Fostering Education in Epilepsy: A Canadian League Against Epilepsy Teaching Initiative.

The Canadian League Against Epilepsy initiated a virtual epilepsy education program, conducting 29 webinars from March 2021 to September 2023. We report our experience, with the goal to inspire other groups to develop inclusive, equitable, and free educational spaces with a worldwide reach. Monthly sessions drew a median attendance of 118 participants, predominantly Canadian but also international, including physicians (58.9%) and trainees (22.8%). Post-webinar surveys (average 40% response rate) noted high satisfaction, a strong inclination to recommend the sessions, and an interest in clinical case-based topics. We plan to consider integrating a self-assessment section evaluating knowledge gained after each seminar.

Fertility treatment for people with epilepsy.

Fertility treatment, including assisted reproductive technology (ART), is increasingly used. Sex hormones influence seizure control as well as interacting with antiseizure medications, and so the hormonal manipulation involved in fertility treatments has direct implications for people with epilepsy. Here, we summarise the various fertility treatments and consider their important influences on epilepsy care. While early observations raised concerns about seizure exacerbation associated with ART, there are limited data to guide best practice in people with epilepsy, and further research is needed.

Feasibility and utilization of a national virtual EEG course for Canadian residents and fellows.

OBJECTIVE: Electroencephalography (EEG) is an essential tool for the diagnosis and management of epilepsy. There is a gap in EEG education for residents in Canadian neurology programs as EEG is only listed in the training requirements as a procedural skill. There is currently no standardized EEG curriculum among Canadian epilepsy fellowship programs. METHODS: We conducted two iterations of a structured virtual EEG course from June to October 2021, and from March to June 2022. Trainees were recruited via Canadian neurology residency and epilepsy fellowship programs and were required to join the Canadian League Against Epilepsy (CLAE) as junior members. We obtained trainee demographic information before and after each course as well as analytical data on the video recordings posted on the CLAE website. RESULTS: A total of 77 trainees registered for the two courses; majority of trainees were adult neurology residents (34%) and adult epilepsy fellows (32%). Prior theoretical EEG teaching was reported as limited by more than half (53%) of participants. The average number of unique viewers per recorded video in 2021 was 29.7 interquartile range (16-35.5), while in 2022, the average was 22.5, interquartile range (16-28). Post-course questionnaire data revealed that 82% of participants strongly agreed that the course enhanced their knowledge. All participants were either likely (27%) or very likely (73%) to recommend the course to their peers. SIGNIFICANCE: National virtual EEG education is both feasible and accessible; therefore, this is a promising modality of teaching to meet the significant demand for high-quality EEG education among neurology trainees.

Emerging Subspecialties in Neurology: Women's Neurology.

The influence of sex and gender on neurologic disease has become increasingly recognized in science and medicine. This is evident across a woman's lifespan especially during periods of hormonal transitions. Leaders in neurology have advocated for the importance of sex and gender-enriched clinical care, education, and research. The scope of women's neurology spans across a woman's life including puberty, adolescence, peripartum care, menopause, and aging. Women's neurology is a new subspecialty that aligns with a specific patient population and intersects with established neurology subspecialties and other specialties such as obstetrics, maternal fetal medicine, endocrinology, and psychiatry. Its establishment and collaboration with existing and emerging fields enables a more comprehensive approach to neurologic illness through the lens of sex and gender. Women's neurology is rapidly evolving through increased focus at academic centers, including expanded women's neurology curricula, dedicated women's neurology fellowship programs, improved understanding of sex and gender issues in neurosciences, and expansion of therapeutic options. Herein, we describe the history of the women's neurology field, emerging need for women's neurology specialists, information about training and career opportunities, and future directions.

Real-world practices in reproductive health and counselling for women with epilepsy: A Canadian perspective.

Canadian women of reproductive potential living with epilepsy present unique care challenges due to the complex interplay of hormones, seizures, and medications. This study explores reproductive health practices and counselling for women with epilepsy. Through a questionnaire developed by the Canadian League Against Epilepsy women with epilepsy (WWE) workgroup, we are the first to report demographic and real-world practice characteristics of Canadian healthcare professionals providing care for WWE with specific focus on family planning, birth plans, and postpartum care counselling. Among respondents, 76.9% routinely reviewed contraception with patients and an intrauterine device (IUD) was the most popular recommended method (85.3%). With regards to preconception planning, 50% of respondents routinely had a preconception drug level prior to pregnancy. A significant proportion, 44.9%, reported not communicating a neurology-informed birth plan to obstetrical health practitioners. The majority recommended breastfeeding for WWE on anti-seizure medications (92.3%) and regularly provided safety counselling for women in the postpartum period (84.6%). Overall, our study demonstrates that Canadian practice patterns conform reasonably well to existing evidence and guidelines, although important gaps in care exist.

When Pregnancy Becomes an Inclusion Criterion in Neuroscience Research.

This Viewpoint discusses the inclusion of pregnant patients in clinical trials for antiseizure medication.

Touch-screen automatisms in the digital age.

OBJECTIVE: To describe a novel set of gestural automatisms related to the use of digital screens on smartphones and tablets in patients with epilepsy. METHODS: Representative patients were selected from among those admitted to the Epilepsy Monitoring Unit at the Toronto Western Hospital between April 2016 and January 2020, and included if they exhibited automatisms clearly related to or mimicking digital device use. RESULTS: In total 5 patients were included, 4 female. All had temporal lobe epilepsy: 2 had left mesial temporal sclerosis and 3 had normal imaging. Nearly equal numbers of seizures began with right (5/9) and left (4/9) temporal onsets, with most automatisms occurring after seizure propagation to bilateral temporal involvement (6/9). Left-handed automatisms were most common (8/9). The majority of the automatisms (7/9) were perseverative on device usage prior to the seizure. CONCLUSION: Gestural automatisms appear related to the contemporary lived experience, culture, and habitual behaviour of patients with epilepsy. In the modern era, the use of smartphones and tablets are both common and habitual for many, and this case series shows that touch-screen automatisms may be added to the semiological panoply of temporal lobe seizures.

Real-world practices for the care of women with epilepsy during pregnancy: A Canadian perspective.

OBJECTIVE: Approximately 150,000 Canadian women live with epilepsy, a population that presents with unique challenges. Our objective was to capture demographic and real-world practice characteristics of Canadian healthcare professionals providing care for women with epilepsy (WWE) with specific focus on reproductive considerations to identify potential gaps in knowledge and care. METHODS: A questionnaire developed by the Canadian League Against Epilepsy WWE workgroup was distributed to Canadian healthcare professionals from February 2021 to October 2022 to capture participant demographic characteristics and practice patterns in key areas of the reproductive cycle in WWE. RESULTS: A total of 156 participants completed the questionnaire, most being physicians (81.4%), epilepsy specialists (69.0%), and those who cared for adult patients (86.5%), with a significant proportion based at an academic center (65.4%). The majority of participants counselled on folic acid supplementation (89.7%). Participants selected lamotrigine and levetiracetam most frequently for either focal or generalized epilepsies during pregnancy. Additionally, 85.9% performed therapeutic drug monitoring during pregnancy. Almost all practitioners always or often counseled WWE on valproic acid on the benefits of switching to a less teratogenic medication (96.2%). Some geographic variability in practice patterns was noted with valproic acid being one of the top three medications selected for patients with generalized epilepsies in Western regions, although participants in Eastern regions had brivaracetam more commonly included as one of their top three agents for this population. SIGNIFICANCE: This is the first report of real-world Canadian practices in epilepsy care for women in pregnancy. Overall, our study reports that Canadian practice patterns conform well to current evidence and best-practice guidelines. Important variations in antiseizure medication selection across different regions were identified.

Ipsilateral preictal alpha rhythm attenuation (IPARA): An EEG sign of side of seizure onset in temporal lobe epilepsy.

PURPOSE: Identification of the seizure onset zone is critically important for outlining the surgical plan in the treatment of pharmacoresistant focal epilepsy. In patients with temporal lobe epilepsy (TLE), bilateral ictal scalp EEG changes frequently occur and can make lateralization of the seizure onset zone difficult. We investigated the incidence and clinical utility of unilateral preictal alpha rhythm attenuation as a lateralizing sign of seizure onset in TLE. METHODS: Scalp EEG recordings of the seizures acquired during presurgical video-EEG monitoring of 57 consecutive patients with TLE were reviewed retrospectively. Included patients had interictal baseline recordings demonstrating symmetrical posterior alpha rhythm and seizures occurring during wakefulness. RESULTS: We identified a total of 649 seizures in the 57 patients, of which 448 seizures in 53 patients fulfilled the inclusion criteria. Among the 53 included patients, 7 patients (13.2%) exhibited a distinct attenuation of the posterior alpha rhythm prior to the first ictal EEG changes, in 26 of 112 (23.2%) included seizures. Preictal alpha rhythm attenuation in these seizures was ipsilateral to the ultimately determined side of seizure onset (based on video-EEG or intracranial EEG findings) in 22 (84.6%) of these seizures and bilateral in 4 (15.4%), and occurred on average 5.9 ± 2.6 s prior to ictal EEG onsets. CONCLUSION: Our findings suggest that in some patients with TLE lateralized preictal attenuation of the posterior alpha rhythm may be a useful indicator of side of seizure onset, presumably due to early disruption of thalamo-temporo-occipital network function, likely mediated through the thalamus.

Obstetrical Outcomes of Patients with Epilepsy in a Canadian Tertiary Care Center (2014-2020).

BACKGROUND: There is a paucity of data on the obstetrical outcomes of Canadian pregnant patients with epilepsy, which may differ from the average Canadian pregnancy and from other populations of pregnant patients with epilepsy. METHODS: Pregnant patients with epilepsy were identified from a prospectively collected database of patients seen at the maternal-fetal medicine obstetrics program of Mount Sinai Hospital (Toronto, Canada) between January 1, 2014, and November 20, 2020. Pregnancy, delivery, and neonatal outcome data were retrieved from this database and described using 95% binomial confidence intervals. Comparisons of obstetrical outcomes over the same period among the Canadian population average, obtained from publicly available national health data, were done using one-proportion Z-tests for nominal variables and one-sample t-tests for continuous variables. RESULTS: In total, 282 pregnancies, from 224 patients, were included, which resulted in 274 live births. Mean maternal age was 32.8 years (s.d. = 4.6; population average [µ] = 30.9; p < 0.01), and 53% were primiparous (CI95% = 49%-61%; µ = 43%; p < 0.01). The observed rates of obstetrical complications were gestational hypertension 9% (CI95%=6%-13%; µ=7%; p=0.19), gestational diabetes 5% (CI95% = 3%-8%; µ = 9%; p = 0.02), cesarean section 44% (CI95% = 38%-50%; µ = 28%; p < 0.01), postpartum hemorrhage 5% (CI95% = 3%-8%; µ = 0.5%; p < 0.01), stillbirth 1% (CI95% = 0%-2%; µ=1%; p > 0.99), and prematurity 9% (CI95% = 6%-13%; µ = 8%; p = 0.44). CONCLUSION: In this cohort of Canadian pregnant patients with epilepsy from an urban tertiary care center, observed rates of obstetrical complications were rare and no higher than in the Canadian population over the same period, with the exception of cesarean section and postpartum hemorrhage. Future prospective studies that include primary care and rural settings are needed to increase the generalizability of those results.

Sex steroid hormones and epilepsy: Effects of hormonal replacement therapy on seizure frequency of postmenopausal women with epilepsy-A systematic review.

BACKGROUND AND PURPOSE: Hormonal replacement therapy (HRT) is used for symptomatic treatment of menopause. Some evidence suggests a proconvulsant effect of estrogen and an anticonvulsant role of progesterone. Thus, the use of exogenous sex steroid hormones might influence the course of epilepsy in peri- and postmenopausal women with epilepsy (WWE). We conducted a systematic review on the impact of HRT on the frequency of seizures of WWE. METHODS: PubMed and Scopus were searched for articles published from inception until August 2022. Abstracts from the past 5 years from the European Academy of Neurology and European Epilepsy Congresses were also reviewed. Article reference lists were screened, and relevant articles were retrieved for consultation. Interventional and observational studies on WWE and animal models of estrogen deficiency were included. Critical appraisal was performed using the revised Cochrane risk-of-bias tool for randomized trials and ROBINS-E tool. RESULTS: Of 497 articles screened, 13 studies were included, including three human studies. One cross-sectional study showed a decrease in seizure frequency in WWE using combined HRT, a case-control study showed an increase in comparison with controls, and a randomized clinical trial found a dose-dependent increase in seizure frequency in women with focal epilepsy taking combined HRT. Ten studies addressing the impact of HRT in rat models were also included, which showed conflicting results. CONCLUSIONS: There is scarce evidence of the impact of HRT in WWE. Further studies should evaluate the harmful potential, and prospective registries are needed for monitoring this population.

Sex differences in neurology: a scoping review.

OBJECTIVE: Historically, neurology research has demonstrated a sex bias with mainly male subjects included in clinical trials as well as lack of reporting of data by sex. In recent years, emphasis has been placed on increased participation of female participants and explicit declaration/evaluation of sex differences in clinical research.We aimed to review the available literature examining sex differences across four subspecialty areas in neurology (demyelination, headache, stroke, epilepsy) and whether sex and gender terms have been used appropriately. DESIGN: This scoping review was performed by searching Ovid MEDLINE, Cochrane Central Registry of Controlled Trials, EMBASE, Ovid Emcare and APA PsycINFO databases from 2014 to 2020. Four independent pairs of reviewers screened titles, abstracts and full texts. Studies whose primary objective was to assess sex or gender differences among adults with one of four neurological conditions were included. We report the scope, content and trends of previous studies that have evaluated sex differences in neurology. RESULTS: The search retrieved 22 745 articles. Five hundred and eighty-five studies met the inclusion criteria in the review. The majority of studies were observational, often examining similar concepts designed for a different country or regional population, with rare randomised controlled trials designed specifically to assess sex differences in neurology. There was heterogeneity observed in areas of sex-specific focus between the four subspecialty areas. Thirty-six per cent (n=212) of articles used the terms sex and gender interchangeably or incorrectly. CONCLUSIONS: Sex and gender are important biological and social determinants of health. However, the more explicit recognition of these factors in clinical literature has not been adequately translated to significant change in neuroscience research regarding sex differences. This study illustrates the ongoing need for more urgent informed action to recognise and act on sex differences in scientific discovery and correct the use of sex and gender terminology. TRIAL REGISTRATION: The protocol for this scoping review was registered with Open Science Framework.

The North American Antiepileptic Drug Pregnancy Registry: A Canadian Subgroup Analysis.

BACKGROUND: The North American AED Pregnancy Registry (NAAPR) provides crucial data for understanding the risks of antiepileptic drug (AED) exposure in pregnancy. This study aims to quantify the Canadian contribution to NAAPR and compare AED usage in pregnancy in Canada and the USA. METHODS: Enrollment rate ratios (ERR) to NAAPR, adjusted for the populations of women of childbearing age, were calculated for the USA, Canada, and for the different Canadian provinces. Methods of enrollment to NAAPR and AED usage were compared between the two countries using chi-squared tests. RESULTS: Between 1997 and 2019, 10,215 pregnant women enrolled into NAAPR: 4.1% were Canadian (n = 432, ERR = 0.39, CI95% = 0.35-0.43). Within Canada, no patients were enrolled from the three northern territories or from Prince Edward Island. While fewer patients than expected enrolled from Quebec (ERR = 0.35, CI95% = 0.19-0.58), Nova Scotia had the highest enrollment rate (ERR = 1.55; CI95% = 0.66-3.11). Compared with their American peers, Canadians were less likely to have been enrolled by their healthcare provider and more likely to have been enrolled via social media (p < 0.01). Canadian women were more likely to be taking carbamazepine (24% vs. 15%; p < 0.01) or valproic acid (8% vs. 4%; p < 0.01). CONCLUSION: The proportion of Canadian enrollees into NAAPR was less than expected based on the relative population size of Canadian women of reproductive age. Greater Canadian enrollment to NAAPR would contribute to ongoing worldwide efforts in assessing the risks of AEDs use in pregnant women and help quantify rates of AED usage, major congenital malformations, and access to subspecialized epilepsy care within Canada.

Sex and gender differences in epilepsy.

Sex and gender differences in epilepsy are important influencing factors in epilepsy care. In epilepsy, the hormonal differences between the sexes are important as they impact specific treatment considerations for patients at various life stages particularly during early adulthood with establishment of the menstrual cycle, pregnancy, perimenopause and menopause. Choice of antiseizure medication may have direct consequences on hormonal cycles, hormonal contraception, pregnancy and fetal risk of major congenital malformation. Conversely hormones whether intrinsic or extrinsically administered may have direct impact on antiseizure medications and seizure control. This chapter explores these important influences on the management of persons with epilepsy.

Women's Issues in Epilepsy.

PURPOSE OF REVIEW: Issues pertaining to women with epilepsy have advanced with a better understanding of multidirectional influences among hormones, seizures, and antiseizure medications, as well as pregnancy-related concerns around fertility, seizure destabilization, and antiseizure medication-associated teratogenicity. This article highlights important developments in this field and reviews best practices in the management of women with epilepsy. RECENT FINDINGS: Important external hormonal influences may impact women with epilepsy particularly in the context of gender-affirming medications, hormonal replacement therapy, and fertility therapies. Fertility for women with epilepsy is influenced by multiple variables; however, in the absence of preexisting fertility issues, epilepsy per se is not associated with significantly impaired fertility. Once women with epilepsy are pregnant, the majority have a stable course. Antiseizure medication use in pregnancy is associated with major congenital malformations 2 to 5 times that of the general population and is highest with high-dose (≥1500 mg or greater total daily) valproate. Carefully considered changes in drug choice and dose may mitigate these risks. Therapeutic drug monitoring plays an important role in pregnancy care, and under expert supervision, women with epilepsy in pregnancy have similar seizure risks as women with epilepsy who are not pregnant. As women with epilepsy age, bone health and menopause may further be impacted by seizures and antiseizure medications. SUMMARY: The care of women with epilepsy is a multifaceted discipline that recognizes the life-long impact of sex and gender influences on epilepsy care.

Sex differences in neurology: a scoping review protocol.

INTRODUCTION: Sex and gender are independently important in health and disease but have been incompletely explored in neurology. This is in part contributed to by the pre-existing male bias in scientific literature that results in fewer females being included in clinical research and the often interchangeable use of sex and gender in the literature. This scoping review intends to identify the advances as well as under-explored aspects of this field to provide a road map for future research. This paper outlines the methods for a scoping review of published, peer-reviewed literature on sex and gender differences in four subspecialty areas of neurology: demyelination, stroke, epilepsy and headache. METHODS AND ANALYSIS: A detailed search strategy will be used to search five databases pertaining only to sex differences. Specific inclusion and exclusion criteria will be applied to capture relevant literature published from 2014 to 2020. Data will be collected and synthesised to provide an overview of information retrieved, a narrative synthesis of each subspecialty area and map of results. ETHICS AND DISSEMINATION: Research ethics board approval was not required for this study. This study will aid in mapping recent trends in sex differences in four major neurological conditions and will help identify areas for further research. A manuscript will be compiled for publication and presentations of findings. REGISTRATION DETAILS: The final protocol is registered with the Open Science Framework (https://osf.io/n937x/).