Long-term prognosis of seizures with onset in childhood

Identification and treatment of surgically-remediable causes of infantile epileptic spasms syndrome

INTRODUCTION

Infantile epileptic spasms syndrome (IESS) is a common developmental and epileptic encephalopathy with poor long-term outcomes. A substantial proportion of patients with IESS have a potentially surgically remediable etiology. Despite this, epilepsy surgery is underutilized in this patient group. Some surgically remediable etiologies, such as focal cortical dysplasia and malformation of cortical development with oligodendroglial hyperplasia in epilepsy (MOGHE), are under-diagnosed in infants and young children. Even when a surgically remediable etiology is recognised, for example, tuberous sclerosis or focal encephalomalacia, epilepsy surgery may be delayed or not considered due to diffuse EEG changes, unclear surgical boundaries, or concerns about operating in this age group.

AREAS COVERED

In this review, the authors discuss the common surgically remediable etiologies of IESS, their clinical and EEG features, and the imaging techniques that can aid in their diagnosis. They then describe the surgical approaches used in this patient group, and the beneficial impact that early epilepsy surgery can have on developing brain networks.

EXPERT OPINION

Epilepsy surgery remains underutilized even when a potentially surgically remediable cause is recognized. Overcoming the barriers that result in under-recognition of surgical candidates and underutilization of epilepsy surgery in IESS will improve long-term seizure and developmental outcomes.

Characterizing Frontal Lobe Seizure Semiology in Children

OBJECTIVE

The objective was to analyze seizure semiology in pediatric frontal lobe epilepsy patients, considering age, to localize the seizure onset zone for surgical resection in focal epilepsy.

METHODS

Fifty patients were identified retrospectively, who achieved seizure freedom after frontal lobe resective surgery at Great Ormond Street Hospital. Video-electroencephalography recordings of preoperative ictal seizure semiology were analyzed, stratifying the data based on resection region (mesial or lateral frontal lobe) and age at surgery (≤4 vs >4).

RESULTS

Pediatric frontal lobe epilepsy is characterized by frequent, short, complex seizures, similar to adult cohorts. Children with mesial onset had higher occurrence of head deviation (either direction: 55.6% vs 17.4%; p = 0.02) and contralateral head deviation (22.2% vs 0.0%; p = 0.03), ictal body-turning (55.6% vs 13.0%; p = 0.006; ipsilateral: 55.6% vs 4.3%; p = 0.0003), and complex motor signs (88.9% vs 56.5%; p = 0.037). Both age groups (≤4 and >4 years) showed hyperkinetic features (21.1% vs 32.1%), contrary to previous reports. The very young group showed more myoclonic (36.8% vs 3.6%; p = 0.005) and hypomotor features (31.6% vs 0.0%; p = 0.003), and fewer behavioral features (36.8% vs 71.4%; p = 0.03) and reduced responsiveness (31.6% vs 78.6%; p = 0.002).

INTERPRETATION

This study presents the most extensive semiological analysis of children with confirmed frontal lobe epilepsy. It identifies semiological features that aid in differentiating between mesial and lateral onset. Despite age-dependent differences, typical frontal lobe features, including hyperkinetic seizures, are observed even in very young children. A better understanding of pediatric seizure semiology may enhance the accuracy of onset identification, and enable earlier presurgical evaluation, improving postsurgical outcomes. ANN NEUROL 2024;95:1138-1148.

The changing incidence of childhood epilepsy in Finland

INTRODUCTION

to investigate the childhood epilepsy incidence, population trends, associated factors, and validate the national population registers.

METHODS

a comprehensive comparative analysis of childhood epilepsy in the population during two distinct time intervals using medical records, appropriate national medical and population registers, and two random samples for control.

RESULTS

In 1961-1964, the average incidence of epilepsy was 38/100,000 and during 1991-2000 65.9 (95 % CI 59.6 to 72.2) and 65.6/100,000 person-years after adjustment for the European Standard Population. This increase was significant (p<0.0001) as was a decline (p<0.003) from 1991 to 1995 to 1996-2000. The decline in incidence for girls occurred at a younger age compared to boys. Epilepsy cases associated with prenatal and perinatal factors were 50 % lower in 1991-2000 than in 1961-1964, especially related to asphyxia, infections, pre-eclampsia, and imminent abortion. The national Register for Healthcare independently identified 94.5 % of relevant cases (University Hospital alone 81.2 %, and Drug Register alone 74.3 %).

DISCUSSION

Over the past five decades, the incidence rate of childhood epilepsy has exhibited a dynamic pattern, with a notable increase until the 1990's, followed by a stabilization at an incidence rate of approximately 60-70 per 100,000 person-years. Our findings, in line with other recent Finnish research, support a significant decrease in incidence since the mid-1990's. The underlying reasons for the increase and decrease remain unclear. Finnish national registers for epilepsy have established themselves as highly dependable resources for conducting epidemiological research.

CONCLUSION

Childhood epilepsy incidence in Finland is similar to other industrialized countries, but there are signs of a declining trend emerging.

Mortality, and life expectancy in Epilepsy and Status epilepticus-current trends and future aspects

Patients with epilepsy carry a risk of premature death which is on average two to three times higher than in the general population. The risk of death is not homogenously distributed over all ages, etiologies, and epilepsy syndromes. People with drug resistant seizures carry the highest risk of death compared to those who are seizure free, whose risk is similar as in the general population. Most of the increased risk is directly related to the cause of epilepsy itself. Sudden unexplained death in epilepsy patients (SUDEP) is the most important cause of epilepsy-related deaths especially in the young and middle-aged groups. Population based studies with long-term follow up demonstrated that the first years after diagnosis carry the highest risk of death, while in the later years the mortality decreases. Improved seizure control and being exposed to a specialized comprehensive care centre may help to reduce the risk of death in patients with epilepsy. The mortality of status epilepticus is substantially increased with case fatality rates between 4.6% and 39%, depending on its cause and duration, and the age of the population studied. The epidemiological data on overall and cause specific mortality as well as their determinants and risk factors are critically reviewed and methodological issues pertinent to the studies on mortality of epilepsy and Status epilepticus are discussed.

Vagus nerve stimulator revision in pediatric epilepsy patients: a technical note and case series

INTRODUCTION

Vagus nerve stimulation (VNS) is an adjunctive treatment in children with intractable epilepsy. When lead replacement becomes necessary, the old leads are often truncated and retained and new leads are implanted at a newly exposed segment of the nerve. Direct lead removal and replacement are infrequently described, with outcomes poorly characterized. We aimed to describe our experience with feasibility of VNS lead removal and replacement in pediatric patients.

METHODS

Retrospective review examined 14 patients, at a single, tertiary-care, children's hospital, who underwent surgery to replace VNS leads, with complete removal of the existing lead from the vagus nerve and placement of a new lead on the same segment of the vagus nerve, via blunt and sharp dissection without use of electrocautery. Preoperative characteristics, stimulation parameters, and outcomes were collected.

RESULTS

Mean age at initial VNS placement was 7.6 years (SD 3.5, range 4.5-13.4). Most common etiologies of epilepsy were genetic (5, 36%) and cryptogenic (4, 29%). Lead replacement was performed at a mean of 6.0 years (SD 3.8, range 2.1-11.7) following initial VNS placement. Reasons for revision included VNS lead breakage or malfunction. There were no perioperative complications, including surgical site infection, voice changes, dysphagia, or new deficits postoperatively. Stimulation parameters after replacement surgery at last follow-up were similar compared to preoperatively, with final stimulation parameters ranging from 0.25 mA higher to 1.5 mA lower to maintain baseline seizure control. The mean length of follow-up was 7.9 years (SD 3.5, range 3.1-13.7).

CONCLUSION

Removal and replacement of VNS leads are feasible and can be safely performed in children. Further characterization of surgical technique, associated risk, impact on stimulation parameters, and long-term outcomes are needed to inform best practices in VNS revision.

Drug-resistant epilepsy and mortality-Why and when do neuromodulation and epilepsy surgery reduce overall mortality

Patients with drug-resistant epilepsy have an increased mortality rate, with the majority of deaths being epilepsy related and 40% due to sudden unexpected death in epilepsy (SUDEP). The impact of epilepsy surgery on mortality has been investigated since the 1970s, with increased interest in this field during the past 15 years. We systematically reviewed studies investigating mortality rate in patients undergoing epilepsy surgery or neuromodulation therapies. The quality of available evidence proved heterogenous and often limited by significant methodological issues. Perioperative mortality following epilepsy surgery was found to be <1%. Meta-analysis of studies that directly compared patients who underwent surgery to those not operated following presurgical evaluation showed that the former have a two-fold lower risk of death and a three-fold lower risk of SUDEP compared to the latter (odds ratio [OR] 0.40, 95% confidence interval [CI]: 0.29-0.56; p < .0001 for overall mortality and OR 0.32, 95% CI: 0.18-0.57; p < .001 for SUDEP). Limited data are available regarding the risk of death and SUDEP in patients undergoing neuromodulation therapies, although some evidence indicates that vagus nerve stimulation might be associated with a lower risk of SUDEP. Several key questions remain to be addressed in future studies, considering the need to better inform patients about the long-term benefit-risk ratio of epilepsy surgery. Dedicated long-term prospective studies will thus be required to provide more personalized information on the impact of surgery and/or neuromodulation on the risk of death and SUDEP.

Efficacy of a specialized inpatient rehabilitation program in patients with early versus chronic epilepsy

OBJECTIVE

To evaluate the efficacy of a specialized inpatient rehabilitation program in patients with early in comparison with chronic epilepsy.

METHODS

We performed a prospective, open pre/post study using a parallel group design. Patients with early epilepsy (EE, treatment with anti-seizure medication [ASM] ≤ 1 year) or with chronic epilepsy (CE, ASM treatment > 5 years) completed questionnaires at the time of their admission to the rehabilitation program and at discharge. Outcome measures comprised scales from the PESOS questionnaire (PErformance, SOciodemographic aspects, Subjective estimation; e.g., emotional adaptation to epilepsy) as well as screening instruments for depression (Neurological Disorders Depression Inventory for Epilepsy, NDDI-E) and anxiety (Generalized Anxiety Disorder Scale, GAD-7). Linear mixed models (LMMs) were used to determine the effects of the program in the total group and to compare the effects between patients with EE and CE.

RESULTS

The analyses included 79 patients with EE and 157 patients with CE. Baseline comparisons revealed differences in disease-related and sociodemographic variables (e.g., patients with EE were older, those with CE had a higher seizure frequency and a higher rate of unemployment; all p < .01). LMMs showed significant improvements in emotional adaptation to epilepsy, depression, anxiety, overall quality of life and overall health as well as in perceived overall restrictions because of epilepsy and the subjective level of information about epilepsy (all p < .001). Despite the different duration of epilepsy, baseline levels as well as improvements did not differ between patients with EE and CE (all p > .05) except for the perceived level of information, which was significantly lower in patients with EE at admission and improved to a higher extent in this group (both p < .001).

CONCLUSION

Both patients with EE and patients with CE who are referred to a specialized comprehensive rehabilitation program benefit from the participation in this program with respect to emotional adaptation to epilepsy, aspects of quality of life, and level of information about epilepsy.

Hippocampus-related cognitive disorders develop in the absence of epilepsy and ataxia in the heterozygous Cacna1a mutant mice tottering

CACNA1A-associated epilepsy and ataxia frequently accompany cognitive impairments as devastating co-morbidities. However, it is unclear whether the cognitive deficits are consequences secondary to the neurological symptoms elicited by CACNA1A mutations. To address this issue, Cacna1a mutant mice tottering (tg), and in particular tg/+ heterozygotes, serve as a suitable model system, given that tg/+ heterozygotes fail to display spontaneous absence epilepsy and ataxia typically observed in tg/tg homozygotes. Here, we examined hippocampus-dependent behaviors and hippocampal learning-related synaptic plasticity in tg mice. In behavioral analyses of tg/+ and tg/tg, acquisition and retention of spatial reference memory were characteristically impaired in the Morris water maze task, while working memory was intact in the eight-arm radial maze and T-maze tasks. tg/+ heterozygotes showed normal motor function in contrast to tg/tg homozygotes. In electrophysiological analyses, Schaffer collateral–CA1 synapses showed a deficit in the maintenance of long-term potentiation in tg/+ and tg/tg mice and an increased paired-pulse facilitation induced by paired pulses with 100 ms in tg/tg mice. Our results indicate that the tg mutation causes a dominant disorder of the hippocampus-related memory and synaptic plasticity, raising the possibility that in CACNA1A-associated human diseases, functionally aberrant Ca_V2.1 Ca²⁺ channels actively induce the observed cognitive deficits independently of the neurological symptoms.

Is there a relationship between socioeconomic factors and prevalence, adherence and outcome in childhood epilepsy? A systematic scoping review

OBJECTIVES

Socioeconomic factors play a role in the outcome of chronic diseases in childhood. Epilepsy is the most common chronic neurological disease in childhood. The relationship between socioeconomic factors and prevalence, adherence and outcome in children with epilepsy has not been systematically reviewed and therefore the aim of our study.

METHODS

Searches were conducted in PubMed, Embase and Cochrane databases from the first documented publications until 31st May 2020. The keywords included socioeconomic status, epilepsy, anticonvulsant, children and systematic review.

RESULTS

The search generated 4687 abstracts. 26 articles were included in the final analysis after the screening process. We found one paper regarding prevalence, 12 regarding adherence and 13 regarding outcome and their relationship to socioeconomic factors. Socioeconomic factors of caregivers impacted school performance, seizure freedom, quality of life and risk of unemployment in adulthood. Lower socioeconomic status was associated with non-adherence. Epilepsy may be more prevalent in children living in lower socioeconomic neighborhoods.

CONCLUSION

Socioeconomic factors of the caregiver, especially their level of education, annual income and marital status, had a significant impact on the outcome and adherence to anticonvulsants in children with epilepsy. Children belonging to a lower socioeconomic group are at risk of having poorer outcomes regarding adherence and hence remission, quality of life and academic achievement. We need to recognize this important aspect and take it into account when making a treatment plan for children with epilepsy.

The clinical, economic, and humanistic burden of Dravet syndrome - A systematic literature review

Dravet syndrome (DS) is a developmental and epileptic encephalopathy with evolving disease course as individuals age. In recent years, the treatment landscape of DS has changed considerably, and a comprehensive systematic review of the contemporary literature is lacking. Here we synthesized published evidence on the occurrence of clinical impacts by age, the economic and humanistic (health-related quality-of-life [HRQoL]) burden, and health state utility. We provide an evidence-based, contemporary visualization of the clinical manifestations, highlighting that DS is not limited to seizures; non-seizure manifestations appear early in life and increase over time, contributing significantly to the economic and humanistic burden of disease. The primary drivers of HRQoL in DS include seizure severity, cognition, and motor and behavioral problems; in turn, these directly affect caregivers through the extent of assistance required and consequent impact on activities of daily living. Unsurprisingly, costs are driven by seizure-related events, hospitalizations, and in-home medical care visits. This systematic review highlights a paucity of longitudinal data; most studies meeting inclusion criteria were cross-sectional or had short follow-up. Nonetheless, available data illustrate the substantial impact on individuals, their families, and healthcare systems and establish the need for novel therapies to address the complex spectrum of DS manifestations.

Differences in brain changes between adults with childhood-onset epilepsy and controls: A prospective population-based study

Purpose

To determine the impact of childhood‐onset uncomplicated epilepsy (COE) on brain aging over 50‐year prospective follow‐up.

Methods

A population‐based cohort of 41 aging subjects with COE and their 46 matched controls participated in a detailed in‐person prospective assessment in 2012 and 2017 to characterize ongoing changes in the aging brain.

Results

The mean age of the COE participants was 63.2 years (SD 4.14, median 63.2, range 55.8–70.6) and 63.0 years (mean, SD 4.13, median 63.3, range 56.0–69.9) years for controls. Neurologic signs were significantly more common in COE participants not in remission (p = .015), and the most frequent abnormalities were cerebellar signs (p < .001). Neurologic signs in general (p = .008) and cerebellar signs in particular (p = .018) were significantly more common in focal than in generalized epilepsies. MRI white matter abnormalities were significantly associated with absence of vocational education (p = .011), and MRI hippocampal atrophy in COE subjects was associated with arterial hypertension versus normal blood pressure (p = .017). In the combined study cohort of COE subjects and controls, presenting neurologic signs increased both in the subjects and in the controls from the 2012 to 2017 study.

Conclusions

At ultra‐long‐term follow‐up, clinical and neuroimaging findings show tendencies to brain aging that is more accelerated in COE participants with active adult childhood‐onset epilepsy, and particularly in focal epilepsy.

Behavioral phenotypes of pediatric temporal lobe epilepsy

OBJECTIVE

A broad spectrum of emotional-behavioral problems have been reported in pediatric temporal lobe epilepsy (TLE), but with considerable variability in their presence and nature of expression, which hampers precise identification and treatment. The present study aimed to empirically identify latent patterns or behavioral phenotypes and their correlates.

METHODS

Data included parental ratings of emotional-behavioral status on the Behavior Assessment System for Children, 2nd Edition (BASC-2) of 81 children (mean age = 11.79, standard deviation [SD] = 3.93) with TLE. The nine clinical subscales were subjected to unsupervised machine learning to identify behavioral subgroups. To explore concurrent validity and the underlying composition of the identified clusters, we examined demographic factors, seizure characteristics, psychosocial factors, neuropsychological performance, psychiatric status, and health-related quality of life (HRQoL).

RESULTS

Three behavioral phenotypes were identified, which included no behavioral concerns (Cluster 1, 43% of sample), externalizing problems (Cluster 2, 41% of sample), and internalizing problems (Cluster 3, 16% of sample). Behavioral phenotypes were characterized by important differences across clinical seizure variables, psychosocial/familial factors, everyday executive functioning, and HRQoL. Cluster 2 was associated with younger child age, lower maternal education, and higher rate of single-parent households. Cluster 3 was associated with older age at epilepsy onset and higher rates of hippocampal sclerosis and parental psychiatric history. Both Cluster 2 and 3 demonstrated elevated family stress. Concurrent validity was demonstrated through the association of psychiatric (i.e., rate of Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) disorders and psychotropic medication) and parent-rated HRQoL variables.

SIGNIFICANCE

Youth with TLE present with three distinct behavioral phenotypes that correspond with important clinical and sociodemographic markers. The current findings demonstrate the variability of behavioral presentations in youth with TLE and provide a preliminary framework for screening and targeting intervention to enhance support for youth with TLE and their families.

Seizures' impact on cognition and quality of life in childhood cancer survivors

BACKGROUND

The objective of this study was to determine the impact of seizure-related factors on neurocognitive, health-related quality of life (HRQOL), and social outcomes in survivors of childhood cancer.

METHODS

Survivors of childhood cancer treated at St. Jude Children's Hospital (n = 2022; 48.3% female; median age, 31.5 years; median time since diagnosis, 23.6 years) completed neurocognitive testing and questionnaires. The presence, severity, resolution, and treatment history of seizures were abstracted from medical records. Adjusting for the age at diagnosis, sex, and prior cancer therapy, multivariable models examined the impact of seizures on neurocognitive and HRQOL outcomes. Mediation analyses were conducted for social outcomes.

RESULTS

Seizures were identified in 232 survivors (11.5%; 29.9% of survivors with central nervous system [CNS] tumors and 9.0% of those without CNS tumors). In CNS tumor survivors, seizures were associated with poorer executive function and processing speed (P < .02); in non-CNS tumor survivors, seizures were associated with worse function in every domain (P < .05). Among non-CNS survivors, seizure severity was associated with worse processing speed (P = .023), and resolution was associated with better executive function (P = .028) and attention (P = .044). In CNS survivors, seizure resolution was associated with improved attention (P = .047) and memory (P < .02). Mediation analysis revealed that the impact of seizures on social outcomes was mediated by neurocognitive function.

CONCLUSIONS

Seizures in cancer survivors adversely affect long-term functional and psychosocial outcomes independently of cancer therapy. The resolution of seizure occurrence is associated with better outcomes. Seizure severity is associated with poorer outcomes and should be a focus of clinical management and patient education.

Self-injury as a predominant challenging behavior in epilepsy: A study in a residential facility for profoundly disabled patients

BACKGROUND

The association between challenging behavior (CB) and epilepsy in people with intellectual disability (ID) remains largely controversial.

AIM

To clarify the correlation between CB and epilepsy, we investigated the clinical characteristics of CB in both people with and without epilepsy among individuals with ID hospitalized in our residential facility.

METHODS AND PROCEDURES

A total of 63 individuals with CB was retrospectively investigated using the Behavior Problems Inventory, and the following items were collected from the medical records: sex, age, hospitalization period, etiology and risk factors, level of ID, type of CB, administration of psychotropic drugs, presence or absence of epilepsy and clinical features of epilepsy.

OUTCOMES AND RESULTS

Almost all individuals with CB showed profound ID. There was no significant difference in the rate of CB between people with and without epilepsy. A type analysis of CB revealed that self-injurious behavior was observed more frequently in epilepsy cases (66.7 %) than in cases without epilepsy (36.4 %) (p =  0.015), and self-injurious behavior was the predominant clinical form in people with epilepsy among the three subgroups of CB (self-injurious, aggressive and self-injurious and aggressive behavior).

CONCLUSIONS AND IMPLICATIONS

The high incidence of self-injurious behavior in epilepsy with profound disabilities may imply the presence of common pathological basis of self-injurious behavior and epilepsy.

Beneficial Effect of Phenytoin and Carbamazepine on GFAP Gene Expression and Mutant GFAP Folding in a Cellular Model of Alexander's Disease

Alexander’s disease (AxD) is a rare, usually relentlessly progressive disorder of astroglial cells in the central nervous system related to mutations in the gene encoding the type III intermediate filament protein, glial fibrillary acidic protein (GFAP). The pathophysiology of AxD is only partially understood. Available data indicate that an excessive GFAP gene expression may play a role. In particular, a “threshold hypothesis” has been reported, suggesting that mutant GFAP representing about 20% of the total cellular GFAP should be sufficient to cause disease. Thus, strategies based on reducing cellular mutant GFAP protein levels and/or activating biological processes involved in the correct protein folding could be effective in counteracting the toxic effect of misfolded GFAP. Considering that clomipramine (CLM), which has been selected by a wide small molecules screening as the greatest inhibitory potential drug against GFAP expression, is contraindicated because of its proconvulsant activity in the infantile form of AxD, which is also characterized by the occurrence of epileptic seizures, two powerful antiepileptic agents, carbamazepine (CBZ) and phenytoin (PHT), which share specific stereochemical features in common with CLM, were taken into consideration in a reliable in vitro model of AxD. In the present work, we document for the first time that CBZ and PHT have a definite inhibitory effect on pathological GFAP cellular expression and folding. Moreover, we confirm previous results of a similar beneficial effect of CLM. In addition, we have demonstrated that CBZ and CLM play a refolding effect on mutant GFAP proteins, likely ascribed at the induction of CRYAB expression, resulting in the decrease of mutant GFAP aggregates formation. As CBZ and PHT are currently approved for use in humans, their documented effects on pathological GFAP cellular expression and folding may indicate a potential therapeutic role as disease-modifying agents of these drugs in the clinical management of AxD, particularly in AxD patients with focal epilepsy with and without secondary generalization.

Factors associated with seizures at initial presentation in pediatric patients with cerebral arteriovenous malformations

OBJECTIVE

Children with cerebral arteriovenous malformations (AVMs) can present with seizures, potentially increasing morbidity and impacting clinical management. However, the factors that lead to seizures as a presenting sign are not well defined. While AVM-related seizures have been described in case series, most studies have focused on adults and have included patients who developed seizures after an AVM rupture. To address this, the authors sought to analyze demographic and morphological characteristics of AVMs in a large cohort of children.

METHODS

The demographic, clinical, and AVM morphological characteristics of 189 pediatric patients from a single-center database were studied. Univariate and multivariate logistic regression models were used to test the effect of these characteristics on seizures as an initial presenting symptom in patients with unruptured brain AVMs.

RESULTS

Overall, 28 of 189 patients initially presented with seizures (14.8%). By univariate comparison, frontal lobe location (p = 0.02), larger AVM size (p = 0.003), older patient age (p = 0.04), and the Supplemented Spetzler-Martin (Supp-SM) grade (0.0006) were associated with seizure presentation. Multivariate analysis confirmed an independent effect of frontal lobe AVM location and higher Supp-SM grade. All patients presenting with seizures had AVMs in the cortex or subcortical white matter.

CONCLUSIONS

While children and adults share some risk factors for seizure presentation, their risk factor profiles do not entirely overlap. Pediatric patients with cortical AVMs in the frontal lobe were more likely to present with seizures. Additionally, the Supp-SM grade was highly associated with seizure presentation. Future clinical research should focus on the effect of therapeutic interventions targeting AVMs on seizure control in these patients.

Neurodevelopmental and psychiatric comorbidities negatively affect outcome in children with unprovoked seizures-A non-systematic review

Children with epilepsy have at least one comorbidity in 80% of cases. This unstructured review provides insights into the most common comorbidities, their effects on seizure prognosis and treatment. We also review the epilepsy terminology and classifications. Neurodevelopmental and psychiatric comorbidities were common in children with seizures and had a negative effect on quality of life, and seizure freedom. Children with seizures were treated with drugs used for attention deficit hyperactivity disorder (ADHD), depression or psychosis, more often than the general population but less often than prevalence rates would suggested. CONCLUSION: Multidisciplinary teams should assess comorbidities in children with epilepsy to improve their care and outcomes.

The long-term prognosis and predictors of epilepsy: a retrospective study in 820 patients

Background

To investigate the prognosis and predictors for seizure control in epileptic patients in China.

Methods

Eight hundred and twenty patients with epilepsy who visited Xuanwu Hospital from October 2017 to January 2020, were enrolled. The clinical information of the patients was obtained by retrospectively reviewing medical records. Prognostic measures of seizure control included remission, relapse and occurrence of drug resistance. The relationship of prognosis of seizure control with factors such as demographics, clinical characteristics and initial electroencephalography (EEG) features was investigated.

Results

A total of 503 (61.3%) patients experienced a 1-year remission and 330 (49.3% of 669) had a 2-year remission. Idiopathic type of epilepsy (P <  0.001), normal EEG (P <  0.05), number of antiepileptic drugs (P <  0.05) and seizure frequency of < 1 /month (P <  0.001) at the first arrival predicted a remission independently. Of the 503 patients who achieved a 1-year remission, 184 (36.6%) experienced a relapse, due to external reversible causes (58 patients) or with unknown reversible triggers (126 patients). No factors were found to be associated with a relapse (P > 0.05). At the end of the study, 322 patients (39.3%) developed drug resistance. The development of drug resistance was associated with the following factors: symptomatic aetiology of epilepsy, epileptiform abnormality in EEG, number of antiepileptic drugs and seizure frequency of ≥1 /month at first arrival (P <  0.001). For symptomatic epilepsy, patients with meningitis/encephalitis (P = 0.007) were more likely to develop drug-resistant epilepsy than these with other causes.

Conclusions

Remission is a common process. The type of epilepsy (idiopathic or symptomatic), EEG features, seizure frequency and treatment history at first arrival are related to both remission and terminal drug resistance. Among various causes of symptomatic epilepsy, meningitis/encephalitis is associated with the worst prognosis of epilepsy.

Seizure outcomes of large volume temporo-parieto-occipital and frontal surgery in children with drug-resistant epilepsy

OBJECTIVE

In this study, we investigate the seizure outcomes of temporo-parieto-occipital (TPO) and frontal disconnections or resections in children with drug-resistant epilepsy (DRE) in order to determine factors which may predict surgical results.

METHODS

Children with DRE, who underwent either TPO or frontal disconnection or resection at Great Ormond Street Hospital for Children between 2000 and 2017, were identified from a prospectively collated operative database. Demographic data, age at surgery, type of surgery, scalp EEGs and operative histopathology were collected. Magnetic resonance imaging (MRI) was assessed to determine completeness of disconnection and presence of radiological lesion beyond the disconnection margins. Seizure outcome at 6, 12, and 24 months post-surgery was assessed using the Engel Scale (ES). Logistic regression was used to identify relationships between data variables and seizure outcome.

RESULTS

46 children (males = 28, females = 18; age range 0.5-16.6 years) who underwent TPO (n = 32, including a re-do disconnection) or frontal disconnection or resection (n = 15) were identified. Patients in the TPO treatment group had more favourable seizure outcomes than those in the frontal treatment group (ES I-II in 56 %vs 47 % at 6 months, 52 % vs 46 % at 12 months). Presence of the lesion beyond disconnection boundaries and older age at the time of surgery were associated with poorer seizure outcome. Gender, surgery type, completeness of disconnection, scalp EEG findings and underlying pathology were not related to seizure outcome, but subgroup numbers were small.

CONCLUSIONS

Both TPO and frontal disconnection are effective treatments for selected children with posterior multi-lobar or diffuse frontal lobe epilepsy. Confinement of the MRI lesion within the disconnection margins and a younger age at surgery are associated with favourable seizure outcomes. Further studies are required to elucidate these findings.

Altered static and dynamic functional network connectivity in temporal lobe epilepsy with different disease duration and their relationships with attention

The brain network alterations associated with temporal lobe epilepsy (TLE) progression are still unclear. The purpose of this study was to investigate altered patterns of static and dynamic functional network connectivity (sFNC and dFNC) in TLE with different durations of disease. In this study, 19 TLE patients with a disease duration of ≤5 years (TLE-SD), 24 TLE patients with a disease duration of >5 years (TLE-LD), and 21 healthy controls (HCs) underwent resting-state functional magnetic resonance imaging and attention network test. We used group independent component analysis to determine the target resting-state networks. Sliding window correlation and k-means clustering analysis methods were used to obtain different dFNC states, temporal properties, and temporal variability. We then compared sFNC and dFNC between groups and found that compared with HCs, TLE-SD patients had increased sFNC between the dorsal attention network and sensorimotor network/visual network (VN), but decreased sFNC between the inferior-posterior default mode network and VN. In the strongly connected dFNC state, TLE-SD patients spent more time, had greater mean dwell time, and showed greater inconsistent abnormal network connectivity. There was a significant negative correlation between the temporal variability of auditory network- left fronto-parietal network connectivity and orienting effect. No significant differences in sFNC and dFNC were detected between TLE-LD and HC groups. These findings suggest that the damage and functional brain network abnormalities gradually occur in TLE patients after the onset of epilepsy, which might lead to functional network reorganization and compensatory remodeling as the disease progresses.

Evaluation and management of drug resistant epilepsy in children

Epilepsy is one of the most common neurological conditions in children. Most children with epilepsy respond to anti- epileptic drugs (AEDs) but approximately 30% of children develop drug resistant epilepsy (DRE) defined as 'the failure of adequate trials of two tolerated, appropriately chosen and used anti-epileptic drugs (AEDs)'. DRE is associated with serious consequences including higher mortality and worse cognitive outcomes. DRE impacts several aspects of the child's and the caregiver's life.

A multivariable prediction model of a major treatment response for focal-onset seizures: A post-hoc analysis of Phase III trials of perampanel

OBJECTIVE

Although 50 % reduction in seizure frequency is a common efficacy endpoint in clinical trials of antiepileptic drugs (AEDs), 75 % or greater reductions may be required to improve patients' health-related quality of life. Identification of clinical factors that are associated with high responder rates may help to inform clinicians on which patients may optimally benefit from treatment. We evaluated potential predictive factors for achieving major treatment responses (≥75 % reduction in seizure frequency per 28 days from study baseline) in patients with drug-resistant focal-onset seizures, with/without focal to bilateral tonic-clonic (FBTC) seizures in perampanel trials designed for regulatory approval.

METHODS

Univariate analyses using logistic regression were performed using data from three double-blind, placebo-controlled Phase III studies of adjunctive perampanel (Studies 304 [NCT00699972], 305 [NCT00699582], 306 [NCT00700310]), and their open-label extension study (OLEx; Study 307 [NCT00735397]). For the double-blind studies, baseline seizure frequency, number of baseline AEDs, baseline seizure type, baseline concomitant enzyme-inducing AEDs (EIAEDs), baseline carbamazepine, lamotrigine, or valproic acid, age at diagnosis, time since diagnosis, etiology, and perampanel plasma concentration were included individually with study treatment. The same factors were included for the OLEx analysis except for plasma concentration and treatment. Variables found to be significant predictors for a major treatment response in univariate analyses were subsequently included in multivariable analyses using backwards and forwards selection.

RESULTS

In the double-blind studies, 175/1374 patients had a major response to placebo (n = 25) or perampanel (n = 150). The best predictors of a major treatment response in multivariable models with forwards and backwards selection were: the presence of FBTC seizures during baseline (P = 0.0002), higher perampanel plasma concentration (P < 0.0001), older age at diagnosis (P = 0.0024 and 0.0045, respectively), and lower baseline seizure frequency (P = 0.0364 and 0.0127, respectively). In the OLEx, 217/1090 patients had a major treatment response. The best predictors of a major treatment response in the final multivariable model, regardless of backwards or forwards selection, were a lower baseline seizure frequency (P = 0.0022), the absence of focal impaired awareness seizures during baseline (P = 0.0011), the presence of FBTC seizures during baseline (P = 0.0164), lower number(s) of baseline AEDs (P = 0.0002), the absence of EIAEDs during baseline (P = 0.0059), an older age at diagnosis (P = 0.0054), and absence of structural etiologies (P = 0.0138).

SIGNIFICANCE

These analyses of placebo-controlled and long-term extension trial data identified a number of potential predictive factors for patients with focal-onset seizures achieving a major treatment response. These factors may help guide clinicians when predicting a patient's response to treatment and optimizing individual treatment regimens.

Trends in pediatric epilepsy surgery: A lower-middle-income country perspective

OBJECTIVE

To study the trends for pediatric epilepsy surgery between 2000 and 2014 in a tertiary epilepsy surgery center in India in order to gain a lower- and middle-income country (LMIC) perspective.

METHODS

Children aged <18 years and undergoing epilepsy surgery were divided into three groups based on the year that they underwent surgery-group 1: year 2000-2004; group 2: year 2005-2009; and group 3: year 2010-2014. Data including the rate of surgery, type of surgery, and duration of epilepsy before referral were analyzed from the medical records and compared.

RESULTS

Between 2000 and 2014, 463 pediatric epilepsy surgeries were performed. The proportion of pediatric epilepsy surgeries showed an increasing trend-218 (total 510 surgeries, 42.74%) in group 3, compared with 115 (total 375 surgeries, 30.66%) in group 1 and 130 (total 466 surgeries, 27.9%) in group 2. A significant decrease in the age at evaluation and duration of epilepsy before referral was noted between 2000 and 2014, particularly in patients belonging to the lowest income group. There was a two-fold increase in the number of extratemporal surgeries over time. The proportion of children undergoing surgery for benign tumors, cortical malformations, and gliosis/atrophy showed an upward trend while that for mesial temporal sclerosis did not show an increase.

SIGNIFICANCE

Promising trends in pediatric epilepsy surgery were noted with increasing number of surgeries and decreasing age at presurgical evaluation. Seen from an LMIC perspective, this reflects an evolution in the practice of pediatric epilepsy surgery, mirroring trends in high-income countries.

Measuring the Barriers to Adherence With Neurology Clinic Appointments for Children With Epilepsy: A Pilot Study

Introduction

Epilepsy is one of the most common neurological disorders in children. Missed appointments reflect missed opportunity to provide care for children with epilepsy. The objective of this study was to identify social determinants of health (SDH) and other factors associated with missed appointments in children with epilepsy and measure the relation between missed appointments and frequency of emergency room (ER) visits and inpatient admissions.

Methods

This was a prospective study conducted in the neurology division at a level 4 epilepsy center. Children (0 to < 18 years of age) with a diagnosis of epilepsy were included and a semi-structured questionnaire was provided to the families. Patients with 2 or more missed neurology clinic appointments in the previous year ("study group", n = 36) were compared to those with 1 or zero missed appointments ("control group", n = 49). A comparison of the clinical characteristics, emergency room visits and hospitalizations in the past year as well as SDH was performed. Statistical analysis was performed using SPSS and p < 0.05 was considered significant.

Results

The mean age, gender distribution and presence of medical refractoriness were comparable between the 2 groups. Families in the study group reported a higher likelihood of having to make special work arrangements for clinic appointments. Children in the study group were noted to have a significantly higher frequency of single mother households, presence of public insurance, father not graduating from high school and household income less than 50,000 dollars. Within the preceding year, children in the study group were noted to have a higher frequency of visits to the emergency department as well as 6 times higher likelihood of inpatient hospitalization for seizures.

Conclusions

Social determinants of health play an important role in determining adherence with neurology clinic visits in children with epilepsy. Children with more missed appointments are likely to have a higher frequency of visits to the emergency department as well as a higher incidence of hospitalization for seizures. Identification of high-risk families and implementation of early interventions may improve adherence to office visits and decrease emergency room visits and hospitalization for seizures.

Quality of Life among Middle and Secondary School Children with Epilepsy

Objectives  Epilepsy is a leading cause of disability in school-going children. The objectives of this study were to estimate the prevalence of epilepsy in middle and secondary school children and to assess their quality of life (QOL).

Materials and Methods  This was a cross-sectional study done in schools under the municipal corporation area of Latur Taluka, Maharashtra. At school, children were screened for epilepsy and the positive children were visited at home. Children with confirmed epilepsy were used to calculate prevalence. The QOL of children diagnosed to have epilepsy was assessed using Quality of Life in Childhood Epilepsy Questionnaire (QOLCE-55) version 1.0.

Statistical Analysis  Mean scores in scales and subscales of QOLCE-55 were calculated. Association between variables was analyzed using unpaired/independent t -test and analysis of variance. Statistically significance was fixed for a p -value less than 0.05.

Results  Prevalence of epilepsy in middle and secondary school children was found to be 3.20 per 1000. In QOLCE-55, physical functioning was the most compromised, with the lowest mean QOL score (mean = 58.3, standard deviation = 20.66). Present age of the child, age at the first seizure episode, and time interval since last seizure had a statistically significant relation with QOL. The treatment gap was found to be 70.4%.

Conclusions  Assessment of QOL in children with epilepsy is important for effective and comprehensive management of epilepsy.

Drug Treatment of Epilepsy Neuropsychiatric Comorbidities in Children

There is increasing recognition that epilepsy can be associated with a broad spectrum of comorbidities. While epileptic seizures are an essential element of epilepsy in children, there is a spectrum of neurological, mental health and cognitive disorders that add to the disease burden of childhood epilepsy resulting in a decreased quality of life. The most common comorbid conditions in childhood epilepsy include depression, anxiety, autism spectrum disorders, sleep disorders, attention deficits, cognitive impairment, and migraine. While epilepsy can result in comorbidities, many of the comorbidities of childhood have a bi-directional association, with the comorbid condition increasing risk for epilepsy and epilepsy increasing the risk for the comorbid condition. The bidirectional feature of epilepsy and the comorbidities suggest a common underlying pathological basis for both the seizures and comorbid condition. While recognition of the comorbid conditions of pediatric epilepsies is increasing, there has been a lag in the development of effective therapies partly out of concern that drugs used to treat the comorbid conditions could increase seizure susceptibility. There is now some evidence that most drugs used for comorbid conditions are safe and do not lower seizure threshold. Unfortunately, the evidence showing drugs are effective in treating many of the childhood comorbidities of epilepsy is quite limited. There is a great need for randomized, placebo-controlled drug trials for efficacy and safety in the treatment of comorbidities of childhood epilepsy.

Predictors of high school dropout, anxiety, and depression in genetic generalized epilepsy

Affective disorders are overrepresented in epilepsy, and people with epilepsy may be at risk of dropping out from school. The aim of the present study was to assess factors influencing high school dropout, anxiety, and depression in genetic generalized epilepsy (GGE). One hundred and ten people with GGE aged 19-40 years underwent a clinical interview, including the Hospital Anxiety and Depression Scale (HADS) questionnaire. Potential predictors of high school dropout were analyzed with logistic regression, and factors influencing total HADS score were analyzed with linear regression. Having felt excluded because of epilepsy was significantly associated with high school dropout (odds ratio 7.80, P = .009), as was total HADS score (odds ratio 1.22, P = .005). If a participant was currently employed or undergoing education, previous high school dropout was less likely (odds ratio 0.07, P = .005). High school dropout was associated with increased current anxiety and depression (β = 0.32, P = .005). Epilepsy severity (current drug resistance, current polytherapy, and active generalized tonic-clonic seizures) was not associated with high school dropout, nor with total HADS score. The issue of stigma in epilepsy must be thoroughly addressed in comprehensive care and may be as important as seizure control when it comes to education and quality of life.

Child neurology services for children with epilepsy in Finland

OBJECTIVE

The aim of the study was to describe healthcare organization, training of and needs for child neurologists, patient accessibility to services, and treatment paths of children with epilepsy in Finland.

METHODS

Data were collected from all geographic healthcare areas over Finland on training capacity in child neurology, number and density of child neurologists, and availability and accessibility of child neurological services. Data sources included the National Physician Register, Central Register of Healthcare Professionals of National Supervisory Authority for Welfare and Health, and phone and email inquiries to the heads of public healthcare units.

RESULTS

The overall density of child neurologists in Finland was 11.9/100 000 children aged 0-15 years or 8402 children per child neurologist (in 2018). There is a remarkable geographic variation, from 7.1 in northern Finland to 15.6 in the metropolitan area. However, waiting times for the treatment are virtually the same all over the country. According to the Finnish current practice recommendation from the year 2013 and again 2020, children with any first nonfebrile or complicated febrile epileptic seizure are invariably admitted to hospital for evaluation. Children with simple febrile seizures are recommended to be treated as outpatients by general practitioners or by experienced pediatricians.

SIGNIFICANCE

Child neurology services are today well provided and organized in Finland. While there is geographic variation in the number of child neurologists, the accessibility is virtually the same all over the country. A gap between the numbers of specialists at near-to-retire age and those in training is a challenge.

Deficits in all aspects of social competence identified in children who have undergone epilepsy surgery

Research on social competence of children who undergo epilepsy surgery is limited. This cross-sectional study aimed to determine the frequency and pattern of impairments in social competence (domains: social skills, social adjustment, and social performance) in a cohort of children who underwent surgery for intractable epilepsy at a single epilepsy surgical center. In addition, we explored the relationships between social competence with epilepsy variables, surgical variables, and seizure outcomes. Fifteen children (5 to 16 years) who underwent focal cortical resection for intractable epilepsy more than 2 years ago (2.58-7.42 years) participated. Parents completed standardized, age-normed questionnaires, assessing three domains of social competence. Demographic and clinical information were obtained from parents and medical records and verified by Pediatric Neurologists and Clinical Nurse Consultant. Individual and group analyses were conducted. Seventy-three percent (n = 11/15) of children were seizure-free. Individual analyses revealed high rates of impairments (scores >1 standard deviation of the mean); 11 out of 15 children (73.3%) obtained a score that fell in the impaired range on at least one domain of social competence, with 5 of these 15 children (30.0%) obtaining impaired scores across domains. Conversely, group analyses of questionnaires completed by parents revealed that compared with norms, children had significant difficulties in all domains of social competence: social skills, social adjustment, and social performance. No significant relationships were found between domains of social competence and epilepsy and surgical variables. In conclusion, children who underwent epilepsy surgery have significantly reduced social competence relative to the norms. Longitudinal studies examining social competence pre- and postsurgery are needed to determine whether surgery improves social competence and whether this is dependent on epilepsy outcomes.

How often do doctors discuss drug withdrawal with their seizure-free patients with epilepsy?

Among patients with epilepsy, almost 70% become seizure-free with the current antiseizure drugs (ASDs) within 20 years following seizure onset. Of those who have been seizure-free for many years, around 70% remain seizure-free after withdrawal of ASDs. The purpose of this study was to determine the extent to which seizure-free patients with epilepsy in Norway discuss drug discontinuation with their physician. An online questionnaire was used; among the respondents were 186 adult patients who had been seizure-free for at least five years and were still using ASDs. Of these, 60 patients (32%) reported that they had discussed the question of drug withdrawal with their treating physician. Those patients who reported being involved in treatment decisions were more likely to have discussed ASD withdrawal. In conclusion, it is our opinion that discontinuation of drug treatment in patients with long-term seizure freedom is discussed far too seldom and that many patients may be living with an unnecessary drug burden.

Psychosocial and functional outcomes in young adults with childhood-onset epilepsy: a 10-year follow-up

AIM

To compare long-term psychosocial and functional outcomes of young adults with uncomplicated childhood-onset epilepsy (COE) to population norm controls utilizing a controlled prospective cohort study.

METHOD

Psychosocial and functional outcomes were assessed at 10-year follow-up. Fifty-three young adults (27 males, 26 females) with COE (n=21 remission; 18y 1mo-30y 9mo; mean age 23y 4mo [SD 3y 4mo]; mean age of epilepsy onset 12y [SD 3y 2mo]) were compared to 55 (23 males, 32 females) first-degree cousin controls (18y 5mo-29y 8mo; mean age 23y 6mo [SD 3y]). Seizure remission status and baseline comorbidities (attention-deficit/hyperactivity disorder [ADHD], depressive disorders, anxiety disorders, and academic problems) were examined as possible risk factors for significant differences in functional outcomes.

RESULTS

Poorer functional outcomes, indicated by patient rated cognition and overall disability, were evident among young adults with epilepsy compared to controls (all p<0.05). These difficulties were due to baseline comorbid ADHD and academic problems. Remission status was not related to measured cognition and overall disability.

INTERPRETATION

Psychosocial outcomes of young adults with COE were similar to controls. In contrast, functional outcomes were worse in epilepsy across cognition and overall disability. Baseline comorbid ADHD and academic problems were identified as risk factors at 10-year follow-up suggesting that these early recognized comorbidities at or near diagnosis have long-term impacts.

WHAT THIS PAPER ADDS

Young adults with childhood-onset epilepsy (COE) and controls have similar psychosocial outcomes 10 years after diagnosis. Young adults with COE report greater limitations in cognition and overall disability than controls. Baseline presence of attention-deficit/hyperactivity disorder and academic problems significantly affect cognitive and overall disability scores.

Posttraumatic epilepsy in intensive care unit-treated pediatric traumatic brain injury patients

OBJECTIVE

Posttraumatic epilepsy (PTE) is a well-described complication of traumatic brain injury (TBI). The majority of the available data regarding PTE stem from the adult population. Our aim was to identify the clinical and radiological risk factors associated with PTE in a pediatric TBI population treated in an intensive care unit (ICU).

METHODS

We used the Finnish Intensive Care Consortium database to identify pediatric (<18 years) TBI patients treated in four academic university hospital ICUs in Finland between 2003 and 2013. Our primary outcome was the development of PTE, defined as the need for oral antiepileptic medication in patients alive at 6 months. We assessed the risk factors associated with PTE using multivariable logistic regression modeling.

RESULTS

Of the 290 patients included in the study, 59 (20%) developed PTE. Median age was 15 years (interquartile range [IQR] 13-17), and 80% had an admission Glasgow Coma Scale (GCS) score ≤12. Major risk factors for developing PTE were age (adjusted odds ratio [OR] 1.08, 95% confidence interval [CI] 1.00-1.16), obliterated suprasellar cisterns (OR 6.53, 95% CI 1.95-21.81), and an admission GCS score of 9-12 in comparison to a GCS score of 13-15 (OR 2.88, 95% CI 1.24-6.69).

SIGNIFICANCE

We showed that PTE is a common long-term complication after ICU-treated pediatric TBI. Higher age, moderate injury severity, obliterated suprasellar cisterns, seizures during ICU stay, and surgical treatment are associated with an increased risk of PTE. Further studies are needed to identify strategies to decrease the risk of PTE.

Long-term employment outcomes after epilepsy surgery in childhood

Objective

To analyze long-term employment outcomes in a population-based cohort of adults who underwent epilepsy surgery in childhood or adolescence and to compare the results to general population reference data.

Methods

Prospective data on epilepsy surgery procedures performed on patients <19 years of age between 1995 and 2012 were extracted from the Swedish National Epilepsy Surgery Register. Five-, 10-, 15- and 20-year follow-up data were analyzed. Patients aged ≥19 years at follow-up were eligible for inclusion. Educational attainment and employment status were analyzed in relation to seizure outcome. Education and employment outcomes of seizure-free patients with a preoperative IQ of ≥70 were compared to general population reference data.

Results

A total of 203 patients were included. The mean age at surgery was 13.6 years and 66% had IQ ≥70. Of these, a majority had attained at least high school education 5 years after surgery. Employment rates were 44%, 69%, 71%, and 77% at the 5-, 10-, 15-, and 20-year follow-ups, respectively. Seizure-free patients were significantly more likely to work full-time. Educational attainment and rates of full-time employment of seizure-free patients were similar to the general population. A majority of patients with IQ <70 had attended special education and were reliant on social benefits.

Conclusion

Long-term overall employment rates were higher compared to most previous studies on surgery in adults. Seizure-free patients with a preoperative IQ ≥70 showed rates of full-time employment similar to the general population. Further research is needed to determine whether this also applies for occupational complexity and wages.

Dealing with the storm: An overview of seizure precipitants and spontaneous seizure worsening in drug-resistant epilepsy

In drug-resistant epilepsy, periods of seizure stability may alternate with abrupt worsening, with frequent seizures limiting the individual's independence and physical, social, and psychological well-being. Here, we review the literature focusing on different clinical scenarios related to seizure aggravation in people with drug-resistant epilepsy. The role of antiseizure medication (ASM) changes is examined, especially focusing on paradoxical seizure aggravation after increased treatment. The external provocative factors that unbalance the brittle equilibrium of seizure control are reviewed, distinguishing between unspecific triggering factors, specific precipitants, and 'reflex' mechanisms. The chance of intervening surgical or medical conditions, including somatic comorbidities and epilepsy surgery failure, causing increased seizures is discussed. Spontaneous exacerbation is also explored, emphasizing recent findings on subject-specific circadian and ultradian rhythms. Awareness of external precipitants and understanding the subject-specific spontaneous epilepsy course may allow individuals to modify their lifestyles. It also allows clinicians to counsel appropriately and to institute suitable medical treatment to avoid sudden loss of seizure control.

Educational achievement, employment, marriage, and driving in adults with childhood-onset epilepsy

BACKGROUND

People with epilepsy (PWE) beginning in childhood often experience psychological and social hold-ups in addition to seizures. The hold-ups relate to education, employment, driving, and marriage.

OBJECTIVE

The objective of this study was to document the impact of long-standing, childhood-onset epilepsy on sociopersonal accomplishments of adults pertaining to education, employment, marriage, and driving.

METHODS

A prospective, questionnaire-based survey was undertaken in a hospital-based sample of PWE and their unaffected (by epilepsy) older siblings within the immediate/extended family unit.

RESULTS

People with epilepsy were significantly more likely to abandon formal education after primary (6; 2.4% compared to none in controls) or secondary (69; 31.1% compared with controls 58; 26.1%) school, less likely to be currently married (97; 43.7%) when compared with their elder siblings (158; 71.2%) (P = 0.0001), and less likely to be currently employed (103; 46.4%) (P = 0.0001) or driving (111; 50%) (P = 0.0001) compared with the older same-gender siblings (employed: 148; 66.7%; driving: 165; 74.3%). In multivariate models, having epilepsy and age were associated with employment status, whereas age and education and employment status were associated with both marriage and driving.

CONCLUSION

Notwithstanding the influence of a number of socioeconomic and epilepsy-related variables, childhood-onset epilepsy stands apart in exerting a huge negative impact on educational achievement, employability, marital status, and driving in adulthood.

A scale for prediction of response to AEDs in patients with MRI-negative epilepsy

OBJECTIVES

Antiepileptic drugs (AEDs) are the first choice in magnetic resonance imaging (MRI)-negative patients with epilepsy, although the responses to AEDs are diverse. Preoperative evaluation and postoperative prognosis in MRI-negative epilepsy have been reported. However, there are few tools for predicting the response to AEDs. Herein, we developed an AED response scale based on clinical factors and video-electroencephalography (VEEG) in MRI-negative patients with epilepsy.

METHODS

A total of 132 consecutive patients with MRI-negative epilepsy at the Epilepsy Center of Henan Provincial People's Hospital between August 2016 and August 2018 were included. Patients were further divided into drug-responsive epilepsy ([DSE-MRI (-)]; n = 101) and drug-resistant epilepsy ([DRE-MRI (-)]; n = 31) groups. The clinical and VEEG factors were evaluated in univariate analyses and multivariate logistic regression analyses. A scale was derived and the scores categorized into 3 risk levels of DRE-MRI (-).

RESULTS

A scale was established based on 4 independent risk factors for DRE-MRI (-). The scale had a sensitivity of 83.87%, specificity of 80.20%, positive likelihood ratio of 4.24, negative likelihood ratio of 0.20, and showed good discrimination with the area under the curve (AUC) of 0.886 (0.826-0.946). The categorization of the risk score based on this scale was: low risk (0-3 points), medium risk (3-5 points), and high risk (>5 points).

CONCLUSION

We established a DRE-MRI (-) scale with a good sensitivity and specificity, which may be useful for clinicians when making medical decisions in patients with MRI-negative epilepsy.

Antiepileptic Drugs in Children : Current Concept

An epileptic seizure is defined as the transient occurrence of signs and/or symptoms due to abnormally excessive or synchronous neuronal activity in the brain. The type of seizure is defined by the mode of onset and termination, clinical manifestation, and by the abnormal enhanced synchrony. If seizures recur, that state is defined as epilepsy. Antiepileptic drugs (AEDs) are the mainstay of treatment. Knowledge about initiating and maintaining adequate AEDs is beneficial for the clinician who treats children with epilepsy. This article will delineate the general principles for selecting, introducing, and discontinuing AEDs and outline guidelines for monitoring adverse effects. In general, AED therapy following a first unprovoked seizure in children is not recommended. However, treatment should be considered after a second seizure. In children and adolescents, if they are seizure-free for at least 2 years, attempts to withdraw medication/s should be made, taking into account the risks vs. benefits for the individual patient. The decision on when and what AED to use should be tailored according to the patient. For optimal treatment, the selection of adequate AEDs can be achieved by considering the precise definition of the patient’s seizure and epilepsy syndrome. Continuous monitoring of both therapeutic and adverse effects is critical for successful treatment with AEDs.

Pediatric epilepsy surgery patients show normal psychosocial development at long-term follow-up despite dissatisfying family dynamics

Drug-resistant pediatric epilepsy involves unpredictable seizures and long-term medical management. Both factors can alter a child's psychosocial development and the dynamics of the family, to the detriment of patient and family wellbeing. While drug-resistant pediatric epilepsy can be successfully treated by neurosurgery in some cases, the outlook for psychosocial and family functioning after surgery remains unclear. A total of 163 participants across four groups took part in the current study: these were (i) individuals who had undergone surgical treatment of drug-resistant focal seizures approximately five years prior as children, and were now largely adolescents or young adults ('Patients'; n = 23), (ii) their caregivers ('Patient Caregivers'; n = 27), (iii) healthy individuals of similar age and gender to the Patients ('Controls'; n = 53), and (iv) their caregivers ('Control Caregivers'; n = 60). Based on similar software validated in adults, we built an interactive computer program, 'Living with Epilepsy', to evaluate the achievement of age-specific developmental tasks in Patients relative to their peers. The Family Adaptability and Cohesion Scale measured family dynamics. The findings showed that in the context of seizure freedom, after pediatric epilepsy surgery, Patients are similar to their healthy peers in terms of attaining developmental tasks, with no differences between the Patient and Control groups (P > .05). Family dynamics, however, seemed resistant to postsurgical adaptation, with Patients reporting lower levels of balanced family dynamics (cohesion, flexibility) and higher rates of unbalanced family dynamics (disengagement, chaos, rigidity, enmeshment) relative to Patient Caregivers (P < .001-0.041), and the Controls (P = .011-0.034). Patients also reported reduced family satisfaction compared with that of Patient Caregivers (P = .002), which was associated with polytherapy prior to surgery; that is, more drug-resistant seizures. These findings suggested that childhood-onset epilepsy has a lasting effect on family functioning, even when the child has an optimal medical and psychosocial outcome. These initial findings have significant implications for the provision of pre- to postoperative family support in pediatric epilepsy cases.

Prevalence and trajectories of depressive symptoms among mothers of children with newly diagnosed epilepsy: A longitudinal 10-year study

OBJECTIVE

Parental depression significantly impacts children's health and well-being. This study aimed to (1) estimate the prevalence of depressive symptoms, at six time points, among mothers over the first 10 years after their child was diagnosed with epilepsy; (2) identify trajectories of maternal depressive symptoms over time; and (3) identify baseline factors associated with each trajectory.

METHODS

Data came from the Health-Related Quality of Life in Children with Epilepsy Study (HERQULES), a Canada-wide prospective cohort study. Data on child, parent, and family characteristics were collected at the time of diagnosis, and follow-ups at 0.5, 1, 2, 8, and 10 years. Maternal depressive symptoms were measured using the Center for Epidemiological Studies Depression Scale. Trajectories of depressive symptoms were evaluated using latent class growth modeling, and multinomial logistic regression was used to identify baseline factors associated with each trajectory.

RESULTS

A total of 356 mothers participated in the study, of whom 57% scored in the at-risk range for major depression disorder (period-prevalence). Four unique trajectories were identified as follows: "Low-Stable" (29% of mothers), "Intermediate-Stable" (46%), "High-Stable" (20%), and "High-Decreasing" (5%). Positive family environment was consistently associated with a better trajectory of depressive symptoms over time; other significant factors included type of seizures, child cognitive comorbidity, maternal age, and maternal education.

SIGNIFICANCE

A substantial proportion of mothers of children with epilepsy are at risk for depression, and this risk is stable over the long term. Family environment at the time of diagnosis has long-term and persistent effects and may be an ideal target for interventions.

Out of thin air: Hyperventilation-triggered seizures

Voluntary hyperventilation triggers seizures in the vast majority of people with absence epilepsy. The mechanisms that underlie this phenomenon remain unknown. Herein, we review observations - many made long ago - that provide insight into the relationship between breathing and absence seizures.

Neurocognition in childhood epilepsy: Impact on mortality and complete seizure remission 50 years later

OBJECTIVE

To study associations of the severity of impairment in childhood neurocognition (NC) with long-term mortality and complete seizure remission.

METHODS

A population-based cohort of 245 subjects with childhood onset epilepsy was followed up for 50 years (median = 45, range = 2-50). Childhood NC before age 18 years was assessed as a combination of formal intelligence quotient scores and functional criteria (school achievement, working history, and psychoneurological development). Impaired NC was categorized with respect to definitions of intellectual functioning in International Classification of Diseases, 10th revision (R41.83, F70-F73). The outcome variables, defined as all-cause mortality and 10-year terminal remission with the 5 past years off medication (10YTR), were analyzed with Cox regression models.

RESULTS

Of the 245 subjects, 119 (49%) had normal childhood NC, whereas 126 (51%) had various degrees of neurocognitive impairment. During the 50-year observation period, 71 (29%) of the subjects died, 13% of those with normal and 44% of those with impaired NC. The hazard of death increased gradually in line with more impaired cognition, reaching significance in moderate, severe, and profound impairment versus normal NC (hazard ratio [Bonferroni corrected 95% confidence interval] = 3.3 [1.2-9.2], 4.2 [1.2-14.2], and 5.5 [2.4-12.3], respectively). The chance for 10YTR was highest among subjects with normal NC (61%), whereas none of those with profound impairment reached 10YTR. In the intermediate categories, the chance was, however, not directly related to the increasing severity of impairment.

SIGNIFICANCE

The severity of neurocognitive impairment during childhood shows a parallel increase in the risk of death. In comparison with normal NC, subjects with lower childhood NC are less likely to enter seizure remission. However, normal NC does not guarantee complete remission or prevent premature death in some individuals with childhood onset epilepsy.

[Epileptogenesis mediated by glial cells]

Epilepsy is one of the most common diseases of the central nervous system. Many epilepsies are controllable because of the existence of different antiepileptic drugs with multiple mechanisms of action. However, about 30% of epilepsy is so-called refractory epilepsy in which existing drugs do not show enough therapeutic effects. Antiepileptic drugs can be roughly divided into two types, i.e., those that suppress the excitability of neuronal cells and those that promote inhibition. Inhibition of excitatory neurons include a variety of ion channel inhibitors such as Na⁺, drugs that inhibit glutamate release and glutamate AMPA receptor, whereas enhancement of inhibitory neurons includes a drug that enhances GABA_A receptor. Both are targeted to neurons. Recent advances in brain science have revealed the importance of the role of glial cells in regulation of brain function and excitability of neurons. Although glia cells themselves are electrically non-excitable cells, they could greatly affect excitability of neurons by controlling extracellular neurotransmitters, glial transmitters, regulating various ions concentration, regulation of energy metabolism, and formation/elimination of synapses. Therefore, when the function of glial cells changes, these regulatory functions also change, which in turn greatly changes the excitability of neurons and neuronal networks. Epilegenicity is a condition in which the brain is likely to undergo spontaneous epileptic seizures and it is suggested that modulation of the above-mentioned glial cell function is greatly related to the acquisition of epileptogenesis. In this article, I focus on astrocytes among glial cells, and describe the relationship between functional modulation and epileptogenesis when changing to the phenotype of reactive astrocytes by epileptic seizures. We also discuss development of antiepileptic drugs targeting reactive astrocytes.

Prevalence of childhood and adolescence epilepsy in Upper Egypt (desert areas)

Background

A high prevalence of epilepsy in children is frequently found in developing countries.

Objective

This study aimed to determine the prevalence and clinical pattern of childhood and adolescence epilepsy in Upper Egypt.

Methods

This is a door-to-door study conducted on all inhabitants < 18 years in Al Kharga district and Al Qusier city (36,195 subjects). The study was conducted through two stages; every stage consisted of two phases (screening and diagnostic).

Results

Lifetime prevalence of childhood and adolescence epilepsy (children < 18 years) in Upper Egypt was 9.7/1000, with higher prevalence among children < 12 years (10.8/1000) than adolescents (7.2/1000). The age-specific prevalence was highest in early childhood (12.01/1000) and least at adolescence (7.2/1000). More than half of the patients (59.4%) had idiopathic epilepsy. The most frequent etiology for structural/metabolic epilepsy was perinatal complications, particularly in infancy, followed by central nervous system (CNS) infections, in childhood, and post-traumatic epilepsy in adolescence. Partial seizures were more frequent in infancy, while generalized seizures were more frequent in late childhood and adolescence. Generalized tonic-clonic seizures (GTCS) were the most frequent type of seizures.

Conclusion

Prevalence of childhood and adolescence epilepsy in Upper Egypt was not so much different from other developing countries. Idiopathic epilepsy was more prevalent than structural/metabolic cases. Perinatal complications, CNS infections, and head injury were the most frequent etiologies, and generalized tonic-clonic seizures were the most frequent seizure type.

Electronic supplementary material

The online version of this article (10.1186/s41983-018-0032-0) contains supplementary material, which is available to authorized users.

A Prediction Model to Determine Childhood Epilepsy After 1 or More Paroxysmal Events

OBJECTIVES

The clinical profile of children who had possible seizures is heterogeneous, and accuracy of diagnostic testing is limited. We aimed to develop and validate a prediction model that determines the risk of childhood epilepsy by combining available information at first consultation.

METHODS

We retrospectively collected data of 451 children who visited our outpatient department for diagnostic workup related to 1 or more paroxysmal event(s). At least 1 year of follow-up was available for all children who were diagnosed with epilepsy or in whom diagnosis remained inconclusive. Clinical characteristics (sex, age of first seizure, event description, medical history) and EEG report were used as predictor variables for building a multivariate logistic regression model. Performance was validated in an external cohort (n = 187).

RESULTS

Model discrimination was excellent, with an area under the receiver operating characteristic curve of 0.86 (95% confidence interval [CI]; 0.80-0.92), a positive predictive value of 0.93 (95% CI 0.83-0.97) and a negative predictive value of 0.76 (95% CI 0.70-0.80). Model discrimination in a selective subpopulation of children with uncertain diagnosis after initial clinical workup was good, with an area under the receiver operating characteristic curve of 0.73 (95% CI 0.58-0.87).

CONCLUSIONS

This model may prove to be valuable because predictor variables together with a first interictal EEG can be available at first consultation. A Web application is provided (http://epilepsypredictiontools.info/first-consultation) to facilitate the diagnostic process for clinicians who are confronted with children with paroxysmal events, suspected of having an epileptic origin.

Long-Term Effects of Early Life Seizures on Endogenous Local Network Activity of the Mouse Neocortex

Understanding the long term impact of early life seizures (ELS) is of vital importance both for researchers and clinicians. Most experimental studies of how seizures affect the developing brain have drawn their conclusions based on changes detected at the cellular or behavioral level, rather than on intermediate levels of analysis, such as the physiology of neuronal networks. Neurons work as part of networks and network dynamics integrate the function of molecules, cells and synapses in the emergent properties of brain circuits that reflect the balance of excitation and inhibition in the brain. Therefore, studying network dynamics could help bridge the cell-to-behavior gap in our understanding of the neurobiological effects of seizures. To this end we investigated the long-term effects of ELS on local network dynamics in mouse neocortex. By using the pentylenetetrazole (PTZ)-induced animal model of generalized seizures, single or multiple seizures were induced at two different developmental stages (P9-15 or P19-23) in order to examine how seizure severity and brain maturational status interact to affect the brain's vulnerability to ELS. Cortical physiology was assessed by comparing spontaneous network activity (in the form of recurring Up states) in brain slices of adult (>5 mo) mice. In these experiments we examined two distinct cortical regions, the primary motor (M1) and somatosensory (S1) cortex in order to investigate regional differences in vulnerability to ELS. We find that the effects of ELSs vary depending on (i) the severity of the seizures (e.g., single intermittent ELS at P19-23 had no effect on Up state activity, but multiple seizures induced during the same period caused a significant change in the spectral content of spontaneous Up states), (ii) the cortical area examined, and (iii) the developmental stage at which the seizures are administered. These results reveal that even moderate experiences of ELS can have long lasting age- and region-specific effects in local cortical network dynamics.

Long-term outcome of seizure-free patients and risk factors of relapse following antiepileptic drug withdrawal

OBJECTIVE

This study aimed to investigate the long-term outcome in seizure-free patients and to explore the risk factors of seizure relapse following antiepileptic drug (AED) withdrawal.

METHODS

This study included 161 patients who had been seizure-free for at least 2 years. These patients were monitored over a follow-up period of at least 3 years or until seizure relapse after AED withdrawal. Patients were grouped into a seizure-free group and a relapse group. Risk factors of seizure relapse were analyzed.

RESULTS

During the follow-up period, 72 patients (44.7%) relapsed while 89 patients (55.3%) did not. The average time of relapse was 19.12 ± 27.17 months after the initiation of AED withdrawal, and majority of cases occurred within the first 24 months of AED withdrawal (73.6%). Univariate analysis showed that the likelihood of relapse was higher in patients with uncontrolled seizures beyond the first 6 months of AED therapy initiation, patients with a history of perinatal injury, patients with multiple seizure types, and patients who had been treated with a combination of AEDs. Multiple logistic regression analysis revealed that uncontrolled seizures beyond the first 6 months of AED treatment and a history of perinatal injury were independent risk factors of seizure relapse.

CONCLUSION

In the majority of cases, epilepsy relapse occurred within the first two years after the initiation of AED withdrawal. The independent risk factors of seizure relapse were uncontrolled seizures beyond the first 6 months of AED therapy and cases with a history of perinatal injury.

Overall and cause-specific premature mortality in epilepsy: A systematic review

BACKGROUND

We conducted a systematic review to ascertain the overall mortality and causes of premature mortality in epilepsy.

METHODOLOGY

We searched PubMed and Embase to identify relevant articles reporting mortality in epilepsy. An assessment of the methodological quality and overall quality of evidence of the identified studies was done using appropriate checklists. We extracted data from these studies reporting measures of overall and cause-specific mortality in epilepsy.

RESULTS

Sixty-three articles from fifty-six cohorts met the eligibility criteria, thirty-three population- or community-based and twenty-three hospital- or institutional-based studies. The majority of studies are from high-income countries (HIC). These studies reported overall excess mortality for people with epilepsy, with wide variability reported for population- or community-based studies and from low- and middle-income countries (LMIC). Twenty-seven articles from twenty-three cohorts reported measures of mortality for cause-specific mortality in epilepsy. People with epilepsy from HIC and LMIC have a higher risk of dying from various causes compared with the general population. Those in LMIC, however, have a particularly high chance of dying from external causes such as drowning and suicide. We observed a decrement over time in measures of overall and cause-specific mortality in cohorts.

CONCLUSIONS

Despite the heterogeneity in reports, our findings support the suggestions that people with epilepsy have an increased risk of premature mortality from various causes. Further work is needed to elucidate the mechanisms, to determine biomarkers for predicting those at risk, and to understand the implications of counseling and preventive strategies.

A Retrospective Analysis of the Long-Term Outcome of Drug-Resistant Epilepsy in Children Treated in Urban India

Objective:

To study the outcome of childhood-onset drug-resistant epilepsy.

Methods:

Fifty-five patients with drug-resistant epilepsy, meeting inclusion criteria, were identified from the Pediatric Neurology Clinic database with seizure onset less than age 13 years and a minimum follow-up of 5 years. Seizure remission was defined as no more than 1 seizure/year. Kaplan-Meier analysis was used to calculate the annual probability of seizure remission. Chi-square/Kruskal-Wallis tests were used to detect differences in predictors between those with seizure remission, ≥75% improvement and <75% improvement based on caregiver reports.

Results:

Median follow-up was 11 years. Of 55, 22 (40%) were in seizure remission at last contact; 14 (25.4%) improved by ≥75%; 19 (34.5%) experienced <75% improvement. Annual remission probability was 3% in IQ ≥70 group and 2.48% in IQ <70 group (P = .126).

Conclusion:

This study shows patients with drug-resistant epilepsy treated in urban India can expect an overall remission rate of 2% per year starting from the third year of follow-up.

Incidence rate of sudden death in epilepsy: A systematic review and meta-analysis

OBJECTIVE

The aim of the study was to summarize the pooled incidence rate of sudden unexpected death in epilepsy (SUDEP) in patients. Meta-regression analysis was applied to identify factors influencing the incidence rate.

DESIGN

The study was a systematic review and critical appraisal with a meta-analysis of cohort studies, both prospective and retrospective.

MATERIAL AND METHOD

In a literature search, a total of 45 cohort studies were identified. A random effect model was used to synthesize the results. Heterogeneity between studies was examined by subgroup and meta-regression analysis. The small-study effect was evaluated and not corrected for by the "trim and fill" method because of great heterogeneity.

RESULTS

A substantial heterogeneity was present. The pooled estimated incidence rate for SUDEP was 1.4/1000 patient years. A meta-regression pinpointed a negative association between the incidence rate of SUDEP and the mean follow-up time and a positive association with the mean age of the patient. The definition of epilepsy showed statistical significance, with a higher incidence rate of SUDEP in studies where the definition of epilepsy was described and clear (p = 0.019) compared with studies having an inadequate or failing epilepsy definition.

CONCLUSION

Evidence from this study suggests a high incidence rate of sudden death in epilepsy. Its incidence rate was 23 times the incidence rate of sudden death in the total population of the same age. There was heterogeneity and variability of incidence rate depending on the quality of the study and on the definition of epilepsy and the mean age of the patients.