The use of monotherapy in patients with epilepsy: an appraisal of the new antiepileptic drugs

The use of antiepileptic drugs (AEDs) in monotherapy is always preferred to a polytherapy regimen because monotherapy facilitates drug compliance, is associated with a lower risk of toxicity, and is less costly. In addition, the yield of polytherapy to render a patient seizure-free when monotherapy regimens did not is relatively low. The available data derived from randomized controlled trials suggest that standard and new AEDs appear to display comparable antiepileptic efficacy but they differ with respect to tolerability and toxicity, which may be related to their pharmacodynamic and pharmacokinetic properties. New AEDs appear to be better tolerated than standard AEDs and to have fewer pharmacokinetic interactions than standard AEDs. In this article, we review the advantages of using AEDs in monotherapy in patients with newly diagnosed and refractory epilepsies, focusing on the individual properties of the drugs that may make them more appropriate in various patient groups

Pharmacotherapy of Mood Disorders in Epilepsy: The Role of Newer Psychotropic Drugs

Depression in patients with epilepsy (PWE) is a relatively common comorbidity that has a significant negative impact on their quality of life. Therefore, recognition and management of a comorbid depressive disorder is paramount to achieve successful comprehensive treatment in PWE. Depression in epilepsy may mimic primary depressive disorders, but in a significant percentage of depressed PWE, the clinical semiology has an atypical presentation and fails to meed any of the diagnostic criteria established in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Despite the relatively high prevalence of depression in epilepsy and its frequent atypical presentation, there has been only one controlled study (in 1979) to establish the safety and efficacy of antidepressant drugs in PWE. Accordingly, clinicians must rely on data from studies of pharmacotherapy of primary depression. These data are adequate to guide the clinician in the basic principles of pharmacotherapy of depression in PWE. Many questions are yet to be answered, including: 1) are the expectations of symptom remission to pharmacotherapy in PWE different in typical and atypical forms of depression, and do they differ from those of patients with primary depression? and 2) are the doses of antidepressant drugs necessary to yield symptom remission different between PWE and those patients with primary mood disorders

Obstructive and central sleep apnoea in a patient with medically intractable epilepsy

A woman in her 30s with medically intractable epilepsy and Lennox-Gastaut Syndrome on multiple antiseizure medications and with a deep brain stimulator presented to the epilepsy monitoring unit with increased seizure frequency. She was noted to have periods of apparent apnoea time linked to bursts of epileptiform activity on continuous video EEG monitoring. Once the clinical seizures were controlled, she was discharged to the sleep laboratory. She was noted to have obstructive and central sleep apnoea, which improved with the use of positive airway pressure. Central sleep apnoeas were time linked to electrographic seizures. Ictal central apnoea can easily be overlooked and is likely more common than currently recognised in patients with epilepsy. Ictal central apnoea may be a biomarker for sudden unexpected death in epilepsy

Epidural cylinder electrodes for presurgical evaluation of intractable epilepsy: technical note

This is a technical report describing a different technique for the insertion of epidural electrodes in the preoperative evaluation of epilepsy surgery. Our experience in 67 cases using this technique is analyzed. Cylinder electrodes with multiple recording nodes spaced 1 cm apart along a Silastic core are placed into the epidural space under general anesthesia through single or multiple burr holes. We reviewed the data on 67 cases of medically intractable epilepsy requiring intracranial monitoring that had epidural cylinder electrodes placed. The electrodes were placed bilaterally or contralateral to subdural grids in 64 of the 67 cases. Continuous monitoring was performed from 1 to 3 weeks. This method was most useful when used bilaterally or contralateral to subdural grids. Definitive surgery was rendered in 48 of 67 cases. After monitoring, all electrodes were removed at bedside or upon return to the operating room for definitive surgery. There were no mortalities, infections, cerebrospinal fluid leaks, neurologic deficits, or electrode malfunctions. Two patients (2/67, 3%) did develop subdural hematomas early in our series after dural injury near the pterion; however, these patients did not sustain permanent deficit. Epidural cylinders are another option for preoperative monitoring, useful for determining lobe or laterality of seizure genesis. They offer an alternate method to EPEs in cases where epidural recording is desirable. The cylinder electrodes are easy to place and can be removed without a return to the operating theater. The electrodes' minimal mass effect allows them to be safely placed bilaterally or contralateral to subdural grids. The epidural cylinders can monitor cortex with a greater density of nodes and can access regions not amenable to EPEs

Predicting white matter targets for direct neurostimulation therapy

A novel depth electrode placement planning strategy is presented for propagating current to distant epileptic tissue during direct neurostimulation therapy. Its goal is to predict optimal lead placement in cortical white matter for influencing the maximal extent of the epileptic circuit. The workflow consists of three fundamental techniques to determine responsive neurostimulation depth lead placement in a patient with bilaterally independent temporal lobe epileptogenic regions. (1) Pre-implantation finite element modeling was used to predict the volume of cortical activation (VOCA). This model estimated the electric field and neural tissue influenced surrounding two adjacent active depth contacts prior to implantation. The calculations included anticipated stimulation parameters. (2) Propagation of stimulation therapy was simulated pre-implantation using the VOCA model positioned in the subject's diffusion tensor imaging (DTI) determined 8 h post-ictally compared to an interictal DTI. (3) Validation of the predicted stimulated anatomical targets was determined 4.3 months post-implantation using subtracted activated SPECT (SAS). Presurgically, the modeling system predicted white matter connectivity and visual side-effects to stimulation. Post-implantation, SAS validated focal blood flow changes in ipsilateral occipital and frontal regions, and contralateral temporal lobe. This workflow demonstrates the feasibility of planning white matter–electrode placement with individual specificity to predict propagation of electrical current throughout an epileptic circuit