Nine-year prospective efficacy and safety of brain-responsive neurostimulation for focal epilepsy.

OBJECTIVE: To prospectively evaluate safety and efficacy of brain-responsive neurostimulation in adults with medically intractable focal onset seizures (FOS) over 9 years. METHODS: Adults treated with brain-responsive neurostimulation in 2-year feasibility or randomized controlled trials were enrolled in a long-term prospective open label trial (LTT) to assess safety, efficacy, and quality of life (QOL) over an additional 7 years. Safety was assessed as adverse events (AEs), efficacy as median percent change in seizure frequency and responder rate, and QOL with the Quality of Life in Epilepsy (QOLIE-89) inventory. RESULTS: Of 256 patients treated in the initial trials, 230 participated in the LTT. At 9 years, the median percent reduction in seizure frequency was 75% (p < 0.0001, Wilcoxon signed rank), responder rate was 73%, and 35% had a ≥90% reduction in seizure frequency. We found that 18.4% (47 of 256) experienced ≥1 year of seizure freedom, with 62% (29 of 47) seizure-free at the last follow-up and an average seizure-free period of 3.2 years (range 1.04-9.6 years). Overall QOL and epilepsy-targeted and cognitive domains of QOLIE-89 remained significantly improved (p < 0.05). There were no serious AEs related to stimulation, and the sudden unexplained death in epilepsy (SUDEP) rate was significantly lower than predefined comparators (p < 0.05, 1-tailed χ2). CONCLUSIONS: Adjunctive brain-responsive neurostimulation provides significant and sustained reductions in the frequency of FOS with improved QOL. Stimulation was well tolerated; implantation-related AEs were typical of other neurostimulation devices; and SUDEP rates were low. CLINICALTRIALSGOV IDENTIFIER: NCT00572195. CLASSIFICATION OF EVIDENCE: This study provides Class IV evidence that brain-responsive neurostimulation significantly reduces focal seizures with acceptable safety over 9 years.

A single case design to examine short-term intracranial EEG patterns during focused meditation.

PURPOSE: This study used a multiple crossover ABAB single case design to examine intracranial EEG data during a breath awareness meditation and an active control task. RESULTS: Visual analyses suggest that a brief breath awareness mediation was consistently associated with increased alpha power when compared to the active control. Less consistent effects were found with theta, beta, and high gamma activity. Nonparametric tests provided additional support for this finding. CONCLUSIONS: Acquiring intracranial EEG patterns during a meditative state may provide more insight into the physiology of meditation with less contamination of high-frequency muscle activity. While access to intracranial EEG during meditation is rarely available, single case design studies are considered adaptations of interrupted time-series designs and can provide an experimental evaluation of intervention effects.

Marijuana use among patients with epilepsy at a tertiary care center.

The expansion of medical and recreational marijuana legalization facilitates patient access to cannabis, and many patients with epilepsy pursue marijuana as a treatment for seizures. We administered a nine-item survey on marijuana use to patients seen in an epilepsy clinic over a 9 month period at a tertiary care center in Oregon where recreational use was legalized in 2015. The majority of respondents (n = 39) reported cannabis use for the purpose of treating epilepsy (87.2%, n = 34), and strongly agreed (53.8%, n = 21) or agreed (28.2%, n = 11) that cannabis use improved seizure control. The most commonly selected cannabis strains were high cannabidiol (CBD) (30.8%, n = 12) or multiple types (30.8%, n = 12), with administration methods of smoking (66.7%, n = 26), edibles (48.7%, n = 19), and concentrates (43.6%, n = 17). More participants reported using marijuana with primarily CBD than primarily tetrahydrocannabinol (THC) or equal CBD:THC content, and very few women reported using marijuana with primarily THC compared with men (10% of female versus 47% of male respondents). Only 2 of 39 participants were able to give an exact dosage used in milligrams. Medical and recreational dispensaries were the most common cannabis sources, followed by homegrown and friends/family members. Although pharmaceutical CBD extract is now Food and Drug Administration (FDA)-approved for certain epilepsy types, access remains limited. Further research is needed to understand recreational cannabis use among patients with epilepsy while clinical research for pharmaceutical cannabis products continues.

Recent advances in epilepsy management.

PURPOSE OF REVIEW: Recent advances in our understanding of seizure generation have resulted in modified recommendations for when seizure treatment should be initiated, revisions to our definition of status epilepticus, and new pharmacological and neuromodulatory therapies. The goal of this review is to provide the anesthesiologist with an overview of the advancements they are most likely to encounter while providing clinical care. RECENT FINDINGS: There have been recent modifications to seizure definitions and treatment recommendations. These include the idea that treatment with antiepileptic therapy should be initiated after the first unprovoked seizure in individuals who are at high risk for another seizure, and that the idea that status epilepticus should be thought of as a two-phase process, related to an initial phase after which intervention should be started, and a second phase after which time risk of long-term sequelae is increased. Additionally, several new therapies have become available that have novel mechanisms of action, which are more efficacious and have fewer side-effects. SUMMARY: As knowledge about mechanisms of seizure generation has improved, there has been a concurrent evolution in our thinking about seizure-related definitions, and indications for initiation of treatment. Several next generation drug therapies with more specific targets have also become available. Taken together, there have been significant improvements in care options.