The safety and efficacy of modifying the admission protocol to the epilepsy monitoring unit in response to the COVID-19 pandemic.

PURPOSE: The coronavirus disease 2019 (COVID-19) pandemic has impacted admission to epilepsy monitoring units (EMUs) for classification and presurgical evaluation of patients with refractory epilepsy. We modified the EMU admission protocol via anti-seizure medications (ASM) withdrawal implemented one day before admission; thus, we aimed to evaluate the efficacy and safety of this modified protocol. METHODS: In January 2021, we initiated ASM tapering 24 h before-rather than on the first day after-EMU admission, contrasting with the previous protocol. We retrospectively reviewed EMU admissions between January and April of 2018, 2019, and 2021, and identified the time required to record the first seizure, and EMU yield to confirm or change the epilepsy classification. We also evaluated the safety of the modified protocol, by monitoring the seizure frequency for up to 5 months after the discharge from the hospital. RESULTS: One hundred four patients were included (mean age: 30 years, men: 43%); excluding a longer disease duration and abundance of normal routine electro-encephalogram (EEG) in patients admitted before the pandemic, no differences were observed in patients' characteristics. On average, it took 41 h and 21 h to record the first seizure using the standard and modified protocols, respectively (p < 0.001, 95% CI: 10-30). Other characteristics were investigated both before and after the COVID-19 pandemic, and epilepsy classifications were confirmed twice using the modified protocol (OR = 2.4, p = 0.04, 95% CI: 1.1-5.5). Multivariate regression analysis confirmed the shorter time to record the first seizure using the modified admission protocol (23 h less, p < 0.001; 95% CI: 12-34). Finally, 36 (86%) patients admitted during the pandemic exhibited no increase in seizure frequency after the discharge from the hospital. CONCLUSIONS: Initiating ASM withdrawal one day before EMU admission was deemed to be an efficient and safe way to confirm epilepsy classification and significantly decrease the length of hospital stay. Ultimately, this will shorten the long waiting list for EMU admission created by the COVID-19 pandemic.

The role of brain magnetic resonance imaging on the timing of antiepileptic drugs withdrawal following mesial temporal lobe epilepsy surgery.

OBJECTIVES: To assess the influence of magnetic resonance imaging (MRI) brain findings on the timing of antiepileptic drugs (AEDs) withdrawal following anterior temporal lobectomy (ATL) in patients with mesial temporal lobe epilepsy (MTLE). METHODS: We conducted a retrospective chart review at King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia from Jan, 2004 - Dec, 2017 of patients with MTLE who underwent ATL and included patients who had a minimum of 2 years of follow-up. We evaluated the association between the time required to start tapering and discontinuing AEDs after ATL in patients with Engel class I outcomes and their preoperative brain MRI. RESULTS: We studied 64 patients who underwent ATL. The majority of patients (63%) had hippocampal sclerosis (HS) on histopathology. Following ATL, the mean time to start tapering AEDs was 10 months and AEDs were discontinued at a mean of 48 months. Abnormal brain MRI was observed in 53 (83%) patients, with findings suggestive of mesial temporal sclerosis (MTS) accounting for 75% of these abnormalities. The presence of any MRI abnormality was associated with a 10-month earlier tapering of AEDs (p<0.01), and an 18-month earlier complete withdrawal of AEDs (p<0.01). The odds of being seizure-free within the first year were higher if MTS was present in the brain MRI (adjusted OR=16). Similarly, this was associated with seizure freedom after the first year (adjusted OR=14.8, p<0.01). The presence of unilateral temporal IEDs on preoperative EEG were also associated with earlier tapering and discontinuation of AEDs as well as a seizure-free state after ATL surgery (OR=8.5 and 4.2, for the first and second year respectively, p<0.01). CONCLUSION: Patients with abnormal MRI findings and unilateral IEDs had earlier tapering of AEDs with an overall shorter AED discontinuation plan. Moreover, the presence of MTS on MRI, along with unilateral IEDs, were predictors of seizure freedom following ATL.

Effects of fasting during Ramadan on seizure control and quality of life in patients with epilepsy.

BACKGROUND: During Ramadan, the ninth month of the lunar Islamic calendar, adult Muslims are obliged to fast, which involves refraining from taking any food, beverages, or oral medications from dawn to sunset. Fasting's effect on seizure control is not fully understood, and a few observational studies have provided inconclusive results. This study aimed to investigate the effect of fasting during Ramadan on seizure control and quality of life in adult patients with epilepsy. METHODS: This was a prospective observational study over a 3-month period (one month before fasting, the fasting month, and one month after fasting). We recruited adult patients with active epilepsy who were able to fast during the month of Ramadan. The primary outcome measures were as follows: 1) seizure control and 2) quality of life score using the Arabic version of the Ferrans and Powers Quality of Life Index (QLI). Changes in anticonvulsant medications were not allowed during the study period. We used a seizure log provided to participants to record the number of seizures during the 3-month period. Quality of life was scored at the end of each month of the study period. RESULTS: Thirty-seven patients were studied (59% males). The mean age was 30 years (range, 14-51 years), and mean age at epilepsy onset was 13 years (range, 0.5-35 years). On average, patients were on three antiepileptic medications at baseline (range: 2-5). A total of 1576 seizures were reported during the 3-month follow-up, where seizures prior to fasting represented 35.5% of all seizures. Multilinear regression analysis revealed a significant decline of seizures by 21% during the fasting month compared with baseline (adjusted coefficient = 0.79, p < 0.01, 95% confidence interval (CI); 0.61-0.98, R2 = 0.81) and by 29% during post fasting compared with baseline (adjusted coefficient = 0.71, p < 0.01, 95% CI; 0.53-0.90, R2 = 0.79). No significant change was found in the QLI scores calculated during the three months of the study period. CONCLUSION: Fasting during Ramadan might have a positive impact on seizure control in patients with epilepsy, which continued during the month following fasting, whereas the quality of life scores were not affected by fasting.

Consanguinity in patients with mesial temporal lobe epilepsy due to hippocampal sclerosis in a Saudi population.

OBJECTIVE: To investigate if there is an association between consanguinity and hippocampal sclerosis (HS) in the Saudi population. METHODS: A retrospective case-control study was conducted by assessing the prevalence of consanguinity in patients with pathologically proven HS, who underwent epilepsy surgery at King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia, between January 2004 and December 2015. We reviewed the medical records to extract data, which included; age, gender, duration of epilepsy, history of febrile seizure, family history of epilepsy in a first or second-degree relative, and pathology reports. RESULTS: A total of 120 patients, out of which 40 patients (65% male) having mesial temporal lobe epilepsy due to HS, and 80 controls (56% male) with cryptogenic epilepsy, were identified. Twenty-two patients (53.5%) in the HS group had a history of consanguinity. In the control group, 30 patients (37.5%) had a history of consanguinity. The odds ratio was 2.04 (95% confidence interval = 0.94 - 4.4, p=0.052). A family history of epilepsy was found in 28% of the patients with HS and 32.5% cryptogenic epilepsy. Only 8 patients (19.5%) with HS reported a history of febrile seizure. CONCLUSION: Our retrospective case-control study suggests that consanguinity might increase the likelihood of developing HS.

Semiology of hypermotor (hyperkinetic) seizures.

BACKGROUND: Hypermotor seizures (HMSs) consist of complex movements involving proximal segments of the limbs and trunk that appear violent and inappropriate for the situation. METHODS: We analyzed hypermotor seizure videos in seizure-free patients (Engel class I) following resective epilepsy surgery. After completion of video analysis, we reviewed EEG and neuroimaging data. RESULTS: Search of our epilepsy surgery database yielded 116 patients classified as having hypermotor seizures between 1996 and 2013. From this subset, 17/31 (55%) patients had been seizure-free for >6months (mean follow-up: 3.3years). Mean seizure duration was 35s (range: 6-91s), of which the HM phase lasted a mean of 22s (range: 3-53s). In 16 patients (95%), hypermotor activity was seen at or within 10s of clinical seizure onset. Type I semiology occurred in 6 patients, type II semiology in 10 patients, and 1 patient exhibited features of both. Type I and type II semiologies were noted in patients who had frontal lobe as well as extrafrontal resections. Nonversive head and body turning occurred in 10 patients (ranging from 90° to 270°) which was ipsilateral to the side of resection in all patients and seen both in frontal and extrafrontal resections. Six out of eleven patients with abnormal MRI and 4/6 patients with nonlesional MRI underwent invasive EEG evaluation. Eight patients (47%) had frontal lobe resection, 4/17 (23%) patients had temporal lobe resection, and one patient each had parietal lobe, insular, temporoparietooccipital, or motor sparing resection; 1 patient had functional hemispherectomy. CONCLUSION: Hypermotor semiology typically occurs at or within 10s after seizure onset. Ipsilateral head/body turning appears to be of lateralizing value whereas asymmetry of limb movement was not lateralizing. Hypermotor semiology is most often seen in frontal lobe epilepsy but may occur in seizures arising from other locations.

Time to FIRE NORSE: A single acronym for a heterogeneous presentation. Further information from a case series and discussion of the literature.

PURPOSE: New-Onset Refractory Status Epilepticus (NORSE) is a rare and severe form of refractory status epilepticus without an apparent underlying cause at presentation or prior history of epilepsy. We aimed to describe the clinical features, etiology, treatment, and outcomes of NORSE in adults in a quaternary-level hospital in Saudi Arabia. METHODOLOGY: In this retrospective cohort study, inclusion criteria involved patients over 14 years old who met the 2018 consensus definition for NORSE. Patients were identified using a combination of medical record admission labels 'status epilepticus' and 'encephalitis', and continuous EEG reports documenting status epilepticus. Demographic, clinical, and radiological data were collected and then analyzed for factors correlated with specific etiologies, better functional outcomes, and future diagnosis of epilepsy. RESULTS: We found 24 patients presenting with NORSE between 2010 and 2021. Fever/infectious symptoms were the most common prodrome. Elevated inflammatory serum and cerebrospinal fluid markers in most patients. Brain MRI revealed T2/FLAIR hyperintensity patterns, predominantly affecting limbic and perisylvian structures. The etiology of NORSE varied, with immune-related causes being the most common. Long-term outcomes were poor, with a high mortality rate and most survivors developing drug-resistant epilepsy. CONCLUSION: This study provides valuable insights into NORSE's clinical characteristics, highlighting the heterogeneity of this condition. The poor outcome is likely related to the progressive nature of the underlying disease, where refractory seizures are a clinical symptom. Thus, we propose to focus future research on the etiology rather than the NORSE acronym.

Association between serum vitamin D levels and age in patients with epilepsy: a retrospective study from an epilepsy center in Saudi Arabia.

BACKGROUND: Vitamin D deficiency has been linked to various medical conditions such as bone loss, decreased mineralization, endocrine disorders, and central nervous system disorders, including epilepsy. Vitamin D deficiency is prevalent among patients with epilepsy (PWE). However, the specific association between vitamin D levels and age in PWE is unclear. OBJECTIVES: Identify the relation between vitamin D level and age in PWE and evaluate factors that may play a role in seizure control. DESIGN: Retrospective analytical medical record review SETTING: Outpatient epilepsy research clinic in Saudi Arabia PATIENTS AND METHODS: Between November 2016 and April 2020, we selected eligible PWE aged older than 14 years whose vita-min D levels were recorded at least once after reviewing 1550 patient electronic files. We analyzed data on serum vitamin D level by age and other factors, vitamin D supplement use, seizure classification, and conducted a multivariate logistic regression to assess associations with seizure control. MAIN OUTCOME MEASURES: Relationships between vitamin D levels and age and factors that might affect seizure control. SAMPLE SIZE: 524 patients RESULTS: The prevalence of low serum vitamin D levels was high (86.8%). The median vitamin D level in all patients was low (38 nmol/L), and was lower in young PWE than in adult PWE (P<.01). Only 146 patients received vitamin D supplements. High vitamin D levels were associated with a 40% seizure reduction. CONCLUSION: Vitamin D deficiency is underestimated in PWE in Saudi Arabia, and is more prevalent among young adults and patients on polytherapy than in other PWE. Patients with high vitamin D levels had good seizure control compared with those with low levels. The effect of vitamin D supplements on seizure control should be further investigated in randomized control trials. LIMITATIONS: Retrospective study and no categorization by presence of supplementation. CONFLICT OF INTEREST: None.

Saudi Arabian Consensus Statement on Vagus Nerve Stimulation for Refractory Epilepsy.

Vagus nerve stimulation (VNS) is an approved adjunctive therapy for refractory epilepsy and used in patients who are not candidates for resective epilepsy surgery. In Saudi Arabia, VNS device implantation is being performed since 2008 by several comprehensive epilepsy programs, but with variable protocols. Therefore, to standardize the use of VNS, a task force was established to create a national consensus. This group consisted of epileptologists, epilepsy surgeons and a VNS nurse coordinator working in comprehensive epilepsy centers and dealing with refractory epilepsy cases. The group intensively reviewed the literature using Medline, EMBASE, Web of Science and Cochrane Library, in addition to physician's manual. Evidence is reported as three stages: preimplantation and patient selection, a perioperative phase involving all stakeholders and post-operative care with specific programming pathways.

Seizure outcome after epilepsy surgery for patients with normal MRI: A Single center experience.

OBJECTIVE: To analyze the surgical outcome in non-lesional intractable focal epilepsies in our center and to find possible predictors for better outcome. METHODS: This is a retrospective study for 40 adult patients with intractable focal epilepsy following at KFSHRC-Riyadh, who underwent presurgical evaluation followed by resective surgery and continued follow up for a minimum of 2 years. The surgery outcome was evaluated based on the type of surgical procedure and histopathology results. RESULTS: Out of all 40 patients studied, seizure freedom was achieved in 19 (47.5 %) and 17 (42.5 %) patients at the first and second year respectively in all non-lesional cases. Seizure freedom in non-lesional temporal lobe surgery was achieved in 10 (45 %) of patients at 2 years, 5 (38 %) in non-lesional frontal lobe patients at 2 years and 8 (44 %), 7 (38 %) for all extratemporal at 1 and 2 years respectively. Good prognosis was seen in patients with localized positron emission tomography (PET), had no aura and had a clear ictal onset either on scalp electroencephalogram (EEG) or subdural invasive electroencephalogram. SIGNIFICANCE: The best surgical outcome is achievable in patients with non-lesional focal epilepsy. This study highlights the prognostic value of the PET scan and ictal scalp/subdural invasive EEG.

The Optimal Dose of Amobarbital in the Wada Test for the Presurgical Evaluation of Patients With Temporal Lobe Epilepsy.

OBJECTIVE: The use of amobarbital in the Wada test varied between epilepsy centers, with no unified dosing or protocols available in the literature to standardize its use. We aimed to determine the dose of amobarbital in the presurgical evaluations of patients with temporal lobe epilepsy. METHODS: A retrospective study of patients with temporal lobe epilepsy seen between January 2004 and December 2018 in King Faisal Specialist Hospital and Research Centre in Jeddah, Saudi Arabia, was conducted, and those who successfully underwent a Wada test were studied. A neuropsychologist or a neurologist will assess the memory and language, using standardized testing. RESULTS: A total of 90 patients were studied. The mean age was 30 years (range, 16-52 years), where 49 (57%) of them were men. All patients had a routine neurological examination, including language and memory. The average dose of amobarbital given was 10.1.1 mg (range, 65.7-150 mg). There was no statistical difference between the dosing given to patients who passed or failed the memory testing (101.4 mg vs 94.7 mg, P = 0.1). Multivariate regression analysis showed that amobarbital dose needed an adjustment to patient's weight only for those older than 30 years, (P < 0.05; 95% confidence interval, 0.1-0.5), where an increase in the dose by 0.3 mg·kg·y was required to execute Wada test successfully. CONCLUSION: It was only the patient's age that could influence the modification of Amobarbital dose in the Wada test, yet establishing a universal protocol is challenging because of the lack of well-defined dose determinants.

Non-convulsive seizures and electroencephalography findings as predictors of clinical outcomes at a tertiary intensive care unit in Saudi Arabia.

OBJECTIVE: Electroencephalography (EEG) in the intensive care unit (ICU) is often done to detect non-convulsive seizures (NCS). The outcome of ICU patients with NCS strongly depends on the underlying etiology. The implication of NCS and other EEG findings on clinical outcome independent from their etiology is not well understood and our aim to investigate it. PATIENTS AND METHODS: We retrospectively identified all adult patients in the ICU who underwent EEG monitoring between January 2008 and December 2011. The main goals were to define the rate of NCS or non-convulsive status epilepticus (NCSE) occurrence in our center among patients who underwent EEG monitoring and to examine if NCS/NCSE are associated with poor outcome [defined as death or dependence] with and without adjustment for underlying etiology. The rate of poor outcome among different EEG categories were also investigated. RESULTS: During the study period, 177 patients underwent EEG monitoring in our ICU. The overall outcome was poor in 62.7% of those undergoing EEG. The rate of occurrence of NCS/NCSE was 8.5% and was associated with poor outcome in 86.7% with an odds ratio (OR) of 5.1 (95% confidence interval [CI] 1.09-23.8). This association was maintained after adjusting for underlying etiologies with OR 5.6 (95% CI 1.05-29.6). The rate of poor outcome was high in the presence of periodic discharges and sharp and slow waves of 75% and 61.5%, respectively. CONCLUSIONS: Our cohort of ICU patients undergoing EEGs had a poor outcome. Those who developed NCS/NCSE experienced an even worse outcome regardless of the underlying etiology.