Epileptic seizures in multiple sclerosis: prevalence, competing causes and diagnostic accuracy

Seizures in inflammatory demyelinating disorders of the central nervous system

BACKGROUND

Multiple sclerosis (MS), neuromyelitis optica spectrum disorder (NMOSD), and myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) may be associated with acute symptomatic seizures and chronic epilepsy as well. The clinical features of the seizures and/or accompanying epilepsy seen in each disease group may vary. In this study, we aimed to contribute to the existing literature by describing the clinical features of seizures and epilepsy in our demyelinating patient population.

METHODS

We retrospectively analyzed patients who were followed up in our tertiary referral center neurology demyelinating diseases outpatient clinic between 2019 and 2024. Patients who had at least one seizure before, simultaneously, or after the diagnosis of demyelinating disease were included in the study.

RESULTS

Among 1735 patients with MS, 40 had experienced at least one epileptic seizure (2.3 %). Thirty patients (1.7 %) had seizures that could not be explained by another factor than MS. When secondary progressive MS (SPMS) and relapsing-remitting MS (RRMS) were compared, the interval between MS-epilepsy diagnosis was longer and seizure recurrence was more in SPMS. However, the prognosis of epilepsy was good in both subtypes. There were 21 patients followed up with antibody-positive neuromyelitis optica spectrum disorder. No patient had a seizure during the follow-up. We identified 56 patients who fulfilled the criteria for MOGAD with high antibody titers. Seizures were observed in three of them (5.4 %). All of them had status epilepticus either at the onset or during the course of the disease.

CONCLUSION

Even rare, seizures constitute one of the important clinical features of the inflammatory demyelinating disorders of the central nervous system. The pathophysiologic mechanism underlying seizures in MS is still not clear. Seizures may occur through different mechanisms in patients where seizures are the initial symptom or a sign of relapse and those that occur spontaneously during the progressive course of the disease. Prevalence of status epilepticus was common in MOGAD patients. Given the rarity of the seizures in CNS demyelinating disorders, it is difficult the define clinical and pathophysiological characteristics of accompanying seizures and epilepsy. Future studies conducted on large patient groups will contribute to the existing literature.

Epileptic seizures at multiple sclerosis onset and their role in disease progression

Background

Epileptic seizures can occur throughout the course of multiple sclerosis (MS) and are associated with increasing disability progression over time. However, there are no data on whether epileptic seizures at the onset of MS also lead to increasing disability.

Objective

To examine disease progression over time for MS patients with epileptic seizures at onset.

Methods

We analyzed the data of 30,713 patients on the German Multiple Sclerosis Register in a case-control study for more than 15 years. MS patients with seizures at onset were further divided into subgroups with polysymptomatic and monosymptomatic onset to assess the impact of additional symptoms on disease progression.

Results

A total of 46 patients had seizures as onset symptoms. Expanded Disability Status Scale (EDSS) within the first year was lower in the group with seizures at onset compared to controls (0.75 versus 1.6, p < 0.05), which changed until the last reported visit (3.11 versus 3.0). Both subgroups revealed increased EDSS progression over time compared to controls.

Conclusion

Epileptic seizures at MS onset are associated with a higher amount of disability progression over time. Additional longitudinal data are needed to further clarify the impact of seizures on the pathophysiology of MS disease progression.

Recent progress in epidemiology, clinical features, and therapy of multiple sclerosis in China

Multiple sclerosis (MS) is a demyelinating disease of the central nervous system characterized by inflammation, demyelination, and neurodegeneration. It mainly affects young adults, imposing a heavy burden on families and society. The epidemiology, clinical features, and management of MS are distinct among different countries. Although MS is a rare disease in China, there are 1.4 billion people in China, so the total number of MS patients is not small. Because of the lack of specific diagnostic biomarkers for MS, there is a high misdiagnosis rate in China, as in other regions. Due to different genetic backgrounds, the clinical manifestations of MS in Chinese are different from those in the West. Herein, this review aims to summarize the disease comprehensively, including clinical profile and the status of disease-modifying therapies in China based on published population-based observation and cohort studies, and also to compare with data from other countries and regions, thus providing help to develop diagnostic guideline and the novel therapeutic drugs. Meanwhile, we also discuss the problems and challenges we face, specifically for the diagnosis and treatment of MS in the middle- and low-income countries.

Anti-NMDA receptor encephalitis in a 73-year-old female with secondary progressive multiple sclerosis: A case report

Anti-NMDA receptor (Anti-NMDAR) encephalitis is an autoimmune disease that presents with diverse symptoms. Since literature is scarce on the overlap with multiple sclerosis (MS), this report aims to elucidate the distinctive clinical presentation and diagnostic challenges of anti-NMDAR encephalitis in MS patients. A 73-year-old woman with secondary progressive multiple sclerosis, after experiencing status epilepticus and subsequent non-convulsive status epilepticus, presented with neuropsychiatric symptoms and autonomic nervous dysfunction. Notably, the patient had not received any immunomodulatory therapy. The clinical picture together with diagnostics (MRI, EEG, cerebro-spinal fluid) let us suspect HSV-meningoencephalitis and empirically treat the patient with IV acyclovir. Due to a lack of clinical improvement, we reconsidered the diagnosis and found the diagnostic criteria for autoimmune encephalitis to be met. Antibodies in blood and CSF were positive and we diagnosed the patient with anti-NMDAR encephalitis. The patient responded well to IV prednisolone treatment, leading to a stable outcome in a six-month follow-up. This case highlights the difficulties in diagnosing anti-NMDAR encephalitis in patients with multiple sclerosis. The presence of epileptic seizures can serve as a crucial diagnostic indicator to distinguish between an MS relapse and an overlapping disease. Compared to patients with other demyelinating diseases, patients with overlapping MS appear to have a higher risk of motor seizures.

Seizure risk in multiple sclerosis patients treated with disease-modifying therapy: A systematic review and network meta-analysis

BACKGROUND

Multiple sclerosis patients experience 3-6 times more seizures than the general population, but observations vary among studies. Seizure risk in disease-modifying therapy recipients remains unknown.

OBJECTIVE

The objective of this study was to compare seizure risk in multiple sclerosis patients receiving disease-modifying therapy versus placebo.

METHODS

MEDLINE(OVID), Embase, CINAHL, and ClinicalTrials.gov were searched from database inception until August 2021. Phase 2-3 randomized, placebo-controlled trials reporting efficacy and safety data for disease-modifying therapies were included. Network meta-analysis followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, using Bayesian random effects model for individual and pooled (by drug target) therapies. Main outcome was log_e seizure risk ratios [95% credible intervals]. Sensitivity analysis included meta-analysis of non-zero-event studies.

RESULTS

A total of 1993 citations and 331 full-texts were screened. Fifty-six included studies (29,388 patients-disease-modifying therapy = 18,909; placebo = 10,479) reported 60 seizures (therapy = 41; placebo = 19). No individual therapy was associated with altered seizure risk ratio. Exceptions were daclizumab (-17.90 [-65.31; -0.65]) and rituximab (-24.86 [-82.71; -1.37]) trending toward lower risk ratio; cladribine (25.78 [0.94; 4.65]) and pegylated interferon-beta-1a (25.40 [0.78; 85.47]) trended toward higher risk ratio. Observations had wide credible intervals. Sensitivity analysis of 16 non-zero-event studies revealed no difference in risk ratio for pooled therapies (l0.32 [-0.94; 0.29]).

CONCLUSION

No evidence of association was found between disease-modifying therapy and seizure risk-this informs seizure management in multiple sclerosis patients.

A pediatric case of autoimmune encephalitis with chronologically moving seizure foci and cortical lesions: A case report

INTRODUCTION

Autoimmune encephalitis (AIE) is a relatively newly described category of immune-mediated diseases involving the central nervous system with a wide spectrum of clinical presentations, ranging from relatively mild or insidious onset of cognitive impairment to more complex forms of encephalopathy with medically refractory seizures. Single or multifocal seizures accompanied by neuropsychiatric symptoms and cognitive or memory impairments are suggestive of clinical features at AIE onset.

CASE REPORT

A six-year-old boy presented with repetitive focal seizures, slowly progressive emotional liability, and attention-deficit/hyperactivity disorder-like symptoms. Seizure types varied during the clinical course, sometimes emerging as clusters or statuses. MRI performed during seizure clustering/status revealed moving signal abnormalities. We successfully treated the patient with high-dose intravenous methylprednisolone. Cerebrospinal fluid analysis revealed pleocytosis and marked elevation of antibodies against N-terminals of N-methyl-d-aspartate type glutamate receptor subunits and granzyme B.

CONCLUSION

We report a case of moving seizure foci with abnormal MRI findings. Although the onset of psychiatric symptoms slowly progressed to those atypical for AIE, responsiveness to immunotherapy, cerebrospinal fluid pleocytosis, and autoantibodies all indicated AIE. We thus suggest that moving seizure foci and abnormal MRI signals may be findings of AIE.

Seizures and multiple sclerosis‑more than an epidemiological association (Review)

In order to increase the quality of life of patients with epilepsy, it is essential to develop tools that facilitate early disease diagnosis and encourage the use of individualized therapies. The association between seizures and other neurological pathologies is well known but incompletely explained, with multiple sclerosis (MS)-seizures correlation being a relevant example. In this context, the present review aimed to highlight the most important facts related to the association between the heterogeneous group of epileptic pathology and MS, in order to provide initial directions for establishing a diagnostic and therapeutic protocol. The first part reviewed the most relevant epidemiological and clinical data on seizures; MS association. Subsequently, it highlighted the most common and actually accepted pathophysiological mechanisms that try to explain the association between the two pathologies. Finally, the importance of paraclinical investigations and the optimal choice of antiseizure-based therapies with respect to seizures associated with MS are presented, also revealing several directions that should be explored in the near future.

Seizures and epilepsy in multiple sclerosis, aquaporin 4 antibody-positive neuromyelitis optica spectrum disorder and myelin oligodendrocyte glycoprotein antibody-associated disease

Seizure is one of the manifestations of central nervous system (CNS) inflammatory demyelinating diseases, which mainly include multiple sclerosis (MS), aquaporin 4 antibody-positive neuromyelitis optica spectrum disorder (AQP4-NMOSD) and myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD). "Acute symptomatic seizures secondary to MS / AQP4-NMOSD / MOGAD" occur in the acute phase of the diseases, and are more frequent in MOGAD. In contrast, recurrent non-provoked seizures, mainly attributed to "autoimmune-associated epilepsy", occur in the non-acute phase of the diseases. Seizures in MS / AQP4-NMOSD / MOGAD mostly have a focal-onset. MS patients with concomitant systemic infections, an earlier onset and a higher disease activity are more likely to have seizures, whereas factors such as higher MS severity, the presence of status epilepticus and cortical damage indicate a greater risk of developing epilepsy. In MOGAD, cerebral cortical encephalitis, acute disseminated encephalomyelitis (ADEM)-like phenotypes (predominately ADEM and multiphasic disseminated encephalomyelitis) indicate a higher seizure risk. Multiple relapses with ADEM-like phenotypes predict epilepsy in pediatrics with MOGAD. Pathophysiologically, acute symptomatic seizures in MS are associated with neuronal hyperexcitability secondary to inflammation and demyelination. Chronic epilepsy in MS is largely due to gliosis, neuronal dysfunction and synaptic abnormalities. The mainstay of treatment for seizures secondary to MS / AQP4-NMOSD / MOGAD include immunotherapy along with antiseizure medications. This critical review discusses the most-updated evidence on epidemiology, clinical correlates, and inflammatory mechanisms underlying seizures and epilepsy in MS / AQP4-NMOSD / MOGAD. Treatment cautions including drug-drug interactions and the impact of treatments on the other are outlined. We also highlight pitfalls and challenges in managing such patients and future research perspectives to address unsolved questions.

Modulation of Pacemaker Channel Function in a Model of Thalamocortical Hyperexcitability by Demyelination and Cytokines

A consensus is yet to be reached regarding the exact prevalence of epileptic seizures or epilepsy in multiple sclerosis (MS). In addition, the underlying pathophysiological basis of the reciprocal interaction among neuroinflammation, demyelination, and epilepsy remains unclear. Therefore, a better understanding of cellular and network mechanisms linking these pathologies is needed. Cuprizone-induced general demyelination in rodents is a valuable model for studying MS pathologies. Here, we studied the relationship among epileptic activity, loss of myelin, and pro-inflammatory cytokines by inducing acute, generalized demyelination in a genetic mouse model of human absence epilepsy, C3H/HeJ mice. Both cellular and network mechanisms were studied using in vivo and in vitro electrophysiological techniques. We found that acute, generalized demyelination in C3H/HeJ mice resulted in a lower number of spike–wave discharges, increased cortical theta oscillations, and reduction of slow rhythmic intrathalamic burst activity. In addition, generalized demyelination resulted in a significant reduction in the amplitude of the hyperpolarization-activated inward current (I_h) in thalamic relay cells, which was accompanied by lower surface expression of hyperpolarization-activated, cyclic nucleotide-gated channels, and the phosphorylated form of TRIP8b (pS237-TRIP8b). We suggest that demyelination-related changes in thalamic I_h may be one of the factors defining the prevalence of seizures in MS.

Epilepsy as a predictor of disease progression in multiple sclerosis

BACKGROUND

Epilepsy development during the course of multiple sclerosis (MS) is considered to be the result of cortical pathology. However, no long-term data exist on whether epilepsy in MS also leads to increasing disability over time.

OBJECTIVE

To examine if epilepsy leads to more rapid disease progression.

METHODS

We analyzed the data of 31,052 patients on the German Multiple Sclerosis Register in a case-control study.

RESULTS

Secondary progressive disease course (odds ratio (OR) = 2.23), age (OR = 1.12 per 10 years), and disability (OR = 1.29 per Expanded Disability Status Scale (EDSS) point) were associated with the 5-year prevalence of epilepsy. Patients who developed epilepsy during the course of the disease had a higher EDSS score at disease onset compared to matched control patients (EDSS 2.0 vs 1.5), progressed faster in each dimension, and consequently showed higher disability (EDSS 4.4 vs 3.4) and lower employment status (40% vs 65%) at final follow-up. After 15 years of MS, 64% of patients without compared to 54% of patients with epilepsy were not severely limited in walking distance.

CONCLUSION

This work highlights the association of epilepsy on disability progression in MS, and the need for additional data to further clarify the underlying mechanisms.

Informed DEcision for cerebrospinal fluid analysis after epiLeptic seizures- the IDEAL-score: A development and validation study

BACKGROUND

This observational study was done to develop a score based on clinical predictors that enables a guided decision for the necessity of cerebrospinal fluid (CSF) analysis after first unprovoked epileptic seizures and to validate this score in a retrospective patient cohort.

METHODS

Clinical predictors were identified by two panels of epilepsy experts and selected according to content validity ratios. Based on these predictors a score was created and applied to a cohort of patients with first epileptic seizures.

RESULTS

The "IDEAL score" consists of 9 items (fever, prolonged disturbance of consciousness, headache, imaging results, cognitive dysfunction, status epilepticus, malignancy, autoimmune encephalitis symptoms) that are collected at two different time points (< 3 h [A-score]; > 3 h [B-score] after hospital admittance). A CSF analysis is recommended, if at least one clinical finding is present, either one of the items evaluated during the acute phase (A-score) or later in the diagnostic process (B-score). In 41 patients (13%) CSF analysis provided essential clues to the cause of the seizure. The combined IDEAL score reached a sensitivity of 98%, a specificity of 53%, a positive predictive value of 24% and a negative predictive value of 99% in this patient cohort.

CONCLUSIONS

A CSF analysis after first epileptic seizures provided decisive etiological findings in only 13% of all investigated patients. The IDEAL score offers clinicians a simple and easy-to-implement algorithm to assess the necessity of a CSF analysis, and to prevent unnecessary diagnostic procedures.

Neuroinflammation: A Signature or a Cause of Epilepsy?

Epilepsy can be both a primary pathology and a secondary effect of many neurological conditions. Many papers show that neuroinflammation is a product of epilepsy, and that in pathological conditions characterized by neuroinflammation, there is a higher probability to develop epilepsy. However, the bidirectional mechanism of the reciprocal interaction between epilepsy and neuroinflammation remains to be fully understood. Here, we attempt to explore and discuss the relationship between epilepsy and inflammation in some paradigmatic neurological and systemic disorders associated with epilepsy. In particular, we have chosen one representative form of epilepsy for each one of its actual known etiologies. A better understanding of the mechanistic link between neuroinflammation and epilepsy would be important to improve subject-based therapies, both for prophylaxis and for the treatment of epilepsy.

Guillain-Barré syndrome spectrum associated with COVID-19: an up-to-date systematic review of 73 cases

Since coronavirus disease-2019 (COVID-19) outbreak in January 2020, several pieces of evidence suggested an association between the spectrum of Guillain-Barré syndrome (GBS) and severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). Most findings were reported in the form of case reports or case series, whereas a comprehensive overview is still lacking. We conducted a systematic review and searched for all published cases until July 20th 2020. We included 73 patients reported in 52 publications. A broad age range was affected (mean 55, min 11-max 94 years) with male predominance (68.5%). Most patients showed respiratory and/or systemic symptoms, and developed GBS manifestations after COVID-19. However, asymptomatic cases for COVID-19 were also described. The distributions of clinical variants and electrophysiological subtypes resemble those of classic GBS, with a higher prevalence of the classic sensorimotor form and the acute inflammatory demyelinating polyneuropathy, although rare variants like Miller Fisher syndrome were also reported. Cerebrospinal fluid (CSF) albuminocytological dissociation was present in around 71% cases, and CSF SARS-CoV-2 RNA was absent in all tested cases. More than 70% of patients showed a good prognosis, mostly after treatment with intravenous immunoglobulin. Patients with less favorable outcome were associated with a significantly older age in accordance with previous findings regarding both classic GBS and COVID-19. COVID-19-associated GBS seems to share most features of classic post-infectious GBS and possibly the same immune-mediated pathogenetic mechanisms. Nevertheless, more extensive epidemiological studies are needed to clarify these issues.

Otolaryngological manifestations of hospitalised patients with confirmed COVID-19 infection

PURPOSE

The aim of our study is to evaluate the incidence and characteristics of otolaryngology symptoms in COVID 19 patients.

METHODS

116 patients with positive PCR test results for COVID-19 and followed up by otolaryngologists at a tertiary referral center/COVID-19 pandemic hospital were questioned in terms of otolaryngology symptoms associated with COVID-19 infection. Data including demographics, disease severity, concomitant diseases, previous otolaryngologic diseases,incidence and duration of new onset symptoms were collected and categorically analyzed. In addition, the severity of loss of smell and taste was evaluated by visual analogue score (VAS).

RESULTS

A total of 58 men and 58 women participated. The mean age of the patients was 57.24 ± 14.32 (19-83). The most common otolaryngological findings were hyposmia/anosmia (37.9%) and hypogeusia/ageusia (41.37%), respectively. These complaints were followed by headache (37.1%), and nausea/vomiting (31%). The most common oropharyngeal symptoms were sore throat (32.7%) and dysphagia (20.6%). The rate of otological/vestibular symptoms was dizziness (31.8%), tinnitus (11%), true vertigo (6%), and hearing impairment (5.1%), respectively. The most of symptoms were more frequent in > 60 years and women. There was a significant correlation between nasal itching and smell disturbance in patients with allergic rhinitis. Considering the duration of symptoms, the longest were hyposmia/anosmia and hypogeusia/ageusia. The mean VAS's in patients with hyposmia/anosmia and hypogeusia/ageusia were 5.52 ± 2.08 and 5.79 ± 2.21, respectively.

CONCLUSION

The most common otolaryngologic symptoms of COVID-19 infection are known as sore throat, smell and/or taste disturbances. However, our study showed that these patients can be seen with different symptoms in otological or laryngeal areas. Therefore, a more careful evaluation should be made in terms of otolaryngologic symptoms when COVID 19 infection is suspected.

A rare case of acute motor axonal neuropathy and myelitis related to SARS-CoV-2 infection

We describe a rare case of post-infective Acute Motor Axonal Neuropathy (AMAN) variant of Guillain-Barrè Syndrome (GBS) associated with myelitis and anti-GD1b positivity after SARS-CoV-2 infection. The patient referred to the hospital reporting a history of ten days lasting moderate fever, myalgia and anosmia, with the onset of progressive quadriparesis and ascending paraesthesias in the four limbs since five days from defervescence. A chest computed tomography demonstrated interstitial pneumonia with “ground glass opacities”, suggesting Coronavirus disease (COVID-19). The patient exhibited three negative reverse-transcription polymerase chain reaction (RT-PCR) nasopharyngeal swabs, while SARS-CoV-2 IgG was found in plasma. The electrophysiological examination demonstrated an AMAN and the spinal cord Magnetic Resonance Imaging (MRI) showed a T2-weighted hyperintense lesion in the posterior part of the spinal cord at the C7-D1 levels. Furthermore, anti-GD1b IgM was detected. GBS and myelitis could exceptionally develop simultaneously. Our findings reasonably support a causality link between COVID-19 and the neurological symptoms, suggesting a post-infective autoimmune reaction.