RESUMEN
PURPOSE: Cenobamate (CNB) is a new antiseizure medication (ASM) for the treatment of focal epilepsy in adults. While efficacy of CNB was confirmed in controlled clinical trials, its effects on cognition are unclear. Cognitive adverse effects of ASM affect quality of life and retention rate. Therefore, we investigated whether the adjunctive treatment with CNB is associated with changes in cognitive performance. METHOD: Efficacy and tolerability of CNB were investigated in an observational study. Fifty patients with pharmacoresistant focal epilepsy aged 18 to 71 years (Mdn = 37.5 years) were tested before (T0) and after reaching the first target dose of CNB, usually after three months (T1). Cognitive performance was assessed using the EpiTrack©, a change-sensitive screening tool for attention and executive functions. RESULTS: The median CNB dose at T1 was 125 mg/day (range: 50 - 250 mg/day). Most patients received 2-3 concomitant ASMs. Individual test scores remained stable in 72%, significantly improved in 16%, and significantly deteriorated in 12% of the patients from T0 to T1. The total group showed a significant improvement in EpiTrack scores (p < .01). Changes in EpiTrack performance from T0 to T1 occurred independently of CNB dose, changes in the total drug load or reduction in seizure frequency. CONCLUSION: Most of the patients showed stable or improved cognitive performance. Thus, there is preliminary evidence that adjunctive CNB is not associated with an increased risk of cognitive side effects for the majority of patients. These findings need to be confirmed in controlled trials encompassing higher doses.
Asunto(s)
Epilepsias Parciales , Epilepsia , Adulto , Humanos , Anticonvulsivantes/efectos adversos , Calidad de Vida , Epilepsia/psicología , Epilepsias Parciales/tratamiento farmacológico , Cognición , Resultado del Tratamiento , Quimioterapia CombinadaRESUMEN
OBJECTIVE: To determine the diagnostic yield of in-hospital video-electroencephalography (EEG) monitoring to document seizures in patients with epilepsy. METHODS: Retrospective analysis of electronic seizure documentation at the University Hospital Freiburg (UKF) and at King's College London (KCL). Statistical assessment of the role of the duration of monitoring, and subanalyses on presurgical patient groups and patients undergoing reduction of antiseizure medication. RESULTS: Of more than 4800 patients with epilepsy undergoing in-hospital recordings at the two institutions since 2005, seizures with documented for 43% (KCL) and 73% (UKF).. Duration of monitoring was highly significantly associated with seizure recordings (p < .0001), and presurgical patients as well as patients with drug reduction had a significantly higher diagnostic yield (p < .0001). Recordings with a duration of >5 days lead to additional new seizure documentation in only less than 10% of patients. SIGNIFICANCE: There is a need for the development of new ambulatory monitoring strategies to document seizures for diagnostic and monitoring purposes for a relevant subgroup of patients with epilepsy in whom in-hospital monitoring fails to document seizures.
RESUMEN
OBJECTIVE: Epileptic seizures with insular genesis are often difficult to distinguish from those originating in the temporal lobe due to their complex and variable semiology. Here, we analyzed differentiating characteristics in the clinical spectrum of insulo-opercular seizures. METHODS: Ictal semiology in patients with a diagnosis of insulo-opercular epilepsy (IOE) based on imaging of epileptogenic lesions or electrophysiological evidence of an insulo-opercular seizure origin was retrospectively analyzed and compared to age-matched controls with mesial temporal lobe epilepsy (MTE). RESULTS: Forty-six IOE and 46 matched MTE patients were included. The most prominent ictal features in IOE were focal motor phenomena in 80.4% of these patients. Somatosensory sensations, version, tonic and clonic features, when present, were more frequent contralateral to the SOZ in MTE patients, while they occurred about equally often ipsilateral and contralateral to the SOZ in IOE patients. Ipsilateral manual automatisms were significantly more frequent in MTE patients than in IOE (p = 0.010). Multivariate analysis correctly identified IOE in 78.3% and MTE in 84.8% using five semiologic features (Chi-square = 53.79 with 5 degrees of freedom, p < 0.0001). A subanalysis comparing patients with purely insular lesions with MTE patients using only the earliest ictal signs showed that somatosensory sensations are significantly more frequent in insular epilepsy (p = 0.010), while automatisms were significantly more frequent in MTE patients (p = 0.06). SIGNIFICANCE: Our study represents the first in-depth analysis of ictal semiology in IOE compared to MTE. Use of these differentiating characteristics can serve for a correct syndrome classification and to steer appropriate diagnostic and local therapeutic procedures.
Asunto(s)
Epilepsia del Lóbulo Frontal , Epilepsia del Lóbulo Temporal , Corteza Cerebral/patología , Electroencefalografía/métodos , Epilepsia del Lóbulo Frontal/diagnóstico por imagen , Epilepsia del Lóbulo Frontal/patología , Epilepsia del Lóbulo Temporal/patología , Humanos , Estudios Retrospectivos , Convulsiones/diagnóstico por imagen , Convulsiones/etiologíaRESUMEN
PURPOSE: Focal cortical dysplasia (FCD) is the major cause of focal intractable epilepsy in childhood. Here we analyze the factors influencing the success of surgical treatment in a large cohort of children with histologically ascertained FCD. METHOD: A retrospective study of the effects of FCD type, surgical intervention, and age at surgery in a pediatric cohort. RESULTS: A total of 113 patients (71 male; mean age at surgery 10.3 years; range 0-18) were analyzed; 45 had undergone lesionectomy, 42 lobectomy, 18 multi-lobectomy, and eight hemispherotomy. Complete seizure control (Engel Ia) was achieved in 56% after two years, 52% at five years, and 50% at last follow-up (18-204 months). Resections were more extensive in younger patients (40% of the surgeries affecting more than one lobe in patients aged nine years or younger vs. 22% in patients older than nine years). While resections were more limited in older children, their long-term outcome tended to be superior (42% seizure freedom in patients aged nine years or younger vs. 56% in patients older than nine years). The outcome in FCD I was not significantly inferior to that in FCD II. CONCLUSIONS: Our data confirm the long-term efficacy of surgery in children with FCD and epilepsy. An earlier age at surgery within this cohort did not predict a better long-term outcome, but it involved less-tailored surgical approaches. The data suggest that in patients with an unclear extent of the dysplastic area, later resections may offer advantages in terms of the precision of surgical-resection planning.
Asunto(s)
Epilepsia/cirugía , Malformaciones del Desarrollo Cortical de Grupo I/cirugía , Procedimientos Neuroquirúrgicos/métodos , Resultado del Tratamiento , Adolescente , Anticonvulsivantes/uso terapéutico , Niño , Preescolar , Estudios de Cohortes , Electroencefalografía , Epilepsia/complicaciones , Epilepsia/diagnóstico por imagen , Femenino , Humanos , Lactante , Recién Nacido , Imagen por Resonancia Magnética , Masculino , Malformaciones del Desarrollo Cortical de Grupo I/complicaciones , Malformaciones del Desarrollo Cortical de Grupo I/diagnóstico por imagen , RecurrenciaRESUMEN
Chronic hypoperfusion may hinder the washout of emboli coming from the heart and facilitate the formation of intra-cavitary thrombi. We investigated whether a decreased total cerebral blood flow (tCBF) resulted in recurrence of stroke and other vascular events in consecutive patients with cardioembolic stroke. We excluded patients with extra-cranial carotid or vertebral stenosis. The recorded tCBF was the sum of blood flow in both the carotid and vertebral extra-cranial arteries as measured with ultrasonography. Patients were followed up to assess stroke recurrence, vascular events and mortality. We also recorded demographic data, vascular risk factors, treatment data, echocardiographic variables and the C congestive heart failure history H Hypertension history A Age D Diabetes S Sex S2 Stroke/TIA/Thromboembolism history Vasc Vascular Disease history (CHA2DS2-VASc) score. We studied 79 patients (age 77.9 ± 8.4 y). Mean tCBF was 65.5 ± 15.7 mL/100 g/min. Cox regression analysis found that CHA2 DS2-VASc score and ejection fraction were associated with tCBF. After a mean follow-up of 22 ± 8.5 mo, 7.6% of patients experienced a recurrent stroke, 12.7% experienced a vascular event and 21.5% of patients died. Clinical outcomes were not predicted by tCBF.
Asunto(s)
Circulación Cerebrovascular/fisiología , Accidente Cerebrovascular/fisiopatología , Tromboembolia/fisiopatología , Anciano , Femenino , Estudios de Seguimiento , Humanos , Masculino , Estudios Prospectivos , Recurrencia , Medición de Riesgo , Accidente Cerebrovascular/complicaciones , Tromboembolia/complicacionesRESUMEN
Atraumatic convexal subarachnoid hemorrhage (cSAH) in elderly patients is a rare entity that has been associated with cerebral amyloid angiopathy (CAA) and intracerebral hematomas (ICH). To characterize this entity and to study these associations, 22 patients over 60 with cSAH were included in a multicenter ambispective cohort study. Clinical data, magnetic resonance imaging (MRI) studies, APOE genotyping, and cerebrospinal fluid (CSF) biomarkers were evaluated. Results were compared with data from healthy controls (HC), non-cSAH CAA patients (CAAo), and Alzheimer disease patients. Convexal subarachnoid hemorrhage presented with transient sensory or motor symptoms. At follow-up (median 30.7 months), 5 patients had died, 6 survivors showed functional disability (modified Rankins Scale (mRS)>2), and 12 cognitive impairment. Four patients had prior ICH and six had an ICH during follow-up. CSF-Aß40 and Aß42 levels were lower in cSAH and CAAo compared with HC. Convexal subarachnoid hemorrhage presented an APOE-É2 overrepresentation and CAAo had an APOE-É4 overrepresentation. On MRI, all patients fulfilled CAA-modified Boston criteria and 9 showed cortical ischemia in the surrounding cortex or the vicinity of superficial siderosis. The neuropathologic study, available in one patient, showed severe CAA and advanced Alzheimer-type pathology. Convexal subarachnoid hemorrhage in the elderly is associated with cognitive impairment and lobar ICH occurrence. Our findings support the existence of an underlying CAA pathology.