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Bjellvi J, Idegård A, Zelano J. Risk factors for status epilepticus after brain disorders in adults: A multi-cohort national register study. Epilepsy Behav 2024; 156:109840. [PMID: 38788662 DOI: 10.1016/j.yebeh.2024.109840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 04/10/2024] [Accepted: 05/12/2024] [Indexed: 05/26/2024]
Abstract
PURPOSE We aimed to describe risks of status epilepticus (SE) after different brain disorders in adults using population-wide register data. Our hypothesis was that SE would be more common in disorders with widespread pathology and that the risk would increase with disorder severity. METHODS We analyzed five large datasets created from the Swedish National Patient Register, the Cause of Death Register, and national quality registers with adults in Sweden with brain infections, dementia, multiple sclerosis (MS), stroke, and traumatic brain injury (TBI). Risk factors were assessed using Cox regression. RESULTS In adults with TBI, stroke, dementia, MS, or brain infections, the incidence rate of SE was highest in survivors of brain infections (64/100,000 person years) and stroke (64/100,000), followed by TBI (37/100,000), dementia (36/100,000), and MS (26/100,000). SE was considerably more common in patients with epilepsy after their brain disorder. Across all datasets severe disorder increased SE-risk. Herpes simplex encephalitis (HR 5.5 95 % CI: 2.6-12), progressive MS (HR 2.3, 95 % CI: 1.1-4.7), structural TBI (2.0, 95 % CI: 1.6-2.6), and intracerebral hemorrhage (HR 1.5, 95 % CI: 1.2-2.0) were the subtypes of brain disorders with the highest relative risk of SE. Having another CNS disorder increased SE-risk in TBI (HR 2.9, 95 % CI: 2.3-3.7), brain infections (HR 2.8, 95 % CI: 1.7-4.5), and dementia (HR 2.5, 95 % CI: 1.5-4.2). CONCLUSION SE-risk increases with disorder severity and number of CNS comorbidities. These findings can guide treatment strategy by allowing identification of high-risk patients. Pathophysiological studies are needed to better understand remote symptomatic SE.
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Affiliation(s)
- Johan Bjellvi
- Institute of Neuroscience and Physiology, Department of Clinical Neuroscience, Sahlgrenska Academy, University of Gothenburg, Blå Stråket 7 413 45, Gothenburg, Sweden; Department of Neurology, Sahlgrenska University Hospital, Member of the ERN EpiCARE, Blå Stråket 7 413 45, Gothenburg, Sweden.
| | - André Idegård
- Institute of Neuroscience and Physiology, Department of Clinical Neuroscience, Sahlgrenska Academy, University of Gothenburg, Blå Stråket 7 413 45, Gothenburg, Sweden; Wallenberg Center of Molecular and Translational Medicine, University of Gothenburg, Box 100 405 30, Gothenburg, Sweden.
| | - Johan Zelano
- Institute of Neuroscience and Physiology, Department of Clinical Neuroscience, Sahlgrenska Academy, University of Gothenburg, Blå Stråket 7 413 45, Gothenburg, Sweden; Department of Neurology, Sahlgrenska University Hospital, Member of the ERN EpiCARE, Blå Stråket 7 413 45, Gothenburg, Sweden; Wallenberg Center of Molecular and Translational Medicine, University of Gothenburg, Box 100 405 30, Gothenburg, Sweden.
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Pozzilli V, Haggiag S, Di Filippo M, Capone F, Di Lazzaro V, Tortorella C, Gasperini C, Prosperini L. Incidence and determinants of seizures in multiple sclerosis: a meta-analysis of randomised clinical trials. J Neurol Neurosurg Psychiatry 2024; 95:612-619. [PMID: 38383156 DOI: 10.1136/jnnp-2023-332996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 01/29/2024] [Indexed: 02/23/2024]
Abstract
BACKGROUND Seizures are reported to be more prevalent in individuals with multiple sclerosis (MS) compared with the general population. Existing data predominantly originate from population-based studies, which introduce variability in methodologies and are vulnerable to selection and reporting biases. METHODS This meta-analysis aims to assess the incidence of seizures in patients participating in randomised clinical trials and to identify potential contributing factors. Data were extracted from 60 articles published from 1993 to 2022. The pooled effect size, representing the incidence rate of seizure events, was estimated using a random-effect model. Metaregression was employed to explore factors influencing the pooled effect size. RESULTS The meta-analysis included data from 53 535 patients and 120 seizure events in a median follow-up of 2 years. The pooled incidence rate of seizures was 68.0 per 100 000 patient-years, significantly higher than the general population rate of 34.6. Generalised tonic-clonic seizures were the most common type reported, although there was a high risk of misclassification for focal seizures with secondary generalisation. Disease progression, longer disease duration, higher disability levels and lower brain volume were associated with a higher incidence of seizures. Particularly, sphingosine-1-phosphate receptor (S1PR) modulators exhibited a 2.45-fold increased risk of seizures compared with placebo or comparators, with a risk difference of 20.5 events per 100 000 patient-years. CONCLUSIONS Patients with MS face a nearly twofold higher seizure risk compared with the general population. This risk appears to be associated not only with disease burden but also with S1PR modulators. Our findings underscore epilepsy as a significant comorbidity in MS and emphasise the necessity for further research into its triggers, preventive measures and treatment strategies.
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Affiliation(s)
- Valeria Pozzilli
- Unit of Neurology, Neurophysiology and Neurobiology, Department of Medicine and Surgery, Campus Bio-Medico University, Roma, Lazio, Italy
- Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Shalom Haggiag
- MS Centre, Department of Neurosciences, San Camillo Forlanini Hospital, Roma, Italy
| | - Massimiliano Di Filippo
- Section of Neurology, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Fioravante Capone
- Unit of Neurology, Neurophysiology and Neurobiology, Department of Medicine and Surgery, Campus Bio-Medico University, Roma, Lazio, Italy
- Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Vincenzo Di Lazzaro
- Unit of Neurology, Neurophysiology and Neurobiology, Department of Medicine and Surgery, Campus Bio-Medico University, Roma, Lazio, Italy
- Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Carla Tortorella
- MS Centre, Department of Neurosciences, San Camillo Forlanini Hospital, Roma, Italy
| | - Claudio Gasperini
- MS Centre, Department of Neurosciences, San Camillo Forlanini Hospital, Roma, Italy
| | - Luca Prosperini
- MS Centre, Department of Neurosciences, San Camillo Forlanini Hospital, Roma, Italy
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Ertürk Çetin Ö, Güngör Doğan İ, Zanapalioğlu Ü, Yadi F, Çetinkaya Tezer D, Demir S. Seizures in inflammatory demyelinating disorders of the central nervous system. Mult Scler Relat Disord 2024; 85:105535. [PMID: 38452647 DOI: 10.1016/j.msard.2024.105535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 02/10/2024] [Accepted: 03/01/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND Multiple sclerosis (MS), neuromyelitis optica spectrum disorder (NMOSD), and myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) may be associated with acute symptomatic seizures and chronic epilepsy as well. The clinical features of the seizures and/or accompanying epilepsy seen in each disease group may vary. In this study, we aimed to contribute to the existing literature by describing the clinical features of seizures and epilepsy in our demyelinating patient population. METHODS We retrospectively analyzed patients who were followed up in our tertiary referral center neurology demyelinating diseases outpatient clinic between 2019 and 2024. Patients who had at least one seizure before, simultaneously, or after the diagnosis of demyelinating disease were included in the study. RESULTS Among 1735 patients with MS, 40 had experienced at least one epileptic seizure (2.3 %). Thirty patients (1.7 %) had seizures that could not be explained by another factor than MS. When secondary progressive MS (SPMS) and relapsing-remitting MS (RRMS) were compared, the interval between MS-epilepsy diagnosis was longer and seizure recurrence was more in SPMS. However, the prognosis of epilepsy was good in both subtypes. There were 21 patients followed up with antibody-positive neuromyelitis optica spectrum disorder. No patient had a seizure during the follow-up. We identified 56 patients who fulfilled the criteria for MOGAD with high antibody titers. Seizures were observed in three of them (5.4 %). All of them had status epilepticus either at the onset or during the course of the disease. CONCLUSION Even rare, seizures constitute one of the important clinical features of the inflammatory demyelinating disorders of the central nervous system. The pathophysiologic mechanism underlying seizures in MS is still not clear. Seizures may occur through different mechanisms in patients where seizures are the initial symptom or a sign of relapse and those that occur spontaneously during the progressive course of the disease. Prevalence of status epilepticus was common in MOGAD patients. Given the rarity of the seizures in CNS demyelinating disorders, it is difficult the define clinical and pathophysiological characteristics of accompanying seizures and epilepsy. Future studies conducted on large patient groups will contribute to the existing literature.
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Affiliation(s)
- Özdem Ertürk Çetin
- University of Health Sciences, Sancaktepe Training and Research Hospital, Department of Neurology, Istanbul, Turkey.
| | - İpek Güngör Doğan
- University of Health Sciences, Sancaktepe Training and Research Hospital, Department of Neurology, Istanbul, Turkey
| | - Ümit Zanapalioğlu
- University of Health Sciences, Sancaktepe Training and Research Hospital, Department of Neurology, Istanbul, Turkey
| | - Feyzullah Yadi
- University of Health Sciences, Sancaktepe Training and Research Hospital, Department of Neurology, Istanbul, Turkey
| | - Damla Çetinkaya Tezer
- University of Health Sciences, Sancaktepe Training and Research Hospital, Department of Neurology, Istanbul, Turkey
| | - Serkan Demir
- University of Health Sciences, Sancaktepe Training and Research Hospital, Department of Neurology, Istanbul, Turkey
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Pelletier J, Sugar D, Koyfman A, Long B. Multiple Sclerosis: An Emergency Medicine-Focused Narrative Review. J Emerg Med 2024; 66:e441-e456. [PMID: 38472027 DOI: 10.1016/j.jemermed.2023.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 11/15/2023] [Accepted: 12/11/2023] [Indexed: 03/14/2024]
Abstract
BACKGROUND Multiple sclerosis (MS) is a rare but serious condition associated with significant morbidity. OBJECTIVE This review provides a focused assessment of MS for emergency clinicians, including the presentation, evaluation, and emergency department (ED) management based on current evidence. DISCUSSION MS is an autoimmune disorder targeting the central nervous system (CNS), characterized by clinical relapses and radiological lesions disseminated in time and location. Patients with MS most commonly present with long tract signs (e.g., myelopathy, asymmetric spastic paraplegia, urinary dysfunction, Lhermitte's sign), optic neuritis, or brainstem syndromes (bilateral internuclear ophthalmoplegia). Cortical syndromes or multifocal presentations are less common. Radiologically isolated syndrome and clinically isolated syndrome (CIS) may or may not progress to chronic forms of MS, including relapsing remitting MS, primary progressive MS, and secondary progressive MS. The foundation of outpatient management involves disease-modifying therapy, which is typically initiated with the first signs of disease onset. Management of CIS and acute flares of MS in the ED includes corticosteroid therapy, ideally after diagnostic testing with imaging and lumbar puncture for cerebrospinal fluid analysis. Emergency clinicians should evaluate whether patients with MS are presenting with new-onset debilitating neurological symptoms to avoid unnecessary testing and admissions, but failure to appropriately diagnose CIS or MS flare is associated with increased morbidity. CONCLUSIONS An understanding of MS can assist emergency clinicians in better diagnosing and managing this neurologically devastating disease.
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Affiliation(s)
- Jessica Pelletier
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Davis Sugar
- Department of Neurology, Virginia Tech Carilion, Roanoke, Virginia
| | - Alex Koyfman
- Department of Emergency Medicine, University of Texas Southwestern, Dallas, Texas
| | - Brit Long
- SAUSHEC (San Antonio Uniformed Services Health Education Consortium), Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas
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Sanchez M, Marone A, Silva WH, Marrodan M, Correale J. Clinical characteristics, course and prognosis of Multiple Sclerosis patients with epilepsy. A case control study: MS and epilepsy. Mult Scler Relat Disord 2024; 83:105422. [PMID: 38219299 DOI: 10.1016/j.msard.2024.105422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 12/27/2023] [Accepted: 01/01/2024] [Indexed: 01/16/2024]
Abstract
BACKGROUND AND PURPOSE Although more common than in the general population, seizures are an atypical manifestation of multiple sclerosis (MS) and their pathophysiology is not well understood. This study aims to examine the prevalence, clinical characteristics, brain imaging findings and course of epilepsy, presenting in patients with MS. METHODS Observational retrospective study of MS patients evaluated at a single MS reference center in Buenos Aires, Argentina, between 2011 and 2022, focusing on those who developed epilepsy (EMS). Clinical, demographic, and prognostic factors were evaluated and compared to a control group of non-epileptic MS patients (NEMS). To analyze specific epilepsy characteristics, a second control group of patients with non-lesional focal epilepsy (FNLE) was also included. RESULTS Twenty-five patients (18 women), were diagnosed with epilepsy, corresponding to a prevalence of 1.95%. Comparison of brain imaging characteristics between EMS and NEMS patients showed brain atrophy (32% vs 6.1%, p<0.01), as well as cortical (26% vs 4%, p=0.03) and juxtacortical lesions (84% vs 55%, p=0.05), were more frequent in EMS patients. However, after multivariate analysis, cortical atrophy was the only variable linked to a significant increase in risk of epilepsy (OR 24, 95%CI=2.3-200, p<0.01). No significant differences in clinical characteristics, disease activity, disability levels, response to disease modified treatment (DMT) or lack of DMT efficacy were observed between MS patients with or without epilepsy. Most patients received anti-seizure medication (ASM), and seizure control was better in EMS than in FNLE patients (92% vs 58%, p=0.022) with no differences found in drug resistance. We did not find predictors of seizure recurrence in the population studied. CONCLUSION We observed a lower prevalence of epilepsy in this group of MS patients, compared to other reported cohorts. Although epilepsy seems to have a benign course in MS patients, cortical atrophy appears to be an important contributor to the development of secondary epilepsy in MS patients. Further investigations will be necessary to identify risk factors or biomarkers predicting increased epilepsy risk in MS.
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Affiliation(s)
| | - Abril Marone
- Departamento de Neurología, Fleni, Buenos Aires, Argentina
| | - Walter H Silva
- Departamento de Neurología, Fleni, Buenos Aires, Argentina
| | | | - Jorge Correale
- Departamento de Neurología, Fleni, Buenos Aires, Argentina; Instituto de Química y Fisicoquímica Biológicas (IQUIFIB), Universidad de Buenos Aires/CONICET, Buenos Aires, Argentina
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Nurre ER, Shah A, Hansen CJ, Dowling C, Thakolwiboon S, Mao-Draayer Y, Mihaylova TG. Multiple sclerosis and seizures: A retrospective observational study in a multiple sclerosis autoimmunity center of excellence. Seizure 2024; 115:44-49. [PMID: 38183827 DOI: 10.1016/j.seizure.2023.12.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 12/21/2023] [Accepted: 12/26/2023] [Indexed: 01/08/2024] Open
Abstract
PURPOSE The prevalence of epilepsy in patients with multiple sclerosis (MS) is three to six times the prevalence in the general population. Mechanisms resulting in increased seizure risk are not fully understood. Our objective is to characterize patients with MS and epilepsy regarding timing of diagnoses, MS and seizure (SZ) type, EEG findings suggesting cortical dysfunction, frequency of status epilepticus (SE), and seizure freedom. METHODS This was a single center retrospective study. Cases were obtained via DataDirect via the University of Michigan electronic medical record from January 1, 2006 through October, 12, 2016. The University of Michigan Health System is a large academic institute with a tertiary referral center and an Autoimmunity Center of Excellence. Patients were included if chart listed one or more of the top 62 epilepsy, and one or more of the top 2 MS, most frequently entered ICD9 and ICD10 codes. Patients with alternative epilepsy etiology were excluded. 74 of 361 patients were included. We collected information regarding demographics, MS and SZ type, age at diagnosis, imaging, EEG, seizure freedom, medications, and SE. RESULTS We found a high percentage of patients with SE. Most patients with imaging had multiple lesions at seizure onset. 27/54 of patients with EEG data showed electrographic evidence of cortical dysfunction. 6/8 of EEGs in PPMS showed features consistent with cortical dysfunction, followed by 9/17 in SPMS and 11/23 in RRMS. 7/8 of patients with PPMS showed EEG evidence of temporal lobe dysfunction. CONCLUSION Time of seizure onset relative to MS diagnosis varied with MS type suggesting distinct pathophysiology. EEG results correspond with reports of increased cortical damage and temporal dysfunction in PPMS, but are unique as a functional modality (EEG) as indicator of gray matter dysfunction. EEG findings differed in RRMS and progressive MS suggesting possibility of supportive diagnostic marker. Our data suggests higher risk of SE in progressive MS and diminished rate of seizure freedom for MS patients with SE. We conclude that early treatment with antiseizure medication would be beneficial for MS patients with SE and with progressive MS forms and SZ, in agreement with previous studies.
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Affiliation(s)
- Emily R Nurre
- University of Michigan Department of Neurology, 1500 E Medical Center Dr # 1914, Ann Arbor, MI 48109, United States; University of Cincinnati College of Medicine, Department of Neurology and Rehabilitation Medicine, Stetson Building Suite 2300, 260 Stetson St., Cincinnati, OH 45267, United States.
| | - Anna Shah
- University of Michigan Department of Neurology, 1500 E Medical Center Dr # 1914, Ann Arbor, MI 48109, United States; University of Colorado School of Medicine, Department of Neurology, 13001 E 17th Pl, Aurora, CO 80045, United States
| | - Craig J Hansen
- University of Michigan Department of Neurology, 1500 E Medical Center Dr # 1914, Ann Arbor, MI 48109, United States; Summa Health Comprehensive Epilepsy Center, 3825 Fishcreek Road, Suite 200, Cuyahoga Falls, OH 44224, United States
| | - Catherine Dowling
- University of Michigan Department of Neurology, 1500 E Medical Center Dr # 1914, Ann Arbor, MI 48109, United States; University of Michigan Office of Research, IRBMED, 2800 Plymouth Road, Building 520, Room 3214, Ann Arbor, MI 48109, United States
| | - Smathorn Thakolwiboon
- University of Michigan Department of Neurology, 1500 E Medical Center Dr # 1914, Ann Arbor, MI 48109, United States
| | - Yang Mao-Draayer
- University of Michigan Department of Neurology, 1500 E Medical Center Dr # 1914, Ann Arbor, MI 48109, United States; Autoimmunity Center of Excellence, University of Michigan, Ann Arbor, MI 48109, United States; Michigan Institute for Neurological Disorders, 28595 Orchard Lake Road, Farmington Hills, MI 48334, United States
| | - Temenuzhka G Mihaylova
- University of Michigan Department of Neurology, 1500 E Medical Center Dr # 1914, Ann Arbor, MI 48109, United States
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Ouyang J, Peng S, Wu G, Liu R. Association Between Neurodegenerative Diseases and an Increased Risk of Epilepsy Based on Single Nucleotide Polymorphisms: A Mendelian Randomization Study. Mol Neurobiol 2024:10.1007/s12035-024-03955-6. [PMID: 38261256 DOI: 10.1007/s12035-024-03955-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Accepted: 01/12/2024] [Indexed: 01/24/2024]
Abstract
Epilepsy is a common neurological disorder characterized by transient brain dysfunction, attributed to a multitude of factors. The purpose of this study is to explore whether neurodegenerative diseases, specifically Alzheimer's disease (AD), Parkinson's disease (PD), amyotrophic lateral sclerosis (ALS), and multiple sclerosis (MS), have a causal effect on epilepsy. Mendelian randomization (MR) methods were used to analyze the causal association between neurodegenerative diseases (AD, PD, ALS, and MS) and epilepsy based on single nucleotide polymorphisms from genome-wide association studies, including inverse-variance weighted, weighted median, MR-Egger, and weighted mode methods. The reliability and stability of the MR analysis results were assessed by the MR-Egger intercept, MR-PRESSO, and heterogeneity tests. Forty-three SNPs were selected for the MR analysis of MS and epilepsy. The inverse-variance weighted method showed a significant causal association between MS and increased risk of epilepsy (odds ratio 1.046; 95% confidence interval 1.001-1.093; P = 0.043). However, AD (P = 0.986), PD (P = 0.894), and ALS (P = 0.533) were not causally associated with epilepsy. Sensitivity analysis showed that the results were robust. The MR study confirmed the causal relationship between genetically predicted MS and epilepsy but did not support the causal relationship between genetically predicted AD, PD, and ALS on epilepsy.
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Affiliation(s)
- Jia Ouyang
- Department of Neurosurgery, Peking University People's Hospital, Beijing, 100044, People's Republic of China
| | - Shijun Peng
- Department of Neurosurgery, Peking University People's Hospital, Beijing, 100044, People's Republic of China
| | - Guangyong Wu
- Department of Neurosurgery, Peking University People's Hospital, Beijing, 100044, People's Republic of China
| | - Ruen Liu
- Department of Neurosurgery, Peking University People's Hospital, Beijing, 100044, People's Republic of China.
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Zuo H, Peng L, Li W, Wang Y, Du X, Zou X, Dong Z, Yi L, Yin H, Quan F, Cheng O. Assessment of bidirectional relationships between multiple sclerosis and epilepsy: A two-sample Mendelian randomization study. Mult Scler Relat Disord 2024; 81:105148. [PMID: 38006848 DOI: 10.1016/j.msard.2023.105148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 11/18/2023] [Accepted: 11/19/2023] [Indexed: 11/27/2023]
Abstract
BACKGROUND AND OBJECTIVE Epidemiological studies indicate that multiple sclerosis (MS) is associated with epilepsy. However, the causality and directionality of this association remain under-elucidated. This study aimed to reveal the causality between MS and epilepsy. METHODS A two-sample Mendelian randomization (MR) analysis was performed by using summarized statistics derived from large genome-wide association studies of MS and epilepsy. We used the inverse variance weighted method as the primary approach, and then four other MR methods to bidirectionally evaluate the causality of the association between MS and epilepsy. Additional sensitivity analyses were performed to measure the robustness of the findings. RESULTS Genetically predicted MS was positively correlated with developing all epilepsy [odds ratio (OR) = 1.027 (1.003-1.051), P = 0.028] and generalized epilepsy [OR = 1.050 (1.008-1.094), P = 0.019]. In the reverse MR analysis, all epilepsy [OR = 1.310 (1.112-1.543), P = 0.001], generalized epilepsy [OR = 1.173 (1.010-1.363), P = 0.037], and focal epilepsy [OR = 1.264 (1.069-1.494), P = 0.006] elevated the risk of developing MS. The result remained robust and congruous across all sensitivity analyses conducted. CONCLUSIONS MS is potentially associated with a higher risk of developing epilepsy. Furthermore, epilepsy may be a causal determinant of MS risk. These findings may further the understanding of the interaction of the two conditions.
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Affiliation(s)
- Hongzhou Zuo
- Department of Neurology, The First Affiliated Hospital, Chongqing Medical University, Chongqing 400016, China
| | - Li Peng
- Department of Neurology, The First Affiliated Hospital, Chongqing Medical University, Chongqing 400016, China; Department of Neurology, Youyang County People's Hospital, Chongqing 409899, China
| | - Wei Li
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Yuzhu Wang
- Department of Neurology, The First Affiliated Hospital, Chongqing Medical University, Chongqing 400016, China
| | - Xinyi Du
- Department of Neurology, The First Affiliated Hospital, Chongqing Medical University, Chongqing 400016, China
| | - Xiaoya Zou
- Department of Neurology, The First Affiliated Hospital, Chongqing Medical University, Chongqing 400016, China
| | - Zhaoying Dong
- Department of Neurology, The First Affiliated Hospital, Chongqing Medical University, Chongqing 400016, China
| | - Li Yi
- Department of Neurology, The First Affiliated Hospital, Chongqing Medical University, Chongqing 400016, China
| | - Huimei Yin
- Department of Neurology, The First Affiliated Hospital, Chongqing Medical University, Chongqing 400016, China
| | - Fengying Quan
- Department of Neurology, The First Affiliated Hospital, Chongqing Medical University, Chongqing 400016, China.
| | - Oumei Cheng
- Department of Neurology, The First Affiliated Hospital, Chongqing Medical University, Chongqing 400016, China.
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Grothe M, Ellenberger D, Rommer PS, Stahmann A, Zettl UK. Epileptic seizures at multiple sclerosis onset and their role in disease progression. Ther Adv Neurol Disord 2023; 16:17562864231192826. [PMID: 37808247 PMCID: PMC10559692 DOI: 10.1177/17562864231192826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 07/20/2023] [Indexed: 10/10/2023] Open
Abstract
Background Epileptic seizures can occur throughout the course of multiple sclerosis (MS) and are associated with increasing disability progression over time. However, there are no data on whether epileptic seizures at the onset of MS also lead to increasing disability. Objective To examine disease progression over time for MS patients with epileptic seizures at onset. Methods We analyzed the data of 30,713 patients on the German Multiple Sclerosis Register in a case-control study for more than 15 years. MS patients with seizures at onset were further divided into subgroups with polysymptomatic and monosymptomatic onset to assess the impact of additional symptoms on disease progression. Results A total of 46 patients had seizures as onset symptoms. Expanded Disability Status Scale (EDSS) within the first year was lower in the group with seizures at onset compared to controls (0.75 versus 1.6, p < 0.05), which changed until the last reported visit (3.11 versus 3.0). Both subgroups revealed increased EDSS progression over time compared to controls. Conclusion Epileptic seizures at MS onset are associated with a higher amount of disability progression over time. Additional longitudinal data are needed to further clarify the impact of seizures on the pathophysiology of MS disease progression.
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Affiliation(s)
- Matthias Grothe
- Department of Neurology, University Medicine Greifswald, Ferdinand-Sauerbruchstraße, Greifswald 17475, Germany
| | - David Ellenberger
- German MS Register by the German MS Society, MS Research and Project Development gGmbH [MSFP], Hanover, Germany
| | - Paulus S. Rommer
- Department of Neurology, Medical University of Vienna, Vienna, Austria
- Department of Neurology, Neuroimmunological Section, University of Rostock, Rostock, Germany
| | - Alexander Stahmann
- German MS Register by the German MS Society, MS Research and Project Development gGmbH [MSFP], Hanover, Germany
| | - Uwe K. Zettl
- Department of Neurology, Neuroimmunological Section, University of Rostock, Rostock, Germany
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10
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Çaksen H. Relationship Between Multiple Sclerosis and Spiritual Distress. JOURNAL OF PEDIATRIC EPILEPSY 2023. [DOI: 10.1055/s-0043-1764149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2023]
Affiliation(s)
- Hüseyin Çaksen
- Divisions of Pediatric Neurology and Genetics, and Behavioral-Developmental Pediatrics, Department of Pediatrics, Meram Medical Faculty, Necmettin Erbakan University, Meram, Konya, Türkiye
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Hurtubise B, Frohman EM, Galetta S, Balcer LJ, Frohman TC, Lisak RP, Newsome SD, Graves JS, Zamvil SS, Amezcua L. MOG Antibody-Associated Disease and Thymic Hyperplasia: From the National Multiple Sclerosis Society Case Conference Proceedings. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2023; 10:e200077. [PMID: 36517233 PMCID: PMC9753285 DOI: 10.1212/nxi.0000000000200077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 10/26/2022] [Indexed: 12/15/2022]
Abstract
Myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) is a recently described CNS inflammatory disorder that may manifest with optic neuritis, myelitis, seizures, and/or acute disseminated encephalomyelitis. While MOG-specific antibodies in patients with MOGAD are IgG1, a T-cell-dependent antibody isotype, immunologic mechanisms of this disease are not fully understood. Thymic hyperplasia can be associated with certain autoimmune diseases. In this report we describe a case of MOGAD associated with thymic hyperplasia in a young adult.
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Affiliation(s)
- Brigitte Hurtubise
- From the Department of Neurology (B.H., L.A.), University of Southern California (USC), Keck School of Medicine; Distinguished Senior Fellows (Sabbatical) Neuroimmunology Laboratory of Professor Lawrence Steinman (E.M.F., T.C.F.), Stanford University School of Medicine, Palo Alto, CA; Departments of Neurology (S.G., L.J.B.), Population Health (L.J.B.) and Ophthalmology (L.J.B., S.G.), New York University Grossman School of Medicine; Department of Neurology (R.P.L.), Wayne State University, Detroit MI; Department of Neurology (S.D.N.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurosciences (J.S.G.), University of California, San Diego; and Department of Neurology and Program in Immunology (S.S.Z.), University of California, San Francisco
| | - Elliot M Frohman
- From the Department of Neurology (B.H., L.A.), University of Southern California (USC), Keck School of Medicine; Distinguished Senior Fellows (Sabbatical) Neuroimmunology Laboratory of Professor Lawrence Steinman (E.M.F., T.C.F.), Stanford University School of Medicine, Palo Alto, CA; Departments of Neurology (S.G., L.J.B.), Population Health (L.J.B.) and Ophthalmology (L.J.B., S.G.), New York University Grossman School of Medicine; Department of Neurology (R.P.L.), Wayne State University, Detroit MI; Department of Neurology (S.D.N.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurosciences (J.S.G.), University of California, San Diego; and Department of Neurology and Program in Immunology (S.S.Z.), University of California, San Francisco
| | - Steven Galetta
- From the Department of Neurology (B.H., L.A.), University of Southern California (USC), Keck School of Medicine; Distinguished Senior Fellows (Sabbatical) Neuroimmunology Laboratory of Professor Lawrence Steinman (E.M.F., T.C.F.), Stanford University School of Medicine, Palo Alto, CA; Departments of Neurology (S.G., L.J.B.), Population Health (L.J.B.) and Ophthalmology (L.J.B., S.G.), New York University Grossman School of Medicine; Department of Neurology (R.P.L.), Wayne State University, Detroit MI; Department of Neurology (S.D.N.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurosciences (J.S.G.), University of California, San Diego; and Department of Neurology and Program in Immunology (S.S.Z.), University of California, San Francisco
| | - Laura J Balcer
- From the Department of Neurology (B.H., L.A.), University of Southern California (USC), Keck School of Medicine; Distinguished Senior Fellows (Sabbatical) Neuroimmunology Laboratory of Professor Lawrence Steinman (E.M.F., T.C.F.), Stanford University School of Medicine, Palo Alto, CA; Departments of Neurology (S.G., L.J.B.), Population Health (L.J.B.) and Ophthalmology (L.J.B., S.G.), New York University Grossman School of Medicine; Department of Neurology (R.P.L.), Wayne State University, Detroit MI; Department of Neurology (S.D.N.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurosciences (J.S.G.), University of California, San Diego; and Department of Neurology and Program in Immunology (S.S.Z.), University of California, San Francisco
| | - Teresa C Frohman
- From the Department of Neurology (B.H., L.A.), University of Southern California (USC), Keck School of Medicine; Distinguished Senior Fellows (Sabbatical) Neuroimmunology Laboratory of Professor Lawrence Steinman (E.M.F., T.C.F.), Stanford University School of Medicine, Palo Alto, CA; Departments of Neurology (S.G., L.J.B.), Population Health (L.J.B.) and Ophthalmology (L.J.B., S.G.), New York University Grossman School of Medicine; Department of Neurology (R.P.L.), Wayne State University, Detroit MI; Department of Neurology (S.D.N.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurosciences (J.S.G.), University of California, San Diego; and Department of Neurology and Program in Immunology (S.S.Z.), University of California, San Francisco
| | - Robert P Lisak
- From the Department of Neurology (B.H., L.A.), University of Southern California (USC), Keck School of Medicine; Distinguished Senior Fellows (Sabbatical) Neuroimmunology Laboratory of Professor Lawrence Steinman (E.M.F., T.C.F.), Stanford University School of Medicine, Palo Alto, CA; Departments of Neurology (S.G., L.J.B.), Population Health (L.J.B.) and Ophthalmology (L.J.B., S.G.), New York University Grossman School of Medicine; Department of Neurology (R.P.L.), Wayne State University, Detroit MI; Department of Neurology (S.D.N.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurosciences (J.S.G.), University of California, San Diego; and Department of Neurology and Program in Immunology (S.S.Z.), University of California, San Francisco
| | - Scott D Newsome
- From the Department of Neurology (B.H., L.A.), University of Southern California (USC), Keck School of Medicine; Distinguished Senior Fellows (Sabbatical) Neuroimmunology Laboratory of Professor Lawrence Steinman (E.M.F., T.C.F.), Stanford University School of Medicine, Palo Alto, CA; Departments of Neurology (S.G., L.J.B.), Population Health (L.J.B.) and Ophthalmology (L.J.B., S.G.), New York University Grossman School of Medicine; Department of Neurology (R.P.L.), Wayne State University, Detroit MI; Department of Neurology (S.D.N.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurosciences (J.S.G.), University of California, San Diego; and Department of Neurology and Program in Immunology (S.S.Z.), University of California, San Francisco
| | - Jennifer S Graves
- From the Department of Neurology (B.H., L.A.), University of Southern California (USC), Keck School of Medicine; Distinguished Senior Fellows (Sabbatical) Neuroimmunology Laboratory of Professor Lawrence Steinman (E.M.F., T.C.F.), Stanford University School of Medicine, Palo Alto, CA; Departments of Neurology (S.G., L.J.B.), Population Health (L.J.B.) and Ophthalmology (L.J.B., S.G.), New York University Grossman School of Medicine; Department of Neurology (R.P.L.), Wayne State University, Detroit MI; Department of Neurology (S.D.N.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurosciences (J.S.G.), University of California, San Diego; and Department of Neurology and Program in Immunology (S.S.Z.), University of California, San Francisco
| | - Scott S Zamvil
- From the Department of Neurology (B.H., L.A.), University of Southern California (USC), Keck School of Medicine; Distinguished Senior Fellows (Sabbatical) Neuroimmunology Laboratory of Professor Lawrence Steinman (E.M.F., T.C.F.), Stanford University School of Medicine, Palo Alto, CA; Departments of Neurology (S.G., L.J.B.), Population Health (L.J.B.) and Ophthalmology (L.J.B., S.G.), New York University Grossman School of Medicine; Department of Neurology (R.P.L.), Wayne State University, Detroit MI; Department of Neurology (S.D.N.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurosciences (J.S.G.), University of California, San Diego; and Department of Neurology and Program in Immunology (S.S.Z.), University of California, San Francisco.
| | - Lilyana Amezcua
- From the Department of Neurology (B.H., L.A.), University of Southern California (USC), Keck School of Medicine; Distinguished Senior Fellows (Sabbatical) Neuroimmunology Laboratory of Professor Lawrence Steinman (E.M.F., T.C.F.), Stanford University School of Medicine, Palo Alto, CA; Departments of Neurology (S.G., L.J.B.), Population Health (L.J.B.) and Ophthalmology (L.J.B., S.G.), New York University Grossman School of Medicine; Department of Neurology (R.P.L.), Wayne State University, Detroit MI; Department of Neurology (S.D.N.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurosciences (J.S.G.), University of California, San Diego; and Department of Neurology and Program in Immunology (S.S.Z.), University of California, San Francisco
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Dang YL, Yong VT, Sharmin S, Perucca P, Kalincik T. Seizure risk in multiple sclerosis patients treated with disease-modifying therapy: A systematic review and network meta-analysis. Mult Scler 2023; 29:657-667. [PMID: 36802988 DOI: 10.1177/13524585231151400] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
BACKGROUND Multiple sclerosis patients experience 3-6 times more seizures than the general population, but observations vary among studies. Seizure risk in disease-modifying therapy recipients remains unknown. OBJECTIVE The objective of this study was to compare seizure risk in multiple sclerosis patients receiving disease-modifying therapy versus placebo. METHODS MEDLINE(OVID), Embase, CINAHL, and ClinicalTrials.gov were searched from database inception until August 2021. Phase 2-3 randomized, placebo-controlled trials reporting efficacy and safety data for disease-modifying therapies were included. Network meta-analysis followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, using Bayesian random effects model for individual and pooled (by drug target) therapies. Main outcome was loge seizure risk ratios [95% credible intervals]. Sensitivity analysis included meta-analysis of non-zero-event studies. RESULTS A total of 1993 citations and 331 full-texts were screened. Fifty-six included studies (29,388 patients-disease-modifying therapy = 18,909; placebo = 10,479) reported 60 seizures (therapy = 41; placebo = 19). No individual therapy was associated with altered seizure risk ratio. Exceptions were daclizumab (-17.90 [-65.31; -0.65]) and rituximab (-24.86 [-82.71; -1.37]) trending toward lower risk ratio; cladribine (25.78 [0.94; 4.65]) and pegylated interferon-beta-1a (25.40 [0.78; 85.47]) trended toward higher risk ratio. Observations had wide credible intervals. Sensitivity analysis of 16 non-zero-event studies revealed no difference in risk ratio for pooled therapies (l0.32 [-0.94; 0.29]). CONCLUSION No evidence of association was found between disease-modifying therapy and seizure risk-this informs seizure management in multiple sclerosis patients.
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Affiliation(s)
- Yew Li Dang
- Department of Neurology, Bladin-Berkovic Comprehensive Epilepsy Program, Austin Health, Melbourne, VIC, Australia/Department of Medicine, Austin Health, The University of Melbourne, Melbourne, VIC, Australia/Melbourne Brain Centre, Melbourne, VIC, Australia
| | - Vivien Ty Yong
- Department of Neurology, The Royal Melbourne Hospital, Melbourne, VIC, Australia/Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand/Department of Neurology, Auckland City Hospital, Auckland, New Zealand
| | - Sifat Sharmin
- CORe, Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia
| | - Piero Perucca
- Department of Neurology, Bladin-Berkovic Comprehensive Epilepsy Program, Austin Health, Melbourne, VIC, Australia/Department of Medicine, Austin Health, The University of Melbourne, Melbourne, VIC, Australia/Department of Neurology, The Royal Melbourne Hospital, Melbourne, VIC, Australia/Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia/Department of Neurology, Alfred Health, Melbourne, VIC, Australia
| | - Tomas Kalincik
- Neuroimmunology Centre, Department of Neurology, The Royal Melbourne Hospital, Melbourne, VIC, Australia/CORe, Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia
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Jamoussi H, Ali NB, Missaoui Y, Cherif A, Oudia N, Anane N, Ftouhi L, Mahmoud MB, Fray S, Fredj M. Cognitive impairment in multiple sclerosis: Utility of electroencephalography. Mult Scler Relat Disord 2023; 70:104502. [PMID: 36657327 DOI: 10.1016/j.msard.2023.104502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 11/11/2022] [Accepted: 01/02/2023] [Indexed: 01/06/2023]
Abstract
OBJECTIVE to evaluate associations between neurocognitive impairment and electroencephalography (EEG) data in Multiple Sclerosis (MS). METHODS patients aged between 18 and 65 years, diagnosed with MS accordingly to the McDonald 2017 criteria and who were in remission for at least one month were included. Cognitive functions were evaluated by validated neuropsychological tests for Tunisian population. Electroencephalography data of each patient were analysed, Grand Total EEG (GTE) score was calculated and we evaluated their statistical links with cognitive impairment. RESULTS Thirty five patients were included. Slower background activity was associated with presence of: reduced information processing speed (IPS) (p = 0,03), verbal memory impairment (p = 0,04) and executive dysfunction (p = 0,016). The score 3 of GTE (reactivity of background activity) was associated with reduced IPS (p = 0,007) and executive dysfunction (p = 0,014). We found a positive correlation between background activity and Tunisian Verbal Test (TVLT) (ρ =0,46 ; p = 0,005) and Symbol Digit Modalities Test (SDMT) (ρ =0,35 ; p = 0,03). Sensitivity of GTE score was 68,4% for executive dysfunction (cut-off=2,5) and 66,7% for reduced IPS (cut-off=2,5). CONCLUSIONS Our results have shown utility of EEG in detecting cortical involvement and its correlation with cognitive impairment in MS patients. SIGNIFICANCE EEG could be a tool for monitoring cortical involvement during MS and predict cognitive impairment.
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Affiliation(s)
- Hela Jamoussi
- Department of neurology, Charles Nicolle Hospital, Tunis 1006, Tunisia; Faculté de Médecine de Tunis, Université de Tunis El Manar, Tunis 1007, Tunisia; Research laboratory LR12SP01, Charles Nicolle Hospital, Tunis 1006, Tunisia.
| | - Nadia Ben Ali
- Department of neurology, Charles Nicolle Hospital, Tunis 1006, Tunisia; Faculté de Médecine de Tunis, Université de Tunis El Manar, Tunis 1007, Tunisia; Research laboratory LR12SP01, Charles Nicolle Hospital, Tunis 1006, Tunisia
| | - Yasmine Missaoui
- Department of neurology, Charles Nicolle Hospital, Tunis 1006, Tunisia; Faculté de Médecine de Tunis, Université de Tunis El Manar, Tunis 1007, Tunisia
| | - Aroua Cherif
- Department of neurology, Charles Nicolle Hospital, Tunis 1006, Tunisia
| | - Nouria Oudia
- Department of neurology, Charles Nicolle Hospital, Tunis 1006, Tunisia
| | - Nadya Anane
- Department of neurology, Charles Nicolle Hospital, Tunis 1006, Tunisia
| | - Lamia Ftouhi
- Department of neurology, Charles Nicolle Hospital, Tunis 1006, Tunisia
| | - Mariem Ben Mahmoud
- Department of neurology, Charles Nicolle Hospital, Tunis 1006, Tunisia; Faculté de Médecine de Tunis, Université de Tunis El Manar, Tunis 1007, Tunisia; Research laboratory LR12SP01, Charles Nicolle Hospital, Tunis 1006, Tunisia
| | - Saloua Fray
- Department of neurology, Charles Nicolle Hospital, Tunis 1006, Tunisia; Faculté de Médecine de Tunis, Université de Tunis El Manar, Tunis 1007, Tunisia; Research laboratory LR12SP01, Charles Nicolle Hospital, Tunis 1006, Tunisia
| | - Mohamed Fredj
- Department of neurology, Charles Nicolle Hospital, Tunis 1006, Tunisia; Faculté de Médecine de Tunis, Université de Tunis El Manar, Tunis 1007, Tunisia; Research laboratory LR12SP01, Charles Nicolle Hospital, Tunis 1006, Tunisia
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Selton M, Mathey G, Soudant M, Manceau P, Anxionnat R, Debouverie M, Jonas J. Prognostic impact of epileptic seizures in multiple sclerosis varies according to time of occurrence and etiology. Eur J Neurol 2022; 29:3537-3546. [PMID: 36083790 PMCID: PMC9826490 DOI: 10.1111/ene.15551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 08/30/2022] [Accepted: 08/31/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND AND PURPOSE Epileptic seizures occur more often in patients with multiple sclerosis (MS) than in the general population. Their association with the prognosis of MS remains unclear. This study was undertaken to evaluate whether epileptic seizures may be a prognostic marker of MS disability, according to when the seizure occurs and its cause. METHODS Data were extracted from a population-based registry of MS in Lorraine, France. Kaplan-Meier curves and log-rank tests were used to compare the probability of different levels of irreversible handicap during the course of MS in patients who experience epileptic seizures or do not, according to the chronology and the cause of the first epileptic seizure. RESULTS Among 6238 patients, 134 had experienced at least one epileptic seizure (2.1%), and 82 (1.2%) had seizures secondary to MS. Patients with epileptic seizure as a first symptom of MS (14 patients) had the same disease progression as other relapsing-remitting MS patients. Patients who developed epileptic seizures during the course of MS (68 patients) had a higher probability of reaching Expanded Disability Status Scale = 3.0 (p = 0.006), 6.0 (p = 0.003), and 7.0 (p = 0.004) than patients without an epileptic background. Patients with a history of epileptic seizures unrelated to MS also had a worse prognosis than patients without an epileptic background. CONCLUSIONS Epileptic seizures might be viewed as a "classic MS relapse" in terms of prognosis if occurring early in MS, or as a marker of MS severity if developing during the disease. Epileptic diseases other than MS may worsen the course of MS.
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Affiliation(s)
- Marion Selton
- Department of Neurology, Nancy Regional University Hospital CenterUniversity of LorraineNancyFrance
| | - Guillaume Mathey
- Department of Neurology, Nancy Regional University Hospital CenterUniversity of LorraineNancyFrance,INSERM, CIC‐1433 Epidemiologie CliniqueNancy Regional University Hospital Center, University of LorraineNancyFrance,EA 4360 APEMACUniversity of LorraineNancyFrance
| | - Marc Soudant
- INSERM, CIC‐1433 Epidemiologie CliniqueNancy Regional University Hospital Center, University of LorraineNancyFrance
| | - Philippe Manceau
- Department of Neurology, Nancy Regional University Hospital CenterUniversity of LorraineNancyFrance
| | - René Anxionnat
- Department of Neuroradiology, Nancy Regional University Hospital CenterUniversity of LorraineNancyFrance
| | - Marc Debouverie
- Department of Neurology, Nancy Regional University Hospital CenterUniversity of LorraineNancyFrance,INSERM, CIC‐1433 Epidemiologie CliniqueNancy Regional University Hospital Center, University of LorraineNancyFrance,EA 4360 APEMACUniversity of LorraineNancyFrance
| | - Jacques Jonas
- Department of Neurology, Nancy Regional University Hospital CenterUniversity of LorraineNancyFrance,CNRS, CRANUniversity of LorraineNancyFrance
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Mahamud Z, Burman J, Zelano J. Temporal trends of epilepsy in multiple sclerosis. Acta Neurol Scand 2022; 146:492-498. [PMID: 35852006 PMCID: PMC9795966 DOI: 10.1111/ane.13671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Revised: 06/23/2022] [Accepted: 07/06/2022] [Indexed: 12/30/2022]
Abstract
OBJECTIVES Epilepsy is associated with advanced multiple sclerosis (MS). We aimed to investigate whether the incidence of epilepsy in MS has been affected by the introduction of disease-modifying treatments (DMT) for MS. MATERIALS AND METHODS This retrospective study included 14,557 patients from the Swedish MS register with MS onset between 1991 and 2018. Incident diagnoses of epilepsy or any seizure were identified through cross-linkage with the National Patient Register. Next, yearly prevalence of epilepsy as well as 5- and 10 years incidence of epilepsy or any seizure for consecutive years of MS onset were estimated, the latter with Kaplan-Meier analysis. Cox regression was used to adjust the association between the year of MS onset and incidence of epilepsy for baseline variables. RESULTS Prevalence of epilepsy in the MS cohort increased from 0.34% in 1991 to 2.54% in 2018 (yearly odds: 1.26 [1.22, 1.29]). The 5 years incidence rate of epilepsy, ranging from 0.4% (95% CI 0.008-0.79%) to 1.3% (95% CI 0.71-1.89%), and the 10 years incidence rate of epilepsy, ranging from 1.1% (95% CI 0.31-1.88%) to 2.6% (95% CI 1.22-3.97%) showed no significant trends (p = .147 and p = .418, respectively). Similarly, no significant trends were found for the incidences of any seizure. The incidence trends of epilepsy remained not significant after adjusting for sex, MS onset type (relapsing or progressive onset), or age at MS onset. CONCLUSIONS Our findings do not support the hypothesis that the introduction of novel DMT for MS has reduced the incidence of epilepsy among MS patients.
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Affiliation(s)
- Zamzam Mahamud
- Department of Clinical Neuroscience, Sahlgrenska AcademyUniversity of Gothenburg and Sahlgrenska University HospitalGothenburgSweden
| | - Joachim Burman
- Department of NeuroscienceUppsala UniversityUppsalaSweden
| | - Johan Zelano
- Department of Clinical Neuroscience, Sahlgrenska AcademyUniversity of Gothenburg and Sahlgrenska University HospitalGothenburgSweden,Wallenberg Centre for Molecular and Translational MedicineSahlgrenska academyGothenburg
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16
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Distinguishing CNS neurosarcoidosis from multiple sclerosis and an approach to “overlap” cases. J Neuroimmunol 2022; 369:577904. [DOI: 10.1016/j.jneuroim.2022.577904] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 05/30/2022] [Accepted: 05/30/2022] [Indexed: 12/17/2022]
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Li EC, Zheng Y, Cai MT, Lai QL, Fang GL, Du BQ, Shen CH, Zhang YX, Wu LJ, Ding MP. Seizures and epilepsy in multiple sclerosis, aquaporin 4 antibody-positive neuromyelitis optica spectrum disorder and myelin oligodendrocyte glycoprotein antibody-associated disease. Epilepsia 2022; 63:2173-2191. [PMID: 35652436 DOI: 10.1111/epi.17315] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 05/30/2022] [Accepted: 05/31/2022] [Indexed: 11/29/2022]
Abstract
Seizure is one of the manifestations of central nervous system (CNS) inflammatory demyelinating diseases, which mainly include multiple sclerosis (MS), aquaporin 4 antibody-positive neuromyelitis optica spectrum disorder (AQP4-NMOSD) and myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD). "Acute symptomatic seizures secondary to MS / AQP4-NMOSD / MOGAD" occur in the acute phase of the diseases, and are more frequent in MOGAD. In contrast, recurrent non-provoked seizures, mainly attributed to "autoimmune-associated epilepsy", occur in the non-acute phase of the diseases. Seizures in MS / AQP4-NMOSD / MOGAD mostly have a focal-onset. MS patients with concomitant systemic infections, an earlier onset and a higher disease activity are more likely to have seizures, whereas factors such as higher MS severity, the presence of status epilepticus and cortical damage indicate a greater risk of developing epilepsy. In MOGAD, cerebral cortical encephalitis, acute disseminated encephalomyelitis (ADEM)-like phenotypes (predominately ADEM and multiphasic disseminated encephalomyelitis) indicate a higher seizure risk. Multiple relapses with ADEM-like phenotypes predict epilepsy in pediatrics with MOGAD. Pathophysiologically, acute symptomatic seizures in MS are associated with neuronal hyperexcitability secondary to inflammation and demyelination. Chronic epilepsy in MS is largely due to gliosis, neuronal dysfunction and synaptic abnormalities. The mainstay of treatment for seizures secondary to MS / AQP4-NMOSD / MOGAD include immunotherapy along with antiseizure medications. This critical review discusses the most-updated evidence on epidemiology, clinical correlates, and inflammatory mechanisms underlying seizures and epilepsy in MS / AQP4-NMOSD / MOGAD. Treatment cautions including drug-drug interactions and the impact of treatments on the other are outlined. We also highlight pitfalls and challenges in managing such patients and future research perspectives to address unsolved questions.
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Affiliation(s)
- Er-Chuang Li
- Department of Neurology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Yang Zheng
- Department of Neurology, First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, China
| | - Meng-Ting Cai
- Department of Neurology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Qi-Lun Lai
- Department of Neurology, Zhejiang Hospital, Hangzhou, China
| | - Gao-Li Fang
- Department of Neurology, Zhejiang Chinese Medicine and Western Medicine Integrated Hospital, Hangzhou, China
| | - Bing-Qing Du
- Department of Neurology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Chun-Hong Shen
- Department of Neurology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Yin-Xi Zhang
- Department of Neurology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Long-Jun Wu
- Department of Neurology, Mayo Clinic, Rochester, MN, United States
| | - Mei-Ping Ding
- Department of Neurology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
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Ciolac D, Gonzalez-Escamilla G, Winter Y, Melzer N, Luessi F, Radetz A, Fleischer V, Groppa SA, Kirsch M, Bittner S, Zipp F, Muthuraman M, Meuth SG, Grothe M, Groppa S. Altered grey matter integrity and network vulnerability relate to epilepsy occurrence in patients with multiple sclerosis. Eur J Neurol 2022; 29:2309-2320. [PMID: 35582936 DOI: 10.1111/ene.15405] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 03/22/2022] [Accepted: 05/13/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND To investigate the relevance of compartmentalized grey matter (GM) pathology and network reorganization in MS patients with concomitant epilepsy. METHODS From 3T MRI scans of 30 MS patients with epilepsy (MSE; age 41±15 years, 21 females, disease duration 8±6 years, median Expanded Disability Status Scale (EDSS) 3), 60 MS patients without epilepsy (MS; age 41±12 years, 35 females, disease duration 6±4 years, EDSS 2), and 60 healthy subjects (HS; age 40±13 years, 27 females) regional volumes of GM lesions and of cortical, subcortical, and hippocampal structures were quantified. Network topology and vulnerability were modeled within the graph theoretical framework. The receiver operating characteristic (ROC) analysis was applied to assess the accuracy of GM pathology measures to discriminate between MSE and MS patients. RESULTS Higher lesion volumes within the hippocampus, mesiotemporal cortex, and amygdala were detected in MSE compared to MS (all p<0.05). MSE displayed lower cortical volumes mainly in temporal and parietal areas compared to MS and HS (all p<0.05). Lower volumes of hippocampal tail and presubiculum were identified in both MSE and MS patients compared to HS (all p<0.05). Network topology in MSE was characterized by higher transitivity and assortativity, and higher vulnerability compared to MS and HS (all p<0.05). Hippocampal lesion volume yielded the highest accuracy (area under the ROC curve 0.80 [0.67-0.91]) in discriminating between MSE and MS patients. CONCLUSIONS High lesion load, altered integrity of mesiotemporal GM structures, and network reorganization are associated with a greater propensity of epilepsy occurrence in MS.
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Affiliation(s)
- Dumitru Ciolac
- Department of Neurology, Focus Program Translational Neuroscience (FTN), Rhine-Main Neuroscience Network (rmn2), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany.,Nicolae Testemitanu State University of Medicine and Pharmacy, Chisinau, Republic of Moldova.,Department of Neurology, Institute of Emergency Medicine, Chisinau, Republic of Moldova
| | - Gabriel Gonzalez-Escamilla
- Department of Neurology, Focus Program Translational Neuroscience (FTN), Rhine-Main Neuroscience Network (rmn2), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Yaroslav Winter
- Mainz Comprehensive Epilepsy and Sleep Medicine Center, Department of Neurology, Johannes Gutenberg University Mainz, Mainz, Germany.,Department of Neurology, Philipps-University, Marburg, Germany
| | - Nico Melzer
- Department of Neurology, Heinrich Heine University, Düsseldorf, Germany
| | - Felix Luessi
- Department of Neurology, Focus Program Translational Neuroscience (FTN), Rhine-Main Neuroscience Network (rmn2), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Angela Radetz
- Department of Neurology, Focus Program Translational Neuroscience (FTN), Rhine-Main Neuroscience Network (rmn2), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Vinzenz Fleischer
- Department of Neurology, Focus Program Translational Neuroscience (FTN), Rhine-Main Neuroscience Network (rmn2), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Stanislav A Groppa
- Nicolae Testemitanu State University of Medicine and Pharmacy, Chisinau, Republic of Moldova.,Department of Neurology, Institute of Emergency Medicine, Chisinau, Republic of Moldova
| | - Michael Kirsch
- Institute for Diagnostic Radiology and Neuroradiology, University Medicine of Greifswald, Germany
| | - Stefan Bittner
- Department of Neurology, Focus Program Translational Neuroscience (FTN), Rhine-Main Neuroscience Network (rmn2), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Frauke Zipp
- Department of Neurology, Focus Program Translational Neuroscience (FTN), Rhine-Main Neuroscience Network (rmn2), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Muthuraman Muthuraman
- Department of Neurology, Focus Program Translational Neuroscience (FTN), Rhine-Main Neuroscience Network (rmn2), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Sven G Meuth
- Department of Neurology, Heinrich Heine University, Düsseldorf, Germany
| | - Matthias Grothe
- Department of Neurology, University Medicine of Greifswald, Greifswald, Germany
| | - Sergiu Groppa
- Department of Neurology, Focus Program Translational Neuroscience (FTN), Rhine-Main Neuroscience Network (rmn2), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
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19
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Villamar MF, Sarkis RA, Pennell P, Kohane I, Beaulieu-Jones BK. Severity of Epilepsy and Response to Antiseizure Medications in Individuals with Multiple Sclerosis: Analysis of a Real-World Dataset. Neurol Clin Pract 2022; 12:e49-e57. [DOI: 10.1212/cpj.0000000000001178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 04/26/2022] [Indexed: 11/15/2022]
Abstract
ABSTRACTBackground and objectives:Epilepsy is an important comorbidity that affects outcomes for people with multiple sclerosis (MS). However, it is unclear if seizure severity among individuals with coexistence of multiple sclerosis and epilepsy (MS+E) is higher than in those with other focal epilepsies. Our goal was to compare the overall severity of epilepsy in individuals with MS+E versus those with focal epilepsy without MS (E-MS) as defined by seizure-related healthcare utilization, frequency and duration of status epilepticus, and frequency of antiseizure medication (ASM) regimen changes.Methods:In this hypothesis-generating study, we analyzed a U.S. commercial nationwide de-identified claims dataset with > 86 million individuals between 1/1/2008 and 8/31/2019. Using validated algorithms, we identified adults with E-MS and those with MS+E. We compared the number and length of seizure-related hospital admissions, the number of claims and unique days with claims for status epilepticus, and the rates of ASM regimen changes between the MS+E and the E-MS groups.Results:During the study period, 66,708 individuals with E-MS and 537 with MS+E had ≥ 2 years of coverage after their initial diagnosis of epilepsy. There was no difference between the MS+E and E-MS groups in the percentage of individuals admitted for seizures and/or status epilepticus. However, MS+E with seizure-related admissions had more admissions and longer hospital stays than those with E-MS. MS+E who experienced status epilepticus had more unique days with status epilepticus claims compared to E-MS. MS+E were more likely to have ASM regimen changes in Year 2 after the initial diagnosis of epilepsy and had more ASM changes during Year 2 compared to E-MS. Among individuals with MS+E, there were no differences in our measures of seizure severity for those treated with sodium channel blockers/modulators versus other ASM classes.Discussion:This study supports the notion that individuals with MS+E can have more severe epilepsy than those with E-MS. Seizure severity among individuals with MS+E treated with sodium-channel blockers/modulators versus other ASM classes shows no significant differences.Classification of evidence:This study provides Class III evidence that individuals with MS+E can have more severe epilepsy than those with E-MS.
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20
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Chaudhary R, Albrecht S, Datunashvili M, Cerina M, Lüttjohann A, Han Y, Narayanan V, Chetkovich DM, Ruck T, Kuhlmann T, Pape HC, Meuth SG, Zobeiri M, Budde T. Modulation of Pacemaker Channel Function in a Model of Thalamocortical Hyperexcitability by Demyelination and Cytokines. Cereb Cortex 2022; 32:4397-4421. [PMID: 35076711 PMCID: PMC9574242 DOI: 10.1093/cercor/bhab491] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 11/26/2021] [Accepted: 11/28/2021] [Indexed: 12/02/2022] Open
Abstract
A consensus is yet to be reached regarding the exact prevalence of epileptic seizures or epilepsy in multiple sclerosis (MS). In addition, the underlying pathophysiological basis of the reciprocal interaction among neuroinflammation, demyelination, and epilepsy remains unclear. Therefore, a better understanding of cellular and network mechanisms linking these pathologies is needed. Cuprizone-induced general demyelination in rodents is a valuable model for studying MS pathologies. Here, we studied the relationship among epileptic activity, loss of myelin, and pro-inflammatory cytokines by inducing acute, generalized demyelination in a genetic mouse model of human absence epilepsy, C3H/HeJ mice. Both cellular and network mechanisms were studied using in vivo and in vitro electrophysiological techniques. We found that acute, generalized demyelination in C3H/HeJ mice resulted in a lower number of spike–wave discharges, increased cortical theta oscillations, and reduction of slow rhythmic intrathalamic burst activity. In addition, generalized demyelination resulted in a significant reduction in the amplitude of the hyperpolarization-activated inward current (Ih) in thalamic relay cells, which was accompanied by lower surface expression of hyperpolarization-activated, cyclic nucleotide-gated channels, and the phosphorylated form of TRIP8b (pS237-TRIP8b). We suggest that demyelination-related changes in thalamic Ih may be one of the factors defining the prevalence of seizures in MS.
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Affiliation(s)
- Rahul Chaudhary
- Institut für Physiologie I, Westfälische Wilhelms-Universität, 48149 Münster, Germany
| | - Stefanie Albrecht
- Institute of Neuropathology, University Hospital Münster, 48149 Münster, Germany
| | - Maia Datunashvili
- Institut für Physiologie I, Westfälische Wilhelms-Universität, 48149 Münster, Germany
| | - Manuela Cerina
- Department of Neurology with Institute of Translational Neurology, Westfälische Wilhelms-Universität, 48149 Münster, Germany
| | - Annika Lüttjohann
- Institut für Physiologie I, Westfälische Wilhelms-Universität, 48149 Münster, Germany
| | - Ye Han
- Vanderbilt University Medical Center, Department of Neurology, Nashville, TN 37232, USA
| | - Venu Narayanan
- Department of Neurology with Institute of Translational Neurology, Westfälische Wilhelms-Universität, 48149 Münster, Germany
| | - Dane M Chetkovich
- Vanderbilt University Medical Center, Department of Neurology, Nashville, TN 37232, USA
| | - Tobias Ruck
- Department of Neurology, Medical Faculty, Heinrich Heine University Düsseldorf, 40225 Düsseldorf, Germany
| | - Tanja Kuhlmann
- Institute of Neuropathology, University Hospital Münster, 48149 Münster, Germany
| | - Hans-Christian Pape
- Institut für Physiologie I, Westfälische Wilhelms-Universität, 48149 Münster, Germany
| | - Sven G Meuth
- Department of Neurology with Institute of Translational Neurology, Westfälische Wilhelms-Universität, 48149 Münster, Germany
- Department of Neurology, Medical Faculty, Heinrich Heine University Düsseldorf, 40225 Düsseldorf, Germany
| | - Mehrnoush Zobeiri
- Address correspondence to Dr Thomas Budde, Wilhelms-Universität, Institut für Physiologie I, Robert-Koch-Str. 27a, D-48149 Münster, Germany. ; Dr Mehrnoush Zobeiri, Wilhelms-Universität, Institut für Physiologie I, Robert-Koch-Str. 27a, D-48149 Münster, Germany.
| | - Thomas Budde
- Address correspondence to Dr Thomas Budde, Wilhelms-Universität, Institut für Physiologie I, Robert-Koch-Str. 27a, D-48149 Münster, Germany. ; Dr Mehrnoush Zobeiri, Wilhelms-Universität, Institut für Physiologie I, Robert-Koch-Str. 27a, D-48149 Münster, Germany.
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21
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Boyko A, Pliskunova Y, Taraskin O, Paleeva A, Efimenko I, Khoroshevsky V. What worries people with multiple sclerosis in Russia? Semantic analysis of patient messages using artificial intelligence tools. Zh Nevrol Psikhiatr Im S S Korsakova 2022; 122:78-83. [DOI: 10.17116/jnevro202212207278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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22
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Rayatpour A, Farhangi S, Verdaguer E, Olloquequi J, Ureña J, Auladell C, Javan M. The Cross Talk between Underlying Mechanisms of Multiple Sclerosis and Epilepsy May Provide New Insights for More Efficient Therapies. Pharmaceuticals (Basel) 2021; 14:ph14101031. [PMID: 34681255 PMCID: PMC8541630 DOI: 10.3390/ph14101031] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 09/30/2021] [Accepted: 10/02/2021] [Indexed: 12/17/2022] Open
Abstract
Despite the significant differences in pathological background of neurodegenerative diseases, epileptic seizures are a comorbidity in many disorders such as Huntington disease (HD), Alzheimer's disease (AD), and multiple sclerosis (MS). Regarding the last one, specifically, it has been shown that the risk of developing epilepsy is three to six times higher in patients with MS compared to the general population. In this context, understanding the pathological processes underlying this connection will allow for the targeting of the common and shared pathological pathways involved in both conditions, which may provide a new avenue in the management of neurological disorders. This review provides an outlook of what is known so far about the bidirectional association between epilepsy and MS.
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Affiliation(s)
- Atefeh Rayatpour
- Department of Physiology, Faculty of Medical Sciences, Tarbiat Modares University, Tehran 14117-13116, Iran; (A.R.); (S.F.)
- Institute for Brain and Cognition, Tarbiat Modares University, Tehran 14117-13116, Iran
| | - Sahar Farhangi
- Department of Physiology, Faculty of Medical Sciences, Tarbiat Modares University, Tehran 14117-13116, Iran; (A.R.); (S.F.)
- Institute for Brain and Cognition, Tarbiat Modares University, Tehran 14117-13116, Iran
| | - Ester Verdaguer
- Department of Cell Biology, Physiology and Immunology, Biology Faculty, Universitat de Barcelona, 08028 Barcelona, Spain; (E.V.); (J.U.)
- Centre for Biomedical Research of Neurodegenerative Diseases (CIBERNED), Instituto de Salud Carlos III, 28029 Madrid, Spain
- Institute of Neuroscience, Universitat de Barcelona, 08035 Barcelona, Spain
| | - Jordi Olloquequi
- Laboratory of Cellular and Molecular Pathology, Biomedical Sciences Institute, Health Sciences Faculty, Universidad Autónoma de Chile, Talca 3460000, Chile;
| | - Jesus Ureña
- Department of Cell Biology, Physiology and Immunology, Biology Faculty, Universitat de Barcelona, 08028 Barcelona, Spain; (E.V.); (J.U.)
- Centre for Biomedical Research of Neurodegenerative Diseases (CIBERNED), Instituto de Salud Carlos III, 28029 Madrid, Spain
- Institute of Neuroscience, Universitat de Barcelona, 08035 Barcelona, Spain
| | - Carme Auladell
- Department of Cell Biology, Physiology and Immunology, Biology Faculty, Universitat de Barcelona, 08028 Barcelona, Spain; (E.V.); (J.U.)
- Centre for Biomedical Research of Neurodegenerative Diseases (CIBERNED), Instituto de Salud Carlos III, 28029 Madrid, Spain
- Institute of Neuroscience, Universitat de Barcelona, 08035 Barcelona, Spain
- Correspondence: (C.A.); (M.J.)
| | - Mohammad Javan
- Department of Physiology, Faculty of Medical Sciences, Tarbiat Modares University, Tehran 14117-13116, Iran; (A.R.); (S.F.)
- Institute for Brain and Cognition, Tarbiat Modares University, Tehran 14117-13116, Iran
- Cell Science Research Center, Department of Brain and Cognitive Sciences, Royan Institute for Stem Cell Biology and Technology, ACECR, Tehran 14117-13116, Iran
- Correspondence: (C.A.); (M.J.)
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23
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Grothe M, Ellenberger D, von Podewils F, Stahmann A, Rommer PS, Zettl UK. Epilepsy as a predictor of disease progression in multiple sclerosis. Mult Scler 2021; 28:942-949. [PMID: 34595974 DOI: 10.1177/13524585211046739] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Epilepsy development during the course of multiple sclerosis (MS) is considered to be the result of cortical pathology. However, no long-term data exist on whether epilepsy in MS also leads to increasing disability over time. OBJECTIVE To examine if epilepsy leads to more rapid disease progression. METHODS We analyzed the data of 31,052 patients on the German Multiple Sclerosis Register in a case-control study. RESULTS Secondary progressive disease course (odds ratio (OR) = 2.23), age (OR = 1.12 per 10 years), and disability (OR = 1.29 per Expanded Disability Status Scale (EDSS) point) were associated with the 5-year prevalence of epilepsy. Patients who developed epilepsy during the course of the disease had a higher EDSS score at disease onset compared to matched control patients (EDSS 2.0 vs 1.5), progressed faster in each dimension, and consequently showed higher disability (EDSS 4.4 vs 3.4) and lower employment status (40% vs 65%) at final follow-up. After 15 years of MS, 64% of patients without compared to 54% of patients with epilepsy were not severely limited in walking distance. CONCLUSION This work highlights the association of epilepsy on disability progression in MS, and the need for additional data to further clarify the underlying mechanisms.
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Affiliation(s)
- Matthias Grothe
- Department of Neurology, University Medicine Greifswald, Ferdinand-Sauerbruchstraße, 17475 Greifswald, Germany.,Department of Neurology, University Medicine Greifswald, Greifswald, Germany
| | - David Ellenberger
- German MS Register by the German MS Society, MS Research and Project Development gGmbH [MSFP], Hanover, Germany
| | - Felix von Podewils
- Department of Neurology, University Medicine Greifswald, Greifswald, Germany
| | - Alexander Stahmann
- German MS Register by the German MS Society, MS Research and Project Development gGmbH [MSFP], Hanover, Germany
| | - Paulus S Rommer
- Department of Neurology, Neuroimmunological Section, University of Rostock, Rostock, Germany/Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Uwe K Zettl
- Department of Neurology, Neuroimmunological Section, University of Rostock, Rostock, Germany
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24
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Zelano J. Recurrence risk after a first remote symptomatic seizure in adults: Epilepsy or not? Epilepsia Open 2021; 6:634-644. [PMID: 34561959 PMCID: PMC8633470 DOI: 10.1002/epi4.12543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 09/16/2021] [Accepted: 09/21/2021] [Indexed: 11/08/2022] Open
Abstract
The ILAE practical definition of epilepsy has a one seizure possibility to diagnose epilepsy after a first seizure if the recurrence risk is very high. The recurrence risk after a first seizure in brain disorders (first remote seizure) is often high, but varies with etiology, so more specific information is needed for clinical practice. This review describes etiology-specific recurrence risks in adults with a first remote seizure in stroke, traumatic brain injury, infections, dementia, multiple sclerosis, and tumors. Most studies are short, single center, and retrospective. Inclusion criteria, outcome ascertainment, and results vary. Few patient categories are clearly above the epilepsy threshold of recurrence risk, and there are surprisingly little data for important etiologies like brain infections. Beside stroke, severe TBI could have a sufficiently high recurrence risk for early epilepsy diagnosis, but more studies are needed, preferably prospective ones. The literature is uninformative regarding which seizures qualify as remote. The clinical implication of the low level of available evidence is that for other etiologies than stroke, seizure recurrence remains the most appropriate indicator of epilepsy for most patients with a first remote seizure. Nonetheless, there are worrying indications of a diagnostic drift, which puts patients with a preexisting brain disorder at risk of misdiagnosis. Although there are drawbacks to an intermediate term like "possible epilepsy," it could perhaps be useful in cases when the recurrence risk is high, but epilepsy criteria are not definitely met after a first remote seizure.
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Affiliation(s)
- Johan Zelano
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden.,Wallenberg Center of Molecular and Translational Medicine, Gothenburg University, Gothenburg, Sweden
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25
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Salim AA, Ali SH, Hussain AM, Ibrahim WN. Electroencephalographic evidence of gray matter lesions among multiple sclerosis patients: A case-control study. Medicine (Baltimore) 2021; 100:e27001. [PMID: 34414988 PMCID: PMC8376360 DOI: 10.1097/md.0000000000027001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 07/30/2021] [Indexed: 01/04/2023] Open
Abstract
This study aimed to investigate evidence of gray matter brain lesions in multiple sclerosis (MS) patients by evaluating the resting state alpha rhythm of brain electrical activity.The study included 50 patients diagnosed with MS recruited from the MS clinic with 50 age and gender-matched control participants. The study investigated parameters of posterior dominant rhythm (PDR) in the electroencephalography (EEG) recordings including wave frequency and amplitude. Functional disability among the patients was evaluated according to the expanded disability status scale. Univariate statistical analysis was completed using one-way analysis of variance and t test with a P value of less than .05 to indicate statistical significance.Patients with MS had significantly lower PDR frequency and amplitude values compared to the controls (P value < .01) and 34% of the MS patients had a PDR frequency of less than 8.5 Hz. The PDR frequency was negatively associated with the level of functional disability among the patients (P value <.001) and 4% of the patients had abnormal epileptiform discharges.Background slowing of resting alpha rhythms and epileptiform discharges are suggestive of gray matter degeneration and may help in the prediction and follow-up of cortical damage and functional disabilities among MS patients. Therefore, electroencephalography monitoring of the PDR spectrum may serve as an alternative or complementary tool with other imaging techniques to detect and monitor cerebral cortical lesions.
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Affiliation(s)
| | - Safaa Hussain Ali
- Department of Physiology, College of Medicine, University of Al-Mustansiriyah, Baghdad, Iraq
| | | | - Wisam Nabeel Ibrahim
- Department of Biomedical Sciences, College of Health Sciences, QU Health, Qatar University, Doha, Qatar
- Biomedical and Pharmaceutical Research Unit, QU Health, Qatar University, Doha, Qatar
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26
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Håkansson S, Karlander M, Larsson D, Mahamud Z, Garcia-Ptacek S, Zelezniak A, Zelano J. Potential for improved retention rate by personalized antiseizure medication selection: A register-based analysis. Epilepsia 2021; 62:2123-2132. [PMID: 34245010 DOI: 10.1111/epi.16987] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 06/16/2021] [Accepted: 06/16/2021] [Indexed: 01/16/2023]
Abstract
OBJECTIVE The first antiseizure medication (ASM) is ineffective or intolerable in 50% of epilepsy cases. Selection between more than 25 available ASMs is guided by epilepsy factors, but also age and comorbidities. Randomized evidence for particular patient subgroups is seldom available. We asked whether register data could be used for retention rate calculations based on demographics, comorbidities, and ASM history, and quantified the potential improvement in retention rates of the first ASM in several large epilepsy cohorts. We also describe retention rates in patients with epilepsy after traumatic brain injury and dementia, patient groups with little available evidence. METHODS We used medical, demographic, and drug prescription data from epilepsy cohorts from comprehensive Swedish registers, containing 6380 observations. By analyzing 381 840 prescriptions, we studied retention rates of first- and second-line ASMs for patients with epilepsy in multiple sclerosis (MS), brain infection, dementia, traumatic brain injury, or stroke. The rank of retention rates of ASMs was validated by comparison to published randomized control trials. We identified the optimal stratification for each brain disease, and quantified the potential improvement if all patients had received the optimal ASM. RESULTS Using optimal stratification for each brain disease, the potential improvement in retention rate (percentage points) was MS, 20%; brain infection, 21%; dementia, 14%; trauma, 21%; and stroke, 14%. In epilepsy after trauma, levetiracetam had the highest retention rate at 80% (95% confidence interval [CI] = 65-89), exceeding that of the most commonly prescribed ASM, carbamazepine (p = .04). In epilepsy after dementia, lamotrigine (77%, 95% CI = 68-84) and levetiracetam (74%, 95% CI = 68-79) had higher retention rates than carbamazepine (p = .006 and p = .01, respectively). SIGNIFICANCE We conclude that personalized ASM selection could improve retention rates and that national registers have potential as big data sources for personalized medicine in epilepsy.
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Affiliation(s)
- Samuel Håkansson
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden.,Institute of Neuroscience and Physiology, Department of Clinical Neuroscience, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden.,Wallenberg Center of Molecular and Translational Medicine, Gothenburg University, Gothenburg, Sweden
| | - Markus Karlander
- Institute of Neuroscience and Physiology, Department of Clinical Neuroscience, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden.,Department of Neurology, Södra Älvsborg Hospital, Borås, Sweden.,Department of Research, Education and Innovation, Region Västra Götaland, Södra Älvsborg Hospital, Borås, Sweden
| | - David Larsson
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden.,Institute of Neuroscience and Physiology, Department of Clinical Neuroscience, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden.,Wallenberg Center of Molecular and Translational Medicine, Gothenburg University, Gothenburg, Sweden
| | - Zamzam Mahamud
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden.,Institute of Neuroscience and Physiology, Department of Clinical Neuroscience, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden.,Wallenberg Center of Molecular and Translational Medicine, Gothenburg University, Gothenburg, Sweden
| | - Sara Garcia-Ptacek
- Division of Clinical Geriatrics, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden.,Inflammation and Aging Theme, Cognitive clinic, Karolinska University Hospital, Stockholm, Sweden
| | - Aleksej Zelezniak
- Department of Biology and Biological Engineering, Division of Systems and Synthetic Biology, Chalmers University of Technology, Gothenburg, Sweden.,Science for Life Laboratory, Stockholm, Sweden
| | - Johan Zelano
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden.,Institute of Neuroscience and Physiology, Department of Clinical Neuroscience, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden.,Wallenberg Center of Molecular and Translational Medicine, Gothenburg University, Gothenburg, Sweden
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27
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Mirmosayyeb O, Shaygannejad V, Nehzat N, Mohammadi A, Ghajarzadeh M. Prevalence of Seizure/Epilepsy in Patients with Multiple Sclerosis: A Systematic Review and Meta-Analysis. Int J Prev Med 2021; 12:14. [PMID: 34084311 PMCID: PMC8106278 DOI: 10.4103/ijpvm.ijpvm_75_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Accepted: 04/22/2020] [Indexed: 11/04/2022] Open
Abstract
Background Seizure and epilepsy are among the initial symptoms of multiple sclerosis (MS), yet different prevalence rates are reported for them in the previous studies. The goal of this systematic review is to estimate the pooled prevalence of seizure and epilepsy in patients with MS. Methods We searched PubMed, Scopus, EMBASE, Web of Science, google scholar, and gray literature including references from identified studies and conference abstracts published up to October 2019. The search strategy included the MeSH terms and text words as ((Epilepsies OR Seizure Disorder OR Seizure Disorders OR Awakening Epilepsy OR Epilepsy, Awakening OR Epilepsy, Cryptogenic OR Cryptogenic Epilepsies OR Cryptogenic Epilepsy OR Epilepsies, Cryptogenic OR epilepsy OR seizure) AND (Multiple Sclerosis OR Sclerosis, Multiple) OR Sclerosis, Disseminated) OR Disseminated Sclerosis) OR MS (Multiple Sclerosis)) OR Multiple Sclerosis, Acute Fulminating). Results The literature review resulted in 4860 articles; 2593 articles remained after eliminating the duplicates. For the final analysis, 39 articles were included, 9 of which were conference abstracts. The pooled prevalence of seizure in MS cases was 2%, 95% confidence interval (CI)(1%-3%) (I2 = 91.8%, P < 0.001). The pooled prevalence of epilepsy in MS cases was 3%, 95% CI (2%-4%) (I2 = 92.9%, P < 0.001). The pooled prevalence of epilepsy in Asia, Europe, and America was 6%, 3%, and 3%, respectively. The level of heterogeneity decreased after subgroup analysis in Asian and American subgroups. Meta-regression analysis showed continent is not a source of heterogeneity (coefficient = -0.007, P = 0.6). Conclusions The result of this systematic review shows that the pooled prevalence of seizure and epilepsy among MS patients is 2% and 3%, respectively.
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Affiliation(s)
- Omid Mirmosayyeb
- Isfahan Neurosciences Research Center, Isfahan University of medical sciences, Isfahan, Iran.,Universal Council of Epidemiology (UCE), Universal Scientific Education and Research Network (USERN), Tehran University of Medical Sciences, Tehran, Iran
| | - Vahid Shaygannejad
- Isfahan Neurosciences Research Center, Isfahan University of medical sciences, Isfahan, Iran.,Department of Neurology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Nasim Nehzat
- Isfahan Neurosciences Research Center, Isfahan University of medical sciences, Isfahan, Iran.,Universal Council of Epidemiology (UCE), Universal Scientific Education and Research Network (USERN), Tehran University of Medical Sciences, Tehran, Iran
| | - Aida Mohammadi
- Universal Council of Epidemiology (UCE), Universal Scientific Education and Research Network (USERN), Tehran University of Medical Sciences, Tehran, Iran
| | - Mahsa Ghajarzadeh
- Universal Council of Epidemiology (UCE), Universal Scientific Education and Research Network (USERN), Tehran University of Medical Sciences, Tehran, Iran.,Multiple Sclerosis Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
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28
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Librizzi L, Vila Verde D, Colciaghi F, Deleo F, Regondi MC, Costanza M, Cipelletti B, de Curtis M. Peripheral blood mononuclear cell activation sustains seizure activity. Epilepsia 2021; 62:1715-1728. [PMID: 34061984 DOI: 10.1111/epi.16935] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 05/07/2021] [Accepted: 05/07/2021] [Indexed: 12/25/2022]
Abstract
OBJECTIVE The influx of immune cells and serum proteins from the periphery into the brain due to a dysfunctional blood-brain barrier (BBB) has been proposed to contribute to the pathogenesis of seizures in various forms of epilepsy and encephalitis. We evaluated the pathophysiological impact of activated peripheral blood mononuclear cells (PBMCs) and serum albumin on neuronal excitability in an in vitro brain preparation. METHODS A condition of mild endothelial activation induced by arterial perfusion of lipopolysaccharide (LPS) was induced in the whole brain preparation of guinea pigs maintained in vitro by arterial perfusion. We analyzed the effects of co-perfusion of human recombinant serum albumin with human PBMCs activated with concanavalin A on neuronal excitability, BBB permeability (measured by FITC-albumin extravasation), and microglial activation. RESULTS Bioplex analysis in supernatants of concanavalin A-stimulated PBMCs revealed increased levels of several inflammatory mediators, in particular interleukin (IL)-1β, tumor necrosis factor (TNF)-α, interferon (INF)-γ, IL-6, IL-10, IL-17A, and MIP3α. LPS and human albumin arterially co-perfused with either concanavalin A-activated PBMCs or the cytokine-enriched supernatant of activated PBMCs (1) modulated calcium-calmodulin-dependent protein kinase II at excitatory synapses, (2) enhanced BBB permeability, (3) induced microglial activation, and (4) promoted seizure-like events. Separate perfusions of either nonactivated PBMCs or concanavalin A-activated PBMCs without LPS/human albumin (hALB) failed to induce inflammatory and excitability changes. SIGNIFICANCE Activated peripheral immune cells, such as PBMCs, and the extravasation of serum proteins in a condition of BBB impairment contribute to seizure generation.
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Affiliation(s)
- Laura Librizzi
- Epilepsy Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Diogo Vila Verde
- Epilepsy Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Francesca Colciaghi
- Epilepsy Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Francesco Deleo
- Epilepsy Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | | | - Massimo Costanza
- Molecular Neuro-Oncology Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Barbara Cipelletti
- Epilepsy Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Marco de Curtis
- Epilepsy Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
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Jacob L, Koyanagi A, Haro JM, Konrad M, Uepping P, Kostev K. Association between inflammatory central nervous system diseases and epilepsy: A retrospective cohort study of 4252 patients in Germany. Epilepsy Behav 2021; 117:107879. [PMID: 33711682 DOI: 10.1016/j.yebeh.2021.107879] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 02/18/2021] [Accepted: 02/18/2021] [Indexed: 12/17/2022]
Abstract
GOAL The goal of this study was to analyze the association between inflammatory central nervous system (CNS) diseases and the incidence of epilepsy in patients followed up for up to 10 years in Germany. METHODS This retrospective cohort study included adults aged ≥ 18 years who had an initial diagnosis of inflammatory CNS disease (i.e. encephalitis, meningitis or brain abscess) in one of 1229 general practices in Germany between 2005 and 2015 (index date). Patients without inflammatory CNS disease were matched (1:1) to those with inflammatory CNS disease by sex, age, follow-up time after index date, Charlson Comorbidity Index, and practice. The index date for patients without inflammatory CNS disease was a randomly selected visit date between 2005 and 2015. Kaplan-Meier curves and Cox regression analyses were used to assess the association between inflammatory CNS diseases and the incidence of epilepsy. RESULTS This study included 2126 individuals with and 2126 patients without inflammatory CNS disease (56.4% women; mean [SD] age 50.0 [12.3] years). Within ten years of the index date, 4.2% of patients with and 1.5% of patients without inflammatory CNS disease had been diagnosed with epilepsy (p < 0.001). This finding was corroborated in the Cox regression analysis, and there was a positive and significant association between inflammatory CNS diseases and epilepsy (HR: 3.82, 95% CI: 2.24-6.52). CONCLUSIONS Based on these results, preventive interventions are urgently warranted to reduce the incidence of epilepsy in individuals with a history of inflammatory CNS disease.
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Affiliation(s)
- Louis Jacob
- Research and Development Unit, Parc Sanitari Sant Joan de Déu, CIBERSAM, Dr. Antoni Pujadas, 42, Sant Boi de Llobregat, Barcelona 08830, Spain; Faculty of Medicine, University of Versailles Saint-Quentin-en-Yvelines, Montigny-le-Bretonneux 78180, France
| | - Ai Koyanagi
- Research and Development Unit, Parc Sanitari Sant Joan de Déu, CIBERSAM, Dr. Antoni Pujadas, 42, Sant Boi de Llobregat, Barcelona 08830, Spain; Institució Catalana de Recerca i Estudis Avançats (ICREA), Pg. Lluis Companys 23, 08010 Barcelona, Spain
| | - Josep Maria Haro
- Research and Development Unit, Parc Sanitari Sant Joan de Déu, CIBERSAM, Dr. Antoni Pujadas, 42, Sant Boi de Llobregat, Barcelona 08830, Spain
| | - Marcel Konrad
- Health & Social, FOM University of Applied Sciences for Economics and Management, Frankfurt am Main, Germany
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Ooi S, Kalincik T, Perucca P, Monif M. The prevalence of epileptic seizures in multiple sclerosis in a large tertiary hospital in Australia. Mult Scler J Exp Transl Clin 2021; 7:2055217321989767. [PMID: 33708413 PMCID: PMC7907940 DOI: 10.1177/2055217321989767] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Revised: 11/08/2020] [Accepted: 01/05/2021] [Indexed: 11/15/2022] Open
Abstract
Rationale To determine the prevalence of epileptic seizures in multiple sclerosis (MS) at an Australian tertiary hospital and to define their clinical features. Methods We retrospectively analysed adult patients at the Royal Melbourne Hospital electronically identified to have ICD codes for MS and seizures and/or epilepsy between 1996 to 2019, utilising paper and electronic-based records. Results Of the 2,125 MS patients identified, 16 (0.75%) experienced epileptic seizures during a mean follow-up period of 12.9 years. Median age of MS diagnosis (SD) was 38 (9.3) years. Four patients had relapsing remitting MS (25%), 10 secondary progressive MS (63.5%), and 2 primary progressive MS (12.5%). More than two-thirds of patients had seizure onset following the diagnosis of MS, and the majority of these had advanced disease (approximate EDSS >6) at the time of seizure onset. Focal onset-seizures occurred in 87.5% of patients with seizures. Conclusion The estimated prevalence of seizures in our cohort was lower than in previous studies (0.75 vs 2-4%). In most cases, seizures occurred after the diagnosis of MS in the context of advanced disease. Further studies are required to determine if MS disease modifying treatments reduce the risk of seizures in this cohort.
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Affiliation(s)
- Suyi Ooi
- Department of Neurology, Royal Melbourne Hospital, Parkville, Australia.,Department of Neurology, Monash Medical Centre, Clayton, Australia
| | - Tomas Kalincik
- Department of Neurology, Royal Melbourne Hospital, Parkville, Australia.,CORe, Department of Medicine, The University of Melbourne, Parkville, Australia
| | - Piero Perucca
- Department of Neurology, Royal Melbourne Hospital, Parkville, Australia.,Department of Neuroscience, Monash University, Melbourne, Australia.,Department of Neurology, Alfred Health, Melbourne, Australia
| | - Mastura Monif
- Department of Neurology, Royal Melbourne Hospital, Parkville, Australia.,Department of Neuroscience, Monash University, Melbourne, Australia.,Department of Neurology, Alfred Health, Melbourne, Australia.,Department of Physiology, The University of Melbourne, Australia
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Ouédraogo O, Rébillard RM, Jamann H, Mamane VH, Clénet ML, Daigneault A, Lahav B, Uphaus T, Steffen F, Bittner S, Zipp F, Bérubé A, Lapalme-Remis S, Cossette P, Nguyen DK, Arbour N, Keezer MR, Larochelle C. Increased frequency of proinflammatory CD4 T cells and pathological levels of serum neurofilament light chain in adult drug-resistant epilepsy. Epilepsia 2021; 62:176-189. [PMID: 33140401 DOI: 10.1111/epi.16742] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 10/02/2020] [Accepted: 10/07/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Adult drug-resistant epilepsy (DRE) is associated with significant morbidity. Infiltration of immune cells is observed in DRE epileptic foci; however, the relation between DRE and the peripheral immune cell compartment remains only partially understood. We aimed to investigate differences in immune cell populations, cytokines, and neurodegenerative biomarkers in the peripheral blood of subjects with epilepsy versus healthy controls, and in DRE compared to well-controlled epilepsy (WCE). METHODS Peripheral blood mononuclear cells and serum from >120 age- and sex-matched adults suffering from focal onset epilepsy and controls were analyzed by multipanel flow cytometry, multiplex immunoassays, and ultrasensitive single molecule array. RESULTS Using a data-driven analytical approach, we identified that CD4 T cells in the peripheral blood are present in a higher proportion in DRE patients. Moreover, we observed that the frequency of CD4 T cells expressing proinflammatory cytokines interleukin (IL)-17A, IL-22, tumor necrosis factor, interferon-γ, and granulocyte-macrophage colony-stimulating factor, but not anti-inflammatory cytokines IL-10 and IL-4, is elevated in the peripheral blood of DRE subjects compared to WCE. In parallel, we found that Th17-related circulating proinflammatory cytokines are elevated, but Th2-related cytokine IL-4 is reduced, in the serum of epilepsy and DRE subjects. As Th17 cells can exert neurotoxicity, we measured levels of serum neurofilament light chain (sNfL), a marker of neuronal injury. We found significantly elevated levels of sNfL in DRE compared to controls, especially among older individuals. SIGNIFICANCE Our data support that DRE is associated with an expansion of the CD4 Tcell subset in the peripheral blood and with a shift toward a proinflammatory Th17/Th1 CD4 Tcell immune profile. Our results further show that pathological levels of sNfL are more frequent in DRE, supporting a potential neurodegenerative component in adult DRE. With this work, we provide evidence for novel potential inflammatory and degenerative biomarkers in DRE.
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Affiliation(s)
- Oumarou Ouédraogo
- Research Center of the University of Montreal Hospital Center, Montreal, QC, Canada
- Department of Microbiology, Immunology, and Infectiology, University of Montreal, Montreal, QC, Canada
| | - Rose-Marie Rébillard
- Research Center of the University of Montreal Hospital Center, Montreal, QC, Canada
- Department of Neurosciences, University of Montreal, Montreal, QC, Canada
| | - Hélène Jamann
- Research Center of the University of Montreal Hospital Center, Montreal, QC, Canada
- Department of Neurosciences, University of Montreal, Montreal, QC, Canada
| | - Victoria Hannah Mamane
- Research Center of the University of Montreal Hospital Center, Montreal, QC, Canada
- Department of Neurosciences, University of Montreal, Montreal, QC, Canada
| | - Marie-Laure Clénet
- Research Center of the University of Montreal Hospital Center, Montreal, QC, Canada
- Department of Microbiology, Immunology, and Infectiology, University of Montreal, Montreal, QC, Canada
| | - Audrey Daigneault
- Research Center of the University of Montreal Hospital Center, Montreal, QC, Canada
| | - Boaz Lahav
- University of Montreal Hospital Center, Montreal, QC, Canada
| | - Timo Uphaus
- Department of Neurology, Focus Program Translational Neuroscience (FTN) and Immunotherapy (FZI), Rhine Main Neuroscience Network, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Falk Steffen
- Department of Neurology, Focus Program Translational Neuroscience (FTN) and Immunotherapy (FZI), Rhine Main Neuroscience Network, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Stefan Bittner
- Department of Neurology, Focus Program Translational Neuroscience (FTN) and Immunotherapy (FZI), Rhine Main Neuroscience Network, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Frauke Zipp
- Department of Neurology, Focus Program Translational Neuroscience (FTN) and Immunotherapy (FZI), Rhine Main Neuroscience Network, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Arline Bérubé
- Department of Neurosciences, University of Montreal, Montreal, QC, Canada
- University of Montreal Hospital Center, Montreal, QC, Canada
| | - Samuel Lapalme-Remis
- Department of Neurosciences, University of Montreal, Montreal, QC, Canada
- University of Montreal Hospital Center, Montreal, QC, Canada
| | - Patrick Cossette
- Research Center of the University of Montreal Hospital Center, Montreal, QC, Canada
- Department of Neurosciences, University of Montreal, Montreal, QC, Canada
- University of Montreal Hospital Center, Montreal, QC, Canada
| | - Dang Khoa Nguyen
- Research Center of the University of Montreal Hospital Center, Montreal, QC, Canada
- Department of Neurosciences, University of Montreal, Montreal, QC, Canada
- University of Montreal Hospital Center, Montreal, QC, Canada
| | - Nathalie Arbour
- Research Center of the University of Montreal Hospital Center, Montreal, QC, Canada
- Department of Neurosciences, University of Montreal, Montreal, QC, Canada
| | - Mark R Keezer
- Research Center of the University of Montreal Hospital Center, Montreal, QC, Canada
- Department of Neurosciences, University of Montreal, Montreal, QC, Canada
- University of Montreal Hospital Center, Montreal, QC, Canada
- Department of Social and Preventive Medicine, School of Public Health, University of Montreal, Montreal, QC, Canada
| | - Catherine Larochelle
- Research Center of the University of Montreal Hospital Center, Montreal, QC, Canada
- Department of Neurosciences, University of Montreal, Montreal, QC, Canada
- University of Montreal Hospital Center, Montreal, QC, Canada
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Neuß F, von Podewils F, Wang ZI, Süße M, Zettl UK, Grothe M. Epileptic seizures in multiple sclerosis: prevalence, competing causes and diagnostic accuracy. J Neurol 2020; 268:1721-1727. [PMID: 33324995 PMCID: PMC8068680 DOI: 10.1007/s00415-020-10346-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 11/22/2020] [Accepted: 12/04/2020] [Indexed: 11/29/2022]
Abstract
Background Multiple sclerosis (MS) is accompanied by an increased risk of epileptic seizures, but data with a detailed description of the competing causes are lacking. Methods We aimed to describe a cohort of patients with both MS and epileptic seizures in a retrospective, population-based study. Results We included 59 out of 2285 MS patients who had at least one epileptic seizure. Out of them, 22 had seizures before the diagnosis of MS, whereas epileptic seizures occurred after MS diagnosis in 37 patients, resulting in a total prevalence of epileptic seizures in MS of 2.6%. Competing causes could be found in 50.8% (30/59) of all patients, with 40.9% (9/22) compared to 56.8% (21/37) of the MS patients with seizures before vs after MS diagnosis. The main alternative causes were traumatic brain injury and cerebral ischemia accounting for more than 30% of the patients, with no difference between the subgroups. 33.3% and 55.6% of MS patients with seizures before/after MS diagnosis had documented pathological EEG alterations.
Conclusion A remarkable percentage of MS patients with epileptic seizures do have alternative competing causes at the time of the first seizure. A detailed diagnostic setup including patient history, EEG and MRI is recommended in the evaluation and choice for the best treatment.
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Affiliation(s)
- Friederike Neuß
- Department of Neurology, University Medicine Greifswald, Ferdinand-Sauerbruchstraße, 17475, Greifswald, Germany
| | - Felix von Podewils
- Department of Neurology, University Medicine Greifswald, Ferdinand-Sauerbruchstraße, 17475, Greifswald, Germany
| | - Zhong Irene Wang
- Epilepsy Center, Neurological Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Marie Süße
- Department of Neurology, University Medicine Greifswald, Ferdinand-Sauerbruchstraße, 17475, Greifswald, Germany
| | - Uwe Klaus Zettl
- Department of Neurology, Neuroimmunological Section, University of Rostock, Rostock, Germany
| | - Matthias Grothe
- Department of Neurology, University Medicine Greifswald, Ferdinand-Sauerbruchstraße, 17475, Greifswald, Germany.
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Lapato AS, Thompson SM, Parra K, Tiwari-Woodruff SK. Astrocyte Glutamate Uptake and Water Homeostasis Are Dysregulated in the Hippocampus of Multiple Sclerosis Patients With Seizures. ASN Neuro 2020; 12:1759091420979604. [PMID: 33297722 PMCID: PMC7734542 DOI: 10.1177/1759091420979604] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
While seizure disorders are more prevalent among multiple sclerosis (MS) patients than the population overall and prognosticate earlier death & disability, their etiology remains unclear. Translational data indicate perturbed expression of astrocytic molecules contributing to homeostatic neuronal excitability, including water channels (AQP4) and synaptic glutamate transporters (EAAT2), in a mouse model of MS with seizures (MS+S). However, astrocytes in MS+S have not been examined. To assess the translational relevance of astrocyte dysfunction observed in a mouse model of MS+S, demyelinated lesion burden, astrogliosis, and astrocytic biomarkers (AQP4/EAAT2/ connexin-CX43) were evaluated by immunohistochemistry in postmortem hippocampi from MS & MS+S donors. Lesion burden was comparable in MS & MS+S cohorts, but astrogliosis was elevated in MS+S CA1 with a concomitant decrease in EAAT2 signal intensity. AQP4 signal declined in MS+S CA1 & CA3 with a loss of perivascular AQP4 in CA1. CX43 expression was increased in CA3. Together, these data suggest that hippocampal astrocytes from MS+S patients display regional differences in expression of molecules associated with glutamate buffering and water homeostasis that could exacerbate neuronal hyperexcitability. Importantly, mislocalization of CA1 perivascular AQP4 seen in MS+S is analogous to epileptic hippocampi without a history of MS, suggesting convergent pathophysiology. Furthermore, as neuropathology was concentrated in MS+S CA1, future study is warranted to determine the pathophysiology driving regional differences in glial function in the context of seizures during demyelinating disease.
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Affiliation(s)
- Andrew S Lapato
- Division of Biomedical Sciences, UCR School of Medicine, Riverside, California, United States.,Center for Glial-Neuronal Interaction, UCR School of Medicine, Riverside, California, United States
| | - Sarah M Thompson
- Division of Biomedical Sciences, UCR School of Medicine, Riverside, California, United States
| | - Karen Parra
- Division of Biomedical Sciences, UCR School of Medicine, Riverside, California, United States
| | - Seema K Tiwari-Woodruff
- Division of Biomedical Sciences, UCR School of Medicine, Riverside, California, United States.,Center for Glial-Neuronal Interaction, UCR School of Medicine, Riverside, California, United States.,Department of Neuroscience, UCR School of Medicine, Riverside, California, United States
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Zelano J, Westman G. Epilepsy after brain infection in adults: A register-based population-wide study. Neurology 2020; 95:e3213-e3220. [PMID: 32989110 DOI: 10.1212/wnl.0000000000010954] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 08/03/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To describe risk and risk factors of epilepsy after hospitalization for brain infection in adults in Sweden. METHODS This was a matched retrospective cohort study based on the comprehensive National Patient and Cause of Death Registers. All individuals age >18 without prior epilepsy who received inpatient care in 2000-2010 for a brain infection were included, with 3 age- and sex-matched unexposed controls per exposed individual (n = 12,101 exposed and 36,228 controls). Kaplan-Meier risks of epilepsy after different brain infections were calculated and risk factors identified by Cox regression. Patients were followed until the end of 2017. RESULTS The 10-year risk of epilepsy was 5.9% (95% confidence interval [CI] 5.5-6.3) in cases and 1.2% (95% CI 1.0-1.4) in controls: 1.7% (95% CI 0.7-2.7) after tick-borne encephalitis, 4.1% (95% CI 3.3-4.9) after bacterial meningitis, 26.0% (95% CI 21.5-30.5) after herpes simplex virus encephalitis, and 30.2% (95% CI 27.1-33.3) after brain abscess. In Cox regression, seizure during the index admission and mechanical ventilation were epilepsy risk factors. CONCLUSIONS Epilepsy is common after several types of brain infections in adults. The type of infection, its severity, and propensity to cause seizures in the acute phase influence the risk of subsequent epilepsy. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that in adults, brain infection is associated with an increased risk of subsequent epilepsy.
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Affiliation(s)
- Johan Zelano
- From the Institute of Neuroscience and Physiology, Department of Clinical Neuroscience (J.Z.), and Department of Neurology (J.Z.), Sahlgrenska Academy, and Wallenberg Center of Molecular and Translational Medicine (J.Z.), Gothenburg University; and Department of Medical Sciences (G.W.), Section of Infectious Diseases, Uppsala University, Sweden.
| | - Gabriel Westman
- From the Institute of Neuroscience and Physiology, Department of Clinical Neuroscience (J.Z.), and Department of Neurology (J.Z.), Sahlgrenska Academy, and Wallenberg Center of Molecular and Translational Medicine (J.Z.), Gothenburg University; and Department of Medical Sciences (G.W.), Section of Infectious Diseases, Uppsala University, Sweden
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The "Treatise on the spleen and stomach" ( Pí Wèi Lùn) as the first record of multiple sclerosis in the medical literature - A hypothesis based on the analysis of clinical presentation and herbal medicine. J Tradit Complement Med 2020; 10:288-300. [PMID: 32670824 PMCID: PMC7340878 DOI: 10.1016/j.jtcme.2020.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 02/24/2020] [Accepted: 02/26/2020] [Indexed: 11/22/2022] Open
Abstract
Background The “Treatise on the spleen and stomach” (Pí Wèi Lùn) is the work of the scholar and physician Li Gao (Jin-Yuan dynasties, 1115–1368 C.E., China). Li Gao described a clinical presentation that today would fall under the diagnosis of Multiple Sclerosis (MS) and proposed the treatment with herbal medicine and nutritional guidelines. The PWL is well known for its application in the treatment of MS and autoimmune conditions. However, this theoretical “MS” has not yet been analyzed through a scientific investigation, and research on its herbal formulations for MS is scant. Methods We analyzed the PWL “MS” clinical presentation considering biomedical diagnostic criteria and neurological correlates. To support our review, we searched Pubmed for studies on the PWL main herbal formulas and their herbs/isolates used for the believed “MS” which treated experimental autoimmune encephalomyelitis (EAE)/MS. Results We found a very close correlation between the PWL “MS” and the current MS diagnosis. Twenty four studies on the herbs-isolates showed significant amelioration of EAE, neuronal damage, and demyelination. Discussion Collectively, Astragali radix, Ginseng radix, Glycyrrhizae radix, and berberine containing Phellodendri cortex reduced the severity of EAE through different signaling pathways and mechanisms of action. These herbs provided a wide range of properties such as anti-inflammatory, anti-oxidant, anti-microglial activation, anti-infiltration of leukocytes, apoptotic/anti-apoptotic balance, and neuronal protection. Conclusion Our review proposes that the PWL is the first record of MS in the medical literature. Its formulas and herbs-isolates offer a fertile area for MS research and an invaluable potential for its treatment. We propose that the Pí Wèi Lùn is the first record of MS in the medical literature. All twenty four studies on the PWL’s selected herbs/isolates showed improvement of EAE. Different signaling pathways/mechanisms of action provided synergistic properties. In the PWL, the gastrointestinal system is key for MS and science supports it. The PWL offers a fertile area of research and enormous potential for MS treatment.
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GÖZÜBATIK ÇELİK RG, KÖSEOĞLU M. Multipl Sklerozda Epileptik Nöbetler. KOCAELI ÜNIVERSITESI SAĞLIK BILIMLERI DERGISI 2020. [DOI: 10.30934/kusbed.735739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Epilepsy and autoimmune diseases: Comorbidity in a national patient cohort. Seizure 2019; 75:89-95. [PMID: 31918165 DOI: 10.1016/j.seizure.2019.12.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 12/05/2019] [Accepted: 12/17/2019] [Indexed: 12/20/2022] Open
Abstract
PURPOSE To examine if autoimmune disorders occur with an increased frequency in patients with epilepsy. An autoimmune etiology of epilepsies has been suggested. By using data from The Norwegian Prescription Database (NorPD) we have surveyed a national cohort of patients with active epilepsy treated with antiepileptic drugs. METHODS NorPD contains all prescriptions of drugs dispensed at pharmacies in Norway since 2004. We received data of all drugs prescribed January 2004 - June 2014 for patients receiving an antiepileptic drug.79 751 patients receiving at least two prescriptions of antiepileptic drugs with the reimbursement code for epilepsy were included. To examine autoimmune comorbidity, medications specific for autoimmune diseases were retrieved. Standardized Incidence Ratios (SIR) with 95 % confidence interval (CI) were used to determine whether the occurrence of the prescribed autoimmune drugs in the epilepsy group deviated from the general population. Subgroups stratified for sex and age were examined. RESULTS The epilepsy patients were more often treated with insulin and insulin analogs, SIR 1.8 (95 % CI 1.7-1.9); thyroid substitution, SIR 1.7 (95 % CI 1.7-1.8); pyridostigmine, SIR 1.5 (95 % CI 1.1-2.1); multiple sclerosis (MS) medications, SIR 4.9 (95 % CI 4.6-5.3); and immunosuppressive drugs SIR 1.2 (95 % CI 1.1-1.2). All epilepsy subgroups were more often than expected treated with thyroid substitution. CONCLUSIONS Based on a large, unselected patient cohort we find that epilepsy patients more often are prescribed medications used to treat type 1 diabetes mellitus, hypothyroidism, myasthenia gravis and MS. This was true for both men and women, and in most age-groups.
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Sriwastava S, Yarraguntla K, Zutshi D, Basha MM, Bernitsas E, Marawar R. Relevance of cerebrospinal fluid findings in patients with multiple sclerosis and seizures. J Neurol Sci 2019; 406:116482. [PMID: 31622901 DOI: 10.1016/j.jns.2019.116482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 08/29/2019] [Accepted: 09/15/2019] [Indexed: 10/26/2022]
Abstract
Seizures occur 2-3 times more frequently in Multiple Sclerosis (MS) patients compared to the general population. The prevalence of seizures is reported to be 1.5-7.8% in MS population. However, it is unclear if seizure is an indirect symptom of neuroinflammation in MS. In our study, we explored the relevance of cerebrospinal fluid (CSF) findings in this unique patient cohort with MS and seizures. We retrospectively reviewed the charts of 32 MS patients with subsequent seizures (MSSS) and 12 patients with seizures followed by MS (SFMS). These two study groups were compared with two control groups - MS without seizures (MSNOS) and seizures without MS (SNOMS). Clinical characteristics and CSF findings between these groups were compared using boot strapped independent t-test. The CSF lymphocyte percentage of the SFMS group (95.6 ± 3) was significantly higher compared to MSNOS (66.0 ± 36.9, p = .04) and SNOMS (81.7 ± 10.0, p = .03). The CSF IgG index was significantly higher in SFMS group (1.9 ± 1.2, p = .02) as compared to MSSS group (0.99 ± 0.4). Patients with seizures as initial symptom of MS may have higher degree of CNS inflammation. Nonspecific clinical symptoms and atypical imaging findings in patients presenting with seizures may warrant close monitoring for development of MS.
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Affiliation(s)
- S Sriwastava
- Multiple Sclerosis Center, Department of Neurology, Wayne State School of Medicine, Detroit Medical Center, United States of America
| | - K Yarraguntla
- Comprehensive Epilepsy Center, Department of Neurology, Wayne State School of Medicine, Detroit Medical Center, United States of America
| | - D Zutshi
- Comprehensive Epilepsy Center, Department of Neurology, Wayne State School of Medicine, Detroit Medical Center, United States of America
| | - M M Basha
- Comprehensive Epilepsy Center, Department of Neurology, Wayne State School of Medicine, Detroit Medical Center, United States of America
| | - E Bernitsas
- Multiple Sclerosis Center, Department of Neurology, Wayne State School of Medicine, Detroit Medical Center, United States of America
| | - R Marawar
- Comprehensive Epilepsy Center, Department of Neurology, Wayne State School of Medicine, Detroit Medical Center, United States of America.
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Mahamud Z, Burman J, Zelano J. Prognostic impact of epilepsy in multiple sclerosis. Mult Scler Relat Disord 2019; 38:101497. [PMID: 31726355 DOI: 10.1016/j.msard.2019.101497] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 10/25/2019] [Accepted: 11/01/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND The incidence of epilepsy, a disease generally associated with increased morbidity and mortality, is increased in multiple sclerosis (MS) but its impact on MS prognosis is largely unknown. OBJECTIVES To investigate the association between acquired epilepsy and mortality in MS and to examine the occurrence of epilepsy as a stated cause of death in MS. To examine the association between acquired epilepsy and subsequent conversion to secondary progressive MS (SPMS). METHODS Using the Swedish MS register, we conducted a nationwide register-based cohort study including 10,383 patients with MS onset between 31/12/1991 and 31/12/2014, and with no history of epilepsy before MS onset. Data on epilepsy diagnosis and cause of death (COD) were extracted from comprehensive national registers. Cox regression was used to estimate hazard ratios (HR) of death stratified by MS course, and SPMS conversion after epilepsy diagnosis. The HRs were adjusted for age at MS onset and sex. RESULTS The adjusted HR of death after epilepsy diagnosis for unselected MS patients was 3.85 (95% CI: 2.53-5.85). Stratifying by disease course, the adjusted HR of death after epilepsy diagnosis in primary progressive MS was 2.28 (95% CI: 0.99-5.26) and in relapsing-onset MS (ROMS), 5.48 (95% CI: 3.33-9.04). Further subdivision of ROMS revealed the adjusted risk of death after epilepsy diagnosis in relapsing remitting MS to be 3.84 (95% CI: 1.57-9.42) and 6.66 (95% CI: 3.18-13.92) in SPMS. Epilepsy was the underlying COD in 4.55% of MS patients with epilepsy. The majority (50%) of MS patients with epilepsy had MS as their stated underlying COD. Adjusted HR of conversion to SPMS after epilepsy diagnosis was 0.83 (95% CI: 0.45-1.56). CONCLUSION Epilepsy in MS is associated with increased mortality although death from epilepsy is rare. Most MS patients with epilepsy died of MS, and epilepsy was most lethal when developed in SPMS. We thus suggest that development of epilepsy is a marker of severe MS. Despite this, we found no association between epilepsy and conversion to SPMS.
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Affiliation(s)
- Zamzam Mahamud
- Department of Clinical Neuroscience, Sahlgrenska Academy, University of Gothenburg and Sahlgrenska University Hospital, Gothenburg, Sweden.
| | - Joachim Burman
- Department of Neuroscience, Uppsala University, Uppsala, Sweden
| | - Johan Zelano
- Department of Clinical Neuroscience, Sahlgrenska Academy, University of Gothenburg and Sahlgrenska University Hospital, Gothenburg, Sweden.
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Bustuchina Vlaicu M. Epilepsy in multiple sclerosis as a network disease. Mult Scler Relat Disord 2019; 36:101390. [DOI: 10.1016/j.msard.2019.101390] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 09/03/2019] [Accepted: 09/07/2019] [Indexed: 01/15/2023]
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41
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Zelano J, Brigo F, Garcia‐Patek S. Increased risk of epilepsy in patients registered in the Swedish Dementia Registry. Eur J Neurol 2019; 27:129-135. [DOI: 10.1111/ene.14043] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 07/15/2019] [Indexed: 01/03/2023]
Affiliation(s)
- J. Zelano
- Department of Clinical Neuroscience Institute of Neuroscience and Physiology Sahlgrenska Academy Gothenburg University GothenburgSweden
- Department of Neurology Sahlgrenska University Hospital Gothenburg Sweden
| | - F. Brigo
- Department of Neuroscience, Biomedicine and Movement Science University of Verona VeronaItaly
- Division of Neurology ‘Franz Tappeiner’ Hospital Merano Italy
| | - S. Garcia‐Patek
- Department of Neurobiology, Care Sciences and Society Division of Clinical Geriatrics Karolinska Institutet StockholmSweden
- Internal Medicine Section for Neurology Södersjukhuset Stockholm Sweden
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42
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Management of seizures in patients with multiple sclerosis; an Iranian consensus. Epilepsy Behav 2019; 96:244-248. [PMID: 31151870 DOI: 10.1016/j.yebeh.2019.04.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 04/12/2019] [Accepted: 04/19/2019] [Indexed: 01/29/2023]
Abstract
PURPOSE Cooccurrence of a seizure in a patient with multiple sclerosis (MS) may complicate the management process. Questions, which may complicate the management process of a patient with MS and seizure, include "how should we approach to the patient", "how should we treat the patient", "how should we modify the patient's MS treatment strategy", etc. METHODS: We searched the electronic database PubMed on March 30, 2018 for articles in English that included the following search terms: "epilepsy" AND "multiple sclerosis" or "seizure" AND "multiple sclerosis" since 2013, to obtain the best recent relevant scientific evidence on the topic. A working group of 6 epilepsy and 5 MS experts took part in two consensus workshops in Tehran, Iran, in 2018. The final consensus manuscript was prepared and approved by all participants. RESULTS The search with words "seizure" and "multiple sclerosis" yielded 121 entries; 10 were relevant to the topic. The search with words "epilepsy" and "multiple sclerosis" yielded 400 entries; 7 were relevant to the topic. We reviewed these 17 articles and also some other references, derived from these articles or relevant to the topic, for the purpose of our review. CONCLUSION Cooccurrence of a seizure in a patient with MS may complicate the management process. In this review, we tried to provide answers to the frequently asked questions, considering the best available scientific evidence and expert opinion.
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Schorner A, Weissert R. Patients With Epileptic Seizures and Multiple Sclerosis in a Multiple Sclerosis Center in Southern Germany Between 2003-2015. Front Neurol 2019; 10:613. [PMID: 31244766 PMCID: PMC6563689 DOI: 10.3389/fneur.2019.00613] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Accepted: 05/24/2019] [Indexed: 12/16/2022] Open
Abstract
Background: So far, many studies have shown that the risk of developing seizures and epilepsy is higher among patients with multiple sclerosis (MS) than in the general population. However, the causal link between these two diseases is still unclear. In addition, it is not clearly understood whether and to what extent the manifestation of seizures and epilepsy in patients with MS affects the clinical course and the long-term prognosis of the disease. We aimed to retrospectively identify and describe patients with MS and with seizures and epilepsy which were seen at the Department of Neurology of the University of Regensburg in Germany between the years 2003-2015. Methods: With the help of the electronic documentation system of hospital admitted patients followed by scrutinizing medical records of patients with MS for evidence of seizures and epilepsy, we identified patients with MS and seizures or epilepsy. Results: We identified 22 individuals (1.74%) out of 1,267 patients with MS with seizures or epilepsy. 18 of these 22 individuals met criteria for epilepsy (1.42%). Nine MS patients (40.9%) suffered from relapsing-remitting MS (RRMS) whereas 11 MS patients (50.0%) showed a secondary progressive disease course (SPMS). Five of those (45.5%) converted from RRMS to SPMS before they acquired epilepsy. None of the identified patients with MS and seizures or epilepsy suffered from primary progressive MS (PPMS). Moreover, two MS patients (9.1%) had a history of seizures before MS onset. Seizures were of focal onset in 17 patients with MS (77.3%). Fourteen out of these 17 MS patients presented with focal to bilateral tonic-clonic seizures (82.4%). Five MS patients (22.7%) showed tonic clonic seizures of unknown onset. Status epilepticus was reported in three patients with MS (13%), for one patient the data was inconclusive. Conclusion: The occurrence of seizures and epilepsy was higher than in the general population, suggesting a causal relationship between both diseases. In most cases, seizures occurred after the first manifestation of MS. The high frequency of focal seizures supports the concept of cerebral lesions in patients with MS playing an important role in precipitation of seizures and epilepsy.
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Affiliation(s)
- Anja Schorner
- Department of Neurology, University of Regensburg, Regensburg, Germany
| | - Robert Weissert
- Department of Neurology, University of Regensburg, Regensburg, Germany
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Validation of the Swedish Multiple Sclerosis Register: Further Improving a Resource for Pharmacoepidemiologic Evaluations. Epidemiology 2019; 30:230-233. [PMID: 30721167 PMCID: PMC6369893 DOI: 10.1097/ede.0000000000000948] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Supplemental Digital Content is available in the text. The Swedish Multiple Sclerosis Register is a national register monitoring treatment and clinical course for all Swedish multiple sclerosis (MS) patients, with high coverage and close integration with the clinic. Despite its great value for epidemiologic research, it has not previously been validated. In this brief report, we summarize a large validation of >3,000 patients in the register using clinical chart review in the context of the COMBAT-MS study. While further improving the data quality for a central cohort of patients available for future epidemiologic research, this study also allowed us to estimate the accuracy and completeness of the register data.
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Langenbruch L, Krämer J, Güler S, Möddel G, Geßner S, Melzer N, Elger CE, Wiendl H, Budde T, Meuth SG, Kovac S. Seizures and epilepsy in multiple sclerosis: epidemiology and prognosis in a large tertiary referral center. J Neurol 2019; 266:1789-1795. [PMID: 31069528 DOI: 10.1007/s00415-019-09332-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Revised: 04/14/2019] [Accepted: 04/23/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND Seizures and epilepsy may substantially add to the burden of disease in multiple sclerosis (MS), whereas the exact prevalence and prognosis of seizures and epilepsy in patients with MS remains largely unknown. OBJECTIVES We aimed to investigate the epidemiology and prognosis of seizures and epilepsy in MS. METHODS We retrospectively analyzed a cohort of 4078 MS patients from a single tertiary referral clinic. RESULTS After excluding 37 patients with unconfirmed MS and alternative seizure etiologies, we found seizures attributable to MS in 1.5% and epilepsy in 0.9% of patients. 40.4% of patients with a follow-up of at least twelve months experienced only a single seizure and 59.6% had recurring seizures. 39% of patients with recurrent seizures were considered drug-resistant, with 9.7% experiencing status epilepticus. Seizure recurrence after a first seizure depended significantly on the MS subtype and was seen more often if the first seizure occurred simultaneously with a MS relapse than in the absence of a relapse. CONCLUSION Our study shows a lower number of seizures and epilepsy in MS than previously reported. While a single seizure in MS usually has a good prognosis, relapse-associated seizures and established epilepsy in MS may not be as benign as previously assumed.
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Affiliation(s)
- Lisa Langenbruch
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Germany
| | - Julia Krämer
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Germany
| | - Sati Güler
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Germany
| | - Gabriel Möddel
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Germany
| | - Sophia Geßner
- Institute of Medical Informatics, University of Münster, Albert-Schweitzer-Campus 1, Gebäude A11, 48149, Münster, Germany
| | - Nico Melzer
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Germany
| | - Christian E Elger
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Germany.,Beta Neurologie, Kompetenzzentrum für Epileptologie, Joseph-Schumpeter-Allee 15, 53277, Bonn, Germany.,Klinik für Neuropädiatrie, Charite, Berlin, Germany
| | - Heinz Wiendl
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Germany
| | - Thomas Budde
- Institute of Physiology I, University of Münster, Robert-Koch-Straße 27a, 48149, Münster, Germany
| | - Sven G Meuth
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Germany
| | - Stjepana Kovac
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Germany.
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Rossor T, Benetou C, Wright S, Duignan S, Lascelles K, Robinson R, Das K, Ciccarelli O, Wassmer E, Hemingway C, Lim M, Hacohen Y. Early predictors of epilepsy and subsequent relapse in children with acute disseminated encephalomyelitis. Mult Scler 2019; 26:333-342. [DOI: 10.1177/1352458518823486] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Objective: To identify predictors of epilepsy and clinical relapses in children presenting with acute disseminated encephalomyelitis (ADEM). Methods: Children presenting with ADEM between 2005 and 2017 and tested clinically for MOG-Ab were identified from three tertiary paediatric neurology centres in the United Kingdom. Patients were followed up for a median of 6 years (range, 1–16 years). Results: A total of 74 children were studied (38 females; median age at first presentation: 4.5 years (range, 1.4–16 years)). MOG-Ab was positive in 50/74 (67.6%) of cases, and 27 (54%) of MOG-Ab positive children presented with a neurological relapse over time. MOG-Ab was more frequently positive in the relapsing group than in the monophasic group (27/31 vs 23/43; odds ratio 5.9 (95% CI: 1.8–19.7); p = 0.002). 16/74 (22%) children had seizures during the acute presentation with ADEM and 12/74 (16.2%) patients were diagnosed with post-ADEM epilepsy. The diagnosis of post-ADEM epilepsy was more frequently observed in children with relapsing disease than monophasic disease (10/31 vs 2/43; odds ratio 9.8 (95% confidence interval (CI): 2.0–48.7); p = 0.003), in children who had positive intrathecal oligoclonal bands than those with negative bands (4/7 vs 4/30; odds ratio 8.7 (95% CI: 1.4–54.0); p = 0.027) and in children who had positive MOG-Ab than negative MOG-Ab cases (11/12 vs 39/62; odds ratio 6.5 (95% CI:0.8–53.6); p = 0.051). Conclusion: A higher relapse rate and a greater risk of post-ADEM epilepsy in children with MOG-Ab-associated disease may indicate a chronic disease with immune-mediated seizures in these children.
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Affiliation(s)
- Thomas Rossor
- Department of Paediatric Neurology, Great Ormond Street Hospital for Children, London, UK
| | - Christina Benetou
- Children’s Neurosciences, Evelina London Children’s Hospital @ Guy’s and St. Thomas’ NHS Foundation Trust, King’s Health Partners Academic Health Science Centre, London, UK
| | - Sukhvir Wright
- Department of Neurology, Birmingham Children’s Hospital, Birmingham, UK
| | - Sophie Duignan
- Department of Paediatric Neurology, Great Ormond Street Hospital for Children, London, UK
| | - Karine Lascelles
- Children’s Neurosciences, Evelina London Children’s Hospital @ Guy’s and St. Thomas’ NHS Foundation Trust, King’s Health Partners Academic Health Science Centre, London, UK
| | - Robert Robinson
- Department of Paediatric Neurology, Great Ormond Street Hospital for Children, London, UK
| | - Krishna Das
- Department of Paediatric Neurology, Great Ormond Street Hospital for Children, London, UK
| | - Olga Ciccarelli
- Department of Neuroinflammation, Queen Square Multiple Sclerosis Centre, UCL Institute of Neurology, London, UK
| | | | - Cheryl Hemingway
- Department of Paediatric Neurology, Great Ormond Street Hospital for Children, London, UK
| | - Ming Lim
- Children’s Neurosciences, Evelina London Children’s Hospital @ Guy’s and St. Thomas’ NHS Foundation Trust, King’s Health Partners Academic Health Science Centre, London, UK; Faculty of Life Sciences & Medicine, King’s College London, London, UK
| | - Yael Hacohen
- Department of Paediatric Neurology, Great Ormond Street Hospital for Children, London, UK; Department of Neuroinflammation, Queen Square Multiple Sclerosis Centre, UCL Institute of Neurology, London, UK
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Chou IJ, Kuo CF, Tanasescu R, Tench CR, Tiley CG, Constantinescu CS, Whitehouse WP. Epilepsy and associated mortality in patients with multiple sclerosis. Eur J Neurol 2018; 26:342-e23. [PMID: 30312502 DOI: 10.1111/ene.13821] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Accepted: 10/04/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND PURPOSE We aimed to determine the prevalence of epilepsy in patients with multiple sclerosis (MS) at diagnosis, the risk of developing epilepsy after the diagnosis of MS and the relative risk of mortality associated with epilepsy. METHODS We used the UK Clinical Practice Research Data-link to identify 2526 patients with incident MS and 9980 age-, sex- and index year-matched non-MS controls from 1997 to 2006. Logistic regression was used to estimate odds ratios [95% confidence interval (CI)] for epilepsy and Cox regression was used to estimate hazard ratios (HRs) (95% CI) for epilepsy and mortality. RESULTS Patients with incident MS were on average 45 years old and 70.9% were female. At diagnosis, the prevalence of epilepsy in patients with MS was 1.30% compared with 0.57% in non-MS controls. At diagnosis, MS was associated with an adjusted odds ratio (95% CI) of 2.11 (1.36-3.27) for pre-existing epilepsy. Among epilepsy-free patients, the cumulative probabilities of developing epilepsy, first recorded within 10 years of the index date, were 2.77% for patients with MS and 0.90% for controls. MS was associated with an adjusted HR (95% CI) of 6.01 (2.94-12.29) for epilepsy. Among patients with MS, epilepsy was associated with an HR (95% CI) of 2.23 (1.02-4.84) for all-cause mortality. CONCLUSIONS This population-based study found an increased prevalence of epilepsy in patients with MS at diagnosis when compared with non-MS controls and the risk of developing epilepsy was also higher following the MS diagnosis. Patients with MS with epilepsy had a higher risk of mortality compared with those without.
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Affiliation(s)
- I J Chou
- Division of Clinical Neuroscience, School of Medicine, University of Nottingham, Nottingham.,Division of Academic Child Health, School of Medicine, University of Nottingham, Nottingham, UK.,Department of Paediatric Neurology, Chang Gung Memorial Hospital, Taoyuan
| | - C F Kuo
- Division of Rheumatology, Allergy and Immunology, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,Division of Rheumatology, Orthopaedics and Dermatology, School of Medicine, University of Nottingham, Nottingham
| | - R Tanasescu
- Division of Clinical Neuroscience, School of Medicine, University of Nottingham, Nottingham
| | - C R Tench
- Division of Clinical Neuroscience, School of Medicine, University of Nottingham, Nottingham
| | - C G Tiley
- Mevagissey Surgery, Mevagissey, Cornwall.,Lander Medical Practice, Truro, UK
| | - C S Constantinescu
- Division of Clinical Neuroscience, School of Medicine, University of Nottingham, Nottingham
| | - W P Whitehouse
- Division of Academic Child Health, School of Medicine, University of Nottingham, Nottingham, UK
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48
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Mahamud Z, Burman J, Zelano J. Risk of epilepsy after a single seizure in multiple sclerosis. Eur J Neurol 2018. [DOI: 10.1111/ene.13618] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Z. Mahamud
- Department of Clinical Neuroscience; Sahlgrenska Academy; University of Gothenburg and Sahlgrenska University Hospital; Gothenburg Sweden
| | - J. Burman
- Department of Neuroscience; Uppsala University; Uppsala Sweden
| | - J. Zelano
- Department of Clinical Neuroscience; Sahlgrenska Academy; University of Gothenburg and Sahlgrenska University Hospital; Gothenburg Sweden
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Dagiasi I, Vall V, Kumlien E, Burman J, Zelano J. Treatment of epilepsy in multiple sclerosis. Seizure 2018; 58:47-51. [PMID: 29656097 DOI: 10.1016/j.seizure.2018.04.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 03/13/2018] [Accepted: 04/01/2018] [Indexed: 10/17/2022] Open
Abstract
PURPOSE The prevalence of epilepsy is increased in multiple sclerosis (MS), but information on AED treatment and seizure outcome is scarce. We describe epilepsy characteristics including the use of AEDs and proportion of seizure-free patients at two tertiary hospitals in Sweden. METHOD We retrospectively studied electronic medical records of all patients with a diagnosis of MS and seizures at Sahlgrenska university hospital and Uppsala university hospital. Clinical data were reviewed until 2017. RESULTS We identified a total of 62 MS patients with at least one seizure. Median age at the first seizure (before or after MS) was 41 years (range 0-80). The most common MS disease course at the first seizure was secondary progressive MS, the neurological disability was considerable, and most patients had several MRI lesions at their first seizure. The first EEG demonstrated epileptiform discharges in 38% and unspecific pathology in 40%. Current seizure status could be determined for 37 patients. Out of these, 46% had been seizure free for more than one year at last follow-up. The majority of patients (65%) were on monotherapy at last follow-up. Carbamazepine was the most commonly used first AED, with a retention rate of 52%. No individual AED was associated with a particularly high rate of seizure freedom. The most common reason for discontinuation of the first AED was side-effects. CONCLUSION Seizure freedom rates were low, perhaps indicating a need for higher ambitions in management. Side effects of AEDs may be a particular concern when treating epilepsy in patients with MS.
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Affiliation(s)
- Ioanna Dagiasi
- Department of clinical neuroscience, Sahlgrenska Academy, University of Gothenburg, Sweden; NÄL Hospital Trollhättan, Sweden
| | - Victor Vall
- Department of Neuroscience, Uppsala University, Uppsala, Sweden
| | - Eva Kumlien
- Department of Neuroscience, Uppsala University, Uppsala, Sweden
| | - Joachim Burman
- Department of Neuroscience, Uppsala University, Uppsala, Sweden
| | - Johan Zelano
- Department of clinical neuroscience, Sahlgrenska Academy, University of Gothenburg, Sweden; Sahlgrenska University Hospital, Gothenburg, Sweden.
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50
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Is There a Relationship Between Multiple Sclerosis and Epilepsy? If So What Does It Tell Us About Epileptogenesis? Epilepsy Curr 2018; 18:95-96. [PMID: 29645004 DOI: 10.5698/1535-7597.18.2.95] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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