Epilepsy Resource Center

Immediate treatment of a first unprovoked seizure may be preferable to delayed treatment over a wide range of patients, including those who are at low risk of recurrent seizures, results of a decision analysis suggest.

Taking into account quality of life, seizure risk, and antiepileptic drug (AED) side effects, a model favored treatment of a patient with a single unprovoked seizure who did not meet the International League Against Epilepsy (ILAE) definition of epilepsy, investigators reported.

The model also favored treatment of patients who did meet ILAE criteria, namely, a 10-year recurrence risk greater than 60% in a patient with a single unprovoked seizure, according to the analysis, which was published in the October 9 issue of Neurology.

Together, these findings suggest that the current ILAE epilepsy definition is “too simplistic” for deciding whether to start or withhold AED treatment after a first unprovoked seizure, said M. Brandon Westover, MD, PhD, Associate Professor of Neurology at Massachusetts General Hospital in Boston, and his coauthors.

“A more precise and patient-personalized definition of epilepsy should encompass not only seizure recurrence probability but also a multitude of other risks and benefits associated with AED treatment,” they said.

Weighing Risks and Benefits

To determine which patients with a first unprovoked seizure might benefit from immediate AED treatment, Dr. Westover and his colleagues used a decision model with measures constructed from retrospective clinical trial data.

The goal of the simulation was to determine which treatment strategy—immediate or delayed AED treatment—would maximize the patient’s expected quality-adjusted life years (QALYs). Toward that end, Dr. Westover and his coinvestigators considered three base cases, which represented various degrees of seizure-recurrence risk.

The first case was a 30-year-old man with no risk factors for recurrent seizure other than having had a first seizure. In that case, immediate and deferred AED treatment resulted in 19.04 and 18.65 QALYs, respectively.

“In dollar values, using the conservative approximation of $50,000/QALY gained, this difference in treatment outcomes would amount to $19,500 gained per individual,” Dr. Westover and his coauthors wrote in their report.

The second case was a 30-year-old woman who presented with a first unprovoked seizure and had positive MRI results that establish a high risk of recurrence. As expected, because of the high recurrence risk, this scenario also favored immediate treatment, with 15.23 and 14.75 QALYs, respectively, for the immediate and deferred strategies.

The final case was a wheelchair-bound 60-year-old woman with a first unprovoked seizure and high risk of recurrence, but also a high risk of AED adverse effects and a smaller expected quality of life reduction from further seizures. In this scenario, in which treatment might be “intuitively discouraged” because of the AED side-effect risk, the cohort simulation favored deferred AED treatment by a small margin, the investigators said.

“A high baseline risk for recurrent seizures does not by itself always favor immediate AED treatment,” they said.

Findings May Shift Discussions About Therapy

The conclusion of this decision analysis by Dr. Westover and colleagues is “likely correct” that early treatment of a first unprovoked seizure could be favorable in a wide range of clinical scenarios, according to the authors of an accompanying editorial.

The decision analysis is based on a reasonable, though not comprehensive, set of parameters to simulate base cases representative of common first-ever seizure clinical scenarios, said editorialists Claire S. Jacobs, MD, PhD, and Jong Woo Lee, MD, PhD, both with the Department of Neurology at Brigham and Women’s Hospital in Boston.

Potentially the most controversial scenario addressed in the decision model, they noted, is the patient with low seizure recurrence risk but substantial quality of life decline upon recurrence. While that patient would not meet the commonly accepted 60% recurrence risk threshold that would indicate that treatment is warranted, this model favors immediate treatment because of the potentially disruptive effect of recurrence.

This study does not address important issues such as the cost of medication and patient preferences, they pointed out, and furthermore, QALYs can be difficult to integrate into clinical decision making.

Nonetheless, the findings are worth considering in clinical practice, the authors suggested. “At the very least, this study should, however subtly, shift the starting point of discussion with the patient toward a default of immediate, rather than deferred, treatment after a first unprovoked seizure and apparent absence of disease,” said Drs. Jacob and Lee.

The study was supported by NINDS.

—Andrew D. Bowser

Suggested Reading

Bao EL, Chao LY, Ni P, et al. Antiepileptic drug treatment after an unprovoked first seizure: a decision analysis. Neurology. 2018;91(15):e1429-e1439.

Jacobs CS, Lee JW. Immediate vs delayed treatment of first unprovoked seizure: to treat, or not to treat? Neurology. 2018;91(15):684-685.

Immediate treatment of a first unprovoked seizure may be preferable to delayed treatment over a wide range of patients, including those who are at low risk of recurrent seizures, results of a decision analysis suggest.

Taking into account quality of life, seizure risk, and antiepileptic drug (AED) side effects, a model favored treatment of a patient with a single unprovoked seizure who did not meet the International League Against Epilepsy (ILAE) definition of epilepsy, investigators reported.

The model also favored treatment of patients who did meet ILAE criteria, namely, a 10-year recurrence risk greater than 60% in a patient with a single unprovoked seizure, according to the analysis, which was published in the October 9 issue of Neurology.

Together, these findings suggest that the current ILAE epilepsy definition is “too simplistic” for deciding whether to start or withhold AED treatment after a first unprovoked seizure, said M. Brandon Westover, MD, PhD, Associate Professor of Neurology at Massachusetts General Hospital in Boston, and his coauthors.

“A more precise and patient-personalized definition of epilepsy should encompass not only seizure recurrence probability but also a multitude of other risks and benefits associated with AED treatment,” they said.

Weighing Risks and Benefits

To determine which patients with a first unprovoked seizure might benefit from immediate AED treatment, Dr. Westover and his colleagues used a decision model with measures constructed from retrospective clinical trial data.

The goal of the simulation was to determine which treatment strategy—immediate or delayed AED treatment—would maximize the patient’s expected quality-adjusted life years (QALYs). Toward that end, Dr. Westover and his coinvestigators considered three base cases, which represented various degrees of seizure-recurrence risk.

The first case was a 30-year-old man with no risk factors for recurrent seizure other than having had a first seizure. In that case, immediate and deferred AED treatment resulted in 19.04 and 18.65 QALYs, respectively.

“In dollar values, using the conservative approximation of $50,000/QALY gained, this difference in treatment outcomes would amount to $19,500 gained per individual,” Dr. Westover and his coauthors wrote in their report.

The second case was a 30-year-old woman who presented with a first unprovoked seizure and had positive MRI results that establish a high risk of recurrence. As expected, because of the high recurrence risk, this scenario also favored immediate treatment, with 15.23 and 14.75 QALYs, respectively, for the immediate and deferred strategies.

The final case was a wheelchair-bound 60-year-old woman with a first unprovoked seizure and high risk of recurrence, but also a high risk of AED adverse effects and a smaller expected quality of life reduction from further seizures. In this scenario, in which treatment might be “intuitively discouraged” because of the AED side-effect risk, the cohort simulation favored deferred AED treatment by a small margin, the investigators said.

“A high baseline risk for recurrent seizures does not by itself always favor immediate AED treatment,” they said.

Findings May Shift Discussions About Therapy

The conclusion of this decision analysis by Dr. Westover and colleagues is “likely correct” that early treatment of a first unprovoked seizure could be favorable in a wide range of clinical scenarios, according to the authors of an accompanying editorial.

The decision analysis is based on a reasonable, though not comprehensive, set of parameters to simulate base cases representative of common first-ever seizure clinical scenarios, said editorialists Claire S. Jacobs, MD, PhD, and Jong Woo Lee, MD, PhD, both with the Department of Neurology at Brigham and Women’s Hospital in Boston.

Potentially the most controversial scenario addressed in the decision model, they noted, is the patient with low seizure recurrence risk but substantial quality of life decline upon recurrence. While that patient would not meet the commonly accepted 60% recurrence risk threshold that would indicate that treatment is warranted, this model favors immediate treatment because of the potentially disruptive effect of recurrence.

This study does not address important issues such as the cost of medication and patient preferences, they pointed out, and furthermore, QALYs can be difficult to integrate into clinical decision making.

Nonetheless, the findings are worth considering in clinical practice, the authors suggested. “At the very least, this study should, however subtly, shift the starting point of discussion with the patient toward a default of immediate, rather than deferred, treatment after a first unprovoked seizure and apparent absence of disease,” said Drs. Jacob and Lee.

The study was supported by NINDS.

—Andrew D. Bowser

Suggested Reading

Bao EL, Chao LY, Ni P, et al. Antiepileptic drug treatment after an unprovoked first seizure: a decision analysis. Neurology. 2018;91(15):e1429-e1439.

Jacobs CS, Lee JW. Immediate vs delayed treatment of first unprovoked seizure: to treat, or not to treat? Neurology. 2018;91(15):684-685.

Immediate treatment of a first unprovoked seizure may be preferable to delayed treatment over a wide range of patients, including those who are at low risk of recurrent seizures, results of a decision analysis suggest.

Taking into account quality of life, seizure risk, and antiepileptic drug (AED) side effects, a model favored treatment of a patient with a single unprovoked seizure who did not meet the International League Against Epilepsy (ILAE) definition of epilepsy, investigators reported.

The model also favored treatment of patients who did meet ILAE criteria, namely, a 10-year recurrence risk greater than 60% in a patient with a single unprovoked seizure, according to the analysis, which was published in the October 9 issue of Neurology.

Together, these findings suggest that the current ILAE epilepsy definition is “too simplistic” for deciding whether to start or withhold AED treatment after a first unprovoked seizure, said M. Brandon Westover, MD, PhD, Associate Professor of Neurology at Massachusetts General Hospital in Boston, and his coauthors.

“A more precise and patient-personalized definition of epilepsy should encompass not only seizure recurrence probability but also a multitude of other risks and benefits associated with AED treatment,” they said.

Weighing Risks and Benefits

To determine which patients with a first unprovoked seizure might benefit from immediate AED treatment, Dr. Westover and his colleagues used a decision model with measures constructed from retrospective clinical trial data.

The goal of the simulation was to determine which treatment strategy—immediate or delayed AED treatment—would maximize the patient’s expected quality-adjusted life years (QALYs). Toward that end, Dr. Westover and his coinvestigators considered three base cases, which represented various degrees of seizure-recurrence risk.

The first case was a 30-year-old man with no risk factors for recurrent seizure other than having had a first seizure. In that case, immediate and deferred AED treatment resulted in 19.04 and 18.65 QALYs, respectively.

“In dollar values, using the conservative approximation of $50,000/QALY gained, this difference in treatment outcomes would amount to $19,500 gained per individual,” Dr. Westover and his coauthors wrote in their report.

The second case was a 30-year-old woman who presented with a first unprovoked seizure and had positive MRI results that establish a high risk of recurrence. As expected, because of the high recurrence risk, this scenario also favored immediate treatment, with 15.23 and 14.75 QALYs, respectively, for the immediate and deferred strategies.

The final case was a wheelchair-bound 60-year-old woman with a first unprovoked seizure and high risk of recurrence, but also a high risk of AED adverse effects and a smaller expected quality of life reduction from further seizures. In this scenario, in which treatment might be “intuitively discouraged” because of the AED side-effect risk, the cohort simulation favored deferred AED treatment by a small margin, the investigators said.

“A high baseline risk for recurrent seizures does not by itself always favor immediate AED treatment,” they said.

Findings May Shift Discussions About Therapy

The conclusion of this decision analysis by Dr. Westover and colleagues is “likely correct” that early treatment of a first unprovoked seizure could be favorable in a wide range of clinical scenarios, according to the authors of an accompanying editorial.

The decision analysis is based on a reasonable, though not comprehensive, set of parameters to simulate base cases representative of common first-ever seizure clinical scenarios, said editorialists Claire S. Jacobs, MD, PhD, and Jong Woo Lee, MD, PhD, both with the Department of Neurology at Brigham and Women’s Hospital in Boston.

Potentially the most controversial scenario addressed in the decision model, they noted, is the patient with low seizure recurrence risk but substantial quality of life decline upon recurrence. While that patient would not meet the commonly accepted 60% recurrence risk threshold that would indicate that treatment is warranted, this model favors immediate treatment because of the potentially disruptive effect of recurrence.

This study does not address important issues such as the cost of medication and patient preferences, they pointed out, and furthermore, QALYs can be difficult to integrate into clinical decision making.

Nonetheless, the findings are worth considering in clinical practice, the authors suggested. “At the very least, this study should, however subtly, shift the starting point of discussion with the patient toward a default of immediate, rather than deferred, treatment after a first unprovoked seizure and apparent absence of disease,” said Drs. Jacob and Lee.

The study was supported by NINDS.

—Andrew D. Bowser

Suggested Reading

Bao EL, Chao LY, Ni P, et al. Antiepileptic drug treatment after an unprovoked first seizure: a decision analysis. Neurology. 2018;91(15):e1429-e1439.

Jacobs CS, Lee JW. Immediate vs delayed treatment of first unprovoked seizure: to treat, or not to treat? Neurology. 2018;91(15):684-685.

Pediatric patients who have been initially diagnosed with epilepsy with myoclonic-atonic seizures (EMAS) are likely to be switched to another diagnosis over time, according to a retrospective chart analysis of 77 children at Children’s Hospital of Colorado.

• Over 50% of patients in this study were switched from suspected EMAS to another epilepsy diagnosis.
• Among the 77 patients, 30 had an initial diagnosis of EMAS and 57 had a final diagnosis of EMAS.
• Among 65% of patients who had more than one diagnosis over time, the first, second, and third diagnoses were provided within 1 year, 3 years, and 10 years after the onset of the disease.
• Signs of Lennox-Gastaut syndrome (LGS), including paroxysmal fast activity, slow spike-and-wave, and tonic seizure, were detected in 50% of the 77 patients but only a minority received a final diagnosis of LGS.

Eschbach K., Moss A, Joshi C, et al. Diagnosis switching and outcomes in a cohort of patients with potential epilepsy with myoclonic-atonic seizures. Epilepsy Res. 2018; 147:95-101. https://doi.org/10.1016/j.eplepsyres.2018.09.011

Pediatric patients who have been initially diagnosed with epilepsy with myoclonic-atonic seizures (EMAS) are likely to be switched to another diagnosis over time, according to a retrospective chart analysis of 77 children at Children’s Hospital of Colorado.

• Over 50% of patients in this study were switched from suspected EMAS to another epilepsy diagnosis.
• Among the 77 patients, 30 had an initial diagnosis of EMAS and 57 had a final diagnosis of EMAS.
• Among 65% of patients who had more than one diagnosis over time, the first, second, and third diagnoses were provided within 1 year, 3 years, and 10 years after the onset of the disease.
• Signs of Lennox-Gastaut syndrome (LGS), including paroxysmal fast activity, slow spike-and-wave, and tonic seizure, were detected in 50% of the 77 patients but only a minority received a final diagnosis of LGS.

Eschbach K., Moss A, Joshi C, et al. Diagnosis switching and outcomes in a cohort of patients with potential epilepsy with myoclonic-atonic seizures. Epilepsy Res. 2018; 147:95-101. https://doi.org/10.1016/j.eplepsyres.2018.09.011

Pediatric patients who have been initially diagnosed with epilepsy with myoclonic-atonic seizures (EMAS) are likely to be switched to another diagnosis over time, according to a retrospective chart analysis of 77 children at Children’s Hospital of Colorado.

• Over 50% of patients in this study were switched from suspected EMAS to another epilepsy diagnosis.
• Among the 77 patients, 30 had an initial diagnosis of EMAS and 57 had a final diagnosis of EMAS.
• Among 65% of patients who had more than one diagnosis over time, the first, second, and third diagnoses were provided within 1 year, 3 years, and 10 years after the onset of the disease.
• Signs of Lennox-Gastaut syndrome (LGS), including paroxysmal fast activity, slow spike-and-wave, and tonic seizure, were detected in 50% of the 77 patients but only a minority received a final diagnosis of LGS.

Eschbach K., Moss A, Joshi C, et al. Diagnosis switching and outcomes in a cohort of patients with potential epilepsy with myoclonic-atonic seizures. Epilepsy Res. 2018; 147:95-101. https://doi.org/10.1016/j.eplepsyres.2018.09.011

Researchers have found that using 256-channel high-density EEG and high-resolution head models of individual patients can help establish precise electrical source imaging of oscillatory features of the onset of a seizure, which in turn improves presurgical planning. Precisely localizing the seizure onset zone in the cortex is important for the best surgical outcomes.

• Using noninvasive electrical source imaging to plan surgery has proven problematic to date because of the interference of noise artifacts and non-seizure activity, which can be superimposed over the seizure signal.
• In this study, high density EEG was combined with exact sensor positioning and individual electrical head models, which were derived from T1 MRI results.
• Among 84 seizures, investigators were able to localize the onset of 56.
• High density EEG with interictal spikes was more accurate than international 10-20 EEG for interictal spikes and ictal onset.

Kuo C-C, Tucker DM, Luu P, et al. EEG source imaging of epileptic activity at seizure onset. Epilepsy Res. 2018;146:160-171. https://doi.org/10.1016/j.eplepsyres.2018.07.006

Researchers have found that using 256-channel high-density EEG and high-resolution head models of individual patients can help establish precise electrical source imaging of oscillatory features of the onset of a seizure, which in turn improves presurgical planning. Precisely localizing the seizure onset zone in the cortex is important for the best surgical outcomes.

• Using noninvasive electrical source imaging to plan surgery has proven problematic to date because of the interference of noise artifacts and non-seizure activity, which can be superimposed over the seizure signal.
• In this study, high density EEG was combined with exact sensor positioning and individual electrical head models, which were derived from T1 MRI results.
• Among 84 seizures, investigators were able to localize the onset of 56.
• High density EEG with interictal spikes was more accurate than international 10-20 EEG for interictal spikes and ictal onset.

Kuo C-C, Tucker DM, Luu P, et al. EEG source imaging of epileptic activity at seizure onset. Epilepsy Res. 2018;146:160-171. https://doi.org/10.1016/j.eplepsyres.2018.07.006

Researchers have found that using 256-channel high-density EEG and high-resolution head models of individual patients can help establish precise electrical source imaging of oscillatory features of the onset of a seizure, which in turn improves presurgical planning. Precisely localizing the seizure onset zone in the cortex is important for the best surgical outcomes.

• Using noninvasive electrical source imaging to plan surgery has proven problematic to date because of the interference of noise artifacts and non-seizure activity, which can be superimposed over the seizure signal.
• In this study, high density EEG was combined with exact sensor positioning and individual electrical head models, which were derived from T1 MRI results.
• Among 84 seizures, investigators were able to localize the onset of 56.
• High density EEG with interictal spikes was more accurate than international 10-20 EEG for interictal spikes and ictal onset.

Kuo C-C, Tucker DM, Luu P, et al. EEG source imaging of epileptic activity at seizure onset. Epilepsy Res. 2018;146:160-171. https://doi.org/10.1016/j.eplepsyres.2018.07.006

The cortical regions of the brains of patients with juvenile myoclonic epilepsy (JME) are more likely to be disassociated from subcortical structures, according to a recent study that compared the MRI readings of JME patients to those of normal children. 

• Investigators from the University of Wisconsin School of Medicine compared 21 children with JME to 22 healthy controls over a 2 year period.
• Normal children had modular cortical development and network integration between cortical and subcortical regions.
• Patients with epilepsy had a less modular cortical network that was disassociated from subcortical structures.
• Children with JME were also found to have weaker modules or communities, as indicated by higher clustering and lower modularity indices.

Garcia-Ramos C, Dabbs K, Lin JJ, et al. Progressive dissociation of cortical and subcortical network development in children with new‐onset juvenile myoclonic epilepsy [Published online ahead of print Oct 3, 2018]. Epilepsia.  https://doi.org/10.1111/epi.14560

The cortical regions of the brains of patients with juvenile myoclonic epilepsy (JME) are more likely to be disassociated from subcortical structures, according to a recent study that compared the MRI readings of JME patients to those of normal children. 

• Investigators from the University of Wisconsin School of Medicine compared 21 children with JME to 22 healthy controls over a 2 year period.
• Normal children had modular cortical development and network integration between cortical and subcortical regions.
• Patients with epilepsy had a less modular cortical network that was disassociated from subcortical structures.
• Children with JME were also found to have weaker modules or communities, as indicated by higher clustering and lower modularity indices.

Garcia-Ramos C, Dabbs K, Lin JJ, et al. Progressive dissociation of cortical and subcortical network development in children with new‐onset juvenile myoclonic epilepsy [Published online ahead of print Oct 3, 2018]. Epilepsia.  https://doi.org/10.1111/epi.14560

The cortical regions of the brains of patients with juvenile myoclonic epilepsy (JME) are more likely to be disassociated from subcortical structures, according to a recent study that compared the MRI readings of JME patients to those of normal children. 

• Investigators from the University of Wisconsin School of Medicine compared 21 children with JME to 22 healthy controls over a 2 year period.
• Normal children had modular cortical development and network integration between cortical and subcortical regions.
• Patients with epilepsy had a less modular cortical network that was disassociated from subcortical structures.
• Children with JME were also found to have weaker modules or communities, as indicated by higher clustering and lower modularity indices.

Garcia-Ramos C, Dabbs K, Lin JJ, et al. Progressive dissociation of cortical and subcortical network development in children with new‐onset juvenile myoclonic epilepsy [Published online ahead of print Oct 3, 2018]. Epilepsia.  https://doi.org/10.1111/epi.14560

Pediatric status epilepticus (SE) is an expensive disorder and is not uncommon in this patient population, according to a recent review of the medical literature.

• Gurcharran et al note that pediatric SE occurs in about 20per 100,000 children each year.
• The disorder carries a mortality of 3%.
• The most common risk factor for morbidity and death is symptomatic etiology, with acute presentation more common than remote.
• A single episode of status epilepticus costs more than $10,000 to manage and can reach more than $100,000 in children with refractory disease.
• The most common cause of the condition is febrile SE, which usually occurs in early childhood.

Gurcharran K, Grinspan ZM. The burden of pediatric status epilepticus: epidemiology, morbidity, and mortality. [Published online ahead of print August 29, 2018] Seizure. https://doi.org/10.1016/j.seizure.2018.08.021.

Pediatric status epilepticus (SE) is an expensive disorder and is not uncommon in this patient population, according to a recent review of the medical literature.

• Gurcharran et al note that pediatric SE occurs in about 20per 100,000 children each year.
• The disorder carries a mortality of 3%.
• The most common risk factor for morbidity and death is symptomatic etiology, with acute presentation more common than remote.
• A single episode of status epilepticus costs more than $10,000 to manage and can reach more than $100,000 in children with refractory disease.
• The most common cause of the condition is febrile SE, which usually occurs in early childhood.

Gurcharran K, Grinspan ZM. The burden of pediatric status epilepticus: epidemiology, morbidity, and mortality. [Published online ahead of print August 29, 2018] Seizure. https://doi.org/10.1016/j.seizure.2018.08.021.

Pediatric status epilepticus (SE) is an expensive disorder and is not uncommon in this patient population, according to a recent review of the medical literature.

• Gurcharran et al note that pediatric SE occurs in about 20per 100,000 children each year.
• The disorder carries a mortality of 3%.
• The most common risk factor for morbidity and death is symptomatic etiology, with acute presentation more common than remote.
• A single episode of status epilepticus costs more than $10,000 to manage and can reach more than $100,000 in children with refractory disease.
• The most common cause of the condition is febrile SE, which usually occurs in early childhood.

Gurcharran K, Grinspan ZM. The burden of pediatric status epilepticus: epidemiology, morbidity, and mortality. [Published online ahead of print August 29, 2018] Seizure. https://doi.org/10.1016/j.seizure.2018.08.021.

While several emerging treatments have been recommended for children with refractory status epilepticus, most of the research supporting these modalities are anecdotal in nature, according to a review published in Seizure.

• Randomized controlled trials have evaluated hypothermia and found it is no more effective than placebo for refractory status epilepticus (RSE) and super-refractory status epilepticus (SRSE).
• Case series have suggested that a ketogenic diet may benefit children with RSE.
• A few case reports involving the ketogenic diet found seizures were stopped within a week in 20-90% of children.
• One double blind trial concluded that brexanolone was no more effective than placebo for weaning patients off 3^rd line anesthetic agents and freedom from RSE after 24 hours.

Arya R, Rotenberg A.  Dietary, immunological, surgical, and other emerging treatments for pediatric refractory status epilepticus.  [Published online ahead of print Sept 14, 2018]. Seizure. https://doi.org/10.1016/j.seizure.2018.09.002.

While several emerging treatments have been recommended for children with refractory status epilepticus, most of the research supporting these modalities are anecdotal in nature, according to a review published in Seizure.

• Randomized controlled trials have evaluated hypothermia and found it is no more effective than placebo for refractory status epilepticus (RSE) and super-refractory status epilepticus (SRSE).
• Case series have suggested that a ketogenic diet may benefit children with RSE.
• A few case reports involving the ketogenic diet found seizures were stopped within a week in 20-90% of children.
• One double blind trial concluded that brexanolone was no more effective than placebo for weaning patients off 3^rd line anesthetic agents and freedom from RSE after 24 hours.

Arya R, Rotenberg A.  Dietary, immunological, surgical, and other emerging treatments for pediatric refractory status epilepticus.  [Published online ahead of print Sept 14, 2018]. Seizure. https://doi.org/10.1016/j.seizure.2018.09.002.

While several emerging treatments have been recommended for children with refractory status epilepticus, most of the research supporting these modalities are anecdotal in nature, according to a review published in Seizure.

• Randomized controlled trials have evaluated hypothermia and found it is no more effective than placebo for refractory status epilepticus (RSE) and super-refractory status epilepticus (SRSE).
• Case series have suggested that a ketogenic diet may benefit children with RSE.
• A few case reports involving the ketogenic diet found seizures were stopped within a week in 20-90% of children.
• One double blind trial concluded that brexanolone was no more effective than placebo for weaning patients off 3^rd line anesthetic agents and freedom from RSE after 24 hours.

Arya R, Rotenberg A.  Dietary, immunological, surgical, and other emerging treatments for pediatric refractory status epilepticus.  [Published online ahead of print Sept 14, 2018]. Seizure. https://doi.org/10.1016/j.seizure.2018.09.002.

Patients will likely develop intolerable psychiatric and behavioral side effects (IPBSE) to an antiepileptic drug if they are already sensitive to another one, according to researchers from Yale and Columbia University.

• A review of the records of over 2,000 patients found that about 20% were taking at least two antiepileptic drug and had at IPBSE to at least one of the drugs.
• Cross sensitivity was detected between zonisamide and levetiracetam.
• The odds of developing said side effects from levetiracetam or from zonisamide were significantly higher in a patient that had had a side effect to another antiepileptic drug than in patients who had no IPBSE to other antiepileptic drugs (20.5% versus 7.5%.)
•  A history of depression and psychosis increase the risk of IPBSE among patients taking antiepileptic medication.

Chen B, Choi H, Hirsch LJ, et al. Cross-sensitivity of psychiatric and behavioral side effects with antiepileptic drug use. [Published online ahead of print Sept 22, 2018]. Seizure. https://doi.org/10.1016/j.seizure.2018.09.014.

Patients will likely develop intolerable psychiatric and behavioral side effects (IPBSE) to an antiepileptic drug if they are already sensitive to another one, according to researchers from Yale and Columbia University.

• A review of the records of over 2,000 patients found that about 20% were taking at least two antiepileptic drug and had at IPBSE to at least one of the drugs.
• Cross sensitivity was detected between zonisamide and levetiracetam.
• The odds of developing said side effects from levetiracetam or from zonisamide were significantly higher in a patient that had had a side effect to another antiepileptic drug than in patients who had no IPBSE to other antiepileptic drugs (20.5% versus 7.5%.)
•  A history of depression and psychosis increase the risk of IPBSE among patients taking antiepileptic medication.

Chen B, Choi H, Hirsch LJ, et al. Cross-sensitivity of psychiatric and behavioral side effects with antiepileptic drug use. [Published online ahead of print Sept 22, 2018]. Seizure. https://doi.org/10.1016/j.seizure.2018.09.014.

Patients will likely develop intolerable psychiatric and behavioral side effects (IPBSE) to an antiepileptic drug if they are already sensitive to another one, according to researchers from Yale and Columbia University.

• A review of the records of over 2,000 patients found that about 20% were taking at least two antiepileptic drug and had at IPBSE to at least one of the drugs.
• Cross sensitivity was detected between zonisamide and levetiracetam.
• The odds of developing said side effects from levetiracetam or from zonisamide were significantly higher in a patient that had had a side effect to another antiepileptic drug than in patients who had no IPBSE to other antiepileptic drugs (20.5% versus 7.5%.)
•  A history of depression and psychosis increase the risk of IPBSE among patients taking antiepileptic medication.

Chen B, Choi H, Hirsch LJ, et al. Cross-sensitivity of psychiatric and behavioral side effects with antiepileptic drug use. [Published online ahead of print Sept 22, 2018]. Seizure. https://doi.org/10.1016/j.seizure.2018.09.014.

Periictal cardiorespiratory dysfunction, sleep-disordered breathing, and endocrine dysfunction have all been linked to sudden unexpected death from epilepsy (SUDEP).

• Investigators conducted a prospective observational study on 30 patients in the Columbia University Medical Center’s adult epilepsy monitoring unit.
• Their analysis found that patients who were at high risk for SUDEP were more likely to experience cardiorespiratory dysfunction (60% vs 27%).
• Sleep-disordered breathing was found in 88% of patients with inpatient or outpatient polysomnography results that were fully scorable.
• The researchers also found endocrine dysfunction in 35% of patients, with men more likely to experience the problem.
• The analysis did not detect a significant relationship between cardiorespiratory dysfunction, sleep-disordered breathing, and neuroendocrine status.

Billakota S, Odom N, Westwood AJ, et al. Sleep-disordered breathing, neuroendocrine function, and clinical SUDEP risk in patients with epilepsy. Epilepsy Behav. 2018;87:78-82.

Periictal cardiorespiratory dysfunction, sleep-disordered breathing, and endocrine dysfunction have all been linked to sudden unexpected death from epilepsy (SUDEP).

• Investigators conducted a prospective observational study on 30 patients in the Columbia University Medical Center’s adult epilepsy monitoring unit.
• Their analysis found that patients who were at high risk for SUDEP were more likely to experience cardiorespiratory dysfunction (60% vs 27%).
• Sleep-disordered breathing was found in 88% of patients with inpatient or outpatient polysomnography results that were fully scorable.
• The researchers also found endocrine dysfunction in 35% of patients, with men more likely to experience the problem.
• The analysis did not detect a significant relationship between cardiorespiratory dysfunction, sleep-disordered breathing, and neuroendocrine status.

Billakota S, Odom N, Westwood AJ, et al. Sleep-disordered breathing, neuroendocrine function, and clinical SUDEP risk in patients with epilepsy. Epilepsy Behav. 2018;87:78-82.

Periictal cardiorespiratory dysfunction, sleep-disordered breathing, and endocrine dysfunction have all been linked to sudden unexpected death from epilepsy (SUDEP).

• Investigators conducted a prospective observational study on 30 patients in the Columbia University Medical Center’s adult epilepsy monitoring unit.
• Their analysis found that patients who were at high risk for SUDEP were more likely to experience cardiorespiratory dysfunction (60% vs 27%).
• Sleep-disordered breathing was found in 88% of patients with inpatient or outpatient polysomnography results that were fully scorable.
• The researchers also found endocrine dysfunction in 35% of patients, with men more likely to experience the problem.
• The analysis did not detect a significant relationship between cardiorespiratory dysfunction, sleep-disordered breathing, and neuroendocrine status.

Billakota S, Odom N, Westwood AJ, et al. Sleep-disordered breathing, neuroendocrine function, and clinical SUDEP risk in patients with epilepsy. Epilepsy Behav. 2018;87:78-82.

Neuropsychological testing may help differentiate epileptic seizures from psychogenic nonepileptic seizures (PNES) according to a study that evaluated data from 72 patients with epilepsy and 33 patients with PNES.

• In the past, psychometric testing has been shown to have limited utility in differentiating PNES from epileptic seizures.
• The new research suggests that multivariate assessment using several psychological tests is more effective in making the differential diagnosis.
• Using logistic regression, investigators found that a combination of 7 neuropsychological tests accurately classified about 85% of patients.
• The researchers acknowledged that video-EEG monitoring remains the gold standard for separating PNES from epileptic seizures but suggest that a standardized battery of neuropsychological tests may improve the clinical decision-making process.

Tyson BT, Baker S, Greenacre M, et al. Differentiating epilepsy from psychogenic nonepileptic seizures using neuropsychological test data. Epilepsy Behav. 2018;87:39-45.

Neuropsychological testing may help differentiate epileptic seizures from psychogenic nonepileptic seizures (PNES) according to a study that evaluated data from 72 patients with epilepsy and 33 patients with PNES.

• In the past, psychometric testing has been shown to have limited utility in differentiating PNES from epileptic seizures.
• The new research suggests that multivariate assessment using several psychological tests is more effective in making the differential diagnosis.
• Using logistic regression, investigators found that a combination of 7 neuropsychological tests accurately classified about 85% of patients.
• The researchers acknowledged that video-EEG monitoring remains the gold standard for separating PNES from epileptic seizures but suggest that a standardized battery of neuropsychological tests may improve the clinical decision-making process.

Tyson BT, Baker S, Greenacre M, et al. Differentiating epilepsy from psychogenic nonepileptic seizures using neuropsychological test data. Epilepsy Behav. 2018;87:39-45.

Neuropsychological testing may help differentiate epileptic seizures from psychogenic nonepileptic seizures (PNES) according to a study that evaluated data from 72 patients with epilepsy and 33 patients with PNES.

• In the past, psychometric testing has been shown to have limited utility in differentiating PNES from epileptic seizures.
• The new research suggests that multivariate assessment using several psychological tests is more effective in making the differential diagnosis.
• Using logistic regression, investigators found that a combination of 7 neuropsychological tests accurately classified about 85% of patients.
• The researchers acknowledged that video-EEG monitoring remains the gold standard for separating PNES from epileptic seizures but suggest that a standardized battery of neuropsychological tests may improve the clinical decision-making process.

Tyson BT, Baker S, Greenacre M, et al. Differentiating epilepsy from psychogenic nonepileptic seizures using neuropsychological test data. Epilepsy Behav. 2018;87:39-45.

Health-related quality of life for children with epilepsy appears to be dependent in part on their parents’ ability to cope with the disorder, according to a recent study published in Epilepsy and Behavior.

• The analysis of 108 children and teens with epilepsy also revealed an association between parental helplessness and poorer quality of life.
• As expected, the severity of the child’s epilepsy was linked to poorer quality of life as well.
• These conclusions were based on parents’ responses to the Illness Cognition Questionnaire-Parent (ICQ-P), and the Quality of Life in Childhood Epilepsy questionnaire (QOLCE).
•  ICQ-P evaluates a parent’s ability to cope with disease with the help of constructs of illness cognition.
• QOLCE helps clinicians evaluates the overall functioning of a child as perceived by parents.

McLaughlin RM, Schraegle WA, Nussbaum NL, et al. Parental coping and its role in predicting health-related quality of life in pediatric epilepsy. [Published online ahead of print August 23, 2018] Epilepsy Behav. doi: 10.1016/j.yebeh.2018.08.009

Health-related quality of life for children with epilepsy appears to be dependent in part on their parents’ ability to cope with the disorder, according to a recent study published in Epilepsy and Behavior.

• The analysis of 108 children and teens with epilepsy also revealed an association between parental helplessness and poorer quality of life.
• As expected, the severity of the child’s epilepsy was linked to poorer quality of life as well.
• These conclusions were based on parents’ responses to the Illness Cognition Questionnaire-Parent (ICQ-P), and the Quality of Life in Childhood Epilepsy questionnaire (QOLCE).
•  ICQ-P evaluates a parent’s ability to cope with disease with the help of constructs of illness cognition.
• QOLCE helps clinicians evaluates the overall functioning of a child as perceived by parents.

McLaughlin RM, Schraegle WA, Nussbaum NL, et al. Parental coping and its role in predicting health-related quality of life in pediatric epilepsy. [Published online ahead of print August 23, 2018] Epilepsy Behav. doi: 10.1016/j.yebeh.2018.08.009

Health-related quality of life for children with epilepsy appears to be dependent in part on their parents’ ability to cope with the disorder, according to a recent study published in Epilepsy and Behavior.

• The analysis of 108 children and teens with epilepsy also revealed an association between parental helplessness and poorer quality of life.
• As expected, the severity of the child’s epilepsy was linked to poorer quality of life as well.
• These conclusions were based on parents’ responses to the Illness Cognition Questionnaire-Parent (ICQ-P), and the Quality of Life in Childhood Epilepsy questionnaire (QOLCE).
•  ICQ-P evaluates a parent’s ability to cope with disease with the help of constructs of illness cognition.
• QOLCE helps clinicians evaluates the overall functioning of a child as perceived by parents.

McLaughlin RM, Schraegle WA, Nussbaum NL, et al. Parental coping and its role in predicting health-related quality of life in pediatric epilepsy. [Published online ahead of print August 23, 2018] Epilepsy Behav. doi: 10.1016/j.yebeh.2018.08.009