Stress as a seizure precipitant: Identification, associated factors, and treatment options

Seizure prediction in stroke survivors who experienced an infection at skilled nursing facilities-a machine learning approach

Background

Infections and seizures are some of the most common complications in stroke survivors. Infections are the most common risk factor for seizures and stroke survivors that experience an infection are at greater risk of experiencing seizures. A predictive model to determine which stroke survivors are at the greatest risk for a seizure after an infection can be used to help providers focus on prevention of seizures in higher risk residents that experience an infection.

Methods

A predictive model was generated from a retrospective study of the Long-Term Care Minimum Data Set (MDS) 3.0 (2014-2018, n = 262,301). Techniques included three data balancing methods (SMOTE for up sampling, ENN for down sampling, and SMOTEENN for up and down sampling) and three feature selection methods (LASSO, Recursive Feature Elimination, and Principal Component Analysis). One balancing and one feature selection technique was applied, and the resulting dataset was then trained on four machine learning models (Logistic Regression, Random Forest, XGBoost, and Neural Network). Model performance was evaluated with AUC and accuracy, and interpretation used SHapley Additive exPlanations.

Results

Using data balancing methods improved the prediction performances of the machine learning models, but feature selection did not remove any features and did not affect performance. With all models having a high accuracy (76.5%-99.9%), interpretation on all four models yielded the most holistic view. SHAP values indicated that therapy (speech, physical, occupational, and respiratory), independence (activities of daily living for walking, mobility, eating, dressing, and toilet use), and mood (severity score, anti-anxiety medications, antidepressants, and antipsychotics) features contributed the most. Meaning, stroke survivors who received fewer therapy hours, were less independent, had a worse overall mood were at a greater risk of having a seizure after an infection.

Conclusion

The development of a tool to predict seizure following an infection in stroke survivors can be interpreted by providers to guide treatment and prevent complications long term. This promotes individualized treatment plans that can increase the quality of resident care.

Parvalbumin neurons in the nucleus accumbens shell modulate seizure in temporal lobe epilepsy

A growing number of clinical and animal studies suggest that the nucleus accumbens (NAc), especially the shell, is involved in the pathogenesis of temporal lobe epilepsy (TLE). However, the role of parvalbumin (PV) GABAergic neurons in the NAc shell involved in TLE is still unclear. In this study, we induced a spontaneous TLE model by intrahippocampal administration of kainic acid (KA), which generally induce acute seizures in first 2 h (acute phase) and then lead to spontaneous recurrent seizures after two months (chronic phase). We found that chemogenetic activation of NAc shell PV neurons could alleviate TLE seizures by reducing the number and period of focal seizures (FSs) and secondary generalized seizures (sGSs), while selective inhibition of PV exacerbated seizure activity. Ruby-virus mapping results identified that the hippocampus (ventral and dorsal) is one of the projection targets of NAc shell PV neurons. Chemogenetic activation of the NAc-Hip PV projection fibers can mitigate seizures while inhibition has no effect on seizure ictogenesis. In summary, our findings reveal that PV neurons in the NAc shell could modulate the seizures in TLE via a long-range NAc-Hip circuit. All of these results enriched the investigation between NAc and epilepsy, offering new targets for future epileptogenesis research and precision therapy.

Efficacy and Safety of Pulse Intravenous Methylprednisolone in Pediatric Epileptic Encephalopathies: Timing and Networks Consideration

Background: Epileptic encephalopathies (EE) are characterized by severe drug-resistant seizures, early onset, and unfavorable developmental outcomes. This article discusses the use of intravenous methylprednisolone (IVMP) pulse therapy in pediatric patients with EE to evaluate its efficacy and tolerability. Methods: This is a retrospective study from 2020 to 2023. Inclusion criteria were ≤18 years at the time of IVMP pulse therapy and at least 6 months of follow-up. Efficacy and outcome, defined as seizure reduction > 50% (responder rate), were evaluated at 6 and 9 months of therapy, and 6 months after therapy suspension; quality of life (QoL) was also assessed. Variables predicting positive post-IVMP outcomes were identified using statistical analysis. Results: The study included 21 patients, with a responder rate of 85.7% at 6 and 9 months of therapy, and 80.9% at 6 months after therapy suspension. Variables significantly predicting favorable outcome were etiology (p = 0.0475) and epilepsy type (p = 0.0475), with the best outcome achieved in patients with genetic epilepsy and those with encephalopathy related to electrical status epilepticus during slow-wave sleep (ESES). All patients evidenced improvements in QoL at the last follow-up, with no relevant adverse events reported. Conclusions: Our study confirmed the efficacy and high tolerability of IVMP pulse therapy in pediatric patients with EE. Genetic epilepsy and ESES were positive predictors of a favorable clinical outcome. QOL, EEG tracing, and postural-motor development showed an improving trend as well. IVMP pulse therapy should be considered earlier in patients with EE.

Group-based parent training programme for children with neurological conditions: a feasibility study

OBJECTIVE AND DESIGN

This study aimed to determine the feasibility and effectiveness of a parent training programme for parents of children with neurological conditions and behaviours that challenge.

SETTING

Child and adolescent mental health service within a specialist children's hospital.

PARTICIPANTS

Parents of 31 children with neurological conditions and behaviours that challenge.

INTERVENTIONS

Parents attended a 6-week evidence-based behavioural parenting programme delivered in a group format, either face-to-face or remote.

MAIN OUTCOME MEASURES

Feasibility was determined by attendance rates. Effectiveness was analysed primarily using parent-reported measures of child behaviour (Strengths and Difficulties Questionnaire, Paediatric Quality of Life and Goal-Based Outcomes). Secondary measures of parental well-being were also reported (Brief Parental Self-Efficacy Scale, Depression Anxiety Stress Scale Short Form and Parental Sense of Competence). Paired t-tests or Wilcoxon rank-sum tests were conducted to analyse differences preintervention and postintervention.

RESULTS

The attendance rates for the face-to-face and remote groups were 80% and 79%, respectively. Medium to large effect sizes were reported for most measures of child behaviour and parental well-being. There were statistically significant improvements found postintervention in children's behaviour (p=0.014), quality of life (p<0.001), goal-based outcomes (p<0.001), parental self-efficacy (p<0.001) and parental anxiety (p=0.030). Anecdotal feedback showed that parents indicated the group format was acceptable.

CONCLUSIONS

The group parenting intervention for parents of children with heterogeneous neurological conditions and behaviours that challenge appears feasible and effective in improving child behaviour and parental well-being.

Flumazenil Treatment for Diazepam-Associated Neurological Signs in a Cat With a Portosystemic Shunt

A 7-month-old female spayed domestic short hair cat was presented for evaluation of inadequate clinical response to medical management for hepatic encephalopathy (HE). An abdominal computed tomography (CT) was to be performed but the cat developed 2 grand mal seizures shortly after presentation. Minimal handling and no drugs had been administered before the seizures. A single dose of diazepam (0.3 mg/kg, IV) was administered after each seizure. Another seizure occurred 24 hours after hospitalization and diazepam (0.5 mg/kg, IV) was once again administered. Seizures ceased but neurological signs worsened and included head pressing, loss of menace response, and a stuporous mentation. Due to unresponsiveness to treatment that included administration of intravenous fluids, levetiracetam, ampicillin/sulbactam, and retention enemas (water with lactulose), a dose of flumazenil (0.01 mg/kg) was administered IV and resulted in immediate but transient improvement of clinical signs. The stuporous state returned after 60 min post-treatment and an additional dose of IV flumazenil (0.01 mg/kg) was administered with the same outcome. Based on this positive clinical response, IV infusion of flumazenil was initiated at 0.01 mg/kg/h following a loading dose of 0.005 mg/kg. Due to minimal improvement in neurological signs, flumazenil IV infusion was increased gradually until reaching the effective dose of 0.1 mg/kg/h. Flumazenil IV infusion was continued for 24 hours with improvements in neurological signs, which did not return upon gradual decrease of the flumazenil dose. This is the first report describing the use of a flumazenil IV infusion to improve neurological signs in a cat with a PSS and HE treated with diazepam.

Factors associated with stress-related symptoms among people with epilepsy in Ethiopia, a cross-sectional study

Introduction

Stress is a common psychological problem present in people with epilepsy and has a serious impact on the health-related satisfaction of people with epilepsy and their cohabiters. This study aimed to assess the magnitude and related factors of stress.

Methods

A hospital-based cross-sectional study was carried out among 301 systematically chosen people with epilepsy. The seven stress-related items of the Depression, Anxiety, and Stress -21 questionnaire was used to measure stress. Data were entered using Epi Info and analyzed by SPSS version 25. Predictors with a p-value < 0.20 in the bivariate logistic regression were transferred into the multivariate model. A p-value of less than 0.05 was viewed as statistically significant.

Result

The prevalence of stress symptoms in this study was 23.9%. Daily labor occupational status with Adjusted Odds ratio [(AOR) = 0.042, 95% CI: 0.004, 0.469], onset of illness at the age of 18 years and above (AOR = 0.188, 95% CI: 0.046, 0.771), perceived stigma (AOR = 3.320, 95% CI: 1.345, 8.200), the presence of anxiety symptoms (AOR = 8.275, 95% CI: 3.345, 20.471), and belief that the condition is untreatable (AOR = 6.360, 95% CI: 1.647, 24.562) were significantly associated factors.

Conclusion

The occurrence of stress was high, and it reinforced that there is a requisite for the identification and handling of stress-related symptoms among people with epilepsy.

Increased vascular risk factors, atherosclerosis, and psychological distress among Indian adults with refractory epilepsy in comparison to well-controlled epilepsy

OBJECTIVE

Comparison of cardiovascular risk factors, atherosclerosis, and psychological distress among adults with refractory versus well-controlled epilepsy.

METHODS

The cross-sectional study consisted of two groups of 40 people each: Group I - People with well-controlled epilepsy, Group II - People with refractory epilepsy. Age- and gender-matched people of 20-50 years were recruited. People who were diabetic, smokers, hypertensive, alcoholic, pregnant, with infections, and lactating women were excluded from the study. Biochemical parameters, fasting glucose, lipid profile, fasting insulin, leptin, adiponectin, Lp[a], hsCRP, TyG INDEX, HOMA1-%S, HOMA1-IR, HOMA1-%B, QUICKI, FIRI, AIP, AC, CLTI, MLTI, CRI-I, CRI-II, and CIMT were estimated. Stress levels [PSS-10, GAD-7 & PHQ-9] were assessed based on the scoring system from the questionnaires.

RESULTS

The existence of metabolic syndrome, levels of triglycerides, TyG index, MDA, OSI, CIMT, AIP, and stress scores [PSS-10, GAD-7 & PHQ-9] were significantly higher in the refractory-epilepsy group in comparison to the well-controlled group. There were associations between LDL -C and CIMT as well as between GAD-7 and CIMT among all the study subjects. There were no significant differences in the levels of glucose homeostasis parameters, hsCRP, leptin, adiponectin, and Lp[a] between the two groups. Based on the ROC analysis, MDA [AUC = 0.853] and GAD-7 [AUC = 0.900] are useful in the differential diagnosis of the study groups.

CONCLUSION

People with refractory epilepsy had increased levels of vascular risk factors, atherosclerosis, and stress levels compared to people with well-controlled epilepsy. Suitable disease management and therapeutic approaches to address cardiovascular and psychological distress could be planned out among people with refractory epilepsy to improve their quality of life.

Metyrapone abolishes spike-wave discharge seizures in genetic absence epilepsy rats from Strasbourg by reducing stress hormones

OBJECTIVE

Stress is one of the most commonly reported triggers for seizures in patients with epilepsy, although the mechanisms that mediate this effect are not established. The clinical evidence supporting this is derived from patients' subjective experience of stress, and how this influences their own seizures. Animal models can be used to explore this phenomenon in controlled environments, free from subjective bias. Here, we used genetic absence epilepsy rats from Strasbourg (GAERS), a genetic rat model of absence epilepsy, to explore the influence of stress and stress hormones on spontaneous seizures.

METHODS

Adult male GAERS (n = 38) and nonepileptic control (NEC) rats (n = 4) were used. First, rats were subjected to 30-min restraint stress to assess hypothalamic-pituitary-adrenal axis function. Next, we assessed the effects of 30-min noise stress, and cage tilt stress, on spike-wave discharge seizures in GAERS. We then performed pharmacological experiments to assess the direct effects of stress hormones on seizures, including corticosterone, metyrapone, and deoxycorticosterone.

RESULTS

GAERS exhibited elevated baseline corticosterone levels, compared to NEC rats. Noise stress and cage tilt stress significantly enhanced seizure incidence (p < .05), but only during stress periods. Exogenous corticosterone administration also significantly increased seizure occurrence (p < .05). Metyrapone, an inhibitor of corticosterone synthesis, completely abolished seizures in GAERS, and seizures remained suppressed for >2 h. However, deoxycorticosterone, the precursor of corticosterone, increased seizures.

SIGNIFICANCE

These results suggest that GAERS exhibit elevations in stress hormones, and this may contribute to seizures. Inhibiting corticosterone synthesis with metyrapone prevents seizures in GAERS, and shows potential for repurposing this drug as a future antiseizure medication.

Translational veterinary epilepsy: A win-win situation for human and veterinary neurology

Epilepsy is a challenging multifactorial disorder with a complex genetic background. Our current understanding of the pathophysiology and treatment of epilepsy has substantially increased due to animal model studies, including canine studies, but additional basic and clinical research is required. Drug-resistant epilepsy is an important problem in both dogs and humans, since seizure freedom is not achieved with the available antiseizure medications. The evaluation and exploration of pharmacological and particularly non-pharmacological therapeutic options need to remain a priority in epilepsy research. Combined efforts and sharing knowledge and expertise between human medical and veterinary neurologists are important for improving the treatment outcomes or even curing epilepsy in dogs. Such interactions could offer an exciting approach to translate the knowledge gained from people and rodents to dogs and vice versa. In this article, a panel of experts discusses the similarities and knowledge gaps in human and animal epileptology, with the aim of establishing a common framework and the basis for future translational epilepsy research.

11β-HSD1 participates in epileptogenesis and the associated cognitive impairment by inhibiting apoptosis in mice

Background

Glucocorticoid signalling is closely related to both epilepsy and associated cognitive impairment, possibly through mechanisms involving neuronal apoptosis. As a critical enzyme for glucocorticoid action, the role of 11β-hydroxysteroid dehydrogenase 1 (11β-HSD1) in epileptogenesis and associated cognitive impairment has not previously been studied.

Methods

We first investigated the expression of 11β-HSD1 in the pentylenetetrazole (PTZ) kindling mouse model of epilepsy. We then observed the effect of overexpressing 11β-HSD1 on the excitability of primary cultured neurons in vitro using whole-cell patch clamp recordings. Further, we assessed the effects of adeno-associated virus (AAV)-induced hippocampal 11β-HSD1 knockdown in the PTZ model, conducting behavioural observations of seizures, assessment of spatial learning and memory using the Morris water maze, and biochemical and histopathological analyses.

Results

We found that 11β-HSD1 was primarily expressed in neurons but not astrocytes, and its expression was significantly (p < 0.05) increased in the hippocampus of PTZ epilepsy mice compared to sham controls. Whole-cell patch clamp recordings showed that overexpression of 11β-HSD1 significantly decreased the threshold voltage while increasing the frequency of action potential firing in cultured hippocampal neurons. Hippocampal knockdown of 11β-HSD1 significantly reduced the severity score of PTZ seizures and increased the latent period required to reach the fully kindled state compared to control knockdown. Knockdown of 11β-HSD1 also significantly mitigated the impairment of spatial learning and memory, attenuated hippocampal neuronal damage and increased the ratio of Bcl-2/Bax, while decreasing the expression of cleaved caspase-3.

Conclusions

11β-HSD1 participates in the pathogenesis of both epilepsy and the associated cognitive impairment by elevating neuronal excitability and contributing to apoptosis and subsequent hippocampal neuronal damage. Inhibition of 11β-HSD1, therefore, represents a promising strategy to treat epilepsy and cognitive comorbidity.

Neurobiological Links between Stress, Brain Injury, and Disease

Stress, which refers to a combination of physiological, neuroendocrine, behavioral, and emotional responses to novel or threatening stimuli, is essentially a defensive adaptation under physiological conditions. However, strong and long-lasting stress can lead to psychological and pathological damage. Growing evidence suggests that patients suffering from mild and moderate brain injuries and diseases often show severe neurological dysfunction and experience severe and persistent stressful events or environmental stimuli, whether in the acute, subacute, or recovery stage. Previous studies have shown that stress has a remarkable influence on key brain regions and brain diseases. The mechanisms through which stress affects the brain are diverse, including activation of endoplasmic reticulum stress (ERS), apoptosis, oxidative stress, and excitatory/inhibitory neuron imbalance, and may lead to behavioral and cognitive deficits. The impact of stress on brain diseases is complex and involves impediment of recovery, aggravation of cognitive impairment, and neurodegeneration. This review summarizes various stress models and their applications and then discusses the effects and mechanisms of stress on key brain regions—including the hippocampus, hypothalamus, amygdala, and prefrontal cortex—and in brain injuries and diseases—including Alzheimer’s disease, stroke, traumatic brain injury, and epilepsy. Lastly, this review highlights psychological interventions and potential therapeutic targets for patients with brain injuries and diseases who experience severe and persistent stressful events.

The metabolic basis of epilepsy

The brain is a highly energy-demanding organ and requires bioenergetic adaptability to balance normal activity with pathophysiological fuelling of spontaneous recurrent seizures, the hallmark feature of the epilepsies. Recurrent or prolonged seizures have long been known to permanently alter neuronal circuitry and to cause excitotoxic injury and aberrant inflammation. Furthermore, pathological changes in bioenergetics and metabolism are considered downstream consequences of epileptic seizures that begin at the synaptic level. However, as we highlight in this Review, evidence is also emerging that primary derangements in cellular or mitochondrial metabolism can result in seizure genesis and lead to spontaneous recurrent seizures. Basic and translational research indicates that the relationships between brain metabolism and epileptic seizures are complex and bidirectional, producing a vicious cycle that compounds the deleterious consequences of seizures. Metabolism-based treatments such as the high-fat, antiseizure ketogenic diet have become mainstream, and metabolic substrates and enzymes have become attractive molecular targets for seizure prevention and recovery. Moreover, given that metabolism is crucial for epigenetic as well as inflammatory changes, the idea that epileptogenesis can be both negatively and positively influenced by metabolic changes is rapidly gaining ground. Here, we review evidence that supports both pathophysiological and therapeutic roles for brain metabolism in epilepsy.

Small cohort of patients with epilepsy showed increased activity on Facebook before sudden unexpected death

Sudden Unexpected Death in Epilepsy (SUDEP) remains a leading cause of death in people with epilepsy. Despite the constant risk for patients and bereavement to family members, to date the physiological mechanisms of SUDEP remain unknown. Here we explore the potential to identify putative predictive signals of SUDEP from online digital behavioral data using text and sentiment analysis tools. Specifically, we analyze Facebook timelines of six patients with epilepsy deceased due to SUDEP, donated by surviving family members. We find preliminary evidence for behavioral changes detectable by text and sentiment analysis tools. Namely, in the months preceding their SUDEP event patient social media timelines show: i) increase in verbosity; ii) increased use of functional words; and iii) sentiment shifts as measured by different sentiment analysis tools. Combined, these results suggest that social media engagement, as well as its sentiment, may serve as possible early-warning signals for SUDEP in people with epilepsy. While the small sample of patient timelines analyzed in this study prevents generalization, our preliminary investigation demonstrates the potential of social media data as complementary data in larger studies of SUDEP and epilepsy.

The effects of coronavirus disease 2019 (COVID-19) pandemic on people with epilepsy (PwE): an online survey-based study

During the unprecedented COVID-19 pandemic in 2020, the whole world faced an unusual health emergency. Medical care of chronic neurological diseases, such as Epilepsy, is being neglected. In this survey, we aimed to evaluate the impact of the COVID-19 pandemic on the care of people with Epilepsy (PwE) and to identify their risk factors for seizure worsening to direct better future medical care. We administered a web-based survey (submitted on August 5, 2020). It included socio-demographic, Epilepsy-related, and psychometric data (The Depression, Anxiety, and Stress Scale—21 Items(DASS21) and The Pittsburgh Sleep Quality Index (PSQI). Regression analysis identified predictors of seizure worsening. We collected responses from an online survey of PwE during the pandemic. Out of 151 responders, 71 patients complained of issues related to Epilepsy management and all of whom reached the treating physician and solved their problems. Sleep quality was compromised in 84 patients (55.6%). Two-thirds of the patients in our cohort (66.2%) reported depression, 72.2% reported anxiety, and 75.5% reported stress. Eight patients (5.3%) got COVID-19 infection, and only one patient suffered from mild worsening of the seizure. The main concerns were shortage of medications for 46 (30.5%) patients, getting Coronavirus infection for 67 (44.4%) patients, and seizure worsening for 32 (21.3%) patients. Thirty-five patients (23.2%) reported seizure worsening, which was best explained by retirement or jobless state, having moderate or severe stress, poor sleep quality, vagus nerve stimulation (VNS), fear of getting COVID-19 infection, fear of worsening of seizures, or shortage of medication. During the current COVID-19 pandemic, a significant percentage of PwE experienced worsening of their seizures. This unusual, challenging experience clarifies the urgent need to establish telemedicine services and home-based management of Epilepsy, including ambulatory EEG, home video, and medication delivery to patients’ homes to provide continuous medical care.

Predictive factors of epilepsy outcome in a sample of Egyptian pre-elderly and elderly population

Background

Elderly people with epilepsy are large, but neglected group. Data on the predictive factors for recurrent seizures in the elderly population are inconclusive or are not known for the majority of patients. This is especially true for the Egyptian population as no specific study was concluded to address this issue before.

Objectives

The aim of this study was to detect the predictive factors of epilepsy outcome in a sample of Egyptian aged population.

Materials and methods

A total of 100 patients aged 50 years or older with epilepsy diagnosed according to International League Against Epilepsy (ILAE) latest definition were included in the study and followed up for 6 months as regards seizure control. All participants were prospectively evaluated for epidemiological, clinical, radiological, electrodiagnostic, and laboratory data.

Results

The outcome was statistically significant affected in relation to absence of medical comorbidities (P = 0.037), seizure etiology (P = 0.007), history of status epilepticus (P <  0.001), MRI brain findings (P = 0.005), EEG changes (P <  0.001), Ca (P = 0.01), and Mg level (P = 0.046).

Conclusion

We conclude that aged Egyptian epileptic population with no medical comorbidities, normal MRI brain, or normal EEG can be predicted to have good outcome of their epilepsy while patients with post stroke epilepsy, abnormal MRI brain, and abnormal EEG, with low serum Ca or Mg level can be predicted to have poor outcome.

Prevalence of depression, anxiety, and psychological distress in patients with epilepsy during COVID-19: A systematic review

OBJECTIVE

COVID-19 pandemic disease has profound consequences for physical and mental health. In this regard, health care for chronic diseases, especially epilepsy is neglected The purpose of this systematic review study was to investigate the epidemic effect of COVID-19 on increasing the prevalence of mental disorders such as depression, anxiety, and sleep disorders in people with epilepsy (PWE).

METHODS

We systematically searched MEDLINE, Cochrane, Embase, Web of science, Scopus, and Psych info databases for studies that estimate the prevalence of mental disorders in PWE during the COVID-19 until December 2020. Inclusion criteria included samples of population, with a confirmed diagnosis of epilepsy.

RESULTS

Irrespective of PWE or people without epilepsy (PWOE), all experienced stress and anxiety during COVID-19 pandemic. Most of the studies showed that PWE and even PWOE during the pandemic, suffer from depression. The highest rate of depression was attributed to female PWE with financial problems (66.7%) and the lowest rate of depression in PWE was reported in 8.6%. 7.1-71.2% and 28.2% of patients reported sleep disorders and insomnia, respectively. Less than 2% experienced a sleep improvement.

LIMITATIONS

Due to a large amount of heterogeneities across the results, we could not evaluate the exact rate of prevalence in spite of using effective measures.

CONCLUSIONS

People with epilepsy were considered as a susceptible group to the impact of the pandemic. Therefore, great attention should be paid to PWE and adequate psychological supports provided in this period to relieve or inhibit risks to mental health in PWE.

PERMIT study: a global pooled analysis study of the effectiveness and tolerability of perampanel in routine clinical practice

The PERaMpanel pooled analysIs of effecTiveness and tolerability (PERMIT) study was a pooled analysis of data from 44 real-world studies from 17 countries, in which people with epilepsy (PWE; focal and generalized) were treated with perampanel (PER). Retention and effectiveness were assessed after 3, 6, and 12 months, and at the last visit (last observation carried forward). Effectiveness assessments included 50% responder rate (≥ 50% reduction in seizure frequency from baseline) and seizure freedom rate (no seizures since at least the prior visit); in PWE with status epilepticus, response was defined as seizures under control. Safety and tolerability were assessed by evaluating adverse events (AEs) and discontinuation due to AEs. The Full Analysis Set included 5193 PWE. Retention, effectiveness and safety/tolerability were assessed in 4721, 4392 and 4617, respectively. Retention on PER treatment at 3, 6, and 12 months was 90.5%, 79.8%, and 64.2%, respectively. Mean retention time on PER treatment was 10.8 months. The 50% responder rate was 58.3% at 12 months and 50.0% at the last visit, and the corresponding seizure freedom rates were 23.2% and 20.5%, respectively; 52.7% of PWE with status epilepticus responded to PER treatment. Overall, 49.9% of PWE reported AEs and the most frequently reported AEs (≥ 5% of PWE) were dizziness/vertigo (15.2%), somnolence (10.6%), irritability (8.4%), and behavioral disorders (5.4%). At 12 months, 17.6% of PWEs had discontinued due to AEs. PERMIT demonstrated that PER is effective and generally well tolerated when used to treat people with focal and/or generalized epilepsy in everyday clinical practice.

Stress-Associated Molecular and Cellular Hippocampal Mechanisms Common for Epilepsy and Comorbid Depressive Disorders

The review discusses molecular and cellular mechanisms common to the temporal lobe epileptogenesis/epilepsy and depressive disorders. Comorbid temporal lobe epilepsy and depression are associated with dysfunction of the hypothalamic-pituitary-adrenocortical axis. Excessive glucocorticoids disrupt the function and impair the structure of the hippocampus, a brain region key to learning, memory, and emotions. Selective vulnerability of the hippocampus to stress, mediated by the reception of glucocorticoid hormones secreted during stress, is the price of the high functional plasticity and pleiotropy of this limbic structure. Common molecular and cellular mechanisms include the dysfunction of glucocorticoid receptors, neurotransmitters, and neurotrophic factors, development of neuroinflammation, leading to neurodegeneration and loss of hippocampal neurons, as well as disturbances in neurogenesis in the subgranular neurogenic niche and formation of aberrant neural networks. These glucocorticoid-dependent processes underlie altered stress response and the development of chronic stress-induced comorbid pathologies, in particular, temporal lobe epilepsy and depressive disorders.

COVID-19 and epilepsy: Russian and international experience

 

This article reviews the issues of epilepsy course in patients with COVID-19 and predictors of the worsening of the course of the disease in the context of the COVID-19 pandemic. Risk of seizures associated with COVID-19 is relatively low both in patients with epilepsy and in general population, with the exception of critically and terminally ill patients. Studies that evaluated the impact of the COVID-19 pandemic on the condition of patients with epilepsy are characterized by complex medical, social and pathophysiological approaches to the problem. Predictors of negative epilepsy dynamics in the context of the COVID-19 pandemic include drug interactions between antiepileptic drugs (AEDs) and drugs used to treat COVID-19; disruption of AEDs supply; stress in patients; comorbid somatic pathology.

Impact of Stress on Epilepsy: Focus on Neuroinflammation-A Mini Review

Epilepsy, one of the most common neurological disorders worldwide, is characterized by recurrent seizures and subsequent brain damage. Despite strong evidence supporting a deleterious impact on seizure occurrence and outcome severity, stress is an overlooked component in people with epilepsy. With regard to stressor duration and timing, acute stress can be protective in epileptogenesis, while chronic stress often promotes seizure occurrence in epilepsy patients. Preclinical research suggests that chronic stress promotes neuroinflammation and leads to a depressive state. Depression is the most common psychiatric comorbidity in people with epilepsy, resulting in a poor quality of life. Here, we summarize studies investigating acute and chronic stress as a seizure trigger and an important factor that worsens epilepsy outcomes and psychiatric comorbidities. Mechanistic insight into the impact of stress on epilepsy may create a window of opportunity for future interventions targeting neuroinflammation-related disorders.

Top Ten Tips Palliative Care Clinicians Should Know About Seizures at the End of Life

Seizures are physically burdensome and emotionally distressing for patients, families, caregivers, and clinicians. Patients with neurological diseases are at increased risk of having complex, difficult-to-control seizures at the end of life. Palliative care (PC) clinicians asked to provide management of these seizures may not be familiar or comfortable with more complex seizures or epilepsy. A team of neurologists and PC specialists have compiled a list of tips to guide clinicians on how to care for patients having seizures and to support their families/caregivers.

Gamma Knife radiosurgery for the treatment of central neurocytoma: a single-institution experience of 25 patients

Central neurocytomas (CNs) are extremely rare tumors that account for 0.1-0.5% of all intracranial neoplasms. Recently, Gamma Knife radiosurgery (GKRS) has become a treatment option in patients with CN. We aimed to evaluate the efficacy and safety of GKRS in 25 CN patients and review the results along with relevant literature. GKRS patient database was searched, and 25 patients who underwent GKRS for CN between 2009 and 2018, were evaluated retrospectively. The study cohort included 15 female and ten male patients with a median age of 32 years (range, 5-60). The most common presenting symptom was headache (88%). The neurological examination was unremarkable in all patients, except for one patient with decreased vision. Twenty patients (80%) had a history of surgical resection. Most of the tumors (92%) were located in the ventricles, and the median tumor volume was 4.8 cm³ (range, 0.8-28.1). The median marginal dose was 14 Gy (range, 12-15) to a median isodose of 50% (range, 40-50). Following a median follow-up of 80 months (range, 36-138), local tumor control was achieved in 100% of patients. Distant recurrence was observed in one patient (4%). No adverse radiation effect was observed. Regarding non-specific post-GKRS symptoms, one patient experienced a prolonged headache, and one epileptic patient experienced a brief partial seizure. In our patient cohort, GKRS yielded favorable local tumor control (100%) during a median follow-up of 6.6 years. Our series demonstrates that GKRS is an effective and safe treatment option for patients with primary or residual CNs.

Does Stress Trigger Seizures? Evidence from Experimental Models

This chapter describes the experimental evidence of stress modulation of epileptic seizures and the potential role of corticosteroids and neurosteroids in regulating stress-linked seizure vulnerability. Epilepsy is a chronic neurological disorder that is characterized by repeated seizures. There are many potential causes for epilepsy, including genetic predispositions, infections, brain injury, and neurotoxicity. Stress is a known precipitating factor for seizures in individuals suffering from epilepsy. Severe acute stress and persistent exposure to stress may increase susceptibility to seizures, thereby resulting in a higher frequency of seizures. This occurs through the stress-mediated release of cortisol, which has both excitatory and proconvulsant properties. Stress also causes the release of endogenous neurosteroids from central and adrenal sources. Neurosteroids such as allopregnanolone and THDOC, which are allosteric modulators of GABA-A receptors, are powerful anticonvulsants and neuroprotectants. Acute stress increases the release of neurosteroids, while chronic stress is associated with severe neurosteroid depletion and reduced inhibition in the brain. This diminished inhibition occurs largely as a result of neurosteroid deficiencies. Thus, exogenous administration of neurosteroids (neurosteroid replacement therapy) may offer neuroprotection in epilepsy. Synthetic neurosteroid could offer a rational approach to control neurosteroid-sensitive, stress-related epileptic seizures.

Hypothalamic-pituitary-adrenal axis targets for the treatment of epilepsy

Stress is a common seizure trigger in persons with epilepsy. The body's physiological response to stress is mediated by the hypothalamic-pituitary-adrenal (HPA) axis and involves a hormonal cascade that includes corticotropin releasing hormone (CRH), adrenocorticotropin releasing hormone (ACTH) and the release of cortisol (in humans and primates) or corticosterone (in rodents). The prolonged exposure to stress hormones may not only exacerbate pre-existing medical conditions including epilepsy, but may also increase the predisposition to psychiatric comorbidities. Hyperactivity of the HPA axis negatively impacts the structure and function of the temporal lobe of the brain, a region that is heavily involved in epilepsy and mood disorders like anxiety and depression. Seizures themselves damage temporal lobe structures, further disinhibiting the HPA axis, setting off a vicious cycle of neuronal damage and increasing susceptibility for subsequent seizures and psychiatric comorbidity. Treatments targeting the HPA axis may be beneficial both for epilepsy and for associated stress-related comorbidities such as anxiety or depression. This paper will highlight the evidence demonstrating dysfunction in the HPA axis associated with epilepsy which may contribute to the comorbidity of psychiatric disorders and epilepsy, and propose treatment strategies that may dually improve seizure control as well as alleviate stress related psychiatric comorbidities.

The perceived impact of COVID-19 and associated restrictions on young people with epilepsy in the UK: Young people and caregiver survey

Purpose

To garner the views of young people with epilepsy and caregivers regarding the impact of COVID-19 and subsequent restrictions in the UK.

Mehods

An online survey was used to explore the views of young people with epilepsy (n = 71) and caregivers (n = 130) in June 2020. It included questions on the impact of the pandemic and associated restrictions on the child’s epilepsy and on child and parental wellbeing.

Results

One in three young people and 29 % of caregivers reported that the young person’s seizures had increased during the pandemic (only 10 % of young people and 8% of caregivers reported a decrease). Half of young people reported that they were more reluctant to go to hospital. Thirty-one percent of young people and 20 % of parents reported difficulties getting epilepsy medication whilst a significant minority of young people (18 %) and caregivers (25 %) reported that the young person had investigations/assessments cancelled by their hospital. The majority of young people reported their sleep (72 %), mood (64 %) and levels of physical activity (53 %) had deteriorated. Caregivers experienced increases in stress (55 %) and anxiety (52 %). Epilepsy nurses were seen as the most helpful support

Conclusions

Results indicate that the pandemic and associated restrictions have had a negative impact on young people with epilepsy. Perceived increases in seizures, reluctance to go to hospital and cancelled investigations are likely to impact on epilepsy management. The wider psychosocial impact is also likely to be significant with increases in child and caregiver mental health problems in an already vulnerable group.

Remote Assessment of Disease and Relapse in Epilepsy: Protocol for a Multicenter Prospective Cohort Study

BACKGROUND

In recent years, a growing body of literature has highlighted the role of wearable and mobile remote measurement technology (RMT) applied to seizure detection in hospital settings, whereas more limited evidence has been produced in the community setting. In clinical practice, seizure assessment typically relies on self-report, which is known to be highly unreliable. Moreover, most people with epilepsy self-identify factors that lead to increased seizure likelihood, including mood, behavior, sleep pattern, and cognitive alterations, all of which are amenable to measurement via multiparametric RMT.

OBJECTIVE

The primary aim of this multicenter prospective cohort study is to assess the usability, feasibility, and acceptability of RMT in the community setting. In addition, this study aims to determine whether multiparametric RMT collected in populations with epilepsy can prospectively estimate variations in seizure occurrence and other outcomes, including seizure frequency, quality of life, and comorbidities.

METHODS

People with a diagnosis of pharmacoresistant epilepsy will be recruited in London, United Kingdom, and Freiburg, Germany. Participants will be asked to wear a wrist-worn device and download ad hoc apps developed on their smartphones. The apps will be used to collect data related to sleep, physical activity, stress, mood, social interaction, speech patterns, and cognitive function, both passively from existing smartphone sensors (passive remote measurement technology [pRMT]) and actively via questionnaires, tasks, and assessments (active remote measurement technology [aRMT]). Data will be collected continuously for 6 months and streamed to the Remote Assessment of Disease and Relapse-base (RADAR-base) server.

RESULTS

The RADAR Central Nervous System project received funding in 2015 from the Innovative Medicines Initiative 2 Joint Undertaking under Grant Agreement No. 115902. This Joint Undertaking receives support from the European Union's Horizon 2020 research and innovation program and European Federation of Pharmaceutical Industries and Associations. Ethical approval was obtained in London from the Bromley Research Ethics Committee (research ethics committee reference: 19/LO/1884) in January 2020. The first participant was enrolled on September 30, 2020. Data will be collected until September 30, 2021. The results are expected to be published at the beginning of 2022.

CONCLUSIONS

RADAR Epilepsy aims at developing a framework of continuous data collection intended to identify ictal and preictal states through the use of aRMT and pRMT in the real-life environment. The study was specifically designed to evaluate the clinical usefulness of the data collected via new technologies and compliance, technology acceptability, and usability for patients. These are key aspects to successful adoption and implementation of RMT as a new way to measure and manage long-term disorders.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/21840.

Seizure control, stress, and access to care during the COVID-19 pandemic in New York City: The patient perspective

Objective

Our epilepsy population recently experienced the acute effects of the COVID‐19 pandemic in New York City. Herein, we aimed to determine patient‐perceived seizure control during the surge, specific variables associated with worsened seizures, the prevalence of specific barriers to care, and patient‐perceived efficacy of epilepsy care delivered via telephone and live video visits during the pandemic.

Methods

We performed a cross‐sectional questionnaire study of adult epilepsy patients who had a scheduled appointment at a single urban Comprehensive Epilepsy Center (Montefiore Medical Center) between March 1, 2020 and May 31, 2020 during the peak of the COVID‐19 pandemic in the Bronx. Subjects able to answer the questionnaire themselves in English or Spanish were eligible to complete a one‐time survey via telephone or secure online platform (REDCap).

Results

Of 1212 subjects screened, 675 were eligible, and 177 adequately completed the questionnaire. During the COVID‐19 pandemic, 75.1% of patients reported no change in seizure control, whereas 17.5% reported that their seizure control had worsened, and 7.3% reported improvement. Subjects who reported worsened seizure control had more frequent seizures at baseline, were more likely to identify stress and headaches/migraines as their typical seizure precipitants, and were significantly more likely to report increased stress related to the pandemic. Subjects with confirmed or suspected COVID‐19 did not report worsened seizure control. Nearly 17% of subjects reported poorer epilepsy care, and 9.6% had difficulty obtaining their antiseizure medications; these subjects were significantly more likely to report worse seizure control.

Significance

Of the nearly 20% of subjects who reported worsened seizure control during the COVID‐19 pandemic, stress and barriers to care appear to have posed the greatest challenge. This unprecedented pandemic exacerbated existing and created new barriers to epilepsy care, which must be addressed.

Epilepsy self-management during a pandemic: Experiences of people with epilepsy

The purpose of this descriptive study was to, from the perspective of adult people with epilepsy (PWE) and caregivers of PWE, explore the effects of the current pandemic and resulting societal changes on epilepsy self-management. Ninety-four respondents completed a mixed-methods quantitative and qualitative survey focused on their epilepsy self-management experiences during the coronavirus disease-19 (COVID-19) pandemic. Respondents noted significant disruption in epilepsy self-management. Lack of ability to obtain medications or see epilepsy providers, as well as increased stress, social isolation, and changes in routine were all reported as troublesome, and more than one-third of the sample reported an increase in seizure frequency since the onset of the pandemic. Suggestions are given regarding how to support PWE during future COVID-19 outbreaks and to better prepare PWE and their caregivers for any life-altering events, such as a pandemic, with robust self-management skills that will allow them to maintain the highest level of function possible.

Physical exercise and seizure activity

Neuroprotective and antiepileptogenic therapies have been extensively investigated for epilepsy prevention and treatment. This review gives an overview of the promising contribution of the ketogenic diet, a complementary treatment, on the intestinal microbiota to reduce seizure susceptibility. Next, the relevance of physical exercise is extensively addressed as a complementary therapy to reduce seizure susceptibility, and thereby impact beneficially on the epilepsy condition. In this context, particular attention is given to the potential risks and benefits of physical exercise, possible precipitant factors related to exercise and proposed mechanisms by which exercise can reduce seizures, and its antiepileptogenic effects. Finally, this review points to emerging evidence of exercise reducing comorbidities from epilepsy and improving the quality of life of people with epilepsy. Based on evidence from current literature, physical or sport activities represent a potential non-pharmacological intervention that can be integrated with conventional therapy for epilepsy.

A Gluten Free Diet in the Management of Epilepsy in People with Coeliac Disease or Gluten Sensitivity

The aim of this review was to assess the effects of a gluten free diet (GFD) in the management of epilepsy in people with coeliac disease (CD) or gluten sensitivity (GS). A systematic approach was used to undertake a literature review. Five electronic databases (PubMed; Scopus; Google Scholar; Cochrane Epilepsy Group specialised register; Cochrane Register of Controlled Trails (CENTRAL) via the Cochrane Register of Online Trials) were searched using predetermined relevant search terms. In total, 668 articles were identified. Duplicates were removed and predefined inclusion and exclusion criteria were applied, and a PRISMA flow chart was produced. Data was extracted using Covidence software. Twelve studies on Epilepsy and CD involving a total of 70 participants were selected for analysis; narrative synthesis was used owing to the small sample sizes in the selected studies. None of the 12 studies meeting inclusion criteria investigated gluten sensitivity and epilepsy. All the included studies support a link between epilepsy and CD. GFD was effective in 44 out of 70 participants across the studies in terms of a reduction of seizures, reduction of antiepileptic drugs (AEDs) or normalisation of EEG pattern. A total of 44 participants showed a reduction in seizures (across eight studies) and complete cessation of seizures was reported in 22 participants. In general, the earlier the GFD is implemented after the onset of seizures, the better the likelihood of the GFD being successful in supporting control of seizures. Mechanisms linking gluten with epilepsy are not fully understood; possible hypotheses include gluten mediated toxicity, immune-induced cortical damage and malabsorption. Evidence suggests the effectiveness of a GFD in supporting the management of epilepsy in patients with CD, although the quality of evidence is low. There appears to be a growing number of neurologists who are prepared to advocate the use of a GFD. A multidisciplinary approaches and further research are recommended. It could be argued that when balancing potential treatments such as AEDs or surgery, a GFD has a low likelihood of harm.

How are results of EEG activation procedures associated with patient perception of seizure provocative factors? A single-center cross-sectional pilot study

PURPOSE

The purpose of this study was to examine the relationship between subjectively perceived seizure provocative factors or inhibitors and objectively recorded changes in epileptiform activity (EA) during EEG activation procedures.

MATERIAL AND METHODS

Consenting epilepsy patients (≥18 years old) were asked to complete a questionnaire by indicating whether items on a list provoke, inhibit or have no effect on their seizures. A scalp EEG was recorded afterwards to evaluate baseline epileptiform activity and its change (increase/decrease in frequency) during a set of activation procedures. These included hyperventilation, intermittent photic stimulation (IPS), eye-closing/eye-opening, tasks of reading aloud in a native and a foreign language, solving a Rubik's cube and crossing-out letters. We used correlation and multiple regression analysis to search for associations between the sum of self-reported provocative/inhibiting items and changes in EA.

RESULTS

Of the 90 patients recruited 75 (83.3%) indicated at least one seizure provocative factor. Sleep deprivation, emotional stress, negative emotions and alcohol use were most frequently selected as provoking seizures. Positive feelings, focused thinking, mental calculation and exercising were the most predominant seizure inhibitors. EEG data revealed a weak, but statistically significant correlation with the sum of items in distinct questionnaire groups (0.20 ≤ Spearman's ρ ≤ 0.39). Sensory stimuli (olfactory, gustatory, auditory and visual), cognitive phenomena (thoughts and feelings) and substance use were found to be significantly correlated with EEG results by being self-reported as both provoking and inhibiting seizures. A statistically significant relationship was also found between the increase in EA while reading aloud in a native language and the number of physiological states (sleep deprivation, stress etc.) indicated as provoking seizures (Spearman's ρ = 0.320, P = 0.005). A suitable stepwise multiple regression model was feasible for this finding (F(3, 71) = 7.396, P < 0.001, adjusted R squared = 0.206) with the additional inclusion of EA change during IPS and epilepsy type as explanatory variables.

CONCLUSION

Our pilot study indicates that there is a previously non-explored association between patients' self-perception of seizure provocative/inhibiting factors and objectively recorded changes in epileptiform activity during activation EEGs. Distinct EEG tests might be useful in activating ictogenic networks that are sensitive to indirect influence by hormonal, emotional or diurnally variable factors.

COVID-19 outbreak: The impact of stress on seizures in patients with epilepsy

Objective

Stress is a known trigger for seizures in patients with epilepsy (PWE). However, the association between stress and seizures has not been thoroughly investigated. In December 2019, an outbreak of coronavirus disease (COVID‐19) occurred in Wuhan, Hubei province, China, causing tremendous collateral stress. This study was designed to evaluate the influence of the COVID‐19 outbreak on seizures in PWE in the most severely affected area, Wuhan, and its surrounding cities.

Methods

In this single‐center, cross‐sectional study, PWE were surveyed via online questionnaires between February 23 and March 5, 2020. Collected data included demographic information, epilepsy‐related characteristics (seizure type, frequency, antiepileptic drugs [AEDs], and medication management), direct and perceived threat of COVID‐19, and changes in seizures during the outbreak. Psychological comorbidities were evaluated by the Patient Health Questionnaire–9, Generalized Anxiety Disorder–7 items, and Insomnia Severity Index (ISI). Multivariate logistic regression was used to identify precipitants for seizure exacerbation.

Results

We received 362 completed questionnaires after excluding 12 duplicates (response rate = 63.51%). A total of 31 (8.56%) patients had increased seizures during the outbreak. Exposure history to COVID‐19 (P = .001), uncontrolled seizure after AED therapy (P = .020), seizure frequency of two or more times per month before the outbreak (P = .005), change of AED regimen during the outbreak (AED reduction, withdrawal, replacement, skipping altogether; P = .002), and worry about the adverse effect of the outbreak on overall seizure‐related issues (severity = moderate to critical; P = .038) were risk factors for increased seizures.

Significance

A minority of PWE experienced seizure exacerbation during the outbreak of COVID‐19. Stress, uncontrolled seizures, and inappropriate change in AED regimen were associated with increased seizures. Based on these findings, stress might be an independent precipitant for triggering seizures in some PWE.

Placebo in epilepsy

Placebos impact epilepsy in a number of ways. Through randomized clinical trials, explicit clinical use, and also through implicit clinical use, placebos play a role in epilepsy. This chapter will discuss the reasons placebo is used, the determinants of placebo response in epilepsy, observations about placebo specific to epilepsy, and ways in which clinical trial design is impacted by placebo.

Severe psychological distress among patients with epilepsy during the COVID-19 outbreak in southwest China

Objective

To compare the severity of psychological distress between patients with epilepsy and healthy controls during the COVID‐19 outbreak in southwest China, as well as identify potential risk factors of severe psychological distress among patients with epilepsy.

Methods

This cross‐sectional case‐control study examined a consecutive sample of patients older than 15 years treated at the epilepsy center of West China Hospital between February 1 and February 29, 2020. As controls, sex‐ and age‐matched healthy visitors of inpatients (unrelated to the patients) were also enrolled during the same period. Data on demographics and attention paid to COVID‐19 were collected by online questionnaire, data on epilepsy features were collected from electronic medical records, and psychological distress was evaluated using the 6‐item Kessler Psychological Distress Scale (K‐6). Potential risk factors of severe psychological distress were identified using multivariate logistic regression.

Results

The 252 patients and 252 controls in this study were similar along all demographic variables except family income. Patients with epilepsy showed significantly higher K‐6 scores than healthy controls and spent significantly more time following the COVID‐19 outbreak (both P < .001). Univariate analyses associated both diagnosis of drug‐resistant epilepsy and time spent paying attention to COVID‐19 with severe psychological distress (defined as K‐6 score >12; both P ≤ .001). Multivariate logistic regression identified two independent predictors of severe psychological distress: time spent paying attention to COVID‐19 (odds ratio [OR] = 1.172, 95% confidence interval [CI] = 1.073‐1.280) and diagnosis of drug‐resistant epilepsy (OR = 0.283, 95% CI = 0.128‐0.623).

Significance

During public health outbreaks, clinicians and caregivers should focus not only on seizure control but also on mental health of patients with epilepsy, especially those with drug‐resistant epilepsy. K‐6 scores > 12 indicate severe psychological distress. This may mean, for example, encouraging patients to engage in other activities instead of excessively following media coverage of the outbreak.

Evaluating the Effectiveness and Cost-Effectiveness of Seizure Dogs in Persons With Medically Refractory Epilepsy in the Netherlands: Study Protocol for a Stepped Wedge Randomized Controlled Trial (EPISODE)

Background: Epilepsy is associated with a high disease burden, impacting the lives of people with epilepsy and their caregivers and family. Persons with medically refractory epilepsy experience the greatest burden, suffering from profound physical, psychological, and social consequences. Anecdotal evidence suggests these persons may benefit from a seizure dog. As the training of a seizure dog is a substantial investment, their accessibility is limited in the absence of collective reimbursement as is seen in the Netherlands. Despite sustained interest in seizure dogs, scientific knowledge on their benefits and costs remains scarce. To substantiate reimbursement decisions stronger evidence is required. The EPISODE study aims to provide this evidence by evaluating the effectiveness and cost-effectiveness of seizure dogs in adults with medically refractory epilepsy.

Methods: The study is designed as a stepped wedge randomized controlled trial that compares the use of seizure dogs in addition to usual care, with usual care alone. The study includes adults with epilepsy for whom current treatment options failed to achieve seizure freedom. Seizure frequency of participants should be at least two seizures per week, and the seizures should be associated with a high risk of injury or dysfunction. During the 3 year follow-up period, participants receive a seizure dog in a randomized order. Outcome measures are taken at multiple time points both before and after receiving the seizure dog. Seizure frequency is the primary outcome of the study and will be recorded continuously using a seizure diary. Questionnaires measuring seizure severity, quality of life, well-being, resource use, productivity, social participation, and caregiver burden will be completed at baseline and every 3 months thereafter. The study is designed to include a minimum of 25 participants.

Discussion: This protocol describes the first randomized controlled trial on seizure dogs. The study will provide comprehensive data on the effectiveness and cost-effectiveness of seizure dogs in adults with medically refractory epilepsy. Broader benefits of seizure dogs for persons with epilepsy and their caregivers are taken into account, as well as the welfare of the dogs. The findings of the study can be used to inform decision-makers on the reimbursement of seizure dogs.

In Up to My Ears and Temporal Lobes: Effects of Early Life Stress on Epilepsy Development

Epilepsy and stress are each significant concerns in today's society, bearing heavy impacts on mental and physical health and overall quality of life. Unfortunately, the intersection between these is potentially even more concerning, as stress is a frequent trigger of seizures and may contribute to neural hyperexcitability. A growing body of research suggests a connection between early life stress (occurring in the prenatal or postnatal stage) and later development of epilepsy. While the larger part of this literature suggests that early life stress increases vulnerability for epilepsy development, there are a number of interacting factors influencing this relationship. These factors include developmental stage at which both stressor and seizure assessment occur, type of stressor, sex effects, and type of seizure (convulsive or non-convulsive). Additionally, a number of potential mechanisms have been identified, including activation of the hypothalamic-pituitary-adrenal axis, neuroinflammation, altered inhibitory/excitatory balance, and temporal lobe structures. Developing a clearer understanding of this relationship between early life stress and epilepsy, the factors that influence it, and underlying mechanisms that may serve as targets for intervention is crucial to improving quality of life for persons with epilepsy.

Optimizing Management of Medically Responsive Epilepsy

PURPOSE OF REVIEW

This article reviews the management of patients with medically responsive epilepsy, including discussion of factors that may lead to transient breakthrough seizures and patient and physician strategies to maintain freedom from seizures.

RECENT FINDINGS

Imperfect adherence, unanticipated changes in ongoing medical therapy, inadvertent use of proconvulsants or concurrent medications that alter epilepsy medication kinetics, and a variety of seizure precipitants such as stress or sleep deprivation may alter long-term seizure control.

SUMMARY

The majority of patients with epilepsy are medically responsive. Many potential factors may lead to breakthrough seizures in these patients. Identification of these factors, patient education, and use of self-management techniques including mindfulness therapy and cognitive-behavioral therapy may play a role in protecting patients with epilepsy against breakthrough seizures.

Targeting Seizure-Induced Neurogenesis in a Clinically Relevant Time Period Leads to Transient But Not Persistent Seizure Reduction

Mesial temporal lobe epilepsy (mTLE), the most common form of medically refractory epilepsy in adults, is usually associated with hippocampal pathophysiology. Using rodent models of mTLE, many studies including work from our laboratory have shown that new neurons born around the onset of severe acute seizures known as status epilepticus (SE) are crucial for the process of epileptogenesis and targeting seizure-induced neurogenesis either genetically or pharmacologically can impact the frequency of chronic seizures. However, these studies are limited in their clinical relevance as none of them determines the potential of blocking new neurons generated after the epileptogenic insult to alleviate the development of chronic seizures. Therefore, using a pilocarpine-induced SE model of mTLE in mice of either sex, we show that >4 weeks of continuous and concurrent ablation of seizure-induced neurogenesis after SE can reduce the formation of spontaneous recurrent seizures by 65%. We also found that blocking post-SE neurogenesis does not lead to long-term seizure reduction as the effect was observed only transiently for 10 d with >4 weeks of continuous and concurrent ablation of seizure-induced neurogenesis. Thus, these findings provide evidence that seizure-induced neurogenesis when adequately reduced in a clinically relevant time period has the potential to transiently suppress recurrent seizures, but additional mechanisms need to be targeted to permanently prevent epilepsy development.SIGNIFICANCE STATEMENT Consistent with morphological and electrophysiological studies suggesting aberrant adult-generated neurons contribute to epilepsy development, ablation of seizure-induced new neurons at the time of the initial insult reduces the frequency of recurrent seizures. In this study, we show that continuous targeting of post-insult new neurons in a therapeutically relevant time period reduces chronic seizures; however, this effect does not persist suggesting possible additional mechanisms.

Cortisol levels and seizures in adults with epilepsy: A systematic review

Stress has been suggested as a trigger factor for seizures in epilepsy patients, but little is known about cortisol levels, as indicators of stress, in adults with epilepsy. This systematic review summarizes the evidence on this topic. Following PRISMA guidelines, 38 articles were selected: 14 analyzing basal cortisol levels, eight examining antiepileptic drugs (AEDs) effects, 13 focused on seizure effects, and three examining stress. Higher basal cortisol levels were found in patients than in healthy people in studies with the most homogeneous samples (45% of 38 total studies). Despite heterogeneous results associated with AEDs, seizures were related to increases in cortisol levels in 77% of 38 total studies. The only study with acute stress administration found higher cortisol reactivity in epilepsy than in healthy controls. In studies using self-reported stress, high seizure frequency was related to increased cortisol levels and lower functional brain connectivity. Findings suggest that epilepsy could be considered a chronic stress model. The potential sensitizing role of accumulative seizures and issues for future research are discussed.

Coping with stress: A pilot study of a self-help stress management intervention for patients with epileptic or psychogenic nonepileptic seizures

PURPOSE

Many patients with epilepsy or psychogenic nonepileptic seizures (PNES) experience high levels of stress. Although psychological interventions have been developed for seizure disorders, few patients can currently access them. We aimed to assess the acceptability and feasibility of a self-help intervention targeting stress in patients with seizures, and to provide preliminary evidence for its effectiveness.

METHOD

Patients were recruited from outpatient neurology clinics and randomized to an immediate intervention group (n = 39), who received the intervention at baseline, or a delayed intervention group (n = 43), who received the intervention one-month postbaseline. Participants completed self-report questionnaires measuring stress (Smith Stress Symptom Inventory [SSSI]), anxiety (Generalized Anxiety Disorder 7-item Scale [GAD-7]), depression (Neurological Disorders Depression Inventory for Epilepsy [NDDI-E]), quality of life (European Quality of Life - 5 Dimensions [EQ-5D]), and seizure severity and frequency (Liverpool Seizure Severity Scale [LSSS-3]) at baseline, and at one- and two-month follow-up. Participants also provided telephone feedback. The intervention consisted of a self-help stress management workbook based on an integrative stress model framework.

RESULTS

Although the rate of participants failing to return follow-up information at two months was approximately 50%, those who completed the trial found the intervention acceptable; with the majority rating it as helpful (63.6%) and that they would recommend it to others with seizures (88.1%). A significant reduction in self-reported stress (P = .01) with a medium effect size (d_z = 0.51) was observed one-month postintervention. There were no significant changes in any other measures.

CONCLUSION

The intervention was perceived to be acceptable, safe, and helpful by participants. It could be a useful complementary treatment option for reducing stress experienced by patients living with seizure disorders. Further evaluation in a larger trial is warranted.

The safety of treating newly diagnosed epilepsy

INTRODUCTION

Epilepsy is a serious chronic neurological disorder manifested by an enduring symptomatic predisposition to seizures. Newly diagnosed individuals face increased morbidity, mortality, and socioeconomic costs. Anti-epileptic drug therapy is the treatment usually prescribed, which has efficacy in seizure control and mitigating long-term mortality.

AREAS COVERED

Safety of anti-epileptic drug therapy in adults with a focus in newly diagnosed patients. Areas covered include the most commonly experienced adverse drug effects, as well as those with the highest impacts on drug tolerability, quality of life, morbidity and mortality. Evidence was also reviewed to identify clinical strategies to improve the safety of anti-epileptic drug therapy.

EXPERT OPINION

Anti-epileptic drugs (AEDs) are mostly effective and well tolerated. However, a lack of standardised reporting of adverse drug effects in trials and in clinical practice provides an obstacle for evaluation of which adverse drug effects need to be prioritised in management. Improvement in the reporting of cognitive and other effects, as well as improved precision medicine and pharmacogenomics to target the incidence of high-mortality idiosyncratic reactions, will help to reduce the harm of AEDs in people newly diagnosed with epilepsy.

Affect-induced reflex seizures (AIRS): A case series based on a systematic literature review

Seizures are commonly thought to occur in a spontaneous, unpredictable manner. However, it is well-established that a subset of patients with epilepsy can experience reflex seizures that are consistently elicited by a specific stimulus. While various forms of reflex epilepsy have been documented in the literature, acute affective states have not been commonly described as a potential reflex seizure trigger. We performed a systematic literature review to determine if acute emotional states can trigger reflex seizures. We included any case in which reflex seizures repeatedly occurred in response to a patient-specific stimulus that was reported as emotionally relevant by the authors. This yielded our case series of ten patients who have been described to have reflex seizures in response to emotional stimuli. We characterized features of these cases including the following: age, gender, developmental and psychiatric history, seizure semiology and duration, emotional triggers, other reflex triggers, relationship between reflex triggers and seizures, investigations, localization, final diagnosis, treatment, and outcome. Considerable variability was found between cases. A trend toward limbic seizure semiology with psychic aura originating in networks involved in emotional processing was noted, with temporal lobe epilepsy being the most common, although without clear laterality or gender predominance. In addition, the report of a significant life stressor occurring at epilepsy onset in three of ten patients as well as the initial suspicion that reflex epileptic seizures were psychogenic in three cases both emphasize the role of electroencephalography in assessment of such presentations to avoid missing a diagnosis of epilepsy. Findings from these ten cases suggest that a patient-specific affective stimulus may trigger reflex seizures in a subset of patients, and that this could be underrecognized or mislabeled as nonepileptic. We encourage future studies with larger numbers to further characterize this phenomenon. Insights gained may enhance our understanding of seizure localization and bear potential treatment implications.

Corticosteroids and the brain

The brain is continuously exposed to varying levels of adrenal corticosteroid hormones such as corticosterone in rodents and cortisol in humans. Natural fluctuations occur due to ultradian and circadian variations or are caused by exposure to stressful situations. Brain cells express two types of corticosteroid receptors, i.e. mineralocorticoid and glucocorticoid receptors, which differ in distribution and affinity. These receptors can mediate both rapid non-genomic and slow gene-mediated neuronal actions. As a consequence of these factors, natural (e.g. stress-induced) shifts in corticosteroid level are associated with a complex mosaic of time- and region-dependent changes in neuronal activity. A series of experiments in humans and rodents have revealed that these time- and region-dependent cellular characteristics are also reflected in distinct cognitive patterns after stress. Thus, directly after a peak of corticosteroids, attention and vigilance are increased, and areas involved in emotional responses and simple behavioral strategies show enhanced activity. In the aftermath of stress, areas involved in higher cognitive functions become activated allowing individuals to link stressful events to the specific context and to store information for future use. Both phases of the brain's response to stress are important to face a continuously changing environment, promoting adaptation at the short as well as long term. We argue that a balanced response during the two phases is essential for resilience. This balance may become compromised after repeated stress exposure, particularly in genetically vulnerable individuals and aggravate disease manifestation. This not only applies to psychiatric disorders but also to neurological diseases such as epilepsy.

Epilepsy

Epilepsy affects all age groups and is one of the most common and most disabling neurological disorders. The accurate diagnosis of seizures is essential as some patients will be misdiagnosed with epilepsy, whereas others will receive an incorrect diagnosis. Indeed, errors in diagnosis are common, and many patients fail to receive the correct treatment, which often has severe consequences. Although many patients have seizure control using a single medication, others require multiple medications, resective surgery, neuromodulation devices or dietary therapies. In addition, one-third of patients will continue to have uncontrolled seizures. Epilepsy can substantially impair quality of life owing to seizures, comorbid mood and psychiatric disorders, cognitive deficits and adverse effects of medications. In addition, seizures can be fatal owing to direct effects on autonomic and arousal functions or owing to indirect effects such as drowning and other accidents. Deciphering the pathophysiology of epilepsy has advanced the understanding of the cellular and molecular events initiated by pathogenetic insults that transform normal circuits into epileptic circuits (epileptogenesis) and the mechanisms that generate seizures (ictogenesis). The discovery of >500 genes associated with epilepsy has led to new animal models, more precise diagnoses and, in some cases, targeted therapies.

Stress, seizures, and epilepsy: Patient narratives

In epilepsy, individual seizures can be triggered by a variety of external and internal stimuli. One of the most common trigger factors reported by patients is stress. However prevalent, stress-related triggering of episodes seems underappreciated in epilepsy for various reasons, and its misinterpretation often leads to other diagnoses, e.g., psychogenic nonepileptic seizures (PNES) or normal reactions. This article illustrates the significant role of stress as a seizure-provoking factor by referring to nine patient narratives. From this perspective, it appears that there are characteristic patterns of stress triggering, e.g., stress-induced sleep disruption, forms of acute stress, or relaxation after stress. Sometimes seizures are mistaken as symptoms of stress. Patient narratives contain interesting clues relating reports about stress and seizure histories to different epilepsy syndromes as well as nonepileptic episodes in a way that can strongly support the diagnostic process. A narrative approach is particularly valuable in this context. Therefore, accounts of stress triggering in seizures and other episodes should not be neglected, but rather taken seriously, sought and actively explored as a crucial element when taking clinical histories in patients with episodic attacks.