Difficulties in the implementation of the ketogenic diet in adult patients with refractory epilepsy.

BACKGROUND: Ketogenic diet therapies (KDT) are appropriate therapeutic options for pediatric and adult patients with intractable epilepsy. The application of KDT among adult patients with refractory epilepsy is limited compared to children for several reasons, including poor compliance. We present the significant reasons for the lack of adherence to KDT in our adult patients with intractable epilepsy. METHODS: This study was conducted retrospectively in adult patients with drug-resistant epilepsy who wereofferedand accepted toimplementKDT between 2014 and 2021. Demographic and clinical data were collected via electronic health records. The eventual outcome of KDT results was obtained from the consultant dietitian. The prevalence and reasons for the failure to implement KDT were investigated. We also obtained detailed information about patients who successfully applied the KDT. RESULTS: A total of 33 patients (18F; median age 28) who wereoffered and accepted to implement KDT were included. Baseline seizure frequency was >4 per week in 49%, and more than half of the patients used >3 anti-seizure medications (ASM). Epilepsy types were temporal in 10 (30%), extratemporal in 10 (30%), generalized in 6 (18%), and unclassified in 7 (22%) patients.Only 3 patients (9%) were able to maintain KDT in the long term. One of them (33%) benefited from this therapy.In the remaining 30 patients, the reasons for failure were inability to contact the dietitian in 5, failure to apply KDT for a particular reason in 7, inappropriate blood test results or any medical/surgical comorbidities in 6, improvement in seizure burden due to change in ASM in 5, still insufficient knowledge of KDT in 3, unresponsiveness to diet due to incorrect implementation in 1 and unidentified reasons in 3 patients. CONCLUSIONS: A significant percentage of adult patients with refractory seizures failed to use KDTin our study(91%).Strategies to improve compliance and minimize the side effects might increase the number of drug-refractory epilepsy patients who could benefit from this therapy.

Comparison of clinical features in patients with vestibular migraine and migraine.

Vestibular migraine (VM) is accepted as the most common cause of spontaneous episodic vertigo. In most patients, vestibular symptoms follow migraine headaches that begin earlier in life. The aim of this multicenter retrospective study was to find out the differences between migraine patients without any vestibular symptoms (MwoV) and VM patients and to delineate the specific clinical features associated with VM. MwoV and VM patients were compared regarding demographic features, migraine headache years, headache attack frequency, intensity, symptoms associated with headache and vertigo attacks, presence of menopause, history of motion sickness and family history of migraine. Four-hundred and forty patients with MwoV and 408 patients with VM were included in the study. Migraine with aura was more frequent in patients with MwoV (p = 0.035). Migraine headache years was longer (p < 0.001) and headache intensity was higher in patients with VM (p = 0.020). Aural fullness/tinnitus was more common in patients with VM (p < 0.001) when all other associated symptoms were more frequent in patients with MwoV (p < 0.001) as well as attack triggers (p < 0.05). Presence of menopause and motion sickness history was reported more frequently by VM patients (p < 0.001). Logistic regression analysis indicated that longstanding history of migraine with severe headache attacks, aural fullness/tinnitus accompanying attacks, presence of menopause, previous motion sickness history were the differentiating clinical features of patients with VM.

Subclinical seizures: The demographic data and scalp video-EEG findings, concordance with the epilepsy type and prognosis.

BACKGROUND: Subclinical seizures(SCSs) are overlooked in clinical practice. This study aims to investigate clinical, electrophysiological features of SCSs detected during video-electroencephalography(EEG) monitorization(VEM), concordance of the epilepsy type and SCSs, and predictors of the concordance. METHODS: The data of drug-resistant epilepsy patients who had undergone video-EEG between 2010 and 2020 were investigated. Ictal activities showing temporospatial evolution lasted ≥ 10 s, without any behavioural changes were considered SCSs. Findings were re-evaluated for ictal localization, lateralization, ictal discharge type, vigilance status, and duration of SCSs to the accompaniment of clinical findings. Additionally, the concordance of epilepsy type and SCSs were analyzed. RESULTS: Fifty-five SCSs were obtained in 24 of 804 patients (2,9 %) who were followed in the VEM unit; the epilepsy type of the patients was temporal in 26 and extratemporal lobe epilepsy in 29 SCSs. Among 55 SCSs recordings, 30 originated from the temporal lobe and 24 from the extratemporal lobe, and seizure localization could not be determined in one. The patients were younger, age at seizure onset was earlier, habitual seizures were more frequent, multiple anti-seizure drug use was higher, seizures more frequently occurred during sleep, cranial MR tended to be abnormal, patients were more likely to have a history of perinatal injury/head trauma, and the concordance of discharge patterns was lower in extratemporal SCSs.The concordance of epilepsy type with localization and lateralization of SCSs was not statistically significant. CONCLUSIONS: SCSs originating from the temporal and extratemporal lobes might show similar characteristics with the epilepsy type, and SCSs might have clinical importance apart from epilepsy surgery.

Sleep disorders and polysomnography findings in patients with autoimmune encephalitis.

BACKGROUND: Sleep disorders in patients with autoimmune encephalitis (AE) are increasingly reported. Early recognition and treatment have significant importance regarding the potential of sleep disorders' effect on morbidity and even mortality. There are a limited number of studies related to polysomnography (PSG) in these patients. Here, we report the clinical and PSG data of patients with AE and sleep disorders, with a particular interest in sleep-related breathing disorders (SRBD). METHODS: Seventeen patients with diagnosed AE and acute or subacute onset sleep complaints who underwent video-electroencephalography-PSG recordings in our tertiary center were investigated. RESULTS: The mean age was 50, with eight females and nine males. The detected antibodies were against leucine-rich glioma-inactivated 1(LGI-1) in 6, anti-contactin-associated protein-2(CASPR2) in 3, voltage-gated potassium channel complex antigens(VGKC) in 1, anti-glycine in 1, dipeptidyl-peptidase-like protein-6(DPPX) in 1, anti-Hu in 1, and anti-amphiphysin in 1. All commercially available and known autoimmune encephalitis-related antibodies were negative in 3 of the patients. Final diagnosis after PSG was circadian rhythm sleep disorder (n = 3), periodic limb movement disorder (n = 3), insomnia (n = 5), central apnea with or without Cheyne-Stokes breathing (CSB) (n = 4), obstructive sleep apnea (OSA) (n = 4), non-rapid eye movement (NREM) and REM parasomnia (n = 8), faciobrachial dystonic seizures (n = 2), and subclinical seizures (n = 1). Sleep microstructure was disrupted in 9, REM periods without atonia occurred in 4, and brief sleep fragments consisting of theta activity interspersed with faster rhythms existed in 7 patients. Nearly half of our patients (47%) had SRBD, and the mean apnea-hypopnea index (AHI) was 14. CONCLUSIONS: Sleep disorders are frequent and essential components of AEs. Systematic clinical questionnaires and routine PSG assessments would significantly impact the correct diagnosis and proper treatment of SRBD and the overall prognosis of AE.

Changes of oxygen saturation in patients with pure temporal lobe epilepsy.

PURPOSE: Ictal hypoxemia is accepted as one of the mechanisms underlying sudden unexpected death in epilepsy (SUDEP). Although ictal hypoxemia is more common in generalized seizures, it also occurs in focal seizures with or without generalization. In this study, we aimed to show the relationship between clinical and electroencephalographic findings of seizures in patients with temporal lobe epilepsy (TLE) with periictal oxygen saturation. METHODS: The data of 55 adult patients who were hospitalized in the Video EEG Monitoring Unit (VEMU) and operated on for drug-resistant TLE between January 2017 and December 2020 were examined. Forty-five seizures from 21 patients with ictal peripheral arterial saturation information and that were seizure-free for at least a year during the follow-up were included in the study. RESULTS: The median patient age was 28 (IQR 25-39.5) years (women: 9, men: 12). Age at epilepsy onset was negatively correlated with saturation at seizure onset. Moreover, the age at VEMU admission was also negatively correlated with saturation at seizure onset and the lowest levels of saturation. The saturation at the end of the seizures and the lowest saturation measured in the periictal period with generalization of EEG were significantly lower than those without generalization. The onset of ictal EEG with the rhythmic theta pattern was significantly associated with the lowest level of saturation (<90%), postictal generalized electroencephalographic suppression (PGES), and the presence of generalization. CONCLUSION: According to the study, rhythmic ictal theta activity, older age, nocturnal seizure, and generalization in ictal EEG might increase the potential risk of SUDEP. Further studies including a greater number of subjects and different epilepsy syndromes may provide more comprehensive information about potential biomarkers for SUDEP.

Vestibular migraine, demographic and clinical features of 415 patients: A multicenter study.

OBJECTIVE: To evaluate demographic and clinical features of vestibular migraine (VM) patients METHODS: Four hundred fifteen patients with VM were evaluated by using a structured questionnaire in addition to clinical examination. RESULTS: The mean age of headache and vertigo onset was 25 years and 39 years, respectively. In 12.3%, benign paroxysmal positional vertigo (BPPV) was detected during the interictal period. Ten percent had hearing loss on audiometry, in 8.7% it was one-sided low-frequency sensory-neural hearing loss below 2000 Hz and the history was typical for Meniere's disease (MD) in addition to VM. Tinnitus was present in 94.4%, aural fullness in 83.4%, nausea in 72.2% and vomiting in 30.5% of patients with VM/MD. The prevalence of these symptoms was higher in patients with VM/MD than in pure VM. Median attack severity determined by visual analog scale measured in centimeters from 0 to 10 was 8 for headache and 7 for vertigo for the whole group. Severe headache was significantly correlated with age of ≤ 43 years (OR: 6.831, 95% CI: [4.10-11.63]; p < 0.001) and severe vertigo was significantly correlated with age ≥ 41 years (OR: 7.073, 95% CI: [4.55-10.98]; p < 0.001). Motion sickness was revealed from past medical history in 51.8%. Family history of migraine was present in 72.5% and the age of onset of both migraine headaches (p = 0.008) and vertigo attacks (p = 0.004) was lower in these patients. CONCLUSION: Younger patients suffered more severe headache attacks whereas vertigo attack severity was higher in the elderly. BPPV and MD were commonly associated with VM and VM/MD was accompanied by aural and autonomic features more frequently than pure VM. Previous history of motion sickness was detected in more than half of the whole group. Family history of migraine was associated with younger onset of migraine headaches and vertigo attacks.

Factors determining the response to treatment in patients with vestibular migraine.

PURPOSE: To find out clinical features associated with poor response to treatment in vestibular migraine (VM). METHODS: VM patients treated with drugs recommended in migraine prophylaxis were included in this multicenter study. Migraine features including type, age of onset of headache and vertigo attacks, attack frequency, intensity, associated symptoms, triggering factors, presence of interictal dizziness/imbalance, anxiety, depression, history of motion sickness, and family history of migraine were noted. Amitriptyline, flunarizine, propranolol, topiramate and venlafaxine were chosen depending on patients' individual requirements. Maximum dose of each drug was tried for 2 months to decide its efficacy. In the case of inefficacy, it was changed with another preventive drug of different class. If there was still no improvement, two drugs of different classes were combined. ≥ 50% reduction in attack frequency and severity in patients using one drug and a combination of two drugs was compared, with patients showing <50% reduction despite combination therapy, regarding their clinical features. RESULTS: The results of 430 VM patients, 65 men and 365 women with a mean age of 42.2 ± 12.2 years (range: 17-74 years), were analyzed. CONCLUSION: Cutaneous allodynia frequently associated with female sex, comorbid anxiety and depression and interictal dizziness/imbalance enhanced with comorbid anxiety were risk factors for reduced treatment response. Aural fullness might be the clue of impending concomitant Meniere's disease not responding to migraine preventives.

Determinants of preventable stroke-Ankara ACROSS stroke preventability study.

BACKGROUND: Unhealthy lifestyle and inadequate control of vascular risk factors are the major contributors of stroke burden. Failure in achieving the target levels in control of these factors, not only designate missed opportunities contributing to the preventability of an incident stroke, but also set the post-stroke treatment goals in a case wise basis. In this study, we analyzed pre-event clinical features that play a role in stroke preventability, and determined the cumulative burden of risk factors that necessitate optimization following the ischemic insult. METHODS: Information about the pre-stroke optimal control of seven major modifiable risk factors (Life's Simple 7: hypertension, diabetes mellitus, hyperlipidemia, smoking, obesity, diet, and physical activity) was prospectively collected in ischemic stroke patients admitted to three tertiary academic centers in Ankara. Stroke preventability was evaluated by the overall number of factors requiring optimization with patients ≥4 risk factor conditions categorized as those suffering from a preventable stroke. Bivariate and multivariate analyzes were performed to uncover predictors of stroke preventability. RESULTS: Among 787 patients, 386 (49.0%) had ≥4 risk factor conditions requiring optimization. Preventable stroke was more common in younger patients, and patients with small artery occlusion. Multivariate analyses taking into account the pre-stroke antithrombotic treatment regimen, have highlighted age (OR: 0.99, 95%CI 0.98-1.00), female gender (1.59, 95%CI 1.17-2.16), coronary artery disease (1.54, 95%CI 1.10-2.14), small artery occlusion (1.90, 95%CI 1.13-3.18), and cardio-aortic embolism (0.53, 95%CI 0.35-0.82) as significant factors associated with preventability. CONCLUSIONS: Approximately half of the ischemic stroke patients have preventable stroke from the perspective of risk factor control. Extra care should be given to strategies directed to risk factor control and lifestyle interventions in certain high-risk groups for the prevention of future complications.

Postherpetic Anti-N-methyl-D-aspartate Receptor Encephalitis after Hemispherotomy in a Patient with Intractable Startle Epilepsy.

Herpes simplex encephalitis (HSE) has been increasingly reported after neurosurgical procedures, mostly after tumor resections in patients with a prior history of HSE. Early detection and appropriate treatment are essential to prevent high mortality of the disease; however, there are diagnostic difficulties due to nonspecific prodromal symptoms. In addition, anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis has been reported after HSE as an immunological relapse. Here, we report a case of postherpetic anti-NMDAR encephalitis following right hemispherotomy for intractable startle-induced seizures, to emphasize the importance of early diagnosis and appropriate treatment. To our knowledge, this is the first reported case of anti-NMDAR encephalitis after postoperative HSE, and the third reported case of hemispherotomy as a curative treatment for startle epilepsy.