Surgical Treatment in Refractory Epilepsy: Seizure Outcome Results Based on Invasive EEG Monitorization.

AIM: To discuss seizure outcomes of patients with invasive electroencephalography (EEG) monitorization (IEM) following their epilepsy surgery at our centre. MATERIAL AND METHODS: Forty-seven patients suffering from refractory epilepsy and who were evaluated by invasive EEG were included in this retrospective study at Istanbul Faculty of Medicine from 2003 to 2017. We examined the Video EEG and invasive EEG monitorization, cranial MRI, SPECT, PET and neuropsychological tests of all patients. Postoperative seizure outcome results were evaluated according to Engel classification. The factors affecting seizure outcomes were discussed. RESULTS: Twenty-six of the patients were female (55.3%), 21 were male (44.7). The average age was 32.0 (± 12.4). Forty-three patients had surgery and the average age of these patients was 26,6 (±11.15). 38.3% of the patients had hippocampal sclerosis (HS), 23.4% had focal cortical dysplasia (FCD), 8.5% had a tumor, 14.9% had sequela lesion and 14.9% had unknown etiology. Postoperative seizure status according to the Engel classification showed that 81.6% of the patients were class I, 10.5% were class II, 2.6% were class III and 5.3% were class IV. CONCLUSION: A significant relation was statistically determined between structural MRI lesion and favorable seizure outcome (p < 0.05). The most frequent etiology was HS in our patients. Of the patients with Engel I, the averages of their ages, ages at onset of epilepsy and ages at surgery were lower than other groups, but the difference was not statistically significant (p > 0.05). We argue that IEM is an essential examination for favorable outcomes for determining the epileptogenic zone and/or the proximity of the functional structures.

Prevalence and clinical characteristics of headache in juvenile myoclonic epilepsy: experience from a tertiary epilepsy center.

The comorbidity of headache and epilepsy is often seen in neurological practice. The objective of this study was to assess the prevalence, types of, and risk factors for headache in juvenile myoclonic epilepsy (JME). We assessed a total of 200 patients and 100 healthy controls in our study. Headache was classified in participants using a self-administered questionnaire. Demographical, clinical features and headache characteristics were recorded. Seizure and headache temporal profiles were noted. Headache was present in 111 (56%) patients and 50 (50%) healthy participants. From these patients, 47 (42.3%) JME patients had migraine [30 (27%) migraine without aura (MO), 17 (15.3%) migraine with aura (MA)], 52 (46.8%) had tension type headache (TTH), 4 (3.6%) had both migraine and TTH, and 8 (7.2%) had other non-primary headaches. In the healthy control group, migraine was detected in 16 (32%) subjects, TTH in 33 (66%), both migraine and TTH in 1 (2%) subject. A positive migraine family history and symptom relief with sleep were more frequent in JME patients (p = 0.01). Headache was classified as inter-ictal in 82 (79.6%) patients and peri-ictal in 21 (20.4%) patients. In conclusion, the present study revealed that headache frequency was not significantly different between JME patients and healthy controls (p > 0.05). However, migraine frequency was higher in JME patients than healthy controls. Some migraine and TTH characteristics were different in between groups. We suggest that our results support both genetic relationship and shared underlying hypothetical pathopysiological mechanisms between JME and headache, especially migraine.

Evaluation of inner retinal layers with optic coherence tomography in vigabatrin-exposed patients.

In order to reveal the underlying retinal pathology leading to dysfunction in vigabatrin-exposed patients, we aimed to evaluate the inner retinal layers encompassing ganglion cell complex (GCC) layer and inner plexiform layer with new generation optic coherence tomography (OCT). Fourteen patients with epilepsy and exposure to vigabatrin and 12 clinically normal individuals, constituting the control group, were included. Retinal images were obtained using spectral-domain OCT (Optovue RTVue Fourier domain). Nasal and superior quadrants of retinal nerve fiber layer (RNFL) were found to be significantly lower in the patient group compared to the controls (p < 0.01). No significant difference was shown in the thickness of GCC layer (p > 0.05). Foveal thickness was significantly higher in the patient group (p: 0.006), but no significant difference was found in perifoveal and parafoveal regions between groups (p > 0.05). The thickness of RNFL was found to be lower in vigabatrin-exposed patients without any reduction in GCC layer in the macular region. However, foveal thickness was found to be significantly higher compared to perifoveal and parafoveal macular regions in vigabatrin-exposed patients. In conclusion, OCT revealed reduced thickness of RNFL without any reduction in ganglion cell layer in our study. The objective quantitative assessment of OCT is a practical noninvasive method and it can have role in future monitoring of these patients.

Teratogenicity of Antiepileptic Drugs.

OBJECTIVE: Antiepileptic drugs (AED) have chronic teratogenic effects, the most common of which are congenital heart disease, cleft lip/palate, urogenital and neural tube defects. The aim of our study is to examine teratogenic effects of AED and the correlation between these malformations and AED in single or multiple pregnancies. METHODS: This is a retrospective study of malformations in children born to mothers currently followed up by our outpatient clinics who used or discontinued AED during their pregnancy. Their children were then investigated using echocardiography, urinary ultrasound, cranial magnetic resonance image, and examined by geneticists and pediatric dentists. RESULTS: One hundred and seventeen children were included in the study. Ninety one of these children were exposed to AED during pregnancy. The most commonly used AED were valproic acid and carbamazepine in monotherapy. The percentage of major anomaly was 6.8% in all children. Dysmorphic features and dental anomalies were observed more in children exposed especially to valproic acid. There were 26 mothers with two and four mothers with three pregnancies from the same fathers. No correlation was found between the distribution of malformations in recurring pregnancies and AED usage. CONCLUSION: Our study has the highest number of dysmorphism examined in literature, found in all the children exposed to valproic acid, which may account for the higher rate of facial dysmorphism and dental anomalies. On lower doses of valproic acid, major malformations are not seen, although the risk increases with polytherapy. Our data also indicate possible effects of genetic and environmental factors on malformations.

Knowledge of epilepsy among persons with epilepsy in Turkey.

PURPOSE: It has been shown in studies that there are knowledge gaps about epilepsy in both developing and developed countries all around the world. Lack of knowledge exists even among people with epilepsy (PWE), and this may affect their lives negatively. This study aimed to evaluate what PWE in Turkey know about their disease. METHOD: A self-completed questionnaire consisting of demographic details, an item about perceived stigmatization, and 24 items about general knowledge of medical and social aspects of epilepsy was developed. Applicants were asked to answer 'true', 'false', or 'do not know' to each statement. The scores of the questionnaire were defined as low (< 15 point), medium (≥ 15-20), and high (≥ 20). RESULTS: The mean score on the questionnaire was 15.17 ± 3.74 (range, 4-24). One hundred twenty-five PWE (37.9%) scored low, 170 PWE (51.5%) scored medium, and 35 PWE (10.6%) scored high. The education level and household income were highly correlated with the knowledge level. Higher education level (r: 0.31) and high income (r: 0.25) were correlated with higher mean scores (p < 0.01). Lack of information was present particularly in terms of etiology, management of seizures, and medication during pregnancy. CONCLUSION: We documented the knowledge deficit of PWE about their disease, a situation that may lead to suboptimal management and negative attitudes. We concluded that study programs should be organized and more education should be provided to PWE in order to overcome these issues.

Misdiagnosis in JME: Still a problem after 17 years?

PURPOSE: Juvenile myoclonic epilepsy (JME) is one of the most common and recognizable idiopathic generalized epilepsy with its characteristic clinical and EEG features. We think despite the well defined diagnostic criteria, and increasing awareness, misdiagnosis in JME may still be a problem. The present study aims to determine misdiagnosis in JME and to compare the results with our previous study reported in 1998. METHODS: Two hundred JME patients examined at epilepsy outpatient clinics of Bakirkoy Prof. Dr. Mazhar Osman Training and Research Hospital for Psychiatric, Neurologic and Neurosurgical Diseases between the years 2014-2015 were enrolled. Medical records of all patients were evaluated retrospectively; demographical, clinical and electrophysiological data and causes of misdiagnosis were collected from chart reviews. RESULTS: Of 200 JME patients, 49 were misdiagnosed at first medical evaluation. The most common presenting seizure types were generalized tonic clonic seizure and myoclonia in misdiagnosed patients and correctly diagnosed patients, respectively. EEG revealed generalized spike wave and polyspike-wave discharges in 52% of the misdiagnosed patients. Unfortunately the physician was a neurologist in 87.8% of cases with misdiagnoses. Nearly half of 49 misdiagnosed patients were prescribed an inappropriate antiepileptic drug, and the other half were prescribed none. CONCLUSIONS: Comparing our new results with the ones in 1998, misdiagnosis rate was less and time to put a correct diagnosis was shorter. However, proper diagnosis at first sight is still a problem among neurologists even the typical EEG changes are present.

Effects of Oxcarbazepine and Levetiracetam on Calcium, Ionized Calcium, and 25-OH Vitamin-D3 Levels in Patients with Epilepsy.

OBJECTIVE: The primary objective of the present study was to further elucidate the effects of oxcarbazepine (OXC) and levetiracetam (LEV) monotherapies on the bone health status of patients with epilepsy. METHODS: This study included 48 patients who attended our epilepsy outpatient clinic, had a diagnosis of epilepsy, and were undergoing either OXC or LEV monotherapy and 42 healthy control subjects. The demographic and clinical features of the patients, including gender, age, onset of disease, daily drug dosage, and duration of disease, were noted. Additionally, the calcium, ionized calcium, and 25-OH vitamin-D3 levels of the participants were prospectively evaluated. RESULTS: The 25-OH vitamin-D3, calcium, and ionized calcium levels of the patients taking OXC were significantly lower than those of the control group. These levels did not significantly differ between the patients taking LEV and the control group, but there was a significant negative relationship between daily drug dose and ionized calcium levels in the LEV patients. CONCLUSION: In the present study, anti-epileptic drugs altered the calcium, ionized calcium, and 25-OH vitamin-D3 levels of epilepsy patients and resulted in bone loss, abnormal mineralization, and fractures. These findings suggest that the calcium, ionized calcium, and 25-OH vitamin-D3 levels of patients with epilepsy should be regularly assessed.

EXTREME DELTA BRUSH EEG PATTERN IN A CASE WITH ANTI-NMDA RECEPTOR ENCEPHALITIS.

Anti-N-methyl-D-aspartate receptor NMDA-R encephalitis is caused by antibodies against the NMDA-R and characterized by a severe encephalopathy with psychosis, epileptic seizures and autonomic disturbances. This disorder is often accompanied with malignancies, especially ovarian teratoma. Some patients' EEGs show a different pattern similar to the waveforms of premature infants and this pattern is specifically named as extreme delta brush (EDB). We report a 24-year-old female having anti-NMDA receptor encephalitis and EDB patern.

Stigmatization and social impacts of epilepsy in Turkey.

OBJECTIVE: Stigma associated with epilepsy has negative effects on psychosocial outcomes, affecting the lives of people with epilepsy (PWE). Obtaining basic social rights can be difficult compared to the general population. The aim of our study was to evaluate the perceived stigma among PWE and social attitude towards the disease and to compare the social measures with the general population in Turkey. METHOD: A self-completed questionnaire consisting of demographic details and items about attitudes and perceived stigmatization was developed. Participants consisted of patients with various types of seizures who were randomly chosen from the epilepsy outpatient clinic. They were requested to complete the questionnaire. RESULTS: Questionnaires were obtained from 330 PWE. One hundred forty individuals (43.3%) out of 323 reported feeling stigmatized. The marriage and total fertility rates were below the national rates of Turkey. Keeping their epilepsy as a secret from society was prevalent. Although the education rate was not below the national rate, unemployment rate was high, and the average monthly wage was significantly lower than that of the general population. The majority thought that their families were protective towards them. Only 2 of the 330 participants were living alone. CONCLUSION: The present study supports the perception of stigma associated with epilepsy and its negative impact on the lives of PWE in Turkey. Clearly, more research is needed to understand the reasons for stigma and how to decrease its impact.

Long-term outcomes in patients with West syndrome: an outpatient clinical study.

PURPOSE: Nearly half of all patients with seizure onset in the first year of life suffer from West syndrome (WS). The prognosis of epilepsy and psychosocial outcomes in children with WS are variable. This study was performed to examine the factors influencing the outcome of this patient population. METHODS: A total of 109 patients with WS followed up regularly for at least 3 years were included in the study. Relevant clinical, laboratory, and imaging data were collected. RESULTS: The male/female ratio was 65/44 (59.6%/40.4%). The mean age at onset of infantile spasm (IS) was 6 ± 6 (1-36) months. With regard to neuro-developmental and social conditions during the final evaluation, 29.4% of the patients were socially dependent on caregivers, 61.8% needed assistance, and 8.8% were normal. Among the patients, 5.9% were free of epilepsy and antiepileptic drugs (AED) for at least 2 years, 49.0% had no seizures with AEDs, and 45.1% had uncontrollable seizures. Parameters with significant negative effects on the long-term outcomes included symptomatic etiology, presence of developmental retardation before the onset of IS, persistence of active epilepsy, and male gender. CONCLUSION: In this study, 37 (33.9%) patients had severe consequences as a result of WS. The majority of the rest could cope with daily life with varying degrees of assistance. Eight percent of the patients had a normal development. These results draw attention to the two-thirds of patients with WS who have the chance of an acceptable quality of life (QoL) with early diagnosis and therapeutic measures.

Panayiotopoulos syndrome and symptomatic occipital lobe epilepsy of childhood: a clinical and EEG study.

AIM: Panayiotopoulos syndrome (PS) is an age-related seizure susceptibility syndrome that affects the central autonomic system. Although the majority of the few ictal recordings obtained so far suggest an occipital origin, semiological and interictal EEG data appear to favour more extensive involvement. In this study, the characteristics (including those based on semiology and EEG) of children with Panayiotopoulos syndrome (n=24) and those with lesion-related, symptomatic occipital lobe epilepsy (SOLE) (n=23) were compared. METHODS: Detailed semiological information and EEG parameters including the localisation, distribution, density (n/sec), reactivity, and morphological characteristics of spike-wave foci and their relationship with different states of vigilance were compared between the two groups. RESULTS: The age at seizure onset was significantly younger in patients with symptomatic occipital lobe epilepsy than in those with PS (mean age at onset: 3.4 versus 5.6 years, respectively; p=0.044). Autonomic seizures (p=0.001) and ictal syncope (p=0.055) were more frequent in PS than in symptomatic occipital lobe epilepsy (87.5% and 37.5% versus 43.5% and 13%, respectively). The interictal spike-wave activity increased significantly during non-rapid eye movement (non-REM) sleep in both groups. The spike waves in non-REM seen in PS tended to spread mainly to central and centro-temporal regions. CONCLUSIONS: The results indicate that although common features do exist, Panayiotopoulos syndrome differs from symptomatic occipital lobe epilepsy and has a unique low epileptogenic threshold related to particular brain circuits.