Patient Preferences for Treatment of Anxiety and Depression in an Adult Epilepsy Clinic
While survey data recommends equipoise between epileptologists for treating anxiety and/or depression through prescribing in the epilepsy clinic versus psychiatry referral, however, the patient therapy priorities are unknown. Clary HM, presented a study in a session at 145th annual meeting of the American Neurological Association (ANA) 2020: Virtual meeting which analysed preference for anxiety and/or depression therapy by neurologists versus psychiatrists in a symptomatic epilepsy clinic sample.
In an adult tertiary care epilepsy clinic, treatment preferences were surveyed for anxiety and/or depression. Individuals who screened positive for anxiety and/or depression on ascertained instruments through a prospective, dual research and clinical screening protocol were recruited. Demographics, social variables, psychiatric treatment history, and therapy priorities and preferences were gathered. Preference was described as a slightly higher than 2:1 ratio in favor neurology or psychiatry; this primary objective was evaluated with a two-sample binomial test. Multinomial logistic regression was performed to analyse a priori multivariable model of therapy preference (secondary objective).
63 symptomatic adults, with 64% women and mean age 42.2 years were included in the study sample. Most patients outlined some past or current therapy for anxiety and/or depression, and therapy for these symptoms was a high or moderate priority in the 65% of the sample. Neurologist medication treatment was preferred nearly 5:1 across psychiatry referral in those who chose neurology or psychiatry (as opposed to neither of the two; p<0.0001, 95% CI 0.702-0.919; 83% of 53). Neither therapy was preferred by multivariable modelling (compared to neurologist treatment), was correlated with low overall therapy prioritization and having never acquired neurologist medication treatment.
Patients showed a strong preference for neurologists to treat anxiety and depression in the epilepsy clinic in this cross-sectional sample.
Rolandic Epilepsy is a Risk for Delay in Development of Visuospatial Functions and Kinesthetic Praxis in Children
One of the most frequent forms of epilepsy in children is benign epileptiform discharges of childhood (BEDC). There are controversies about influences of this epilepsy on the neurocognitive abilities in children. Hence, it is essential to do further researchers for clarifying this impact. th Kiselev S, presented a study in a session at 145th annual meeting of the American Neurological Association (ANA) 2020: Virtual meeting which explained the impact of rolandic epilepsy on neurocognitive abilities in children at the age of 7-8.
21 children with Rolandic epilepsy were included in the experimental group (M = 7.45 years, SD = 0.75, 17 boys and 4 girls) and 21 typically developing children were included in the control group. Children from experimental and control group were matched for gender and age. Luria’s neuropsychological assessment battery was used to analyse children from both groups. Battery comprise of 16 subtests which outlined to analyse 5 neurocognitive domains – visuospatial functions, memory, sensorimotor functions, language and executive abilities. One-way analysis of variance (ANOVA) was used for disclosing group differences in the execution of subtests.
A substantial difference (p≤ 0.05) was shown among groups for performance of 3 neuropsychological subtests which outlined to analyse visuospatial functions (head subtest, mental rotation, design copying), and for performance of subtest for evaluation of kinesthetic praxis. Children with rolandic epilepsy executed these subtests worse as compared to typically developing children.
Rolandic epilepsy leads to delay in the enhancement of visuospatial abilities and kinesthetic praxis in children at the age of 7-8. But, further research is needed for showing the impact of rolandic epilepsy on neurocognitive development of children. Especially, longitudinal analysis of children with this epilepsy can be done one year later.
A Rare Case of Autonomic Epilepsy
Autonomic seizures are focal non-motor seizures that predominantly impact the central autonomic network. Idiculla PS, presented a study in a session at 145th annual meeting of the American Neurological Association (ANA) 2020: Virtual meeting which yielded a descriptive review of autoimmune epilepsy with more focus on the clinical features of the condition; along with an illustrative case report.
A 71-year-old female, with a past medical history of hypertension admitted to the clinic with episodes of ‘syncope’ that initiated 24 years ago, after a concussion from a motor vehicle collision. Nevertheless, the occurrence of her spells had enhanced across the past 15 years, it almost always happened in the middle of the night and are stereotypical. Each spell initiated with a feeling of hot sensation, nausea, and the urge to have a bowel movement. On getting out of bed, she feels dizzy and sweats extremely which she outlined as ‘drenching’. She vomits or has a bowel movement later wakes up on the bathroom floor with no memory of what happened. She feels dizzy on retrieving consciousness, however makes it to her bed, falls asleep, and feels tired all over the following day. Her daughter witnessed her last spell on an afternoon and the whole episode lasted 2-5 minutes, correlated with bladder incontinence. Her neurological analysis was unremarkable and workup incorporating extended 1-hour video electroencephalogram (EEG) was normal. Magnetic resonance imaging (MRI) of the brain without contrast exhibited bilateral parenchymal volume loss in the hippocampi and mesial temporal lobes with prominent temporal horns. She was diagnosed with autonomic epilepsy and managed traditionally with oral levetiracetam. The keyword ‘autonomic seizures’ was used for the literature search on PubMed. Studies in the english language literature were definitively evaluated for the review.
1. The international league against epilepsy (ILAE) 2017 categorised autonomic seizures as non-motor focal seizures. 2. Manifestations – changes in blood pressure, heart rate; gastrointestinal and respiratory symptoms; pallor, flushing, piloerection, and sweating; urinary symptoms; sexual auras, and sexual automatisms. 3. Diagnosis is clinical and evidence-based guidelines for treatment are inaccessible. 4. Epilepsy surgery is recommended in cases with uncontrolled seizures. 5. Seizure control is imperative to inhibit sudden unexplained death.
Autonomic epilepsy is diagnosed if the primary manifestation is autonomic symptoms with or without deterioration of consciousness. Recognition is crucial, anti-epileptic medications are efficacious and seizure control is significant to inhibit complications like sudden unexplained death.
The Effect of Human Herpes Virus 6 on Hippocampal Volumes in Temporal Lobe Epilepsy
A mesial temporal sclerosis (MTS) is the most frequent pathology in mesial temporal lobe epilepsy (MTLE) and one of the most frequent drug-resistant epilepsy syndromes, characterized by focal gliosis and neuronal loss. Several studies have brought confirmation about persistent human herpes virus 6 (HHV-6) replication in resections of MTLE/MTS patients. Theodore W, presented a study in a session at 145th annual meeting of the American Neurological Association (ANA) 2020: Virtual meeting which analysed patterns of hippocampal volume loss in a prospective case series of 41 patients (19 men) who had temporal lobectomy and estimation of HHV-6 in resected hippocampal tissue.
Mean age of seizure onset, presurgical epilepsy duration, and age at surgery were 10.07, 24.96, and 35.03 years respectively. Viral deoxyribonucleic acid (DNA) was diagnosed through real-time and digital droplet polymerase chain reaction (PCR). Freesufer 6.0 was used to measure hippocampal volumes. The volumes among patients with and without confirmation for persistent HHV-6 viral DNA replication was compared with statistical package for the social sciences (SPSS) in resected surgical specimens. Statistical analyses by SPSS incorporated student’s T-test for independent sample means and examination of variance. Significance was set at p<0.05. 22 HHV-6 positive and 19 negative patients were noticed. Mean hippocampal volume ipsilateral to the seizure focus was decreased in those without HHV-6 as compared to with HHV6 (2618.21 vs. 3122.80, p=0.01). HHV-6 negative patients showed uniformly lower ipsilateral/contralateral ratios for whole hippocampal and subfield volumes as compared to HHV-6 positive patients (p=0.02). HHV6-negative exhibited 29.53 of pre-surgical epilepsy duration and 21.36 for HHV-6 positive patients (p=0.02). But, only HHV-6 status showed a substantial impact on hippocampal volume in multivariate examination.
A multiple prospective etiologies were recommended for MTS. HHV-6 negative hippocampi showed substantially higher preoperative atrophy as compared to hippocampi positive for virus. HHV-6 may have a less acute impact on hippocampus as compared to other etiologies.
Risk Factors Associated with Hyperammonemia Following Unprovoked Convulsive Seizures – Systematic Literature Review
Hyperammonemia has been described in correlation with generalized convulsive seizures. Thus, serum ammonia levels have been frequently used in the emergency department to differentiate convulsive seizures from nonconvulsive and non-epileptic seizures, as it is a low-priced, and easily available test. An ammonia levels have been estimated in several studies, for patients presenting with seizures. Karim N, presented a study in a session at 145th annual meeting of the American Neurological Association (ANA) 2020: Virtual meeting which reviewed the first systematic literature in an effort to discover a correlation among hyperammonemia for an unprovoked convulsive seizure and potential correlations, with the hope of explaining the true diagnostic value of a serum ammonia level.
The preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines were used for the systemic review of the PubMed database. Keywords used to describe the search incorporated: “seizure” and “hyperammonemia”. 302 Studies were detected. Case reports, studies in which patients were on valproic acid, literature reviews, pediatric, non-English, and animal studies were excluded. Studies that targeted on patients with underlying metabolic disorders or malignancies that predisposed them to seizures were also excluded. 4 studies met the inclusion criteria. The hyperammonemia group showed higher proportion of males as compared to females (77.4% vs. 22.5%, respectively, p < 0.0001). But, the non-hyperammonemia group showed no difference in the proportion of males or females (51.8% vs. 48.1%, respectively, p = 0.38978). The difference in average ammonia levels in patients with unprovoked seizures were deliberately with the aid of two studies. As expected, the hyperammonemia patients with convulsive seizures showed a substantially higher ammonia level (p = 0.02561) as compared to the non-hyperammonemia group. Because of limitations in the number of studies, an investigation could not be performed on differences in ammonia levels among convulsive vs. non-convulsive seizures.
Review of the literature recommends that male patients with unprovoked convulsive seizures showed greater ammonia levels. The diagnostic role of prospective ammonia levels was affirmed in this review; however, is limited by the lack of studies that have followed these patient groups over time. To estimate the role of ammonia in severe patients with epilepsy, further examination is warranted.
Non-convulsive Seizure as Initial Manifestation of Posterior Reversible Encephalopathy Syndrome (PRES)
Tariq M, presented a study in a session at 145th annual meeting of the American Neurological Association (ANA) 2020: Virtual meeting which analysed whether non-convulsive seizure is an initial indication of posterior reversible encephalopathy syndrome (PRES). PRES is typically subacute at onset and distinguished by impaired consciousness, headache, vision abnormalities, seizures, nausea, vomiting, and focal neurological symptoms. Impairment of consciousness may vary in extremity from confusion, somnolence, and lethargy to encephalopathy or coma. Nonconvulsive seizure is distinguished by electrographic seizure activity on electroencephalogram (EEG) correlated with minimal or no motor activities, typically with correlated modification of awareness. It is very significant to know that PRES patients with impaired consciousness may show nonconvulsive seizure activity, which may be mistaken frequently for postictal confusion or changed mental status because of other causes.
A 34-year-old female with history of morbid obesity, hypertension (HTN), type 2 diabetes mellitus (T2DM), chronic kidney disease (CKD) presented with acute mountain sickness (AMS) in the setting of uncontrolled HTN, hyperglycemia & acute kidney injury (AKI) on CKD. As per mother, patient had problem of headaches, nausea, and vomiting for the last week. In emergency department (ED), blood pressure (BP) was 261/142, and labs exhibited sodium (Na) 129 mmol/L, potassium (K) 5.1 mmol/L, glucose 516 mg/dL, carbon dioxide (CO ) 21 mmol/L, chromium (Cr) 2.39 mg/dL, 2 glycated hemoglobin (HbA1c) 12.1%, lactic acid 1.26 mmol/L, prerenal AKI, and metabolic acidosis. Urine drug screen (UDS) was negative. Chest X-ray (CXR) and urinanalysis (UA) were normal. Coronavirus disease (COVID) test was negative. Computed tomography (CT) of the head showed no acute intracranial pathology. Analysis was substantial for A&Ox0, not following commands, no blink to threat bilaterally, pupillary reflexes sluggish, and intermittent withdrawal to pain on all extremities. Magnetic resonance imaging (MRI) exhibited diffusion-weighted imaging (DWI) signal abnormality in the bilateral parieto-occipital regions. Magnetic resonance angiography (MRA) was unremarkable. Infectious workup was negative. Mentation did not enhance with BP control and glycemic control. EEG exhibited focal nonconvulsive seizure movement in the right temporo-occipital region. Phenytoin was then started, and consequently the electrographic seizure activity stopped, coexisting with substantial enhancement in mentation. She was A&Ox2 with no agitation by the next day.
CKD and AKI are both frequently present in patients with PRES. It is necessary to consider PRES in the differential diagnosis in a patient with renal disease, HTN, and quickly developing neurologic symptoms. Patients may present with nonconvulsive seizure activity providing to modification of awareness. It was outlined that nonconvulsive seizure happened in 3 out of 46 patients with PRES. Nonconvulsive status should be suspected in patients with prolonged conditions of modified consciousness. The patient’s mentation was enhanced following therapy of her nonconvulsive seizure activity. Hence, timely diagnosis and therapy of nonconvulsive seizure activity are necessary for patient recovery in addition to optimal BP treatment.
A Case Report of Mesial Temporal Lobe Epilepsy Misdiagnosed as Cyclic Vomiting Syndrome
Patients with mesial temporal lobe seizures often present with diminished consciousness or memory. Aura, ictal automatisms, and changes in heart rate are well-known characteristics of mesial temporal lobe seizures. However, unusual presentations of seizures of the mesial temporal lobe can easily be misdiagnosed or mistaken for other medical etiologies. Chang MM, presented a study in a session at 145th annual meeting of the American Neurological Association (ANA) 2020: Virtual meeting which present the case of a young woman with a repetitive vomiting right hemispheric seizure and an initial diagnosis of cyclic vomiting syndrome.
Case: With her third lifelong generalized seizure, a 31-year-old Caucasian female previously diagnosed with cyclic vomiting syndrome with no official diagnosis of epilepsy presented to the hospital. This was followed by what the patient described as intractable nausea and vomiting for several days. She recorded that she had recurring bouts of nausea and vomiting every few months for most of adulthood, each of which would last for around one to two weeks. She self-medicated with marijuana during these periods to help alleviate her symptoms. She was found to have a low serum phosphate level on initial examination and her seizure was presumed to be secondary to electrolyte derangements.
On continuous electroencephalogram (EEG), she was tracked, and her electrolytes were corrected to within normal limits. Even after electrolyte repletion, however, a total of 15 seizures that occurred over the right cerebral hemisphere were electrographically captured within 48 hours, all of which were highest in the temporal zone. Clinically, some of these incidents were associated with lip smacking and extreme nausea. She underwent brain magnetic resonance imaging (MRI) with and without comparison, which showed that the right hippocampus provided an increased T2 fluid attenuated inversion recovery (FLAIR) signal. She was initiated on levetiracetam and lacosamide. To date, her seizures have not recurred.
Temporal lobe seizures can have extremely variable symptoms and may be misdiagnosed, which can lead to a lack of effective care for many years. Current literature states that temporal seizures and usually non-dominant lateralization are correlated with ictal emesis. Owing to stereotypical episodes of vomiting and marijuana use, the previously described patient was diagnosed with cyclic vomiting syndrome. To allow for earlier diagnosis and care, it is important to include epileptic seizures on the list of potential diagnoses in patients with otherwise unexplained nausea and vomiting.
Clinical, Radiographic, and Electroencephalographic Findings of Seizures Associated with Stroke: A Retrospective Study
Cerebrovascular disorder is a frequent cause of seizures, mainly in older adults. Data from the stroke registry exhibited that 5-20% patients with stroke progress to seizures. Saleem S, presented a study in a session at 145th annual meeting of the American Neurological Association (ANA) 2020: Virtual meeting which analysed the clinical, radiographic, and electroencephalographic (EEG) findings and results of patients with seizures correlated with stroke. This is a retrospective study of database for patients analysed among 2017-19 in comprehensive stroke and epilepsy center. Early-onset seizures were described as seizure incident in the first 7 days following stroke, and late onset following 7 or more days. Based on age, type of stroke (ischemic vs. hemorrhagic), location (cortical vs. subcortical), the data was stratified and the vascular territory entailed was based on careful review of available imaging studies.
Total 1665 patients with seizures were enrolled in the study from the epilepsy database, 135 (8.10%) patients showed post-stroke seizures. The mean age was 64.17±15.86 years, with 51.12% men and 49.83% women and the median age of seizure onset was 55.45±18.68 years. 8.14% patients showed early-onset and 91.85% patients showed late-onset seizures. 73.33% patients had ischemic stroke, 22.96% patients had hemorrhagic stroke, and 2.22% of patients had ischemic stroke with hemorrhagic transformation per European cooperative acute stroke study (ECASS) III classification. 66.6% patients showed only cortical involvement, 18.51% showed both cortical and sub-cortical involvement, whereas 12.59% patients were unknown. In 73.33% patients, location of the stroke was middle cerebral artery (MCA), followed with 17.77% patients had anterior cerebral artery (ACA) and 11.11% patients had posterior cerebral artery (PCA). 62.96% patients showed focal seizures, and 36.29% patients showed focal to bilateral tonic-clonic. Lobar involvement based on EEG findings were temporal in 50.37%, frontal in 22.22%, parietal in 5.91% and occipital in 2.22% patients. EEG findings in these patients were focal slowing in 5.18% and generalized slowing in 27.40%. 34.81% patients showed focal epileptiform activity. 32.59% patients had normal EEG. Approximately 83% of patients were not well controlled and 26.6% patients reached the criteria for intractable epilepsy. Only 17.03% accomplished seizure freedom. About 4.24% patients showed status epilepticus.
Cerebrovascular disorder is a frequent cause of seizures incorporating approximately 8% of patients in the database. Most patients showed late onset of seizures (mean duration 10.1 years). Focal seizures were the most frequent type and temporal lobe involvement was most frequently noted in patients with seizures. The result of post-stroke seizures was poor as only 17% of patients accomplished a seizure free state.
Repetitive Transcranial Magnetic Stimulation to Assess Cortical Plasticity & Suppress Spikes in Pediatric Epilepsy
Children with benign epilepsy with centrotemporal spikes (BECTS), the most common pediatric epilepsy condition, have a mild seizure disorder but have moderate language problems, which are generally unexplained in pathophysiology. Many claim that interictal epileptiform discharges (IEDs) resulting from one or both motor cortices, likely by driving atypical interactions between the motor and language networks, disrupt language production. A special method for researching brain dynamics is transcranial magnetic stimulation combined with electromyography and electroencephalography (TMS-EMG, TMS-EEG) that directly tests the downstream effect of the stimulated cortex. In addition, repetitive trains of TMS (rTMS) cause focal changes in cortical excitability and are therefore a possible treatment for IEDs. Baumer F, presented a study in a session at 145th annual meeting of the American Neurological Association (ANA) 2020: Virtual meeting which piloted the use of TMS-EMG-EEG in children with BECTS to evaluate whether the motor cortex’s electrophysiological properties correlate with language function and to determine whether rTMS reduces IEDs.
Intelligence quotient (IQ), concentration, and language learning (California Verbal Learning Task- Edition) children’s tests were performed by nine right-handed children with BECTS. Then the children were exposed to TMS-EMG-EEG of the left motor cortex. The TMS-EEG evoked potential (TEP) baseline amplitude was measured and then 1 Hz rTMS was applied to induce long-term depression (LTD)-like changes. To measure use-dependent plasticity, post-rTMS TEP amplitudes were compared with pre-rTMS amplitudes and assessed whether plasticity correlated with learning scores. Finally, 10 minutes before and after rTMS, IEDs were counted in order to test the impact of rTMS on IED frequency.
TMS was tolerated by children with BECTS; no seizures were provoked. Also after correcting for full-scale IQ or attention, rTMS-induced shifts in TEP amplitude correlated strongly with scores on the language learning task (r= 0.71, p=0.03). During the baseline era, 6 children had IEDs; the other 3 did not have IEDs before or after rTMS. Five out of six children had a decrease in the frequency of IEDs after rTMS (reduction of 1-92 IEDs/10 minutes) and one child had an increase (increase of 49 IEDs/10 minutes); the infant had only right-sided discharges with the increase, while the other children had left-sided or bilateral IEDs.
For children with BECTS, TMS is safe and feasible. Motor cortex plasticity not only predicts motor learning but also language learning, suggesting a mechanism by which seizures of the motor cortex can interfere with the development of language. TMS-EEG-based connectivity measurements will be used in future studies to evaluate the effect of IEDs on connectivity and to more definitively assess whether rTMS decreases IEDs in BECTS.
Risk Factors for Diagnosis of Seizure in the Inpatient Stroke Code Population
An inpatient stroke code (ISC) is activated if an acute neurological incident is considered in a hospitalized patient. Even though the primary aim of an ISC is to quickly respond to a prospective stroke interference case, anecdotal observation recommends that this pathway is activated for any acute neurological change. Emmerson D, presented a study in a session at 145th annual meeting of the American Neurological Association (ANA) 2020: Virtual meeting which analysed the risk factors for the diagnosis of seizures as it is vital to rapidly distinguish among stroke, seizure and other diagnoses in order to assign diagnostic and curative resources properly. It was hypotheses that an independent predictors of seizure can be recognised within the ISC patient population. An institutional review board (IRB) approved, retrospective examination of potentially acquired data was executed for all ISCs in March 2017 and May 2018. Patients were recognised based on chart review, diagnosis code, and electroencephalogram (EEG) findings for the diagnosis of seizure. These were compared to all others. Variables of interest incorporated demographics, comorbidities, and potential clinical risk factors. A continuous data was obtained using Wilcoxon ranked sum tests and Chi-square tests of proportion or Fisher’s exact test (for low expected frequencies) for categorical.
21 patients out of 211 inpatient stroke codes, were diagnosed with seizure as well as 75 patients with stroke and 115 with other diagnoses. Patients with seizure were younger, (median age 66 vs. 72; p= 0.038); showed a shorter time after last seen normal (15 vs. 60 minutes (p=0.025) and were more likely to show decreased consciousness (85.7% vs. 61.1%; p=0.026), unconsciousness (61.9% vs. 11.6%; p <0.001), gaze deviation (28.6% vs. 5.8%; p=0.003), aphasia (76.2% vs. 43.7%, p=0.005), or motor weakness (81% vs. 56.3%, p=0.03). None of the 21 patients with seizure showed an acute stroke on imaging. Gender, diabetes, dialysis within 6 hours, sedative use, antiplatelet treatment, increased level of care, neglect, dysarthria, sensory symptoms, ataxia, facial droop, dizziness, blood glucose abnormalities, and blood pressure did not substantially anticipated seizure.
Patients having a seizure or other acute event that was not a stroke showed a substantial portion of ISC responses. Patients with seizure were younger and showed shorter time interval after last seen normal. Patients with seizure were substantially more likely to show reduced level of consciousness, unconsciousness, gaze deviation, aphasia, and motor weakness as compared to other diagnoses. This data will lead future enhancement projects with goals of making quick accurate diagnosis, lead appropriate response and therapy, and eventually enhance results of hospitalized patients with acute neurological incident.
