Seizure outcome in medically treated patients with adult-onset epilepsy and cerebral cavernous malformation.

PURPOSE: We evaluated long-term seizure outcomes of antiseizure medications (ASMs) and risk factors for drug resistance in patients with adult-onset epilepsy associated with cerebral cavernous malformation (CCM). MATERIALS AND METHODS: This retrospective observational study included patients newly diagnosed with adult-onset focal epilepsy associated with CCM. Patients received individualized treatments with ASMs. All patients were followed-up for at least 2 years. The main outcome measure was terminal 2 year seizure freedom (2-YSF). RESULTS: Forty eight subjects (28 men and 20 women) were included. Thirty-one (64.6%) subjects achieved a terminal 2-YSF (range 2.0-17.0 years). After treatment with the first drug regimen, 31 (64.6%) subjects achieved 2-YSF, with 23 remaining seizure-free until final follow-up visit. Of the 23 subjects treated with the second drug regimen and the six treated with the third drug regimen, ten (43.5%) and one (16.7%), respectively, achieved a terminal 2-YSF. Stepwise logistic regression analyses showed that terminal 2-YSF was negatively associated with epileptiform discharge on EEG at the time of diagnosis (odds ratio = 0.214, p = 0.047) and tended to be associated with age ≥ 45 years at seizure onset (odds ratio = 4.260, p = 0.056). CONCLUSION: The present study found that 64.6% of CCM patients with adult-onset epilepsy achieved terminal 2-YSF after ASM initiation. Interictal epileptiform discharge on EEG at the time of diagnosis was associated with poor prognosis. Failure to achieve sustained seizure freedom after two ASMs may indicate the need for surgical treatment.

Effects of Continuous Positive Airway Pressure on Sleep State Misperception in Patients With Obstructive Sleep Apnea.

BACKGROUND: Little is known regarding the effects of continuous positive airway pressure (CPAP) on sleep misperception in obstructive sleep apnea (OSA). METHODS: Sleep state perception was measured by subtracting the objective total sleep time from the subjective sleep duration. Sleep underestimation and overestimation were defined as ± 60 minutes sleep perception. Insomnia and depressive symptoms were assessed using questionnaires. Finally, nonparametric statistical analyses were performed. RESULTS: Of the 339 patients with OSA included in the study, 90 (26.5%) and 45 (13.3%) showed sleep underestimation and overestimation, respectively. Overall, a significant underestimation of sleep was noted during CPAP titration comparing to a diagnostic PSG (P < 0.001). OSA patients with insomnia or depressive symptoms did not show any changes in sleep perception between diagnostic and CPAP titration studies, whereas those without insomnia or depressed mood showed significantly underestimated sleep duration during CPAP titration. Patients with OSA and either underestimated or overestimated misperception showed perceptual improvements during CPAP titration regardless of the presence of insomnia or depressive symptoms. However, of 204 patients with normal sleep perception, 138 (67.6%) and 10 (4.9%) had underestimation and overestimation of sleep during CPAP titration. CONCLUSION: CPAP titration may improve sleep perception with moderate to severe OSA who have sleep misperception. However, CPAP titration may result in sleep misperception especially underestimation of sleep in those who have normal sleep perception.

Comparisons of impulsivity among patients with different subtypes of epilepsy.

PURPOSE: This study assessed whether patients with epilepsy have a higher level of impulsivity than healthy controls, and compared impulsivity among patients with different subtypes of epilepsy. METHODS: The multicenter study included 108 subjects with epilepsy and 56 healthy volunteers. Subjects were evaluated by the Barratt Impulsiveness Scale-11 (BIS-11) and Patient Health Questionnaire-9, with BIS-11 scores analyzed as both dichotomized and continuous variables. High impulsivity was defined as a total BIS-11 score ≥ 67. RESULTS: Of the 108 subjects with epilepsy, 36 had idiopathic generalized epilepsy (IGE), 47 had temporal lobe epilepsy (TLE), and 25 had frontal lobe epilepsy (FLE). A significantly higher percentage of subjects with epilepsy (22.2%) than controls (1.8%) had BIS-11 scores ≥ 67 (p = 0.001), although mean BIS-11 scores were similar in subjects with epilepsy (59.5 ± 10.0) and controls (58.8 ± 4.6). Higher percentages of subjects with IGE and FLE had BIS-11 scores ≥ 67 than subjects with TLE and controls. Mean total BIS-11 scores did not differ between controls and subjects with IGE and FLE, but were lower in subjects with TLE than in controls. Differences in impulsivity among controls and subjects with epilepsy subtypes varied depending on BIS-11 subscale. CONCLUSIONS: Patients with epilepsy, particularly IGE and FLE, were more likely to have high impulsivity scores, defined by a certain cutoff on the BIS-11, than controls and subjects with TLE. However, mean impulsivity scores did not differ among controls and subjects with IGE and FLE. Dichotomizing BIS-11 scores may be necessary to avoid false negative results in subjects with epilepsy.

Sex Differences in Excessive Daytime Sleepiness Among Patients With Obstructive Sleep Apnea.

BACKGROUND AND PURPOSE: To identify sex differences in daytime sleepiness associated with apnea severity and periodic limb movements during sleep (PLMS) in subjects with obstructive sleep apnea (OSA). METHODS: This study used the Epworth Sleepiness Scale (ESS), Beck Depression Inventory (BDI), and Sleep Hygiene Index (SHI) in logistic regression analyses with interaction terms. Severe OSA, excessive daytime sleepiness (EDS), and PLMS were defined as an apnea-hypopnea index of ≥30, an ESS score of ≥11, and a periodic limb movements index of >15, respectively. RESULTS: The 1,624 subjects with OSA (males, 79.1%) comprised 45.3%, 38.2%, and 16.4% with severe OSA, EDS, and PLMS, respectively. Multiple logistic regression without interaction terms showed that sex, severe OSA, and PLMS were not significantly associated with EDS. However, significant interactions were noted between sex and severe OSA and PLMS in EDS in both crude and adjusted models (all p values<0.05). In the adjusted model, severe OSA was associated with EDS in males (p=0.009) but not in females. PLMS were more likely to be associated with EDS in females (p=0.013), whereas PLMS were less likely to be associated with EDS in males (p=0.041). The models were adjusted by the BDI score, SHI, and presence of medical comorbidities. CONCLUSIONS: There are significant sex differences in subjective daytime sleepiness in subjects with severe OSA and PLMS. Severe OSA and PLMS may influence daytime sleepiness more in males and females, respectively.

Aggression is more strongly associated with suicidality, independent of depression, than emotional instability and impulsivity in people with epilepsy.

PURPOSE: We evaluated the relative contributions of emotional instability, impulsivity, and aggression to the presence of suicide risk in people with epilepsy after adjusting for depressive symptoms. METHODS: This was a cross-sectional study that used the short form of the Affective Lability Scale (ALS-18), the Barratt Impulsiveness Scale Version 11 (BIS-11), the Brief Aggression Questionnaire (BAQ), and the Patient Health Questionnaire-9 (PHQ-9). Suicidality was assessed using the Mini International Neuropsychiatric Interview (MINI), and the presence of suicide risk was defined as a MINI suicidality score ≥1. Stepwise logistic regression and mediation analyses using a two-stage regression method were performed. RESULTS: Of the 171 subjects (63.2% men) included, suicide risk was present in 38 subjects (22.2%). The stepwise logistic regression analysis identified four variables that were independently associated with suicide risk: higher PHQ-9 score, higher BAQ score, longer duration of epilepsy, and unemployment. The univariate analysis showed that ALS-18 and BIS-11 scores were significantly associated with suicide risk; however, they were backward eliminated from the logistic model according to the criterion of p > 0.1. The mediating effects of ALS-18 and BIS-11 scores on suicide risk via PHQ-9 scores (but not BAQ scores) were significant, with the proportion mediated 61.5% and 54.0% of the total effect, respectively. CONCLUSIONS: Alongside depressive symptoms, aggression may be a more useful concept than emotional instability and impulsivity for identifying suicidal risk in people with epilepsy.

Factors associated with sleep state misperception in patients with obstructive sleep apnea.

PURPOSE: Little is known regarding the prevalence of sleep state misperception and the factors related to this in patients with obstructive sleep apnea (OSA). METHODS: This retrospective study included patients with OSA defined by an apnea-hypopnea index (AHI) of ≥ 5 and used the Insomnia Severity Index (ISI), the Epworth sleepiness scale, the Patient Health Questionnaire-9, and the Generalized Anxiety Disorder-7. Underestimation and overestimation of sleep state perception were defined as < 80% and > 120%, respectively, of the ratio between subjective and objective total sleep time. An ISI score > 14 indicated clinically significant insomnia and an AHI ≥ 30 indicated severe OSA. A multinomial logistic regression was conducted with the category of sleep state perception as an outcome variable. RESULTS: Of the 707 patients with OSA, underestimation and overestimation of sleep state perception were noted in 22.5% and 10.6% of subjects, respectively. The median absolute differences (and percentages of the ratio) between subjective and objective total sleep time were 116 min (66.9%) and 87 min (127.3%) in the underestimated and overestimated perception groups, respectively. In the adjusted model, the underestimated group was more likely to have an ISI score > 14 (OR = 1.812, P = .006). The overestimated group was more likely to be older (OR = 1.025, P = .025) and has severe OSA (OR = 1.729, P = .035). CONCLUSIONS: There are two patterns of sleep state misperception in patients with OSA: underestimation associated with comorbid insomnia symptoms and overestimation associated with severe OSA. These findings enhance understanding of the pathophysiology of sleep state misperception in patients with OSA.

Impulsivity in persons with epilepsy: Association with seizure severity and suicide risk.

PURPOSE: Clinical research regarding impulsivity in patients with epilepsy is limited. The present study investigated the associations between impulsivity and seizure-related factors or suicidality in patients with epilepsy, independent of depression and anxiety. METHODS: The multicenter study included 146 subjects (63% men). We utilized the Barratt Impulsiveness Scale-11 (BIS-11), Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7), and suicidality module of the Mini International Neuropsychiatric Interview (MINI). Stepwise regression analyses and an analysis of covariance with interaction terms were performed. RESULTS: The mean BIS-11 score was 59.3 (SD = 10.7). Psychiatric pathologies, including suicidality, were reported in relatively large proportions of patients, including PHQ-9 score ≥ 10 in 29 (19.9%) patients, GAD-7 score ≥ 7 in 35 (24.0%) patients, and MINI suicidality score ≥ 6 in 15 (10.3%) patients. Stepwise linear regression revealed that BIS-11 score was positively associated with the PHQ-9 scores (p < 0.001), antiseizure medication polytherapy (p < 0.001), use of lamotrigine (p = 0.009), and recurrence of generalized or focal to bilateral tonic clonic seizures (p = 0.010). The coefficient of determination for the model was 0.397. Generalized or focal to bilateral tonic clonic seizure recurrence tended to be positively associated with total BIS-11 scores in men but not in women. In subscale analyses, somewhat different variables were associated with different BIS-11subscales. A trend for a positive association between BIS-11 score and suicidality was found (p = 0.066). CONCLUSIONS: This study identified a positive association between clinical seizure severity and impulsivity, and found that this association tended to be sex-specific, occurring only in males. Impulsivity could potentially be weakly associated with suicidality in patients with epilepsy.

Insomnia moderates the association between recurrent seizures and emotional instability in persons with epilepsy.

PURPOSE: We investigated the moderating effect of sleep disturbance on the association between seizure recurrence and emotional instability in patients with epilepsy, independent of psychological distress. METHODS: This was a cross-sectional study. Patients completed the short form of the Affective Lability Scale (ALS-18), Insomnia Severity Index (ISI), Patient Health Questionnaire-9 (PHQ-9), and Generalized Anxiety Disorder-7 (GAD-7). A stepwise linear regression analysis and an analysis of covariance with an interaction term were performed. RESULTS: A total of 171 subjects (63.2% men) were included. The mean ALS-18 score was 15.6 ±â€¯11.3. An ISI ≥ 15, PHQ-9 ≥ 10, and GAD-7 ≥ 7 were noted in 20.5%, 18.1%, and 23.4% of subjects, respectively. A stepwise linear regression analysis found that recurrent seizures in the last year, an ISI ≥ 15, a GAD-7 ≥ 7, and use of levetiracetam were significant and independent factors that were positively associated with higher ALS-18 scores. The coefficient of determination for the model was 0.331. The interaction between recurrent seizures and an ISI ≥ 15 had a significant effect on the ALS-18 scores (F = 6.812, p = 0.010, partial eta2 = 0.040). An ISI ≥ 15 was associated with ALS-18 scores in patients without seizure recurrence (p < 0.001). This association almost reached significance (p = 0.084) in those with recurrent seizures. In contrast, the presence of recurrent seizures was associated with ALS-18 scores in patients with an ISI < 15 (p < 0.001), but not in those with an ISI ≥ 15 (p = 0.360). CONCLUSIONS: The significant interaction between insomnia and seizure status may have an effect on emotional instability. These findings have clinical implications in the development of potential interventions for emotional instability in patients with epilepsy.

Difficulties obtaining private insurance reported by persons with epilepsy in Korea.

PURPOSE: This study determined the proportion of persons with epilepsy (PWE) that possessed insurance policies and the difficulties they experienced in trying to obtain insurance in South Korea. METHODS: Persons with epilepsy and healthy control subjects were asked to complete a questionnaire in which they were asked if they had experienced problems obtaining four types of insurance, including life, medical indemnity, critical illness, and motor insurance. Insurance policies obtained before diagnosis of epilepsy were excluded in the analysis. RESULTS: This study included 106 adults with epilepsy and 87 healthy control subjects. The proportion of patients covered by at least one insurance type was significantly lower (54.7%) than that of controls (90.8%; p < 0.001). The proportions of patients insured did not differ according to freedom from seizures. Of 86 patients who tried to obtain insurance, 66% thought that it was much more difficult for them to obtain insurance than for those without epilepsy, and 48% had been refused one or more types of insurance because of their epilepsy. Difficulties in obtaining insurance differed depending on the types of insurance. Medical information about epilepsy was requested from 13% of patients. Of the insured patients, 71% did not disclose their epilepsy; 32% of these patients said it was because they were worried the insurance company would refuse to insure them. CONCLUSIONS: Persons with epilepsy reported that obtaining private insurance was very difficult for them in South Korea. The findings suggest that PWE per se are excluded from private insurance in South Korea and emphasize the need for an evidence-based individual risk assessment for PWE.

Different scoring rules for respiratory event-related leg movements: effects on the prevalence of periodic limb movements during sleep and their association with depressive symptoms in patients with obstructive sleep apnea.

BACKGROUND: We compared the prevalence of periodic leg movements during sleep (PLMS) according to two different scoring rules of the American Academy of Sleep Medicine (AASM) 2012 and World Association of Sleep Medicine (WASM) 2016 and determined their association with depressed mood in patients with obstructive sleep apnea (OSA). METHODS: PLMS, defined as a periodic leg movements index of >15, were diagnosed on a diagnostic and continuous positive airway pressure (CPAP) titration polysomnography using the AASM 2012 and WASM 2016 rules. The Beck Depression Inventory (BDI) and Epworth Sleepiness Scale (ESS) were used, and multiple regression analyses were performed. RESULTS: Among 160 OSA patients, the proportion with PLMS scored by the WASM 2016 criteria was significantly higher than that scored by the AASM 2012 criteria in a diagnostic study (20.6% vs. 16.3%, respectively; P = 0.016) but not in CPAP titration study and only in patients with severe OSA. In adjusted models, PLMS were positively associated with BDI scores and a BDI of ≥10 on both diagnostic and CPAP titration studies when scored by the WASM 2016. By contrast, when scored by the AASM 2012, PLMS were associated with BDI scores (but not BDI of ≥10) only in a CPAP titration study. CONCLUSIONS: There are significant differences in the prevalence of PLMS and their association with depressed mood depending on the scoring rules in patients with OSA. The current AASM scoring criteria underestimate the prevalence of PLMS, and PLMS are more likely associated with depressed mood according to the WASM scoring criteria.

The Effect of Cognitive Training in a Day Care Center in Patients with Early Alzheimer's Disease Dementia: A Retrospective Study.

OBJECTIVE: This study aimed to evaluate the effect of cognitive training programs on the progression of dementia in patients with early stage Alzheimer's disease dementia (ADD) at the day care center. METHODS: From January 2015 to December 2018, a total of 119 patients with early ADD were evaluated. All subjects were classified into two groups according to participate in cognitive training program in addition to usual standard clinical care. Changes in scores for minimental status examination-dementia screening (MMSE-DS) and clinical dementia rating-sum of boxes (CDR-SOB) during the 12 months were compared between two groups. Multivariable logistic regression analyses were performed. RESULTS: As compared to case-subjects (n=43), the MMSE-DS and CDR-SOB scores were significantly worse at 12 months in the control-subjects (n=76). A statistically significant difference between the two groups was observed due to changes in MMSE-DS (p=0.012) and CDR-SOB (p<0.001) scores. Multivariable logistic regression analysis showed that the cognitive training program (odds ratio and 95% confidence interval: 0.225, 0.070-0.725) was independently associated with less progression of ADD. CONCLUSION: The cognitive training program was associated with benefits in maintaining cognitive function for patients with earlystage ADD that were receiving medical treatment.

Computed tomography-negative symptomatic intracerebral hemorrhage in a patient with cerebral small vessel disease: A case report.

RATIONALE: Computed tomography plays a key role in the initial evaluation of suspected acute stroke by ruling out the possibility of hemorrhage before thrombolysis. Recently, many reports have described cases of symptomatic microbleeds, and there may also have been a case of computed tomography- negative intracerebral hemorrhage. PATIENT CONCERNS: A 70-year-old female patient who had a history of lacunar infarction and severe small vessel disease developed dysarthria. On brain non-contrast computed tomography there was no evidence of intracerebral hemorrhage. However, brain magnetic resonance imaging performed at 3 hours after the initial computed tomography showed cerebral hemorrhage. DIAGNOSES: The diagnosis was computed tomography-negative intracerebral hemorrhage. INTERVENTIONS: The patient was treated with cilostazole 100 mg twice a day with blood pressure management. OUTCOMES: The dysarthria was fully recovered within 5 days and the patient did not suffer recurrent stroke symptoms over the following 2 years. LESSONS: In patients with underlying severe small vessel disease and microbleeds, there could be computed tomography-negative hemorrhage and susceptibility weighted magnetic resonance image could be needed. More attention is required before applying thrombolysis therapy because there is a possibility of cerebral hemorrhage in those patients.