Practice parameter: treatment of the child with a first unprovoked seizure: Report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society

Implementing Clinical Practice Guidelines: Considerations for Epileptologists

Over 5000 epilepsy-related articles are indexed annually, posing a challenge for clinicians to stay updated on all relevant research. Clinical Practice Guidelines (CPGs) are vital tools for translating evidence into practice and promoting equitable, high-quality care while addressing practice variations. This review examines CPG applicability for epileptologists, emphasizing the nuances between primary and specialty care, addressing disparities, and comparing guideline usage in the United States and internationally. CPGs are utilized differently across specialties. General practitioners often manage initial epilepsy cases guided by first-seizure and new-onset epilepsy guidelines. Specialists, dealing with complex cases like treatment-resistant epilepsy, face challenges as guidelines may lag behind emerging therapies. Yet, evidence shows specialists heavily rely on CPGs to ensure optimal care. The use of race in medical algorithms highlights disparities, with examples like race-based adjustments in glomerular filtration rate calculations raising equity concerns. While frameworks exist to reduce biases, ongoing monitoring and inclusive approaches are critical. Globally, CPG implementation varies. The UK's centralized system integrates cost-effectiveness analyses, while the United States adopts a decentralized approach prioritizing clinical efficacy. Emerging technologies, such as electronic medical records and clinical decision support systems, improve CPG adoption and patient outcomes. Success stories like the "Get with the Guidelines" stroke program illustrate the potential of structured CPG frameworks. However, challenges persist, such as inconsistencies in epilepsy guidelines for acute seizure management. Ultimately, bridging the gap between evidence and practice requires rigorous, inclusive guideline development, effective communication, and proactive implementation strategies tailored to diverse healthcare systems.

First Seizures, Acute Repetitive Seizures, and Status Epilepticus

OBJECTIVE

This article provides current evidence on how and when to treat unprovoked first seizures in children and adults, guides intervention with appropriate doses and types of modern and effective therapies for acute repetitive (cluster) seizures, and reviews evidence for the diagnosis and management of established, refractory and super-refractory status epilepticus.

LATEST DEVELOPMENTS

Artificial intelligence shows promise as a clinical assistant in decision making after a first seizure. For nonanoxic convulsive refractory status epilepticus third-phase treatment, equipoise exists regarding whether it is better to add a second IV nonsedating antiseizure medication given via loading dose (eg, brivaracetam, lacosamide, levetiracetam, fosphenytoin or valproic acid) or to start an anesthetizing continuous IV infusion antiseizure medication such as ketamine, midazolam, propofol or pentobarbital.

ESSENTIAL POINTS

After a first seizure, the risk of a second seizure is about 36% at 2 years and 46% after 5 years. The risk is doubled in the presence of EEG epileptiform discharges, a brain imaging abnormality, a nocturnal first seizure, or prior brain trauma. For acute repetitive seizures, providers should give a proper dose of benzodiazepines based on the patient's weight and needs. First-phase treatment for convulsive established status epilepticus is the immediate administration of full doses of benzodiazepines. Second-phase treatment for convulsive established status epilepticus is a full loading dose of IV fosphenytoin, levetiracetam, valproic acid, or if necessary, phenobarbital.

Implementing Guidelines and Measures in Epilepsy Care

ABSTRACT

People with epilepsy must receive up-to-date, high-quality care that aligns with current understanding of basic disease mechanisms, improved diagnostic testing, and evolving medical and surgical treatments. Varying progress has been made in identifying, measuring, and mitigating epilepsy care gaps. Epilepsy guidelines and quality measures should be developed using rigorous processes informed by systematic reviews of best evidence in conjunction with prioritization of need. Epilepsy measures help operationalize guidelines and practice parameters. Most epilepsy quality indicators are process-based metrics defined by delivering care to the patient. Systematic and reliable tracking and documentation of seizure frequency using consistent language is required as a patient-reported outcome within individuals over time and across populations. Emerging literature has demonstrated gaps in epilepsy care, perhaps highlighting limitations in the dissemination and implementation of guidelines and quality measures in clinical practice. Quality improvement methods applied to clinical data registries and learning health systems may afford new opportunities to iteratively, collaboratively, and feasibly disseminate guidelines and quality measures, measure epilepsy care quality, allow for the testing of interventions to mitigate identified care gaps, and, ultimately, improve care for patients with epilepsy.

The ASAM/AAAP Clinical Practice Guideline on the Management of Stimulant Use Disorder

The American Society of Addiction Medicine/American Academy of Addiction Psychiatry (ASAM/AAAP) Clinical Practice Guideline on the Management of Stimulant Use Disorder provides guidance on evidence-based strategies for the treatment of stimulant use disorders (StUDs), stimulant intoxication, and stimulant withdrawal, as well as secondary and tertiary prevention of harms associated with stimulant use. The Clinical Guideline Committee (CGC) comprised experts from ASAM and AAAP representing a range of clinical settings and patient populations. The guideline was developed following modified GRADE methodology. The process included a systematic literature review as well as several targeted supplemental searches. The CGC utilized Evidence to Decision tables to review available evidence and rate the strength of each recommendation. The clinical practice guideline was revised based on external stakeholder review. Key takeaways included: Contingency management represents the current standard of care for treatment of StUDs; Pharmacotherapies may be utilized off-label to treat StUDs; Acute stimulant intoxication can result in life-threatening complications that should be addressed in an appropriate level of care; Secondary and tertiary prevention strategies should be used to reduce harms related to risky stimulant use.

Predicting seizure recurrence after an initial seizure-like episode from routine clinical notes using large language models: a retrospective cohort study

BACKGROUND

The evaluation and management of first-time seizure-like events in children can be difficult because these episodes are not always directly observed and might be epileptic seizures or other conditions (seizure mimics). We aimed to evaluate whether machine learning models using real-world data could predict seizure recurrence after an initial seizure-like event.

METHODS

This retrospective cohort study compared models trained and evaluated on two separate datasets between Jan 1, 2010, and Jan 1, 2020: electronic medical records (EMRs) at Boston Children's Hospital and de-identified, patient-level, administrative claims data from the IBM MarketScan research database. The study population comprised patients with an initial diagnosis of either epilepsy or convulsions before the age of 21 years, based on International Classification of Diseases, Clinical Modification (ICD-CM) codes. We compared machine learning-based predictive modelling using structured data (logistic regression and XGBoost) with emerging techniques in natural language processing by use of large language models.

FINDINGS

The primary cohort comprised 14 021 patients at Boston Children's Hospital matching inclusion criteria with an initial seizure-like event and the comparison cohort comprised 15 062 patients within the IBM MarketScan research database. Seizure recurrence based on a composite expert-derived definition occurred in 57% of patients at Boston Children's Hospital and 63% of patients within IBM MarketScan. Large language models with additional domain-specific and location-specific pre-training on patients excluded from the study (F1-score 0·826 [95% CI 0·817-0·835], AUC 0·897 [95% CI 0·875-0·913]) performed best. All large language models, including the base model without additional pre-training (F1-score 0·739 [95% CI 0·738-0·741], AUROC 0·846 [95% CI 0·826-0·861]) outperformed models trained with structured data. With structured data only, XGBoost outperformed logistic regression and XGBoost models trained with the Boston Children's Hospital EMR (logistic regression: F1-score 0·650 [95% CI 0·643-0·657], AUC 0·694 [95% CI 0·685-0·705], XGBoost: F1-score 0·679 [0·676-0·683], AUC 0·725 [0·717-0·734]) performed similarly to models trained on the IBM MarketScan database (logistic regression: F1-score 0·596 [0·590-0·601], AUC 0·670 [0·664-0·675], XGBoost: F1-score 0·678 [0·668-0·687], AUC 0·710 [0·703-0·714]).

INTERPRETATION

Physician's clinical notes about an initial seizure-like event include substantial signals for prediction of seizure recurrence, and additional domain-specific and location-specific pre-training can significantly improve the performance of clinical large language models, even for specialised cohorts.

FUNDING

UCB, National Institute of Neurological Disorders and Stroke (US National Institutes of Health).

Safely Shifting MRIs for Seizure Evaluation to the Outpatient Setting

BACKGROUND AND OBJECTIVES

When a patient is admitted for seizure-like activity, in addition to obtaining a thorough history and physical exam, the evaluation may include a neurology consultation, EEG, and brain MRI. The cost of an inpatient MRI is significant and only 2% of MRIs yield clinically significant findings. At our institution, there was a 20% increase in patients undergoing inpatient MRI from 2018 to 2020. Our aim: Decrease the percentage of patient encounters receiving inpatient brain MRIs for seizure evaluation from 50% to 40% in 6 months by safely shifting MRIs to the outpatient setting.

METHODS

Initially, provider variability in ordering practices of MRIs was analyzed. Stakeholders were gathered and a local guideline was developed to standardize MRI utilization. A process map was created and highlighted barriers to obtaining an outpatient MRI. A new standard process was developed that streamlined and automated processes, and reduced delays and reliance on patients' families.

RESULTS

Since implementation of the new clinical guideline, the percentage of inpatient MRIs ordered for patient encounters presenting with seizures and seizure-like episodes decreased from a mean of 50% to 26%. Significant reductions occurred for patients with complex febrile seizures, provoked but afebrile seizures, and unprovoked seizures. The MRI guideline recommendations were followed in 93% of encounters in the final 12 months. None of the patients who underwent outpatient MRI required readmission for acute findings.

CONCLUSIONS

In this project, the percentage of inpatient MRIs was safely decreased with the implementation of a clinical guideline and standardized process.

Risk of recurrence in patients with an unprovoked tonic-clonic seizure and generalized epileptiform discharges on EEG

OBJECTIVE

The decision to initiate treatment in patients with a first unprovoked seizure remains controversial. Studies have reported a recurrence rate ranging from 21%-50%, but most have included patients with different etiologies, electroencephalography (EEG) findings, and seizure types. This study aimed to determine the risk of recurrence in patients with a first unprovoked generalized tonic-clonic (GTC) seizure with evidence of generalized spike-wave discharges (GSWDs) on EEG and compare the efficacy of antiseizure medications (ASMs) in preventing recurrence.

METHODS

This prospective study included consecutive patients who presented with a single GTC seizure, evidence of GSWDs on EEG, and a follow-up period of at least 1 year. All patients underwent extensive evaluation, including a 3-hour sleep-deprived video-EEG recording and an epilepsy protocol brain magnetic resonance imaging (MRI). Treatment with ASMs was recommended for all patients. The decision regarding the specific ASM to be used was left to the treating physician's discretion.

RESULTS

A total of 57 patients with a median age of 19 years were included. A total of 41 patients agreed to be started on an ASM while 16 declined. Seizure recurred in 6 of 41 patients (14.6%) in the treated group compared to 11 of 16 (68.8%) in the untreated group (p = .00006). Valproate was significantly more efficacious than levetiracetam or lamotrigine (p = .04). Of the 15 patients who discontinued ASM treatment after remaining seizure-free for an average of 30 months, 6 (40%) experienced a seizure recurrence.

SIGNIFICANCE

Patients with a first unprovoked GTC seizure and evidence of GSWDs on EEG have a high risk of recurrence if left untreated. Valproate is the most efficacious ASM for preventing recurrence in this population. A sizeable proportion of patients can be successfully tapered off medication after a period of seizure freedom. This study provides valuable information for guiding treatment decisions in this patient population.

Retrospective Clinical Analysis of Epilepsy Treatment for Children with Drug-Resistant Epilepsy (A Single-Center Experience)

Objectives: This retrospective cohort study investigated the clinical characteristics and seizure outcomes of patients aged 1−14 years with drug-resistant epilepsy (DRE) who were treated by different typologies of therapy. Methods: Four hundred and eighteen children with DRE were recruited from Sanbo Brain Hospital of Capital Medical University from April 2008 to February 2015. The patients were divided into three groups: medication (n = 134, 32.06%), resection surgery (n = 185, 44.26%), and palliative surgery (n = 99, 23.68%) groups. Demographic characteristics were attained from medical records. All patients were followed up for at least 5 years, with seizure outcomes classified according to International League Against Epilepsy criteria. The psychological outcome was evaluated with the development quotient and Wechsler Intelligence Quotient Scale for children (Chinese version). Results: The most frequent seizure type was generalized tonic seizure in 53.83% of patients. Age at seizure onset in 54.55% of patients was <3 years. The most frequent etiologies were focal cortical dysplasia (FCD). West syndrome was the most common epilepsy syndrome. Favorable seizure outcomes at the 5-year follow-up in the medication, resection surgery, and palliative surgery groups were 5.22%, 77.30%, and 14.14%, respectively. The patients showed varying degrees of improvement in terms of developmental and intellectual outcomes post-treatment. Conclusions: Pediatric patients with DRE were characterized by frequent seizures, a variety of seizure types, and complex etiology. Recurrent seizures severely affected the cognitive function and development of children. Early surgical intervention would be beneficial for seizure control and prevention of mental retardation. Palliative surgery was also a reasonable option for patients who were not suitable candidates for resection surgery.

The longitudinal effect of oxcarbazepine on thyroid function in children and adolescents with epilepsy

OBJECTIVE

Thyroid hormone abnormalities have been linked to antiseizure medications (ASMs). Oxcarbazepine is considered safer than carbamazepine because it induces the hepatic cytochrome P450 metabolic enzymes less than the carbamazepine does. However, limited data exist for the influence of oxcarbazepine on thyroid function in children and adolescents. The objective of this study was to determine the effect of oxcarbazepine on thyroid function in these patients.

METHODS

A total of 162 pediatric patients with epilepsy who started oxcarbazepine for the first time between April 2003 and May 2020 were enrolled. The longitudinal effects of oxcarbazepine for thyroid functions were confirmed using general estimating equations.

RESULTS

Serum triiodothyronine (T3), thyroxine (T4), and free thyroxine (fT4) levels decreased significantly during 5 years of follow-up (all p's < .001). In particular, T3 and fT4 levels were reduced steeply in the first 2 years of oxcarbazepine treatment. There was no significant change in thyroid-stimulating hormone during oxcarbazepine treatment.

SIGNIFICANCE

Serum T3, T4, and fT4 levels decreased significantly during oxcarbazepine use, and this change was maintained during the treatment period. In patients receiving oxcarbazepine, it is recommended that periodic thyroid function testing should be performed, especially within the first 2 years after starting this ASM. Our results indicate that oxcarbazepine-induced hypothyroidism does not appear to be accompanied by a significant increase in TSH, and consequently might be missed if TSH alone is monitored as a measure of thyroid dysfunction.

Anti-Epileptic Drugs in Geriatric Neurosurgery: A Review of 669 Neurosurgical Cases

Background and Purpose

Patients over the age of 75 are more likely to develop epilepsy than children under the age of 10. Patients of all ages are prescribed anti-epileptic drugs; however, those over the age of 65 are the most typically prescribed group.

Methods

This is a retrospective study of geriatric cases admitted to the Neurosurgery Department in Khoula Hospital from January 1, 2016 to December 31, 2019. A medical records of 669 patients were identified. Patients’ demographics, risk factors, usage of anti-epileptic drug (AED), type of tumor, tumor location, neuro-vital signs diagnosis, Glasgow coma scale on arrival, treatment types, and length of stay (LOS) were recorded.

Results

The prevalence of AEDs use was 19%. Patients with traumatic brain injury (TBI) were found to have a higher rate of using AEDs (32.1%) followed by patients with oncological and vascular pathologies, respectively (30.1% and 21.6%). There was a significant relationship between the utilization of AEDs among different neurological diseases investigated (p<0.05). Patients who received surgical interventions were using AEDs much more than patients with conservative management (p=0.001). There was a significant difference in the LOS and the usage of AEDs. Added to that, the results signify a relationship between the intensive care unit (ICU) admission and the utilization of AEDs in which the majority of the patients who were not on AEDs were not admitted to the ICU (p<0.05). Phenytoin was the most commonly used AED among different neurosurgical pathologies in the present study (n=110).

Conclusions

AEDs are used as prophylaxis to prevent seizures before most neurosurgical procedures and were commonly prescribed in TBI patients. Phenytoin was found to be the commonest AEDs utilized among the different neurosurgical categories followed by levetiracetam.

Evaluation of First Seizure and Newly Diagnosed Epilepsy

PURPOSE OF REVIEW

This article focuses on the evaluation of children and adults who present with new-onset seizures, with an emphasis on differential diagnosis, classification, evaluation, and management.

RECENT FINDINGS

New-onset seizures are a common presentation in neurologic practice, affecting approximately 8% to 10% of the population. Accurate diagnosis relies on a careful history to exclude nonepileptic paroxysmal events. A new classification system was accepted in 2017 by the International League Against Epilepsy, which evaluates seizure type(s), epilepsy type, epilepsy syndrome, etiology, and comorbidities. Accurate classification informs the choice of investigations, treatment, and prognosis. Guidelines for neuroimaging and laboratory and genetic testing are summarized.

SUMMARY

Accurate diagnosis and classification of first seizures and new-onset epilepsy are key to choosing optimal therapy to maximize seizure control and minimize comorbidities.

Risk of seizure recurrence after a first unprovoked seizure in childhood

OBJECTIVE

The aim of this study was to assess the risk of recurrence after a first unprovoked seizure in childhood and to explore the correlation between the first and second seizures in recurrent patients.

METHODS

In a prospective study, we included 467 children aged 1 month to 16 years, who were attended to between November 1, 2008 and October 31, 2016 following a first seizure. Children who had been started on treatment with antiepileptic drugs were excluded. Recurrence rates were calculated using Kaplan-Meier survival analyses. Univariate and multivariate analyses for recurrence risk were performed using the Cox proportional hazards model. The kappa coefficient of correlation for categorical data was calculated.

RESULTS

Recurrences occurred in 280 children (60.0%), of which 75 (26.8%) occurred in the first month, 184 (65.7%) within 6 months, and 256 (91.4%) within 2 years. None of the patients had new neurologic sequelae after their first or second seizure. The estimates of seizure recurrence risk were 39.5%, 48.1%, 55.1%, 60.8%, 61.8% and 61.8% at 0.5, 1, 2, 5, 8, and 10 years after the first seizure, respectively. Multivariate analysis showed that abnormal electroencephalogram and neuroimaging findings significantly increased the risk of recurrence. First and second seizures were significantly associated with state of arousal, status epilepticus, and multiple seizures in recurrent patients.

CONCLUSION

Over half of untreated children had recurrence after a first unprovoked seizure, but prognosis was good overall.

Sudden unexpected death in epilepsy: Experience of neurologists in Saudi Arabia

IMPORTANCE

Sudden unexpected death in epilepsy (SUDEP) may account for up to 17% of all deaths in epilepsy. However, it is unknown if neurologists discuss this risk with patients.

OBJECTIVE

This study aimed to examine the understanding and practices of SUDEP by neurologists in Saudi Arabia.

METHODS

An electronic web-based survey was sent to 125 neurologists using the mailing list of the Saudi Neurology Society. The survey questions included respondents' demographics, frequency of SUDEP discussion, reasons for discussing/not discussing SUDEP, and perceived patient reactions. Respondents' knowledge of the SUDEP risk factors was examined using 12 items from the currently available literature. Logistic regression analyses were applied to examine the factors that influence the frequency of SUDEP discussions and perceived patient reactions.

PARTICIPANTS

The participants were neurologists who had completed postgraduate training, devoted >5% of their time to clinical care, and had at least one patient with epilepsy in their independent neurology clinic.

RESULTS

A total of 60 respondents met the eligibility criteria and completed the surveys. Of them, 25% discussed SUDEP most of the time, 65% sometimes or rarely, and 10% never discussed it. Of those who discussed SUDEP with their patients, 63.3% did it if the patient was at high risk. Poor compliance with antiepileptic drugs (AEDs) was the most common patient factor highlighted (81.7%). The perceived patients' reactions were variable, with positive reactions (motivation to comply and appreciation) being the most frequent. The majority of respondents (78.3%) had incomplete understanding of the published SUDEP risk factors, with SUDEP knowledge scores ≤2.5 (≤50% of the possible total score). The most identified risk factors were frequent generalized tonic-clonic seizures (83.3%), long duration of epilepsy (53.3%), lack of use or sub-therapeutic levels of AEDs (50%), and AED polytherapy (50%). No association was found between how often SUDEP was discussed and other factors, including training in epilepsy, ≥10 years in practice, seeing ≥100 patients, and having SUDEP cases in the past two years. It was found that patients positively reacted to discussion on SUDEP if neurologists had a good understanding of the SUDEP risk factors (χ² = 5.773, p = 0.016).

CONCLUSIONS

Neurologists in Saudi Arabia do not often discuss SUDEP with patients that have epilepsy. Moreover, when they do, they stress a more individualized approach despite having only a limited understanding of the SUDEP risk factors. Our findings suggest that more guidance should be provided to practitioners on how best to counsel their patients about SUDEP.

High-Frequency Oscillations on Interictal Epileptiform Discharges in Routinely Acquired Scalp EEG: Can It Be Used as a Prognostic Marker?

Introduction

Despite all the efforts for optimizing epilepsy management in children over the past decades, there is no clear consensus regarding whether to treat or not to treat epileptiform discharges (EDs) after a first unprovoked seizure or the optimal duration of therapy with anti-seizure medication (ASM). It is therefore highly needed to find markers on scalp electroencephalogram (EEG) that can help identify pathological EEG discharges that require treatment.

Aim of the study

This retrospective study aimed to identify whether the coexistence of ripples/high-frequency oscillations (HFOs) with interictal EDs (IEDs) in routinely acquired scalp EEG is associated with a higher risk of seizure recurrence and could be used as a prognostic marker.

Methods

100 children presenting with new onset seizure to Children’s Medical Center- Dallas during 2015–2016, who were not on ASM and had focal EDs on an awake and sleep EEG recorded with sample frequency of 500 HZ, were randomly identified by database review. EEGs were analyzed blinded to the data of the patients. HFOs were visually identified using review parameters including expanded time base and adjusted filter settings.

Results

The average age of patients was 6.3 years (±4.35 SD). HFOs were visually identified in 19% of the studied patients with an inter-rater reliability of 99% for HFO negative discharges and 78% agreement for identification of HFOs. HFOs were identified more often in the younger age group; however, they were identified in 11% of patients >5 years old. They were more frequently associated with spikes than with sharp waves and more often with higher amplitude EDs. Patients with HFOs were more likely to have a recurrence of seizures in the year after the first seizure (P < 0.05) and to continue to have seizures after 2 years (P < 0.0001). There was no statistically significant difference between the two groups with regards to continuing ASM after 2 years.

Conclusion

Including analysis for HFOs in routine EEG interpretation may increase the yield of the study and help guide the decision to either start or discontinue ASM. In the future, this may also help to identify pathological discharges with deleterious effects on the growing brain and set a new target for the management of epilepsy.

Ambulatory EEG Usefulness in Epilepsy Management

SUMMARY

Long-term video-EEG monitoring has been the gold standard for diagnosis of epileptic and nonepileptic events. Medication changes, safety, and a lack of recording EEG in one's habitual environment may interfere with diagnostic representation and subsequently affect management. Some spells defy standard EEG because of ultradian and circadian times of occurrence, manifest nocturnal expression of epileptiform activity, and require classification for clarifying diagnostic input to identify optimal treatment. Some patients may be unaware of seizures, have frequent events, or subclinical seizures that require quantification before optimal management. The influence on antiseizure drug management and clinical drug research can be enlightened by long-term outpatient ambulatory EEG monitoring. With recent governmental shifts to focus on mobile health, ambulatory EEG monitoring has grown beyond diagnostic capabilities to target the dynamic effects of medical and nonmedical treatment for patients with epilepsy in their natural environment. Furthermore, newer applications in ambulatory monitoring include additional physiologic parameters (e.g., sleep, detection of myogenic signals, etc.) and extend treatment relevance to patients beyond seizure reduction alone addressing comorbid conditions. It is with this focus in mind that we direct our discussion on the present and future aspects of using ambulatory EEG monitoring in the treatment of patients with epilepsy.

Evaluation of an educational video providing key messages for doctors to counsel families following a first afebrile seizure

AIM

The aim was to evaluate an educational video in educating doctors on the key messages and follow-up pathways following a first afebrile seizure presentation. A multidisciplinary expert team developed the video (http://www.pennsw.org.au/families/resources/first-seizure-pack-and-video) based on available evidence and best-practice. It contains a role-play between the parent/child and physician. It addresses: key messages to impart following a first seizure, seizure first aid, safety messages including necessary precautions post-discharge, contents of the First Seizure Pack for families, follow-up pathway and issues for discussion with the paediatrician at a later appointment.

METHODS

Paediatric/Emergency department (ED) trainees across three Australian sites were recruited during terms 1 and 2, 2019. A repeated measures design was used. Multilevel modelling analyses were performed. The primary outcome was clinician knowledge. Secondary outcomes were confidence in answering questions and counselling families. Qualitative data on the utility, strengths and weaknesses of the video were evaluated.

RESULTS

A total of 127 participants consented, one withdrew prior to commencing. A total of 126 baseline surveys, 115 follow-up surveys and 45 1-month follow-up surveys were returned. Viewing the video significantly improved knowledge of key messages at immediate follow-up (P < 0.001) and 1-month follow-up (P = 0.048). Likewise, confidence was significantly improved; 96.5% of responders found the video useful, 90.3% were likely to use the resource in the future and 82% would change their approach to counselling. Most liked aspects of the resource were clarity/conciseness of the information (n = 70) and comprehensiveness (n = 38).

CONCLUSION

This education video significantly improved clinician knowledge and confidence in counselling families following first seizure.

Manufacturer switch of anti-seizure drugs may not increase the risk of seizure recurrence in Children: A nationwide study of prescription data in Germany

OBJECTIVE

Several publications on the exchangeability of antiepileptic drugs in clinical settings revealed an increased risk for seizure recurrence after changing the manufacturer of anti-seizure drugs (ASD) in adults, possibly due to a decline of adherence. It is unclear whether this holds true in children and adolescents.

METHODS

Patient data of children and adolescents (<18 years) were collected anonymously from 236 German pediatricians and pediatric neurologists between January 2011 and December 2018 using the IMS® Disease Analyzer database (IQVIA, Frankfurt, Germany). Patients with epilepsy were included if at least 2 prescriptions within 360 days and 1 within 180 days prior to the index date were available. The cohort was separated into a seizure group and seizure-free controls. Both groups were matched 1:1 according to age, gender, insurance status, and treating pediatrician. The risk for seizure recurrence after a manufacturer switch of the same ASD at the last prescription before the index date was analyzed using a multivariate regression model.

RESULTS

A total of 678 children and adolescents with epilepsy were included (each group: n = 339; age: 9.6 ± 4.4 years). Comparing both groups, the risk for seizures recurrence was not increased after a manufacturer switch had occurred. Albeit changes during the last prescription before the index date had occurred more often in the seizure-free group, neither change of branded and generic products nor substances reached significance. Only change of ASD strength showed a significantly reduced odds ratio for seizures (OR 0.40, 95% CI 0.24-0.65, p < 0.001).

SIGNIFICANCE

In contrast to the available evidence in adults, changing the manufacturer did not appear to increase the risk for seizure recurrence in previously seizure-free children and adolescents with epilepsy.

Acute Seizures-Work-Up and Management in Children

Seizures are common in the pediatric population; however, most children do not go on to develop epilepsy later in life. Selecting appropriate diagnostic modalities to determine an accurate diagnosis and appropriate treatment as well as with counseling families regarding the etiology and prognosis of seizures, is essential. This article will review updated definitions of seizures, including provoked versus unprovoked, as well as the International League Against Epilepsy operational definition of epilepsy. A variety of specific acute symptomatic seizures requiring special consideration are discussed, along with neonatal seizures and seizure mimics, which are common in pediatric populations.

Scalp Ripples Can Predict Development of Epilepsy After First Unprovoked Seizure in Childhood

OBJECTIVE

Identification of children at risk of developing epilepsy after a first unprovoked seizure can be challenging. Interictal epileptiform discharges are associated with higher risk but have limited sensitivity and specificity. High frequency oscillations (HFOs) are newer biomarkers for epileptogenesis. We prospectively evaluated the predictive value of HFOs for developing epilepsy in scalp electroencephalogram (EEG) of children after a first unprovoked seizure.

METHODS

After their first seizure, 56 children were followed prospectively over 12 months and then grouped in "epilepsy" or "no epilepsy." Initial EEGs were visually analyzed for spikes, spike ripples, and ripples. Inter-group comparisons of spike-rates and HFO-rates were done by Mann-Whitney U test. Predictive values and optimal thresholds were calculated by receiver operating characteristic (ROC) curves.

RESULTS

In the epilepsy group (n = 26, 46%), mean rates of ripples (0.3 vs 0.09 / minute, p < 0.0001) and spike ripples (0.6 vs 0.06 / minute, p < 0.05) were significantly higher, with no difference in spike rates (1.7 vs 3.0 / minute, p = 0.38). Of those 3 markers, ripples showed the best predictive value (area under the curve [AUC]_ripples = 0.88). The optimal threshold for ripples was calculated to be ≥ 0.125 / minute with a sensitivity of 87% and specificity of 85%. Ripple rates were negatively correlated to days passing before epilepsy-diagnosis (R = -0.59, p < 0.0001) and time to a second seizure (R = -0.64, 95% confidence interval [CI] = -0.77 to 0.43, p < 0.0001).

INTERPRETATION

We could show that in a cohort of children with a first unprovoked seizure, ripples predict the development of epilepsy better than spikes or spike ripples and might be useful biomarkers in the estimation of prognosis and question of treatment. ANN NEUROL 2021;89:134-142.

Characterization of Anti-seizure Medication Treatment Pathways in Pediatric Epilepsy Using the Electronic Health Record-Based Common Data Model

The purpose of this pilot study was to analyze treatment pathways of pediatric epilepsy using the common data model (CDM) based on electronic health record (EHR) data. We also aimed to reveal whether CDM analysis was feasible and applicable to epilepsy research. We analyzed the treatment pathways of pediatric epilepsy patients from our institute who underwent antiseizure medication (ASM) treatment for at least 2 years, using the Observational Medical Outcomes Partnership (OMOP)-CDM. Subgroup analysis was performed for generalized or focal epilepsy, varying age of epilepsy onset, and specific epilepsy syndromes. Changes in annual prescription patterns were also analyzed to reveal the different trends. We also calculated the proportion of drug-resistant epilepsy by applying the definition of seizure persistence after application of two ASMs for a sufficient period of time (more than 6 months). We identified 1,192 patients who underwent treatment for more than 2 years (mean ± standard deviation: 6.5 ± 3.2 years). In our pediatric epilepsy cohort, we identified 313 different treatment pathways. Drug resistance, calculated as the application of more than three ASMs during the first 2 years of treatment, was 23.8%. Treatment pathways and ASM resistance differed between subgroups of generalized vs. focal epilepsy, different onset age of epilepsy, and specific epilepsy syndromes. The frequency of ASM prescription was similar between onset groups of different ages; however, phenobarbital was frequently used in children with epilepsy onset < 4 years. Ninety-one of 344 cases of generalized epilepsy and 187 of 835 cases of focal epilepsy were classified as medically intractable epilepsy. The percentage of drug resistance was markedly different depending on the specific electro-clinical epilepsy syndrome [79.0% for Lennox-Gastaut syndrome (LGS), 7.1% for childhood absence epilepsy (CAE), and 9.0% for benign epilepsy with centrotemporal spikes (BECTS)]. We could visualize the annual trend and changes of ASM prescription for pediatric epilepsy in our institute from 2004 to 2017. We revealed that CDM analysis was feasible and applicable for epilepsy research. The strengths and limitations of CDM analysis should be carefully considered when planning the analysis, result extraction, and interpretation of results.

Antiepileptic Drug Treatment of Epilepsy in Children

PURPOSE OF REVIEW

The treatment of epilepsy in children is highly individualized at each and every major step in the management. This review examines various factors that modify the treatment from the point of initiation of therapy to the decision to stop an antiepileptic drug (AED).

RECENT FINDINGS

AED therapy leads to seizure freedom in about 70% of all children with epilepsy. AED initiation could be delayed until a second seizure in most children and may be avoided altogether in many children with self-limited childhood focal epilepsies. Three key factors influence the choice of AED: seizure type(s), efficacy of the drug for the seizure type, and the side effect profile of the drug(s). For epileptic spasms, steroids and vigabatrin are the most effective treatment options. For absence seizures, ethosuximide and valproic acid are superior to lamotrigine. For focal seizures, many newer AEDs have favorable side effect profiles with efficacy comparable to older-generation drugs. For generalized epilepsies, valproic acid remains the most effective drug for a broad range of seizure types. Genetic and metabolic etiologies may guide unique treatment choices in some children. After 2 years or more of seizure freedom, if the recurrence risk after AED withdrawal is acceptable, slow weaning of AEDs should be done over the span of 6 weeks or longer. After discontinuation, about 70% of patients remain seizure free, and of those with recurrence, the majority achieve seizure control with restarting an AED. When treatment with two or more AEDs fails, other treatment opportunities for drug-resistant epilepsy, including epilepsy surgery, vagal nerve stimulation, and dietary therapies should be considered.

SUMMARY

Carefully selected medical therapy guided by seizure type and AED characteristics is effective in more than two-thirds of children with epilepsy.

New-onset seizure survey of epilepsy centers in the United States

OBJECTIVES

Children presenting with new-onset seizures have variable access to resources and may not receive timely and adequate treatment. Some may experience adverse consequences when not evaluated in a timely manner by appropriate medical providers. Consequences can be especially severe for children under the age of two and for children who have psychiatric, cognitive, and behavioral comorbidities. There are no published data on how children with new-onset seizure are evaluated and treated across the US. Our goal was to gain insight into how different epilepsy centers across the country evaluate and treat children with new-onset seizures.

METHODS

We conducted a survey of Epilepsy Centers in the US that are part of the Pediatric Epilepsy Research Consortium (PERC) and focused on children presenting with new-onset seizures; PERC is a group of pediatric epilepsy providers and researchers who participate in collaborative multicenter research in pediatric epilepsy with the goal of improving outcomes in children with pediatric epilepsy. The questionnaire was developed by the authors of this study. It was designed to provide a descriptive assessment of the consistency and variability in how patients with new-onset seizure are evaluated and treated at epilepsy sites across the country. The questionnaire was designed to assure all points of interest were explored. The questions were aimed at describing access to care, how care is delivered, whether centers prioritize based on clinical presentation and/or age, and availability of resources. The survey was sent to 80 epileptologists at 42 different Epilepsy Centers that are part of PERC.

RESULTS

Respondents included 29 pediatric epileptologists representing 24 unique centers. In the cases where there were multiple respondents from each center, response of the most senior epileptologist was used. It is possible that the senior epileptologist may have not known about the center as much as a junior epileptologist, but this was used to establish consistencies among centers with multiple respondents. Results showed that 30% of centers had a dedicated new-onset seizure clinic. The median time for children to be seen was two to four weeks, and 12% reported that it takes more than five weeks until the patient is seen. There was a trend toward centers with new-onset seizure clinic having less wait times. Most centers identified lack of adequate care based on insurance coverage, resources, long wait times, and long travel times.

SIGNIFICANCE

Most centers (70%) do not have a dedicated new-onset seizure clinic. Children presenting with new-onset seizures often do not receive timely and comprehensive care because of limitations in resources and lack of established standard of care. Standardizing care for patients presenting with new-onset seizures has not yet occurred in the US. Many centers do not have a screening process and employ staff other than physicians or nurses for screening and triaging patients. This study shows that having a neurologist or epileptologist in charge of triaging does not reduce wait times. This survey revealed that there is substantial variability in how these patients are evaluated. Although this study shows a trend for epilepsy centers with new-onset seizure clinic having less wait times, even when there is a new-onset seizure clinic, wait times can be greater than five weeks. Overall, however, a new-onset seizure clinic may be an effective way to improve access to timely and efficient care for these patients.

Levetiracetam administration is correlated with lower mortality in patients with mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes: a retrospective study

Background:

Studies on the relationship between antiepileptic drug (AED) administration and clinical outcomes in patients with mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes (MELAS) remain scarce. Levetiracetam (LEV) is an AED that is neuroprotective in various neurologic disorders. This study aimed to determine the impact of LEV on the outcome of MELAS.

Methods:

A retrospective, single-center study was performed based on a large cohort of patients with MELAS with a history of seizures (n = 102). Decisions on antiepileptic therapies were made empirically. Patients were followed up for 1 to 8 years (median, 4 years) and divided into 2 groups based on whether LEV was administered (LEV or non-LEV). The modified Rankin scale (mRS) scores and mortality risks were analyzed in all patients.

Results:

LEV, carbamazepine, benzodiazepines, topiramate, oxcarbazepine, valproate, and lamotrigine were administered in 48, 37, 18, 13, 11, 9, and 9 patients, singly or in combination, respectively. The mean mRS score of the LEV group (n = 48) was lower than that of the non-LEV group (n = 54; mean ± standard deviation, 2.79 ± 1.47 vs. 3.83 ± 1.93, P = 0.006) up to the end of the study. Nevertheless, there was no difference in the proportion of subjects without disability (mRS ranging 0–1) between the groups (P = 0.37). The multivariate regressions revealed that LEV treatment was associated with lower mRS scores (odds ratio 0.32, 95% confidence interval [CI] 0.15–0.68, P = 0.003) and mortality rates (hazard ratio 0.24, 95% CI 0.08–0.74, P = 0.013). There was a significant difference in the Kaplan-Meier survival curves between the groups (χ² = 4.29, P = 0.04).

Conclusions:

The LEV administration is associated with lower mortality in patients with MELAS in this retrospective study. Further laboratory research and prospective cohort studies are needed to confirm whether LEV has neuroprotective effects on patients with mitochondrial diseases.

Antiepileptic Drugs in Children : Current Concept

An epileptic seizure is defined as the transient occurrence of signs and/or symptoms due to abnormally excessive or synchronous neuronal activity in the brain. The type of seizure is defined by the mode of onset and termination, clinical manifestation, and by the abnormal enhanced synchrony. If seizures recur, that state is defined as epilepsy. Antiepileptic drugs (AEDs) are the mainstay of treatment. Knowledge about initiating and maintaining adequate AEDs is beneficial for the clinician who treats children with epilepsy. This article will delineate the general principles for selecting, introducing, and discontinuing AEDs and outline guidelines for monitoring adverse effects. In general, AED therapy following a first unprovoked seizure in children is not recommended. However, treatment should be considered after a second seizure. In children and adolescents, if they are seizure-free for at least 2 years, attempts to withdraw medication/s should be made, taking into account the risks vs. benefits for the individual patient. The decision on when and what AED to use should be tailored according to the patient. For optimal treatment, the selection of adequate AEDs can be achieved by considering the precise definition of the patient’s seizure and epilepsy syndrome. Continuous monitoring of both therapeutic and adverse effects is critical for successful treatment with AEDs.

Effects of levetiracetam and valproic acid treatment on liver function tests, plasma free carnitine and lipid peroxidation in childhood epilepsies

BACKGROUND AND AIMS

The relationship between anti-epileptic usage and oxidative damage has not yet been clearly understood. In our study, we investigated oxidative stress parameters, carnitine levels, liver function tests (LFT) and their relationship in epileptic children treated with valproic acid or levetiracetam.

METHOD

LFTs, serum free carnitine and oxidative damage markers and their relations with each other were determined in patients who are on valproic acid or levetiracetam treatment at least for 6 months. 25 patients on therapeutic doses of valproic acid, 26 patients on therapeutic doses of levetiracetam and 26 healthy volunteers as controls were included. LFTs, ammonia, carnitine, lipid peroxidation biomarker malondialdehyde (MDA) and a sensitive marker of DNA damage, 8-hydroxy-2-deoxyguanosine (8-OHdG) levels were measured. Results of patients are compared to healthy controls. The data is evaluated with IBM SPSS Statistics 22.0.

RESULTS

Ammonia and MDA levels were elevated in patients using levetiracetam; 8-OHdG levels were elevated in both patient groups. Carnitine levels were significantly low in patients under valproic acid therapy, however they were not found to be correlated with MDA, 8-OHdG or LFTs. MDA showed positive correlation with ammonia and 8-OHdG in the levetiracetam group.

CONCLUSION

We did not observe hepatotoxicity in patients under therapeutic doses of valproic acid. However, epileptic children under therapeutic doses of levetiracetam showed significantly elevated levels of MDA and 8-OHdG, which is supportive for oxidative damage under levetiracetam therapy. This result was observed for the first time in childhood epilepsies and further studies are needed to understand its mechanism.

Clinical Use and Monitoring of Antiepileptic Drugs

Background

Antiepileptic drugs (AEDs) have been used for the treatment of epilepsy and other neurological disorders since the late 19th century. There are currently several classes of AEDs available for epilepsy management, many of which are also used to treat migraines, bipolar disorder, schizophrenia, depression, and neuropathic pain. Because of their molecular and mechanistic diversity, as well as the potential for drug–drug interactions, AEDs are prescribed and monitored in a highly personalized manner.

Content

This review provides a general overview of the use of AEDs with a focus on the role of therapeutic drug monitoring. Discussed topics include mechanisms of action, guidelines on the clinical applications of AEDs, clinical tests available for AED monitoring, and genetic factors known to affect AED efficacy.

Summary

Implementation of AED therapies is highly individualized, with many patient-specific factors considered for drug and dosage selection. Both therapeutic efficacy and target blood concentrations must be established for each patient to achieve seizure mitigation or cessation. The use of an AED with any additional drug, including other AEDs, requires an evaluation of potential drug–drug interactions. Furthermore, AEDs are commonly used for nonepilepsy indications, often in off-label administration to treat neurological or psychiatric disorders.

Advocacy for children with epilepsy: Leveraging the WHA resolution. Advocacy Task Force, Commission of Pediatrics, International League Against Epilepsy

In May 2015 the World Health Assembly (WHA) approved the Resolution on the Global Burden of Epilepsy. This report addresses how the Resolution can be leveraged to improve the care of children with epilepsy worldwide. Children with epilepsy have unique needs and face unique challenges from stigma at all levels of society. Children lack a voice to lobby for their own needs, including their right to have access to education. Effective leadership and governance should be enhanced through the support of stakeholders empowered to counsel, advise, and lobby for appropriate care. National health care plans should integrate primary and specialist care, and they need to be adapted to local specificities. Antiepileptic medicines should be widely accessible in appropriate, sustained, and affordable ways. Public awareness initiatives are needed to improve the inclusion of affected children in society and to reduce stigma. Cost-effective interventions are also needed to address preventable causes of epilepsy. Without greater investment in research, evidence-based interventions cannot be implemented. Through all of this, civil society must be engaged to ensure that the multivariate dimensions from the clinic to the community are addressed to fulfil the needs of children with epilepsy.

Treatment of Epileptic Encephalopathies: Current State of the Art

Childhood epileptic encephalopathies are age-dependent disorders of the brain whose hallmarks include loss of neurologic function over time, abnormal electroencephalographic findings, and seizures. Ictal and interictal electrographic activity are conjointly thought to be at the root of the often devastating neuropsychological deterioration, which is specific to the maturing brain. The goals of treatment are not only to control seizures, but also to prevent or reverse neurologic loss of function. In general, time is of the essence in diagnosis, and experienced specialists should promptly design a treatment plan. Hormonal and immune therapies are at the forefront of treatment in many cases, with traditional antiepileptic drugs and surgery (when an identifiable lesion is present) playing a limited role. However, gold standard evidence for treatment of epileptic encephalopathies remains limited. Ongoing clinical and basic research may lead to better understanding of these catastrophic conditions and to better and more effective therapies.

Adult onset seizures: Clinical, etiological, and radiological profile

Introduction:

Adult onset seizure disorder is a major public health concern in terms of burden of disease, nature of illness, and its impact on individual, family, and community. This study was done to assess the clinical profile and etiology of adult onset seizures and correlates of clinical and radiological pattern.

Materials and Methods:

This was a prospective cross-sectional hospital-based study conducted on 100 cases presenting with adult onset seizures.

Results:

Adult onset seizures were most prevalent in the young and middle-aged adults than elderly; generalized seizures were more common than focal seizures. However, the incidence of generalized seizures showed a falling trend as the age advanced whereas focal seizures increased in incidence with advancing age. Overall, the most common etiology of seizures was stroke, followed by idiopathic and central nervous system infections; yet, most common etiology of adult onset generalized and focal seizures was idiopathic and stroke, respectively. Regarding etiology, among younger adults, idiopathic seizures were predominant, whereas among middle aged and elderly, stroke was the most common etiology.

Conclusions:

It is mandatory to deal carefully with each case of adult onset seizure with a tailor-made approach. Identification and awareness about the etiological factors and seizure type help in better management of these patients. Primary care physicians play a pivotal role in identifying patients with adult onset seizures and should encourage these patients to undergo neuroimaging so as to arrive at an appropriate etiological diagnosis. In the face of recent advances in neuroimaging techniques, the future prospective management of adult onset seizures appears bright and convincing.

Quality and reporting of guidelines on the diagnosis and management of dystonia

BACKGROUND AND PURPOSE

The quality of clinical practice guidelines on dystonia has not yet been assessed. Our aim was to appraise the methodological quality of guidelines worldwide and to analyze the consistency of their recommendations.

METHODS

We searched for clinical practice guidelines on dystonia diagnosis/treatment in the National Guideline Clearinghouse, PubMed, National Institute for Health and Care Excellence, Guidelines International Network and Web of Science databases. We also searched for guidelines on homepages of international neurological societies. We asked for guidelines from every Management Committee member of the BM1101 Action of the Cooperation between Science and Technology European framework and every member of the International Parkinson and Movement Disorders Society with special interest in dystonia.

RESULTS

Fifteen guidelines were evaluated. Among guidelines on treatment, only one from the American Academy of Neurology could be considered as high quality. Among guidelines on diagnosis and therapy, the guideline from the European Federation of Neurological Societies was recommended by the appraisers. Clinical applicability and reports of editorial independence were the greatest shortcomings. The rigor of development was poor and stakeholder involvement was also incomplete in most guidelines. Discrepancies among recommendations may result from the weight given to consensus statements and expert opinions due to the lack of evidence, as well as inaccuracy of disease classification.

CONCLUSIONS

The quality of appraised guidelines was low. It is necessary to improve the quality of guidelines on dystonia, and the applied terminology of dystonia also needs to be standardized.

Clinical characteristics and electroencephalogram analysis of levetiracetam in the treatment of children with febrile seizure recurrence

Febrile seizure is the most common neurologic disorder in infants and children. This study aimed to elaborate safe and effective therapy for preventing FS recurrence by levetiracetam (LEV). A prospective study was performed in two groups of children, the no treatment group (n=51, 24.1±9.0 months) and the LEV treatment group (n=45, 23.3±8.9 months). The findings demonstrated that a significant difference (P<0.01) was observed between the no treatment group 51.0% (26/51) and LEV treatment group 15.5% (7/45) in terms of FS recurrence after 50 weeks. FS recurrence/fever episode was 12.4% (12/97) in the LEV treatment group and 51.8% (57/110) in the no treatment group. Furthermore, LEV administration significantly improved (P<0.001) epileptiform + nonspecific EEG abnormalities (17.8%; 8/45), as compared with the no treatment group (68.6%; 35/51). In conclusion, LEV could function as an effective therapeutic agent for the prevention of FS recurrence and reducing the frequency of fever episodes. Furthermore, LEV administration significantly improved nonspecific EEG abnormalities, which may be used as a clinical monitoring index for LEV treatment in patients with FS.

Diagnostic and Therapeutic Management of a First Unprovoked Seizure in Children and Adolescents With a Focus on the Revised Diagnostic Criteria for Epilepsy

By definition, unprovoked seizures are not precipitated by an identifiable factor, such as fever or trauma. A thorough history and physical examination are essential to caring for pediatric patients with a potential first unprovoked seizure. Differential diagnosis, EEG, neuroimaging, laboratory tests, and initiation of treatment will be reviewed. Treatment is typically initiated after 2 unprovoked seizures, or after 1 seizure in select patients with distinct epilepsy syndromes. Recent expansion of the definition of epilepsy by the ILAE allows for the diagnosis of epilepsy to be made after the first seizure if the clinical presentation and supporting diagnostic studies suggest a greater than 60% chance of a second seizure. This review summarizes the current literature on the diagnostic and therapeutic management of first unprovoked seizure in children and adolescents while taking into consideration the revised diagnostic criteria of epilepsy.

Educational Intervention Improves Compliance With AAN Guidelines for Return Epilepsy Visits: A Quality Improvement Project

In 2011, the American Academy of Neurology (AAN) released guidelines for return seizure visits detailing 8 points that should be addressed during such visits. These guidelines are designed to improve routine follow-up care for epilepsy patients. The authors performed a quality improvement project aimed at increasing compliance with these guidelines after educating providers about them. The authors performed a chart review before and after an intervention which included: education regarding the guidelines, providing materials to remind providers of the guidelines, and templates to facilitate compliance. The authors reviewed charts at 2 and 6 months after the intervention. Significant improvement in documentation of 4 of the 8 measures was observed after this educational intervention. This suggests that simple educational interventions may help providers change practice and can improve compliance with new guidelines while requiring minimal time and resources to implement.

Evaluation of an E-learning resource on approach to the first unprovoked seizure

AIM

To develop and evaluate an online educational package instructing paediatricians and trainees in the diagnosis and management of a first unprovoked seizure in children.

METHODS

The E-learning content was created following a comprehensive literature review that referenced current international guidelines. Rigorous consultation with local paediatric neurologists, paediatricians and epilepsy nurses was undertaken. A series of learning modules was created and sequenced to reflect steps needed to achieve optimal diagnosis and management in a real-life situation of a child presenting with a paroxysmal event. Paediatric registrars and advanced trainees from the Sydney Children's Hospitals Network were assessed before and after using the E-learning Resource. Measures included general epilepsy knowledge, case-based scenario knowledge; self-rated measures of satisfaction with instruction and confidence regarding clinical approach to the child with first unprovoked seizure; and open ended questions evaluating the usefulness of the E-learning resource.

RESULTS

Performance on measures of general epilepsy knowledge and on the seizure-related case scenarios improved significantly following completion of the E-learning as did self-rated satisfaction with instruction and confidence across all aspects of managing first seizure.

CONCLUSIONS

The E-learning resource has been validated as a useful educational resource regarding the first afebrile unprovoked seizure for paediatricians.

Utility of Obtaining a Serum Basic Metabolic Panel in the Setting of a First-Time Nonfebrile Seizure

New-onset nonfebrile seizures in an otherwise healthy child are common, affecting 25 000 to 40 000 U.S. children annually. We hypothesized seizure-provoking electrolyte disturbances such as hyponatremia, hypoglycemia, and hypocalcemia are uncommon in these children. From January 1, 2009 to May 31, 2009, 358 children aged 29 days to 18 years with a diagnosis code of 780.39 ("other convulsions" including "first time seizure," etc) were included for potential retrospective review. Children with known epilepsy and febrile seizures were excluded. Electrolytes were obtained in nearly all children with a history suggestive of an underlying abnormality (13 of 14, 93%) but also in half of children with a reassuring history (62 of 119, 52%). No child with an unremarkable history and exam was found to have electrolyte abnormalities falling below levels most likely to be associated with acute symptomatic seizures. Electrolytes are unlikely to be abnormal in an otherwise well-appearing child after a first-time nonfebrile seizure.

Seizure Recurrence in Developmentally and Neurologically Normal Children With a Newly Diagnosed Unprovoked Seizure

This study aims to assess recurrence risk in developmentally and neurologically normal children with a newly diagnosed unprovoked seizure. The medical record was retrospectively reviewed in 393 children who had a newly diagnosed, unprovoked seizure. A total of 152 children met inclusion criteria. The relationship between seizure recurrence and variables was examined. Seventy cases had recurrent seizures. Total 113 cases had follow-up data and 70 cases of these (63.7%) experienced recurrent seizures. EEG was abnormal in 65 (44.8%): focal epileptiform abnormality in 34 cases (23.4%) and generalized epileptiform abnormality in 23 cases (15.9%). Brain MRI revealed any structural abnormality in 14 of 86 cases (16.3%). Neither EEG abnormality nor brain MRI abnormality was statistically significantly associated with increased seizure recurrence in this cohort. Further study is required to confirm the EEG and brain MRI findings in otherwise normal children with a newly diagnosed unprovoked seizure.

Epilepsy in glioma patients: mechanisms, management, and impact of anticonvulsant therapy

Seizures are a well-recognized symptom of primary brain tumors, and anticonvulsant use is common. This paper provides an overview of epilepsy and the use of anticonvulsants in glioma patients. Overall incidence and mechanisms of epileptogenesis are reviewed. Factors to consider with the use of antiepileptic drugs (AEDs) including incidence during the disease trajectory and prophylaxis along with considerations in the selection of anticonvulsant use (ie, potential side effects, drug interactions, adverse effects, and impact on survival) are also reviewed. Finally, areas for future research and exploring the pathophysiology and use of AEDs in this population are also discussed.

Update on diagnosis and management of childhood epilepsies

OBJECTIVES

To review the current evidence base for the diagnosis and management of the childhood epilepsies and to draw attention to the current gaps in this evidence base. The focus will be on therapeutic aspects. Current International League Against Epilepsy (ILAE) terminology will be described and used throughout the discussion. The review will draw attention to recent advances that have been made in both our understanding and treatment of the childhood epilepsies. Potential future directions for research and treatment options will be discussed.

SOURCES

Original articles relevant to the subject were obtained from the MedLine database using pertinent MeSH terms. Relevant papers were read and assimilated. Citation searching was used.

SUMMARY OF THE FINDINGS

Epilepsy is a major cause of global disease burden. Childhood epilepsies are a heterogeneous group of conditions. A multi-axial diagnostic approach should be taken prior to making treatment and management decisions for any individual patient. For the majority of patients, successful control of seizures can be achieved with a single medication. However, a significant minority develops refractory disease. Epilepsy surgery can provide cure for a carefully selected group of these cases.

CONCLUSIONS

There remain significant gaps the evidence base for treatment in several areas of childhood epilepsy. Concerted multi-center efforts should be made to try to close these gaps. A personalized medicine approach may help to reduce the proportion of refractory cases of childhood epilepsy in future.

Developmental effects of antiepileptic drugs and the need for improved regulations

Antiepileptic drugs (AEDs) are among the most common teratogenic drugs prescribed to women of childbearing age. AEDs can induce both anatomical (malformations) and behavioral (cognitive/behavioral deficits) teratogenicity. Only in the last decade have we begun to truly discriminate differential AED developmental effects. Fetal valproate exposure carries a special risk for both anatomical and behavioral teratogenic abnormalities, but the mechanisms and reasons for individual variability are unknown. Intermediate anatomical risks exist for phenobarbital and topiramate. Several AEDs (e.g., lamotrigine and levetiracetam) appear to possess low risks for both anatomical and behavioral teratogenesis. Despite advances in the past decade, our knowledge of the teratogenic risks for most AEDs and the underlying mechanisms remain inadequate. Further, the long-term effects of AEDs in neonates and older children remain uncertain. The pace of progress is slow given the lifelong consequences of diminished developmental outcomes, exposing children unnecessarily to potential adverse effects. It is imperative that new approaches be employed to determine risks more expediently. Our recommendations include a national reporting system for congenital malformations, federal funding of the North American AED Pregnancy Registry, routine meta-analyses of cohort studies to detect teratogenic signals, monitoring of AED prescription practices for women, routine preclinical testing of all new AEDs for neurodevelopmental effects, more specific Food and Drug Administration requirements to establish differential AED cognitive effects in children, and improved funding of basic and clinical research to fully delineate risks and underlying mechanisms for AED-induced anatomical and behavioral teratogenesis.