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Objectives: Posterior location affects the clinical presentation and outcome of ischemic stroke, but little is known about occipital intracerebral hemorrhage (ICH). We studied non-traumatic occipital ICH phenotype, outcome, and post-ICH epilepsy., Materials and Methods: Occipital ICH patients were retrospectively identified from the Helsinki ICH Study registry of 1013 consecutive ICH patients treated in our tertiary center in 2005-2010. They were compared to non-occipital ICH patients to evaluate the effect of location on functional outcome at discharge (dichotomized modified Rankin Scale, mRS), 3- and 12-month mortality, and incidence of epilepsy., Results: We found 19 occipital ICH patients (5.3% of lobar and 1.9% of all ICH). Compared to non-occipital lobar ICHs, they were younger (median age 63 vs 71 years, P = .007) and had lower National Institutes of Health Stroke Scale on admission (1 vs 8, P < .001), smaller hematoma volume (6.3 vs 17.7 ML, P = .008), and more frequently structural etiology underlying the ICH (26% vs 7%, P = .01). Mortality at both 3 and 12 months was 6%, whereas 84% reached favorable outcome (mRS 0-2) at discharge. Occipital location was associated with favorable outcome at discharge in lobar ICH (OR 11.02, 95% CI 1.55-78.20). Incidence of post-ICH epilepsy (median follow-up 2.7 years) was 18%, equaling to that of non-occipital lobar ICH., Conclusions: Occipital ICH patients are younger, have less severe clinical presentation, smaller hematoma volume, more often structural etiology, and better outcome than other ICH patients. They exhibit a similar risk of epilepsy as non-occipital ICHs., (© 2020 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Objectives: We aimed to determine the regional incidence and mortality of adult epilepsy, compare mortality rates with the expected in the general population, and identify predictors of shorter survival., Materials and Methods: We included all consecutive newly diagnosed epilepsy visited at a university hospital in Spain throughout 2012. We collected all relevant clinical data up to December 2018. We analyzed the incidence of epilepsy in our catchment area, studied mortality rates, and explored factors predictive of shorter survival., Results: The annual incidence of epilepsy among adults was 37.7 cases/100,000 inhabitants. We studied 110 patients with newly diagnosed epilepsy. Mean age was 52.6 years, and 53.6% were men. Eighty-nine patients (80.9%) had focal epilepsy, 50 (45.5%) had a structural etiology, and 45 (40.9%) had an unknown cause. Nineteen patients died over a median follow-up of 5.3 years. Mortality was almost four times higher than expected in general population and was increased in patients aged 40-59 years. Mortality rates were 5.5%, 12%, and 16.8% in the first, second, and third year, after which they remained stable to the end of follow-up. Independent predictors of mortality were age (p = 0.001), tumor-related epilepsy (p = 0.003), and generalized seizures (p = 0.020)., Conclusions: There is a high incidence of epilepsy among adults in our geographic area, with a mortality rate quadrupling that expected for the general population. Age, generalized seizures, and tumor-related epilepsy are independently associated with a higher risk of death., (© 2020 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Objectives: Sudden death is a recognized consequence of epilepsy. Little is known about the practice of confirming the cause of sudden death from most nations. We sought to determine how often autopsy is undertaken, clinician confidence in cause of death and identify the factors which may influence autopsy utilization., Materials & Methods: An online questionnaire survey was sent to all International League Against Epilepsy (ILAE) chapters chairpersons, asking them to complete the survey based on their perceptions in their country. Questions included: confidence in cause of death in people with epilepsy, frequency of autopsy uptake, and perceived barriers to an accurate diagnosis and ongoing research work. Data were analyzed by chi-squared, Kruskal-Wallis and Spearman rank analysis., Results: Responses were obtained from 77 of 114 individual chapter leaders (68%). Legal, coronial, family attitudes, including cultural and religious factors, to autopsy were considered the major barriers to obtaining an accurate diagnosis. Only 13% had a high level of confidence in the accuracy of the cause of death. There was greater confidence in the diagnosis of the causes of sudden death in epilepsy in the countries with higher autopsy rates. Sixty-six percent of responders were not aware of published or unpublished research or audits on sudden death in epilepsy in their country in the last decade., Conclusions: Significant disparities exist in the investigation of sudden death in epilepsy across countries and identified factors in this study provide an opportunity to formulate a global public health strategy to help overcome this gap., (© 2019 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Sudden unexpected death in epilepsy (SUDEP) is one of the most important direct epilepsy-related causes of death, with an incidence in adults of 1.2 per 1000 person-years. Generalized tonic-clonic seizures have consistently emerged as the leading risk factor for SUDEP, particularly when such seizures are uncontrolled. High seizure burden, lack of antiepileptic drug (AED) treatment, polytherapy, intellectual disability, and prone position at the time of death are other key risk factors. Unfortunately, despite advances in treatment, overall mortality rates in epilepsy are rising. It is imperative that we learn more about SUDEP so that effective prevention strategies can be implemented. To help identify persons at greater risk of SUDEP and in need of closer monitoring, biomarkers are needed. Candidate biomarkers include electrocardiographic, electroencephalographic, and imaging abnormalities observed more frequently in those who have died suddenly and unexpectedly. As our knowledge of the pathophysiologic mechanisms behind SUDEP has increased, various preventative measures have been proposed. These include lattice pillows, postictal oxygen therapy, selective serotonin reuptake inhibitors, and inhibitors of opiate and adenosine receptors. Unfortunately, no randomized clinical trials are available to definitively conclude these measures are effective. Rather, gaining the best control of seizures possible (with AEDs, devices, and resective surgery) still remains the intervention with the best evidence to reduce the risk of SUDEP. In this evidence-based review, we explore the incidence of SUDEP and review the risk factors, biomarkers, and latest prevention strategies., (© 2018 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

People with epilepsy (PWE) have a higher risk of mortality in comparison with the general population. This in part reflects intrinsic factors or associated comorbidities, but poor adherence to anti-epileptic drugs (AED) has also been shown to contribute to increased risk of death and increased utilization of unscheduled care. The aim of this review was to determine the prevalence of non-adherence to AED in PWE, evaluate whether specific clinical and demographic features can allow clinicians to identify those at highest risk and identify the methods and techniques that can be used to improve adherence in clinical settings. We identified relevant studies for the prevalence of medication non-adherence in PWE by searching MEDLINE (1946-7 Dec 2015), EMBASE (1947-7 Dec 2015) and Cochrane Library (1946-7 Dec 2015) as per predefined inclusion and exclusion criteria. We included 17 research studies from our review of the medical literature to determine the prevalence of medication non-adherence in epilepsy. The prevalence of significant medication non-adherence in epilepsy has been reported to vary between 26% and 79%. This variation partly reflects the differences in defining what clinically significant medication adherence is, the methods used to estimate the scale of the problem and the underlying population heterogeneity. A number of clinical and demographic features have been associated with poor adherence allowing clinicians to identify those at greatest risk. Educating patients and their carers about the risks associated with poor adherence, certain behavioural interventions and simplifying their drug regimens have been shown to improve adherence., (© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Objectives: Lamotrigine (LTG) has recently been shown to inhibit the cardiac rapid delayed rectifier potassium ion current (Ikr). Ikr-blocking drugs may increase the risk of cardiac arrhythmia and sudden unexpected death. With this background, it may be of importance that in our outpatient clinic between August 1, 1995 and August 1, 2005 we registered four consecutive cases of sudden unexpected death in epilepsy (SUDEP) in non-hospitalized patients that were all being treated with LTG in monotherapy. Here we describe and discuss these cases, the relevant literature, and the reasons to question whether these events were as a result of coincidence alone., Methods: All the cases were collected consecutively at the outpatient clinic, Department of Neurology, Stavanger University Hospital, Norway. Clinical and pathological data were obtained and the relevant literature reviewed., Results: All were females with idiopathic epilepsy., Conclusions: A systematic study is needed to reveal whether LTG may increase the risk of SUDEP in certain groups of patients.

Objective: To assess the prognosis of epilepsy, the possibility of achieving remission of seizures, in patients who were identified in a population-based study carried out in Junín, a city of about 70,000 inhabitants in Buenos Aires Province, Argentina. On January 1, 1991 (prevalence day), 106 people had epilepsy, including 64 (60%) with the condition active., Methods: Eight years later, we revisited the patients identified in the prevalence study. We analyzed risk factors in relation to remission of seizures. We also confirmed the specific cause of death., Results: Ninety-six patients were revisited (10 were completely lost to follow-up). We divided them into two groups: the group in terminal remission (defined as a seizure-free period that extended from prevalence day until the visit day in 1998) which included 64 people (66.7%), and the group of those who continued to have seizures which included 32 (33.3%) patients, of whom eight (25%) died. The overall standardized mortality ratio was 2.45; the rate was two and a half times that of the general national population., Conclusion: The better prognosis was observed in the group with generalized idiopathic epilepsy syndrome. Patients with epilepsy secondary to underlying structural causes had the worst prognosis, with higher mortality.

Objective: To examine the secular trend in the mortality associated with chronic epilepsy., Material and Methods: Using data from the Chalfont Centre for Epilepsy, UK, a residential centre for people with epilepsy, we determined the standardized mortality ratio (SMR) in the Chalfont population for each 5-year epoch from 1896 to 1965., Results: The SMR was found to be between 2 and 3 for most 5 year epochs from 1896 to 1965., Conclusion: Changes in the average age and disability of the residents at the Chalfont Centre confound a definite conclusion, but the evidence suggests the possibility that an excess mortality has been associated with chronic epilepsy for 100 years despite major changes in treatment.

All patients over the age of 60 who experienced seizures between 1979-83, were registered. The number of deaths was registered until July 2, 1985. Included were 162 patients who received no anti-epileptic drugs prior to the study period; 87 patients had established epilepsy at the time of admission. The number of deaths among previously untreated patients significantly exceeded expectation. Mortality was not significantly correlated to severity of epilepsy. In patients with brain tumor all but one died within the first year. Mortality among patients with postapoplectic seizures was significantly higher than expected being especially during the first year. Numbers of deaths among patients with seizures of unknown cause did not differ from the expected, neither did causes of death. Numbers of deaths in patients with established epilepsy at the time of admission was significantly higher than expected although none had malignant tumours and only 4 had postapoplectic seizures thus illustrating the influence of selecting patients with chronic active epilepsy. Eleven patients died suddenly and unexpectedly of unknown cause, which was more than expected. These patients were found dead under circumstances compatible with death occurring during seizure. Epilepsy was mentioned on the death certificate in only one case, indicating that the frequency of sudden, unexpected death among epileptics could easily be underestimated.

A defined general population of 159,200 male and female native Swedes born in the period 1911-1940 from an urban catchment area of the then only general hospital, was followed over a decade (1970-79) with regard to in-patient hospitalization for all kinds of diagnoses. As a part of this population cohort study, multiple sclerosis cases (n = 351) and epilepsy cases (n = 648) were studied for association with other diseases. Unexpectedly, a cluster of diseases encompassing tuberculosis, bronchial asthma, diabetes mellitus and myocardial infarction, among the diseases associated with multiple sclerosis, also forms a gradient; this suggests a quantitative rather than a qualitative multifactorial model of disease for the understanding of the pathogenesis of MS. In epilepsy, heterogeneity was suggested as being mainly linked to the presence or absence of co-existing alcoholism. Brain tumours in cases of epilepsy were found almost exclusively in the latter subset and prevailing among younger people independent of sex (with an almost 100-fold excess rate of that disease combination as expected by chance only).

In a material of sudden, unexpected death of epileptic patients treated with one or more of the anticonvulsants phenobarbitone, phenytoin and carbamazepine we found subtherapeutic drug levels in half of the cases and lethal concentrations, mainly of phenobarbitone, in one third of the cases. The results illustrate the severe consequences of noncompliance in epilepsy, and stress the value of blood drug level control.