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Ryu HU, Kim HJ, Shin BS, Kang HG. Clinical approaches for poststroke seizure: a review. Front Neurol 2024; 15:1337960. [PMID: 38660095 PMCID: PMC11039895 DOI: 10.3389/fneur.2024.1337960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 03/26/2024] [Indexed: 04/26/2024] Open
Abstract
Poststroke seizure is a potential complication of stroke, which is the most frequent acute symptomatic seizure in adults. Patients with stroke may present with an abnormal or aggressive behavior accompanied by altered mental status and symptoms, such as hemiparesis, dysarthria, and sensory deficits. Although stroke manifestations that mimic seizures are rare, diagnosing poststroke seizures can be challenging when accompanied with negative postictal symptoms. Differential diagnoses of poststroke seizures include movement disorders, syncope, and functional (nonepileptic) seizures, which may present with symptoms similar to seizures. Furthermore, it is important to determine whether poststroke seizures occur early or late. Seizures occurring within and after 7 d of stroke onset were classified as early and late seizures, respectively. Early seizures have the same clinical course as acute symptomatic seizures; they rarely recur or require long-term antiseizure medication. Conversely, late seizures are associated with a risk of recurrence similar to that of unprovoked seizures in a patient with a focal lesion, thereby requiring long-term administration of antiseizure medication. After diagnosis, concerns regarding treatment strategies, treatment duration, and administration of primary and secondary prophylaxis often arise. Antiseizure medication decisions for the initiation of short-term primary and long-term secondary seizure prophylaxis should be considered for patients with stroke. Antiseizure drugs such as lamotrigine, carbamazepine, lacosamide, levetiracetam, phenytoin, and valproate may be administered. Poststroke seizures should be diagnosed systematically through history with differential diagnosis; in addition, classifying them as early or late seizures can help to determine treatment strategies.
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Affiliation(s)
- Han Uk Ryu
- Department of Neurology, Jeonbuk National University Medical School and Hospital, Jeonju, Republic of Korea
- Research Institute of Clinical Medicine of Jeonbuk National University – Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, Republic of Korea
| | - Hong Jin Kim
- Department of Neurology, Jeonbuk National University Medical School and Hospital, Jeonju, Republic of Korea
- Research Institute of Clinical Medicine of Jeonbuk National University – Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, Republic of Korea
| | - Byoung-Soo Shin
- Department of Neurology, Jeonbuk National University Medical School and Hospital, Jeonju, Republic of Korea
- Research Institute of Clinical Medicine of Jeonbuk National University – Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, Republic of Korea
| | - Hyun Goo Kang
- Department of Neurology, Jeonbuk National University Medical School and Hospital, Jeonju, Republic of Korea
- Research Institute of Clinical Medicine of Jeonbuk National University – Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, Republic of Korea
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Lemus HN, Gururangan K, Fields MC, Jetté N, Bolden D, Yoo JY. Analysis of Electrocorticography in Epileptic Patients With Responsive Neurostimulation Undergoing Scalp Electroencephalography Monitoring. J Clin Neurophysiol 2023; 40:574-581. [PMID: 35294419 DOI: 10.1097/wnp.0000000000000936] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
PURPOSE To describe the relationship of electrocorticography events detected by a brain-responsive neurostimulation system (RNS) and their association with ictal and interictal activity detected on simultaneous scalp EEG. METHODS We retrospectively identified patients with drug-resistant epilepsy implanted with RNS who subsequently underwent long-term scalp EEG monitoring. RNS detections were correlated to simultaneous activity recorded on scalp EEG to determine the characteristics of electrocorticography-stored long episodes associated with seizures or other findings on scalp EEG. RESULTS Eleven patients were included with an average of 3.6 days of monitoring. Most RNS detections were of very brief duration (<10 seconds, 92.9%) and received one stimulation therapy (80.8%). A high proportion of long episodes (67.1%) were not identified as electrographic seizures on scalp EEG. Of those ictal-appearing (71.2%) long episodes, 68.2% had seizure correlates. Long episodes associated with seizures on scalp EEG had a longer median duration compared with those without (39.7 vs. 16.8 seconds, P < 0.002) and had broader spread pattern and were of higher amplitude on electrocorticography. Brief potentially ictal rhythmic discharges were the most common EEG findings associated with long episodes that did not have scalp EEG seizure correlates (100% for ictal- and 50% for non-ictal-appearing long episodes). CONCLUSIONS Longer, broader spread and higher amplitude intracranial RNS detections are more likely to manifest as electrographic seizures on scalp EEG. Brief potentially ictal rhythmic discharges may serve as a scalp EEG biomarker of ictal intracranial episodes that are detected as long episodes by the RNS but not identified as electrographic seizures on scalp EEG.
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Affiliation(s)
- Hernan Nicolas Lemus
- Department of Neurology, Icahn School of Medicine at Mount Sinai Downtown, New York, New York, U.S.A
| | - Kapil Gururangan
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, U.S.A.; and
| | - Madeline Cara Fields
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, U.S.A.; and
| | - Nathalie Jetté
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, U.S.A.; and
| | - Dina Bolden
- Department of Neurology, Icahn School of Medicine at Mount Sinai West, New York, New York, U.S.A
| | - Ji Yeoun Yoo
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, U.S.A.; and
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Fong MWK, Pu K, Jadav R, Khan T, Hirsch LJ, Zaveri HP. Quantitative assessment of burst suppression as a predictor of seizure recurrence in refractory status epilepticus. Clin Neurophysiol 2023; 150:98-105. [PMID: 37060844 DOI: 10.1016/j.clinph.2023.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 02/15/2023] [Accepted: 03/11/2023] [Indexed: 03/31/2023]
Abstract
OBJECTIVE To determine whether quantitative EEG analysis of burst suppression can predict seizure recurrence in patients with refractory status epilepticus (RSE) being treated with anesthetic doses of continuous IV antiseizure medications (cIVASM). METHODS Quantitative assessment of burst suppression (including epileptiform discharges [EDs] and evolution) in 31 occasions (from 27 patients), and correlation with seizure recurrence up to 48 hours post sedative wean. RESULTS Occasions resulting in seizure recurrence (vs. no seizure recurrence) had lower burst (8.4 vs. 10.6 µV) and interburst interval (IBI) (4.2 vs. 4.8 µV) average amplitude, duration (bursts 2.8 vs. 3.6 s: IBIs 3.6 vs. 4.4 s); and burst total power (0.4 vs. 0.7 µV2). Bursts (0.86 vs. 0.60) and IBIs (0.28 vs. 0.07) with EDs, higher number of EDs within bursts (mean 2.1 vs. 1.4) and IBIs (0.6 vs. 0.2), and positive evolution measures all predicted seizure recurrence, although EDs had the greatest adjusted odds ratio on multivariate analysis. CONCLUSIONS For patients in burst suppression, successful wean of cIVASM was not determined by classical burst suppression measures, but instead how "epileptiform" bursts and IBIs were, as determined by EDs in both bursts and IBIs and surrogates for evolution within bursts. SIGNIFICANCE If confirmed, these objective measures could be used during clinical care to help determine when to wean cIVASM in patients with RSE.
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Affiliation(s)
- Michael W K Fong
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, CT, USA; Westmead Comprehensive Epilepsy Unit, Westmead Hospital, University of Sydney, Sydney, Australia.
| | - Kelly Pu
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Rakesh Jadav
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, CT, USA; Department of Neurology, Manipal Hospitals, Bengaluru, India
| | - Tasleema Khan
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, CT, USA; University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Lawrence J Hirsch
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Hitten P Zaveri
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
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Dalic LJ, Warren AEL, Spiegel C, Thevathasan W, Roten A, Bulluss KJ, Archer JS. Paroxysmal fast activity is a biomarker of treatment response in deep brain stimulation for Lennox-Gastaut syndrome. Epilepsia 2022; 63:3134-3147. [PMID: 36114808 PMCID: PMC10946931 DOI: 10.1111/epi.17414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Revised: 09/15/2022] [Accepted: 09/16/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVE Epilepsy treatment trials typically rely on seizure diaries to determine seizure frequency, but these are time-consuming and difficult to maintain accurately. Fast, reliable, and objective biomarkers of treatment response are needed, particularly in Lennox-Gastaut syndrome (LGS), where high seizure frequency and comorbid cognitive and behavioral issues are additional obstacles to accurate diary-keeping. Here, we measured generalized paroxysmal fast activity (GPFA), a key interictal electrographic feature of LGS, and correlated GPFA burden with seizure diaries during a thalamic deep brain stimulation (DBS) treatment trial (Electrical Stimulation of the Thalamus in Epilepsy of Lennox-Gastaut Phenotype [ESTEL]). METHODS GPFA and electrographic seizure counts from intermittent, 24-h electroencephalograms (EEGs) were compared to 3-month diary-recorded seizure counts in 17 young adults with LGS (mean age ± SD = 24.9 ± 6.6) in the ESTEL study, a randomized clinical trial of DBS lasting 12 months (comprising a 3-month baseline and 9 months of postimplantation follow-up). RESULTS Baseline median seizures measured by diaries numbered 2.6 (interquartile range [IQR] = 1.4-5) per day, compared to 284 (IQR = 120.5-360) electrographic seizures per day, confirming that diaries capture only a small fraction of seizure burden. Across all patient EEGs, the average number of GPFA discharges per hour of sleep was 138 (IQR =72-258). GPFA duration and frequency, quantified over 2-h windows of sleep EEG, were significantly associated with diary-recorded seizure counts over 3-month intervals (p < .001, η2 p = .30-.48). For every GPFA discharge, there were 20-25 diary seizures witnessed over 3 months. There was high between-patient variability in the ratio between diary seizure burden and GPFA burden; however, within individual patients, the ratio was similar over time, such that the percentage change from pre-DBS baseline in seizure diaries strongly correlated with the percentage change in GPFA. SIGNIFICANCE When seeking to optimize treatment in patients with LGS, monitoring changes in GPFA may allow rapid titration of treatment parameters, rather than waiting for feedback from seizure diaries.
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Affiliation(s)
- Linda J. Dalic
- Department of Medicine, Austin HealthUniversity of MelbourneHeidelbergVictoriaAustralia
- Department of Neurology, Austin HealthHeidelbergVictoriaAustralia
| | - Aaron E. L. Warren
- Department of Medicine, Austin HealthUniversity of MelbourneHeidelbergVictoriaAustralia
- The Florey Institute of Neuroscience and Mental HealthHeidelbergVictoriaAustralia
- Murdoch Children's Research InstituteParkvilleVictoriaAustralia
| | - Chloe Spiegel
- Department of Neurology, Austin HealthHeidelbergVictoriaAustralia
| | - Wesley Thevathasan
- Department of Medicine, Austin HealthUniversity of MelbourneHeidelbergVictoriaAustralia
- Bionics InstituteEast MelbourneVictoriaAustralia
- Department of MedicineUniversity of Melbourne, and Department of Neurology, Royal Melbourne HospitalParkvilleVictoriaAustralia
| | - Annie Roten
- Department of Neurology, Austin HealthHeidelbergVictoriaAustralia
| | - Kristian J. Bulluss
- Bionics InstituteEast MelbourneVictoriaAustralia
- Department of Neurosurgery, Austin HealthHeidelbergVictoriaAustralia
- Department of SurgeryUniversity of MelbourneParkvilleVictoriaAustralia
| | - John S. Archer
- Department of Medicine, Austin HealthUniversity of MelbourneHeidelbergVictoriaAustralia
- Department of Neurology, Austin HealthHeidelbergVictoriaAustralia
- The Florey Institute of Neuroscience and Mental HealthHeidelbergVictoriaAustralia
- Murdoch Children's Research InstituteParkvilleVictoriaAustralia
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Kong THJ, Abdul Azeem M, Naeem A, Allen S, Kim JA, Struck AF. Epileptiform activity predicts epileptogenesis in cerebral hemorrhage. Ann Clin Transl Neurol 2022; 9:1475-1480. [PMID: 36030385 PMCID: PMC9463945 DOI: 10.1002/acn3.51637] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 07/09/2022] [Accepted: 07/14/2022] [Indexed: 12/15/2022] Open
Abstract
This retrospective case-controlled study was performed to evaluate whether Epileptiform Activity, suspected clinical seizures, and/or 2HELPS2B/S after nontraumatic Intraparenchymal Hemorrhage or Subarachnoid Hemorrhage can predict Epilepsy. Hundred and thirty-two patients were included-29 (Epilepsy), 103 (Control Group). After matching, the average effect for all three risk factors was significant as follows: (1) Epileptiform Activity (p = 0.012, odds ratio 3.14), (2) suspected seizures (p = 0.021, odds ratio 3.78), and (3) 2HELPS2B/S score (p < 0.001, odds ratio 4.94). This study shows that Epileptiform Activity, suspected seizures, and particularly, the 2HELPS2B/S score in the acute phase are risk factors for the development of epilepsy after nontraumatic intraparenchymal and subarachnoid hemorrhage.
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Affiliation(s)
| | | | - Ayesha Naeem
- Department of NeurologyUniversity of Wisconsin‐MadisonMadisonWisconsinUSA
| | - Shawn Allen
- Department of NeurologyUniversity of Wisconsin‐MadisonMadisonWisconsinUSA
| | | | - Aaron F. Struck
- Department of NeurologyUniversity of Wisconsin‐MadisonMadisonWisconsinUSA
- William S. Middleton Veterans Administration HospitalMadisonWisconsinUSA
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Yoo JY. BIRDs (Brief Potentially Ictal Rhythmic Discharges) watching during EEG monitoring. Front Neurol 2022; 13:966480. [PMID: 36081872 PMCID: PMC9445572 DOI: 10.3389/fneur.2022.966480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Accepted: 07/29/2022] [Indexed: 11/13/2022] Open
Abstract
Brief Potentially Ictal Rhythmic Discharges (BIRDs), initially described in neonates, have been shown to correlate with increased risk of seizures in both critically ill and non-critically ill adults. In critically ill patients, BIRDs are associated with acute brain injury and worse functional outcomes. In non-critically ill adults, BIRDs are seen in patients with epilepsy with a greater likelihood of having drug resistance. The location of BIRDs seems to better predict the seizure onset zone compared to other interictal epileptiform discharges. The definition of BIRDs includes Paroxysmal Fast Activity (PFA), and they have similar clinical significance regardless of the exact cut-off frequencies. Their potential as a biomarker for seizure activity and seizure onset zone has been suggested. In patients with status epilepticus, BIRDs also resolve or decrease when seizures resolve. Thus, if BIRDs are observed on scalp EEG, more extended EEG monitoring is recommended to estimate their seizure burden and to guide treatment. With the recent addition of BIRDs in the critical care EEG terminology, with future investigations, we may soon be able to reach a consensus about the definition of electrographic seizures and better understand their neurophysiology and clinical significance.
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