Improved ictal assessment performance in the epilepsy monitoring unit via standardization.

OBJECTIVE: To determine whether the standardization and implementation of an ictal testing protocol in the Epilepsy Monitoring Unit (EMU) leads to improvements in ictal testing performance. METHODS: Ictal assessments completed in the EMU from a single center were retrospectively reviewed over a two-month period. Each assessment was evaluated to determine whether 8 high-yield aspects of the ictal assessment were performed. Following observation of performance, a standardized ictal testing protocol was developed based on a root cause analysis and review of consensus guidelines. This protocol was disseminated to staff in conjunction with an annual epilepsy education seminar. Ictal assessment performance was re-assessed during the subsequent two months (short-term follow-up) and again during a five- to seven-month period (long-term follow-up) beyond the initial intervention. For sub-group analysis, event characteristics (event type, time of assessment) and patient characteristics (age, gender) were also evaluated and analyzed in relation to ictal testing performance. RESULTS: All eight individual ictal testing elements were more likely to be assessed in short-term and long-term follow-up periods when compared to pre-intervention assessments. The cumulative difference in ictal testing was 20.4% (95% CI 3.7-37.2, p = 0.02) greater for the short-term period and 16.7% (95% CI -0.3% to 33.8%, p = 0.05) greater in the long-term period when compared to baseline testing. CONCLUSIONS: Utilization of a standardized ictal testing battery in conjunction with staff education leads to an objective improvement in ictal assessment performance. Further research is warranted to assess the replicability of our findings.

Epilepsy education in gliomas: engaging patients and caregivers to improve care.

BACKGROUND: Tumor-related epilepsy (TRE) is the most common cause of hospitalizations in patients with malignant gliomas leading to increased distress and decreased quality of life (QOL) for patients and caregivers. PURPOSE: We sought to determine the feasibility of incorporating a structured TRE-specific education intervention into clinical practice while assessing effect on distress and TRE knowledge. METHODS: We prospectively enrolled glioma patients and their caregivers on an IRB-approved study. Subjects underwent a pre-test to assess baseline knowledge regarding seizure management. A neuro-oncology provider guided subjects through a presentation focused on safety and home management of seizures. Seizure-related distress was measured before and after the educational intervention using a distress thermometer. A post-test was completed. At 2 and 6 months, distress was re-assessed and post-tests were repeated. Subject satisfaction was assessed. RESULTS: Fifty subjects (23 patients, 27 caregivers) were enrolled. Median age was 59. Fifty-seven percent of patients had TRE. Median time to completion was 21.5 min. Median baseline distress scores were 2/10 for patients and 5/10 for caregivers. Distress scores decreased by a mean of 1.5 points and TRE knowledge increased by 2 points for all subjects between the initial and 2-month visit. Ninety-eight percent of subjects strongly agreed that the education was helpful and informative. Caregivers reported more distress despite better baseline seizure knowledge than patients. CONCLUSION: Structured TRE education is feasible in patients with gliomas and their caregivers and may be effective in reducing distress. Further prospective studies are warranted to assess effects on hospitalizations, cost, and QOL.

Discontinuation of Antiseizure Medications in Patients With Brain Tumors.

Patients with brain tumors will experience seizures during their disease course. While providers can use antiseizure medications to control these events, patients with brain tumors can experience side effects, ranging from mild to severe, from these medications. Providers in subspecialties such as neurology, neuro-oncology, neurosurgery, radiation oncology, and medical oncology often work with patients with brain tumor to balance seizure control and the adverse toxicity of antiseizure medications. In this study, we sought to explore the problem of brain tumor-related seizures/epilepsy in the context of how and when to consider antiseizure medication discontinuation. Moreover, we thoroughly evaluate the literature on antiseizure medication discontinuation for adult and pediatric patients and highlight recommendations relevant to patients with both brain tumors and seizures.

Neurologic Complications of Acute Posterior Multifocal Placoid Pigment Epitheliopathy: A Case Series of 4 Patients.

Acute posterior multifocal placoid pigment epitheliopathy (APMPPE) is a self-limited idiopathic inflammatory ophthalmologic condition with characteristic funduscopic and fluorescein angiography findings. It is typically characterized by a flu-like prodrome followed by monocular or binocular vision loss. Often, prognosis is excellent with complete or near-complete recovery of vision. Rarely, however, APMPPE is associated with neurologic complications, including meningitis, cerebral vasculitis, and stroke. Treatment in patients with central nervous system (CNS) involvement involves steroids and ultimately other immunosuppressive therapy, as there can be significant resulting morbidity and mortality otherwise. Evidence or guidelines regarding duration of treatment are lacking. We present 4 patients diagnosed with APMPPE who demonstrate the spectrum of neurologic sequelae associated with APMPPE. The first 2 cases highlight cerebrospinal fluid lymphocytic pleocytosis as an indicator of active CNS inflammation and the potential utility of serial lumbar punctures (LPs) to guide treatment duration. Cases 3 and 4 demonstrate the neurovascular complications seen in CNS vasculitis. Case 4 also highlights the potential use of magnetic resonance vessel wall imaging (VWI) as a noninvasive means for disease surveillance and treatment guidance. This case series emphasizes the importance of recognition by neurologists of APMPPE as an entity associated with strokes and cerebral vasculitis in order to provide appropriate and timely treatment. Active CNS inflammation warrants continued aggressive immunosuppressant treatment, and we propose that serial LPs and/or magnetic resonance VWIs may be effective tools to guide disease surveillance and subsequent treatment duration.

Acute care in glioblastoma: the burden and the consequences.

BACKGROUND: The utilization of inpatient medical services by patients with glioblastoma (GBM) is not well studied. We sought to describe causes, frequency, and outcomes of acute care visits in GBM. METHODS: We conducted a retrospective study of 158 GBM patients at the University of Rochester over 5 years. Electronic medical records were reviewed to identify all local and outside acute care visits. Acute care visits were defined as any encounter resulting in an emergency department visit or inpatient admission. RESULTS: Seventy-one percent (112/158) of GBM patients had 235 acute care visits corresponding to 163 hospitalizations (69%) and 72 emergency department visits (31%). Sixty-three percent of patients had multiple visits. Admission diagnoses were seizure (33%), neurosurgical procedure (15%), infection (12%), focal neurologic symptoms (9%), and venous thromboembolism (VTE, 9%). Forty-six patients had 1 or more visits for seizures. Median time to first acute care visit was 65.6 days and 22% of patients had an acute care visit within 30 days of diagnosis. Median length of stay was 5 days. Thirty-five percent of admitted patients were discharged home; 62% required a higher level of care than prior to admission (23% were discharged home with services, 17% to a nursing facility, 16% to hospice, 6% to acute rehab) and 3% died. Thirty-eight percent of patients had ACV within 30 days of death. Median survival was 14 months for patients who had acute care visits and 22.2 months for patients who did not. CONCLUSION: The majority of GBM patients utilize acute care, most commonly for seizures. The high number of emergency department visits, short length of stay, and many patients discharged home suggest that some acute care visits may be avoidable.

Qualitative analysis of double inversion recovery MRI in drug-resistant epilepsy.

PURPOSE: To determine whether Double Inversion Recovery (DIR) on 3T MRI can enhance detection of epileptogenic lesions Methods: 29 adult patients with DRE were enrolled in a prospective pilot study. Brain MRIs were obtained using a specialized protocol that included: (1) Fast-Spin EchoT2, (2) T2 fluid attenuated inversion recovery (FLAIR), and (3) DIR sequences. Two neuroradiologists blinded to clinical information independently reviewed each sequence in the order listed above for T2-hyperintense lesions. Cortical lesions were determined to be concordant with the epileptic focus based upon available clinical and electrodiagnostic testing. RESULTS: Of 29 studies, 21 had a lesion identified with 13/21 abnormalities being non-specific. Of 8 remaining studies, 3 revealed a lesion only with DIR sequencing. DIR-lesions were concordant with clinical data in 1 subject, non-discordant in 1 subject, and discordant in 1 subject. SIGNIFICANCE: DIR has the potential to be more sensitive in detecting cortically based lesions relative to standard imaging. More data are needed to assess the sensitivity and specificity of DIR, particularly as it pertains to identification of epileptogenic lesions using electrodiagnostic testing and outcome after surgery.

Considerations in prophylaxis for tumor-associated epilepsy: prevention of status epilepticus and tolerability of newer generation AEDs.

OBJECTIVE: To identify risk factors for the development of tumor-associated epilepsy (TAE) and potential benefit of newer generation AEDs in seizure prevention. METHODS: We performed an IRB approved retrospective study of newly diagnosed GBM patients at the University of Rochester between 1/1/05 and 5/13/11. Records were reviewed to describe demographics, seizure incidence, occurrence of status epilepticus, and AED use and toxicity. RESULTS: 172 patients with newly diagnosed GBM were included in the study. 53.4% developed TAE. 31.4% had seizure prior to diagnosis. 118 patients were seizure-free at diagnosis: 32.2% developed post-diagnosis TIE (PostTAE) and 60.2% remained seizure-free. 70 seizure-free patients received an AED peri-operatively. 36 were weaned off AEDs and 31 were continued. Incidence of PostTAE and time to first seizure were comparable in AED-treated and untreated patients. 4 PostTAE patients presented with status epilepticus (SE), all were not AED treated. AEDs were withdrawn in 10 patients due to toxicity: 9 from phenytoin and 1 from levetiracetam. CONCLUSION: There is a high incidence of PostTAE in GBM. Prophylactic AED therapy did not reduce PostTAE but may have prevented SE. Minimal toxicity was observed on 2nd generation AEDs. The high burden of epilepsy in this population and tolerability of newer AEDS suggest that AAN guidelines should be revisited.