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Gouider R, Souissi A, Mrabet S, Gharbi A, Abida Y, Kacem I, Gargouri-Berrechid A. Environmental factors related to multiple sclerosis progression. J Neurol Sci 2024; 464:123161. [PMID: 39137699 DOI: 10.1016/j.jns.2024.123161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2024] [Revised: 07/29/2024] [Accepted: 07/29/2024] [Indexed: 08/15/2024]
Abstract
Multiple Sclerosis (MS) is a complex neurological disease which prevalence is increasing worldwide. The impact of environmental factors on MS susceptibility has already been defined and highlighted in many previous reports, particularly vitamin D or ultraviolet B light exposure, Epstein-Barr virus (EBV) infection, obesity, and smoking. There is increasing evidence that environmental and lifestyle factors are not only important in triggering MS but are also implicated in MS progression. Low sun exposure and vitamin D deficiency exhibit a strong relationship with disease progression in both animal and human studies. The gestational period seems also to impact long-term disease progression as January's babies had a higher risk of requiring walking assistance than those born in other months. The implication of EBV in neurodegeneration and MS progression was also suggested even though its specific targets and mechanisms are still unclear. Cigarette smoking is correlated with faster clinical progression. The association of obesity and smoking seems to be associated with a faster progression and an increased rate of brain atrophy. Although the effect of air pollution on MS pathogenesis remains not fully understood, exposure to polluted air can stimulate several mechanisms that might contribute to MS severity. People with MS with active disease have an altered microbiota compared to patients in the remission phase. Cardiovascular comorbidities, epilepsy, and depression are also associated with a more severe disability accrual. Knowledge about MS modifiable risk factors of progression need to be incorporated into everyday clinical practice in order to ameliorate disease outcomes.
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Affiliation(s)
- Riadh Gouider
- Department of Neurology, Clinical Investigation Centre Neurosciences and Mental Health LR 18SP03, Razi University Hospital - Manouba, Tunis, Tunisia; University of Tunis El Manar, Faculty of Medicine of Tunis, 1007, Tunisia.
| | - Amira Souissi
- Department of Neurology, Clinical Investigation Centre Neurosciences and Mental Health LR 18SP03, Razi University Hospital - Manouba, Tunis, Tunisia; University of Tunis El Manar, Faculty of Medicine of Tunis, 1007, Tunisia
| | - Saloua Mrabet
- Department of Neurology, Clinical Investigation Centre Neurosciences and Mental Health LR 18SP03, Razi University Hospital - Manouba, Tunis, Tunisia; University of Tunis El Manar, Faculty of Medicine of Tunis, 1007, Tunisia
| | - Alya Gharbi
- Department of Neurology, Clinical Investigation Centre Neurosciences and Mental Health LR 18SP03, Razi University Hospital - Manouba, Tunis, Tunisia; University of Tunis El Manar, Faculty of Medicine of Tunis, 1007, Tunisia
| | - Youssef Abida
- Department of Neurology, Clinical Investigation Centre Neurosciences and Mental Health LR 18SP03, Razi University Hospital - Manouba, Tunis, Tunisia; University of Tunis El Manar, Faculty of Medicine of Tunis, 1007, Tunisia
| | - Imen Kacem
- Department of Neurology, Clinical Investigation Centre Neurosciences and Mental Health LR 18SP03, Razi University Hospital - Manouba, Tunis, Tunisia; University of Tunis El Manar, Faculty of Medicine of Tunis, 1007, Tunisia
| | - Amina Gargouri-Berrechid
- Department of Neurology, Clinical Investigation Centre Neurosciences and Mental Health LR 18SP03, Razi University Hospital - Manouba, Tunis, Tunisia; University of Tunis El Manar, Faculty of Medicine of Tunis, 1007, Tunisia
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Ouyang J, Peng S, Wu G, Liu R. Association Between Neurodegenerative Diseases and an Increased Risk of Epilepsy Based on Single Nucleotide Polymorphisms: A Mendelian Randomization Study. Mol Neurobiol 2024; 61:5950-5957. [PMID: 38261256 DOI: 10.1007/s12035-024-03955-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Accepted: 01/12/2024] [Indexed: 01/24/2024]
Abstract
Epilepsy is a common neurological disorder characterized by transient brain dysfunction, attributed to a multitude of factors. The purpose of this study is to explore whether neurodegenerative diseases, specifically Alzheimer's disease (AD), Parkinson's disease (PD), amyotrophic lateral sclerosis (ALS), and multiple sclerosis (MS), have a causal effect on epilepsy. Mendelian randomization (MR) methods were used to analyze the causal association between neurodegenerative diseases (AD, PD, ALS, and MS) and epilepsy based on single nucleotide polymorphisms from genome-wide association studies, including inverse-variance weighted, weighted median, MR-Egger, and weighted mode methods. The reliability and stability of the MR analysis results were assessed by the MR-Egger intercept, MR-PRESSO, and heterogeneity tests. Forty-three SNPs were selected for the MR analysis of MS and epilepsy. The inverse-variance weighted method showed a significant causal association between MS and increased risk of epilepsy (odds ratio 1.046; 95% confidence interval 1.001-1.093; P = 0.043). However, AD (P = 0.986), PD (P = 0.894), and ALS (P = 0.533) were not causally associated with epilepsy. Sensitivity analysis showed that the results were robust. The MR study confirmed the causal relationship between genetically predicted MS and epilepsy but did not support the causal relationship between genetically predicted AD, PD, and ALS on epilepsy.
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Affiliation(s)
- Jia Ouyang
- Department of Neurosurgery, Peking University People's Hospital, Beijing, 100044, People's Republic of China
| | - Shijun Peng
- Department of Neurosurgery, Peking University People's Hospital, Beijing, 100044, People's Republic of China
| | - Guangyong Wu
- Department of Neurosurgery, Peking University People's Hospital, Beijing, 100044, People's Republic of China
| | - Ruen Liu
- Department of Neurosurgery, Peking University People's Hospital, Beijing, 100044, People's Republic of China.
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Ertürk Çetin Ö, Güngör Doğan İ, Zanapalioğlu Ü, Yadi F, Çetinkaya Tezer D, Demir S. Seizures in inflammatory demyelinating disorders of the central nervous system. Mult Scler Relat Disord 2024; 85:105535. [PMID: 38452647 DOI: 10.1016/j.msard.2024.105535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 02/10/2024] [Accepted: 03/01/2024] [Indexed: 03/09/2024]
Abstract
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.
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Affiliation(s)
- Özdem Ertürk Çetin
- University of Health Sciences, Sancaktepe Training and Research Hospital, Department of Neurology, Istanbul, Turkey.
| | - İpek Güngör Doğan
- University of Health Sciences, Sancaktepe Training and Research Hospital, Department of Neurology, Istanbul, Turkey
| | - Ümit Zanapalioğlu
- University of Health Sciences, Sancaktepe Training and Research Hospital, Department of Neurology, Istanbul, Turkey
| | - Feyzullah Yadi
- University of Health Sciences, Sancaktepe Training and Research Hospital, Department of Neurology, Istanbul, Turkey
| | - Damla Çetinkaya Tezer
- University of Health Sciences, Sancaktepe Training and Research Hospital, Department of Neurology, Istanbul, Turkey
| | - Serkan Demir
- University of Health Sciences, Sancaktepe Training and Research Hospital, Department of Neurology, Istanbul, Turkey
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Sanchez M, Marone A, Silva WH, Marrodan M, Correale J. Clinical characteristics, course and prognosis of Multiple Sclerosis patients with epilepsy. A case control study: MS and epilepsy. Mult Scler Relat Disord 2024; 83:105422. [PMID: 38219299 DOI: 10.1016/j.msard.2024.105422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 12/27/2023] [Accepted: 01/01/2024] [Indexed: 01/16/2024]
Abstract
BACKGROUND AND PURPOSE Although more common than in the general population, seizures are an atypical manifestation of multiple sclerosis (MS) and their pathophysiology is not well understood. This study aims to examine the prevalence, clinical characteristics, brain imaging findings and course of epilepsy, presenting in patients with MS. METHODS Observational retrospective study of MS patients evaluated at a single MS reference center in Buenos Aires, Argentina, between 2011 and 2022, focusing on those who developed epilepsy (EMS). Clinical, demographic, and prognostic factors were evaluated and compared to a control group of non-epileptic MS patients (NEMS). To analyze specific epilepsy characteristics, a second control group of patients with non-lesional focal epilepsy (FNLE) was also included. RESULTS Twenty-five patients (18 women), were diagnosed with epilepsy, corresponding to a prevalence of 1.95%. Comparison of brain imaging characteristics between EMS and NEMS patients showed brain atrophy (32% vs 6.1%, p<0.01), as well as cortical (26% vs 4%, p=0.03) and juxtacortical lesions (84% vs 55%, p=0.05), were more frequent in EMS patients. However, after multivariate analysis, cortical atrophy was the only variable linked to a significant increase in risk of epilepsy (OR 24, 95%CI=2.3-200, p<0.01). No significant differences in clinical characteristics, disease activity, disability levels, response to disease modified treatment (DMT) or lack of DMT efficacy were observed between MS patients with or without epilepsy. Most patients received anti-seizure medication (ASM), and seizure control was better in EMS than in FNLE patients (92% vs 58%, p=0.022) with no differences found in drug resistance. We did not find predictors of seizure recurrence in the population studied. CONCLUSION We observed a lower prevalence of epilepsy in this group of MS patients, compared to other reported cohorts. Although epilepsy seems to have a benign course in MS patients, cortical atrophy appears to be an important contributor to the development of secondary epilepsy in MS patients. Further investigations will be necessary to identify risk factors or biomarkers predicting increased epilepsy risk in MS.
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Affiliation(s)
| | - Abril Marone
- Departamento de Neurología, Fleni, Buenos Aires, Argentina
| | - Walter H Silva
- Departamento de Neurología, Fleni, Buenos Aires, Argentina
| | | | - Jorge Correale
- Departamento de Neurología, Fleni, Buenos Aires, Argentina; Instituto de Química y Fisicoquímica Biológicas (IQUIFIB), Universidad de Buenos Aires/CONICET, Buenos Aires, Argentina
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Li J, Qi H, Chen Y, Zhu X. Epilepsy and demyelination: Towards a bidirectional relationship. Prog Neurobiol 2024; 234:102588. [PMID: 38378072 DOI: 10.1016/j.pneurobio.2024.102588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Accepted: 02/13/2024] [Indexed: 02/22/2024]
Abstract
Demyelination stands out as a prominent feature in individuals with specific types of epilepsy. Concurrently, individuals with demyelinating diseases, such as multiple sclerosis (MS) are at a greater risk of developing epilepsy compared to non-MS individuals. These bidirectional connections raise the question of whether both pathological conditions share common pathogenic mechanisms. This review focuses on the reciprocal relationship between epilepsy and demyelination diseases. We commence with an overview of the neurological basis of epilepsy and demyelination diseases, followed by an exploration of how our comprehension of these two disorders has evolved in tandem. Additionally, we discuss the potential pathogenic mechanisms contributing to the interactive relationship between these two diseases. A more nuanced understanding of the interplay between epilepsy and demyelination diseases has the potential to unveiling the molecular intricacies of their pathological relationships, paving the way for innovative directions in future clinical management and treatment strategies for these diseases.
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Affiliation(s)
- Jiayi Li
- Department of Pharmacology, Medical School of Southeast University, Nanjing, China; Clinical Medicine, Medical School of Southeast University, Nanjing, China
| | - Honggang Qi
- Department of Pharmacology, Medical School of Southeast University, Nanjing, China
| | - Yuzhou Chen
- Department of Pharmacology, Medical School of Southeast University, Nanjing, China; Clinical Medicine, Medical School of Southeast University, Nanjing, China
| | - Xinjian Zhu
- Department of Pharmacology, Medical School of Southeast University, Nanjing, China.
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Zuo H, Peng L, Li W, Wang Y, Du X, Zou X, Dong Z, Yi L, Yin H, Quan F, Cheng O. Assessment of bidirectional relationships between multiple sclerosis and epilepsy: A two-sample Mendelian randomization study. Mult Scler Relat Disord 2024; 81:105148. [PMID: 38006848 DOI: 10.1016/j.msard.2023.105148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 11/18/2023] [Accepted: 11/19/2023] [Indexed: 11/27/2023]
Abstract
BACKGROUND AND OBJECTIVE Epidemiological studies indicate that multiple sclerosis (MS) is associated with epilepsy. However, the causality and directionality of this association remain under-elucidated. This study aimed to reveal the causality between MS and epilepsy. METHODS A two-sample Mendelian randomization (MR) analysis was performed by using summarized statistics derived from large genome-wide association studies of MS and epilepsy. We used the inverse variance weighted method as the primary approach, and then four other MR methods to bidirectionally evaluate the causality of the association between MS and epilepsy. Additional sensitivity analyses were performed to measure the robustness of the findings. RESULTS Genetically predicted MS was positively correlated with developing all epilepsy [odds ratio (OR) = 1.027 (1.003-1.051), P = 0.028] and generalized epilepsy [OR = 1.050 (1.008-1.094), P = 0.019]. In the reverse MR analysis, all epilepsy [OR = 1.310 (1.112-1.543), P = 0.001], generalized epilepsy [OR = 1.173 (1.010-1.363), P = 0.037], and focal epilepsy [OR = 1.264 (1.069-1.494), P = 0.006] elevated the risk of developing MS. The result remained robust and congruous across all sensitivity analyses conducted. CONCLUSIONS MS is potentially associated with a higher risk of developing epilepsy. Furthermore, epilepsy may be a causal determinant of MS risk. These findings may further the understanding of the interaction of the two conditions.
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Affiliation(s)
- Hongzhou Zuo
- Department of Neurology, The First Affiliated Hospital, Chongqing Medical University, Chongqing 400016, China
| | - Li Peng
- Department of Neurology, The First Affiliated Hospital, Chongqing Medical University, Chongqing 400016, China; Department of Neurology, Youyang County People's Hospital, Chongqing 409899, China
| | - Wei Li
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Yuzhu Wang
- Department of Neurology, The First Affiliated Hospital, Chongqing Medical University, Chongqing 400016, China
| | - Xinyi Du
- Department of Neurology, The First Affiliated Hospital, Chongqing Medical University, Chongqing 400016, China
| | - Xiaoya Zou
- Department of Neurology, The First Affiliated Hospital, Chongqing Medical University, Chongqing 400016, China
| | - Zhaoying Dong
- Department of Neurology, The First Affiliated Hospital, Chongqing Medical University, Chongqing 400016, China
| | - Li Yi
- Department of Neurology, The First Affiliated Hospital, Chongqing Medical University, Chongqing 400016, China
| | - Huimei Yin
- Department of Neurology, The First Affiliated Hospital, Chongqing Medical University, Chongqing 400016, China
| | - Fengying Quan
- Department of Neurology, The First Affiliated Hospital, Chongqing Medical University, Chongqing 400016, China.
| | - Oumei Cheng
- Department of Neurology, The First Affiliated Hospital, Chongqing Medical University, Chongqing 400016, China.
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Grothe M, Ellenberger D, Rommer PS, Stahmann A, Zettl UK. Epileptic seizures at multiple sclerosis onset and their role in disease progression. Ther Adv Neurol Disord 2023; 16:17562864231192826. [PMID: 37808247 PMCID: PMC10559692 DOI: 10.1177/17562864231192826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 07/20/2023] [Indexed: 10/10/2023] Open
Abstract
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.
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Affiliation(s)
- Matthias Grothe
- Department of Neurology, University Medicine Greifswald, Ferdinand-Sauerbruchstraße, Greifswald 17475, Germany
| | - David Ellenberger
- German MS Register by the German MS Society, MS Research and Project Development gGmbH [MSFP], Hanover, Germany
| | - Paulus S. Rommer
- Department of Neurology, Medical University of Vienna, Vienna, Austria
- Department of Neurology, Neuroimmunological Section, University of Rostock, Rostock, Germany
| | - Alexander Stahmann
- German MS Register by the German MS Society, MS Research and Project Development gGmbH [MSFP], Hanover, Germany
| | - Uwe K. Zettl
- Department of Neurology, Neuroimmunological Section, University of Rostock, Rostock, Germany
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Marrie RA, Fisk JD, Fitzgerald K, Kowalec K, Maxwell C, Rotstein D, Salter A, Tremlett H. Etiology, effects and management of comorbidities in multiple sclerosis: recent advances. Front Immunol 2023; 14:1197195. [PMID: 37325663 PMCID: PMC10266935 DOI: 10.3389/fimmu.2023.1197195] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 05/19/2023] [Indexed: 06/17/2023] Open
Abstract
Comorbid conditions commonly affect people with multiple sclerosis (MS). Population-based studies indicate that people with MS have an increased incidence of ischemic heart disease, cerebrovascular disease, peripheral vascular disease, and psychiatric disorders as compared to people without MS. People with MS from underrepresented minority and immigrant groups have higher comorbidity burdens. Comorbidities exert effects throughout the disease course, from symptom onset through diagnosis to the end of life. At the individual level, comorbidity is associated with higher relapse rates, greater physical and cognitive impairments, lower health-related quality of life, and increased mortality. At the level of the health system and society, comorbidity is associated with increased health care utilization, costs and work impairment. A nascent literature suggests that MS affects outcomes from comorbidities. Comorbidity management needs to be integrated into MS care, and this would be facilitated by determining optimal models of care.
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Affiliation(s)
- Ruth Ann Marrie
- Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- Department of Community Health Sciences, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - John D. Fisk
- Nova Scotia Health and the Departments of Psychiatry, Psychology & Neuroscience, and Medicine, Dalhousie University, Halifax, NS, Canada
| | - Kathryn Fitzgerald
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Kaarina Kowalec
- College of Pharmacy, University of Manitoba, Winnipeg, MB, Canada
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden
| | - Colleen Maxwell
- Schools of Pharmacy and Public Health & Health Systems, University of Waterloo, Waterloo, ON, Canada
| | - Dalia Rotstein
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- St. Michael’s Hospital, Toronto, ON, Canada
| | - Amber Salter
- Department of Neurology, UT Southwestern, Dallas, TX, United States
| | - Helen Tremlett
- Department of Medicine (Neurology) and the Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC, Canada
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Dang YL, Yong VT, Sharmin S, Perucca P, Kalincik T. Seizure risk in multiple sclerosis patients treated with disease-modifying therapy: A systematic review and network meta-analysis. Mult Scler 2023; 29:657-667. [PMID: 36802988 DOI: 10.1177/13524585231151400] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
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 loge 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.
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Affiliation(s)
- Yew Li Dang
- Department of Neurology, Bladin-Berkovic Comprehensive Epilepsy Program, Austin Health, Melbourne, VIC, Australia/Department of Medicine, Austin Health, The University of Melbourne, Melbourne, VIC, Australia/Melbourne Brain Centre, Melbourne, VIC, Australia
| | - Vivien Ty Yong
- Department of Neurology, The Royal Melbourne Hospital, Melbourne, VIC, Australia/Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand/Department of Neurology, Auckland City Hospital, Auckland, New Zealand
| | - Sifat Sharmin
- CORe, Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia
| | - Piero Perucca
- Department of Neurology, Bladin-Berkovic Comprehensive Epilepsy Program, Austin Health, Melbourne, VIC, Australia/Department of Medicine, Austin Health, The University of Melbourne, Melbourne, VIC, Australia/Department of Neurology, The Royal Melbourne Hospital, Melbourne, VIC, Australia/Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia/Department of Neurology, Alfred Health, Melbourne, VIC, Australia
| | - Tomas Kalincik
- Neuroimmunology Centre, Department of Neurology, The Royal Melbourne Hospital, Melbourne, VIC, Australia/CORe, Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia
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Mahamud Z, Burman J, Zelano J. Temporal trends of epilepsy in multiple sclerosis. Acta Neurol Scand 2022; 146:492-498. [PMID: 35852006 PMCID: PMC9795966 DOI: 10.1111/ane.13671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Revised: 06/23/2022] [Accepted: 07/06/2022] [Indexed: 12/30/2022]
Abstract
OBJECTIVES Epilepsy is associated with advanced multiple sclerosis (MS). We aimed to investigate whether the incidence of epilepsy in MS has been affected by the introduction of disease-modifying treatments (DMT) for MS. MATERIALS AND METHODS This retrospective study included 14,557 patients from the Swedish MS register with MS onset between 1991 and 2018. Incident diagnoses of epilepsy or any seizure were identified through cross-linkage with the National Patient Register. Next, yearly prevalence of epilepsy as well as 5- and 10 years incidence of epilepsy or any seizure for consecutive years of MS onset were estimated, the latter with Kaplan-Meier analysis. Cox regression was used to adjust the association between the year of MS onset and incidence of epilepsy for baseline variables. RESULTS Prevalence of epilepsy in the MS cohort increased from 0.34% in 1991 to 2.54% in 2018 (yearly odds: 1.26 [1.22, 1.29]). The 5 years incidence rate of epilepsy, ranging from 0.4% (95% CI 0.008-0.79%) to 1.3% (95% CI 0.71-1.89%), and the 10 years incidence rate of epilepsy, ranging from 1.1% (95% CI 0.31-1.88%) to 2.6% (95% CI 1.22-3.97%) showed no significant trends (p = .147 and p = .418, respectively). Similarly, no significant trends were found for the incidences of any seizure. The incidence trends of epilepsy remained not significant after adjusting for sex, MS onset type (relapsing or progressive onset), or age at MS onset. CONCLUSIONS Our findings do not support the hypothesis that the introduction of novel DMT for MS has reduced the incidence of epilepsy among MS patients.
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Affiliation(s)
- Zamzam Mahamud
- Department of Clinical Neuroscience, Sahlgrenska AcademyUniversity of Gothenburg and Sahlgrenska University HospitalGothenburgSweden
| | - Joachim Burman
- Department of NeuroscienceUppsala UniversityUppsalaSweden
| | - Johan Zelano
- Department of Clinical Neuroscience, Sahlgrenska AcademyUniversity of Gothenburg and Sahlgrenska University HospitalGothenburgSweden,Wallenberg Centre for Molecular and Translational MedicineSahlgrenska academyGothenburg
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Willumsen JS, Grytten N, Aarseth J, Myklebust TÅ, Myhr KM, Midgard R. Mortality and cause of death in multiple sclerosis in western Norway 1950-2021: a registry-based linkage study. J Neurol Neurosurg Psychiatry 2022; 93:jnnp-2022-329169. [PMID: 36096665 PMCID: PMC9606487 DOI: 10.1136/jnnp-2022-329169] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 08/08/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Persons with multiple sclerosis (pwMS) have higher risk of mortality compared with the general population. Longitudinal studies are important for understanding the evolution of survival in pwMS. OBJECTIVE Examine changes in mortality among pwMS during the past seven decades. METHODS We followed pwMS from Hordaland and Møre and Romsdal in Western Norway, with disease onset from before 1950, identified from population-based epidemiological surveys and the Norwegian MS Registry and Biobank, until 1 January 2021. Data were linked to the Norwegian Cause of Death Registry to obtain underlying cause of death. We examined all-cause, and cause-specific mortality using standardised mortality ratios (SMR) and excess death rates (EDR). We calculated life expectancies and assessed survival stratified by sex, age and disease phenotype at onset. We compared hazard ratios (HRs) for mortality, in pwMS diagnosed before and after the era of disease-modifying treatment (DMT). RESULTS Of 3624 pwMS, 964 (55.5% women) had died, predominantly of multiple sclerosis (49.0%). Median life expectancy for pwMS was 74.3 years (95% CI 73.3 to 75.3), compared with 83.1 years for the general population (p<0.001). From disease onset, pwMS survived 14.6 years shorter than the general population (p<0.001). Overall, SMR was 2.3 (95% CI 2.13 to 2.42) and EDR was 6.8 (95% CI 6.42 to 7.09) for pwMS. Treatment-eligible pwMS diagnosed in the DMT era had the lowest risk of mortality, HR 0.49 (95% CI 0.34 to 0.70,p<0.001). CONCLUSION Excess mortality among pwMS declined during the past seven decades, possibly due to improved diagnostics, better symptomatic treatment and access to DMTs.
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Affiliation(s)
- Johannes Sverre Willumsen
- Department of Neurology, Møre og Romsdal Hospital Trust, Molde, Norway
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, Trondheim, Norway
| | - Nina Grytten
- Norwegian Multiple Sclerosis Competence Centre, Department of Neurology, Haukeland Universitetssjukehus, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Neuro-SysMed, Department of Neurology, Haukeland Universitetssjukehus, Bergen, Norway
| | - Jan Aarseth
- Norwegian Multiple Sclerosis Competence Centre, Department of Neurology, Haukeland Universitetssjukehus, Bergen, Norway
- Neuro-SysMed, Department of Neurology, Haukeland Universitetssjukehus, Bergen, Norway
- Norwegian MS Registry and Biobank, Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Tor Åge Myklebust
- Department of Research and Innovation, Møre og Romsdal Hospital Trust, Ålesund, Norway
| | - Kjell-Morten Myhr
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Neuro-SysMed, Department of Neurology, Haukeland Universitetssjukehus, Bergen, Norway
| | - Rune Midgard
- Department of Neurology, Møre og Romsdal Hospital Trust, Molde, Norway
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Li EC, Zheng Y, Cai MT, Lai QL, Fang GL, Du BQ, Shen CH, Zhang YX, Wu LJ, Ding MP. Seizures and epilepsy in multiple sclerosis, aquaporin 4 antibody-positive neuromyelitis optica spectrum disorder and myelin oligodendrocyte glycoprotein antibody-associated disease. Epilepsia 2022; 63:2173-2191. [PMID: 35652436 DOI: 10.1111/epi.17315] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 05/30/2022] [Accepted: 05/31/2022] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Er-Chuang Li
- Department of Neurology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Yang Zheng
- Department of Neurology, First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, China
| | - Meng-Ting Cai
- Department of Neurology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Qi-Lun Lai
- Department of Neurology, Zhejiang Hospital, Hangzhou, China
| | - Gao-Li Fang
- Department of Neurology, Zhejiang Chinese Medicine and Western Medicine Integrated Hospital, Hangzhou, China
| | - Bing-Qing Du
- Department of Neurology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Chun-Hong Shen
- Department of Neurology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Yin-Xi Zhang
- Department of Neurology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Long-Jun Wu
- Department of Neurology, Mayo Clinic, Rochester, MN, United States
| | - Mei-Ping Ding
- Department of Neurology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
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13
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Villamar MF, Sarkis RA, Pennell P, Kohane I, Beaulieu-Jones BK. Severity of Epilepsy and Response to Antiseizure Medications in Individuals with Multiple Sclerosis: Analysis of a Real-World Dataset. Neurol Clin Pract 2022; 12:e49-e57. [DOI: 10.1212/cpj.0000000000001178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 04/26/2022] [Indexed: 11/15/2022]
Abstract
ABSTRACTBackground and objectives:Epilepsy is an important comorbidity that affects outcomes for people with multiple sclerosis (MS). However, it is unclear if seizure severity among individuals with coexistence of multiple sclerosis and epilepsy (MS+E) is higher than in those with other focal epilepsies. Our goal was to compare the overall severity of epilepsy in individuals with MS+E versus those with focal epilepsy without MS (E-MS) as defined by seizure-related healthcare utilization, frequency and duration of status epilepticus, and frequency of antiseizure medication (ASM) regimen changes.Methods:In this hypothesis-generating study, we analyzed a U.S. commercial nationwide de-identified claims dataset with > 86 million individuals between 1/1/2008 and 8/31/2019. Using validated algorithms, we identified adults with E-MS and those with MS+E. We compared the number and length of seizure-related hospital admissions, the number of claims and unique days with claims for status epilepticus, and the rates of ASM regimen changes between the MS+E and the E-MS groups.Results:During the study period, 66,708 individuals with E-MS and 537 with MS+E had ≥ 2 years of coverage after their initial diagnosis of epilepsy. There was no difference between the MS+E and E-MS groups in the percentage of individuals admitted for seizures and/or status epilepticus. However, MS+E with seizure-related admissions had more admissions and longer hospital stays than those with E-MS. MS+E who experienced status epilepticus had more unique days with status epilepticus claims compared to E-MS. MS+E were more likely to have ASM regimen changes in Year 2 after the initial diagnosis of epilepsy and had more ASM changes during Year 2 compared to E-MS. Among individuals with MS+E, there were no differences in our measures of seizure severity for those treated with sodium channel blockers/modulators versus other ASM classes.Discussion:This study supports the notion that individuals with MS+E can have more severe epilepsy than those with E-MS. Seizure severity among individuals with MS+E treated with sodium-channel blockers/modulators versus other ASM classes shows no significant differences.Classification of evidence:This study provides Class III evidence that individuals with MS+E can have more severe epilepsy than those with E-MS.
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14
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Grothe M, Ellenberger D, von Podewils F, Stahmann A, Rommer PS, Zettl UK. Epilepsy as a predictor of disease progression in multiple sclerosis. Mult Scler 2021; 28:942-949. [PMID: 34595974 DOI: 10.1177/13524585211046739] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Matthias Grothe
- Department of Neurology, University Medicine Greifswald, Ferdinand-Sauerbruchstraße, 17475 Greifswald, Germany.,Department of Neurology, University Medicine Greifswald, Greifswald, Germany
| | - David Ellenberger
- German MS Register by the German MS Society, MS Research and Project Development gGmbH [MSFP], Hanover, Germany
| | - Felix von Podewils
- Department of Neurology, University Medicine Greifswald, Greifswald, Germany
| | - Alexander Stahmann
- German MS Register by the German MS Society, MS Research and Project Development gGmbH [MSFP], Hanover, Germany
| | - Paulus S Rommer
- Department of Neurology, Neuroimmunological Section, University of Rostock, Rostock, Germany/Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Uwe K Zettl
- Department of Neurology, Neuroimmunological Section, University of Rostock, Rostock, Germany
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Mahamud Z, Håkansson S, Burman J, Zelano J. Retention of antiseizure medications for epilepsy in multiple sclerosis: A retrospective observational study. Epilepsy Behav 2021; 121:108034. [PMID: 34004524 DOI: 10.1016/j.yebeh.2021.108034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 04/22/2021] [Accepted: 04/24/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Epilepsy in multiple sclerosis (MS) is rare, and longitudinal clinical studies evaluating treatment with antiseizure medications (ASMs) are difficult to conduct. We instead designed a nationwide register study to estimate retention rates of ASMs prescribed as initial monotherapy for epilepsy in MS and investigated factors influencing their retention. METHODS multiple sclerosis patients with a first prescription of ASM for epilepsy were identified by cross-referencing the Swedish MS register with comprehensive national registers. One and five-year retention rates of ASMs were estimated using Kaplan-Meier analysis. Cox proportional regression was employed to estimate hazard ratios (HR) of discontinuation for different ASMs as well as for baseline predictors. RESULTS One hundred and twenty-nine MS patients were included. The most commonly prescribed ASMs were: carbamazepine (n = 38, 29.5%), lamotrigine (n = 33, 25.6%) and levetiracetam (n = 19, 14.7%). One-year retention rates (95% CI) were: lamotrigine 87.5% [76, 98.9], carbamazepine 60.5% [45, 76], levetiracetam 60.2% [37.2, 83.2], valproate 51.3% [23, 79.6] and phenytoin 44.4% [11.8, 77]. Fiveyear retention rates (95% CI) were: lamotrigine 74.4% [57.3, 91.5], carbamazepine 52.2% [34.9, 69.4], valproate 51.3% [23.1, 79.5] and phenytoin 14.8% [0, 40.9]. With carbamazepine as reference, lamotrigine was the only ASM that displayed a lower hazard of discontinuation, HR 0.41 [0.17, 0.99]. We could not identify any baseline factors that influenced the risk of discontinuation. CONCLUSION Lamotrigine displayed the lowest risk of discontinuation when prescribed as initial monotherapy for epilepsy in MS. Newer ASMs generally compared well to older ones, at least suggesting non-inferiority.
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Affiliation(s)
- Zamzam Mahamud
- Department of Clinical Neuroscience, Sahlgrenska Academy, University of Gothenburg and Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Samuel Håkansson
- Department of Clinical Neuroscience, Sahlgrenska Academy, University of Gothenburg and Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Joachim Burman
- Department of Neuroscience, Uppsala University, Uppsala, Sweden
| | - Johan Zelano
- Department of Clinical Neuroscience, Sahlgrenska Academy, University of Gothenburg and Sahlgrenska University Hospital, Gothenburg, Sweden; Wallenberg Centre for Molecular and Translational Medicine, Sahlgrenska Academy, Gothenburg, Sweden.
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16
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Neuroinflammation: A Signature or a Cause of Epilepsy? Int J Mol Sci 2021; 22:ijms22136981. [PMID: 34209535 PMCID: PMC8267969 DOI: 10.3390/ijms22136981] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 06/11/2021] [Accepted: 06/23/2021] [Indexed: 12/21/2022] Open
Abstract
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.
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