Estimation of the burden of active and life-time epilepsy: a meta-analytic approach

Drug-resistant epilepsy in Morocco: description, prevalence and predictive factors in Casablanca-Settat region

Drug-resistant epilepsy (DRE) affects about one-third of people with epilepsy (PWE). Our study aims to estimate the DRE prevalence and its predictive factors in Morocco. A cross-sectional study was conducted over 18 months. PWE with clinical diagnosis of epilepsy, and with an antiseizure treatment duration >12 months were examined in the neurology, neurosurgery, psychiatry, and pediatrics departments, of different sampled clinical sectors for the Casablanca-Settat region. Sociodemographic and clinical data were collected using a questionnaire during consultations. Antiseizure multi-therapy, a seizure freedom duration <12 months, compliance, and adequate posology were the determining factors for classifying DRE. Data were analyzed using Statistical Package for Social Sciences (SPSS) software, version 21.0. Statistical significance was set at p < 0.05 and logistic regression was performed to determine the predictive factors. In our sample of 446 PWE, the median age is 25 years (IQR: 11.75-44.00). The DRE estimated prevalence was 29.4 %. Pseudo-resistant epilepsy (PRE) was 18.0 %. Multivariate logistic regression analysis reports that single marital status (ORa = 1.94; CI95%: 1.02-3.71), comorbidities and concomitant affections (ORa = 2.14; CI95%: 1.27-3.59), structural etiology (ORa = 1.96; CI95%: 1.16-3.30), pre-ictal aura (ORa = 1.90; CI95%: 1.09-3.29), inter-ictal EEG abnormalities (ORa = 2.45; CI95%: 1.24-4.84) and allopathic treatment use (ORa = 2.10; CI95%: 1.30-3.39) are the predictive factors for DRE. We report an alarming DRE prevalence. Associated factors found may contribute to the prognosis and early management. PWE awareness, facilitating healthcare access and the development of epilepsy surgery are the key points to limit DRE in Morocco and prevent its various complications, especially for the pediatric population.

Seizure Detection Based on Lightweight Inverted Residual Attention Network

Timely and accurately seizure detection is of great importance for the diagnosis and treatment of epilepsy patients. Existing seizure detection models are often complex and time-consuming, highlighting the urgent need for lightweight seizure detection. Additionally, existing methods often neglect the key characteristic channels and spatial regions of electroencephalography (EEG) signals. To solve these issues, we propose a lightweight EEG-based seizure detection model named lightweight inverted residual attention network (LRAN). Specifically, we employ a four-stage inverted residual mobile block (iRMB) to effectively extract the hierarchical features from EEG. The convolutional block attention module (CBAM) is introduced to make the model focus on important feature channels and spatial information, thereby enhancing the discrimination of the learned features. Finally, convolution operations are used to capture local information and spatial relationships between features. We conduct intra-subject and inter-subject experiments on a publicly available dataset. Intra-subject experiments obtain 99.25% accuracy in segment-based detection and 0.36/h false detection rate (FDR) in event-based detection, respectively. Inter-subject experiments obtain 84.32% accuracy. Both sets of experiments maintain high classification accuracy with a low number of parameters, where the multiply accumulate operations (MACs) are 25.86[Formula: see text]M and the number of parameters is 0.57[Formula: see text]M.

Prevalence of all epilepsies in urban informal settlements in Nairobi, Kenya: a two-stage population-based study

BACKGROUND

WHO estimates that more than 50 million people worldwide have epilepsy and 80% of cases are in low-income and middle-income countries. Most studies in Africa have focused on active convulsive epilepsy in rural areas, but there are few data in urban settings. We aimed to estimate the prevalence and spatial distribution of all epilepsies in two urban informal settlements in Nairobi, Kenya.

METHODS

We did a two-stage population-based cross-sectional study of residents in a demographic surveillance system covering two informal settlements in Nairobi, Kenya (Korogocho and Viwandani). Stage 1 screened all household members using a validated epilepsy screening questionnaire to detect possible cases. In stage 2, those identified with possible seizures and a proportion of those screening negative were invited to local clinics for clinical and neurological assessments by a neurologist. Seizures were classified following the International League Against Epilepsy recommendations. We adjusted for attrition between the two stages using multiple imputations and for sensitivity by dividing estimates by the sensitivity value of the screening tool. Complementary log-log regression was used to assess prevalence differences by participant socio-demographics.

FINDINGS

A total of 56 425 individuals were screened during stage 1 (between Sept 17 and Dec 23, 2021) during which 1126 were classified as potential epilepsy cases. A total of 873 were assessed by a neurologist in stage 2 (between April 12 and Aug 6, 2022) during which 528 were confirmed as epilepsy cases. 253 potential cases were not assessed by a neurologist due to attrition. 30 179 (53·5%) of the 56 425 individuals were male and 26 246 (46·5%) were female. The median age was 24 years (IQR 11-35). Attrition-adjusted and sensitivity-adjusted prevalence for all types of epilepsy was 11·9 cases per 1000 people (95% CI 11·0-12·8), convulsive epilepsy was 8·7 cases per 1000 people (8·0-9·6), and non-convulsive epilepsy was 3·2 cases per 1000 people (2·7-3·7). Overall prevalence was highest among separated or divorced individuals at 20·3 cases per 1000 people (95% CI 15·9-24·7), unemployed people at 18·8 cases per 1000 people (16·2-21·4), those with no formal education at 18·5 cases per 1000 people (16·3-20·7), and adolescents aged 13-18 years at 15·2 cases per 1000 people (12·0-18·5). The epilepsy diagnostic gap was 80%.

INTERPRETATION

Epilepsy is common in urban informal settlements of Nairobi, with large diagnostic gaps. Targeted interventions are needed to increase early epilepsy detection, particularly among vulnerable groups, to enable prompt treatment and prevention of adverse social consequences.

FUNDING

National Institute for Health Research using Official Development Assistance.

Knowledge, attitudes, and practices of caregivers with children diagnosed with epilepsy attending a pediatric outpatient clinic: a descriptive, cross-sectional, questionnaire-based study in Addis Ababa, Ethiopia

BACKGROUND

Caregivers' knowledge and attitudes influence help-seeking behavior and treatment decisions of patients with epilepsy, which in turn significantly impacts epilepsy care. In Ethiopia, epilepsy is often misunderstood, associated with misconceptions and accompanied by persistent negative attitudes. The objective of this study is to assess the knowledge, attitude, and practice of caregivers of children with epilepsy.

METHODS

We conducted a hospital-based survey at the Yekatit 12 Hospital Pediatric Neurology Clinic, Addis Ababa, Ethiopia, between May and July 2022. We invited caregivers of children with epilepsy taking one or more daily anti-seizure medications to participate. Caregivers were invited to complete a structured questionnaire with guidance from a trained nurse to estimate knowledge and attitudes towards epilepsy and its treatment. Knowledge and attitudes were categorized as "good" and "favorable" (correct answers to ≥ 50% of questions) or "bad" and "unfavorable" (< 50% correct answers), respectively. Attitudes towards standard care versus non-standard (e.g., spiritual) care were also estimated.

RESULTS

A total of 120 caregivers completed the questionnaire. Many caregivers were familiar with the term 'epilepsy', with more than half (51.7%) having heard or read about it previously. The reported causes of epilepsy varied, with birth injury being the most common cause (44 out of 120 caregivers). Notably, there was association between the caregiver's gender and their knowledge score, with a p-value = 0.05. Caregivers exposed to information about epilepsy through hearing or reading demonstrated significantly higher levels of knowledge, with a p-value < 0.001. Additionally, knowing someone with epilepsy other than the index child was significantly associated with higher knowledge scores (p-value < 0.001). The study also revealed negative attitudes toward epilepsy: for example, 56.7% of surveyed caregivers believed it is unlikely that a child with epilepsy has normal cognitive abilities and 39.1% believed they should never be allowed to attend regular school. Additionally, a high proportion of caregivers (70%) sought alternative treatments (e.g., spiritual help) alongside standard medical care.

CONCLUSIONS

A significant knowledge gap was identified among caregivers, revealing prevalent misconceptions and negative attitudes. Improving epilepsy awareness, attitudes, and practices among caregivers will potentially contribute to overall improved quality of life for children with epilepsy.

New epilepsy therapies in development

Epilepsy is a common brain disorder, characterized by spontaneous recurrent seizures, with associated neuropsychiatric and cognitive comorbidities and increased mortality. Although people at risk can often be identified, interventions to prevent the development of the disorder are not available. Moreover, in at least 30% of patients, epilepsy cannot be controlled by current antiseizure medications (ASMs). As a result of considerable progress in epilepsy genetics and the development of novel disease models, drug screening technologies and innovative therapeutic modalities over the past 10 years, more than 200 novel epilepsy therapies are currently in the preclinical or clinical pipeline, including many treatments that act by new mechanisms. Assisted by diagnostic and predictive biomarkers, the treatment of epilepsy is undergoing paradigm shifts from symptom-only ASMs to disease prevention, and from broad trial-and-error treatments for seizures in general to mechanism-based treatments for specific epilepsy syndromes. In this Review, we assess recent progress in ASM development and outline future directions for the development of new therapies for the treatment and prevention of epilepsy.

Global burden and management of women with epilepsy in pregnancy: A modeling study

BACKGROUND

Most pregnant women with epilepsy do not receive proper medical care, which creates a special burden worldwide. We aimed to qualify this special global burden and assess the impact of different clinical management strategies to reduce it.

METHODS

The data used in this study were extracted from articles published between 2005 and 2022. We calculated the economic costs associated with major burdens experienced by pregnant women with epilepsy. We developed a microsimulation model to estimate the different effects of various interventions and their combinations as integrated strategies for pregnant women with epilepsy and related burden reduction. We also compared the regional differences in disease burden and interventions.

FINDINGS

The total economic burden for pregnant women with epilepsy is estimated to reach $1.8 billion globally annually, which is more than three times the burden for epilepsy alone. Folic acid supplementation is projected to be the most effective intervention, with a 9.1% reduction in major congenital malformations, a 14.9% reduction in autism spectrum disorder, and a 10.8% reduction in offspring-related economic burden globally annually. Integrated strategies are associated with a reduced economic burden of up to $37.7 million annually globally. Folic acid supplementation is the most effective intervention in high- and upper-middle-income countries, whereas changes in antiseizure medication prescriptions are more effective in lower-middle- and low-income countries.

CONCLUSION

This study highlights the huge burden for pregnant women with epilepsy and actions that must be taken to improve their quality of life.

FUNDING

This work was supported by the Sichuan Science and Technology Program (2023YFS0047).

Diagnostic pattern of mental, neurological and substance use disorders at primary health care facilities in Uganda

Integration of diagnosis and treatment for mental, neurological, and substance use (MNS) disorders into primary health care is a recommended strategy to improve access to services in low-and middle-income countries. Despite numerous initiatives for integration of mental health care in Uganda, there has not been an evaluation of health management information system (HMIS) records to determine whether MNS disorders are routinely diagnosed. We sought to determine diagnostic pattern of MNS disorders at primary health facilities in Wakiso and Kampala districts, the most populous regions of Uganda. Lower-level primary health facilities were visited to obtain records from HMIS registers, to document diagnoses of MNS disorders. Secondary data analysis was conducted and descriptive statistics reported. A total of 40 primary health care facilities were visited representing 58.6% of the health facilities in the study districts. More than half (54.8%) and almost all (87.5%) of the lower-level health facilities in Wakiso district and Kampala district respectively were visited. The proportion of MNS disorders diagnosed at lower-level primary health facilities in Uganda is very low with Epilepsy the most common MNS diagnosis recorded. Reasons for such low numbers of diagnoses at primary health facilities are discussed as are possible solutions.

Characterization of anti-seizure medication reduction and discontinuation rates following epilepsy surgery

OBJECTIVE

Many patients pursue epilepsy surgery with the hope of reducing or stopping anti-seizure medications (ASMs), in addition to reducing their seizure frequency and severity. While ASM decrease is primarily driven by surgical outcomes and patient preferences, preoperative estimates of meaningful ASM reduction or discontinuation are uncertain, especially when accounting for the various forking paths possible following intracranial EEG (iEEG), including resection, neuromodulation, or even the absence of further surgery. Here, we characterize in detail the ASM reduction in a large cohort of patients who underwent iEEG, facilitating proactive, early counseling for a complicated cohort considering surgical treatment.

METHODS

We identified a multi-institutional cohort of patients who underwent iEEG between 2001 and 2022, with a minimum of two years follow-up. The total number of ASMs prescribed immediately prior to surgery, choice of investigation modality, and subsequent surgical treatment were extracted for each patient. Primary endpoints included decreases in ASM counts from preoperative baseline to various follow-up intervals.

RESULTS

A total of 284 patients were followed for a median of 6.0 (range 2,22) years after iEEG surgery. Patients undergoing resection saw an average reduction of ∼ 0.5 ASMs. Patients undergoing neuromodulation saw no decrease and trended towards requiring increased ASM usage during long-term follow-up. Only patients undergoing resection were likely to completely discontinue all ASMs, with an increasing probability over time approaching ∼ 10 %. Up to half of resection patients saw ASM decreases, which was largely stable during long-term follow-up, whereas only a quarter of neuromodulation patients saw a reduction, though their ASM reduction decreased over time.

CONCLUSIONS

With the increasing use of stereotactic EEG and non-curative neuromodulation procedures, realistic estimates of ASM reduction and discontinuation should be considered preoperatively. Almost half of patients undergoing resective surgery can expect to reduce their ASMs, though only a tenth can expect to discontinue ASMs completely. If reduction is not seen early, it likely does not occur later during long-term follow-up. Less than a third of patients undergoing neuromodulation can expect ASM reduction, and instead most may require increased usage during long-term follow-up.

Association between dietary zinc intake and epilepsy: findings from NHANES 2013-2018 and a Mendelian randomization study

Background

The association between dietary zinc intake and epilepsy remains unclear. This study aimed to investigate the relationship between zinc intake from the diet and epilepsy, employing Mendelian randomization (MR) to explore potential causal links between zinc and epilepsy.

Methods

The cross-sectional study utilized data from the National Health and Nutrition Examination Survey (NHANES) conducted between 2013 and 2018. Among the 4,434 participants included, 1.5% (67/4,434) reported having epilepsy. Restricted cubic spline models and logistic regression models were employed to examine the relationships between dietary zinc intakes and epilepsy. Subsequently, a 2-sample Mendelian randomization (MR) analysis was conducted using the inverse variance weighted (IVW) approach as the primary analysis.

Results

In the restricted cubic spline (RCS) analysis, the relationship between dietary zinc consumption and epilepsy displayed an L-shaped curve (nonlinear, p = 0.049). After multivariate adjustments, the adjusted odds ratios for epilepsy in T2 (5.0-11.0 mg/day) and T3 (≥11.0 mg/day) were 0.49 (95% confidence interval [CI]: 0.26-0.92, p = 0.026) and 0.60 (95% CI: 0.31-1.17, p = 0.132), respectively, compared to the lowest dietary zinc consumption tertile (T1, ≤5.0 mg/day). The IVW method indicated that genetically predicted zinc intake per standard-deviation increase was inversely associated with three types of epilepsy, including all types of epilepsy (OR = 1.06, 95% CI: 1.02-1.11, p = 0.008), generalized epilepsy (OR = 1.13, 95% CI: 1.01-1.25, p = 0.030), and focal epilepsy (documented hippocampal sclerosis) (OR = 1.01, 95% CI: 1.00-1.02, p = 0.025).

Conclusion

Our findings suggest that a daily zinc intake ranging from 5.0 to 11.0 mg is associated with the lowest risk of epilepsy. Furthermore, Mendelian randomization (MR) studies provide additional support for the existence of a causal relationship between zinc and epilepsy.

High precision in epileptic seizure self-reporting with an app diary

People with epilepsy frequently under- or inaccurately report their seizures, which poses a challenge for evaluating their treatment. The introduction of epilepsy health apps provides a novel approach that could improve seizure documentation. This study assessed the documentation performance of an app-based seizure diary and a conventional paper seizure diary. At two tertiary epilepsy centers patients were asked to use one of two offered methods to report their seizures (paper or app diary) during their stay in the epilepsy monitoring unit. The performances of both methods were assessed based on the gold standard of video-EEG annotations. In total 89 adults (54 paper and 35 app users) with focal epilepsy were included in the analysis, of which 58 (33 paper and 25 app users) experienced at least one seizure and made at least one seizure diary entry. We observed a high precision of 85.7% for the app group, whereas the paper group's precision was lower due to overreporting (66.9%). Sensitivity was similar for both methods. Our findings imply that performance of seizure self-reporting is patient-dependent but is more precise for patients who are willing to use digital apps. This may be relevant for treatment decisions and future clinical trial design.

Effects of co-administration of lamotrigine on valproate transfer across the placenta and its brain entry in developing Genetic Absence Epilepsy Rats from Strasbourg (GAERS)

During development, embryos and foetuses may be exposed to maternally ingested antiseizure medications (ASM), valproate and lamotrigine, essential in some patients to control their epilepsy symptoms. Often, the two drugs are co-administered to reduce required doses of valproate, a known potential teratogen. This study used Genetic Absence Epilepsy Rat from Strasbourg to evaluate transfer of valproate and lamotrigine across late gestation placenta and their entry into cerebrospinal fluid (CSF) and brain of developing rats, in mono- and combination therapies. Animals at embryonic day (E) 19, postnatal day (P) 0, 4 and 21, and adults were administered valproate (30 mg/kg) or lamotrigine (6 mg/kg) with their respective [3H]-tracers, either alone or in combination. In chronic experiments, females consumed valproate-containing diet from 2 weeks prior to mating until offspring were used at E19 and P0. Drugs were injected 30 min before blood, CSF and brain samples were collected from terminally anaesthetised animals. Radioactivity in samples was measured. In acute monotherapy brain entry of valproate was higher in foetal than postnatal animals, correlating with its plasma protein binding. Brain entry of lamotrigine was not age-dependent. Combination therapy enhanced entry of lamotrigine into the adult brain but had no effects on brain and CSF entry of valproate. Following chronic valproate exposure, placental transfer of valproate decreased in combination therapy; however, foetal brain entry increased. Results suggest that during pregnancy, the use of combination therapy of valproate and lamotrigine may mitigate overall foetal exposure to valproate but potential risks to foetal brain development are less clear.

Reduced expression of NUPR1 alleviates epilepsy progression via attenuating ER stress

Epilepsy is a neurological disorder characterized by recurring seizures. It is necessary to further understand the mechanisms of epilepsy in order to develop novel strategies for its prevention and treatment. Abnormal endoplasmic reticulum stress (ERS) activation is related to the pathogenesis of epilepsy. Nuclear protein 1, transcriptional regulator (NUPR1) is involved in ERS and it might play a role in epilepsy progression. In the present study, we generated an epileptic mouse model using pilocarpine induction. After 72 h of pilocarpine treatment, the expression of NUPR1 was increased in epileptic mice. Furthermore, NUPR1 knockdown reduced the number of spontaneous recurrent seizures and alleviated hippocampal damage in these mice. Interestingly, NUPR1 knockdown also reduced the protein expression levels of LC3, PINK1, and Parkin in the mitochondria, and decreased the PINK1 expression in hippocampus. Additionally, the expression of ERS-related proteins-cleaved caspase-12, ATF4, and CHOP-decreased in epileptic mice following NUPR1 knockdown. In vitro experiments showed that the absence of NUPR1 reduced the expression of ATF4, CHOP, and cleaved caspase-12 in hippocampal neurons and inhibited the neuron apoptosis. In all, our study suggested that NUPR1 maybe a potential molecular target for epilepsy therapy.

Effects of levetiracetam on bone mineral density and bone metabolism in patients with epilepsy: A systematic review and meta-analysis

PURPOSE

The effects of levetiracetam (LEV) on bone mineral density (BMD) and bone metabolism are currently inconclusive, and this study was designed to answer this question.

METHODS

Citations from PubMed, Embase, Cochrane Library, and Web of Science databases (up to February 4, 2024) were reviewed. The effects of LEV on BMD as well as bone metabolism indicators were measured by calculating the standardized mean difference (SMD) with a 95% confidence interval (CI). This study was registered with PROSPERO (CRD42024509560).

RESULTS

A total of 612 individuals from 13 studies were included in the present analysis. Of the items related to bone metabolism, LEV was found to be associated significantly with decreased serum calcium with an SMD of -0.47 (95 % CI, -0.77- -0.16; p = 0.04). However, changes in other markers (including serum phosphorus, 25-hydroxyvitamin D, alkaline phosphatase, and parathyroid hormone) were not statistically significantly correlated with the use of LEV (p > 0.05). Also, when compared to the control groups, the changes in BMD of the observation groups were not significant (p > 0.05).

CONCLUSIONS

The use of LEV may significantly reduce serum calcium in patients with epilepsy, and regular monitoring of bone metabolism-related indicators is recommended.

Distinct plasma metabolomic signatures differentiate autoimmune encephalitis from drug-resistant epilepsy

OBJECTIVE

Differentiating forms of autoimmune encephalitis (AE) from other causes of seizures helps expedite immunotherapies in AE patients and informs studies regarding their contrasting pathophysiology. We aimed to investigate whether and how Nuclear Magnetic Resonance (NMR)-based metabolomics could differentiate AE from drug-resistant epilepsy (DRE), and stratify AE subtypes.

METHODS

This study recruited 238 patients: 162 with DRE and 76 AE, including 27 with contactin-associated protein-like 2 (CASPR2), 29 with leucine-rich glioma inactivated 1 (LGI1) and 20 with N-methyl-d-aspartate receptor (NMDAR) antibodies. Plasma samples across the groups were analyzed using NMR spectroscopy and compared with multivariate statistical techniques, such as orthogonal partial least squares discriminant analysis (OPLS-DA).

RESULTS

The OPLS-DA model successfully distinguished AE from DRE patients with a high predictive accuracy of 87.0 ± 3.1% (87.9 ± 3.4% sensitivity and 86.3 ± 3.6% specificity). Further, pairwise OPLS-DA models were able to stratify the three AE subtypes. Plasma metabolomic signatures of AE included decreased high-density lipoprotein (HDL, -(CH2)n-, -CH3), phosphatidylcholine and albumin (lysyl moiety). AE subtype-specific metabolomic signatures were also observed, with increased lactate in CASPR2, increased lactate, glucose, and decreased unsaturated fatty acids (UFA, -CH2CH=) in LGI1, and increased glycoprotein A (GlycA) in NMDAR-antibody patients.

INTERPRETATION

This study presents the first non-antibody-based biomarker for differentiating DRE, AE and AE subtypes. These metabolomics signatures underscore the potential relevance of lipid metabolism and glucose regulation in these neurological disorders, offering a promising adjunct to facilitate the diagnosis and therapeutics.

Narrative Review of Brivaracetam: Preclinical Profile and Clinical Benefits in the Treatment of Patients with Epilepsy

One third of patients with epilepsy will continue to have uncontrolled seizures despite treatment with antiseizure medications (ASMs). There is therefore a need to develop novel ASMs. Brivaracetam (BRV) is an ASM that was developed in a major drug discovery program aimed at identifying selective, high-affinity synaptic vesicle protein 2A (SV2A) ligands, the target molecule of levetiracetam. BRV binds to SV2A with 15- to 30-fold higher affinity and greater selectivity than levetiracetam. BRV has broad-spectrum antiseizure activity in animal models of epilepsy, a favorable pharmacokinetic profile, few clinically relevant drug-drug interactions, and rapid brain penetration. BRV is available in oral and intravenous formulations and can be initiated at target dose without titration. Efficacy and safety of adjunctive BRV (50-200 mg/day) treatment of focal-onset seizures was demonstrated in three pivotal phase III trials (NCT00490035/NCT00464269/NCT01261325), including in patients who had previously failed levetiracetam. Efficacy and safety of adjunctive BRV were also demonstrated in adult Asian patients with focal-onset seizures (NCT03083665). In several open-label trials (NCT00150800/NCT00175916/NCT01339559), long-term safety and tolerability of adjunctive BRV was established, with efficacy maintained for up to 14 years, with high retention rates. Evidence from daily clinical practice highlights BRV effectiveness and tolerability in specific epilepsy patient populations with high unmet needs: the elderly (≥ 65 years of age), children (< 16 years of age), patients with cognitive impairment, patients with psychiatric comorbid conditions, and patients with acquired epilepsy of specific etiologies (post-stroke epilepsy/brain tumor related epilepsy/traumatic brain injury-related epilepsy). Here, we review the preclinical profile and clinical benefits of BRV from pivotal trials and recently published evidence from daily clinical practice.

Focal cooling: An alternative treatment for drug-resistant epilepsy in a mesial temporal lobe epilepsy primate model-A preliminary study

OBJECTIVE

Focal cooling is emerging as a relevant therapy for drug-resistant epilepsy (DRE). However, we lack data on its effectiveness in controlling seizures that originate in deep-seated areas like the hippocampus. We present a thermoelectric solution for focal brain cooling that specifically targets these brain structures.

METHODS

A prototype implantable device was developed, including temperature sensors and a cannula for penicillin injection to create an epileptogenic zone (EZ) near the cooling tip in a non-human primate model of epilepsy. The mesial temporal lobe was targeted with repeated penicillin injections into the hippocampus. Signals were recorded from an sEEG (Stereoelectroencephalography) lead placed 2 mm from the EZ. Once the number of seizures had stabilized, focal cooling was applied, and temperature and electroclinical events were monitored using a customized detection algorithm. Tests were performed on two Macaca fascicularis monkeys at three temperatures.

RESULTS

Hippocampal seizures were observed 40-120 min post-injection, their duration and frequency stabilized at around 120 min. Compared to the control condition, a reduction in the number of hippocampal seizures was observed with cooling to 21°C (Control: 4.34 seizures, SD 1.704 per 20 min vs Cooling to 21°C: 1.38 seizures, SD 1.004 per 20 min). The effect was more pronounced with cooling to 17°C, resulting in an almost 80% reduction in seizure frequency. Seizure duration and number of interictal discharges were unchanged following focal cooling. After several months of repeated penicillin injections, hippocampal sclerosis was observed, similar to that recorded in humans. In addition, seizures were identified by detecting temperature variations of 0.3°C in the EZ correlated with the start of the seizures.

SIGNIFICANCE

In epilepsy therapy, the ultimate aim is total seizure control with minimal side effects. Focal cooling of the EZ could offer an alternative to surgery and to existing neuromodulation devices.

Effects of an intervention program to improve mental health and epilepsy care in Madagascar

BACKGROUND

Despite the high prevalence of mental disorders and epilepsy in low- and middle-income countries, nearly 80% of patients are not treated. In Madagascar, initiatives to improve access to epilepsy and mental health care, including public awareness and training of general practitioners (GPs), were carried out between 2013 and 2018. Our study's main objective was to assess the effectiveness of these initiatives, two to five years post-intervention.

METHODS

This quasi-experimental study (intervention vs. control areas) included five surveys assessing: general population's Knowledge Attitudes and Practices (KAP), GPs' KAP , number of epilepsy and mental health consultations at different levels of the healthcare system, diagnostic accuracy, and treatments' availability.

OUTCOMES

In the general population, KAP scores were higher in intervention areas for epilepsy (11.4/20 vs. 10.3/20; p = 0.003). For mental disorders, regardless of the area, KAP scores were low, especially for schizophrenia (1.1/20 and 0.1/20). Among GPs, KAP scores were higher in intervention areas for schizophrenia (6.0/10 vs. 4.5/10; p = 0.008) and epilepsy (6.9/10 vs. 6.2/10; p = 0.044). Overall, there was a greater proportion of mental health and epilepsy consultations in intervention areas (4.5% vs 2.3%). Although low, concordance between GPs' and psychiatrists' diagnoses was higher in intervention areas. There was a greater variety of anti-epileptic and psychotropic medications available in intervention areas.

INTERPRETATION

This research has helped to better understand the effectiveness of initiatives implemented in Madagascar to improve epilepsy and mental health care and to identify barriers which will need to be addressed.

FUNDING

Sanofi Global Health, as part of the Fight Against STigma Program.

Quality of life and associated factors among people with epilepsy in Ethiopia: a systematic review and meta-analysis

BACKGROUND

Epilepsy is a global health and economic burden with major problems that have an impact on physical, psychological, and social activities. Quality of life (QoL) is often disturbed and can be influenced by many factors, like anti-seizure medication side effects, the sociocultural environment, and various disease-related factors. The aim of this systematic review and meta-analysis is to provide an overview of the most recent information available regarding the pooled prevalence of poor quality of life and associated factors among adult people with epilepsy in Ethiopia.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) is an appropriate set of guidelines for reporting systematic reviews and meta-analyses. This systematic review and meta-analysis protocol was registered on the International Prospective Register of Systematic Reviews (PROSPERO) with CRD42024527914. To find publications for the systematic review and meta-analysis, we used both manual and electronic searches. The publications were searched by PubMed, MEDLINE, EMBASE, Cochrane Library, Scopus, and other grey publications were searched by Google Scholar. The Joanna Briggs Institute (JBI) for cross-sectional study quality assessment was employed to evaluate the methodological quality of the studies included in this review. The data was extracted in Microsoft Excel, and then it was exported into STATA 11.0 for analysis. A funnel plot and an objective examination of Egger's regression test were used to check for publication bias.

RESULTS

We have included 7 studies conducted in Ethiopia with 2123 study participants, of whom 1163 (54.78%) were male individuals, and 1196 (56.34%) of the participants were living without marriage (either single, divorced, or widowed). The pooled prevalence of poor quality of life among people with epilepsy in Ethiopia is 45.07 (95% CI: 39.73-50.42%). Further, in subgroup analysis regarding the assessment tool of poor quality of life of people with epilepsy, QOLIE-31 accounted for 50.05% (95%CI: 46.65-53.45) and WHO QOL BREF accounted for 39.72% (95%CI: 27.67-51.78). Among the associated factors, being unable to read and write, anxiey and depression were significantly linked to the quality of life of people with epilepsy.

CONCLUSION

This review found that there was a high pooled prevalence of poor quality of life related to people with epilepsy in Ethiopia. This study may provide further information to concerned bodies that do early screening and manage the quality of life of individuals with epilepsy. Also, screening and intervention for anxiety and depression problems should be considered in regular epilepsy care management.

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.

Automatic detection of epilepsy from EEGs using a temporal convolutional network with a self-attention layer

BACKGROUND

Over 60% of epilepsy patients globally are children, whose early diagnosis and treatment are critical for their development and can substantially reduce the disease's burden on both families and society. Numerous algorithms for automated epilepsy detection from EEGs have been proposed. Yet, the occurrence of epileptic seizures during an EEG exam cannot always be guaranteed in clinical practice. Models that exclusively use seizure EEGs for detection risk artificially enhanced performance metrics. Therefore, there is a pressing need for a universally applicable model that can perform automatic epilepsy detection in a variety of complex real-world scenarios.

METHOD

To address this problem, we have devised a novel technique employing a temporal convolutional neural network with self-attention (TCN-SA). Our model comprises two primary components: a TCN for extracting time-variant features from EEG signals, followed by a self-attention (SA) layer that assigns importance to these features. By focusing on key features, our model achieves heightened classification accuracy for epilepsy detection.

RESULTS

The efficacy of our model was validated on a pediatric epilepsy dataset we collected and on the Bonn dataset, attaining accuracies of 95.50% on our dataset, and 97.37% (A v. E), and 93.50% (B vs E), respectively. When compared with other deep learning architectures (temporal convolutional neural network, self-attention network, and standardized convolutional neural network) using the same datasets, our TCN-SA model demonstrated superior performance in the automated detection of epilepsy.

CONCLUSION

The proven effectiveness of the TCN-SA approach substantiates its potential as a valuable tool for the automated detection of epilepsy, offering significant benefits in diverse and complex real-world clinical settings.

Drug-Resistant Epilepsy: Experience From a Tertiary Care Center in Saudi Arabia

Objectives This study aimed to describe the clinical characteristics, investigational results, and management strategies in patients with drug-resistant epilepsy (DRE). Methods This retrospective cohort study included all adult and adolescent patients (aged 14 years or older) diagnosed with DRE who visited the adult neurology clinic at King Abdulaziz Medical City, Jeddah, Saudi Arabia from January 2019 to December 2021. DRE was defined as failure to achieve seizure freedom despite undergoing adequate trials of two well-tolerated and appropriately selected antiseizure medications. Results This study included 299 patients with DRE. Most patients were in their second to fourth decade, with a mean age of 37 ± 17 years. Focal onset epilepsy was diagnosed in 52.5% of the patients, and an etiology for epilepsy was determined in 44.1% of the patients. Findings in brain magnetic resonance imaging were abnormal in 49% of the patients, whereas abnormal findings in electroencephalograms were found in 27.5%. The most common antiseizure medication was levetiracetam (67.6% of cases). Conclusion The findings of this study confirm the challenges in diagnosing and managing patients with DRE and emphasize the necessity for careful and comprehensive patient evaluation. Further research is needed to investigate the effectiveness, safety, and accessibility of diagnostic and therapeutic resources for patients with DRE.

Attention deficit hyperactivity disorder in children with epilepsy: a multicenter cross-sectional analysis in China

BACKGROUND

The diagnosis and treatment of attention deficit hyperactivity disorder (ADHD) comorbid with epilepsy have been insufficiently addressed in China. We conducted a study in China to investigate the current status, diagnosis, and treatment of ADHD in children to further our understanding of ADHD comorbid with epilepsy, strengthen its management, and improve patients' quality of life.

METHODS

We carried out a multicenter cross-sectional survey of children with epilepsy across China between March 2022 and August 2022. We screened all patients for ADHD and compared various demographic and clinical factors between children with and without ADHD, including gender, age, age at epilepsy onset, duration of epilepsy, seizure types, seizure frequency, presence of epileptiform discharges, and treatment status. Our objective was to explore any possible associations between these characteristics and the prevalence of ADHD.

RESULTS

Overall, 395 epilepsy patients aged 6-18 years were enrolled. The age at seizure onset and duration of epilepsy ranged from 0.1-18 to 0.5-15 years, respectively. Focal onset seizures were observed in 212 (53.6%) patients, while 293 (76.3%) patients had epileptiform interictal electroencephalogram (EEG) abnormalities. Among the 370 patients treated with anti-seizure medications, 200 (54.1%) had monotherapy. Although 189 (47.8%) patients had ADHD, only 31 received treatment for it, with the inattentive subtype being the most common. ADHD was more common in children undergoing polytherapy compared to those on monotherapy. Additionally, poor seizure control and the presence of epileptiform interictal EEG abnormalities may be associated with a higher prevalence of ADHD.

CONCLUSIONS

While the prevalence of ADHD was higher in children with epilepsy than in normal children, the treatment rate was notably low. This highlights the need to give more importance to the diagnosis and treatment of ADHD in children with epilepsy.

Estimating the active and lifetime prevalence and incidence of epilepsy in Asian Countries: A systematic review and meta-analysis

OBJECTIVE

In the current era of the World Health Organization's Intersectoral Global Action Plan on Epilepsy and Other Neurological Disorders 2022-2031 (IGAP), precise and updated estimates of epilepsy burden are vital in formulating policies to improve the care of persons with epilepsy, especially in Asian countries with significant treatment gap. Hence, we aimed to consolidate the available data and quantify epilepsy prevalence and incidence estimates in Asian countries.

METHODS

We systematically searched PubMed, Embase, Ovid, and Scopus databases from inception until March 2023 for studies reporting epilepsy prevalence and incidence in Asian countries. We applied random effects meta-analysis to generate the pooled prevalence and incidence using the Meta package in R. Additionally, we performed a subgroup meta-analysis to explore the potential sources of heterogeneity. A meta-regression analysis was conducted to examine the trend of epilepsy over time.

RESULTS

A total of 99 studies with 100,654,124 participants were included in the meta-analysis. The pooled prevalence was 5.6 per 1000 (95 % confidence interval (CI) 4.4-6.8) for active epilepsy and 6.7 per 1000 (95 % CI 5.7-7.9) for lifetime epilepsy. The pooled incidence rate of epilepsy was 52.5 per 100,000 person-years (95 % CI 42.7-79.4). The subgroup analysis revealed a higher prevalence of active epilepsy (6.7/1000) and lifetime epilepsy (8.6/1000) in West Asia than in other regions. The funnel plot and Egger's test (p-value =<0.0001) revealed publication bias for active epilepsy.

CONCLUSION

Our findings highlight a high prevalence of active and lifetime epilepsy in West Asia and emphasize the necessity of implementing and formulating specific strategies to tackle the epilepsy burden in this region. Furthermore, high-quality epidemiological studies incorporating economic burdens and comorbidities associated with epilepsy in Asia are still needed.

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

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

Improving epilepsy diagnosis across the lifespan: approaches and innovations

Epilepsy diagnosis is often delayed or inaccurate, exposing people to ongoing seizures and their substantial consequences until effective treatment is initiated. Important factors contributing to this problem include delayed recognition of seizure symptoms by patients and eyewitnesses; cultural, geographical, and financial barriers to seeking health care; and missed or delayed diagnosis by health-care providers. Epilepsy diagnosis involves several steps. The first step is recognition of epileptic seizures; next is classification of epilepsy type and whether an epilepsy syndrome is present; finally, the underlying epilepsy-associated comorbidities and potential causes must be identified, which differ across the lifespan. Clinical history, elicited from patients and eyewitnesses, is a fundamental component of the diagnostic pathway. Recent technological advances, including smartphone videography and genetic testing, are increasingly used in routine practice. Innovations in technology, such as artificial intelligence, could provide new possibilities for directly and indirectly detecting epilepsy and might make valuable contributions to diagnostic algorithms in the future.

Anti-epileptic and Neuroprotective Effects of Ultra-low Dose NADPH Oxidase Inhibitor Dextromethorphan on Kainic Acid-induced Chronic Temporal Lobe Epilepsy in Rats

Neuroinflammation mediated by microglia and oxidative stress play pivotal roles in the development of chronic temporal lobe epilepsy (TLE). We postulated that kainic acid (KA)-Induced status epilepticus triggers microglia-dependent inflammation, leading to neuronal damage, a lowered seizure threshold, and the emergence of spontaneous recurrent seizures (SRS). Extensive evidence from our laboratory suggests that dextromethorphan (DM), even in ultra-low doses, has anti-inflammatory and neuroprotective effects in many animal models of neurodegenerative disease. Our results showed that administration of DM (10 ng/kg per day; subcutaneously via osmotic minipump for 4 weeks) significantly mitigated the residual effects of KA, including the frequency of SRS and seizure susceptibility. In addition, DM-treated rats showed improved cognitive function and reduced hippocampal neuronal loss. We found suppressed microglial activation-mediated neuroinflammation and decreased expression of hippocampal gp91phox and p47phox proteins in KA-induced chronic TLE rats. Notably, even after discontinuation of DM treatment, ultra-low doses of DM continued to confer long-term anti-seizure and neuroprotective effects, which were attributed to the inhibition of microglial NADPH oxidase 2 as revealed by mechanistic studies.

Respiratory activity during seizures induced by pentylenetetrazole

This study investigated the respiratory activity in adult Wistar rats across different behavioral seizure severity induced by pentylenetetrazole (PTZ). Animals underwent surgery for electrodes implantation, allowing simultaneous EEG and diaphragm EMG (DIAEMG) recordings and the respiratory frequency and DIAEMG amplitude were measured. Seizures were acutely induced through PTZ injection and classified based on a pre-established score, with absence-like seizures (spike wave discharge (SWD) events on EEG) representing the lowest score. The respiratory activity was grouped into the different seizure severities. During absence-like and myoclonic jerk seizures, the breathing frequency decreased significantly (∼50% decrease) compared to pre- and post-ictal periods. Pronounced changes occurred with more severe seizures (clonic and tonic) with periods of apnea, especially during tonic seizures. Apnea duration was significantly higher in tonic compared to clonic seizures. Notably, during PTZ-induced tonic seizures the apnea events were marked by tonic DIAEMG contraction (tonic-phase apnea). In the majority of animals (5 out of 7) this was a fatal event in which the seizure-induced respiratory arrest preceded the asystole. In conclusion, we provide an assessment of the respiratory activity in the PTZ-induced acute seizures and showed that breathing dysfunction is more pronounced in seizures with higher severity.

Insights into epileptogenesis from post-traumatic epilepsy

Post-traumatic epilepsy (PTE) accounts for 5% of all epilepsies. The incidence of PTE after traumatic brain injury (TBI) depends on the severity of injury, approaching one in three in groups with the most severe injuries. The repeated seizures that characterize PTE impair neurological recovery and increase the risk of poor outcomes after TBI. Given this high risk of recurrent seizures and the relatively short latency period for their development after injury, PTE serves as a model disease to understand human epileptogenesis and trial novel anti-epileptogenic therapies. Epileptogenesis is the process whereby previously normal brain tissue becomes prone to recurrent abnormal electrical activity, ultimately resulting in seizures. In this Review, we describe the clinical course of PTE and highlight promising research into epileptogenesis and treatment using animal models of PTE. Clinical, imaging, EEG and fluid biomarkers are being developed to aid the identification of patients at high risk of PTE who might benefit from anti-epileptogenic therapies. Studies in preclinical models of PTE have identified tractable pathways and novel therapeutic strategies that can potentially prevent epilepsy, which remain to be validated in humans. In addition to improving outcomes after TBI, advances in PTE research are likely to provide therapeutic insights that are relevant to all epilepsies.

Replacement of traditional vagus nerve stimulation with cardiac-based device and seizure reduction: A systematic review and meta-analysis

INTRODUCTION

For patients with drug-resistant epilepsy (DRE) who are not suitable for surgical resection, neuromodulation with vagus nerve stimulation (VNS) is an established approach. However, there is limited evidence of seizure reduction when replacing traditional VNS (tVNS) device with a cardiac-based one (cbVNS). This meta-analysis compares the seizure reduction achieved by replacing tVNS with cbVNS in a population with DRE.

METHODS

We systematically searched PubMed, Embase, and Cochrane Central following PRISMA guidelines. The main outcomes were number of patients experiencing a ≥ 50 % and ≥80 % reduction in seizures, as defined by the McHugh scale. Additionally, we assessed the number of patients achieving freedom from seizures.

RESULTS

We included 178 patients with DRE from 7 studies who were initially treated with tVNS and subsequently had it replaced by cbVNS. The follow-up for cbVNS ranged from 6 to 37.5 months. There was a statistically significant reduction in seizure frequency with the replacement of tVNS by cbVNS, using a ≥ 50 % (OR 1.79; 95 % CI 1.07 to 2.97; I²=0 %; p = 0.03) and a ≥ 80 % (OR 2.06; 95 % CI 1.17 to 3.62; I²=0 %; p = 0.01) reduction threshold. Nineteen (13 %) participants achieved freedom from seizures after switching to cbVNS. There was no difference in the rate of freedom from seizures between groups (OR 1.85; 95 % CI 0.81 to 4.21; I²=0 %; p = 0.14).

CONCLUSION

In patients with DRE undergoing battery replacement, cbVNS might be associated with seizure reduction (≥50 % and ≥80 % threshold) after switching from tVNS. Randomised controlled trials are necessary to validate these findings.

Mediating effects of sleep quality between clinical characteristics and quality of life in children with epilepsy: A cross-sectional study from Southwest China

BACKGROUND

Although sleep quality (SQ) reportedly affects the health-related quality of life (QOL) of patients with epilepsy, little is known about the potential association between SQ and QOL, particularly in children with epilepsy (CWE). Our study aimed to investigate the mediating effect of SQ on the QOL of CWE to obtain more information for the prevention and treatment of epilepsy in children.

METHODS

We collected general demographic and clinical data of 212 CWE and 79 controls (children who visited the Health Examination Department), and their guardians were instructed to answer the Children's Sleep Habits Questionnaire (CSHQ) and the optimized Quality of Life in Childhood Epilepsy Questionnaire-16 (QOLCE-16). The t-test, analysis of variance, chi-square test, and Fisher's exact test were used for between group comparisons. The Pearson correlation was used to analyze the correlation between variables. The direct, indirect, and total effects of predictors on the QOL of CWE were estimated based on an adjusted mediation model.

RESULTS

CWE had significantly smaller long-term urban residence rates, less educated guardians, higher total CSHQ score, higher incidence of poor SQ, higher bedtime resistance, more sleep anxiety, worse sleep-disordered breathing, increased parasomnia, more daytime sleepiness, more frequent night waking, and greater sleep onset delay than controls (P < 0.05 for all). The univariable analysis showed significant differences in total CSHQ scores between CWE with different seizure frequency in the last month, whether or not drug-resistant epilepsy (DRE), and with different video electroencephalogram (VEEG) findings (P < 0.05 for all). Differences in QOLCE-16 scores between CWE with different guardian's employment status, age at diagnosis, number of anti-seizure medication (ASM) types, seizure frequency in the last month, DRE status, seizure type, VEEG findings, neuropsychological evaluation findings, magnetic resonance imaging (MRI) findings, and etiology were statistically significant (P < 0.05 for all). The correlation study indicated that the total CSHQ score was negatively correlated with the QOLCE-16 score (P < 0.05). The mediation analysis showed that DRE and VEEG abnormalities had a standardized direct effect on the QOL. Seizure frequency in the last month, DRE, and VEEG abnormalities had an indirect effect on the QOL through SQ, and their mediating effect values of SQ were 31.61 %, 13.45 %, and 14.35 %, respectively.

CONCLUSION

Our findings uncovered the relationship of some clinical characteristics with SQ and QOL and characterized the nature of factors affecting the QOL of CWE. SQ could be a key factor in the prognosis of CWE experiencing epileptic seizures, and more attention should be paid on the management of SQ in interventions for epilepsy.

Behavioral and neurotransmitter changes on antiepileptic drugs treatment in the zebrafish pentylenetetrazol-induced seizure model

Epilepsy, a recurrent neurological disorder involving abnormal neurotransmitter kinetics in the brain, has emerged as a global health concern. The mechanism of epileptic seizures is thought to involve a relative imbalance between excitatory and inhibitory neurotransmitters. Despite the recent advances in clinical and basic research on the pathogenesis of epilepsy, the complex relationship between the neurotransmitter changes and behavior with and without antiepileptic drugs (AEDs) during seizures remains unclear. To investigate the effects of AEDs such as levetiracetam (LEV), carbamazepine (CBZ), and fenfluramine (FFR) on key neurotransmitters in the pentylenetetrazol (PTZ)-induced seizures in adult zebrafish, we examined the changes in glutamic acid, gamma-aminobutyric acid (GABA), serotonin (5-HT), 5-hydroxyindoleacetic acid (5-HIAA), choline, acetylcholine, norepinephrine, dopamine (DA), 3,4-dihydroxyphenylacetic acid (DOPAC), and adenosine. In this study, we observed that 5-HT and DA levels in the brain increased immediately after PTZ-induced seizures. Behavioral tests clearly showed that all of these AEDs suppressed the PTZ-induced seizures. Upon treatment of PTZ-induced seizures with these AEDs, CBZ decreased the glutamic acid and FFR increased the GABA levels; however, no neurotransmitter changes were observed in the brain after LEV administration. Thus, we demonstrated a series of neurotransmitter changes linked to behavioral changes during PTZ-induced epileptic seizures when LEV, CBZ, or FFR were administered. These findings will lead to a more detailed understanding of the pathogenesis of epilepsy associated with behavioral and neurotransmitter changes under AED treatment.

Canadian Practice and Recommendations on Functional MRI to Lateralize Language in Epilepsy

BACKGROUND/OBJECTIVE

Identifying a patient's dominant language hemisphere is an important evaluation performed prior to epilepsy surgery and is commonly assessed using functional magnetic resonance imaging (fMRI). However, the lack of standardization and resultant heterogeneity of fMRI paradigms used in clinical practice limits the ability of cross-center comparisons to be made regarding language laterality results.

METHODS

Through surveying Canadian Epilepsy Centres in combination with reviewing supporting literature, current fMRI language lateralization practices for the clinical evaluation of patients with epilepsy were assessed. To encourage standardization of this practice, we outlined a two-part paradigm series that demonstrates widespread acceptance, reliability and accessibility in lateralizing various aspects of language functioning in individuals with average or near-average IQ and normal literacy skills.

RESULTS

The collected data confirm a lack of standardization in fMRI laterality assessments leading to clinical heterogeneity in stimulation and control tasks, paradigm design and timing, laterality index calculations, thresholding values and analysis software and technique. We suggest a Sentence Completion (SC) and Word Generation (WG) paradigm series as it was most commonly employed across Canada, demonstrated reliability in lateralizing both receptive and expressive language areas in supporting literature, and could be readily intelligible to an inclusive population.

CONCLUSION

Through providing recommendations for a two-part paradigm series, we hope to contribute to the standardization of this practice across Canada to reduce clinical heterogeneity, encourage communicability between institutions, and enhance methodologies for the surgical treatment of epilepsy for the benefit of all individuals living with epilepsy in Canada.

Multiscale distribution entropy analysis of short epileptic EEG signals

This paper proposes an information-theoretic measure for discriminating epileptic patterns in short-term electroencephalogram (EEG) recordings. Considering nonlinearity and nonstationarity in EEG signals, quantifying complexity has been preferred. To decipher abnormal epileptic EEGs, i.e., ictal and interictal EEGs, via short-term EEG recordings, a distribution entropy (DE) is used, motivated by its robustness on the signal length. In addition, to reflect the dynamic complexity inherent in EEGs, a multiscale entropy analysis is incorporated. Here, two multiscale distribution entropy (MDE) methods using the coarse-graining and moving-average procedures are presented. Using two popular epileptic EEG datasets, i.e., the Bonn and the Bern-Barcelona datasets, the performance of the proposed MDEs is verified. Experimental results show that the proposed MDEs are robust to the length of EEGs, thus reflecting complexity over multiple time scales. In addition, the proposed MDEs are consistent irrespective of the selection of short-term EEGs from the entire EEG recording. By evaluating the Man-Whitney U test and classification performance, the proposed MDEs can better discriminate epileptic EEGs than the existing methods. Moreover, the proposed MDE with the moving-average procedure performs marginally better than one with the coarse-graining. The experimental results suggest that the proposed MDEs are applicable to practical seizure detection applications.

Mental health and neurodevelopmental patient-reported outcome measures (PROMs) for children and young people with epilepsy: A systematic review

Children and young people with epilepsy are at higher risk of mental health disorders and atypical neurodevelopmental outcomes compared to the general population. It is essential to detect such comorbidities early in children with epilepsy and provide appropriate interventions, to improve clinical outcomes. We aimed to identify and evaluate the measurement properties of Patient-Reported Outcome Measures (PROMs) that have been validated specifically to measure mental health and neurodevelopmental outcomes in children and/or young people with epilepsy. We searched Embase, Medline, and PsycINFO in May 2023 for relevant studies. Mental health was defined as psychological symptoms (e.g., anxiety, depression, psychosis) and/or behavioural difficulties (e.g., conduct disorders). Neurodevelopmental outcomes included neurodevelopmental disorder traits such as attention-deficit hyperactivity disorder (ADHD) and autistic spectrum disorders. We assessed methodological quality using Consensus-based Standards for the selection of health Measurement Instruments (COSMIN) guidance. Twelve papers were identified that psychometrically evaluated 13 relevant PROMs (two epilepsy-specific, eleven generic). The appraisal of the PROMs was limited by the availability of only one or two published articles for each, and incomplete psychometric evaluations in some cases. The tool demonstrating the strongest evidence was The Neurological Disorders Depression Inventory-Epilepsy for Youth. The ADHD Rating Scale-IV and The Paediatric Symptom Checklist -17 demonstrated good evidence in favour of at least two measurement properties. This review identified only a small number of mental health and neurodevelopmental PROMs evaluated specifically in paediatric epilepsy. There is a need for further validation of mental health and neurodevelopmental PROMs in children with epilepsy.

Underrepresented and Underserved Populations in Neurological Research

Underserved and underrepresented populations have historically been excluded from neurological research. This lack of representation has implications for translation of research findings into clinical practice given the impact of social determinants of health on neurological disease risk, progression, and outcomes. Lack of inclusion in research is driven by individual-, investigator-, and study-level barriers as well as larger systemic injustices (e.g., structural racism, discriminatory practices). Although strategies to increase inclusion of underserved and underrepresented populations have been put forth, numerous questions remain about the most effective methodology. In this article, we highlight inclusivity patterns and gaps among the most common neurological conditions and propose best practices informed by our own experiences in engagement of local community organizations and collaboration efforts to increase underserved and underrepresented population participation in neurological research.

Epilepsy and neurocysticercosis in rural areas of the Bolivian Chaco: What has changed during the last 30 years?

OBJECTIVE

Neurocysticercosis (NCC) is considered the major cause of epilepsy in endemic regions. In the rural areas of the Bolivian Chaco prevalence of NCC among people with epilepsy (PWE) was 27.4%, according to a population-based survey carried out in 1994. The aim of the study was to estimate the prevalence of Epilepsy Associated with Tonic-Clonic Seizures (EATCS) and to evaluate the prevalence of NCC among PWE in the rural communities of the Bolivian Chaco after 30 years.

METHODS

Twenty-two rural communities (total population 12 852) were involved in the study. PWE in the study area were ascertained by multiple sources and the diagnosis was confirmed by a neurologist. All PWE identified were invited to undergo brain CT scan examination and diagnosis of NCC was sought according to the revised Del Brutto criteria.

RESULTS

Seventy-eight PWE (30 men, 38.4%; mean age at onset was 12.7 ± 13.2 years) with EATCS were identified giving a crude prevalence of 6.1/1000 (95% CI: 4.7-7.3). Due to the COVID-19 lockdown, the study was interrupted in 2020 and only 36 PWE (46%) of the whole sample underwent CT scan examination. Of these, 8 (22.2%) fulfilled the criteria for NCC of whom 6 (75%) presented only single or multiple calcifications.

SIGNIFICANCE

This is the first study reassessing the prevalence of NCC among PWE after 30 years, in the same rural area and using a population-based design. T. solium is still endemic in the Bolivian Chaco where more than 20% of EATCS may be attributable to NCC. Our findings show a substantially unchanged prevalence of NCC over the past 30 years despite improved knowledge, underlining the need for active intervention programs to control T. solium transmission in this area.

PLAIN LANGUAGE SUMMARY

Neurocysticercosis is still endemic in the Bolivian Chaco. The proportion of epilepsy attributable to neurocysticercosis is about 22%. Systematic efforts towards elimination of neurocysticercosis in these areas should be implemented.

Inhibition of Granule Cell Dispersion and Seizure Development by Astrocyte Elevated Gene-1 in a Mouse Model of Temporal Lobe Epilepsy

Although granule cell dispersion (GCD) in the hippocampus is known to be an important feature associated with epileptic seizures in temporal lobe epilepsy (TLE), the endogenous molecules that regulate GCD are largely unknown. In the present study, we have examined whether there is any change in AEG-1 expression in the hippocampus of a kainic acid (KA)-induced mouse model of TLE. In addition, we have investigated whether the modulation of astrocyte elevated gene-1 (AEG-1) expression in the dentate gyrus (DG) by intracranial injection of adeno-associated virus 1 (AAV1) influences pathological phenotypes such as GCD formation and seizure susceptibility in a KA-treated mouse. We have identified that the protein expression of AEG-1 is upregulated in the DG of a KA-induced mouse model of TLE. We further demonstrated that AEG-1 upregulation by AAV1 delivery in the DG-induced anticonvulsant activities such as the delay of seizure onset and inhibition of spontaneous recurrent seizures (SRS) through GCD suppression in the mouse model of TLE, while the inhibition of AEG-1 expression increased susceptibility to seizures. The present observations suggest that AEG-1 is a potent regulator of GCD formation and seizure development associated with TLE, and the significant induction of AEG-1 in the DG may have therapeutic potential against epilepsy.

Transcranial electrical stimulation during functional magnetic resonance imaging in patients with genetic generalized epilepsy: a pilot and feasibility study

Objective

A third of patients with epilepsy continue to have seizures despite receiving adequate antiseizure medication. Transcranial direct current stimulation (tDCS) might be a viable adjunct treatment option, having been shown to reduce epileptic seizures in patients with focal epilepsy. Evidence for the use of tDCS in genetic generalized epilepsy (GGE) is scarce. We aimed to establish the feasibility of applying tDCS during fMRI in patients with GGE to study the acute neuromodulatory effects of tDCS, particularly on sensorimotor network activity.

Methods

Seven healthy controls and three patients with GGE received tDCS with simultaneous fMRI acquisition while watching a movie. Three tDCS conditions were applied: anodal, cathodal and sham. Periods of 60 s without stimulation were applied between each stimulation condition. Changes in sensorimotor cortex connectivity were evaluated by calculating the mean degree centrality across eight nodes of the sensorimotor cortex defined by the Automated Anatomical Labeling atlas (primary motor cortex (precentral left and right), supplementary motor area (left and right), mid-cingulum (left and right), postcentral gyrus (left and right)), across each of the conditions, for each participant.

Results

Simultaneous tDCS-fMRI was well tolerated in both healthy controls and patients without adverse effects. Anodal and cathodal stimulation reduced mean degree centrality of the sensorimotor network (Friedman's ANOVA with Dunn's multiple comparisons test; adjusted p = 0.02 and p = 0.03 respectively). Mean degree connectivity of the sensorimotor network during the sham condition was not different to the rest condition (adjusted p = 0.94).

Conclusion

Applying tDCS during fMRI was shown to be feasible and safe in a small group of patients with GGE. Anodal and cathodal stimulation caused a significant reduction in network connectivity of the sensorimotor cortex across participants. This initial research supports the feasibility of using fMRI to guide and understand network modulation by tDCS that might facilitate its clinical application in GGE in the future.

Activatable Dual-Optical Molecular Probe for Bioimaging Superoxide Anion in Epilepsy

Superoxide anion (O2•-) plays a pivotal role in the generation of other reactive oxygen species within the body and is closely linked to epilepsy. Despite this connection, achieving precise imaging of O2•- during epilepsy pathology remains a formidable challenge. Herein, we develop an activatable molecular probe, CL-SA, to track the fluctuation of the level of O2•- in epilepsy through simultaneous fluorescence imaging and chemiluminescence sensing. The developed probe CL-SA demonstrated its efficacy in imaging of O2•- in neuronal cells, showcasing its dual optical imaging capability for O2•- in vitro. Furthermore, CL-SA was successfully used to observe aberrantly expressed O2•- in a mouse model of epilepsy. Overall, CL-SA provides us with a valuable tool for chemical and biomedical studies of O2•-, promoting the investigation of O2•- fluctuations in epilepsy, as well as providing a reliable means to explore the diagnosis and therapy of epilepsy.

Factors affecting seizure recurrence in the emergency department

Background

Information on Emergency Department (ED) follow-up of patients presenting with epileptic seizures is limited.

Objectives

It was planned to investigate the factors affecting the recurrence of epileptic seizures in the follow-up of patients presenting to the ED with the complaint of epileptic seizures.

Materials and methods

This prospective, observational, single-center study was carried out in an adult population presenting to the ED. The study included patients older than 18 years of age presenting to the ED with the complaint of epileptic seizures.

Results

Of the 205 patients included in the study, 68 (33.2%) had seizure recurrence during the 6 h. In the univariable analysis, advanced age, prolonged post-ictal duration, increased seizure duration, generalized tonic clonic seizure, alcohol consumption within past 24 h, hypertension, coronary artery disease, Alzheimer's disease, prior ischemic cerebrovascular disease, low Glascow Coma Scale (GCS), high glucose, high C-Reactive Protein, high phosphorus, low potassium, high blood urea nitrogen, high lactate, increased anion gap, high osmolarity were statistically significant in predicting recurrent seizure recurrence within 6 h. According to the logistic regression, postictal duration, GCS score, and age were independent predictors in our model. The cut-off value of postictal duration in predicting seizure recurrence at the highest sensitivity (66.2%) and specificity (89.8%) was 22.5 min.

Conclusion

A prolonged postictal state, low GCS score, advanced age may be an indication of seizure recurrence. Therefore, patients with a long postictal duration, low GCS score, advanced age should be followed up more carefully in terms of recurrent seizures in the ED.

Prevalence, incidence, and trends of epilepsy among children and adolescents in Africa: a systematic review and meta-analysis

BACKGROUND

Epilepsy contributes to a significant disease burden in children and adolescents worldwide. The incidence of childhood epilepsy is threefold higher in low and middle income countries compared in high-income countries. Epilepsy is a serious neurological condition associated with stigma and discrimination, an impaired quality of life, and other mental health related problems.

OBJECTIVE

This study is aimed to synthesize existing evidence and estimate the pooled prevalence and incidence of epilepsy in children and adolescents in Africa.

METHODS

A comprehensive and systematic search of relevant databases was conducted. The quality of each study was assessed using the Newcastle-Ottawa Quality Assessment Scale adapted for meta-analysis. Two reviewers screened retrieved articles, conducted critical appraisals, and extracted the data. Heterogeneity between studies was assessed by visual inspection of forest plots and statistically using Cochran's Q statistics and the I2 test. Publication bias was checked by visual inspection of funnel plots as well as statistically using Egger's correlation and Begg's regression tests. Finally, the pooled prevalence and incidence of childhood epilepsy were computed with 95% confidence intervals.

RESULT

In this review and meta-analysis 42 studies with 56 findings were included to compute the pooled prevalence of childhood epilepsy. On the other hand, 6 studies were included to estimate the combined incidence. The pooled prevalence of cumulative epilepsy was 17.3 per 1000 children. Whereas the pooled prevalence of active and lifetime epilepsy was 6.8 and 18.6 per 1000 children respectively. The pooled incidence of childhood epilepsy was 2.5 per 1000 children.

CONCLUSION

Nearly 1 in 50 children are suffering from epilepsy in Africa. However, little attention has been paid to the prevention and treatment of childhood epilepsy. Mass epilepsy screening, scaling up treatment coverage, and designing strict treatment follow up and monitoring mechanisms are recommended.

Association between cognitive impairment and antiseizure medication adherence among people with epilepsy in Addis Ababa, Ethiopia

BACKGROUND

Cognitive impairment is one of the most common and most troublesome comorbidities among people with epilepsy (PWE). Adherent use of antiseizure medications (ASM) can control seizure episodes in 70% of the cases. However, the relationship between adherent use of ASMs and cognitive impairment in epilepsy is complex.

OBJECTIVE

To assess the association between adherence to ASMs and cognitive status among PWE.

METHODS

We performed a cross-sectional observational study with prospective data collection from PWE using translated and content-validated Amharic versions of the Montreal cognitive assessment tool (MOCA-B) and a four-item Morisky Medication Adherence Scale (Morski-4). Ordinal logistic regression analysis was performed to evaluate the potential risk factors for cognitive impairment, including ASM adherence, physical exercise, and level of education.

RESULTS

A total of 214 individuals with epilepsy were included in this study; 53.7 % were female, and the mean age was 34 years ± 12. The mean age at seizure occurrence was 19 years ± 9. The most common epilepsy type among participants was generalized epilepsy (69 %). The prevalence of poor medication adherence to ASM was 54.2 %. The prevalence of mild cognitive impairment was 65.4 %, and 18.2 % had moderate cognitive impairment, particularly affecting verbal fluency (60.8 %) and memory (43.9 %). Cognitive impairment was significantly associated with poor ASM adherence (AOR = 12.0, 95 %CI, (1.53, 93.75), lower level of physical exercise (AOR = 16.30, 95 %CI (1.24, 214.99), and poor educational attainment with both no formal education (AOR = 0.04, 95 %CI (0.02, 0.14)) and primary or secondary level education (AOR = 0.32, 95 %CI, (0.15, 0.70).

CONCLUSIONS

There is a high rate of cognitive impairment and non-adherence to ASMs in PWE living in Addis Ababa, Ethiopia. Poor ASM adherence is a possible risk factor for cognitive impairment. PWE can benefit from interventions to improve ASM adherence, physical exercise, and better educational attainment.

Variations in the Neurosurgical Management of Depressed Skull Fractures in Adults: An International Cross-Sectional Survey

BACKGROUND

 Depressed skull fractures have been well described since antiquity, yet its management remains controversial. Contentious issues include the use of prophylactic antibiotics and antiepileptics, the role of nonoperative management, and the replacement/removal of bone fragments. Our objective was to explore the management patterns of closed and open depressed skull fractures across the world.

METHODS

 A 23-item, web-based survey was distributed electronically to the members of national neurosurgical associations, and on social media platforms. The survey was open for data collection from December 2020 to April 2021.

RESULTS

 A total of 218 respondents completed the survey, representing 56 countries.With regard to open fractures, most respondents (85.8%) treated less than 50 cases annually. Most respondents (79.4%) offered prophylactic antibiotics to all patients with open fractures, with significant geographical variation (p < 0.001). Less than half of the respondents (48.2%) offered prophylactic antiepileptics. Almost all respondents (>90%) reported the following indications as important for surgical management: (1) grossly contaminated wound, (2) dural penetration, (3) depth of depression, and (4) underlying contusion/hematoma with mass effect. Most respondents treated less than 50 cases of closed depressed skull fractures annually. Most European respondents (81.7%) did not offer prophylactic antiepileptics in comparison to most Asian respondents (52.7%; p < 0.001). Depth of depression, an underlying hematoma/contusion with mass effect, and dural penetration were the most important surgical indications.

CONCLUSIONS

 There remains a great degree of uncertainty in the management strategies employed across the world in treating depressed fractures, and future work should involve multinational randomized trials.

Very high epilepsy prevalence in rural Southern Rwanda: The underestimated burden of epilepsy in sub-Saharan Africa

OBJECTIVES

Up to 85% of people living with epilepsy (PwE) reside in low-and middle-income countries. In sub-Saharan Africa, the lifetime prevalence of epilepsy is 16 per 1000 persons. In Northern rural Rwanda, a 47.7 per 1000 prevalence has been reported. As variations in prevalence across geographical areas have been observed, we studied the prevalence in Southern rural Rwanda using the same robust methodology as applied in the North.

METHODS

We conducted a three-stage, cross-sectional, door-to-door survey in two rural villages in Southern Rwanda from June 2022 to April 2023. First, trained enumerators administered the validated Limoges questionnaire for epilepsy screening. Second, neurologists examined the persons who had screened positively to confirm the epilepsy diagnosis. Third, cases with an inconclusive assessment were separately reexamined by two neurologists to reevaluate the diagnosis.

RESULTS

Enumerators screened 1745 persons (54.4% female, mean age: 24 ± 19.3 years), of whom 304 (17.4%) screened positive. Epilepsy diagnosis was confirmed in 133 (52.6% female, mean age: 30 ± 18.2 years) and active epilepsy in 130 persons. Lifetime epilepsy prevalence was 76.2 per 1000 (95% CI: 64.2-89.7‰). The highest age-specific rate occurred in the 29-49 age group. No gender-specific differences were noted. In 22.6% of the PwE, only non-convulsive seizures occurred. The treatment gap was 92.2%, including a diagnosis gap of 79.4%.

CONCLUSION

We demonstrated a very high epilepsy prevalence in Southern rural Rwanda, with over 20% of cases having only non-convulsive seizures, which are often underdiagnosed in rural Africa. In line with previous Rwandan reports, we reiterate the high burden of the disease in the country. Geographic variation in prevalence throughout Africa may result from differences in risk and aetiological factors. Case-control studies are underway to understand such differences and propose adapted health policies for epilepsy prevention.

Prevalence and factors associated with depressive symptoms among patients with epilepsy in Ethiopia: a national-based systematic review and meta-analysis

Background

Depression is a major public health problem and negatively affects the quality of life of patients with epilepsy. Despite multiple studies investigating the magnitude and predictors, the results have been inconsistent. Therefore, this study aimed to estimate the pooled prevalence and factors associated with depressive symptoms among patients with epilepsy in Ethiopia.

Methods

The primary articles were searched using databases like PubMed, Google Scholar, CINAHL, SCOPUS, EMBASE, and African Journal Online. A total of 10 primary articles that assessed the prevalence and factors associated with depressive symptoms among patients with epilepsy in Ethiopia were included. A Microsoft Excel spreadsheet was used to extract the data, which was then exported to Stata version 14 for further analysis. The statistical heterogeneity was evaluated using the I2 test. Due to heterogeneity, a random effect meta-analysis model was employed. Publication bias was checked through Egger's weighted regression test and funnel plot.

Results

A total of 10 primary studies with 3,532 participants were included. The pooled prevalence of depressive symptoms among patients with epilepsy was found to be 41.69% (95% CI, 37.70, 45.68). The pooled prevalence of depressive symptoms was 48.61, 42.98, 40.68, 38.27, and 34.80% in Oromia, SNNPs, Amhara, Addis Ababa, and Tigray, respectively, based on a sub-group analysis per regional state. Perceived stigma (AOR = 3.30, 95% CI: 1.40, 7.80), seizure frequency (AOR = 3.81, 95% CI: 1.03, 14.09), and perceived stress (AOR = 4.6, 95% CI: 1.05, 20.06) were factors associated with depressive symptoms.

Conclusion

We found that depressive symptoms affects at least four out of ten patients with epilepsy, indicating an immense burden. Depressive symptoms were extremely prevalent in those who had high levels of stigma, a monthly seizure frequency of once or more, and perceived stress. Therefore, physicians should take extra precautions when treating patients with epilepsy who have certain conditions.

Systematic review registration

This study was registered according to The International Prospective Register of Systemic Review (PROSPERO) with the registration ID (CRD42023484308).

Measuring quality and safety of epilepsy monitoring units in Brazil: Adoption of quality indicators

PURPOSE

Drug-resistant epilepsy affects a substantial proportion (30-40 %) of patients with epilepsy, often necessitating video-electroencephalography (video-EEG) monitoring. In 2016, Sauro et al. introduced a set of measures aimed at improving the quality and safety indicators reported in video-EEG evaluations. This study aims to report our experience with the implementation of these measures.

METHODS

We analyzed video-EEG data regarding quality and safty from a period spanning January 2016 to January 2018, involving a total of 101 patients monitored in our video-EEG unit.

RESULTS

Among the patients included in the study, a definitive diagnosis was attainable for 92.1 %, with 36.6 % experiencing a change in diagnosis and 65.3 % undergoing a change in treatment as a result of the video-EEG evaluation. Additionally, the referral question was fully addressed in 60.4 % of admissions, and video-EEG was considered to be very useful or extremely useful in 66.4 % of cases. Adverse events were observed in 26.7 % of patients, with the most common being the progression of focal seizures to bilateral tonic-clonic seizures (11.9 %) and the occurrence of seizure clusters (5.9 %).

CONCLUSION

Our findings support the implementation of Sauro et al.'s set of measures, as they provide valuable criteria for improving the reporting of video-EEG quality and safety indicators. However, challenges may arise due to variations in terminology across studies and the lack of standardized criteria for defining essential questions in video-EEG evaluations. Further research utilizing these measures is necessary to enhance their effectiveness and encourage consistent reporting of results from epilepsy monitoring units.

Implementation of a 7T Epilepsy Task Force consensus imaging protocol for routine presurgical epilepsy work-up: effect on diagnostic yield and lesion delineation

OBJECTIVE

Recently, the 7 Tesla (7 T) Epilepsy Task Force published recommendations for 7 T magnetic resonance imaging (MRI) in patients with pharmaco-resistant focal epilepsy in pre-surgical evaluation. The objective of this study was to implement and evaluate this consensus protocol with respect to both its practicability and its diagnostic value/potential lesion delineation surplus effect over 3 T MRI in the pre-surgical work-up of patients with pharmaco-resistant focal onset epilepsy.

METHODS

The 7 T MRI protocol consisted of T1-weighted, T2-weighted, high-resolution-coronal T2-weighted, fluid-suppressed, fluid-and-white-matter-suppressed, and susceptibility-weighted imaging, with an overall duration of 50 min. Two neuroradiologists independently evaluated the ability of lesion identification, the detection confidence for these identified lesions, and the lesion border delineation at 7 T compared to 3 T MRI.

RESULTS

Of 41 recruited patients > 12 years of age, 38 were successfully measured and analyzed. Mean detection confidence scores were non-significantly higher at 7 T (1.95 ± 0.84 out of 3 versus 1.64 ± 1.19 out of 3 at 3 T, p = 0.050). In 50% of epilepsy patients measured at 7 T, additional findings compared to 3 T MRI were observed. Furthermore, we found improved border delineation at 7 T in 88% of patients with 3 T-visible lesions. In 19% of 3 T MR-negative cases a new potential epileptogenic lesion was detected at 7 T.

CONCLUSIONS

The diagnostic yield was beneficial, but with 19% new 7 T over 3 T findings, not major. Our evaluation revealed epilepsy outcomes worse than ILAE Class 1 in two out of the four operated cases with new 7 T findings.

Identification of potential crucial genes and therapeutic targets for epilepsy

BACKGROUND

Epilepsy, a central neurological disorder, has a complex genetic architecture. There is some evidence suggesting that genetic factors play a role in both the occurrence of epilepsy and its treatment. However, the genetic determinants of epilepsy are largely unknown. This study aimed to identify potential therapeutic targets for epilepsy.

METHODS

Differentially expressed genes (DEGs) were extracted from the expression profiles of GSE44031 and GSE1834. Gene co-expression analysis was used to confirm the regulatory relationship between newly discovered epilepsy candidate genes and known epilepsy genes. Expression quantitative trait loci analysis was conducted to determine if epilepsy risk single-nucleotide polymorphisms regulate DEGs' expression in human brain tissue. Finally, protein-protein interaction analysis and drug-gene interaction analysis were performed to assess the role of DEGs in epilepsy treatment.

RESULTS

The study found that the protein tyrosine phosphatase receptor-type O gene (PTPRO) and the growth arrest and DNA damage inducible alpha gene (GADD45A) were significantly upregulated in epileptic rats compared to controls in both datasets. Gene co-expression analysis revealed that PTPRO was co-expressed with RBP4, NDN, PAK3, FOXG1, IDS, and IDS, and GADD45A was co-expressed with LRRK2 in human brain tissue. Expression quantitative trait loci analysis suggested that epilepsy risk single-nucleotide polymorphisms could be responsible for the altered PTPRO and GADD45A expression in human brain tissue. Moreover, the protein encoded by GADD45A had a direct interaction with approved antiepileptic drug targets, and GADD45A interacts with genistein and cisplatin.

CONCLUSIONS

The results of this study highlight PTPRO and GADD45A as potential genes for the diagnosis and treatment of epilepsy.

Pathophysiology to Risk Factor and Therapeutics to Treatment Strategies on Epilepsy

Epilepsy represents a condition in which abnormal neuronal discharges or the hyperexcitability of neurons occur with synchronicity, presenting a significant public health challenge. Prognostic factors, such as etiology, electroencephalogram (EEG) abnormalities, the type and number of seizures before treatment, as well as the initial unsatisfactory effects of medications, are important considerations. Although there are several third-generation antiepileptic drugs currently available, their multiple side effects can negatively affect patient quality of life. The inheritance and etiology of epilepsy are complex, involving multiple underlying genetic and epigenetic mechanisms. Different neurotransmitters play crucial roles in maintaining the normal physiology of different neurons. Dysregulations in neurotransmission, due to abnormal transmitter levels or changes in their receptors, can result in seizures. In this review, we address the roles played by various neurotransmitters and their receptors in the pathophysiology of epilepsy. Furthermore, we extensively explore the neurological mechanisms involved in the development and progression of epilepsy, along with its risk factors. Furthermore, we highlight the new therapeutic targets, along with pharmacological and non-pharmacological strategies currently employed in the treatment of epileptic syndromes, including drug interventions employed in clinical trials related to epilepsy.