Seizure prediction: Time for new, multimodal and ultra-long-term approaches

Seizure forecasting: Where do we stand?

A lot of mileage has been made recently on the long and winding road toward seizure forecasting. Here we briefly review some selected milestones passed along the way, which were discussed at the International Conference for Technology and Analysis of Seizures-ICTALS 2022-convened at the University of Bern, Switzerland. Major impetus was gained recently from wearable and implantable devices that record not only electroencephalography, but also data on motor behavior, acoustic signals, and various signals of the autonomic nervous system. This multimodal monitoring can be performed for ultralong timescales covering months or years. Accordingly, features and metrics extracted from these data now assess seizure dynamics with a greater degree of completeness. Most prominently, this has allowed the confirmation of the long-suspected cyclical nature of interictal epileptiform activity, seizure risk, and seizures. The timescales cover daily, multi-day, and yearly cycles. Progress has also been fueled by approaches originating from the interdisciplinary field of network science. Considering epilepsy as a large-scale network disorder yielded novel perspectives on the pre-ictal dynamics of the evolving epileptic brain. In addition to discrete predictions that a seizure will take place in a specified prediction horizon, the community broadened the scope to probabilistic forecasts of a seizure risk evolving continuously in time. This shift of gears triggered the incorporation of additional metrics to quantify the performance of forecasting algorithms, which should be compared to the chance performance of constrained stochastic null models. An imminent task of utmost importance is to find optimal ways to communicate the output of seizure-forecasting algorithms to patients, caretakers, and clinicians, so that they can have socioeconomic impact and improve patients' well-being.

Cyclical underreporting of seizures in patient-based seizure documentation

OBJECTIVE

Circadian and multidien cycles of seizure occurrence are increasingly discussed as to their biological underpinnings and in the context of seizure forecasting. This study analyzes if patient reported seizures provide valid data on such cyclical occurrence.

METHODS

We retrospectively studied if circadian cycles derived from patient-based reporting reflect the objective seizure documentation in 2003 patients undergoing in-patient video-EEG monitoring.

RESULTS

Only 24.1% of more than 29000 seizures documented were accompanied by patient notifications. There was cyclical underreporting of seizures with a maximum during nighttime, leading to significant deviations in the circadian distribution of seizures. Significant cyclical deviations were found for focal epilepsies originating from both, frontal and temporal lobes, and for different seizure types (in particular, focal unaware and focal to bilateral tonic-clonic seizures).

INTERPRETATION

Patient seizure diaries may reflect a cyclical reporting bias rather than the true circadian seizure distributions. Cyclical underreporting of seizures derived from patient-based reports alone may lead to suboptimal treatment schemes, to an underestimation of seizure-associated risks, and may pose problems for valid seizure forecasting. This finding strongly supports the use of objective measures to monitor cyclical distributions of seizures and for studies and treatment decisions based thereon.

Importance of methodological choices in data manipulation for validating epileptic seizure detection models

Epilepsy is a chronic neurological disorder that affects a significant portion of the human population and imposes serious risks in the daily life. Despite advances in machine learning and IoT, small, non-stigmatizing wearable devices for continuous monitoring and detection in outpatient environments are not yet widely available. Part of the reason is the complexity of epilepsy itself, including highly imbalanced data, multimodal nature, and very subject-specific signatures. However, another problem is the heterogeneity of methodological approaches in research, leading to slower progress, difficulty in comparing results, and low reproducibility. Therefore, this article identifies a wide range of methodological decisions that must be made and reported when training and evaluating the performance of epilepsy detection systems. We characterize the influence of individual choices using a typical ensemble random-forest model and the publicly available CHB-MIT database, providing a broader picture of each decision and giving good-practice recommendations, based on our experience, where possible.