The Role of Surgery in the Management of Lennox–Gastaut Syndrome: A Systematic Review and Meta-Analysis of the Clinical Evidence

Abstract, originally published in Epilepsia

Lennox–Gastaut syndrome (LGS) is a severe form of childhood onset epilepsy in which patients require multiple medications and may be candidates for palliative surgical intervention. In this meta-analysis, we sought to evaluate the impact of palliative vagus nerve stimulation (VNS), corpus callosotomy (CC), and resective surgery (RS) by analyzing their impact on seizure control, antiepileptic drug (AED) usage, quality of life (QOL), behavior, cognition, prognostic factors, and complications.

A systematic search of PubMed MEDLINE, Scopus, and Cochrane Database of Systematic Reviews was performed to find articles that met the following criteria: (1) prospective/retrospective study with original data, (2) at least one LGS surgery patient aged less than 18 years, and (3) information on seizure frequency reduction (measured as percentage, Engel class, or qualitative comment).

Seizures were analyzed quantitatively in a meta-analysis of proportions and a random-effects model, whereas other outcomes were analyzed qualitatively. Forty studies with 892 LGS patients met the selection criteria, with 19 reporting on CC, 17 on VNS, four on RS, two on RS + CC, one on CC + VNS, and one on deep brain stimulation. CC seizure reduction rate was 74.1% (95% confidence interval [CI] = 64.5%–83.7%), and VNS was 54.6% (95% CI = 42.9%–66.3%), which was significantly different (p < .001). RS seizure reduction was 88.9% (95% CI = 66.1%–99.7%).

Many VNS patients reported alertness improvements, and most had no major complications. VNS was most effective for atonic/tonic seizures; higher stimulation settings correlated with better outcomes. CC patients reported moderate cognitive and QOL improvements; disconnection syndrome, transient weakness, and respiratory complications were noted. Greater callosotomy extent correlated with better outcomes. AED usage most often did not change after surgery. RS showed considerable QOL improvements for patients with localized seizure foci.

In the reported literature, corpus callosotomy appeared to be more effective than vagus nerve stimulation for seizure reduction. Vagus nerve stimulation may provide a similar or higher level of quality of life improvement with lower aggregate risk of complications. Patient selection, anatomy, and seizure type will inform decision-making.

Cognitive and Behavioral Profiles of Pediatric Surgical Candidates With Frontal and Temporal Lobe Epilepsy

Abstract, originally published in Epilepsy & Behavior

Background: We aimed to prospectively analyze memory and executive and social cognitive functioning in patients with drug-resistant frontal lobe epilepsy (FLE) and temporal lobe epilepsy (TLE) with focal lesions and isolate the impact of intellectual ability on specific deficits.

Methods: A neuropsychological evaluation was performed in 23 children with FLE, 22 children with TLE, and 36 healthy pediatric controls (HCs). Patients in the epilepsy groups had a range of lesions, including low-grade epilepsy-associated tumors (LEAT), focal cortical dysplasia (FCD) type II, and mesial temporal sclerosis (MS).

Results: There were no significant differences between children with FLE and TLE regarding memory, executive, or social cognitive functioning. General Ability Index (GAI) was a predictor of memory, executive function, and social cognition scores and was influenced by age at onset, duration of epilepsy, and number of antiepileptic drugs (AEDs) prescribed at the time of assessment. Working Memory Index scores of patients with TLE, which measure verbal mnesic processing, were significantly lower than those of HCs and patients with TLE. The greatest differences in both clinical groups compared to HCs were recorded in cognitive executive functions, and patients with FLE had lower scores in this domain. Regarding behavioral executive functions, patients with TLE presented impaired emotional control and impulse inhibition and patients with FLE exhibited decreased flexibility.

Conclusion: Consistent with previous research, our findings provide further detailed evidence of small differences in cognitive performance among children with frontal lobe epilepsy and temporal lobe epilepsy. These differences emerge on analysis of the factors with which deficits are associated.

Short-Term Outcomes in Pediatric and Adolescent Patients with Psychogenic Nonepileptic Events Seen by Telemedicine During the COVID-19 Pandemic

Abstract, originally published in Epilepsy & Behavior

Introduction: Psychogenic nonepileptic events (PNEE) are a type of Functional Neurological Symptom Disorder that present with events that appear epileptic but are not associated with abnormal electrical activity in the brain. In response to the global COVID-19 pandemic, our PNEE clinic switched to a telemedicine format, and we present here our experience with providing care to children and adolescents with PNEE in this format.

Methods: The multidisciplinary clinic shifted to a telemedicine platform in March 2020 with the same joint provider format. Follow-up phone calls are completed at one and three months following the visit. Data are presented with descriptive statistics. Referral volume and outcomes data are compared to historical patients, including rates of diagnosis acceptance, linkage to counseling, and change in event frequency.

Results: Twenty-three patients were scheduled to be seen via telemedicine or hybrid visits from March through June, twenty completed their visits. Sixteen (70%) were reached for follow-up at one month. Of those reached, twelve (75%) accepted the diagnosis, eight (50%) were linked with counseling, and fourteen (88%) with improvement in event frequency. Of the sixteen reached at three months, eleven (69%) had accepted the diagnosis, ten (63%) were linked with counseling, and all but two reported improvement in event frequency. In comparison, the previously published results showed 3-month rates of 75% of patients accepting the diagnosis, 76% linked with counseling, and 75% with improvement in event frequency.

Conclusions: Video telemedicine visits are a feasible and effective way to provide care for children and adolescents with psychogenic non-epileptic events. At 3 months, patients seen by telemedicine had similar acceptance rates, decreased connection to counseling, and increased rate of improvement in event frequency. This study suggests telemedicine may have some benefits over traditional clinic visits, such as improved show rates and access to clinic; so should be considered a reasonable alternative to in-person visits.

Creation and Implementation of an Electronic Health Record Note for Quality Improvement in Pediatric Epilepsy: Practical Considerations and Lessons Learned

Summary, originally published in Epilepsia Open

Objective: To describe the development of the Pediatric Epilepsy Outcome-Informatics Project (PEOIP) at Alberta Children’s Hospital (ACH), which was created to provide standardized, point of care data entry; near-time data analysis and availability of outcomes dashboards as a baseline on which to pursue Quality Improvement.

Methods: Stakeholders involved in the PEOIP met weekly to determine the most important outcomes for patients diagnosed with epilepsy, create a standardized electronic note with defined fields (patient demographics, seizure and syndrome type and frequency and specific outcomes (seizure type and frequency, adverse effects, emergency department visits, hospitalization) and care pathways for clinical decision support. These were embedded in the electronic health record from which the fields were extracted into a data display platform that provided patient and population level dashboards updated every 36 hours. Provider satisfaction and family experience surveys were performed to assess the impact of the standardized electronic note.

Results: In the last 5 years, 3,245 unique patients involving 13, 831 encounters had prospective, longitudinal, standardized epilepsy data accrued via point of care data entry into an electronic note as part of routine clinical care. A provider satisfaction survey of the small number of users involved indicated that the vast majority believed that the note makes documentation more efficient. A family experience survey indicated that being provided with the note was considered ‘valuable’ or ‘really valuable’ by 86% of respondents and facilitated communication with family members, school and advocacy organizations.

Significance: The Pediatric Epilepsy Outcomes-Informatics Project serves as a proof of principle that information obtained as part of routine clinical care can be collected in a prospective, standardized, efficient manner and be used to construct filterable, process/outcomes dashboards, updated in near time (36 hours). This information will provide the necessary baseline data on which a multiple of QI projects to improve meaningful outcomes for children with epilepsy will be based.

Developmental Outcome After Corpus Callosotomy for Infants and Young Children with Drug-Resistant Epilepsy

Abstract, originally published in Epilepsy & Behavior

Aim: To examine the developmental and seizure outcomes after corpus callosotomy (CC) in early childhood.

Methods: We retrospectively identified 106 patients who underwent CC for drug-resistant epilepsy before the age of 6 years, at the Nagasaki Medical Center, between July 2002 and July 2016. Patients’ developmental outcomes were evaluated one year after CC using the Kinder Infant Development Scale.

Results: The mean preoperative developmental quotient (DQ) was 25.0 (standard deviation [SD], 20.8), and the mean difference between preoperative DQ and one-year postoperative DQ was -1.6 points (SD, 11.6). However, 42.5% of patients had a mean DQ increase of 6.5 points (SD, 6.4), one year after CC from that before surgery. Factors related to the improvement in postoperative DQ were ‘low preoperative DQ’, ‘developmental gain 1 month postoperatively’, and ‘postoperative seizure-free state’. Approximately 21.7% of patients were seizure-free 1 year after CC.

Interpretation: Performing corpus callosotomy, in infancy and early childhood for patients with drug-resistant epilepsy and severe developmental impairment, was associated with improved development in 42.5% of patients. Remission of seizures, even if only for a short period, contributed to developmental improvement. From a developmental perspective, corpus callosotomy for drug-resistant epilepsy in early childhood is an effective treatment.

“Sleep Hygiene” Should Be Integrated Into Epilepsy Diagnosis and Management – Study

Summary, originally published by University of Birmingham

Children with epilepsy sleep poorly compared to healthy children, and are more likely to experience disruptions such as night terrors, sleep walking or sleep disordered breathing, according to a new study.

A team at the University of Birmingham’s Centre for Human Brain Health analyzed 19 published studies on sleep and epilepsy in children and adolescents to try to better understand and articulate the links between them.

Their findings, published in Sleep Medicine Reviews, highlight the significantly poorer sleep experienced by children and adolescents with epilepsy, and present a strong argument for screening children for sleep problems as an integral part of diagnosis and management of the condition.

Lead author Alice Winsor explains: “We know that sleep and epilepsy have a bidirectional relationship: Epilepsy has an impact on sleep, because of seizures waking children up in the night, for example. At the same time, disrupted sleep can increase the likelihood of seizures. Despite the available research, however, sleep is not routinely evaluated by clinicians during the diagnosis and care of this condition.”

The Severe Epilepsy Syndromes of Infancy: A Population-Based Study

Abstract, originally published in Epilepsia

Objective: To study the epilepsy syndromes among the severe epilepsies of infancy and assess their incidence, etiologies, and outcomes.

Methods: A population-based cohort study was undertaken of severe epilepsies with onset before age 18 months in Victoria, Australia. Two epileptologists reviewed clinical features, seizure videos, and electroencephalograms to diagnose International League Against Epilepsy epilepsy syndromes. Incidence, etiologies, and outcomes at age 2 years were determined.

Results: Seventy-three of 114 (64%) infants fulfilled diagnostic criteria for epilepsy syndromes at presentation, and 16 (14%) had “variants” of epilepsy syndromes in which there was one missing or different feature, or where all classical features had not yet emerged. West syndrome (WS) and “WS-like” epilepsy (infantile spasms without hypsarrhythmia or modified hypsarrhythmia) were the most common syndromes, with a combined incidence of 32.7/100 000 live births/year. The incidence of epilepsy of infancy with migrating focal seizures (EIMFS) was 4.5/100 000 and of early infantile epileptic encephalopathy (EIEE) was 3.6/100 000. Structural etiologies were common in “WS-like” epilepsy (100%), unifocal epilepsy (83%), and WS (39%), whereas single gene disorders predominated in EIMFS, EIEE, and Dravet syndrome. Eighteen (16%) infants died before age 2 years. Development was delayed or borderline in 85 of 96 (89%) survivors, being severe–profound in 40 of 96 (42%). All infants with EIEE or EIMFS had severe–profound delay or were deceased, but only 19 of 64 (30%) infants with WS, “WS-like,” or “unifocal epilepsy” had severe–profound delay, and only two of 64 (3%) were deceased.

Significance: Three quarters of severe epilepsies of infancy could be assigned an epilepsy syndrome or “variant syndrome” at presentation. In this era of genomic testing and advanced brain imaging, diagnosing epilepsy syndromes at presentation remains clinically useful for guiding etiologic investigation, initial treatment, and prognostication.

Mechanism Connects Epilepsy and Enzyme Deficiency

Summary, originally published in JCI Insight

Researchers from Kyushu University’s Medical Institute of Bioregulation in collaboration with Nihon University, Yasuda Woman’s University, and Nagoya University now report a better understanding of a mechanism causing epilepsy in infants as the result of a deficiency of an enzyme known as inosine triphosphatase, or ITPA.

The new study could also give insight into possible risks for the 2% of the Japanese population in which both copies of the gene for ITPA produce versions with reduced activity.

Using mice that were genetically engineered such that ITPA production is disrupted only in the nervous system, the researchers found that ITPA deficiency led to a reduction in the negative charge inside the neurons when signals are not being sent, a phenomenon known as depolarization. This depolarization in turn results in frequent excitation of neurons and epileptic seizures in the mice.

The new results indicate that Early Infantile Epileptic Encephalopathy 35 (EIEE35), a neurological disorder characterized by epileptic seizures and associated with deficiency of ITPA, may involve cell membranes becoming more excitable because of depolarization caused by ITPA deficiency.

Epilepsy Research News: January 2021

This month’s research news includes announcements about CURE Epilepsy’s Frontiers in Research seminar series, and an announcement from the CDC about an incidence and etiology funding opportunity.

We also share that the NINDS Clinical Trials Methodology Course is accepting applications, and that the deadline to apply to the National Science Foundation Enabling Discovery Through Genomics (EDGE) Program is March 16.

These news items are summarized below.

Research Highlights

CURE Epilepsy’s Frontiers in Research Seminar Series has gone virtual!

As part of our on-going commitment to supporting the research community through these difficult times, we are conducting our research seminar series virtually with the topics below. Mark your calendars!

The virtual Frontiers in Research Seminar Series is sponsored by the Nussenbaum-Vogelstein Family.

Learn more

CDC Epilepsy Incidence and Etiology Funding Opportunity Announcement
Projects are intended to inform incidence and social determinants of epilepsy including risk factors and protective factors that affect epilepsy incidence. Information about epilepsy incidence will provide invaluable information to help better guide interventions or services for preventing epilepsy, treating and rehabilitating people with epilepsy, and minimizing their health disparities and adverse outcomes.

Click here for details. Search opportunity number by RFA-DP-21-004 and SIP 21-007.

Learn More

NINDS Clinical Trials Methodology Course-Application Deadline February 28
The NINDS Clinical Trials Methodology Course (CTMC) is accepting applications for the 2021 cohort. The overarching goal of the CTMC is to help investigators develop scientifically rigorous, yet practical clinical trial protocols. The focus is on investigators who have not previously designed their own prospective, interventional clinical trials.

Learn More

National Science Foundation Enabling Discovery Through Genomics (EDGE) Program-Application Deadline March 16
The goal of the EDGE program is to provide support for genomic research and associated theory, approaches, tools, and infrastructure development to address the mechanistic basis of complex traits in diverse organisms within the context (environmental, developmental, social, and/or genomic) in which they function.

Learn More

Cerebral Palsy and Epilepsy in Children: Clinical Perspectives on a Common Comorbidity

Abstract, originally published in Children

Cerebral palsy (CP) is a frequent cause of childhood disability often associated with a complex group of disorders, including epilepsy, which is reported to impact approximately 40% of affected individuals. This retrospective study involved a group of children affected by CP, some of whom also had comorbid epilepsy. The aim of this study was to report our experience of analyzing, in particular, (a) some of the clinical aspects of the different type of CP, and (b) the relationship between the clinical data of children affected by CP plus epilepsy and each type of CP.

Methods: This retrospective single-center study was performed with 93 children admitted to the Pediatric Department of the University of Catania, Italy, affected by CP and distinguished according to the type of motor clinical presentation, with 46 showing epileptic seizures, compared to a control group of 136 children affected by epilepsy without other neurologic disorders.

Results: Among the 93 CP children, 25 (27%) had spastic quadriplegia (plus one patient with dystonic quadriplegia), 39 (42%) had spastic hemiplegia, 11 (12%) had spastic diplegia (plus two with ataxia and one with dyskinetic CP), and 14 (15%) did not have a well-defined type of CP. The frequency of epilepsy was higher in affected CP children who showed major motor dysfunction (GMFCS IV-V types). As regards the 46 children with CP plus epilepsy, compared to the group of the control, the age of epilepsy onset was found to be statistically significant: 21 ± 35.1 months vs. 67 ± 39.7.

Conclusions: Epilepsy represents one of the most frequent comorbidities of cerebral palsy. In children with CP, particular attention should be paid to the early identification and treatment of comorbid epilepsy.