Amy McGregor

Right-sided Vagus Nerve Stimulation as a Treatment for Refractory Epilepsy in Humans

Summary:  Purpose: We present three children who underwent right‐sided vagus nerve stimulation (R‐VNS). This treatment option for people with refractory epilepsy has not been described in children.

Prospective Study of the Emfit Movement Monitor

Sudden unexplained death in epilepsy (SUDEP) is associated with generalized tonic-clonic seizures and occurs most often when patients are in bed. There are several seizure detection monitors on the market, but little data are available on the sensitivity and specificity of these devices. We recently tested 2 models of seizure detection alarms with disappointing results. Here we tested the Emfit movement monitor on children with various seizure types who also had standard video electroencephalography (EEG), cardiopulmonary, and nursing monitoring. Video EEG records were reviewed to detect any seizures. In 45 patients, 78 seizures were recorded by video EEG. The Emfit movement monitor captured 23 seizure events (30%) in total, and 15 of the 28 (54%) that occurred during sleep. Most importantly, the alarm was activated with 11 of the 13 (85%) generalized tonic-clonic seizures that occurred in sleeping children. The Emfit movement monitor performed very well in comparison to previously tested devices.

Rapid Infusion of a Loading Dose of Intravenous Levetiracetam With Minimal Dilution: A Safety Study

Intravenous antiepileptic drugs are required in patients needing urgent treatment or unable to take oral medication. The safety of intravenous levetiracetam has been established in prospective studies of adult epilepsy and healthy participants. The authors performed a prospective, single-center study to evaluate the safety of a rapid loading dose of intravenous levetiracetam. Patients were divided into 3 equal dosing groups (N = 15 each): 20, 40, and 60 mg/kg (corresponding to maximum doses of 1, 2, and 3 g). Electrocardiogram and safety assessment were performed during the infusion. Ages were 4 to 32 years. Postinfusion serum levetiracetam concentrations were 14 to 189 μg/mL. There were no significant changes in blood pressure, no local infusion site reactions, and no electrocardiogram abnormalities. The authors concluded that high serum levels of parenteral levetiracetam can be achieved rapidly and safely, in a small infusion volume. This finding has important implications for the treatment of status epilepticus.

Benign Rolandic Epilepsy—Perhaps Not So Benign: Use of Magnetic Source Imaging as a Predictor of Outcome

The purpose of this study was to evaluate children with benign rolandic epilepsy, a childhood epilepsy characterized by centrotemporal/rolandic spike-wave discharges with infrequent partial seizures that may secondarily generalize. Recently, some investigators have questioned whether benign rolandic epilepsy is indeed “benign” or whether long-term cognitive outcome may be adversely affected. We initiated an ongoing study to identify children with benign rolandic epilepsy. The children were evaluated in the Texas Comprehensive Epilepsy Program using outpatient or continuous video-electroencephalographic monitoring, brain magnetic resonance imaging, magnetoencephalography, and neuropsychological testing. Neuropsychological testing revealed fine motor dysfunction, visuomotor integration deficits, dyscalculia, and/or expressive language deficits in all of the 9 patients evaluated, reaffirming that benign rolandic epilepsy is not necessarily a benign disorder. Our study shows a high concordance of motor and cognitive deficits in benign rolandic epilepsy, as others have previously suggested. Furthermore, magnetic source imaging shows a higher resolution of dipole localization compared with conventional electroencephalography, which may ultimately improve prediction of deficits. This reaffirms that magnetoencephalography is a valuable diagnostic tool in the evaluation of children with benign rolandic epilepsy.

Prospective study of 2 bed alarms for detection of nocturnal seizures

For parents of children with epilepsy, seizures occurring in sleep are a major concern. Risk factors for sudden unexplained death in epilepsy patients include being in bed and generalized tonic-clonic seizures. A device for detecting nocturnal seizure activity would be valuable. Children with various seizure types undergoing evaluation had standard video electroencephalography (EEG), cardiopulmonary and nursing monitoring, and 1 of 2 models (ST-2 and MP5) of a Medpage bed alarm. The video EEG record was reviewed to detect any seizures missed by the bed alarms or caregivers. The ability of the bed alarms to detect motor seizures in general and specific seizure types was tested. In 15 patients, 69 seizures were recorded by video EEG. The ST-2 did not detect any nocturnal seizures. The MP5 alarm detected 1 of 15 in sleeping patients: a generalized tonic-clonic seizure. The Medpage seizure alarms do not appear to adequately detect nocturnal seizures.

SmartWatch by SmartMonitor: Assessment of Seizure Detection Efficacy for Various Seizure Types in Children, a Large Prospective Single-Center Study

INTRODUCTION Patients with epilepsy and their caregivers are constantly burdened with the possibility of a seizure and its consequences, such as accidents, injuries, and sudden unexplained death in epilepsy. It is the unpredictable nature of seizures that often affects both patients with seizures and their caregivers, limits independence, and hinders quality of life. There are several types of motion detectors on the market, each with varying degrees of sensitivity. MATERIAL AND METHODS We prospectively tested the SmartWatch, a wrist-worn monitor, on children, adolescents, and young adults with various types of seizures in an epilepsy monitoring unit. Confirmation of seizure type and if there was rhythmic upper extremity jerking associated with the seizure was determined by review of the video electroencephalograph. This was compared with the standard detection system of the watch. RESULTS This study analyzed a total of 191 seizures in 41 patients aged 5-41 years. Fifty-one of the seizures were generalized tonic-clonic. Forty-seven of the seizures had a rhythmic arm movement component. The SmartWatch detected 30 seizures (16%) of the total, 16 (31%) of the generalized tonic-clonic seizures, and 16 (34%) seizures associated with rhythmic arm movements. DISCUSSION Overall, only a minority of generalized tonic-clonic seizures or seizures with rhythmic movements were detected, highlighting the need for an effective seizure detection device.

Pediatric Experience With Sudden Unexplained Death in Epilepsy at a Tertiary Epilepsy Center

Sudden unexplained death in epilepsy is rare in children, and few studies report risk factors. We reviewed our experience with 17 cases of sudden unexplained death in epilepsy to determine risk factors in children. The charts of all patients with onset of epilepsy at less than age 18 years who suffered sudden unexplained death in epilepsy between August 1992 and April 2004 at our epilepsy center were retrospectively reviewed. Deaths were classified as possible, probable, or definite sudden unexplained death in epilepsy. There were seven cases of definite, nine cases of probable, and one case of possible sudden unexplained death in epilepsy. Generalized tonic-clonic seizures and prone position during sleep were found to be major risk factors. Sudden unexplained death in epilepsy in children and adolescents is associated with convulsive seizures, and aggressive treatment of nocturnal generalized tonic-clonic seizures might help lower the occurrence. (J Child Neurol 2006;21:782—787; DOI 10.2310/7010.2006.00175).

Passive language mapping with magnetoencephalography in pediatric patients with epilepsy

OBJECT Functional mapping is important for determining surgical candidacy and also in epilepsy surgery planning. However, in young children and uncooperative patients, language mapping has been particularly challenging despite the advances in performing noninvasive functional studies. In this study the authors review a series of children with epilepsy who underwent language mapping with magnetoencephalography (MEG) while sedated or sleeping, to determine receptive language localization for presurgical evaluation. METHODS The authors undertook a retrospective review of patients who underwent MEG between December 2007 and July 2009, and identified 15 individuals who underwent passive language testing as part of their presurgical evaluation because they were unable to participate in traditional language testing, such as Wada or functional MRI. Factors necessitating passive language testing included age and neurocognitive development. RESULTS Three of the 15 patients were deemed candidates for epilepsy surgery based on the results from standard preoperative testing, including video electroencephalography, MRI, and passive receptive language testing using MEG technology. The MEG studies were used successfully to localize language in all 3 patients, creating opportunities for seizure freedom through surgery that would not otherwise have been available. All 3 patients then underwent resective epilepsy surgery without experiencing postoperative language deficits. CONCLUSIONS This case series is the first to look at language mapping during sleep (passive language mapping) in which MEG was used and is the first to evaluate passive language testing in a patient population with intracranial pathological entities. This case series demonstrates that MEG can provide an alternative method for receptive language localization in patients with barriers to more traditional language testing, and in these 3 cases surgery was performed safely based on the results.

Clinical Applications of Transcranial Magnetic Stimulation in Pediatric Neurology

Noninvasive brain stimulation is now an accepted technique that is used as a diagnostic aid and in the treatment of neuropsychiatric disorders in adults, and is being increasingly used in children. In this review, we will discuss the basic principles and safety of one noninvasive brain stimulation method, transcranial magnetic stimulation. Improvements in the spatial accuracy of transcranial magnetic stimulation are described in the context of image-guided transcranial magnetic stimulation. The article describes and provides examples of the current clinical applications of transcranial magnetic stimulation in children as an aid in the diagnosis and treatment of neuropsychiatric disorders and discusses future potential applications. Transcranial magnetic stimulation is a noninvasive tool that is safe for use in children and adolescents for functional mapping and treatment, and for many children it aids in the preoperative evaluation and the risk-benefit decision making.

Cerebellar seizures: Report of 2 cases

Epilepsy, especially with refractory seizures, is thought to arise only from cortical lesions or substrate. The authors report on 2 patients with refractory epilepsy and cerebellar lesions. Depth electrodes were placed within the cerebellar lesions in both patients, and intracranial electroencephalographic recordings showed seizure origin from the cerebellar lesions. One patient eventually attained seizure control with antiepileptic drugs. The other case involved a child with generalized myoclonic epilepsy associated with a pilocytic astrocytoma of the cerebellum. This patient obtained seizure control following gross-total resection of the tumor.