"Chance Takers Are Accident Makers": Are Patients With Epilepsy Really Taking a Chance When They Drive?

Predictive Power of Interictal Epileptiform Discharges in Fitness-to-Drive Evaluation

BACKGROUND AND OBJECTIVES

This study aimed to evaluate and predict the effects of interictal epileptiform discharges (IEDs) on driving ability using simple reaction tests and a driving simulator.

METHODS

Patients with various epilepsies were evaluated with simultaneous EEGs during their response to visual stimuli in a single-flash test, a car-driving video game, and a realistic driving simulator. Reaction times (RTs) and missed reactions or crashes (miss/crash) during normal EEG and IEDs were measured. IEDs, as considered in this study, were a series of epileptiform potentials (>1 potential) and were classified as generalized typical, generalized atypical, or focal. RT and miss/crash in relation to IED type, duration, and test type were analyzed. RT prolongation, miss/crash probability, and odds ratio (OR) of miss/crash due to IEDs were calculated.

RESULTS

Generalized typical IEDs prolonged RT by 164 ms, compared with generalized atypical IEDs (77.0 ms) and focal IEDs (48.0 ms) (p < 0.01). Generalized typical IEDs had a session miss/crash probability of 14.7% compared with a zero median for focal and generalized atypical IEDs (p < 0.01). Long repetitive bursts of focal IEDs lasting >2 seconds had a 2.6% miss/crash probabilityIED. Cumulated miss/crash probability could be predicted from RT prolongation: 90.3 ms yielded a 20% miss/crash probability. All tests were nonsuperior to each other in detecting miss/crash probabilitiesIED (zero median for all 3 tests) or RT prolongations (flash test: 56.4 ms, car-driving video game: 75.5 ms, simulator 86.6 ms). IEDs increased the OR of miss/crash in the simulator by 4.9-fold compared with normal EEG. A table of expected RT prolongations and miss/crash probabilities for IEDs of a given type and duration was created.

DISCUSSION

IED-associated miss/crash probability and RT prolongation were comparably well detected by all tests. Long focal IED bursts carry a low risk, while generalized typical IEDs are the primary cause of miss/crash. We propose a cumulative 20% miss/crash risk at an RT prolongation of 90.3 ms as a clinically relevant IED effect. The IED-associated OR in the simulator approximates the effects of sleepiness or low blood alcohol level while driving on real roads. A decision aid for fitness-to-drive evaluation was created by providing the expected RT prolongations and misses/crashes when IEDs of a certain type and duration are detected in routine EEG.

Driving regulations for epilepsy in Europe

BACKGROUND

Across Europe, there are differences regarding driving restrictions for patients with epilepsies and seizures. In the light of increasing mobility, knowledge about those different regulations is of high importance for counseling patients, and physicians.

METHODS

A structured online survey was sent to the official representatives of the different European ILAE chapters, asking for the local driving restrictions for patients with epilepsies, first seizures, syncopes, and psychogenic non-epileptic seizures.

RESULTS

The survey was sent to 38 chapters or representatives of 47 European Countries. 33 chapters answered. The majority of countries require 1 year of seizure-freedom for the ability to drive (Group 1, former categories A, B, B + E, F, G. H, K, L, and P; driving license which authorizes its holder to drive vehicle classes categories of the motor vehicle), usually with the need to continue antiseizure medication (ASM). Some countries have much stricter regulations before allowing for driving. Legal regulations after a first unprovoked seizure differ between 6 months for Group 1 license holders in most European countries, and one year in Luxembourg and Malta. In Serbia, there is no legal regulation for this special situation. The situation after a first seizure is even more complex for Group 2 license holders (former categories C1, C1+E, C, C + E, D1, D1+E, D, D + E).

CONCLUSION

Knowledge of the different recommendations of the individual European countries is of high relevance in the counseling of epilepsy patients. Europe-wide regulations, e.g. following the IBE-recommendations are needed to facilitate the patients' situation.

Cardiac disease and driver fatality

To determine the role of cardiac disease in driver fatalities, a retrospective review of autopsy files at Forensic Science SA in Adelaide, Australia, was undertaken over a 13-year-period January 2005-December 2017 for individuals aged ≥ 40 years who had died while driving a motor vehicle. The incidence of significant coronary artery atherosclerosis (CAA) and cardiomegaly was evaluated with comparisons between drivers and a control group of passengers. Autopsy examinations were performed on 303 drivers and 72 passengers who died of trauma and on 63 drivers who died of a cardiac event while driving. The average age for drivers dying of trauma was 58.5 years (range 40-93 years) with 48 (15.8%) having CAA and 31 (10.2%) having cardiomegaly. This was not statistically different to passengers (aged 63.3 years; range 40-93 years; 20.8% having CAA; 11 (15.2%) cardiomegaly; (p > 0.2). Drivers with significant cardiac disease did not, therefore, have increased rates of death in crashes, although a distinct subgroup of drivers consisted of those who had died from cardiac events and not trauma, while driving. The latter may be increasing in number given the aging population.

Characterizing the driving dilemma among patients with psychogenic nonepileptic seizures: A single-center prospective cohort study

OBJECTIVE

Driving is a critical topic to counsel among patients with epileptic seizures (ES) and psychogenic nonepileptic seizures (PNES), with significant legal and public health implications. This prospective cohort study examined the frequency of ES and PNES in a single institution's Epilepsy Monitoring Unit (EMU) and assessed driving-related issues between each group.

METHODS

Adult patients from the Mayo Clinic Arizona Epilepsy Monitoring Unit (EMU) were given comprehensive surveys addressing driving history. Descriptive analysis and statistics were used to summarize differences between patients with ES and PNES. Differences between patients with epilepsy and PNES were determined by Pearson chi-square.

RESULTS

Nearly half (n = 75/163) of all patients admitted to the EMU were diagnosed with PNES. Although the PNES group had a statistically significant higher frequency of events (p = 0.01), 87.7% of these patients reported compliance with the driving law recommendations, suggesting a trend that patients who have been counseled regarding fitness-to-drive are likely to follow the recommendation. One-third of patients with PNES reported an event while operating a motor vehicle and 8% (n = 2/25) resulted in a motor vehicle collision severe enough to require hospitalization. In contrast to those with ES, 25% of patients reported a typical event while driving and 25% (n = 2/8) of those resulted in a collision requiring hospitalization. The incidence of habitual events while driving is higher in the population with PNES (n = 25) when compared to those with ES (n = 8); however, it appears that patients with PNES were less likely to become involved in an accident resulting in seriously bodily injury than in ES.

CONCLUSIONS

Compared to patients with PNES, patients with ES have less frequent events but more severe collisions. This study reinforces the need for diligent driving counseling to help prevent driving-related injuries in patients with PNES and ES.

Hit-and-run: a Swedish nationwide cohort study of serious transport accidents and convictions due to traffic offenses in obsessive-compulsive disorder

PURPOSE

Individuals with obsessive-compulsive disorder (OCD) often report driving-related obsessions, such as fears of causing accidents, but the risk of transport accidents in OCD is unknown. We investigated whether individuals with OCD have an increased risk of serious transport accidents and convictions due to traffic offenses and explored the role of psychiatric comorbidities.

METHODS

We included all individuals ≥ 18 years living in Sweden between 1997 and 2013 (N = 5,760,734). A total of 23,126 individuals had a diagnosis of OCD in the National Patient Register. We also identified 16,607 families with full siblings discordant for OCD. Cox proportional hazards regression models estimated hazard ratios (HRs) with 95% confidence intervals (CIs) for the risk of three outcomes in individuals with OCD, compared to unexposed individuals and their unexposed full siblings: injuries or deaths due to transport accidents, injuries or deaths due to motor vehicle accidents, and convictions related to traffic offenses. Psychiatric comorbidities were systematically adjusted for.

RESULTS

Women, but not men, with OCD had a marginally increased risk of serious transport accidents (adjusted HR = 1.20 [95% CI 1.13-1.28]) and motor vehicle accidents (adjusted HR = 1.20 [95% CI 1.09-1.31]), compared to unaffected individuals. Neither women nor men with OCD had a significantly increased risk of convictions. The sibling comparisons showed no significant associations. When psychiatric comorbidities were adjusted for, several observed associations became non-significant or inversed (HRs and 95% CIs below one).

CONCLUSION

The risks of serious transport accidents and driving-related criminal convictions in OCD are negligible and heavily influenced by psychiatric comorbidity.

Seizure and social outcomes in patients with non-surgically treated temporal lobe epilepsy

OBJECTIVES

To investigate the seizure outcome with medical treatment in patients with temporal lobe epilepsy (TLE) and its associated factors. We also investigated the social outcome of the patients.

METHODS

This was a retrospective study of a prospectively built electronic database of patients with epilepsy. All patients with a diagnosis of TLE were studied at the outpatient epilepsy clinic at Shiraz University of Medical Sciences, Shiraz, Iran, from 2008 until 2019. In a phone call to the patients, at least 24 months after their diagnosis at our center, we investigated their current seizure control and social status.

RESULTS

Two hundred and twenty-two patients were studied; 101 patients (45.5%) were seizure free. A lower number of the prescribed drugs was the only factor with a significant association with the seizure-free outcome (Odds Ratio: 1.460; p = 0.001). At the time of the phone call, 76 patients (37.6%) reported having a college education, 103 patients (51%) were employed, 146 patients (72.3%) were married, and 81 patients (40%) reported driving a motor vehicle. The employment status, college education, and driving a motor vehicle were significantly associated with a seizure-free outcome status. The social achievements of the patients, who were partially responsive to medical therapy, were significantly worse than those who were seizure free.

CONCLUSION

Many patients with TLE may suffer from drug-resistant seizures. Ongoing seizures in these patients may affect their social lives substantially. Seizure reduction (not freedom) is not good enough to help the patients with TLE enjoy a healthy life with satisfactory social achievements.

Driving rate in patients with seizures: Epilepsy vs. functional seizures

OBJECTIVES

We investigated the rate of driving in patients with seizures [i.e., epilepsy or functional seizures (FS)]. We also investigated the factors that may be associated with NOT driving a motor vehicle.

METHODS

This was a retrospective study of an electronic database of patients with seizures that has been built prospectively over more than a decade. All patients, 20 years of age or older, with a diagnosis of idiopathic generalized epilepsy (IGE), focal epilepsy, or FS were studied at the outpatient epilepsy clinic at Shiraz University of Medical Sciences, Shiraz, Iran, from 2008 until 2020.

RESULTS

One thousand four hundred and ninety-two patients were studied (918 patients with focal epilepsy, 338 people with IGE, and 236 individuals with FS). In total, 387 patients (25.9%) reported driving a motor vehicle. Driving rate in patients with IGE was 26.9%, in people with focal epilepsy was 27.0%, and in individuals with FS was 20.3%; the difference was not significant (p = 0.10). Female sex and a younger age at the onset of seizures were significantly associated with not driving a motor vehicle. Being married and having any education were significantly inversely associated with not driving a motor vehicle.

CONCLUSION

Most patients with seizures (either people with epilepsy or those with FS alike) do not drive a motor vehicle in their routine daily lives. Demographic factors (e.g., sex, marital status, and education) have significant associations with not driving a motor vehicle.

A reappraisal of injuries and accidents in people with epilepsy

PURPOSE OF REVIEW

We review data on injuries and traffic accidents affecting people with epilepsy with emphasis on the overall risk of injuries, specific types of injuries, and risk factors.

RECENT FINDINGS

Population-based studies of incident epilepsy cohorts indicate that the risk of physical injuries in people with epilepsy in general is increased only modestly. The risk is higher in selected populations that attend epilepsy clinics or referral centers. Soft tissue injuries, dislocations, and fractures are the most common injures, whereas the greatest increase in risk is reported for more uncommon injuries such as drowning. People with epilepsy are at a two-fold to four-fold increased risk for fatal injuries. Comorbidities contribute to fatal as well as nonfatal injuries. The other major risk factor is poorly controlled major convulsive seizures (generalized as well as focal to bilateral tonic-clonic seizures). Serious transport accidents associated with increased risks for people with epilepsy include pedestrian, bicycle, as well as car accidents.

SUMMARY

Individualized information on the risk of physical injuries and accidents should be part of counseling of patients with epilepsy. Improved seizure control is likely the most effective way to reduce risks, but work place and home adjustments should also be considered.