scholarly journals Practical Drug Treatment Recommendations on the Drug Refractory Epilepsy Patients: 2021 Clinical Guideline Subcommittee for Epilepsy in the Korean Neurological Association

2021 ◽  
Vol 39 (4) ◽  
pp. 255-269
Author(s):  
Dong Jin Shin ◽  
Young-Min Shon ◽  
Ki-Young Jung ◽  
Yong Seo Koo ◽  
Daeyoung Kim ◽  
...  
Keyword(s):  
Clinical Guideline ◽  
American Association ◽  
Refractory Epilepsy ◽  
Treatment Options ◽  
Clinical Decision ◽  
Seizure Reduction ◽  
Generalized Epilepsy ◽  
Rating Scheme ◽  
Drug Refractory Epilepsy ◽  
Control Seizure

One third of the overall epilepsy population are estimated to be a drug refractory epilepsy (DRE), defined as the patients who failed to control seizure reduction, even tried two or more appropriate antiepileptic drugs (AEDs) trials. Those people need additional AEDs trials or other treatment options (resective surgery, neuromoulation, etc.). Here, we, clinical guideline committee of the Korean Neurological Association (KNA) introduce the recommendations of AEDs treatments including not only old and new AEDs currently available in Korea but also AEDs planned to be launched in the new future for DRE patients with literature review to help efficient decision of the clinician. The authors reviewed literatures and assessed efficacy and tolerability on 12 currently available and four newly introduced/or planned AEDs applied to DRE patients, published from November 2015 to July 2021. Brivaracetam, eslicarbazepine, canabidiol and cenobamate are the four AEDs that are newly introduced or planned to be launched soon. The reviewed articles are publications after November 2015, 2018 American Association of Neurology guideline, new AEDs which were introduced or planned to be launched as of 2021. All AEDs are classified based on the therapeutic rating scheme, generating recommendations. Overall 173 papers have been reviewed and analyzed for recommendation rationales. KNA introduce additional add-on treatment or conversional monotherapy guidelines on the drug refractory focal and generalized epilepsy. We hope these guidelines or recommendations to help clinical decision for the treatment of drug refractory epilepsy patients

scholarly journals Defining the optimal target for anterior thalamic deep brain stimulation in patients with drug-refractory epilepsy

2020 ◽  
pp. 1-10 ◽  
Author(s):  
Wendy Guo ◽  
Bang-Bon Koo ◽  
Jae-Hun Kim ◽  
Rafeeque A. Bhadelia ◽  
Dae-Won Seo ◽  
...  
Keyword(s):  
Deep Brain Stimulation ◽  
Brain Stimulation ◽  
Refractory Epilepsy ◽  
Drug Resistant ◽  
Seizure Reduction ◽  
Optimal Target ◽  
Drug Resistant Epilepsy ◽  
Drug Refractory Epilepsy ◽  
Deep Brain

OBJECTIVEThe anterior thalamic nucleus (ATN) is a common target for deep brain stimulation (DBS) for the treatment of drug-refractory epilepsy. However, no atlas-based optimal DBS (active contacts) target within the ATN has been definitively identified. The object of this retrospective study was to analyze the relationship between the active contact location and seizure reduction to establish an atlas-based optimal target for ATN DBS.METHODSFrom among 25 patients who had undergone ATN DBS surgery for drug-resistant epilepsy between 2016 and 2018, those who had follow-up evaluations for more than 1 year were eligible for study inclusion. After an initial stimulation period of 6 months, patients were classified as responsive (≥ 50% median decrease in seizure frequency) or nonresponsive (< 50% median decrease in seizure frequency) to treatment. Stimulation parameters and/or active contact positions were adjusted in nonresponsive patients, and their responsiveness was monitored for at least 1 year. Postoperative CT scans were coregistered nonlinearly with preoperative MR images to determine the center coordinate and atlas-based anatomical localizations of all active contacts in the Montreal Neurological Institute (MNI) 152 space.RESULTSNineteen patients with drug-resistant epilepsy were followed up for at least a year following bilateral DBS electrode implantation targeting the ATN. Active contacts located more adjacent to the center of gravity of the anterior half of the ATN volume, defined as the anterior center (AC), were associated with greater seizure reduction than those not in this location. Intriguingly, the initially nonresponsive patients could end up with much improved seizure reduction by adjusting the active contacts closer to the AC at the final postoperative follow-up.CONCLUSIONSPatients with stimulation targeting the AC may have a favorable seizure reduction. Moreover, the authors were able to obtain additional good outcomes after electrode repositioning in the initially nonresponsive patients. Purposeful and strategic trajectory planning to target this optimal region may predict favorable outcomes of ATN DBS.

Treatment-Refractory Epilepsy: An Evidence-Based Approach to Antiepileptic Monotherapy

CNS Spectrums ◽  
2005 ◽  
Vol 10 (S3) ◽  
pp. 1-16
Author(s):  
Cynthia L. Harden ◽  
David L. Ginsberg ◽  
Andres M. Kanner ◽  
Jocelyn F. Bautista ◽  
Thomas R. Browne
Keyword(s):  
Refractory Epilepsy ◽  
Treatment Options ◽  
Initial Therapy ◽  
Evidence Based ◽  
Drug Selection ◽  
New Antiepileptic Drugs ◽  
Treatment Refractory ◽  
Generalized Epilepsy ◽  
Evidence Based Guidelines ◽  
Refractory Partial Epilepsy

AbstractTreatment options for epilepsy have increased in the last decade with the introduction of several new antiepileptic drugs (AEDs). As drug selection becomes more challenging, the use of evidence-based guidelines to aid in treatment decisions has become increasingly valued. The American Academy of Neurology's (AAN) guidelines for the use of new AEDs in refractory epilepsy offers many benefits, including expert panel recommendations based on clinically relevant questions with evidence-based responses. However, lack of evidence from randomized-controlled trials, particularly as they relate to monotherapy, limits the recommendations and their use in practice. The studies of new AEDs as monotherapy in treatment-refractory epilepsy are difficult to incorporate into clinical use because they are driven by Food and Drug Administration requirements to show superiority over placebo or pseudoplacebo (ie, low dose of active drug) rather than by clinical questions. However, based on Class I evidence, the AAN guidelines have granted Level A recommendations (established effectiveness) for oxcarbazepine and topiramate monotherapy, and a Level B recommendation (probable effectiveness) for lamotrigine monotherapy in the use of refractory partial epilepsy. There is insufficient evidence to recommend gabapentin, levetiracetam, tiagabine, or zonisamide monotherapy. No monotherapy AED trials have been conducted in refractory generalized epilepsy. Because no differences in efficacy have been reported for AEDs as initial therapy of partial seizures, differences in adverse events, such as weight gain, tremor, and hair loss, are key in drug selection. More comparative studies between the AEDs are necessary for both monotherapy and add-on therapy for treatment-refractory epilepsy.

Management of thoracic aortic lesions - the future is endovascular

VASA ◽  
2012 ◽  
Vol 41 (3) ◽  
pp. 163-176 ◽  
Author(s):  
Weidenhagen ◽  
Bombien ◽  
Meimarakis ◽  
Geisler ◽  
A. Koeppel
Keyword(s):  
Thoracic Aorta ◽  
Clinical Decision Making ◽  
Treatment Options ◽  
Clinical Decision ◽  
Clinical Results ◽  
Treatment Modalities ◽  
Traumatic Rupture ◽  
Descending Thoracic Aorta ◽  
New Treatment ◽  
Aneurysm Dissection

Open surgical repair of lesions of the descending thoracic aorta, such as aneurysm, dissection and traumatic rupture, has been the “state-of-the-art” treatment for many decades. However, in specialized cardiovascular centers, thoracic endovascular aortic repair and hybrid aortic procedures have been implemented as novel treatment options. The current clinical results show that these procedures can be performed with low morbidity and mortality rates. However, due to a lack of randomized trials, the level of reliability of these new treatment modalities remains a matter of discussion. Clinical decision-making is generally based on the experience of the vascular center as well as on individual factors, such as life expectancy, comorbidity, aneurysm aetiology, aortic diameter and morphology. This article will review and discuss recent publications of open surgical, hybrid thoracic aortic (in case of aortic arch involvement) and endovascular repair in complex pathologies of the descending thoracic aorta.

scholarly journals Comparison of an oncology clinical decision-support system’s recommendations with actual treatment decisions

2021 ◽  
Author(s):  
Suthida Suwanvecho ◽  
Harit Suwanrusme ◽  
Tanawat Jirakulaporn ◽  
Surasit Issarachai ◽  
Nimit Taechakraichana ◽  
...  
Keyword(s):  
Decision Support ◽  
Clinical Decision Support ◽  
Treatment Options ◽  
Stage Iv ◽  
Clinical Decision ◽  
Treatment Decisions ◽  
Therapeutic Options ◽  
Cancer Type ◽  
The Us ◽  
Rectal Cancers

Abstract Objective IBM(R) Watson for Oncology (WfO) is a clinical decision-support system (CDSS) that provides evidence-informed therapeutic options to cancer-treating clinicians. A panel of experienced oncologists compared CDSS treatment options to treatment decisions made by clinicians to characterize the quality of CDSS therapeutic options and decisions made in practice. Methods This study included patients treated between 1/2017 and 7/2018 for breast, colon, lung, and rectal cancers at Bumrungrad International Hospital (BIH), Thailand. Treatments selected by clinicians were paired with therapeutic options presented by the CDSS and coded to mask the origin of options presented. The panel rated the acceptability of each treatment in the pair by consensus, with acceptability defined as compliant with BIH’s institutional practices. Descriptive statistics characterized the study population and treatment-decision evaluations by cancer type and stage. Results Nearly 60% (187) of 313 treatment pairs for breast, lung, colon, and rectal cancers were identical or equally acceptable, with 70% (219) of WfO therapeutic options identical to, or acceptable alternatives to, BIH therapy. In 30% of cases (94), 1 or both treatment options were rated as unacceptable. Of 32 cases where both WfO and BIH options were acceptable, WfO was preferred in 18 cases and BIH in 14 cases. Colorectal cancers exhibited the highest proportion of identical or equally acceptable treatments; stage IV cancers demonstrated the lowest. Conclusion This study demonstrates that a system designed in the US to support, rather than replace, cancer-treating clinicians provides therapeutic options which are generally consistent with recommendations from oncologists outside the US.

Genetic variations of adenosine kinase as predictable biomarkers of efficacy of vagus nerve stimulation in patients with pharmacoresistant epilepsy

2021 ◽  
pp. 1-10
Author(s):  
Yifan Zhang ◽  
Xiongfei Wang ◽  
Chongyang Tang ◽  
Yuguang Guan ◽  
Fan Chen ◽  
...  
Keyword(s):  
Vagus Nerve ◽  
Nerve Stimulation ◽  
Vagus Nerve Stimulation ◽  
Refractory Epilepsy ◽  
Genetic Variations ◽  
Adenosine Kinase ◽  
Minor Allele ◽  
Seizure Freedom ◽  
Seizure Reduction ◽  
Genes Encoding

OBJECTIVE Vagus nerve stimulation (VNS) is an alternative treatment option for individuals with refractory epilepsy, with nearly 40% of patients showing no benefit after VNS and only 6%–8% achieving seizure freedom. It is presently unclear why some patients respond to treatment and others do not. Therefore, identification of biomarkers to predict efficacy of VNS is of utmost importance. The objective of this study was to explore whether genetic variations in genes involved in adenosine kinase (ADK), ecto-5′-nucleotidase (NT5E), and adenosine A1 receptor (A1R) are linked to outcome of VNS in patients with refractory epilepsy. METHODS Thirty single-nucleotide polymorphisms (SNPs), including 9 in genes encoding ADK, 3 in genes encoding NT5E, and 18 in genes encoding A1R, were genotyped in 194 refractory epilepsy patients who underwent VNS. The chi-square test and binary logistic regression were used to determine associations between genetic differences and VNS efficacy. RESULTS A significant association between ADK SNPs rs11001109, rs7899674, and rs946185 and seizure reduction with VNS was found. Regardless of sex, age, seizure frequency and type, antiseizure drug use, etiology, and prior surgical history, all patients (10/10 patients [100%]) with minor allele homozygosity at rs11001109 (genotype AA) or rs946185 (AA) achieved > 50% seizure reduction and 4 patients (4/10 [40%]) achieved seizure freedom. VNS therapy demonstrated higher efficacy among carriers of minor allele rs7899674 (CG + GG) (68.3% vs 48.8% for patients with major allele homozygosity). CONCLUSIONS Homozygous ADK SNPs rs11001109 (AA) and rs946185 (AA), as well as minor allele rs7899674 (CG + GG), may serve as useful biomarkers for prediction of VNS therapy outcome.

scholarly journals Epilepsy in children with perinatal arterial ischemic stroke

2021 ◽  
Author(s):  
Fabienne Kühne ◽  
Alexander Jungbluth ◽  
Joanna Schneider ◽  
Christoph Bührer ◽  
Christine Prager ◽  
...  
Keyword(s):  
Cerebral Palsy ◽  
Ischemic Stroke ◽  
Neonatal Period ◽  
Refractory Epilepsy ◽  
Late Onset ◽  
Cognitive Outcome ◽  
Response To Treatment ◽  
Arterial Ischemic Stroke ◽  
Structural Epilepsy ◽  
Drug Refractory Epilepsy

Purpose: Perinatal ischemic stroke (PIS) is a frequent cause for perinatal brain structure defects resulting in epilepsy, cerebral palsy and disability. Since the severity of symptoms is variable, the aim of this study was to evaluate the outcome of children with PIS and seizures/epilepsy to aid parental counseling and therapy decisions. Material: We studied retrospectively patients with arterial PIS and structural epilepsy or seizures in the newborn treated at a single center in 2000-2019. Specifically, signs and symptoms of cerebral palsy (CP), developmental and motor delay, epilepsy and thrombophilia were assessed. Results: From the identified 69 individuals with arterial PIS, we only included the 50 patients (64% male) who had structural epilepsy at the time of investigation or previously in their medical history.The mean age of the included patients was 7.1 years (range 0.08-22) at last consultation. Infarct localisation was predominantly unilateral (86%), left sided (58%) and affecting the middle cerebral artery (94%). Genetic thrombophilia was identified in 52% of the patients examined with genetic testing. More than half of the individuals had CP (52%), and 38.5% had a cognitive outcome below average. First seizures occurred in the neonatal period in 58% of patients and developed into drug-refractory epilepsy in 24.1%. Children with late-onset of epilepsy were twice as likely to develop drug-refractory epilepsy (52.4%). Discussion: Our study shows that patients with PIS and seizures as common sequela often also develop CP. Children with later onset of epilepsy have a worse outcome. Patients with seizure onset in the neonatal period and reccuring seizures have a good response to treatment. Therefore, early diagnosis, follow-up examination and adequate therapy are important. Most children need intensive physiotherapy and speech therapy; however, participation in life is usually age-appropriate.

Clinical spectrum of pediatric drug refractory epilepsy secondary to parieto-occipital gliosis

2021 ◽  
pp. 106804
Author(s):  
Somdattaa Ray ◽  
Raghavendra Kenchaiah ◽  
Ajay Asranna ◽  
Hansashree Padmanabha ◽  
Karthik Kulanthaivelu ◽  
...  
Keyword(s):  
Refractory Epilepsy ◽  
Clinical Spectrum ◽  
Pediatric Drug ◽  
Drug Refractory Epilepsy

Aortoiliac Reconstruction

2017 ◽  
Author(s):  
Mark K. Eskandari ◽  
Michael J Nooromid
Keyword(s):  
Clinical Decision Making ◽  
Preoperative Evaluation ◽  
Treatment Options ◽  
Surgical Techniques ◽  
Clinical Decision ◽  
Occlusive Disease ◽  
Aortobifemoral Bypass ◽  
Aortoiliac Occlusive Disease ◽  
Atherosclerotic Occlusive Disease ◽  
Aortoiliac Reconstruction

This review outlines the preoperative evaluation, clinical decision making, and surgical treatment options for patients with aortoiliac occlusive disease. It also details the open surgical techniques for the treatment of aortoiliac occlusive disease and reviews endovascular treatment options. The discussion of treatment options includes the potential complications and expected outcomes, as well as steps that can be taken to optimize surgical results. Key words: aortobifemoral bypass, aortoiliac reconstruction, atherosclerotic occlusive disease, endovascular reconstruction, femoral endarterectomy, iliac angioplasty, iliac stenting, peripheral vascular disease 

Neuralgic amyotrophy: a paradigm shift in diagnosis and treatment

2020 ◽  
Vol 91 (8) ◽  
pp. 879-888 ◽  
Author(s):  
Clemens Gstoettner ◽  
Johannes A Mayer ◽  
Stephanie Rassam ◽  
Laura A Hruby ◽  
Stefan Salminger ◽  
...  
Keyword(s):  
High Resolution ◽  
Peripheral Nerve ◽  
Clinical Decision Making ◽  
Current Knowledge ◽  
Treatment Options ◽  
Treatment Algorithm ◽  
Clinical Decision ◽  
Neuralgic Amyotrophy ◽  
Positive Effects ◽  
Nerve Surgery

Neuralgic amyotrophy (NA), also known as Parsonage-Turner syndrome, is characterised by sudden pain attacks, followed by patchy muscle paresis in the upper extremity. Recent reports have shown that incidence is much higher than previously assumed and that the majority of patients never achieve full recovery. Traditionally, the diagnosis was mainly based on clinical observations and treatment options were confined to application of corticosteroids and symptomatic management, without proven positive effects on long-term outcomes. These views, however, have been challenged in the last years. Improved imaging methods in MRI and high-resolution ultrasound have led to the identification of structural peripheral nerve pathologies in NA, most notably hourglass-like constrictions. These pathognomonic findings have paved the way for more accurate diagnosis through high-resolution imaging. Furthermore, surgery has shown to improve clinical outcomes in such cases, indicating the viability of peripheral nerve surgery as a valuable treatment option in NA. In this review, we present an update on the current knowledge on this disease, including pathophysiology and clinical presentation, moving on to diagnostic and treatment paradigms with a focus on recent radiological findings and surgical reports. Finally, we present a surgical treatment algorithm to support clinical decision making, with the aim to encourage translation into day-to-day practice.

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