The application of artificial intelligence to understand the pathophysiological basis of psychogenic nonepileptic seizures

Psychogenic nonepileptic seizures (PNES) are episodes of paroxysmal impairment associated with a range of motor, sensory, and mental manifestations, which perfectly mimic epileptic seizures. Several patterns of neural abnormalities have been described without identifying a definite neurobiological substrate. In this multicenter cross-sectional study, we applied a multivariate classification algorithm on morphological brain imaging metrics to extract reliable biomarkers useful to distinguish patients from controls at an individual level. Twenty-three patients with PNES and 21 demographically matched healthy controls (HC) underwent an extensive neuropsychiatric/neuropsychological and neuroimaging assessment. One hundred and fifty morphological brain metrics were used for training a random forest (RF) machine-learning (ML) algorithm. A typical complex psychopathological construct was observed in PNES. Similarly, univariate neuroimaging analysis revealed widespread neuroanatomical changes affecting patients with PNES. Machine-learning approach, after feature selection, was able to perform an individual classification of PNES from controls with a mean accuracy of 74.5%, revealing that brain regions influencing classification accuracy were mainly localized within the limbic (posterior cingulate and insula) and motor inhibition systems (the right inferior frontal cortex (IFC)). This study provides Class II evidence that the considerable clinical and neurobiological heterogeneity observed in individuals with PNES might be overcome by ML algorithms trained on surface-based magnetic resonance imaging (MRI) data.

Clinical features and outcome of 6 new patients carrying de novo KCNB1 gene mutations

Objective

To describe electroclinical features and outcome of 6 patients harboring KCNB1 mutations.

Methods

Clinical, EEG, neuropsychological, and brain MRI data analysis. Targeted next-generation sequencing of a 95 epilepsy gene panel.

Results

The mean age at seizure onset was 11 months. The mean follow-up of 11.3 years documented that 4 patients following an infantile phase of frequent seizures became seizure free; the mean age at seizure offset was 4.25 years. Epilepsy phenotypes comprised West syndrome in 2 patients, infantile-onset unspecified generalized epilepsy, myoclonic and photosensitive eyelid myoclonia epilepsy resembling Jeavons syndrome, Lennox-Gastaut syndrome, and focal epilepsy with prolonged occipital or clonic seizures in each and every one. Five patients had developmental delay prior to seizure onset evolving into severe intellectual disability with absent speech and autistic traits in one and stereotypic hand movements with impulse control disorder in another. The patient with Jeavons syndrome evolved into moderate intellectual disability. Mutations were de novo, 4 missense and 2 nonsense, 5 were novel, and 1 resulted from somatic mosaicism.

Conclusions

KCNB1-related manifestations include a spectrum of infantile-onset generalized or focal seizures whose combination leads to early infantile epileptic encephalopathy including West, Lennox-Gastaut, and Jeavons syndromes. Long-term follow-up highlights that following a stormy phase, seizures subside or cease and treatment may be eased or withdrawn. Cognitive and motor functions are almost always delayed prior to seizure onset and evolve into severe, persistent impairment. Thus, KCNB1 mutations are associated with diffuse brain dysfunction combining seizures, motor, and cognitive impairment.

Cognitive outcome after epilepsy surgery in children: A controlled longitudinal study

OBJECTIVE

To analyze the determinants of cognitive outcome two years after surgery for drug-resistant epilepsy in a cohort of 31 children when compared to a control group of 14 surgical candidates who had yet to undergo surgery two years after the first neuropsychological assessment.

METHODS

Controlled longitudinal study including three evaluations of IQ (Intelligence Quotient) scores or GDQ (General Developmental Quotient) for each group depending on the patient's age: prior to surgery (T0), one year (T1) and two years (T2) after surgery for the surgical group; baseline (T0) and one year (T1) and 2years (T2) after the first evaluation for the control-group. At follow-up, 25 children (80%) of the surgical group were seizure free, while seizure outcome was unsatisfactory in the remaining six (20%). To analyze language, visuomotor skills, memory, reading, visual attention, and behavior, we selected 11 school age children in the surgical group and nine controls. We reported performance prior to (T0) and one year after surgery (T1).

RESULTS

There was a significant correlation between earlier age at seizure onset and lower IQ/GDQ at T0 (r=0.39; p=0.03) in the overall cohort. IQ/GDQ scores did not significantly differ between the surgical and control groups when analyzed at T0 and T2. However, they evolved differently with an improved developmental trajectory becoming identifiable only in the surgical group (F_1,31=5.33 p=0.028; η²=0.15). There was also a significant increase of forward digit span (Z=2.33; p=0.02) and Rey recall scores (Z=1.97; p=0.049) in the surgical school age subgroup at T1 versus T0.

SIGNIFICANCE

We identified significantly different developmental trajectories in operated versus non- operated children with improved IQ/GDQ scores in operated children only. We also observed a significant increase of digit span scores and Rey recall scores a year after surgery. Further studies including larger samples with longer follow-ups are needed to confirm these preliminary findings.

Clinical and genetic study of a family with a paternally inherited 15q11-q13 duplication

Interstitial chromosome 15q11-q13 duplications are associated with developmental delay, behavioral problems and additional manifestations, including epilepsy. In most affected individuals the duplicated chromosome is maternally derived, whereas paternal inheritance is more often associated with a normal phenotype. Seizures have not been described in patients with paternal dup 15q11-q13. We describe a family with five individuals in three generations with a paternally-inherited 15q11-q13 duplication, four of whom exhibited abnormal phenotypic characteristics, including seizures. The 18-year-old female proband presented with moderate intellectual disability, obesity, and epilepsy. Her brother manifested learning disability and behavioral problems. They both inherited the 15q11-q13 dup from their father who had a normal phenotype. Their paternal uncle and grandfather also had the duplication and were reported to have had seizures. Array-CGH and MLPA analyses showed that the duplication included the TUBGCP5, CYFIP1, MKRN3, MAGEL2, NDN, SNRPN, UBE3A, ATP10A, GABRB3, GABRA5, GABRG3, and OCA2 genes. This report provides evidence for intrafamilial phenotypic variability of paternal dup 15q11-q13, ranging from normal to intellectual disability and seizures, and potentially expanding the phenotype of paternal 15q11-q13 interstitial duplications.

Retinal eccentricity effects on reaction time to imagined stimuli

To cast light on the possible neural substrate of visual imagery we tested normal participants and one hemianopic patient on simple reaction time (RT) to real and imagined visual stimuli. In one experiment participants were to detect as quickly as possible a luminous square presented at one out of two different retinal eccentricities. A well known effect with visual stimuli is that RT is slower for peripheral versus central stimuli. We found that imagined stimuli showed an eccentricity effect similar to that obtained with real stimuli. However, this was not the case in a patient with a hemianopic visual field loss (quadrantanopia) as a result of damage to the optic radiation. Even though the patient showed no difficulty in imaging stimuli in the affected hemifield she did not show an eccentricity effect as was the case in her intact side. In a second experiment, normal participants showed faster RT to stimuli of larger size with either real or imagined stimuli. Overall, these results show that visual perception and imagination share a similar visuotopic organisation that is disrupted following deafferentation of the visual cortex.

Reality orientation therapy to delay outcomes of progression in patients with dementia. A retrospective study

OBJECTIVE

To evaluate the impact of continued Reality Orientation Therapy (ROT) in delaying the outcomes of dementia progression.

DESIGN

Retrospective study. Data collection was based on review of clinical charts and on telephone interviews performed with patients or primary caregivers.

SETTING

Day hospital of the Alzheimer's Disease Unit, Brescia (Italy).

SUBJECTS

Seventy-four patients enrolled in at least one cycle of ROT from 1994 to 1998 were studied.

INTERVENTIONS

Rehabilitative intervention based on formal ROT.

MAIN OUTCOME MEASURES

This study analysed the time to the occurrence of any of the following: cognitive decline on Mini-Mental State Examination scores, urinary incontinence as an index of functional decline, institutionalization, and death.

RESULTS

Data on a 30-month period after the first ROT session were analysed. We compared 46 patients (treatment group) who completed from 2 to 10 ROT cycles (corresponding to 8-40 weeks of training; mean = 15.48) with 28 patients (control group) who completed only one ROT cycle (4 weeks). Treatment group showed higher estimated survival rates than control group on cognitive decline (p = 0.022) and institutionalization (p = 0.002). The relative risks for cognitive decline and institutionalization in the control group compared with treatment group were 0.60 (p = 0.014), and 0.42 (p = 0.021), respectively.

CONCLUSIONS

Continued ROT classes during the early to middle stages of dementia may delay nursing home placement and slow down the progression of cognitive decline.

The Itel-MMSE: an Italian telephone version of the Mini-Mental State Examination

METHOD

We compared performance in an Italian telephone version of the Mini-Mental Status Examination (Itel-MMSE) with performance in the standard MMSE administered face to face to 104 inpatients affected by cognitive deficit.

RESULTS

Their cognitive ability varied from mildly to severely impaired. Total scores of the two MMSE versions correlated strongly for all patients (r=0.85) and for very mildly (r=0.77), mildly (r=0.79), and moderately (r=0.72) demented. A weak but statistically significant correlation was observed for severely demented patients (r=0.46). The study establishes the validity and reliability of the Itel-MMSE as well as between rater and test-retest reliability. We calculated a regression equation for use in predicting MMSE scores from Itel-MMSE scores. Data fit a linear regression model.