Posts Tagged seizures

[Infographic] First Seizure Management

 

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[Infographic] Operational Classification of Seizure Types

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[WEB SITE] Stem cell-derived neurons stop seizures and improve cognitive function

People with untreatable epilepsy may one day have a treatment: ‘Convincing’ their own cells to become the neurons they need

IMAGE

IMAGE: THIS IS ASHOK K. SHETTY. 
CREDIT: TEXAS A&M UNIVERSITY HEALTH SCIENCE CENTER.

About 3.4 million Americans, or 1.2 percent of the population, have active epilepsy. Although the majority respond to medication, between 20 and 40 percent of patients with epilepsy continue to have seizures even after trying multiple anti-seizure drugs. Even when the drugs do work, people may develop cognitive and memory problems and depression, likely from the combination of the underlying seizure disorder and the drugs to treat it.

A team led by Ashok K. Shetty, PhD, a professor in the Department of Molecular and Cellular Medicine at the Texas A&M College of Medicine, associate director of the Institute for Regenerative Medicine and a research career scientist at the Olin E. Teague Veterans’ Medical Center, part of the Central Texas Veterans Health Care System, is working on a better and permanent treatment for epilepsy. Their results published this week in the Proceedings of the National Academy of Sciences (PNAS).

Seizures are caused when the excitatory neurons in the brain fire too much and inhibitory neurons–the ones that tell the excitatory neurons to stop firing–aren’t as abundant or aren’t operating at their optimal level. The main inhibitory neurotransmitter in the brain is called GABA, short for gamma-Aminobutyric acid.

Over the last decade, scientists have learned how to create induced pluripotent stem cells from ordinary adult cells, like a skin cell. These stem cells can then be coaxed to become virtually any type of cells in the body, including neurons that use GABA, called GABAergic interneurons.

“What we did is transplant human induced pluripotent stem cell-derived GABAergic progenitor cells into the hippocampus in an animal model of early temporal lobe epilepsy,” Shetty said. The hippocampus is a region in the brain where seizures originate in temporal lobe epilepsy, which is also important for learning, memory and mood. “It worked very well to suppress seizures and even to improve cognitive and mood function in the chronic phase of epilepsy.”

Further testing showed that these transplanted human neurons formed synapses, or connections, with the host excitatory neurons. “They were also positive for GABA and other markers of specialized subclasses of inhibitory interneurons, which was the goal,” Shetty said. “Another fascinating aspect of this study is that transplanted human GABAergic neurons were found to be directly involved in controlling seizures, as silencing the transplanted GABAergic neurons resulted in an increased number of seizures.”

“This publication by Dr. Shetty and his colleagues is a major step forward in treating otherwise incurable diseases of the brain,” said Darwin J. Prockop, MD, PhD, the Stearman Chair in Genomic Medicine, director of the Texas A&M Institute for Regenerative Medicine and professor at the Texas A&M College of Medicine. “One important aspect of the work is that the same cells can be obtained from a patient.” This type of process, called autologous transplant, is patient specific, meaning that there would be no risk of rejection of the new neurons, and the person wouldn’t need anti-rejection medication.

“We will need to make sure that we’re doing more good than harm,” Shetty said. “Going forward, we need to make sure that all of the cells transplanted have turned into neurons, because putting undifferentiated pluripotent stem cells into the body could lead to tumors and other problems.”

The development of epilepsy often happens after a head injury, which is why the Department of Defense is interested in funding the development of better treatment and prevention options.

“A great deal of research is required before patients can be safely treated,” Prockop said. “But this publication shows a way in which patients can someday be treated with their own cells for the devastating effects of epilepsy but perhaps also other diseases such as Parkinsonism and Alzheimer’s disease.”

Shetty cautioned that these tests were early interventions after the initial brain injury induced by status epilepticus, which is a state of continuous seizures lasting more than five minutes in humans. The next step is to see if similar transplants would work for cases of chronic epilepsy, particularly drug-resistant epilepsy. “Currently, there is no effective treatment for drug-resistant epilepsy accompanying with depression, memory problems, and a death rate five to 10 times that of the general population,” he said. “Our results suggest that induced pluripotent stem cell-derived GABAergic cell therapy has the promise for providing a long-lasting seizure control and relieving co-morbidities associated with epilepsy.”

 

via Stem cell-derived neurons stop seizures and improve cognitive function | EurekAlert! Science News

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[Editorial] New Directions in the Management of Status Epilepticus – Neurology

Status Epilepticus (SE) is a neurological emergency and has high morbidity and mortality. The International League Against Epilepsy (ILAE) recently updated their definition to specify that, “SE is a condition resulting either from the failure of the mechanisms responsible for seizure termination or from the initiation of mechanisms, which lead to abnormally, prolonged seizures.” Such phenomena can lead to long-term neurological complications due to neuronal death, glia, neurological injury, aberrant neuroplasticity, oxidative stress and inflammation, and alteration of neuronal networks. Depending upon the type and duration of SE, these mechanisms are quite variable. Therefore, in response to the updated definition of SE, novel avenues of research are required to address the specified involvement of the underlying mechanisms and pathophysiology resulting in the development of and outcomes from SE.

Improving the basic science understanding of SE will facilitate essential clinical trials. One can envision such experiments to include device and compound-based technological interventions directed at aborting the seizure activity and improving clinical outcomes. Benzodiazepines remain one of the cornerstones of treatment, and studies are underway to study new delivery options, including intranasal, buccal, and intramuscular midazolam, in addition to rectal diazepam, with the goal of aborting the seizure activity outside the hospitals, as rapidly as possible. Approved and off-label anticonvulsants, such as phenytoin, phenobarbital, valproate, topiramate, levetiracetam, lacosamide, steroids, immunosuppressants, and neuroprotective compounds, have also shown some efficacy at treating SE. However, substantial challenges remain in optimally managing SE and minimizing the short- and long-term complications. Such difficulties can be overcome by innovative approaches targeting the underlying mechanisms of neuronal excitability, glia, neuronal death, neuroplasticity, oxidative stress, inflammation, and neuroinflammation.

The book comprises six original research articles and four reviews. Collectively, the materials provide insights into the pathophysiology, clinical presentation, treatment, recent advances and future directions in the management of SE, with the goal of providing an in-depth view and advancing the field to improve management of SE.

The book opens with an original research article by Kristin Phillips et al. which showed the role of hypothermia as a neuroprotective agent for preventing the development of calcium plateau against SE-induced delayed hippocampal injury. Hypothermia-mediated neuroprotection after pilocarpine-induced SE was evident from decreased Fluoro-Jade C+ neurons in the hippocampus. The second original article by Matos et al. described SE-induced changes in spontaneous locomotor activity and the temporal expression of genes related to circadian rhythms (Clock, Bmal1, Cry1, Cry2, Per1, Per2, and Per3) in the hippocampus at both early post-SE and chronic epilepsy phases. Authors propose that seizures can act as a non-photic cue and altered temporal expression of clock genes likely contributes to the pathogenesis of mesial temporal lobe epilepsy. The third original article by Hutson et al. presented an interesting case study which showed evidence of brain dynamics resetting after successful anticonvulsant treatment following SE utilizing stereo encephalography (SEEG) data.

A review by Kirmani et al. conferred the current literature about autoimmune SE including therapeutic options and future directions. An original research article by Wyatt-Johnson et al. reported that SE-induced morphological alterations in microglia at different time-points and discussed the role of such changes on epileptogenesis. Another research article by Kortland et al. addressed the socioeconomic outcome and quality of life outcome in adults after status epilepticus in their original article. The authors conducted a multicenter, longitudinal, matched case-control analysis and concluded that relatively favorable outcomes seen in patients with refractory and super refractory SE as compared to non-refractory SE cases underlying the need of effective therapeutic choices.

An original research article by Bertoglio et al. compared the effects of two different protocols of kainate-induced SE in two strains of rats on neurodegeneration and chronic epilepsy development. The findings revealed that severe neuron loss after SE does not necessarily correlate with a higher seizure rate in the chronic phase after SE. In a review article, Castro et al. discussed the efficacy and promise of resveratrol, a phytoalexin found in the skin of red grapes, for easing SE-induced neurodegeneration, neuroinflammation, aberrant neurogenesis and for restraining the evolution of SE-induced brain injury into a chronic epileptic state. Sharma et al. by reviewing methods of induction and characterization of behavioral SE and EEG correlates in mice and rats, highlighted the advantages of a repeated low dose of kainate protocol for minimizing the variability in the initial SE severity and reducing the mortality rate. The last original article by Lucchi et al. described the role peroxisome proliferator-activated receptor gamma in the anticonvulsant properties of EP-80317, a Ghrelin receptor antagonist in pilocarpine-induced SE rat model and repeated 6 Hz corneal stimulation model in mice.

via Frontiers | Editorial: New Directions in the Management of Status Epilepticus | Neurology

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[Abstract] Antiepileptic drug treatment during pregnancy and delivery in women with epilepsy – A retrospective single center study

Highlights

Pregnancies in women with epilepsy (WWE) increased significantly during our 11-year study period (41% increase).

Twelve different AEDs were prescribed to WWE during pregnancies in the 11-year period investigated (2005-2015) with Lamotrigine (36.1%), Carbamazepine (25.0%), and Valproic Acid (13.5%) most commonly used.

Valproic acid use was markedly reduced comparing the years 2005-2010 (18.4%) and 2011-2015 (9.4%), a reduction of 48%.

Unfortunately, a trend towards an increase in treating WWE with more than one AED was observed.

Cover image Epilepsy ResearchAbstract

Purpose

Antiepileptic drugs (AED) are among the most common teratogenic drugs prescribed to women of childbearing age. During pregnancy, the risk of seizures has to be weight against the use of AED treatment. Primary goal was to observe and describe AED treatment policy and its changes during an eleven-year period at our third referral center.

Methods

We scrutinized the medical health records for all cases of female epileptic patients admitted for labor at the Rabin Medical Center during the years 2005 – 2015.

Results

A total of 296 deliveries were recorded with 136 labors occurring in the period 2005-2010 (22.7/y) and 160 in 2011-2015 (32.0/y; increase of 41%). Twelve different AEDs were prescribed to WWE during pregnancies in the 11-year period investigated (2005-2015). Most commonly used AEDs during pregnancy were Lamotrigine (36.1%), Carbamazepine (25.0%), and Valproic Acid (13.5%). Comparing their use during the years 2005-2010 and 2011-2015, Lamotrigine (35.3% vs. 36.9%) and Carbamazepine use (23.5% vs. 26.0%) increased slightly. Valproic acid use was markedly reduced in the second period: 18.4% in the years 2005-2010 lowered to 9.4% during 2011-2015, a reduction of 48%. Unfortunately, a trend towards an increase in treating WWE with more than one AED was observed.

Conclusions

The proportion of WWE treated with VPA during pregnancy was significantly reduced in the observed period (2005-2015). Change in fetal outcome during this period for WWE could not be detected.

via Antiepileptic drug treatment during pregnancy and delivery in women with epilepsy—A retrospective single center study – ScienceDirect

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[Abstract + References] Efficacy and Safety of Cannabidiol in Epilepsy: A Systematic Review and Meta-Analysis

Abstract

Background

Approximately one-third of patients with epilepsy presents seizures despite adequate treatment. Hence, there is the need to search for new therapeutic options. Cannabidiol (CBD) is a major chemical component of the resin of Cannabis sativa plant, most commonly known as marijuana. The anti-seizure properties of CBD do not relate to the direct action on cannabinoid receptors, but are mediated by a multitude of mechanisms that include the agonist and antagonist effects on ionic channels, neurotransmitter transporters, and multiple 7-transmembrane receptors. In contrast to tetra-hydrocannabinol, CBD lacks psychoactive properties, does not produce euphoric or intrusive side effects, and is largely devoid of abuse liability.

Objective

The aim of the study was to estimate the efficacy and safety of CBD as adjunctive treatment in patients with epilepsy using meta-analytical techniques.

Methods

Randomized, placebo-controlled, single- or double-blinded add-on trials of oral CBD in patients with uncontrolled epilepsy were identified. Main outcomes included the percentage change and the proportion of patients with ≥ 50% reduction in monthly seizure frequency during the treatment period and the incidence of treatment withdrawal and adverse events (AEs).

Results

Four trials involving 550 patients with Lennox–Gastaut syndrome (LGS) and Dravet syndrome (DS) were included. The pooled average difference in change in seizure frequency during the treatment period resulted 19.5 [95% confidence interval (CI) 8.1–31.0; p = 0.001] percentage points between the CBD 10 mg and placebo groups and 19.9 (95% CI 11.8–28.1; p < 0.001) percentage points between the CBD 20 mg and placebo arms, in favor of CBD. The reduction in all-types seizure frequency by at least 50% occurred in 37.2% of the patients in the CBD 20 mg group and 21.2% of the placebo-treated participants [risk ratio (RR) 1.76, 95% CI 1.07–2.88; p = 0.025]. Across the trials, drug withdrawal for any reason occurred in 11.1% and 2.6% of participants receiving CBD and placebo, respectively (RR 3.54, 95% CI 1.55–8.12; p = 0.003) [Chi squared = 2.53, degrees of freedom (df) = 3, p = 0.506; I2 = 0.0%]. The RRs to discontinue treatment were 1.45 (95% CI 0.28–7.41; p = 0.657) and 4.20 (95% CI 1.82–9.68; p = 0.001) for CBD at the doses of 10 and 20 mg/kg/day, respectively, in comparison to placebo. Treatment was discontinued due to AEs in 8.9% and 1.8% of patients in the active and control arms, respectively (RR 5.59, 95% CI 1.87–16.73; p = 0.002). The corresponding RRs for CBD at the doses of 10 and 20 mg/kg/day were 1.66 (95% CI 0.22–12.86; p = 0.626) and 6.89 (95% CI 2.28–20.80; p = 0.001). AEs occurred in 87.9% and 72.2% of patients treated with CBD and placebo (RR 1.22, 95% CI 1.11–1.33; p < 0.001). AEs significantly associated with CBD were somnolence, decreased appetite, diarrhea, and increased serum aminotransferases.

Conclusions

Adjunctive CBD in patients with LGS or DS experiencing seizures uncontrolled by concomitant anti-epileptic treatment regimens is associated with a greater reduction in seizure frequency and a higher rate of AEs than placebo.

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via Efficacy and Safety of Cannabidiol in Epilepsy: A Systematic Review and Meta-Analysis | SpringerLink

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[WEB SITE] New epilepsy warning device could save thousands of lives — ScienceDaily

Nightwatch bracelet on the arm of a young epilepsy patient.
Credit: LivAssured

A new high-tech bracelet, developed by scientists from the Netherlands detects 85 percent of all severe night-time epilepsy seizures. That is a much better score than any other technology currently available. The researchers involved think that this bracelet, called Nightwatch, can reduce the worldwide number of unexpected night-time fatalities in epilepsy patients. They published the results of a prospective trial in the scientific journal Neurology.

SUDEP, sudden unexpected death in epilepsy, is a major cause of mortality in epilepsy patients. People with an intellectual disability and severe therapy resistant epilepsy, may even have a 20% lifetime risk of dying from epilepsy. Although there are several techniques for monitoring patients at night, many attacks are still being missed.

Consortium researchers have therefore developed a bracelet that recognizes two essential characteristics of severe attacks: an abnormally fast heartbeat, and rhythmic jolting movements. In such cases, the bracelet will send a wireless alert to carers or nurses.

The research team prospectively tested the bracelet, known as Nightwatch, in 28 intellectually handicapped epilepsy patients over an average of 65 nights per patient. The bracelet was restricted to sounding an alarm in the event of a severe seizure. The patients were also filmed to check if there were any false alarms or attacks that the Nightwatch might have missed. This comparison shows that the bracelet detected 85 percent of all serious attacks and 96% of the most severe ones (tonic-clonic seizures), which is a particularly high score.

For the sake of comparison, the current detection standard, a bed sensor that reacts to vibrations due to rhythmic jerks, was tested at the same time. This signalled only 21% of serious attacks. On average, the bed sensor therefore remained unduly silent once every 4 nights per patient. The Nightwatch, on the other hand, only missed a serious attack per patient once every 25 nights on average. Furthermore, the patients did not experience much discomfort from the bracelet and the care staff were also positive about the use of the bracelet.

These results show that the bracelet works well, says neurologist and research leader Prof. Dr. Johan Arends. The Nightwatch can now be widely used among adults, both in institutions and at home. Arends expects that this may reduce the number of cases of SUDEP by two-thirds, although this also depends on how quickly and adequately care providers or informal carers respond to the alerts. If applied globally, it can save thousands of lives.

Watch the video here: https://youtu.be/0G_BQK4LK88

Story Source:

Materials provided by Eindhoven University of TechnologyNote: Content may be edited for style and length.


Journal Reference:

  1. Johan Arends, Roland D. Thijs, Thea Gutter, Constantin Ungureanu, Pierre Cluitmans, Johannes Van Dijk, Judith van Andel, Francis Tan, Al de Weerd, Ben Vledder, Wytske Hofstra, Richard Lazeron, Ghislaine van Thiel, Kit C.B. Roes, Frans Leijten. Multimodal nocturnal seizure detection in a residential care settingNeurology, 2018; 10.1212/WNL.0000000000006545 DOI: 10.1212/WNL.0000000000006545

via New epilepsy warning device could save thousands of lives — ScienceDaily

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[WEB SITE] New Epilepsy Bracelet Could Save Thousands of Lives

High-Tech “Nightwatch” is Capable of Detecting 85 Percent of Severe Night-Time Epileptic Seizures

Scientists in the Netherlands are optimistic that their new device will reduce the number of sudden unexpected death in epilepsy (SUDEP) patients worldwide. Currently, for people with an intellectual disability and severe treatment-resistant epilepsy, the outlook is poor, with a possible 20 percent lifetime risk of dying from epilepsy. While several techniques exist for monitoring patients at night, many seizures are still being missed.

With this in mind, a consortium of researchers (from Kempenhaeghe epilepsy centre, Eindhoven University of Technology, the Foundation for Epilepsy Institutions in the Netherlands (SEIN), UMC Utrecht, the Epilepsy Fund, patient representatives, and LivAssured) developed Nightwatch, a bracelet that recognizes unusually fast heartbeat and rhythmic jolting movements, two critical characteristics of severe attacks. When these occur, the device sends a wireless alert to caregivers or nurses.

In a test among 28 intellectually handicapped patients with epilepsy, over an average of 65 nights, Nightwatch detected 85 percent of all serious attacks and 96 percent of the most severe ones (tonic-clonic seizures). In comparison, a bed sensor, which is the current detection standard, sounded the alarm for only 21 percent of serious attacks. While the bed sensor was silent once every four nights per patient, the Nightwatch only missed a serious attack once every 25 nights, on average.

Prof. Dr. Johan Arends, neurologist and research leader, expects that the bracelet may reduce the number of SUDEP cases by two-thirds, although this also depends on the speed and efficiency with which caregivers respond to the alerts.

Source: MedicalXpress.com, October 29, 2018

 

via New Epilepsy Bracelet Could Save Thousands of Lives | Managed Care magazine

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[WEB SITE] Importance of Taking Medication on Schedule – Epilepsy Foundation

Taking Your Medication Regularly is Essential to Controlling Your Seizures

Taking seizure medications regularly, and as recommended by your doctor, is vitally important! It gives you the best chance to achieve the goals of epilepsy therapy: no seizures and no side effects. On the flip side, noncompliance with seizure medicines can have significant and possibly disastrous consequences.

Taking medicines regularly is easiest when you know about epilepsytreatment, and how to manage your seizures and medications. Managing medicines isn’t easy, but it certainly can be done! Think of it as a team approach involving your doctor, nurse, pharmacist, counselor, family and friends, and of course YOU. You are the captain of the team, because only you can decide if you are going to take the medicine. Only you can work together with the team to find ways to manage your meds best.

Here’s A Few Points About Why Adherence Is So Important.

  • You need to follow the doctor’s directions. If thos directions are confusing or complex, ask questions until you are sure you understand.
  • Seizure medicines must be taken each and every day as prescribed. If the right amount is not taken at the right time, the medicine may not be able to prevent seizures, or might cause unwanted side effects.
  • If the first medicine doesn’t work, others may be more successful.
  • Finding the right medicine at the right dose taken at the right time(s) of the day requires teamwork.
  • Any medication change recommended by the doctor is based on the assumption that the person has been taking the medicine the way it was intended. If this isn’t true, then the change may not work or may be the wrong thing to do!

Here are some thoughts by Joyce Cramer, a former president of the Epilepsy Therapy Project, that emphasizes the importance of medication compliance: The Titanic Impact of Medication Compliance on Epilepsy.

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via Importance of Taking Medication on Schedule | Epilepsy Foundation

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[WEB SITE] Driving and Epilepsy: Issues to Discuss With Your Patients

epilepsy, driving

Dr Sanchez is Assistant Professor and Dr Krumholz is Professor Emeritus, Department of Neurology, University of Maryland School of Medicine, Baltimore, MD.

Worldwide there are more than 65 million individuals with epilepsy.1In the US because driving an automobile is such an important aspect of our culture, driving restriction is an enormous problem for many of these individuals and their families. Indeed, surveys find individuals with epilepsy report driving as a major concern.2 Physicians and other medical providers play an important role educating and counseling people with seizures and their families regarding driving. Here, we provide some background and guidance regarding this issue.

Individuals with seizures are restricted from driving because of concerns that a seizure while driving might result in loss of control of the vehicle and a crash, potentially injuring the driver or others, and damaging property. Tragically, such crashes cause fatalities.3 Therefore every state in the US restricts some individuals with epilepsy from driving. Driving restrictions vary by state and are ultimately determined by the Department of Motor Vehicles (DMV).4 Physicians and other medical providers are involved to varying degrees throughout this process of driving regulation and restriction. They serve as advisers to patients, with a duty to inform patients regarding rules and regulations as well as consultants to state regulatory authorities.

To properly counsel patents, it is important that physicians and other medical providers are familiar with the rules governing driving for patients with seizure disorders. Our recommended approach to counseling patients with seizures and epilepsy regarding driving is illustrated in some of the following examples and discussion.

Case example
A 23-year-old woman presents to your office with new-onset seizures. She generally feels well, has no other relevant history, and her examination is normal. Brain MRI with and without contrast and EEG were performed and were normal.

Question: As the medical provider, how would you counsel this patient regarding driving after her first unprovoked seizure (a seizure not related to an acute precipitating cause)?

Answer: She should be informed that a seizure while driving could be dangerous and result in a motor vehicle crash. Since she has had a seizure, she is at risk for further seizures. Regulations exist in an effort to prevent injury, death, or property damage that might result if a seizure were to occur while driving. She should be informed to stop driving and that patients are required by law to report their seizures to the DMV in their state. In some states, physicians and other medical providers are also required to report (Table 1) that a patient has had a seizure.4 The DMV will determine when she may resume driving.

A seizure-free interval is typically necessary for the DMV to approve a person to drive after a first seizure, this too varies by state. The typically required seizure-free interval may be as short as three months to as long as one year.4 There may be positive or negative modifiers that shorten or lengthen the seizure-free interval (Table 2).5 Antiseizure medication (ASM) is not always prescribed after a first seizure; this is a variable that may be considered on a case by case basis.6

After reporting her seizures to the DMV, the patient and the medical provider are required to complete paperwork regarding the condition. A medical advisory board or similar type of state review will consider the case and make recommendations. Then a final decision regarding any driving restrictions will be made by the DMV. Decisions may be appealed by the patient.

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via Driving and Epilepsy: Issues to Discuss With Your Patients | Neurology Times

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