Publications by authors named "Selim R Benbadis"

116 Publications

Fish soup for the falling sickness: Tracing epilepsy through Hmong and Western beliefs.

Epilepsy Behav 2021 02 9;115:107725. Epub 2021 Jan 9.

University of South Florida Morsani College of Medicine, Department of Neurology, Tampa, FL, USA.

Hmong communities originated in China but today are located across the globe. Salvation, health, and well-being in Hmong tradition are contingent upon pleasing spirits and ancestors. While most diseases are believed to reflect the displeasure of spirits and ancestors, epilepsy is unique in that it portends a heightened capacity for achieving an elevated level of spirituality, which has led it to be deemed honorable by Hmong society members. This stands in stark contrast to some contexts within which epilepsy has been historically understood in the West in which the disease was believed to originate from sin and evil. If and how societal response toward persons with epilepsy (PWE) in Hmong communities differ from that in other Western communities in a way that parallels these differences in beliefs regarding the etiology and significance of the seizures is unknown. Understanding this may have implications that guide efforts in combatting stigma affecting PWE.
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http://dx.doi.org/10.1016/j.yebeh.2020.107725DOI Listing
February 2021

Driving a motor vehicle and psychogenic nonepileptic seizures: ILAE Report by the Task Force on Psychogenic Nonepileptic Seizures.

Epilepsia Open 2020 Sep 9;5(3):371-385. Epub 2020 Jun 9.

Academic Department of Neurosciences University of Sheffield Royal Hallamshire Hospital Sheffield UK.

Objectives: This International League Against Epilepsy (ILAE) Report: (a) summarizes the literature about "driving and psychogenic nonepileptic seizures (PNES)"; (b) presents the views of international experts; and (c) proposes an approach to assessing the ability of persons with PNES (PwPNES) to drive.

Methods: Phase 1: Systematic literature review. Phase 2: Collection of international expert opinion using SurveyMonkey®. Experts included the members of the ILAE PNES Task Force and individuals with relevant publications since 2000. Phase 3: Joint analysis of the findings and refinement of conclusions by all participants using email. As an ILAE Report, the resulting text was reviewed by the Psychiatry Commission, the ILAE Task Force on Driving Guidelines, and Executive Committee.

Results: Eight studies identified by the systematic review process failed to provide a firm evidence base for PNES-related driving regulations, but suggest that most health professionals think restrictions are appropriate. Twenty-six experts responded to the survey. Most held the view that decisions about driving privileges should consider individual patient and PNES characteristics and take account of whether permits are sought for private or commercial driving. Most felt that those with active PNES should not be allowed to drive unless certain criteria were met and that PNES should be thought of as "active" if the last psychogenic seizure had occurred within 6 months.

Significance: Recommendations on whether PwPNES can drive should be made at the individual patient level. Until future research has determined the risk of accidents in PwPNES a proposed algorithm may guide decisions about driving advice.
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http://dx.doi.org/10.1002/epi4.12408DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7469780PMC
September 2020

The Yield of Ambulatory EEG-Video Monitoring.

Clin EEG Neurosci 2021 Jul 18;52(4):274-279. Epub 2020 Aug 18.

Department of Neurology, Comprehensive Epilepsy Center, 7831University of South Florida, Tampa, FL, USA.

Introduction: The availability of EEG-video monitoring gives an alternative to traditional inpatient EEG-video, but its yield and diagnostic value are not well known. This study evaluates the yield of ambulatory EEG-video for the diagnosis of epilepsy.

Methods: We retrospectively reviewed the ambulatory EEG-video monitoring data from 200 consecutive and unselected patients aged 12 years and older performed by a single company (RSC Diagnostic Services) between January 2018 and May 2018. Studies were processed by two senior certified long-term monitoring EEG technologists and interpreted by neurologists.

Results: Of the 200 patients, 130 (65%) were women, mean age was 45 years. Mean duration of studies were 76.6 hours (range 23-175 hours). There were 110 studies (55%) with events recorded and 101 (92%) were captured on video. Epileptic events accounted for 17.8% (18/101) of the events captured and 9% (18/200) of our total cohort. Nonepileptic diagnosis accounted for 38% of the total number of patients in study (76/200).

Conclusion: Ambulatory EEG-video monitoring may be a useful alternative to inpatient epilepsy monitoring unit, particularly with high clinical suspicion for nonepileptic events.
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http://dx.doi.org/10.1177/1550059420949768DOI Listing
July 2021

Functional seizures? "So I still have seizures, right?"

Authors:
Selim R Benbadis

Epilepsy Behav 2020 08 22;109:107082. Epub 2020 May 22.

University of South Florida, 2 Tampa General Circle, Tampa, FL 33606, United States. Electronic address:

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http://dx.doi.org/10.1016/j.yebeh.2020.107082DOI Listing
August 2020

The role of EEG in patients with suspected epilepsy.

Epileptic Disord 2020 Apr;22(2):143-155

Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, USA.

Despite the advances in imaging, EEG remains a critical test for the diagnosis of epilepsy. Not only can it confirm the diagnosis, but it can also clarify the type of epilepsy. There are many different types of EEG recordings depending on duration, the presence of video, and inpatient or outpatient setting, each with its pros and cons. Interictal epileptiform abnormalities are very specific to epilepsy, but they can be over-interpreted by inexperienced readers. In addition to diagnosis of epilepsy, EEG also has a role in the decision to discontinue treatment in seizure-free patients, and in assessing critically ill patients for possible status epilepticus and encephalopathies. EEG reports should be relatively standardized and clear to the clinician who requested the EEG.
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http://dx.doi.org/10.1684/epd.2020.1151DOI Listing
April 2020

Cone Waves: Another Normal Variant Overread as Epileptiform Discharges.

Eur Neurol 2020 3;83(1):87-88. Epub 2020 Apr 3.

Department of Neurology, University of South Florida, Tampa, Florida, USA.

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http://dx.doi.org/10.1159/000506106DOI Listing
April 2020

Two Epilepsy Types (Not Seizure Types) in the Same Patient: A Rare but Interesting Occurrence.

Eur Neurol 2020 30;83(1):89-90. Epub 2020 Mar 30.

University of South Florida, Tampa, Florida, USA.

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http://dx.doi.org/10.1159/000506197DOI Listing
March 2020

Assessment of the Predictive Value of Outpatient Smartphone Videos for Diagnosis of Epileptic Seizures.

JAMA Neurol 2020 05;77(5):593-600

Department of Neurology, Mayo Clinic, Rochester, Minnesota.

Importance: Misdiagnosis of epilepsy is common. Video electroencephalogram provides a definitive diagnosis but is impractical for many patients referred for evaluation of epilepsy.

Objective: To evaluate the accuracy of outpatient smartphone videos in epilepsy.

Design, Setting, And Participants: This prospective, masked, diagnostic accuracy study (the OSmartViE study) took place between August 31, 2015, and August 31, 2018, at 8 academic epilepsy centers in the United States and included a convenience sample of 44 nonconsecutive outpatients who volunteered a smartphone video during evaluation and subsequently underwent video electroencephalogram monitoring. Three epileptologists uploaded videos for physicians from the 8 epilepsy centers to review.

Main Outcomes And Measures: Measures of performance (accuracy, sensitivity, specificity, positive predictive value, and negative predictive value) for smartphone video-based diagnosis by experts and trainees (the index test) were compared with those for history and physical examination and video electroencephalogram monitoring (the reference standard).

Results: Forty-four eligible epilepsy clinic outpatients (31 women [70.5%]; mean [range] age, 45.1 [20-82] years) submitted smartphone videos (530 total physician reviews). Final video electroencephalogram diagnoses included 11 epileptic seizures, 30 psychogenic nonepileptic attacks, and 3 physiologic nonepileptic events. Expert interpretation of a smartphone video was accurate in predicting a video electroencephalogram monitoring diagnosis of epileptic seizures 89.1% (95% CI, 84.2%-92.9%) of the time, with a specificity of 93.3% (95% CI, 88.3%-96.6%). Resident responses were less accurate for all metrics involving epileptic seizures and psychogenic nonepileptic attacks, despite greater confidence. Motor signs during events increased accuracy. One-fourth of the smartphone videos were correctly diagnosed by 100% of the reviewing physicians, composed solely of psychogenic attacks. When histories and physical examination results were combined with smartphone videos, correct diagnoses rose from 78.6% to 95.2%. The odds of receiving a correct diagnosis were 5.45 times greater using smartphone video alongside patient history and physical examination results than with history and physical examination alone (95% CI, 1.01-54.3; P = .02).

Conclusions And Relevance: Outpatient smartphone video review by experts has predictive and additive value for diagnosing epileptic seizures. Smartphone videos may reliably aid psychogenic nonepileptic attacks diagnosis for some people.
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http://dx.doi.org/10.1001/jamaneurol.2019.4785DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6990754PMC
May 2020

Avoiding complacency when treating uncontrolled seizures: why and how?

Expert Rev Neurother 2020 03 15;20(3):227-235. Epub 2020 Jan 15.

Department of Neurology, University of South Florida, Tampa, FL, USA.

: Despite the advances in the diagnosis and treatment of epilepsy, approximately 30% of the patients remain intractable. Uncontrolled seizures have deleterious consequences, including brain damage, cognitive decline, decreased quality of life, and increased mortality.: In this article, the authors discuss the treatment gap in patients with intractable epilepsy and the possible mechanisms of drug resistance. The authors provide a treatment algorithm for patients with intractable epilepsy, including non-pharmacological treatment options, such as diet, neurostimulation (vagus nerve stimulation, responsive neurostimulation, and deep brain stimulation), curative surgeries, and palliative surgeries.: There are currently several gaps in the management of seizures. Thirty percent of the 1% of the population with epilepsy is drug resistant. Non-pharmacologic treatments have improved in the last 30 years and continue to do so, but epilepsy surgery in general is still vastly under-utilized. Resective surgery is the only potentially curative procedure. Neurostimulation is generally palliative and is also improving, with smarter types of neurostimulation and paradigms.
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http://dx.doi.org/10.1080/14737175.2020.1713100DOI Listing
March 2020

Outcome of prolonged video-EEG monitoring in a new VA monitoring unit.

Epilepsy Behav 2020 01 3;102:106696. Epub 2019 Dec 3.

James A. Haley Veterans' Hospital, University of South Florida, United States of America. Electronic address:

Background And Objective: For patients with refractory seizures or seizure-like activity, prolonged inpatient video-electroencephalography (EEG) (v-EEG) is standard of care to guide diagnosis and management. The purpose of this study was to describe the outcome of v-EEG in a new Veterans' Administration (VA) hospital epilepsy monitoring unit (EMU).

Methods: We reviewed all prolonged (>24 h) inpatient v-EEGs performed in our EMU (2 beds) at the James A Haley VA in Tampa, FL over a five-and-a-half-year period (11/2013-07/2019). A total of 216 prolonged v-EEGs were performed. The patient population consisted of adult veterans (185 males, 31 females) ranging from 21 years to 89 years old (mean 52.5). The duration of monitoring ranged from 24 h to 9 days (mean 3.6 days).

Results: Of the 216 studies, 39 (18%) exclusively had epileptic seizures (ES). Of these, 37 (95%) had focal seizures, and 2 (5%) had generalized seizures. Of the 37 cases with focal seizures, all but 2 had clear ictal changes on EEG. Eighteen (8.5%) EEG studies revealed interictal epileptiform abnormalities without a clinical event. Sixty-eight (31.5%) of the v-EEGs had exclusively nonepileptic events (NEE). Of these, 27 (12.5%) were psychogenic nonepileptic seizures (PNES), and 41 (19%) were other NEE. Ninety-one (42%) of the studies were inconclusive, either because of lack of events captured (63) or because the events recorded were not the patient's typical episodes (27).

Significance: Compared to non-VA series, we found a lower proportion of PNES, and a higher proportion of inconclusive studies.
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http://dx.doi.org/10.1016/j.yebeh.2019.106696DOI Listing
January 2020

Reversing the myth of phase reversals.

Expert Rev Neurother 2020 01 27;20(1):3-5. Epub 2019 Nov 27.

Epilepsy and EEG, Department of Neurology, University of South Florida, Tampa, FL, USA.

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http://dx.doi.org/10.1080/14737175.2020.1696193DOI Listing
January 2020

The next level of care in epilepsy: Delays, more delays, delays everywhere.

Neurol Clin Pract 2019 Aug;9(4):284-285

Department of Neurology (SRB), University of South Florida and Tampa General Hospital, Tampa, FL; and Departments of Neurology (JE), Neurobiology, and Psychiatry and Biobehavioral Sciences, and the Brain Research Institute, David Geffen School of Medicine at UCLA, Los Angeles, CA.

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http://dx.doi.org/10.1212/CPJ.0000000000000625DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6745747PMC
August 2019

Teaching NeuroImages: Sleep-onset REM period during routine EEG.

Neurology 2019 09;93(11):e1123-e1124

From the Department of Neurology, Morsani College of Medicine, University of South Florida, Tampa.

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http://dx.doi.org/10.1212/WNL.0000000000008108DOI Listing
September 2019

The Role of EEG in the Erroneous Diagnosis of Epilepsy.

J Clin Neurophysiol 2019 Jul;36(4):294-297

Department of Neurology, University of South Florida, Tampa, Florida, U.S.A.

Errors in diagnosis are relatively common in medicine and occur in all specialties. The consequences can be serious for both patients and physicians. Errors in neurology are often because of the overemphasis on 'tests' over the clinical picture. The diagnosis of epilepsy in general is a clinical one and is typically based on history. Epilepsy is more commonly overdiagnosed than underdiagnosed. An erroneous diagnosis of epilepsy is often the result of weak history and an 'abnormal' EEG. Twenty-five to 30% of patients previously diagnosed with epilepsy who did not respond to initial antiepileptic drug treatment do not have epilepsy. Most patients misdiagnosed with epilepsy turn out to have either psychogenic nonepileptic attacks or syncope. Reasons for reading a normal EEG as an abnormal one include over-reading normal variants or simple fluctuations of background rhythms. Reversing the diagnosis of epilepsy is challenging and requires reviewing the 'abnormal' EEG, which can be difficult. The lack of mandatory training in neurology residency programs is one of the main reasons for normal EEGs being over-read as abnormal. Tests (including EEG) should not be overemphasized over clinical judgment. The diagnosis of epilepsy can be challenging, and some seizure types may be underdiagnosed. Frontal lobe hypermotor seizures may be misdiagnosed as psychogenic events. Focal unaware cognitive seizures in elderly maybe be blamed on dementia, and ictal or interictal psychosis in frontal and temporal lobe epilepsies may be mistaken for a primary psychiatric disorder.
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http://dx.doi.org/10.1097/WNP.0000000000000572DOI Listing
July 2019

EEG Findings in Posterior Reversible Encephalopathy Syndrome.

Clin EEG Neurosci 2019 Sep 19;50(5):366-369. Epub 2019 Jun 19.

1 University of South Florida, Tampa, FL, USA.

. Posterior reversible encephalopathy syndrome (PRES) is a relatively common cause of encephalopathy in the hospital setting, and the EEG findings have not been well described. The purpose of this study was to review the EEG findings in a series of patients with PRES. . We retrospectively reviewed our electronic medical record database to identify patients who received a diagnosis of PRES at Tampa General Hospital from January 2016 to October 2017. The diagnosis of PRES was suspected on clinical presentation and confirmed by magnetic resonance imaging. We selected patients with PRES who had received at least 1 EEG. EEGs were interpreted by 2 board-certified electroencephalographers. . From January 2016 to October 2017, 19 patients were diagnosed with PRES at Tampa General Hospital. Of those, 10 received at least 1 EEG. Four patients were male, 6 were female. The ages ranged from 21 to 87 (mean was 47). The patients had the following clinical presentations: 5 with encephalopathy, 8 with seizures, 2 with vision changes, and 3 with headache (some patients had more than 1 symptom). EEGs findings were as follows: 3 were normal; 3 showed intermittent generalized slowing; 2 showed continuous generalized slowing; 3 showed background slowing; 1 showed background suppression; 1 showed generalized rhythmic delta activity (GRDA); 1 showed GRDA, plus spike/sharp-wave discharges; 1 showed generalized periodic discharges. The etiologies were as follows: 9 from hypertension, 1 secondary to eclampsia, 3 due to posttransplant immunosuppression, and 1 patient was undergoing chemotherapy (some were multifactorial). . EEG findings in PRES are diverse, with no specific or even predominant pattern, based on this small sample size.
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http://dx.doi.org/10.1177/1550059419856968DOI Listing
September 2019

Classification of paroxysmal events and the four-dimensional epilepsy classification system.

Epileptic Disord 2019 02;21(1):1-29

Case Medical Center - Pediatrics, Cleveland, Ohio, USA.

This educational review describes the classification of paroxysmal events and a four-dimensional epilepsy classification system. Paroxysmal events are classified as epileptic and non-epileptic paroxysmal events. Non-epileptic events are, in turn, classified as psychogenic and organic paroxysmal events. The following four dimensions are used to classify epileptic paroxysmal events: ictal semiology, the epileptogenic zone, etiology, and comorbidities. Efforts are made to keep these four dimensions as independent as possible. The review also includes 12 educational vignettes and three more detailed case reports classified using the 2017 classification of the ILAE and the four-dimensional epilepsy classification. In addition, a case is described which is classified using the four-dimensional epilepsy classification with different degrees of precision by an emergency department physician, a neurologist, and an epileptologist. [Published with video sequences on www.epilepticdisorders.com].
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http://dx.doi.org/10.1684/epd.2019.1033DOI Listing
February 2019

Psychogenic nonepileptic seizures, conversion, and somatic symptom disorders.

Authors:
Selim R Benbadis

Neurology 2019 02 4;92(7):311-312. Epub 2019 Jan 4.

From the University of South Florida, Tampa.

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http://dx.doi.org/10.1212/WNL.0000000000006838DOI Listing
February 2019

Association Between Positive Occipital Sharp Transients of Sleep and Lambda Waves.

Clin EEG Neurosci 2019 May 14;50(3):219-221. Epub 2018 Nov 14.

1 University of South Florida, Tampa, FL, USA.

Positive occipital sharp transients of sleep (POSTS) and lambda waves have similar morphology and location. We studied a possible association between these 2 normal EEG patterns. We reviewed a series of consecutive unselected ambulatory EEGs during a 3-month period (October 16, 2017 to January 19, 2018) and identified records with POSTS and records with lambda waves. Statistical analysis was performed using a chi-square test. A total of 140 ambulatory EEGs were reviewed. Duration of EEGs ranged from 24 to 168 hours (mean 76 hours). The population was 34% males, with ages ranging from 3 to 93 years (mean 48 years). Of the 140 records, 30 were abnormal, including 20 with epileptiform abnormalities. A chi-square test for independence (with Yates continuity correction) indicated a significant association between POSTS and lambda waves, χ(1, n = 140) = 69.208, p < .001, φ = 0.72. In addition, 100% of records with lambda waves had POSTS, and 72% of records with POSTS had lambda waves. There is a high association between lambda waves and POSTS. This suggests a strong similarity between the 2 waveforms, and possibly a common occipital generator.
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http://dx.doi.org/10.1177/1550059418813020DOI Listing
May 2019

Managing Antiepileptic Medication in Dialysis Patients.

Curr Treat Options Neurol 2018 Sep 27;20(11):45. Epub 2018 Sep 27.

Comprehensive Epilepsy Program University of South Florida, Department of Neurology, University of South Florida, 2 Tampa General Circle, Tampa, FL, 33606, USA.

Purpose Of Review: The purpose of this review is to summarize and discuss available information on the management of epilepsy patients on renal replacement therapy. Older and newer antiepileptic drugs (AEDs) pharmacology will be reviewed, as well as the need to supplement dosages during or after hemodialysis, peritoneal dialysis, and continuous renal replacement treatment.

Recent Findings: The great majority of anticonvulsants have been studied in patients with renal failure. Many of them have also been assessed during renal replacement therapy. For some, data are scant, and choice of management must be decided through information on pharmacology. Trials have been conducted in patients with hemodialysis and results have been extrapolated to other types of dialysis. Furthermore, decision on dose supplementation for some of the newer AEDs involves a combination of analysis of the clinical situation and physician expertise. In this paper, we discuss the basis of renal failure and renal replacement therapy as well as antiepileptic pharmacology and the options for dosage replacement during dialysis. Based on pharmacology of each AED, a dosage supplementation is required in cases where there is sufficient clearance of the drug by the method of dialysis chosen. This depends greatly on physicochemical characteristics of the drug: lipophilicity, volume of distribution, protein binding, and molecular weight; and on characteristics of dialysis membrane, mechanism of clearance and blood or dialysate flow. There are studies done for most AEDs in hemodialysis, but more trials are needed in peritoneal dialysis and continuous replacement therapies. There is insufficient information for the newest AEDs, and for some, the recommendation is to simply avoid them in renal failure and dialysis. More studies are necessary in the topic.
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http://dx.doi.org/10.1007/s11940-018-0530-5DOI Listing
September 2018

Putting it all together: Options for intractable epilepsy: An updated algorithm on the use of epilepsy surgery and neurostimulation.

Epilepsy Behav 2018 11 18;88S:33-38. Epub 2018 Sep 18.

University of South Florida, Tampa, FL, United States.

For drug-resistant epilepsy, nonpharmacologic treatments should be considered early rather than late. Of the nondrug treatments, only resective surgery can be curative. Neurostimulation is palliative, i.e., not expected to achieve a seizure-free outcome. While resective surgery is the goal, other options are necessary because the majority of patients with drug-resistant epilepsy are not surgical candidates, and others have seizures that fail to improve with surgery or have only partial improvement but not seizure freedom. Neurostimulation modalities include vagus nerve stimulation (VNS), responsive neurostimulation (RNS), and deep brain stimulation (DBS), each with its own advantages, disadvantages, and side effects. In most scenarios, determined by noninvasive evaluation, especially EEG and MRI, several strategies are reasonable. For focal epilepsies, the choices are between resective surgery, with or without intracranial EEG, and all three modalities of neurostimulation. In situations where resective surgery is likely to result in seizure freedom, such as mesiotemporal lobe epilepsy or lesional focal epilepsy, resection (standard, laser, or radiofrequency) is preferred. For difficult cases like extratemporal nonlesional epilepsies, neurostimulation offers a less invasive option than resective surgery. For generalized and multifocal epilepsies, VNS is an option, RNS is not, and DBS has only limited evidence. "This article is part of the Supplement issue Neurostimulation for Epilepsy."
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http://dx.doi.org/10.1016/j.yebeh.2018.05.030DOI Listing
November 2018

Neurostimulation for the treatment of epilepsy.

Authors:
Selim R Benbadis

Epilepsy Behav 2018 11 19;88S. Epub 2018 Aug 19.

University of South Florida and Tampa General Hospital, Tampa, FL, United States. Electronic address:

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http://dx.doi.org/10.1016/j.yebeh.2018.05.001DOI Listing
November 2018

Psychiatric and cognitive adverse events: A pooled analysis of three phase III trials of adjunctive eslicarbazepine acetate for partial-onset seizures.

Epilepsy Behav 2018 05 28;82:119-127. Epub 2018 Mar 28.

Sunovion Pharmaceuticals Inc., 84 Waterford Dr, Marlborough, MA 01752, USA.

Objective: To evaluate the nature and incidence of psychiatric and cognitive adverse events (AEs) reported with eslicarbazepine acetate (ESL) used as adjunctive treatment for refractory partial-onset seizures (POS) in adults.

Methods: This was a post-hoc analysis of data pooled from three randomized double-blind, placebo-controlled trials (BIA-2093-301, -302, -304). After an 8-week baseline period, patients received placebo or adjunctive ESL 400mg (studies 301 and 302 only), 800mg, or 1200mg once daily (QD) for 14weeks (2-week titration period, 12-week maintenance period). Psychiatric and cognitive AEs were identified from individual patient data. Suicidality was also evaluated using the Columbia-Classification Algorithm of Suicide Assessment (C-CASA), or the Columbia-Suicide Severity Rating Scale (C-SSRS). P-values were obtained using the chi-square test of independence or Fisher's exact test, without correcting for multiplicity.

Results: The analysis population included 1447 patients (ESL, n=1021; placebo, n = 426). Psychiatric treatment-emergent AEs (TEAEs) occurred in 10.8% of patients receiving ESL, and in a comparable proportion (10.3%) of patients receiving placebo (p=0.802). The incidence of depression and suicidality-related TEAEs was higher for ESL (7.4%) vs. placebo (3.8%) (p=0.009). The occurrence of these TEAEs differed between treatment groups (p = 0.010), but there was no notable trend between increasing ESL dose and increasing incidence of depression and suicidality-related TEAEs. Aggression/hostility-related TEAEs occurred in <0.1% of patients taking ESL vs. 0.9% taking placebo. The incidence of cognitive TEAEs was higher for ESL (7.1%) vs. placebo (4.0%) (p=0.023); incidences of memory impairment, attention disturbance, apathy, and aphasia were higher for ESL 1200mg than for other treatment groups. Incidences of psychiatric and cognitive serious AEs (SAEs) were 0.6% and 0.2% with ESL, and 0.5% and 0% with placebo, respectively. Psychiatric and cognitive TEAEs leading to discontinuation occurred in 1.9% and 1.4% of patients taking ESL, and 0.7% and 0.5% taking placebo, respectively.

Conclusions: In phase III clinical trials of adjunctive ESL for treatment-refractory POS, psychiatric and cognitive TEAEs were reported infrequently with ESL and placebo. The incidences of depression and suicidality-related TEAEs and of cognitive TEAEs were higher for patients taking ESL vs. placebo. Incidences of psychiatric and cognitive SAEs, and TEAEs leading to discontinuation, were low with ESL and placebo.
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http://dx.doi.org/10.1016/j.yebeh.2017.12.017DOI Listing
May 2018

Cannabidiol in patients with seizures associated with Lennox-Gastaut syndrome (GWPCARE4): a randomised, double-blind, placebo-controlled phase 3 trial.

Lancet 2018 03 26;391(10125):1085-1096. Epub 2018 Jan 26.

Greenwich Biosciences, Research Triangle Park, NC, USA; Duke University, Durham, NC, USA.

Background: Patients with Lennox-Gastaut syndrome, a rare, severe form of epileptic encephalopathy, are frequently treatment resistant to available medications. No controlled studies have investigated the use of cannabidiol for patients with seizures associated with Lennox-Gastaut syndrome. We therefore assessed the efficacy and safety of cannabidiol as an add-on anticonvulsant therapy in this population of patients.

Methods: In this randomised, double-blind, placebo-controlled trial done at 24 clinical sites in the USA, the Netherlands, and Poland, we investigated the efficacy of cannabidiol as add-on therapy for drop seizures in patients with treatment-resistant Lennox-Gastaut syndrome. Eligible patients (aged 2-55 years) had Lennox-Gastaut syndrome, including a history of slow (<3 Hz) spike-and-wave patterns on electroencephalogram, evidence of more than one type of generalised seizure for at least 6 months, at least two drop seizures per week during the 4-week baseline period, and had not responded to treatment with at least two antiepileptic drugs. Patients were randomly assigned (1:1) using an interactive voice response system, stratified by age group, to receive 20 mg/kg oral cannabidiol daily or matched placebo for 14 weeks. All patients, caregivers, investigators, and individuals assessing data were masked to group assignment. The primary endpoint was percentage change from baseline in monthly frequency of drop seizures during the treatment period, analysed in all patients who received at least one dose of study drug and had post-baseline efficacy data. All randomly assigned patients were included in the safety analyses. This study is registered with ClinicalTrials.gov, number NCT02224690.

Findings: Between April 28, 2015, and Oct 15, 2015, we randomly assigned 171 patients to receive cannabidiol (n=86) or placebo (n=85). 14 patients in the cannabidiol group and one in the placebo group discontinued study treatment; all randomly assigned patients received at least one dose of study treatment and had post-baseline efficacy data. The median percentage reduction in monthly drop seizure frequency from baseline was 43·9% (IQR -69·6 to -1·9) in the cannibidiol group and 21·8% (IQR -45·7 to 1·7) in the placebo group. The estimated median difference between the treatment groups was -17·21 (95% CI -30·32 to -4·09; p=0·0135) during the 14-week treatment period. Adverse events occurred in 74 (86%) of 86 patients in the cannabidiol group and 59 (69%) of 85 patients in the placebo group; most were mild or moderate. The most common adverse events were diarrhoea, somnolence, pyrexia, decreased appetite, and vomiting. 12 (14%) patients in the cannabidiol group and one (1%) patient in the placebo group withdrew from the study because of adverse events. One patient (1%) died in the cannabidiol group, but this was considered unrelated to treatment.

Interpretation: Add-on cannabidiol is efficacious for the treatment of patients with drop seizures associated with Lennox-Gastaut syndrome and is generally well tolerated. The long-term efficacy and safety of cannabidiol is currently being assessed in the open-label extension of this trial.

Funding: GW Pharmaceuticals.
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http://dx.doi.org/10.1016/S0140-6736(18)30136-3DOI Listing
March 2018

An analysis of quality of life (QOL) in patients with epilepsy and comorbid psychogenic nonepileptic seizures (PNES) after vagus nerve stimulation (VNS).

Epilepsy Behav 2017 08 23;73:208-213. Epub 2017 Jun 23.

Department of Neurosurgery, University of South Florida, Tampa, FL, United States; Department of Neurology, University of South Florida, Tampa, FL, United States. Electronic address:

Purpose: Patients with epilepsy (PWE) may suffer from comorbid psychogenic nonepileptic seizures (PNES). The efficacy of vagus nerve stimulation (VNS) in the treatment of epilepsy and depression is established, however the impact on PNES is unknown. Since many patients with PNES have comorbid depression, we explored the impact on quality of life (QOL) that VNS has on PWE and PNES.

Methods: The video electroencephalogram (vEEG) of all patients who underwent VNS at our institution was reviewed. Patients diagnosed with both psychogenic seizures and epileptic seizures on their vEEG were included in this study. These patients were contacted, and given a QOLIE-31 survey to assess their quality of life after VNS. Patients also completed a separate survey created by our group to categorize the quartile of their improvement. Pre-operative psychiatric disease was retrospectively reviewed.

Results: From a period of 2001 to 2016, 518 patients underwent placement of VNS for drug resistant epilepsy (DRE) at our institution. In total, 16 patients were diagnosed with both epilepsy and PNES. 11/16 patients responded to our questionnaire and survey. 9 out of 11 patients felt that their epileptic seizures had improved after VNS, while 7 of the 11 patients felt that their psychogenic episodes had improved. 2(28.6%), 1 (14.3%), and 4 (57.1%) of participants said their PNES improved by 25-50%, 50-75%, and 75-100%, respectively. 3(27.3%), 3 (27.3%), 1 (9.1%), and 4 (36.4%) of the participants said their epileptic seizures improved by 0-25%, 25-50%, 50-75%, and 75-100%, respectively. The average overall score for quality of life for the study participants was found to be 51 (±8) out of 100.

Conclusion: Patients with epilepsy and comorbid PNES may benefit from VNS. It is unclear whether the benefit is conferred strictly from decreased epileptic seizure burden. The possible effect on PNES may be related to the known effect of VNS on depression. Further studies are necessary to elucidate the role of VNS in the treatment of PNES and possibly other psychiatric disease.
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http://dx.doi.org/10.1016/j.yebeh.2017.05.035DOI Listing
August 2017

When EEG is bad for you.

Clin Neurophysiol 2017 04 28;128(4):656-657. Epub 2017 Jan 28.

Université de Nice-Sophia Antipolis, Service de Neurologie et Unité d'Epileptologie, Hôpital Pasteur 2, 30, Voie Romaine, 06002 Nice, France. Electronic address:

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http://dx.doi.org/10.1016/j.clinph.2016.12.033DOI Listing
April 2017

Carbamazepine-related antiepileptic drugs for the treatment of epilepsy - a comparative review.

Expert Opin Pharmacother 2016 ;17(7):885-8

c Comprehensive Epilepsy Center , University of South Florida and Tampa General Hospital , Tampa , FL , USA.

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http://dx.doi.org/10.1517/14656566.2016.1168399DOI Listing
September 2016

Utility of Green's Word Memory Test Free Recall Subtest as a Measure of Verbal Memory: Initial Evidence from a Temporal Lobe Epilepsy Clinical Sample.

Arch Clin Neuropsychol 2016 Feb 12;31(1):79-87. Epub 2015 Dec 12.

Department of Psychiatry and Behavioral Neurosciences, Morsani College of Medicine, University of South Florida, Tampa, FL, USA Department of Neurosurgery and Brain Repair, Morsani College of Medicine, University of South Florida, Tampa, FL, USA Department of Neurology, Morsani College of Medicine, University of South Florida, Tampa, FL, USA

This study investigated the Word Memory Test (WMT) Free Recall (FR) subtest as a conventional memory measure. Nineteen participants with pharmacoresistant left temporal lobe epilepsy (LTLE) and 16 with right temporal lobe epilepsy (RTLE) completed the WMT, Rey Auditory Verbal Learning Test (RAVLT), and Wechsler Memory Scale-Fourth Edition Logical Memory (LM) subtest during presurgical evaluation. LTLE participants performed significantly worse on FR subtest (p < .05, [Formula: see text]) and RAVLT Trial 7 (p < .01, [Formula: see text]), but not on LM subtest. Age was a significant covariate for FR (p < .01, [Formula: see text]). Logistic regression revealed FR plus age and RAVLT age-adjusted T-scores both yielded 77.1% classification accuracy and respective diagnostic odds ratios of 11.36 and 11.84. Receiver operating characteristic curves to classify seizure laterality found that RAVLT and FR were significant (area under the curve [AUC] = 0.82 and 0.74), whereas LM was nonsignificant (AUC = 0.67). Cut scores and positive/negative predictive values were established for improved clinical classification.
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http://dx.doi.org/10.1093/arclin/acv084DOI Listing
February 2016

Automatic Vagus Nerve Stimulation Triggered by Ictal Tachycardia: Clinical Outcomes and Device Performance--The U.S. E-37 Trial.

Neuromodulation 2016 Feb 13;19(2):188-95. Epub 2015 Dec 13.

Cyberonics, Inc., Houston, TX, USA.

Objectives: The Automatic Stimulation Mode (AutoStim) feature of the Model 106 Vagus Nerve Stimulation (VNS) Therapy System stimulates the left vagus nerve on detecting tachycardia. This study evaluates performance, safety of the AutoStim feature during a 3-5-day Epilepsy Monitoring Unit (EMU) stay and long- term clinical outcomes of the device stimulating in all modes.

Materials And Methods: The E-37 protocol (NCT01846741) was a prospective, unblinded, U.S. multisite study of the AspireSR(®) in subjects with drug-resistant partial onset seizures and history of ictal tachycardia. VNS Normal and Magnet Modes stimulation were present at all times except during the EMU stay. Outpatient visits at 3, 6, and 12 months tracked seizure frequency, severity, quality of life, and adverse events.

Results: Twenty implanted subjects (ages 21-69) experienced 89 seizures in the EMU. 28/38 (73.7%) of complex partial and secondarily generalized seizures exhibited ≥20% increase in heart rate change. 31/89 (34.8%) of seizures were treated by Automatic Stimulation on detection; 19/31 (61.3%) seizures ended during the stimulation with a median time from stimulation onset to seizure end of 35 sec. Mean duty cycle at six-months increased from 11% to 16%. At 12 months, quality of life and seizure severity scores improved, and responder rate was 50%. Common adverse events were dysphonia (n = 7), convulsion (n = 6), and oropharyngeal pain (n = 3).

Conclusions: The Model 106 performed as intended in the study population, was well tolerated and associated with clinical improvement from baseline. The study design did not allow determination of which factors were responsible for improvements.
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http://dx.doi.org/10.1111/ner.12376DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5064739PMC
February 2016