The IN-MIDAZ study - Intranasal midazolam in aborting seizures - An epilepsy monitoring unit based randomized controlled trial for efficacy.

OBJECTIVE: To compare efficacy and safety of Intranasal and Intramuscular routes of midazolam administration in terminating seizures. METHOD: This was an open label Randomized controlled trial (RCT). People with drug resistant epilepsy (DRE) undergoing Video Electroencephalogram (VEEG) monitoring, were randomized in a 1:1 ratio to receive either Intranasal (IN) or Intramuscular (IM) midazolam, for prolonged seizures: longer than 5 min for focal, and longer than 2 min for focal to bilateral tonic-clonic. Outcome assessor was blinded to the allocation arm. Primary outcome was time to electrographic seizure termination after administration of midazolam. All adverse events in both the groups were noted. RESULT: A total of 1108 seizures were recorded in 130 subjects, of which 110 (65 seizures in 23 subjects in IN group; 45 seizures in 18 subjects in IM group) seizures required midazolam administration and were included in final analysis. Mean time to electrographic seizure termination after midazolam administration was 45.1 ± 23.8 s in the IM group and 90.4 ± 59.0 s in the IN group (p = 0.0014); mean time to clinical seizure termination was 53.9 ± 25.8 s in IM group and 104.3 ± 66.4 s in the IN group (p = 0.002). Local side effects were more in IN group; hypotension as serious adverse event was noted in the IM group. SIGNIFICANCE: Though mean time to electrographic and clinical seizure termination was significantly lesser in Intramuscular group for both adults and pediatric population, it was still under 2 min in the Intranasal midazolam group.IN midazolam is a useful option for terminating seizures.

Utility of a questionnaire tool (QUARAS) for localizing and lateralizing seizures in the epilepsy monitoring unit (EMU).

OBJECTIVES: An accurate description of the seizure semiology improves the recognition of the ictal onset zone and helps in hypothesizing the possible epileptogenic zone (EZ). Semiology based on a reliable description of seizures may be as good as investigative modalities, as has been shown by numerous studies. The main objective of this study was to apply a questionnaire-tool for auras and semiology (QUARAS) in refractory epilepsy cohort and compare its yield to that of standard history-taking. METHODS: A drug refractory epilepsy cohort of 139 subjects was selected, based on inclusion and exclusion criteria. All subjects underwent routine history-taking, and a structured interview with QUARAS (in Hindi language) about 3-6 months later when they were admitted for pre-surgical work-up (Video-EEG, MRI, SPECT and PET), by an epilepsy nurse. Seizures were localised and lateralised at the each step separately, in a blinded manner; concordance with the final hypothesis was checked, after the epilepsy-surgery case-conference, and statistical significance of the difference calculated. RESULTS: Auras were reported in significantly more number of patients after administration of QUARAS (p<0.001); there was also higher concordance between the final hypothesis and the localization and lateralization based on QUARAS than an unstructured history (p<0.001). CONCLUSION: Administering a structured questionnaire in the native language of patients by trained personnel leads to better localisation and lateralisation and may help arrive at a hypothesis about the EZ.

Evaluation of Ictal Consciousness in Temporal and Extra Temporal Epilepsy: Observations from a Tertiary Care Hospital in India.

BACKGROUND AND PURPOSE: Differences in consciousness during seizures depend on the location of the seizure onset. METHODS: The present study evaluates ictal consciousness using the ictal consciousness inventory (ICI) in drug refractory mesial temporal (MTLE), neocortical temporal (NTLE) and extra temporal epilepsy (ETLE). This was a cross sectional cohort study with 45 patients with mesial temporal epilepsy, 47 with extra temporal and 11 patients with neocortical temporal epilepsy. The ICI a 20 item questionnaire was used to calculate the scores for level (L, question 1-10) and content (C, question 11-20) of consciousness. RESULTS: The patients in mesial temporal group had higher ICI-L scores, p = 0.0129 as compared to the extra temporal group, but no difference was observed in the content of consciousness. The ICI-L and C scores were not different in the mesial temporal and the neocortical temporal group (p = 0.53 and 0.65) respectively. CONCLUSIONS: Patients with mesial temporal epilepsy had a higher level of consciousness than the extra temporal group but there was no difference in the content. Also there was no difference in the level and content of consciousness between mesial and the neocortical temporal group.