Poststroke Seizures May Mimic Stroke Recurrence and Should Be Examined Carefully for Appropriate Treatment

Epileptic seizures with postictal negative symptoms represent 20% of all suspected strokes and should be considered in the differential diagnosis of stroke in any patient presenting with an acute neurological deficit, mostly in absence of convulsions.

Seizures may also occur at stroke onset, and the latter need to be promptly recognized in order to timely administer reperfusion therapies and reduce the risk of irreversible brain injury. Neuroimaging is essential in differentiating between postictal negative symptoms and deficits due to stroke.

Poststroke seizures may worsen or cause the reappearance of neurological deficits and consciousness impairment; they can be also misinterpreted as stroke recurrence and lead to delayed treatment with antiepileptic drugs. It is mandatory to maintain a low threshold for suspecting epileptic seizures, and require appropriate electroencephalographic and neuroimaging investigations to promptly ascertain the etiology of any unexplained change in the neurological status and provide the most adequate treatment.

This article is part of the Special Issue “Seizures & Stroke”.

Migraine Comorbidity in New Focal Epilepsy Not Associated With Cognitive Impairment

Among those with new onset focal epilepsy, migraine comorbidity has shown no correlation with objective cognitive scores, according to a study published in Epilepsy and Behavior. Symptoms of depression and anxiety may have a mediating effect on the association between subjective memory deficit and migraine comorbidity among those with epilepsy and comorbid migraine.

This post hoc analysis included 349 participants with newly diagnosed focal epilepsy, all of whom were recruited for the Human Epilepsy Project. Participants were screened for migraine via the 13-question American Migraine Prevalence and Prevention (AMPP) study, for anxiety via the Generalized Anxiety Disorder-7 scale, and for depression via the Center for Epidemiologic Studies Depression Scale and Neurological Disorder Depression Inventory for Epilepsy. The Cogstate Brief Battery and Aldenkamp–Baker Neuropsychological Assessment Schedule (ABNAS) was used to assess cognition.

Migraine was diagnosed among 21.2% (n=74) of those with focal epilepsy. Compared with participants without comorbid migraine, those with migraine were more likely to be women (75.7% vs 55.6%; P = .0018), less likely to have full-time employment (50% vs 66.2%; P = .011), more likely to have symptoms of depression (P = .0037), and more likely to have symptoms of anxiety (P = .039), although anxiety was minimally reported. An association was also identified between migraine comorbidity and ABNAS memory score (P = .015), though no association was found between migraine comorbidity and Cogstate or ABNAS total/domain scores. ABNAS memory score was associated with depression (beta 0.16; significance 0.028) and anxiety (beta 0.37; significance 2.06E-7).

Limitations of this study included post hoc design, reliance on questionnaires for diagnosis, lack of accounting for migraine aura, and lack of data on antiepileptic medications and headache/seizure frequency.

Systematic Review Highlights the Value of the Epilepsy Specialist Nurse to Patients, Families and Other Health Care Professionals

Epilepsy Specialist Nurses (ESNs) have been called ‘the glue that connects services to people with epilepsy’. They are in an ideal position to act as an expert resource and point of first contact for patients, carers and professionals alike. ESN roles are diverse across the three main sub-specialties: adult, pediatrics and learning disability. ESN involvement in epilepsy surgery pathways and multi-disciplinary teams has been identified as essential. Despite this, ESNs are still seen as an expensive luxury in some areas, with wide, geographical discrepancies in UK service provision.

The ESPENTE study creates much needed context to the argument for the development of the ESN as an integral part of the care provided to people with epilepsy, their family and carers. It provides a critical review of the available evidence and, most importantly, highlights the limitations of the current, published literature, while identifying priorities for future studies. This study provides a sound basis for nurses and academics, planning empirical studies to examine the effectiveness and impact of ESN roles in the future.

Status Epilepticus in Pregnancy: Large-Scale Multicenter Studies Suggested to Create a Uniform Treatment Protocol

BACKGROUND: There is lack of uniform treatment protocol for status epilepticus (SE) in pregnancy, with majority of data being limited to individual cases or case series. Devising a uniform treatment protocol will facilitate prompt control of SE in pregnancy and reduce adverse maternal and fetal outcomes.

METHODS: Literature search was done in various databases including PubMed, CINAHL, EMBASE, TRIP, and the gray literature, including relevant organizational websites, for the topics “Status Epilepticus” and “Pregnancy”. English language original research articles, case reports, and systematic reviews that were published in the last 18 years (2000-2018) and addressed SE in relation to pregnancy (i.e., antepartum, labor, or postpartum) were considered for inclusion.

RESULTS: Over the past 15 years, a total of seven articles reporting 29 cases of SE related to pregnancy, satisfying the inclusion criteria were analyzed. The most common cause of SE was posterior reversible encephalopathy syndrome (PRES)/reversible cerebral vasoconstriction syndrome (RCVS) spectrum (n = 11, 38%), followed by cortical venous sinus thrombosis (CVT) and autoimmune encephalitis (n = 5, 17%). Twenty-three out of 29 cases (79%) had good maternal outcomes in terms of recovery to baseline. Seventeen fetuses (58%) were delivered at term and seven at preterm (2.4%). First-line agent used was lorazepam in 15 patients (52%) and midazolam in two patients (7%). The most common antiepileptic drug (AED) and anesthesia used for treatment of SE and refractory SE were phenytoin/fosphenytoin (n = 21, 72%) and midazolam (n = 12, 52%), respectively. In all cases due to eclampsia (n = 5), magnesium sulfate was the preferred first-line drug.

CONCLUSION: Management of status epilepticus [SE] in pregnancy is influenced by etiology [cause] of SE and duration of pregnancy. It carries a good prognosis if detected early and treated appropriately. Large-scale multicentric studies are warranted for formulating definite guidelines for management of SE in pregnancy.

Why Do Some Women with Epilepsy Use Valproic Acid Despite Current Guidelines? A Single-Center Cohort Study

OBJECTIVE: Current guidelines and regulations strongly discourage the use of valproic acid (VPA) in women of childbearing age because of the risk of congenital malformations and neurodevelopmental disability in children exposed to VPA in utero. Our goal was to establish the reasons for continued use of VPA in a cohort of women with epilepsy (WWE) and to characterize the subgroup of WWE who do not consent to withdraw VPA despite potential risks.

MATERIAL AND METHODS: The study included consecutive adult premenopausal WWE who visited an outpatient epilepsy clinic between April 2017 and March 2018. Data on demographics (age, age at onset of epilepsy), characteristics of epilepsy (types and frequency of seizures), and its treatment were collected from medical records and seizure diaries. All WWE taking VPA were regularly informed about VPA-related risks and had the opportunity to discuss the withdrawal of VPA.

RESULTS: The study involved 353 WWE (mean age: 31.7 years). Focal epilepsy was diagnosed in 244 (69.1%) patients; 180 (51.0%) women had no seizures during last 12 months before the study visit, and 228 patients (64.6%) were on monotherapy. A total of 146 (41.3%) patients used VPA in the past, and 98 (27.8%) never used VPA. Of women who were currently on VPA (n = 109, 30.9%), 30 had concurrent severe disabilities that would make future pregnancy extremely unlikely, in further 15 patients, VPA was recommenced because of failure of alternative treatment and 64 women did not accept the plan of VPA withdrawal. Women currently on VPA were more likely to have genetic generalized epilepsy and to be on monotherapy (both p << 0.001). Among 64 WWE who decided to continue therapy with VPA, 35 (55.5%) had generalized epilepsy and 35 (55.5%) were in remission, 27 (42.2%) had at least one child, 9 (14.1%) planned to have a child in the near future but only 15 (23.4%) used effective contraception.

CONCLUSION: Treatment with valproic acid is unavoidable in many women with epilepsy of childbearing age despite recent regulations. About 60% of women with epilepsy currently treated with valproic acid do not consent to withdraw valproic acid treatment after thorough consideration of potential risks and other 40% use VPA because pregnancy is highly unlikely and/or other treatments failed.

Persons With Alzheimer’s Disease More Likely To Experience Recurring Epileptic Seizures

Individuals living with Alzheimer’s disease experience epileptic seizures up to six-and-a-half times more often than people without dementia, according to new research reported at the Alzheimer’s Association International Conference (AAIC) 2019 in Los Angeles. Also reported at AAIC 2019, persons with dementia are at higher risk of having recurring seizures and of experiencing seizures for the first time at a younger age, compared to people without dementia.

“There appears to be a mechanism at work that puts people living with dementia at higher risk and recurrence of all types of seizures,” said Maria C. Carrillo, Ph.D., chief science officer, Alzheimer’s Association. “While we continue our push to find treatments and preventions for Alzheimer’s and other dementias, doctors should be aware of how common seizures are in this population to better monitor and treat these individuals.”

“At the research level, we need additional studies to understand more about the shared mechanisms between epilepsy and Alzheimer’s that might help us better understand the impact seizures have on the brain in order to better treat both seizures and cognitive decline,” Carrillo added.

Study Finds Support for Early Surgery for Better Results in Frontal Lobe Epilepsy

In a large cohort of patients, researchers analyzed the longitudinal outcomes and predictors of seizure outcomes after frontal lobe epilepsy (FLE) surgery, the second most common focal resective surgery for drug-resistant epilepsy. The study sample consisted of 73 consecutive patients who had FLE surgery between January 1997 and May 2015 with a minimum follow-up of 1 year (range 1-16 years). Older age at surgery, longer duration of epilepsy, presence of interictal epileptiform discharges in post-operative EEG on 7th day, 3 months and 1 year were predictors of seizure recurrence on multivariate analysis. Having epilepsy for less than 2 years prior to surgery significantly predicted achieving freedom from seizure in subgroup analysis.

For better outcome in frontal lobe epilepsy, these outcomes support early surgery. A good long-term outcome predictor is still EEG.

Antiepileptic Drugs with the Lowest Risk to Influence Cardiac Function Should be Considered for Treatment

Epilepsy is often comorbid with either neurological or nonneurological diseases. The association between epilepsy and cardiac arrhythmias is not infrequent, mostly in patients with severe forms of epilepsy or critically ill.

Remarkably, these medical conditions share many similarities. Vascular and genetic disorders may predispose to both seizures and abnormalities of cardiac electrophysiology. Repeated and uncontrolled seizures may favor potentially life-threatening arrhythmias.

Antiepileptic drugs (AEDs) may facilitate the occurrence of cardiac arrhythmias by acting on ionic channels at heart level. Antiarrhythmic drugs (AADs) can have effects on ionic channels expressed in the brain, as suggested by their efficacy in treating patients with rare forms of epilepsy; AADs may also be proconvulsant, mainly during their overdosage.

In clinical practice, the AEDs with the lowest risk to influence cardiac electrophysiology are to be preferred in patients presenting with either seizures or arrhythmias. Traditional AEDs should be avoided because of their arrhythmogenic properties and enzyme-inducing effects, which may make ineffective the concomitant treatment with AADs. Some of the newer AEDs can rarely affect cardiac rhythm, and electrocardiogram (ECG) monitoring should be warranted.

Seizures May Reduce Brain Cell Production, Result in Poor Spatial Discrimination, Mouse Study Suggests

Spontaneous seizures reduce the production of new brain cells, and result in poor spatial discrimination — a common occurrence in people with Alzheimer’s disease, according to a mouse study. The study, “Early Seizure Activity Accelerates Depletion of Hippocampal Neural Stem Cells and Impairs Spatial Discrimination in an Alzheimer’s Disease Model,” was published in Cell Reports.

As disease progresses, Alzheimer’s patients may lose their perception of depth. They can misjudge distances, or changes in height, and have trouble distinguishing between two-dimensional and three-dimensional objects, researchers say. An exact mechanism has not been identified as the trigger for these visuospatial problems. But one hypothesis on the table points to disturbances in the production of new nerve cells by neural stem cells, or neurogenesis, within the adult hippocampus — a brain region crucial for memory formation and cognition. For a long time, neurogenesis was thought to solely occur during embryonic development. However, evidence now indicates neurogenesis does occur in the hippocampus of adults.

Study Finds Greater Involvement of Pediatric Neurologist is Associated Decreased Mortality in Period After Transition to Adult Services

Background: Concerns have been raised about variation in care quality and outcomes among children and young people with epilepsy in England. This team aimed to investigate the association between quality of pediatric care, hospital admissions, and all-cause deaths among epilepsy patients.

Methods: In this longitudinal data linkage study of pediatric epilepsy services in England, researchers linked unit-level data from round 1 (2009–11) and round 2 (2013–14) of the Epilepsy12 national clinical audit, with death registrations from the UK Office for National Statistics and data for unplanned hospital admissions from Hospital Episode Statistics. The team investigated the association between unit-level performance in involving a pediatrician with epilepsy expertise, an epilepsy specialist nurse, and a pediatric neurologist (where appropriate) in round 1 and the proportion of adolescents (aged 10–18 years) with epilepsy admitted to each unit who subsequently died during the study period (April 1, 2009, to March 31, 2015). They also investigated whether change in Epilepsy12 performance between the two audit rounds was associated with changes in the standardized ratio of observed-to-expected unplanned epilepsy admissions over the same period.

Findings: In 99 units with data for the analyses relating to pediatricians with epilepsy expertise and epilepsy specialist nurses, 134 (7%) of 1795 patients died during the study period, 88 (5%) of whom died after the transition to adult service. In 55 units with data for the analyses relating to pediatric neurologists, 79 (7%) of 1164 patients died, 54 (5%) of whom did so after the transition. In regression models adjusting for population, unit, and hospital activity characteristics, absolute reductions in total mortality risk (6·4 percentage points, 95% CI 0·1–12·7) and mortality risk after transition (5·7 percentage points, 0·6–10·8) were found when comparing units where all versus no eligible patients were seen by a pediatric neurologist. Units where all eligible patients were seen by a pediatric neurologist were estimated to have absolute reductions of 4·6 percentage points (0·3–8·9) in total mortality and of 4·6 percentage points (1·2–8·0) in post-transition mortality, compared with units where no or some eligible patients were seen by a pediatric neurologist. There was no significant association between performance on being seen by an epilepsy specialist nurse or by a pediatrician with epilepsy expertise and mortality. In units where access to an epilepsy specialist nurse decreased, the standardized ratio of epilepsy admissions increased by a mean of 0·21 (0·01–0·42).

Interpretation: Among adolescents with epilepsy, greater involvement of tertiary specialists in pediatric care is associated with decreased all-cause mortality in the period after transition to adult services. Reduced access to an epilepsy specialist nurse was associated with an increase in pediatric epilepsy admissions.