[Depression in patients with epilepsy. Pathophysiological and clinical concepts and therapeutic strategies]. / Depresión en pacientes con epilepsia. Conceptos fisiopatológicos, clínicos y estrategias terapéuticas.

INTRODUCTION: Depression and epilepsy are highly prevalent diseases and represent a worldwide public health problem. DEVELOPMENT: A non-systematic search was performed in PubMed (MEDLINE) considering current topics in pathophysiological, clinical concepts and treatment strategies in people with epilepsy and depression. RESULTS AND CONCLUSIONS: Depression and epilepsy have a bidirectional relationship and share some pathophysiological substrates. Depression is the most common neuropsychiatric manifestation in epilepsy; screening and diagnosis are important to start a timely treatment. Antidepressant drugs does not increase the frequency of seizures, on the contrary, it is believed that antidepressants may help reducing the frequency of seizures. In addition, other antidepressant therapies such as Cognitive Behavioral Therapy and neuromodulation may be also effective for reducing the frequency of seizures. However the evidence regarding antidepressant treatment(s) in epilepsy is limited and further prospective studies are needed to better characterize the possible therapeutic strategies and develop standarized treatment guidelines.

TITLE: Depresión en pacientes con epilepsia. Conceptos fisiopatológicos, clínicos y estrategias terapéuticas.Introducción. La depresión y la epilepsia son entidades altamente prevalentes y representan un problema de salud pública a nivel mundial. Desarrollo. Realizamos una búsqueda no sistemática en PubMed (MEDLINE) acerca de los conceptos fisiopatológicos y clínicos y las estrategias terapéuticas en pacientes con epilepsia y depresión. Resultados y conclusiones. La depresión y la epilepsia tienen una relación bidireccional y comparten algunos sustratos fisiopatológicos. La depresión es la manifestación neuropsiquiátrica más frecuente en la epilepsia; es importante el cribado y el diagnóstico para el manejo oportuno. El tratamiento con la mayoría de los medicamentos antidepresivos no incrementa la frecuencia de crisis, al contrario, se cree que puede incluso ayudar a disminuir el número de crisis de epilepsia. Además, existen otras terapias antidepresivas, como la terapia cognitivo-conductual y terapias con neuromodulación, que también llegan a ser eficaces en la reducción de la frecuencia de las crisis de epilepsia. Sin embargo, la evidencia respecto al tratamiento es limitada y se requiere un mayor número de estudios prospectivos para la caracterización de las estrategias terapéuticas y la creación de guías estandarizadas.

Depresión en pacientes con epilepsia. Conceptos fisiopatológicos, clínicos y estrategias terapéuticas / Depression in patients with epilepsy. Pathophysiological and clinical concepts and therapeutic strategies

Introducción: La depresión y la epilepsia son entidades altamente prevalentes y representan un problema de salud pública a nivel mundial. Desarrollo: Realizamos una búsqueda no sistemática en PubMed (MEDLINE) acerca de los conceptos fisiopatológicos y clínicos y las estrategias terapéuticas en pacientes con epilepsia y depresión. Resultados y conclusiones. La depresión y la epilepsia tienen una relación bidireccional y comparten algunos sustratos fisiopatológicos. La depresión es la manifestación neuropsiquiátrica más frecuente en la epilepsia; es importante el cribado y el diagnóstico para el manejo oportuno. El tratamiento con la mayoría de los medicamentos antidepresivos no incrementa la frecuencia de crisis, al contrario, se cree que puede incluso ayudar a disminuir el número de crisis de epilepsia. Además, existen otras terapias antidepresivas, como la terapia cognitivo-conductual y terapias con neuromodulación, que también llegan a ser eficaces en la reducción de la frecuencia de las crisis de epilepsia. Sin embargo, la evidencia respecto al tratamiento es limitada y se requiere un mayor número de estudios prospectivos para la caracterización de las estrategias terapéuticas y la creación de guías estandarizadas.(AU)

Introduction. Depression and epilepsy are highly prevalent diseases and represent a worldwide public health problem. Development: A non-systematic search was performed in PubMed (MEDLINE) considering current topics in pathophysiological, clinical concepts and treatment strategies in people with epilepsy and depression. Results and conclusions: Depression and epilepsy have a bidirectional relationship and share some pathophysiological substrates. Depression is the most common neuropsychiatric manifestation in epilepsy; screening and diagnosis are important to start a timely treatment. Antidepressant drugs does not increase the frequency of seizures, on the contrary, it is believed that antidepressants may help reducing the frequency of seizures. In addition, other antidepressant therapies such as Cognitive Behavioral Therapy and neuromodulation may be also effective for reducing the frequency of seizures. However the evidence regarding antidepressant treatment(s) in epilepsy is limited and further prospective studies are needed to better characterize the possible therapeutic strategies and develop standarized treatment guidelines.(AU)

Epilepsia con patrón catamenial / Epilepsy with catamenial pattern

La epilepsia con patrón catamenial se define como el aumento en la frecuencia de crisis epilépticas durante una etapa específica del ciclo menstrual respecto al basal. Se ha descrito que alrededor de un tercio de las mujeres con epilepsia presenta patrón catamenial. Los cambios en el patrón de crisis epilépticas se explicarían por la influencia de las fluctuaciones catameniales de las hormonas gonadales femeninas sobre la excitabilidad neuronal. La progesterona, a través de su metabolito alopregnanolona, desempeña un papel protector incrementando la transmisión gabérgica; sin embargo, su efecto en los receptores de progesterona cerebral puede incrementar la excitabilidad neuronal. Los efectos de los estrógenos son complejos y tienden a incrementar la excitabilidad neuronal, aunque dependen de su concentración y tiempo de exposición. Se han propuesto tres patrones catameniales de exacerbación de crisis epilépticas: el patrón perimenstrual, el patrón periovulatorio y el patrón lúteo. El abordaje diagnóstico se realiza mediante un proceso sistemático de cuatro pasos: a) historia clínica del patrón del ciclo menstrual y de las crisis epilépticas; b) métodos diagnósticos para caracterizar el ciclo menstrual y el patrón de las crisis epilépticas; c) comprobar los criterios diagnósticos, y d) categorizar el patrón catamenial. Las opciones de tratamiento estudiadas requieren mayor nivel de evidencia, y no existe ningún tratamiento específico aprobado por la Food and Drug Administration. Se recomienda la optimización del tratamiento anti crisis epilépticas convencional como primera opción terapéutica. Otras opciones terapéuticas, como tratamientos no hormonales y hormonales, podrían ser de utilidad en caso de que la primera opción terapéutica resulte ineficaz.(AU)

Catamenial pattern epilepsy is defined as an increase in the frequency of seizures during a specific stage of the menstrual cycle compared to baseline. It has been described that around a third of women with epilepsy have a catamenial pattern. The changes in the seizure pattern would be explained by the influence of catamenial fluctuations, of female gonadal hormones on neuronal excitability. Progesterone through its metabolite allopregnanolone plays a protective role by increasing GABAergic transmission; however, its effect on brain progesterone receptors can increase neuronal excitability. The effects of estrogens are complex, they tend to increase neuronal excitability, although their effects depend on their concentration and exposure time. Three catamenial patterns of seizure exacerbation have been proposed: the perimenstrual pattern, the periovulatory pattern, and the luteal pattern. The diagnostic approach is carried out through a systematic process of 4 steps: a) clinical history of the pattern of the menstrual cycle and epileptic seizures; b) diagnostic methods to characterize the menstrual cycle and the pattern of seizures; c) check diagnostic criteria; and d) categorize the catamenial pattern. The treatment options studied require a higher level of evidence, and there is no specific treatment. Optimization of conventional antiseizure treatment is recommended as the first therapeutic option. Other therapeutic options, such as non-hormonal and hormonal treatments, could be useful in case the first therapeutic option proves to be ineffective.(AU)

[Epilepsy with catamenial pattern]. / Epilepsia con patrón catamenial.

Catamenial pattern epilepsy is defined as an increase in the frequency of seizures during a specific stage of the menstrual cycle compared to baseline. It has been described that around a third of women with epilepsy have a catamenial pattern. The changes in the seizure pattern would be explained by the influence of catamenial fluctuations, of female gonadal hormones on neuronal excitability. Progesterone through its metabolite allopregnanolone plays a protective role by increasing GABAergic transmission; however, its effect on brain progesterone receptors can increase neuronal excitability. The effects of estrogens are complex, they tend to increase neuronal excitability, although their effects depend on their concentration and exposure time. Three catamenial patterns of seizure exacerbation have been proposed: the perimenstrual pattern, the periovulatory pattern, and the luteal pattern. The diagnostic approach is carried out through a systematic process of 4 steps: a) clinical history of the pattern of the menstrual cycle and epileptic seizures; b) diagnostic methods to characterize the menstrual cycle and the pattern of seizures; c) check diagnostic criteria; and d) categorize the catamenial pattern. The treatment options studied require a higher level of evidence, and there is no specific treatment. Optimization of conventional antiseizure treatment is recommended as the first therapeutic option. Other therapeutic options, such as non-hormonal and hormonal treatments, could be useful in case the first therapeutic option proves to be ineffective.

TITLE: Epilepsia con patrón catamenial.La epilepsia con patrón catamenial se define como el aumento en la frecuencia de crisis epilépticas durante una etapa específica del ciclo menstrual respecto al basal. Se ha descrito que alrededor de un tercio de las mujeres con epilepsia presenta patrón catamenial. Los cambios en el patrón de crisis epilépticas se explicarían por la influencia de las fluctuaciones catameniales de las hormonas gonadales femeninas sobre la excitabilidad neuronal. La progesterona, a través de su metabolito alopregnanolona, desempeña un papel protector incrementando la transmisión gabérgica; sin embargo, su efecto en los receptores de progesterona cerebral puede incrementar la excitabilidad neuronal. Los efectos de los estrógenos son complejos y tienden a incrementar la excitabilidad neuronal, aunque dependen de su concentración y tiempo de exposición. Se han propuesto tres patrones catameniales de exacerbación de crisis epilépticas: el patrón perimenstrual, el patrón periovulatorio y el patrón lúteo. El abordaje diagnóstico se realiza mediante un proceso sistemático de cuatro pasos: a) historia clínica del patrón del ciclo menstrual y de las crisis epilépticas; b) métodos diagnósticos para caracterizar el ciclo menstrual y el patrón de las crisis epilépticas; c) comprobar los criterios diagnósticos, y d) categorizar el patrón catamenial. Las opciones de tratamiento estudiadas requieren mayor nivel de evidencia, y no existe ningún tratamiento específico aprobado por la Food and Drug Administration. Se recomienda la optimización del tratamiento anti crisis epilépticas convencional como primera opción terapéutica. Otras opciones terapéuticas, como tratamientos no hormonales y hormonales, podrían ser de utilidad en caso de que la primera opción terapéutica resulte ineficaz.

An update on Neurocysticercosis-related epilepsy.

Neurocysticercosis (NCC) is considered a public health problem in various parts of the world and is one of the preventable causes of epilepsy in developing countries. Epileptic seizures are the most common manifestation of NCC and can occur in any stage of the disease. The development of neurocysticercosis-related epilepsy continues to be poorly understood. Some potential explanations include a direct causal relationship, a result of an initial precipitating injury or linked to an external factor, and the remote possibility of coincidence. Various factors contributing to epileptogenesis have been proposed, including calcified lesions, residual gliosis, inflammatory immune response (influenced by genetic factors) and a potential association with hippocampal sclerosis. Treating NCC with antihelminthics, corticosteroids or antiseizure medications have ensured a large percentage of patients can adequately control their epileptic seizures. Cases of refractory epilepsy are rare. Finally, more prospective studies are still needed to have a better understanding of this disease.

[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%.

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 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.

High-dose corticosteroids for acute cytomegalovirus-associated transverse myelitis in the immunocompetent patient: a case report and systematic review.

We present an immunocompetent patient with transverse myelitis (TM) during acute cytomegalovirus (CMV) infection, as evidenced by a reactive serum CMV IgM and CMV viremia. The patient had an excellent outcome after receiving only high-dose methylprednisolone. Given concerns that practitioners may have around the use of immunosuppressive therapy for this potentially infectious myelopathy, we systematically reviewed the literature to assess outcomes after administration of high-dose corticosteroids to this population. Despite severe disease at clinical nadir with inability to ambulate, immunocompetent patients with acute CMV-associated TM who received high-dose corticosteroids had good clinical outcomes 1 month to 1 year after presentation.

Prognostic factors in patients with refractory idiopathic generalized epilepsy.

OBJECTIVE: Idiopathic generalized epilepsy (IGE) is an epileptic condition with good response to antiepileptic drugs (AED). Major syndromes are epilepsy with generalized tonic-clonic seizures (GTCS) alone, absence epilepsy and juvenile myoclonic epilepsy. However, clinical practice shows drug-resistant patients. Endpoint is to identify clinical features related with refractoriness in IGE and in its each individual syndrome. METHODS: We retrospectively collected 279 consecutive patients with IGE assessed in the Epilepsy Clinic of our institution. We defined drug-resistant epilepsy as a failure of adequate trials of 2 tolerated and appropriately chosen and used AED schedules. We classified patients in two groups: drug-resistant and drug-responsive. Clinical features were compared among these groups, in the whole IGE group as well as in each syndrome. RESULTS: There were 122 drug-resistant, 105 drug- responsive; 52 were undefined and excluded from the analysis. After multivariate analysis, early seizures onset (age <13), long-time epilepsy, several generalized seizure types, status epilepticus, EEG with generalized epileptiform activity, mainly polyspikes, and side effects with AED brought up as poor outcome factors. Additionally, 50.6% identified modifiable seizure triggers. Regarding syndromes, epilepsy with generalized tonic-clonic seizures alone had the same factors except several seizure types; presence of additional GTCS, polyspikes, history of AED side effects and psychiatric disorder were poor factors for absence epilepsy; only psychiatric comorbidity revealed significance in juvenile myoclonic epilepsy. SIGNIFICANCE: Refractoriness in IGE and its major syndromes is associated with clinical and electrographic parameters. Moreover, lifestyle advices from neurologists to the patients might help them to achieve a better seizure control.

[Diagnosis and treatment of non-triggered single epileptic seizures]. / Diagnostico y tratamiento de la crisis epileptica unica no provocada.

Epileptic seizures are one of the main reasons for neurological visits in an emergency department. Convulsions represent a traumatic event for the patient and the family, with significant medical and social consequences. Due to their prevalence and impact, the initial management is of vital importance. Although following the first epileptic seizure, early recurrence diminishes after establishing treatment with antiepileptic drugs, the forecast for developing epilepsy and long-term outcomes are not altered by any early intervention. Detailed questioning based on the symptoms of the convulsions, the patient's medical history and a full electroencephalogram and neuroimaging study make it possible to define the risk of recurrence of the seizure and the possible diagnosis of epilepsy. Epileptic abnormalities, the presence of old or new potentially epileptogenic brain lesions, as well as nocturnal seizures, increase the risk of recurrence. Physicians must assess each patient on an individual basis to determine the most suitable treatment, and explain the risk of not being treated versus the risk that exists if treatment with antiepileptic drugs is established.

TITLE: Diagnostico y tratamiento de la crisis epileptica unica no provocada.Las crisis epilepticas son una de las principales causas de consulta neurologica en el servicio de urgencias. Un episodio convulsivo representa un evento traumatico para el paciente y la familia, con consecuencias medicas y sociales significativas. Por su prevalencia e impacto, el abordaje inicial es de vital importancia. Si bien despues de una primera crisis epileptica la recurrencia temprana disminuye con el inicio de farmacos antiepilepticos, el pronostico para el desarrollo de epilepsia y los desenlaces a largo plazo no se alteran por ninguna intervencion temprana. El interrogatorio detallado basado en la semiologia del episodio, los antecedentes del paciente y un estudio completo con electroencefalograma y neuroimagen permiten definir el riesgo de recurrencia de la crisis y el posible diagnostico de epilepsia. Las anormalidades epilepticas, la presencia de lesiones cerebrales con potencial epileptogeno antiguas o nuevas, asi como las crisis nocturnas, incrementan el riesgo de recurrencia. Los medicos deben evaluar a cada paciente de manera individual para determinar un tratamiento idoneo, explicando el riesgo de no tratar frente al riesgo existente con el inicio de farmacos antiepilepticos.

4-T fMRI of the motor and sensory cortices in patients with polymicrogyria and epilepsy.

OBJECTIVE: Malformations of cortical development (MCD) are an increasingly recognized cause of medically intractable epilepsy. We assessed the role of fMRI in evaluating the motor and somatosensory cortices, as well as if there is possible reorganization of these vital areas in patients with polymicrogyria. METHODS: We included 2 patients with polymicrogyria and epilepsy. Somatosensory and motor cortices were assessed with a 4T fMRI. These findings were compared with direct cortical stimulation. RESULTS: Localization of the sensorimotor cortices was adequately identified by fMRI. These vital areas did not reorganize outside the malformation of cortical development. CONCLUSION: fMRI is a tool that can allow identification of these vital areas of the brain in a non-invasive manner. PRACTICE IMPLICATIONS: Adequate localization of the sensorimotor cortices is important for optimal patient selection, surgical strategy, and to determine the maximal extent of the resection. The clinical implications for such understanding are not limited to it; these findings should help researchers understand more of the neurobiology of MCDs and even possibly clues to the mechanisms of epileptogenesis associated with such malformations.

Prevalence of childhood epilepsy in Canada.

RATIONALE: Few data exist on the frequency and burden of childhood epilepsy in Canada and on the impact in the general population. We have assessed the point prevalence of childhood epilepsy in Canada. METHODS: We analyzed data from the National Longitudinal Survey of Children and Youth (N=20 025 for Cycle 2, and N= 31 960 for cycle 3). Each cycle was collected over a two year period (2: 1996-1997, 3: 1998-1999). In the survey the following specific question was asked to the person most knowledgeable in the household: "Does the child have any of the following long-term conditions that have been diagnosed by a health professional?" The list of responses included Epilepsy and certain co-morbid conditions. In addition, a subsequent question identified whether the condition was treated by means of a specific anticonvulsant medication. (anticonvulsants or anti-epileptic pills?). Prevalence was based on the national standard population at the time of each survey. RESULTS: In Cycle 2, 80 of 20 025 subjects from 0 to 13 years old were described to have the diagnosis of epilepsy, yielding a weighted point prevalence of 4.03 per 1 000. In Cycle 3 161 of 31 960 children from 0 to 15 were described as having epilepsy, yielding a weighted point prevalence of 5.26 per 1 000. The rate of epilepsy was higher for males and increases with age. CONCLUSION: The overall rates for this age cohort are consistent with those obtained in other developed countries and seem to coincide with rates for youth and adults in Canada.

Impact of seizures on morbidity and mortality after stroke: a Canadian multi-centre cohort study.

INTRODUCTION: Limited information is available about the impact of seizures on stroke outcome, health care delivery and resource utilization. OBJECTIVE: To determine whether the presence of seizures after stroke increases disability, mortality and health care utilization (length of hospital stay, ICU admission, consults, discharge to a long-term care facility). METHODS: This cohort study included consecutive patients with acute stroke between July 2003 and June 2005 from the Registry of the Canadian Stroke Network (RCSN), the largest clinical database of patients in Canada with acute stroke seen at selected acute care hospitals. We compared clinical characteristics and outcomes amongst patients experiencing stroke without and with seizures occurring during inpatient stay. Main outcome measures included: case-fatality, disability at discharge, length-of-stay, and discharge disposition. A logistic regression analysis was used to determine whether the presence of seizures was associated with poor stroke outcomes. RESULTS: Amongst 5027 patients included in the study; seizures occurred in 138 (2.7%) patients with stroke. Patients with seizures had a higher mortality at 30-day (36.2% vs. 16.8%, P < 0.0001) and at 1-year post-stroke (48.6% vs. 27.7%, P < 0.001), longer hospitalization, and greater disability at discharge (P < 0.001). Multivariate analysis revealed that stroke severity, hemorrhagic stroke, and presence of neglect were associated to occurrence of seizures after stroke. CONCLUSIONS: The presence of seizures after stroke was associated with increased resources utilization, length of hospital stay, whilst decreasing both 30-day and 1-year survival. Quality improvement strategies targeting patients with seizures may help optimize the management of this subgroup of more disabled patients.

Can I go out for a smoke? A nursing challenge in the epilepsy monitoring unit.

Cigarette smoking is common in patients with intractable epilepsy. As a preliminary assessment of epilepsy and smoking, we evaluated the impact of breaks for smoking on the investigation of epilepsy patients admitted to our epilepsy monitoring unit. Absences from the epilepsy unit at the London Health Sciences Center were monitored for 6 months by nursing personnel. During these absences, events that occurred were registered as well. This is possible using portable EEG recorders (XLTEK) that patients carry with them all the time. A disadvantage is that video recording is not available if the patient has a seizure outside the unit. Information was entered consecutively in a datasheet. Diagnosis, duration of hospital stay, frequency of breaks, and time outside the unit were recorded. Descriptive and statistical analysis was performed. Two thousand two hundred and ninety trips were recorded. Mean duration of stay was 10 days for smokers and 8.5 for non-smokers. Non-smokers had a total of 439 seizures of which 6 (1.4%) were not recorded, while the smokers had 213, of which 11 (5.2%) were not recorded. Five events did not have electroencephalographic correlation, raising a suspicion of non-epileptic events (pseudoseizures). Despite the low number of events missed, precious information may be lost during smoking trips by patients admitted to the epilepsy unit. Ways to avoid such trips should be implemented in epilepsy monitoring units allowing smoking breaks for patients.

Adult-onset epilepsy associated with dysembryoplastic neuroepithelial tumors.

RATIONALE: Dysembryoplastic neuroepithelial tumors (DNET) are benign, localized lesions that typically cause localization-related epilepsy of childhood onset. Although excellent seizure outcomes are expected following surgical resection of focal, benign lesions, reports in pediatric epilepsy series suggest that this may not be the case with DNETs, which may exhibit complex and often multifocal epileptogenesis. We report the characteristics and surgical outcome of an adult- and childhood-onset cohort with this condition. METHODS: Retrospective cohort of 23 patients seen at two major epilepsy centers, with localization-related epilepsy associated with histopathologically demonstrated DNETs. We assessed clinical, electrographic and surgical outcome features in patients with adult- and childhood-onset epilepsy. We were particularly interested in the level of congruence of EEG and MRI data and the need for intracranial recordings. We evaluated seizure outcomes at last follow-up. RESULTS: The mean age was 33.3 years (range: 5-56 years). Ten patients had adult-onset epilepsy. Thirteen patients (57%) had simple partial, 21 (91%) had complex partial, 16 (70%) had secondarily generalized seizures and 5 patients had only simple partial seizures. Status epilepticus did not occur. Non-enhancing lesions on MRI were located in the temporal lobe in 17 patients, the frontal lobe in 3 patients and the parietal/occipital region in 2 patients. One patient had a DNET that involved both frontal and temporal areas. Ictal scalp EEG and MRI were congruent in 17 patients (74%). Eleven patients (48%) underwent lesionectomies, while the rest required some resection of extralesional cortex as well. Five patients required intracranial EEG. There was no association with cortical dysplasia. Seventeen patients (74%) had an Engel class 1 outcome, in a follow-up period that ranging from 5 to 98 months. CONCLUSIONS: We found no difference in outcomes between adult- and childhood-onset cases. Although epileptogenicity was complex, congruence between electro-clinical and neuroimaging studies was high and allowed good surgical outcomes at 1 year of follow-up.

A systematic review on MEG and its use in the presurgical evaluation of localization-related epilepsy.

BACKGROUND: Magnetoencephalography (MEG), also referred to as magnetic source imaging (MSI) when combined with structural imaging, provides a new, noninvasive tool for epilepsy localization. In contrast to EEG, the magnetic fields generated by electrical discharges are minimally affected by intervening tissue layers. The purpose of this study was to determine the effectiveness of MEG/MSI in the presurgical evaluation of localization-related epilepsies by means of a systematic review. METHODS: We searched MEDLINE, the Cochrane library, and EMBASE between 1987 and 2006 for English articles. References of reviews and book chapters were searched. In addition, we contacted experts in MEG and epilepsy. Studies including a minimum of four patients with at least 6 months follow-up after surgery were reviewed. In each study, surgical outcome (seizure freedom) was correlated with the concordance of MEG source localization and resection area. RESULTS: The literature search generated 192 articles. Twenty-eight papers satisfied the inclusion criteria. Eleven of the 28 articles were excluded due to an inability to determine the concordance between the MEG epileptic focus and the resected area based on the published data. Analysis of the 17 remaining studies allowed us to obtain sensitivity (range: 0.20-1.0) values for all articles, and specificity (0.06-1.00) values, positive likelihood ratios (0.67-2.0) and negative likelihood ratios (0.40-2.13) for some articles. CONCLUSIONS: There is insufficient evidence in the current literature to support the relationship between the use of MEG in surgical planning and seizure-free outcome after epilepsy surgery. Additional studies are needed.

Evaluating the development of a SPECT protocol in a Canadian epilepsy unit.

BACKGROUND: Functional neuroimaging can address some challenges of seizure localization, and sometimes preclude the need for EEG recording using intracranial electrodes. Ictal Single Photon Emission Computed Tomography (SPECT) has developed into an important tool in the presurgical evaluation of patients with medically-intractable localization-related epilepsy. The purpose of the study was to determine whether the development of a programme using trained nurses to perform ictal injections enabled a more efficient delivery of radiopharmaceuticals and therefore a greater sensitivity and specificity of outcome. METHODS: In our epilepsy unit, nursing staff inject 99mTc-HMPAO at bedside, during or at seizure onset. Brain SPECT is performed later on a gamma camera. RESULTS: Since the implementation of the new protocol (February 2005), 57 scans have been performed: 22 ictal and 35 interictal. Latency of ictal injection was found to be 5-40 seconds (mean 19.7 sec, standard deviation (SD) 10.4). Only 20% of reconstituted radiopharmaceutical vials were not used. Contamination rate was nil. Sixty three percent of SPECT studies were concordant with standard presurgical evaluation. CONCLUSION: The latency of injections and the percentage of unused vials indicated an efficient and effective protocol compared to the literature. Our results show that ictal SPECT can be a safe, noninvasive procedure performed on a routine basis in the epilepsy unit when appropriately trained support staff are incorporated into a structured multidisciplinary programme.