Outcomes of newly diagnosed idiopathic generalized epilepsy syndromes in a non-pediatric setting

Drug-resistant juvenile myoclonic epilepsy: A literature review

The ILAE's Task Force on Nosology and Definitions revised in 2022 its definition of juvenile myoclonic epilepsy (JME), the most common idiopathic generalized epilepsy disorder, but this definition may well change again in the future. Although good drug response could almost be a diagnostic criterion for JME, drug resistance (DR) is observed in up to a third of patients. It is important to distinguish this from pseudoresistance, which is often linked to psychosocial problems or psychiatric comorbidities. After summarizing these aspects and the various definitions applied to JME, the present review lists the risk factors for DR-JME that have been identified in numerous studies and meta-analyses. The factors most often cited are absence seizures, young age at onset, and catamenial seizures. By contrast, photosensitivity seems to favor good treatment response, at least in female patients. Current hypotheses on DR mechanisms in JME are based on studies of either simple (e.g., cortical excitability) or more complex (e.g., anatomical and functional connectivity) neurophysiological markers, bearing in mind that JME is regarded as a neural network disease. This research has revealed correlations between the intensity of some markers and DR, and above all shed light on the role of these markers in associated neurocognitive and neuropsychiatric disorders in both patients and their siblings. Studies of neurotransmission have mainly pointed to impaired GABAergic inhibition. Genetic studies have generally been inconclusive. Increasing restrictions have been placed on the use of valproate, the standard antiseizure medication for this syndrome, owing to its teratogenic and developmental risks. Levetiracetam and lamotrigine are prescribed as alternatives, as is vagal nerve stimulation, and there are several other promising antiseizure drugs and neuromodulation methods. The development of better alternative treatments is continuing to take place alongside advances in our knowledge of JME, as we still have much to learn and understand.

Outpatient visit behavior in patients with epilepsy: Generalized Epilepsy is more frequently non-attendance than Focal Epilepsy

BACKGROUND

Patients with epilepsy (PWE), especially those with Idiopathic Epilepsy (GE), are at a high risk of disadvantage caused by non-adherence. It has been suggested that medical visit behavior may be a surrogate indicator of medication adherence. We hypothesized that patients with IGE would adhere poorly to visits.

METHODS

This was a retrospective study of PWE who visited the Department of Psychiatry and Neurology at Hokkaido University Hospital between January 2017 and December 2019. Demographic and clinical information on PWE were extracted from medical records and visit data from the medical information system. Non-attendance of outpatient appointments was defined as "not showing up for the day of an appointment without prior notice." Mixed-effects logistic regression analysis was conducted with non-attendance as the objective variable.

RESULTS

Of the 9151 total appointments, 413 were non-attendances, with an overall non-attendance rate of 4.5%. IGE was a more frequent non-attendance than Focal Epilepsy (FE) (odds ratio (OR) 1.94; 95% confidence interval (CI) 1.17-3.21; p = 0.010). History of public assistance receipt was associated with higher non-attendance (OR 2.04; 95% CI 1.22-3.43; p = 0.007), while higher education (OR 0.64; 95% CI 0.43-0.93; p = 0.021) and farther distance to a hospital (OR 0.33; 95% CI 0.13-0.88; p = 0.022), and higher frequency of visits (OR 0.18; 95% CI 0.04-0.86; p = 0.031) were associated with fewer non-attendances. In a subgroup analysis of patients with GE, women were associated with fewer non-attendance (OR 0.31; 95% CI 0.14-0.72; p = 0.006).

CONCLUSIONS

GE was more frequent in the non-attendance group than in the FE group. Among patients with GE, females were found to have non-attendance less frequently; however, there was no clear difference in the odds of non-attendance between Juvenile Myoclonic Epilepsy (JME) and IGE other than JME.

Clinical and Instrumental Follow-Up of Childhood Absence Epilepsy (CAE): Exploration of Prognostic Factors

Background: Idiopathic generalized epilepsies (IGEs) represent 15−20% of all cases of epilepsy in children. This study explores predictors of long-term outcome in a sample of children with childhood absence epilepsy (CAE). Methods: The medical records of patients with CAE treated at a university paediatric hospital between 1995 and 2022 were systematically reviewed. Demographics and relevant clinical data, including electroencephalogram, brain imaging, and treatment outcome were extracted. Outcomes of interest included success in seizure control and seizure freedom after anti-seizure medication (ASM) discontinuation. An analysis of covariance using the diagnostic group as a confounder was performed on putative predictors. Results: We included 106 children (age 16.5 ± 6.63 years) with CAE with a mean follow-up of 5 years. Seizure control was achieved in 98.1% (in 56.6% with one ASM). Headache and generalized tonic-clonic seizures (GTCS) were more frequent in children requiring more than one ASM (p < 0.001 and p < 0.002, respectively). Of 65 who discontinued ASM, 54 (83%) remained seizure-free, while 11 (17%) relapsed (mean relapse time 9 months, range 0−18 months). Relapse was associated with GTCS (p < 0.001) and number of ASM (p < 0.002). Conclusions: A history of headache or of GTCS, along with the cumulative number of ASMs utilized, predicted seizure recurrence upon ASM discontinuation. Withdrawing ASM in patients with these characteristics requires special attention.

Treatment outcomes in women with idiopathic generalized epilepsy

Objectives

To evaluate the changes in prescription patterns in the treatment of idiopathic generalized epilepsy (IGE) due to updated treatment recommendations and to assess seizure outcomes of valproate compared to other antiseizure medications (ASMs), with emphasis on women with epilepsy (WWE).

Materials and Methods

Records of IGE patients treated at Tampere University Hospital between 1 January 2009 and 31 December 2018 were retrospectively inspected. Data were analysed for two subgroups based on age and sex. Seizure control with reference to the efficacy of different ASMs and their combinations was examined for each subgroup.

Results

The study compiled 263 subjects (166 females and 97 males). Of all patients, 72.6% remained seizure free. There was no difference in seizure control between sexes (OR 1.25, p = .48). Males used valproate more often than females while females used lamotrigine and levetiracetam more often than males. Lamotrigine and levetiracetam were used especially as monotherapy in WWE, and mostly as part of combination therapy in males. Valproate alternatives were found as effective as valproate when used in monotherapy in adults. Valproate remained the most used ASM in the paediatric subgroup.

Conclusions

The use of valproate has decreased in daily clinical use with the simultaneous increased use of alternative ASMs compared to our previous study. Decreasing use of valproate in WWE did not increase the risk of seizure recurrence; therefore, valproate alternatives could be considered as first‐line ASMs for WWE. Overall, IGE patients demonstrated good clinical outcomes with valproate or other broad‐spectrum ASMs as monotherapy.

Electroclinical Features and Long-term Seizure Outcome in Patients With Eyelid Myoclonia With Absences

BACKGROUND AND OBJECTIVES

Eyelid myoclonia with absences (EMA) is a generalized epilepsy syndrome whose prognosis and clinical characteristics are still partially undefined. We investigated electroclinical endophenotypes and long-term seizure outcome in a large cohort of EMA patients.

METHODS

In this multicenter retrospective study, EMA patients with ≥5 years of follow-up were included. We investigated prognostic patterns and sustained terminal remission (STR), along with their prognostic factors. Moreover, a two-step cluster analysis was used to investigate the presence of distinct EMA endophenotypes.

RESULTS

We included 172 patients, with a median age at onset of 7 years (interquartile range (IQR) 5-10) and a median follow-up duration of 14 years (IQR 8.25-23.75). Sixty-six patients (38.4%) displayed a non-remission pattern, whereas remission and relapse patterns were encountered in 56 (32.6%) and 50 (29.1%) subjects. Early epilepsy onset, history of febrile seizures (FS) and eyelid myoclonia (EM) status epilepticus significantly predicted a non-remission pattern according to multinomial logistic regression analysis. STR was achieved by 68 (39.5%) patients with a mean latency of 14.05 years (SD ± 12.47). Early epilepsy onset, psychiatric comorbidities, and a history of FS and generalized tonic-clonic seizures (GTCS) were associated with a lower probability of achieving STR according to a Cox regression proportional hazards model. Antiseizure medication (ASM) withdrawal was attempted in 62/172 patients, and seizures relapsed in 74.2%. Cluster analysis revealed two distinct clusters with 86 patients each. Cluster 2, which we defined as "EMA-plus", was characterized by an earlier age at epilepsy onset, higher rate of intellectual disability, EM status epilepticus, generalized paroxysmal fast activity, self-induced seizures, FS, and poor ASM response, whereas Cluster 1, the "EMA-only" cluster, was characterized by a higher rate of seizure remission and more favorable neuropsychiatric outcome.

DISCUSSION

Early epilepsy onset was the most relevant prognostic factor for poor treatment response. A long latency between epilepsy onset and ASM response was observed, suggesting the impact of age-related brain changes in EMA remission. Finally, our cluster analysis showed a clear-cut distinction of EMA patients into an EMA-plus insidious subphenotype and an EMA-only benign cluster that strongly differed in terms of remission rates and cognitive outcomes.

Genetic generalized epilepsies in adults - challenging assumptions and dogmas

Genetic generalized epilepsy (GGE) syndromes start during childhood or adolescence, and four commonly persist into adulthood, making up 15-20% of all cases of epilepsy in adults. These four GGE syndromes are childhood absence epilepsy, juvenile absence epilepsy, juvenile myoclonic epilepsy and epilepsy with generalized tonic-clonic seizures alone. However, in ~20% of patients with GGE, characteristics of more than one syndrome are present. Novel insights into the genetic aetiology, comorbidities and prognosis of the GGE syndromes have emerged and challenge traditional concepts about these conditions. Evidence has shown that the mode of inheritance in GGE is mostly polygenic. Neuropsychological and imaging studies indicate similar abnormalities in unaffected relatives of patients with GGE, supporting the concept that underlying alterations in bilateral frontothalamocortical networks are genetically determined. Contrary to popular belief, first-line anti-seizure medication often fails to provide seizure freedom in combination with good tolerability. Nevertheless, long-term follow-up studies have shown that with advancing age, many patients can discontinue their anti-seizure medication without seizure relapses. Several outcome predictors have been identified, but prognosis across the syndromes is more homogeneous than previously assumed. Overall, overlap in pathophysiology, seizure types, treatment responses and outcomes support the idea that GGEs are not separate nosological entities but represent a neurobiological continuum.

Reconsidering the role of selective sodium channel blockers in genetic generalized epilepsy

OBJECTIVE

Selective sodium channel blockers (SSCBs) have a limited use in genetic generalized epilepsy (GGE), due to their well-known risk of seizure worsening. Although their therapeutic potential in GGE has been suggested by recent evidence, electro-clinical data supporting their prescription are lacking. We aimed to investigate SSCB safety and effectiveness in a GGE cohort.

METHODS

Subjects who received SSCBs and had ≥5-year follow-up were enrolled. Lamotrigine was excluded from analysis due to its broader pharmacodynamic spectrum and its better-documented efficacy in GGE.

RESULTS

Fifty-six patients (median follow-up 28.5 years) were included. The most used SSCB was carbamazepine in 40 subjects. At the last medical observation, only 9 subjects were still receiving SSCBs. The occurrence of generalized polyspike-wave discharges (GPSWDs) predicted reduced SSCB retention in Cox multivariate analysis. A seizure reduction ≥50% occurred in 53.5% (30/56) of subjects when considering all seizure types; however, the proportion of responders increased to 67.9% when considering only generalized tonic-clonic seizures (GTCS). GPSWDs were significantly associated with a reduced response rate, whereas GGE with GTCS only syndrome with a better outcome. The switch from SSCBs to antiseizure medications licensed for GGE improved seizure control in 65% of patients. Seizure worsening was reported in 5/56 patients; juvenile myoclonic epilepsy and a family history of epilepsy were significantly associated with seizure aggravation.

CONCLUSION

SSCBs appeared effective on GTCS, but epilepsy aggravation and unsatisfactory control of other seizure types were not uncommon. Our study contributes to identifying new clinical and EEG variables associated with SSCB effectiveness and safety which may help neurologists in patients' management.

Brainwaves beyond diagnosis: Wider applications of electroencephalography in idiopathic generalized epilepsy

Electroencephalography (EEG) has long been used as a versatile and noninvasive diagnostic tool in epilepsy. With the advent of digital EEG, more advanced applications of EEG have emerged. Compared with technologically advanced practice in focal epilepsies, the utilization of EEG in idiopathic generalized epilepsy (IGE) has been lagging, often restricted to a simple diagnostic tool. In this narrative review, we provide an overview of broader applications of EEG beyond this narrow scope, discussing how the current clinical and research applications of EEG may potentially be extended to IGE. The current literature, although limited, suggests that EEG can be used in syndromic classification, guiding antiseizure medication therapy, predicting prognosis, unraveling biorhythms, and investigating functional brain connectivity of IGE. We emphasize the need for longer recordings, particularly 24-h ambulatory EEG, to capture discharges reflecting circadian and sleep-wake cycle-associated variations for wider EEG applications in IGE. Finally, we highlight the challenges and limitations of the current body of literature and suggest future directions to encourage and enhance more extensive applications of this potent tool.

Clinical and EEG factors associated with antiseizure medication resistance in idiopathic generalized epilepsy

OBJECTIVE

We sought to determine which combination of clinical and electroencephalography (EEG) characteristics differentiate between an antiseizure medication (ASM)-resistant vs ASM-responsive outcome for patients with idiopathic generalized epilepsy (IGE).

METHODS

This was a case-control study of ASM-resistant cases and ASM-responsive controls with IGE treated at five epilepsy centers in the United States and Australia between 2002 and 2018. We recorded clinical characteristics and findings from the first available EEG study for each patient. We then compared characteristics of cases vs controls using multivariable logistic regression to develop a predictive model of ASM-resistant IGE.

RESULTS

We identified 118 ASM-resistant cases and 114 ASM-responsive controls with IGE. First, we confirmed our recent finding that catamenial epilepsy is associated with ASM-resistant IGE (odds ratio [OR] 3.53, 95% confidence interval [CI] 1.32-10.41, for all study subjects) after covariate adjustment. Other independent factors seen with ASM resistance include certain seizure-type combinations (absence, myoclonic, and generalized tonic-clonic seizures [OR 7.06, 95% CI 2.55-20.96]; absence and generalized tonic-clonic seizures [OR 4.45, 95% CI 1.84-11.34]), as well as EEG markers of increased generalized spike-wave discharges (GSWs) in sleep (OR 3.43, 95% CI 1.12-11.36 for frequent and OR 7.21, 95% CI 1.50-54.07 for abundant discharges in sleep) and the presence of generalized polyspike trains (GPTs; OR 5.49, 95% CI 1.27-38.69). The discriminative ability of our final multivariable model, as measured by area under the receiver-operating characteristic curve, was 0.80.

SIGNIFICANCE

Multiple clinical and EEG characteristics independently predict ASM resistance in IGE. To improve understanding of a patient's prognosis, clinicians could consider asking about specific seizure-type combinations and track whether they experience catamenial epilepsy. Obtaining prolonged EEG studies to record the burden of GSWs in sleep and assessing for the presence of GPTs may provide additional predictive value.

The prognosis of epilepsy patients with CACNA1H missense variants: A longitudinal cohort study

OBJECTIVE

CACNA1H is regarded as a gene conferring susceptibility to generalised epilepsy. However, the prognosis of epilepsy patients carrying the CACNA1H missense variants of uncertain significance (VUS) is unknown. A prospective cohort was generated to determine the deleterious effects of these variants and to check whether the presence of these variants affects the prognosis of epilepsy patients.

METHOD

This study was conducted at Xijing Hospital in Xian, China. All patients were followed up for at least 1 year. Previous reports were searched for previously reported variants. Ensembl database was searched for variants in the general population. Combined Annotation Dependent Depletion (CADD) was used to evaluate the deleterious effect of variants. Logistic regression and Cox regression were used for data analysis.

RESULTS

The study included 176 epilepsy patients with or without CACNA1H variants. In epilepsy patients with missense variants, we found 35 different variants, including 33 variants with uncertain significance and 2 likely benign variants. No significant difference was observed between the distribution of CADD scores of the variants from this cohort, of the general population, and of those found in previous reports. Among epilepsy patients with missense variants, the number of antiepileptic drugs (AEDs) administered to the patients, a first-degree family history of epilepsy, and possibly the presence of abnormalities in brain radiology findings were correlated with the poorer prognosis. Among the entire cohort, the type of epilepsy, number of AEDs administered, and presence of abnormalities in brain radiology findings were associated with the prognosis of these patients. The deleterious effect of CACNA1H missense variants or their presence was not related to the prognosis of epilepsy patients.

CONCLUSION

The results of our study suggest that CACNA1H variants are related to multiple epilepsy syndromes. However, there is no strong evidence of the correlation between CACNA1H missense variants and a certain type of epilepsy. In our study cohort, both the deleterious effects and the presence of CACNA1H variants were found to be unrelated to the prognosis of patients with epilepsy. These findings suggest that CACNA1H missense variants that are classified as VUS might not influence the outcome of epilepsy.

Recent Advances in Neuroimaging of Epilepsy

Human neuroimaging has had a major impact on the biological understanding of epilepsy and the relationship between pathophysiology, seizure management, and outcomes. This review highlights notable recent advancements in hardware, sequences, methods, analyses, and applications of human neuroimaging techniques utilized to assess epilepsy. These structural, functional, and metabolic assessments include magnetic resonance imaging (MRI), positron emission tomography (PET), and magnetoencephalography (MEG). Advancements that highlight non-invasive neuroimaging techniques used to study the whole brain are emphasized due to the advantages these provide in clinical and research applications. Thus, topics range across presurgical evaluations, understanding of epilepsy as a network disorder, and the interactions between epilepsy and comorbidities. New techniques and approaches are discussed which are expected to emerge into the mainstream within the next decade and impact our understanding of epilepsies. Further, an increasing breadth of investigations includes the interplay between epilepsy, mental health comorbidities, and aberrant brain networks. In the final section of this review, we focus on neuroimaging studies that assess bidirectional relationships between mental health comorbidities and epilepsy as a model for better understanding of the commonalities between both conditions.

Mortality in adult epilepsy patients in Malaysia: a hospital-based study

BACKGROUND

The standardized mortality ratio (SMR) of epilepsy in Asia ranges from 2.5 to 5.1. However, there are no such published data in Malaysia to date. Understanding the mortality rate and related factors will allow us to better assess and monitor the health status of PWE, thereby, preventing premature deaths among PWE. Hence, this study aimed to determine the mortality rate of adults with epilepsy (PWE) at the University Malaya Medical Centre (UMMC), a tertiary hospital in Malaysia.

METHOD

A total of 2218 PWE were recruited retrospectively into this study. Deceased cases from 2009-2018 were identified from the National Registry Department of Malaysia. Age-, gender-, and ethnic-specific SMR were calculated.

RESULT

There was a total of 163 deaths, of which 111 (68.1%) were male. The overall case-fatality rate (CFR) was 7.3%. Male PWE had higher CFR (9.2%) compared to females (5.1%, p<0.001). The annual death rate of PWE was 867 per 100, 000 persons. The overall all-cause SMR was 1.6 (CI 95% 1.3-1.8). The SMR for younger age groups (15-19 and 20-29 years) were higher (5.4-5.5) compared to other age groups (0.4-2.5). Overall SMR for male PWE (1.8, 95% CI 1.5-2.1) was higher than females (1.2, 95% CI 0.9-1.6). However, the SMR for female PWE in the younger age groups (15-19, 20-29 and 30-39 years) was higher. SMR among the Indian PWE was the highest (1.6, 95% CI 1.2-2.0) compared to the Chinese (1.5, 95% CI 1.2-1.9) and the Malays (1.4, 95% 1.0-1.9). The CFR was higher in those with focal epilepsy (8.5% vs. 2.5-3.7% in genetic and other generalized epilepsies, p=0.003), epilepsy with structural cause (9.5% vs. 5.9% in others, p=0.005) and uncontrolled seizures (7.9% vs. 5.2% in seizure-free group, p<0.001).

CONCLUSION

The mortality rate of PWE in Malaysia is higher than that of the general population but lower compared to other Asian countries. Specifically, the rates are higher in the younger age group, male gender, and Indian ethnicity. Those with focal epilepsy, structural causes and uncontrolled seizures have higher mortality rates.

Clinical Management of Drug Resistant Epilepsy: A Review on Current Strategies

Drug resistant epilepsy (DRE) is defined as the persistence of seizures despite at least two syndrome-adapted antiseizure drugs (ASD) used at efficacious daily dose. Despite the increasing number of available ASD, about a third of patients with epilepsy still suffer from drug resistance. Several factors are associated with the risk of evolution to DRE in patients with newly diagnosed epilepsy, including epilepsy onset in the infancy, intellectual disability, symptomatic epilepsy and abnormal neurological exam. Pharmacological management often consists in ASD polytherapy. However, because quality of life is driven by several factors in patients with DRE, including the tolerability of the treatment, ASD management should try to optimize efficacy while anticipating the risks of drug-related adverse events. All patients with DRE should be evaluated at least once in a tertiary epilepsy center, especially to discuss eligibility for non-pharmacological therapies. This is of paramount importance in patients with drug resistant focal epilepsy in whom epilepsy surgery can result in long-term seizure freedom. Vagus nerve stimulation, deep brain stimulation or cortical stimulation can also improve seizure control. Lastly, considering the effect of DRE on psychologic status and social integration, comprehensive care adaptations are always needed in order to improve patients' quality of life.

Spectral power of interictal EEG in the diagnosis and prognosis of idiopathic generalized epilepsies

INTRODUCTION

Idiopathic generalized epilepsies (IGE) are characterized by generalized interictal epileptiform discharges (IEDs) on a normal background electroencephalography (EEG). However, the yield of IEDs can be low. Approximately 20% of patients with IGE fail to achieve seizure control with antiepileptic drug (AED) treatment. Currently, there are no reliable prognostic markers for early identification of drug-resistant epilepsy (DRE). We examined spectral power of the interictal EEG in patients with IGE and healthy controls, to identify potential diagnostic and prognostic biomarkers of IGE.

METHODS

A 64-channel EEG was recorded under standard conditions in patients with well-controlled IGE (WC-IGE, n = 19), drug-resistant IGE (DR-IGE, n = 18), and age-matched controls (n = 20). After preprocessing, fast Fourier transform was performed to obtain 1D frequency spectra for each EEG channel. The 1D spectra (averaged over channels) and 2D topographic maps (averaged over canonical frequency bands) were computed for each participant. Power spectra in the 3 cohorts were compared using one-way analysis of variance (ANOVA), and power spectra images were compared using T-contrast tests. A post hoc analysis compared peak alpha power between the groups.

RESULTS

Compared with controls, participants with IGE had higher interictal EEG spectral power in the delta band in the midline central region, in the theta band in the midline, in the beta band over the left hemisphere, and in the gamma band over right hemisphere and left central regions. There were no differences in spectral power between cohorts with WC-IGE and DR-IGE. Peak alpha power was lower in WC-IGE and DR-IGE than controls.

CONCLUSIONS

Electroencephalography spectral power analysis could form part of a clinically useful diagnostic biomarker for IGE; however, it did not correlate with response to AED in this study.

Development and validation of a predictive model of drug-resistant genetic generalized epilepsy

OBJECTIVE

To develop and validate a clinical prediction model for antiepileptic drug (AED)-resistant genetic generalized epilepsy (GGE).

METHOD

We performed a case-control study of patients with and without drug-resistant GGE, nested within ongoing longitudinal observational studies of AED response at 2 tertiary epilepsy centers. Using a validation dataset, we tested the predictive performance of 3 candidate models, developed from a training dataset. We then tested the candidate models' predictive ability on an external testing dataset.

RESULTS

Of 5,189 patients in the ongoing longitudinal study, 121 met criteria for AED-resistant GGE and 468 met criteria for AED-responsive GGE. There were 66 patients with GGE in the external dataset, of whom 17 were cases. Catamenial epilepsy, history of a psychiatric condition, and seizure types were strongly related with drug-resistant GGE case status. Compared to women without catamenial epilepsy, women with catamenial epilepsy had about a fourfold increased risk for AED resistance. The calibration of 3 models, assessing the agreement between observed outcomes and predictions, was adequate. Discriminative ability, as measured with area under the receiver operating characteristic curve (AUC), ranged from 0.58 to 0.65.

CONCLUSION

Catamenial epilepsy, history of a psychiatric condition, and the seizure type combination of generalized tonic clonic, myoclonic, and absence seizures are negative prognostic factors of drug-resistant GGE. The AUC of 0.6 is not consistent with truly effective separation of the groups, suggesting other unmeasured variables may need to be considered in future studies to improve predictability.

Genetic generalized and focal epilepsy prevalence in the North American SUDEP Registry

Objective

To assess relative rates and clinical features of patients with genetic generalized epilepsy (GGE), focal epilepsy (FE), and developmental encephalopathic epilepsy (DEE) in the North American SUDEP Registry (NASR).

Methods

We identified all adjudicated definite, definite plus, and probable sudden unexpected death in epilepsy (SUDEP) cases (n = 262) and determined epilepsy type (GGE, FE, or DEE) from medical record review including history, imaging and EEG results, genetics, and next-of-kin interviews.

Results

Of the 262 SUDEP cases, 41 occurred in GGE, 95 in FE, 24 in DEE, and 102 were unclassifiable. GGE cases comprised 26% of NASR cases with an epilepsy syndrome diagnosis. The relative frequency of FE:GGE was slightly lower (2.3:1) than in population cohorts (2.1–6:1). Compared to patients with FE, patients with GGE had similar (1) ages at death and epilepsy onset and rates of (2) terminal and historical antiseizure medication adherence; (3) abnormal cardiac pathology; (4) illicit drug/alcohol use histories; and (5) sleep state when SUDEP occurred.

Conclusions

GGE cases were relatively overrepresented in NASR. Because GGEs are less often treatment-resistant than FE or DEE, seizure type rather than frequency may be critical. Many people with GGE predominantly have generalized tonic-clonic seizures (GTCS) when they have uncontrolled or breakthrough seizures, whereas patients with FE more commonly experience milder seizures. Future mechanistic SUDEP studies should assess primary and focal-to-bilateral GTCS to identify potential differences in postictal autonomic and arousal disorders and to determine the differential role that lifestyle factors have on breakthrough seizures and seizure types in GGE vs FE to effectively target SUDEP mechanisms and prevention.

Risk factors associated with drug resistant focal epilepsy in adults: A case control study

PURPOSE

Using an adult cohort of patients with focal epilepsy, we aimed to identify risk factors for development of drug-resistant epilepsy, which if identifiable would allow patients to receive appropriate counsel and earlier surgical treatment.

METHODS

This is a case-control study nested within a cohort, 146 adult patients with focal epilepsy were included. Definitions were used in accordance with ILAE criteria. The odds ratio and its confidence interval were calculated. We performed a logistic regression analysis.

RESULTS

Seventy-one [48.6%] patients met the criteria for drug-resistant epilepsy [cases] and 75 [51.4%] patients were controls. The mean age of patients was 44.5 ± 16.4 years. The most significant variables associated with developing drug-resistant epilepsy include younger age at diagnosis [18.75 vs. 32.2, p < 0.001], years of evolution of epilepsy [22.54 vs. 16.05, p < 0.001], number of AED [4.8 vs. 2.87, p < 0.001], complex partial seizures [51 vs. 35 OR 2.9, p = 0.002], having more than one seizure per month [51 vs. 38, p = 0.009], bi-temporal focus [14 vs. 4 p = 0.008] and mesial temporal sclerosis [23 vs. 11 p = 0.01]. Good response to first AED [7 vs. 29 OR 0.2, p = 0.001] and epilepsy secondary to encephalomalacia [8 vs. 20 OR 0.35, p = 0.018] might be protective factors against drug resistant epilepsy.

CONCLUSIONS

Longer time of epilepsy evolution, high frequency of seizures, complex partial seizure presentation, higher number of antiepileptic drugs, mesial temporal sclerosis and bitemporal epilepsy are predictive factors of subsequent pharmacoresistance.

Multivariable prediction model of drug resistance in adult patients with generalized epilepsy from Colombia: A case-control study

INTRODUCTION

Patients with drug-resistant epilepsy (DRE) account for most of the burden of epilepsy, and they have poor prognosis in seizure control, higher morbidity, and mortality.

OBJECTIVES

The objective of the study was to develop a prognostic model of drug resistance in adult patients with generalized epilepsy from Colombia.

METHODS

In this case-control study of patients with generalized epilepsy, patients were separated into two groups: one group with DRE (cases) according to the new International League Against Epilepsy (ILAE) definition after a complete evaluation performed by an epileptologist and the other group without DRE (control). Variables were analyzed to identify statistical differences between groups and were then selected to construct a prognostic model from a logistic regression.

RESULTS

One hundred thirty-three patients with generalized epilepsy were studied. Thirty-eight (28.5%) patients had DRE, and 95 (71.5%) did not have DRE. History of status epilepticus, abnormal findings from neurological examination, aura, any degree of cognitive impairment, epileptic seizures at any moment of the day, and any comorbidity were risk factors. The presence of seizures only in the waking state and idiopathic etiology were protective factors. A prognostic model was constructed with previously reported risk factors for DRE and other variables available in the population of this study. In the multivariable analysis, the history of status epilepticus (odds ratio (OR): 5.6, confidence interval (CI): 1.1-20.0, p = 0.031), abnormal findings from neurological examination (OR: 5.7, CI: 2.3-13.9, p = 0.000), and aura (OR: 6.1, CI: 1.8-20.8, p = 0.003) were strongly associated with DRE.

CONCLUSIONS

In adult patients with generalized epilepsy, aura, abnormal findings from neurological examination, and history of status epilepticus were predictive factors for DRE.

Sleep convulsive seizures predict lack of remission in genetic generalized epilepsies: A retrospective study from a single epilepsy center in Egypt

BACKGROUND

Genetic generalized epilepsies (GGEs) represent 15-20% of all epilepsies. There are no studies on the outcome of GGEs in the Middle East.

AIMS

To investigate the long-term prognosis of GGEs and identify prognostic predictors in Egypt.

MATERIAL & METHODS

This is a retrospective cohort study of consecutive children and adults with GGEs seen in an epilepsy clinic in Cairo, Egypt, followed for 10+ years. Follow-up visits were scheduled every 3-6 months or earlier. Demographic and clinical prognostic predictors were collected. Presence and number of seizure types were noted along with the number and doses of drugs. The outcome was defined as 5-year remission (5yrR), relapse, or no remission. The probability of 5yrR was calculated using Kaplan-Meier curves. Prognostic predictors were assessed with Cox proportional models.

RESULTS

Included were 120 patients (males, 41.7%), mean age at onset 13.6 years, followed for a mean of 12.5 years (range 10-20). Generalized tonic-clonic seizures were present in 93.3% of cases, followed by myoclonic (65%) and absence seizures (37.5%). 85 cases (70.8%) attained 5yrR (18 of them off-medications) and 59.1% had a relapse. The cumulative probability of starting 5yrR was 6.7%, 30.8%, and 50% at onset, 5 and 10 years. Only absence of sleep seizures was an independent predictor of 5yrR (Hazard ratio, 2.08; 95% CI 1.01-4.33).

DISCUSSION

Our findings are in keeping with others. The negative effects of sleep seizures are not unexpected because further unrecognized seizures might be expected.

CONCLUSIONS

Prolonged remission of GGEs is high and compatible with treatment discontinuation. Sleep seizures are negative prognostic predictors.

Prognostic factors in patients with refractory idiopathic generalized epilepsy

OBJECTIVE

Idiopathic generalized epilepsy (IGE) is an epileptic condition with good response to antiepileptic drugs (AED). Major syndromes are epilepsy with generalized tonic-clonic seizures (GTCS) alone, absence epilepsy and juvenile myoclonic epilepsy. However, clinical practice shows drug-resistant patients. Endpoint is to identify clinical features related with refractoriness in IGE and in its each individual syndrome.

METHODS

We retrospectively collected 279 consecutive patients with IGE assessed in the Epilepsy Clinic of our institution. We defined drug-resistant epilepsy as a failure of adequate trials of 2 tolerated and appropriately chosen and used AED schedules. We classified patients in two groups: drug-resistant and drug-responsive. Clinical features were compared among these groups, in the whole IGE group as well as in each syndrome.

RESULTS

There were 122 drug-resistant, 105 drug- responsive; 52 were undefined and excluded from the analysis. After multivariate analysis, early seizures onset (age <13), long-time epilepsy, several generalized seizure types, status epilepticus, EEG with generalized epileptiform activity, mainly polyspikes, and side effects with AED brought up as poor outcome factors. Additionally, 50.6% identified modifiable seizure triggers. Regarding syndromes, epilepsy with generalized tonic-clonic seizures alone had the same factors except several seizure types; presence of additional GTCS, polyspikes, history of AED side effects and psychiatric disorder were poor factors for absence epilepsy; only psychiatric comorbidity revealed significance in juvenile myoclonic epilepsy.

SIGNIFICANCE

Refractoriness in IGE and its major syndromes is associated with clinical and electrographic parameters. Moreover, lifestyle advices from neurologists to the patients might help them to achieve a better seizure control.

EEG correlates of seizure freedom in genetic generalized epilepsies

Background

We investigated the association between epileptiform EEG abnormalities and the preceding duration of seizure freedom in genetic generalized epilepsies (GGE).

Methods

We analyzed 24-hour ambulatory EEG recordings of patients with GGE diagnosed and classified according to the International League Against Epilepsy criteria. We quantified epileptiform EEG abnormalities into density scores (total duration of epileptiform discharges per hour) and estimated the preceding seizure-free duration at the time of EEG recording based on the last self-reported seizure. We then employed regression analysis to quantitate the relationship between the duration of seizure freedom and EEG variables.

Results

We analyzed 6,923 epileptiform discharges from 105 patients with abnormal 24-hour EEGs. In the regression analysis exploring the crude associations, we found significant correlations between 6 EEG variables and the duration of seizure freedom indicating that shorter duration of seizure freedom was associated with higher spike densities and longer paroxysms. These associations were not affected by confounders such as syndrome, age at EEG, age at epilepsy onset, sex, duration of epilepsy, or number of antiepileptic drugs.

Conclusions

Higher densities and longer durations of epileptiform discharges may be retrospectively associated with a shorter duration of self-reported seizure freedom. Hence, EEG can potentially be used as a biomarker of prognosis in GGE. These findings need to be validated in a prospective study in order to define EEG markers of future seizure freedom.

Outcomes in newly diagnosed epilepsy in adolescents and adults: Insights across a generation in Scotland

The outpatient services at the Epilepsy Unit in the Western Infirmary, Glasgow, Scotland was set up in September 1982. From the outset patient data were collected prospectively. A focused approach to patients with newly diagnosed epilepsy was developed and a series of 4 analyses have been undertaken over the intervening years, with results from the latest still being written up for publication. A total of 16 published papers have described patient outcomes over the years, focusing on response to different drug schedules. A number of factors contributing to a poorer prognosis has been identified and follow up data over 30 years has confirmed the lack of overall improvement in prognosis despite the introduction of 14 new AEDs for the common epilepsies in the UK with different mechanisms of action over this time. Patterns of response have confirmed that a majority of patients will go into remission with around 25% of the population appearing to have refractory epilepsy de novo. Since all available options are antiseizure and not antiepilepsy drugs, some patients, who are initially well controlled, are seen to relapse over time and to develop refractory epilepsy. A new approach in identifying and treating epileptogenesis is necessary, if this disappointing scenario is to be reversed with the next generation of antiepileptic drugs.

Valproic acid after five decades of use in epilepsy: time to reconsider the indications of a time-honoured drug

Since the serendipitous discovery of its anticonvulsant properties more than 50 years ago, valproic acid has become established as an effective broad-spectrum antiepileptic drug that is particularly useful for the management of generalised epilepsies, for which treatment alternatives are few. However, during the past few years increasing evidence has accumulated that intake of valproic acid during pregnancy is associated with a significant risk of dose-dependent teratogenic effects and impaired postnatal cognitive development in children. Because of these risks, valproic acid should not be used as a first-line drug in women of childbearing potential whenever equally or more effective alternative drugs are available-as in the case of focal epilepsy. In some generalised epilepsy syndromes, such as juvenile myoclonic epilepsy, valproic acid has better documented efficacy than alternative drugs and drug selection should be a shared decision between the clinician and the informed patient based on careful risk-benefit assessment.

A prospective study of the modified Atkins diet for adults with idiopathic generalized epilepsy

For children with pharmacoresistant epilepsy, the ketogenic diet is an established treatment option worldwide. However, for adults, this treatment is less frequently offered, and its efficacy less well-documented. The aim of this study was to examine efficacy and tolerability of such a diet as an adjuvant therapy to antiepileptic drugs for adult patients with pharmacoresistant generalized epilepsy. Thirteen patients (12 women) aged 16-57 years were included prospectively. They were treated with a modified Atkins diet for 12 weeks. Nine of the 13 participants had juvenile myoclonic epilepsy (JME), two had childhood absence epilepsy, one had Jeavons syndrome, and one had generalized epilepsy of unknown type. Six participants, all with JME, completed the 12-week study period. Among these six, four had >50% seizure reduction. Their seizure severity, using the revised Liverpool Seizure Severity Scale, was reduced by 1, 5, 57.5, and 70 points, respectively (scale: 1-100 points). In three of these four responders, quality of life, assessed by QOLIE-89, increased more than 20 points (scale: 0-100 points). Mean reduction of body weight after 12 weeks on diet was 6.5 (range: 4.3-8.1) kg. Lack of motivation, poor compliance, and seizure aggravation were the main reasons for premature termination of the diet. Apart from one patient who developed gallstones when ending the treatment after 10 months, no adverse effects were noted. In conclusion, using a modified Atkins diet for 12 weeks led to a clinically relevant reduction of seizure frequency in four of thirteen adult patients with pharmacoresistant generalized epilepsy. All responders were diagnosed with JME. In three of the four, the benefits of diet were so considerable that they chose to continue the treatment.

Predicting drug resistance in adult patients with generalized epilepsy: A case-control study

OBJECTIVES

Using an adult cohort of patients with generalized epilepsy, we aimed to identify risk factors for development of drug-resistant epilepsy (DRE), which if identifiable would allow patients to receive earlier treatment and more specifically individualized treatment plans.

METHODS

For the case-control study, 118 patients with generalized epilepsy (GE) between the ages of 18 and 75 were included after selection from a database of 800 patients referred from throughout the Saskatchewan Epilepsy Program. Definitions were used in accordance with ILAE criteria. The odds ratio and its confidence interval were calculated. We performed a logistic regression analysis.

RESULTS

Forty-four (37%) patients fulfilled the definition of DRE (cases), and seizures in 74 (63%) patients were not intractable (controls). Patients with DRE were significantly younger than the controls at the onset of epilepsy (6.6 vs. 18.8 years, p=<0.001). Significant variables on univariate analysis were the following: epilepsy diagnosed prior to 12 years (OR: 12.1, CI: 4.8-29.9, p<0.001), previous history of status epilepticus (OR: 15.1, CI: 3.2-70.9, p<0.001), developmental delay (OR: 12.6, CI: 4.9-32, p<0.001), and cryptogenic epilepsy (OR: 10.5, CI: 3.9-27.8, p<0.001). Our study showed some protective factors for DRE such as a good response to first AED, idiopathic etiology, and history of febrile seizures. In the logistic regression analysis, two variables remained statistically significant: developmental delay and more than one seizure type.

CONCLUSION

Our study has identified a set of variables that predict DRE in patients with generalized epilepsy. Risk factors identified in our study are similar to those previously identified in pediatric studies, however, our study is specifically tailored to adult patients with generalized epilepsy.

Third International Congress on Epilepsy, Brain, and Mind: Part 2

Epilepsy is both a disease of the brain and the mind. Here, we present the second of two papers with extended summaries of selected presentations of the Third International Congress on Epilepsy, Brain and Mind (April 3-5, 2014; Brno, Czech Republic). Humanistic, biologic, and therapeutic aspects of epilepsy, particularly those related to the mind, were discussed. The extended summaries provide current overviews of epilepsy, cognitive impairment, and treatment, including brain functional connectivity and functional organization; juvenile myoclonic epilepsy; cognitive problems in newly diagnosed epilepsy; SUDEP including studies on prevention and involvement of the serotoninergic system; aggression and antiepileptic drugs; body, mind, and brain, including pain, orientation, the "self-location", Gourmand syndrome, and obesity; euphoria, obsessions, and compulsions; and circumstantiality and psychiatric comorbidities.

Choice of Antiepileptic Drugs in Idiopathic Generalized Epilepsy: UAE Experience

We retrospectively reviewed the electroencephalogram (EEG) reports of patients at our EEG lab from the years 2005–2010 to identify patients referred from the epilepsy clinic, with a confirmed diagnosis of idiopathic generalized epilepsy (IGE) by EEG criteria. We sought to report our experience in UAE of how often patients with IGE are placed on nonspecific antiepileptic drugs (AEDs) before being evaluated at an epilepsy referral clinic. 109 patients with a confirmed diagnosis of IGE based on EEG criteria were identified. When initially seen, 32.11% were taking a broad-spectrum (specific) AED only, 25.69% were taking a narrow-spectrum (nonspecific) AED, and 15.59% were placed on various combinations. Of the total patients who were receiving nonspecific AEDs, 35.71% were seizure-free and 64.28% were poorly controlled accounting for “pseudointractability status.” When converted to broad-spectrum (specific) AEDs, 50% became well controlled. Furthermore, 26.6% of patients, who were previously on no AED prior to the clinic visit, became well controlled once placed on specific AED.

Pharmacotherapy for tonic-clonic seizures

INTRODUCTION

Occurrence of generalized tonic-clonic seizures (GTCS) is one of the most important risk factors of seizure-related complications and comorbidities in patients with epilepsy. Their prevention is therefore an important aspect of therapeutic management both in idiopathic generalized epilepsies and in focal epilepsies.

AREAS COVERED

It has been shown that the efficacy of antiepileptic drugs (AEDs) varies across epilepsy syndromes, with some AEDs efficacious against focal seizures with secondary GTCS (sGTCS) but aggravating primary GTCS (pGTCS). In patients with pGTCS, evidence-based data support the preferential use of valproic acid, lamotrigine, levetiracetam and topiramate. In patients with sGTCS, all AEDs approved in the treatment of focal epilepsies might be used.

EXPERT OPINION

Both in pGTCS and sGTCS, additional data are required, specifically to inform about the relative efficacy of AEDs in relation to each other. Although valproic acid might be the most efficacious drug in idiopathic generalized epilepsies, it should be avoided in women of childbearing age due to its safety profile. In patients with sGTCS, AEDs for which the impact on this seizure type has been formally evaluated and which have demonstrated greater efficacy than placebo might preferentially be used, such as lacosamide, perampanel and topiramate.

Racial and ethnic differences in epilepsy classification among probands in the Epilepsy Phenome/Genome Project (EPGP)

Little is known about the ethnic and racial differences in the prevalence of generalized and focal epilepsy among patients with non-acquired epilepsies. In this study, we examined epilepsy classification and race/ethnicity in 813 probands from sibling or parent-child pairs with epilepsy enrolled in the Epilepsy Genome/Phenome Project (EPGP). Subjects were classified as generalized epilepsy (GE), non-acquired focal epilepsy (NAFE), mixed epilepsy syndrome (both generalized and focal), and unclassifiable, based on consensus review of semiology and available clinical, electrophysiology, and neuroimaging data. In this cohort, 628 (77.2%) subjects identified exclusively as Caucasian/white and 65 (8.0%) subjects reported African ancestry, including subjects of mixed-race. Of the Caucasian/white subjects, 357 (56.8%) had GE, 207 (33.0%) had NAFE, 32 (5.1%) had a mixed syndrome, and 32 (5.1%) were unclassifiable. Among subjects of African ancestry, 28 (43.1%) had GE, 27 (41.5%) had NAFE, 2 (3.1%) had a mixed syndrome, and 8 (12.3%) were unclassifiable. There was a higher proportion of subjects with GE compared to other syndromes among Caucasians/whites compared to subjects with African ancestry (OR 1.74, 95% CI: 1.04-2.92, two-tailed Fisher's exact test, p=0.036). There was no difference in the rate of GE among subjects reporting Hispanic ethnicity (7.6% of total) when adjusted for race (Caucasian/white vs non-Caucasian/white; OR 0.65, 95% CI: 0.40-1.06, p>0.05). The proportion of participants with unclassifiable epilepsy was significantly greater in those of African-American descent. In a group of patients with epilepsy of unknown etiology and an affected first degree relative, GE is more common among Caucasian/white subjects than among those with African ancestry. These findings suggest there may be geographical differences in the distribution of epilepsy susceptibility genes and an effect of genetic background on epilepsy phenotype. However, the results should be interpreted with caution because of the low numbers of African-Americans in this cohort and more limited diagnostic data available for epilepsy classification in these subjects compared to Caucasians/whites.

Prognostic value of EEG asymmetries for development of drug-resistance in drug-naïve patients with genetic generalized epilepsies

OBJECTIVE

Previous studies based solely on visual EEG analysis reported equivocal results regarding an association of pharmaco-resistance with EEG asymmetries in genetic generalized epilepsies (GGE). We addressed this issue by applying both visual and quantitative methods to the pretreatment EEG of GGE patients.

METHODS

Socio-demographic/disease characteristics and response to treatment/discontinuation trial for these patients were recorded at 6months and at last follow up. The first EEG was retrospectively, blindly, and visually assessed for focal slowing, focal discharges and also quantitatively analyzed for amplitude or latency asymmetries of generalized discharges. Association between these variables and development of drug-resistance was evaluated.

RESULTS

Out of 51 subjects, 40% had some type of EEG asymmetry by visual, 37% by quantitative and 54% by combined analysis. Drug-resistance was identified in 52% of patients after 6months and in 24% at the end of the follow up period (∼4.2years). 27% of patients underwent a discontinuation trial; 43% unsuccessfully. There was no association between baseline EEG asymmetries of any type and refractoriness to medical therapy, regardless of analytical method used.

CONCLUSIONS

In a carefully selected cohort of medication-naïve GGE patients, visual and quantitative asymmetries in the first EEG were not associated with the development of pharmaco-resistance.

SIGNIFICANCE

These findings do not provide support for utilization of EEG asymmetries as a prognostic tool in GGE.

Idiopathic generalized epilepsy: Phenotypic and electroencephalographic observations in a large cohort from South India

PURPOSE

We studied the phenotype and electroencephalographic (EEG) features, and therapeutic aspects of idiopathic generalized epilepsies (IGEs) in South Indian population.

PATIENTS AND METHODS

This prospective cross-sectional hospital-based study was carried out on non-consecutive 287 patients (age 22.2 ± 7.7 years; M:F = 139:148) with IGE syndrome. Their clinical and EEG observations were analyzed.

RESULTS

Majority of the patients had onset of seizures <20 years of age (n = 178; 62%). Thirty one patients (10.8%) had family history of epilepsy. Nearly half of them (49.9%) had <5 years of duration of seizures. The type of IGEs included Juvenile myoclonic epilepsy (JME): 115 (40.1%); IGE with generalized tonic-clonic seizures (GTCS) only: 102 (39.02%); childhood absence epilepsy (CAE): 35 (12.2%); GTCS on awakening: 15 (5.2%); Juvenile absence epilepsy (JAE): 11 (3.8%); and unclassified seizures: 9 (3.1%). The triggering factors noted in 45% were sleep deprivation (20%), non-compliance and stress in 5% each. The EEG (n = 280) showed epileptiform discharges in about 50% of patients. Epileptiform discharges during activation was observed in 40/249 patients (16.1%): Hyperventilation in 32 (12.8%) and photic stimulation in 19 (7.6%). The seizures were well controlled with anti-epileptic drugs (AEDs) in 232 (80.8%) patients and among them, 225 (78.4%) patients were on monotherapy. Valproate (n = 131) was the most frequently prescribed as monotherapy.

CONCLUSIONS

This is one of the largest cohort of patients with IGE. This study reiterates the importance of segregating IGE syndrome and such analysis will aid to the current understanding and management.

Polytherapy for migraine prophylaxis

Migraine is a chronic neurological disorder with episodic manifestations, progressive in some individuals. Preventive treatment is recommended for patients with frequent or disabling attacks. A sizeable proportion of migraineurs in need of preventive treatment does not significantly benefit from monotherapy. This short review evaluates the role of pharmacological polytherapy in migraine prevention.

The prognosis of idiopathic generalized epilepsy

Prognosis describes the trajectory and long-term outcome of a condition. Most studies indicate a better prognosis in idiopathic generalized epilepsy (IGE) in comparison with other epilepsy syndromes. Studies looking at the long-term outcome of different IGE syndromes are relatively scant. Childhood absence epilepsy appears to have a higher rate of remission compared to juvenile absence epilepsy. In absence epilepsies, development of myoclonus and generalized tonic-clonic seizures predicts lower likelihood of remission. Although most patients with juvenile myoclonic epilepsy (JME) achieve remission on antiepileptic drug therapy, <20% appear to remain in remission without treatment. Data on the prognosis of other IGE syndromes are scarce. There are contradictory findings reported on the value of electroencephalography as a predictor of prognosis. Comparisons are made difficult by study heterogeneity, particularly in methodology and diagnostic criteria.

The adolescent or adult with generalized tonic-clonic seizures

Primary and secondary generalized tonic-clonic seizures (GTCs) together constitute up to 50% of adolescent and adult patients with epilepsy as diagnosed by history and EEG. Syncope and psychogenic nonepileptic seizures are major differential diagnoses and must be carefully excluded in therapy-resistant cases. Individual episodes can have up to seven phases in secondarily generalized GTCs. The distinction between primary and secondary GTCs depends mainly on history and EEG, and yield can be improved with sleep deprivation or overnight recording. Epilepsies with primary or unclassified GTCs can respond to any one of the five broad-spectrum antiepileptic drugs (AEDs): valproate, lamotrigine, levetiracetam, topiramate and zonisamide. Unless a focal onset is clearly confirmed, a sodium-channel blocking AED should not be used in the initial treatment of these conditions.

Do lamotrigine and levetiracetam solve the problem of using sodium valproate in women with epilepsy?

Women with epilepsy, especially those of child-bearing age, are faced with difficult choices when it comes to choosing the most suitable antiepileptic drug (AED). This is particularly so for those with idiopathic generalized epilepsies, or those for whom seizure syndrome is not immediately apparent, where sodium valproate is still considered the drug of choice. While with treatment most might expect to become seizure free, without any adverse effects, other considerations for women mean that valproate is usually initially avoided, with other AEDs such as lamotrigine or levetiracetam being chosen in preference. Based on current information, this article attempts to provide an overview on whether or not the availability of these and other broad-spectrum AEDs have solved the difficulties of using valproate in women of child-bearing age.

Newly diagnosed epilepsy and pharmacogenomics research: a step in the right direction?

Pharmacogenomics holds the promise of selecting the right drug at the right dose for the right person. Its research and application in epilepsy are in their infancy. Although advances have been made in identifying genetic markers of adverse effects in terms of severe cutaneous reactions, there has been little progress in predicting efficacy. Most studies have been retrospective and case-control in design, despite the associated problems of recall bias and a usually undefined relationship between genotype and outcome. We describe the epidemiological framework necessary to detect genetic influences on antiepileptic drug response, and propose an ambitious prospective outcome study of newly diagnosed epilepsy across all age ranges, countries, and continents, which would provide the template for a global pharmacogenomic project. Other epidemiological considerations and statistical constraints and issues related to study design, databases, and ethics that are critical for advancement in the field are also discussed.

Outcome of lamotrigine treatment in juvenile myoclonic epilepsy

OBJECTIVES

To determine the response rate of patients with juvenile myoclonic epilepsy (JME) to lamotrigine (LTG) and identify predictive factors for treatment response.

MATERIAL AND METHODS

Medical records of 62 patients with JME were reviewed for demographic, clinical, and EEG parameters. We determined clinical response to LTG and compared LTG responders with non-responders.

RESULTS

There were 35 LTG responders (56%) and 27 non-responders (44%). JME patients without generalized tonic clonic seizures (GTCS) responded better to LTG (P = 0.04). Valproic acid (VPA) failure because of adverse events rather than lack of efficacy (P = 0.069) and delay in diagnosis (P = 0.07) showed a tendency toward good response to LTG.

CONCLUSIONS

LTG should be considered a drug of first choice for JME patients without GTCS. LTG as second-line treatment after VPA failure seems more appropriate for those patients whose reason for VPA failure is poor tolerability rather than lack of efficacy.

Idiopathic generalized epilepsies: a follow-up study in a single-center

OBJECTIVE

To characterize adult patients with idiopathic generalized epilepsies (IGEs) with precise evaluation and to assess factors related to refractoriness.

MATERIALS AND METHODS

Hospital records of all our patients with IGEs (n = 128) were evaluated in 2005 and followed-up until 2008.

RESULTS

In 2005, 76% of patients were 1-year seizure-free. Seizure freedom increased to 82% during the 3-year follow-up. Seizure freedom was not significantly associated with age, age at diagnosis, epilepsy duration, exposure to inappropriate initial antiepileptic drug (AED), or delay time between starting initial AED and appropriate AED. Women constituted 78% of patients with merely provoked seizures. In 58% of women with recent seizure, one to two avoidable precipitating factors, such as lack of sleep, alcohol, and forgetting to take AED, were observed. In 2008, all patients with no medication, 91% of monotherapy patients, 60% of patients on two AED, and 14% of patients on three AED were seizure-free.

CONCLUSIONS

Most of patients with IGEs can be successfully treated with monotherapy. Refractory seizures in some patients may be because of avoidable factors, especially in young women.

Valproate in children with newly diagnosed idiopathic generalized epilepsy

OBJECTIVES

Sparse information on dose-response characteristics for initial antiepileptic drug monotherapy in children with idiopathic generalized epilepsy (IGE) is available. The aim of this study is to characterize the therapeutic dose of valproate in children with newly diagnosed IGE.

MATERIALS AND METHODS

Effect of initial valproate monotherapy and doses associated with seizure freedom were examined in consecutive children with IGE identified from a New Onset Seizure Clinic.

RESULTS

Of 84 patients identified, 48 (57%) became seizure-free on valproate monotherapy and another 10 patients became seizure-free but discontinued VPA because of adverse effects. The mean dose in seizure-free children was 15.7 mg/kg/day and over 95% of IGE patients will respond below 25 mg/kg/day.

CONCLUSIONS

Half of children became seizure-free on valproate monotherapy and did so at modest doses.