues to be a major clinical problem in the therapeutic management of canine epilepsies with substantial implications for quality of life and survival times. Experimental and clinical data from human medicine provided evidence for relevant contributions of intrinsic severity of the disease as well as alterations in pharmacokinetics and -dynamics to failure to respond to antiseizure medications. In addition, several modulatory factors have been identified that can be associated with the level of therapeutic responses. Among others, the list of potential modulatory factors comprises genetic and epigenetic factors, inflammatory mediators, and metabolites. Regarding data from dogs, there are obvious gaps in knowledge when it comes to our understanding of the clinical patterns and the mechanisms of drug-resistant canine epilepsy. So far, seizure density and the occurrence of cluster seizures have been linked with a poor response to antiseizure medications. Moreover, evidence exists that the genetic background and alterations in epigenetic mechanisms might influence the efficacy of antiseizure medications in dogs with epilepsy. Further molecular, cellular, and network alterations that may affect intrinsic severity, pharmacokinetics, and -dynamics have been reported. However, the association with drug responsiveness has not yet been studied in detail. In summary, there is an urgent need to strengthen clinical and experimental research efforts exploring the mechanisms of resistance as well as their association with different etiologies, epilepsy types, and clinical courses.

Evaluation of epilepsy surgery scope and training in Latin America

INTRODUCTION

To describe the variety of surgical epilepsy procedures offered in Latin America and characterize the training in surgical management for epilepsy and neurophysiology fellows.

MATERIALS & METHODS

A 15-question survey was sent to Spanish-speaking epilepsy specialists in Latin America (members of the International Consortium in Epilepsy Surgery Education) to characterize their epilepsy surgery practices and formal training programs when present, including fellowship program characteristics, trainee involvement, and assessment of trainee performance. Epilepsy surgery procedures included resective/ablative interventions and neuromodulation therapies approved for drug-resistant epilepsy. Associations between categorical variables were evaluated using the Fisher Exact test.

RESULTS

There were 42 responses from a total of 57 survey recipients (73% response rate). Most surgical programs performed either 1 to 10 procedures (36%) or 11 to 30 procedures (31%) per year. Most centers (88%) performed resective procedures, while none of the surveyed institutions performed laser ablations. Most of the centers performing intracranial EEG (88%) and advanced neuromodulation (93%) were in South America. Centers with formal fellowship training programs were more likely to perform intracranial EEG procedures compared to centers without fellows (92% vs 48%, respectively, OR = 12.2 [95% CI 1.45-583], p = 0.007).

DISCUSSION

There is significant variability in surgical procedures performed across epilepsy centers in a Latin American educational consortium. Advanced surgical diagnostic procedures and interventions are performed in a fair number of surveyed institutions. Strategies to enhance access to epilepsy surgery procedures and facilitate formal training in surgical management are necessary.

Should antiseizure medications be withdrawn after an extended period of seizure freedom in individuals with adult-onset epilepsy?

Unlike several epilepsies with onset in pediatric age, adult-onset epilepsies do not typically have a time course that is predictably self-remitting in the large majority of people. Still, about one-half of individuals with adult-onset epilepsy who have been seizure-free for an extended period (two years or longer) on antiseizure medications (ASMs) will remain in remission when their drug therapy is discontinued. Although a number of predictors of outcome have been identified (including specific adult-onset syndromes associated with a low probability of spontaneous remission), in most cases, the only way to establish whether the epilepsy has remitted in a given individual is to gradually withdraw ASMs. ASM withdrawal can be beneficial, particularly when the currently used treatment is not well tolerated, or could lead to adverse outcomes in the future (i.e., teratogenic effects should pregnancy occur in a female of childbearing potential). However, the risks associated with ASM withdrawal are significant. Relapse of seizures can have major adverse psychosocial consequences and also may carry a risk of morbidity and mortality. Most importantly, evidence suggests that in about 20% of individuals whose seizure relapsed following ASM withdrawal, re-institution of pharmacological therapy may not readily restore seizure control. Ultimately, management decisions should prioritize the preference of the well-informed person with epilepsy. Particularly, when adverse drug effects are a concern, options to be discussed should include not only withdrawal or continuation of the current treatment but also dose reduction or substitution with a different ASM.

A phase 1 open-label trial evaluating focused ultrasound unilateral anterior thalamotomy for focal onset epilepsy

OBJECTIVE

Focused ultrasound ablation (FUSA) is an emerging treatment for neurological and psychiatric diseases. We describe the initial experience from a pilot, open-label, single-center clinical trial of unilateral anterior nucleus of the thalamus (ANT) FUSA in patients with treatment-refractory epilepsy.

METHODS

Two adult subjects with treatment-refractory, focal onset epilepsy were recruited. The subjects received ANT FUSA using the Exablate Neuro (Insightec) system. We determined the safety and feasibility (primary outcomes), and changes in seizure frequency (secondary outcome) at 3, 6, and 12 months. Safety was assessed by the absence of side effects, that is, new onset neurological deficits or performance deterioration on neuropsychological testing. Feasibility was defined as the ability to create a lesion within the anterior nucleus. The monthly seizure frequency was compared between baseline and postthalamotomy.

RESULTS

The patients tolerated the procedure well, without neurological deficits or serious adverse events. One patient experienced a decline in verbal fluency, attention/working memory, and immediate verbal memory. Seizure frequency reduced significantly in both patients; one patient was seizure-free at 12 months, and in the second patient, the frequency reduced from 90-100 seizures per month to 3-6 seizures per month.

SIGNIFICANCE

This is the first known clinical trial to assess the safety, feasibility, and preliminary efficacy of ANT FUSA in adult patients with treatment-refractory focal onset epilepsy.

Long-Term Pharmacological and Psychosocial Outcomes of Adolescent-Onset Epilepsy: A Single-Center Experience

Purpose: Despite the high incidence of epilepsy during adolescence, little attention has been paid to the outcomes and prognosis of adolescent-onset epilepsy. The aim of this study was to investigate the long-term pharmacological and psychosocial outcomes of adolescent-onset epilepsy.Methods: From 1993 to 2019, the electronic medical records of adolescent-onset epilepsy patients were retrieved from Asan Medical Center Children’s Hospital. Seizure outcomes were evaluated based on the seizure-free period at last contact. Possible predictors of remission, relapse, and intractability were investigated. Neuropsychiatric comorbidities, socioeconomic status, and transition outcomes were also assessed. Results: In total, 137 patients were enrolled in this study. The median age at diagnosis of epilepsy was 14 years and the mean duration of therapy was 13.0 years. During follow-up, 93 patients (67.9%) achieved terminal remission, of which 27 cases (19.7%) resolved. Relapse after withdrawal of medication occurred in 74 patients (54.0%), and the presence of electroencephalographic abnormalities (odds ratio [OR], 8.23; 95% confidence interval [CI], 1.39 to 48.87; P=0.020), poor adherence (OR, 4.84; 95% CI, 2.13 to 11.02; P=0.000), and history of febrile seizures (OR, 4.10; 95% CI, 1.21 to 13.93; P=0.024) were risk factors for relapse. Neurodevelopmental and psychological comorbidities were documented in 17 (12.4%) and 12 (8.8%) patients, respectively. Thirty-six (26.3%) patients transferred to adult clinics, at a mean age of 21.9 years. Conclusion: This study showed overall favorable seizure outcomes with a high rate of remission, but with frequent relapse after withdrawal.

Perampanel outcomes at different stages of treatment in people with focal and generalized epilepsy treated in clinical practice: Evidence from the PERMIT study

Introduction

The PERMIT study is the largest pooled analysis of perampanel (PER) clinical practice data conducted to date.

Methods

This post-hoc analysis of PERMIT investigated the effectiveness, safety and tolerability of PER when used as early add-on therapy (after failure of one or two previous antiseizure medications) in comparison with late add-on therapy (after failure of three or more previous antiseizure medications). Retention and effectiveness were assessed after 3, 6, and 12 months, and at the last visit (last observation carried forward). Effectiveness was assessed by seizure type (total seizures, focal seizures, generalized tonic-clonic seizures [GTCS]) and assessments included seizure freedom rate and responder rate. Safety and tolerability were assessed by evaluating adverse events (AEs) and discontinuation due to AEs.

Results

The Full Analysis Set included 1184 and 2861 PWE treated with PER as early and late add-on therapy, respectively. Compared to the late add-on subgroup, the early add-on subgroup was characterized by later mean age at epilepsy onset, shorter mean duration of epilepsy, lower rates of intellectual disability and psychiatric comorbidity, and lower frequency of seizures per month, suggesting a less severe form of epilepsy in this subgroup. After 12 months, retention was significantly higher in the early versus late add-on subgroup (67.7% vs. 62.4%; p = 0.004). At the last visit, responder rates in the early versus late add-on subgroup were significantly higher for total seizures (68.2% vs. 39.3%; p &lt; 0.001), focal seizures (65.0% vs. 36.8%; p &lt; 0.001) and GTCS (83.7% vs. 67.2%; p &lt; 0.001), as were seizure freedom rates (total seizures, 35.9% vs. 11.9% [p &lt; 0.001]; focal seizures, 29.4% vs. 8.7% [p &lt; 0.001]; GTCS, 69.0% vs. 48.1% [p &lt; 0.001]). Incidence of AEs was significantly lower in the early versus late add-on subgroup (42.1% vs. 54.7%; p &lt; 0.001), as was the rate of discontinuation due to AEs over 12 months (15.0% vs. 18.1%; p = 0.031).

Discussion

This study demonstrated that PER was effective and generally well tolerated when initiated as early or late add-on therapy, but it was significantly more effective and better tolerated when initiated early. These findings support PER's use as a broad-spectrum, early add-on therapy for use in PWE with focal and generalized seizures.

Withdrawal of antiseizure medications - for whom, when, and how?

INTRODUCTION

Epilepsy is a chronic disorder of the brain characterized by an enduring predisposition to generate epileptic seizures. Most patients can achieve complete seizure control (seizure freedom) with antiseizure medications (ASMs). In some of them, the withdrawal of ASMs can be considered. Guidance is required to identify patients in whom drug discontinuation can be safely attempted and to inform when and how ASM withdrawal can be done.

AREAS COVERED

In this perspective, the authors discuss the evidence on ASM withdrawal in epilepsy patients who are seizure-free and provide some suggestions on how to do it effectively in clinical practice, minimizing the risk of seizure recurrence.

EXPERT OPINION

The decision of discontinuing ASMs in epilepsy patients should rely on an accurate estimate of seizure recurrence risk. Whenever possible, such a risk should be assessed on an individual basis. The decision should also consider the psychosocial and personal consequences of seizure relapse. No robust evidence is available on the safest tapering regimen.

Corticosteroids in childhood epilepsies: A systematic review

Corticosteroids have been used for the treatment of patients with epilepsy for more than 6 decades, based on the hypothesis of inflammation in the genesis and/or promotion of epilepsy. We, therefore, aimed to provide a systematic overview of the use of corticosteroid regimes in childhood epilepsies in line with the PRISMA guidelines. We performed a structured literature search via PubMed and identified 160 papers with only three randomized controlled trials excluding the substantial trials on epileptic spasms. Corticosteroid regimes, duration of treatment (days to several months), and dosage protocols were highly variable in these studies. Evidence supports the use of steroids in epileptic spasms; however, there is only limited evidence for a positive effect for other epilepsy syndromes, e.g., epileptic encephalopathy with spike-and-wave activity in sleep [(D)EE-SWAS] or drug-resistant epilepsies (DREs). In (D)EE-SWAS (nine studies, 126 patients), 64% of patients showed an improvement either in the EEG or in their language/cognition following various steroid treatment regimes. In DRE (15 studies, 436 patients), a positive effect with a seizure reduction in 50% of pediatric and adult patients and seizure freedom in 15% was identified; however, no recommendation can be drawn due to the heterozygous cohort. This review highlights the immense need for controlled studies using steroids, especially in DRE, to offer patients new treatment options.

Assessment of Treatment Outcome and Its Associated Factors among Adult Epileptic Patients in Public Hospitals in the Southern Ethiopia: A Multi-center Cross-sectional Study

Background

Epilepsy accounts for 0.5 % of the world's disease burden. Around 80 % of these are living in low and middle-income countries. In Ethiopia, the prevalence is 0.6 to 5 per 1000 population. There is a little study in our study area on the treatment and predictors of response of adult epilepsy. The purpose of this study was to determine the treatment outcome and its associated factors among adult epileptic patients in public hospitals in southern Ethiopia.

Methods

Multi-centered, Hospital-based cross-sectional study was conducted from October 2021 - august 2022. Data were collected by face-to-face interviews and record review. Data was analysed using SPSS. The bivariate and multivariable logistic regression analyses have been performed between the dependent and the independent variables.

Result

Of the total 422 participants, 55.9 % were males and 62.6% were below 30 years of age. The most common type of seizure was a generalized tonic-clonic seizure. Most (87.9 %) were treated by immunotherapy. Phenobarbitone is most common medication (77.5). One-quarter reported adverse effects of medication. The majority (78%) had good control (seizure free for at least one year) and 22% had poor control. Poor medication adherence (AOR=4.03) and shorter duration of seizure before treatment (AOR=4.233) were associated with poor control.

Conclusion

A significant number of patients had poor control of seizures. Early identification of issues on medication adherence and early initiation of treatment will improve treatment outcome.

Project ECHO telementoring program in epilepsy for school nurses

OBJECTIVES

Many children with epilepsy experience seizures at school. School nurses must have the clinical expertise to deliver high-quality, safe care for students with epilepsy. However, in some regions of the U.S. access to interactive, epilepsy evidence-based education programs is limited. The objective of this project was to assess the feasibility of adapting the Epilepsy Foundation's (EFs) school nurse education program to the ECHO model and evaluate its impact on school nurse knowledge and self-efficacy in managing epilepsy in students with seizures and program satisfaction.

METHODS

The EFs educational program for school nurses was adapted to the ECHO model and delivered by a team of interdisciplinary epilepsy specialists via videoconferencing. Retrospective post-program surveys were administered at program completion. Data from 32 participants with complete post-program surveys were used for the analysis of knowledge and confidence. Descriptive statistics and the sign test were conducted.

RESULTS

Participants were 166 school nurses from 13 states. The majority had > 15 years of school nurse experience and served schools in suburban or rural areas. Improvements in knowledge and confidence were reported on most survey items. The highest improvements in self-reported knowledge and confidence were in psychosocial aspects of care, comorbidities, and recognition of nonepileptic events. Program satisfaction was rated as high by over 90% of participants.

CONCLUSIONS

Telementoring using the ECHO methodology is a feasible modality to educate and link epilepsy specialists and providers with school nurses nationwide. Findings suggest that attending the MSS ECHO provided an educational and meaningful learning experience. The gains in knowledge and confidence in psychosocial aspects of epilepsy care and comorbidities highlight the importance of the inclusion of this content in educational programs.

Investigation of the low glutamate diet as an adjunct treatment for pediatric epilepsy: A pilot randomized controlled trial

INTRODUCTION

Current dietary therapies for epilepsy have side effects and are low in nutrients, which would make an alternative dietary treatment, which addresses these issues, advantageous. One potential option is the low glutamate diet (LGD). Glutamate is implicated in seizure activity. Blood brain barrier permeability in epilepsy could enable dietary glutamate to reach the brain and contribute to ictogenesis.

OBJECTIVE

to assess the LGD as an adjunct treatment for pediatric epilepsy.

METHODS

This study was a nonblinded, parallel, randomized clinical trial. The study was conducted virtually due to COVID-19 and registered on clinicaltrials.gov (NCT04545346). Participants were eligible if they were between the ages of 2 and 21 with ≥4 seizures per month. Baseline seizures were assessed for 1-month, then participants were allocated via block randomization to the intervention month (N=18), or a wait-listed control month followed by the intervention month (N=15). Outcome measures included seizure frequency, caregiver global impression of change (CGIC), non-seizure improvements, nutrient intake, and adverse events.

RESULTS

Nutrient intake significantly increased during the intervention. No significant differences in seizure frequency were observed between intervention and control groups. However, efficacy was assessed at 1-month compared to the standard 3-months in diet research. Additionally, 21% of participants were observed to be clinical responders to the diet. Overall health (CGIC) significantly improved in 31%, 63% experienced ≥1 non-seizure improvements, and 53% experienced adverse events. Clinical response likelihood decreased with increasing age (0.71 [0.50-0.99], p=0.04), as did the likelihood of overall health improvement (0.71 [0.54-0.92], p=0.01).

DISCUSSION

This study provides preliminary support for the LGD as an adjunct treatment before epilepsy becomes drug resistant, which is in contrast to the role of current dietary therapies in drug resistant epilepsy.

Early identification of seizure freedom with medical treatment in patients with mesial temporal lobe epilepsy and hippocampal sclerosis

BACKGROUND

Mesial temporal lobe epilepsy with hippocampal sclerosis (MTLE-HS) is usually associated with a poor response to antiseizure medications. We focused on MTLE-HS patients who were seizure free on medication to: (1) determine the clinical factors associated with seizure freedom and (2) develop a machine-learning classifier to better earlier identify those patients.

METHODS

We performed a retrospective, multicentric study comparing 64 medically treated seizure-free MTLE-HS patients with 200 surgically treated drug-resistant MTLE-HS patients. First, we collected medical history and seizure semiology data. Then, we developed a machine-learning classifier based on clinical data.

RESULTS

Medically treated seizure-free MTLE-HS patients were seizure-free for at least 2 years, and for a median time of 7 years at last follow-up. Compared to drug-resistant MTLE-HS patients, they exhibited: an older age at epilepsy onset (22.5 vs 8.0 years, p < 0.001), a lesser rate of: febrile seizures (39.0% vs 57.5%, p = 0.035), focal aware seizures (previously referred to as aura)(56.7% vs 90.0%, p < 0.001), autonomic focal aware seizures in presence of focal aware seizure (17.6% vs 59.4%, p < 0.001), dystonic posturing of the limbs (9.8% vs 47.0%, p < 0.001), gestural (27.4% vs 94.0%, p < 0.001), oro-alimentary (32.3% vs 75.5%, p < 0.001) or verbal automatisms (12.9% vs 36.0%, p = 0.001). The classifier had a positive predictive value of 0.889, a sensitivity of 0.727, a specificity of 0.962, a negative predictive value of 0.893.

CONCLUSIONS

Medically treated seizure-free MTLE-HS patients exhibit a distinct clinical profile. A classifier built with readily available clinical data can identify them accurately with excellent positive predictive value. This may help to individualize the management of MTLE-HS patients according to their expected pharmacosensitivity.

WADA test for postoperative memory prediction in left TLE. Is it still useful in the 21st century?

BACKGROUND

Epilepsy surgery offers an effective treatment to achieve seizure freedom in refractory temporal lobe epilepsy. Since left temporal lobe surgery can be associated with verbal memory deterioration, control of cognitive decline is a main goal of therapy. This study analyzes the prognostic value of intracarotid amobarbital procedure (Wada test) in addition to specific neuropsychological and clinical variables for postoperative memory changes.

METHOD

Between 2013 and 2021 thirty-six patients (18 females, 18 males, mean age 41.0 years) from the Epilepsy Center Erlangen (ECE) with left hemispheric temporal lobe epilepsy underwent neuropsychological assessment preoperatively - including the Wada test - and six months postoperatively. In addition, a group of 92 patients (40 females, 52 males, mean age 36.1 years) with left or right hemispheric focus who underwent Wada test and surgery before 2013 was included as a standardization group. In all patients Wada test was carried out preoperatively to determine language dominance and memory capacity.

RESULTS

Postoperative verbal memory scores showed no significant difference from preoperative performance. Preoperative verbal memory performance as well as the hippocampal resection extent is particularly important in predicting postoperative verbal memory change. After left temporal lobe surgery, a significantly higher postoperative functional level was shown for figural memory. Specifically, a good contralateral hemispheric performance level assessed by the Wada test proved to be a compensatory factor for postoperative losses.

CONCLUSION

The Wada test is no longer necessary as a diagnostic tool for a broad group of patients with temporal lobe epilepsy. However, it can be useful for a subgroup of patients with clinical indicators such as nonspecific or incongruent preoperative verbal and figural memory impairments. In this study, Wada test data about the functional level of the contralateral hemisphere specifically allowed estimation of postoperative figural memory changes.

Epilepsy and proxy-reported health-related quality of life in children and young people with non-ambulatory cerebral palsy

AIM

To assess the association between epilepsy characteristics and proxy-reported health-related quality of life (HRQoL) in children and young people with non-ambulatory cerebral palsy (CP) and seizures.

METHOD

This was a cross-sectional study of 164 children and young people (74 females, 90 males; mean age 10 years 6 months, range 2-21 years, SD 5 years 5 months). Caregivers completed the Child Health Index of Life with Disabilities (CPCHILD) in an outpatient setting. We utilized univariable linear regression and multivariable modeling to study relationships between variables and CPCHILD scores.

RESULTS

Gross Motor Function Classification System levels were 37% IV and 63% V. Sociodemographic factors included the Child Opportunity Index (median 51, interquartile range [IQR] 25-80). A median of 2 (IQR 1-3) antiseizure medications (ASMs) were used, and days with seizures ranged from 0 (30%) to 28 (20%) days in the previous 4 weeks. Total CPCHILD scores decreased 2.3 points for each ASM (95% confidence interval [CI] -4.1 to -0.42). Compared to persons with focal epilepsy, those with generalized epilepsy had lower total CPCHILD scores (-5.7; 95% CI -11 to -0.55). Number of days with seizures was not associated with total CPCHILD scores.

INTERPRETATION

Proxy-reported HRQoL was affected by epilepsy-specific features in children and young people with severe CP.

WHAT THIS PAPER ADDS

Health-related quality of life (HRQoL) was lower with increasing numbers of antiseizure medications. Overall quality of life (QoL) scores were lower by a similar amount, independent of seizure frequency. HRQoL was lower in persons with recent hospital admissions for epilepsy.

Neuroimaging in Adults and Children With Epilepsy

OBJECTIVE

This article discusses the fundamental importance of optimal epilepsy imaging using the International League Against Epilepsy-endorsed Harmonized Neuroimaging of Epilepsy Structural Sequences (HARNESS) protocol and the use of multimodality imaging in the evaluation of patients with drug-resistant epilepsy. It outlines a methodical approach to evaluating these images, particularly in the context of clinical information.

LATEST DEVELOPMENTS

Epilepsy imaging is rapidly evolving, and a high-resolution epilepsy protocol MRI is essential in evaluating newly diagnosed, chronic, and drug-resistant epilepsy. The article reviews the spectrum of relevant MRI findings in epilepsy and their clinical significance. Integrating multimodality imaging is a powerful tool in the presurgical evaluation of epilepsy, particularly in "MRI-negative" cases. For example, correlation of clinical phenomenology, video-EEG with positron emission tomography (PET), ictal subtraction single-photon emission computerized tomography (SPECT), magnetoencephalography (MEG), functional MRI, and advanced neuroimaging such as MRI texture analysis and voxel-based morphometry enhances the identification of subtle cortical lesions such as focal cortical dysplasias to optimize epilepsy localization and selection of optimal surgical candidates.

ESSENTIAL POINTS

The neurologist has a unique role in understanding the clinical history and seizure phenomenology, which are the cornerstones of neuroanatomic localization. When integrated with advanced neuroimaging, the clinical context has a profound impact on identifying subtle MRI lesions or finding the "epileptogenic" lesion when multiple lesions are present. Patients with an identified lesion on MRI have a 2.5-fold improved chance of achieving seizure freedom with epilepsy surgery compared with those without a lesion. This clinical-radiographic integration is essential to accurate classification, localization, determination of long-term prognosis for seizure control, and identification of candidates for epilepsy surgery to reduce seizure burden or attain seizure freedom.

Identification of Novel Gene Variants in Children With Drug-Resistant Epilepsy: Expanding the Genetic Spectrum

BACKGROUND

Resistance to antiseizure drugs is an important problem in the treatment of individuals with epilepsy. Identifying the molecular etiology of drug-resistant epilepsy (DRE) is crucial for better management of epilepsy. Here, we explore the utility of whole exome sequencing (WES) in identifying causative gene variants in children with DRE.

METHODS

Forty-five children with DRE who underwent WES tests were included. Genetic examination of all patients included chromosomal analysis and clinical chromosomal microarray followed by WES. The identified variants by WES analysis were classified for pathogenicity based on the American College of Medical Genetics and Genomics guidelines and in silico protein prediction tools.

RESULTS

The overall diagnostic yield was 55.5% (25 of 45). A total of 26 variants spanning 22 genes were identified in 25 patients. Of note, only 19 of these genes were examined as novel. Ten patients (22.2%) had a pathogenic or likely pathogenic variant. There was a trend associated with a diagnostic genetic test result in girls compared with boys in DRE (P = 0.028).

CONCLUSION

Our findings expand the mutational spectrum of genes related to DRE. To form disease-specific treatment in children with DRE, the WES analysis should be included in the diagnostic algorithm because of its high diagnostic efficiency.

A pilot study on identifying gene signatures as markers for predicting patient response to antiseizure medications

The majority of the biomarkers were associated with the diagnosis of epilepsy and few of them can be applied to predict the response to antiseizure medications (ASMs). In this study, we identified 26 significantly up-regulated genes and 32 down-regulated genes by comparing the gene expression profiles of patients with epilepsy that responded to valproate with those without applying any ASM. The results of gene set enrichment analysis indicated that the ferroptosis pathway was significantly impacted (p = 0.0087) in patients who responded to valproate. Interestingly, the gene NCOA4 in this pathway exhibited significantly different expression levels between the two groups, indicating that NCOA4 could serve as a potential biomarker to better understand the mechanism of valproate resistance. In addition, six up-regulated genes SF3A2, HMGN2, PABPN1, SSBP3, EFTUD2, and CREB3L2 as well as six down-regulated genes ZFP36L1, ACRC, SUB1, CALM2, TLK1, and STX2 also showed significantly different expression patterns between the two groups. Moreover, based on the gene expression profiles of the patients with the treatment of valproate, carbamazepine, and phenytoin, we proposed a strategy for predicting the response to the ASMs by using the Connectivity Map scoring method. Our findings could be helpful for better understanding the mechanisms of drug resistance of ASMs and improving the clinical treatment of epilepsy.

Optimization of closed-loop electrical stimulation enables robust cerebellar-directed seizure control

Additional treatment options for temporal lobe epilepsy are needed, and potential interventions targeting the cerebellum are of interest. Previous animal work has shown strong inhibition of hippocampal seizures through on-demand optogenetic manipulation of the cerebellum. However, decades of work examining electrical stimulation-a more immediately translatable approach-targeting the cerebellum has produced very mixed results. We were therefore interested in exploring the impact that stimulation parameters may have on seizure outcomes. Using a mouse model of temporal lobe epilepsy, we conducted on-demand electrical stimulation of the cerebellar cortex, and varied stimulation charge, frequency and pulse width, resulting in over 1000 different potential combinations of settings. To explore this parameter space in an efficient, data-driven, manner, we utilized Bayesian optimization with Gaussian process regression, implemented in MATLAB with an Expected Improvement Plus acquisition function. We examined three different fitting conditions and two different electrode orientations. Following the optimization process, we conducted additional on-demand experiments to test the effectiveness of selected settings. Regardless of experimental setup, we found that Bayesian optimization allowed identification of effective intervention settings. Additionally, generally similar optimal settings were identified across animals, suggesting that personalized optimization may not always be necessary. While optimal settings were effective, stimulation with settings predicted from the Gaussian process regression to be ineffective failed to provide seizure control. Taken together, our results provide a blueprint for exploration of a large parameter space for seizure control and illustrate that robust inhibition of seizures can be achieved with electrical stimulation of the cerebellum, but only if the correct stimulation parameters are used.

Treatment Outcomes of Newly Diagnosed Epilepsy: A Systematic Review and Meta-analysis

BACKGROUND AND OBJECTIVES

Understanding the multi-faceted treatment outcomes of newly diagnosed epilepsy is critical for developing rational therapeutic strategies. A meta-analysis was conducted to derive pooled estimates of a range of seizure outcomes in children and adults with newly diagnosed epilepsy commenced on antiseizure medication treatment, and to identify factors associated with different outcomes.

METHODS

PubMed/EMBASE were screened for eligible articles between 1 January, 1995 and 1 May, 2021 to include unselected cohort studies with a ≥ 12-month follow-up of seizure outcomes. Proportions of patients seizure free at different follow-up timepoints and their characteristics at the study population level were extracted. The patients were group-wise aggregated using a random-effects model. Primary outcomes were proportions of patients with cumulative 1-year seizure freedom (C1YSF), and 1-year and 5-year terminal seizure freedom (T1YSF and T5YSF). Secondary outcomes included the proportions of patients with early sustained seizure freedom, drug-resistant epilepsy and seizure-free off antiseizure medication at the last follow-up (off antiseizure medications). A separate random-effects meta-analysis was performed for nine predictors of importance.

RESULTS

In total, 39 cohorts (total n = 21,139) met eligibility criteria. They included 15 predominantly adult cohorts (n = 12,024), 19 children (n = 6569), and 5 of mixed-age groups (n = 2546). The pooled C1YSF was 79% (95% confidence interval [CI] 74-83). T1YSF was 68% (95% CI 63-72) and T5YSF was 69% (95% CI 62-75). Children had higher C1YSF (85% vs 68%, p < 0.001) and T1YSF than adult cohorts (74% vs 61%, p = 0.007). For secondary outcomes, 33% (95% CI 27-39) of patients achieved early sustained seizure freedom, 17% (95% CI 13-21) developed drug resistance, and 39% (95% CI 30-50) were off antiseizure medications at the last follow-up. Studies with a longer follow-up duration correlated with higher C1YSF (p < 0.001) and being off antiseizure medications (p = 0.045). Outcomes were not associated with study design (prospective vs retrospective), cohort size, publication year, or the earliest date of recruitment. Predictors of importance in newly diagnosed epilepsy include etiology, epilepsy type, abnormal diagnostics (neuroimaging, examination, and electroencephalogram findings), number of seizure types, and pre-treatment seizure burden.

CONCLUSIONS

Seizure freedom is achieved with currently available antiseizure medications in most patients with newly diagnosed epilepsy, yet this is often not immediate, may not be sustainable, and has not improved over recent decades. Symptomatic etiology, abnormal neuro-diagnostics, and increased pre-treatment seizure burden and seizure types are important predictors for unfavorable outcomes in newly diagnosed epilepsy. The study findings may be used as a quantitative benchmark on the efficacy of future antiseizure medication therapy for this patient population.

Efficacy and safety of traditional Chinese medicine for the treatment of epilepsy: A updated meta-analysis of randomized controlled trials

OBJECTIVE

To evaluate the efficacy and safety of Traditional Chinese Medicine (TCM) in the treatment of epilepsy.

METHODS

A comprehensive search of the database in both Chinese and English was performed. Data from the selected studies were extracted and analyzed independently by two authors.

RESULTS

30 randomized controlled trials (RCTs) were included in the meta-analysis with a total of 2471 patients. Among them, 4 trials (n = 235) focused on TCM monotherapy, while the other 26 trials (n = 2236) assessed the benefit of TCM as an add-on therapy to antiseizure medications (ASMs). For the efficacy, the meta-analysis found (1) The effective rate in TCM monotherapy group was higher than that in control group (OR = 4.92, 95 % CI: 2.29-10.57, Z = 4.08, P 0.0001); (2) The add-on of TCM also increased the effective rate (OR = 3.37, 95 % CI: 2.65-4.30, Z = 9.85, P 0.00001) and seizure freedom rate (OR = 1.93, 95 % CI: 1.53-2.44, Z = 5.58, P 0.00001). In terms of safety, the add-on of TCM reduced the rate of total adverse events (OR = 0.46, 95 % CI: 0.31-0.67, Z = 3.96, P 0.0001) as well as adverse events of the gastrointestinal and nervous system. 26 different TCM prescriptions were used in these included RCTs. Among them, the 5 most frequently used herbs were Acorus tatarinowii (19 out of 26), Glycyrrhiza uralensis (13 out of 26), Gastrodia elata (12 out of 26), Pinellia ternata (11 out of 26) and Poria cocos (11 out of 26).

CONCLUSION

This study suggested that TCM may be a relatively efficacious and safe clinical strategy for the treatment of epilepsy. Several limitations still exist, such as the risk of bias in the included studies, the diversified composition of TCM prescriptions, and the relatively low quality of study design.

The utility of mobile telephone-recorded videos as adjuncts to the diagnosis of seizures and paroxysmal events in children with suspected epileptic seizures

BACKGROUND

Epilepsy is often diagnosed through clinical description, but inter-observer interpretations can be diverse and misleading.

OBJECTIVE

To assess the utility of smartphone videos in the diagnosis of paediatric epilepsy.

METHODS

The literature was reviewed for evidence to support the use of smartphone videos, inclusive of advantages, ethical practice and potential disadvantages. An existing adult-based quality of video (QOV) scoring tool was adapted for use in children. A pilot study used convenience sampling of videos from 25 patients, which were reviewed to assess the viability of the adapted QOV tool against the subsequent diagnosis for the patients with videos. The referral mechanism of the videos was reviewed for the source and consent processes followed.

RESULTS

A total of 14 studies were identified. Methodologies varied; only three focused on videos of children, and QOV was formally scored in three. Studies found that smartphone videos of good quality assisted the differentiation of epilepsy from non-epileptic events, especially with accompanying history and with more experienced clinicians. The ethics and risks of circulation of smartphone videos were briefly considered in a minority of the reports. The pilot study found that the adapted QOV tool correlated with videos of moderate and high quality and subsequent diagnostic closure.

CONCLUSIONS

Data relating to the role of smartphone video of events in children is lacking, especially from low- and middle-income settings. Guidelines for caregivers to acquire good-quality videos are not part of routine practice. The ethical implications of transfer of sensitive material have not been adequately addressed for this group. Prospective multicentre studies are needed to formally assess the viability of the adapted QOV tool for paediatric videos.

Association of SCN1A Gene Polymorphism with Phenytoin Response in Patients with Epilepsy: Relevance of Stratification by the History of Febrile Seizure

AIM: The SCN1A gene encodes the NaV1.1 sodium channel in the central nervous system that serves as the target for phenytoin. Our study aimed to investigate the association of SCN1A polymorphism (SNP rs3812718) with phenytoin response. MATERIALS AND METHODS: A total of 120 epileptic patients who had received phenytoin for at least 1 year were enrolled in the study and genotyped using the TaqMan assay. They were classified into phenytoin-responsive (n = 62) and phenytoin unresponsive groups (n = 58). Patients were also stratified according to the history of febrile seizure (24 in the febrile seizure subgroup; 96 patients in the no history of febrile seizure subgroup) and epilepsy etiology (47 in idiopathic; 73 in the symptomatic + cryptogenic subgroup). RESULTS: The frequency of AA (19% vs. 11.3%) and AG genotypes (43.1% vs. 40.3%) was found to be more frequent in phenytoin unresponsive. GG genotypes dominated in the phenytoin responsive group (37.9% vs. 48.4%) but were not statistically significant (p > 0.05). We identified two variables associated with phenytoin response: the etiology of epilepsy (p = 0.012) and history of febrile seizure (0.014). A significant positive association between the rs3812718 genotype and phenytoin response was found when patients were stratified by a history of febrile seizures. In patients without a history of febrile seizures, the AA genotype had a higher risk of phenytoin unresponsiveness than the GG genotype (p = 0.048; OR 3.73, 95% CI: 1.01–13.78). CONCLUSION: There was no significant association between the rs3812718 polymorphism and phenytoin responsiveness in patients with epilepsy. In the patients without a history of febrile seizure subgroup, AA increased the risk of phenytoin unresponsiveness compared to the GG genotype.

Unmet needs and perspectives in management of drug resistant focal epilepsy: An Italian study

This study aimed to evaluate the consensus level between a representative group of Italian neurologists and people with Drug-Resistant Epilepsy (DRE) regarding a series of statements about different aspects involved in the management of epilepsy to identify the unmet needs of the People with Epilepsy (PwE) and the future perspectives for the management of this disease. This observational study was conducted using a classic Delphi technique. A 19-statement questionnaire was administered anonymously through an online platform to a panel of expert clinicians and a panel of PwE, analyzing three main topics of interest: drug resistance, access to care, and PwE's experience. The consensus was achieved on 8 of the 19 statements administered to the panel of medical experts and on 4 of the 14 submitted to the panel of PwE, particularly on the definition of DRE and its consequences on treatment, Quality of Life (QoL), and autonomy of PwE. Most of the items, however, did not reach a consensus and highlighted the lack of a shared univocal view on some topics, such as accessibility to care throughout the country and the role of emerging tools such as telemedicine, narrative medicine, and digital devices. In many cases, the two panels expressed different views on the statements. The results outlined many fields of possible intervention, such as the need for educational initiatives targeted at physicians and PwE - for example, regarding telemedicine, digital devices, and narrative medicine - as well as the spread of better knowledge about epilepsy among the general population, in order to reduce epilepsy stigma. Institutions, moreover, could take a cue from this survey to develop facilities aimed at enhancing PwE's autonomy and promoting more equal access to care throughout the country.

Minimally invasive surgical techniques in patients with intractable epilepsy with CT-guided stereotactic cryoablation as a superior alternative: a systematic review

Background

Stereotactic cryoablation is a minimally invasive surgical technique that has been used to treat disorders of the brain in the past; however, in current practice, it is primarily used for the treatment of liver, kidney, lung, prostate, and breast neoplasms. In this paper, currently used surgical methods to treat medically refractory seizure disorder are reviewed, and a case is made for the use of stereotactic cryoablation.

Main body

Anterior temporal lobectomy is the gold standard for temporal. There are also several variations of this procedure. Since this is a resective surgery, it can result in neurological defects. To obviate this problem, minimally invasive surgical techniques such as radio frequency ablation and laser interstitial thermal therapy are currently being used for intracranial targets. Cryoablation offers certain advantages over thermal ablations. Cryoablation studies in brain, renal, breast, and other neoplasms have shown that cryoablation has superior abilities to monitor the ablation zone in real time via computerized tomography imaging and also has the capability to create lesions of both smaller and larger sizes. This allows for safer and more effective tumor destruction.

Short conclusion

Based on the review, the authors conclude that further investigation of the use of stereotactic cryoablation in patients with medically intractable epilepsy is needed.

Response to subsequent antiseizure medications after first antiseizure medication failure in newly diagnosed epilepsy

Objective

There is a lack of studies using the International League Against Epilepsy (ILAE) recommendation to define drug-resistant epilepsy (DRE). This study evaluated the seizure freedom rates of substitution or add-on and subsequent antiseizure medication (ASM) therapies using different proposed definitions of DRE or ASM trials in patients with a failed first ASM. We also identified prognostic factors for 1-year seizure freedom.

Methods

This study included 459 patients with epilepsy of whom 151 were not seizure-free after the first ASM. Multilevel mixed-effects logistic regression was used to examine the correlation between observations from the same patient.

Results

The overall seizure freedom rate with the first and subsequent ASMs was 88.0% (404/459). The rate of DRE when defined as the failure of two ASMs for any reason was 20.0%, and according to the ILAE definition of DRE, it was 16.3%. After failing the first ASM, 63.6% of patients (96/151) became seizure free with subsequent ASMs and tried an average of 1.9 ASMs (range 1–5). Of the patients who achieved 1-year seizure freedom, 10.1% (41/404) were taking polytherapy and there was no difference between substitution and add-on. All the patients with generalized epilepsy were seizure-free. A favorable prognostic factor was age >60 years and an EEG without epileptiform activity. The efficacies of the different ASMs were largely similar, but drugs that enhanced GABA-mediated inhibitory neurotransmission had the lowest seizure freedom rate.

Significance

In adults with newly-diagnosed epilepsy, 1-year seizure freedom was achieved for almost 90% of the patients. After failing the first ASM, two-thirds of the patients responded to subsequent ASM regimens. Our results support the feasibility and applicability of the ILAE concept of an adequate ASM trial and the failure of two ASMs as a definition of DRE.

Effect of the COVID-19 Pandemic on Seizure Control Status in Patients with Epilepsy

BACKGROUND

Previous studies have shown that patients with epilepsy (PWE) perceived significant disruption in the quality and provision of care due to the coronavirus disease 2019 (COVID-19) pandemic. The present study aimed to investigate the effect of this pandemic on seizure control status and changes in seizure frequency in PWE.

METHODS

A consecutive sample of adult PWE registered in the database of Shiraz Epilepsy Center (Shiraz, Iran) was included in the study. In July 2021, phone interviews were conducted with all selected patients. Information such as age, sex, last seizure, seizure type, and frequency during the 12 months before the study, and history of COVID-19 contraction was extracted. The seizure control status of the patients in 2019 (pre-pandemic) was compared with that during the COVID-19 pandemic. Data were analyzed using SPSS software with the Fisher's exact test and Pearson's Chi squared test. P<0.05 was considered statistically significant.

RESULTS

A total of 158 patients were included in the study, out of which 62 (39.2%) patients had a stable seizure control status, 47 (29.7%) had fewer seizures, and 50 (31.6%) had more seizures. Breakthrough seizures were reported by 32 (34.4%) patients. Seizure frequency increased in 18 (27.7%) and decreased in 46 (70.7%) patients.

CONCLUSION

Overall, the COVID-19 pandemic has not been a major precipitating factor nor has it affected the seizure control status of PWE. In treated epilepsy, a fluctuating course with periods of seizure freedom followed by relapses is part of its natural history.

Perampanel monotherapy for the treatment of epilepsy: Clinical trial and real-world evidence

Perampanel, a selective, non-competitive α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor antagonist, is a once-daily oral anti-seizure medication (ASM) for focal-onset seizures (FOS) and generalized tonic-clonic seizures (GTCS). In the US, perampanel is approved for the treatment of FOS (adjunctive and monotherapy), with or without focal to bilateral tonic-clonic seizures (FBTCS), in patients aged ≥4 years, and as adjunctive treatment of GTCS in patients aged ≥12 years. The monotherapy approvals in the US were based on the Food and Drug Administration's (FDA's) policy allowing extrapolation of adjunctive data to the monotherapy setting in the absence of randomized controlled monotherapy trials; since then, perampanel monotherapy has received approvals in approximately 48 countries. As there are key differences in clinical evidence of perampanel as adjunctive therapy vs monotherapy, we review the clinical outcomes of perampanel when administered as primary or secondary monotherapy. Eight publications reporting the efficacy and safety outcomes of perampanel monotherapy in clinical trial and real-world settings were selected during our literature search and are included; these comprise three Eisai-sponsored studies in patients with epilepsy: one prospective, open-label, Phase III clinical trial of patients with newly diagnosed epilepsy (Study 342 [FREEDOM]) and two retrospective, real-world Phase IV studies of patients with epilepsy who received perampanel during routine clinical care (Studies 504 and 506 [PROVE]); and five retrospective, real-world studies in patients with epilepsy who were prescribed perampanel during routine clinical care. Results from these studies demonstrated that seizure freedom may be achieved following treatment with perampanel monotherapy (either primary or secondary), with favorable retention rates and safety profiles. Overall, the clinical evidence supports the use of perampanel monotherapy both in newly diagnosed patients and in those who have been unable to control their seizures with other ASMs.

Efficacy and safety of adjunctive padsevonil in adults with drug-resistant focal epilepsy: Results from two double-blind, randomized, placebo-controlled trials

OBJECTIVE

To characterize efficacy, safety/tolerability, and pharmacokinetics of padsevonil (PSL) administered concomitantly with ≤3 antiseizure medications (ASMs) for observable focal seizures in adults with drug-resistant epilepsy in two multicenter, randomized, double-blind, placebo-controlled, parallel-group trials.

METHODS

The phase 2b dose-finding trial (EP0091/NCT03373383) randomized patients 1:1:1:1:1 to PSL 50/100/200/400 mg or placebo twice daily (b.i.d.). The phase 3 efficacy trial (EP0092/NCT03739840) randomized patients 1:1:1:1 to PSL 100/200/400 mg or placebo b.i.d. Patients with observable (focal aware with motor symptoms, focal impaired awareness, focal to bilateral tonic-clonic) focal seizures for ≥3 years, experiencing them ≥4 times per 28 days including during the 4-week baseline period despite treatment with ≥4 lifetime ASMs including current ASMs, were enrolled.

RESULTS

In EP0091 and EP0092, 410 and 231 patients, respectively, were randomized and received at least one dose of trial medication. In patients in EP0091 on PSL 50/100/200/400 mg b.i.d. (n = 80/82/81/81, respectively) versus placebo (n = 81), outcomes included percentage reductions over placebo in observable focal seizure frequency during the 12-week maintenance period: 17.2%, 19.1% (p = 0.128), 19.2% (p = 0.128), 12.4% (p = 0.248); 75% responder rates (p-values for odds ratios): 13.8%, 12.2% (p = 0.192), 11.1% (p = 0.192), 16.0% (p = 0.124) versus 6.2%; 50% responder rates: 33.8% (p = 0.045), 31.7% (p = 0.079), 25.9% (p = 0.338), 32.1% (p = 0.087), versus 21.0%; TEAEs were reported by 82.7% (67/81), 78.3% (65/83), 74.4% (61/82), 90.1% (73/81) versus 78.3% (65/83). In patients in EP0092 on PSL 100/200/400 mg b.i.d. (n = 60/56/56, respectively) versus placebo (n = 54), outcomes included percentage reductions over placebo: -5.6% (p = 0.687), 6.5% (p = 0.687), 6.3% (p = 0.687); 75% responder rates: 15.3% (p = 0.989), 12.5% (p = 0.989), 14.3% (p = 0.989) versus 13.0%; 50% responder rates: 35.6% (p = 0.425), 33.9% (p = 0.625), and 42.9% (p = 0.125) versus 27.8%; TEAEs were reported by 80.0% (48/60), 78.9% (45/57), 83.1% (49/59) versus 67.3% (37/55).

SIGNIFICANCE

In both trials, the primary outcomes did not reach statistical significance in any PSL dose group compared with placebo. PSL was generally well tolerated, and no new safety signals were identified.

Localizing targets for neuromodulation in drug-resistant epilepsy using intracranial EEG and computational model

Neuromodulation has emerged as a promising technique for the treatment of epilepsy. The target for neuromodulation is critical for the effectiveness of seizure control. About 30% of patients with drug-resistant epilepsy (DRE) fail to achieve seizure freedom after surgical intervention. It is difficult to find effective brain targets for neuromodulation in these patients because brain regions are damaged during surgery. In this study, we propose a novel approach for localizing neuromodulatory targets, which uses intracranial EEG and multi-unit computational models to simulate the dynamic behavior of epileptic networks through external stimulation. First, we validate our method on a multivariate autoregressive model and compare nine different methods of constructing brain networks. Our results show that the directed transfer function with surrogate analysis achieves the best performance. Intracranial EEGs of 11 DRE patients are further analyzed. These patients all underwent surgery. In three seizure-free patients, the localized targets are concordant with the resected regions. For the eight patients without seizure-free outcome, the localized targets in three of them are outside the resected regions. Finally, we provide candidate targets for neuromodulation in these patients without seizure-free outcome based on virtual resected epileptic network. We demonstrate the ability of our approach to locate optimal targets for neuromodulation. We hope that our approach can provide a new tool for localizing patient-specific targets for neuromodulation therapy in DRE.

The correlation of temporal changes of neutrophil-lymphocyte ratio with seizure severity and the following seizure tendency in patients with epilepsy

Background

Changes in the neutrophil-lymphocyte ratio (NLR) has been reported to be associated with epilepsy. Here we aim to investigate the correlation of temporal changes of NLR level with seizure severity and the follow-up seizure attacks in patients with epilepsy (PWE).

Methods

We performed a retrospective analysis of the laboratory data including leukocyte count and NLR within 24 h of acute seizure and during the follow-up period of 5–14 days after acute seizure (NLR1, NLR2, respectively) in 115 PWE, and 98 healthy individuals were included as controls in this study. The correlation of laboratory data with seizure types, etiology of epilepsy, anti-seizure drugs (ASDs), seizure severity, and the follow-up seizure attacks in PWE was studied.

Results

Leukocyte count (P < 0.001) and NLR level (P < 0.001) were found significantly different between PWE and controls. On the other hand, a multivariable logistic regression analysis showed that NLR1 level (OR = 2.992, P = 0.001) and admission leukocyte (OR = 2.307, P = 0.002) were both independently associated with acute epileptic seizures. Especially, higher NLR1 level was significantly associated with status epileptics (P = 0.013) and recurrent seizures after admission (P < 0.001). Furthermore, the multivariable logistic regression analysis indicated that higher NLR1 was a predictor for the tendency of the following recurrent seizure attacks (OR = 1.144, P = 0.002). NLR2 was inversely correlated with ASDs taken (P = 0.011). Levels of NLR1 (r = 0.441, P < 0.001) and NLR2 (r = 0.241, P = 0.009) were both positively correlated with seizure severity.

Conclusions

Seizures were correlated with the alterations of systemic inflammation reflected by leukocyte and NLR. NLR1 and admission leukocyte were both independently associated with acute epileptic seizures. Higher NLR1 was associated with status epilepticus and independently predicted the tendency of the following epileptic seizures. NLR2 was significantly associated with ASDs taken. Besides, NLR may be used as a biomarker for seizure severity.

Safety evaluation of perampanel as monotherapy or first adjunctive therapy in patients with epilepsy

INTRODUCTION

There is a need for anti-seizure medications (ASMs) that are well tolerated and effective as monotherapy or first adjunctive therapy to reduce the need for adjunctive ASMs to treat newly diagnosed epilepsy, and to reduce the number of concomitant ASMs in patients with refractory epilepsy. Although the pivotal trials of perampanel evaluated its adjunctive use in patients with refractory seizures, open-label/real-world studies support its use in first/second-line settings.

AREAS COVERED

This paper reviews the pharmacology, efficacy, and safety/tolerability of perampanel, focusing on its use as monotherapy or first adjunctive therapy. The safety of perampanel in special populations and its safety/tolerability compared with that of other ASMs is also discussed.

EXPERT OPINION

Perampanel is a favorable candidate for initial or first adjunctive therapy due to its favorable efficacy and safety/tolerability as monotherapy and adjunctive therapy, its long half-life and ease of use, and its limited drug-drug interactions. The proposed mitigation strategies for managing the risk of serious psychiatric adverse events are appropriate patient selection, use of low doses, and slow titration. The growing body of evidence might shift current treatment strategies towards the early use of perampanel and its use at a low dose (4 mg/day).

Comparison of outcomes after stereoelectroencephalography and subdural grid monitoring in pediatric tuberous sclerosis complex

OBJECTIVE

Patients with tuberous sclerosis complex (TSC) epilepsy present with unique clinical challenges such as early seizure onset and high rates of intractability and multifocality. Although there are numerous studies about the safety and efficacy of stereoelectroencephalography (SEEG), this topic has not been studied in TSC patients who have distinct epilepsy profiles. The authors investigated subdural grid (SDG) and SEEG monitoring to determine whether these procedures lead to similar seizure and safety outcomes and to identify features unique to this pediatric population.

METHODS

TSC patients who underwent SDG or SEEG placement and a second epilepsy surgery during the period from 2007 to 2021 were included in this single-center retrospective cohort analysis. Various patient, hospitalization, and epilepsy characteristics were collected.

RESULTS

A total of 50 TSC patients were included in this study: 30 were included in the SDG cohort and 20 in the SEEG cohort. Baseline weekly seizure count did not significantly differ between the 2 groups (p = 0.412). The SEEG group had a greater mean baseline number of antiepileptic drugs (AEDs) (3.0 vs 2.0, p = 0.003), higher rate of previous surgical interventions (25% vs 0%, p = 0.007), and larger proportion of patients who underwent bilateral monitoring (50% vs 13.3%, p = 0.005). Despite this, there was no significant difference in seizure freedom between the SDG and SEEG cohorts. The mean reduction in seizure count was 84.9% and 47.8% of patients were seizure free at last follow-up (mean 79.4 months). SEEG trended toward being a safer procedure than SDG monitoring, with a shorter mean ICU stay (0.7 days vs 3.9 days, p < 0.001), lower blood transfusion rate (0% vs 13.3%, p = 0.140), and lower surgical complication rate (0% vs 10%, p = 0.265).

CONCLUSIONS

In the comparison of the SDG and SEEG cohorts, the SEEG group included patients who appeared to receive more aggressive management and have a higher rate of multifocality, more prior surgical interventions, more AEDs at baseline, and a higher rate of bilateral invasive monitoring. Despite this, the SEEG cohort had similar seizure outcomes and a trend toward increased safety. Based on these findings, SEEG appears to allow for monitoring of a wider breadth of TSC patients given its minimally invasive nature and its relative simplicity for monitoring numerous regions of the brain.

Increased interictal synchronicity of respiratory related brain pulsations in epilepsy

Respiratory brain pulsations have recently been shown to drive electrophysiological brain activity in patients with epilepsy. Furthermore, functional neuroimaging indicates that respiratory brain pulsations have increased variability and amplitude in patients with epilepsy compared to healthy individuals. To determine whether the respiratory drive is altered in epilepsy, we compared respiratory brain pulsation synchronicity between healthy controls and patients. Whole brain fast functional magnetic resonance imaging was performed on 40 medicated patients with focal epilepsy, 20 drug-naïve patients and 102 healthy controls. Cerebrospinal fluid associated respiratory pulsations were used to generate individual whole brain respiratory synchronization maps, which were compared between groups. Finally, we analyzed the seizure frequency effect and diagnostic accuracy of the respiratory synchronization defect in epilepsy. Respiratory brain pulsations related to the verified fourth ventricle pulsations were significantly more synchronous in patients in frontal, periventricular and mid-temporal regions, while the seizure frequency correlated positively with synchronicity. The respiratory brain synchronicity had a good diagnostic accuracy (ROC_AUC = 0.75) in discriminating controls from medicated patients. The elevated respiratory brain synchronicity in focal epilepsy suggests altered physiological effect of cerebrospinal fluid pulsations possibly linked to regional brain water dynamics involved with interictal brain physiology.

Development and Validation of a Deep Learning Model for Predicting Treatment Response in Patients With Newly Diagnosed Epilepsy

Importance

Selection of antiseizure medications (ASMs) for epilepsy remains largely a trial-and-error approach. Under this approach, many patients have to endure sequential trials of ineffective treatments until the "right drugs" are prescribed.

Objective

To develop and validate a deep learning model using readily available clinical information to predict treatment success with the first ASM for individual patients.

Design, Setting, and Participants

This cohort study developed and validated a prognostic model. Patients were treated between 1982 and 2020. All patients were followed up for a minimum of 1 year or until failure of the first ASM. A total of 2404 adults with epilepsy newly treated at specialist clinics in Scotland, Malaysia, Australia, and China between 1982 and 2020 were considered for inclusion, of whom 606 (25.2%) were excluded from the final cohort because of missing information in 1 or more variables.

Exposures

One of 7 antiseizure medications.

Main Outcomes and Measures

With the use of the transformer model architecture on 16 clinical factors and ASM information, this cohort study first pooled all cohorts for model training and testing. The model was trained again using the largest cohort and externally validated on the other 4 cohorts. The area under the receiver operating characteristic curve (AUROC), weighted balanced accuracy, sensitivity, and specificity of the model were all assessed for predicting treatment success based on the optimal probability cutoff. Treatment success was defined as complete seizure freedom for the first year of treatment while taking the first ASM. Performance of the transformer model was compared with other machine learning models.

Results

The final pooled cohort included 1798 adults (54.5% female; median age, 34 years [IQR, 24-50 years]). The transformer model that was trained using the pooled cohort had an AUROC of 0.65 (95% CI, 0.63-0.67) and a weighted balanced accuracy of 0.62 (95% CI, 0.60-0.64) on the test set. The model that was trained using the largest cohort only had AUROCs ranging from 0.52 to 0.60 and a weighted balanced accuracy ranging from 0.51 to 0.62 in the external validation cohorts. Number of pretreatment seizures, presence of psychiatric disorders, electroencephalography, and brain imaging findings were the most important clinical variables for predicted outcomes in both models. The transformer model that was developed using the pooled cohort outperformed 2 of the 5 other models tested in terms of AUROC.

Conclusions and Relevance

In this cohort study, a deep learning model showed the feasibility of personalized prediction of response to ASMs based on clinical information. With improvement of performance, such as by incorporating genetic and imaging data, this model may potentially assist clinicians in selecting the right drug at the first trial.

Integrative Analyses Identify KCNJ15 as a Candidate Gene in Patients with Epilepsy

INTRODUCTION

Although there is accumulating evidence that genetic factors play a vital role in the pathogenesis of epilepsy, few epilepsy-associated genes have been identified. Additionally, the role of KCNJ15 in epilepsy has not been evaluated so far.

METHODS

Here, we performed differentially expressed gene analysis, expression quantitative trait loci analysis, gene co-expression analysis, and protein-protein interaction analysis to evaluate the role of KCNJ15 in epilepsy.

RESULTS

Analysis of gene expression and expression quantitative trait loci data revealed that KCNJ15 was significantly downregulated in patients with epilepsy (adjusted P = 0.0146 and log₂ Fold change = - 1.0025), and an epilepsy-associated polymorphism (rs2833098) was linked to altered KCNJ15 expression level in human temporal lobe brain tissue (P = 0.0036). Gene co-expression analysis revealed that KCNJ15 was co-expressed with genes that have been reported to be associated with epilepsy in human brain tissue. Furthermore, protein-protein interaction analysis revealed strong supportive evidence for the role of KCNJ15 in epilepsy.

CONCLUSION

Our results show that KCNJ15 may be a candidate target for epilepsy. Functional analysis of KCNJ15 may provide novel insights for epilepsy treatment.

Current and future pharmacotherapy options for drug-resistant epilepsy

INTRODUCTION

Epilepsy is one of the most common and serious neurological conditions, affecting over 70 million individuals worldwide and despite advances in treatment, the proportion of drug-resistant patients has remained largely unchanged.

AREAS COVERED

The present paper reviews current and future (under preclinical and clinical development) pharmacotherapy options for the treatment of drug-resistant focal and generalized epilepsies.

EXPERT OPINION

Current pharmacotherapy options for drug-resistant epilepsy include perampanel, brivaracetam and the newly approved cenobamate for focal epilepsies; cannabidiol (Epidiolex) for Lennox-Gastaut Syndrome (LGS), Dravet and Tuberous Sclerosis Complex (TSC); fenfluramine for Dravet syndrome and ganaxolone for seizures in Cyclin-dependent kinase-like 5 (CDKL5) deficiency disorder. Many compounds are under clinical development and may hold promise for future pharmacotherapies. For adult focal epilepsies, padsevonil and carisbamate are at a more advanced Phase III stage of clinical development followed by compounds at Phase II like selurampanel, XEN1101 and JNJ-40411813. For specific epilepsy syndromes, XEN 496 is under Phase III development for potassium voltage-gated channel subfamily Q member 2 developmental and epileptic encephalopathy (KCNQ2-DEE), carisbamate is under Phase III development for LGS and Ganaxolone under Phase III development for TSC. Finally, in preclinical models several molecular targets including inhibition of glycolysis, neuroinflammation and sodium channel inhibition have been identified in animal models although further data in animal and later human studies are needed.

Seizure first aid for people with epilepsy: opinions and knowledge of caregivers and healthcare professionals

OBJECTIVE

We investigated the opinions and knowledge of the caregivers of people with epilepsy (PWE) and the related healthcare professionals (i.e., nurses and physicians) in Iran about first aid measures for helping a person experiencing a seizure.

METHODS

In this exploratory and descriptive study, we surveyed the caregivers of all PWE admitted to the epilepsy monitoring unit at Namazi Hospital, Shiraz, Iran, in May 2022. We also surveyed all the nurses at this hospital. A similar survey was distributed in the WhatsApp groups of the neurology, pediatrics, internal medicine, family physician, psychiatry, and neurosurgery physicians working at places affiliated with Shiraz University of Medical Sciences, Shiraz, Iran.

RESULTS

In total, 583 nurses, 70 physicians, and 133 caregivers participated in this study. On most questions, more caregivers provided inappropriate responses than nurses and physicians (e.g., not timing the seizure; not loosening the clothes around the neck; not rolling the patient onto the side if unconscious). On two questions, more caregivers provided appropriate responses than nurses and physicians (i.e., not putting something into the mouth; not always calling for emergency medical services).

CONCLUSION

While some actions may help prevent or reduce the chance of harmful consequences of epileptic seizures, many caregivers of PWE and healthcare professionals do not apply appropriate measures to help a patient experiencing a seizure. The scientific community should develop standardized seizure first aid training programs for the general public and healthcare professionals alike.

Levetiracetam Modulates EEG Microstates in Temporal Lobe Epilepsy

To determine the effects of Levetiracetam (LEV) therapy using EEG microstates analysis in a population of newly diagnosed Temporal Lobe Epilepsy (TLE) patients. We hypothesized that the impact of LEV therapy on the electrical activity of the brain can be globally explored using EEG microstates. Twenty-seven patients with TLE were examined. We performed resting-state microstate EEG analysis and compared microstate metrics between the EEG performed at baseline (EEG_pre) and after 3 months of LEV therapy (EEG_post). The microstates A, B, C and D emerged as the most stable. LEV induced a reduction of microstate B and D mean duration and occurrence per second (p < 0.01). Additionally, LEV treatment increased the directional predominance of microstate A to C and microstate B to D (p = 0.01). LEV treatment induces a modulation of resting-state EEG microstates in newly diagnosed TLE patients. Microstates analysis has the potential to identify a neurophysiological indicator of LEV therapeutic activity. This study of EEG microstates in people with epilepsy opens an interesting path to identify potential LEV activity biomarkers that may involve increased neuronal inhibition of the epileptic network.

Photobiomodulation regulates adult neurogenesis in the hippocampus in a status epilepticus animal model

Status epilepticus (SE) refers to a single seizure that lasts longer than typical seizures or a series of consecutive seizures. The hippocampus, which is vulnerable to the effects of SE, has a critical role in memory storage and retrieval. The trisynaptic loop in the hippocampus connects the substructures thereof, namely the dentate gyrus (DG), CA3, and CA1. In an animal model of SE, abnormal neurogenesis in the DG and aberrant neural network formation result in sequential neural degeneration in CA3 and CA1. Photobiomodulation (PBM) therapy, previously known as low-level laser (light) therapy (LLLT), is a novel therapy for the treatment of various neurological disorders including SE. However, the effects of this novel therapeutic approach on the recovery process are poorly understood. In the present study, we found that PBM transformed SE-induced abnormal neurogenesis to normal neurogenesis. We demonstrated that PBM plays a key role in normal hippocampal neurogenesis by enhancing the migration of maturing granular cells (early neuronal cells) to the GCL, and that normal neurogenesis induced by PBM prevents SE-induced hippocampal neuronal loss in CA1. Thus, PBM is a novel approach to prevent seizure-induced neuronal degeneration, for which light devices may be developed in the future.

The interaction between circadian rhythm and epilepsy

Evidence about the interaction between circadian rhythms (CR) and epilepsy has been expanded with the application of advanced detection technology. An adequate understanding of how circadian system and epilepsy interact with each other could contribute to more accurate seizure prediction as well as rapid development of potential treatment timed to specific phases of CR. In this review, we present the reciprocal relationship between CR and epileptic activities from aspects of sleep effect, genetic modulation and brain biochemistry. It has been found that sleep-wake patterns, circadian timing systems and multidien rhythms have essential roles in seizure activities and interictal epileptiform discharge (IED). For instance, specific distribution patterns of seizures and IED have been reported, i.e., lighter non-rapid eye movement (NREM) sleep stage (stage 2) induces seizures while deeper NREM sleep stage (stage 3) activates IEDs. Furthermore, the epilepsy type, seizure type and seizure onset zone can significantly affect the rhythms of seizure occurrence. Apart from the common seizure types, several specific epilepsy syndromes also have a close correlation with sleep-wakefulness patterns. Sleep influences the epilepsy rhythm, and conversely, epilepsy alters the sleep rhythm through multiple pathways. Clock genes accompanied by two feedback loops of regulation have an important role in cortical excitability and seizure occurrence, which may be involved in the mTORopathy. The suprachiasmatic nuclei (SCN) has a rhythm of melatonin and cortisol secretion under the circadian pattern, and then these hormones can feed back into a central oscillator to affect the SCN-dependent rhythms, leading to variable but prominent influence on epilepsy. Furthermore, we discuss the precise predictive algorithms and chronotherapy strategies based on different temporal patterns of seizure occurrence for patients with epilepsy, which may offer a valuable indication for non-invasive closed-loop treatment system. Optimization of the time and dose of antiseizure medications, and resynchronization of disturbed CR (by hormone therapy, light exposure, ketogenic diet, novel small molecules) would be beneficial for epileptic patients in the future. Before formal clinical practice, future large-scale studies are urgently needed to assist prediction and treatment of circadian seizure activities and address unsolved restrictions.