Fourteen Days vs 28 Days of Albendazole Therapy for Neurocysticercosis in Children: An Open Label Randomized Controlled Trial

Background: There is a paucity of literature to support 14-days albendazole therapy for neurocysticercosis (NCC). Objective: To compare the efficacy of 14-day and 28-day albendazole therapy in the management of children with newly diagnosed active NCC. Study design: Open-labelled randomized controlled trial Participants: Children aged 1-14 years with newly diagnosed active neurocysticercosis. Intervention: Albendazole (15 mg/kg/day) for either 14 days or 28 days. Outcome: The primary outcome measure was proportion of children with radiological resolution of active lesion at 6-month follow up. Secondary outcome measures were proportion of children with seizure recurrence, duration to seizure recurrence and calcification on follow up imaging. Results: 65 children with newly diagnosed NCC were randomized to receive albendazole therapy for 14 days (n=32) or 28 days (n=33). The proportion of children with complete resolution was comparable between the two groups [6 (18.8%) vs. 9 (27.3%); OR (95%CI):0.61 (0.19 to 1.98); P=0.56]. Similarly, proportion of children with seizure recurrence [5(15.6%) vs 2(6.1%); OR (95%CI): 2.87(0.51-16.0); P=0.26] and proportion of children with calcification on follow-up imaging [26(81.2%) vs 23(69.7%); OR (95%CI): 1.88 (0.59-5.99); P=0.39] were also comparable. There were no major side-effects noted during the study. Conclusion: 14-day treatment with albendazole therapy is as effective as 28-day treatment in achieving radiological resolution at six-month follow up. However, high rate of calcification in both the groups indicates need for further evaluation with an adequately powered study and longer follow up

Evaluación y manejo de primera crisis epiléptica / Assessment and management of the first epileptic seizure

RESUMEN Las crisis epilépticas son una causa frecuente de consulta en la emergencia y en la atención ambulatoria. La evaluación de una primera crisis epiléptica reviste gran trascendencia en este contexto, ya que la ocurrencia de ésta no implica necesariamente el diagnóstico de epilepsia (dos o más crisis no provocadas separadas por más de 24 horas; una crisis única con alto riesgo de recurrencia (>60%); o la evidencia de un síndrome epiléptico - definición de la Liga Internacional para la Lucha Contra la Epilepsia, ILAE) y el tratamiento subsecuente. Por otro lado, no todo paciente con primera crisis debe ser dejado en observación sin recibir el manejo apropiado. Esta decisión está en función del riesgo de recurrencia de crisis. Para ello, la Academia Americana de Neurología (AAN de sus siglas en inglés) recomienda la clasificación de la primera crisis epiléptica en cinco grupos y dependiendo del riesgo de recurrencia de crisis establecido para cada uno de ellos, se tendrá una guía para proceder o no con el tratamiento antiepiléptico. Los grupos son: pacientes con crisis epiléptica provocadas; pacientes con crisis sintomáticas agudas; pacientes con crisis sintomática remotas; primera crisis asociada a síndromes epilépticos; primera crisis de causa desconocida. La guía publicada por AAN en el 2015 para el manejo de primera crisis, sugiere que los pacientes con crisis sintomáticas remotas (lesiones cerebrales pasadas no evolutivas), pacientes con anormalidades epileptiformes interictales; pacientes con estudios de imagen anormales (RMN y TC); y pacientes con crisis nocturnas, tienen un riesgo elevado para recurrencia de crisis (>60%) por lo que deben ser tratadas. La evidencia disponible a la fecha sugiere también que no hay diferencia significativa en el inicio precoz o diferido del tratamiento antiepiléptico para el control de las crisis a largo plazo.

SUMMARY Epileptic seizures are a common cause of medical consultation in the emergency room and in outpatient settings. The evaluation of the first epileptic seizure is of upmost importance as not all patients presenting with seizures have epilepsy (two or more unprovoked crises separated more than 24 hours; one single crisis with a high risk of recurrence (>60%); or evidence of an epileptic syndrome needing treatment based on the definition by the International League against Epilepsy). On the other hand, not every patient with a first episode should be just observed not offering proper treatment. This decision is based on the risk of recurrence. For that purpose, the American Academy of Neurology (AAN) recommends classifying the first seizures into five groups depending on the risk of recurrence, these groups are: patients with provoked seizures; patients with acute symptomatic seizures; patients with remote symptomatic seizures; first seizure associated with an epileptic syndrome, and first seizure of unknown origin. The AAN guidelines for the management of the first seizure published in 2015 suggests that patients with symptomatic remote seizures (non-evolutive and old cerebral lesions), patients with interictal epileptiform abnormalities, patients with abnormal findings on MRI or CT scan, and patients with nocturnal seizures had a high risk for recurrence (>60%) and should be treated. Current evidence suggests that there is no difference in early or delay treatment for controlling seizures at the long-term.

Intermittent clobazam prophylaxis in simple febrile convulsions: a randomised controlled trial

Background: Febrile seizure (FS) is the most common type of childhood seizure disorder with a prevalence of 2-5% in children less than 5 years. Although the prognosis of febrile seizure is usually good, however, the possibility of recurrence keeps many parents and families in a state of anxiety and concerned, for years after the first seizure. Thus, intermittent prophylactic treatment might be advised in children with high risk of recurrence.Methods: The study was a prospective randomized, double blind, placebo-controlled trial conducted at Department of Pediatrics, Umaid Hospital, Dr S N Medical College, Jodhpur on neurologically normal children aged from 6 months to 5 years with a history of simple febrile seizures and normal electroencephalogram without any evidence of acute central nervous system infection. Subjects were randomly prescribed oral clobazam according to weight of child and placebo when they developed a febrile disease during the first 48 h of the onset of fever.' Temperature reduction measures with paracetamol and tepid sponging were also advised. Patients were followed up for the frequency and time of febrile seizure recurrence, febrile episodes and side effects of drugs for 12 months.Results: Ten (3.8%) of 257 episodes in clobazam group and 38 (14.07%) episodes in placebo group had seizure recurrence (p value <0.001). The two groups were not significantly different in terms of side effects. (p >0.05).Conclusions: Intermittent oral clobazam therapy is a very effective measure in preventing recurrence of febrile seizures.

The Clinical Characteristics and the Prognosis of Poststroke Seizures after Ischemic Cerebral Infarction / 대한간질학회지

BACKGROUND: Although stroke is one of the most frequent causes of seizures in adulthood, there has been constant controversy concerning risk factors and prognosis of poststroke seizures. This study was performed to investigate clinical manifestations, risk factors and prognosis in patients with poststroke seizures (PSS). METHODS: A total of 2048 patients with cerebral infarction were recruited for this study. Patients with PSS were reviewed retrospectively regarding stroke subtype, etiology, lesion location, and functional disability of the stroke as well as seizure types, treatment and recurrence rate. Patients with traumatic or hemorrhagic brain lesion or a history of previous seizures were excluded. RESULTS: PSS developed in 4.2% of ischemic stroke patients (85/2048; 46 men and 39 women, mean age 65.4 years). PSS developed within one week of stroke onset in 18.8% (16/85) whereas after one week in 81.2% (69/85). PSS was more common in patients with cortical lesions than subcortical lesions (15.1% and 0.8%; p=0.076). Status epilepticus more frequently manifested in early onset seizures compared to late onset seizures (31.3% and 10.1%; p=0.029). Seizure recurrence was observed in 44.3% of PSS patients, mostly due to poor compliance to treatment or due to inadequate drug treatment. Only 7.1% of PSS patients were drug resistant and all of these patients had late onset seizures. CONCLUSION: Seizures after ischemic infarction developed more commonly after one week of stroke onset, and in patients with cortical lesions. Seizure recurrence occurred in about half of the patients, and the rate of drug resistance was higher in late onset seizures.

Surgery in Patients with Previous Resection of the Epileptogenic Zone Due to Intractable Epilepsy

PURPOSES: This study reports the possible causes of seizure recurrence in patients underwent previous epilepsy surgery, and surgical strategy for resection of the additional epileptogenic zone locating at the distant area to the site of first resection. METHODS: A total of 10 patients with previous surgery due to intractable epilepsy were studied. Five of these underwent standard temporal lobectomy, four extratemporal resection, and one corticoamygdalectomy. Seizure outcome of these were class III-IV. Evaluation methods for reoperation included MRI, 3D-surface rendering of MRI, PET, prologned video-EEG recording with surface electrodes and subdural grid electrodes. Additional resection was done in the frontal lobe in two, in the temporal lobe in three, in the parietal lobe in two, and in the supplementary sensori-motor area in two. Tumor in the superior frontal gyrus in the left hemisphere was removed in one patient. Extent of resection was decided based on the results of ictal subdural grid EEGs and MRI findings. Awake anesthesia and electrocortical stimulation were performed in the two patients for defining the eloquent area. RESULTS: Histopathologic findings revealed extratemporal cortical dysplasia in six, hippocampal sclerosis and cortical dysplasia of the temporal neocortex in one, neuronal gliosis in two, and meningioma in one. Previous pathology of the five patients with cortical dysplasia in the second operation was hippocampal sclerosis plus cortical dysplasia of the temporal neocortex. After reoperation, seizure outcomes were class I in six, class II in three, class III in one at the mean follow-up period of 17.5 months. Characteristically, patients in class II-III after reoperation showed histopathologic findings of hippocampal sclerosis plus temporal neocortical cortical dysplasia plus extratemporal cortical dysplasia. CONCLUSIONS: Seizure recurrence after epilepsy surgery was related with the presence of an additional epileptogenic zone distant to the site of first operation, and the majority of the histopathology of the surgical specimens was cortical dysplasia. In particular, hippocampal sclerosis plus temporal neocortical cortical dysplasia was highly related with seizure recurrence in patients with previous operation. In these patients, multimodal evaluation methods were necessary in defining the additional epileptogenic zone.

The prognostic factors of seizure recurrence in newly diagnosed epilepsy

BACKGROUND: To evaluate the prognostic factors of seizure recurrence in newly diagnosed epilepsy at 1 year follow up. METHODS: From the IUED (Inje University Epilepsy Database) we retrieved the epilepsy patients who had never before taken any antiepileptics (AED) and were followed up for 1 year. We retrospectively reviewed the medical records with special attention to : a) age of onset, b) history of antecedents, c) seizure frequency before starting AED, d) abnormal neurological examination, e) MRI findings, f) EEG findings, g) epileptic syndrome classification. We defined seizure recurrence as any seizure occurring during the 1 year evaluation follow up except during the AED titra-tion period, having only an aura and being in poor compliance. We analyzed the prognostic factors that could reliably predict the seizure recurrence at 1 year follow up. RESULTS: We found 104 patients (64 male, 40 female) who met the inclusion criteria. The mean age of onset was 23.7 years. Of 104 patients 19 had generalized epilepsy, 82 had partial epilepsy and 3 had unclassified epilepsy. Thirteen percent (13/104) developed seizure recurrence at the 1 year follow up. Significant univariate associations were noted between seizure recurrence and these factors: presence of antecedents [odds ratio (OR) 4.8; 95% confidence interval (CI) 1.2-18.5 ], post-encephalitic epilepsy (OR 7.7; 95% CI 2.1 ~ 28), and abnormal neurological examination(OR 14.6; 95% CI 3.9-55). With multivariate logistic regression, the independent predictor of seizure recurrence was the abnormal neurological examination (OR 9.7; 95% CI 2.4 ~ 39.4). CONCLUSIONS: The chance of developing a seizure recurrence at the 1 year follow up was 13 percent and the prognostic factors were the presence of antecedents, post-encephalitic epilepsy and an abnormal neurological examination.

The risk of seizure recurrence of pediatric epileptic patients while receiving anticonvulsant drugs treatment

To evaluate the risk and factors associated with seizure recurrence in children with epilepsy while receiving the adequate anticonvulsant treament, we studied 58 patients with newly diagnosed epilepsy who were followed prospectively for a median of 26 months (range 7 to 54). The results were as follows: 1) Forty-four of the 58 patients (75.9%) had recurrence of seizure. 2) The rate of recurrence according to type of seizure was observed to be 22 patients (68.8%) in generalized tonic-clonic seizure, 6 patients (85.7%) in simple partial seizure, 5 patients (83.3%) in complex partial seizure, 3 patients (100%) in mixed seizure, 2 patients (100%) in absence, 3 patients (100%) in infantile spasm, 1 patient (100%) in atonic seizure, 2 patients (50%) in secondary generalized seizure. There was no significant difference in the risk of recurrence observed among these seizure types. 3) The risk of recurrence varied according to the history of seizure, seizure recurrence was observed in 100% of the cases with history of neonatal seizure, 72.7% of the cases with febrile convulsion, and 73.3% of the cases with non-specific history. No significant difference was observed among these past history of seizure. 4) The rate of seizure recurrence according to electroencephalographic abnormalities did not differ significantly. Seizure recurrence was noted in 13 of the 18 patients with mildly disordered tracings (72.2%), 15 of the 20 patients with moderate abnormality (75.0%), and 12 of the 16 patients with severe abnormality (75.0%). 5) Recurrence rate according to cause of seizure was more significantly frequent in those with symptomatic epilepsy than in those with idiopathic type (100% vs 70.2%, p<0.05). 6) The frequency percentage of seizure recurrence by age groups of below 1 year, 1 to 3 years, 4 to 6 years, and above 6 years at onset of seizure were 100, 66.7, 57.1, and 72.7, respectively. The rate of seizure recurrence was significantly highest in patients aged below 1 year at onset of seizure. 7) There was significant difference in seizure recurrence between those with and without abnormalities as shown by neurologic examination (100% vs 70.8%, p<0.05). 8) There was no consistent difference in valproic acid serum levels between those who had a recurrence and those who did not. The patients receiving phenobarbital had significantly high serum levels of the phenobarbital in recurrent groups than those who had no recurrence. In conclusion, factors associated with an increased risk of seizure recurrence were early age at onset of epilepsy, symptomatic epilepsy, and neurologic abnormalities. We found no associations between risks of recurrence and types of epilepsy, or electroencephalographic abnormalities.