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Au YK, Kananeh MF, Rahangdale R, Moore TE, Panza GA, Gaspard N, Hirsch LJ, Fernandez A, Shah SO. Treatment of Refractory Status Epilepticus With Continuous Intravenous Anesthetic Drugs: A Systematic Review. JAMA Neurol 2024; 81:534-548. [PMID: 38466294 DOI: 10.1001/jamaneurol.2024.0108] [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] [Indexed: 03/12/2024]
Abstract
Importance Multiple continuous intravenous anesthetic drugs (CIVADs) are available for the treatment of refractory status epilepticus (RSE). There is a paucity of data comparing the different types of CIVADs used for RSE. Objective To systematically review and compare outcome measures associated with the initial CIVAD choice in RSE in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Evidence Review Data sources included English and non-English articles using Embase, MEDLINE, PubMed, and Web of Science (January 1994-June 2023) as well as manual search. Study selection included peer-reviewed studies of 5 or more patients and at least 1 patient older than 12 years with status epilepticus refractory to a benzodiazepine and at least 1 standard antiseizure medication, treated with continuously infused midazolam, ketamine, propofol, pentobarbital, or thiopental. Independent extraction of articles was performed using prespecified data items. The association between outcome variables and CIVAD was examined with an analysis of variance or χ2 test where appropriate. Binary logistic regressions were used to examine the association between outcome variables and CIVAD with etiology, change in mortality over time, electroencephalography (EEG) monitoring (continuous vs intermittent), and treatment goal (seizure vs burst suppression) included as covariates. Risk of bias was addressed by listing the population and type of each study. Findings A total of 66 studies with 1637 patients were included. Significant differences among CIVAD groups in short-term failure, hypotension, and CIVAD substitution during treatment were observed. Non-epilepsy-related RSE (vs epilepsy-related RSE) was associated with a higher rate of CIVAD substitution (60 of 120 [50.0%] vs 11 of 43 [25.6%]; odds ratio [OR], 3.11; 95% CI, 1.44-7.11; P = .006) and mortality (98 of 227 [43.2%] vs 7 of 63 [11.1%]; OR, 17.0; 95% CI, 4.71-109.35; P < .001). Seizure suppression was associated with mortality (OR, 7.72; 95% CI, 1.77-39.23; P = .005), but only a small subgroup was available for analysis (seizure suppression: 17 of 22 [77.3%] from 3 publications vs burst suppression: 25 of 98 [25.5%] from 12 publications). CIVAD choice and EEG type were not predictors of mortality. Earlier publication year was associated with mortality, although the observation was no longer statistically significant after adjusting SEs for clustering. Conclusions and Relevance Epilepsy-related RSE was associated with lower mortality compared with other RSE etiologies. A trend of decreasing mortality over time was observed, which may suggest an effect of advances in neurocritical care. The overall data are heterogeneous, which limits definitive conclusions on the choice of optimal initial CIVAD in RSE treatment.
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Affiliation(s)
- Yu Kan Au
- Department of Neurosciences, Hartford Hospital, University of Connecticut, Hartford, Connecticut
- Department of Neurology, University of Connecticut, Farmington
| | - Mohammed F Kananeh
- Department of Neurology, Hackensack University Medical Center, Hackensack, New Jersey
- Department of Neurology, Hackensack Meridian School of Medicine, Hackensack, New Jersey
| | - Rahul Rahangdale
- Neuroscience Institute, Ascension St John Medical Center, Tulsa, Oklahoma
| | - Timothy Eoin Moore
- Statistical Consulting Services, Center for Open Research Resources & Equipment, University of Connecticut, Storrs
| | - Gregory A Panza
- Department of Research, Hartford HealthCare, Hartford, Connecticut
| | - Nicolas Gaspard
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut
- Université Libre de Bruxelles and Service de Neurologie, Hôpital Universitaire de Bruxelles - Hôpital Erasme, Brussels, Belgium
| | - Lawrence J Hirsch
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut
| | - Andres Fernandez
- Department of Neurology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Syed Omar Shah
- Department of Neurology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
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Hanin A, Muscal E, Hirsch LJ. Second-line immunotherapy in new onset refractory status epilepticus. Epilepsia 2024; 65:1203-1223. [PMID: 38430119 DOI: 10.1111/epi.17933] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 02/06/2024] [Accepted: 02/12/2024] [Indexed: 03/03/2024]
Abstract
Several pieces of evidence suggest immune dysregulation could trigger the onset and modulate sequelae of new onset refractory status epilepticus (NORSE), including its subtype with prior fever known as febrile infection-related epilepsy syndrome (FIRES). Consensus-driven recommendations have been established to guide the initiation of first- and second-line immunotherapies in these patients. Here, we review the literature to date on second-line immunotherapy for NORSE/FIRES, presenting results from 28 case reports and series describing the use of anakinra, tocilizumab, or intrathecal dexamethasone in 75 patients with NORSE. Among them, 52 patients were managed with anakinra, 21 with tocilizumab, and eight with intrathecal dexamethasone. Most had elevated serum or cerebrospinal fluid cytokine levels at treatment initiation. Treatments were predominantly initiated during the acute phase of the disease (92%) and resulted, within the first 2 weeks, in seizure control for up to 73% of patients with anakinra, 70% with tocilizumab, and 50% with intrathecal dexamethasone. Cytokine levels decreased after treatment for most patients. Anakinra and intrathecal dexamethasone were mainly initiated in children with FIRES, whereas tocilizumab was more frequently prescribed for adults, with or without a prior febrile infection. There was no clear correlation between the response to treatment and the time to initiate the treatment. Most patients experienced long-term disability and drug-resistant post-NORSE epilepsy. Initiation of second-line immunotherapies during status epilepticus (SE) had no clear effect on the emergence of post-NORSE epilepsy or long-term functional outcomes. In a small number of cases, the initiation of anakinra or tocilizumab several years after SE onset resulted in a reduction of seizure frequency for 67% of patients. These data highlight the potential utility of anakinra, tocilizumab, and intrathecal dexamethasone in patients with NORSE. There continues to be interest in the utilization of early cytokine measurements to guide treatment selection and response. Prospective studies are necessary to understand the role of early immunomodulation and its associations with epilepsy and functional outcomes.
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Affiliation(s)
- Aurélie Hanin
- Comprehensive Epilepsy Center, Department of Neurology, 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
- Epilepsy Unit and Clinical Neurophysiology Department, DMU Neurosciences 6, Assistance Publique - Hôpitaux de Paris, Hôpital de la Pitié-Salpêtrière, Paris, France
| | - Eyal Muscal
- Department of Pediatrics, Section of Rheumatology, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
| | - Lawrence J Hirsch
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, Connecticut, USA
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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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Punia V, Daruvala S, Dhakar MB, Zafar SF, Rubinos C, Ayub N, Hirsch LJ, Sivaraju A. Immediate and long-term management practices of acute symptomatic seizures and epileptiform abnormalities: A cross-sectional international survey. Epilepsia 2024; 65:909-919. [PMID: 38358383 DOI: 10.1111/epi.17915] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 01/31/2024] [Accepted: 01/31/2024] [Indexed: 02/16/2024]
Abstract
OBJECTIVES Acute symptomatic seizures (ASyS) and epileptiform abnormalities (EAs) on electroencephalography (EEG) are commonly encountered following acute brain injury. Their immediate and long-term management remains poorly investigated. We conducted an international survey to understand their current management. METHODS The cross-sectional web-based survey of 21 fixed-response questions was based on a common clinical encounter: convulsive or suspected ASyS following an acute brain injury. Respondents selected the option that best matched their real-world practice. Respondents completing the survey were compared with those who accessed but did not complete it. RESULTS A total of 783 individuals (44 countries) accessed the survey; 502 completed it. Almost everyone used anti-seizure medications (ASMs) for secondary prophylaxis after convulsive or electrographic ASyS (95.4% and 97.2%, respectively). ASM dose escalation after convulsive ASyS depends on continuous EEG (cEEG) findings: most often increased after electrographic seizures (78% of respondents), followed by lateralized periodic discharges (LPDs; 41%) and sporadic epileptiform discharges (sEDs; 17.5%). If cEEG is unrevealing, one in five respondents discontinue ASMs after a week. In the absence of convulsive and electrographic ASyS, a large proportion of respondents start ASMs due to LPD (66.7%) and sED (44%) on cEEG. At hospital discharge, most respondents (85%) continue ASM without dose change. The recommended duration of outpatient ASM use is as follows: 1-3 months (36%), 3-6 months (30%), 6-12 months (13%), >12 months (11%). Nearly one-third of respondents utilized ancillary testing before outpatient ASM taper, most commonly (79%) a <2 h EEG. Approximately half of respondents had driving restrictions recommended for 6 months after discharge. SIGNIFICANCE ASM use for secondary prophylaxis after convulsive and electrographic ASyS is a universal practice and is continued upon discharge. Outpatient care, particularly the ASM duration, varies significantly. Wide practice heterogeneity in managing acute EAs reflects uncertainty about their significance and management. These results highlight the need for a structured outpatient follow-up and optimized care pathway for patients with ASyS.
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Affiliation(s)
- Vineet Punia
- Epilepsy Center, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Sanaya Daruvala
- Department of Neurology, Warren Alpert School of Medicine, Providence, Rhode Island, USA
| | - Monica B Dhakar
- Department of Neurology, Warren Alpert School of Medicine, Providence, Rhode Island, USA
| | - Sahar F Zafar
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Clio Rubinos
- University of North Carolina, Chapel Hill, North Carolina, USA
| | - Neishay Ayub
- Department of Neurology, Warren Alpert School of Medicine, Providence, Rhode Island, USA
| | - Lawrence J Hirsch
- Comprehensive Epilepsy Center, Department of Neurology, Yale University, New Haven, Connecticut, USA
| | - Adithya Sivaraju
- Comprehensive Epilepsy Center, Department of Neurology, Yale University, New Haven, Connecticut, USA
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Hanin A, Eschbach K, Gofton TE, Gopaul M, Howe CL, Lai YC, Koh S, Shen H, Hirsch LJ. New onset refractory status epilepticus: Summary of the NORSE Institute roundtable during the 2023 American Epilepsy Society meeting, Orlando, Florida. Epilepsia 2024; 65:1145-1146. [PMID: 38421053 DOI: 10.1111/epi.17934] [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: 02/11/2024] [Accepted: 02/13/2024] [Indexed: 03/02/2024]
Affiliation(s)
- Aurélie 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, AP-HP, 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
| | - Krista Eschbach
- Department of Pediatrics, Section of Neurology, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Teneille E Gofton
- University Hospital, London Health Sciences Center, London, Ontario, Canada
| | - Margaret Gopaul
- Department of Neurology, Comprehensive Epilepsy Center, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Charles L Howe
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Yi-Chen Lai
- Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Sookyong Koh
- Children's Hospital and Medical Center, Department of Pediatrics, University of Nebraska, Omaha, Nebraska, USA
| | - Haying Shen
- Children's Hospital and Medical Center, Department of Pediatrics, University of Nebraska, Omaha, Nebraska, USA
| | - Lawrence J Hirsch
- Department of Neurology, Comprehensive Epilepsy Center, Yale University School of Medicine, New Haven, Connecticut, USA
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Ney JP, Nuwer MR, Hirsch LJ, Burdelle M, Trice K, Parvizi J. The Cost of After-Hour Electroencephalography. Neurol Clin Pract 2024; 14:e200264. [PMID: 38585440 PMCID: PMC10997216 DOI: 10.1212/cpj.0000000000200264] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 11/21/2023] [Indexed: 04/09/2024]
Abstract
Background and Objectives High costs associated with after-hour electroencephalography (EEG) constitute a barrier for financially constrained hospitals to provide this neurodiagnostic procedure outside regular working hours. Our study aims to deepen our understanding of the cost elements involved in delivering EEG services during after-hours. Methods We accessed publicly available data sets and created a cost model depending on 3 most commonly seen staffing scenarios: (1) technologist on-site, (2) technologist on-call from home, and (3) a hybrid of the two. Results Cost of EEG depends on the volume of testing and the staffing plan. Within the various cost elements, labor cost of EEG technologists is the predominant expenditure, which varies across geographic regions and urban areas. Discussion We provide a model to explain why access to EEGs during after-hours has a substantial expense. This model provides a cost calculator tool (made available as part of this publication in eAppendix 1, links.lww.com/CPJ/A513) to estimate the cost of EEG platform based on site-specific staffing scenarios and annual volume.
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Affiliation(s)
- John P Ney
- School of Medicine (JPN), Boston University, MA; Departments of Neurology (MRN), University of California Los Angeles David Geffen School of Medicine; Department of Neurology (LJH), Yale University School of Medicine, New Haven, CT; Department of Neurology and Neurological Sciences (MB, JP), Stanford University School of Medicine, CA; and Neurodiagnostic Technology Programs (KT), Institute of Health Sciences, Hunt Valley, MD
| | - Marc R Nuwer
- School of Medicine (JPN), Boston University, MA; Departments of Neurology (MRN), University of California Los Angeles David Geffen School of Medicine; Department of Neurology (LJH), Yale University School of Medicine, New Haven, CT; Department of Neurology and Neurological Sciences (MB, JP), Stanford University School of Medicine, CA; and Neurodiagnostic Technology Programs (KT), Institute of Health Sciences, Hunt Valley, MD
| | - Lawrence J Hirsch
- School of Medicine (JPN), Boston University, MA; Departments of Neurology (MRN), University of California Los Angeles David Geffen School of Medicine; Department of Neurology (LJH), Yale University School of Medicine, New Haven, CT; Department of Neurology and Neurological Sciences (MB, JP), Stanford University School of Medicine, CA; and Neurodiagnostic Technology Programs (KT), Institute of Health Sciences, Hunt Valley, MD
| | - Mark Burdelle
- School of Medicine (JPN), Boston University, MA; Departments of Neurology (MRN), University of California Los Angeles David Geffen School of Medicine; Department of Neurology (LJH), Yale University School of Medicine, New Haven, CT; Department of Neurology and Neurological Sciences (MB, JP), Stanford University School of Medicine, CA; and Neurodiagnostic Technology Programs (KT), Institute of Health Sciences, Hunt Valley, MD
| | - Kellee Trice
- School of Medicine (JPN), Boston University, MA; Departments of Neurology (MRN), University of California Los Angeles David Geffen School of Medicine; Department of Neurology (LJH), Yale University School of Medicine, New Haven, CT; Department of Neurology and Neurological Sciences (MB, JP), Stanford University School of Medicine, CA; and Neurodiagnostic Technology Programs (KT), Institute of Health Sciences, Hunt Valley, MD
| | - Josef Parvizi
- School of Medicine (JPN), Boston University, MA; Departments of Neurology (MRN), University of California Los Angeles David Geffen School of Medicine; Department of Neurology (LJH), Yale University School of Medicine, New Haven, CT; Department of Neurology and Neurological Sciences (MB, JP), Stanford University School of Medicine, CA; and Neurodiagnostic Technology Programs (KT), Institute of Health Sciences, Hunt Valley, MD
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Sivaraju A, Quraishi I, Collins E, McGrath H, Ramos A, Turk-Browne NB, Zaveri H, Damisah E, Spencer DD, Hirsch LJ. Systematic 1 Hz direct electrical stimulation for seizure induction: A reliable method for localizing seizure onset zone and predicting seizure freedom. Brain Stimul 2024; 17:339-345. [PMID: 38490472 DOI: 10.1016/j.brs.2024.03.011] [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: 11/10/2023] [Revised: 02/21/2024] [Accepted: 03/12/2024] [Indexed: 03/17/2024] Open
Abstract
OBJECTIVE To prospectively investigate the utility of seizure induction using systematic 1 Hz stimulation by exploring its concordance with the spontaneous seizure onset zone (SOZ) and relation to surgical outcome; comparison with seizures induced by non-systematic 50 Hz stimulation was attempted as well. METHODS Prospective cohort study from 2018 to 2021 with ≥ 1 y post-surgery follow up at Yale New Haven Hospital. With 1 Hz, all or most of the gray matter contacts were stimulated at 1, 5, and 10 mA for 30-60s. With 50 Hz, selected gray matter contacts outside of the medial temporal regions were stimulated at 1-5 mA for 0.5-3s. Stimulation was bipolar, biphasic with 0.3 ms pulse width. The Yale Brain Atlas was used for data visualization. Variables were analyzed using Fisher's exact, χ2, or Mann-Whitney test. RESULTS Forty-one consecutive patients with refractory epilepsy undergoing intracranial EEG for localization of SOZ were included. Fifty-six percent (23/41) of patients undergoing 1 Hz stimulation had seizures induced, 83% (19/23) habitual (clinically and electrographically). Eighty two percent (23/28) of patients undergoing 50 Hz stimulation had seizures, 65% (15/23) habitual. Stimulation of medial temporal or insular regions with 1 Hz was more likely to induce seizures compared to other regions [15/32 (47%) vs. 2/41 (5%), p < 0.001]. Sixteen patients underwent resection; 11/16 were seizure free at one year and all 11 had habitual seizures induced by 1 Hz; 5/16 were not seizure free at one year and none of those 5 had seizures with 1 Hz (11/11 vs 0/5, p < 0.0001). No patients had convulsions with 1 Hz stimulation, but four did with 50 Hz (0/41 vs. 4/28, p = 0.02). SIGNIFICANCE Induction of habitual seizures with 1 Hz stimulation can reliably identify the SOZ, correlates with excellent surgical outcome if that area is resected, and may be superior (and safer) than 50 Hz for this purpose. However, seizure induction with 1 Hz was infrequent outside of the medial temporal and insular regions in this study.
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Affiliation(s)
- Adithya Sivaraju
- Comprehensive Epilepsy Center, Dept. of Neurology, School of Medicine, Yale University, Yale-New Haven Hospital, New Haven, CT, USA.
| | - Imran Quraishi
- Comprehensive Epilepsy Center, Dept. of Neurology, School of Medicine, Yale University, Yale-New Haven Hospital, New Haven, CT, USA.
| | - Evan Collins
- Comprehensive Epilepsy Center, Dept. of Neurosurgery, School of Medicine, Yale University, Yale-New Haven Hospital, New Haven, CT, USA.
| | - Hari McGrath
- Comprehensive Epilepsy Center, Dept. of Neurosurgery, School of Medicine, Yale University, Yale-New Haven Hospital, New Haven, CT, USA.
| | - Alexander Ramos
- Comprehensive Epilepsy Center, Dept. of Neurology, School of Medicine, Yale University, Yale-New Haven Hospital, New Haven, CT, USA; MidAtlantic Epilepsy and Sleep Center, Dept of Neurology, Bethesda, MD, USA.
| | - Nicholas B Turk-Browne
- Department of Psychology, Yale University, New Haven, CT, USA; Wu Tsai Institute, Yale University, New Haven, CT, USA.
| | - Hitten Zaveri
- Comprehensive Epilepsy Center, Dept. of Neurology, School of Medicine, Yale University, Yale-New Haven Hospital, New Haven, CT, USA.
| | - Eyiyemisi Damisah
- Comprehensive Epilepsy Center, Dept. of Neurosurgery, School of Medicine, Yale University, Yale-New Haven Hospital, New Haven, CT, USA.
| | - Dennis D Spencer
- Comprehensive Epilepsy Center, Dept. of Neurosurgery, School of Medicine, Yale University, Yale-New Haven Hospital, New Haven, CT, USA.
| | - Lawrence J Hirsch
- Comprehensive Epilepsy Center, Dept. of Neurology, School of Medicine, Yale University, Yale-New Haven Hospital, New Haven, CT, USA.
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Rivier CA, Clocchiatti-Tuozzo S, Misra S, Zelano J, Mazumder R, Sansing LH, de Havenon A, Hirsch LJ, Liebeskind DS, Gilmore EJ, Sheth KN, Kim JA, Worrall BB, Falcone G, Mishra NK. Polygenic Risk of Epilepsy and Post-Stroke Epilepsy. medRxiv 2023:2023.09.18.23295739. [PMID: 37790357 PMCID: PMC10543238 DOI: 10.1101/2023.09.18.23295739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/05/2023]
Abstract
Background and Aims Epilepsy is highly heritable, with numerous known genetic risk loci. However, the genetic predisposition's role in post-acute brain injury epilepsy remains understudied. This study assesses whether a higher genetic predisposition to epilepsy raises post-stroke or Transient Ischemic Attack (TIA) survivor's risk of Post-Stroke Epilepsy (PSE). Methods We conducted a three-stage genetic analysis. First, we identified independent epilepsy-associated ( p <5x10 -8 ) genetic variants from public data. Second, we estimated PSE-specific variant weights in stroke/TIA survivors from the UK Biobank. Third, we tested for an association between a polygenic risk score (PRS) and PSE risk in stroke/TIA survivors from the All of Us Research Program. Primary analysis included all ancestries, while a secondary analysis was restricted to European ancestry only. A sensitivity analysis excluded TIA survivors. Association testing was conducted via multivariable logistic regression, adjusting for age, sex, and genetic ancestry. Results Among 19,708 UK Biobank participants with stroke/TIA, 805 (4.1%) developed PSE. Likewise, among 12,251 All of Us participants with stroke/TIA, 394 (3.2%) developed PSE. After establishing PSE-specific weights for 39 epilepsy-linked genetic variants in the UK Biobank, the resultant PRS was associated with elevated odds of PSE development in All of Us (OR:1.16[1.02-1.32]). A similar result was obtained when restricting to participants of European ancestry (OR:1.23[1.02-1.49]) and when excluding participants with a TIA history (OR:1.18[1.02-1.38]). Conclusions Our findings suggest that akin to other forms of epilepsy, genetic predisposition plays an essential role in PSE. Because the PSE data were sparse, our results should be interpreted cautiously.
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9
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Dhakar MB, Sheikh ZB, Desai M, Desai RA, Sternberg EJ, Popescu C, Baron-Lee J, Rampal N, Hirsch LJ, Gilmore EJ, Maciel CB. Developing a Standardized Approach to Grading the Level of Brain Dysfunction on EEG. J Clin Neurophysiol 2023; 40:553-561. [PMID: 35239553 DOI: 10.1097/wnp.0000000000000919] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
PURPOSE To assess variability in interpretation of electroencephalogram (EEG) background activity and qualitative grading of cerebral dysfunction based on EEG findings, including which EEG features are deemed most important in this determination. METHODS A web-based survey (Qualtrics) was disseminated to electroencephalographers practicing in institutions participating in the Critical Care EEG Monitoring Research Consortium between May 2017 and August 2018. Respondents answered 12 questions pertaining to their training and EEG interpretation practices and graded 40 EEG segments (15-second epochs depicting patients' most stimulated state) using a 6-grade scale. Fleiss' Kappa statistic evaluated interrater agreement. RESULTS Of 110 respondents, 78.2% were attending electroencephalographers with a mean of 8.3 years of experience beyond training. Despite 83% supporting the need for a standardized approach to interpreting the degree of dysfunction on EEG, only 13.6% used a previously published or an institutional grading scale. The overall interrater agreement was fair ( k = 0.35). Having Critical Care EEG Monitoring Research Consortium nomenclature certification (40.9%) or EEG board certification (70%) did not improve interrater agreement ( k = 0.26). Predominant awake frequencies and posterior dominant rhythm were ranked as the most important variables in grading background dysfunction, followed by continuity and reactivity. CONCLUSIONS Despite the preference for a standardized grading scale for background EEG interpretation, the lack of interrater agreement on levels of dysfunction even among experienced academic electroencephalographers unveils a barrier to the widespread use of EEG as a clinical and research neuromonitoring tool. There was reasonable agreement on the features that are most important in this determination. A standardized approach to grading cerebral dysfunction, currently used by the authors, and based on this work, is proposed.
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Affiliation(s)
- Monica B Dhakar
- Department of Neurology, Warren Alpert Medical School of Brown University, Providence, Rhode Island, U.S.A
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut, U.S.A
| | - Zubeda B Sheikh
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut, U.S.A
- Department of Neurology, West Virginia University School of Medicine, Morgantown, West Virginia, U.S.A
| | - Masoom Desai
- Department of Neurology, University of Oklahoma Health Science Center, Oklahoma City, Oklahoma, U.S.A
| | - Raj A Desai
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida College of Pharmacy, Gainesville, Florida, U.S.A
| | - Eliezer J Sternberg
- Division of Neurology, Milford Regional Medical Center, Milford, Massachusetts, U.S.A
- Department of Neurology, University of Massachusetts Medical School, Worcester, Massachusetts, U.S.A
| | - Cristina Popescu
- Department of Social and Public Health, Ohio University, Athens, Ohio, U.S.A
| | - Jacqueline Baron-Lee
- Department of Neurology, UF-Health Shands Hospital, University of Florida College of Medicine, Gainesville, Florida, U.S.A.; and
| | | | - Lawrence J Hirsch
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut, U.S.A
| | - Emily J Gilmore
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut, U.S.A
| | - Carolina B Maciel
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut, U.S.A
- Department of Neurology, UF-Health Shands Hospital, University of Florida College of Medicine, Gainesville, Florida, U.S.A.; and
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10
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Leitinger M, Gaspard N, Hirsch LJ, Beniczky S, Kaplan PW, Husari K, Trinka E. Diagnosing nonconvulsive status epilepticus: Defining electroencephalographic and clinical response to diagnostic intravenous antiseizure medication trials. Epilepsia 2023; 64:2351-2360. [PMID: 37350392 DOI: 10.1111/epi.17694] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 06/17/2023] [Accepted: 06/20/2023] [Indexed: 06/24/2023]
Abstract
OBJECTIVE The Salzburg criteria for nonconvulsive status epilepticus (NCSE) and the American Clinical Neurophysiology Society (ACNS) Standardized Critical Care EEG Terminology 2021 include a diagnostic trial with intravenous (IV) antiseizure medications (ASMs) to assess electroencephalographic (EEG) and clinical response as a diagnostic criterion for definite NCSE and possible NCSE. However, how to perform this diagnostic test and assessing the EEG and clinical responses have not been operationally defined. METHODS We performed a Delphi process involving six experts to standardize the diagnostic administration of IV ASM and propose operational criteria for EEG and clinical response. RESULTS Either benzodiazepines (BZDs) or non-BZD ASMs can be used as first choice for a diagnostic IV ASM trial. However, non-BZDs should be considered in patients who already have impaired alertness or are at risk of respiratory depression. Levetiracetam, valproate, lacosamide, brivaracetam, or (if the only feasible drug) fosphenytoin or phenobarbital were deemed appropriate for a diagnostic IV trial. The starting dose should be approximately two thirds to three quarters of the full loading dose recommended for treatment of status epilepticus, with an additional smaller dose if needed. ASMs should be administered during EEG recording under supervision. A monitoring time of at least 15 min is recommended. If there is no response, a second trial with another non-BDZ or BDZs may be considered. A positive EEG response is defined as the resolution of the ictal-interictal continuum pattern for at least three times the longest previously observed spontaneous interval of resolution (if any), but minimum of one continuous minute. For a clinical response, physicians should use a standardized examination before and after IV ASM administration. We suggest a definite time-locked improvement in a focal deficit or at least one-step improvement on a new dedicated one-domain 10-level NCSE response scale. SIGNIFICANCE The proposed standardized approach of a diagnostic IV ASM trial further refines the ACNS and Salzburg diagnostic criteria for NCSE.
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Affiliation(s)
- Markus Leitinger
- Department of Neurology, member of European Reference Network EpiCARE, Center for Cognitive Neuroscience, Christian Doppler University Hospital, Paracelsus Medical University, Salzburg, Austria
- Neuroscience Institute, Center for Cognitive Neuroscience, Christian Doppler University Hospital, Paracelsus Medical University, Salzburg, Austria
| | - Nicolas Gaspard
- Hôpital Universitaire de Bruxelles-Hôpital Erasme, Brussels, Belgium
- Université Libre de Bruxelles, Brussels, Belgium
| | - Lawrence J Hirsch
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Sándor Beniczky
- Department of Clinical Neurophysiology, Danish Epilepsy Center, Dianalund, Denmark
- Department of Clinical Neurophysiology, Aarhus University Hospital and Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Peter W Kaplan
- Department of Neurology, Johns Hopkins University School of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland, USA
| | - Khalil Husari
- Department of Neurology, Johns Hopkins University School of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland, USA
| | - Eugen Trinka
- Department of Neurology, member of European Reference Network EpiCARE, Center for Cognitive Neuroscience, Christian Doppler University Hospital, Paracelsus Medical University, Salzburg, Austria
- Neuroscience Institute, Center for Cognitive Neuroscience, Christian Doppler University Hospital, Paracelsus Medical University, Salzburg, Austria
- Institute of Public Health, Medical Decision Making and Health Technology Assessment, University for Health Sciences, Medical Informatics, and Technology, Hall in Tyrol, Austria
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11
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Snider SB, Fong MWK, Nolan NM, Ruiz AR, Wang W, LaRoche S, Hirsch LJ, Lee JW. Clinical and Electroencephalographic Predictors of Seizures and Status Epilepticus in 12,450 Critically Ill Adults: A Retrospective Cohort Study. Crit Care Med 2023; 51:1001-1011. [PMID: 37010290 DOI: 10.1097/ccm.0000000000005872] [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] [Indexed: 04/04/2023]
Abstract
OBJECTIVES Status epilepticus (SE) is associated with significantly higher morbidity and mortality than isolated seizures. Our objective was to identify clinical diagnoses and rhythmic and periodic electroencephalogram patterns (RPPs) associated with SE and seizures. DESIGN Retrospective cohort study. SETTING Tertiary-care hospitals. SUBJECTS Twelve thousand four hundred fifty adult hospitalized patients undergoing continuous electroencephalogram (cEEG) monitoring in selected participating sites in the Critical Care EEG Monitoring Research Consortium database (February 2013 to June 2021). INTERVENTIONS Not applicable. MEASUREMENTS AND MAIN RESULTS We defined an ordinal outcome in the first 72 hours of cEEG: no seizures, isolated seizures without SE, or SE (with or without isolated seizures). Composite groups included isolated seizures or SE (AnySz) and no seizure or isolated seizures. In this cohort (mean age: 60 ± 17 yr), 1,226 patients (9.8%) had AnySz and 439 patients (3.5%) had SE. In a multivariate model, factors independently associated with SE were cardiac arrest (9.2% with SE; adjusted odds ratio, 8.8 [6.3-12.1]), clinical seizures before cEEG (5.7%; 3.3 [2.5-4.3]), brain neoplasms (3.2%; 1.6 [1.0-2.6]), lateralized periodic discharges (LPDs) (15.4%; 7.3 [5.7-9.4]), brief potentially ictal rhythmic discharges (BIRDs) (22.5%; 3.8 [2.6-5.5]), and generalized periodic discharges (GPDs) (7.2%; 2.4 [1.7-3.3]). All above variables and lateralized rhythmic delta activity (LRDA) were also associated with AnySz. Factors disproportionately increasing odds of SE over isolated seizures were cardiac arrest (7.3 [4.4-12.1]), clinical seizures (1.7 [1.3-2.4]), GPDs (2.3 [1.4-3.5]), and LPDs (1.4 [1.0-1.9]). LRDA had lower odds of SE compared with isolated seizures (0.5 [0.3-0.9]). RPP modifiers did not improve SE prediction beyond RPPs presence/absence ( p = 0.8). CONCLUSIONS Using the largest existing cEEG database, we identified specific predictors of SE (cardiac arrest, clinical seizures prior to cEEG, brain neoplasms, LPDs, GPDs, and BIRDs) and seizures (all previous and LRDA). These findings could be used to tailor cEEG monitoring for critically ill patients.
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Affiliation(s)
- Samuel B Snider
- Division of Neurocritical Care, Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Michael W K Fong
- Westmead Comprehensive Epilepsy Unit, Westmead Hospital, University of Sydney, Sydney, NSW, Australia
- Comprehensive Epilepsy Center, Dept. of Neurology, Yale University School of Medicine, New Haven, CT
| | - Neal M Nolan
- Division of Neurocritical Care, Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | | | - Wei Wang
- Division of Sleep Medicine, Departments of Medicine and Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Suzette LaRoche
- Department of Neurology, University of North Carolina, Chapel Hill, NC
| | - Lawrence J Hirsch
- Comprehensive Epilepsy Center, Dept. of Neurology, Yale University School of Medicine, New Haven, CT
| | - Jong W Lee
- Division of Epilepsy, Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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12
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Hanin A, Cespedes J, Pulluru Y, Gopaul M, Aronica E, Decampo D, Helbig I, Howe CL, Huttner A, Koh S, Navarro V, Taraschenko O, Vezzani A, Wilson MR, Xian J, Gaspard N, Hirsch LJ. Review and standard operating procedures for collection of biospecimens and analysis of biomarkers in new onset refractory status epilepticus. Epilepsia 2023; 64:1444-1457. [PMID: 37039049 PMCID: PMC10756682 DOI: 10.1111/epi.17600] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 03/27/2023] [Accepted: 03/28/2023] [Indexed: 04/12/2023]
Abstract
New onset refractory status epilepticus (NORSE), including its subtype with a preceding febrile illness known as febrile infection-related epilepsy syndrome (FIRES), is one of the most severe forms of status epilepticus. The exact causes of NORSE are currently unknown, and there is so far no disease-specific therapy. Identifying the underlying pathophysiology and discovering specific biomarkers, whether immunologic, infectious, genetic, or other, may help physicians in the management of patients with NORSE. A broad spectrum of biomarkers has been proposed for status epilepticus patients, some of which were evaluated for patients with NORSE. Nonetheless, none has been validated, due to significant variabilities in study cohorts, collected biospecimens, applied analytical methods, and defined outcome endpoints, and to small sample sizes. The NORSE Institute established an open NORSE/FIRES biorepository for health-related data and biological samples allowing the collection of biospecimens worldwide, promoting multicenter research and sharing of data and specimens. Here, we suggest standard operating procedures for biospecimen collection and biobanking in this rare condition. We also propose criteria for the appropriate use of previously collected biospecimens. We predict that the widespread use of standardized procedures will reduce heterogeneity, facilitate the future identification of validated biomarkers for NORSE, and provide a better understanding of the pathophysiology and best clinical management for these patients.
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Affiliation(s)
- Aurélie Hanin
- Department of Neurology and Immunobiology, Yale University School of Medicine, New Haven, Connecticut, USA
- Sorbonne Université, Institut du Cerveau ICM, Paris Brain Institute, Inserm, CNRS, Assistance Publique -Hôpitaux de Paris, Hôpital de la Pitié-Salpêtrière, DMU Neurosciences 6, Paris, France
- Assistance Publique -Hôpitaux de Paris, Hôpital de la Pitié-Salpêtrière, DMU Neurosciences 6, Epilepsy Unit and Department of Clinical Neurophysiology, Paris, France
| | - Jorge Cespedes
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, Connecticut, USA
- Universidad Autonoma de Centro America, School of Medicine, San Jose, Costa Rica
| | - Yashwanth Pulluru
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, Connecticut, USA
- Nebraska Medical Center, Omaha, Nebraska, USA
| | - Margaret Gopaul
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Eleonora Aronica
- Department of (Neuro) Pathology, Amsterdam Neuroscience, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Danielle Decampo
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Epilepsy NeuroGenetics Initiative, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Biomedical and Health Informatics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ingo Helbig
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Epilepsy NeuroGenetics Initiative, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Biomedical and Health Informatics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Charles L. Howe
- Division of Experimental Neurology, Mayo Clinic, Rochester, Minnesota, USA
- Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Anita Huttner
- Department of Pathology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Sookyong Koh
- Department of Pediatrics, Children’s Hospital Medical Center, University of Nebraska, Omaha, Nebraska, USA
| | - Vincent Navarro
- Sorbonne Université, Institut du Cerveau ICM, Paris Brain Institute, Inserm, CNRS, Assistance Publique -Hôpitaux de Paris, Hôpital de la Pitié-Salpêtrière, DMU Neurosciences 6, Paris, France
- Assistance Publique -Hôpitaux de Paris, Hôpital de la Pitié-Salpêtrière, DMU Neurosciences 6, Epilepsy Unit and Department of Clinical Neurophysiology, Paris, France
| | - Olga Taraschenko
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Annamaria Vezzani
- Department of Acute Brain Injury, Istituto di Recerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Michael R. Wilson
- Weill Institute for Neurosciences, Department of Neurology, University of California San Francisco, California, San Francisco, USA
| | - Julie Xian
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Epilepsy NeuroGenetics Initiative, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Biomedical and Health Informatics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Nicolas Gaspard
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, Connecticut, USA
- Université Libre de Bruxelles, Hôpital Erasme, Brussels, Belgium
| | - Lawrence J. Hirsch
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, Connecticut, USA
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13
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Sheikh Z, Hirsch LJ. A practical approach to in-hospital management of new-onset refractory status epilepticus/febrile infection related epilepsy syndrome. Front Neurol 2023; 14:1150496. [PMID: 37251223 PMCID: PMC10213694 DOI: 10.3389/fneur.2023.1150496] [Citation(s) in RCA: 2] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 04/12/2023] [Indexed: 05/31/2023] Open
Abstract
New-onset refractory status epilepticus (NORSE) is "a clinical presentation, not a specific diagnosis, in a patient without active epilepsy or other preexisting relevant neurological disorder, with new onset of refractory status epilepticus without a clear acute or active structural, toxic, or metabolic cause." Febrile infection related epilepsy syndrome (FIRES) is "a subcategory of NORSE that requires a prior febrile infection, with fever starting between 2 weeks and 24 h before the onset of refractory status epilepticus, with or without fever at the onset of status epilepticus." These apply to all ages. Extensive testing of blood and CSF for infectious, rheumatologic, and metabolic conditions, neuroimaging, EEG, autoimmune/paraneoplastic antibody evaluations, malignancy screen, genetic testing, and CSF metagenomics may reveal the etiology in some patients, while a significant proportion of patients' disease remains unexplained, known as NORSE of unknown etiology or cryptogenic NORSE. Seizures are refractory and usually super-refractory (i.e., persist despite 24 h of anesthesia), requiring a prolonged intensive care unit stay, often (but not always) with fair to poor outcomes. Management of seizures in the initial 24-48 h should be like any case of refractory status epilepticus. However, based on the published consensus recommendations, the first-line immunotherapy should begin within 72 h using steroids, intravenous immunoglobulins, or plasmapheresis. If there is no improvement, the ketogenic diet and second-line immunotherapy should start within seven days. Rituximab is recommended as the second-line treatment if there is a strong suggestion or proof of an antibody-mediated disease, while anakinra or tocilizumab are recommended for cryptogenic cases. Intensive motor and cognitive rehab are usually necessary after a prolonged hospital stay. Many patients will have pharmacoresistant epilepsy at discharge, and some may need continued immunologic treatments and an epilepsy surgery evaluation. Extensive research is in progress now via multinational consortia relating to the specific type(s) of inflammation involved, whether age and prior febrile illness affect this, and whether measuring and following serum and/or CSF cytokines can help determine the best treatment.
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Affiliation(s)
- Zubeda Sheikh
- Department of Neurology, West Virginia University School of Medicine, Morgantown, WV, United States
- Epilepsy Division, Department of Neurology, Yale School of Medicine, New Haven, CT, United States
| | - Lawrence J. Hirsch
- Epilepsy Division, Department of Neurology, Yale School of Medicine, New Haven, CT, United States
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14
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Lamsam L, Brigido MM, Sivaraju A, Hirsch LJ, Spencer DD, Chiang V, Damisah E. Transfrontal Approach to the Amygdala for Ablation With Laser Interstitial Thermal Therapy: An Epilepsy Case Report. Oper Neurosurg (Hagerstown) 2023; 24:e381-e384. [PMID: 36715982 PMCID: PMC10158899 DOI: 10.1227/ons.0000000000000576] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 10/06/2022] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND AND IMPORTANCE Stereotactic laser amygdalohippocampotomy (SLAH) using laser interstitial thermal therapy is a minimally invasive surgery used to treat mesial temporal lobe epilepsy. It uses laser probes inserted through occipital and temporo-occipital trajectories to ablate the hippocampus and amygdala. However, these trajectories are limited in their ability to ablate the superior amygdala and entorhinal cortex (ERC). We present a trajectory through the middle frontal gyrus as an alternative to the temporo-occipital trajectory, which provides more complete ablation of the amygdala and anterior ERC through a single pass. CLINICAL PRESENTATION A 70-year-old woman with seizures characterized by fear were localized to the left superomedial amygdala on intracranial electroencephalography. They developed after resection of a left temporal arteriovenous malformation and were refractory to medication. Her age and prior craniotomy made open resection less desirable. A frontal and occipital SLAH achieved Engel 1a at 1-year follow-up without decline in neuropsychological performance scores. CONCLUSION Typical SLAH uses trajectories that have limited ability to ablate the superior and medial amygdala and ERC in a single passage. A combined approach using an occipital and frontal trajectory allows more complete ablation of the amygdala, hippocampus, and ERC.
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Affiliation(s)
- Layton Lamsam
- Department of Neurosurgery, Yale School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Mauricio Mandel Brigido
- Department of Neurosurgery, Yale School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Adithya Sivaraju
- Department of Neurology, Yale School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Lawrence J. Hirsch
- Department of Neurology, Yale School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Dennis D. Spencer
- Department of Neurosurgery, Yale School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Veronica Chiang
- Department of Neurosurgery, Yale School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Eyiyemisi Damisah
- Department of Neurosurgery, Yale School of Medicine, Yale University, New Haven, Connecticut, USA
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15
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Hanin A, Cespedes J, Huttner A, Strelnikov D, Gopaul M, DiStasio M, Vezzani A, Hirsch LJ, Aronica E. Neuropathology of New-Onset Refractory Status Epilepticus (NORSE). J Neurol 2023:10.1007/s00415-023-11726-x. [PMID: 37079033 DOI: 10.1007/s00415-023-11726-x] [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] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 04/11/2023] [Accepted: 04/12/2023] [Indexed: 04/21/2023]
Abstract
New-Onset Refractory Status Epilepticus (NORSE), including its subtype with a preceding febrile illness known as FIRES (Febrile Infection-Related Epilepsy Syndrome), is one of the most severe forms of status epilepticus. Despite an extensive workup (clinical evaluation, EEG, imaging, biological tests), the majority of NORSE cases remain unexplained (i.e., "cryptogenic NORSE"). Understanding the pathophysiological mechanisms underlying cryptogenic NORSE and the related long-term consequences is crucial to improve patient management and preventing secondary neuronal injury and drug-resistant post-NORSE epilepsy. Previously, neuropathological evaluations conducted on biopsies or autopsies have been found helpful for identifying the etiologies of some cases that were previously of unknown cause. Here, we summarize the findings of studies reporting neuropathology findings in patients with NORSE, including FIRES. We identified 64 cryptogenic cases and 66 neuropathology tissue samples, including 37 biopsies, 18 autopsies, and seven epilepsy surgeries (the type of tissue sample was not detailed for 4 cases). We describe the main neuropathology findings and place a particular emphasis on cases for which neuropathology findings helped establish a diagnosis or elucidate the pathophysiology of cryptogenic NORSE, or on described cases in which neuropathology findings supported the selection of specific treatments for patients with NORSE.
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Affiliation(s)
- Aurélie Hanin
- Department of Neurology and Immunobiology, Yale University School of Medicine, New Haven, CT, USA.
- Institut du Cerveau, Paris Brain Institute, ICM, Inserm, CNRS, AP-HP, Hôpital de La Pitié-Salpêtrière, Sorbonne Université, DMU Neurosciences 6, Paris, France.
- Epilepsy Unit and Department of Clinical Neurophysiology, AP-HP, Hôpital de La Pitié-Salpêtrière, DMU Neurosciences 6, Paris, France.
| | - Jorge Cespedes
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
- School of Medicine, Universidad Autonoma de Centro America, San Jose, Costa Rica
| | - Anita Huttner
- Department of Pathology, Yale University School of Medicine, New Haven, CT, USA
| | - David Strelnikov
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Margaret Gopaul
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Marcello DiStasio
- Department of Neurology and Immunobiology, Yale University School of Medicine, New Haven, CT, USA
- Department of Pathology, Yale University School of Medicine, New Haven, CT, USA
| | - Annamaria Vezzani
- Department of Acute Brain Injury, Istituto di Recerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Lawrence J Hirsch
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Eleonora Aronica
- Department of (Neuro)Pathology, Amsterdam UMC, University of Amsterdam, Amsterdam Neuroscience, Meibergdreef 9, 1105, Amsterdam, The Netherlands
- Stichting Epilepsie Instellingen Nederland (SEIN), Heemstede, The Netherlands
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Gopaul MT, Hanin A, Cespedes J, Pulluru Y, Kazazian K, van Baalen A, Gofton TE, Gaspard N, Hirsch LJ. The Seasonality of New-Onset Refractory Status Epilepticus (NORSE). Epilepsia 2023. [PMID: 37013696 DOI: 10.1111/epi.17606] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 03/30/2023] [Accepted: 03/31/2023] [Indexed: 04/05/2023]
Abstract
The etiology of New-Onset Refractory Status Epilepticus (NORSE), including its subtype with prior fever known as FIRES (Febrile Infection-Related Epilepsy Syndrome), remains uncertain. Several arguments suggest NORSE is a disorder of immunity, likely post-infectious. Consequently, seasonal occurrence might be anticipated. Here, we investigated if seasonality is a notable factor regarding NORSE presentation. We combined four different datasets with a total of 342 cases, all from the northern hemisphere, and 62% adults. The incidence of NORSE cases differed between seasons (p=0.0068) and was highest in summer (32.2%) (p=0.0022) and lowest in spring (19.0%, p=0.010). While both FIRES and non-FIRES cases occurred most commonly during the summer, there was a trend towards FIRES cases being more likely to occur in winter than non-FIRES cases (OR 1.62, p=0.071). The seasonality of NORSE cases differed according to the etiology (p=0.024). NORSE cases eventually associated with autoimmune/paraneoplastic encephalitis occurred most frequently in summer (p=0.032) and least frequently in winter (p=0.047), while there was no seasonality for cryptogenic cases. This study suggests that NORSE overall and NORSE related to autoimmune/paraneoplastic encephalitis are more common in summer, but that there is no definite seasonality in cryptogenic cases.
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Affiliation(s)
- Margaret T Gopaul
- Comprehensive Epilepsy Center, Dept. of Neurology, Yale University School of Medicine New Haven, CT, USA
| | - Aurélie Hanin
- Dept. of Neurology and Immunobiology, Yale University School of Medicine, New Haven, CT, USA
- Sorbonne Université, Institut du Cerveau, Paris Brain Institute, ICM, Inserm, CNRS, AP-HP, Hôpital de la Pitié-Salpêtrière, DMU Neurosciences 6, Paris, France
- AP-HP, Hôpital de la Pitié-Salpêtrière, DMU Neurosciences 6, Epilepsy Unit and Dept. of Clinical Neurophysiology, Paris, France
| | - Jorge Cespedes
- Comprehensive Epilepsy Center, Dept. of Neurology, Yale University School of Medicine New Haven, CT, USA
- Universidad Autonoma de Centro America, School of Medicine. San Jose, Costa Rica
| | - Yashwanth Pulluru
- Comprehensive Epilepsy Center, Dept. of Neurology, Yale University School of Medicine New Haven, CT, USA
- Nebraska Medical Center, Omaha, NE, USA
| | - Karnig Kazazian
- University Hospital London Health Sciences Centers, London, ON, Canada
- Schulich School of Medicine and Dentistry Western University, Department of Clinical Neurological Sciences, London, ON, Canada
| | - Andreas van Baalen
- Department of Neuropediatrics, University Medical Center Schleswig-Holstein, Kiel University (CAU), Kiel, Germany
| | - Teneille E Gofton
- University Hospital London Health Sciences Centers, London, ON, Canada
- Schulich School of Medicine and Dentistry Western University, Department of Clinical Neurological Sciences, London, ON, Canada
| | - Nicolas Gaspard
- Comprehensive Epilepsy Center, Dept. of Neurology, Yale University School of Medicine New Haven, CT, USA
- Université Libre de Bruxelles, Hôpital Erasme, Brussels, Belgium
| | - Lawrence J Hirsch
- Comprehensive Epilepsy Center, Dept. of Neurology, Yale University School of Medicine New Haven, CT, USA
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17
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Hirsch LJ. Editorial: Seizure disorders: 2023 update. Curr Opin Neurol 2023; 36:59-60. [PMID: 36862012 DOI: 10.1097/wco.0000000000001139] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/03/2023]
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18
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Hanin A, Cespedes J, Dorgham K, Pulluru Y, Gopaul M, Gorochov G, Hafler DA, Navarro V, Gaspard N, Hirsch LJ. Cytokines in New-Onset Refractory Status Epilepticus Predict Outcomes. Ann Neurol 2023. [PMID: 36871188 DOI: 10.1002/ana.26627] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Revised: 03/03/2023] [Accepted: 03/03/2023] [Indexed: 03/06/2023]
Abstract
OBJECTIVE The objective of this study was to investigate inflammation using cerebrospinal fluid (CSF) and serum cytokines/chemokines in patients with new-onset refractory status epilepticus (NORSE) to better understand the pathophysiology of NORSE and its consequences. METHODS Patients with NORSE (n = 61, including n = 51 cryptogenic), including its subtype with prior fever known as febrile infection-related epilepsy syndrome (FIRES), were compared with patients with other refractory status epilepticus (RSE; n = 37), and control patients without SE (n = 52). We measured 12 cytokines/chemokines in serum or CSF samples using multiplexed fluorescent bead-based immunoassay detection. Cytokine levels were compared between patients with and without SE, and between the 51 patients with cryptogenic NORSE (cNORSE) and the 47 patients with a known-etiology RSE (NORSE n = 10, other RSE n = 37), and correlated with outcomes. RESULTS A significant increase of IL-6, TNF-α, CXCL8/IL-8, CCL2, MIP-1α, and IL-12p70 pro-inflammatory cytokines/chemokines was observed in patients with SE compared with patients without SE, in serum and CSF. Serum innate immunity pro-inflammatory cytokines/chemokines (CXCL8, CCL2, and MIP-1α) were significantly higher in patients with cNORSE compared to non-cryptogenic RSE. Patients with NORSE with elevated innate immunity serum and CSF cytokine/chemokine levels had worse outcomes at discharge and at several months after the SE ended. INTERPRETATION We identified significant differences in innate immunity serum and CSF cytokine/chemokine profiles between patients with cNORSE and non-cryptogenic RSE. The elevation of innate immunity pro-inflammatory cytokines in patients with NORSE correlated with worse short- and long-term outcomes. These findings highlight the involvement of innate immunity-related inflammation, including peripherally, and possibly of neutrophil-related immunity in cNORSE pathogenesis and suggest the importance of utilizing specific anti-inflammatory interventions. ANN NEUROL 2023.
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Affiliation(s)
- Aurélie Hanin
- Department of Neurology and Immunobiology, Yale University School of Medicine, New Haven, CT, United States.,Sorbonne Université, Institut du Cerveau, Paris Brain Institute, ICM, Inserm, CNRS, AP-HP, Hôpital de la Pitié-Salpêtrière, Paris, France.,Department of Clinical Neurophysiology, Epilepsy Unit, DMU Neurosciences 6, AP-HP, Hôpital de la Pitié-Salpêtrière, Paris, France
| | - Jorge Cespedes
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, CT, United States.,Universidad Autonoma de Centro America, School of Medicine, San Jose, Costa Rica
| | - Karim Dorgham
- Department of Immunology, Sorbonne Université, Inserm, Centre d'Immunologie et des Maladies Infectieuses, AP-HP, Hôpital de la Pitié-Salpêtrière, Paris, France
| | - Yashwanth Pulluru
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, CT, United States.,Division of Epilepsy, Nebraska Medical Center, Omaha, NE, United States
| | - Margaret Gopaul
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, CT, United States
| | - Guy Gorochov
- Department of Immunology, Sorbonne Université, Inserm, Centre d'Immunologie et des Maladies Infectieuses, AP-HP, Hôpital de la Pitié-Salpêtrière, Paris, France
| | - David A Hafler
- Department of Neurology and Immunobiology, Yale University School of Medicine, New Haven, CT, United States
| | - Vincent Navarro
- Sorbonne Université, Institut du Cerveau, Paris Brain Institute, ICM, Inserm, CNRS, AP-HP, Hôpital de la Pitié-Salpêtrière, Paris, France.,Department of Clinical Neurophysiology, Epilepsy Unit, DMU Neurosciences 6, AP-HP, Hôpital de la Pitié-Salpêtrière, Paris, France.,Center of Reference for Rare Epilepsies, AP-HP, Hôpital de la Pitié-Salpêtrière, Paris, France
| | - Nicolas Gaspard
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, CT, United States.,Department of Neurology, Université Libre de Bruxelles, Hôpital Erasme, Brussels, Belgium
| | - Lawrence J Hirsch
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, CT, United States
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19
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Chen Y, Li S, Ge W, Jing J, Chen HY, Doherty D, Herman A, Kaleem S, Ding K, Osman G, Swisher CB, Smith C, Maciel CB, Alkhachroum A, Lee JW, Dhakar MB, Gilmore EJ, Sivaraju A, Hirsch LJ, Omay SB, Blumenfeld H, Sheth KN, Struck AF, Edlow BL, Westover MB, Kim JA. Quantitative epileptiform burden and electroencephalography background features predict post-traumatic epilepsy. J Neurol Neurosurg Psychiatry 2023; 94:245-249. [PMID: 36241423 PMCID: PMC9931627 DOI: 10.1136/jnnp-2022-329542] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 09/26/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Post-traumatic epilepsy (PTE) is a severe complication of traumatic brain injury (TBI). Electroencephalography aids early post-traumatic seizure diagnosis, but its optimal utility for PTE prediction remains unknown. We aim to evaluate the contribution of quantitative electroencephalograms to predict first-year PTE (PTE1). METHODS We performed a multicentre, retrospective case-control study of patients with TBI. 63 PTE1 patients were matched with 63 non-PTE1 patients by admission Glasgow Coma Scale score, age and sex. We evaluated the association of quantitative electroencephalography features with PTE1 using logistic regressions and examined their predictive value relative to TBI mechanism and CT abnormalities. RESULTS In the matched cohort (n=126), greater epileptiform burden, suppression burden and beta variability were associated with 4.6 times higher PTE1 risk based on multivariable logistic regression analysis (area under the receiver operating characteristic curve, AUC (95% CI) 0.69 (0.60 to 0.78)). Among 116 (92%) patients with available CT reports, adding quantitative electroencephalography features to a combined mechanism and CT model improved performance (AUC (95% CI), 0.71 (0.61 to 0.80) vs 0.61 (0.51 to 0.72)). CONCLUSIONS Epileptiform and spectral characteristics enhance covariates identified on TBI admission and CT abnormalities in PTE1 prediction. Future trials should incorporate quantitative electroencephalography features to validate this enhancement of PTE risk stratification models.
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Affiliation(s)
- Yilun Chen
- Neurology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Songlu Li
- Neurology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Wendong Ge
- Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jin Jing
- Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Hsin Yi Chen
- Neurology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Daniel Doherty
- Neurology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Alison Herman
- Neurology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Safa Kaleem
- Neurology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Kan Ding
- Neurology, UT Southwestern Medical Center, Dallas, Texas, USA
| | | | - Christa B Swisher
- Neurology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Christine Smith
- Neurology, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Carolina B Maciel
- Neurology, Yale School of Medicine, New Haven, Connecticut, USA
- Neurology, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Ayham Alkhachroum
- Neurology, University of Miami Miller School of Medicine, Miami, Florida, USA
- Neurology, Jackson Memorial Hospital, Miami, Florida, USA
| | - Jong Woo Lee
- Neurology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Monica B Dhakar
- Neurology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Emily J Gilmore
- Neurology, Yale School of Medicine, New Haven, Connecticut, USA
| | | | | | - Sacit B Omay
- Neurosurgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - Hal Blumenfeld
- Neurology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Kevin N Sheth
- Neurology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Aaron F Struck
- Neurology, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
- Neurology, William S Middleton Memorial Veterans Hospital, Madison, Wisconsin, USA
| | - Brian L Edlow
- Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Jennifer A Kim
- Neurology, Yale School of Medicine, New Haven, Connecticut, USA
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20
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Fong MW, Pu K, Jadav R, Khan T, Hirsch LJ, Zaveri HP. Quantitative assessment of burst suppression as a predictor of seizure recurrence in refractory status epilepticus. Clin Neurophysiol 2023; 150:98-105. [PMID: 37060844 DOI: 10.1016/j.clinph.2023.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 02/15/2023] [Accepted: 03/11/2023] [Indexed: 03/31/2023]
Abstract
OBJECTIVE To determine whether quantitative EEG analysis of burst suppression can predict seizure recurrence in patients with refractory status epilepticus (RSE) being treated with anesthetic doses of continuous IV antiseizure medications (cIVASM). METHODS Quantitative assessment of burst suppression (including epileptiform discharges [EDs] and evolution) in 31 occasions (from 27 patients), and correlation with seizure recurrence up to 48 hours post sedative wean. RESULTS Occasions resulting in seizure recurrence (vs. no seizure recurrence) had lower burst (8.4 vs. 10.6 µV) and interburst interval (IBI) (4.2 vs. 4.8 µV) average amplitude, duration (bursts 2.8 vs. 3.6 s: IBIs 3.6 vs. 4.4 s); and burst total power (0.4 vs. 0.7 µV2). Bursts (0.86 vs. 0.60) and IBIs (0.28 vs. 0.07) with EDs, higher number of EDs within bursts (mean 2.1 vs. 1.4) and IBIs (0.6 vs. 0.2), and positive evolution measures all predicted seizure recurrence, although EDs had the greatest adjusted odds ratio on multivariate analysis. CONCLUSIONS For patients in burst suppression, successful wean of cIVASM was not determined by classical burst suppression measures, but instead how "epileptiform" bursts and IBIs were, as determined by EDs in both bursts and IBIs and surrogates for evolution within bursts. SIGNIFICANCE If confirmed, these objective measures could be used during clinical care to help determine when to wean cIVASM in patients with RSE.
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21
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Sivaraju A, Hirsch LJ. Do acute EEG findings add to clinical features in predicting outcomes after status epilepticus and acute symptomatic seizures? Epilepsy Behav 2023; 141:109134. [PMID: 36848748 DOI: 10.1016/j.yebeh.2023.109134] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 02/02/2023] [Indexed: 02/27/2023]
Abstract
Status epilepticus is a potentially life-threatening medical emergency associated with poor functional outcomes. Improving our ability to accurately predict functional outcomes is beneficial to optimizing treatment strategies. Currently, there are four published status epilepticus scores in adults: STESS (Status Epilepticus Severity Score), EMSE (Epidemiology-Based Mortality Score in Status Epilepticus), END-IT (Encephalitis-Nonconvulsive-Diazepam resistance-Imaging-Tracheal intubation), and recently published ACD (Age-level of Consciousness-Duration of status epilepticus) score. The only available scale in the pediatric population is PEDSS (Pediatric CPC scale-EEG (normal vs abnormal)-Drug refractoriness-critical Sickness-Semiology). While these scores are useful research tools, currently there is little evidence to suggest their utility during real-time clinical care. Except for EMSE, none of the scores incorporate EEG findings for prognostication. Adding EEG features improves prognostic accuracy, as has been shown with the EMSE scale with and without the EEG component. Acute symptomatic seizures (AsyS) and early epileptiform abnormalities, especially nonconvulsive seizures, and periodic discharges, markedly increase the risk for subsequent unprovoked seizures. However, many of these patients may not need lifelong anti-seizure medications (ASMs). Continuous EEG monitoring shows that the majority of ASyS are nonconvulsive and can identify epileptic patterns. Dedicated specialty clinics for these patients, known as Post Acute Symptomatic Seizure (PASS) clinics, already exist in the United States. Post Acute Symptomatic Seizure clinics are ideal for both long-term clinical care and answering important research questions related to epileptogenesis, duration of ASM treatment required, and evolution of EEG findings. This topic was presented at the 8th London-Innsbruck Colloquium on Status Epilepticus and Acute Seizures held in September 2022. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
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Affiliation(s)
- Adithya Sivaraju
- Comprehensive Epilepsy Center, Department of Neurology, Yale University, New Haven, CT, United States.
| | - Lawrence J Hirsch
- Comprehensive Epilepsy Center, Department of Neurology, Yale University, New Haven, CT, United States
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22
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Rubinos C, Bruzzone MJ, Blodgett C, Tsai C, Patel P, Hianik R, Jadav R, Boudesseul J, Liu C, Zhu H, Wilson SE, Olm-Shipman C, Meeker R, Hirsch LJ. Association of Serum Pyridoxal Phosphate Levels with Established Status Epilepticus. Neurocrit Care 2023; 38:41-51. [PMID: 36071331 DOI: 10.1007/s12028-022-01579-z] [Citation(s) in RCA: 2] [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] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 07/27/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND The objective of this study was to determine the prevalence of pyridoxine deficiency, measured by pyridoxal phosphate (PLP) levels, in patients admitted to the hospital with established (benzodiazepine-resistant) status epilepticus (SE) (eSE) and to compare to three control groups: intensive care unit (ICU) patients without SE (ICU-noSE), non-ICU inpatients without SE (non-ICU), and outpatients with or without a history of epilepsy (outpatient). METHODS This retrospective cohort study was conducted at the University of North Carolina Hospitals and Yale New Haven Hospital. Participants included inpatients and outpatients who had serum PLP levels measured during clinical care between January 2018 and March 2021. The first PLP level obtained was categorized as normal (> 30 nmol/L), marginal (≤ 30 nmol/L), deficient (≤ 20 nmol/L), and severely deficient (≤ 5 nmol/L). RESULTS A total of 293 patients were included (52 eSE, 40 ICU-noSE, 44 non-ICU, and 157 outpatient). The median age was 55 (range 19-99) years. The median PLP level of the eSE group (12 nmol/L) was lower than that of the ICU-noSE (22 nmol/L, p = 0.003), non-ICU (16 nmol/L, p = 0.05), and outpatient groups (36 nmol/L, p < 0.001). Patients with eSE had a significantly higher prevalence of marginal and deficient PLP levels (90 and 80%, respectively) than patients in each of the other three groups (ICU-noSE: 70, 50%; non-ICU: 63, 54%; outpatient: 38, 21%). This significantly higher prevalence persisted after correcting for critical illness severity and timing of PLP level collection. CONCLUSIONS Our study confirms previous findings indicating a high prevalence of pyridoxine deficiency (as measured by serum PLP levels) in patients with eSE, including when using a more restricted definition of pyridoxine deficiency. Prevalence is higher in patients with eSE than in patients in all three control groups (ICU-noSE, non-ICU, and outpatient). Considering the role of pyridoxine, thus PLP, in the synthesis of γ-aminobutyric acid and its easy and safe administration, prospective studies on pyridoxine supplementation in patients with eSE are needed.
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Affiliation(s)
- Clio Rubinos
- Department of Neurology, Division of Critical Care Neurology and Division of Epilepsy, University of North Carolina at Chapel Hill, 170 Manning Drive, Physician Office, Chapel Hill, NC, USA.
| | - Maria Jose Bruzzone
- Department of Neurology, University of Florida, Gainesville, FL, CB 7025, USA
| | - Courtney Blodgett
- Department of Neurology, Division of Critical Care Neurology and Division of Epilepsy, University of North Carolina at Chapel Hill, 170 Manning Drive, Physician Office, Chapel Hill, NC, USA
| | - Carolyn Tsai
- Department of Neurology, Division of Critical Care Neurology and Division of Epilepsy, University of North Carolina at Chapel Hill, 170 Manning Drive, Physician Office, Chapel Hill, NC, USA
| | - Puja Patel
- School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Rachel Hianik
- School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Rakesh Jadav
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | | | - Chuning Liu
- Department of Biostatistics, University of North Carolina, Chapel Hill, NC, USA
| | - Hongtu Zhu
- Department of Biostatistics, University of North Carolina, Chapel Hill, NC, USA
| | - Susan E Wilson
- Department of Neurology, Division of Critical Care Neurology and Division of Epilepsy, University of North Carolina at Chapel Hill, 170 Manning Drive, Physician Office, Chapel Hill, NC, USA
| | - Casey Olm-Shipman
- Department of Neurology, Division of Critical Care Neurology and Division of Epilepsy, University of North Carolina at Chapel Hill, 170 Manning Drive, Physician Office, Chapel Hill, NC, USA
| | - Rick Meeker
- Department of Neurology, Division of Critical Care Neurology and Division of Epilepsy, University of North Carolina at Chapel Hill, 170 Manning Drive, Physician Office, Chapel Hill, NC, USA
| | - Lawrence J Hirsch
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
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23
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Abou Khaled KJ, Bou Nasif M, Freiji C, Hirsch LJ, Fong MW. Rapid response EEG with needle electrodes in an intensive care unit with limited resources. Clin Neurophysiol Pract 2023; 8:44-48. [PMID: 36949936 PMCID: PMC10025002 DOI: 10.1016/j.cnp.2023.02.002] [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: 09/12/2022] [Revised: 01/17/2023] [Accepted: 02/14/2023] [Indexed: 02/24/2023] Open
Abstract
Objective Continuous EEG (cEEG) is the gold standard for detecting seizures and rhythmic and periodic patterns (RPPs) in critically ill patients but is often not available in health systems with limited resources. The current study aims to determine the feasibility and utility of low-cost, practical, limited montage, sub-dermal needle electrode EEG in a setting where otherwise no EEG would be available. Methods The study included all adult patients admitted to the intensive care unit of a single center over a 24-month period. Members of the existing ICU care team, mostly nurses, were trained to place 8 sub-dermal needle EEG electrodes to achieve rapid, limited montage-EEG recording. Clinical outcomes were recorded, including any reported major complications; and the EEG findings documented, including background characterization, RPPs, and seizures. Results One hundred twenty-three patients, mean age 68 years, underwent an average of 15.6 min of EEG recording. There were no complications of electrode placement. Overall, 13.0% had seizures (8.1% qualifying as status epilepticus [SE]), 18.7 % had generalized periodic discharges (GPDs), 4.9% had lateralized periodic discharges (LPDs), and 11.4 % sporadic epileptiform discharges (sEDs). Greater mortality was observed in patients with worse background EEGs, seizures, LPDs, or sEDs. Conclusions Rapid, limited montage EEG could be achieved safely and inexpensively in a broad population of critically ill patients following minimal training of existing care teams. Significance For resource poor centers or centers outside of major metropolitan areas who otherwise have no access to EEG, this may prove a useful method for screening for non-convulsive seizures and status epilepticus.
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Affiliation(s)
- Karine J. Abou Khaled
- Department of Neurology, Hotel-Dieu de France Hospital, Saint-Joseph University, Beirut, Lebanon
- Corresponding author.
| | - Mei Bou Nasif
- Department of Medicine, Hotel-Dieu de France Hospital, Saint-Joseph University, Beirut, Lebanon
| | - Claudia Freiji
- Illinois Risk Lab, Department of Mathematics, University of Illinois at Urbana-Champaign, Champaign, IL, USA
| | - Lawrence J. Hirsch
- Comprehensive Epilepsy Center, Yale School of Medicine, New Haven, CT, USA
| | - Michael W.K. Fong
- Comprehensive Epilepsy Center, Yale School of Medicine, New Haven, CT, USA
- Westmead Comprehensive Epilepsy Unit, Westmead Hospital, University of Sydney, Sydney, Australia
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24
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Jafarpour S, Fong MWK, Detyniecki K, Khan A, Jackson-Shaheed E, Wang X, Lewis S, Benjamin R, Gaínza-Lein M, O'Bryan J, Hirsch LJ, Loddenkemper T. Prevalence and Predictors of Seizure Clusters in Pediatric Patients With Epilepsy: The Harvard-Yale Pediatric Seizure Cluster Study. Pediatr Neurol 2022; 137:22-29. [PMID: 36208614 DOI: 10.1016/j.pediatrneurol.2022.08.014] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 08/30/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND Determine the prevalence of seizure clusters (two or more seizures in six hours), use of rescue medications, and adverse outcomes associated with seizure clusters in pediatric patients with a range of epilepsy severities, and identify risk factors predictive of seizure clusters. METHODS Prospective observational two-center study, including phone call and seizure diary follow-up for 12 months in patients with epilepsy aged one month to 18 years. We classified patients into three risk groups based on seizures within the prior year: high, seizure cluster (two or more seizures within one day); intermediate, at least one seizure but no days with two or more seizures; low, no seizures. RESULTS One-third (32.3%; high risk, 72.4%; intermediate risk, 30.4%; low risk, 3.1%) of 297 patients had a seizure cluster during the study, including half (46.2%) of the patients with active seizures at baseline (intermediate- and high-risk groups combined). Emergency room visits or injuries were no more likely due to a seizure cluster than an isolated seizure. Rescue medications were utilized in 15.8% of patients in the high-risk group and 19.2% in the intermediate-risk group. History of status epilepticus (adjusted odds ratio [aOR], 2.13; confidence interval [CI], 1.09 to 4.16]), seizure frequency greater than four per month (aOR, 4.27; CI, 1.92 to 9.50), and high-risk group status (aOR, 6.42; CI, 2.97 to 13.87) were associated with greater odds of seizure cluster. CONCLUSIONS Seizure clusters are common in pediatric patients with epilepsy. High seizure frequency was the strongest predictor of clusters. Rescue medications were underutilized. Future studies should evaluate the applicability and effectiveness of these medications for optimization of pediatric seizure cluster treatment and reduction of seizure-related emergency department visits, injuries, and mortality.
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Affiliation(s)
- Saba Jafarpour
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts; Division of Neurology, Children's Hospital of Los Angeles, Los Angeles, California
| | - Michael W K Fong
- Department of Neurology, Comprehensive Epilepsy Center, Yale University School of Medicine, New Haven, Connecticut; TY Nelson Department of Neurology, The Children's Hospital at Westmead, Sydney, Australia; Westmead Comprehensive Epilepsy Unit, Westmead Hospital, University of Sydney, Sydney, Australia
| | - Kamil Detyniecki
- Department of Neurology, Comprehensive Epilepsy Center, Yale University School of Medicine, New Haven, Connecticut; Comprehensive Epilepsy Center, Department of Neurology, University of Miami, Miami, Florida
| | - Ambar Khan
- Department of Neurology, Comprehensive Epilepsy Center, Yale University School of Medicine, New Haven, Connecticut; Larkin Community Hospital, South Miami, Florida
| | - Ebony Jackson-Shaheed
- Department of Neurology, Comprehensive Epilepsy Center, Yale University School of Medicine, New Haven, Connecticut; VA Connecticut Healthcare System, West Haven, Connecticut
| | - Xiaofan Wang
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Samuel Lewis
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts; Department of Emergency Medicine, University of Washington, Seattle, Washington
| | - Robert Benjamin
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts; Department of Surgery, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Marina Gaínza-Lein
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts; Instituto dr Pediatria, Facultad de Medicina, Universidad Austral de Chile, Valdivia, Chile; Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Jane O'Bryan
- Department of Neurology, Comprehensive Epilepsy Center, Yale University School of Medicine, New Haven, Connecticut
| | - Lawrence J Hirsch
- Department of Neurology, Comprehensive Epilepsy Center, Yale University School of Medicine, New Haven, Connecticut
| | - Tobias Loddenkemper
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts.
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25
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Alkhachroum A, Appavu B, Egawa S, Foreman B, Gaspard N, Gilmore EJ, Hirsch LJ, Kurtz P, Lambrecq V, Kromm J, Vespa P, Zafar SF, Rohaut B, Claassen J. Electroencephalogram in the intensive care unit: a focused look at acute brain injury. Intensive Care Med 2022; 48:1443-1462. [PMID: 35997792 PMCID: PMC10008537 DOI: 10.1007/s00134-022-06854-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 07/31/2022] [Indexed: 02/04/2023]
Abstract
Over the past decades, electroencephalography (EEG) has become a widely applied and highly sophisticated brain monitoring tool in a variety of intensive care unit (ICU) settings. The most common indication for EEG monitoring currently is the management of refractory status epilepticus. In addition, a number of studies have associated frequent seizures, including nonconvulsive status epilepticus (NCSE), with worsening secondary brain injury and with worse outcomes. With the widespread utilization of EEG (spot and continuous EEG), rhythmic and periodic patterns that do not fulfill strict seizure criteria have been identified, epidemiologically quantified, and linked to pathophysiological events across a wide spectrum of critical and acute illnesses, including acute brain injury. Increasingly, EEG is not just qualitatively described, but also quantitatively analyzed together with other modalities to generate innovative measurements with possible clinical relevance. In this review, we discuss the current knowledge and emerging applications of EEG in the ICU, including seizure detection, ischemia monitoring, detection of cortical spreading depolarizations, assessment of consciousness and prognostication. We also review some technical aspects and challenges of using EEG in the ICU including the logistics of setting up ICU EEG monitoring in resource-limited settings.
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Affiliation(s)
- Ayham Alkhachroum
- Department of Neurology, University of Miami, Miami, FL, USA
- Department of Neurology, Jackson Memorial Hospital, Miami, FL, USA
| | - Brian Appavu
- Department of Child Health and Neurology, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
- Department of Neurosciences, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Satoshi Egawa
- Neurointensive Care Unit, Department of Neurosurgery, and Stroke and Epilepsy Center, TMG Asaka Medical Center, Saitama, Japan
| | - Brandon Foreman
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, 231 Albert Sabin Way, Cincinnati, OH, USA
| | - Nicolas Gaspard
- Department of Neurology, Erasme Hospital, Free University of Brussels, Brussels, Belgium
| | - Emily J Gilmore
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
- Neurocritical Care and Emergency Neurology, Department of Neurology, Ale University School of Medicine, New Haven, CT, USA
| | - Lawrence J Hirsch
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Pedro Kurtz
- Department of Intensive Care Medicine, D'or Institute for Research and Education, Rio de Janeiro, Brazil
- Neurointensive Care, Paulo Niemeyer State Brain Institute, Rio de Janeiro, Brazil
| | - Virginie Lambrecq
- Department of Clinical Neurophysiology and Epilepsy Unit, AP-HP, Pitié Salpêtrière Hospital, Reference Center for Rare Epilepsies, 75013, Paris, France
| | - Julie Kromm
- Departments of Critical Care Medicine and Clinical Neurosciences, Cumming School of Medicine, Calgary, AB, Canada
- Hotchkiss Brain Institute, Cumming School of Medicine, Calgary, AB, Canada
| | - Paul Vespa
- Brain Injury Research Center, Department of Neurosurgery, University of California, Los Angeles, USA
| | - Sahar F Zafar
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Benjamin Rohaut
- Department of Neurology, Sorbonne Université, Pitié-Salpêtrière-AP-HP and Paris Brain Institute, ICM, Inserm, CNRS, Paris, France
| | - Jan Claassen
- Department of Neurology, Neurological Institute, Columbia University, New York Presbyterian Hospital, 177 Fort Washington Avenue, MHB 8 Center, Room 300, New York, NY, 10032, USA.
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26
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Quraishi IH, Brown FC, Johnson MH, Hirsch LJ. Hippocampal recording via the RNS system reveals marked ipsilateral activation of epileptiform activity during Wada testing. Epilepsy Behav 2022; 134:108854. [PMID: 35905518 DOI: 10.1016/j.yebeh.2022.108854] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 07/13/2022] [Accepted: 07/14/2022] [Indexed: 11/03/2022]
Abstract
Wada testing remains an important component of pre-surgical testing to assess the feasibility of temporal lobectomy for patients with intractable epilepsy. In this procedure, an anesthetic is injected into either internal carotid artery while memory and language testing is performed, simulating the effect of temporal lobe resection. The mechanism remains poorly understood because the hippocampal vasculature is predominantly via the posterior circulation. We recorded hippocampal EEG during bilateral methohexital Wada testing in three patients who had previously been implanted with a responsive neurostimulation system (RNS) to determine the effect of the injections on hippocampal activity. In all six injections from three patients, methohexital caused immediate, transient increases in hippocampal spikes. With at least two of these injections, the electrographic changes were consistent with electrographic seizures. In all cases, the epileptiform activity was not apparent on scalp EEG and was without obvious clinical correlate other than the negative findings expected from the anesthetic. The results demonstrate the utility of intracranial EEG during Wada testing and suggest that the elicitation of seizures or continuous spiking might contribute to dysfunction of the hippocampus during the Wada test. We hypothesize that this effect is due to disconnection and disinhibition of medial temporal structures.
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Affiliation(s)
- Imran H Quraishi
- Yale Comprehensive Epilepsy Center, Department of Neurology, Yale School of Medicine, PO Box 208018, New Haven, CT 06520-8018, USA.
| | - Franklin C Brown
- Yale Comprehensive Epilepsy Center, Department of Neurology, Yale School of Medicine, PO Box 208018, New Haven, CT 06520-8018, USA.
| | - Michele H Johnson
- Departments of Radiology and Biomedical Imaging and of Neurosurgery, Yale School of Medicine, PO Box 208042, New Haven, CT 06520-8042, USA.
| | - Lawrence J Hirsch
- Yale Comprehensive Epilepsy Center, Department of Neurology, Yale School of Medicine, PO Box 208018, New Haven, CT 06520-8018, USA.
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27
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Rubinos C, Waters B, Hirsch LJ. Predicting and Treating Post-traumatic Epilepsy. Curr Treat Options Neurol 2022. [DOI: 10.1007/s11940-022-00727-2] [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: 11/27/2022]
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28
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Kim JA, Zheng WL, Elmer J, Jing J, Zafar SF, Ghanta M, Moura V, Gilmore EJ, Hirsch LJ, Patel A, Rosenthal E, Westover MB. High epileptiform discharge burden predicts delayed cerebral ischemia after subarachnoid hemorrhage. Clin Neurophysiol 2022; 141:139-146. [PMID: 33812771 PMCID: PMC8429508 DOI: 10.1016/j.clinph.2021.01.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 11/30/2020] [Accepted: 01/04/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To investigate whether epileptiform discharge burden can identify those at risk for delayed cerebral ischemia (DCI) after subarachnoid hemorrhage (SAH). METHODS Retrospective analysis of 113 moderate to severe grade SAH patients who had continuous EEG (cEEG) recordings during their hospitalization. We calculated the burden of epileptiform discharges (ED), measured as number of ED per hour. RESULTS We find that many SAH patients have an increase in ED burden during the first 3-10 days following rupture, the major risk period for DCI. However, those who develop DCI have a significantly higher hourly burden from days 3.5-6 after SAH vs. those who do not. ED burden is higher in DCI patients when assessed in relation to the onset of DCI (area under the receiver operator curve 0.72). Finally, specific trends of ED burden over time, assessed by group-based trajectory analysis, also help stratify DCI risk. CONCLUSIONS These results suggest that ED burden is a useful parameter for identifying those at higher risk of developing DCI after SAH. The higher burden rate associated with DCI supports the theory of metabolic supply-demand mismatch which contributes to this complication. SIGNIFICANCE ED burden is a novel biomarker for predicting those at high risk of DCI.
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Affiliation(s)
- Jennifer A Kim
- Department of Neurology, Yale University, New Haven, CT 06520, USA.
| | - Wei-Long Zheng
- Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Jonathan Elmer
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | - Jin Jing
- Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Sahar F Zafar
- Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Manohar Ghanta
- Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Valdery Moura
- Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Emily J Gilmore
- Department of Neurology, Yale University, New Haven, CT 06520, USA
| | | | - Aman Patel
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Eric Rosenthal
- Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA
| | - M Brandon Westover
- Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA
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29
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Wickstrom R, Taraschenko O, Dilena R, Payne ET, Specchio N, Nabbout R, Koh S, Gaspard N, Hirsch LJ. International consensus recommendations for management of New Onset Refractory Status Epilepticus (NORSE) incl. Febrile Infection-Related Epilepsy Syndrome (FIRES): Statements and Supporting Evidence. Epilepsia 2022; 63:2840-2864. [PMID: 35997591 PMCID: PMC9828002 DOI: 10.1111/epi.17397] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 07/14/2022] [Accepted: 08/18/2022] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To develop consensus-based recommendations for the management of adult and paediatric patients with NORSE/FIRES based on best evidence and experience. METHODS The Delphi methodology was followed. A facilitator group of 9 experts was established, who defined the scope, users and suggestions for recommendations. Following a review of the current literature, recommendation statements concerning diagnosis, treatment and research directions were generated which were then voted on a scale of 1 (strongly disagree) to 9 (strongly agree) by a panel of 48 experts in the field. Consensus that a statement was appropriate was reached if the median score was greater or equal to 7, and inappropriate if the median score was less than or equal to 3. The analysis of evidence was mapped to the results of each statement included in the Delphi survey. RESULTS Overall, 85 recommendation statements achieved consensus. The recommendations are divided into five sections: 1) disease characteristics, 2) diagnostic testing and sampling, 3) acute treatment, 4) treatment in the post-acute phase, and 5) research, registries and future directions in NORSE/FIRES. The detailed results and discussion of all 85 statements are outlined herein. A corresponding summary of findings and practical flowsheets are presented in a companion article. SIGNIFICANCE This detailed analysis offers insight into the supporting evidence and the current gaps in the literature that are associated with expert consensus statements related to NORSE/FIRES. The recommendations generated by this consensus can be used as a guide for the diagnosis, evaluation, and management of patients with NORSE/FIRES, and for planning of future research.
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Affiliation(s)
- Ronny Wickstrom
- Neuropaediatric UnitDepartment of Women's and Children's HealthKarolinska Institutet and Karolinska University HospitalStockholmSweden
| | - Olga Taraschenko
- Department of Neurological SciencesUniversity of Nebraska Medical CenterOmahaNebraskaUSA
| | - Robertino Dilena
- Neuropathophysiology UnitFoundation IRCCS Ca' Granda Ospedale Maggiore PoliclinicoMilanItaly
| | - Eric T. Payne
- Department of Pediatrics, Section of NeurologyAlberta Children's HospitalCalgaryAlbertaCanada
| | - Nicola Specchio
- Rare and Complex Epilepsy Unit, Department of NeurosciencesBambino Gesù Children's Hospital, IRCCS, Full Member of European Reference Network EpiCARERomeItaly
| | - Rima Nabbout
- Department of Pediatric Neurology, APHP, Member of EPICARE ERN, Centre de Reference Epilepsies RaresUniversite de Paris, Institut Imagine, INSERM 1163ParisFrance
| | - Sookyong Koh
- Department of Pediatrics, Children's Hospital and Medical CenterUniversity of NebraskaOmahaNebraskaUSA
| | | | - Lawrence J. Hirsch
- Department of Neurology, Comprehensive Epilepsy CenterYale UniversityNew HavenConnecticutUSA
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30
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Wickström R, Taraschenko O, Dilena R, Payne ET, Specchio N, Nabbout R, Koh S, Gaspard N, Hirsch LJ. International consensus recommendations for management of New Onset Refractory Status Epilepticus (NORSE) including Febrile Infection-Related Epilepsy Syndrome (FIRES): Summary and Clinical Tools. Epilepsia 2022; 63:2827-2839. [PMID: 35951466 PMCID: PMC9826478 DOI: 10.1111/epi.17391] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 08/10/2022] [Accepted: 08/10/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVE To develop consensus-based recommendations for the management of adult and pediatric patients with NORSE/FIRES based on best available evidence and expert opinion. METHODS The Delphi methodology was followed. A facilitator group of 9 experts was established, who defined the scope, users and suggestions for recommendations. Following a review of the current literature, recommendation statements concerning diagnosis, treatment and research directions were generated which were then voted on a scale of 1 (strongly disagree) to 9 (strongly agree) by a panel of 48 experts in the field. Consensus that a statement was appropriate was reached if the median score was greater than or equal to 7, and inappropriate if the median score was less than or equal to 3. RESULTS Overall, 85 recommendation statements achieved consensus. The recommendations are divided into five sections: 1) disease characteristics, 2) diagnostic testing and sampling, 3) acute treatment, 4) treatment in the post-acute phase, and 5) research, registries and future directions in NORSE/FIRES. These are summarized in this article along with two practical clinical flowsheets: one for diagnosis and evaluation and one for acute treatment. A corresponding evidence-based analysis of all 85 recommendations alongside responses by the Delphi panel is presented in a companion article. SIGNIFICANCE The recommendations generated by this consensus can be used as a guide for the diagnosis, evaluation, and management of patients with NORSE/FIRES, and for planning of future research.
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Affiliation(s)
- Ronny Wickström
- Neuropaediatric Unit, Department of Women's and Children's HealthKarolinska Institutet and Karolinska University HospitalStockholmSweden
| | - Olga Taraschenko
- Department of Neurological SciencesUniversity of Nebraska Medical CenterOmahaNebraskaUSA
| | - Robertino Dilena
- Neuropathophysiology UnitFoundation IRCCS Ca' Granda Ospedale Maggiore PoliclinicoMilanItaly
| | - Eric T. Payne
- Department of Pediatrics, Section of NeurologyAlberta Children's HospitalCalgaryAlbertaCanada
| | - Nicola Specchio
- Rare and Complex Epilepsy Unit, Department of NeurosciencesBambino Gesù Children's Hospital, IRCCS, Full Member of European Reference Network EpiCARERomeItaly
| | - Rima Nabbout
- Department of Pediatric Neurology, APHP, Member of EPICARE ERN, Centre de Reference Epilepsies RaresUniversite de Paris, Institut Imagine, INSERM 1163ParisFrance
| | - Sookyong Koh
- Department of Pediatrics, Children's Hospital and Medical CenterUniversity of NebraskaOmahaNebraskaUSA
| | - Nicolas Gaspard
- Hôpital Erasme, Université Libre de BruxellesBrusselsBelgium
| | - Lawrence J. Hirsch
- Department of Neurology, Comprehensive Epilepsy CenterYale UniversityNew HavenConnecticutUSA
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31
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Busl KM, Fong MWK, Newcomer Z, Patel M, Cohen SA, Jadav R, Smith CN, Mitropanopoulos S, Bruzzone M, Hella M, Eisenschenk S, Robinson CP, Roth WH, Ameli PA, Babi MA, Pizzi MA, Gilmore EJ, Hirsch LJ, Maciel CB. Pregabalin for Recurrent Seizures in Critical Illness: A Promising Adjunctive Therapy, Especially for cyclic Seizures. Neurocrit Care 2022; 37:140-148. [PMID: 35217998 DOI: 10.1007/s12028-022-01459-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 11/23/2021] [Accepted: 01/27/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Pregabalin (PGB) is an effective adjunctive treatment for focal epilepsy and acts by binding to the alpha2-delta subunit of voltage-gated calcium channels to reduce excitatory neurotransmitter release. Limited data exist on its use in the neurocritical care setting, including cyclic seizures-a pattern of recurrent seizures occurring at nearly regular intervals. Although the mechanism underpinning cyclic seizures remains elusive, spreading excitation linked to spreading depolarizations may play a role in seizure recurrence and periodicity. PGB has been shown to increase spreading depolarization threshold; hence, we hypothesized that the magnitude of antiseizure effect from PGB is more pronounced in patients with cyclic versus noncyclic seizures in a critically ill cohort with recurrent seizures. METHODS We conducted a retrospective case series of adults admitted to two academic neurointensive care units between January 2017 and March 2019 who received PGB for treatment of seizures. Data collected included demographics, etiology of brain injury, antiseizure medications, and outcome. Continuous electroencephalogram recordings 48 hours before and after PGB administration were reviewed by electroencephalographers blinded to the administration of antiseizure medications to obtain granular data on electrographic seizure burden. Cyclic seizures were determined quantitatively (i.e., < 50% variation of interseizure intervals for at least 50% of consecutive seizures). Coprimary outcomes were decrease in hourly seizure burden in minutes and decrease in seizure frequency in the 48 hours after PGB initiation. We used nonparametric tests for comparison of seizure frequency and burden and segmented linear regression to assess PGB effect. RESULTS We included 16 patients; the median age was 69 years, 11 (68.7%) were women, three (18.8%) had undergone a neurosurgical procedure, and five (31%) had underlying epilepsy. All seizures had focal onset; ten patients (62.5%) had cyclic seizures. The median hourly seizure burden over the 48 hours prior to PGB initiation was 1.87 min/hour (interquartile range 1.49-8.53), and the median seizure frequency was 1.96 seizures/hour (interquartile range 1.06-3.41). In the 48 hours following PGB (median daily dose 300 mg, range 75-300 mg), the median number of seizures per hour was reduced by 0.80 seizures/hour (95% confidence interval 0.19-1.40), whereas the median hourly seizure burden decreased by 1.71 min/hour (95% confidence interval 0.38-3.04). When we compared patients with cyclic versus noncyclic seizures, there was a relative decrease in hourly seizure frequency (- 86.7% versus - 2%, p = 0.04) and hourly seizure burden (- 89% versus - 7.8%, p = 0.03) at 48 hours. CONCLUSIONS PGB was associated with a relative reduction in seizure burden in neurocritically ill patients with recurrent seizures, especially those with cyclic seizures, and may be considered in the therapeutic arsenal for refractory seizures. Whether this effect is mediated via modulation of spreading depolarization requires further study.
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Affiliation(s)
- Katharina M Busl
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, USA.,Department of Neurosurgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Michael W K Fong
- Westmead Comprehensive Epilepsy Unit, Westmead Hospital, University of Sydney, Sydney, Australia.,Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | | | - Mitesh Patel
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Scott A Cohen
- Department of Emergency Medicine, University of Florida College of Medicine, Gainesville, FL, USA
| | - Rakesh Jadav
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Christine N Smith
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, USA
| | | | - Maria Bruzzone
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, USA
| | | | - Stephan Eisenschenk
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Christopher P Robinson
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, USA.,Department of Neurosurgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - William H Roth
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, USA.,Department of Neurosurgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Pouya Alexander Ameli
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, USA.,Department of Neurosurgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Marc-Alain Babi
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, USA.,Department of Neurosurgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Michael A Pizzi
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, USA.,Department of Neurosurgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Emily J Gilmore
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Lawrence J Hirsch
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Carolina B Maciel
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, USA. .,Department of Neurosurgery, University of Florida College of Medicine, Gainesville, FL, USA. .,Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, CT, USA. .,Department of Neurology, University of Utah, Salt Lake City, UT, 81432, USA. .,Neurocritical Care, McKnight Brain Institute, 1149 Newell Drive, L3-100, Gainesville, FL, 32610, USA.
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32
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Blond BN, Hirsch LJ. Updated review of rescue treatments for seizure clusters and prolonged seizures. Expert Rev Neurother 2022; 22:567-577. [PMID: 35862983 DOI: 10.1080/14737175.2022.2105207] [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] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Although the treatment of epilepsy primarily focuses on prevention, recurrent seizures are unfortunately an ongoing reality, particularly in people with epilepsy who live with chronic refractory seizures. Rescue medications are agents which can be administered in urgent/emergent seizure episodes such as seizure clusters or prolonged seizures with the goal of terminating seizure activity, preventing morbidity, and decreasing the risk of further seizures. AREAS COVERED This review first discusses clinical opportunities for rescue medications, with particular attention focused on seizure clusters and prolonged seizures, including their epidemiology, risk factors, and associated morbidity. Current rescue medications, their indications, efficacy, and adverse effects are discussed. We then discuss rescue medications and formulations which are currently under development, concentrating on practical aspects relevant for clinical care. EXPERT OPINION Rescue medications should be considered for all people with epilepsy with ongoing seizures. Recent rescue medications including intranasal formulations provide considerable advantages. New rescue medications are being developed which may expand opportunities for effective treatment. In the future, combining rescue medications with seizure detection and seizure prediction technologies should further expand opportunities for use and should reduce the morbidity of seizures and provide increased comfort, control, and quality of life for people living with epilepsy.
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Affiliation(s)
- Benjamin N Blond
- Department of Neurology, Stony Brook University Renaissance School of Medicine, Stony Brook, NY
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33
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Fong MWK, Norris S, Percy J, Hirsch LJ, Herlopian A. Hemisphere-Dependent Ictal Tachycardia Versus Ictal Bradycardia in a Critically Ill Patient. J Clin Neurophysiol 2022; 39:e15-e18. [PMID: 34860703 DOI: 10.1097/wnp.0000000000000873] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
SUMMARY Tachycardia is a common ictal phenomenon; however, ictal bradycardia is less commonly reported and rarely presents as ictal asystole/syncope. In critically ill patients, seizures are much less likely to manifest with overt clinical signs, i.e., are more likely to be subtle or nonconvulsive. In this setting, changes in heart rate may be the only clue that seizures are occurring. The authors report an exemplary case of a 78-year-old right-handed man who presented with spontaneous left frontal intraparenchymal hemorrhages. During standard clinical monitoring in the Neuro-Intensive Care Unit, the patient had discrete paroxysms of relative sinus tachycardia, independent episodes of sinus bradycardia, and 3 to 4 seconds of sinus pause. The cardiac investigation was unrevealing, but continuous EEG revealed the answer. The episodes of mild tachycardia were associated with seizures from the left temporal region, whereas those with bradycardia were associated with independent seizures from the right temporal region. The case stands as a stark reminder to remain vigilant of seizures in high-risk patients, especially as a cause for paroxysmal autonomic changes.
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Affiliation(s)
- Michael W K Fong
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, Connecticut, U.S.A
- Westmead Comprehensive Epilepsy Unit, Westmead Hospital, University of Sydney, Sydney, Australia
| | - Sarah Norris
- University of New England, Armidale, New South Wales, Australia; and
| | - Jennifer Percy
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, Connecticut, U.S.A
- Division of Neurology, University of British Columbia, Vancouver, BC, Canada
| | - Lawrence J Hirsch
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, Connecticut, U.S.A
| | - Aline Herlopian
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, Connecticut, U.S.A
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34
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Baang HY, Chen HY, Herman AL, Gilmore EJ, Hirsch LJ, Sheth KN, Petersen NH, Zafar SF, Rosenthal ES, Westover MB, Kim JA. The Utility of Quantitative EEG in Detecting Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage. J Clin Neurophysiol 2022; 39:207-215. [PMID: 34510093 PMCID: PMC8901442 DOI: 10.1097/wnp.0000000000000754] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
SUMMARY In this review, we discuss the utility of quantitative EEG parameters for the detection of delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage in the context of the complex pathophysiology of DCI and the limitations of current diagnostic methods. Because of the multifactorial pathophysiology of DCI, methodologies solely assessing blood vessel narrowing (vasospasm) are insufficient to detect all DCI. Quantitative EEG has facilitated the exploration of EEG as a diagnostic modality of DCI. Multiple quantitative EEG parameters such as alpha power, relative alpha variability, and alpha/delta ratio show reliable detection of DCI in multiple studies. Recent studies on epileptiform abnormalities suggest that their potential for the detection of DCI. Quantitative EEG is a promising, continuous, noninvasive, monitoring modality of DCI implementable in daily practice. Future work should validate these parameters in larger populations, facilitated by the development of automated detection algorithms and multimodal data integration.
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Affiliation(s)
| | - Hsin Yi Chen
- Dept of Neurology, Yale University, New Haven, CT USA 06520
| | | | | | | | - Kevin N Sheth
- Dept of Neurology, Yale University, New Haven, CT USA 06520
| | | | - Sahar F Zafar
- Dept of Neurology, Massachussetts General Hospital, Boston, MA USA 02114
| | - Eric S Rosenthal
- Dept of Neurology, Massachussetts General Hospital, Boston, MA USA 02114
| | - M Brandon Westover
- Dept of Neurology, Massachussetts General Hospital, Boston, MA USA 02114
| | - Jennifer A Kim
- Dept of Neurology, Yale University, New Haven, CT USA 06520
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Chen HY, Elmer J, Zafar SF, Ghanta M, Moura Junior V, Rosenthal ES, Gilmore EJ, Hirsch LJ, Zaveri HP, Sheth KN, Petersen NH, Westover MB, Kim JA. Combining Transcranial Doppler and EEG Data to Predict Delayed Cerebral Ischemia After Subarachnoid Hemorrhage. Neurology 2022; 98:e459-e469. [PMID: 34845057 PMCID: PMC8826465 DOI: 10.1212/wnl.0000000000013126] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [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: 05/07/2021] [Accepted: 11/08/2021] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Delayed cerebral ischemia (DCI) is the leading complication of subarachnoid hemorrhage (SAH). Because DCI was traditionally thought to be caused by large vessel vasospasm, transcranial Doppler ultrasounds (TCDs) have been the standard of care. Continuous EEG has emerged as a promising complementary monitoring modality and predicts increased DCI risk. Our objective was to determine whether combining EEG and TCD data improves prediction of DCI after SAH. We hypothesize that integrating these diagnostic modalities improves DCI prediction. METHODS We retrospectively assessed patients with moderate to severe SAH (2011-2015; Fisher 3-4 or Hunt-Hess 4-5) who had both prospective TCD and EEG acquisition during hospitalization. Middle cerebral artery (MCA) peak systolic velocities (PSVs) and the presence or absence of epileptiform abnormalities (EAs), defined as seizures, epileptiform discharges, and rhythmic/periodic activity, were recorded daily. Logistic regressions were used to identify significant covariates of EAs and TCD to predict DCI. Group-based trajectory modeling (GBTM) was used to account for changes over time by identifying distinct group trajectories of MCA PSV and EAs associated with DCI risk. RESULTS We assessed 107 patients; DCI developed in 56 (51.9%). Univariate predictors of DCI are presence of high-MCA velocity (PSV ≥200 cm/s, sensitivity 27%, specificity 89%) and EAs (sensitivity 66%, specificity 62%) on or before day 3. Two univariate GBTM trajectories of EAs predicted DCI (sensitivity 64%, specificity 62.75%). Logistic regression and GBTM models using both TCD and EEG monitoring performed better. The best logistic regression and GBTM models used both TCD and EEG data, Hunt-Hess score at admission, and aneurysm treatment as predictors of DCI (logistic regression: sensitivity 90%, specificity 70%; GBTM: sensitivity 89%, specificity 67%). DISCUSSION EEG and TCD biomarkers combined provide the best prediction of DCI. The conjunction of clinical variables with the timing of EAs and high MCA velocities improved model performance. These results suggest that TCD and cEEG are promising complementary monitoring modalities for DCI prediction. Our model has potential to serve as a decision support tool in SAH management. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that combined TCD and EEG monitoring can identify delayed cerebral ischemia after SAH.
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Affiliation(s)
- Hsin Yi Chen
- From the Department of Neurology (H.Y.C., E.J.G., L.J.H., H.P.Z., K.N.S., N.H.P., J.A.K.), Yale University, New Haven, CT; Department of Critical Care Medicine (J.E.), University of Pittsburgh Medical Center, PA; and Department of Neurology (S.F.Z., M.G., V.M.J., E.S.R., M.B.W.), Massachusetts General Hospital, Boston
| | - Jonathan Elmer
- From the Department of Neurology (H.Y.C., E.J.G., L.J.H., H.P.Z., K.N.S., N.H.P., J.A.K.), Yale University, New Haven, CT; Department of Critical Care Medicine (J.E.), University of Pittsburgh Medical Center, PA; and Department of Neurology (S.F.Z., M.G., V.M.J., E.S.R., M.B.W.), Massachusetts General Hospital, Boston
| | - Sahar F Zafar
- From the Department of Neurology (H.Y.C., E.J.G., L.J.H., H.P.Z., K.N.S., N.H.P., J.A.K.), Yale University, New Haven, CT; Department of Critical Care Medicine (J.E.), University of Pittsburgh Medical Center, PA; and Department of Neurology (S.F.Z., M.G., V.M.J., E.S.R., M.B.W.), Massachusetts General Hospital, Boston
| | - Manohar Ghanta
- From the Department of Neurology (H.Y.C., E.J.G., L.J.H., H.P.Z., K.N.S., N.H.P., J.A.K.), Yale University, New Haven, CT; Department of Critical Care Medicine (J.E.), University of Pittsburgh Medical Center, PA; and Department of Neurology (S.F.Z., M.G., V.M.J., E.S.R., M.B.W.), Massachusetts General Hospital, Boston
| | - Valdery Moura Junior
- From the Department of Neurology (H.Y.C., E.J.G., L.J.H., H.P.Z., K.N.S., N.H.P., J.A.K.), Yale University, New Haven, CT; Department of Critical Care Medicine (J.E.), University of Pittsburgh Medical Center, PA; and Department of Neurology (S.F.Z., M.G., V.M.J., E.S.R., M.B.W.), Massachusetts General Hospital, Boston
| | - Eric S Rosenthal
- From the Department of Neurology (H.Y.C., E.J.G., L.J.H., H.P.Z., K.N.S., N.H.P., J.A.K.), Yale University, New Haven, CT; Department of Critical Care Medicine (J.E.), University of Pittsburgh Medical Center, PA; and Department of Neurology (S.F.Z., M.G., V.M.J., E.S.R., M.B.W.), Massachusetts General Hospital, Boston
| | - Emily J Gilmore
- From the Department of Neurology (H.Y.C., E.J.G., L.J.H., H.P.Z., K.N.S., N.H.P., J.A.K.), Yale University, New Haven, CT; Department of Critical Care Medicine (J.E.), University of Pittsburgh Medical Center, PA; and Department of Neurology (S.F.Z., M.G., V.M.J., E.S.R., M.B.W.), Massachusetts General Hospital, Boston
| | - Lawrence J Hirsch
- From the Department of Neurology (H.Y.C., E.J.G., L.J.H., H.P.Z., K.N.S., N.H.P., J.A.K.), Yale University, New Haven, CT; Department of Critical Care Medicine (J.E.), University of Pittsburgh Medical Center, PA; and Department of Neurology (S.F.Z., M.G., V.M.J., E.S.R., M.B.W.), Massachusetts General Hospital, Boston
| | - Hitten P Zaveri
- From the Department of Neurology (H.Y.C., E.J.G., L.J.H., H.P.Z., K.N.S., N.H.P., J.A.K.), Yale University, New Haven, CT; Department of Critical Care Medicine (J.E.), University of Pittsburgh Medical Center, PA; and Department of Neurology (S.F.Z., M.G., V.M.J., E.S.R., M.B.W.), Massachusetts General Hospital, Boston
| | - Kevin N Sheth
- From the Department of Neurology (H.Y.C., E.J.G., L.J.H., H.P.Z., K.N.S., N.H.P., J.A.K.), Yale University, New Haven, CT; Department of Critical Care Medicine (J.E.), University of Pittsburgh Medical Center, PA; and Department of Neurology (S.F.Z., M.G., V.M.J., E.S.R., M.B.W.), Massachusetts General Hospital, Boston
| | - Nils H Petersen
- From the Department of Neurology (H.Y.C., E.J.G., L.J.H., H.P.Z., K.N.S., N.H.P., J.A.K.), Yale University, New Haven, CT; Department of Critical Care Medicine (J.E.), University of Pittsburgh Medical Center, PA; and Department of Neurology (S.F.Z., M.G., V.M.J., E.S.R., M.B.W.), Massachusetts General Hospital, Boston
| | - M Brandon Westover
- From the Department of Neurology (H.Y.C., E.J.G., L.J.H., H.P.Z., K.N.S., N.H.P., J.A.K.), Yale University, New Haven, CT; Department of Critical Care Medicine (J.E.), University of Pittsburgh Medical Center, PA; and Department of Neurology (S.F.Z., M.G., V.M.J., E.S.R., M.B.W.), Massachusetts General Hospital, Boston
| | - Jennifer A Kim
- From the Department of Neurology (H.Y.C., E.J.G., L.J.H., H.P.Z., K.N.S., N.H.P., J.A.K.), Yale University, New Haven, CT; Department of Critical Care Medicine (J.E.), University of Pittsburgh Medical Center, PA; and Department of Neurology (S.F.Z., M.G., V.M.J., E.S.R., M.B.W.), Massachusetts General Hospital, Boston.
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Mishra NK, Engel J, Liebeskind DS, Sharma VK, Hirsch LJ, Kasner SE, French JA, Devinsky O, Friedman A, Dawson J, Quinn TJ, Selim M, de Havenon A, Yasuda CL, Cendes F, Benninger F, Zaveri HP, Burneo JG, Srivastava P, Bhushan Singh M, Bhatia R, Vishnu VY, Bentes C, Ferro J, Weiss S, Sivaraju A, Kim JA, Galovic M, Gilmore EJ, Pitkänen A, Davis K, Sansing LH, Sheth KN, Paz JT, Singh A, Sheth S, Worrall BB, Grotta JC, Casillas-Espinos PM, Chen Z, Nicolo JP, Yan B, Kwan P. International Post Stroke Epilepsy Research Consortium (IPSERC): A consortium to accelerate discoveries in preventing epileptogenesis after stroke. Epilepsy Behav 2022; 127:108502. [PMID: 34968775 DOI: 10.1016/j.yebeh.2021.108502] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 12/07/2021] [Indexed: 12/18/2022]
Affiliation(s)
| | - Jerome Engel
- Department of Neurology, University of California Los Angeles, Los Angeles, USA
| | - David S Liebeskind
- Department of Neurology, University of California Los Angeles, Los Angeles, USA
| | - Vijay K Sharma
- YLL School of Medicine, National University of Singapore and Division of Neurology, National University Health System, Singapore
| | | | - Scott E Kasner
- Department of Neurology, University of Pennsylvania, Philadelphia, USA
| | - Jacqueline A French
- Department of Neurology, NYU Grossman School of Medicine, New York City, USA
| | - Orrin Devinsky
- Department of Neurology, NYU Grossman School of Medicine, New York City, USA
| | - Alon Friedman
- Department of Brain and Cognitive Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel; Department of Medical Neuroscience, Dalhousie University, Halifax, Canada
| | - Jesse Dawson
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Scotland, UK
| | - Terence J Quinn
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Scotland, UK
| | - Magdy Selim
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | | | - Clarissa L Yasuda
- Department of Neurology, School of Medical Sciences, University of Campinas - UNICAMP, Sao Paulo, Brazil
| | - Fernando Cendes
- Department of Neurology, School of Medical Sciences, University of Campinas - UNICAMP, Sao Paulo, Brazil
| | - Felix Benninger
- Department of Neurology, Rabin Medical Center, Tel Aviv, Israel
| | | | - Jorge G Burneo
- Epilepsy Program, Department of Clinical Neurological Sciences, and Neuroepidemiology Unit, Western University, London, Ontario, Canada
| | - Padma Srivastava
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Mamta Bhushan Singh
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Rohit Bhatia
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - V Y Vishnu
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Carla Bentes
- Department of Neurology, University of Lisboa, Lisbon, Portugal
| | - Jose Ferro
- Department of Neurology, University of Lisboa, Lisbon, Portugal
| | - Shennan Weiss
- Department of Neurology, State University of New York (SUNY) Downstate, NY, USA
| | | | - Jennifer A Kim
- Department of Neurology, Yale University, New Haven, USA
| | - Marian Galovic
- Department of Neurology, University of Zurich, Zurich, Switzerland
| | | | - Asla Pitkänen
- A.I. Virtanen Institute for Molecular Sciences, University of Eastern Finland, Kuopio, Finland
| | - Kathryn Davis
- Department of Neurology, University of Pennsylvania, Philadelphia, USA
| | | | - Kevin N Sheth
- Department of Neurology, Yale University, New Haven, USA
| | - Jeanne T Paz
- Gladstone Institute of Neurological Disease, Gladstone Institutes, San Francisco, USA; Department of Neurology, University of California San Francisco, San Francisco, USA
| | - Anuradha Singh
- Department of Neurology, Icahn School of Medicine at Mt. Sinai, NY, USA
| | - Sunil Sheth
- Department of Neurology, University of Texas Health Sciences Center, Houston, USA
| | - Bradford B Worrall
- Departments of Neurology and Public Health Sciences, University of Virginia, Charlottesville, USA
| | - James C Grotta
- Department of Neurology, Memorial-Hermann Texas Medical Center, Houston, USA
| | - Pablo M Casillas-Espinos
- Department of Neuroscience, Monash University, Alfred Hospital, Melbourne, Australia; Departments of Neurology and Medicine, The University of Melbourne, Royal Melbourne Hospital, Melbourne, Australia
| | - Zhibin Chen
- Department of Neuroscience, Monash University, Alfred Hospital, Melbourne, Australia; Departments of Neurology and Medicine, The University of Melbourne, Royal Melbourne Hospital, Melbourne, Australia
| | - John-Paul Nicolo
- Department of Neuroscience, Monash University, Alfred Hospital, Melbourne, Australia; Departments of Neurology and Medicine, The University of Melbourne, Royal Melbourne Hospital, Melbourne, Australia
| | - Bernard Yan
- Departments of Neurology and Medicine, The University of Melbourne, Royal Melbourne Hospital, Melbourne, Australia
| | - Patrick Kwan
- Department of Neuroscience, Monash University, Alfred Hospital, Melbourne, Australia; Departments of Neurology and Medicine, The University of Melbourne, Royal Melbourne Hospital, Melbourne, Australia.
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Maciel CB, Teixeira FJP, Dickinson KJ, Spana JC, Merck LH, Rabinstein AA, Sergott R, Shan G, Miao G, Peloquin CA, Busl KM, Hirsch LJ. Early vigabatrin augmenting GABA-ergic pathways in post-anoxic status epilepticus (VIGAB-STAT) phase IIa clinical trial study protocol. Neurol Res Pract 2022; 4:4. [PMID: 35067230 PMCID: PMC8785535 DOI: 10.1186/s42466-022-00168-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 12/30/2021] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Nearly one in three unconscious cardiac arrest survivors experience post-anoxic status epilepticus (PASE). Historically, PASE has been deemed untreatable resulting in its exclusion from status epilepticus clinical trials. However, emerging reports of survivors achieving functional independence following early and aggressive treatment of PASE challenged this widespread therapeutic nihilism. In the absence of proven therapies specific to PASE, standard of care treatment leans on general management strategies for status epilepticus. Vigabatrin—an approved therapy for refractory focal-onset seizures in adults—inhibits the enzyme responsible for GABA catabolism, increases brain GABA levels and may act synergistically with anesthetic agents to abort seizures. Our central hypothesis is that early inhibition of GABA breakdown is possible in the post-cardiac arrest period and may be an effective adjunctive treatment in PASE.
Methods
This is a phase IIa, single-center, open-label, pilot clinical trial with blinded outcome assessment, of a single dose of vigabatrin in 12 consecutive PASE subjects. Subjects will receive a single loading dose of 4500 mg of vigabatrin (or dose adjusted in moderate and severe renal impairment) via enteric tube within 48 h of PASE onset. Vigabatrin levels will be monitored at 0- (baseline), 0.5-, 1-, 2-, 3-, 6-, 12-, 24-, 48-, 72- and 168-h (7 days) post-vigabatrin. Serum biomarkers of neuronal injury will be measured at 0-, 24-, 48-, 72- and 96-h post-vigabatrin. The primary feasibility endpoint is the proportion of enrolled subjects among identified eligible subjects receiving vigabatrin within 48 h of PASE onset. The primary pharmacokinetic endpoint is the measured vigabatrin level at 3 h post-administration. Descriptive statistics with rates and proportions will be obtained regarding feasibility outcomes, along with the noncompartmental method for pharmacokinetic analyses. The area under the vigabatrin concentration-time curve in plasma from zero to the time of the last quantifiable concentration (AUC0-tlqc) will be calculated to estimate dose-linear pharmacokinetics.
Perspective
Vigabatrin demonstrates high potential for synergism with current standard of care therapies. Demonstration of the feasibility of vigabatrin administration and preliminary safety in PASE will pave the way for future efficacy and safety trials of this pharmacotherapeutic.
Trial Registration NCT04772547.
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Kuohn LR, Herman AL, Soto AL, Brown SC, Gilmore EJ, Hirsch LJ, Matouk CC, Sheth KN, Kim JA. Hospital Revisits for Post-Ischemic Stroke Epilepsy after Acute Stroke Interventions. J Stroke Cerebrovasc Dis 2022; 31:106155. [PMID: 34688213 PMCID: PMC8766898 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106155] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 07/09/2021] [Revised: 09/28/2021] [Accepted: 10/02/2021] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVES Improvements in acute stroke care have led to an increase in ischemic stroke survivors, who are at risk for development of post-ischemic stroke epilepsy (PISE). The impact of therapies such as thrombectomy and thrombolysis on risk of hospital revisits for PISE is unclear. We utilized administrative data to investigate the association between stroke treatment and PISE-related visits. MATERIALS AND METHODS Using claims data from California, New York, and Florida, we performed a retrospective analysis of adult survivors of acute ischemic strokes. Patients with history of epilepsy, trauma, infections, or tumors were excluded. Included patients were followed for a primary outcome of revisits for seizures or epilepsy. Cox proportional hazards regression was used to identify covariates associated with PISE. RESULTS In 595,545 included patients (median age 74 [IQR 21], 52% female), the 6-year cumulative rate of PISE-related revisit was 2.20% (95% CI 2.16-2.24). In multivariable models adjusting for demographics, comorbidities, and indicators of stroke severity, IV-tPA (HR 1.42, 95% CI 1.31-1.54, p<0.001) but not MT (HR 1.62, 95% CI 0.90-1.50, p=0.2) was associated with PISE-related revisit. Patients who underwent decompressive craniectomy experienced a 2-fold increase in odds for returning with PISE (HR 2.35, 95% CI 1.69-3.26, p<0.001). In-hospital seizures (HR 4.06, 95% CI 3.76-4.39, p<0.001) also elevated risk for PISE. SIGNIFICANCE We demonstrate that ischemic stroke survivors who received IV-tPA, underwent decompressive craniectomy, or experienced acute seizures were at increased risk PISE-related revisit. Close attention should be paid to these patients with increased potential for long-term development of and re-hospitalization for PISE.
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Affiliation(s)
- Lindsey R Kuohn
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, New Haven, CT
| | - Alison L Herman
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, New Haven, CT
| | - Alexandria L Soto
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, New Haven, CT
| | - Stacy C Brown
- Neuroscience Institute, The Queen’s Medical Center, Honolulu, HI
| | - Emily J Gilmore
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, New Haven, CT
| | - Lawrence J Hirsch
- Division of Epilepsy and EEG, Department of Neurology, Yale School of Medicine, New Haven, CT
| | - Charles C Matouk
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT
| | - Kevin N Sheth
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, New Haven, CT
| | - Jennifer A Kim
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, New Haven, CT,Correspondence Author. Jennifer A. Kim, MD, Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale University School of Medicine, 15 York St., LLCI Room 1004B, P.O. Box 208018, New Haven, CT 06520, USA,
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Kumar A, Martin R, Chen W, Bauerschmidt A, Youngblood MW, Cunningham C, Si Y, Ezeani C, Kratochvil Z, Bronen J, Thomson J, Riordan K, Yoo JY, Shirka R, Manganas L, Krestel H, Hirsch LJ, Blumenfeld H. Simulated driving in the epilepsy monitoring unit: Effects of seizure type, consciousness, and motor impairment. Epilepsia 2021; 63:e30-e34. [PMID: 34816425 DOI: 10.1111/epi.17136] [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] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 11/10/2021] [Accepted: 11/11/2021] [Indexed: 11/29/2022]
Abstract
People with epilepsy face serious driving restrictions, determined using retrospective studies. To relate seizure characteristics to driving impairment, we aimed to study driving behavior during seizures with a simulator. Patients in the Yale New Haven Hospital undergoing video-electroencephalographic monitoring used a laptop-based driving simulator during ictal events. Driving function was evaluated by video review and analyzed in relation to seizure type, impairment of consciousness/responsiveness, or motor impairment during seizures. Fifty-one seizures in 30 patients were studied. In terms of seizure type, we found that focal to bilateral tonic-clonic or myoclonic seizures (5/5) and focal seizures with impaired consciousness/responsiveness (11/11) always led to driving impairment; focal seizures with spared consciousness/responsiveness (0/10) and generalized nonmotor (generalized spike-wave bursts; 1/19) usually did not lead to driving impairment. Regardless of seizure type, we found that seizures with impaired consciousness (15/15) or with motor involvement (13/13) always led to impaired driving, but those with spared consciousness (0/20) or spared motor function (5/38) usually did not. These results suggest that seizure types with impaired consciousness/responsiveness and abnormal motor function contribute to impaired driving. Expanding this work in a larger cohort could further determine how results with a driving simulator may translate into real world driving safety.
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Affiliation(s)
- Avisha Kumar
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Reese Martin
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - William Chen
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Andrew Bauerschmidt
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Mark W Youngblood
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Courtney Cunningham
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Yang Si
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Cel Ezeani
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Zachary Kratochvil
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Jared Bronen
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - James Thomson
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Katherine Riordan
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Ji Yeoun Yoo
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Romina Shirka
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Louis Manganas
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Heinz Krestel
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut, USA.,Epilepsy Center of Frankfurt, Rhine-Main, Center for Personalized Translational Epilepsy Research, University Hospital Frankfurt, Goethe University, Frankfurt, Germany
| | - Lawrence J Hirsch
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Hal Blumenfeld
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut, USA.,Department of Neuroscience, Yale University School of Medicine, New Haven, Connecticut, USA.,Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
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Ryvlin P, Rheims S, Hirsch LJ, Sokolov A, Jehi L. Neuromodulation in epilepsy: state-of-the-art approved therapies. Lancet Neurol 2021; 20:1038-1047. [PMID: 34710360 DOI: 10.1016/s1474-4422(21)00300-8] [Citation(s) in RCA: 95] [Impact Index Per Article: 31.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 08/22/2021] [Accepted: 09/03/2021] [Indexed: 12/20/2022]
Abstract
Three neuromodulation therapies have been appropriately tested and approved in refractory focal epilepsies: vagus nerve stimulation (VNS), deep brain stimulation of the anterior nucleus of the thalamus (ANT-DBS), and closed-loop responsive neurostimulation of the epileptogenic zone or zones. These therapies are primarily palliative. Only a few individuals have achieved complete freedom from seizures for more than 12 months with these therapies, whereas more than half have benefited from long-term reduction in seizure frequency of more than 50%. Implantation-related adverse events primarily include infection and pain at the implant site. Intracranial haemorrhage is a frequent adverse event for ANT-DBS and responsive neurostimulation. Other stimulation-specific side-effects are observed with VNS and ANT-DBS. Biomarkers to predict response to neuromodulation therapies are not available, and high-level evidence to aid decision making about when and for whom these therapies should be preferred over other antiepileptic treatments is scant. Future studies are thus needed to address these shortfalls in knowledge, approve other forms of neuromodulation, and develop personalised closed-loop therapies with embedded machine learning. Until then, neuromodulation could be considered for individuals with intractable seizures, ideally after the possibility of curative surgical treatment has been carefully assessed and ruled out or judged less appropriate.
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Affiliation(s)
- Philippe Ryvlin
- Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.
| | - Sylvain Rheims
- Department of Functional Neurology and Epileptology, Hospices Civils de Lyon, Lyon 1 University Lyon Neuroscience Research Center, Institut National de la Santé et de la Recherche Médicale U1028/CNRS UMR 5292 Epilepsy Institute, Lyon, France
| | - Lawrence J Hirsch
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Arseny Sokolov
- Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Lara Jehi
- Epilepsy Center, Cleveland Clinic, Cleveland, OH, USA
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Chung S, Szaflarski JP, Choi EJ, Wilson JC, Kharawala S, Kaur G, Hirsch LJ. A systematic review of seizure clusters: Prevalence, risk factors, burden of disease and treatment patterns. Epilepsy Res 2021; 177:106748. [PMID: 34521043 DOI: 10.1016/j.eplepsyres.2021.106748] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 08/05/2021] [Accepted: 08/24/2021] [Indexed: 11/17/2022]
Abstract
Seizure clusters (SCs) are episodes of consecutive seizures that occur within a short period. The treatment patterns of rescue medications (RMs), as well as the burden of SCs, have not been assessed. A systematic literature search on Embase.com (in PubMed and Embase), supplemented with keyword-based and bibliographic searches, identified 44 articles for disease burden, three treatment guidelines, and three articles for treatment patterns. Common SC definitions were ≥3 seizures/24 h, ≥2/24 h and ≥2/6 h. The rate of SCs in prospective studies ranged from 21.7 %-42.5 %. The frequency of status epilepticus (SE) was higher in SC patients. SCs were associated with higher seizure frequency, higher risk of treatment resistance, and lower likelihood of seizure remission. Quality of life (QoL) was lower in children with SCs than in those with isolated seizures. Seizure-related hospitalization was more common in SC than non-SC patients. SCs adversely affected the productivity of patients and their caregivers. In outpatients with SCs, RMs were prescribed to 24.6 %-89.6 % and utilized by 15.6 %-44.5 %, with rates being higher in children. Key reasons for RM under-utilization were lack of seizure action plans, poor physician-patient communication, and concerns with administration route. In conclusion, SCs are associated with a higher risk of SE, treatment resistance, and low rate of seizure remission. They adversely affect patient and caregiver QoL and work productivity. However, RMs are under-prescribed, and there is an urgent need to improve recognition of SCs, improve use of seizure action plans, and remove barriers to RM use.
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Affiliation(s)
- Steve Chung
- Banner University Medical Center, University of Arizona, Phoenix, AZ, USA.
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Quraishi IH, Szekely AM, Shirali AC, Mistry PK, Hirsch LJ. Miglustat Therapy for SCARB2-Associated Action Myoclonus-Renal Failure Syndrome. Neurol Genet 2021; 7:e614. [PMID: 34337151 PMCID: PMC8320328 DOI: 10.1212/nxg.0000000000000614] [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] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 06/11/2021] [Indexed: 11/15/2022]
Abstract
Objective We evaluated whether substrate reduction therapy with miglustat could alter the course of action myoclonus-renal failure syndrome (AMRF), a rare, progressive myoclonic epilepsy with early mortality caused by scavenger receptor class B member 2 (SCARB2) gene mutations. Methods We identified an AMRF patient with a biallelic combination of SCARB2 mutations determined by whole exome sequencing. SCARB2 encodes a protein that traffics β-glucocerebrosidase to the lysosomal membrane. Mutations lead to a complex pattern of glucosylceramide accumulation and neurologic symptoms including progressive action myoclonus, seizures, and ataxia. We then evaluated the effect of inhibiting glucosylceramide synthesis, as is used in Gaucher disease. The patient was treated for 3 years with miglustat after several years of steady worsening. Results Progression of myoclonus halted, dysphagia resolved, some skills were reacquired, and seizures remained well controlled. Conclusions The response suggests that neurologic symptoms of SCARB2-associated AMRF could be ameliorated, at least partly, by targeting glycosphingolipid metabolism with available medications.
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Affiliation(s)
- Imran H Quraishi
- Yale Comprehensive Epilepsy Center (I.H.Q., L.J.H.), Yale University School of Medicine; Department of Neurology (I.H.Q., A.M.S., L.J.H.), Yale University School of Medicine; Section of Nephrology (A.C.S.), Department of Internal Medicine, Yale University School of Medicine; and Section of Digestive Diseases (P.K.M.), Department of Internal Medicine; Departments of Pediatrics and Cellular and Molecular Physiology, Yale University School of Medicine, New Haven, CT
| | - Anna M Szekely
- Yale Comprehensive Epilepsy Center (I.H.Q., L.J.H.), Yale University School of Medicine; Department of Neurology (I.H.Q., A.M.S., L.J.H.), Yale University School of Medicine; Section of Nephrology (A.C.S.), Department of Internal Medicine, Yale University School of Medicine; and Section of Digestive Diseases (P.K.M.), Department of Internal Medicine; Departments of Pediatrics and Cellular and Molecular Physiology, Yale University School of Medicine, New Haven, CT
| | - Anushree C Shirali
- Yale Comprehensive Epilepsy Center (I.H.Q., L.J.H.), Yale University School of Medicine; Department of Neurology (I.H.Q., A.M.S., L.J.H.), Yale University School of Medicine; Section of Nephrology (A.C.S.), Department of Internal Medicine, Yale University School of Medicine; and Section of Digestive Diseases (P.K.M.), Department of Internal Medicine; Departments of Pediatrics and Cellular and Molecular Physiology, Yale University School of Medicine, New Haven, CT
| | - Pramod K Mistry
- Yale Comprehensive Epilepsy Center (I.H.Q., L.J.H.), Yale University School of Medicine; Department of Neurology (I.H.Q., A.M.S., L.J.H.), Yale University School of Medicine; Section of Nephrology (A.C.S.), Department of Internal Medicine, Yale University School of Medicine; and Section of Digestive Diseases (P.K.M.), Department of Internal Medicine; Departments of Pediatrics and Cellular and Molecular Physiology, Yale University School of Medicine, New Haven, CT
| | - Lawrence J Hirsch
- Yale Comprehensive Epilepsy Center (I.H.Q., L.J.H.), Yale University School of Medicine; Department of Neurology (I.H.Q., A.M.S., L.J.H.), Yale University School of Medicine; Section of Nephrology (A.C.S.), Department of Internal Medicine, Yale University School of Medicine; and Section of Digestive Diseases (P.K.M.), Department of Internal Medicine; Departments of Pediatrics and Cellular and Molecular Physiology, Yale University School of Medicine, New Haven, CT
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Vaddiparti A, McGrath H, Benjamin CF, Sivaraju A, Spencer DD, Hirsch LJ, Damisah E, Quraishi IH. Gerstmann Syndrome Deconstructed by Cortical Stimulation. Neurology 2021; 97:420-422. [PMID: 34187861 DOI: 10.1212/wnl.0000000000012441] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 06/03/2021] [Indexed: 11/15/2022] Open
Affiliation(s)
- Aparna Vaddiparti
- Comprehensive Epilepsy Center, Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Hari McGrath
- Comprehensive Epilepsy Center, Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
| | - Christopher F Benjamin
- Comprehensive Epilepsy Center, Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Adithya Sivaraju
- Comprehensive Epilepsy Center, Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Dennis D Spencer
- Comprehensive Epilepsy Center, Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
| | - Lawrence J Hirsch
- Comprehensive Epilepsy Center, Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Eyiyemisi Damisah
- Comprehensive Epilepsy Center, Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
| | - Imran H Quraishi
- Comprehensive Epilepsy Center, Department of Neurology, Yale School of Medicine, New Haven, CT, USA
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Quraishi IH, Hirsch LJ. Patient-detectable responsive neurostimulation as a seizure warning system. Epilepsia 2021; 62:e110-e116. [PMID: 34018182 DOI: 10.1111/epi.16933] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 01/04/2021] [Revised: 05/02/2021] [Accepted: 05/03/2021] [Indexed: 11/30/2022]
Abstract
Many people with epilepsy are not aware of their seizures or do not have reliable auras. The responsive neurostimulation system (RNS) delivers stimulation triggered by intracranial epileptiform activity. If an epileptiform pattern continues, the RNS repeats stimulation up to five times per event. The RNS can cause acute stimulation-related symptoms that can be avoided by reducing stimulation. Because each of the five therapies can be programmed independently, it may be possible to program the latter therapies to induce a seizure warning. The goal of this study was to determine what proportion of patients could have tolerable symptoms safely elicited by stimulation, ultimately for the purpose of subjective seizure recognition. Of 18 patients, 12 (67%) had induced symptoms, which were tolerable in 11. Phosphenes were most common. We also present one patient in whom the fifth therapy was set to induce a symptom for early recognition and treatment of clusters of focal impaired awareness seizures, which were previously unrecognized and had led to days of disabling cognitive impairment. This protocol prevented disabling clusters successfully for several years. The findings suggest the RNS can provide a seizure warning, potentially improving safety and quality of life, and leading to prevention of clinical seizures or clusters in select patients.
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Affiliation(s)
- Imran H Quraishi
- Department of Neurology, Yale Comprehensive Epilepsy Center, Yale School of Medicine, New Haven, Connecticut, USA
| | - Lawrence J Hirsch
- Department of Neurology, Yale Comprehensive Epilepsy Center, Yale School of Medicine, New Haven, Connecticut, USA
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Jobst BC, Conner KR, Coulter D, Fried I, Guilfoyle S, Hirsch LJ, Hogan RE, Hopp JL, Naritoku D, Plueger M, Schevon C, Smith G, Valencia I, Gaillard WD. Highlights From AES2020, a Virtual American Epilepsy Society Experience. Epilepsy Curr 2021; 21:15357597211018219. [PMID: 33998298 PMCID: PMC8512915 DOI: 10.1177/15357597211018219] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Due to COVID-19 a live, in-person meeting was not possible for the American Epilepsy Society in 2020. An alternative, virtual event, the AES2020, was held instead. AES2020 was a great success with 4679 attendees from 70 countries. The educational content was outstanding and spanned the causes, treatments, and outcomes from epileptic encephalopathy to the iatrogenicity of epilepsy interventions to neurocognitive disabilities to the approach to neocortical epilepsies. New gene therapy approaches such as antisense oligonucleotide treatment for Dravet syndrome were introduced and neuromodulation devices were discussed. There were many other topics discussed in special interest groups and investigators' workshops. A highlight was having a Nobel prize winner speak about memory processing. Human intracranial electrophysiology contributes insights into memory processing and complements animal work. In a special COVID symposium, the impact of COVID on patients with epilepsy was reviewed. Telehealth has been expanded rapidly and may be well suited for some parts of epilepsy care. In summary, the epilepsy community was alive and engaged despite being limited to a virtual platform.
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Affiliation(s)
| | | | | | | | - Shanna Guilfoyle
- Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
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Lin L, Al‐Faraj A, Ayub N, Bravo P, Das S, Ferlini L, Karakis I, Lee JW, Mukerji SS, Newey CR, Pathmanathan J, Abdennadher M, Casassa C, Gaspard N, Goldenholz DM, Gilmore EJ, Jing J, Kim JA, Kimchi EY, Ladha HS, Tobochnik S, Zafar S, Hirsch LJ, Westover MB, Shafi MM. Electroencephalographic Abnormalities are Common in COVID-19 and are Associated with Outcomes. Ann Neurol 2021; 89:872-883. [PMID: 33704826 PMCID: PMC8104061 DOI: 10.1002/ana.26060] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 03/08/2021] [Accepted: 03/08/2021] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The aim was to determine the prevalence and risk factors for electrographic seizures and other electroencephalographic (EEG) patterns in patients with Coronavirus disease 2019 (COVID-19) undergoing clinically indicated continuous electroencephalogram (cEEG) monitoring and to assess whether EEG findings are associated with outcomes. METHODS We identified 197 patients with COVID-19 referred for cEEG at 9 participating centers. Medical records and EEG reports were reviewed retrospectively to determine the incidence of and clinical risk factors for seizures and other epileptiform patterns. Multivariate Cox proportional hazards analysis assessed the relationship between EEG patterns and clinical outcomes. RESULTS Electrographic seizures were detected in 19 (9.6%) patients, including nonconvulsive status epilepticus (NCSE) in 11 (5.6%). Epileptiform abnormalities (either ictal or interictal) were present in 96 (48.7%). Preceding clinical seizures during hospitalization were associated with both electrographic seizures (36.4% in those with vs 8.1% in those without prior clinical seizures, odds ratio [OR] 6.51, p = 0.01) and NCSE (27.3% vs 4.3%, OR 8.34, p = 0.01). A pre-existing intracranial lesion on neuroimaging was associated with NCSE (14.3% vs 3.7%; OR 4.33, p = 0.02). In multivariate analysis of outcomes, electrographic seizures were an independent predictor of in-hospital mortality (hazard ratio [HR] 4.07 [1.44-11.51], p < 0.01). In competing risks analysis, hospital length of stay increased in the presence of NCSE (30 day proportion discharged with vs without NCSE: HR 0.21 [0.03-0.33] vs 0.43 [0.36-0.49]). INTERPRETATION This multicenter retrospective cohort study demonstrates that seizures and other epileptiform abnormalities are common in patients with COVID-19 undergoing clinically indicated cEEG and are associated with adverse clinical outcomes. ANN NEUROL 2021;89:872-883.
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Affiliation(s)
- Lu Lin
- Beth Israel Deaconess Medical Center, Department of NeurologyHarvard Medical SchoolBostonMA
| | | | - Neishay Ayub
- Massachusetts General Hospital, Department of NeurologyHarvard Medical SchoolBostonMA
| | - Pablo Bravo
- Department of NeurologyYale UniversityNew HavenCT
| | - Sudeshna Das
- Massachusetts General Hospital, Department of NeurologyHarvard Medical SchoolBostonMA
| | - Lorenzo Ferlini
- Hôspital Erasme, Département de NeurologieUniversité Libre de BruxellesBruxellesBelgium
| | | | - Jong Woo Lee
- Brigham and Women's Hospital, Department of NeurologyHarvard Medical SchoolBoston, MA
| | - Shibani S. Mukerji
- Massachusetts General Hospital, Department of NeurologyHarvard Medical SchoolBostonMA
| | | | | | | | - Charles Casassa
- Beth Israel Deaconess Medical Center, Department of NeurologyHarvard Medical SchoolBostonMA
| | - Nicolas Gaspard
- Department of NeurologyYale UniversityNew HavenCT
- Hôspital Erasme, Département de NeurologieUniversité Libre de BruxellesBruxellesBelgium
| | - Daniel M. Goldenholz
- Beth Israel Deaconess Medical Center, Department of NeurologyHarvard Medical SchoolBostonMA
| | | | - Jin Jing
- Massachusetts General Hospital, Department of NeurologyHarvard Medical SchoolBostonMA
| | | | - Eyal Y. Kimchi
- Massachusetts General Hospital, Department of NeurologyHarvard Medical SchoolBostonMA
| | | | - Steven Tobochnik
- Brigham and Women's Hospital, Department of NeurologyHarvard Medical SchoolBoston, MA
| | - Sahar Zafar
- Massachusetts General Hospital, Department of NeurologyHarvard Medical SchoolBostonMA
| | | | - M. Brandon Westover
- Massachusetts General Hospital, Department of NeurologyHarvard Medical SchoolBostonMA
| | - Mouhsin M. Shafi
- Beth Israel Deaconess Medical Center, Department of NeurologyHarvard Medical SchoolBostonMA
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Sivaraju A, Spencer DD, Hirsch LJ. Intrastimulation discharges during electrical stimulation mapping May help identify seizure onset network. Brain Stimul 2021; 14:652-654. [PMID: 33826933 DOI: 10.1016/j.brs.2021.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 02/03/2021] [Accepted: 04/01/2021] [Indexed: 10/21/2022] Open
Affiliation(s)
- Adithya Sivaraju
- Comprehensive Epilepsy Center, Department of Neurology, Yale University, New Haven, CT, USA.
| | - Dennis D Spencer
- Comprehensive Epilepsy Center, Department of Neurosurgery, Yale University, New Haven, CT, USA
| | - Lawrence J Hirsch
- Comprehensive Epilepsy Center, Department of Neurology, Yale University, New Haven, CT, USA
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Cutillo G, Tolba H, Hirsch LJ. Anti-seizure medications and efficacy against focal to bilateral tonic-clonic seizures: A systematic review with relevance for SUDEP prevention. Epilepsy Behav 2021; 117:107815. [PMID: 33640562 DOI: 10.1016/j.yebeh.2021.107815] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 01/20/2021] [Accepted: 01/20/2021] [Indexed: 11/17/2022]
Abstract
We conducted a systematic review of anti-seizure medications (ASMs) and their efficacy for the control of focal to bilateral tonic-clonic seizures (FBTCS). FBTCS, especially when nocturnal, are recognized as one of the major risk factors for Sudden Unexpected Death in Epilepsy (SUDEP). We searched different online databases for all the randomized, double-blinded, and placebo-controlled clinical trials of ASMs that were FDA-approved after 1990 and that reported specifically on the reduction in FBTCS; when possible, this was compared to reduction in focal impaired awareness (FIA) seizures. The ASMs that yielded the most data (3 or more studies) were topiramate (TPM), followed by tiagabine (TGB), brivaracetam (BRV), and lamotrigine (LTG). TPM trials showed a reduction in FBTCS of 44.8% to 100% (4.5-99% over placebo); TGB 21.8% to 46.7% (21.8-61% over placebo); BRV 33.9% to 82.1% (11.6-57.4% over placebo); and LTG 55.2% (20.3-52% over placebo). Promising results, but with data from only one or two studies, were seen with cenobamate (18-59% efficacy above placebo), lacosamide (45.1-78.7%), levetiracetam (40.1-60.3%), oxcarbazepine (58.5-81.5%), and gabapentin (50-53.8%). Higher responses were often seen at higher doses, including at doses above those currently approved by the FDA. Results specific to nocturnal FBTCS were never reported for any ASM. Moreover, complete freedom from FBTCS specifically was very rarely reported, despite its relevance for SUDEP prevention. In conclusion, there are few data specifically comparing the efficacy of ASMs for prevention of FBTCS despite the known strong association of BTCS with SUDEP. This review was our attempt at filling a gap in the literature and calling for universal reporting of data specific to BTC seizure reduction in all future studies, preferably including specific reporting on nocturnal BTCS. This will help enable rational ASM selection to minimize BTC seizures and thereby decrease the risk of SUDEP.
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Affiliation(s)
- Gianni Cutillo
- Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, MA 02215, USA
| | - Hatem Tolba
- Department of Neurology, Medical College of Wisconsin, Milwaukee, WI, USA; Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Lawrence J Hirsch
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, CT, USA.
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Buchhalter J, Shafer PO, Buelow JM, French JA, Gilchrist B, Hirsch LJ, Nasuta M, Santilli N. Preferred practices for rescue treatment of seizure clusters: A consensus-driven, multi-stakeholder approach. Epilepsy Behav 2021; 117:107836. [PMID: 33640567 DOI: 10.1016/j.yebeh.2021.107836] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [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: 12/22/2020] [Accepted: 01/30/2021] [Indexed: 01/22/2023]
Abstract
BACKGROUND Some of the most difficult issues in the care of people living with epilepsy (PWE) regard the definition, treatment, and communication of unexpected increase(s) in seizure frequency over a relatively short duration of time. In order to address this issue, the Epilepsy Foundation established the Rescue Therapy Project in Epilepsy to understand the gaps, needs, and barriers facing people with epilepsy who use or may benefit from rescue therapies (RTs) for "seizure clusters". The intent was to provide consensus-derived recommendations from a broad stakeholder group including PWE, their caregivers, epilepsy specialist physicians, nurses, pharmacists, and representatives of epilepsy & neurology advocacy and professional organizations. METHODS During Phase 1, a group of epilepsy experts and stakeholders (N = 54) were divided into 3 workgroups that met by conference calls and in-person. Content of workgroups was developed into preferred practices related to RTs. In Phase 2, these recommendations were evaluated by a larger more diverse group of healthcare professionals, PWE, and caregivers. Agreement with recommended preferred practices at 80% or greater was set as the level to achieve consensus. RESULTS The preferred practices were centered around four core themes identified by the experts and key stakeholders: the importance of a common language; when RTs should be prescribed; assessing the need for RTs; and education/communication about RTs. Consensus from experts and key stakeholders was reached for 27 recommended preferred practices using the Delphi method. "Rescue therapy" or "rescue medicine" was the preferred term to describe what to name a treatment intervention in this context, and seizure action plans was the preferred term to communicate how to respond to a seizure or SCs and the use of RTs. In Phase 2, 23 of the recommendations reached final consensus, including the need for a common language, and the need to consider RTs and seizure action plans in all PWE in an individualized manner, several circumstances in which RTs should be prescribed, and the importance of education regarding RTs and SAPs.
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Affiliation(s)
| | - Patricia O Shafer
- Osborne Health Consulting LLC, Boston, MA, USA; Epilepsy Foundation, Landover, MD, USA
| | | | - Jaqueline A French
- Department of Neurology, NYU Grossman School of Medicine, New York City, NY, USA; Epilepsy Foundation, Landover, MD, USA
| | | | - Lawrence J Hirsch
- Comprehensive Epilepsy Center, Dept. of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Mary Nasuta
- Harford County Public Schools, Bel Air, MD, USA
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Kazazian K, Kellogg M, Wong N, Eschbach K, Moeller RF, Gaspard N, Hirsch LJ, Hocker S, Gofton T. How to Help Your Patients Enroll in the New-Onset Refractory Status Epilepticus (NORSE) and Febrile Infection-Related Epilepsy Syndrome (FIRES) Family Registry, and Other Rare Epilepsy Registries. Epilepsy Curr 2021; 21:15357597211002869. [PMID: 33769129 PMCID: PMC8655258 DOI: 10.1177/15357597211002869] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Affiliation(s)
- Karnig Kazazian
- Schulich School of Medicine and
Dentistry, Western University, London, Ontario, Canada
| | | | | | - Krista Eschbach
- University of Colorado, Children’s
Hospital Colorado, Aurora, CO, USA
| | - Raquel Farias Moeller
- Medical College of Wisconsin,
Department of Neurology, Children’s Wisconsin, Milwaukee, WI, USA
| | - Nicolas Gaspard
- Service de Neurologie, Université Libre
de Bruxelles–Hôpital Erasme, Brussels, Belgium
| | - Lawrence J. Hirsch
- Department of Neurology, Yale
University, Comprehensive Epilepsy Center, New Haven, CT, USA
| | - Sara Hocker
- Division of Critical Care Neurology,
Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Teneille Gofton
- Schulich School of Medicine and
Dentistry, Western University, London, Ontario, Canada
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