Epilepsy Currents and Pearls. Eniko Nagy-Wilde, MD Medical Director of Epilepsy and Clinical Neurophysiology Sutter Medical Center, Sacramento

Transcription

1 Epilepsy Currents and Pearls Eniko Nagy-Wilde, MD Medical Director of Epilepsy and Clinical Neurophysiology Sutter Medical Center, Sacramento

2 No disclosures Presenter Disclosure Information

3 Learning Objectives To familiarize the audience with the New definition of epilepsy Management of first-time seizure Management of drug resistant epilepsy MRI guided laser ablation EEG and cardiac arrest Epilepsy emergencies

4 Case XF 46-year-old woman First seizure in 1995 in sleep Semiology Deja-vu feeling sick to her stomach Orofacial automatisms Speech arrest Delayed response Some of the seizures presenting with secondary GTCS She has been experiencing these spells as young as 5 years of age

5 Case XF Failed AEDs Dilantin, Tegretol, Topamax, Zonisamide, Lamotrigine, Lacosamide After failing numerous AEDs and still having approximately 30 seizures per month in spite of being treated with 2 AEDs, she was referred to Sutter for surgical evaluation

6 Demographics ~3 million Americans are diagnosed with epilepsy and an estimated 50 million people around the world 150,000 new cases per year Lifetime risk ~3% Third most prevalent chronic neurological disorder Global disease burden = lung cancer in men and breast cancer in women Epilepsy Across the Spectrum: Promoting Health and Understanding. IOM Report 2012

7 Diagnosis of Epilepsy Practical Definition of Epilepsy Recently redefined as a disease characterized by one or more seizures with a relatively high recurrence risk (60% or >) Provoked seizures Trauma, brain hemorrhage, metabolic dyscrasias, or drug exposures Heightened tendency toward spontaneous recurrent seizures Unprovoked Occur spontaneously without provocation American Academy of Neurology, Continuum, Volume 22, No 1, February 2016

8 Diagnosis of Epilepsy Seizure types Focal dyscognitive seizures instead of the older term complex partial seizures Now a new term focal seizure with loss of awareness including the specific ictal behavior (eg, focal motor seizure) Focal non- dyscognitive seizures instead of the older term simple partial seizures Focal seizure without loss of awareness Academy of Neurology, Continuum, Volume 22, No 1, February 2016

9 Academy of Neurology, Continuum, Volume 22, No 1, February 2016 Diagnosis of Epilepsy

10 Diagnosis of Epilepsy - Electroencephalography AAN recommendations Inclusion of photic stimulation, hyperventilation and sleep deprivation in adults as part of the protocol Epileptiform pattern on EEG after first seizure 30-70% of seizure recurrence in the first year Treatment should be considered even before a diagnosis of epilepsy The involvement of at least 6 cm² of cerebral cortex to generate a scalp recorded epileptiform discharge Normal interictal EEG studies do not exclude the presence of a seizure disorder Epilepsy Clinical diagnosis and the EEG serves to provide supporting evidence Treatment of the patient and not of the EEG American Academy of Neurology, Continuum, Volume 22, No 1, February 2016

11 Diagnosis of Epilepsy Magnetic Resonance Imaging 3 Tesla MRI to identify pathologic findings associated with focal or generalized seizures All individuals with seizures should undergo an MRI Individuals with a single seizure 29% with abnormal MRI 12% of patients in one series of 1013 patients with a first seizure had an abnormal MRI in the presence of a normal CT head American Academy of Neurology, Continuum, Volume 22, No 1, February 2016

12 Management of first-time seizure acute versus remote symptomatic seizures Academy of Neurology, Continuum, Volume 22, No 1, February 2016

13 Management of first-time seizure AAN Practice Guidelines and Practice Parameters The risk of seizure recurrence is greatest in the first 2 years Immediate AED therapy is likely to reduce the risk of a second unprovoked seizure by about 35% over the next 2 years Delay in initiating therapy until after second unprovoked seizure did not influence the chance of long-term remission American Academy of Neurology, Continuum, Volume 22, No 1, February 2016

14 Management of first-time seizure Academy of Neurology, Continuum, Volume 22, No 1, February 2016

15 Management of first-time seizure Academy of Neurology, Continuum, Volume 22, No 1, February 2016

16 1910 Phenobarbit al Sleeping pill Many derivatives A History Lesson 1940 Phenytoin Partial seizures Secondary generalized seizures 1958 Ethosuximid e Absence Seizures 1968 Carbamazepin e Partial seizures Trigeminal Neuralgia 1978 Valproic Acid Primary generalized epilepsy Partial seizures Source:

17 Gabapentin (Neurontin) Lacosamide (Vimpat) Lamotrigine (Lamictal) Used for conversion to monotherapy Levetiracetam (Keppra) Oxcarbazepine (Trileptal) Tiagabine (Gabitril) Topiramate (Topamax) Zonisamide (Zonegran) Clobazam (Onfi) Perampanel (Fycompa) A New Generation

18 ANTIEPILEPTIC DRUGS (AEDs) Academy of Neurology, Continuum, Volume 22, No 1, February 2016

19 Management of Drug-Resistant Epilepsy Failure of 2 or more appropriately selected and adequately tried anticonvulsive medications to achieve seizure freedom Approximately 1500 surgeries in the United States Low number in comparison to the estimated 750,000 patients with DRE Under utilized therapy Patients with DRE Increased risk for premature death, injuries, psychosocial problems, and death American Academy of Neurology, Continuum, Volume 22, No 1, February 2016

20 Management of Drug-Resistant Epilepsy Academy of Neurology, Continuum, Volume 22, No 1, February 2016

21 Management of Drug-Resistant Epilepsy Academy of Neurology, Continuum, Volume 22, No 1, February 2016

22 Management of Drug-Resistant Epilepsy Resective Epilepsy Surgery Gold standard therapeutic option for DRE Candidate for surgery Whether the epilepsy is well localized based on testing Whether seizures are disabling Whether the seizure focus is away from eloquent regions of the brain Consideration of the risks to cognition and memory if surgery is performed Early Randomized Surgical Epilepsy Trial (ERSET) 73% of patients who underwent epilepsy surgery within 2 years of developing DRE were seizure-free compared to 0% in the medical arm after 2 years of follow-up American Academy of Neurology, Continuum, Volume 22, No 1, February 2016

23 Management of Drug-Resistant Epilepsy- Presurgical Evaluation High resolution 3 Tesla MRI scan Functional MRI (fmri) Continuous video-eeg monitoring Positron Emission Tomography (PET) with EEG Neuropsychological evaluation Wada test Magnetoencephalography Phase II invasive monitoring Stereotactic EEG American Academy of Neurology, Continuum, Volume 22, No 1, February 2016

24 Management of Drug-Resistant Epilepsy Vagus Nerve Stimulation (VNS) Adjunctive/alternative treatment for medically intractable epilepsy when epilepsy surgery is not an option Approved in the US in 1997 Open loop stimulation 50.9% of patients achieved a 50% or greater reduction of seizure frequency from VNS Responsive Neurostimulation (RNS) For patients 18 years and older with medically refractory partial epilepsy who have no more than 2 epileptic foci Closed loop stimulation Stimulation given only when the system detects a seizure 53% mean reduction from baseline seizure frequency at 2 years American Academy of Neurology, Continuum, Volume 22, No 1, February 2016

25 MR guided stereotactic laser ablation Allows for real-time thermal monitoring of the ablation process and feedback control over the laser energy delivery Minimally invasive surgical technique and an alternative to more conventional techniques Particularly advantageous in deep-seated epileptogenic pathologies Benefits Better morbidity rate Real-time visualization Real-time ablation control MR-guided stereotactic laser ablation of epileptogenic foci in children Daniel J. Curry a, Ashok Gowda c,roger J. McNichols c, Angus A. Wilfong b

26 Laser Thermal Ablation Less pain Less blood Less work, time in OR Less infection Faster back to work and life Decreased healthcare resource utilization

27 Laser Thermal Ablation VS Open Resection Naming (dominant) and object recognition (non-dominant) deficits are more pervasive after open resection (ATL, SAH) then previously recognized Standard resections: 82% (32/39) had significant declines in one or more measures (p<.001) Naming declined in 95% (21 of 22) dominant (left) patients Face recognition and familiarity declined in 85% (11 of 17) nondominant (right) patients Drane et al., Epilepsia 56(1):101-13

28 XF Interictal

29 XF Interictal

30 XF Seizure

31 XF Seizure

32 XF Seizure

33 XF Seizure

34 XF Seizure

35 XF Electrocorticography

36 XF Electrocorticography

37 XF Post Visualase Laser Ablation Surface EEG

38 EEG after Cardiac Arrest Uncertain prognosis in patients in coma after cardiac arrest Despite treatment in ICU, approximately half have poor outcome as a result of severe post anoxic encephalopathy (Zandbergen et al., 1998) Absent SSEP responses and absent pupillary or corneal reflexes at 72 hours after cardiac arrest included in the current guidelines Reliable predictors of a poor outcome (Sandroni et al., 2015) EEG is very sensitive to detection of hypoxia induced cerebral damage (Hofmeijer and van Putten, 2012) Journal of Clinical Neurophysiology, Volumes 33, Number 3, 6/2016

39 EEG after Cardiac Arrest Accurate prediction of either a poor or good outcome possible by specific pathologic or physiologic EEG patterns Quick improvement is the rule when recovery is observed Very good prognosis continuous, physiologic EEG rhythms occur within 12 hours Poor prognosis Lack of clinical improvement after several days (Zandebergen et al., 1998) Poor outcome Absence of relevant improvement within 24 hours persistent isoelectric, low voltage, or burst suppression with identical burst pattern Journal of clinical neurophysiology, volumes 33, Number 3, 6/2016

40 EEG after Cardiac Arrest First 24 hours Largest differences between patients with and without chances of recovery Predicted values for good and poor outcome (Hofmeijer et al period, 2015a; Sivaraju et al period, 2015) Interpretation of EEG for outcome prediction Cerebral Recovery Index (Tjepkema-Cloostermans et al, 2013) Single number mean amplitude Alpha/delta ratio Entropy Measure of continuity Journal of clinical neurophysiology, volumes 33, Number 3, 6/2016

41 EEG after Cardiac Arrest/Conclusion EEG characteristics quickly change in conditions of compromised energy supply Noninvasive and safe In patients in coma after cardiac arrest, adjudication of the EEG background pattern in relation to the time elapsed since cardiac arrest allows accurate prediction of either a poor or good outcome Cerebral Recovery Index (CRI) can assist in prediction of both poor and good outcome in postanoxic patients, within 24 hours after cardiac arrest. EEGs of patients with good neurologic outcome improve faster than those of patients with poor outcome The predictive value of the EEG is the highest in the window from 12 to 24 hours after cardiac arrest It is important to start the EEG registration within the first 24 hours after cardiac arrest for maximal diagnostic yield EEG will most likeley be included in future guidelines Journal of clinical neurophysiology, volumes 33, Number 3, 6/2016

42 EEG after Cardiac Arrest

43 EEG after Cardiac Arrest

44 EEG after Cardiac Arrest

45 Epilepsy Emergencies Status Epilepticus Definition 30 minutes of continuous seizure activity or multiple seizures without return to neurologic baseline Irreversible damage to neurons after continuous seizure activity in animals and in vitro Refractory status epilepticus Seizures that continue despite first and second line treatments Super refractory status epilepticus Third line agents (IV anesthetics) fail Epidemiology 10 per 100, per 100,000 American Academy of Neurology, Continuum, Volume 22, No 1, February 2016

46 Epilepsy Emergencies - Status Epilepticus (SE) Etiology of a Refractory SE Infection/inflammation Pre-existing epilepsy Metabolic Stroke or tumor Drug withdrawal Anoxia Intoxication Trauma American Academy of Neurology, Continuum, Volume 22, No 1, February 2016

47 Epilepsy Emergencies - Status Epilepticus Classification Convulsive Nonconvulsive

48 Epilepsy Emergencies - Status Epilepticus Epilepsy Currents, Vol. 16, No.1 (January/February January) 2016 pp

49 Epilepsy Emergencies - Status Epilepticus

50 Epilepsy Emergencies - Status Epilepticus

51 Epilepsy Emergencies - Status Epilepticus Rapid Anticonvulsant Medications Prior to Arrival Trial (RAMPART) Better efficacy for IM midazolam than for the standard IV lorazepam Speed and ease of IM administration IM Midazolam(10 mg) stopped seizures prior to ER arrival in 73.4% of patients compared to IV lorazepam (4 mg) in 63.4% of patients Other routes of administration Intranasal midazolam Buccal midazolam Rectal diazepam American Academy of Neurology, Continuum, Volume 22, No 1, February 2016

52 Epilepsy Emergencies - Status Epilepticus

53 Epilepsy Emergencies - Status Epilepticus

54 American Academy of Neurology, Continuum, Volume 22, No 1, February 2016 Case 1

55 Case 1 - EEG American Academy of Neurology, Continuum, Volume 22, No 1, February 2016

56 XF Letter

57 Conclusion Epilepsy recently redefined as a disease characterized by one or more seizures with a relatively high recurrence risk (60% or >) The risk of seizure recurrence is greatest in the first 2 years Immediate AED therapy is likely to reduce the risk of a second unprovoked seizure by about 35% over the next 2 years MRI guided laser ablation over temporal lobectomy Start continuous video EEG monitoring at least within the first 24 hours after cardiac arrest Status epilepticus treatment

58 References American Academy of Neurology, Continuum, Volume 22, No 1, February 2016 Epilepsy Currents, Vol. 16, No.1 (January/February January) 2016 pp Journal of Clinical Neurophysiology, Volumes 33, Number 3, 6/2016 MR-guided stereotactic laser ablation of epileptogenic foci in children Daniel J. Curry a, Ashok Gowda c,roger J. McNichols c, Angus A. Wilfong Tjepkema-Cloostermans et al. Critical Care 2013, 17:R252