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Jimenez AD, Gopaul M, Asbell H, Aydemir S, Basha MM, Batra A, Damien C, Day GS, Eka O, Eschbach K, Fatima S, Fields MC, Foreman B, Gerard EE, Gofton TE, Haider HA, Hantus ST, Hocker S, Jongeling A, Kalkach Aparicio M, Kandula P, Kang P, Kazazian K, Kellogg MA, Kim M, Lee JW, Marcuse LV, McGraw CM, Mohamed W, Orozco J, Pimentel C, Punia V, Ramirez AM, Steriade C, Struck AF, Taraschenko O, Treister AK, Yoo JY, Zafar S, Zhou DJ, Zutshi D, Gaspard N, Hirsch LJ, Hanin A. Comparative analysis of patients with new onset refractory status epilepticus preceded by fever (febrile infection-related epilepsy syndrome) versus without prior fever: An interim analysis. Epilepsia 2024. [PMID: 38625055 DOI: 10.1111/epi.17988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 04/04/2024] [Accepted: 04/04/2024] [Indexed: 04/17/2024]
Abstract
Febrile infection-related epilepsy syndrome (FIRES) is a subset of new onset refractory status epilepticus (NORSE) that involves a febrile infection prior to the onset of the refractory status epilepticus. It is unclear whether FIRES and non-FIRES NORSE are distinct conditions. Here, we compare 34 patients with FIRES to 30 patients with non-FIRES NORSE for demographics, clinical features, neuroimaging, and outcomes. Because patients with FIRES were younger than patients with non-FIRES NORSE (median = 28 vs. 48 years old, p = .048) and more likely cryptogenic (odds ratio = 6.89), we next ran a regression analysis using age or etiology as a covariate. Respiratory and gastrointestinal prodromes occurred more frequently in FIRES patients, but no difference was found for non-infection-related prodromes. Status epilepticus subtype, cerebrospinal fluid (CSF) and magnetic resonance imaging findings, and outcomes were similar. However, FIRES cases were more frequently cryptogenic; had higher CSF interleukin 6, CSF macrophage inflammatory protein-1 alpha (MIP-1a), and serum chemokine ligand 2 (CCL2) levels; and received more antiseizure medications and immunotherapy. After controlling for age or etiology, no differences were observed in presenting symptoms and signs or inflammatory biomarkers, suggesting that FIRES and non-FIRES NORSE are very similar conditions.
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Affiliation(s)
- Anthony D Jimenez
- Department of Neurology, Comprehensive Epilepsy Center, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Margaret Gopaul
- Department of Neurology, Comprehensive Epilepsy Center, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Hannah Asbell
- Section of Neurology, Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Seyhmus Aydemir
- Department of Neurology, Weill Cornell Medicine, New York, New York, USA
| | - Maysaa M Basha
- Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Ayush Batra
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Charlotte Damien
- Department of Neurology, Hôpital Universitaire de Bruxelles-Hôpital Erasme, Brussels, Belgium
| | - Gregory S Day
- Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Onome Eka
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Krista Eschbach
- Section of Neurology, Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Safoora Fatima
- Department of Neurology, University of Wisconsin, Madison, Wisconsin, USA
| | | | - Brandon Foreman
- Division of Neurocritical Care, Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Elizabeth E Gerard
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Teneille E Gofton
- University Hospital London Health Sciences Center, London, Ontario, Canada
| | - Hiba A Haider
- Epilepsy Center, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
| | - Stephen T Hantus
- Epilepsy Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Sara Hocker
- Mayo Clinic, Minnesota, Rochester, Minnesota, USA
| | - Amy Jongeling
- NYU Comprehensive Epilepsy Center, NYU Langone Medical Center, New York, New York, USA
| | | | - Padmaja Kandula
- Department of Neurology, Weill Cornell Medicine, New York, New York, USA
| | - Peter Kang
- Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Karnig Kazazian
- University Hospital London Health Sciences Center, London, Ontario, Canada
| | | | - Minjee Kim
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Jong Woo Lee
- Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Lara V Marcuse
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Christopher M McGraw
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Wazim Mohamed
- Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Janet Orozco
- Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Cederic Pimentel
- Neurocritical Care, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Vineet Punia
- Epilepsy Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Alexandra M Ramirez
- Division of Neurocritical Care, Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Claude Steriade
- NYU Comprehensive Epilepsy Center, NYU Langone Medical Center, New York, New York, USA
| | - Aaron F Struck
- Department of Neurology, University of Wisconsin, Madison, Wisconsin, USA
| | - Olga Taraschenko
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | | | - Ji Yeoun Yoo
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Sahar Zafar
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Daniel J Zhou
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Deepti Zutshi
- Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Nicolas Gaspard
- Department of Neurology, Comprehensive Epilepsy Center, Yale University School of Medicine, New Haven, Connecticut, USA
- Department of Neurology, Hôpital Universitaire de Bruxelles-Hôpital Erasme, Brussels, Belgium
| | - Lawrence J Hirsch
- Department of Neurology, Comprehensive Epilepsy Center, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Aurelie Hanin
- Department of Neurology, Comprehensive Epilepsy Center, Yale University School of Medicine, New Haven, Connecticut, USA
- Sorbonne Université, Institut du Cerveau, Paris Brain Institute, ICM, Inserm, CNRS, Assistance Publique- Hôpitaux de Paris, Hôpital de la Pitié-Salpêtrière, Paris, France
- Assistance Publique - Hôpitaux de Paris, Hôpital de la Pitié-Salpêtrière, DMU Neurosciences, Epilepsy Unit and Department of Clinical Neurophysiology, Paris, France
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Decker BM, Clary HM, Holmes MG, Al-Faraj AO, Esmaeili B, Waldman G, Becker DA, Johnson J, Voinescu PE, Gerard EE. Letter regarding "Seizure control in women with epilepsy undergoing assisted reproductive technology". Epilepsia 2024; 65:1141-1144. [PMID: 38098189 DOI: 10.1111/epi.17862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 12/12/2023] [Indexed: 03/01/2024]
Affiliation(s)
- Barbara M Decker
- Department of Neurological Sciences, University of Vermont Medical Center, Burlington, Vermont, USA
| | - Heidi Munger Clary
- Department of Neurology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Manisha G Holmes
- Department of Neurology, Westchester Medical Center Health Network, Valhalla, New York, USA
| | - Abrar O Al-Faraj
- Department of Neurology, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Behnaz Esmaeili
- Department of Neurology, University of Washington, Seattle, Washington, USA
| | - Genna Waldman
- Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Danielle A Becker
- Department of Neurology, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Julia Johnson
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Vermont Medical Center, Burlington, Vermont, USA
| | - Paula E Voinescu
- Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Elizabeth E Gerard
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Cohen MJ, Meador KJ, Loring DW, Matthews AG, Brown C, Robalino CP, Birnbaum AK, Voinescu PE, Kalayjian LA, Gerard EE, Gedzelman ER, Hanna J, Cavitt J, Sam MC, French JA, Hwang ST, Pack AM, Pennell PB. Behavioral Outcomes and Neurodevelopmental Disorders Among Children of Women With Epilepsy. JAMA Neurol 2024; 81:19-29. [PMID: 37983058 PMCID: PMC10660252 DOI: 10.1001/jamaneurol.2023.4315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Accepted: 09/21/2023] [Indexed: 11/21/2023]
Abstract
Importance The association of fetal exposure to antiseizure medications (ASMs) with outcomes in childhood are not well delineated. Objective To examine the association of fetal ASM exposure with subsequent adaptive, behavioral or emotional, and neurodevelopmental disorder outcomes at 2, 3, and 4.5 years of age. Design, Setting, and Participants The Maternal Outcomes and Neurodevelopmental Effects of Antiepileptic Drugs (MONEAD) study is a prospective, observational cohort study conducted at 20 epilepsy centers in the US. A total of 456 pregnant women with epilepsy or without epilepsy were enrolled from December 19, 2012, to January 13, 2016. Children of enrolled women were followed up with formal assessments at 2, 3, 4.5, and 6 years of age. Statistical analysis took place from August 2022 to May 2023. Exposures Exposures included mother's epilepsy status as well as mother's ASM blood concentration in the third trimester (for children of women with epilepsy). Women with epilepsy were enrolled regardless of ASM regimen. Main Outcomes and Measures The primary outcome was the Adaptive Behavior Assessment System, Third Edition (ABAS-3) General Adaptive Composite (GAC) score among children at 4.5 years of age. Children of women with epilepsy and children of women without epilepsy were compared, and the associations of ASM exposures with outcomes among exposed children were assessed. Secondary outcomes involved similar analyses of other related measures. Results Primary analysis included 302 children of women with epilepsy (143 boys [47.4%]) and 84 children of women without epilepsy (45 boys [53.6%]). Overall adaptive functioning (ABAS-3 GAC score at 4.5 years) did not significantly differ between children of women with epilepsy and children of women without epilepsy (parameter estimate [PE], 0.4 [95% CI, -2.5 to 3.4]; P = .77). However, in adjusted analyses, a significant decrease in functioning was seen with increasing third-trimester maximum ASM blood concentrations (PE, -7.8 [95% CI, -12.6 to -3.1]; P = .001). This decrease in functioning was evident for levetiracetam (PE, -18.9 [95% CI, -26.8 to -10.9]; P < .001) and lamotrigine (PE, -12.0 [95% CI, -23.7 to -0.3]; P = .04), the ASMs with sample sizes large enough for analysis. Results were similar with third-trimester maximum daily dose. Conclusions and Relevance This study suggests that adaptive functioning of children of women with epilepsy taking commonly used ASMs did not significantly differ from that of children of women without epilepsy, but there was an exposure-dependent association of ASMs with functioning. Thus, psychiatric or psychological screening and referral of women with epilepsy and their offspring are recommended when appropriate. Additional research is needed to confirm these findings.
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Affiliation(s)
- Morris J. Cohen
- Pediatric Neuropsychology International LLC, Augusta, Georgia
| | - Kimford J. Meador
- Department of Neurology & Neurological Sciences, Stanford University, Palo Alto, California
| | - David W. Loring
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia
| | - Abigail G. Matthews
- Department of Biostatistics, The Emmes Company, Rockville, Maryland
- Department of Project Leadership, The Emmes Company, Rockville, Maryland
| | - Carrie Brown
- Department of Biostatistics, The Emmes Company, Rockville, Maryland
- Department of Project Leadership, The Emmes Company, Rockville, Maryland
| | - Chelsea P. Robalino
- Department of Biostatistics, The Emmes Company, Rockville, Maryland
- Department of Project Leadership, The Emmes Company, Rockville, Maryland
| | - Angela K. Birnbaum
- Epilepsy Research and Education Program, Experimental & Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis
| | - Paula E. Voinescu
- Department of Neurology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Elizabeth E. Gerard
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Northwestern University, Chicago, Illinois
| | - Evan R. Gedzelman
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia
| | - Julie Hanna
- Adult Epilepsy, Minnesota Epilepsy Group, St Paul
| | - Jennifer Cavitt
- Division of Epilepsy, Department of Neurology, University of Cincinnati, Cincinnati, Ohio
| | - Maria C. Sam
- Department of Neurology, Wake Forest University, Winston-Salem, North Carolina
| | - Jacqueline A. French
- Department of Neurology and Comprehensive Epilepsy Center, New York University Comprehensive Epilepsy Center, New York
| | - Sean T. Hwang
- Department of Neurology, Northwell Health, Great Neck, New York
| | - Alison M. Pack
- Department of Neurology, Columbia University, New York, New York
| | - Page B. Pennell
- Department of Neurology, University of Pittsburgh, Pittsburgh, Pennsylvania
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4
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Gerard EE, Meador KJ, Robalino CP, Brown CA, Matthews AG, Voinescu PE, Kalayjian LA, Gedzelman E, Hanna J, Cavitt J, Sam M, French JA, Pack AM, Hwang ST, Tsai JJ, Taylor C, Pennell PB. Initiation and Duration of Breastfeeding in the Maternal Outcomes and Neurodevelopmental Effects of Antiepileptic Drugs Study. Neurology 2023; 101:e2266-e2276. [PMID: 37816636 PMCID: PMC10727216 DOI: 10.1212/wnl.0000000000207812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 08/24/2023] [Indexed: 10/12/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Breastfeeding has important health benefits for both mother and child. We characterize breastfeeding initiation and duration in mothers with epilepsy relative to control mothers in a large prospective cohort. METHODS The Maternal Outcomes and Neurodevelopmental Effects of Antiepileptic Drugs study is a prospective, multicenter observational, US cohort study. Pregnant individuals with and without epilepsy, aged 14-45 years, were enrolled between December 19, 2012, and February 11, 2016. Exclusion criteria included intelligence quotient (IQ) <70, and gestational age >20 weeks at enrollment. Breastfeeding was assessed through electronic diary and at study visits until 2 years postpartum. Odds of initiating breastfeeding was compared between cohorts using unadjusted and adjusted logistic regression models. Duration of breastfeeding was compared between cohorts using the log-rank test. RESULTS Three hundred fifty-one pregnant individuals with epilepsy and 105 pregnant controls were enrolled. Breastfeeding data were available for 325 mothers with epilepsy and 98 controls. Study cohorts were similar demographically except race (p = 0.008); 84.9% of mothers with epilepsy and 71.4% of controls were White. The mean IQ was lower in mothers with epilepsy compared with that in controls (97.7 vs 104.2, p < 0.001). Breastfeeding was initiated by 74.8% mothers with epilepsy and 88.8% controls; this difference was significant in unadjusted logistic regression (odds ratio [OR] 0.4 [95% CI 0.2, 0.7], p = 0.004), but not in adjusted model (OR 0.5 [95% CI 0.2, 1.0], p = 0.051). Factors associated with breastfeeding were higher maternal education and IQ. There was no difference in duration of breastfeeding between mothers with and without epilepsy (median duration 8.5 months vs 9.9 months, p = 0.793). Among mothers with epilepsy, both convulsive seizures and all seizures that impair awareness during pregnancy were associated with lower breastfeeding initiation (OR 0.4 [95% CI 0.2, 0.8], p = 0.013) and (OR 0.4 [95% CI 0.2, 0.8], p = 0.003, respectively). Any peripartum seizures were associated with shorter breastfeeding duration (median 6 months vs 9.7 months, [p = 0.040]). DISCUSSION Mothers with epilepsy were less likely to initiate breastfeeding compared with controls; however, this difference was not significant when controlling for maternal IQ and education level. Continuation of breastfeeding once initiated was not different between mothers with and without epilepsy. Seizure control was associated with breastfeeding initiation and duration in mothers with epilepsy. TRIAL REGISTRATION INFORMATION ClinicalTrials.gov identifier NCT01730170.
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Affiliation(s)
- Elizabeth E Gerard
- From the Northwestern University (E.E.G.), Chicago, IL; Stanford University (K.J.M.), Palo Alto, CA; The Emmes Company, LLC, (C.P.R., C.A.B., A.G.M.), Rockville, MD; Harvard University (P.E.V.), Boston, MA; University of Southern California (L.A.K.), Los Angeles, CA; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (J.H.), Minneapolis, MN; University of Cincinnati (J.C.), OH; Wake Forest University (M.S.), Winston-Salem, NC; New York University (J.A.F.); Columbia University (A.M.P.), New York, NY; Zucker School of Medicine at Hofstra Northwell (S.T.H.), Hempsted, NY; University of Washington (J.J.T.), Seattle, WA; Geisinger Medical Center (C.T.), Danville, PA; and University of Pittsburgh (P.B.P.), PA.
| | - Kimford J Meador
- From the Northwestern University (E.E.G.), Chicago, IL; Stanford University (K.J.M.), Palo Alto, CA; The Emmes Company, LLC, (C.P.R., C.A.B., A.G.M.), Rockville, MD; Harvard University (P.E.V.), Boston, MA; University of Southern California (L.A.K.), Los Angeles, CA; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (J.H.), Minneapolis, MN; University of Cincinnati (J.C.), OH; Wake Forest University (M.S.), Winston-Salem, NC; New York University (J.A.F.); Columbia University (A.M.P.), New York, NY; Zucker School of Medicine at Hofstra Northwell (S.T.H.), Hempsted, NY; University of Washington (J.J.T.), Seattle, WA; Geisinger Medical Center (C.T.), Danville, PA; and University of Pittsburgh (P.B.P.), PA
| | - Chelsea P Robalino
- From the Northwestern University (E.E.G.), Chicago, IL; Stanford University (K.J.M.), Palo Alto, CA; The Emmes Company, LLC, (C.P.R., C.A.B., A.G.M.), Rockville, MD; Harvard University (P.E.V.), Boston, MA; University of Southern California (L.A.K.), Los Angeles, CA; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (J.H.), Minneapolis, MN; University of Cincinnati (J.C.), OH; Wake Forest University (M.S.), Winston-Salem, NC; New York University (J.A.F.); Columbia University (A.M.P.), New York, NY; Zucker School of Medicine at Hofstra Northwell (S.T.H.), Hempsted, NY; University of Washington (J.J.T.), Seattle, WA; Geisinger Medical Center (C.T.), Danville, PA; and University of Pittsburgh (P.B.P.), PA
| | - Carrie Anne Brown
- From the Northwestern University (E.E.G.), Chicago, IL; Stanford University (K.J.M.), Palo Alto, CA; The Emmes Company, LLC, (C.P.R., C.A.B., A.G.M.), Rockville, MD; Harvard University (P.E.V.), Boston, MA; University of Southern California (L.A.K.), Los Angeles, CA; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (J.H.), Minneapolis, MN; University of Cincinnati (J.C.), OH; Wake Forest University (M.S.), Winston-Salem, NC; New York University (J.A.F.); Columbia University (A.M.P.), New York, NY; Zucker School of Medicine at Hofstra Northwell (S.T.H.), Hempsted, NY; University of Washington (J.J.T.), Seattle, WA; Geisinger Medical Center (C.T.), Danville, PA; and University of Pittsburgh (P.B.P.), PA
| | - Abigail G Matthews
- From the Northwestern University (E.E.G.), Chicago, IL; Stanford University (K.J.M.), Palo Alto, CA; The Emmes Company, LLC, (C.P.R., C.A.B., A.G.M.), Rockville, MD; Harvard University (P.E.V.), Boston, MA; University of Southern California (L.A.K.), Los Angeles, CA; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (J.H.), Minneapolis, MN; University of Cincinnati (J.C.), OH; Wake Forest University (M.S.), Winston-Salem, NC; New York University (J.A.F.); Columbia University (A.M.P.), New York, NY; Zucker School of Medicine at Hofstra Northwell (S.T.H.), Hempsted, NY; University of Washington (J.J.T.), Seattle, WA; Geisinger Medical Center (C.T.), Danville, PA; and University of Pittsburgh (P.B.P.), PA
| | - P Emanuela Voinescu
- From the Northwestern University (E.E.G.), Chicago, IL; Stanford University (K.J.M.), Palo Alto, CA; The Emmes Company, LLC, (C.P.R., C.A.B., A.G.M.), Rockville, MD; Harvard University (P.E.V.), Boston, MA; University of Southern California (L.A.K.), Los Angeles, CA; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (J.H.), Minneapolis, MN; University of Cincinnati (J.C.), OH; Wake Forest University (M.S.), Winston-Salem, NC; New York University (J.A.F.); Columbia University (A.M.P.), New York, NY; Zucker School of Medicine at Hofstra Northwell (S.T.H.), Hempsted, NY; University of Washington (J.J.T.), Seattle, WA; Geisinger Medical Center (C.T.), Danville, PA; and University of Pittsburgh (P.B.P.), PA
| | - Laura A Kalayjian
- From the Northwestern University (E.E.G.), Chicago, IL; Stanford University (K.J.M.), Palo Alto, CA; The Emmes Company, LLC, (C.P.R., C.A.B., A.G.M.), Rockville, MD; Harvard University (P.E.V.), Boston, MA; University of Southern California (L.A.K.), Los Angeles, CA; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (J.H.), Minneapolis, MN; University of Cincinnati (J.C.), OH; Wake Forest University (M.S.), Winston-Salem, NC; New York University (J.A.F.); Columbia University (A.M.P.), New York, NY; Zucker School of Medicine at Hofstra Northwell (S.T.H.), Hempsted, NY; University of Washington (J.J.T.), Seattle, WA; Geisinger Medical Center (C.T.), Danville, PA; and University of Pittsburgh (P.B.P.), PA
| | - Evan Gedzelman
- From the Northwestern University (E.E.G.), Chicago, IL; Stanford University (K.J.M.), Palo Alto, CA; The Emmes Company, LLC, (C.P.R., C.A.B., A.G.M.), Rockville, MD; Harvard University (P.E.V.), Boston, MA; University of Southern California (L.A.K.), Los Angeles, CA; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (J.H.), Minneapolis, MN; University of Cincinnati (J.C.), OH; Wake Forest University (M.S.), Winston-Salem, NC; New York University (J.A.F.); Columbia University (A.M.P.), New York, NY; Zucker School of Medicine at Hofstra Northwell (S.T.H.), Hempsted, NY; University of Washington (J.J.T.), Seattle, WA; Geisinger Medical Center (C.T.), Danville, PA; and University of Pittsburgh (P.B.P.), PA
| | - Julie Hanna
- From the Northwestern University (E.E.G.), Chicago, IL; Stanford University (K.J.M.), Palo Alto, CA; The Emmes Company, LLC, (C.P.R., C.A.B., A.G.M.), Rockville, MD; Harvard University (P.E.V.), Boston, MA; University of Southern California (L.A.K.), Los Angeles, CA; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (J.H.), Minneapolis, MN; University of Cincinnati (J.C.), OH; Wake Forest University (M.S.), Winston-Salem, NC; New York University (J.A.F.); Columbia University (A.M.P.), New York, NY; Zucker School of Medicine at Hofstra Northwell (S.T.H.), Hempsted, NY; University of Washington (J.J.T.), Seattle, WA; Geisinger Medical Center (C.T.), Danville, PA; and University of Pittsburgh (P.B.P.), PA
| | - Jennifer Cavitt
- From the Northwestern University (E.E.G.), Chicago, IL; Stanford University (K.J.M.), Palo Alto, CA; The Emmes Company, LLC, (C.P.R., C.A.B., A.G.M.), Rockville, MD; Harvard University (P.E.V.), Boston, MA; University of Southern California (L.A.K.), Los Angeles, CA; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (J.H.), Minneapolis, MN; University of Cincinnati (J.C.), OH; Wake Forest University (M.S.), Winston-Salem, NC; New York University (J.A.F.); Columbia University (A.M.P.), New York, NY; Zucker School of Medicine at Hofstra Northwell (S.T.H.), Hempsted, NY; University of Washington (J.J.T.), Seattle, WA; Geisinger Medical Center (C.T.), Danville, PA; and University of Pittsburgh (P.B.P.), PA
| | - Maria Sam
- From the Northwestern University (E.E.G.), Chicago, IL; Stanford University (K.J.M.), Palo Alto, CA; The Emmes Company, LLC, (C.P.R., C.A.B., A.G.M.), Rockville, MD; Harvard University (P.E.V.), Boston, MA; University of Southern California (L.A.K.), Los Angeles, CA; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (J.H.), Minneapolis, MN; University of Cincinnati (J.C.), OH; Wake Forest University (M.S.), Winston-Salem, NC; New York University (J.A.F.); Columbia University (A.M.P.), New York, NY; Zucker School of Medicine at Hofstra Northwell (S.T.H.), Hempsted, NY; University of Washington (J.J.T.), Seattle, WA; Geisinger Medical Center (C.T.), Danville, PA; and University of Pittsburgh (P.B.P.), PA
| | - Jacqueline A French
- From the Northwestern University (E.E.G.), Chicago, IL; Stanford University (K.J.M.), Palo Alto, CA; The Emmes Company, LLC, (C.P.R., C.A.B., A.G.M.), Rockville, MD; Harvard University (P.E.V.), Boston, MA; University of Southern California (L.A.K.), Los Angeles, CA; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (J.H.), Minneapolis, MN; University of Cincinnati (J.C.), OH; Wake Forest University (M.S.), Winston-Salem, NC; New York University (J.A.F.); Columbia University (A.M.P.), New York, NY; Zucker School of Medicine at Hofstra Northwell (S.T.H.), Hempsted, NY; University of Washington (J.J.T.), Seattle, WA; Geisinger Medical Center (C.T.), Danville, PA; and University of Pittsburgh (P.B.P.), PA
| | - Alison M Pack
- From the Northwestern University (E.E.G.), Chicago, IL; Stanford University (K.J.M.), Palo Alto, CA; The Emmes Company, LLC, (C.P.R., C.A.B., A.G.M.), Rockville, MD; Harvard University (P.E.V.), Boston, MA; University of Southern California (L.A.K.), Los Angeles, CA; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (J.H.), Minneapolis, MN; University of Cincinnati (J.C.), OH; Wake Forest University (M.S.), Winston-Salem, NC; New York University (J.A.F.); Columbia University (A.M.P.), New York, NY; Zucker School of Medicine at Hofstra Northwell (S.T.H.), Hempsted, NY; University of Washington (J.J.T.), Seattle, WA; Geisinger Medical Center (C.T.), Danville, PA; and University of Pittsburgh (P.B.P.), PA
| | - Sean T Hwang
- From the Northwestern University (E.E.G.), Chicago, IL; Stanford University (K.J.M.), Palo Alto, CA; The Emmes Company, LLC, (C.P.R., C.A.B., A.G.M.), Rockville, MD; Harvard University (P.E.V.), Boston, MA; University of Southern California (L.A.K.), Los Angeles, CA; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (J.H.), Minneapolis, MN; University of Cincinnati (J.C.), OH; Wake Forest University (M.S.), Winston-Salem, NC; New York University (J.A.F.); Columbia University (A.M.P.), New York, NY; Zucker School of Medicine at Hofstra Northwell (S.T.H.), Hempsted, NY; University of Washington (J.J.T.), Seattle, WA; Geisinger Medical Center (C.T.), Danville, PA; and University of Pittsburgh (P.B.P.), PA
| | - Jeffrey J Tsai
- From the Northwestern University (E.E.G.), Chicago, IL; Stanford University (K.J.M.), Palo Alto, CA; The Emmes Company, LLC, (C.P.R., C.A.B., A.G.M.), Rockville, MD; Harvard University (P.E.V.), Boston, MA; University of Southern California (L.A.K.), Los Angeles, CA; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (J.H.), Minneapolis, MN; University of Cincinnati (J.C.), OH; Wake Forest University (M.S.), Winston-Salem, NC; New York University (J.A.F.); Columbia University (A.M.P.), New York, NY; Zucker School of Medicine at Hofstra Northwell (S.T.H.), Hempsted, NY; University of Washington (J.J.T.), Seattle, WA; Geisinger Medical Center (C.T.), Danville, PA; and University of Pittsburgh (P.B.P.), PA
| | - Cora Taylor
- From the Northwestern University (E.E.G.), Chicago, IL; Stanford University (K.J.M.), Palo Alto, CA; The Emmes Company, LLC, (C.P.R., C.A.B., A.G.M.), Rockville, MD; Harvard University (P.E.V.), Boston, MA; University of Southern California (L.A.K.), Los Angeles, CA; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (J.H.), Minneapolis, MN; University of Cincinnati (J.C.), OH; Wake Forest University (M.S.), Winston-Salem, NC; New York University (J.A.F.); Columbia University (A.M.P.), New York, NY; Zucker School of Medicine at Hofstra Northwell (S.T.H.), Hempsted, NY; University of Washington (J.J.T.), Seattle, WA; Geisinger Medical Center (C.T.), Danville, PA; and University of Pittsburgh (P.B.P.), PA
| | - Page B Pennell
- From the Northwestern University (E.E.G.), Chicago, IL; Stanford University (K.J.M.), Palo Alto, CA; The Emmes Company, LLC, (C.P.R., C.A.B., A.G.M.), Rockville, MD; Harvard University (P.E.V.), Boston, MA; University of Southern California (L.A.K.), Los Angeles, CA; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (J.H.), Minneapolis, MN; University of Cincinnati (J.C.), OH; Wake Forest University (M.S.), Winston-Salem, NC; New York University (J.A.F.); Columbia University (A.M.P.), New York, NY; Zucker School of Medicine at Hofstra Northwell (S.T.H.), Hempsted, NY; University of Washington (J.J.T.), Seattle, WA; Geisinger Medical Center (C.T.), Danville, PA; and University of Pittsburgh (P.B.P.), PA
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Meador KJ, Cohen MJ, Loring DW, Matthews AG, Brown C, Robalino CP, Birnbaum AK, Voinescu PE, Kalayjian LA, Gerard EE, Gedzelman ER, Hanna J, Cavitt J, Sam M, French JA, Hwang S, Pack AM, Pennell PB. Cognitive outcomes at age 3 years in children with fetal exposure to antiseizure medications (MONEAD study) in the USA: a prospective, observational cohort study. Lancet Neurol 2023; 22:712-722. [PMID: 37479375 PMCID: PMC10423009 DOI: 10.1016/s1474-4422(23)00199-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 05/16/2023] [Accepted: 05/18/2023] [Indexed: 07/23/2023]
Abstract
BACKGROUND The neurodevelopmental effects of fetal exposure to most antiseizure medications are unclear. We aimed to investigate the effects of fetal exposure to commonly used antiseizure medications on neuropsychological outcomes at age 3 years. METHODS The Maternal Outcomes and Neurodevelopmental Effects of Antiepileptic Drugs (MONEAD) study is a prospective, observational, multicentre cohort study at 20 specialty epilepsy centres in the USA. We have investigated pregnancy outcomes in women (aged 14-45 years) with and without epilepsy who were enrolled during pregnancy (≤20 weeks' gestational age), and their children. The primary outcome for children at age 3 years was a blindly assessed Verbal Index score, which was calculated by averaging scores on the Naming Vocabulary and Verbal Comprehension subtests of Differential Ability Scales-II, Expressive Communication and Auditory Comprehension subscales of Preschool Language Scale-5, and Peabody Picture Vocabulary Test-4. Children of women with and without epilepsy were compared, and the associations of medication exposures to outcomes in exposed children were assessed. The MONEAD study is registered with ClinicalTrials.gov, NCT0730170, and is ongoing. FINDINGS Between Dec 19, 2012, and Jan 13, 2016, 456 pregnant women (351 with epilepsy and 105 without epilepsy) were enrolled into the study. 345 children were born to women with epilepsy and 106 children were born to women without epilepsy. Verbal Index scores at age 3 years did not differ for children of women with epilepsy (n=284; adjusted least-square mean 102·7, 95% CI 101·4 to 103·9) versus those without epilepsy (n=87; 102·3, 99·8 to 104·7). Significant risk factors for reduced Verbal Index scores included maternal intelligence quotient, maternal education, post-birth anxiety, gestational age at enrolment, child's sex, and child's ethnicity. For Verbal Index scores, antiseizure medication exposure effects were not seen for maximum third trimester blood concentrations (n=258; adjusted parameter estimate -2·9, 95% CI -6·7 to 1·0). However, in secondary analyses, exposure-dependent effects were present on multiple cognitive measures, which varied by medication. INTERPRETATION We found no difference in neurodevelopmental outcomes between children with fetal exposure to newer antiseizure medications compared with unexposed children. However, some exposure-dependent antiseizure medication effects were seen in secondary analyses. The adverse effects of maternal post-birth anxiety emphasise the importance of screening mothers during pregnancy and postpartum and implementing interventions. Additional studies are needed to clarify the exposure-dependent effects. FUNDING National Institutes of Health, National Institute of Neurological Disorders and Stroke, and National Institute of Child Health and Development.
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Affiliation(s)
| | - Morris J Cohen
- Pediatric Neuropsychology International, Augusta, GA, USA
| | | | | | | | | | | | - Paula E Voinescu
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | | | | | - Julie Hanna
- Minnesota Epilepsy Group, Roseville, MN, USA
| | | | - Maria Sam
- Wake Forest University, Winston-Salem, NC, USA
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Happ HC, Sadleir LG, Zemel M, de Valles-Ibáñez G, Hildebrand MS, McConkie-Rosell A, McDonald M, May H, Sands T, Aggarwal V, Elder C, Feyma T, Bayat A, Møller RS, Fenger CD, Klint Nielsen JE, Datta AN, Gorman KM, King MD, Linhares ND, Burton BK, Paras A, Ellard S, Rankin J, Shukla A, Majethia P, Olson RJ, Muthusamy K, Schimmenti LA, Starnes K, Sedláčková L, Štěrbová K, Vlčková M, Laššuthová P, Jahodová A, Porter BE, Couque N, Colin E, Prouteau C, Collet C, Smol T, Caumes R, Vansenne F, Bisulli F, Licchetta L, Person R, Torti E, McWalter K, Webster R, Gerard EE, Lesca G, Szepetowski P, Scheffer IE, Mefford HC, Carvill GL. Neurodevelopmental and Epilepsy Phenotypes in Individuals With Missense Variants in the Voltage-Sensing and Pore Domains of KCNH5. Neurology 2023; 100:e603-e615. [PMID: 36307226 PMCID: PMC9946193 DOI: 10.1212/wnl.0000000000201492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 09/14/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES KCNH5 encodes the voltage-gated potassium channel EAG2/Kv10.2. We aimed to delineate the neurodevelopmental and epilepsy phenotypic spectrum associated with de novo KCNH5 variants. METHODS We screened 893 individuals with developmental and epileptic encephalopathies for KCNH5 variants using targeted or exome sequencing. Additional individuals with KCNH5 variants were identified through an international collaboration. Clinical history, EEG, and imaging data were analyzed; seizure types and epilepsy syndromes were classified. We included 3 previously published individuals including additional phenotypic details. RESULTS We report a cohort of 17 patients, including 9 with a recurrent de novo missense variant p.Arg327His, 4 with a recurrent missense variant p.Arg333His, and 4 additional novel missense variants. All variants were located in or near the functionally critical voltage-sensing or pore domains, absent in the general population, and classified as pathogenic or likely pathogenic using the American College of Medical Genetics and Genomics criteria. All individuals presented with epilepsy with a median seizure onset at 6 months. They had a wide range of seizure types, including focal and generalized seizures. Cognitive outcomes ranged from normal intellect to profound impairment. Individuals with the recurrent p.Arg333His variant had a self-limited drug-responsive focal or generalized epilepsy and normal intellect, whereas the recurrent p.Arg327His variant was associated with infantile-onset DEE. Two individuals with variants in the pore domain were more severely affected, with a neonatal-onset movement disorder, early-infantile DEE, profound disability, and childhood death. DISCUSSION We describe a cohort of 17 individuals with pathogenic or likely pathogenic missense variants in the voltage-sensing and pore domains of Kv10.2, including 14 previously unreported individuals. We present evidence for a putative emerging genotype-phenotype correlation with a spectrum of epilepsy and cognitive outcomes. Overall, we expand the role of EAG proteins in human disease and establish KCNH5 as implicated in a spectrum of neurodevelopmental disorders and epilepsy.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Heather C. Mefford
- From the Ken and Ruth Davee Department of Neurology (K.C.H., E.E.G., G.L.C.), Northwestern University Feinberg School of Medicine, Chicago, IL; University of Otago (L.G.S.), Wellington, New Zealand; University of Washington (M.Z.), Seattle; Department of Medicine (G.d.V.-I., R.W., I.E.S.), Epilepsy Research Centre, The University of Melbourne, Austin Health, Heidelberg, Victoria, Australia; Duke University Medical Center (A.M.-R., M.M.), Durham, NC; Institute for Genomic Medicine (H.M., T.S.), Columbia University Irving Medical Center, New York, NY; Departments of Pathology and Cell Biology (V.A.), and Neurology (C.E.), Columbia University Irving Medical Center, New York, NY; Gillette Children's Specialty Healthcare (T.F.), St. Paul, MN; Department of Epilepsy Genetics and Personalized Medicine (A.B., R.S.M., C.D.F.), Danish Epilepsy Center, Dianalund, Denmark; Institute of Regional Health Research (A.B., R.S.M.), University of Southern Denmark; Amplexa Genetics (C.D.F.), Odense, Denmark; Department of Clinical Medicine (J.E.K.N.), Zealand University Hospital, Roskilde, Denmark; University of British Columbia (A.N.D.), Vancouver, Canada; The Department of Neurology and Clinical Neurophysiology (K.M.G., M.D.K.), Children's Health Ireland at Temple St., Dublin 1, Ireland; School of Medicine and Medical Science (K.M.G., M.D.K.), University College Dublin, Ireland; Genuity Science (N.L.), Dublin, Ireland; Ann & Robert H. Lurie Children's Hospital of Chicago (B.K.B., A.P.), Chicago, IL; Department of Pediatrics (B.K.B., A.P., G.L.C.), Northwestern University Feinberg School of Medicine, Chicago, IL; Exeter Genomics Laboratory (S.E.), Royal Devon University Healthcare NHS Foundation Trust, Exeter, United Kingdom; Institute of Clinical and Biomedical Science (S.E.), University of Exeter, United Kingdom; Department Clinical Genetics (J.R.), Royal Devon University Healthcare NHS Foundation Trust, Exeter, United Kingdom; Department of Medical Genetics (A.S., P.M.), Kasturba Medical College, Manipal, Manipal Academy of Higher Education, India; Center for Individualized Medicine (R.J.O., K.M., L.A.S.), Mayo Clinic, Rochester, MN; Departments of Clinical Genomics (K.M., L.A.S.), and Neurology (K.S.), Mayo Clinic, Rochester, MN; Neurogenetic Laboratory (L.S., P.J.), Department of Pediatric Neurology, Second Faculty of Medicine, Charles University in Prague and Motol University Hospital, Czech Republic; Epilepsy Research Centre Prague—EpiReC Consortium (L.S., K.S., M.V., P.L., A.J.); Motol University Hospital is a full member of the ERN EpiCARE; Department of Pediatric Neurology (K.S., A.J.), Second Faculty of Medicine, Charles University in Prague and Motol University Hospital, Czech Republic; Biology and Medical Genetics (M.V.), Second Faculty of Medicine, Charles University in Prague and Motol University Hospital, Czech Republic; Stanford University School of Medicine (B.E.P.), Palo Alto, CA; Laboratoire de Biologie médicale multisites Seqoia-FMG2025 (N.C., C.C.), Laboratoire Génétique Moléculaire Robert-Debré, Paris, France; Service de Génétique (E.C., C.P.), CHU d'Angers, Angers, France; University Lille (T.S.), CHU Lille, ULR7364—RADEME, Institut de Genetique Medicale, France; University Lille (R.C.), CHU Lille, ULR7364—RADEME, Clinique de Genetique, France; Univeristy Medical Center Groningen (F.V.), Groningen, the Netherlands; Department of Biomedical and NeuroMotor Sciences (F.B.), University of Bologna, Italy; IRCCS Istituto delle Scienze Neurologiche di Bologna (F.B., L.L.), Full Member of the ERN EpiCARE Bologna, Italy; GeneDx (R.P., E.T., K.M.), Gaithersburg, MD; T.Y. Nelson Department of Neurology and Neurosurgery (R.W.), Children's Hospital at Westmead, Westmead, New South Wales, Australia; Department of Medical Genetics (G.L.), University Hospital of Lyon, Claude Bernard Lyon 1 University, France; INSERM, Aix-Marseille University (P.S.), INMED, France; Department of Neurology (I.E.S.), Royal Children's Hospital, Department of Paediatrics, The University of Melbourne, and Murdoch Children's Research Institute, Parkville, Victoria, Australia; The Florey Institute of Neuroscience and Mental Health (I.E.S.), Victoria, Australia; Center for Pediatric Neurological Disease Research (H.C.M.), St. Jude Children's Research Hospital, Memphis, TN; and Department of Pharmacology (G.L.C.), Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Gemma L. Carvill
- From the Ken and Ruth Davee Department of Neurology (K.C.H., E.E.G., G.L.C.), Northwestern University Feinberg School of Medicine, Chicago, IL; University of Otago (L.G.S.), Wellington, New Zealand; University of Washington (M.Z.), Seattle; Department of Medicine (G.d.V.-I., R.W., I.E.S.), Epilepsy Research Centre, The University of Melbourne, Austin Health, Heidelberg, Victoria, Australia; Duke University Medical Center (A.M.-R., M.M.), Durham, NC; Institute for Genomic Medicine (H.M., T.S.), Columbia University Irving Medical Center, New York, NY; Departments of Pathology and Cell Biology (V.A.), and Neurology (C.E.), Columbia University Irving Medical Center, New York, NY; Gillette Children's Specialty Healthcare (T.F.), St. Paul, MN; Department of Epilepsy Genetics and Personalized Medicine (A.B., R.S.M., C.D.F.), Danish Epilepsy Center, Dianalund, Denmark; Institute of Regional Health Research (A.B., R.S.M.), University of Southern Denmark; Amplexa Genetics (C.D.F.), Odense, Denmark; Department of Clinical Medicine (J.E.K.N.), Zealand University Hospital, Roskilde, Denmark; University of British Columbia (A.N.D.), Vancouver, Canada; The Department of Neurology and Clinical Neurophysiology (K.M.G., M.D.K.), Children's Health Ireland at Temple St., Dublin 1, Ireland; School of Medicine and Medical Science (K.M.G., M.D.K.), University College Dublin, Ireland; Genuity Science (N.L.), Dublin, Ireland; Ann & Robert H. Lurie Children's Hospital of Chicago (B.K.B., A.P.), Chicago, IL; Department of Pediatrics (B.K.B., A.P., G.L.C.), Northwestern University Feinberg School of Medicine, Chicago, IL; Exeter Genomics Laboratory (S.E.), Royal Devon University Healthcare NHS Foundation Trust, Exeter, United Kingdom; Institute of Clinical and Biomedical Science (S.E.), University of Exeter, United Kingdom; Department Clinical Genetics (J.R.), Royal Devon University Healthcare NHS Foundation Trust, Exeter, United Kingdom; Department of Medical Genetics (A.S., P.M.), Kasturba Medical College, Manipal, Manipal Academy of Higher Education, India; Center for Individualized Medicine (R.J.O., K.M., L.A.S.), Mayo Clinic, Rochester, MN; Departments of Clinical Genomics (K.M., L.A.S.), and Neurology (K.S.), Mayo Clinic, Rochester, MN; Neurogenetic Laboratory (L.S., P.J.), Department of Pediatric Neurology, Second Faculty of Medicine, Charles University in Prague and Motol University Hospital, Czech Republic; Epilepsy Research Centre Prague—EpiReC Consortium (L.S., K.S., M.V., P.L., A.J.); Motol University Hospital is a full member of the ERN EpiCARE; Department of Pediatric Neurology (K.S., A.J.), Second Faculty of Medicine, Charles University in Prague and Motol University Hospital, Czech Republic; Biology and Medical Genetics (M.V.), Second Faculty of Medicine, Charles University in Prague and Motol University Hospital, Czech Republic; Stanford University School of Medicine (B.E.P.), Palo Alto, CA; Laboratoire de Biologie médicale multisites Seqoia-FMG2025 (N.C., C.C.), Laboratoire Génétique Moléculaire Robert-Debré, Paris, France; Service de Génétique (E.C., C.P.), CHU d'Angers, Angers, France; University Lille (T.S.), CHU Lille, ULR7364—RADEME, Institut de Genetique Medicale, France; University Lille (R.C.), CHU Lille, ULR7364—RADEME, Clinique de Genetique, France; Univeristy Medical Center Groningen (F.V.), Groningen, the Netherlands; Department of Biomedical and NeuroMotor Sciences (F.B.), University of Bologna, Italy; IRCCS Istituto delle Scienze Neurologiche di Bologna (F.B., L.L.), Full Member of the ERN EpiCARE Bologna, Italy; GeneDx (R.P., E.T., K.M.), Gaithersburg, MD; T.Y. Nelson Department of Neurology and Neurosurgery (R.W.), Children's Hospital at Westmead, Westmead, New South Wales, Australia; Department of Medical Genetics (G.L.), University Hospital of Lyon, Claude Bernard Lyon 1 University, France; INSERM, Aix-Marseille University (P.S.), INMED, France; Department of Neurology (I.E.S.), Royal Children's Hospital, Department of Paediatrics, The University of Melbourne, and Murdoch Children's Research Institute, Parkville, Victoria, Australia; The Florey Institute of Neuroscience and Mental Health (I.E.S.), Victoria, Australia; Center for Pediatric Neurological Disease Research (H.C.M.), St. Jude Children's Research Hospital, Memphis, TN; and Department of Pharmacology (G.L.C.), Northwestern University Feinberg School of Medicine, Chicago, IL
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Gerard EE. Too Much of a Good Thing? High-Dose Folic Acid in Pregnancy and Childhood Cancer. Epilepsy Curr 2023; 23:102-104. [PMID: 37122408 PMCID: PMC10131577 DOI: 10.1177/15357597221147357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
[Box: see text]
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Affiliation(s)
- Elizabeth E. Gerard
- Department of Neurology, Northwestern University, Feinberg School of Medicine
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8
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Gerard EE. "Not Valproic Acid" Is Not Without Risk: In Utero Exposure to Topiramate Is Associated With an Increased Risk of Neurodevelopmental Disorders. Epilepsy Curr 2023; 23:14-17. [PMID: 36923329 PMCID: PMC10009118 DOI: 10.1177/15357597221130878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2023] Open
Abstract
Association of Prenatal Exposure to Antiseizure Medication With Risk of Autism and Intellectual Disability Bjørk M-H, Zoega H, Leinonen MK, Cohen JM, Dreier JW, Furu K, Gilhus NE, Gissler M, Hálfdánarson Ó, Igland J, Sun Y, Tomson T, Alvestad S, Christensen J. JAMA Neurol. 2022;79(7):1-10. doi:10.1001/jamaneurol.2022.1269 Importance: Women with epilepsy frequently need antiseizure medication (ASM) to prevent seizures in pregnancy. Risk of neurodevelopmental disorders after prenatal exposure to AMSs is uncertain. Objective: To determine whether children exposed prenatally to ASMs in monotherapy and duotherapy have increased risk of neurodevelopmental disorders. Design, setting, and participants: The Nordic register-based study of antiepileptic drugs in pregnancy (SCAN-AED) is a population-based cohort study using health register and social register data from Denmark, Finland, Iceland, Norway, and Sweden (1996-2017; analysis performed February 2022). From 4 702 774 alive-born children with available mother-child identities and maternal prescription data, this study included 4 494 926 participants. Children from a multiple pregnancy or with chromosomal disorders or uncertain pregnancy length were excluded (n = 207 848). Exposures: Prenatal exposure to ASM determined from maternal prescription fills between last menstrual period and birth. Main outcomes and measures: We estimated cumulative incidence at age 8 years in exposed and unexposed children. Cox regression adjusted for potential confounders yielded adjusted hazard ratios (aHRs) with 95% CIs for autism spectrum disorder (ASD), intellectual disability (ID), or any neurodevelopmental disorder (ASD and/or ID). Results: A total of 4 494 926 children were included; 2 306 993 (51.3%) were male, and the median (IQR) age at end of follow-up was 8 (4.0-12.1) years. Among 21 634 unexposed children of mothers with epilepsy, 1.5% had a diagnosis of ASD and 0.8% (numerators were not available because of personal data regulations in Denmark) of ID by age 8 years. In same-aged children of mothers with epilepsy exposed to topiramate and valproate monotherapy, 4.3% and 2.7%, respectively, had ASD, and 3.1% and 2.4% had ID. The aHRs for ASD and ID after topiramate exposure were 2.8 (95% CI, 1.4-5.7) and 3.5 (95% CI, 1.4-8.6), respectively, and after valproate exposure were 2.4 (95% CI, 1.7-3.3) and 2.5 (95% CI, 1.7-3.7). The aHRs were elevated with higher ASM doses compared with children from the general population. The duotherapies levetiracetam with carbamazepine and lamotrigine with topiramate were associated with increased risks of neurodevelopmental disorders in children of women with epilepsy: levetiracetam with carbamazepine: 8-year cumulative incidence, 5.7%; aHR, 3.5; 95% CI, 1.5-8.2; lamotrigine with topiramate: 8-year cumulative incidence, 7.5%; aHR, 2.4; 95% CI, 1.1-4.9. No increased risk was associated with levetiracetam with lamotrigine (8-year cumulative incidence, 1.6%; aHR, 0.9; 95% CI, 0.3-2.5). No consistently increased risks were observed for neurodevelopmental disorders after prenatal exposure to monotherapy with lamotrigine, levetiracetam, carbamazepin, oxcarbazepine, gapapentin, pregabalin, clonazepam, or phenobarbital. Conclusions and relevance: In this cohort study, prenatal exposure to topiramate, valproate, and several duotherapies were associated with increased risks of neurodevelopmental disorders.
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Toprani S, Meador KJ, Robalino CP, Brown CA, Matthews AG, Gerard EE, Penovich P, Gedzelman E, Cavitt J, Hwang ST, Kalayjian LA, Sam M, Pack A, Pennell PB. Effect of Epilepsy on Sleep Quality During Pregnancy and Postpartum. Neurology 2022; 99:e1584-e1597. [PMID: 35853745 PMCID: PMC9559942 DOI: 10.1212/wnl.0000000000200959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 05/25/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES This study seeks to understand how sleep is affected in pregnant women with epilepsy (WWE) relative to healthy pregnant women during pregnancy and postpartum and to nonpregnant WWE during comparative periods. Sleep affects maternal health and mood during pregnancy. Maternal sleep disturbances are related to poor fetal growth and increased fetal deaths. Epilepsy is the most common neurologic condition in pregnancy. Sleep disruption can worsen epileptic seizures. The interplay between epilepsy, pregnancy, and sleep is poorly understood. METHODS The Maternal Outcomes and Neurodevelopmental Effects of Antiepileptic Drugs (MONEAD) study is an NIH-funded, prospective, observational, multicenter study, enrolling women from December 2012 through January 2016. Sleep quality was assessed using the average Pittsburgh Sleep Quality Index collected during pregnancy, postpartum, or analogous periods. Sleep scores range from 0 to 21 with higher scores indicating worse sleep quality; scores >5 are associated with poor sleep quality. RESULTS Of 351 pregnant WWE, 105 healthy pregnant women, and 109 nonpregnant WWE enrolled in the MONEAD study, data from 241 pregnant WWE, 74 healthy pregnant women, and 84 nonpregnant WWE were analyzed. Pregnant WWE had worse sleep (a higher mean sleep score) during pregnancy compared with healthy pregnant women in unadjusted analysis (p = 0.006), but no longer significant in adjusted analysis (p = 0.062); pregnant WWE (least square mean sleep score [95% CI] = 5.8 [5.5-6.1]) vs healthy pregnant women (5.1 [4.6-5.7]). During postpartum period, WWE (5.6 [5.4-5.9]) had similarly impaired sleep compared with healthy women (5.7 [5.2-6.2]; adjusted p = 0.838). Sleep was significantly worse in pregnant WWE vs nonpregnant WWE (for comparable period) in pregnancy and postpartum in unadjusted and adjusted analyses; adjusted scores for pregnant WWE in pregnancy (5.7 [5.4-6.0]) and those in postpartum (5.7 [5.4-6.0]) compared with those for nonpregnant WWE (4.7 [4.2-5.3]; p = 0.002) and (4.1 [3.6-4.7]; p < 0.001), respectively. Sleep quality between pregnancy and postpartum varied only in healthy pregnant women (change in mean score = 0.8 [0.2-1.3]; p = 0.01), whose sleep was worse in postpartum. DISCUSSION Pregnant WWE had worse sleep during pregnancy and postpartum period than nonpregnant WWE during comparable periods in the adjusted analysis. TRIAL REGISTRATION INFORMATION The study is registered at ClinicalTrials.gov as NCT01730170.
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Affiliation(s)
- Sheela Toprani
- From the Stanford University (S.T., K.J.M.), Palo Alto, CA; Emmes (C.P.R., C.A.B., A.G.M.), Rockville, MD; Northwestern University (E.E.G.), Chicago, IL; Minnesota Epilepsy Group (P.P.), Roseville; Emory University (E.G.), Atlanta, GA; University of Cincinnati (J.C.), OH; Northwell Health (S.T.H.), New Hyde Park, NY; University of Southern California (L.A.K.), Los Angeles; Wake Forest University Health Sciences (M.S.), Winston-Salem, NC; Columbia University (A.P.), New York; and University of Pittsburgh Medical Center (P.B.P.), PA.
| | - Kimford J Meador
- From the Stanford University (S.T., K.J.M.), Palo Alto, CA; Emmes (C.P.R., C.A.B., A.G.M.), Rockville, MD; Northwestern University (E.E.G.), Chicago, IL; Minnesota Epilepsy Group (P.P.), Roseville; Emory University (E.G.), Atlanta, GA; University of Cincinnati (J.C.), OH; Northwell Health (S.T.H.), New Hyde Park, NY; University of Southern California (L.A.K.), Los Angeles; Wake Forest University Health Sciences (M.S.), Winston-Salem, NC; Columbia University (A.P.), New York; and University of Pittsburgh Medical Center (P.B.P.), PA
| | - Chelsea P Robalino
- From the Stanford University (S.T., K.J.M.), Palo Alto, CA; Emmes (C.P.R., C.A.B., A.G.M.), Rockville, MD; Northwestern University (E.E.G.), Chicago, IL; Minnesota Epilepsy Group (P.P.), Roseville; Emory University (E.G.), Atlanta, GA; University of Cincinnati (J.C.), OH; Northwell Health (S.T.H.), New Hyde Park, NY; University of Southern California (L.A.K.), Los Angeles; Wake Forest University Health Sciences (M.S.), Winston-Salem, NC; Columbia University (A.P.), New York; and University of Pittsburgh Medical Center (P.B.P.), PA
| | - Carrie Anne Brown
- From the Stanford University (S.T., K.J.M.), Palo Alto, CA; Emmes (C.P.R., C.A.B., A.G.M.), Rockville, MD; Northwestern University (E.E.G.), Chicago, IL; Minnesota Epilepsy Group (P.P.), Roseville; Emory University (E.G.), Atlanta, GA; University of Cincinnati (J.C.), OH; Northwell Health (S.T.H.), New Hyde Park, NY; University of Southern California (L.A.K.), Los Angeles; Wake Forest University Health Sciences (M.S.), Winston-Salem, NC; Columbia University (A.P.), New York; and University of Pittsburgh Medical Center (P.B.P.), PA
| | - Abigail G Matthews
- From the Stanford University (S.T., K.J.M.), Palo Alto, CA; Emmes (C.P.R., C.A.B., A.G.M.), Rockville, MD; Northwestern University (E.E.G.), Chicago, IL; Minnesota Epilepsy Group (P.P.), Roseville; Emory University (E.G.), Atlanta, GA; University of Cincinnati (J.C.), OH; Northwell Health (S.T.H.), New Hyde Park, NY; University of Southern California (L.A.K.), Los Angeles; Wake Forest University Health Sciences (M.S.), Winston-Salem, NC; Columbia University (A.P.), New York; and University of Pittsburgh Medical Center (P.B.P.), PA
| | - Elizabeth E Gerard
- From the Stanford University (S.T., K.J.M.), Palo Alto, CA; Emmes (C.P.R., C.A.B., A.G.M.), Rockville, MD; Northwestern University (E.E.G.), Chicago, IL; Minnesota Epilepsy Group (P.P.), Roseville; Emory University (E.G.), Atlanta, GA; University of Cincinnati (J.C.), OH; Northwell Health (S.T.H.), New Hyde Park, NY; University of Southern California (L.A.K.), Los Angeles; Wake Forest University Health Sciences (M.S.), Winston-Salem, NC; Columbia University (A.P.), New York; and University of Pittsburgh Medical Center (P.B.P.), PA
| | - Patricia Penovich
- From the Stanford University (S.T., K.J.M.), Palo Alto, CA; Emmes (C.P.R., C.A.B., A.G.M.), Rockville, MD; Northwestern University (E.E.G.), Chicago, IL; Minnesota Epilepsy Group (P.P.), Roseville; Emory University (E.G.), Atlanta, GA; University of Cincinnati (J.C.), OH; Northwell Health (S.T.H.), New Hyde Park, NY; University of Southern California (L.A.K.), Los Angeles; Wake Forest University Health Sciences (M.S.), Winston-Salem, NC; Columbia University (A.P.), New York; and University of Pittsburgh Medical Center (P.B.P.), PA
| | - Evan Gedzelman
- From the Stanford University (S.T., K.J.M.), Palo Alto, CA; Emmes (C.P.R., C.A.B., A.G.M.), Rockville, MD; Northwestern University (E.E.G.), Chicago, IL; Minnesota Epilepsy Group (P.P.), Roseville; Emory University (E.G.), Atlanta, GA; University of Cincinnati (J.C.), OH; Northwell Health (S.T.H.), New Hyde Park, NY; University of Southern California (L.A.K.), Los Angeles; Wake Forest University Health Sciences (M.S.), Winston-Salem, NC; Columbia University (A.P.), New York; and University of Pittsburgh Medical Center (P.B.P.), PA
| | - Jennifer Cavitt
- From the Stanford University (S.T., K.J.M.), Palo Alto, CA; Emmes (C.P.R., C.A.B., A.G.M.), Rockville, MD; Northwestern University (E.E.G.), Chicago, IL; Minnesota Epilepsy Group (P.P.), Roseville; Emory University (E.G.), Atlanta, GA; University of Cincinnati (J.C.), OH; Northwell Health (S.T.H.), New Hyde Park, NY; University of Southern California (L.A.K.), Los Angeles; Wake Forest University Health Sciences (M.S.), Winston-Salem, NC; Columbia University (A.P.), New York; and University of Pittsburgh Medical Center (P.B.P.), PA
| | - Sean T Hwang
- From the Stanford University (S.T., K.J.M.), Palo Alto, CA; Emmes (C.P.R., C.A.B., A.G.M.), Rockville, MD; Northwestern University (E.E.G.), Chicago, IL; Minnesota Epilepsy Group (P.P.), Roseville; Emory University (E.G.), Atlanta, GA; University of Cincinnati (J.C.), OH; Northwell Health (S.T.H.), New Hyde Park, NY; University of Southern California (L.A.K.), Los Angeles; Wake Forest University Health Sciences (M.S.), Winston-Salem, NC; Columbia University (A.P.), New York; and University of Pittsburgh Medical Center (P.B.P.), PA
| | - Laura A Kalayjian
- From the Stanford University (S.T., K.J.M.), Palo Alto, CA; Emmes (C.P.R., C.A.B., A.G.M.), Rockville, MD; Northwestern University (E.E.G.), Chicago, IL; Minnesota Epilepsy Group (P.P.), Roseville; Emory University (E.G.), Atlanta, GA; University of Cincinnati (J.C.), OH; Northwell Health (S.T.H.), New Hyde Park, NY; University of Southern California (L.A.K.), Los Angeles; Wake Forest University Health Sciences (M.S.), Winston-Salem, NC; Columbia University (A.P.), New York; and University of Pittsburgh Medical Center (P.B.P.), PA
| | - Maria Sam
- From the Stanford University (S.T., K.J.M.), Palo Alto, CA; Emmes (C.P.R., C.A.B., A.G.M.), Rockville, MD; Northwestern University (E.E.G.), Chicago, IL; Minnesota Epilepsy Group (P.P.), Roseville; Emory University (E.G.), Atlanta, GA; University of Cincinnati (J.C.), OH; Northwell Health (S.T.H.), New Hyde Park, NY; University of Southern California (L.A.K.), Los Angeles; Wake Forest University Health Sciences (M.S.), Winston-Salem, NC; Columbia University (A.P.), New York; and University of Pittsburgh Medical Center (P.B.P.), PA
| | - Alison Pack
- From the Stanford University (S.T., K.J.M.), Palo Alto, CA; Emmes (C.P.R., C.A.B., A.G.M.), Rockville, MD; Northwestern University (E.E.G.), Chicago, IL; Minnesota Epilepsy Group (P.P.), Roseville; Emory University (E.G.), Atlanta, GA; University of Cincinnati (J.C.), OH; Northwell Health (S.T.H.), New Hyde Park, NY; University of Southern California (L.A.K.), Los Angeles; Wake Forest University Health Sciences (M.S.), Winston-Salem, NC; Columbia University (A.P.), New York; and University of Pittsburgh Medical Center (P.B.P.), PA
| | - Page B Pennell
- From the Stanford University (S.T., K.J.M.), Palo Alto, CA; Emmes (C.P.R., C.A.B., A.G.M.), Rockville, MD; Northwestern University (E.E.G.), Chicago, IL; Minnesota Epilepsy Group (P.P.), Roseville; Emory University (E.G.), Atlanta, GA; University of Cincinnati (J.C.), OH; Northwell Health (S.T.H.), New Hyde Park, NY; University of Southern California (L.A.K.), Los Angeles; Wake Forest University Health Sciences (M.S.), Winston-Salem, NC; Columbia University (A.P.), New York; and University of Pittsburgh Medical Center (P.B.P.), PA
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10
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Meador KJ, Stowe ZN, Brown CA, Robalino CP, Matthews AG, Kalayjian LA, Voinescu PE, Gerard EE, Penovich P, Gedzelman E, Cavitt J, Pennell PB. A Prospective Cohort Study of Depression During Pregnancy and the Postpartum Period in Women With Epilepsy vs Control Groups. Neurology 2022; 99:e1573-e1583. [PMID: 35977832 PMCID: PMC9559950 DOI: 10.1212/wnl.0000000000200958] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 05/25/2022] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE Assess the incidence and factors associated with major depressive episodes (MDE) and symptoms of depression and anxiety during pregnancy and postpartum periods in pregnant women with epilepsy (PWWE) compared to healthy pregnant women (HPW) and to non-pregnant women with epilepsy (NPWWE) in comparable timeframes. BACKGROUND Previous studies have reported higher rates of postpartum depression in women with epilepsy compared to women without epilepsy. However, the incidence of MDE using a structured interview during pregnancy and postpartum has not been directly compared to control groups, and the comparison of depression and anxiety symptoms and the role of associated factors remain ambiguous. DESIGN /Methods. The Maternal Outcomes and Neurodevelopmental Effects of Antiepileptic Drugs (MONEAD) study is a multicenter NIH-funded prospective observational parallel-group cohort study of PWWE and their children. This report examines mood disorders. Unlike prior epilepsy pregnancy studies, the Structured Clinical Interview for DSM-IV (SCID) provided lifetime diagnoses, and repeated SCID mood modules assessed for MDE, the a priori primary outcome. Symptoms of depression (Beck Depression Inventory (BDI), Edinburg Postnatal Depression Scale (EPDS)) and anxiety (Beck Anxiety Inventory (BAI)) were also assessed along with multiple clinical factors. RESULTS The study included PWWE (n=331) and HPW (n=102) during pregnancy and postpartum, and NPWWE (n=102) at comparable times. No difference in SCID-diagnosed MDE incidence was found across groups, but BDI depressive symptoms were worse during pregnancy in PWWE vs NPWWE, and during postpartum vs HPW and NPWWE. BAI anxiety symptoms were worse during pregnancy in PWWE vs HPW and NPWWE, and during postpartum vs HPW. Factors associated with MDE during pregnancy/postpartum for PWWE included >1 seizure/90 days, anticonvulsant polytherapy, unplanned pregnancy, and lifetime history of mood disorder. Suicidal ideation from BDI or EPDS was related to BAI anxiety symptoms. CONCLUSIONS Although SCID-based MDE did not differ across groups, this prospective study confirms higher rates of psychiatric symptoms in patients with epilepsy during pregnancy and postpartum, provides new data on associated factors, and underscores the importance of anxiety in risk for depression and thoughts of death/dying or suicide. Given the risks, PWWE should be routinely assessed, and symptomatic patients should be offered treatment.The study is registered at clinicaltrials.gov as NCT01730170.
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Calhoun JD, Aziz MC, Happ HC, Gunti J, Gleason C, Mohamed N, Zeng K, Hiller M, Bryant E, Mithal DS, Bellinski I, Kinsley L, Grimmel M, Schwaibold EMC, Smith-Hicks C, Chassevent A, Scala M, Accogli A, Torella A, Striano P, Capra V, Bird LM, Ben-Sahra I, Ekhilevich N, Hershkovitz T, Weiss K, Millichap J, Gerard EE, Carvill GL. mTORC1 functional assay reveals SZT2 loss-of-function variants and a founder in-frame deletion. Brain 2022; 145:1939-1948. [PMID: 35773235 PMCID: PMC9630660 DOI: 10.1093/brain/awab451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 10/27/2021] [Accepted: 11/19/2021] [Indexed: 11/14/2022] Open
Abstract
Biallelic pathogenic variants in SZT2 result in a neurodevelopmental disorder with shared features, including early-onset epilepsy, developmental delay, macrocephaly, and corpus callosum abnormalities. SZT2 is as a critical scaffolding protein in the amino acid sensing arm of the mTORC1 signalling pathway. Due to its large size (3432 amino acids), lack of crystal structure, and absence of functional domains, it is difficult to determine the pathogenicity of SZT2 missense and in-frame deletions, but these variants are increasingly detected and reported by clinical genetic testing in individuals with epilepsy. To exemplify this latter point, here we describe a cohort of 12 individuals with biallelic SZT2 variants and phenotypic overlap with SZT2-related neurodevelopmental disorders. However, the majority of individuals carried one or more SZT2 variants of uncertain significance (VUS), highlighting the need for functional characterization to determine, which, if any, of these VUS were pathogenic. Thus, we developed a novel individualized platform to identify SZT2 loss-of-function variants in the context of mTORC1 signalling and reclassify VUS. Using this platform, we identified a recurrent in-frame deletion (SZT2 p.Val1984del) which was determined to be a loss-of-function variant and therefore likely pathogenic. Haplotype analysis revealed that this single in-frame deletion is a founder variant in those of Ashkenazi Jewish ancestry. Moreover, this approach allowed us to tentatively reclassify all of the VUS in our cohort of 12 individuals, identifying five individuals with biallelic pathogenic or likely pathogenic variants. Clinical features of these five individuals consisted of early-onset seizures (median 24 months), focal seizures, developmental delay and macrocephaly similar to previous reports. However, we also show a widening of the phenotypic spectrum, as none of the five individuals had corpus callosum abnormalities, in contrast to previous reports. Overall, we present a rapid assay to resolve VUS in SZT2, identify a founder variant in individuals of Ashkenazi Jewish ancestry, and demonstrate that corpus callosum abnormalities is not a hallmark feature of this condition. Our approach is widely applicable to other mTORopathies including the most common causes of the focal genetic epilepsies, DEPDC5, TSC1/2, MTOR and NPRL2/3.
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Affiliation(s)
- Jeffrey D Calhoun
- Ken and Ruth Davee Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL 60610, USA
| | - Miriam C Aziz
- Ken and Ruth Davee Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL 60610, USA
| | - Hannah C Happ
- Ken and Ruth Davee Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL 60610, USA
| | - Jonathan Gunti
- Ken and Ruth Davee Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL 60610, USA
| | - Colleen Gleason
- Ken and Ruth Davee Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL 60610, USA
| | - Najma Mohamed
- Ken and Ruth Davee Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL 60610, USA
| | - Kristy Zeng
- Ken and Ruth Davee Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL 60610, USA
| | - Meredith Hiller
- Ken and Ruth Davee Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL 60610, USA
| | - Emily Bryant
- Ann and Robert H. Lurie Children's Hospital of Chicago Epilepsy Center and Division of Neurology, Chicago, IL 60610, USA
| | - Divakar S Mithal
- Ann and Robert H. Lurie Children's Hospital of Chicago Epilepsy Center and Division of Neurology, Chicago, IL 60610, USA
| | - Irena Bellinski
- Ken and Ruth Davee Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL 60610, USA
| | - Lisa Kinsley
- Ken and Ruth Davee Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL 60610, USA
| | - Mona Grimmel
- Ann & Robert H. Lurie Children's Hospital of Chicago, Department of Pediatrics, Epilepsy Center and Division of Neurology, Chicago, IL 60610, USA
| | - Eva M C Schwaibold
- Institute of Human Genetics, Heidelberg University, Heidelberg 69120, Germany
| | - Constance Smith-Hicks
- Department of Neurogenetics, Kennedy Krieger Institute, Baltimore, MD 21205, USA.,Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Anna Chassevent
- Department of Neurogenetics, Kennedy Krieger Institute, Baltimore, MD 21205, USA
| | - Marcello Scala
- Giannina Gaslini Children's Hospital, Genova, GE 16147, Italy.,Medical Genetic Unit, IRCCS Istituto G.Gaslini, 16147 Genoa, Italy
| | - Andrea Accogli
- Division of Medical Genetics, Department of Specialized Medicine, Montreal Children's Hospital, McGill University Health Centre (MUHC), Montreal, QC, H4A 3J1, Canada.,Department of Human Genetics, McGill University, Montreal, QC, Canada
| | - Annalaura Torella
- Division of Medical Genetics, Department of Specialized Medicine, Montreal Children's Hospital, McGill University Health Centre (MUHC), Montreal, QC, H4A 3J1, Canada
| | - Pasquale Striano
- Giannina Gaslini Children's Hospital, Genova, GE 16147, Italy.,Medical Genetic Unit, IRCCS Istituto G.Gaslini, 16147 Genoa, Italy
| | - Valeria Capra
- Giannina Gaslini Children's Hospital, Genova, GE 16147, Italy.,Medical Genetic Unit, IRCCS Istituto G.Gaslini, 16147 Genoa, Italy
| | - Lynne M Bird
- Department of Human Genetics, McGill University, Montreal, QC, Canada
| | - Issam Ben-Sahra
- Telethon Institute of Genetics and Medicine (TIGEM), Pozzuoli, NA 80078, Italy
| | - Nina Ekhilevich
- San Diego Department of Pediatrics and Rady Children's Hospital Division of Dysmorphology/Genetics, University of California, San Diego, CA 92161, USA
| | - Tova Hershkovitz
- San Diego Department of Pediatrics and Rady Children's Hospital Division of Dysmorphology/Genetics, University of California, San Diego, CA 92161, USA.,Department of Biochemistry and Molecular Genetics, Northwestern Feinberg School of Medicine, Chicago, IL 60610, USA
| | - Karin Weiss
- San Diego Department of Pediatrics and Rady Children's Hospital Division of Dysmorphology/Genetics, University of California, San Diego, CA 92161, USA.,Department of Biochemistry and Molecular Genetics, Northwestern Feinberg School of Medicine, Chicago, IL 60610, USA
| | - John Millichap
- Ken and Ruth Davee Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL 60610, USA.,Ann and Robert H. Lurie Children's Hospital of Chicago Epilepsy Center and Division of Neurology, Chicago, IL 60610, USA
| | - Elizabeth E Gerard
- Ken and Ruth Davee Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL 60610, USA
| | - Gemma L Carvill
- Ken and Ruth Davee Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL 60610, USA.,Genetics Institute, Rambam Medical Center, Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.,Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa 3200003, Israel
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Abstract
PURPOSE OF REVIEW Caring for women with epilepsy requires specialized knowledge about potential teratogenicity of antiseizure medications, interactions with hormonal contraception, and pregnancy outcomes. RECENT FINDINGS There has been an improvement in understanding the cognitive outcomes of infants exposed in utero in recent years. Folic acid supplementation helps mitigate the cognitive teratogenicity of antiseizure medications. Recent updates provide reassurance that seizure frequency tends to remain stable throughout pregnancy. There is conflicting evidence about the fecundity impact of epilepsy and antiseizure medications in women with epilepsy. SUMMARY Recent research highlights the importance of early counseling about the risks and interactions of contraception, pregnancy, and antiseizure medications. More research is needed to understand fertility in women with epilepsy.
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Affiliation(s)
- Alexa King
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Gerard EE. Family Ties: Reproductive Decision Making Among Members of Multiplex Epilepsy Families. Epilepsy Curr 2021; 21:344-345. [PMID: 34924831 PMCID: PMC8655248 DOI: 10.1177/15357597211032047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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15
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Meador KJ, Cohen MJ, Loring DW, May RC, Brown C, Robalino CP, Matthews AG, Kalayjian LA, Gerard EE, Gedzelman ER, Penovich PE, Cavitt J, Hwang S, Sam M, Pack AM, French J, Tsai JJ, Pennell PB. Two-Year-Old Cognitive Outcomes in Children of Pregnant Women With Epilepsy in the Maternal Outcomes and Neurodevelopmental Effects of Antiepileptic Drugs Study. JAMA Neurol 2021; 78:927-936. [PMID: 34096986 DOI: 10.1001/jamaneurol.2021.1583] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Importance The neurodevelopmental risks of fetal exposure are uncertain for many antiseizure medications (ASMs). Objective To compare children at 2 years of age who were born to women with epilepsy (WWE) vs healthy women and assess the association of maximum ASM exposure in the third trimester and subsequent cognitive abilities among children of WWE. Design, Setting, and Participants The Maternal Outcomes and Neurodevelopmental Effects of Antiepileptic Drugs (MONEAD) study is a prospective, observational, multicenter investigation of pregnancy outcomes that enrolled women from December 19, 2012, to January 13, 2016, at 20 US epilepsy centers. Children are followed up from birth to 6 years of age, with assessment at 2 years of age for this study. Of 1123 pregnant women assessed, 456 were enrolled; 426 did not meet criteria, and 241 chose not to participate. Data were analyzed from February 20 to December 4, 2020. Main Outcomes and Measures Language domain score according to the Bayley Scales of Infant and Toddler Development, Third Edition (BSID-III), which incorporates 5 domain scores (language, motor, cognitive, social-emotional, and general adaptive), and association between BSID-III language domain and ASM blood levels in the third trimester in children of WWE. Analyses were adjusted for multiple potential confounding factors, and measures of ASM exposure were assessed. Results The BSID-III assessments were analyzed in 292 children of WWE (median age, 2.1 [range, 1.9-2.5] years; 155 female [53.1%] and 137 male [46.9%]) and 90 children of healthy women (median age, 2.1 [range, 2.0-2.4] years; 43 female [47.8%] and 47 male [52.2%]). No differences were found between groups on the primary outcome of language domain (-0.5; 95% CI, -4.1 to 3.2). None of the other 4 BSID-III domains differed between children of WWE vs healthy women. Most WWE were taking lamotrigine and/or levetiracetam. Exposure to ASMs in children of WWE showed no association with the language domain. However, secondary analyses revealed that higher maximum observed ASM levels in the third trimester were associated with lower BSID-III scores for the motor domain (-5.6; 95% CI, -10.7 to -0.5), and higher maximum ASM doses in the third trimester were associated with lower scores in the general adaptive domain (-1.4; 95% CI, -2.8 to -0.05). Conclusions and Relevance Outcomes of children at 2 years of age did not differ between children of WWE taking ASMs and children of healthy women. Trial Registration ClinicalTrials.gov Identifier: NCT01730170.
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Affiliation(s)
- Kimford J Meador
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Palo Alto, California
| | - Morris J Cohen
- Pediatric Neuropsychology International, Augusta, Georgia
| | - David W Loring
- Department of Neurology, Emory University, Atlanta, Georgia
| | | | | | | | | | - Laura A Kalayjian
- Department of Neurology, University of Southern California, Los Angeles
| | | | | | | | - Jennifer Cavitt
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio
| | | | - Maria Sam
- Department of Neurology, Wake Forest University, Winston-Salem, North Carolina
| | - Alison M Pack
- Department of Neurology, Columbia University, New York, New York
| | | | - Jeffrey J Tsai
- Department of Neurology, University of Washington, Seattle
| | - Page B Pennell
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Gerard EE. What Should We Do When the Kids Grow Up? Studying the Long-Term Cognitive Effects of In-Utero Anti-Seizure Medication Exposure. Epilepsy Curr 2021; 21:165-167. [PMID: 34867094 PMCID: PMC8609582 DOI: 10.1177/15357597211005477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Enduring Language Deficits in Children of Women With Epilepsy and the Potential Role of Intrauterine Exposure to Antiepileptic Drugs Unnikrishnan G, Jacob NS, Salim S, et al. Epilepsia . 2020;61(11):2442-2451. doi:10.1111/epi.16685 Objective: Exposure to certain intrauterine antiepileptic drugs (AEDs) can negatively influence the language skills and intelligence of young children. It remains unanswered whether these deficits are transient or persist as children grow up. This study aims to evaluate the language function of children of women with epilepsy (CWE) aged 9 to 13 years in comparison with their peers, and its relationship with intrauterine AED exposure. Methods: We included 191 CWE in our study from the Kerala Registry of Epilepsy and Pregnancy. Children in the same age group (n = 144) and without maternal epilepsy or antenatal AED exposure served as controls. We used Clinical Examination for Language Function version IV to assess language in both groups. Relevant data related to maternal epilepsy and AED use were obtained from the registry records. Results: The average Core Language Scaled Score (CLSS) was significantly lower in CWE as compared to controls (83.19 vs 90.18, P = .001). Similarly, the mean scaled scores in other language parameters were also significantly lower in CWE. In the multivariate analysis, compared to control children, the average CLSS in CWE was 4.5 units lower (95% CI = −8.8 to −0.2, P = .04) with AED monotherapy exposure and 7.3 units lower with exposure to AED polytherapy (95% CI = −13.8 to −0.8, P = .03). Intrauterine exposure to phenobarbitone (n = 61) and valproate (n = 55) as either monotherapy or polytherapy showed a negative effect on CLSS in CWE as compared to control children. However, carbamazepine (n = 75) and phenytoin (n = 37) use was not associated with significant variation of CLSS. In head-to-head comparisons between AED monotherapies in CWE, phenobarbitone showed a negative effect on CLSS (−14.7, 95% CI = −23.1 to −6.4, P = .001) as compared to carbamazepine. Significance: Intrauterine exposure to phenobarbitone and valproate impairs language development in CWE, with effects persisting into the second decade.
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Mikhaeil-Demo Y, Holmboe E, Gerard EE, Wayne DB, Cohen ER, Yamazaki K, Templer JW, Bega D, Culler GW, Bhatt AB, Shafi N, Barsuk JH. Simulation-Based Assessments and Graduating Neurology Residents' Milestones: Status Epilepticus Milestones. J Grad Med Educ 2021; 13:223-230. [PMID: 33897956 PMCID: PMC8054597 DOI: 10.4300/jgme-d-20-00832.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 10/05/2020] [Accepted: 01/06/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The American Board of Psychiatry and Neurology and the Accreditation Council for Graduate Medical Education (ACGME) developed Milestones that provide a framework for residents' assessment. However, Milestones do not provide a description for how programs should perform assessments. OBJECTIVES We evaluated graduating residents' status epilepticus (SE) identification and management skills and how they correlate with ACGME Milestones reported for epilepsy and management/treatment by their program's clinical competency committee (CCC). METHODS We performed a cohort study of graduating neurology residents from 3 academic medical centers in Chicago in 2018. We evaluated residents' skills identifying and managing SE using a simulation-based assessment (26-item checklist). Simulation-based assessment scores were compared to experience (number of SE cases each resident reported identifying and managing during residency), self-confidence in identifying and managing these cases, and their end of residency Milestones assigned by a CCC based on end-of-rotation evaluations. RESULTS Sixteen of 21 (76%) eligible residents participated in the study. Average SE checklist score was 15.6 of 26 checklist items correct (60%, SD 12.2%). There were no significant correlations between resident checklist performance and experience or self-confidence. The average participant's level of Milestone for epilepsy and management/treatment was high at 4.3 of 5 (SD 0.4) and 4.4 of 5 (SD 0.4), respectively. There were no significant associations between checklist skills performance and level of Milestone assigned. CONCLUSIONS Simulated SE skills performance of graduating neurology residents was poor. Our study suggests that end-of-rotation evaluations alone are inadequate for assigning Milestones for high-stakes clinical skills such as identification and management of SE.
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Affiliation(s)
- Yara Mikhaeil-Demo
- Yara Mikhaeil-Demo, MD, is Assistant Professor, Department of Neurology, Northwestern University, Feinberg School of Medicine
| | - Eric Holmboe
- Eric Holmboe, MD, MACP, FRCP, is Chief Research, Milestone Development, and Evaluation Officer, Accreditation Council for Graduate Medical Education (ACGME)
| | - Elizabeth E. Gerard
- Elizabeth E. Gerard, MD, is Director, Clinical Neurophysiology Fellowship, and Associate Professor, Department of Neurology, Northwestern University, Feinberg School of Medicine
| | - Diane B. Wayne
- Diane B. Wayne, MD, is Vice Dean for Education, Chair, Department of Medical Education, and Professor of Medicine and Medical Education, Northwestern University, Feinberg School of Medicine
| | - Elaine R. Cohen
- Elaine R. Cohen, MEd, is Research Associate, Department of Medicine, Northwestern University, Feinberg School of Medicine
| | - Kenji Yamazaki
- Kenji Yamazaki, PhD, is Senior Analyst, Milestones Research and Evaluation, ACGME
| | - Jessica W. Templer
- Jessica W. Templer, MD, is Director, Epilepsy Fellowship, and Assistant Professor, Department of Neurology, Northwestern University, Feinberg School of Medicine
| | - Danny Bega
- Danny Bega, MD, is Director, Neurology Residency Program, and Assistant Professor, Department of Neurology, Northwestern University, Feinberg School of Medicine
| | - George W. Culler
- George W. Culler, MD, is Epilepsy Fellow, Department of Neurology, Northwestern University, Feinberg School of Medicine
| | - Amar B. Bhatt
- Amar B. Bhatt, MD, is Assistant Professor, Department of Neurological Sciences, Rush University
| | - Neelofer Shafi
- Neelofer Shafi, MD, is Director, Students and Faculty Development, and Assistant Professor, Department of Neurology and Rehabilitation, University of Illinois Chicago
| | - Jeffrey H. Barsuk
- Jeffrey H. Barsuk, MD, MS, is Director, Simulation and Patient Safety, and Professor of Medicine and Medical Education, Northwestern University, Feinberg School of Medicine
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Hirsch LJ, Fong MW, Leitinger M, LaRoche SM, Beniczky S, Abend NS, Lee JW, Wusthoff CJ, Hahn CD, Westover MB, Gerard EE, Herman ST, Haider HA, Osman G, Rodriguez-Ruiz A, Maciel CB, Gilmore EJ, Fernandez A, Rosenthal ES, Claassen J, Husain AM, Yoo JY, So EL, Kaplan PW, Nuwer MR, van Putten M, Sutter R, Drislane FW, Trinka E, Gaspard N. American Clinical Neurophysiology Society's Standardized Critical Care EEG Terminology: 2021 Version. J Clin Neurophysiol 2021; 38:1-29. [PMID: 33475321 PMCID: PMC8135051 DOI: 10.1097/wnp.0000000000000806] [Citation(s) in RCA: 308] [Impact Index Per Article: 102.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Affiliation(s)
- Lawrence J. Hirsch
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, Connecticut, U.S.A
| | - Michael W.K. Fong
- Westmead Comprehensive Epilepsy Unit, Westmead Hospital, University of Sydney, Sydney, Australia
| | - Markus Leitinger
- Department of Neurology, Christian Doppler Klinik, Paracelsus Medical University, Salzburg, Austria
| | - Suzette M. LaRoche
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, U.S.A
| | - Sandor Beniczky
- Department of Clinical Neurophysiology, Danish Epilepsy Center, Dianalund and Aarhus University Hospital, Aarhus, Denmark
| | - Nicholas S. Abend
- Departments of Neurology and Pediatrics, The Children’s Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Jong Woo Lee
- Brigham and Women’s Hospital, Boston, Massachusetts, U.S.A
| | | | - Cecil D. Hahn
- Division of Neurology, The Hospital for Sick Children, and Department of Pediatrics, University of Toronto, Toronto, Canada
| | | | - Elizabeth E. Gerard
- Comprehensive Epilepsy Center, Department of Neurology, Northwestern University, Chicago, Illinois, U.S.A
| | | | - Hiba Arif Haider
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, U.S.A
| | - Gamaleldin Osman
- Department of Neurology, Henry Ford Hospital, Detroit, Michigan, U.S.A
| | - Andres Rodriguez-Ruiz
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, U.S.A
| | - Carolina B. Maciel
- Division of Neurocritical Care, Department of Neurology, University of Florida, Gainesville, Florida, U.S.A
| | - Emily J. Gilmore
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, Connecticut, U.S.A
| | - Andres Fernandez
- Department of Neurology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, U.S.A
| | - Eric S. Rosenthal
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Jan Claassen
- Neurocritical Care, Department of Neurology, Columbia University, New York, New York, U.S.A
| | - Aatif M. Husain
- Department of Medicine (Neurology), Duke University Medical Center, and Veterans Affairs Medical Center, Durham, North Carolina, U.S.A
| | - Ji Yeoun Yoo
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, U.S.A
| | - Elson L. So
- Division of Epilepsy, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Peter W. Kaplan
- Department of Neurology, Johns Hopkins University School of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland, U.S.A
| | - Marc R. Nuwer
- Department of Neurology, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California, U.S.A
| | - Michel van Putten
- Medisch Spectrum Twente and University of Twente, Enschede, The Netherlands
| | - Raoul Sutter
- Medical Intensive Care Units and Department of Neurology, University Hospital Basel, Basel, Switzerland
| | - Frank W. Drislane
- Department of Neurology, Harvard Medical School, and Comprehensive Epilepsy Center, Beth Israel Deaconess Medical Center, Boston, Massachusetts, U.S.A
| | - Eugen Trinka
- Department of Neurology, Christian Doppler Klinik, Paracelsus Medical University, Salzburg, Austria
| | - Nicolas Gaspard
- Department of Neurology, Université Libre de Bruxelles, Hôpital Erasme, Brussels, Belgium
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Abstract
OBJECTIVE The objective of the study was to describe the effect of the vaginal ring and transdermal patch on lamotrigine serum levels in women with epilepsy. BACKGROUND Previous studies demonstrate that oral hormonal contraceptives containing synthetic estrogen increase lamotrigine clearance through induction of glucuronidation. This leads to variable lamotrigine serum concentrations throughout monthly cycles in women who are on combined oral contraceptives (COCs). The effects of estrogen-containing nonoral hormonal contraceptive methods, including the vaginal ring and transdermal patch, on lamotrigine pharmacokinetics are not well described. METHODS Retrospective chart review was performed to identify serum lamotrigine levels drawn from women with epilepsy while on the active phase of vaginal ring or transdermal patch and while off contraception. Wilcoxon signed-rank tests for paired data were used to compare the difference in dose-corrected lamotrigine concentration in plasma between values while on hormonal contraception to those while off contraception in patients using a vaginal ring. RESULTS Six patients were using the vaginal ring, and one patient was using the transdermal patch. Lamotrigine dose-corrected concentrations were decreased during the active phase of the vaginal ring compared with concentrations during the period off contraception (p = .04). There was one patient without a decrease in concentration, but the other five patients on the vaginal ring had a decrease in dose-corrected lamotrigine concentration ranging from 36 to 70% while on the vaginal ring. Similarly, one patient using the transdermal patch had a decrease of 37% in dose-corrected lamotrigine concentration while on the patch. CONCLUSIONS The findings support that the vaginal ring contraceptive method decreases lamotrigine concentrations during the active phase of treatment. This has important implications for contraceptive counseling and maintaining therapeutic levels in women of childbearing age with epilepsy.
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Affiliation(s)
- Alexa King
- Department of Neurology, Feinberg School of Medicine, Northwestern University, 710 N. Lakeshore Drive, Chicago, IL 60611, USA
| | - Elizabeth Bachman
- Department of Neurology, Feinberg School of Medicine, Northwestern University, 710 N. Lakeshore Drive, Chicago, IL 60611, USA
| | - Micheal P Macken
- Department of Neurology, Feinberg School of Medicine, Northwestern University, 710 N. Lakeshore Drive, Chicago, IL 60611, USA
| | - Jungwha Lee
- Biostatistics Collaboration Center, Northwestern University Feinberg School of Medicine, 680 North Lake Shore Drive, Suite 1400, Chicago, IL 60611, USA
| | - Elizabeth E Gerard
- Department of Neurology, Feinberg School of Medicine, Northwestern University, 710 N. Lakeshore Drive, Chicago, IL 60611, USA.
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20
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Mikhaeil-Demo Y, Barsuk JH, Culler GW, Bega D, Salzman DH, Cohen ER, Templer JW, Gerard EE. Use of a simulation-based mastery learning curriculum for neurology residents to improve the identification and management of status epilepticus. Epilepsy Behav 2020; 111:107247. [PMID: 32603805 DOI: 10.1016/j.yebeh.2020.107247] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Revised: 06/06/2020] [Accepted: 06/06/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Appropriate and timely treatment of status epilepticus (SE) decreases morbidity and mortality. Therefore, skill-based training in the identification and management of SE is crucial for clinicians. OBJECTIVE The objective of the study was to develop and evaluate the impact of a simulation-based mastery learning (SBML) curriculum to train neurology residents on the identification and management of SE. METHODS We used pretest-posttest design with a retention test on SE skills for this study. Neurology residents in the second postgraduate year (PGY-2) were eligible to participate in the SE SBML curriculum. Learners completed a baseline-simulated SE skills assessment (pretest) using a 26-item dichotomous skills checklist. Next, they participated in a didactic session about the identification and management of SE, followed by deliberate skills practice. Subsequently, participants completed another skills assessment (posttest) using the same 26-item checklist. All participants were required to meet or exceed a minimum passing standard (MPS) determined by a panel of 14 SE experts using the Mastery Angoff standard setting method. After meeting the MPS at posttest, participants were reassessed during an unannounced in situ simulation session on the medical wards. We compared pretest with posttest simulated SE skills performance and posttest with reassessment in situ performance. RESULTS The MPS was set at 88% (23/26) checklist items correct. Sixteen neurology residents participated in the intervention. Participant performance improved from a median of 44.23% (Interquartile range (IQR): 34.62-55.77) at pretest to 94.23% (IQR: 92.13-100) at the posttest after SBML (p < .001). There was no significant difference in scores between the posttest and in situ test up to 8 months later (94.23%; IQR: 92.31-100 vs. 92.31%; IQR: 88.46-96.15; p = .13). CONCLUSIONS Our SBML curriculum significantly improved residents' SE identification and management skills that were largely retained during an unannounced simulated encounter in the hospital setting.
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Affiliation(s)
- Yara Mikhaeil-Demo
- Department of Neurology, University of Illinois, Chicago, IL; Department of Medical Education, Northwestern University, Feinberg School of Medicine, Chicago, IL..
| | - Jeffrey H Barsuk
- Department of Medical Education, Northwestern University, Feinberg School of Medicine, Chicago, IL.; Department of Medicine, Northwestern University, Feinberg School of Medicine, Chicago, IL
| | - George W Culler
- Department of Neurology, Northwestern University, Feinberg School of Medicine, Chicago, IL
| | - Danny Bega
- Department of Neurology, Northwestern University, Feinberg School of Medicine, Chicago, IL
| | - David H Salzman
- Department of Medical Education, Northwestern University, Feinberg School of Medicine, Chicago, IL.; Department of Emergency Medicine, Northwestern University, Feinberg School of Medicine, Chicago, IL
| | - Elaine R Cohen
- Department of Medicine, Northwestern University, Feinberg School of Medicine, Chicago, IL
| | - Jessica W Templer
- Department of Neurology, Northwestern University, Feinberg School of Medicine, Chicago, IL
| | - Elizabeth E Gerard
- Department of Neurology, Northwestern University, Feinberg School of Medicine, Chicago, IL
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21
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Birnbaum AK, Meador KJ, Karanam A, Brown C, May RC, Gerard EE, Gedzelman ER, Penovich PE, Kalayjian LA, Cavitt J, Pack AM, Miller JW, Stowe ZN, Pennell PB. Antiepileptic Drug Exposure in Infants of Breastfeeding Mothers With Epilepsy. JAMA Neurol 2020; 77:441-450. [PMID: 31886825 DOI: 10.1001/jamaneurol.2019.4443] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Importance There is limited information on infant drug exposure via breastfeeding by mothers who are receiving antiepileptic drug therapy. Objective To provide direct, objective information on antiepileptic drug exposure through breast milk. Design, Setting, and Participants This prospective cohort study was conducted between December 2012 to October 2016, with follow-up in children until 6 years of age at 20 sites across the United States. Data were collected via an observational multicenter investigation (Maternal Outcomes and Neurodevelopmental Effects of Antiepileptic Drugs [MONEAD]) of outcomes in pregnant mothers with epilepsy and their children. Pregnant women with epilepsy who were aged 14 to 45 years, had pregnancies that had progressed to less than 20 weeks' gestational age, and had measured IQ scores of more than 70 points were enrolled and followed up through pregnancy and 9 postpartum months. Their infants were enrolled at birth. Data were analyzed from May 2014 to August 2019. Exposures Antiepileptic drug exposure in infants who were breastfed. Main Outcomes and Measures The percentage of infant-to-mother concentration of antiepileptic drugs. Antiepileptic drug concentrations were quantified from blood samples collected from infants and mothers at the same visit, 5 to 20 weeks after birth. Concentrations of antiepileptic drugs in infants at less than the lower limit of quantification were assessed as half of the lower limit. Additional measures collected were the total duration of all daily breastfeeding sessions and/or the volume of pumped breast milk ingested from a bottle. Results A total of 351 women (of 865 screened and 503 eligible individuals) were enrolled, along with their 345 infants (179 female children [51.9%]; median [range] age, 13 [5-20] weeks). Of the 345 infants, 222 (64.3%) were breastfed; the data collection yielded 164 matching infant-mother concentration pairs from 138 infants. Approximately 49% of all antiepileptic drug concentrations in nursing infants were less than the lower limit of quantification. The median percentage of infant-to-mother concentration for all 7 antiepileptic drugs and 1 metabolite (carbamazepine, carbamazepine-10,11-epoxide, levetiracetam, lamotrigine, oxcarbazepine, topiramate, valproate, and zonisamide) ranged from 0.3% (range, 0.2%-0.9%) to 44.2% (range, 35.2%-125.3%). In multiple linear regression models, maternal concentration was a significant factor associated with lamotrigine concentration in infants (Pearson correlation coefficient, 0.58; P < .001) but not levetiracetam concentration in infants. Conclusions and Relevance Overall, antiepileptic drug concentrations in blood samples of infants who were breastfed were substantially lower than maternal blood concentrations. Given the well-known benefits of breastfeeding and the prior studies demonstrating no ill effects when the mother was receiving antiepileptic drugs, these findings support the breastfeeding of infants by mothers with epilepsy who are taking antiepileptic drug therapy.
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Affiliation(s)
- Angela K Birnbaum
- Experimental & Clinical Pharmacology, University of Minnesota, Minneapolis
| | - Kimford J Meador
- Department of Neurology & Neurological Sciences, Stanford University, Stanford, California
| | - Ashwin Karanam
- Experimental & Clinical Pharmacology, University of Minnesota, Minneapolis
| | | | - Ryan C May
- The Emmes Corporation, Rockville, Maryland
| | | | | | | | - Laura A Kalayjian
- Department of Neurology, University of Southern California, Los Angeles
| | | | | | - John W Miller
- Department of Neurology, University of Washington, Seattle.,Department of Neurological Surgery, University of Washington, Seattle
| | - Zachary N Stowe
- Department of Psychiatry, University of Wisconsin at Madison, Madison
| | - Page B Pennell
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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22
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Pavlova M, Gerard EE, Cascino GD. Patients with generalized epilepsy are also at risk for SUDEP. Neurology 2020; 94:689-690. [DOI: 10.1212/wnl.0000000000009286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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23
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Abstract
PURPOSE OF REVIEW This article reviews epilepsy emergencies, including status epilepticus, acute repetitive seizures, autoimmune encephalitis, and the current perspective on their diagnosis and treatment. RECENT FINDINGS Recent guidelines on the treatment of status epilepticus from the Neurocritical Care Society in 2012 and the American Epilepsy Society in 2016 highlight areas of consensus in the treatment of status epilepticus as well as areas of uncertainty. The TRENdS (Treatment of Recurrent Electrographic Nonconvulsive Seizures) trial is the first prospective randomized clinical trial to evaluate the efficacy of IV antiseizure medications in controlling nonconvulsive seizures on continuous EEG. It demonstrated that IV lacosamide is noninferior to fosphenytoin in this setting. Autoimmune encephalitis is an increasingly recognized cause of new-onset seizures or status epilepticus. Recently described scoring systems, the Antibody Prevalence in Epilepsy score and the Response to Immunotherapy in Epilepsy score, can help in the assessment of autoimmune encephalitis. SUMMARY Status epilepticus, acute repetitive seizures, and autoimmune encephalitis are neurologic emergencies. For all these conditions, rapid and appropriate treatment may influence patient prognosis and mitigate neuronal injury. For convulsive status epilepticus, there is reasonable consensus on the initial steps that need to be taken. There is less agreement about the management of acute repetitive seizures and nonconvulsive status epilepticus. An increasingly recognized etiology of status epilepticus is autoimmune encephalitis, which may not be as rare as previously thought.
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24
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Husain AM, Lee JW, Kolls BJ, Hirsch LJ, Halford JJ, Gupta PK, Minazad Y, Jones JM, LaRoche SM, Herman ST, Swisher CB, Sinha SR, Palade A, Dombrowski KE, Gallentine WB, Hahn CD, Gerard EE, Bhapkar M, Lokhnygina Y, Westover MB. Randomized trial of lacosamide versus fosphenytoin for nonconvulsive seizures. Ann Neurol 2019; 83:1174-1185. [PMID: 29733464 DOI: 10.1002/ana.25249] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Revised: 04/25/2018] [Accepted: 04/25/2018] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The optimal treatment of nonconvulsive seizures in critically ill patients is uncertain. We evaluated the comparative effectiveness of the antiseizure drugs lacosamide (LCM) and fosphenytoin (fPHT) in this population. METHODS The TRENdS (Treatment of Recurrent Electrographic Nonconvulsive Seizures) study was a noninferiority, prospective, multicenter, randomized treatment trial of patients diagnosed with nonconvulsive seizures (NCSs) by continuous electroencephalography (cEEG). Treatment was randomized to intravenous (IV) LCM 400mg or IV fPHT 20mg phenytoin equivalents/kg. The primary endpoint was absence of electrographic seizures for 24 hours as determined by 1 blinded EEG reviewer. The frequency with which NCS control was achieved in each arm was compared, and the 90% confidence interval (CI) was determined. Noninferiority of LCM to fPHT was to be concluded if the lower bound of the CI for relative risk was >0.8. RESULTS Seventy-four subjects were enrolled (37 LCM, 37 fPHT) between August 21, 2012 and December 20, 2013. The mean age was 63.6 years; 38 were women. Seizures were controlled in 19 of 30 (63.3%) subjects in the LCM arm and 16 of 32 (50%) subjects in the fPHT arm. LCM was noninferior to fPHT (p = 0.02), with a risk ratio of 1.27 (90% CI = 0.88-1.83). Treatment emergent adverse events (TEAEs) were similar in both arms, occurring in 9 of 35 (25.7%) LCM and 9 of 37 (24.3%) fPHT subjects (p = 1.0). INTERPRETATION LCM was noninferior to fPHT in controlling NCS, and TEAEs were comparable. LCM can be considered an alternative to fPHT in the treatment of NCSs detected on cEEG. Ann Neurol 2018;83:1174-1185.
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Affiliation(s)
- Aatif M Husain
- Department of Neurology, Duke University Medical Center, Durham, NC.,Neurodiagnostic Center, Veterans Affairs Medical Center, Durham, NC.,Duke Clinical Research Institute, Durham, NC
| | - Jong W Lee
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Bradley J Kolls
- Department of Neurology, Duke University Medical Center, Durham, NC.,Duke Clinical Research Institute, Durham, NC
| | - Lawrence J Hirsch
- Department of Neurology, Yale University School of Medicine, New Haven, CT
| | - Jonathan J Halford
- Department of Neurology, Medical University of South Carolina, Charleston, SC
| | - Puneet K Gupta
- Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas, TX
| | - Yafa Minazad
- Neurosciences Center, Huntington Memorial Hospital, Pasadena, CA
| | | | - Suzette M LaRoche
- Department of Neurology, Mission Health, Asheville, NC.,Department of Neurology, Emory University, Atlanta, GA
| | - Susan T Herman
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | | | - Saurabh R Sinha
- Department of Neurology, Duke University Medical Center, Durham, NC.,Neurodiagnostic Center, Veterans Affairs Medical Center, Durham, NC
| | - Adriana Palade
- Department of Neurology, University of Louisville, Louisville, KY
| | - Keith E Dombrowski
- Department of Neurology, Duke University Medical Center, Durham, NC.,Neurodiagnostic Center, Veterans Affairs Medical Center, Durham, NC
| | - William B Gallentine
- Department of Pediatrics (Neurology), Duke University Medical Center, Durham, NC
| | - Cecil D Hahn
- Division of Neurology, Hospital for Sick Children and Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Elizabeth E Gerard
- Department of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | | | - Yuliya Lokhnygina
- Duke Clinical Research Institute, Durham, NC.,Department of Biostatistics and Bioinformatics, Duke University, Durham, NC
| | - M Brandon Westover
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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25
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Nobis WP, González Otárula KA, Templer JW, Gerard EE, VanHaerents S, Lane G, Zhou G, Rosenow JM, Zelano C, Schuele S. The effect of seizure spread to the amygdala on respiration and onset of ictal central apnea. J Neurosurg 2019; 132:1313-1323. [PMID: 30952127 DOI: 10.3171/2019.1.jns183157] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 01/14/2019] [Indexed: 01/07/2023]
Abstract
OBJECTIVE Sudden unexpected death in epilepsy (SUDEP) is the leading cause of death for patients with refractory epilepsy, and there is increasing evidence for a centrally mediated respiratory depression as a pathophysiological mechanism. The brain regions responsible for a seizure's inducing respiratory depression are unclear-the respiratory nuclei in the brainstem are thought to be involved, but involvement of forebrain structures is not yet understood. The aim of this study was to analyze intracranial EEGs in combination with the results of respiratory monitoring to investigate the relationship between seizure spread to specific mesial temporal brain regions and the onset of respiratory dysfunction and apnea. METHODS The authors reviewed all invasive electroencephalographic studies performed at Northwestern Memorial Hospital (Chicago) since 2010 to identify those cases in which 1) multiple mesial temporal electrodes (amygdala and hippocampal) were placed, 2) seizures were captured, and 3) patients' respiration was monitored. They identified 8 investigations meeting these criteria in patients with temporal lobe epilepsy, and these investigations yielded data on a total of 22 seizures for analysis. RESULTS The onset of ictal apnea associated with each seizure was highly correlated with seizure spread to the amygdala. Onset of apnea occurred 2.7 ± 0.4 (mean ± SEM) seconds after the spread of the seizure to the amygdala, which was significantly earlier than after spread to the hippocampus (10.2 ± 0.7 seconds; p < 0.01). CONCLUSIONS The findings suggest that activation of amygdalar networks is correlated with central apnea during seizures. This study builds on the authors' prior work that demonstrates a role for the amygdala in voluntary respiratory control and suggests a further role in dysfunctional breathing states seen during seizures, with implications for SUDEP pathophysiology.
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Affiliation(s)
- William P Nobis
- 1Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee; and.,Departments of2Neurology and
| | | | | | | | | | | | | | - Joshua M Rosenow
- 3Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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26
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Abstract
OBJECTIVE To understand the frequency of electrographic and clinical seizures in patients with stroke-like migraine attacks after radiation therapy (SMART), and determine whether SMART warrants comprehensive electroencephalographic (EEG) monitoring and aggressive seizure management. METHODS We searched our magnetic resonance brain imaging report database for all patients between January 2013 and December 2015 for suspected SMART syndrome. Clinical inclusion criteria were further applied as follows: inpatient adults (>18 years of age) with history of cranial radiation presenting with acute neurologic deficits as primary admission reason who lacked evidence of recurrent or new brain malignancy, stroke, or infectious agents in cerebrospinal fluid. Six patients were identified. All 6 patients underwent prolonged video EEG monitoring as part of our standard protocol. RESULTS All patients but 1 were found to have multiple or prolonged electrographic seizures consistent with status epilepticus during video EEG monitoring. Their neurological deficit and/or mental status change improved in parallel with resolution of the seizure activity. SIGNIFICANCE SMART is likely a misnomer that underestimates the significance of seizures and status epilepticus in the pathophysiology and clinical presentation of the syndrome. Systematic continuous EEG monitoring and appropriate seizure management is warranted to reduce symptom duration and optimize clinical outcome.
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Affiliation(s)
- Emily Peien Fan
- Department of Neurology, Northwestern Memorial Hospital, Chicago, IL, USA
| | - Gabriel Heiber
- Department of Psychiatry, Northwestern Memorial Hospital, Chicago, IL, USA
| | - Elizabeth E Gerard
- Department of Neurology, Northwestern Memorial Hospital, Chicago, IL, USA
| | - Stephan Schuele
- Department of Neurology, Northwestern Memorial Hospital, Chicago, IL, USA
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27
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Mikhaeil-Demo Y, Gavvala JR, Bellinski II, Macken MP, Narechania A, Templer JW, VanHaerents S, Schuele SU, Gerard EE. Clinical classification of post anoxic myoclonic status. Resuscitation 2017; 119:76-80. [DOI: 10.1016/j.resuscitation.2017.07.035] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Revised: 07/17/2017] [Accepted: 07/31/2017] [Indexed: 11/26/2022]
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Espinera AR, Gavvala J, Bellinski I, Kennedy J, Macken MP, Narechania A, Templer J, VanHaerents S, Schuele SU, Gerard EE. Counseling by epileptologists affects contraceptive choices of women with epilepsy. Epilepsy Behav 2016; 65:1-6. [PMID: 27829186 DOI: 10.1016/j.yebeh.2016.08.021] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Accepted: 08/20/2016] [Indexed: 11/25/2022]
Abstract
INTRODUCTION There are several important interactions between antiepileptic drugs (AEDs) and hormonal contraception that need to be carefully considered by women with epilepsy (WWE) and their practitioners. Many AEDs induce hepatic enzymes and decrease the efficacy of hormonal contraception. In addition, estrogen-containing hormonal contraception can increase the metabolism of lamotrigine, the most commonly prescribed AED in women of childbearing age. The intrauterine device (IUD) is a highly effective form of reversible contraception without AED drug interactions that is considered by many to be the contraceptive of choice for WWE. Women with epilepsy not planning pregnancy require effective contraceptive counseling that should include discussion of an IUD. There are no guidelines, however, on who should deliver these recommendations. The objective of this study was to explore the hypothesis that contraceptive counseling by a neurologist can influence the contraceptive choices of WWE. In particular, we explored the relationship between contraceptive counseling in the epilepsy clinic and the likelihood that patients would obtain an IUD. METHODS We conducted a retrospective chart review of female patients age 18-45 seen at our institution for an initial visit between 2010 and 2014 to ascertain the type of contraceptive counseling each patient received as well as AED use and contraceptive methods. Patients who were pregnant or planning pregnancy at the first visit were excluded from further analyses as were patients with surgical sterilization. We also examined a subgroup of 95 patients with at least 4 follow-up visits to evaluate the efficacy of epileptologists' counseling. Specifically, we looked at the likelihood a patient obtained an IUD based on the type of counseling she had received. Fisher exact tests assessed associations between counseling type and whether patients had obtained an IUD. RESULTS Three hundred and ninety-seven women met criteria for inclusion. Only 35% of female patients were counseled about contraception at the first visit. If women were not counseled at the first visit, they were unlikely to be counseled at subsequent visits; only 37% had ever received counseling by their fourth visit. Of the 95 patients who completed 4 visits, 28.4% were counseled about an IUD as an optimal contraceptive choice, 38.9% were generally counseled about contraceptive interactions, and 32.6% were not counseled about contraception. Women with epilepsy who received IUD-specific counseling were significantly more likely to switch to an IUD (44.4%) compared with women who received no contraceptive counseling (6.5%; p=0.0009). Women with epilepsy who received IUD-specific counseling also tended to switch to an IUD more often than those women receiving general counseling about AEDs and contraceptive interactions (18.9%; p=0.027). There was no significant difference in the likelihood of acquiring an IUD between the general counseling and no counseling groups. CONCLUSIONS Contraceptive counseling by epileptologists and specific mention of an IUD is significantly associated with patient selection of an IUD as a contraceptive method. This suggests that neurologists can play an important role in patients' contraceptive choices.
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Affiliation(s)
- Alyssa R Espinera
- Department of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Jay Gavvala
- Department of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Irena Bellinski
- Department of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Jeffrey Kennedy
- Department of Neurology, University of California, Davis, CA, USA
| | - Micheal P Macken
- Department of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Aditi Narechania
- Department of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Jessica Templer
- Department of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Stephen VanHaerents
- Department of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Stephan U Schuele
- Department of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Elizabeth E Gerard
- Department of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
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Abstract
PURPOSE OF REVIEW Caring for a woman with epilepsy requires familiarity with the implications of antiepileptic drugs (AEDs) for pregnancy and contraception as well as an understanding of the effects of female hormones on epilepsy. RECENT FINDINGS AED pregnancy registries and prospective studies of cognitive development continue to confirm that valproate poses a significantly increased risk of structural and cognitive teratogenesis. In contrast, data thus far suggest that lamotrigine and levetiracetam are associated with a relatively low risk for both anatomic and developmental adverse effects, although further studies are needed for these and other AEDs. The intrauterine device is a good contraceptive option for many women with epilepsy as it is highly effective and not subject to the drug-drug interactions seen between hormonal contraception and many AEDs. Hormonal-sensitive seizures are common among women with epilepsy; however, highly effective treatments for refractory catamenial seizures are limited. SUMMARY Women with epilepsy should be counseled early and regularly about reproductive health as it relates to epilepsy. AED selection for women of childbearing age should take future pregnancies and contraceptive needs into consideration.
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Abstract
Antiepileptic drugs (AEDs) are prescribed commonly to women of childbearing age. In utero exposure to some AEDs can have significant cognitive and behavioral consequences for the unborn child. Recently, prospective studies of women taking AEDs during pregnancy have added significantly to our understanding of cognitive and behavioral teratogenic risks posed by fetal AED exposure. Valproate is clearly associated with impaired cognitive development as well as an increased risk of disorders such as autism and autism spectrum disorder. Exposure to carbamazepine, lamotrigine, levetiracetam, or phenytoin monotherapy is associated with more favorable cognitive and behavioral outcomes than valproate, but more data are required to clarify if these AEDs have more subtle effects on cognition and behavior. There are insufficient data on the developmental effects of other AEDs in humans. Further, the underlying mechanisms of cognitive teratogenesis are poorly understood, including the genetic factors that affect susceptibility to AEDs.
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Affiliation(s)
- Elizabeth E Gerard
- Department of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, United States
| | - Kimford J Meador
- Department of Neurology and Neurological Sciences, Stanford University, Stanford, California, United States
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Haider HA, Esteller R, Hahn CD, Westover MB, Halford JJ, Lee JW, Shafi MM, Gaspard N, Herman ST, Gerard EE, Hirsch LJ, Ehrenberg JA, LaRoche SM. Sensitivity of quantitative EEG for seizure identification in the intensive care unit. Neurology 2016; 87:935-44. [PMID: 27466474 DOI: 10.1212/wnl.0000000000003034] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Accepted: 05/19/2016] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To evaluate the sensitivity of quantitative EEG (QEEG) for electrographic seizure identification in the intensive care unit (ICU). METHODS Six-hour EEG epochs chosen from 15 patients underwent transformation into QEEG displays. Each epoch was reviewed in 3 formats: raw EEG, QEEG + raw, and QEEG-only. Epochs were also analyzed by a proprietary seizure detection algorithm. Nine neurophysiologists reviewed raw EEGs to identify seizures to serve as the gold standard. Nine other neurophysiologists with experience in QEEG evaluated the epochs in QEEG formats, with and without concomitant raw EEG. Sensitivity and false-positive rates (FPRs) for seizure identification were calculated and median review time assessed. RESULTS Mean sensitivity for seizure identification ranged from 51% to 67% for QEEG-only and 63%-68% for QEEG + raw. FPRs averaged 1/h for QEEG-only and 0.5/h for QEEG + raw. Mean sensitivity of seizure probability software was 26.2%-26.7%, with FPR of 0.07/h. Epochs with the highest sensitivities contained frequent, intermittent seizures. Lower sensitivities were seen with slow-frequency, low-amplitude seizures and epochs with rhythmic or periodic patterns. Median review times were shorter for QEEG (6 minutes) and QEEG + raw analysis (14.5 minutes) vs raw EEG (19 minutes; p = 0.00003). CONCLUSIONS A panel of QEEG trends can be used by experts to shorten EEG review time for seizure identification with reasonable sensitivity and low FPRs. The prevalence of false detections confirms that raw EEG review must be used in conjunction with QEEG. Studies are needed to identify optimal QEEG trend configurations and the utility of QEEG as a screening tool for non-EEG personnel. CLASSIFICATION OF EVIDENCE REVIEW This study provides Class II evidence that QEEG + raw interpreted by experts identifies seizures in patients in the ICU with a sensitivity of 63%-68% and FPR of 0.5 seizures per hour.
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Affiliation(s)
- Hiba A Haider
- From the Department of Neurology (H.A.H., J.A.E., S.M.L.), Emory University School of Medicine, Atlanta, GA; Neuropace Inc. (R.E.), Mountain View, CA; Division of Neurology (C.D.H.), The Hospital for Sick Children, and Department of Paediatrics, University of Toronto, Canada; Department of Neurology (M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Neurology (J.J.H.), Medical University of South Carolina, Charleston; Brigham and Women's Hospital (J.W.L., M.M.S., S.T.H.), Harvard Medical School, Boston, MA; Université Libre de Bruxelles (N.G.), Brussels, Belgium; Department of Neurology (E.E.G.), Northwestern University Feinberg School of Medicine, Chicago, IL; and Yale University Hospital (L.J.H.), New Haven, CT.
| | - Rosana Esteller
- From the Department of Neurology (H.A.H., J.A.E., S.M.L.), Emory University School of Medicine, Atlanta, GA; Neuropace Inc. (R.E.), Mountain View, CA; Division of Neurology (C.D.H.), The Hospital for Sick Children, and Department of Paediatrics, University of Toronto, Canada; Department of Neurology (M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Neurology (J.J.H.), Medical University of South Carolina, Charleston; Brigham and Women's Hospital (J.W.L., M.M.S., S.T.H.), Harvard Medical School, Boston, MA; Université Libre de Bruxelles (N.G.), Brussels, Belgium; Department of Neurology (E.E.G.), Northwestern University Feinberg School of Medicine, Chicago, IL; and Yale University Hospital (L.J.H.), New Haven, CT
| | - Cecil D Hahn
- From the Department of Neurology (H.A.H., J.A.E., S.M.L.), Emory University School of Medicine, Atlanta, GA; Neuropace Inc. (R.E.), Mountain View, CA; Division of Neurology (C.D.H.), The Hospital for Sick Children, and Department of Paediatrics, University of Toronto, Canada; Department of Neurology (M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Neurology (J.J.H.), Medical University of South Carolina, Charleston; Brigham and Women's Hospital (J.W.L., M.M.S., S.T.H.), Harvard Medical School, Boston, MA; Université Libre de Bruxelles (N.G.), Brussels, Belgium; Department of Neurology (E.E.G.), Northwestern University Feinberg School of Medicine, Chicago, IL; and Yale University Hospital (L.J.H.), New Haven, CT
| | - M Brandon Westover
- From the Department of Neurology (H.A.H., J.A.E., S.M.L.), Emory University School of Medicine, Atlanta, GA; Neuropace Inc. (R.E.), Mountain View, CA; Division of Neurology (C.D.H.), The Hospital for Sick Children, and Department of Paediatrics, University of Toronto, Canada; Department of Neurology (M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Neurology (J.J.H.), Medical University of South Carolina, Charleston; Brigham and Women's Hospital (J.W.L., M.M.S., S.T.H.), Harvard Medical School, Boston, MA; Université Libre de Bruxelles (N.G.), Brussels, Belgium; Department of Neurology (E.E.G.), Northwestern University Feinberg School of Medicine, Chicago, IL; and Yale University Hospital (L.J.H.), New Haven, CT
| | - Jonathan J Halford
- From the Department of Neurology (H.A.H., J.A.E., S.M.L.), Emory University School of Medicine, Atlanta, GA; Neuropace Inc. (R.E.), Mountain View, CA; Division of Neurology (C.D.H.), The Hospital for Sick Children, and Department of Paediatrics, University of Toronto, Canada; Department of Neurology (M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Neurology (J.J.H.), Medical University of South Carolina, Charleston; Brigham and Women's Hospital (J.W.L., M.M.S., S.T.H.), Harvard Medical School, Boston, MA; Université Libre de Bruxelles (N.G.), Brussels, Belgium; Department of Neurology (E.E.G.), Northwestern University Feinberg School of Medicine, Chicago, IL; and Yale University Hospital (L.J.H.), New Haven, CT
| | - Jong W Lee
- From the Department of Neurology (H.A.H., J.A.E., S.M.L.), Emory University School of Medicine, Atlanta, GA; Neuropace Inc. (R.E.), Mountain View, CA; Division of Neurology (C.D.H.), The Hospital for Sick Children, and Department of Paediatrics, University of Toronto, Canada; Department of Neurology (M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Neurology (J.J.H.), Medical University of South Carolina, Charleston; Brigham and Women's Hospital (J.W.L., M.M.S., S.T.H.), Harvard Medical School, Boston, MA; Université Libre de Bruxelles (N.G.), Brussels, Belgium; Department of Neurology (E.E.G.), Northwestern University Feinberg School of Medicine, Chicago, IL; and Yale University Hospital (L.J.H.), New Haven, CT
| | - Mouhsin M Shafi
- From the Department of Neurology (H.A.H., J.A.E., S.M.L.), Emory University School of Medicine, Atlanta, GA; Neuropace Inc. (R.E.), Mountain View, CA; Division of Neurology (C.D.H.), The Hospital for Sick Children, and Department of Paediatrics, University of Toronto, Canada; Department of Neurology (M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Neurology (J.J.H.), Medical University of South Carolina, Charleston; Brigham and Women's Hospital (J.W.L., M.M.S., S.T.H.), Harvard Medical School, Boston, MA; Université Libre de Bruxelles (N.G.), Brussels, Belgium; Department of Neurology (E.E.G.), Northwestern University Feinberg School of Medicine, Chicago, IL; and Yale University Hospital (L.J.H.), New Haven, CT
| | - Nicolas Gaspard
- From the Department of Neurology (H.A.H., J.A.E., S.M.L.), Emory University School of Medicine, Atlanta, GA; Neuropace Inc. (R.E.), Mountain View, CA; Division of Neurology (C.D.H.), The Hospital for Sick Children, and Department of Paediatrics, University of Toronto, Canada; Department of Neurology (M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Neurology (J.J.H.), Medical University of South Carolina, Charleston; Brigham and Women's Hospital (J.W.L., M.M.S., S.T.H.), Harvard Medical School, Boston, MA; Université Libre de Bruxelles (N.G.), Brussels, Belgium; Department of Neurology (E.E.G.), Northwestern University Feinberg School of Medicine, Chicago, IL; and Yale University Hospital (L.J.H.), New Haven, CT
| | - Susan T Herman
- From the Department of Neurology (H.A.H., J.A.E., S.M.L.), Emory University School of Medicine, Atlanta, GA; Neuropace Inc. (R.E.), Mountain View, CA; Division of Neurology (C.D.H.), The Hospital for Sick Children, and Department of Paediatrics, University of Toronto, Canada; Department of Neurology (M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Neurology (J.J.H.), Medical University of South Carolina, Charleston; Brigham and Women's Hospital (J.W.L., M.M.S., S.T.H.), Harvard Medical School, Boston, MA; Université Libre de Bruxelles (N.G.), Brussels, Belgium; Department of Neurology (E.E.G.), Northwestern University Feinberg School of Medicine, Chicago, IL; and Yale University Hospital (L.J.H.), New Haven, CT
| | - Elizabeth E Gerard
- From the Department of Neurology (H.A.H., J.A.E., S.M.L.), Emory University School of Medicine, Atlanta, GA; Neuropace Inc. (R.E.), Mountain View, CA; Division of Neurology (C.D.H.), The Hospital for Sick Children, and Department of Paediatrics, University of Toronto, Canada; Department of Neurology (M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Neurology (J.J.H.), Medical University of South Carolina, Charleston; Brigham and Women's Hospital (J.W.L., M.M.S., S.T.H.), Harvard Medical School, Boston, MA; Université Libre de Bruxelles (N.G.), Brussels, Belgium; Department of Neurology (E.E.G.), Northwestern University Feinberg School of Medicine, Chicago, IL; and Yale University Hospital (L.J.H.), New Haven, CT
| | - Lawrence J Hirsch
- From the Department of Neurology (H.A.H., J.A.E., S.M.L.), Emory University School of Medicine, Atlanta, GA; Neuropace Inc. (R.E.), Mountain View, CA; Division of Neurology (C.D.H.), The Hospital for Sick Children, and Department of Paediatrics, University of Toronto, Canada; Department of Neurology (M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Neurology (J.J.H.), Medical University of South Carolina, Charleston; Brigham and Women's Hospital (J.W.L., M.M.S., S.T.H.), Harvard Medical School, Boston, MA; Université Libre de Bruxelles (N.G.), Brussels, Belgium; Department of Neurology (E.E.G.), Northwestern University Feinberg School of Medicine, Chicago, IL; and Yale University Hospital (L.J.H.), New Haven, CT
| | - Joshua A Ehrenberg
- From the Department of Neurology (H.A.H., J.A.E., S.M.L.), Emory University School of Medicine, Atlanta, GA; Neuropace Inc. (R.E.), Mountain View, CA; Division of Neurology (C.D.H.), The Hospital for Sick Children, and Department of Paediatrics, University of Toronto, Canada; Department of Neurology (M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Neurology (J.J.H.), Medical University of South Carolina, Charleston; Brigham and Women's Hospital (J.W.L., M.M.S., S.T.H.), Harvard Medical School, Boston, MA; Université Libre de Bruxelles (N.G.), Brussels, Belgium; Department of Neurology (E.E.G.), Northwestern University Feinberg School of Medicine, Chicago, IL; and Yale University Hospital (L.J.H.), New Haven, CT
| | - Suzette M LaRoche
- From the Department of Neurology (H.A.H., J.A.E., S.M.L.), Emory University School of Medicine, Atlanta, GA; Neuropace Inc. (R.E.), Mountain View, CA; Division of Neurology (C.D.H.), The Hospital for Sick Children, and Department of Paediatrics, University of Toronto, Canada; Department of Neurology (M.B.W.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Neurology (J.J.H.), Medical University of South Carolina, Charleston; Brigham and Women's Hospital (J.W.L., M.M.S., S.T.H.), Harvard Medical School, Boston, MA; Université Libre de Bruxelles (N.G.), Brussels, Belgium; Department of Neurology (E.E.G.), Northwestern University Feinberg School of Medicine, Chicago, IL; and Yale University Hospital (L.J.H.), New Haven, CT
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Gaspard N, Foreman BP, Alvarez V, Cabrera Kang C, Probasco JC, Jongeling AC, Meyers E, Espinera A, Haas KF, Schmitt SE, Gerard EE, Gofton T, Kaplan PW, Lee JW, Legros B, Szaflarski JP, Westover BM, LaRoche SM, Hirsch LJ. New-onset refractory status epilepticus: Etiology, clinical features, and outcome. Neurology 2015; 85:1604-13. [PMID: 26296517 DOI: 10.1212/wnl.0000000000001940] [Citation(s) in RCA: 266] [Impact Index Per Article: 29.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Accepted: 07/06/2015] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVES The aims of this study were to determine the etiology, clinical features, and predictors of outcome of new-onset refractory status epilepticus. METHODS Retrospective review of patients with refractory status epilepticus without etiology identified within 48 hours of admission between January 1, 2008, and December 31, 2013, in 13 academic medical centers. The primary outcome measure was poor functional outcome at discharge (defined as a score >3 on the modified Rankin Scale). RESULTS Of 130 cases, 67 (52%) remained cryptogenic. The most common identified etiologies were autoimmune (19%) and paraneoplastic (18%) encephalitis. Full data were available in 125 cases (62 cryptogenic). Poor outcome occurred in 77 of 125 cases (62%), and 28 (22%) died. Predictors of poor outcome included duration of status epilepticus, use of anesthetics, and medical complications. Among the 63 patients with available follow-up data (median 9 months), functional status improved in 36 (57%); 79% had good or fair outcome at last follow-up, but epilepsy developed in 37% with most survivors (92%) remaining on antiseizure medications. Immune therapies were used less frequently in cryptogenic cases, despite a comparable prevalence of inflammatory CSF changes. CONCLUSIONS Autoimmune encephalitis is the most commonly identified cause of new-onset refractory status epilepticus, but half remain cryptogenic. Outcome at discharge is poor but improves during follow-up. Epilepsy develops in most cases. The role of anesthetics and immune therapies warrants further investigation.
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Affiliation(s)
- Nicolas Gaspard
- From the Yale University School of Medicine (N.G., L.J.H.), Department of Neurology, Division of Epilepsy and Clinical Neurophysiology and Comprehensive Epilepsy Center, New Haven, CT; Université Libre de Bruxelles-Hôpital Erasme (N.G., B.L.), Brussels, Belgium; University of Cincinnati Department of Neurology and Rehabilitation Medicine (B.P.F.), OH; Department of Neurology (V.A.), Hôpital de Sion; Department of Clinical Neurosciences (V.A.), Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland; Department of Neurology (V.A., J.W.L.), Brigham and Women's Hospital, Harvard Medical School, Boston MA; Emory University School of Medicine (C.C.K., S.M.L.), Atlanta, GA; Johns Hopkins Bayview Medical Center (J.C.P., P.W.K.), Department of Neurology, and Johns Hopkins University School of Medicine, Baltimore MD; Department of Neurology (A.C.J., E.M.), Columbia University, New York, NY; Vanderbilt University Medical Center (K.F.H.), Nashville, TN; Hospital of the University of Pennsylvania (S.E.S.), Philadelphia; Feinberg School of Medicine (A.E., E.E.G.), Northwestern University, Chicago, IL; University of Western Ontario (T.G.), Canada; University of Alabama at Birmingham (J.P.S.); and Department of Neurology (B.M.W.), Massachusetts General Hospital, Boston.
| | - Brandon P Foreman
- From the Yale University School of Medicine (N.G., L.J.H.), Department of Neurology, Division of Epilepsy and Clinical Neurophysiology and Comprehensive Epilepsy Center, New Haven, CT; Université Libre de Bruxelles-Hôpital Erasme (N.G., B.L.), Brussels, Belgium; University of Cincinnati Department of Neurology and Rehabilitation Medicine (B.P.F.), OH; Department of Neurology (V.A.), Hôpital de Sion; Department of Clinical Neurosciences (V.A.), Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland; Department of Neurology (V.A., J.W.L.), Brigham and Women's Hospital, Harvard Medical School, Boston MA; Emory University School of Medicine (C.C.K., S.M.L.), Atlanta, GA; Johns Hopkins Bayview Medical Center (J.C.P., P.W.K.), Department of Neurology, and Johns Hopkins University School of Medicine, Baltimore MD; Department of Neurology (A.C.J., E.M.), Columbia University, New York, NY; Vanderbilt University Medical Center (K.F.H.), Nashville, TN; Hospital of the University of Pennsylvania (S.E.S.), Philadelphia; Feinberg School of Medicine (A.E., E.E.G.), Northwestern University, Chicago, IL; University of Western Ontario (T.G.), Canada; University of Alabama at Birmingham (J.P.S.); and Department of Neurology (B.M.W.), Massachusetts General Hospital, Boston
| | - Vincent Alvarez
- From the Yale University School of Medicine (N.G., L.J.H.), Department of Neurology, Division of Epilepsy and Clinical Neurophysiology and Comprehensive Epilepsy Center, New Haven, CT; Université Libre de Bruxelles-Hôpital Erasme (N.G., B.L.), Brussels, Belgium; University of Cincinnati Department of Neurology and Rehabilitation Medicine (B.P.F.), OH; Department of Neurology (V.A.), Hôpital de Sion; Department of Clinical Neurosciences (V.A.), Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland; Department of Neurology (V.A., J.W.L.), Brigham and Women's Hospital, Harvard Medical School, Boston MA; Emory University School of Medicine (C.C.K., S.M.L.), Atlanta, GA; Johns Hopkins Bayview Medical Center (J.C.P., P.W.K.), Department of Neurology, and Johns Hopkins University School of Medicine, Baltimore MD; Department of Neurology (A.C.J., E.M.), Columbia University, New York, NY; Vanderbilt University Medical Center (K.F.H.), Nashville, TN; Hospital of the University of Pennsylvania (S.E.S.), Philadelphia; Feinberg School of Medicine (A.E., E.E.G.), Northwestern University, Chicago, IL; University of Western Ontario (T.G.), Canada; University of Alabama at Birmingham (J.P.S.); and Department of Neurology (B.M.W.), Massachusetts General Hospital, Boston
| | - Christian Cabrera Kang
- From the Yale University School of Medicine (N.G., L.J.H.), Department of Neurology, Division of Epilepsy and Clinical Neurophysiology and Comprehensive Epilepsy Center, New Haven, CT; Université Libre de Bruxelles-Hôpital Erasme (N.G., B.L.), Brussels, Belgium; University of Cincinnati Department of Neurology and Rehabilitation Medicine (B.P.F.), OH; Department of Neurology (V.A.), Hôpital de Sion; Department of Clinical Neurosciences (V.A.), Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland; Department of Neurology (V.A., J.W.L.), Brigham and Women's Hospital, Harvard Medical School, Boston MA; Emory University School of Medicine (C.C.K., S.M.L.), Atlanta, GA; Johns Hopkins Bayview Medical Center (J.C.P., P.W.K.), Department of Neurology, and Johns Hopkins University School of Medicine, Baltimore MD; Department of Neurology (A.C.J., E.M.), Columbia University, New York, NY; Vanderbilt University Medical Center (K.F.H.), Nashville, TN; Hospital of the University of Pennsylvania (S.E.S.), Philadelphia; Feinberg School of Medicine (A.E., E.E.G.), Northwestern University, Chicago, IL; University of Western Ontario (T.G.), Canada; University of Alabama at Birmingham (J.P.S.); and Department of Neurology (B.M.W.), Massachusetts General Hospital, Boston
| | - John C Probasco
- From the Yale University School of Medicine (N.G., L.J.H.), Department of Neurology, Division of Epilepsy and Clinical Neurophysiology and Comprehensive Epilepsy Center, New Haven, CT; Université Libre de Bruxelles-Hôpital Erasme (N.G., B.L.), Brussels, Belgium; University of Cincinnati Department of Neurology and Rehabilitation Medicine (B.P.F.), OH; Department of Neurology (V.A.), Hôpital de Sion; Department of Clinical Neurosciences (V.A.), Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland; Department of Neurology (V.A., J.W.L.), Brigham and Women's Hospital, Harvard Medical School, Boston MA; Emory University School of Medicine (C.C.K., S.M.L.), Atlanta, GA; Johns Hopkins Bayview Medical Center (J.C.P., P.W.K.), Department of Neurology, and Johns Hopkins University School of Medicine, Baltimore MD; Department of Neurology (A.C.J., E.M.), Columbia University, New York, NY; Vanderbilt University Medical Center (K.F.H.), Nashville, TN; Hospital of the University of Pennsylvania (S.E.S.), Philadelphia; Feinberg School of Medicine (A.E., E.E.G.), Northwestern University, Chicago, IL; University of Western Ontario (T.G.), Canada; University of Alabama at Birmingham (J.P.S.); and Department of Neurology (B.M.W.), Massachusetts General Hospital, Boston
| | - Amy C Jongeling
- From the Yale University School of Medicine (N.G., L.J.H.), Department of Neurology, Division of Epilepsy and Clinical Neurophysiology and Comprehensive Epilepsy Center, New Haven, CT; Université Libre de Bruxelles-Hôpital Erasme (N.G., B.L.), Brussels, Belgium; University of Cincinnati Department of Neurology and Rehabilitation Medicine (B.P.F.), OH; Department of Neurology (V.A.), Hôpital de Sion; Department of Clinical Neurosciences (V.A.), Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland; Department of Neurology (V.A., J.W.L.), Brigham and Women's Hospital, Harvard Medical School, Boston MA; Emory University School of Medicine (C.C.K., S.M.L.), Atlanta, GA; Johns Hopkins Bayview Medical Center (J.C.P., P.W.K.), Department of Neurology, and Johns Hopkins University School of Medicine, Baltimore MD; Department of Neurology (A.C.J., E.M.), Columbia University, New York, NY; Vanderbilt University Medical Center (K.F.H.), Nashville, TN; Hospital of the University of Pennsylvania (S.E.S.), Philadelphia; Feinberg School of Medicine (A.E., E.E.G.), Northwestern University, Chicago, IL; University of Western Ontario (T.G.), Canada; University of Alabama at Birmingham (J.P.S.); and Department of Neurology (B.M.W.), Massachusetts General Hospital, Boston
| | - Emma Meyers
- From the Yale University School of Medicine (N.G., L.J.H.), Department of Neurology, Division of Epilepsy and Clinical Neurophysiology and Comprehensive Epilepsy Center, New Haven, CT; Université Libre de Bruxelles-Hôpital Erasme (N.G., B.L.), Brussels, Belgium; University of Cincinnati Department of Neurology and Rehabilitation Medicine (B.P.F.), OH; Department of Neurology (V.A.), Hôpital de Sion; Department of Clinical Neurosciences (V.A.), Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland; Department of Neurology (V.A., J.W.L.), Brigham and Women's Hospital, Harvard Medical School, Boston MA; Emory University School of Medicine (C.C.K., S.M.L.), Atlanta, GA; Johns Hopkins Bayview Medical Center (J.C.P., P.W.K.), Department of Neurology, and Johns Hopkins University School of Medicine, Baltimore MD; Department of Neurology (A.C.J., E.M.), Columbia University, New York, NY; Vanderbilt University Medical Center (K.F.H.), Nashville, TN; Hospital of the University of Pennsylvania (S.E.S.), Philadelphia; Feinberg School of Medicine (A.E., E.E.G.), Northwestern University, Chicago, IL; University of Western Ontario (T.G.), Canada; University of Alabama at Birmingham (J.P.S.); and Department of Neurology (B.M.W.), Massachusetts General Hospital, Boston
| | - Alyssa Espinera
- From the Yale University School of Medicine (N.G., L.J.H.), Department of Neurology, Division of Epilepsy and Clinical Neurophysiology and Comprehensive Epilepsy Center, New Haven, CT; Université Libre de Bruxelles-Hôpital Erasme (N.G., B.L.), Brussels, Belgium; University of Cincinnati Department of Neurology and Rehabilitation Medicine (B.P.F.), OH; Department of Neurology (V.A.), Hôpital de Sion; Department of Clinical Neurosciences (V.A.), Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland; Department of Neurology (V.A., J.W.L.), Brigham and Women's Hospital, Harvard Medical School, Boston MA; Emory University School of Medicine (C.C.K., S.M.L.), Atlanta, GA; Johns Hopkins Bayview Medical Center (J.C.P., P.W.K.), Department of Neurology, and Johns Hopkins University School of Medicine, Baltimore MD; Department of Neurology (A.C.J., E.M.), Columbia University, New York, NY; Vanderbilt University Medical Center (K.F.H.), Nashville, TN; Hospital of the University of Pennsylvania (S.E.S.), Philadelphia; Feinberg School of Medicine (A.E., E.E.G.), Northwestern University, Chicago, IL; University of Western Ontario (T.G.), Canada; University of Alabama at Birmingham (J.P.S.); and Department of Neurology (B.M.W.), Massachusetts General Hospital, Boston
| | - Kevin F Haas
- From the Yale University School of Medicine (N.G., L.J.H.), Department of Neurology, Division of Epilepsy and Clinical Neurophysiology and Comprehensive Epilepsy Center, New Haven, CT; Université Libre de Bruxelles-Hôpital Erasme (N.G., B.L.), Brussels, Belgium; University of Cincinnati Department of Neurology and Rehabilitation Medicine (B.P.F.), OH; Department of Neurology (V.A.), Hôpital de Sion; Department of Clinical Neurosciences (V.A.), Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland; Department of Neurology (V.A., J.W.L.), Brigham and Women's Hospital, Harvard Medical School, Boston MA; Emory University School of Medicine (C.C.K., S.M.L.), Atlanta, GA; Johns Hopkins Bayview Medical Center (J.C.P., P.W.K.), Department of Neurology, and Johns Hopkins University School of Medicine, Baltimore MD; Department of Neurology (A.C.J., E.M.), Columbia University, New York, NY; Vanderbilt University Medical Center (K.F.H.), Nashville, TN; Hospital of the University of Pennsylvania (S.E.S.), Philadelphia; Feinberg School of Medicine (A.E., E.E.G.), Northwestern University, Chicago, IL; University of Western Ontario (T.G.), Canada; University of Alabama at Birmingham (J.P.S.); and Department of Neurology (B.M.W.), Massachusetts General Hospital, Boston
| | - Sarah E Schmitt
- From the Yale University School of Medicine (N.G., L.J.H.), Department of Neurology, Division of Epilepsy and Clinical Neurophysiology and Comprehensive Epilepsy Center, New Haven, CT; Université Libre de Bruxelles-Hôpital Erasme (N.G., B.L.), Brussels, Belgium; University of Cincinnati Department of Neurology and Rehabilitation Medicine (B.P.F.), OH; Department of Neurology (V.A.), Hôpital de Sion; Department of Clinical Neurosciences (V.A.), Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland; Department of Neurology (V.A., J.W.L.), Brigham and Women's Hospital, Harvard Medical School, Boston MA; Emory University School of Medicine (C.C.K., S.M.L.), Atlanta, GA; Johns Hopkins Bayview Medical Center (J.C.P., P.W.K.), Department of Neurology, and Johns Hopkins University School of Medicine, Baltimore MD; Department of Neurology (A.C.J., E.M.), Columbia University, New York, NY; Vanderbilt University Medical Center (K.F.H.), Nashville, TN; Hospital of the University of Pennsylvania (S.E.S.), Philadelphia; Feinberg School of Medicine (A.E., E.E.G.), Northwestern University, Chicago, IL; University of Western Ontario (T.G.), Canada; University of Alabama at Birmingham (J.P.S.); and Department of Neurology (B.M.W.), Massachusetts General Hospital, Boston
| | - Elizabeth E Gerard
- From the Yale University School of Medicine (N.G., L.J.H.), Department of Neurology, Division of Epilepsy and Clinical Neurophysiology and Comprehensive Epilepsy Center, New Haven, CT; Université Libre de Bruxelles-Hôpital Erasme (N.G., B.L.), Brussels, Belgium; University of Cincinnati Department of Neurology and Rehabilitation Medicine (B.P.F.), OH; Department of Neurology (V.A.), Hôpital de Sion; Department of Clinical Neurosciences (V.A.), Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland; Department of Neurology (V.A., J.W.L.), Brigham and Women's Hospital, Harvard Medical School, Boston MA; Emory University School of Medicine (C.C.K., S.M.L.), Atlanta, GA; Johns Hopkins Bayview Medical Center (J.C.P., P.W.K.), Department of Neurology, and Johns Hopkins University School of Medicine, Baltimore MD; Department of Neurology (A.C.J., E.M.), Columbia University, New York, NY; Vanderbilt University Medical Center (K.F.H.), Nashville, TN; Hospital of the University of Pennsylvania (S.E.S.), Philadelphia; Feinberg School of Medicine (A.E., E.E.G.), Northwestern University, Chicago, IL; University of Western Ontario (T.G.), Canada; University of Alabama at Birmingham (J.P.S.); and Department of Neurology (B.M.W.), Massachusetts General Hospital, Boston
| | - Teneille Gofton
- From the Yale University School of Medicine (N.G., L.J.H.), Department of Neurology, Division of Epilepsy and Clinical Neurophysiology and Comprehensive Epilepsy Center, New Haven, CT; Université Libre de Bruxelles-Hôpital Erasme (N.G., B.L.), Brussels, Belgium; University of Cincinnati Department of Neurology and Rehabilitation Medicine (B.P.F.), OH; Department of Neurology (V.A.), Hôpital de Sion; Department of Clinical Neurosciences (V.A.), Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland; Department of Neurology (V.A., J.W.L.), Brigham and Women's Hospital, Harvard Medical School, Boston MA; Emory University School of Medicine (C.C.K., S.M.L.), Atlanta, GA; Johns Hopkins Bayview Medical Center (J.C.P., P.W.K.), Department of Neurology, and Johns Hopkins University School of Medicine, Baltimore MD; Department of Neurology (A.C.J., E.M.), Columbia University, New York, NY; Vanderbilt University Medical Center (K.F.H.), Nashville, TN; Hospital of the University of Pennsylvania (S.E.S.), Philadelphia; Feinberg School of Medicine (A.E., E.E.G.), Northwestern University, Chicago, IL; University of Western Ontario (T.G.), Canada; University of Alabama at Birmingham (J.P.S.); and Department of Neurology (B.M.W.), Massachusetts General Hospital, Boston
| | - Peter W Kaplan
- From the Yale University School of Medicine (N.G., L.J.H.), Department of Neurology, Division of Epilepsy and Clinical Neurophysiology and Comprehensive Epilepsy Center, New Haven, CT; Université Libre de Bruxelles-Hôpital Erasme (N.G., B.L.), Brussels, Belgium; University of Cincinnati Department of Neurology and Rehabilitation Medicine (B.P.F.), OH; Department of Neurology (V.A.), Hôpital de Sion; Department of Clinical Neurosciences (V.A.), Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland; Department of Neurology (V.A., J.W.L.), Brigham and Women's Hospital, Harvard Medical School, Boston MA; Emory University School of Medicine (C.C.K., S.M.L.), Atlanta, GA; Johns Hopkins Bayview Medical Center (J.C.P., P.W.K.), Department of Neurology, and Johns Hopkins University School of Medicine, Baltimore MD; Department of Neurology (A.C.J., E.M.), Columbia University, New York, NY; Vanderbilt University Medical Center (K.F.H.), Nashville, TN; Hospital of the University of Pennsylvania (S.E.S.), Philadelphia; Feinberg School of Medicine (A.E., E.E.G.), Northwestern University, Chicago, IL; University of Western Ontario (T.G.), Canada; University of Alabama at Birmingham (J.P.S.); and Department of Neurology (B.M.W.), Massachusetts General Hospital, Boston
| | - Jong W Lee
- From the Yale University School of Medicine (N.G., L.J.H.), Department of Neurology, Division of Epilepsy and Clinical Neurophysiology and Comprehensive Epilepsy Center, New Haven, CT; Université Libre de Bruxelles-Hôpital Erasme (N.G., B.L.), Brussels, Belgium; University of Cincinnati Department of Neurology and Rehabilitation Medicine (B.P.F.), OH; Department of Neurology (V.A.), Hôpital de Sion; Department of Clinical Neurosciences (V.A.), Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland; Department of Neurology (V.A., J.W.L.), Brigham and Women's Hospital, Harvard Medical School, Boston MA; Emory University School of Medicine (C.C.K., S.M.L.), Atlanta, GA; Johns Hopkins Bayview Medical Center (J.C.P., P.W.K.), Department of Neurology, and Johns Hopkins University School of Medicine, Baltimore MD; Department of Neurology (A.C.J., E.M.), Columbia University, New York, NY; Vanderbilt University Medical Center (K.F.H.), Nashville, TN; Hospital of the University of Pennsylvania (S.E.S.), Philadelphia; Feinberg School of Medicine (A.E., E.E.G.), Northwestern University, Chicago, IL; University of Western Ontario (T.G.), Canada; University of Alabama at Birmingham (J.P.S.); and Department of Neurology (B.M.W.), Massachusetts General Hospital, Boston
| | - Benjamin Legros
- From the Yale University School of Medicine (N.G., L.J.H.), Department of Neurology, Division of Epilepsy and Clinical Neurophysiology and Comprehensive Epilepsy Center, New Haven, CT; Université Libre de Bruxelles-Hôpital Erasme (N.G., B.L.), Brussels, Belgium; University of Cincinnati Department of Neurology and Rehabilitation Medicine (B.P.F.), OH; Department of Neurology (V.A.), Hôpital de Sion; Department of Clinical Neurosciences (V.A.), Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland; Department of Neurology (V.A., J.W.L.), Brigham and Women's Hospital, Harvard Medical School, Boston MA; Emory University School of Medicine (C.C.K., S.M.L.), Atlanta, GA; Johns Hopkins Bayview Medical Center (J.C.P., P.W.K.), Department of Neurology, and Johns Hopkins University School of Medicine, Baltimore MD; Department of Neurology (A.C.J., E.M.), Columbia University, New York, NY; Vanderbilt University Medical Center (K.F.H.), Nashville, TN; Hospital of the University of Pennsylvania (S.E.S.), Philadelphia; Feinberg School of Medicine (A.E., E.E.G.), Northwestern University, Chicago, IL; University of Western Ontario (T.G.), Canada; University of Alabama at Birmingham (J.P.S.); and Department of Neurology (B.M.W.), Massachusetts General Hospital, Boston
| | - Jerzy P Szaflarski
- From the Yale University School of Medicine (N.G., L.J.H.), Department of Neurology, Division of Epilepsy and Clinical Neurophysiology and Comprehensive Epilepsy Center, New Haven, CT; Université Libre de Bruxelles-Hôpital Erasme (N.G., B.L.), Brussels, Belgium; University of Cincinnati Department of Neurology and Rehabilitation Medicine (B.P.F.), OH; Department of Neurology (V.A.), Hôpital de Sion; Department of Clinical Neurosciences (V.A.), Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland; Department of Neurology (V.A., J.W.L.), Brigham and Women's Hospital, Harvard Medical School, Boston MA; Emory University School of Medicine (C.C.K., S.M.L.), Atlanta, GA; Johns Hopkins Bayview Medical Center (J.C.P., P.W.K.), Department of Neurology, and Johns Hopkins University School of Medicine, Baltimore MD; Department of Neurology (A.C.J., E.M.), Columbia University, New York, NY; Vanderbilt University Medical Center (K.F.H.), Nashville, TN; Hospital of the University of Pennsylvania (S.E.S.), Philadelphia; Feinberg School of Medicine (A.E., E.E.G.), Northwestern University, Chicago, IL; University of Western Ontario (T.G.), Canada; University of Alabama at Birmingham (J.P.S.); and Department of Neurology (B.M.W.), Massachusetts General Hospital, Boston
| | - Brandon M Westover
- From the Yale University School of Medicine (N.G., L.J.H.), Department of Neurology, Division of Epilepsy and Clinical Neurophysiology and Comprehensive Epilepsy Center, New Haven, CT; Université Libre de Bruxelles-Hôpital Erasme (N.G., B.L.), Brussels, Belgium; University of Cincinnati Department of Neurology and Rehabilitation Medicine (B.P.F.), OH; Department of Neurology (V.A.), Hôpital de Sion; Department of Clinical Neurosciences (V.A.), Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland; Department of Neurology (V.A., J.W.L.), Brigham and Women's Hospital, Harvard Medical School, Boston MA; Emory University School of Medicine (C.C.K., S.M.L.), Atlanta, GA; Johns Hopkins Bayview Medical Center (J.C.P., P.W.K.), Department of Neurology, and Johns Hopkins University School of Medicine, Baltimore MD; Department of Neurology (A.C.J., E.M.), Columbia University, New York, NY; Vanderbilt University Medical Center (K.F.H.), Nashville, TN; Hospital of the University of Pennsylvania (S.E.S.), Philadelphia; Feinberg School of Medicine (A.E., E.E.G.), Northwestern University, Chicago, IL; University of Western Ontario (T.G.), Canada; University of Alabama at Birmingham (J.P.S.); and Department of Neurology (B.M.W.), Massachusetts General Hospital, Boston
| | - Suzette M LaRoche
- From the Yale University School of Medicine (N.G., L.J.H.), Department of Neurology, Division of Epilepsy and Clinical Neurophysiology and Comprehensive Epilepsy Center, New Haven, CT; Université Libre de Bruxelles-Hôpital Erasme (N.G., B.L.), Brussels, Belgium; University of Cincinnati Department of Neurology and Rehabilitation Medicine (B.P.F.), OH; Department of Neurology (V.A.), Hôpital de Sion; Department of Clinical Neurosciences (V.A.), Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland; Department of Neurology (V.A., J.W.L.), Brigham and Women's Hospital, Harvard Medical School, Boston MA; Emory University School of Medicine (C.C.K., S.M.L.), Atlanta, GA; Johns Hopkins Bayview Medical Center (J.C.P., P.W.K.), Department of Neurology, and Johns Hopkins University School of Medicine, Baltimore MD; Department of Neurology (A.C.J., E.M.), Columbia University, New York, NY; Vanderbilt University Medical Center (K.F.H.), Nashville, TN; Hospital of the University of Pennsylvania (S.E.S.), Philadelphia; Feinberg School of Medicine (A.E., E.E.G.), Northwestern University, Chicago, IL; University of Western Ontario (T.G.), Canada; University of Alabama at Birmingham (J.P.S.); and Department of Neurology (B.M.W.), Massachusetts General Hospital, Boston
| | - Lawrence J Hirsch
- From the Yale University School of Medicine (N.G., L.J.H.), Department of Neurology, Division of Epilepsy and Clinical Neurophysiology and Comprehensive Epilepsy Center, New Haven, CT; Université Libre de Bruxelles-Hôpital Erasme (N.G., B.L.), Brussels, Belgium; University of Cincinnati Department of Neurology and Rehabilitation Medicine (B.P.F.), OH; Department of Neurology (V.A.), Hôpital de Sion; Department of Clinical Neurosciences (V.A.), Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland; Department of Neurology (V.A., J.W.L.), Brigham and Women's Hospital, Harvard Medical School, Boston MA; Emory University School of Medicine (C.C.K., S.M.L.), Atlanta, GA; Johns Hopkins Bayview Medical Center (J.C.P., P.W.K.), Department of Neurology, and Johns Hopkins University School of Medicine, Baltimore MD; Department of Neurology (A.C.J., E.M.), Columbia University, New York, NY; Vanderbilt University Medical Center (K.F.H.), Nashville, TN; Hospital of the University of Pennsylvania (S.E.S.), Philadelphia; Feinberg School of Medicine (A.E., E.E.G.), Northwestern University, Chicago, IL; University of Western Ontario (T.G.), Canada; University of Alabama at Birmingham (J.P.S.); and Department of Neurology (B.M.W.), Massachusetts General Hospital, Boston
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Guth JC, Gerard EE, Nemeth AJ, Liotta EM, Prabhakaran S, Naidech AM, Maas MB. Subarachnoid extension of hemorrhage is associated with early seizures in primary intracerebral hemorrhage. J Stroke Cerebrovasc Dis 2014; 23:2809-2813. [PMID: 25194742 DOI: 10.1016/j.jstrokecerebrovasdis.2014.07.023] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Revised: 06/26/2014] [Accepted: 07/07/2014] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Seizures are common in patients with subarachnoid hemorrhage, potentially by inciting cortical irritability. Seizures are also commonly seen after intracerebral hemorrhage (ICH), although the mechanisms and risk factors within that population are not well understood. The objective of this study is to evaluate whether subarachnoid hemorrhage extension (SAHE) is associated with early seizures in patients with primary ICH. METHODS Patients with primary ICH were enrolled into a prospective registry between December 2006 and July 2012. Patients were managed per a structured protocol. SAHE was identified on imaging by expert reviewers blinded to outcomes. Electroencephalograms were routinely obtained in patients with unexplained, poor level of arousal. Seizure was determined by clinically observed convulsions or traditional electroencephalographic criteria. Early seizures were defined as occurring within 3 days of hemorrhage. A binary logistic regression model was developed to test whether the occurrence of SAHE was independently associated with seizures. RESULTS A total of 234 patients were studied. Of these, 93 (40%) had SAHE and 9 (4%) had early seizures. SAHE was associated with early seizures (P = .03). No additional variables were identified by regression modeling to mediate the association between SAHE and early seizures (odds ratio 5.62 [95% confidence interval 1.14-27.7], P = .034). CONCLUSIONS SAHE is associated with early seizures in patients with primary ICH. Further study is needed to confirm these findings and determine whether modifications to routine care based on the presence of SAHE would be of benefit.
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Affiliation(s)
- James C Guth
- Division of Vascular and Critical Care Neurology, Department of Neurology, Northwestern University, Chicago, IL.
| | - Elizabeth E Gerard
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Northwestern University, Chicago, IL
| | - Alexander J Nemeth
- Division of Neuroradiology, Department of Radiology, Northwestern University, Chicago, IL
| | - Eric M Liotta
- Division of Vascular and Critical Care Neurology, Department of Neurology, Northwestern University, Chicago, IL
| | - Shyam Prabhakaran
- Division of Vascular and Critical Care Neurology, Department of Neurology, Northwestern University, Chicago, IL
| | - Andrew M Naidech
- Division of Vascular and Critical Care Neurology, Department of Neurology, Northwestern University, Chicago, IL
| | - Matthew B Maas
- Division of Vascular and Critical Care Neurology, Department of Neurology, Northwestern University, Chicago, IL
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Sen-Gupta I, Schuele SU, Macken MP, Kwasny MJ, Gerard EE. "Ictal" lateralized periodic discharges. Epilepsy Behav 2014; 36:165-70. [PMID: 24935085 DOI: 10.1016/j.yebeh.2014.05.014] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Revised: 05/04/2014] [Accepted: 05/18/2014] [Indexed: 12/26/2022]
Abstract
OBJECTIVE Whether lateralized periodic discharges (LPDs) represent ictal or interictal phenomena, and even the circumstances in which they may represent one or the other, remains highly controversial. Lateralized periodic discharges are, however, widely accepted as being ictal when they are time-locked to clinically apparent symptoms. We sought to investigate the characteristics of "ictal" lateralized periodic discharges (ILPDs) defined by time-locked clinical symptoms in order to explore the utility of using this definition to dichotomize LPDs into "ictal" and "nonictal" categories. METHODS Our archive of all continuous EEG (cEEG) reports of adult inpatients undergoing prolonged EEG monitoring for nonelective indications between 2007 and 2011 was searched to identify all reports describing LPDs. Lateralized periodic discharges were considered ILPDs when they were reported as being consistently time-locked to clinical symptoms; LPDs lacking a clear time-locked correlate were considered to be "nonictal" lateralized periodic discharges (NILPDs). Patient charts and available neuroimaging studies were also reviewed. Neurophysiologic localization of LPDs, imaging findings, presence of seizures, discharge outcomes, and other demographic factors were compared between patients with ILPDs and those with NILPDs. p-Values were adjusted for false discovery rate (FDR). RESULTS One thousand four hundred fifty-two patients underwent cEEG monitoring at our institution between 2007 and 2011. Lateralized periodic discharges were reported in 90 patients, 10 of whom met criteria for ILPDs. Nine of the patients with ILPDs demonstrated motor symptoms, and the remaining patient experienced stereotyped sensory symptoms. Ictal lateralized periodic discharges had significantly increased odds for involving central head regions (odds ratio [OR]=11; 95% confidence interval [CI]=2.16-62.6; p=0.018, FDR adjusted), with a trend towards higher proportion of lesions involving the primary sensorimotor cortex (p=0.09, FDR adjusted). CONCLUSIONS When defined by the presence of a time-locked clinical correlate, ILPDs appear to be strongly associated with a central EEG localization. This is likely due to cortical irritability in central head regions having greater propensity to manifest with positive, clinically apparent, and time-locked symptoms. Thus, dichotomization of ILPDs and NILPDs on this basis principally reflects differences in underlying anatomical locations of the periodic discharges rather than providing a clinically salient categorization.
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Affiliation(s)
- Indranil Sen-Gupta
- Feinberg School of Medicine, Northwestern University, 710 N Lakeshore Drive, Chicago, IL 60611, USA.
| | - Stephan U Schuele
- Feinberg School of Medicine, Northwestern University, 710 N Lakeshore Drive, Chicago, IL 60611, USA.
| | - Micheal P Macken
- Feinberg School of Medicine, Northwestern University, 710 N Lakeshore Drive, Chicago, IL 60611, USA.
| | - Mary J Kwasny
- Feinberg School of Medicine, Northwestern University, 710 N Lakeshore Drive, Chicago, IL 60611, USA.
| | - Elizabeth E Gerard
- Feinberg School of Medicine, Northwestern University, 710 N Lakeshore Drive, Chicago, IL 60611, USA.
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Narechania AP, Garić II, Sen-Gupta I, Macken MP, Gerard EE, Schuele SU. Assessment of a quasi-piezoelectric mattress monitor as a detection system for generalized convulsions. Epilepsy Behav 2013; 28:172-6. [PMID: 23747502 DOI: 10.1016/j.yebeh.2013.04.017] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2013] [Revised: 04/26/2013] [Accepted: 04/28/2013] [Indexed: 10/26/2022]
Abstract
The risk of sudden unexpected death in epilepsy (SUDEP) is highest with nocturnal, unattended generalized convulsions, and basic resuscitation may be able to prevent SUDEP. This study investigates an under-mattress device (ElectroMechanical Film - Emfit®) which is triggered by rhythmic motor activity of a specifiable duration, frequency, and intensity using a quasi-piezoelectric material sensitive to changes in mattress pressure. The device was tested during inpatient video-EEG monitoring. Eighteen GTCSs were recorded, 10 out of wakefulness and 8 out of sleep. Sixteen of the 18 seizures (89%) resulted in Emfit® activation with both false negative alarms occurring during wakefulness. On average, the device was activated within 9 s of onset of bilateral clonic motor movements (range: -37 to +39 s) and occurred, on average, 45 s before seizure end (range: 19 to 76 s). Only 21 false alarms were encountered, all occurring during wakefulness (PPV: 43%). The data suggest that the Emfit® detection device has a high predictive value for generalized convulsions, offers caregivers a reliable and early warning to assist the patient during convulsions, and may be a novel way to prevent SUDEP.
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Affiliation(s)
- Aditi P Narechania
- Comprehensive Epilepsy Center, Department of Neurology, Northwestern University Feinberg School of Medicine, USA
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Sen-Gupta I, Bernstein RA, Macken MP, Schuele SU, Gerard EE. Ictal sensory periodic lateralized epileptiform discharges. Epilepsy Behav 2011; 22:796-8. [PMID: 22018801 DOI: 10.1016/j.yebeh.2011.09.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2011] [Revised: 09/13/2011] [Accepted: 09/16/2011] [Indexed: 10/16/2022]
Abstract
We describe the case of a 74-year-old man with left parietal arteriovenous malformation (AVM) and cerebral white matter radiation necrosis who developed persistent subjective right-sided groin pulsations. The EEG revealed left parietal periodic lateralized epileptiform discharges (PLEDs) time-locked to these sensations, confirming that the patient's symptoms represented sensory seizures with ictal PLEDs as the electrographic correlate. To our knowledge, this is the first reported case of ictal PLEDs manifesting as sensory seizures.
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Affiliation(s)
- Indranil Sen-Gupta
- Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
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Schuele SU, Afshari M, Afshari ZS, Macken MP, Asconape J, Wolfe L, Gerard EE. Ictal central apnea as a predictor for sudden unexpected death in epilepsy. Epilepsy Behav 2011; 22:401-3. [PMID: 21816679 DOI: 10.1016/j.yebeh.2011.06.036] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2011] [Revised: 06/24/2011] [Accepted: 06/28/2011] [Indexed: 11/30/2022]
Abstract
Epidemiological evidence associating ictal hypoventilation during focal seizures with a heightened risk for subsequent sudden unexpected death in epilepsy (SUDEP) is lacking. We describe a patient with temporal lobe epilepsy with two focal seizures recorded in the epilepsy monitoring unit that were associated with central apnea lasting 57 and 58 seconds. During these events, she demonstrated oxygen desaturation down to 68 and 62%. The patient subsequently died at home from autopsy-confirmed SUDEP. The family was not alerted of any seizure activity by the auditory alarm system in her room nor by sleeping in the adjacent room with open doors. This case emphasizes the fact that ictal hypoxia and SUDEP may occur in seizures without noticeable convulsive activity. The report gives credibility to the growing body of literature suggesting that epilepsies affecting the autonomic nervous system may predispose to SUDEP independent of the effects of a secondary generalized convulsion.
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Affiliation(s)
- Stephan U Schuele
- Department of Neurology, Northwestern University, Chicago, IL 60611, USA.
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