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ObjectiveThe use of medical cannabis among people with epilepsy (PWE) has been garnering increasing interest. In this scoping review, we aimed to summarize the literature on recreational/non-medical cannabis (NMC) use in PWE, focusing on the experience, habits, and beliefs of PWE regarding NMC.MethodsFour databases (OVID Medline, OVID Embase, Ovid APA PsycInfo, and Web of Science) were searched for studies describing NMC use in PWE. NMC was defined as cannabis products procured from sources other than by prescription. Studies that consisted in original research and that detailed the experience, habits, and/or beliefs of PWE regarding NMC use were included in the analysis. Data pertaining to study identification, demographics, NMC use, and epilepsy characteristics were extracted. Descriptive statistical analyses and reflexive thematic analyses were performed to map these data.ResultsIn total, 3,228 records were screened, and 66 were included for analysis: 45 had mainly adult samples, whereas 21 had mainly pediatric samples. Most studies were published after 2010, originated from the USA, and were cross-sectional. The median number of PWE using cannabis in these studies was 24.5 (1–37,945). No studies showcased elderly PWE, and most had predominantly Caucasian samples. The lifetime prevalence of NMC use in PWE was variable, ranging between 0.69 and 76.8%. Factors frequently associated with NMC use in PWE were male sex, younger adult age, and lower education status. Children with epilepsy took NMC primarily for seizure control, using high CBD/THC ratios, and only orally. Adults with epilepsy took NMC for various reasons including recreationally, using variable CBD/THC ratios, and predominantly through smoking. The majority of PWE across all studies perceived that NMC aided in seizure control. Other aspects pertaining to NMC use in PWE were rarely reported and often conflicting.ConclusionThe literature on NMC use in PWE is sparse and heterogeneous, with many salient knowledge gaps. Further research is necessary to better understanding the experience, habits, and beliefs of PWE pertaining to NMC.

IntroductionMechanisms underlying sudden unexpected death in epilepsy (SUDEP) are unclear, but autonomic disorders are thought to play a critical role. However, those dysfunctions have mainly been reported in the peri-ictal context of generalized tonic–clonic seizures. Here, we explored whether heart rate variability (HRV), heart rate (HR), and breathing rate (BR) changes could be observed perictally during focal seizures with or without impaired awareness as well as interictally to assess the risk of SUDEP. We report the case of a 33-year-old patient with drug-resistant bilateral temporal lobe epilepsy who died at home probably from an unwitnessed nocturnal seizure (“probable SUDEP”).MethodsIctal and interictal HRV as well as postictal cardiorespiratory analyses were conducted to assess autonomic functions and overall SUDEP risk. The SUDEP patient was compared to two living male patients from our local database matched for age, sex, and location of the epileptic focus.ResultsInterictal HRV analysis showed that all sleep HRV parameters and most awake HRV parameters of the SUDEP patient were significantly lower than those of our two control subjects with bitemporal lobe epilepsy without SUDEP (p < 0.01). In two focal with impaired awareness seizures (FIAS) of the SUDEP patient, increased postictal mean HR and reduced preictal mean high frequency signals (HF), known markers of increased seizure severity in convulsive seizures, were seen postictally. Furthermore, important autonomic instability and hypersensitivity were seen through fluctuations in LF/HF ratio following two seizures of the SUDEP patient, with a rapid transition between sympathetic and parasympathetic activity. In addition, a combination of severe hypopnea (202 s) and bradycardia (10 s), illustrating autonomic dysfunction, was found after one of the SUDEP patient’s FIAS.DiscussionThe unusual cardiorespiratory and HRV patterns found in this case indicated autonomic abnormalities that were possibly predictive of an increased risk of SUDEP. It will be interesting to perform similar analyses in other SUDEP cases to see whether our findings are anecdotal or instead suggestive of reliable biomarkers of high SUDEP risk in focal epilepsy, in particular focal with or without impaired awareness seizures.

Abstract Distinguishing non-epileptic events, especially psychogenic non-epileptic seizures (PNES), from epileptic seizures (ES) constitutes a diagnostic challenge. Misdiagnoses are frequent, especially when video-EEG recording, the gold-standard for PNES confirmation, cannot be completed. The issue is further complicated in cases of combined PNES with ES. In emergency units, a misdiagnosis can lead to extreme antiepileptic drug escalade, unnecessary resuscitation measures (intubation, catheterization, etc.), as well as needless biologic and imaging investigations. Outside of the acute window, an incorrect diagnosis can lead to prolonged hospitalization or increase of unhelpful antiepileptic drug therapy. Early recognition is thus desirable to initiate adequate treatment and improve prognosis. Considering experience-based strategies and a thorough review of the literature, we aimed to present the main clinical clues for physicians facing PNES in non-specialized units, before management is transferred to epileptologists and neuropsychiatrists. In such conditions, patient recall or witness-report provide the first orientation for the diagnosis, recognizing that collected information may be inaccurate. Thorough analysis of an event (live or based on home-video) may lead to a clinical diagnosis of PNES with a high confidence level. Indeed, a fluctuating course, crying with gestures of frustration, pelvic thrusting, eye closure during the episode, and the absence of postictal confusion and/or amnesia are highly suggestive of PNES. Moreover, induction and/or inhibition tests of PNES have a good diagnostic value when positive. Prolactinemia may also be a useful biomarker to distinguish PNES from epileptic seizures, especially following bilateral tonic-clonic seizures. Finally, regardless the level of certainty in the diagnosis of the PNES, it is important to subsequently refer the patient for epileptological and neuropsychiatric follow-up.

Functional near-infrared spectroscopy (fNIRS) is currently the only non-invasive method allowing for continuous long-term assessment of cerebral hemodynamic. We evaluate the feasibility of using continueous electroencephalgraphy (cEEG)-fNIRS to study the cortical hemodynamic associated with status epilepticus (SE), burst suppression (BS) and periodic discharges (PDs). Eleven adult comatose patients admitted to the neuroICU for SE were recruited, and cEEG-fNIRS monitoring was performed to measure concentration changes in oxygenated (HbO) and deoxygenated hemoglobin (HbR). Seizures were associated with a large increase HbO and a decrease in HbR whose durations were positively correlated with the seizures' length. Similar observations were made for hemodynamic changes associated with bursts, showing overall increases in HbO and decreases in HbR relative to the suppression periods. PDs were seen to induce widespread HbO increases and HbR decreases. These results suggest that normal neurovascular coupling is partially retained with the hemodynamic response to the detected EEG patterns in these patients. However, the shape and distribution of the response were highly variable. This work highlighted the feasibility of conducting long-term cEEG-fNIRS to monitor hemodynamic changes over a large cortical area in critically ill patients, opening new routes for better understanding and management of abnormal EEG patterns in neuroICU.

Background: Epilepsy surgery failure is not uncommon, with several explanations having been proposed. In this series, we detail cases of epilepsy surgery failure subsequently attributed to insular involvement. Methods: We retrospectively identified patients investigated at the epilepsy monitoring units of two Canadian tertiary care centers (2004–2020). Included patients were adults who had undergone epilepsy surgeries with recurrence of seizures post-operatively and who were subsequently determined to have an insular epileptogenic focus. Clinical, electrophysiological, neuroimaging, and surgical data were synthesized. Results: We present 14 patients who demonstrated insular epileptic activity post-surgery-failure as detected by intracranial EEG, MEG, or seizure improvement after insular resection. Seven patients had manifestations evoking possible insular involvement prior to their first surgery. Most patients (8/14) had initial surgeries targeting the temporal lobe. Seizure recurrence ranged from the immediate post-operative period to one year. The main modality used to determine insular involvement was MEG (8/14). Nine patients underwent re-operations that included insular resection; seven achieved a favorable post-operative outcome (Engel I or II). Conclusions: Our series suggests that lowering the threshold for suspecting insular epilepsy may be necessary to improve epilepsy surgery outcomes. Detecting insular epilepsy post-surgery-failure may allow for re-operations which may lead to good outcomes.