However, cognitive impairment is very common in epilepsy patients and may be negatively or positively affected by surgery. Amidst the long-standing discussion of whether a particular surgical approach for temporal lobe epilepsy patients may be superior with regards to seizure control, a recent meta-analysis indicated that this is the case for more extended resections. Larger temporal lobe resections, however, raise concerns that more unaffected and functional tissues may be involved, thus causing worse cognitive outcome. This review is based on published reports collected over a long period, with changing diagnostics and surgical methods, and focuses mainly on the experiences of one epilepsy centre. The review highlights the effects of standard
versus selective surgery, the different surgical approaches in selective surgery, determinants other than surgery which may affect cognitive outcome, and the methodologically-important question of outcome assessment and how neuropsychological test selection may bias the result. Overall, from a neuropsychological point of view, individual and selective surgery is preferred in which the aim is to achieve seizure control with minimal effect on the functional integrity of tissues or fibre tracts. Cognition is important for the functions of everyday life and this should be kept in mind, irrespective of which kind of surgery is preferred.
Devender Bhalla, Pierre-Marie Preux, Claude Mignard, Didier Smadja, Achille Edem Tchalla, Benoît Marin, Pierre Jallon
Island, in which the same methodology was used.</p><p>We extracted data from three studies in which the incidence of seizures was estimated and aetiologies identified. Data was extracted and analysed using STATA. Group comparison was performed firstly for each study as a single group, and secondly by considering Martinique and the Reunion Island as an overseas group, in comparison with Geneva, considered as a mainland group. Uncorrected χ
2was used and statistical significance (two-sided,
p=0.05) was determined for each aetiology per cohort.</p><p>The incidence of newly-diagnosed epileptic seizures per 100,000 was 71.0, 80.6, and 100.4 in Geneva, Martinique, and the Reunion Island, respectively. A bimodal distribution and predominance of generalised seizures was noted. The male to female ratio was higher in Martinique (∼2.0) than other populations (∼1.5). Status epilepticus was noted in Geneva and more so in the Reunion Island. The incidence of provoked seizures per 100,000 was 25.2, 16.4, and 17.7, and for unprovoked seizures was 45.6, 64.1, and 81.2 in Geneva, Martinique, and the Reunion Island, respectively. There was a greater risk of provoked seizures in Geneva relative to the overseas group, which was due to tumours, use of toxic substances, and drug abuse. The risk of unprovoked seizures in Geneva was due to trauma and infections. In Martinique, alcoholism and HIV were foremost factors for provoked and unprovoked seizures, and stroke was an important aetiology in both Martinique (provoked seizures) and the Reunion Island (unprovoked seizures).</p><p>The risk of provoked seizures was greatest in Geneva and risk of unprovoked seizures was greatest in the Reunion Island. Toxic substances, alcohol, infection, and trauma constituted major factors for epileptic seizures in Geneva, while alcoholism, HIV, and stroke were major factors in the overseas group. Relative eradication of tropical infections has paved a way for the emergence of non-communicable aetiologies (stroke, alcoholism). Males from Martinique demonstrated the greatest risk of epileptic seizures, signifying the importance of alcoholism, HIV,
etc. Three steps should follow: follow-up studies (mortality), strong mechanisms for prevention (or control) of risk factors, guidelines on whether to treat or not.</p>
Kanitpong Phabphal, Alan Geater, Kitti Limapichart, Pornchai Sathirapanya, Suwanna Setthawatcharawanich
are variable. To date, there is no report of a prospective study in Thai adults. Herein, we investigated the aetiology, clinical features, factors of predicted poor outcome, and treatment strategies in Thai adult patients who presented with convulsive status epilepticus. A total of 180 patients, whose ages ranged from 15 to 106 years, were included. Of these, 121 patients (67.2%) had acute symptomatic aetiology. The most common aetiology of status epilepticus was encephalitis (36.1%), followed by scarring of the cerebral hemisphere (15%). The median duration of status epilepticus before treatment was three hours. The rate of mortality in the study was 26.7%. Poor outcome was identified in 112 (62.2%) patients. For referral patients, all received only intravenous drugs before referral. The variables that correlated with poor outcome were aetiology and duration of status epilepticus. An approach to incorporate improved prevention of encephalitis, a more effective transportation system, and provision of the essential intravenous antiepileptic drugs would effectively increase the response to treatment.
Mario Arturo Alonso-Vanegas, José Miguel Cisneros-Franco, Carlos Castillo-Montoya, Alma Rosa Martínez-Rosas, María Esther Gómez-Pérez, Francisco Rubio-Donnadieu
results from the Quality of Life in Epilepsy questionnaire (QOLIE-31) and selective memory tests of the Barcelona Battery and the Rey-Osterrieth figure.</p><p>We retrospectively analysed the records of 60 TLE patients and correlated patient variables (
e.g. gender, aetiology; mesial TLE with hippocampal sclerosis [HS]
versus lesional TLE, side of ictal onset, age, age at onset, duration of epilepsy, seizure frequency, and use of AEDs) with selective memory test scores and self-reported QoL.</p><p>Right ictal onset was associated with lower emotional well-being scores. MTLE-HS patients had lower QOLIE-31 scores for seizure worry, social function, overall QoL, energy/fatigue, cognitive function, and obtained a lower overall score, compared to those with lesional TLE. Older age at epilepsy onset was associated with worse emotional well-being, energy/fatigue, medication effects, and seizure worry outcomes. Higher seizure frequency and older age at time of evaluation were associated with lower cognitive function scores. Generalised seizures were associated with lower scores based on the variables: seizure worry, overall quality of life, emotional well-being, and cognitive function. Regarding memory tests, only visuospatial memory correlated positively with cognitive function score. Patients with MTLE-HS underwent evaluation for pharmacoresistant epilepsy, on average, 10 years later than those with lesional TLE.</p><p>MTLE-HS, right-sided epileptogenic zone, late onset, and higher seizure frequency were associated with worse QoL. Objective testing revealed specific memory deficits that were not reflected in self-reported QoL scores.</p>
Xuelian He, Ying Li, Zhisheng Liu, Xin Yue, Peiwei Zhao, Jiasheng Hu, Gefei Wu, Bing Mao, Dan Sun, Huanian Zhang, Xinwen Song, Yang Wang, Jianbo Shao
elements of epilepsy. Targeting brain inflammation may represent a novel therapeutic strategy for epilepsy and refractory epilepsy. In this study, we investigated the association of a tag SNP of the
CCL2 gene, rs1024611 (originally designated as -2578G>A or -2518G>A) with drug-resistant epilepsy in Chinese children with epilepsy. We enrolled 484 epilepsy patients, including 98 drug-resistant patients and 386 drug-responsive patients. The rs1024611 was genotyped by PCR-RPLP. The rs1024611 AA genotype was associated with a greater susceptibility to drug-resistant epilepsy (
p=0.008; OR=2.51, 95% CI: 1.33-4.72), adjusted for age, sex, and seizure type, and the association remained significant after Bonferroni correction for multiple testing (
p<0.05). Our results demonstrate that the
CCL2 genetic polymorphism is associated with drug-resistant epilepsy in Chinese paediatric patients.
Sophie Dupont, Arnaud Biraben, Gilles Lavernhe, Thierry Marquet, Bashar Allaf
naturalistic study, conducted by neurologists in France. Patients who had started zonisamide treatment at least three months prior to inclusion were eligible. Data were collected at routine consultations at inclusion (Visit 1) and three to six months later (Visit 2). At Visit 1, investigators documented epilepsy-related variables based on patient records before initiation of zonisamide and at inclusion. At Visit 2, the investigators re-evaluated seizure activity and rated effectiveness. Adverse events were also documented.</p><p>A total of 428 patients were included in the study based on evaluation by 132 neurologists. Zonisamide was initiated at a daily dose of 50 mg and 25 mg in 61% and 31.8% of patients, respectively. The median maintenance dose was 300 mg/day. Prior to initiation of zonisamide, the mean seizure frequency was 16.0 seizures/month. This was reduced to 8.7 seizures/month at Visit 1 and to 7.1 seizures/month at Visit 2. The response rate and proportion of seizure-free patients was 61.9 and 31.1% at Visit 1 and 65.9 and 25.6% at Visit 2, respectively. The frequency of seizures at Visit 2 decreased significantly (
p<0.05) for all seizure type subgroups, except for simple partial seizures. Responder rates were >60% for all analysed subgroups. The proportion of seizure-free patients was significantly higher in patients receiving bitherapy, compared to the others (
p=0.007). The most frequently reported adverse event was somnolence (5.1%); three serious adverse events were reported.</p><p>In everyday practice, zonisamide is principally used in association with other antiepileptic drugs for the treatment of focal epilepsy in adults. It is effective in improving seizure control and quality of life, and is generally well-tolerated.</p>
Jianming Liu, Zhiliang Liu, Hu Ding, Xiaohong Yang
study was carried out on patients who had no change in treatment regimen over the last six months. Data on adherence to medication and related factors for each patient were gathered using a questionnaire.</p><p>Of a total of 368 patients studied, 48.1% of patients were non-adherent with regards to AEDs. There were no demographic differences (based on gender, age, seizure type, and rural or urban location) between adherent and non-adherent patients. Adherence was positively and significantly correlated with duration of illness (
p=0.007). The primary reason for non-adherence was forgetfulness or not having medication on hand (69.6%), followed by a negative attitude (12.8%), a bad patient-prescriber relationship (9.5%), side effects (5.4%), inability to buy drugs (1.9%), and other reasons (0.8%).</p><p>The non-adherence of epilepsy patients is common in China. Targeted management programs and communication strategies are necessary to improve adherence to AED treatments in patients with epilepsy and avoid the clinical consequences of poor adherence.</p>
May Shawki, Lamia El Wakeel, Rania Shatla, Gamila EL-Saeed, Samira Ibrahim, Osama Badary
Methods. A prospective, randomised, single-blinded, controlled, crossover pilot study. Five healthy children were included as controls. Thirty intractable epileptic children were randomly assigned to either Group I or II. Group I received placebo for four weeks, followed by a two-week washout period, and subsequently black seed oil for four weeks. Group II received the same intervention but in the reverse order. All patients received AEDs throughout the study period. Prior to allocation, all patients underwent a neurological assessment and evaluation of oxidative stress markers; total antioxidant capacity (TAC) and malondialehyde (MDA). Patients were assessed at Weeks 4 and 10 for oxidative stress markers and seizure frequency and severity.
Results. At baseline, both groups (I, II) had significantly lower serum TAC levels relative to healthy controls (
p=0.007), while MDA levels were unchanged. After the 4-week period of black seed oil administration, there was no significant difference between the two groups with regards to seizure frequency, severity, or oxidative stress markers (TAC and MDA;
p>0.05). Eight patients had >50% reduction in seizure frequency/severity after black seed oil
Conclusion. Children with intractable epilepsy show evidence of oxidative stress. Administration of 40-80 mg/kg/day of black seed oil as add-on therapy did not alter either oxidative stress markers or seizure frequency or severity in intractable epileptic patients.
Bong Su Kang, Hye Jin Moon, Young-Soo Kim, Soon-Tae Lee, Keun-Hwa Jung, Kon Chu, Sang Kun Lee
at the Seoul National University Hospital between January 2007 and March 2009 were evaluated. Patients who underwent brain surgery for seizure control or who had associated progressive disease were excluded from this study. The electronic medical records of these patients were reviewed retrospectively.</p><p>A total of 568 patients were recruited, including 124 patients with generalised epilepsy. The mean duration of the follow-up period was 29.3 months. The seizure-free rate was 33.6% and was higher in patients with generalised epilepsy (51.6%) than patients with localisation-related epilepsy (28.6%). There was a strong correlation between initial response and dose-up response in 351 patients with increased dosage during the follow-up period. A total of 486 adverse events developed in 316 patients. The most common adverse event (24.3%) was irritability, which was associated with a high rate of drug discontinuation. Previous history of mood disorder was the only factor related to the development of irritability in patients using this medication.</p><p>Levetiracetam was effective and safe as monotherapy and add-on therapy for partial and generalised epilepsy. The initial response to levetiracetam may provide useful information for predicting the response to increased dose of levetiracetam. However, the use of this medication was associated with a rate of irritability that was higher than expected in patients with a history of mood disorders.</p>
Feray Bolukbasi, Sakir Delil, Eser Bulus, Asli Senturk, Naz Yeni, Naci Karaagac
this drug has less of a sedative effect and is well tolerated, compared to phenobarbital. Barbexaclone was widely used in Turkey until 2009 when its production ended, however, it gave rise to an epidemic for which we were not prepared. Since then, no standardised management protocol has been developed and each patient has been evaluated individually, thereby creating tailor-made solutions based on the extent of each patient's supply of remaining drug (from a few tablets to a stock which might last for six months).
The rate of seizure freedom was 37.7% under barbexaclone treatment and dropped to 32.2% in the follow-up period after discontinuation of the drug. In the majority of cases, a new antiepileptic drug was added and this was commonly levetiracetam, a more expensive drug. In this article, we share our experiences of a general problem: the withdrawal of an antiepileptic drug from the market. Although there was prior notification regarding barbexaclone withdrawal, it was not possible to contact all patients since such a database is not available in Turkey. Although no conclusions regarding the efficacy of the drug or comparison of efficacy with other antiepileptic drugs is provided, it is nonetheless noteworthy to share these experiences since some patients had lost seizure control for reasons that could not be explained.
Francesco Brigo, Stanley C Igwe, Raffaele Nardone, Frediano Tezzon, Luigi Giuseppe Bongiovanni, Eugen Trinka
safety were estimated using a common-reference based indirect comparison meta-analysis (CRBMA) methodology.</p><p>Randomised controlled trials (RCTs) investigating the use of IV-VPA or IV-PB
versus intravenous phenytoin (IV-PHT) for GCSE were identified by a systematic search of the literature. A random effects model was used to estimate Mantel-Haenszel odds ratios (ORs) for efficacy and safety of IV-VPA or IV-PB
versus IV-PHT in a standard meta-analysis. Adjusted indirect comparisons were then made between VPA and PB using the obtained results.</p><p>CRBMA showed that VPA does not lead to significantly higher seizure cessation (OR 1.00; 95% CI: 0.36-2.76) compared to PB, although it exhibits fewer adverse effects (OR 0.17; 95% CI: 0.04-0.71). Results of this CRBMA are consistent with results of a recently published head-to-head comparison of IV-VPA and IV-PB.</p><p>There is insufficient evidence to demonstrate superiority of IV-VPA over IV-PB for the treatment of GCSE in terms of efficacy. Some direct and indirect comparisons suggest that VPA has a better safety profile than PB. However, the limited numbers of underpowered RCTs included in this meta-analysis are not sufficient to justify a change in clinical practice. More rigorous and appropriately powered RCTs are therefore required to definitively determine the efficacy and tolerability of VPA for the treatment of GCSE.</p>
Katrina Peariso, Shannon M Standridge, Barbara E Hallinan, James L Leach, Lili Miles, Francesco T Mangano, Hansel M Greiner
and brain MRI demonstrating atrophy of the left cerebral and right cerebellar hemispheres.</p><p>The patient presented with occasional partial seizures consisting of a left calf sensation followed by left leg clonic jerking. Initial brain MRI showed left cerebral and right cerebellar atrophy with T2 hyperintensity in the left parietal region. After six months, the seizure frequency increased and semiology evolved to include frequent clonic movements of the left side of the face, arm and leg and epilepsia partialis continua (EPC) of the left arm and leg. There was progressive weakness of the left leg and, to a lesser extent, her left arm. MRI at this time demonstrated an additional T2 hyperintensity in the right frontal lobe. An extensive evaluation for paraneoplastic, mitochondrial, and genetic epilepsy syndromes was unrevealing. On biopsy evaluation, chronic T-cell mediated encephalitis was demonstrated within bilateral frontal lobes. Treatment with immunomodulatory therapy resulted in some improvement in her seizure frequency and motor function.</p><p>Rasmussen's encephalitis can be a challenging diagnosis. The patient's clinical history, including EPC, with bilateral frontal lobe biopsies confirming a T-cell mediated encephalitis supports a diagnosis of bilateral Rasmussen encephalitis. This case highlights the diagnostic challenges and treatment dilemmas that arise in an adolescent presenting with bilateral inflammatory lesions of Rasmussen's encephalitis. [
Published with video sequences]</p>
Maysaa M Basha, Guadalupe Fernández-Baca Vaca, Hans O Lüders
of preoperative MRI and post-electrode implantation CAT allowed for anatomical localisation of electrode contacts. Electrical stimulation of electrodes over the dorsal and ventral banks of the cingulate cortex on the left produced right foot dorsiflexion and right wrist and elbow flexion, respectively, demonstrating detailed representation of cingulate motor function in humans, somatotopically distributed along the banks of the cingulate sulcus, as seen in the non-human primate. [
Published with video sequences]
Fadime Irsel Tezer, Kadriye Agan, Ingo Borggraefe, Soheyl Noachtar
by invasive recordings, was reflected by change from hyperkinetic movements to arrest of activity with mild oral and manual automatisms. [
Published with video sequences]
Bruno Zanotelli Monnerat, Tonicarlo Rodrigues Velasco, Frederico Nakane Nakano, Alexandre Veriano Júnior, Ana Paula Pinheiro Martins, Américo Ceiki Sakamoto
previously unrecognised aetiology of this condition. The patient was a 23-year-old female admitted for investigation of focal myoclonic status epilepticus in the right side of the face and glossopharyngeal area. Intravenous corticosteroid was administered and improvement was observed in seizure activity and overall general health. A video sequence of opercular myoclonia is included. Due to the presence of inflammatory elements based on brain MRI and CSF studies, a decision to investigate autoimmune encephalitis was undertaken. Anti-GAD65 radioimmunoassay was markedly positive. This case study highlights the need for awareness of the clinical presentation of GADA-associated encephalitis. [
Published with video sequences]
Elisabeth Ruppert, Laurence Lalanne, Jack Foucher, Marie-Agathe Zimmermann, Edouard Hirsch, Pierre Vidailhet
between antipsychotic and antiepileptic drugs. Some antipsychotic drugs also decrease the seizure threshold. We report the case of a 49-year-old man with a hypothalamic hamartoma, with a history of both gelastic and temporal lobe seizures. The patient was rendered seizure-free after three neurosurgical procedures but developed a drug-resistant paranoid psychosis. He was treated with electroconvulsive therapy (ECT). After two weeks with six stimulations that resulted in seizures, the psychiatric phenomena disappeared completely. There was no relapse of either the psychiatric symptoms or the seizures during the 42 months of follow-up. This case report suggests that ECT might be safe for psychosis in patients with a history of seizures that have previously been successfully treated with neurosurgery, although caution should be exercised in drawing general conclusions from a single case report.
Kousuke Nakano, Katsuhiro Kobayashi, Satoshi Maniwa, Nobuyuki Kodani, Yoko Ohtsuka
of early-onset epileptic encephalopathy characterised by myoclonus and focal seizures that are highly resistant to treatment, lidocaine and CBZ may prove effective in treating this disorder. Future studies should be performed in order to determine whether there are common specific mechanisms of seizure generation related to the sodium channel in these patients.
Rocco Salvatore Calabrò, Rosaria De Luca, Patrizia Pollicino, Placido Bramanti
of serotoninergic drugs, including antidepressants and atypical antipsychotics, is a common cause of situational anorgasmia. Pregabalin is a new antiepileptic drug, structurally related to gabapentin, and commonly used as adjunctive therapy for partial epilepsy and treatment of neuropathic pain in adults. Herein, we describe three men with epilepsy, who experienced severe anorgasmia after pregabalin add-on treatment.
Anselm C. Hoppner, Susanne Fauser, Frank Kerling
perampanel are not available. Here, we describe the first case of a 34-year-old patient with perampanel intoxication and attempted suicide, in which the recommended daily dose of perampanel was exceeded ten-fold. Clinical signs of the intoxication and possible psychotropic effects are described.