•The sleep state is dynamic, and various sleep stages have sleep influence seizures in different ways that have clinical importance.•Interictal discharges are more commonly seen during ...sleep.•Initiation and propagation of seizures can change depending on sleep state.•Anticonvulsant drugs can modulate sleep itself, and also have influences on sleep disorder.
Sleep is a dynamic process, during which the electrical rhythms of the brain orchestrate a complicated progression of changing frequencies, patterns and connectivity. Each stage of sleep is different electrophysiologically from wakefulness, and from other sleep stages. It should be no surprise, then, that the various sleep states influence the origin, suppression, and spread of seizures, and that different seizure types are affected in individual (and sometimes contradictory) ways. While much of the electrical symphony that occurs in both normal and epileptic brains is incompletely understood, at the basic level some interesting and often clinically important influences of the various sleep states have been identified.
While interictal epileptiform activity is not a seizure, these markers of epilepsy are affected by sleep. Both initiation and propagation of various seizure types are affected by sleep, and these are discussed separately. Finally, the relationship between sleep and epilepsy is clearly reciprocal, and the final sections will explore the changes in sleep that seizures and antiepileptic drugs can induce.
Seizure- and epilepsy-related complications are a common cause of emergency medical evaluation, accounting for 5% of 911 calls and 1% of emergency department visits. Emergency physicians and ...neurologists must be able to recognize and treat seizure- and epilepsy-related emergencies. This review describes the emergency evaluation and management of new onset seizures, breakthrough seizures in patients with known epilepsy, status epilepticus, acute symptomatic seizures, and acute adverse effects of antiepileptic drugs.
Summary
Objective
The dynamics of the postictal period, which may demonstrate such dramatic clinical phenomena as focal neurological deficits, prolonged coma and immobility, and even sudden death, ...are poorly understood. We sought to classify and characterize postictal phases of bilateral tonic–clonic seizures based on electroencephalographic (EEG) criteria and associated clinical features.
Methods
We performed a detailed electroclinical evaluation of the postictal period in a series of 31 bilateral tonic–clonic seizures in 16 patients undergoing epilepsy surgery evaluations for focal pharmacoresistant epilepsy with intracranial electrodes and time‐locked video.
Results
The postictal EEG demonstrated three clearly differentiated phases as follows: attenuation, a burst‐attenuation pattern, and a return to continuous background, with abrupt, synchronized transitions between phases. Postictal attenuation was common, occurring in 84% of seizures in 94% of patients in this study. There was increased power in gamma frequencies (>25 Hz) during postictal attenuation periods relative to preictal baseline in 88% of seizures demonstrating the attenuation pattern (n = 25 seizures, P < 0.002). Such increases were seen in >90% of channels in 13 seizures (52%) and <10% of channels in three seizures (12%). Postictal immobility was seen in 87% of seizures, with either a flaccid (58%) or rigid/dystonic (29%) appearance. Clinical motor manifestations, including focal dystonic posturing, automatisms, head and eye deviation, and myoclonic jerking, continued or emerged within the first minute following seizure termination in 48% of seizures, regardless of EEG appearance.
Significance
Intracranial postictal attenuation, which may be diffuse or focal, is so common that it should be regarded as a ubiquitous feature of bilateral tonic‐clonic seizures, rather than an unusual event. The prominence of high‐frequency activity coupled with emerging clinical features, including rigid immobility and semiologies such as automatisms, during the postictal period supports the presence of ongoing seizure‐related neuronal activity in unrecorded brain regions.
Summary
Objective
Selective laser amygdalohippocampotomy (SLAH) using magnetic resonance–guided laser interstitial thermal therapy (MRgLITT) is emerging as a treatment option for drug‐resistant ...mesial temporal lobe epilepsy (MTLE). SLAH is less invasive than open resection, but there are limited series reporting its safety and efficacy, particularly in patients without clear evidence of mesial temporal sclerosis (MTS).
Methods
We report seizure outcomes and complications in our first 30 patients who underwent SLAH for drug‐resistant MTLE between January 2013 and December 2016. We compare patients who required stereoelectroencephalography (SEEG) to confirm mesial temporal onset with those treated based on imaging evidence of MTS.
Results
Twelve patients with SEEG‐confirmed, non‐MTS MTLE and 18 patients with MRI‐confirmed MTS underwent SLAH. MTS patients were older (median age 50 vs 30 years) and had longer standing epilepsy (median 40.5 vs 5.5 years) than non‐MTS patients. Engel class I seizure freedom was achieved in 7 of 12 non‐MTS patients (58%, 95% confidence interval CI 30%‐86%) and 10 of 18 MTS patients (56%, 95% CI 33%‐79%), with no significant difference between groups (odds ratio OR 1.12, 95% CI 0.26‐4.91, P = .88). Length of stay was 1 day for most patients (range 0‐3 days). Procedural complications were rare and without long‐term sequelae.
Significance
We report similar rates of seizure freedom following SLAH in patients with MTS and SEEG‐confirmed, non‐MTS MTLE. Consistent with early literature, these rates are slightly lower than typically observed with surgical resection (60%‐80%). However, SLAH is less invasive than open surgery, with shorter hospital stays and recovery, and severe procedural complications are rare. SLAH may be a reasonable first‐line surgical option for patients with both MTS and SEEG confirmed, non‐MTS MTLE.
Sleep deprivation may be particularly detrimental to intensive care unit (ICU) patients. Polysomnography has demonstrated abnormal sleep in medical and surgical ICU populations. Both environmental ...factors and circadian disruption have been implicated. We hypothesized that patients in a neurologic ICU would demonstrate similar sleep disturbances and that a combination of sleep-promoting interventions would increase sleep time.
Twelve patients were enrolled in this pilot-randomized, controlled, study in a neurologic ICU. For adult patients undergoing continuous EEG for clinical purposes, noise-cancelling headphones and eye masks were worn, and an oral dose of melatonin was administered for 3 days, or until EEG was stopped. Sleep was scored according to standard criteria; EEG was characterized and analyzed quantitatively.
Sixty-five percent of the patients' recordings were unscorable based on accepted standardized criteria; therefore, sleep measures could not be compared. For those with sleep that could be scored, total sleep time was normal, although sleep was fragmented and time spent in slow-wave or rapid eye movement sleep was notably decreased. Patients with unscorable recordings had worse injury severity measures, absent or significantly slower posterior dominant rhythm, and less coherence of posterior faster frequencies. Clinical outcomes were similar between intervention and control groups.
Although sleep-promoting interventions were feasible, sleep quantification based on currently accepted criteria limited the ability to score sleep. Similar to other ICUs, sleep in the neurologic ICU is abnormal; patients with unscorable sleep-like states have greater injury severity. This study was limited by strict enrollment criteria. A reliable method to quantify sleep and sleep-like states in the ICU is needed.
Sleep disturbance is common in epilepsy, the nature of sleep disturbances in epilepsy is diverse, and the etiologies are complex. Evidence suggests that having epilepsy and the occurrence of ...seizures, as well as some AEDs, are associated with significant sleep disruption. The occurrence of seizures can have profound effects on sleep architecture lasting much longer than the postictal period. Persistent daytime drowsiness in patients with epilepsy is not always due to the side effects of some AEDs and may be independently linked with sleep fragmentation. Significant sleep disruption in epilepsy has been associated with impaired quality of life and impaired seizure control. All aspects of sleep medicine are important in the management of epilepsy and are confounded by the occurrence of seizures, the location of seizures, and the beneficial and detrimental effects of AEDs. Sleep should be proactively evaluated, and sleep disturbances should be treated as part of the total care of patients with epilepsy.
Epilepsy surgery is considered to reduce the risk of epilepsy-related mortality, including sudden unexpected death in epilepsy (SUDEP), though data from existing surgical series are conflicting. We ...retrospectively examined all-cause mortality and SUDEP in a population of 590 epilepsy surgery patients and a comparison group of 122 patients with pharmacoresistant focal epilepsy who did not undergo surgery, treated at Columbia University Medical Center between 1977 and 2014.
There were 34 deaths in the surgery group, including 14 cases of SUDEP. Standardized mortality ratio (SMR) for the surgery group was 1.6, and SUDEP rate was 1.9 per 1000 patient-years. There were 13 deaths in the comparison group, including 5 cases of SUDEP. Standardized mortality ratio for the comparison group was 3.6, and SUDEP rate was 4.6 per 1000 patient-years. Both were significantly greater than in the surgery group (p < 0.05). All but one of the surgical SUDEP cases, and all of the comparison group SUDEP cases, had a history of bilateral tonic–clonic seizures (BTCS). Of postoperative SUDEP cases, one was seizure-free, and two were free of BTCS at last clinical follow-up. Time to SUDEP in the surgery group was longer than in the comparison group (10.1 vs 5.9 years, p = 0.013), with 10 of the 14 cases occurring >10 years after surgery.
All-cause mortality was reduced after epilepsy surgery relative to the comparison group. There was an early benefit of surgery on the occurrence of SUDEP, which was reduced after 10 years. A larger, multicenter study is needed to further investigate the time course of postsurgical SUDEP.
•All-cause mortality is reduced after surgery in patients with pharmacoresistant focal epilepsy.•Sudden unexpected death in epilepsy (SUDEP) rate is reduced after surgery in patients with pharmacoresistant focal epilepsy.•The benefit of epilepsy surgery on SUDEP occurrence is seen early but is reduced after 10 years.
OBJECTIVE:We examined the complex relationship between depression, anxiety, and seizure control and quality of life (QOL) outcomes after epilepsy surgery.
METHODS:Seven epilepsy centers enrolled 373 ...patients and completed a comprehensive diagnostic workup and psychiatric and follow-up QOL evaluation. Subjects were evaluated before surgery and then at 3, 6, 12, 24, 48, and 60 months after surgery. Standardized assessments included the Quality of Life in Epilepsy Inventory–89, Beck Depression Inventory (BDI), and Beck Anxiety Inventory (BAI). A mixed-model repeated-measures analysis was used to analyze associations of depression, anxiety, seizure outcome, and seizure history with overall QOL score and QOL subscores (cognitive distress, physical health, mental health, epilepsy-targeted) prospectively.
RESULTS:The groups with excellent and good seizure control showed a significant positive effect on the overall QOL compared to the groups with fair and poor seizure control. The BDI and BAI scores were both highly and negatively associated with overall QOL; increases in BDI and BAI scores were associated with decreased overall QOL score.
CONCLUSIONS:Depression and anxiety are strongly and independently associated with worse QOL after epilepsy surgery. Interestingly, even partial seizure control, controlling for depression and anxiety levels, improved QOL. Management of mood and anxiety is a critical component to postsurgical care.
Summary
Objective
To examine the seizure trajectories of adults with epilepsy developing drug‐resistant epilepsy (DRE) and to identify the predictors of seizure trajectory outcome.
Methods
Adult ...patients failing two antiepileptic drugs (AEDs) due to inefficacy and starting their third AED at a tertiary epilepsy center were followed for seizure trajectory outcome during medical management. Seizure trajectories were categorized into one of four patterns: (1) course with constant seizures; (2) fluctuating course; (3) delayed attainment of seizure freedom (seizure freedom delayed for >12 months after start of the study, but patient stayed in seizure freedom); and (4) early attainment of seizure freedom (within 12 months of starting study). Multiple ordinal logistic regression models were used to estimate the association between trajectory categories and clinical factors.
Results
Four hundred three adult patients met the eligibility criteria. Of these, 212 (53%) never achieved a seizure‐free period of a year or more. The trajectories of 63 patients (16%) had a complex fluctuating trajectory, 62 (15%) had delayed onset of seizure freedom, and 66 (16%) had an early seizure freedom. Independent predictors associated with more favorable outcome trajectories were epilepsy type and length of follow‐up. Specifically, compared to patients with focal epilepsy of temporal lobe, patients with focal epilepsy of occipital lobe (OR 3.80, 95% confidence interval CI 1.00–14.51, p = 0.04), generalized genetic (OR 3.23, 95% CI 1.88–5.57, p < 0.0001), unclear epilepsy type (OR 3.82, 95% CI 1.53–9.52, p < 0.005), and both focal and generalized epilepsy(OR 11.73, 95% CI 1.69–81.34, p = 0.01) were significantly more likely to experience a better trajectory pattern.
Significance
Examination of patterns of seizure trajectory of patients with incident DRE showed that 31% were in continuous seizure freedom at the end of the observation period.
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