Epilepsy in elderly patients: does age of onset make a difference?

INTRODUCTION: Epilepsy is most frequent in children and elderly people. Today's population is ageing and epilepsy prevalence is increasing. The type of epilepsy and its management change with age. METHODS: We performed a retrospective, observational study comparing patients aged ≥ 65 years with epilepsy diagnosed before and after the age of 65, and describing epilepsy characteristics and comorbidities in each group. RESULTS: The sample included 123 patients, of whom 61 were diagnosed at < 65 years of age (group A), 62 at ≥ 65 of age (group B). Sex distribution was similar in both groups, with 39 men (62.9%) in group A and 37 (60.7%) in group B. Mean age was 69.97 ±â€¯5.6 years in group A and 77.29 ±â€¯6.73 in group B. The most common aetiology was cryptogenic in group A (44.3%, n = 27) and vascular in group B (74.2%, n = 46). History of stroke was present in 12 patients from group A (19.7%) and 32 (51.6%) in group B. Antiepileptic drugs were prescribed at lower doses in group A. Statistically significant differences were found between groups for history of ischaemic stroke, cognitive impairment, psychiatric disorders, and diabetes mellitus; degree of dependence; and number of antiepileptic drugs. CONCLUSION: Age of onset ≥ 65 years is closely related to cardiovascular risk factors; these patients require fewer antiepileptic drugs and respond to lower doses. Some cases initially present as status epilepticus.

[Temporal plus epilepsy: a review]. / Epilepsia del lóbulo temporal plus: revisión.

Temporal plus epilepsy is defined as focal epilepsy in which the primary epileptogenic area extends beyond the temporal lobe. It involves the neighboring regions such as the insula, the suprasilvian opercular cortex, the orbitofrontal cortex and the temporo-parieto-occipital junction. The objective of this review is to provide an update in temporal plus epilepsy. A previous history of brain trauma, a history of tonic clonic seizures, and previous central nervous system infection are risk factors. They likely allowed the generation of complex hippocampal and extrahypocampic neural networks. Clinical manifestations will depend on the location of the epileptogenic zone as well as the rapid propagation into temporal mesial structures. Video-electroencephalography usually shows involvement of the temporal lobe, with rapid propagation into the perisilvian, orbitofrontal or temporo-parieto-occipital regions. The magnetoelectroencephaography has lesser muscle contamination and could be considered as a biomarker of early states in the diagnosis process. Brain MRI is usually negative or shows non-specific mesial temporal abnormalities. Stereoelectroencephalography is the invasive method of choice. Temporal plus epilepsy is considered to be the most common cause of temporal lobe epilepsy surgery failure and represents up to 30%.

TITLE: Epilepsia del lóbulo temporal plus: revisión.La epilepsia del lóbulo temporal plus se define como la epilepsia en la cual la zona epileptógena primaria se localiza en el lóbulo temporal y se extiende a regiones vecinas, como la ínsula, la corteza opercular suprasilviana, la corteza orbitofrontal y la unión temporoparietooccipital. El objetivo de esta revisión es proveer una actualización de la información en la epilepsia del lóbulo temporal plus. La historia de traumatismo craneoencefálico, infección cerebral (meningitis-encefalitis) o crisis epiléptica tonicoclónica generalizada está involucrada en su etiología, y permite la generación de redes neuronales complejas hipocámpicas y extrahipocámpicas. Las manifestaciones clínicas dependen de la zona epileptógena involucrada y de su rápida proyección a las estructuras temporales mesiales. El videoelectroencefalograma evidencia actividad interictal extensa e ictal en el lóbulo temporal, pero con rápida propagación perisilviana, orbitofrontal o temporoparietooccipital. La magnetoelectroencefalografía tiene menos contaminación muscular y podría considerarse como un biomarcador de estados tempranos en el proceso diagnóstico. La resonancia cerebral generalmente es negativa o muestra una ligera alteración de señal en la zona mesial temporal en grado variable. El estereoelectroencefalograma es el método invasivo de elección, especialmente guiado por robot. La epilepsia temporal plus se considera la causa más frecuente de fracaso de la cirugía de la epilepsia del lóbulo temporal, hasta un 30%.

The role of the epilepsy monitoring unit in the investigation of patients with epilepsy and intellectual disabilities.

BACKGROUND: A significant proportion of the people with intellectual disabilities (ID) has epilepsy and lives in institutions. These patients tend to have atypical presentations of epileptic seizures with an increased risk of misdiagnoses. They often have drug-resistant epilepsy (DRE) requiring polypharmacy with increased risk of morbidity. The aim of this study was to determine the usefulness of Epilepsy Monitoring Unit (EMU) in the diagnosis and management of these patients. METHODS: This is a retrospective observational study of people with epilepsy and ID living in institutions that were admitted to the EMU at London Health Sciences Center (LHSC), from January 2014 to December 2016. RESULTS: Out of 1121 patients admitted to the EMU at the LHSC, 1.96% (N = 22) fulfilled the inclusion criteria for this study. The mean age was 34.5 years (interquartile range [IQR]: 28.8-53); 50%(N = 11) were female. Fourteen (63.6%) had generalized epilepsy. Six (27.3%) had a history of status epilepticus. The mean number of antiseizure medications (ASMs) in those patients was three (IQR: 2-4). Eight (36.4%) patients had severely impaired or no language skills and seven (31.8%) required wheelchair. Eleven (50%) had a mood disorder and seven (31.8%) of them were taking antipsychotic medications. The mean duration of admission duration was 6.6 days (IQR: 3.5-8.5). There was a clinical-electrographic correlation between the behavioral events and epileptic seizures in nineteen (86.4%) of the patients. CONCLUSIONS: Admission to the EMU provided an accurate characterization of transient events in people with ID and epilepsy with improvement in their medical management.

Experience on the use of Vagus Nerve Stimulation during pregnancy.

OBJECTIVE: Vagus Nerve Stimulation (VNS) is a neuromodulation device approved for the treatment of medically refractory epilepsy. Worldwide, only 35 cases of pregnancies that has been described. This study aims to continue to increase the limited knowledge of the use of VNS during pregnancy. METHODS: We interrogated the database of the Epilepsy program at Western University (1998-2018), and identified those patients who were implanted with VNS and became pregnant. RESULTS: From 114 patients implanted with VNS in our centre, four patients had a total of seven pregnancies. This is the first report with one woman implanted with VNS having three pregnancies. Three patients had genetic generalized epilepsy and one focal epilepsy due to periventricular nodular heterotopia. The median duration since implantation was 3.17 years (IQR: 1.33-4.33) and the output was 2.75 mA (IQR: 1.5-3.5). No modifications in stimulation settings were made in any patient during pregnancy. Three patients had obstetric complications, requiring c-sections. All babies were healthy, except one with intellectual disabilities of unclear severity. CONCLUSION: Our small sample suggests VNS could increase the obstetrical complications, but is likely safe for the fetus. However, a larger sample size should be collected to determine safety and potential teratogenicity of VNS.

Epilepsy in elderly patients: does age of onset make a difference? / Epilepsia en el anciano: ¿la edad de inicio marca la diferencia?

INTRODUCTION: Epilepsy is most frequent in children and elderly people. Today's population is ageing and epilepsy prevalence is increasing. The type of epilepsy and its management change with age. METHODS: We performed a retrospective, observational study comparing patients aged ≥ 65 years with epilepsy diagnosed before and after the age of 65, and describing epilepsy characteristics and comorbidities in each group. RESULTS: The sample included 123 patients, of whom 61 were diagnosed at <65 years of age (group A), 62 at ≥ 65 of age (group B). Sex distribution was similar in both groups, with 39 men (62.9%) in group A and 37 (60.7%) in group B. Mean age was 69.97±5.6 years in group A and 77.29±6.73 in group B. The most common aetiology was unknown in group A (44.3%, n=27) and vascular in group B (74.2%, n=46). History of stroke was present in 12 patients from group A (19.7%) and 32 (51.6%) in group B. Antiepileptic drugs were prescribed at lower doses in group A. Statistically significant differences were found between groups for history of ischaemic stroke, cognitive impairment, psychiatric disorders, and diabetes mellitus; degree of dependence; and number of antiepileptic drugs. CONCLUSION: Age of onset ≥ 65 years is closely related to cardiovascular risk factors; these patients require fewer antiepileptic drugs and respond to lower doses. Some cases initially present as status epilepticus.

[Epilepsy surgery for refractory neurocysticercosis-related epilepsy]. / Cirugia en epilepsia refractaria debida a neurocisticercosis.

INTRODUCTION: Neurocysticercosis is one of the most frequent causes of epilepsy worldwide, with some cases going into refractoriness. For that reason, surgical treatment should be considered, particularly lesionectomy, with or without temporal lobectomy. CASE REPORTS: From our series of patients with drug-resistant epilepsy from 2008 to 2018, we selected all cases with one or more lesions suggestive of neurocysticercosis who underwent epilepsy surgery. Three patients fulfilled the inclusion criteria, with an average age of 39.33 year-old, two were female, epilepsy onset was at a mean age of 17.33 years. One case had multiple neurocysticercosis lesions and mesial temporal sclerosis, the other two cases had single neurocysticercosis lesions in the temporal region. In all cases, the epileptogenic zone was located in the temporal lobe. One patient underwent a temporal lobectomy, while the other two underwent lesionectomy. Pathology confirmed neurocysticercosis granuloma. All three cases remain seizure free. CONCLUSION: Evaluation of patients with neurocysticercosis-related refractory epilepsy for potential surgery is indicated, as this procedure can be quite successful.

TITLE: Cirugia en epilepsia refractaria debida a neurocisticercosis.Introduccion. La neurocisticercosis es una causa frecuente de crisis epileptica en el mundo, y en algunos casos puede llegar a ser farmacorresistente, por lo cual las opciones quirurgicas deben estar presentes y la lesionectomia, con o sin lobectomia temporal, es la cirugia de eleccion. Casos clinicos. De la serie de pacientes con epilepsia farmacorresistente entre los años 2008 a 2018, se seleccionaron los que tenian una o varias lesiones sugerentes de neurocisticercosis y que se sometieron a cirugia de la epilepsia. Tres pacientes cumplian los criterios de seleccion, dos de ellos mujeres, con una edad media de 39,33 años. La edad media de inicio de la epilepsia fue a los 17,33 años, con diagnostico de cisticercosis confirmado a la edad de 30. Uno de los casos tenia multiples lesiones de neurocisticercosis junto con esclerosis mesial temporal, y los otros dos, lesiones unicas en el lobulo temporal. En todos los pacientes, la zona epileptogena se localizo en el lobulo temporal correspondiente. Por lo tanto, en dos casos se realizo una lesionectomia, y en el otro, con multiples lesiones, una lobectomia temporal. La patologia de las lesiones sugiere estadios cronicos de neurocisticercosis. Todos los pacientes estan libres de crisis en el momento actual. Conclusion. La evaluacion para cirugia de la epilepsia en pacientes con epilepsia refractaria debida a neurocisticercosis esta recomendada y puede ser eficaz en el control y tratamiento de las crisis.

Headache after carotid artery stenting. / Cefalea post-stent carotídeo.

INTRODUCTION AND OBJECTIVES: Headache after carotid artery stenting is a headache with onset during the procedure or in the first few hours after it, and where there is no evidence to suggest a complication of that procedure. The purpose of this study is to describe the main features of these headaches based on our clinical experience. PATIENTS AND METHODS: Observational prospective study of a sample of patients undergoing carotid artery stenting at Hospital Clínico Universitario Lozano Blesa, in Zaragoza, Spain. We recorded sociodemographic characteristics, cardiovascular risk factors, carotid artery disease, and history of primary headache; data were gathered using structured interviews completed before and 24hours after the procedure. RESULTS: We included 56 patients (mean age 67±9.52 years); 84% were men. Twelve patients (21.4%) experienced headache, 83.3% of whom were men; mean age was 60.58±9.31 years. Headache appeared within the first 6hours in 7 patients (58.4%) and during the procedure in 4 (33.3%). Pain lasted less than 10minutes in 4 patients (33.3%) and between 10 and 120minutes in 5 (41.7%). Headache affected the frontotemporal area in 7 patients (58.3%); 7 patients (58.3%) described pain as unilateral. It was oppressive in 8 patients (66.7%) and of moderate intensity in 6 (50%). Nine patients (75%) required no analgesics. We found no statistically significant associations with any of the variables except for age (P=.007; t test). CONCLUSIONS: In our sample, headache after carotid artery stenting was mild to moderate in intensity, unilateral, oppressive, and short-lasting. Further studies are necessary to gain a deeper knowledge of its characteristics and associated risk factors.

The Spanish Society of Neurology's official clinical practice guidelines for epilepsy. Special considerations in epilepsy: comorbidities, women of childbearing age, and elderly patients.

INTRODUCTION: The characteristics of some population groups (patients with comorbidities, women of childbearing age, the elderly) may limit epilepsy management. Antiepileptic treatment in these patients may require adjustments. DEVELOPMENT: We searched articles in Pubmed, clinical practice guidelines for epilepsy, and recommendations by the most relevant medical societies regarding epilepsy in special situations (patients with comorbidities, women of childbearing age, the elderly). Evidence and recommendations are classified according to the prognostic criteria of Oxford Centre of Evidence-Based Medicine (2001) and the European Federation of Neurological Societies (2004) for therapeutic interventions. CONCLUSIONS: Epilepsy treatment in special cases of comorbidities must be selected properly to improve efficacy with the fewest side effects. Adjusting antiepileptic medication and/or hormone therapy is necessary for proper seizure management in catamenial epilepsy. Exposure to antiepileptic drugs (AED) during pregnancy increases the risk of birth defects and may affect fetal growth and/or cognitive development. Postpartum breastfeeding is recommended, with monitoring for adverse effects if sedative AEDs are used. Finally, the elderly are prone to epilepsy, and diagnostic and treatment characteristics in this group differ from those of other age groups. Although therapeutic limitations may be more frequent in older patients due to comorbidities, they usually respond better to lower doses of AEDs than do other age groups.