Reducing Sudden Unexpected Death in Epilepsy: Considering Risk Factors, Pathophysiology and Strategies

Purpose of Review Sudden Unexpected Death in Epilepsy (SUDEP) is the commonest cause of epilepsy-related premature mortality in people with chronic epilepsy. It is the most devastating epilepsy outcome. We describe and discuss risk factors and possible pathophysiological mechanisms to elucidate possible preventative strategies to avert SUDEP. Recent Findings Sudden death accounts for a significant proportion of premature mortality in people with epilepsy compared to the general population. Unmodifiable risk factors include a history of neurologic insult, younger age of seizure-onset, longer epilepsy duration, a history of convulsions, symptomatic epilepsy, intellectual disability, and non-ambulatory status. Modifiable risk factors include the presence of convulsive seizures, increased seizure frequency, timely and appropriate use of antiseizure medications, polytherapy, alcoholism, and supervision while sleeping. Pathophysiology is unclear, but several possible mechanisms such as direct alteration of cardiorespiratory function, pulmonary impairment, electrocerebral shutdown, adenosine dysfunction, and genetic susceptibility suggested. Summary Methods to prevent SUDEP include increasing awareness of SUDEP, augmenting knowledge of unmodifiable risk factors, obtaining full seizure remission, addressing lifestyle factors such as supervision and prone positioning, and enacting protocols to increase the detection of and intervention for SUDEP. Further studies are required to characterize precisely and comprehensively SUDEP risk factors and pathophysiological drivers and develop evidence-based algorithms to minimize SUDEP in people with epilepsy.

P.095 The many clinical facets of pediatric occipital spikes and the predictive value of consistent EEG dipole

Background: Pediatric occipital epileptiform discharges (OEDS) occur in various clinical settings, including benign and symptomatic epilepsies. The study objective is to determine electro-clinical predictors for aetiology and prognosis in children with OEDs. Methods: 205 patients with OEDs were classified into seizure groups: symptomatic (n=98), idiopathic focal (IF) (n=57), idiopathic generalized (IG) (n=18), no-seizures (n=27) and febrile seizures (n=5). Results: The median age of seizure onset was 3 years (range: 0-19). There was more EEG background slowing (P<0.05) in the symptomatic; photosensitivity (P<0.0001) and GSW (P<0.0001) in IG; and presence of consistent EEG spike dipole in IF group. The symptomatic had more DD (P< 0.0001), autism (P <0.019), and school difficulties (P<0.001) than the IF and IG groups, but not different from the no-seizure group. Conclusions: OEDs with consistent dipole spike is predictive of IF epilepsy. In contrast to frontal and temporal lobe epilepsy, only 30% with symptomatic epilepsy had occipital-predominant neuro-imaging abnormalities. Notably, neuro-psychiatric co-morbidities were similar between the symptomatic and no-seizure group.

Gradual dilatation of an occluded transverse sinus associated with dural arteriovenous fistula after balloon angioplasty with sinus packing: A case report

Background There is no consensus as to whether balloon angioplasty alone or stent placement is effective for sinus occlusion associated with dural arteriovenous fistula (DAVF). Herein, we first report a case of transverse sinus occlusion associated with DAVF in which gradual sinus dilatation was observed after balloon angioplasty with embolization of the affected sinus with shunt flow. Case presentation A 69-year-old man presented with executive dysfunction. Magnetic resonance imaging revealed left transverse sinus–sigmoid sinus DAVF with occlusion of the left jugular vein and right transverse sinus. Before endovascular treatment, the patient had symptomatic epilepsy and subarachnoid hemorrhage. Retrograde leptomeningeal venous drainage disappeared with packing of the left transverse sinus–sigmoid sinus. Subsequently, balloon angioplasty of the right occluded transverse sinus was performed to maintain the normal venous drainage and remaining shunt outflow. Dilatation of the right transverse sinus was poor immediately after surgery. However, angiography after 10 days and 6 months revealed gradual dilatation of the right transverse sinus. Conclusion Sinus occlusion, which is thought to be caused by sinus hypertension associated with DAVF rather than chronic organized thrombosis or thrombophilia, may dilate over time after balloon angioplasty and shunt flow reduction if occluded sinus is necessary for facilitating normal venous drainage.

Management of symptomatic epilepsy after surgery due to drug resistance

The issue of managing patients who were operated due to drug resistance has not been accomplished not only in Ukraine, but throughout the world. But these patients exist, their number is growing, and the neurologists who observe them need a direct understanding of this process. Nowadays, there is no enough evidence base to substantiate rational recommendations regarding the post-surgical drug treatment. Despite the fact that the International League Against Epilepsy (ILAE) classification and the classification previously proposed by J. Engel Jr have many headings that indicate the improvement of patients and possible improvement in their quality of life, the treatment that has achieved seizure control can be considered successful only in patients who meet qualification point 1 according to the ILAE classification or IA according to the Engel classification, and only those who meet these criteria for at least one year. This understanding is very important when choosing further therapeutic management. Taking into account the fact that after surgical treatment the drug resistance should be overcome, further drug treatment should be carried out in the same way as in patients without drug resistant epilepsy. The issue of managing people with epilepsy who received surgical treatment due to drug resistance requires further studies, especially in the context of an increase in the number of such patients. The authors indicate that all the questions and aspects that were presented in the work are controversial and can be adjusted depending on the clinical situation.

Stereotactic Radiosurgery in the Complex Treatment of Patients With Epilepsy Associated With Various Structural Brain Lesions

BACKGROUND Structural damage to the brain substance in adults is one of the most common causes of epilepsy. Currently, such patients are prescribed drug therapy and/or surgery. With this approach, epileptic symptoms can persist in a significant proportion of patients (up to 30%, depending on the disease).AIM OF STUDY To clarify the efficacy of stereotactic radiosurgery (STS) as part of the complex treatment of patients suffering from pharmacoresistant symptomatic epilepsy with hippocampal sclerosis, vascular malformations, and some benign tumors of the brain and its membranes.MATERIAl AND METHODS Examination and radiosurgical treatment were carried out in 45 patients with various brain diseases accompanied by symptomatic epilepsy, provided that the previous conservative or surgical treatment was insufficiently effective. During the observation period, the frequency of seizures was assessed and the presence and nature of postoperative complications were recorded.RESUlTS With a median follow-up of 30 months, good outcomes (class I–II according to J. Engel’s scale) were observed in 5 out of 8 patients with hippocampal sclerosis who underwent STS after amygdaloghippocamplobectomy; seizure frequency decreased in all patients. Complications of STS were noted in 2 patients and had a transient nature. In the group of patients with meningiomas, in 4 out of 8 patients, seizures completely stopped, in 3 patients the frequency of seizures decreased by more than 90%, in another 1 the frequency of seizures decreased by 60%. There were no complications of STS during the observation period. Inintracerebral tumors (diffuse astrocytoma), Engel Ia outcome was observed in both patients. In the group of patients with cavernous angiomas, there were good outcomes (class I–II according to J. Engel’s scale) in 17 patients (85%). Deterioration (Engel IVc outcome) was observed in 1 patient (5%), 2 patients (10%) had complications of STS. In the group of patients with arteriovenous malformations, good outcomes (classes I–II according to J. Engel’s scale) were found in all 7 patients. The complication after STS was revealed in 1 patient.CONClUSION The presented results confirm the high efficiency and low risk of side effects when using stereotactic radiosurgery in the complex treatment of patients with epilepsy associated with common structural brain lesions.

Neurological manifestations of tuberous sclerosis in children (own observations)

Tuberous sclerosis (Pringle-Burneville disease) is a polysystemic genetic disease and occurs in the population with a frequency of 1:50000. Objective of the study. To study neuropsychic status and dynamics of tuberous sclerosis development in children. Material and Methods. Have been examined 33 children aged from 1 to 14 years, who were observed in the neurological pediatric department of the University Clinic ("Aksay") of Asfendiyarov KazNMU. All children had apigmented spots and coffee-milk stains on the torso and extremities, not protruding above the skin level. All children showed characteristic neuroimaging changes in the brain by magnetic resonance imaging (MRI) and computed tomography (CT) - areas of dyshinesia cortically and subcortically, i.e. tubercles. As well as changes in internal organs (hamartoma variants). All children underwent a complete laboratory examination (general blood count, standard biochemical parameters), electroencephalography of the brain (EEG), as well as ultrasound examination of internal organs. Results and conclusions. As a result of our study, it was revealed that the main symptom confirming the diagnosis of tuberous sclerosis is the presence of tubers (95-100% of patients). Moreover, there is a topographical relationship between tubers detected during MRI examination and the presence of foci on the EEG. Thus, a particular manifestation of the disease in patients is symptomatic epilepsy with onset in the first months of life (96% of patients). Keywords: tuberous sclerosis, epilepsy, children, hamartomas, pigmented spots, cortical dysgenesis, tubers.