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Semiologic stratification of generalized tonic clonic seizures and post-ictal electrographic findings [Meeting Abstract]

Carlson, C; Berk, T; French, J; Kuzniecky, R; Dugan, P; Gazzola, D; Friedman, D
Rationale: The Generalized Tonic-Clonic Convulsion (GTCC) is often associated with post-ictal electrographic slowing, and at times suppression. The mechanism of post-ictal EEG suppression is not known but may reflect involvement of bilateral subcortical networks. We examined the electrographic activity occurring after seizures with bilateral movement to determine if there are post-ictal features unique to the GTCC. Methods: We reviewed the video EEG of 100 consecutive inpatients of the NYU Comprehensive Epilepsy Center that had bilateral movement as part of their seizure semiology. Each seizure was reviewed by 2 reviewers; any records in which the patient was obscured on the video were excluded from further analysis. Any seizure with bilateral symmetric tonic, vibratory and clonic phases (defined as bilateral movement > and < 5 Hz respectively) in that order was categorized as "typical GTCC" (tGTCC). If one phase was absent, asymmetric or the progression was different, it was considered an "atypical GTCC" (aGTCC). If two phases were absent it was not a GTCC (nGTCC). All aGTCC were reviewed by at least 3 reviewers. The post-ictal EEG was categorized as: "suppression", defined as background voltage <10uV; "slowing" defined as decreased amplitude and/or frequency compared to baseline while still >10uV; or "no change from baseline." Results: 104 seizures from 100 patients were reviewed, 5 patients were excluded due to obscured video or EEG, leaving 97 seizures reviewed. 41 were tGTCC, 14 were aGTCC and 42 were nGT
EMBASE:71197052
ISSN: 1535-7597
CID: 612712

Semiologic stratification of generalized tonic clonic seizures [Meeting Abstract]

Berk, T; Friedman, D; Gazzola, D; Dugan, P; Carlson, C; Kuzniecky, R; French, J
Rationale: The Generalized Tonic-Clonic Convulsion (GTCC) has been described as a stereotyped seizure consisting of a symmetric tonic posture, followed by vibratory and clonic phases - defined as movements at a frequency of >5 Hz and <5 Hz respectively. We examined how frequently the classic GTCC occurs in a population and what factors, if any, contributed to deviations from this pattern. Methods: We reviewed the video EEG of 100 consecutive inpatients of the NYU Comprehensive Epilepsy Center that had bilateral limb movements as part of their seizure semiology. Each seizure was reviewed by 2 reviewers; any records in which the patient was obscured on the video were excluded from further analysis. Any seizure with bilateral symmetric tonic, vibratory and clonic phases in that order was categorized as "typical GTCC" (tGTCC), if one phase was absent, asymmetric or in the wrong order of progression it was considered "atypical GTCC" (aGTCC), if two phases were absent it was not a GTCC (nGTCC). All aGTCC were reviewed by at least 3 reviewers. Results: 104 seizures (41 from women) from 100 patients were reviewed, 2 patients were excluded due to obscured video. 45 had a tGTCC while 15 were aGTCC, and 42 were nGT
EMBASE:71196668
ISSN: 1535-7597
CID: 612752

Psychogenic nonepileptic seizures and chronic pain: A retrospective case-controlled study

Gazzola, Deana M; Carlson, Chad; Rugino, Angela; Hirsch, Scott; Starner, Karen; Devinsky, Orrin
PURPOSE: Psychogenic nonepileptic seizures (PNES) can be challenging to diagnose, but certain clinical features can help to distinguish PNES from epileptic seizures. The purpose of this study is to assess chronic pain and prescribed pain medication use in PNES patients. METHODS: A case-controlled, retrospective analysis was performed examining pain medication use in 85 PNES patients versus an active control group of 85 patients with idiopathic generalized epilepsy (IGE). RESULTS: Chronic pain was more frequent among PNES patients (N=40) than active controls (N=10) (p<0.0001). Reported use of prescription pain medication was higher among PNES patients (N=20) versus active controls (N=6) (p=0.0048). The Positive Predictive Value of prescription pain medications for PNES patients was 76.9%. Opioid use in the PNES population was higher compared with active controls (p=0.0096). When excluding patients with a dual diagnosis of PNES and epilepsy from the latter two analyses and comparing these results to those that included this patient population, no statistically significant difference in results was found. CONCLUSIONS: Patients with PNES are more likely than those with IGE to report chronic pain disorders. A history of chronic pain and opioid use among patients with seizures raises the possibility of PNES. Among patients with PNES and chronic pain, a psychogenic etiology for pain and non-opiate pain management strategies should be considered.
PMID: 23165141
ISSN: 1525-5050
CID: 197382

Normal neuroimaging and epilepsy treatment: A retrospective consecutive case series [Meeting Abstract]

Werely, J; Carlson, C; French, J A; Dugan, P; Cahill, M; Gazzola, D M
Rationale: In patients with refractory focal epilepsy, surgery remains an important treatment option for achieving seizure freedom. However, the existing data suggest that for patients with normal neuroimaging, the likelihood of achieving seizure freedom is significantly reduced compared to patients with lesional neuroimaging. This study assesses the utilization of resective surgery versus medical management in patients with normal neuroimaging. Specifically, the study aims to determine how frequently patients with normal brain MRIs are referred for epilepsy surgery and whether there is a difference in outcome (i.e. seizure control) between medically managed and surgically managed patients. Methods: Following approval through the Institutional Review Board at New York University School of Medicine, patients were retrospectively identified by querying the surgical multidisciplinary case (MDC) conference registry. The records were reviewed from January 1, 2007 - July 31, 2008 to identify patients. Inclusion criteria were: age >=18 years, focal epilepsy diagnosis >=2 years, failed >=1 medication, and >=1 seizure three months prior to admission. Of all patients meeting these criteria, 193 were presented at the MDC conference and 33 had normal MRIs upon review. Seizure frequency data were collected by chart review, and when data were incomplete, the patient's primary epileptologist at the NYU Comprehensive Epilepsy Center was contacted. Comparisons were made between the two groups (surgical versus nonsurgical treatment) utilizing the Student's t-test and Fisher's exact test. Results: Of the 33 patients with normal neuroimaging who were presented at MDC, 19 went on to epilepsy surgery (9 women) and 14 were managed medically (7 women); all patients undergoing invasive monitoring underwent resective surgery. The mean age at the time of MDC did not differ between groups (surgery: 30.1+/-10.4, medical: 29+/-10.6; p>0.76). Although a trend for a younger mean age at seizure onset was seen for medically managed patients (surgery: 16.6+/-9.3, medical: 10.9+/-8.8; p>0.09), no significant difference was seen for duration (in years) of epilepsy at the time of MDC (surgery: 13.6+/-10.2, medical: 18.1+/-12.5; p>0.26). At the time of last follow-up, 7 (36.8%) surgical patients were seizure free and 3 (21.4%) medically managed patients were seizure free (p=0.46). Conclusions: Across one and a half years, only 33 of 193 (17.1%) patients reviewed at MDC had normal neuroimaging and focal epilepsy. Ten (30.3%) of the 33 patients were completely seizure free (Engel IA) at last follow-up (with either medical or surgical management). Nineteen of the patients with normal neuroimaging went on to resective surgery with seven (36.8%) becoming seizure free, whereas three (21.4%) of the 14 who were managed medically became seizure free. These data demonstrate that patients with normal neuroimaging represent a minority of those presented at MDC. Although not seen in the majority of cases with normal neuroimaging, seizure freedom can be achieved through either surgical or medical management
EMBASE:70829996
ISSN: 1535-7597
CID: 174513

Newer antiepileptic drugs

Chapter by: Gazzola, DM; Delanty, N; French, JA
in: Wyllie's Treatment of Epilepsy: Principles and Practice by
pp. 771-778
ISBN: 9781451153484
CID: 2171092

New generation antiepileptic drugs: what do they offer in terms of improved tolerability and safety?

French, Jacqueline A; Gazzola, Deana M
Over the last two decades a total of 11 antiepileptic drugs (AEDs) have been introduced to the US market. Randomized, placebo-controlled trials have yielded information about each drug's efficacy, tolerability, and safety profile; however, few studies have compared the newer generation AEDs directly with the older generation. Comparative studies are not always straightforward in their interpretation, as many characteristics of drugs, both favorable and unfavorable, may not be highlighted by such studies. In general, findings from the literature suggest that the newer generation AEDs (including vigabatrin, felbamate, gabapentin, lamotrigine, tiagabine, topiramate, levetiracetam, oxcarbazepine, zonisamide, pregabalin, rufinamide, and lacosamide) enjoy both improved tolerability and safety compared with older agents such as phenobarbital, phenytoin, carbamazepine, and valproate. This is partially supported by some of the findings of the QSS and the TTA Committee of the American Academy of Neurology (AAN), whose review of four AEDs (gabapentin, lamotrigine, topiramate, and tiagabine) is discussed. Briefly, when compared with carbamazepine, lamotrigine was better tolerated; topiramate adverse events (AEs) were fairly comparable to carbamazepine and valproate; and tiagabine compared with placebo was associated with a higher discontinuation rate due to AEs. The findings of the SANAD trial are also presented; when administered to patients with partial epilepsy, carbamazepine was most likely to fail due to AEs, and lamotrigine and gabapentin were least likely to fail due to AEs. When administered to patients with idiopathic generalized epilepsy, topiramate was most frequently associated with AE-related discontinuation, followed by valproate; and while valproate was the most efficacious drug in this arm of the study, lamotrigine was more tolerable. What makes the SANAD study valuable and somewhat unique is its head-to-head comparison of one drug with another. Such comparative trials are overall lacking for new AEDs, although some conclusions can be drawn from the available data. In the end, however, AED selection must be based on individual patient and drug characteristics.
PMCID:4110862
PMID: 25083209
ISSN: 2042-0986
CID: 1090422

Differentiating between nonepileptic and epileptic seizures

Devinsky, Orrin; Gazzola, Deana; LaFrance, W Curt Jr
Psychogenic nonepileptic seizures (PNES) resemble epileptic seizures and are often misdiagnosed and mistreated as the latter. Occasionally, epileptic seizures are misdiagnosed and mistreated as PNES. 70% of PNES cases develop between the second and fourth decades of life, but this disease can also affect children and the elderly. At least 10% of patients with PNES have concurrent epileptic seizures or have had epileptic seizures before being diagnosed with PNES. Psychological stress exceeding an individual's coping capacity often precedes PNES. Clinicians can find differentiating between PNES and epileptic seizures challenging. Some clinical features can help distinguish PNES from epileptic seizures, but other features associated with PNES are nonspecific and occur during both types of seizures. Diagnostic errors often result from an overreliance on specific clinical features. Note that no single feature is pathognomonic for PNES. When typical seizures can be recorded, video-EEG is the diagnostic gold standard for PNES, and in such cases a diagnosis can be made with high accuracy. When video-EEG reveals no epileptiform activity before, during or after the ictus, thorough neurological and psychiatric histories can be used to confirm the diagnosis of PNES. In this article, we review the clinical features that can help clinicians differentiate between PNES and epileptic seizures
PMID: 21386814
ISSN: 1759-4766
CID: 134078

Epilepsy [Comment]

Gazzola, Deana M; Kuzniecky, Ruben I
PMID: 18418323
ISSN: 1545-2913
CID: 95776

Clinical trials in epilepsy: the SANAD study [Comment]

Gazzola, Deana M; French, Jacqueline A
PMID: 18418324
ISSN: 1545-2913
CID: 96099

Seizure-free outcome in randomized add-on trials of the new antiepileptic drugs

Gazzola, Deana M; Balcer, Laura J; French, Jacqueline A
PURPOSE: The goal of this study is to (1) provide clinically useful, previously unpublished comparative analyses of seizure-freedom rates for newer antiepileptic drugs (AEDs), and (2) recommend a standard for data presentation and analysis. METHODS: Data were reviewed from placebo-controlled adjunctive trials in refractory patients of gabapentin (GPN), lamotrigine (LTG), topiramate (TOP), tiagabine (TGB), oxcarbazepine (OXC), levetiracetam (LEV), zonisamide (ZNS), and pregabalin (PGB). Seizure-freedom analyses in these publications, if included at all, consistently included both patients who completed the trial, and those who dropped out prior to completion (last observation carried forward, LOCF). This has the potential to increase reported seizure-free outcomes. Pharmaceutical companies were contacted for the provision of unpublished seizure-free data in the patients who completed the entire study. RESULTS: In most cases, LOCF analysis produced a higher rate of seizure freedom compared to complete analysis. A total of 0%-1.1% of the LOCF population was seizure-free in the GPN trials (complete data not available). For the remaining AEDs, seizure-freedom results in the LOCF versus complete populations were: 0.7% versus 0.8% (LTG trial); 12% versus 2.6% (OXC trial); 3.6%-6.4% versus 3.9%-7.1% (LEV trial); 3.7%-7.9% versus 1.3%-1.4% (PGB trial); and 6.0% versus 3.0% (ZNS trial, minus titration period). CONCLUSIONS: By employing LOCF, a clinically unrealistic picture of seizure-free rates may be reported. Access to complete data is informative, as it includes only those patients who were able to tolerate the drug at doses that produced seizure freedom. Ideally, data from both ITT and complete analyses should be made available
PMID: 17521343
ISSN: 0013-9580
CID: 74773