COVID-19 vaccination-related exacerbation of seizures in persons with epilepsy.

Although vaccines are generally safe in persons with epilepsy (PWE), seizures can be associated with vaccination, including COVID-19. This study assessed the occurrence of COVID-19 vaccination-related seizure exacerbations in PWE. Adult PWE who had received a COVID-19 vaccine were consecutively recruited at a tertiary epilepsy clinic between June 2021 and April 2022. Patient demographics, including epilepsy history, vaccination details, and reported adverse effects were recorded. Seizure exacerbation, defined as occurring within one week of vaccination, was assessed. Five hundred and thirty PWE received the COVID-19 vaccine. 75 % received the Comirnaty (Pfizer) vaccine as their initial dose. Most patients (72 %) were taking ≥ 2 antiseizure medications (ASM) and had focal epilepsy (73 %). One-third were 12 months seizure free at their first vaccination. 13 patients (2.5 %) reported a seizure exacerbation following their first vaccination, three of whom required admission. None were seizure-free at baseline. Six of these patients (46 %) had a further exacerbation of seizures with their second vaccine. An additional four patients reported increased seizures only with the second vaccine dose. Seizure exacerbations are infrequently associated with COVID-19 vaccination, mainly in patients with ongoing seizures. The likelihood of COVID-19 infection complications in PWE outweighs the risk of vaccination-related seizure exacerbations.

When is it safe to return to driving following first-ever seizure?

OBJECTIVES: The risk of recurrence following a first-ever seizure is 40-50%, warranting driving restriction during the early period of highest risk. This restriction must be balanced against the occupational, educational and social limitations that result from patients being ineligible to drive. The recommended duration of non-driving after a first seizure varies widely between jurisdictions, influenced by various factors including the community perception of an acceptable relative level of risk for an accident (the accident risk ratio; ARR). Driving restrictions may be based on individualised risk assessments or across-the-board guidelines, but these approaches both require accurate data on the risk of seizure recurrence. METHODS: 1386 patients with first-ever seizure were prospectively analysed. Seizure recurrence was evaluated using survival analysis. The duration of non-driving required for a range of risks of seizure recurrence and ARRs was calculated. Additionally, the actual occurrence of seizures while driving was prospectively determined during follow-up. RESULTS: For a risk of seizure recurrence to fall to 2.5% per month, corresponding to a monthly risk of a seizure while driving of 1.04 per thousand and an ARR of 2.6, non-driving periods of 8 months are required for unprovoked first-ever seizure, and 5 months for provoked first-ever seizure. Of patients with a seizure recurrence, 14 (2%) occurred while driving, with the monthly risk falling to less than 1/1000 after 6 months. CONCLUSIONS: Our data provide a quantitative approach to decisions regarding a return to driving in patients with first-ever provoked or unprovoked seizure.

Injuries due to seizures in persons with epilepsy: a population-based study.

BACKGROUND: Previous studies of injuries due to epileptic seizures predominantly involved patients with intractable epilepsy. These studies may have overestimated the risk of injuries in persons with epilepsy. METHODS: Patients consisted of 247 Rochester, MN, residents who were diagnosed with epilepsy between 1975 and 1984. Seizure-related injuries were defined as any injury, other than orolingual trauma, resulting from a seizure, sufficient for the patient to seek medical attention or for injury occurrence to be determined during the course of medical care. To identify risk factors for injury, characteristics of patients with seizure-related injury were compared with those without injury. RESULTS: During a total of 2,714 patient-years of follow-up, 62 seizure-related injuries were identified in 39 patients (16%, one injury in every 44 person-years). Most injuries involved cranial soft tissue contusions or lacerations (79%). The majority of seizure-related injuries (82%) occurred during generalized convulsive seizures. Univariate analyses identified five potential risk factors for seizure-related injury: greater number of antiepileptic drugs used, less independent living situation, higher Rankin score, history of generalized convulsive seizures or drop attacks, and higher seizure frequency score. Seizure frequency, however, was the only significant risk factor identified by multivariate analysis (p < 0.001; relative risk, 1.33). CONCLUSIONS: This population-based study shows that seizure-related injuries are infrequent and generally of minor severity. In most epilepsy patients, excessive restriction of daily activities to avoid injury is unnecessary. Effective seizure control reliably reduces the risk of seizure-related injuries.

The morbidity of Guillain-Barré syndrome admitted to the intensive care unit.

Patients with severe forms of Guillain-Barré syndrome (GBS) require intensive care. Specific treatment, catheterization, and devices may increase morbidity in the intensive care unit (ICU). To understand the spectrum of morbidity associated with ICU care, the authors studied 114 patients with GBS. Major morbidity occurred in 60% of patients. Complications were uncommon if ICU stay was less than 3 weeks. Respiratory complications such as pneumonia and tracheobronchitis occurred in half of the patients and were linked to mechanical ventilation. Systemic infection occurred in one-fifth of patients and was more frequent with increasing duration of ICU admission. Direct complications of treatment and invasive procedures occurred infrequently. Life-threatening complications such as gastrointestinal bleeding and pulmonary embolism were very uncommon. Pulmonary morbidity predominates in patients with severe GBS admitted to the ICU. Attention to management of mechanical ventilation and weaning is important to minimize this complication of GBS. Other causes of morbidity in a tertiary center ICU are uncommon.

Adynamic ileus in severe Guillain-Barré syndrome.

Adynamic ileus occurred in 17 of 114 patients (15%) with severe Guillain-Barré syndrome (GBS). Cardiovascular dysautonomia coincided with ileus in only five patients. In four patients, mechanical ventilation and immobilization could be implicated; and in eight patients, preexisting conditions such as prior abdominal surgery or incremental doses of opioids could be linked to ileus. Medical management was successful in all patients. Patients with GBS infrequently develop ileus as a manifestation of dysautonomia.

Anticipating mechanical ventilation in Guillain-Barré syndrome.

CONTEXT: The combination of multiple clinical factors culminates in neuromuscular respiratory failure in up to 30% of the patients with Guillain-Barré syndrome (GBS). Although guidelines exist as to when to proceed with intubation, early indicators of subsequent progression to respiratory failure have not been established. OBJECTIVES: To identify clinical and respiratory features associated with progression to respiratory failure and to examine patterns of respiratory decline in patients with severe GBS. DESIGN: Retrospective survey. SETTING: Tertiary care hospital. PATIENTS: One hundred fourteen consecutive patients with severe GBS admitted to the intensive care unit between January 1, 1976, and December 31, 1996. MAIN OUTCOME MEASURES: Early markers of impending respiratory failure, requirement for mechanical ventilation, and patterns of respiratory decline. METHODS: The clinical and electrophysiologic features of 60 patients receiving mechanical ventilation were compared with 54 patients with severe GBS who did not receive mechanical ventilation. Daily preventilation maximal inspiratory and maximal expiratory respiratory pressures and vital capacity were analyzed. Multivariate predictors of the necessity for mechanical ventilation were assessed using logistic regression analysis. RESULTS: Progression to mechanical ventilation was highly likely to occur in those patients with rapid disease progression, bulbar dysfunction, bilateral facial weakness, or dysautonomia. Factors associated with progression to respiratory failure included vital capacity of less than 20 mL/kg, maximal inspiratory pressure less than 30 cm H(2)O, maximal expiratory pressure less than 40 cm H(2)O or a reduction of more than 30% in vital capacity, maximal inspiratory pressure, or maximal expiratory pressure. No clinical features predicted the pattern of respiratory decline; however, serial measurements of pulmonary function tests allowed detection of those at risk for respiratory failure. CONCLUSIONS: While inherently unpredictable, the course of patients with severe GBS can, to some extent, be predicted on the basis of clinical information and simple bedside tests of respiratory function. These data may be used in the decisions regarding admission to the intensive care unit and preparation for elective intubation.

Multifocal periodic lateralized epileptiform discharges (PLEDs): EEG features and clinical correlations.

OBJECTIVE: To analyze the clinical and EEG findings of patients with multifocal periodic lateralized epileptiform discharges (PLEDs). METHODS: EEGs containing multifocal PLEDs (3 or more foci of PLEDs) were reviewed. Thirty-five patients (15 males and 20 females), from 2.5 months to 91 years old, met the criteria for multifocal PLEDs. RESULTS: The disease processes identified in the patients included vascular lesions in 9, central nervous system infections in 7, metabolic/toxic disorders in 6, exacerbation of a chronic seizure disorder in 6, hypoxic ischemic insults in 3, and fat embolism, paraneoplastic encephalitis, cerebral metastasis, and multiple sclerosis in one each. Twenty patients died. Detection of the spatiotemporal distribution of multifocal PLEDs was facilitated by the use of Laplacian montages. CONCLUSIONS: Multifocal PLEDs were recorded in 35 patients and were associated with processes resulting in diffuse or multifocal cerebral dysfunction. Multifocal PLEDs indicate a significant disturbance of cerebral function and are associated with a mortality rate of 57%.

Long-term outcome in patients with Guillain-Barré syndrome requiring mechanical ventilation.

OBJECTIVE: To analyze long-term recovery and predictors of outcome in patients with Guillain-Barré syndrome (GBS) requiring mechanical ventilation. METHODS: The clinical and electrophysiologic data of 114 patients with GBS admitted to the intensive care unit between 1976 and 1996 (60 mechanically ventilated, 54 nonventilated) were reviewed. Functional disability and predictors of outcome were determined at 1 year and at maximal recovery using the Hughes scale. Good outcome was defined as ability to ambulate without assistance; poor outcome was defined as inability to ambulate independently. RESULTS: Mechanical ventilation was required in 81% of patients with a poor outcome. Mortality was 20% in patients ventilated for GBS. However, ventilated patients who survived did well, with 79% eventually regaining independent ambulation. Nineteen percent of patients improved at least one functional grade beyond 1 year. Univariate predictors of poor maximal recovery in ventilated GBS patients were increased age (p < 0.001)), upper limb paralysis (p = 0.004), duration of ventilation (p = 0.006), and delay of more than 2 days to transfer to a tertiary center (p < 0.001). However, only age (OR 1.99, p = 0.004) and delayed transfer (OR 19.8, p = 0.002) were independently predictive of poor outcome on multivariate analysis. CONCLUSION: Mechanically ventilated patients constitute the majority of GBS patients with a poor outcome, and mortality remains substantial in this subgroup (20%). Although recovery from severe GBS may be prolonged, most survivors regain independent ambulation.

Post-intubation pulmonary function test in Guillain-Barré syndrome.

The value of daily postintubation respiratory function tests in predicting duration of ventilation in 37 mechanically ventilated patients with Guillain-Barré syndrome (GBS) was studied. Patients ventilated for less than 3 weeks were compared with those ventilated more than 3 weeks. Daily vital capacity and maximal inspiratory and expiratory pressures were summed to an integrated pulmonary function (PF) score. We calculated the PF ratio, which represents the PF score at day 12 after intubation divided by the PF score on the day of intubation. The PF ratio was greater than 1 in all 10 patients ventilated less than 3 weeks and was less than 1 in 19 of 27 patients ventilated for longer (P = 0.0001, Fisher exact test). The sensitivity of a PF ratio less than 1 for predicting duration of ventilation greater than 3 weeks was 70%; the specificity and positive predictive value were 100%. This study thus suggests that serial postintubation respiratory tests can provide a measure of respiratory status in patients with GBS. These parameters may help predict duration of ventilation and need for tracheostomy. If, at day 12, the PF ratio is less than 1, it is highly unlikely that patients will be weaned within 3 weeks, and tracheostomy should be performed. If the ratio is greater than 1, tracheostomy should be deferred, because a substantial proportion of these patients may be successfully weaned from the ventilator within 3 weeks.

Tracheostomy in Guillain-Barré syndrome.

Specific treatment has been shown to shorten the duration of mechanical ventilation in Guillain-Barré syndrome (GBS) and could obviate the need for tracheostomy in a significant proportion of patients. However, the factors predictive of prolonged ventilation are undetermined, and the timing and use of tracheostomy in patients with GBS have not been systematically studied. The medical records of 60 patients ventilated for GBS were reviewed. Only 13 patients (22%) could be weaned within 3 weeks. Patients ventilated longer were significantly older (P = 0.04), and 21% had underlying pulmonary disease. Median duration of ventilation in patients treated with plasma exchange (n = 31) was not shortened. Fifty-two patients (87%) received a tracheostomy at a median of 9 days after intubation. In this series, where patients with comorbidity were included, tracheostomy was still necessary in the majority of ventilated patients. This procedure can be anticipated in elderly patients and in the presence of preexisting pulmonary disease.

Fatal Guillain-Barré syndrome.

Fourteen of 320 patients (4%) admitted with Guillain-Barré syndrome (GBS) died as a direct result of the illness. Deaths most commonly resulted from ventilator-associated pneumonia. In comparison with 101 other patients with severe GBS admitted to the intensive care unit, the patients who died were older (p = 0.006) and more likely to have underlying pulmonary disease (p = 0.004). In a specialized center, the primary event leading to death in GBS was ventilator-associated pulmonary infection, predominantly in elderly patients with significant comorbidity.