Epilepsy Specialist Symposium: Algorithms in the Diagnosis … · 2015-12-02 · Epilepsy Specialist Symposium: Algorithms in the Diagnosis and Treatment of Epilepsy Symposium Chair:

Epilepsy Specialist Symposium:

Algorithms in the Diagnosis and Treatment of Epilepsy

Symposium Chair:

Fred Lado, MD, Chair Montefiore Medical Center

Albert Einstein College of Medicine Bronx, NY

Friday, November 30, 2012 Convention Center – Room 6A, Upper Level

8:30 am – 11:30 am

OVERVIEW This symposium will discuss common problems encountered in caring for patients with new onset or difficult to control seizures. The topics will include:(i) The diagnosis and treatment of a first seizure – who is at risk of recurrence, the risks and benefit balance of starting treatment, and how long to treat. (ii) How to approach the pre-operative evaluation to localize the epileptic onset zone non-invasively and how to plan invasive recordings to localize the seizure onset zone. (iii) Patient selection for treatment by neurostimulator devices (VNS, DBS) to palliate seizures and optimization of stimulation parameters. (iv) Discussing SUDEP – when to have the discussion, with which patients, and how to approach the topic with patients at risk. The speakers will present the audience with algorithms that identify key decisions in the evaluation and treatment of seizures. LEARNER OUTCOMES

Manage patients with first seizure by applying risk/benefit analysis using prediction of seizure recurrence based on presentation and ancillary tests

Evaluate patients for epilepsy surgery, weighing the advantages / disadvantages of different approaches and understanding the rationale for selecting a specific approach

Appropriately refer patients for implantation of and successfully treat them with neurostimulator devices

Recognize when and how to initiate discussion of SUDEP in patients who are at risk. TARGET AUDIENCE Basic: Those new to epilepsy treatment or whose background is limited, e.g., students, residents, general physicians, general neurologists and neurosurgeons, other professionals in epilepsy care, administrators. Intermediate: Epilepsy fellows, epileptologists, epilepsy neurosurgeons “mid-level” providers with experience in epilepsy care (e.g., advanced practice nurses, nurses, physician assistants), neuropsychologists, psychiatrists, basic and translational researchers. AGENDA 8:30 – 8:45 am Introduction and Overview

Fred A. Lado, M.D., Ph.D. 8:45 – 9:15 am First Seizure: Diagnosis, Treatment and Prognosis

Sheryl Haut, M.D. 9:15 – 10:15 am Debate: Surgical Planning for Extratemporal Non-lesional Surgery?

Ashesh Mehta, M.D. and Francois Dubeau, M.D.

10:15 – 10:45 am Treatment of Epilepsy with Implanted Devices: What Are Indications and

Benefits? Barbara Jobst, M.D.

10:45 – 11:20 am Discussing SUDEP: If, When, How

Jeff Buchhalter, M.D., Ph.D. 11:20 – 11:30 am Conclusions

Fred Lado, M.D., Ph.D.

ACCREDITATION The American Epilepsy Society is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. CREDIT DESIGNATION The American Epilepsy Society designates this educational activity for a maximum of 3.0 AMA PRA Category 1 CreditsTM. Physicians should only claim credit commensurate with the extent of their participation in the activity. ACKNOWLEDGEMENT This program is supported in part by an educational grant from UCB, Inc. and Cyberonics, Inc. NURSING CREDIT EDUPRO Resources LLC is an approved provider of continuing nursing education by Pennsylvania State Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation, Provider number P208-8/08-11. EDUPRO is also an approved provider by the California Board of Registered Nursing, Provider number CEP-14387. Disclaimer: Accreditation refers to educational content only and does not imply endorsement of products by PSNA, ANCC, CBRN, or EDUPRO Resources LLC. Nurses may claim up to 3.0 contact hours for this session. PHARMACY ACCREDITATION INFORMATION

Projects In Knowledge® is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.

This knowledge-based activity provides up to 3.0 contact hours. Following attendance, completion of the activity evaluation and verification of attendance, participants will be provided an electronic statement of credit. ACPE Universal Activity Number (UAN) is 0052-9999-12-2313-L04-P and provides 3.0 contact hours. International Credits: The American Medical Association has determined that non-U.S. licensed physicians who participate in this CME activity are eligible for AMA PRA Category 1 CreditTM. ABPN Core Competencies The American Board of Psychiatry and Neurology has reviewed the Epilepsy Specialist Symposium and has approved this program as part of a comprehensive lifelong learning program, which is mandated by the ABMS as a necessary component of maintenance of certification. Core Competencies: Medical Knowledge, Professionalism, and Practice-Based Learning and Improvement FACULTY/PLANNER DISCLOSURES It is the policy of the AES to make disclosures of financial relationships of faculty, planners and staff involved in the development of educational content transparent to learners. All faculty participating in continuing medical education activities are expected to disclose to the program audience (1) any real

or apparent conflict(s) of interest related to the content of their presentation and (2) discussions of unlabeled or unapproved uses of drugs or medical devices. AES carefully reviews reported conflicts of interest (COI) and resolves those conflicts by having an independent reviewer from the Council on Education validate the content of all presentations for fair balance, scientific objectivity, and the absence of commercial bias. The American Epilepsy Society adheres to the ACCME’s Essential Areas and Elements regarding industry support of continuing medical education; disclosure by faculty of commercial relationships, if any, and discussions of unlabeled or unapproved uses will be made. FACULTY / PLANNER BIO AND DISCLOSURES Fred Lado, M.D., Ph.D. (Chair) Dr. Lado is an member of the Comprehensive Epilepsy Center of Montefiore Medical Center and Associate Professor of Clinical Neurology of the Albert Einstein College of Medicine in Bronx, NY. Dr. Lado obtained his MD-PhD from New York University, completing his doctoral research with Dr. Rodolfo Llinas in the area of magnetoencephalography. His residency training was at NY Hospital - Cornell, followed by an EEG fellowship at Montefiore Medical Center. Dr. Lado currently serves as the Chair of the Education Development Committee of the AES. Fred Lado, M.D., Ph.D. has nothing to disclose. Jeffrey Buchhalter, M.D., Ph.D. Dr. Buchhalter is Director of the Pediatric Epilepsy Program at Alberta Children’s Hospital. He received his MD and PhD in Neurosciences from UCLA. He did his neurology residency at the Harvard-Longwood Neurology program in Boston, where he completed fellowships in basic and clinical neurophysiology. Dr. Buchhalter’s main research interests are risk factors for epilepsy surgery outcome in children, ketogenic diet, trials of new antiepileptic drugs, epilepsy genetics, and most recently application of informatics to epilepsy classification. He participates in several national committees including as chair of the AES SUDEP Task Force. Jeffrey Buchhalter, M.D., Ph.D. discloses receiving support as Honoraria from Commercial Sources from American Academy of Neurology- webinars Eisai LTd, sponsored SUDEP webinar. Francois Dubeau, M.D. MD, Associate Professor of Clinical Neurology and Electroencephalography, Department of Neurology and Neurosurgery, McGill University, and Head, EEG Laboratory and Epilepsy Monitoring Unit, Montreal Neurological Hospital and Institute, McGill University Health Center. Francois Dubeau, M.D. has nothing to disclose. Sheryl Haut, M.D. Dr. Sheryl Haut is Director of the Montefiore-Einstein Adult Epilepsy Program and Director of Neurology Residency Training at Albert Einstein College of Medicine. She is also the Chair of the North American Commission of the International League Against Epilepsy. Her research interests include: the temporal distribution of seizures, with emphasis on seizure clustering; seizure prediction and pre-emption; and alternative therapies for epilepsy. Dr. Haut has a Masters in Clinical Research Methods, and completed a K23 career development award from the NIH. She maintains an active adult epilepsy practice at Montefiore Medical Center, Bronx NY. Sheryl Haut, M.D. discloses receiving support as Consulting/Advisory Board Activity from MAP Pharmaceuticals; Vivus; Neuronex; Upsher Smith. Barbara Jobst, M.D.

Dr. Barbara Jobst is currently director of the Dartmouth-Hitchcock Epilepsy Center and is Associate Professor of Neurology at Geisel School of Medicine at Dartmouth. She has special expertise in the field of epilepsy surgery, specifically neocortical epilepsy, and in brain stimulation as a therapeutic options. She has extensively published in those areas, is member of the editorial boards of several high impact journals and is current topic chair for epilepsy at the American Academy of Neurology. high impact journals and is current topic chair for epilepsy at the American Academy of Neurology. Other research of hers focuses the study and treatment of cognitive impairment in epilepsy patients. Barbara Jobst, M.D. discloses receiving support as Consulting/Advisory Board Activity from Advisory Committee Lundbeck Inc. Advisory Committee Neuropace, Inc, in the past; as Honoraria from Commercial Sources from Authorship in Medlink database; as Research Funding from For Profit Commercial Sources/Principle Investigator from Fellowship funding from Pfizer Inc.; as Federal/State/Not-for Profit Funding from NIH RO1 NS074450. Ashesh Mehta, M.D., Ph.D. Ashesh Mehta, MD, PhD, is a neurosurgeon, Assistant Professor of Neurosurgery and Director of Epilepsy Surgery at the Hofstra North Shore LIJ School of Medicine. Dr. Mehta received his MD and PhD in Neuroscience from Albert Einstein College of Medicine and completed his residency in neurosurgery at Cornell University-New York Presbyterian Hospital. Clinical interests including epilepsy surgery and neurostimulation. Dr. Mehta is Director of the Laboratory of Multimodal Brain Mapping at the Feinstein Institute of Medical Research, and research interests include functional brain mapping, cognitive neurophysiology and neuroimaging. Ashesh Mehta, M.D., Ph.D. has nothing to disclose. Paul Levisohn (Medical Content Specialist) Dr. Levisohn is Associate Professor of Pediatrics and Neurology at the University of Colorado School of Medicine and Children’s Hospital Colorado. He is former medical director of the Epilepsy Monitoring Unit at The Children's Hospital. He has served as chair of the AES Practice Committee, is co-chair of the advisory committee for the National Center for Project Access at the Epilepsy Foundation and is a member of the EF Professional Advisory Board. He currently serves as consultant to AES on medical content of AES continuing medical education activities. Paul Levisohn, M.D. has nothing to disclose. Christopher Anderson, MD (Liaison Reviewer) Dr. Christopher Todd Anderson is an assistant professor of neurology at the University of Pennsylvania. He works there as a clinical epileptologist. He is the director of the epilepsy monitoring unit at the Hospital of the University of Pennsylvania. He specializes in EEG, EMU monitoring, presurgical evaluations and epilepsy surgery. Christopher Anderson, M.D. discloses receiving support as Honoraria from Commercial Sources from 1000 USD, Cyberonics Inc. DISCLAIMER Opinions expressed with regard to unapproved uses of products are solely those of the faculty and are not endorsed by the American Epilepsy Society or any manufacturers of pharmaceuticals. MEDICAL EDUCATION EVALUATOR® AND CERTIFICATES The Medical Education Evaluator® is an online system allows any attendee to self-manage the process of completing course evaluations, tracking credits and printing out the appropriate certificate for either AMA PRA Category 1 CreditsTM, CE or ACPE pharmacy statement of credits.

Log on to the Evaluator via the AES website at www.aesnet.org. Once you are on the Evaluator, you will be asked to enter your MyAES ID # and password. The certificate(s) are saved to your personal account page which is cumulative. You may print the certificate(s) in PDF format at any time. To help support this process, AES members who want CME will be asked to pay $35 before January 18 and $50 between January 19 and February 28. Non-AES attendees who want CME will be asked to pay $50 before January 18 and $75 between January 19 and February 28. The online Evaluator will be left open through February 28, 2013. You must complete the evaluations and credit tracking by that date. By completing this information online, attendees greatly assist the Council on Education and Annual Meeting Committee with important needs assessment data whereby the AES can further plan and address educational gaps to meet the needs of our learners. A meeting attendance certificate will be available for international meeting attendees at the registration desk. SYLLABUS Syllabi for the educational symposia are available to print in the AES Virtual Tote Bag. Paper handouts will not be provided on site.

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11/13/2012

1

Extratemporal NonlesionalEpilepsy

November 30, 2012

Ashesh D. Mehta, M.D., Ph.D.Department of Neurosurgery

Hofstra Northshore LIJ School of Medicine

!"#$%&'( )*%+#*,- ./&%#0- 1 !""#$% &''()"*

Disclosure

None

!"#$%&'( )*%+#*,- ./&%#0- 1 !""#$% &''()"* +,-+

Learning Objectives

Recognize the role of grid, strip and depth electrodes for nonlesional epilepsy with respect to hypotheses generated by noninvasive t titesting

Recognize the value for grid electrodes to perform functional mapping

Recognize the value of grid and strip electrodes to define network properties of the ictal onset zone.

!"#$%&'( )*%+#*,- ./&%#0- 1 !""#$% &''()"* +,-+

HistoryHistory23 year old right handed male23 year old right handed maleOnset: age 12Onset: age 12Risk Factors: noneRisk Factors: noneSeizure Frequency: 1/monthSeizure Frequency: 1/monthSemiology: consistentSemiology: consistentgygy–– No aurasNo auras–– Behavioral arrest, staring into spaceBehavioral arrest, staring into space–– Head turn to the leftHead turn to the left–– BlinkingBlinking–– Raises left armRaises left arm–– secondary GTCsecondary GTC–– amnesiaamnesia

History (cntd.)History (cntd.)

Precipitating factors: Heat, dehydration, Precipitating factors: Heat, dehydration, alcohol usealcohol useMedications: LTG, ZNSMedications: LTG, ZNST i l LVT OXCT i l LVT OXCTrials: LVT, OXCTrials: LVT, OXCGoals: increase independence, complete Goals: increase independence, complete culinary schoolculinary schoolPhysical Exam: nonfocalPhysical Exam: nonfocal

Video EEG, noninvasive interictalVideo EEG, noninvasive interictal

Bifrontal (R>L?) dischargesBifrontal (R>L?) discharges

11/13/2012

2

Video EEG, noninvasive interictalVideo EEG, noninvasive interictal

Cz montageCz montage

Video EEG, Ictal (transverse Video EEG, Ictal (transverse montage)montage)

Video EEG, IctalVideo EEG, Ictal Video EEG, IctalVideo EEG, Ictal

MRIMRI

NormalNormal

2FDG2FDG--PETPET

Bitemporal Bitemporal h b lh b lhypometabolism hypometabolism –– (R worse than (R worse than

left)left)

11/13/2012

3

Neuropsychological testing / WadaNeuropsychological testing / WadaDeficits in:Deficits in:–– Attention, executive functioningAttention, executive functioning–– Visual memoryVisual memory–– Visual construction skillsVisual construction skills

Preservation of:Preservation of:Fine motor/dexterityFine motor/dexterity–– Fine motor/dexterityFine motor/dexterity

–– LanguageLanguage–– Verbal memoryVerbal memory

WadaWada–– Left memory 11/12 after right injectionLeft memory 11/12 after right injection–– Right memory 7/12 after left injectionRight memory 7/12 after left injection–– Bilateral language (L>R) with automatic speech and Bilateral language (L>R) with automatic speech and

naming preserved after left injection.naming preserved after left injection.

Presurgical ConferencePresurgical ConferenceMedicationMedication--resistant epilepsyresistant epilepsyVideo EEG Video EEG –– right sided onsets with possible broad fieldright sided onsets with possible broad field–– Frontal lobe involvement with possible temporal onsetFrontal lobe involvement with possible temporal onset

PETPET–– Right (temporal) sided abnormalityRight (temporal) sided abnormality

Neuropsychological testingNeuropsychological testing–– Evidence for frontal (executive) and temporal (visual Evidence for frontal (executive) and temporal (visual

memory) dysfunctionmemory) dysfunction–– Wada memory suggestive of greater right temporal Wada memory suggestive of greater right temporal

dysfunction dysfunction –– Wada language raises concern about right sided languageWada language raises concern about right sided language

Plan

Plan:Plan:–– Frontotemporal grid for language mapping Frontotemporal grid for language mapping

and determination of location and extent of and determination of location and extent of ictal onset zoneictal onset zonecta o set o ecta o set o e

–– Strips to cover frontal pole, orbitofrontal Strips to cover frontal pole, orbitofrontal cortex, interhemispheric fissure, inferior cortex, interhemispheric fissure, inferior temporal and temporal poletemporal and temporal pole

–– Depth electrodes into amygdala and Depth electrodes into amygdala and hippocampushippocampus

ImplantationImplantation

M L

A

P

Right frontotemporal craniotomy for implantation of 64 channel grid, multiple strip electrodes and depth electrodes into hippocampus and amygdala.

fMRI coregistered to implantfMRI coregistered to implant

Grid centered over the frontotemporal areaGrid centered over the frontotemporal areaHand Motor area at posterior superior aspect of gridHand Motor area at posterior superior aspect of gridFrontal: Interhemispheric, orbital and dorsolateralFrontal: Interhemispheric, orbital and dorsolateralTemporal: Mesial, inferior and lateral temporal coverageTemporal: Mesial, inferior and lateral temporal coverage

Depth Electrodes to Sample Mesial Depth Electrodes to Sample Mesial Temporal StructuresTemporal Structures

Use of Frameless Stereotaxy

11/13/2012

4

Invasive EEG Invasive EEG –– InterictalInterictal

Anterior/ Superior Grid

Superior Frontal Strip

Invasive EEG, interictalInvasive EEG, interictalFrontal Grid

Frontal St i

Temporal Grid

Broad discharges across posterior frontal strip and Broad discharges across posterior frontal strip and anterior superior gridanterior superior grid

Strips

Temporal Strips

Depths

Invasive EEG, interictalInvasive EEG, interictal

Frontal Grid

Temporal Grid

Frontal Strips

Temporal Strips

Depths

Invasive EEG, HFOInvasive EEG, HFO

Frontal Grid

Temporal Grid

Frontal Strips

Temporal Strips

Depths

Invasive EEG, IctalInvasive EEG, Ictal

Frontal Grid

Temporal Grid

Frontal Strips

Temporal Strips

Depths

Interictal/Preictal Repetitive Discharges

Invasive EEG, ictalInvasive EEG, ictalFrontal Grid

Temporal Grid

Frontal Strips

Temporal Strips

Depths

Attenuation and discharges from anterior frontal strips and anterior frontal aspect of grid. Minimal behavioral correlate.

11/13/2012

5


Frontal Grid

Temporal Grid

Frontal Strips

Temporal Strips

Depths


Frontal Grid

Temporal Grid

Significant evolution in anterior frontal strips and anterior frontal aspect of grid prior to head turn

Frontal Strips

Temporal Strips

Depths

Left head turn


Frontal Grid

Temporal Grid

Frontal Strips

Temporal Strips

Depths

Head turning to left Bilateral Hip abduction and flexion

Left hand extension, elbow flexion

Bilateral clonic jerking


Frontal Grid

Temporal Grid

Frontal Strips

Temporal Strips

Depths

Seizure spread patternSeizure spread pattern

-. /01 -2++. 3- 42 5 --2 -6 -52 +7 +62 8,4. /0&+4. /0&+ 888. /0!+ 8

High Gamma Power Coherence

Seed

Coherence maps calculated with seed in midfrontal strip (left) and anterior frontal grid electrode (right).Slow (0.1-1Hz) fluctuations of gamma power reveal a pathological network that includes anterior dorsolateral frontal, orbitofrontal, and anterior mesial frontal areas.

11/13/2012

6

Electrical Stimulation Mapping

Cleared for language function

Example of Dominant Hemisphere Electrical Stimulation Example of Dominant Hemisphere Electrical Stimulation Mapping Results (different patient)Mapping Results (different patient)

Postoperative FollowupPostoperative Followup

SeizureSeizure--free at 1 year.free at 1 year.No neurological deficitsNo neurological deficits

Impact on Clinical Care and Impact on Clinical Care and PracticePractice

Exploratory for localization when Exploratory for localization when lateralization is clearlateralization is clearFunctional mappingFunctional mappingG d f l i t k tiG d f l i t k tiGood for exploring network properties Good for exploring network properties Depth electrodes may be supplementedDepth electrodes may be supplemented

Main Disadvantages:Main Disadvantages:–– morbidity/discomfortmorbidity/discomfort–– patient willingness to proceedpatient willingness to proceed

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Algorithms in the Diagnosis and Treatment of Epilepsy

Debate 2: Surgical Planning for ExtratemporalNon-lesional Surgery?

November 30, 2012

François Dubeau, MDMontreal Neurological Hospital and Institute, McGill University, Montréal, Canada

American Epilepsy Society | Annual Meeting

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No disclosure

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3),(+"+/ 456)$."7)#• To review decision making process for pre-surgical planning;

• To discuss of the indications and utility of invasive intracranial EEG in preoperativeinvasive intracranial EEG in preoperative assessment.

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Pre-surgical strategy- principles

Diagnosis of intractable epilepsy and disabling seizures, and no contraindications;

Demonstration that the EZ lies within a well defined resectable cortical tissue; and delineation of the extent of the pathological area and of the eloquent/vital tissue;of the pathological area and of the eloquent/vital tissue;

There is no single test that provides complete and definitive information; no clinical evaluation or technique used to evaluate patients for surgery as high sensitivity or high specificity. Therefore different tests are combined in order to form a hypothesis regarding the location and extent of the EZ. They are also necessary to measure the impact of surgery on brain function.

8

NNon on lesionallesional cryptogenic extracryptogenic extra--temporal lobe temporal lobe epilepsy epilepsy –– case reportcase report

SA. 33 yo R-handed man, electrical engineer, with seizures since age 16:

• Obstetrical history was uneventful. No past medical and surgical antecedents. No family history. Normal development and IQ;

• Seizures started at 16 and rapidly became refractory. Typically, nocturnal or sleep-related, in clusters, of short duration, and followed by immediate recuperation;

• 1o VAP, 2o PTH ( LFTs), 3o CBZ (allergic skin rash), 4o LEV LEV + GBP LEV + GBP + PB LEV + TPM.

9

NNon on lesionallesional cryptogenic extracryptogenic extra--temporal lobe temporal lobe epilepsy epilepsy –– case report case report cont`dcont`d

Seizure semiologySeizure semiology

Arousal, possible aura, poorly defined,duration 10 to 20s: stares briefly, discreet tonic posture, blinking pout occasional H and E to Lblinking, pout, occasional H and E to L,immediate or almost immediate recuperation, goes back to sleep. Amnestic. Important fatigue next morning,occ. 2ary G.

Seizures are frequent, mostly nocturnal, in clusters but with questionable disability.

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22

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1st intracerebral depthelectrodes implantationscheme proposal:

- exploratory

- bilateral- mesial and cortical

aspects of FT structuresant cyng

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right

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RR

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RR

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+4

+2

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SA. Surface-based analysis

thickness manually segmented FCD lesion(volume: 1,713 mm3)

0

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0

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Composite z-scoreComposite z-score

SA. EEG/MEG acquisition with 53 EEG electrodes and 271 MEG sensors:- very frequent low amplitude MEG spikes R FC- rare slow sharp waves at FC2, FC4, F2 and F4from E Kobayashi

MEG spikes (n = 58) source localization along the averaged spike peak

Surface-based analysis MEG spikes source localization

SA. Concordant findings between surface base analysisand MEG source localization.

Composite z-scoreComposite z-score


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ant cyng

mid cyng

Right

aspects of FT structures,R > L.

mid cyng


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Hc

Right

SA.

2nd intracerebral depthelectrodes implantationscheme proposal:

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PrePre--surgical strategysurgical strategy

Non-invasive tests (PHASE 1):

1. strong and primary focus on seizure semiology, scalp EEG findings and structural imaging; and strict adherence to a complete neuropsychological evaluation for localization p y gof brain damage and assessment of functional cortex.

08

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PrePre--surgical strategy surgical strategy cont’dcont’d

Non-invasive tests (PHASE 1):

2. In PHASE 1 evaluation, we also put strong focus on structural/morphological (post-processing analysis) and neurophysiological/functional (EEG/fMRI) imaging:( ) g g

quantitative structural MRI methods demonstrate an increased diagnostic yield of epileptic lesions, and provide better options to patients with 'cryptogenic' epilepsy (Bernasconi et al., Nat Rev Neurol 2011; Epilepsia 2011);

EEG/fMRI help to delineate the epileptic focus, and to understand neuronal networks related to focal discharges (Pitau et al., Neurology 2102 and Fahoum et al., Epilepsia 2012).

09

Moeller et al., Neurology 2009. F8 spikes related-BOLD response showed anactivation over the lateral R OF region overlapping an occult FCD.

EEG/fMRI help to delineate the epileptic focus, and to understand neuronal networks related to focal discharges

Fahoum et al., Epilepsia 2012. Group analysis results of TLE patients (n=32).

EEG/fMRI help to delineate the epileptic focus, and to understand neuronal networks related to focal discharges PrePre--surgical strategy surgical strategy cont’dcont’d

Invasive tests (PHASE 2):3. considered when there is evidence for conflicting

results, lack of concordance or incomplete information between clinical picture, neuropsychological and imaging data:

• to improve spatial resolution regarding the location and extent of the seizure generator and EZ;

• to precise relationship existing between seizure focus and lesion;

• to define seizure propagation and understand neuronal networks involved during epileptic attacks.

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or to define a deep-seated epileptic generator localized in buried structures inaccessible to scalp EEG (in which cases intracranial EEG probably provides a better sampling),

or to determine relationship between EZ and lesionor to determine relationship between EZ and lesion(overlap, peri-lesional or remote);

• For functional mapping when EZ overlaps with eloquentcortex (cortical electrodes and grids are better suited for mapping of cortical function);

• In multifocal epilepsy e.g. bilateral TLE, or in multifocal or diffuse lesions with however congruent semiology and scalp EEG findings.

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• No clear hypothesis about the localization of the EZ;

• Generalized or diffuse epileptiform abnormalities on scalp EEG, or multifocal epilepsy;

• Risks for unacceptable complications due to eloquentcortex or risks for unacceptable complications due tocortex, or risks for unacceptable complications due to medical conditions.

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Type Recording areas Advantages Disadvantages

Intracerebral depth electrodes (within cortex)

Deep limbic and paralimbicburied structures: Am, Hcentorhinal cortex and paraHc, and insula; inter-hemispheric cortical structures; depth of the sulci; hypothalamus, thalamus and basal ganglia; deep-seated and peri-ventricular lesions

Good sampling of deep structures; findings can be standardized in a common stereotaxic space allowing inter-subject comparisons; and low morbidity.

Limited sampling of neocortical structures; not adapted for exhaustive cortical functional mapping.

Intracerebral EEG methods and characteristics: advantages and disadvantages

and peri-ventricular lesions.

Grids(subdural surface)

Cortical convexity, basal and interhemispheric neocortical surface.

Broad coverage of neocortical areas; well-suited for mapping of cortical function by electrical stimulation.

Large craniotomy andhigher morbidity; no good sampling from deep buried structures; needs to be immediately followed by resective surgery.

Strips(subdural surface)

Cortical convexity, basal and interhemispheric neocortical surface.

Good coverage of neocortical areas; low morbidity.

No good sampling from deep buried structures.

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DEFINITIONS

What is SUDEP?

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SUDEP DefinitionAnnegers


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SUDEP DefinitionNashef

sudden unexpected, non-traumatic and non-drowning death in an individual with epilepsy with or without evidence for aepilepsy with or without evidence for a seizure and excluding documented status epilepticus where post-mortem examination does not reveal a cause for death

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SUDEP Definition

The role of autopsy confirmation is the most problematic issue for research studies of SUDEPSUDEP

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• Allows looking at a population, rather than an individual

• PY = total of all yrs that all patients were followed / number of events of interest– e.g. 10 patients followed for 10 yrs each = 100 pt yrs

– 1 case of cancer = 1 case per 100 pt years

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Two pediatric studies

Donner et al, Ontario, Neurology, 200127 cases, all with autopsies

Symptomatic 52%, cryptogenic 18%, idiopathic, 30% idiopathic. All with GTCs30% idiopathic. All with GTCs

No relationship to number or level of AEDsCamfields, Nova Scotia, Sem Ped Neurol, 2005

629 children with epilepsyNeuro normal- no increased risk of death, 1/4 SUDEP

Neuro abnormal- 22x higher than gen pop, 1/22

SUDEP- risk among children

Victoria, Australia 0.36 per 1000

Ontario, Canada 0.2

Switzerland 0.3

Nova Scotia, Canada 0.11

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Tellez-Zento Epilepsy Res 2005;65:101-115

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SUDEP- Associated Seizure TypesHistory of GTCs (88-100% in case series)

> 3 increased risk by 8 fold

Complex partial seizures (reported, rare)

Absence & myoclonic only (no reports)

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Association of British Neurologists Survey

National Institute for Clinical Excellence guidelines,

2004

should be given information on SUDEP...should be given information on SUDEP

387 of 738 questionnaires returned

Open-ended questions

Morton, Richardson & Duncan. (2005). Sudden unexpected death in epilepsy: don t ask, don t tell? J Neurol Neurosurg Psychiatry 77, 199-202. 8'>?/?)> /,'* L)== I?),O5B7

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Discuss with majority of 99 25 6

Morton (2006) Table 1: Analysis of responses from medical personnel

Discuss with majority of patients

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Discuss with very few of my patients

237 61.2

Discuss with none of my patients

29 7.5

Total number of respondents

383 100

Informing patients about sudden unexpected death in epilepsy: A survey of specialist nurses

250 postal questionnaires to Epilepsy Nurse Association, 58% returned

Lewis, Higgins. Brit J Neurosci Nursing 2008; 4:30-34

Discussed with all 6%

Discussed with majority 50%

Discussed with few37%

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Two questionnaires

- Parents/guardians of children at pediatric epilepsy clinic

100 given- 67 (1st), 47 (2nd)

- Physicians, UK based pediatric neurologists71 mailed, 45 (56%) returned

Results

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Impact of SUDEP disclosure

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Epilepsy Specialist Symposium: Algorithms in the Diagnosis … · 2015-12-02 · Epilepsy Specialist Symposium: Algorithms in the Diagnosis and Treatment of Epilepsy Symposium Chair: