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- Ben-Menachem, Elinor, 1945, et al.
(författare)
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VNS Therapy versus the latest antiepileptic drug.
- 2005
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Ingår i: Epileptic disorders : international epilepsy journal with videotape. - 1294-9361. ; 7 Suppl 1
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Tidskriftsartikel (refereegranskat)abstract
- Pro AED: The central issue in medical decision-making is risk-benefit assessment. Surgery of any type is still considered to be a major undertaking. To warrant these risks, the patient has a right to expect that they have a greater chance of a good outcome with an invasive therapy than with a non-invasive one. The main question is when, if ever, this becomes the case when comparing implantation of a VNS Therapy System versus adding an antiepileptic drug (AED)? After the first drug? The second? After all AEDs have failed? To date, no randomized trial comparing the addition of an AED against vagus nerve stimulation (VNS Therapy) has been undertaken, although several are currently being contemplated. Without this information, it is more difficult to make a case for early implementation of VNS Therapy. Unfortunately, few data are available regarding the potential for patients to become seizure-free after implantation of a VNS Therapy System. Another issue is side effects. It is important to remember that VNS Therapy also produces adverse events, albeit very different in character than those associated with AEDs, to which physicians have become accustomed. These include cough, dyspnea, pharyngitis, voice alteration and sleep apnea. A less frequently discussed, potentially negative consequence of VNS Therapy relates to the ability to obtain imaging of the patient. Patients who have undergone VNS Therapy System implantation are not candidates for imaging of the chest, breast, or abdomen. A second issue is that imaging of the brain can only be performed with MRI scanners that meet certain requirements, and as MRI technology develops, scanners meeting these requirements may become harder to find. However, to summarize, VNS Therapy is an excellent and useful treatment choice. Fortunately, the choice between AEDs and VNS Therapy is not an "either/or" decision. Each has a role in the treatment of patients with epilepsy, and the advantages and disadvantages of each should be kept in perspective. Pro VNS Therapy: VNS Therapy is no longer a new treatment for patients with refractory epilepsy. The first implant was performed in l988, and since then more than 30,000 patients have received this therapy. It is no longer considered an unusual or dangerous procedure, but it is still used almost exclusively for refractory epilepsy patients and it has not been generally accepted for use as a first line or even second line therapy. However, compared to the new AEDs, VNS Therapy has similar efficacy results in clinical trials and in many epilepsy syndromes and the long-term efficacy results are even more positive, with continued improvement in seizure reduction for up to two years. Two of the major reasons for not using VNS Therapy early are that it is a surgical procedure, and its safety during MRI procedures, especially with 3 Tesla, has not yet been elucidated. The safety profile of VNS Therapy is very favorable; the side effects being totally different from those seen with AEDs. The most important aspects are that there have been no pharmacological interactions, cognitive or sedative side effects reported, and it is safe for use in all age groups. Side effects are restricted to local irritation, hoarseness, coughing and, in a few cases, swallowing difficulties when the stimulator is on, but these tend to disappear with time. No idiosyncratic side effect has emerged during the 16 years of use. Compliance is guaranteed. The cost of the implantation of the VNS Therapy System, when spread out over 8 years (battery life), is actually less than the cost of using a new AED over an eight-year period, and real savings as regards hospital costs due to seizures can be expected.
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- Eeg-Olofsson, Orvar, et al.
(författare)
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MRI in rolandic epilepsy
- 2000
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Ingår i: Epileptic disorders. - 1294-9361. ; 2:Suppl 1, s. S51-3
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Tidskriftsartikel (refereegranskat)abstract
- Hippocampal and/or white matter abnormalities have been found on the MRIs in 10/18 children with typical rolandic epilepsy. The etiology of the first-mentioned is not evident, whereas the latter may be a result of a maturational delay involving a defective myelination. Both abnormalities may cause cognitive dysfunction. In order to get a better understanding of rolandic epilepsy both MRI and neuropsychological studies are wanted in groups of children with typical rolandic seizures with and without rolandic sharp waves, as well as in groups of children with typical rolandic sharp waves and atypical seizures.
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- Krysl, David, et al.
(författare)
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The COVID-19 outbreak and approaches to performing EEG in Europe
- 2020
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Ingår i: Epileptic Disorders. - : Wiley. - 1294-9361 .- 1950-6945. ; 22:5, s. 548-554
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Tidskriftsartikel (refereegranskat)abstract
- Aims. The coronavirus SARS-CoV-2 disease (COVID-19) pandemic affects availability and performance of neurophysiological diagnostic methods, including EEG. Our objective was to outline the current situation regarding EEG-based investigations across Europe. Methods. A web-based survey was distributed to centres within the European Reference Network on rare and complex epilepsies (ERN EpiCARE). Responses were collected between April 9 and May 15, 2020. Results were analysed with Microsoft Excel, Python Pandas and SciPy. Results. Representants from 47 EpiCARE centres from 22 countries completed the survey. At the time of completing the survey, inpatient video-EEGs had been stopped or restricted in most centres (61.7% vs. 36.2% for adults, and 38.3% vs. 53.2% for children). Invasive investigations and epilepsy surgery were similarly affected. Acute EEGs continued to be performed, while indications for outpatient EEGs were limited and COVID-19 triage put in place. The strictness of measures varied according to extent of the outbreak in a given country. Conclusions. The results indicate a profound impact of COVID-19 on neurophysiological diagnostics, especially inpatient video-EEGs, invasive investigations, and epilepsy surgery. The COVID-19 pandemic may hamper care for patients in need of EEG-based investigations, particularly patients with seizure disorders. ERN EpiCARE will work on recommendations on how to rapidly adapt to such situations in order to alleviate consequences for our patients.
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- Rados, Matea, et al.
(författare)
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Diagnostic value of MRI in the presurgical evaluation of patients with epilepsy: influence of field strength and sequence selection: a systematic review and meta-analysis from the E-PILEPSY Consortium.
- 2022
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Ingår i: Epileptic disorders. - : Wiley. - 1950-6945 .- 1294-9361. ; 24:2, s. 323-342
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Tidskriftsartikel (refereegranskat)abstract
- MRI is a cornerstone in presurgical evaluation of epilepsy. Despite guidelines, clinical practice varies. In light of the E-PILEPSY pilot reference network, we conducted a systematic review and meta-analysis on the diagnostic value of MRI in the presurgical evaluation of epilepsy patients. We included original research articles on diagnostic value of higher MRI field strength and guideline-recommended and additional MRI sequences in detecting an epileptogenic lesion in adult or paediatric epilepsy surgery candidates. Lesion detection rate was used as a metric in meta-analysis. Eighteen studies were included for MRI field strength and 25 for MRI sequences, none were free from bias. In patients with normal MRI at lower-field strength, 3T improved lesion detection rate by 18% and 7T by 23%. Field strengths higher than 1.5T did not have higher lesion detection rates in patients with hippocampal sclerosis (HS). The lesion detection rate of epilepsy-specific MRI protocols was 83% for temporal lobe epilepsy (TLE) patients. Dedicated MRI protocols and evaluation by an experienced epilepsy neuroradiologist increased lesion detection. For HS, 3DT1, T2, and FLAIR each had a lesion detection rate at around 90%. Apparent diffusion coefficient indices had a lateralizing value of 33% for TLE. DTI fractional anisotropy and mean diffusivity had a localizing value of 8% and 34%. A dedicated MRI protocol and expert evaluation benefits lesion detection rate in epilepsy surgery candidates. If patients remain MRI negative, imaging at higher-field strength may reveal lesions. In HS, apparent diffusion coefficient indices may aid lateralization and localization more than increasing field strength. DTI can add further diagnostic information. For other additional sequences, the quality and number of studies is insufficient to draw solid conclusions. Our findings may be used as evidence base for developing new high-quality MRI studies and clinical guidelines.
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- Strandberg, Maria, et al.
(författare)
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Pre-surgical epilepsy evaluation using 3T MRI. Do surface coils provide additional information?
- 2008
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Ingår i: Epileptic Disorders. - 1294-9361. ; 10:2, s. 83-92
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Tidskriftsartikel (refereegranskat)abstract
- Purpose. To assess if 3T MRI can be further improved by adding surface coil imaging, in the context of detection and characterization of cerebral lesions in patients with drug-resistant epilepsy. Methods. Twenty five patients with drug-resistant epilepsy undergoing evaluation for epilepsy surgery were examined with high resolution 3T MRI. The patients were MRI-negative (n = 15), or had unclear findings (n = 10), on previous MRI at 1.0-1.5T. Surface coils were applied over the suspected epileptogenic zone after imaging in the head coil. In MRI-negative patients, placement of the coils was defined by semiological analysis, extracranial video-EEG, and, in selected cases, subtraction ictal SPECT co-registered with MRI and PET. Coil placement was re-analyzed and graded, based on the degree of convergence between different investigational modalities. Results. Surface coil MRI allowed visualization of the cortical lesions with somewhat better demarcation and detail, but did not contribute to detection of previously undiagnosed lesions and did not provide additional information regarding type of lesion. Possible epileptogenic lesions were detected on 3T MRI in 12 patients. No abnormalities were found in the remaining 13 patients. 3T MRI provided new or additional information about the cortex, compared with reports from previous 1.0-1.5T MRI in 5 patients (20%). Conclusion. 3T MRI with high resolution is valuable for lesion detection, especially MCD, in patients with drug-resistant epilepsy. We question the additional contribution from supplementary surface coil imaging at 3T MRI.
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- Tomson, T., et al.
(författare)
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The pharmacological treatment of epilepsy in adults
- 2023
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Ingår i: Epileptic Disorders. - 1294-9361. ; 25:5, s. 649-669
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Tidskriftsartikel (refereegranskat)abstract
- The pharmacological treatment of epilepsy entails several critical decisions that need to be based on an individual careful risk- benefit analysis. These include when to initiate treatment and with which antiseizure medication (ASM). With more than 25 ASMs on the market, physicians have opportunities to tailor the treatment to individual patients needs. ASM selection is primarily based on the patient's type of epilepsy and spectrum of ASM efficacy, but several other factors must be considered. These include age, sex, comorbidities, and concomitant medications to mention the most important. Individual susceptibility to adverse drug effects, ease of use, costs, and personal preferences should also be taken into account. Once an ASM has been selected, the next step is to decide on an individual target maintenance dose and a titration scheme to reach this dose. When the clinical circumstances permit, a slow titration is generally preferred since it is associated with improved tolerability. The maintenance dose is adjusted based on the clinical response aiming at the lowest effective dose. Therapeutic drug monitoring can be of value in efforts to establish the optimal dose. If the first monotherapy fails to control seizures without significant adverse effects, the next step will be to gradually switch to an alternative monotherapy, or sometimes to add another ASM. If an add -on is considered, combining ASMs with different modes of action is usually recommended. Misdiagnosis of epilepsy, non-adherence and suboptimal dosing are frequent causes of treatment failure and should be excluded before a patient is regarded as drug-resistant. Other treatment modalities, including epilepsy surgery, neuromodulation, and dietary therapies, should be considered for truly drug-resistant patients. After some years of seizure freedom, the question of ASM withdrawal often arises. Although successful in many, withdrawal is also associated with risks and the decision needs to be based on careful risk- benefit analysis.
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| 18. |
- Zelano, Johan, 1981, et al.
(författare)
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How to diagnose and treat post-stroke seizures and epilepsy
- 2020
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Ingår i: Epileptic Disorders. - : Wiley. - 1294-9361 .- 1950-6945. ; 22:3, s. 252-263
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Tidskriftsartikel (refereegranskat)abstract
- Stroke is one of the commonest causes of seizures and epilepsy, mainly among the elderly and adults. This seminar paper aims to provide an updated overview of post-stroke seizures and post-stroke epilepsy (PSE) and offers clinical guidance to anyone involved in the treatment of patients with seizures and stroke. The distinction between acute symptomatic seizures occurring within seven days from stroke (early seizures) and unprovoked seizures occurring afterwards (late seizures) is crucial regarding their different risks of recurrence. Asingle late post-stroke seizure carries a risk of recurrence as high as 71.5% (95% confidence interval: 59.7-81.9) at ten years and is diagnostic of PSE. Several clinical and stroke characteristics are associated with increased risk of post-stroke seizures and PSE. So far, there is no evidence supporting the administration of antiepileptic drugs as primary prevention, and evidence regarding their use in PSE is scarce.
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