Epilepsia最新文献

Objective: In 2021, the US Food and Drug Administration issued a safety warning concerning lamotrigine use in patients with underlying cardiac disorders. This warning was based on in vitro data that predicted class Ib antiarrhythmic activity for lamotrigine. Therefore, we investigated the proarrhythmic potential of lamotrigine in the murine heart and compared its effect with flecainide.

Methods: Murine hearts were perfused with clinically relevant concentrations of lamotrigine 3.8 μg/mL (15 μmol·L^-1) or flecainide .4 μg/mL (1 μmol·L^-1).

Results: Ex vivo electrocardiography revealed a high prevalence of ventricular tachycardia (VT) in lamotrigine-perfused hearts (7/9 hearts), whereas only two hearts exposed to flecainide evidenced VT. Optical voltage mapping showed that lamotrigine preferentially decreased ventricular conduction velocity (CV) in the longitudinal direction at all pacing frequencies tested (-22% ± 8.6%, -30% ± 15.4%, and -33% ± 13.3% for pacing frequency of 200-ms, 180-ms, and 150-ms cycle length, respectively, p ≤ .05) compared to the transverse direction, which only slowed CV at the fastest pacing frequency (-15% ± 16% for pacing frequency of 150-ms cycle length, p ≤ .01). Notably, the preferential CV slowing in the longitudinal direction altered the anisotropic ratio, giving rise to a functional substrate for reentrant VT. In contrast, flecainide slowed CV uniformly in both longitudinal and transverse directions (-30% ± 8.5% vs. -27% ± 5.3%, -32% ± 9.4% vs. -29% ± 6.9%, and - 29% ± 8.3% vs. -27% ± 10% for pacing frequency of 200-ms, 180-ms, and 150-ms cycle length, respectively, p ≤ .05).

Significance: Our findings provide mechanistic insight into the proarrhythmic impact of lamotrigine.

Objective: The ketogenic diet has been the mainstay of treatment of drug-resistant epilepsy (DRE). No comparative trials have been conducted to assess the efficacy of the two less strict ketogenic diets: modified Atkins diet (MAD) and low glycemic index treatment (LGIT). This study assesses the non-inferiority of LGIT compared with MAD.

Methods: This was an open-label randomized non-inferiority trial. Children with DRE were randomized to receive either MAD or LGIT as an add-on to anti-seizure medications. The primary endpoint was percentage seizure reduction at the end of 24 weeks of therapy compared to the baseline. The non-inferiority margin of -15% was predefined to calculate the sample size.

Results: Ninety-one children were enrolled and randomized to receive either MAD (n = 45) or LGIT (n = 46). Intention-to-treat analysis done at the end of 24 weeks of therapy showed a mean (±standard deviation [SD]) percentage seizure reduction of 60.7% (±41.3) in the MAD sub-group and 57% (±39.4) in the LGIT sub-group (p = 0.664). The absolute difference between the means of percentage seizure reduction was -3.7 (-20.5 to 13.2) and crossed the non-inferiority margin. Ten children in the MAD group and nine children in the LGIT group did not complete 24 weeks of therapy. Adverse effects were comparable between the arms (MAD, 66.6%; LGIT, 50%), although serious adverse effects were higher in the MAD arm. The most common adverse effect was decreased acceptance (24.2%) followed by decreased satiety (9.9%), vomiting (9.9%), weight loss (5.5%), constipation (5.5%), and diarrhea (3.3%). Dyslipidemia was more commonly seen in the MAD group (MAD, six; LGIT, one). One death in the LGIT arm was unrelated to therapy. Although there was no statistically significant difference in improvement in cognition, behavior, and quality of life scales, improvement was noted from baseline scores.

Significance: LGIT may be non-inferior to MAD in the treatment of children with DRE with the advantage of increased acceptance and fewer adverse effects.

Objective: This study aims to improve genetic diagnosis in childhood onset epilepsy with neurodevelopmental problems by utilizing RNA sequencing of fibroblasts to identify pathogenic variants that may be missed by exome sequencing and copy number variation analysis.

Methods: We enrolled 41 individuals with childhood onset epilepsy and neurodevelopmental problems who previously had inconclusive genetic testing. Fibroblast samples were cultured and analyzed using RNA sequencing to detect aberrant expression, aberrant splicing, and monoallelic expression using the Detection of RNA Outlier Pipeline (DROP) pipeline. Detected events were correlated with phenotypes, and long-read genome sequencing was performed on individuals with strong candidate events to identify the causal genomic variant. A systematic literature review on RNA sequencing in rare disorders was conducted to contextualize our findings.

Results: RNA sequencing identified five strong candidate events in four individuals, affecting the genes QRICH1, TSC1, SMARCA1, GNAI1, and PTEN. (Likely) pathogenic genomic variants affecting expression of QRICH1, TSC1, and SMARCA1 were detected, resulting in a diagnostic yield of 7% (3/41). Two variants were not covered in the initial exome sequencing data but were revealed through long-read sequencing. The identification of a pathogenic TSC1 variant led to a previously unrecognized diagnosis of tuberous sclerosis complex. This prompted guideline-based screening, which revealed tuberous sclerosis lesions in the brain and lung, directly impacting clinical care. Notably, two of the three pathogenic events would not have been detected using whole blood due to the lack of expression of the involved genes. The lower yield of this study compared to studies in other rare disorders reflects the genetic heterogeneity of epilepsy and neurodevelopmental disorders, and the inaccessibility of affected tissue.

Significance: This research underscores RNA sequencing of cultured fibroblasts as a valuable tool in genetic diagnostics for childhood onset epilepsy, particularly when conventional methods fail. Expanding the control dataset with age-matched samples and incorporating RNA sequencing with nonsense-mediated decay inhibition could further enhance diagnostic yield.

Clinical practice guidelines (CPGs) and consensus-based recommendations (CBRs) require considerable effort, collaboration, and time-all within the constraints of finite resources. Professional societies, such as the International League Against Epilepsy (ILAE), must prioritize what topics and questions to address. Implementing evidence-based care remains a crucial challenge in clinical practice. Using rigorous processes to ensure that the best available research evidence informs health care recommendations is of the utmost importance. We aimed to develop a structured and transparent process for prioritizing future CPGs and CBRs supported by the ILAE. A multidisciplinary group of researchers and experts from the ILAE Prioritization Task Force conducted a scoping review to identify prioritization approaches for CPG and CBR development. This scoping review was reported according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) and Cochrane recommendations. A Problem/population, Concept, and Context (PCC) strategy was applied to the literature search and selection of the studies. We searched Medline/PubMed, Embase, Web of Science, and Scopus without time or language limits. The findings were synthesized qualitatively. A consensus-based process was followed to develop a prioritization scoring tool for CPGs and another for CBRs. Thirty-nine participants, including clinicians, experts in the field, methodologists, and other relevant stakeholders, contributed to developing the final instrument (based on a 5-point Likert scale). Of 721 unique citations, 8 papers reporting prioritization approaches for guideline development were included. Based on these, we developed an initial tool with 10 criteria. It was iteratively optimized and revised by the ILAE Standards and Best Practice Council, which unanimously approved the instrument. The ILAE Executive Committee subsequently approved its final version. The ILAE Prioritization Tool is intended to standardize the prioritization processes and optimize the ILAE's use of resources to select CPGs and CBRs for endorsement.

Seizure detection devices (SDDs) offer promising technological advancements in epilepsy management, providing real-time seizure monitoring and alerts for patients and caregivers. This critical review explores user perspectives and experiences with SDDs to better understand factors influencing their adoption and sustained use. An electronic literature search identified 34 relevant studies addressing common themes such as usability, motivation, comfort, accuracy, barriers, and the financial burden of these devices. Usability emerged as the most frequently discussed factor, with patients and caregivers also emphasizing the importance of ease of use, long battery life, and waterproof design. Although validated devices showed high user satisfaction, technical challenges, false negatives, and false positives need much improvement. Motivation to use SDDs was driven by enhanced safety, symptom tracking, and health care professional recommendations. Comfort and wearability were also critical aspects, with users favoring lightweight, breathable, and discreet designs for long-term wear. Users reported the devices as "comfortable" and preferring wrist or arm-worn devices for the long term. Accuracy-particularly minimizing false positives and false negatives-was a priority for users. Barriers to adoption included device cost, limited insurance reimbursement, discomfort, and concerns about data privacy. Despite these challenges, many users were willing to use SDDs. Recommendations from health care professionals significantly increased user motivation. This review highlights the need for SDD designs that address user concerns regarding usability, comfort, looks, and accuracy, while also reducing financial and technical barriers. Enhancing clinical involvement and tailoring devices to specific patient needs may be crucial to promoting wider SDD adoption. Further research is needed to evaluate the impact of SDDs on quality of life and to explore ways to mitigate challenges in long-term use.

Objective: Gain-of-function variants in the KCNT1 gene, which encodes a sodium-activated potassium ion channel, drive severe early onset developmental epileptic encephalopathies including epilepsy of infancy with migrating focal seizures and sleep-related hypermotor epilepsy. No therapy provides more than sporadic or incremental improvement. Here, we report suppression of seizures in a genetic mouse model of KCNT1 epilepsy by reducing Kcnt1 transcript with divalent small interfering RNA (siRNA), an emerging variant of oligonucleotide technology developed for the central nervous system.

Methods: The ATL-201 molecule is two identical synthetic double-stranded siRNAs, covalently linked, with 100% nucleotide base pair match to sequence present in both human KCNT1 and mouse Kcnt1 that does not contain any known pathogenic variant. ATL-201 activity was tested in cortical neurons cultured from wild-type mice and in mice homozygous for Kcnt1-Y777H, the mouse ortholog to the human pathogenic KCNT1-Y796H missense variant. Seizures and nest-building behavior were measured in freely behaving Kcnt1-Y777H mice. The number and duration of seizures were measured by electrocorticography in mice dosed with ATL-201 or phosphate-buffered saline in a 6-month durability study and in a 2-month dose-efficacy study.

Results: In vitro, ATL-201 reduced KCNT1 transcript from whole-cell lysate and eliminated potassium currents from KCNT1 channels in heterologous expression. ATL-201 also eliminated sodium-activated potassium currents recorded from individual cortical neurons. In vivo, ATL-201 suppressed seizures in Kcnt1-Y777H homozygous mice in a dose-dependent manner with near-complete suppression from 2 weeks to at least 4 months. Kcnt1-Y777H mice had defects in nest building, whereas in ATL-201-treated mice nest building was equivalent to wild-type mice.

Significance: Patients with KCNT1-driven epilepsy experience up to hundreds of seizures per day and have severe impairment in cognitive, motor, and language development and high mortality. The dose-dependent efficacy and long durability of ATL-201 in mice show promise for ATL-201 as a disease-modifying treatment of KCNT1 epilepsy.

Objective: This study aimed to identify prescribing behaviors in women of childbearing potential (WOCP) with epilepsy already taking valproate (VPA), and to investigate the relationship between VPA maintenance, substitution, reduction, or withdrawal as part of polytherapy, and seizure worsening or relapse.

Methods: We retrospectively reviewed the prescription behaviors and seizure outcomes in WOCP (16-50 years of age) with epilepsy, referred to eight Italian epilepsy centers, who were taking VPA for at least 1 year between 2014 and 2019.

Results: Among 750 women (~12% of all WOCP), 528 (70.4%) maintained VPA unchanged throughout the observation period, 103 (13.7%) replaced VPA with another antiseizure medication (ASM), 90 (12%) reduced VPA, and 29 (3.9%) discontinued VPA in polytherapy. Focal epilepsy was most strongly associated with VPA withdrawal (odds ratio [OR] 2.96, 95% confidence interval [CI] 1.38-6.38), whereas generalized epilepsy was most associated with its non-withdrawal (reduction/switch/maintenance) (OR .31, 95% CI .14-.68). Intellectual disability, higher seizure frequency, and higher VPA doses were linked to VPA continuation. VPA withdrawal from polytherapy was associated with a higher risk of tonic-clonic seizure worsening (OR 2.91, 95% CI 1.09-7.77) compared to non-withdrawal.

Significance: VPA was rarely withdrawn or substituted in WOCP with epilepsy, in secondary and tertiary care settings following European regulatory restrictions. This likely reflects a population with severe epilepsies where VPA is difficult to replace; whereas women with milder epilepsies likely discontinued VPA earlier, as evidenced by its low overall prescription frequency. Withdrawal of VPA from a polytherapy regimen was associated with a threefold increased risk of seizure exacerbation.

Mental health (MH) comorbidities are prevalent among people with epilepsy (PWE), but many experience challenges accessing care. To address this, suggestions have been made to integrate MH care into epilepsy care settings, yet the current approaches, benefits, and implementation determinants to MH care integration are unclear. This review aims to synthesize existing integrated MH care models for PWE to inform the development and planning of future initiatives. We searched Embase, Medline, PsycINFO, and Cochrane for articles that described any activity within a health care setting that addressed MH as routine care for PWE. Year of publication was restricted to 2000 onward. At least two authors reviewed articles and extracted data. Barriers, facilitators, and future recommendations were identified through thematic synthesis using NVivo. Study quality was assessed for articles reporting clinical outcomes. Following review of 7520 abstracts and 596 full-text articles, 65 met eligibility criteria and were included. Most (k = 43, 66%) described routine MH screening, with 11 reporting on uptake and acceptability, which was generally high. Interventions included psychological interventions (k = 23, 35%), psychoeducation (k = 9, 14%), and pharmacotherapy (k = 6, 9%). Thirteen articles (20%) reported on changes in MH outcomes, all of which indicated some improvements in MH, but 33% were rated as poor quality. Thirty-four (52%) articles reported on barriers and facilitators, and 34 (37%) articles provided recommendations for future initiatives. Overall, diverse approaches to integrated MH care for PWE were identified, with promising uptake, acceptability, and impacts on MH outcomes. Qualitative analysis informed a proposed framework for future integrated MH care initiatives. The framework outlines fundamental components of care activities, such as MH screening, psychoeducation, and care pathways, as well as key facilitators for their establishment (e.g., policies, infrastructure, staffing) and effective delivery (e.g., staff incentives, acceptability, evaluation).

Objective: Lennox-Gastaut syndrome (LGS) is typically characterized by drug-resistant epilepsy and subsequent cognitive deterioration. Surgery is a rare but viable option for the control of seizures in a subset of patients with LGS. This study aimed to describe the organization of the epileptogenic zone network (EZN) in patients with LGS using stereoelectroencephalography (SEEG) and to report the outcome of post-SEEG treatment.

Methods: A quantitative SEEG signal analysis was conducted in 14 consecutive patients with LGS, in whom a potentially localized EZN was suggested based on a comprehensive noninvasive evaluation. The EZN and the irritative zone network were identified using relevant biomarkers during ictal (epileptogenicity index and connectivity epileptogenicity index) and interictal (spikes and high-frequency oscillations) recordings. The applied post-SEEG treatments were assessed, including SEEG-guided radiofrequency thermocoagulation (RF-TC), surgery, and neurostimulation.

Results: The seizure onset patterns showed some specificity by seizure type, with 84% of tonic seizures involving low-voltage fast activity. The EZN of patients with LGS was often, but not always, complex and extensive, involving two or more lobes (79%) and both hemispheres (64%). The lateral neocortical structures, particularly the lateral premotor and dorsolateral prefrontal cortices, were identified as being most frequently involved in the EZN. Among the explored subcortical structures, only the pulvinar, central-lateral thalamic nucleus, and hypothalamic hamartoma belonged to the EZN. Twelve patients (86%) underwent SEEG-guided RF-TC, with 50% experiencing a >50% reduction in baseline seizure frequency. Four patients (29%) underwent curative surgery for significant involvement of a lesion in the EZN, and one case achieved an Engel class I outcome.

Significance: This is the first quantitative SEEG study in patients with LGS to demonstrate the utility of SEEG in identifying patients who may benefit from surgery and to perform SEEG-guided RF-TC. Nevertheless, the indications for SEEG should be carefully assessed, as localized EZN is uncommon in LGS.

Objective: Epilepsy has negative socioeconomic impacts on those affected, resulting not only from actual disability but also from social stigma. However, longitudinal studies examining occupational consequences following an epilepsy diagnosis are limited. We aimed to investigate the occupational outcomes of newly diagnosed epilepsy among Korean employees.

Methods: We conducted a nationwide population-based retrospective cohort study using the Korean National Health Insurance Service database. We included newly diagnosed people with epilepsy (PWE) aged 25 to 54 years, identified by diagnostic codes and antiseizure medication (ASM) prescriptions, who were employed at diagnosis between 2004 and 2018. The employment status of PWE was determined based on their enrollment in the employer-provided health insurance scheme. We analyzed the rates of job loss and reemployment, associated factors, and income changes following diagnosis.

Results: Among the 13 122 newly diagnosed PWE, the overall first-year job loss rate across the study period was 21.7%, which was 1.62-2.54 times higher than that of the general population for each year. The excesses of job loss among PWE in safe occupations were comparable to those in safety-sensitive occupations. Central nervous system illness (adjusted hazard ratio [aHR] = 1.12), psychiatric disease (aHR = 1.19), ≥2 emergency room visits or hospitalizations (aHR = 3.00), and ≥4 ASM attempts (aHR = 1.26) increased the risk of job loss. Among individuals who lost their job during the first year, 22.4% were reemployed within 1 year, with similar risk factors hindering reemployment. The income distribution of regained jobs showed a downward shift compared to previous jobs.

Significance: Newly diagnosed PWE were at risk of job loss, irrespective of the occupational hazards related to seizures. Poor disease control and comorbidities partially contributed to unemployment. Alongside active seizure management, guidance for suitable occupations and the implementation of tailored restrictions based on occupational risk stratification are imperative to improve the job security of PWE.