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Aroniadou-Anderjaska V, Figueiredo TH, De Araujo Furtado M, Pidoplichko VI, Lumley LA, Braga MFM. Alterations in GABA A receptor-mediated inhibition triggered by status epilepticus and their role in epileptogenesis and increased anxiety. Neurobiol Dis 2024; 200:106633. [PMID: 39117119 DOI: 10.1016/j.nbd.2024.106633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Revised: 07/31/2024] [Accepted: 08/05/2024] [Indexed: 08/10/2024] Open
Abstract
The triggers of status epilepticus (SE) in non-epileptic patients can vary widely, from idiopathic causes to exposure to chemoconvulsants. Regardless of its etiology, prolonged SE can cause significant brain damage, commonly resulting in the development of epilepsy, which is often accompanied by increased anxiety. GABAA receptor (GABAAR)-mediated inhibition has a central role among the mechanisms underlying brain damage and the ensuing epilepsy and anxiety. During SE, calcium influx primarily via ionotropic glutamate receptors activates signaling cascades which trigger a rapid internalization of synaptic GABAARs; this weakens inhibition, exacerbating seizures and excitotoxicity. GABAergic interneurons are more susceptible to excitotoxic death than principal neurons. During the latent period of epileptogenesis, the aberrant reorganization in synaptic interactions that follow interneuronal loss in injured brain regions, leads to the formation of hyperexcitable, seizurogenic neuronal circuits, along with disturbances in brain oscillatory rhythms. Reduction in the spontaneous, rhythmic "bursts" of IPSCs in basolateral amygdala neurons is likely to play a central role in anxiogenesis. Protecting interneurons during SE is key to preventing both epilepsy and anxiety. Antiglutamatergic treatments, including antagonism of calcium-permeable AMPA receptors, can be expected to control seizures and reduce excitotoxicity not only by directly suppressing hyperexcitation, but also by counteracting the internalization of synaptic GABAARs. Benzodiazepines, as delayed treatment of SE, have low efficacy due to the reduction and dispersion of their targets (the synaptic GABAARs), but also because themselves contribute to further reduction of available GABAARs at the synapse; furthermore, benzodiazepines may be completely ineffective in the immature brain.
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Affiliation(s)
- Vassiliki Aroniadou-Anderjaska
- Department of Anatomy, Physiology, and Genetics, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, 20814, USA; Department of Psychiatry, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, 20814, USA.
| | - Taiza H Figueiredo
- Department of Anatomy, Physiology, and Genetics, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, 20814, USA.
| | - Marcio De Araujo Furtado
- Department of Anatomy, Physiology, and Genetics, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, 20814, USA
| | - Volodymyr I Pidoplichko
- Department of Anatomy, Physiology, and Genetics, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, 20814, USA.
| | - Lucille A Lumley
- U.S. Army Medical Research Institute of Chemical Defense, Aberdeen, Proving Ground, MD, USA.
| | - Maria F M Braga
- Department of Anatomy, Physiology, and Genetics, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, 20814, USA; Department of Psychiatry, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, 20814, USA.
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Adiga S, Mundlamuri RC, Asranna A, Vishwanathan LG, Raghavendra K, Nanjaiah ND, Prathyusah PV, Kulanthaivelu K, Sinha S. New onset status epilepticus and its long-term outcome: A cohort study. Epilepsy Res 2024; 206:107442. [PMID: 39208568 DOI: 10.1016/j.eplepsyres.2024.107442] [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: 01/17/2024] [Revised: 08/10/2024] [Accepted: 08/19/2024] [Indexed: 09/04/2024]
Abstract
PURPOSE New onset status epilepticus (NOSE), a subtype of status epilepticus, is a neurological emergency associated with significant morbidity and mortality. This study aimed to analyze the phenotypic spectrum and outcomes of patients presenting with NOSE. METHODS This prospective and retrospective descriptive study included patients presenting with NOSE over a 10-year period. Data collected included patient demographics, phenotypic characteristics of SE and its etiology, Status Epilepticus Severity Score (STESS), SE classification Axis-II, and Modified Rankin Scale (mRS) scores at admission and discharge. Functional outcomes and seizure status were assessed at least 6 months post-discharge. Prognostic factors for mortality and the development of epilepsy were also analyzed. RESULTS A total of 208 patients were included, with a mean age of 41.97 ± 21.66 years, and a male predominance (57.1 %). Focal to bilateral tonic-clonic seizures were observed in 47.5 % of patients. The etiology was acute symptomatic in 35.57 % and remote symptomatic in 24 %. The median hospital stay was 4 days (range: 2.25-10.75 days). The mortality rate was 26.5 %, and 23 % of patients developed epilepsy with a median follow-up of 9 months. Higher age (≥ 50 years), elevated STESS, ICU admission, use of anesthetic agents, refractory status epilepticus (RSE), and new-onset refractory status epilepticus (NORSE) were significant risk factors for mortality (p<0.05). The development of epilepsy was associated with a higher number of antiseizure medications (ASM) at discharge, ICU admission, use of anesthetic agents, RSE, and NORSE (p<0.05). CONCLUSION NOSE is a neurological emergency with a variable etiology and significant long-term consequences. Approximately one-fourth of patients presenting with NOSE died, and another quarter developed epilepsy during a median follow-up of 9 months. Identifying and addressing the predictors of mortality and epilepsy development following NOSE may improve long-term outcomes.
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Affiliation(s)
| | | | - Ajay Asranna
- Department of Neurology, NIMHANS, Bengaluru, India.
| | | | | | | | | | | | - Sanjib Sinha
- Department of Neurology, NIMHANS, Bengaluru, India.
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Orlandi N, Giovannini G, Cioclu MC, Biagioli N, Madrassi L, Vaudano AE, Pugnaghi M, Lattanzi S, Meletti S. Remote seizures and drug-resistant epilepsy after a first status epilepticus in adults. Eur J Neurol 2024; 31:e16177. [PMID: 38258477 PMCID: PMC11235869 DOI: 10.1111/ene.16177] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Revised: 11/21/2023] [Accepted: 11/23/2023] [Indexed: 01/24/2024]
Abstract
BACKGROUND AND PURPOSE Long-term consequences after status epilepticus (SE) represent an unsettled issue. We investigated the incidence of remote unprovoked seizures (RS) and drug-resistant epilepsy (DRE) in a cohort of first-ever SE survivors. METHODS A retrospective, observational, and monocentric study was conducted on adult patients (age ≥ 14 years) with first SE who were consecutively admitted to the Modena Academic Hospital, Italy (September 2013-March 2022). Kaplan-Meier survival analyses were used to calculate the probability of seizure freedom following the index event, whereas Cox proportional hazard regression models were used to identify outcome predictors. RESULTS A total of 279 patients were included, 57 of whom (20.4%) developed RS (mean follow-up = 32.4 months). Cumulative probability of seizure freedom was 85%, 78%, and 68% respectively at 12 months, 2 years, and 5 years. In 45 of 57 patients (81%), the first relapse occurred within 2 years after SE. The risk of RS was higher in the case of structural brain damage (hazard ratio [HR] = 2.1, 95% confidence interval [CI] = 1.06-4.01), progressive symptomatic etiology (HR = 2.7, 95% CI = 1.44-5.16), and occurrence of nonconvulsive evolution in the semiological sequence of SE (HR = 2.9, 95% CI = 1.37-6.37). Eighteen of 57 patients (32%) developed DRE; the risk was higher in the case of super-refractory (p = 0.006) and non-convulsive SE evolution (p = 0.008). CONCLUSIONS The overall risk of RS was moderate, temporally confined within 2 years after the index event, and driven by specific etiologies and SE semiology. Treatment super-refractoriness and non-convulsive SE evolution were associated with DRE development.
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Affiliation(s)
- Niccolò Orlandi
- Neurology UnitOspedale CivileAzienda Ospedaliera–Universitaria di ModenaModenaItaly
- Department of BiomedicalMetabolic, and Neural ScienceCenter for Neuroscience and NeurotechnologyUniversity of Modena and Reggio EmiliaModenaItaly
| | - Giada Giovannini
- Neurology UnitOspedale CivileAzienda Ospedaliera–Universitaria di ModenaModenaItaly
| | - Maria Cristina Cioclu
- Department of BiomedicalMetabolic, and Neural ScienceCenter for Neuroscience and NeurotechnologyUniversity of Modena and Reggio EmiliaModenaItaly
| | - Niccolò Biagioli
- Neurology UnitOspedale CivileAzienda Ospedaliera–Universitaria di ModenaModenaItaly
- Department of BiomedicalMetabolic, and Neural ScienceCenter for Neuroscience and NeurotechnologyUniversity of Modena and Reggio EmiliaModenaItaly
| | - Laura Madrassi
- Neurology UnitOspedale CivileAzienda Ospedaliera–Universitaria di ModenaModenaItaly
- Department of BiomedicalMetabolic, and Neural ScienceCenter for Neuroscience and NeurotechnologyUniversity of Modena and Reggio EmiliaModenaItaly
| | - Anna Elisabetta Vaudano
- Neurology UnitOspedale CivileAzienda Ospedaliera–Universitaria di ModenaModenaItaly
- Department of BiomedicalMetabolic, and Neural ScienceCenter for Neuroscience and NeurotechnologyUniversity of Modena and Reggio EmiliaModenaItaly
| | - Matteo Pugnaghi
- Neurology UnitOspedale CivileAzienda Ospedaliera–Universitaria di ModenaModenaItaly
| | - Simona Lattanzi
- Neurological ClinicDepartment of Experimental and Clinical MedicineMarche Polytechnic UniversityAnconaItaly
| | - Stefano Meletti
- Neurology UnitOspedale CivileAzienda Ospedaliera–Universitaria di ModenaModenaItaly
- Department of BiomedicalMetabolic, and Neural ScienceCenter for Neuroscience and NeurotechnologyUniversity of Modena and Reggio EmiliaModenaItaly
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Lattanzi S, Orlandi N, Giovannini G, Brigo F, Trinka E, Meletti S. The risk of unprovoked seizure occurrence after status epilepticus in adults. Epilepsia 2024; 65:1006-1016. [PMID: 38339985 DOI: 10.1111/epi.17912] [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: 11/11/2023] [Revised: 01/25/2024] [Accepted: 01/25/2024] [Indexed: 02/12/2024]
Abstract
OBJECTIVE Status epilepticus (SE) may lead to long-term consequences. This study evaluated the risk and predictors of seizure occurrence after SE, with a focus on SE due to acute symptomatic etiologies. METHODS Prospectively collected data about adults surviving a first non-hypoxic SE were reviewed. The outcome was the occurrence of unprovoked seizures during the follow-up. Kaplan-Meier survival curve analysis and log-rank test were used to analyze the time to seizure occurrence and determine the statistical significance between etiological groups. Three subcategories within acute etiology were considered according to the presence of the following: (1) structural lesion (acute-primary); (2) brain involvement during systemic disorders (acute-secondary); and (3) drug or alcohol intoxication/withdrawal (acute-toxic). Cox proportional hazards model was adopted to estimate hazard ratios (HRs) with the 95% confidence intervals (CIs). RESULTS Two hundreds fifty-seven individuals were included. Fifty-four subjects (21.0%) developed seizures after a median of 9.9 (interquartile range 4.3-21.7) months after SE. The estimated 1-, 2-, and 5-year rates of seizure occurrence according to acute SE etiologies were 19.4%, 23.4%, and 30.1%, respectively, for acute-primary central nervous system (CNS) pathology; 2.2%, 2.2%, and 8.7%, respectively, for acute-secondary CNS pathology; and 0%, 9.1%, and 9.1%, respectively, for acute-toxic causes. Five-year rates of seizure occurrence for non-acute SE causes were 33.9% for remote, 65.7% for progressive, and 25.9% for unknown etiologies. In multivariate Cox regression model, progressive etiology (adjusted HR [adjHR] 2.27, 95% CI 1.12-4.58), SE with prominent motor phenomena evolving in non-convulsive SE (adjHR 3.17, 95% CI 1.38-7.25), and non-convulsive SE (adjHR 2.38, 95% CI 1.16-4.90) were independently associated with higher hazards of unprovoked seizures. Older people (adjHR .98, 95% CI .96-.99) and people with SE due to acute-secondary CNS pathology (adjHR .18, 95% CI .04-.82) were at decreased risk of seizure occurrence. SIGNIFICANCE SE carries a risk of subsequent seizures. Both the underlying cause and epileptogenic effects of SE are likely to contribute.
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Affiliation(s)
- Simona Lattanzi
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Niccolò Orlandi
- Neurology Unit, OCB Hospital, AOU Modena, Modena, Italy
- Department of Biomedical, Metabolic and Neural Science, Center for Neuroscience and Neurotechnology, University of Modena and Reggio Emilia, Modena, Italy
| | - Giada Giovannini
- Neurology Unit, OCB Hospital, AOU Modena, Modena, Italy
- PhD Program in Clinical and Experimental Medicine, University of Modena and Reggio Emilia, Modena, Italy
| | - Francesco Brigo
- Department of Neuroscience, Biomedicine and Movement Science, University of Verona, Verona, Italy
- Division of Neurology, "Franz Tappeiner" Hospital, Merano, Italy
| | - Eugen Trinka
- Department of Neurology, Neurointensive Care, and Neurorehabilitation, Christian Doppler University Hospital, Paracelsus Medical University, Member of EpiCARE, Salzburg, Austria
- Neuroscience Institute, Center for Cognitive Neuroscience, Christian Doppler University Hospital Salzburg, Salzburg, Austria
- Public Health, Health Services Research and HTA, University for Health Sciences, Medical Informatics and Technology, Hall i.T, Austria
| | - Stefano Meletti
- Neurology Unit, OCB Hospital, AOU Modena, Modena, Italy
- Department of Biomedical, Metabolic and Neural Science, Center for Neuroscience and Neurotechnology, University of Modena and Reggio Emilia, Modena, Italy
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Lattanzi S, Trinka E, Meletti S. What is the risk of unprovoked seizures after acute symptomatic status epilepticus? Epilepsia 2023; 64:3408-3409. [PMID: 37857472 DOI: 10.1111/epi.17792] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Accepted: 09/15/2023] [Indexed: 10/21/2023]
Affiliation(s)
- Simona Lattanzi
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Eugen Trinka
- Department of Neurology, Christian Doppler Klinik, Paracelsus Medical University, Salzburg, Austria
- Center for Cognitive Neuroscience, Salzburg, Austria
- Public Health, Health Services Research, and HTA, University for Health Sciences, Medical Informatics, and Technology, Hall in Tirol, Austria
| | - Stefano Meletti
- Neurology Unit, OCB Hospital, AOU Modena, Modena, Italy
- Department of Biomedical, Metabolic, and Neural Science, Center for Neuroscience and Neurotechnology, University of Modena and Reggio Emilia, Modena, Italy
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Rodrigo-Gisbert M, Abraira L, Quintana M, Gómez-Dabó L, López-Maza S, Sueiras M, Thonon V, Campos-Fernández D, Lallana S, Fonseca E, Toledo M, Santamarina E. Risk assessment of long-term epilepsy after de novo status epilepticus with clinical and electroencephalographic biomarkers: The AFTER score. Epilepsy Behav 2023; 149:109531. [PMID: 37995538 DOI: 10.1016/j.yebeh.2023.109531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 10/18/2023] [Accepted: 11/06/2023] [Indexed: 11/25/2023]
Abstract
BACKGROUND The risk of developing epilepsy after de novo status epilepticus (SE) is nonnegligible. The individualized management of patients with high risk of subsequent epilepsy could improve long-term quality of life and cognitive impairment. We aimed to ascertain potential biomarkers of subsequent epilepsy and to construct a scoring system possessing predictive value for the diagnosis of post-SE epilepsy during follow-up. METHODS The study data were obtained from a prospective registry of all SE episodes occurring in patients over 16 years attended in our tertiary center from February 2011 to April 2022. Clinical data, electroencephalography findings, treatment, and long-term clinical data were prospectively recorded. We selected SE patients at risk of developing epilepsy (acute symptomatic and cryptogenic etiologies with no previous history of epilepsy) and analyzed the risk of developing subsequent epilepsy. RESULTS We included 230 patients. Median age was 65 years ± 16.9 SD and 112/230 (48.7 %) were women. One-hundred ninety-eight patients (86.1 %) had an acute symptomatic SE, whereas 32 patients (13.9 %) presented with a cryptogenic SE. A total of 55 patients (23.9 %) developed an unprovoked remote seizure and were diagnosed with epilepsy. After adjusting for identifiable confounders in a multivariable Cox regression analysis cryptogenic etiology (HR 2.24 [1.13-4.46], p = 0.022), first-line treatment initiation ≥1 h (HR 2.12 [1.03-4.36], p = 0.041], RDA/LPD/GPD EEG patterns (HR 1.88 [1.07-3.32], p = 0.028), and super-refractoriness (HR 2.90 [1.40-5.99], p = 0.004) emerged as independent predictors of post-SE epilepsy. Based on these findings, we constructed the AFTER score (1 point for each item) with a robust capability to predict post-SE epilepsy at 5 years (AUC 74.3 %, 95 %CI 64.3-84.3 %, p < 0.001). CONCLUSIONS The AFTER score is a robust predictor of the development of epilepsy after new onset SE using clinical and electroencephalographic biomarkers (such as etiology, time to first-line treatment initiation, EEG pattern and super-refractoriness). Prospective studies are warranted to validate the score in other populations.
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Affiliation(s)
- Marc Rodrigo-Gisbert
- Neurology Department. Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Laura Abraira
- Epilepsy Unit, Neurology Department. Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain; Research group on Status Epilepticus and Acute Seizures, Vall d'Hebron Research Institute (VHIR), Barcelona, Spain.
| | - Manuel Quintana
- Epilepsy Unit, Neurology Department. Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain; Research group on Status Epilepticus and Acute Seizures, Vall d'Hebron Research Institute (VHIR), Barcelona, Spain
| | - Laura Gómez-Dabó
- Neurology Department. Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Samuel López-Maza
- Epilepsy Unit, Neurology Department. Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain; Research group on Status Epilepticus and Acute Seizures, Vall d'Hebron Research Institute (VHIR), Barcelona, Spain
| | - María Sueiras
- Neurophysiology Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Vanesa Thonon
- Neurophysiology Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Daniel Campos-Fernández
- Epilepsy Unit, Neurology Department. Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain; Research group on Status Epilepticus and Acute Seizures, Vall d'Hebron Research Institute (VHIR), Barcelona, Spain
| | - Sofía Lallana
- Epilepsy Unit, Neurology Department. Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain; Research group on Status Epilepticus and Acute Seizures, Vall d'Hebron Research Institute (VHIR), Barcelona, Spain
| | - Elena Fonseca
- Epilepsy Unit, Neurology Department. Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain; Research group on Status Epilepticus and Acute Seizures, Vall d'Hebron Research Institute (VHIR), Barcelona, Spain
| | - Manuel Toledo
- Epilepsy Unit, Neurology Department. Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain; Research group on Status Epilepticus and Acute Seizures, Vall d'Hebron Research Institute (VHIR), Barcelona, Spain
| | - Estevo Santamarina
- Epilepsy Unit, Neurology Department. Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain; Research group on Status Epilepticus and Acute Seizures, Vall d'Hebron Research Institute (VHIR), Barcelona, Spain
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Santamarina E, Rodrigo-Gisbert M, Abraira L, Campos-Fernández D, Quintana M, Gómez-Dabó L, Fonseca E, Lallana S, Toledo M. Response: "What is the risk of unprovoked seizures after acute symptomatic status epilepticus?". Epilepsia 2023; 64:3410-3411. [PMID: 37804071 DOI: 10.1111/epi.17790] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 10/04/2023] [Indexed: 10/08/2023]
Affiliation(s)
- Estevo Santamarina
- Epilepsy Unit, Neurology Department, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Marc Rodrigo-Gisbert
- Epilepsy Unit, Neurology Department, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Laura Abraira
- Epilepsy Unit, Neurology Department, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Daniel Campos-Fernández
- Epilepsy Unit, Neurology Department, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Manuel Quintana
- Epilepsy Unit, Neurology Department, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Laura Gómez-Dabó
- Epilepsy Unit, Neurology Department, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Elena Fonseca
- Epilepsy Unit, Neurology Department, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Sofía Lallana
- Epilepsy Unit, Neurology Department, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Manuel Toledo
- Epilepsy Unit, Neurology Department, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
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