P.106 Intravenous lacosamide use in pre-school children

Background: Data on intravenous lacosamide use in young pediatric patients is scarce, especially of pre-school age. Methods: We retrospectively reviewed the medical records of all patients less than 6 years old who received intravenous lacosamide at our tertiary pediatric hospital. Data on dose, timing and order of administration was collected. Clinical and electrographic response was independently assessed with EEG interpretation blinded to time of administration. For adverse effects surveillance, heart rate was noted before and 1 hour after dose. Results: Eleven patients (8 boys), received lacosamide between 2013 and 2018. Mean age was 2 years (11 days – 5,3 years). Medical indications were: refractory status epilepticus (n=6), repetitive seizures (n=4), and inability to take oral lacosamide (n=1). On average, lacosamide was the fifth (1st-8th) IV antiepileptic drug administered 78 hours (SD 11 hours) after presentation. The most frequent dose was 5 mg/kg. Clinical response was confirmed in 7 patients, while electrographic response was proven in 3 patients. Seizure relapse at 24 hours was noted in 6 patients. No bradycardia occurred post-lacosamide. Conclusions: Although very safe, therapeutic response to lacosamide in young pediatric patients was inconclusive, mostly due to delay in administration, suboptimal dose, and high number of other IV antiepileptic drugs previously given.

Evaluation of electroencephalographic changes in patients with the new onset suspicious seizure movements

Background: Abnormal EEG is a predictor of seizure relapse. Obtaining data related to the diagnosis and outcome of the first seizures is necessary for improving care for these patients, whereas data for these studies is scarce and is limited to a few a few centres. The aim was evaluation of the EEG changes in patients with first suspicious movements of seizure.Methods: All of the patients with first suspicious movements of seizure referred to Alavi hospital of Ardabil from March 2019 to March 2020 enrolled in this study. Data including age, gender, etiology of the seizure, seizure type and EEG changes gathered. Collected data were analyzed by statistical methods in SPSS version 21.Results: 71 patients were studied. Based on the seizure type, 50 (70.4%) patients had motor, 10 (14.1%) patients had nonmotor and 11 (15.5%) patients had focal seizures type impaired awareness. EEG findings were normal in 46 patients (64.8%). There were slowing waves and epileptic discharge in 12 (16.9%) and 13 (18.3%) patients, respectively. Abnormal EEGs recorded in routine modality in 16 patients (64%), H. V. modality in 2 patients (8%), Ph. S. modality in 2 patients (8%) and both routine and excitatory modalities in 5 (20%) patients.Conclusions: There was not a significant relationship between EEG findings and age, gender, seizure etiology and seizure type. Also there was not a significant relationship between abnormal waves in different modalities and type and etiology of the seizures.

Contralateral insular epileptogenic hub causing seizure relapse after opercular focal cortical dysplasia surgery and response to radiofrequency thermocoagulation: illustrative case

BACKGROUND The reevaluation and management of seizure relapse following resective surgery in magnetic resonance imaging (MRI)-negative pharmacoresistant epilepsy remains a significant challenge. OBSERVATIONS A 25-year-old right-handed male with medically refractory epilepsy presented with nonlocalizing electroencephalography (EEG) and MRI. Stereo-EEG (SEEG) implantation based on semiology and positron emission tomography imaging revealed a left frontal opercular focus with rapid bilateral insular ictal synchrony. The initial epileptogenic zone was resected and pathologically proven to be type 2A focal cortical dysplasia (FCD). Seizure relapse after 9 months was eventually reinvestigated, and repeat SEEG revealed a secondary epileptogenic focus in the contralateral insula. A novel technique of volumetric stereotactic radiofrequency ablation (vRFA) was utilized for the right insular focus, following which, the patient remains seizure-free for 20 months. He suffered a transient bilateral opercular syndrome following the second intervention that eventually resolved. LESSONS The authors present clinical evidence to suggest epileptogenic nodes distant from the primary focus as a mechanism for seizure relapse following FCD surgery and the importance of bilateral insular SEEG coverage. The authors also describe a novel technique of minimally invasive vRFA that allows ablation of a larger volume of cerebral cortex when compared to conventional bedside SEEG electrode thermocoagulation.

Comparison of Long-Term Outcomes of Monotherapy and Polytherapy in Seizure-Free Patients With Epilepsy Following Antiseizure Medication Withdrawal

Objective: The objectives of this study were to compare the risk and timing of seizure relapse in seizure-free patients with epilepsy following the withdrawal of monotherapy or polytherapy and to identify relevant influencing factors.Methods: Patients who had achieved at least a 2-year seizure remission and started the withdrawal of antiseizure medication (ASM) were enrolled in this study. All patients were followed for at least 3 years or until seizure relapse. According to the number of ASMs at the time of withdrawalwas about twice than that, patients were divided into two groups: monotherapy group and polytherapy group. The Cox proportional hazards model was used to compare the recurrence risk of the two groups. Univariate analysis and multiple logistic regression analysis were used to analyze potential confounding variables between patients treated with monotherapy and polytherapy.Results: A total of 188 patients (119 males and 69 females) were included. The average prescribed daily dose of most ASMs at the time of withdrawal was moderate or low (30–50% defined daily dose). The recurrence of most patients (89.2%) occurred within the first 3 years after withdrawal. The recurrence risk in patients treated with polytherapy at the time of withdrawal was about twice than that of the monotherapy group [p = 0.001, hazard ratio (HR) = 2.152, 95% confidence interval (CI) = 1.350–3.428]. Multivariate analysis showed that patients treated with polytherapy were significantly older at seizure onset [p = 0.024, odd ratio (OR) = 1.027, 95% CI = 1.004–1.052] and had a significantly longer duration of epilepsy before treatment (p = 0.004, OR = 1.009, 95% CI = 1.003–1.015) compared to patients in the monotherapy group. In addition, a history of perinatal injury was found to be an independent risk factor of seizure relapse in patients with ASM withdrawal.Conclusion: The average prescribed daily dose of most ASMs at the time of withdrawal was moderate or low. Patients who received polytherapy at the time of withdrawal, particularly those with later seizure onset age and longer epilepsy duration before treatment, had a higher recurrence risk after ASMs withdrawal compared to patients treated with monotherapy.

Response to antiseizure medications in epileptic patients with malformation of cortical development

Background: Malformation of cortical development (MCD) is one of the most common causes of pharmacoresistant epilepsy. Improving the knowledge of antiseizure medications (ASMs) treatment response in epileptic patients with MCD is crucial for optimal treatment options, either pharmacological therapy or non-pharmacological intervention. Aim: To investigate the patterns of medical treatment outcome and the predictors for seizure freedom (SF) with ASM regimens in epilepsy caused by MCD. Methods: The epileptic patients with MCD were consecutively enrolled from March 2013 to June 2019. SF was defined as no seizures for at least 12 months or three times the longest pretreatment inter-seizure interval, whichever was longer. Outcomes were classified into three patterns: pattern A: patients achieved SF at one point and remained so throughout follow-up; pattern B: patients’ seizures fluctuated between periods of SF and relapse; pattern C: SF never attained. The terminal SF was defined if the patients remained SF at the last follow-up visit. Results: A total of 164 epileptic patients with MCD were included. Pattern A was observed in 22, pattern B in 42, and pattern C in 100 patients. SF was ever achieved in 64 (pattern A and B) patients. Twenty-nine patients had terminal SF after a median follow-up time of 4.3 years. With continuing ASM treatment, seizure relapse risk was very low after a 5-year seizure-free period. The pretreatment seizure frequency was the only independent predictor for pattern A and seizure relapse. Sodium channel blockers monotherapy (33.8%) was more effective than levetiracetam (4.5%) in rendering SF in the initial ASM regimen. Conclusion: Medical treatment can be successful in a minority of epileptic patients with MCD, and pretreatment seizure frequency helps to predict the treatment outcome. An unequal efficacy of ASMs in epilepsy caused by MCD suggests etiological evaluation is vital in the management of focal epilepsy.

Epilepsy surgery for Rasmussen encephalitis: the UCLA experience

OBJECTIVERasmussen encephalitis (RE) is a rare inflammatory neurological disorder typically involving one hemisphere and resulting in drug-resistant epilepsy and progressive neurological decline. Here, the authors present seizure outcomes in children who underwent epilepsy surgery for RE at a single institution.METHODSThe records of consecutive patients who had undergone epilepsy surgery for RE at the UCLA Mattel Children’s Hospital between 1982 and 2018 were retrospectively reviewed. Basic demographic information, seizure history, procedural notes, and postoperative seizure and functional outcome data were analyzed.RESULTSThe cohort included 44 patients, 41 of whom had sufficient data for analysis. Seizure freedom was achieved in 68%, 48%, and 22% of the patients at 1, 5, and 10 years, respectively. The median time to the first seizure for those who experienced seizure recurrence after surgery was 39 weeks (IQR 11–355 weeks). Anatomical hemispherectomy, as compared to functional hemispherectomy, was independently associated with a longer time to postoperative seizure recurrence (HR 0.078, p = 0.03). There was no statistically significant difference in postoperative seizure recurrence between patients with complete hemispherectomy and those who had less-than-hemispheric surgery. Following surgery, 68% of the patients could ambulate and 84% could speak regardless of operative intervention.CONCLUSIONSA large proportion of RE patients will have seizure relapse after surgery, though patients with anatomical hemispherectomies may have a longer time to postoperative seizure recurrence. Overall, the long-term data in this study suggest that hemispheric surgery can be seen as palliative treatment for seizures rather than a cure for RE.