Clinical characteristics of patients with treated epilepsy in Korea: a nationwide epidemiologic study

Demographics, Clinical Characteristics, and Management Strategies of Epilepsy in Saudi Arabia: A Systematic Review

Epilepsy accounts for a large part of the global burden of neurological disorders. This review aimed to assess the demographics, clinical characteristics, and management of patients with epilepsy in Saudi Arabia based on studies published from 2018 to 2023. A systematic review was carried out using PubMed, Medline, Embase, and Cochrane Library from January 2018 to January 2023, where key terms related to the epidemiology, clinical characteristics, treatment, and management strategy of epilepsy in Saudi Arabia were used to search for related studies. All relevant articles published in this period in the English language were included, and data about authors, year of the study, sample size, study design, demographic characteristics, clinical characteristics, and treatment strategy were collected. A male preponderance, a 6-24.9% family history of epilepsy, an equal distribution of focal and tonic-clonic epilepsy, EEG abnormalities of 19.7-70%, and a higher prevalence of monotherapy regimens were the main findings of this review.

Clinical risk factors related to post-stroke epilepsy patients in Indonesia: a hospital-based study

Background

Stroke had been accounted to cause almost 50% of epilepsy in the elderly and may lead to poor functional outcomes. Many studies examining the risk factors have been conducted despite showing inconsistent results and currently still difficult to predict the occurrence of post-stroke epilepsy. The study aimed to determine risk factors related to post-stroke epilepsy that influence clinical seizure, electroencephalography (EEG), and functional outcome of patients. Analytic retrospective case–control study was conducted with a total sampling of 62 samples of post-stroke epilepsy and 62 samples of control from all stroke patients in the Neurology Clinic from January 2019 to December 2021. Epilepsy was classified according to the criteria of the International League Against Epilepsy (ILAE) in 2017. The relevant demographic and clinical data were collected.

Result

The study involved 62 patients in the case group (average age of onset = 57.69; 42 men, 20 women; 51 ischemic stroke, 11 hemorrhagic stroke) and 62 patients in the control group (average age of onset = 56.90; 24 men, 38 women; 52 ischemic stroke, 10 hemorrhagic stroke). We found that 31 patients had focal-to-bilateral seizures, 26 patients had generalized seizures and 5 patients had focal seizures. Men (p = 0.001; OR 3.325) and NIHSS Score (p = 0.027; OR 5.094) had significant correlations with post-stroke epilepsy. Ischemic stroke had a significant correlation (p = 0.008) with seizure onset. Women also had a significant correlation (p = 0.012) with EEG abnormalities. The study found that 59 of 62 post-stroke epilepsy patients had poor functional outcomes (mRS > 2).

Conclusion

Our study confirmed that most patients had focal-to-bilateral seizure patterns that occurred in 1–2 years after stroke, and had poor functional outcomes. Men had 3.325 times more likely to develop post-stroke epilepsy than women. Also, NIHSS score ≥ 15 correlated and 5.094 times more likely to develop post-stroke epilepsy. Ischemic stroke had a peak of epilepsy onset at 1–2 years after stroke and women had significant showing abnormalities on EEG recording than men.

Sex-related Differences in Glial Fibrillary Acidic Protein-positive GABA Regulate Neuropathology Following Pilocarpine-induced Status Epilepticus

Status epilepticus (SE) is a life-threatening neurological disorder that causes neuronal death and glial activation. Studies have explained the clinical side effects and lack of effectiveness of neurological disorder treatments based on sex-related differences in brain structure and function. However, the sex-specific outcomes of seizure disorders and the underlying mechanisms remain unknown. We compared SE-induced behavioral and pathophysiological changes in male and female mice. The time taken to reach stage 6 seizure following pilocarpine injection was shorter in male mice than in female mice, and the prevalence of SE was higher in male mice than in female mice. Fluoro-Jade B staining revealed more extensive SE-induced hippocampal neuronal death in male mice than in female mice. Glial cells were more activated in male mice than in female mice. In contrast, astrocyte-derived γ-aminobutyric acid (GABA)-immunostaining was less expressed in male mice than in female mice. Moreover, the mRNA levels of inflammatory cytokines released from activated glial cells were higher in male mice than in female mice. Notably, the mRNA level of astrocytic γ-aminobutyric acid transporter (GAT-3) involved in extracellular GABA uptake was lower in female mice than in male mice, while the mRNA levels of glutamate/aspartate transporter (GLAST (EAAT1)) and glutamate transporter (GLT-1 (EAAT2)) involved in extracellular glutamate uptake were higher in female mice. Our findings suggest that male mice are more vulnerable to SE than female mice, resulting in more extensive neuronal cell death and glial activation in male mice, partly due to increased GAT-3 expression that subsequently leads to reduced glial fibrillary acidic protein (GFAP)-positive GABA content assessed with anti-GABA antibodies.

A vitamin D enriched diet attenuates sex-specific behavioral deficits, increases the lifespan, but does not rescue bone abnormalities in a mouse model of cortical dysplasia

Individuals who experience recurrent spontaneous seizures often show behavioral and physiological comorbidities. Those with epilepsy are at a high risk of bone fractures (independent of seizure-related falls) and show a higher rate of a diagnosis of Autism Spectrum Disorder. The neural subset-specific (NS) Pten knockout (KO) mouse has an epilepsy phenotype, has been characterized to show autistic-like deficits, and has an osteoporosis phenotype. The current study examined the effect of a vitamin D enriched diet (20,000 IU VD) in the NS-Pten KO and wildtype mice. Mice were placed onto a vitamin D enriched diet at 4 weeks of age and maintained on that diet throughout testing. Behavioral testing began at 6 weeks of age and included tests for general activity, anxiety, repetitive behaviors, social behaviors, and memory. Results indicated that a vitamin D diet attenuated hypoactivity levels in male KO mice (p < 0.05). In a social partition task, vitamin D increased sociability in male wildtype mice, (p < 0.05). Most significantly, vitamin D fortified diet increased percent survival in KO animals and decreased the level of microglia marker IBA-1 and mTOR (mammalian target of rapamycin) downstream targets pS6 and pAKT. A high vitamin D diet did not reverse bone deficits in male or female KO mice. Overall, these findings suggest that a vitamin D enriched diet had a significant impact on the behavioral phenotype of NS-Pten KO mice, suggesting that dietary manipulations could be a potential therapeutic option for autistic-like behavior.

Brain structural and neuroendocrine basis of sex differences in epilepsy

This chapter reviews the current information about sex differences in epilepsy and potential mechanisms underlying sex differences in seizure susceptibility and epilepsy. The susceptibility to and occurrence of seizures are generally higher in men than women. There is gender-specific epilepsies such as catamenial epilepsy, a neuroendocrine condition in which seizures are most often clustered around the perimenstrual or periovulatory period in adult women. Structural differences in cerebral morphology, the structural and functional circuits may render men and women differentially vulnerable to seizure disorders and epileptogenic processes. Changes in seizure sensitivity are evident at puberty, pregnancy, and menopause, often attributed to circulating steroid hormones and neurosteroids as well as neuroplasticity in receptor systems. An improved understanding of the sexual dimorphism in neural circuits and the neuroendocrine basis of sex differences or resistance to protective drugs is essential to develop sex-specific therapies for seizure conditions.

Association between IDH mutational status and tumor-associated epilepsy or venous thromboembolism in patients with grade II and III astrocytoma

In previous studies, isocitrate dehydrogenase (IDH) mutations were associated with tumor-associated epilepsy (TAE) and venous thromboembolism (VTE). We examined the relationship between IDH mutations in grade II/III astrocytomas and TAE/VTE according to the 2016 World Health Organization classification. The clinical data of patients with newly diagnosed grade II/III gliomas who were treated at Tohoku University Hospital from January 2010 to December 2018 were reviewed. Associations between TAE or VTE and the clinical/biological characteristics, histology, and IDH1/2 mutational status in patients with grade II/III gliomas were evaluated. Of the initial 137 patients (290 hospitalizations), 117 patients (203 hospitalizations) were included in the TAE group and 124 patients (213 hospitalizations) were included in the VTE group. Seventy-eight patients (66.7%) in the TAE group were diagnosed with astrocytoma and 38/78 (48.3%) presented with TAE. According to the multivariable analysis, the IDH mutational status and male sex were associated independently with an increased risk of TAE (p < 0.05). Eighty-five patients (68.5%) in the VTE group were diagnosed with astrocytoma. VTE was observed in 16/161 (9.9%) hospitalizations. According to the multivariable analysis, age, diffuse astrocytoma histology, and resection were associated independently with an increased risk of VTE. The decision tree analysis showed that TAE was more frequent in younger patients while VTE was more frequent in older patients. This study demonstrated that the IDH mutational status was associated with TAE but not with VTE. Therefore, a future large-scale study is needed to provide sufficient evidence. TAE was more common in young patients, while VTE was more common in the elderly.

Molecular mechanisms of sex differences in epilepsy and seizure susceptibility in chemical, genetic and acquired epileptogenesis

This article provides a succinct overview of sex differences in epilepsy and putative molecular mechanisms underlying sex differences in seizure susceptibility in chemical, genetic, and acquired epileptogenesis. The susceptibility to excitability episodes and occurrence of epileptic seizures are generally higher in men than women. The precise molecular mechanisms remain unclear, but differences in regional morphology and neural circuits in men and women may explain differential vulnerability to seizures and epileptogenic cascades. Changes in seizure sensitivity can be attributed to steroid hormones, including fluctuations in neurosteroids as well as neuroplasticity in their receptor signaling systems. Other potential neurobiological bases for sex differences in epilepsies include differences in brain development, neurogenesis, neuronal chloride homeostasis, and neurotrophic and glial responses. In catamenial epilepsy, a gender-specific neuroendocrine condition, epileptic seizures are most often clustered around a specific menstrual period in adult women. A deeper understanding of the molecular and neural network basis of sex differences in seizures and response to antiepileptic drugs is highly warranted for designing effective, sex-specific therapies for epilepsy, epileptogenesis, and seizure disorders.

Gender and Socioeconomic Disparities in Global Burden of Epilepsy: An Analysis of Time Trends From 1990 to 2017

Objective: The objective of the study is to investigate the gender and socioeconomic disparities in the global burden of epilepsy by prevalence and disability-adjusted life-years (DALYs).

Methods: The global, regional, and national gender-specific prevalence and DALYs caused by epilepsy by year and age were extracted from the Global Burden of Disease (GBD) Study 2017. The Gini coefficient and concentration index (CI) were calculated to demonstrate the trends in between-country inequality in the epilepsy burden from 1990 to 2017. Paired Wilcoxon signed rank test, Pearson correlation, and linear regression analyses were performed to analyze the association of gender disparity in epilepsy and socio-demographic index (SDI).

Results: The DALYs number of epilepsies increased from 1990 to 2017 by 13.8%, whereas age-standardized DALY rates showed a substantial reduction (16.1%). Men had a higher epilepsy burden than women of the same period. The epilepsy burden appeared to be higher in countries with lower socioeconomic development (CI < 0). The Gini coefficient decreased from 0.273 in 1995 to 0.259 in 2017, representing a decline in the between-country gap. Age-standardized prevalence and DALY rates of men were higher than those of women in each SDI-based country group (p < 0.0001). Male-minus-female difference (r = −0.5100, p < 0.0001) and male-to-female ratio (r = −0.3087, p < 0.0001) of age-standardized DALY rates were negatively correlated with SDI.

Conclusion: Although global health care of epilepsy is in progress, the epilepsy burden was concentrated in males and developing countries. Our findings highlight the importance of formulating gender-sensitive health policies and providing more services in developing countries.

Real-world prescribing trends of valproate in women with epilepsy in Korea

Avoiding valproate is recommended in women of childbearing age due to possible teratogenicity and infertility. We aimed to examine the recent trend of valproate prescriptions in Korea to review the adequacy of anticonvulsant prescriptions in women with epilepsy (WWE). Oral valproate utilization was assessed using nationwide and unselected data from the Korean National Health Insurance Service from 2009 to 2017. The temporal trends of the proportions of valproate prescriptions were analyzed using the Poisson regression model and expressed as average annual percentage change (AAPC). Among the WWE of childbearing age, valproate was prescribed in 37.0% overall and 29.4% as initial prescription in 2017. The proportion of valproate utilization showed a decreasing trend in overall prescription (AAPC = -1.10%) and initial prescription (AAPC = -2.63%). However, the proportion was static over time in the initial monotherapy group (AAPC = -0. 53%), while it was significantly decreasing in the initial polytherapy group (AAPC = -8.25%). A noticeable proportion of WWE was still being prescribed valproate in Korea. In particular, the use of valproate for initial monotherapy has not decreased over the past nine years. This result calls not only for reinforcement of education regarding anticonvulsant selection but also for monitoring the actual prescription.

WITHDRAWN: Evaluation of the factors that may contribute to the responsiveness of anti-epileptic treatments in pediatric patients, a study from Jordan

This article has been withdrawn at the request of the editor and publisher. The publisher regrets that an error occurred which led to the publication of this paper, which had been rejected by the editor. This error bears no reflection on the editor. The publisher apologizes to the authors, editor and the readers for this unfortunate error. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/our-business/policies/article-withdrawal.

Quality of Life in Children With Sturge-Weber Syndrome

AIM

We assessed the utilization of the National Institutes of Health Quality of Life in Neurological Disorders (Neuro-QoL) in pediatric patients with Sturge-Weber syndrome, a rare neurovascular disorder which frequently results in seizures, brain atrophy, calcification, and a range of neurological impairments.

METHODS

Subjects were seen clinically and consented for research. All 22 patients filled out the Pediatric Neuro-QoL. The Neuro-QoL subscores were converted to T-scores to compare with the referenced control population. Twenty-one participants also filled out the Brain Vascular Malformation Consortium Database Questionnaire containing data pertaining to Sturge-Weber syndrome-related medical history, medications, comorbidities, and family history. All data were analyzed with a significance threshold of P < 0.05.

RESULTS

Cognitive function quality of life was significantly lower (P < 0.001) in pediatric patients with Sturge-Weber syndrome compared with referenced control subjects. Male gender (P = 0.02) was associated with lower cognitive function Neuro-QoL. The extent of skin (R = -0.46, P = 0.04), total eyelid port-wine birthmark (R = -0.56, P = 0.007), eye (R = -0.58, P = 0.005), and total Sturge-Weber syndrome involvement (R = -0.63, P = 0.002) were negatively correlated with cognitive function Neuro-QoL. A younger age at seizure onset was associated with lower cognitive function Neuro-QoL (hazard ratio = 0.90, P = 0.004) even after controlling for extent of brain, skin, or eye involvement. Antidepressant use was associated with lower cognitive function Neuro-QoL (P = 0.005), and cognitive function Neuro-QoL was negatively correlated with depression Neuro-QoL; however, after adjusting for depression this relationship was no longer significant.

CONCLUSIONS

The results suggest targeting cognitive function Neuro-QoL in treatment trials and reiterate the prognostic value of early seizure onset. In addition, sex-related differences were noted, which should be further studied.

Comparison of new-onset and persistent epilepsy in the elderly

BACKGROUND

Previous studies on elderly epilepsy included only patients with new-onset disease, but there are many patients who developed epilepsy earlier and aged.

AIM

We compared the characteristics of new-onset and persistent epilepsy in the elderly.

METHODS

We performed a 10-year retrospective analysis of elderly patients with epilepsy divided into two groups according to the onset of seizure: new-onset epilepsy (onset age ≥65) and persistent epilepsy (onset age<65).

RESULTS

Nearly half (78/172, 45.3%) of patients in the new-onset group presented as status epilepticus, and one-fourth of these (19/78, 24.4%) died during the initial treatment for status epilepticus. Patients in the new-onset epilepsy group presented more frequently as status epilepticus (59/153 vs 12/78, P < 0.001) and had a past history of status epilepticus (63/153 vs 20/78, P = 0.02). History of stroke (81/153 vs 30/78, P = 0.04), hypertension (83/153 vs 29/78, P = 0.01), and dyslipidemia (53/153 vs 17/78, P = 0.05) was more common in the new-onset group, but patients in the persistent group used more antiepileptic drugs (AEDs; P = 0.036) and total AED drug loads (P = 0.028).

CONCLUSIONS

Our study shows that new-onset epilepsy has a higher incidence of status epilepticus and more stroke-related risk factors but may require fewer AEDs for epilepsy control.

Seizure in code stroke: Stroke mimic and initial manifestation of stroke

BACKGROUND

Although seizure is one of the common causes of stroke mimics and can be an initial manifestation of acute stroke, accurate diagnosis of seizure during acute stroke management is frequently difficult. The objective of this study was to analyze the frequency, characteristics and results of neuroimaging including CT perfusion in patients with seizures manifesting initially as stroke-like symptoms.

METHODS

We retrospectively reviewed the medical records of patients who were treated with code stroke alarming system. We studied the frequency and characteristics of patients who were finally diagnosed with seizures and further correlated their clinical features with the results of neuroimaging including CT perfusion.

RESULTS

Among the 4673 patients who were treated with code stroke alarming system, seizure was the third most frequent diagnosis (188 patients, 4.0%) among the causes of stroke mimics including 27 patients who manifested seizure as an initial manifestation of acute stroke. CT perfusion showed perfusion changes in more than 25% of them (49 of 188 patients, 26.1%). Thrombolysis was not performed in six patients who presented with seizure as an initial presentation of stroke for delayed diagnosis while one patient underwent thrombolysis for misdiagnosis of seizure.

CONCLUSIONS

Seizure is a frequent final diagnosis in acute stroke management. However, careful interpretation of clinical features and results of perfusion imaging is necessary to avoid unnecessary thrombolysis in patients with seizure as a stroke mimic and thrombolysis failure due to delayed diagnosis of seizure as an initial manifestation of stroke.

Epilepsy in Asia: Disease burden, management barriers, and challenges

This article reviews the burden of epilepsy in Asia, the challenges faced by people with epilepsy, and the management of epilepsy. Comparison is made with other parts of the world. For this narrative review, data were collected using specified search criteria. Articles investigating the epidemiology of epilepsy, diagnosis, comorbidities and associated mortality, stigmatization, and treatment were included. Epilepsy is a global health care issue affecting up to 70 million people worldwide. Nearly 80% of people with epilepsy live in low- and middle-income countries with limited resources. People with epilepsy are prone to physical and psychological comorbidities, including anxiety and depression, which can negatively impact their quality of life. Furthermore, people with epilepsy are at higher risk of premature death than people without epilepsy. Discrimination or stigmatization of people with epilepsy is common in Asia and can affect their education, work, and marriage opportunities. Access to epilepsy treatment varies throughout Asia. Although highly advanced treatment is available in some countries, up to 90% of people with epilepsy are not adequately treated or are not treated with conventional antiepileptic therapy in resource-limited countries. People in remote areas often do not receive any epilepsy care. First-generation antiepileptic drugs (AEDs) are available, but usually only in urban areas, and second-generation AEDs are not available in all countries. Newer AEDs tend to have more favorable safety profiles than first-generation AEDs and provide options to tailor therapy for individual patients, especially those with comorbidities. Active epilepsy surgery centers are present in some countries, although epilepsy surgery is often underutilized given the number of patients who could benefit. Further epidemiologic research is needed to provide accurate epilepsy data across the Asian region. Coordinated action is warranted to improve access to treatment and care.

Observational multicentre study into the use of antiepileptic drugs in Spanish neurology consultations

INTRODUCTION

The study aims to quantify the types of antiepileptic drugs (AED) prescribed in neurology consultations.

MATERIAL AND METHOD

This descriptive, observational study included a sample of 559 patients older than 14 years, diagnosed with epilepsy, and receiving pharmacological treatment. Data were collected at outpatient consultations by 47 Spanish neurologists in May 2016. Epilepsy was defined based on the International League Against Epilepsy classification. According to the year of marketing, AEDs were categorised as classic (before 1990) or new (after 1990). We performed a descriptive analysis of qualitative and quantitative variables.

RESULTS

Female patients accounted for 54.6% of the sample. Mean age was 42.7 years; mean age of onset was 22.4. Regarding epilepsy type, 75.7% of patients experienced partial seizures, 51.5% were symptomatic,32.4% had refractory epilepsy, 35.6% had been seizure-free for the previous year, and 59.2% had associated comorbidities.A total of 1103 AED prescriptions were made; 64.6% of prescriptions were for new AEDs; 85.4% of patients received new AEDs. Patients received a mean of 2 AEDs (range, 1-5). A total of 59.6% of patients received polytherapy.The most frequently prescribed AEDs were levetiracetam (42.6%), valproic acid (25.4%), lamotrigine (19.5%), carbamazepine (17.9%), and lacosamide (17.5%). No AED was employed exclusively as monotherapy. The most frequently prescribed AEDs for generalised and partial seizures were valproic acid (48.2%) and levetiracetam (43.2%), respectively. Valproic acid was less frequently prescribed to female patients. Patients with refractory epilepsy or with associated comorbidities were more frequently prescribed a combination of new and classic AEDs (48.7% and 45.6%, respectively) than only one type of AED.

CONCLUSIONS

The majority of patients received new AEDs. The combination of classic and new AEDs was more frequently prescribed to patients with refractory epilepsy or with associated comorbidities.

The neuroendocrine basis of sex differences in epilepsy

Epilepsy affects people of all ages and both genders. Sex differences are well known in epilepsy. Seizure susceptibility and the incidence of epilepsy are generally higher in men than women. In addition, there are gender-specific epilepsies such as catamenial epilepsy, a neuroendocrine condition in which seizures are most often clustered around the perimenstrual or periovulatory period in adult women with epilepsy. Changes in seizure sensitivity are also evident at puberty, pregnancy, and menopause. Sex differences in seizure susceptibility and resistance to antiseizure drugs can be studied in experimental models. An improved understanding of the neuroendocrine basis of sex differences or resistance to protective drugs is essential to develop targeted therapies for sex-specific seizure conditions. This article provides a brief overview of the current status of sex differences in seizure susceptibility and the potential mechanisms underlying the gender differences in seizure sensitivity.

Sex differences in the neurobiology of epilepsy: a preclinical perspective

When all of the epilepsies are considered, sex differences are not always clear, despite the fact that many sex differences are known in the normal brain. Sex differences in epilepsy in laboratory animals are also unclear, although robust effects of sex on seizures have been reported, and numerous effects of gonadal steroids have been shown throughout the rodent brain. Here we discuss several reasons why sex differences in seizure susceptibility are unclear or are difficult to study. Examples of robust sex differences in laboratory rats, such as the relative resistance of adult female rats to the chemoconvulsant pilocarpine compared to males, are described. We also describe a novel method that has shed light on sex differences in neuropathology, which is a relatively new technique that will potentially contribute to sex differences research in the future. The assay we highlight uses the neuronal nuclear antigen NeuN to probe sex differences in adult male and female rats and mice. In females, weak NeuN expression defines a sex difference that previous neuropathological studies have not described. We also show that in adult rats, social isolation stress can obscure the normal effects of 17β-estradiol to increase excitability in area CA3 of the hippocampus. These data underscore the importance of controlling behavioral stress in studies of seizure susceptibility in rodents and suggest that behavioral stress may be one factor that has led to inconsistencies in outcomes of sex differences research. These and other issues have made it difficult to translate our increasing knowledge about the effects of gonadal hormones on the brain to improved treatment for men and women with epilepsy.