El ejercicio como estrategia terapéutica en la epilepsia: revisión bibliográfica / Exercise as a therapeutic strategy in epilepsy: a literature review

INTRODUCCIÓN: La epilepsia es una enfermedad neurológica común con consecuencias emocionales y físicas significativas. Hasta el 30% de los pacientes son refractarios a los fármacos antiepilépticos, por lo que se han planteado terapias no farmacológicas coadyuvantes, como la actividad física. OBJETIVO: Se realizó una búsqueda en la bibliografía sobre actividad física en personas con epilepsia, con el fin de evaluar los beneficios, potenciales efectos secundarios, el impacto en las comorbilidades, la clasificación de riesgo de cada deporte y las barreras existentes para su práctica. DESARROLLO: Múltiples modelos en animales y en humanos evalúan los beneficios del ejercicio en la epilepsia, explicados por efectos en neurotransmisores, hormonas y factores neurotróficos; además, demuestran efectos positivos en comorbilidades como la obesidad, las enfermedades cardiovasculares, la depresión y la osteoporosis. A pesar de ser una práctica que ha mostrado ser segura, las personas con epilepsia son menos activas físicamente debido a barreras que limitan su práctica. CONCLUSIONES: La actividad física es beneficiosa y segura para las personas con epilepsia. La bibliografía sugiere un mejor control de las crisis epilépticas, además de beneficios psicosociales y sobre las comorbilidades. Hay un bajo riesgo de lesiones asociadas con esta práctica. El ejercicio debería promoverse después de una evaluación clínica cuidadosa, considerando el control de crisis en el último año, posibles factores precipitantes y el tipo de deporte que se va a practicar

INTRODUCTION: Epilepsy is a common neurologic disease with emotional and physical consequences. Thirty percent of patients have drug-resistant epilepsy, therefore adjuvant non-pharmacological therapies, such as physical activity, have been proposed. AIM: This study reviews the literature about physical activity in people with epilepsy, to evaluate the benefits, potential side effects, impact on comorbidities, the risk classification of sports, and the barriers to their practice. DEVELOPMENT: Multiple animal and human models evaluate the benefits of exercise in epilepsy, explained by modulation on neurotransmitters, hormones, and neurotrophic factors. Furthermore, exercise demonstrates positive impact on comorbidities such as obesity, cardiovascular disease, depression, and osteoporosis. Despite being a practice that has been shown to be safe, people with epilepsy are less physically active due to barriers that limit their practice. CONCLUSIONS: Physical activity is beneficial and safe for people with epilepsy. Literature suggests better control of seizures, psychosocial benefits, and improvements on the comorbidities. There is a low risk of injury associated. Exercise should be promoted after a careful clinical evaluation, considering seizure control in the last year, potential triggering factors and the sport chosen

The Use of Cannabis as a Treatment for Epilepsy in Adult Patients: Are Side Effects a Limitation of Use?

Marijuana is the dried leaves, stems, and flowers of a 1- to 5-m weed originating from Central Asia. The most common varieties are Cannabis sativa and Cannabis indica. It is usually inhaled as smoke but can also be used as a vapor, taken by mouth as a spray, ingested in tea or as butter in baked goods, or in capsule form and used as an oil. Cannabis has been widely used to treat many medical conditions such as multiple sclerosis symptoms, mood disorders, pain, sleep disorders, and seizures among others. Preclinical and clinical studies have been done over the past decade, among them there are few randomized placebo-controlled trials. In the last few years, Cannabis has been proposed as a potential therapy for patients with drug-resistant epilepsy. This review analyzes the best information about the use of cannabis in adult patients, reviewing aspects of efficacy and safety.

Experience of psychogenic nonepileptic seizures in the Canadian league against epilepsy: A survey describing current practices by neurologists and epileptologists.

PURPOSE: Psychogenic nonepileptic seizures (PNES) are one of the most common differential diagnoses of epilepsy. Our objective is to describe current medical care in Canada and identify patterns of practice and service gaps. METHODS: In 2015, a 36-question survey was sent via email to the 131 members of the Canadian League Against Epilepsy. The questions were designed after literature review and discussion with the ILAE PNES Task Force. Questions were separated into 5 sections: 1) the role of the respondent and their exposure to PNES, 2) diagnostic methods, 3) management of PNES, 4) etiological factors, and 5) problems accessing health care. RESULTS: Sixty-two questionnaires were analyzed (response rate: 47%). Most respondents were epileptologists (76%). The majority of respondents personally diagnosed PNES and communicated the diagnosis to the patient, but only 55% provided follow-up within their practice and only 50% recommended or arranged treatment. Many (35%) were either unfamiliar with the diagnosis of PNES or inexperienced in arranging or offering treatment. Most (79%) provided follow-up to patients with concomitant epilepsy, but when PNES was the sole diagnosis follow-up rates were low. Although 84% of respondents felt that individualized psychological therapy was the most effective treatment, 40% of patients were not referred to psychotherapy and in most cases availability such therapy was low (30-60%). CONCLUSIONS: Canadian health professionals' understanding of PNES mostly reflects current international expert opinion. Once diagnosis is made however, the majority of patients are discharged from neurological services without appropriate psychological care.

Percepciones y actitudes de los pacientes frente a la cirugía de la epilepsia: conceptos equivocados en Colombia / Patients' perceptions of and attitudes towards epilepsy surgery: mistaken concepts in Colombia

Introducción. Los pacientes con epilepsia focal farmacorresistente se podrían beneficiar de la cirugía de la epilepsia; sin embargo, existen demoras en la realización del procedimiento. El objetivo de este estudio fue evaluar el conocimiento y las actitudes de los pacientes hacia la cirugía de epilepsia e identificar barreras que pudieran retrasar el tratamiento. Pacientes y métodos. Se aplicó un cuestionario de 10 minutos a pacientes con epilepsia en Colombia. La encuesta evaluó el conocimiento de la opción quirúrgica, las percepciones sobre el riesgo de la cirugía frente al riesgo de crisis no controladas, la discapacidad producida por la enfermedad, las metas del tratamiento y las variables demográficas y socioeconómicas. Resultados. Se seleccionaron 88 pacientes con epilepsia focal. El 56% de los pacientes no sabía que la cirugía podría ser una opción terapéutica. El 60% consideró que la cirugía de la epilepsia es muy o moderadamente peligrosa. Una gran proporción pensaba que la muerte (41%), el ictus (47%), la pérdida visual (56%), los cambios en la personalidad (56%), la parálisis (61%), las dificultades para hablar (69%) y la pérdida de la memoria (60%) eran efectos secundarios comunes. La mayoría (62%) consideraba el procedimiento como la última opción de tratamiento. Conclusiones. Existe una actitud negativa por parte de los pacientes frente a la cirugía de la epilepsia fundamentada en la sobreestimación del riesgo de adquirir déficits neurológicos secundarios al procedimiento, lo que refleja la falta de conocimiento hacia este tratamiento. Estas percepciones erróneas pueden contribuir a demoras en la atención quirúrgica

Introduction. Selected patients with drug-resistant focal epilepsy benefit from epilepsy surgery, however significant delays remain. The aim of this study was to assess knowledge and attitudes toward epilepsy surgery among patients with epilepsy and identify barriers that might delay the treatment. Patients and methods. A 10-minute questionnaire was administered to patients with epilepsy in Colombia. Survey assessed the following: knowledge of surgical options, perceptions about the risks of surgery vs. ongoing seizures, disease disability, treatment goals, and demographic and socioeconomic variables. Results. We recruited 88 patients with focal epilepsy. More than half of patients (56%) were not aware that surgery might be an option. Apprehension about epilepsy surgery was evident, 60% of patients perceived epilepsy surgery to be very or moderately dangerous. A large proportion of patients believe death (41%), stroke (47%), vision loss (56%), personality change (56%), paralysis (62%), difficulties in speaking (69%), and memory loss (60%) were frequent side effects. The majority of patients (62%) consider the surgical procedure as the last option of treatment. Conclusions. There is a negative attitude toward epilepsy surgery based on the patients' misperceptions of suffering neurological deficits during the surgery, reflecting lack of knowledge toward this type of treatment. These perceptions can contribute to delays in surgical care

Barreras de acceso a la cirugía de la epilepsia: revisión de la bibliografía / Barriers impeding access to epilepsy surgery: a review of the literature

La epilepsia farmacorresistente es una condición crónica con consecuencias a largo plazo que puede ser tratada quirúrgicamente. La eficacia y la seguridad de la cirugía de la epilepsia del lóbulo temporal se han establecido a través de un gran número de estudios de cohorte retrospectivos y prospectivos y dos ensayos clínicos controlados aleatorizados. A pesar de los excelentes resultados comunicados con la cirugía, la bibliografía sugiere que este procedimiento es un tratamiento subutilizado. Aunque no existe evidencia de esto, entre algunos de los motivos descritos se apuntan el fallo de los médicos de atención primaria y los neurólogos en proveer información, identificar y remitir a los pacientes a un centro de cirugía; los diferentes niveles de tecnología en los centros, lo que provoca distintas estrategias de selección de los candidatos; la creencia de que la cirugía de la epilepsia es un procedimiento arriesgado que debería contemplarse sólo como última opción; la preferencia del paciente por evitar la cirugía; el deseo de los padres de esperar hasta que sus hijos sean lo suficientemente mayores para participar en el proceso de toma de decisiones; el hecho de que las aseguradoras no cubran los gastos asociados con las evaluaciones prequirúrgicas o la carencia de un seguro médico, y la desigualdad racial y social, entre otros. En este artículo se revisan los datos epidemiológicos disponibles en relación con la falta de acceso a la cirugía de la epilepsia (AU)

Drug-resistant epilepsy, a chronic condition with long-term consequences can be treated with surgery. The efficacy and safety of surgery for temporal lobe epilepsy have been established through a large number of retrospective and prospective cohort studies and two randomized controlled clinical trials. Despite the excellent outcomes reported after surgery, the literature suggests that this procedure is an underutilized treatment. While evidence is lacking as to why epilepsy surgery is underused, cited reasons include: failure of primary care physicians and neurologists to provide information and identify patients who could be referred for surgery; different levels of technology at various centers, resulting in different candidate selection strategies; the belief that epilepsy surgery is a risky procedure and that it should be only viewed as the last option; patient preference to avoid surgery; parents wanting to wait until their child is old enough to participate in the decision-making process regarding surgery; unwillingness of insurers to cover the expenses associated with presurgical evaluations or lack of insurance; racial and social disparities, among others. In this paper we review the available epidemiological data about lack of utilization of epilepsy surgery (AU)

Update on Minimal Standards for Electroencephalography in Canada: A Review by the Canadian Society of Clinical Neurophysiologists.

Surface electroencephalogram (EEG) recording remains the gold standard for noninvasive assessment of electrical brain activity. It is the most efficient way to diagnose and classify epilepsy syndromes as well as define the localization of the epileptogenic zone. The EEG is useful for management decisions and for establishing prognosis in some types of epilepsy. Electroencephalography is an evolving field in which new methods are being introduced. The Canadian Society of Clinical Neurophysiologists convened an expert panel to develop new national minimal guidelines. A comprehensive evidence review was conducted. This document is organized into 10 sections, including indications, recommendations for trained personnel, EEG yield, paediatric and neonatal EEGs, laboratory minimal standards, requisitions, reports, storage, safety measures, and quality assurance.

Diagnóstico y tratamiento de la crisis epiléptica única no provocada / Diagnosis and treatment of non-triggered single epileptic seizures

Las crisis epilépticas son una de las principales causas de consulta neurológica en el servicio de urgencias. Un episodio convulsivo representa un evento traumático para el paciente y la familia, con consecuencias médicas y sociales signifi cativas. Por su prevalencia e impacto, el abordaje inicial es de vital importancia. Si bien después de una primera crisis epiléptica la recurrencia temprana disminuye con el inicio de fármacos antiepilépticos, el pronóstico para el desarrollo de epilepsia y los desenlaces a largo plazo no se alteran por ninguna intervención temprana. El interrogatorio detallado basado en la semiología del episodio, los antecedentes del paciente y un estudio completo con electroencefalograma y neuroimagen permiten defi nir el riesgo de recurrencia de la crisis y el posible diagnóstico de epilepsia. Las anormalidades epilépticas, la presencia de lesiones cerebrales con potencial epileptógeno antiguas o nuevas, así como las crisis nocturnas, incrementan el riesgo de recurrencia. Los médicos deben evaluar a cada paciente de manera individual para determinar un tratamiento idóneo, explicando el riesgo de no tratar frente al riesgo existente con el inicio de fármacos antiepilépticos (AU)

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 signifi cant medical and social consequences. Due to their prevalence and impact, the initial management is of vital importance. Although following the fi rst epileptic seizure, early recurrence diminishes after establishing treatment with antiepileptic drugs, the forecast for developing epilepsy and longterm 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 defi ne 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 (AU)

Clinical Benefit of 3 Tesla Magnetic Resonance Imaging Rescanning in Patients With Focal Epilepsy and Negative 1.5 Tesla Magnetic Resonance Imaging.

BACKGROUND: Magnetic resonance imaging is an essential tool in the pre-surgical evaluation of patients with drug-resistant epilepsy. OBJECTIVE: Our aim was to assess the value of re-imaging patients with focal drug-resistant epilepsy. METHODS: Thirty patients with negative or non-conclusive 1.5 Tesla magnetic resonance imaging were rescanned with 1.5T and 3T. All of them had previous 1.5 scans with no seizure protocol in a non-specialized center. Two neuroradiologists who were blinded to prior imaging results randomly reviewed the magnetic resonance images. Kappa score was used to assess the reliability. RESULTS: Mean age of patients was 30 (SD ± 11) years. The intra-observer agreement for the first radiologist was 0.74 for 1.5T and 0.71 for 3T. In the second radiologist it was 0.82 and 0.66, respectively. Three lesions (10%) were identified by general radiologists in non-specialized centers using a 1.5T standard protocol. In our center a consensus between two neuroradiologists using epilepsy protocol identified seven lesions (23%) using 1.5T and 10 (33%) using 3T (p < 0.01). In 28% of patients this additional information resulted in a change in clinical management. CONCLUSIONS: 3T magnetic resonance imaging rescanning improves the diagnostic yield in patients with focal epilepsy and previous negative 1.5T magnetic resonance imaging. Use of 3T magnetic resonance imaging, epilepsy protocols, and interpretation by experienced neuroradiologists is highly recommended.

Diagnostic yield of the palmomental reflex in patients with suspected frontal lesion.

BACKGROUND: The purpose of this study was to determine the diagnostic value of the palmomental reflex in order to identify frontal lesions in neurological outpatients. METHODS: Two hundred twenty-six neurological patients with suspected intracranial lesion with an indication for magnetic resonance imaging (MRI) were included. All patients underwent the same MRI protocol. The reflex was elicited by trained and standardized nurses, and was evaluated by two neurologists. The evaluation was blind and independent. The test's accuracy was calculated. The Kappa coefficient was used to calculate the interobserver and intra-observer reliability. RESULTS: The interobserver reliability between neurologists was 0.53 with 93% of agreement (p<0.001). The diagnostic accuracy measures were as follow: sensitivity of 19%, specificity of 93%, positive predictive value of 30%, negative predictive value of 88%, positive likelihood ratio of 2.7 and negative likelihood ratio of 0.87. The area under the curve was 0.56. CONCLUSION: The palmomental reflex is associated with frontal structural lesions but the sensitivity is low, indicating a high percentage of frontal lesions with a negative reflex. When the test is used on its own, it is insufficient to detect frontal damage.

Obesity and its association with generalised epilepsy, idiopathic syndrome, and family history of epilepsy.

Aim. Previous studies support the concept that obesity is a common comorbid condition in patients with epilepsy (PWE). In this study, we present the body mass index (BMI) and data from a survey to assess physical activity in a sample of PWE from an epilepsy clinic. Methods. Between June of 2011 and January of 2013, 100 PWE from an adult epilepsy clinic were included. We obtained BMI, waist circumference, and information regarding physical activity using a standardised questionnaire. Clinical, demographic, electrographic, and imaging parameters were collected from charts. Results. Mean age of patients was 40 ± 14 (18-77) years. The BMI distribution was as follows: 2 patients (2%) underweight, 26 (26%) normal weight, 34 (34%) overweight, 25 (25%) obese, and 13 (13%) with morbid obesity. In our study, obesity was defined as having a BMI ≥ 30. We found 38 (38%) patients in this range. There was no difference in the rate of drug-resistant epilepsy between obese and non-obese patients (55 vs. 55%; p=0.05). Leisure time habit was reported in 82% of obese patients and 79% of patients without obesity. Overall, the most frequent activity was walking (70%). Factors associated with obesity were generalised epilepsy (OR: 2.7, 1.1-6.6; p=0.012), idiopathic syndrome (OR: 2.7, 1.04-7; p=0.018), and family history of epilepsy (OR: 6.1, 1.5-24.2; p=0.002). Conclusion. Our study suggests an association between obesity, idiopathic generalised epilepsy, and family history of epilepsy. Our study shows that PWE are physically active and there is no clear relation between exercise and obesity. We could not identify any association between drug-resistant epilepsy and obesity. Absence of direct comparison with a control non-epileptic population; a cross-sectional design not allowing evaluation of a causal association among variables; and reliance on self-reported physical activity are to be considered as limitations of the present study.

Management of antiepileptic drugs following epilepsy surgery: a meta-analysis.

OBJECTIVE: No consensus exists regarding the management of antiepileptic drugs (AEDs) after successful epilepsy surgery (ES). We performed a meta-analysis with the most relevant evidence in this topic. Our aim was to provide evidence-based estimates of results on AEDs discontinuation after ES. METHODS: We searched MEDLINE and Embase using Medical Subject Headings and keywords related to AEDs discontinuation after ES. Two reviewers independently applied the following inclusion criteria: original published research that directly compared seizure outcomes in patients having or not AEDs discontinuation after ES. Two investigators independently extracted data, resolving disagreements through discussion. A random and fixed-effect model was used to derive a pooled odds ratio (OR) for either seizure recurrence in both groups. RESULTS: Of 257 abstracts initially identified by the search, 57 were reviewed as full text. Sixteen articles fulfilled eligibility criteria and described outcomes in 1456 patients with AEDs discontinuation and 685 patients with no discontinuation. The odds of having seizure recurrence after AEDs discontinuation was 0.39 times lower in patients with attempted discontinuation after surgery (OR 0.39, CI 95% 0.300-0.507, p<0.001). Most likely the difference is related with a selected population where discontinuation was attempted. SIGNIFICANCE: Seizure recurrence was higher for patients without AED modification than for the withdrawal group. Patients with seizure recurrence after discontinuation can be managed easily after re-start of medications. The discontinuation of medications should be done in good candidates and the decision should be individualized taking into account clinical, electrographical, imaging and histopathological variables.