scholarly journals Neuromodulation for Refractory Epilepsy

2021 ◽  
pp. 153575972110655
Author(s):  
Philippe Ryvlin ◽  
Lara E. Jehi
Keyword(s):  
Focal Epilepsy ◽  
Refractory Status Epilepticus ◽  
Seizure Freedom ◽  
Treatment Pathways ◽  
Refractory Status ◽  
High Level ◽  
Implanted Device ◽  
Term Data ◽  
Deep Brain

Three neuromodulation therapies, all using implanted device and electrodes, have been approved to treat adults with drug-resistant focal epilepsy, namely, the vagus nerve stimulation in 1995, deep brain stimulation of the anterior nucleus of the thalamus (ANT-DBS) in 2018 (2010 in Europe), and responsive neurostimulation (RNS) in 2014. Indications for VNS have more recently extended to children down to age of 4. Limited or anecdotal data are available in other epilepsy syndromes and refractory/super-refractory status epilepticus. Overall, neuromodulation therapies are palliative, with only a minority of patients achieving long-term seizure freedom, justifying favoring such treatments in patients who are not good candidates for curative epilepsy surgery. About half of patients implanted with VNS, ANT-DBS, and RNS have 50% or greater reduction in seizures, with long-term data suggesting increased efficacy over time. Besides their impact on seizure frequency, neuromodulation therapies are associated with various benefits and drawbacks in comparison to antiseizure drugs. Yet, we lack high-level evidence to best position each neuromodulation therapy in the treatment pathways of persons with difficult-to-treat epilepsy.

scholarly journals Nine-year prospective efficacy and safety of brain-responsive neurostimulation for focal epilepsy

Neurology ◽  
2020 ◽  
Vol 95 (9) ◽  
pp. e1244-e1256 ◽  
Author(s):  
Dileep R. Nair ◽  
Kenneth D. Laxer ◽  
Peter B. Weber ◽  
Anthony M. Murro ◽  
Yong D. Park ◽  
...  
Keyword(s):  
Quality Of Life ◽  
Seizure Frequency ◽  
Focal Epilepsy ◽  
Responder Rate ◽  
Seizure Freedom ◽  
Open Label ◽  
Cognitive Domains ◽  
Signed Rank

ObjectiveTo prospectively evaluate safety and efficacy of brain-responsive neurostimulation in adults with medically intractable focal onset seizures (FOS) over 9 years.MethodsAdults treated with brain-responsive neurostimulation in 2-year feasibility or randomized controlled trials were enrolled in a long-term prospective open label trial (LTT) to assess safety, efficacy, and quality of life (QOL) over an additional 7 years. Safety was assessed as adverse events (AEs), efficacy as median percent change in seizure frequency and responder rate, and QOL with the Quality of Life in Epilepsy (QOLIE-89) inventory.ResultsOf 256 patients treated in the initial trials, 230 participated in the LTT. At 9 years, the median percent reduction in seizure frequency was 75% (p < 0.0001, Wilcoxon signed rank), responder rate was 73%, and 35% had a ≥90% reduction in seizure frequency. We found that 18.4% (47 of 256) experienced ≥1 year of seizure freedom, with 62% (29 of 47) seizure-free at the last follow-up and an average seizure-free period of 3.2 years (range 1.04–9.6 years). Overall QOL and epilepsy-targeted and cognitive domains of QOLIE-89 remained significantly improved (p < 0.05). There were no serious AEs related to stimulation, and the sudden unexplained death in epilepsy (SUDEP) rate was significantly lower than predefined comparators (p < 0.05, 1-tailed χ2).ConclusionsAdjunctive brain-responsive neurostimulation provides significant and sustained reductions in the frequency of FOS with improved QOL. Stimulation was well tolerated; implantation-related AEs were typical of other neurostimulation devices; and SUDEP rates were low.ClinicalTrials.gov identifierNCT00572195.Classification of evidenceThis study provides Class IV evidence that brain-responsive neurostimulation significantly reduces focal seizures with acceptable safety over 9 years.

scholarly journals Higher mortality rate is associated with advanced age and periodic lateralized epileptiform discharges in patients with refractory status epilepticus

2013 ◽  
Vol 71 (3) ◽  
pp. 153-158 ◽  
Author(s):  
Paulo Breno Noronha Liberalesso ◽  
Eliana Garzon ◽  
Elza M.T. Yacubian ◽  
Américo C. Sakamoto
Keyword(s):  
Status Epilepticus ◽  
Mortality Rate ◽  
Clinical Data ◽  
Focal Epilepsy ◽  
Refractory Status Epilepticus ◽  
Advanced Age ◽  
Neurological Sequelae ◽  
Epileptiform Discharges ◽  
Refractory Status ◽  
Treatment Morbidity

ObjectiveTo evaluate clinical data, electroencephalogram, etiology, classification, treatment, morbidity, and mortality in acute refractory status epilepticus.MethodsFifteen patients, mean age of 41.3 years-old, six males, with refractory status epilepticus, were retrospectively studied. All of them were followed by serial electroencephalogram or continuous electroencephalographic monitoring.ResultsThe most common comorbidity was hypertension. Seven (46.7%) patients were diagnosed with previous symptomatic focal epilepsy. More than one etiology was identified in 40.0% of the cases. Status epilepticus partial complex was the most common (n=14, 93.3%), and discrete seizures were the most observed initial ictal pattern. Continuous intravenous midazolam was used in nine (60.0%) patients and continuous thiopental in three (20.0%). Nine (60.0%) participants died, one (6.6%) had neurological sequelae, and five (33.3%) presented no neurological sequelae.ConclusionsHigher mortality rate was associated with advanced age and periodic lateralized epileptiform discharges. Midazolam proved to be a safe drug. The refractory status epilepticus is related to high mortality.

Neuromodulatory Approaches to the Management of Medically Refractory Cluster Headache

2010 ◽  
Vol 5 (1) ◽  
pp. 97
Author(s):  
Arne May ◽  
Peter J Goadsby ◽  
◽  
Keyword(s):  
Cluster Headache ◽  
Treatment Options ◽  
Primary Headache ◽  
Chronic Cluster Headache ◽  
Primary Headache Disorders ◽  
Greater Occipital Nerve ◽  
Term Data ◽  
Deep Brain ◽  
Stimulation Of

The trigeminal autonomic cephalalgias are a group of primary headache disorders characterised by unilateral trigeminal distribution of pain that occurs in association with ipsilateral cranial autonomic features. The most prominent one is cluster headache, a dreadful disease with excrutiating pain attacks. These attacks last no longer than two hours but may occur several times per day. It is mandatory to find an efficient therapy for these patients, but some are unresponsive to all treatments. In these intractable cases invasive procedures are introduced, but the available evidence (while conflicting) illustrates that trigeminal denervation may not be effective in preventing the headache attacks or autonomic symptoms of chronic cluster headache. Modern neurostimulating approaches, such as stimulation of the greater occipital nerve and hypothalamic deep brain stimulation, supersede neurodestructive procedures. Both stimulation methods are exquisite and potentially lifesaving treatment options in otherwise intractable patients, but they need to be better characterised and further long-term data are needed.

Centromedian thalamic nuclei deep brain stimulation in refractory status epilepticus

2012 ◽  
Vol 5 (4) ◽  
pp. 594-598 ◽  
Author(s):  
Antonio Valentín ◽  
Huy Q. Nguyen ◽  
Alena M. Skupenova ◽  
Zaloa Agirre-Arrizubieta ◽  
Sharon Jewell ◽  
...  
Keyword(s):  
Status Epilepticus ◽  
Deep Brain Stimulation ◽  
Brain Stimulation ◽  
Refractory Status Epilepticus ◽  
Thalamic Nuclei ◽  
Refractory Status ◽  
Deep Brain

scholarly journals New-onset super-refractory status epilepticus

Neurology ◽  
2020 ◽  
Vol 95 (16) ◽  
pp. e2280-e2285 ◽  
Author(s):  
Elizabeth Matthews ◽  
Ayham Alkhachroum ◽  
Nina Massad ◽  
Riva Letchinger ◽  
Kevin Doyle ◽  
...  
Keyword(s):  
Status Epilepticus ◽  
Medical Center ◽  
Case Series ◽  
Refractory Status Epilepticus ◽  
Hospital Length Of Stay ◽  
Post Discharge ◽  
Refractory Status ◽  
New Onset

ObjectiveTo better understand the heterogeneous population of patients with new-onset refractory status epilepticus (NORSE), we studied the most severe cases in patients who presented with new-onset super-refractory status epilepticus (NOSRSE).MethodsWe report a retrospective case series of 26 adults admitted to the Columbia University Irving Medical Center neurologic intensive care unit (NICU) from February 2009 to February 2016 with NOSRSE. We evaluated demographics, diagnostic studies, and treatment course. Outcomes were modified Rankin Scale score (mRS) at hospital discharge and most recent follow-up visit (minimum of 2 months post discharge), NICU and hospital length of stay, and long-term antiepileptic drug use.ResultsOf the 252 patients with refractory status epilepticus, 27/252 had NORSE and 26/27 of those had NOSRSE. Age was bimodally distributed with peaks at 27 and 63 years. The majority (96%) had an infectious or psychiatric prodrome. Etiology was cryptogenic in 73%, autoimmune in 19%, and infectious in 8%. Seven patients (27%) underwent brain biopsy, autopsy, or both; 3 (12%) were diagnostic (herpes simplex encephalitis, candida encephalitis, and acute demyelinating encephalomyelitis). On discharge, 6 patients (23%) had good or fair outcome (mRS 0–3). Of the patients with long-term follow-up data (median 9 months, interquartile range 2–22 months), 12 patients (71%) had mRS 0–3.ConclusionAmong our cohort, nearly all patients with NORSE had NOSRSE. The majority were cryptogenic with few antibody-positive cases identified. Neuropathology was diagnostic in 12% of cases. Although only 23% of patients had good or fair outcome on discharge, 71% met these criteria at follow-up.

Determinants of mortality and long-term outcome in children with refractory and super refractory status epilepticus

2022 ◽  
Vol 97 ◽  
pp. 12-16
Author(s):  
Sita Jayalakshmi ◽  
Anuja Patil ◽  
Anusha Challa ◽  
Mihir Parekh ◽  
Harsh Khandelia ◽  
...  
Keyword(s):  
Status Epilepticus ◽  
Refractory Status Epilepticus ◽  
Term Outcome ◽  
Long Term Outcome ◽  
Refractory Status

Technical Challenges Facing Regulators–Assessment of Long-Term Materials Performance

1987 ◽  
Vol 112 ◽  
Author(s):  
Kenneth W. Stephens
Keyword(s):  
Real Time ◽  
Waste Disposal ◽  
Time Frame ◽  
High Level Waste ◽  
Short Term ◽  
Long Time ◽  
Computer Codes ◽  
High Level ◽  
Term Data

AbstractFor a number of years, nuclear regulators have grappled with difficult questions such as: “How safe is safe enough?” Such issues take on new dimensions in the long time-frame of high-level waste disposal.Many of the challenges facing regulators involve assessment of long-term materials performance. Because real-time experiments cannot be conducted, it is necessary to rely extensively on modeling. This raises issues regarding the extent to which long-term extrapolations of short-term data are justified, the question of how closely models must represent reality to be trusted, and practical matters such as methods for validating unique computer codes.Issues such as these illustrate how regulators must make decisions in a climate of uncertainty. Methods used by non-technical disciplines to make decisions under uncertainty have been examined and offer solutions for regulators and licensees alike.

Early and late epilepsy surgery in focal epilepsies associated with long-term epilepsy-associated tumors

2017 ◽  
Vol 127 (5) ◽  
pp. 1147-1152 ◽  
Author(s):  
Veronica Pelliccia ◽  
Francesco Deleo ◽  
Francesca Gozzo ◽  
Ivana Sartori ◽  
Roberto Mai ◽  
...  
Keyword(s):  
Temporal Lobe ◽  
Epilepsy Surgery ◽  
Focal Epilepsy ◽  
Large Population ◽  
Complete Resection ◽  
Seizure Outcome ◽  
Seizure Freedom ◽  
Determinant Factors ◽  
Associated Tumors

OBJECTIVEEpilepsy surgery is an effective means of treating focal epilepsy associated with long-term epilepsy-associated tumors. This study evaluated a large population of surgically treated patients with childhood onset of epilepsy and a histologically confirmed diagnosis of long-term epilepsy-associated tumors. The authors analyzed long-term seizure outcomes to establish whether the time of surgery and patients' ages were determinant factors.METHODSThe authors separately investigated several presurgical, surgical, and postsurgical variables in patients operated on before (pediatric group) and at or after (adult group) the age of 18 years. Patients with < 24 months of postsurgical follow-up were excluded from the analysis.RESULTSThe patients who underwent surgery before 18 years of age showed better seizure outcomes than those after 18 years of age (80% vs 53.3% Engel Class Ia outcome, respectively; p < 0.001). Multivariate analysis showed that the only variables significantly associated with seizure freedom were complete resection of the lesion, a shorter duration of epilepsy, and temporal lobe resection.CONCLUSIONSThe findings of this study indicate that pediatric patients are more responsive to epilepsy surgery and that a shorter duration of epilepsy, complete resection, and a temporal lobe localization are determinant factors for a positive seizure outcome.

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