Vagus nerve stimulation for treatment of seizures?
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Electric Stimulation↗
Biomedical subjects
R S McLachlan
Publications and source records attributed to R S McLachlan.
The Canadian Epilepsy Database and Registry.
Epilepsy encompasses medical, psychological, social and demographic factors which are best studied in large populations. The Canadian Epilepsy Database and Registry (CEDAR) is a comprehensive English language, multicentre epilepsy database which has been developed to study the impact of these and other factors on epilepsy in Canada. In addition, it can be used locally in the clinic for office record keeping, automated printout of a referral letter or graphing seizures and other data over time. The data in CEDAR are similar to what is found in the patient's chart. There are 20 participating centres across Canada which have entered data on over 8000 adult and pediatric epilepsy patients. The information in CEDAR will be available for research purposes to centres entering data as well as to academic researchers, the pharmaceutical industry and government agencies.
Canada↗
Drug-induced pseudolymphoma secondary to lamotrigine.
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Adult↗
Antiepileptic drug treatment following temporal lobectomy.
Antiepileptic drug use was documented before and after temporal lobectomy. Carbamazepine, phenytoin, and clobazam were the most commonly used drugs, both pre- and postoperatively. Preoperatively, polytherapy was used in 78% of patients; at 6 months follow-up, 47%; at 12 months, 18%; and at 24 months, 14%. Preoperatively, monotherapy was used in 20% of patients; at 6 months follow-up, 49%; at 12 months, 55%; and at 24 months, 42%. No medication was used preoperatively by 2% of patients; at 6 months follow-up, 2%; at 12 months, 27%; and at 24 months, 44% (p < 0.001). After 2 years, 53% of patients who were seizure free had stopped taking medication, as had 33% who had some seizures after surgery.
Adolescent↗
MR in temporal lobe epilepsy: analysis with pathologic confirmation.
PURPOSE: We evaluated the MR findings in patients with temporal lobe epilepsy to determine the predictive value of MR imaging in assessing patient outcome. METHODS: MR studies from 186 of 274 consecutive patients who underwent temporal lobectomy for intractable epilepsy were reviewed retrospectively. Images were interpreted by an experienced neuroradiologist, who was blinded to the side of seizure activity and to pathologic findings. RESULTS: MR imaging exhibited 93% sensitivity and 83% specificity in detecting hippocampal/amygdalar abnormalities (n = 121), and 97% sensitivity and 97% specificity in detecting abnormalities in the rest of the temporal lobe (n = 60). Abnormal high signal of the hippocampus on T2-weighted images had a sensitivity of 93% and specificity of 74% in predicting mesial temporal sclerosis (n = 115). The presence of hippocampal atrophy on MR correlated with the duration of seizures. Sensitivity and specificity of MR imaging in detecting temporal lobe tumors (n = 42) were 83% and 97%, respectively, based on abnormal signal and mass effect. After surgery, 63% of patients were seizure free and 28% had a significant reduction of seizure frequency at an average of 24 months (range, 12 to 78 months) after surgery. Patients with a single lesion in the anterior temporal lobe or hippocampus/amygdala had a better outcome than patients with multiple lesions (n = 22). Interrater agreement varied from 0.4 to 0.93, with best agreement for tumors or abnormal hippocampal signal on T2-weighted images. CONCLUSION: MR imaging is highly sensitive in detecting and locating abnormalities in the temporal lobe and the hippocampus/amygdala in patients with temporal lobe epilepsy. Hippocampal atrophy appears to correspond to the duration of seizure disorder.
Adult↗
Health-related quality of life and seizure control in temporal lobe epilepsy.
We conducted a prospective study over 24 months to compare health-related quality of life in surgically and medically treated patients with intractable temporal lobe epilepsy. Seizure frequency and health-related quality of life were assessed in 81 patients before and 6, 12, and 24 months after treatment. Using the Epilepsy Surgery Inventory 55 (ESI-55), we compared (1) different seizure outcome groups and (2) temporal lobectomy with continuing medical management. Follow-up was satisfactory in 72 patients (89%), 51 treated with temporal lobectomy and 21 with no surgery. Pretreatment seizures and health-related quality of life were comparable in the two groups. Seizure outcome was significantly better at 6, 12, and 24 months after surgery. At 24 months, seizure-free patients and those with at least a 90% reduction in seizure frequency reported significant improvements in health-related quality of life (on 5 of 10 subscales and overall Epilepsy Surgery Inventory 55 scale). Deterioration in quality of life occurred with less than 90% seizure reduction. Only one Epilepsy Surgery Inventory 55 subscale at 6 months and two subscales at 12 months showed a significant difference. Patients with good seizure outcome experience improved health-related quality of life after treatment. Since temporal lobectomy results in considerably better seizure control than continued medical management, the findings support surgery as the preferred treatment, although changes in health-related quality of life may not be evident until the second postoperative year.
Adolescent↗
An electroencephalographic classification for coma.
BACKGROUND: The assessment of thalamocortical function in comatose patients in the intensive care unit (ICU) can be difficult to determine. Since the electroencephalogram (EEG) affords such assessment, we have developed an EEG classification for comatose patients in our general ICU. METHODS: One hundred EEGs were classified in a blinded fashion by two EEGers, using our method and that of Synek. Interobserver agreement was assessed using kappa score determination. RESULTS: Kappa scores were 0.90 for our system and 0.75 for the Synek system. (The Kappa score represents the inter-rater agreement that is beyond chance; 0.90 is almost perfect agreement, while 0.75 is substantial agreement). CONCLUSION: Our system for classifying EEGs in comatose patients has a higher interobserver reliability than one that was previously published. This EEG classification scheme should be useful in clinical electrophysiological research involving ICU patients, allowing for internal consistency and comparisons among centres.
Adult↗
Epilepsy and driving: a survey of Canadian neurologists.
BACKGROUND: A seizure is the most common cause of loss of driving privileges for medical reasons but there is variability in how physicians and the authorities who regulate driving approach this issue. METHODS: A questionnaire regarding epilepsy and driving was sent to all adult neurologists in Canada (n = 494). RESULTS: Of 289 (59%) neurologists responding, 50% usually report patients with seizures to the department of motor vehicles compared to only 4% for stroke/TIA, 26% for dementia and 8% for other neurologic disorders (p < 0.0001). In the five provinces with mandatory reporting laws, seizures were reported most of the time by 84% compared to only 19% in the five provinces with discretionary reporting (p < 0.0001). Nationwide, 44% agreed with mandatory reporting but this also differed in provinces with and without mandatory reporting legislation (63% vs. 37%, p < 0.0001). Only 49% agreed with the current recommendation of at least one year seizure free interval before resuming driving. CONCLUSIONS: Seizures are disproportionately reported compared to other neurological conditions. Many neurologists disagree with the recommended Canadian standards for duration of driving restriction after seizures. Variability in the attitude and practice of neurologists in regard to reporting of seizures is confirmed.
Adult↗
Influence of seizure content on interpreting psychopathology on the MMPI-2 in patients with epilepsy.
We investigated whether seizure content items inflate MMPI-2 scores in persons with epilepsy. A mean MMPI-2 profile was generated for 100 epilepsy patients. Two expert raters then identified MMPI-2 items reflecting seizure symptoms. When individual profiles were rescored to remove elevations caused by seizure content, some statistically significant (but not clinically significant) decreases were observed. The MMPI-2 appears to be a valid assessment instrument in epilepsy. In most cases seizure content did not alter clinical interpretation. When the interest is in detecting symptom change, assessing both statistical and clinical significance is recommended in future MMPI-2 research.
Adult↗
Propofol sedation during awake craniotomy for seizures: electrocorticographic and epileptogenic effects.
This prospective study evaluated the effects of propofol sedation on the incidence of intraoperative seizures and the adequacy of electrocorticographic (ECoG) recordings during awake craniotomy performed for the management of refractory epilepsy. Thirty patients scheduled for temporal or frontal lobectomy for epilepsy under bupivacaine scalp block were randomized to receive patient-controlled propofol sedation (PCS) combined with a basal infusion of propofol (n = 15) or neurolept analgesia using an initial bolus dose of fentanyl (0.7 microg/kg) and droperidol (0.04 mg/kg) followed by a fentanyl infusion (n = 15). Propofol administration was suspended 15 min before ECoG recording in the PCS group. The occurrence of inappropriate intraoperative seizures was noted and, based on blind review, the adequacy of ECoG recordings was compared. A higher incidence of intraoperative seizures was noted among the neurolept patients (6 vs 0, P = 0.008). Intraoperatively, ECoG recordings were adequate to proceed with resection in both groups. Evidence of low spike activity on ECoG did not correlate with the type of sedation administered. Higher frequency background ECoG activity was noted among patients who received propofol, but this did not interfere with ECoG interpretation. The use of propofol sedation does not appear to interfere with ECoG during epilepsy surgery, provided administration is suspended at least 15 min before recording.
Adjuvants, Anesthesia↗
Vagus nerve stimulation for intractable epilepsy: a review.
Electrical stimulation of the vagus nerve in the neck by using a programmable stimulator similar to a cardiac pacemaker is being explored as a treatment for epilepsy. There is sound rationale based on studies of animal seizure models for pursuing this treatment modality, and early clinical trials provide support for efficacy in patients with intractable epilepsy at least equivalent to that of some of the new antiepileptic drugs. Safety and tolerability have been demonstrated in >800 patients worldwide since the first implant in 1988. Most of these had partial seizures for which resective epilepsy surgery was not feasible or had failed, but efficacy of vagal stimulation appears to be the same for both partial and generalized epilepsy. Specific selection criteria for this procedure have yet to be established, and further studies are warranted to determine whether vagal stimulation becomes an accepted procedure for epilepsy management.
Adult↗
Effective temporal lobectomy in childhood without invasive EEG.
Temporal lobectomy abolished complex partial seizures (CPSs) in 14 consecutive children (12 years or younger) whose presurgical evaluation included clinical analysis, scalp EEG, and neuroimaging. Seizures of 13 of 14 patients began with a simple partial component whose symptoms were suggestive of limbic system involvement. EEG recorded clinically typical seizures arising from the ultimately operated on temporal lobe in seven (50%) and never falsely lateralized seizure origin. Most active interictal spikes arose from the epileptogenic temporal lobe in 13 (93%) and never falsely lateralized epileptogenesis. Neuroimaging disclosed epileptogenic lesions in all: magnetic resonance imaging (MRI; 11 patients) and computed tomography (CT; three patients). Children may obtain relief from CPSs by temporal lobectomy without invasive electroencephalography.
Age Factors↗
Febrile convulsions in selected large families: a single-major-locus mode of inheritance?
As part of a genetic linkage study of febrile convulsions, families with at least four members with the disorder were identified. By applying known principles of human inheritance, possible modes of transmission of febrile convulsions and factors which might impede progress in understanding their inheritance were analyzed. In eight families, 75 of 333 members had febrile convulsions. Inheritance of the disorder occurred in 43, 51, and 46% of children, siblings and all first-degree relatives of probands respectively. Vertical transmission occurred through three to four generations, including from male to male. In these families with multiple affected members, the findings support an autosomal dominant mode of inheritance of febrile convulsions.
Electroencephalography↗
The MMPI-2 as an adjunct to the diagnosis of pseudoseizures.
Although the original Minnesota multiphasic personality inventory (MMPI) showed promise in the psychometric discrimination of patients with epileptic seizures and pseudoseizures, inconsistencies and relatively low rates of accuracy have been reported. The present study evaluated the restandardized MMPI-2 for its accuracy in discriminating patients with pseudoseizures in a population with intractable epilepsy. MMPI-2 profiles for 139 consecutive adult inpatients (24 with pseudoseizures) were classified as a pseudoseizure pattern if they had (a) a T score on Scale 1 and/or 3 > or = 65, (b) Scale 1 or 3 in the 2-point high code, and (c) if 1 or 3 was not the highest scale, it was < or = 6T from the highest scale. Compared to studies using the original MMPI, it was expected the MMPI-2 would more accurately classify patients in each group. Preliminary analyses revealed pseudoseizure patients had a greater history of mental health interventions and were older when their seizure disorder began, relative to the epilepsy patients. A classification accuracy of 92% was found for pseudoseizures and 94% for epilepsy patients. For the pseudoseizure group, clinically meaningful MMPI-2 elevations followed a 3-1-2 pattern. No mean elevations above a T value of 65 were seen in the epilepsy group.
Adult↗
Neuroticism in temporal lobe epilepsy: assessment and implications for pre- and postoperative psychosocial adjustment and health-related quality of life.
We assessed 77 candidates for epilepsy surgery to determine the association among neuroticism (a dimension of personality characterized by chronic negative emotions and behaviors), psychosocial adjustment as measured by the Washington Psychosocial Seizure Inventory (WPSI), and health-related quality of life (HRQOL) as measured by the Epilepsy Surgery Inventory 55 (ESI-55). Minnesota Multiphasic Personality Inventory 2 (MMPI-2) Neuroticism scale scores were significantly correlated with many domains of patient -perceived psychosocial adjustment and HRQOL regardless of frequency or type of seizures. We then followed 45 of the patients who subsequently underwent epilepsy surgery to determine the influence of neuroticism on postoperative functioning. Two-way analysis of variance (ANOVA) indicated that patients with high preoperative neuroticism had significantly poorer postoperative psychosocial adjustment and HRQOL scores than patients who had low or moderate preoperative neuroticism scores. These results support the validity of the MMPI-2 as a useful measure of neuroticism. Preoperative neuroticism has an important influence on postoperative psychosocial adjustment and HRQOL that is independent of postoperative seizure outcome. Understanding the influence of personality variables, such as neuroticism, on psychosocial functioning both before and after epilepsy surgery is essential in managing intractable seizures.
Adaptation, Psychological↗
Psychiatric disorders in candidates for surgery for epilepsy.
OBJECTIVE: To provide a descriptive analysis of the prevalence and pattern of psychiatric morbidity among 300 consecutive epileptic patients refractive to treatment and admitted during a six year period for evaluation of their candidature for surgery. METHODS: Patients underwent detailed observation of their seizure and standardised psychiatric assessment. Patients were considered to be refractory to treatment if they continued to manifest seizures with an average frequency of at least once every month even with polytherapy using up to three different anti-convulsants for a period of at least two years. Of the 300 patients, 231 had a temporal lobe focus, 43 had a non-temporal lobe focus, and 26 patients had a generalised and multifocal seizure onset. RESULTS AND CONCLUSIONS: With the DSM-III-R criteria 142 (47.3%) patients emerged as psychiatric cases. A principal axis I diagnosis was made in 88 (29.3%), and an axis II diagnosis (personality disorder) in another 54 (18.0%) patients. The most common axis I diagnosis was anxiety disorders (10.7%). A schizophrenia-like psychosis was seen in 13 (4.3%). Most patients with personality disorders showed dependent and avoidant personality traits. There was a significantly higher psychotic subscore on the present state examination in the temporal than with the non-temporal group of patients. These findings were not significant when compared with patients with a generalised and multifocal seizure disorder. There were no significant findings between the different seizure focus groups on the neurotic subscores. The findings with regard to laterality of seizure focus and the neurotic or psychotic subscores were not significant.
Adult↗
Prospective neuropsychological assessment of nondemented patients with biopsy proven senile plaques.
Senile plaques are characteristic of Alzheimer's disease but also occur as an age-related change in some neurologically normal individuals at autopsy. The significance of these "incidental" senile plaques, with regard to the development of dementia, is unknown and cannot be assessed by postmortem studies. Patients with biopsy proven senile plaques offer an important opportunity for prospective followup. We identified senile plaques in temporal lobectomy specimens, removed in the surgical treatment of intractable epilepsy, from 11 patients. Review of preoperative neuropsychological test results showed no suggestion of dementia in any of the patients with senile plaques and no significant difference compared with controls. Postoperative followup ranged from 2 to 7 years (mean, 3.7 yr). There was no evidence of generalized cognitive deterioration in any of the study patients. These findings indicate that an abundance of senile plaques may be present without associated dementia and without cognitive deterioration for at least several years.
Adult↗
Treatment of Rasmussen's syndrome with ganciclovir.
Since cytomegalovirus (CMV) has been implicated in the pathogenesis of Rasmussen's syndrome, we treated four patients with ganciclovir, a potent anti-CMV drug. A 7-year-old girl with seizures escalating to 60/day over 3 months despite triple antiepileptic drug therapy became seizure-free 5 days after initiation of treatment with no recurrence at 1.5 years follow-up. Focal neurologic signs, cognitive function, and the EEG returned to normal. Two patients treated 34 and 72 months after disease onset in association with epilepsy surgery had a reduction in seizures and one had no response. CMV genome was detected in the brains of two of the three patients in whom it was assessed. The response to antiviral therapy supports a viral etiology for chronic encephalitis of Rasmussen. If the disease is suspected, treatment with ganciclovir should be considered as early as possible.
Adult↗