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Introduction: Epilepsy affects around 50 million people worldwide and is associated with lower quality of life scores, an increased risk of premature death, and significant socio-economic implications. The lack of updated evidence on current epidemiology and patient characterization creates considerable uncertainty regarding the epilepsy burden in Portugal. The study aims to characterize and quantify the epilepsy patients who have been hospitalized, with medical or surgical procedures involved, and to analyze their associated comorbidities and mortality rates., Methods: A multicenter retrospective study was conducted using hospital production data of epilepsy patients. The study included all patients diagnosed with epilepsy-related International Classification of Diseases-9/10 codes between 2015 and 2018 in 57 Portuguese National Health Service (NHS) hospitals (n = 57 institutions). Patient characterization and quantification were done for all patients with an epilepsy diagnosis, with specific analyses focusing on those whose primary diagnosis was epilepsy. Baseline, demographic, and clinical characteristics were analyzed using descriptive statistics., Results: Between 2015 and 2018, a total of 80,494 hospital episodes (i.e., patient visit that generates hospitalization and procedures) were recorded, with 18 % to 19 % directly related to epilepsy. Among these epilepsy-related hospital episodes, 13.0 % led to short term hospitalizations (less than 24 h). Additionally, the average length of stay for all these epilepsy-related episodes was 8 days. A total of 49,481 patients were identified with epilepsy based on ICD-9/10 codes. The median age of patients was 64 years (min: 0; max: 104), with a distribution of 4.8 patients per 1,000 inhabitants. From the total of deaths (9,606) between 2015 and 2018, 14% were associated with patients whose primary diagnosis was epilepsy, with 545 of these being epilepsy-related deaths. Among patients with a primary diagnosis of epilepsy, the most common comorbidities were hypertension (24%) and psychiatric-related or similar comorbidities (15%), such as alcohol dependance, depressive and major depressive disorders, dementia and other convulsions., Conclusion: This study showed similar results to other European countries. However, due to methodological limitations, a prospective epidemiological study is needed to support this observation. Furthermore, the present study provides a comprehensive picture of hospitalized epilepsy patients in Portugal, their comorbidities, mortality, and hospital procedures., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier Inc.)

Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Background: Cerebrovascular disease (CVD) is a major contributor to epilepsy; however, patients with epilepsy also have a significantly increased risk of stroke. The way in which epilepsy contributes to the increased risk of stroke is still uncertain and is ill-characterized in neuropathological studies. A neuropathological characterization of cerebral small vessel disease (cSVD) in patients with chronic epilepsy was performed., Methods: Thirty-three patients with refractory epilepsy and hippocampal sclerosis (HS) submitted to epilepsy surgery from a reference center were selected between 2010 and 2020 and compared with 19 autopsy controls. Five randomly selected arterioles from each patient were analyzed using a previously validated scale for cSVD. The presence of CVD disease imaging markers in pre-surgical brain magnetic resonance imaging (MRI) was studied., Results: There were no differences in age (43.8 vs. 41.6 years; p = 0.547) or gender distribution (female gender 60.6% vs. male gender 52.6%; p = 0.575) between groups. Most CVD findings in brain MRI were mild. Patients had a mean time between the epilepsy onset and surgery of 26 ± 14.7 years and were medicated with a median number of three antiseizure medication (ASMs) [IQR 2-3]. Patients had higher median scores in arteriolosclerosis (3 vs. 1; p < 0.0001), microhemorrhages (4 vs. 1; p < 0.0001) and total score value (12 vs. 8.9; p = 0.031) in comparison with controls. No correlation was found between age, number of years until surgery, number of ASMs or cumulative defined daily dosage of ASM., Conclusion: The present study provides evidence supporting the increased burden of cSVD in the neuropathological samples of patients with chronic epilepsy., (© 2023 European Academy of Neurology.)

Objective: Epilepsy is a neurological disease that affects ~50 million people worldwide, 30% of which have refractory epilepsy and recurring seizures, which may contribute to higher anxiety levels and poorer quality of life. Seizure detection may contribute to addressing some of the challenges associated with this condition, by providing information to health professionals regarding seizure frequency, type, and/or location in the brain, thereby improving diagnostic accuracy and medication adjustment, and alerting caregivers or emergency services of dangerous seizure episodes. The main focus of this work was the development of an accurate video-based seizure-detection method that ensured unobtrusiveness and privacy preservation, and provided novel approaches to reduce confounds and increase reliability., Methods: The proposed approach is a video-based seizure-detection method based on optical flow, principal component analysis, independent component analysis, and machine learning classification. This method was tested on a set of 21 tonic-clonic seizure videos (5-30 min each, total of 4 h and 36 min of recordings) from 12 patients using leave-one-subject-out cross-validation., Results: High accuracy levels were observed, namely a sensitivity and specificity of 99.06% ± 1.65% at the equal error rate and an average latency of 37.45 ± 1.31 s. When compared to annotations by health care professionals, the beginning and ending of seizures was detected with an average offset of 9.69 ± 0.97 s., Significance: The video-based seizure-detection method described herein is highly accurate. Moreover, it is intrinsically privacy preserving, due to the use of optical flow motion quantification. In addition, given our novel independence-based approach, this method is robust to different lighting conditions, partial occlusions of the patient, and other movements in the video frame, thereby setting the base for accurate and unobtrusive seizure detection., (© 2023 International League Against Epilepsy.)

Importance: Acute symptomatic seizures occurring within 7 days after ischemic stroke may be associated with an increased mortality and risk of epilepsy. It is unknown whether the type of acute symptomatic seizure influences this risk., Objective: To compare mortality and risk of epilepsy following different types of acute symptomatic seizures., Design, Setting, and Participants: This cohort study analyzed data acquired from 2002 to 2019 from 9 tertiary referral centers. The derivation cohort included adults from 7 cohorts and 2 case-control studies with neuroimaging-confirmed ischemic stroke and without a history of seizures. Replication in 3 separate cohorts included adults with acute symptomatic status epilepticus after neuroimaging-confirmed ischemic stroke. The final data analysis was performed in July 2022., Exposures: Type of acute symptomatic seizure., Main Outcomes and Measures: All-cause mortality and epilepsy (at least 1 unprovoked seizure presenting >7 days after stroke)., Results: A total of 4552 adults were included in the derivation cohort (2547 male participants [56%]; 2005 female [44%]; median age, 73 years [IQR, 62-81]). Acute symptomatic seizures occurred in 226 individuals (5%), of whom 8 (0.2%) presented with status epilepticus. In patients with acute symptomatic status epilepticus, 10-year mortality was 79% compared with 30% in those with short acute symptomatic seizures and 11% in those without seizures. The 10-year risk of epilepsy in stroke survivors with acute symptomatic status epilepticus was 81%, compared with 40% in survivors with short acute symptomatic seizures and 13% in survivors without seizures. In a replication cohort of 39 individuals with acute symptomatic status epilepticus after ischemic stroke (24 female; median age, 78 years), the 10-year risk of mortality and epilepsy was 76% and 88%, respectively. We updated a previously described prognostic model (SeLECT 2.0) with the type of acute symptomatic seizures as a covariate. SeLECT 2.0 successfully captured cases at high risk of poststroke epilepsy., Conclusions and Relevance: In this study, individuals with stroke and acute symptomatic seizures presenting as status epilepticus had a higher mortality and risk of epilepsy compared with those with short acute symptomatic seizures or no seizures. The SeLECT 2.0 prognostic model adequately reflected the risk of epilepsy in high-risk cases and may inform decisions on the continuation of antiseizure medication treatment and the methods and frequency of follow-up.

More than half of adults with epilepsy undergoing resective epilepsy surgery achieve long-term seizure freedom and might consider withdrawing antiseizure medications. We aimed to identify predictors of seizure recurrence after starting postoperative antiseizure medication withdrawal and develop and validate predictive models. We performed an international multicentre observational cohort study in nine tertiary epilepsy referral centres. We included 850 adults who started antiseizure medication withdrawal following resective epilepsy surgery and were free of seizures other than focal non-motor aware seizures before starting antiseizure medication withdrawal. We developed a model predicting recurrent seizures, other than focal non-motor aware seizures, using Cox proportional hazards regression in a derivation cohort (n = 231). Independent predictors of seizure recurrence, other than focal non-motor aware seizures, following the start of antiseizure medication withdrawal were focal non-motor aware seizures after surgery and before withdrawal [adjusted hazard ratio (aHR) 5.5, 95% confidence interval (CI) 2.7-11.1], history of focal to bilateral tonic-clonic seizures before surgery (aHR 1.6, 95% CI 0.9-2.8), time from surgery to the start of antiseizure medication withdrawal (aHR 0.9, 95% CI 0.8-0.9) and number of antiseizure medications at time of surgery (aHR 1.2, 95% CI 0.9-1.6). Model discrimination showed a concordance statistic of 0.67 (95% CI 0.63-0.71) in the external validation cohorts (n = 500). A secondary model predicting recurrence of any seizures (including focal non-motor aware seizures) was developed and validated in a subgroup that did not have focal non-motor aware seizures before withdrawal (n = 639), showing a concordance statistic of 0.68 (95% CI 0.64-0.72). Calibration plots indicated high agreement of predicted and observed outcomes for both models. We show that simple algorithms, available as graphical nomograms and online tools (predictepilepsy.github.io), can provide probabilities of seizure outcomes after starting postoperative antiseizure medication withdrawal. These multicentre-validated models may assist clinicians when discussing antiseizure medication withdrawal after surgery with their patients., (© The Author(s) 2022. Published by Oxford University Press on behalf of the Guarantors of Brain. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background and Objectives: The efficacy of deep brain stimulation of the anterior nucleus of the thalamus (ANT DBS) in patients with drug-resistant epilepsy (DRE) was demonstrated in the double-blind Stimulation of the Anterior Nucleus of the Thalamus for Epilepsy randomized controlled trial. The Medtronic Registry for Epilepsy (MORE) aims to understand the safety and longer-term effectiveness of ANT DBS therapy in routine clinical practice., Methods: MORE is an observational registry collecting prospective and retrospective clinical data. Participants were at least 18 years old, with focal DRE recruited across 25 centers from 13 countries. They were followed for at least 2 years in terms of seizure frequency (SF), responder rate (RR), health-related quality of life (Quality of Life in Epilepsy Inventory 31), depression, and safety outcomes., Results: Of the 191 patients recruited, 170 (mean [SD] age of 35.6 [10.7] years, 43% female) were implanted with DBS therapy and met all eligibility criteria. At baseline, 38% of patients reported cognitive impairment. The median monthly SF decreased by 33.1% from 15.8 at baseline to 8.8 at 2 years ( p < 0.0001) with 32.3% RR. In the subgroup of 47 patients who completed 5 years of follow-up, the median monthly SF decreased by 55.1% from 16 at baseline to 7.9 at 5 years ( p < 0.0001) with 53.2% RR. High-volume centers (>10 implantations) had 42.8% reduction in median monthly SF by 2 years in comparison with 25.8% in low-volume center. In patients with cognitive impairment, the reduction in median monthly SF was 26.0% by 2 years compared with 36.1% in patients without cognitive impairment. The most frequently reported adverse events were changes (e.g., increased frequency/severity) in seizure (16%), memory impairment (patient-reported complaint, 15%), depressive mood (patient-reported complaint, 13%), and epilepsy (12%). One definite sudden unexpected death in epilepsy case was reported., Discussion: The MORE registry supports the effectiveness and safety of ANT DBS therapy in a real-world setting in the 2 years following implantation., Classification of Evidence: This study provides Class IV evidence that ANT DBS reduces the frequency of seizures in patients with drug-resistant focal epilepsy., Trial Registration Information: MORE ClinicalTrials.gov Identifier: NCT01521754, first posted on January 31, 2012., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Neurology.)

Background: Decompressive surgery has proven to be lifesaving in patients with a malignant anterior circulation ischemic stroke. Recently, some studies have shown a high frequency of epileptic seizures in patients undergoing this procedure. However, the quantification of this risk and its associated factors have not been extensively investigated., Objective: To determine the frequency of epileptic seizures and epilepsy in patients with an anterior circulation ischemic stroke admitted to our Stroke Unit from January 2006 to March 2019 that have been submitted to craniectomy and to study their associated demographic, clinical, imagiological and neurophysiological features., Methods: Retrospective observational study of 56 consecutive patients with an anterior circulation ischemic stroke that have undergone craniectomy. The frequency of seizures was both clinically and neurophysiologically assessed after reviewing clinical records, discharge or death reports and all EEGs performed during the hospital admission. Bivariate analysis was used to compare patients with and without seizures., Results: Sixteen patients (28,6%) had epileptic seizures. Bivariate analysis showed an association between the occurrence of unprovoked seizures and the median ASPECTS from the first CT performed., Conclusions: In this study, the frequency of epileptic seizures after a malignant stroke submitted to craniectomy was high, albeit lower than that reported in previous studies. The size of infarction at hospital admission appears to be a risk factor for the occurrence of epilepsy in this group of patients., Competing Interests: Declaration of Competing Interest On behalf of all authors, the corresponding author states that there is no conflict of interest., (Copyright © 2022. Published by Elsevier Ltd.)

Objective: The purpose of this study was to identify risk factors for acute symptomatic seizures and post-stroke epilepsy after acute ischemic stroke and evaluate the effects of reperfusion treatment., Methods: We assessed the risk factors for post-stroke seizures using logistic or Cox regression in a multicenter study, including adults from 8 European referral centers with neuroimaging-confirmed ischemic stroke. We compared the risk of post-stroke seizures between participants with or without reperfusion treatment following propensity score matching to reduce confounding due to treatment selection., Results: In the overall cohort of 4,229 participants (mean age 71 years, 57% men), a higher risk of acute symptomatic seizures was observed in those with more severe strokes, infarcts located in the posterior cerebral artery territory, and strokes caused by large-artery atherosclerosis. Strokes caused by small-vessel occlusion carried a small risk of acute symptomatic seizures. 6% developed post-stroke epilepsy. Risk factors for post-stroke epilepsy were acute symptomatic seizures, more severe strokes, infarcts involving the cerebral cortex, and strokes caused by large-artery atherosclerosis. Electroencephalography findings within 7 days of stroke onset were not independently associated with the risk of post-stroke epilepsy. There was no association between reperfusion treatments in general or only intravenous thrombolysis or mechanical thrombectomy with the time to post-stroke epilepsy or the risk of acute symptomatic seizures., Interpretation: Post-stroke seizures are related to stroke severity, etiology, and location, whereas an early electroencephalogram was not predictive of epilepsy. We did not find an association of reperfusion treatment with risks of acute symptomatic seizures or post-stroke epilepsy. ANN NEUROL 2021;90:808-820., (© 2021 The Authors. Annals of Neurology published by Wiley Periodicals LLC on behalf of American Neurological Association.)

An epileptic seizure is one of the causes of so-called "transient neurological events" (TNEs). The differential diagnosis of a TNE relies mainly on history and physical examination. Laboratory markers are less frequently useful. After diagnosing an epileptic seizure, a distinction must be made between an acute symptomatic and an unprovoked seizure, since they have different treatments and prognosis. History, physical examination and other examinations (laboratory and imaging) are paramount in this distinction. After the diagnosis of a first unprovoked seizure, an EEG should be requested which may aid in establishing the diagnosis, evaluating the recurrence risk or ascertaining the self-limited nature of the seizure. 3T-MRI with an epilepsy protocol can be considered when CT has not clarified the aetiology. The decision to treat should be discussed with the patient/relatives, taking into account the risk of recurrence, the clinical characteristics (aetiology, seizure type, age, job, epileptic seizure schedule, comorbidities and polymedication), probability of AED side effects, and stigmatization. Nowadays, the chosen regimen is usually monotherapy with a second-generation AED that better suits the patient's characteristics, comorbidities and concurrent medication. Counselling should include first aid, precipitating factors, sport and physical exercise in order to avoid possible driving restrictions, the need for therapy compliance, and risk of recurrence and SUDEP.

Purpose: Periodic discharges (PDs) are common in acute structural or metabolic brain lesions, but their occurrence during follow-up of epileptic patients in an outpatient setting is rare. Aim of this article was to study whether PDs on the routine outpatient scalp EEG of patients with epilepsy, as compared with nonperiodic epileptiform discharges, are associated with drug refractoriness and the decompensation of epilepsy and particular etiologies., Methods: A retrospective case-control study. EEG reports were screened for PDs and their variants. The inclusion criteria were as follows: a diagnosis of epilepsy, epileptogenic lesion on imaging, or a normal 3-T MRI. Inpatient EEGs or EEGs performed in patients with acute cerebral lesions were excluded. Age- and sex-matched controls presenting with other epileptiform EEG abnormalities were selected, and similar selection criteria were applied., Results: Forty-one patients with PDs and 82 controls were selected. There were no significant differences between the cases and controls in the rates of epilepsy decompensation at the time of EEG collection or drug refractoriness. Stroke, hippocampal sclerosis, and malformations of cortical development were the most frequent etiologies, without significant differences between the groups., Conclusions: By performing a case-control study, the authors have shown that PDs are not a marker of epilepsy decompensation and drug refractoriness and that the finding of PDs is not suggestive of particular epilepsy etiologies, when compared with other epileptiform abnormalities., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2020 by the American Clinical Neurophysiology Society.)

Stroke is the leading cause of seizures and epilepsy in older adults. Patients who have larger and more severe strokes involving the cortex, are younger, and have acute symptomatic seizures and intracerebral haemorrhage are at highest risk of developing post-stroke epilepsy. Prognostic models, including the SeLECT and CAVE scores, help gauge the risk of epileptogenesis. Early electroencephalogram and blood-based biomarkers can provide information additional to the clinical risk factors of post-stroke epilepsy. The management of acute versus remote symptomatic seizures after stroke is markedly different. The choice of an ideal antiseizure medication should not only rely on efficacy but also consider adverse effects, altered pharmacodynamics in older adults, and the influence on the underlying vascular co-morbidity. Drug-drug interactions, particularly those between antiseizure medications and anticoagulants or antiplatelets, also influence treatment decisions. In this review, we describe the epidemiology, risk factors, biomarkers, and management of seizures after an ischaemic or haemorrhagic stroke. We discuss the special considerations required for the treatment of post-stroke epilepsy due to the age, co-morbidities, co-medication, and vulnerability of stroke survivors.

Background: In cases undergoing epilepsy surgery, postoperative psychogenic nonepileptic seizures (PNES) may be underdiagnosed complicating the assessment of postsurgical seizures' outcome and the clinical management. We conducted a survey to investigate the current practices in the European epilepsy monitoring units (EMUs) and the data that EMUs could provide to retrospectively detect cases with postoperative PNES and to assess the feasibility of a subsequent postoperative PNES research project for cases with postoperative PNES., Methods: We developed and distributed a questionnaire survey to 57 EMUs. Questions addressed the number of patients undergoing epilepsy surgery, the performance of systematic preoperative and postoperative psychiatric evaluation, the recording of sexual or other abuse, the follow-up period of patients undergoing epilepsy surgery, the performance of video-electroencephalogram (EEG) and postoperative psychiatric assessment in suspected postoperative cases with PNES, the existence of electronic databases to allow extraction of cases with postoperative PNES, the data that these bases could provide, and EMUs' interest to participate in a retrospective postoperative PNES project., Results: Twenty EMUs completed the questionnaire sheet. The number of patients operated every year/per center is 26.7 ( ± 19.1), and systematic preoperative and postoperative psychiatric evaluation is performed in 75% and 50% of the EMUs accordingly. Sexual or other abuse is systematically recorded in one-third of the centers, and the mean follow-up period after epilepsy surgery is 10.5 ± 7.5 years. In suspected postoperative PNES, video-EEG is performed in 85% and psychiatric assessment in 95% of the centers. An electronic database to allow extraction of patients with PNES after epilepsy surgery is used in 75% of the EMUs, and all EMUs that sent the sheet completed expressed their interest to participate in a retrospective postoperative PNES project., Conclusion: Postoperative PNES is an underestimated and not well-studied entity. This is a European survey to assess the type of data that the EMUs surgical cohorts could provide to retrospectively detect postoperative PNES. In cases with suspected PNES, most EMUs perform video-EEG and psychiatric assessment, and most EMUs use an electronic database to allow extraction of patients developing PNES., Competing Interests: Declaration of competing interest None of the authors has any conflict of interest to disclose., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Our goal was to assess the interrater agreement (IRA) of photoparoxysmal response (PPR) using the classification proposed by a task force of the International League Against Epilepsy (ILAE), and a simplified classification system proposed by our group. In addition, we evaluated IRA of epileptiform discharges (EDs) and the diagnostic significance of the electroencephalographic (EEG) abnormalities. We used EEG recordings from the European Reference Network (EpiCARE) and Standardized Computer-based Organized Reporting of EEG (SCORE). Six raters independently scored EEG recordings from 30 patients. We calculated the agreement coefficient (AC) for each feature. IRA of PPR using the classification proposed by the ILAE task force was only fair (AC = 0.38). This improved to a moderate agreement by using the simplified classification (AC = 0.56; P = .004). IRA of EDs was almost perfect (AC = 0.98), and IRA of scoring the diagnostic significance was moderate (AC = 0.51). Our results suggest that the simplified classification of the PPR is suitable for implementation in clinical practice., (© 2020 International League Against Epilepsy.)

Cerebrovascular disease is the leading cause of epilepsy in adults, although post-stroke seizures reported frequency is variable and few studies used EEG in their identification. To describe and compare EEG and clinical epileptic manifestations frequency in patients with an anterior circulation ischaemic stroke. Prospective study of acute anterior circulation ischaemic stroke patients, consecutively admitted to a Stroke Unit over 24 months and followed-up for 1 year. All patients underwent standardized clinical and diagnostic assessment. Seizure occurrence was clinically evaluated during hospitalization and by a telephone interview at 6 months and a clinical appointment at 12 months after stroke. Video-EEG was performed in the first 72 h (1st EEG), daily after the 1st EEG for the first 7 days after the stroke, or later if neurological worsening, at discharge, and at 12 months. 151 patients were included (112 men) with a mean age of 67.4 (11.9) years. In the 1st year after stroke, 38 patients (25.2%) had an epileptic seizure. During hospitalization, 27 patients (17.9%) had epileptiform activity (interictal or ictal) in the EEG, 7 (25.9%) of them electrographic seizures. During the first week after stroke, 22 (14.6%) patients had a seizure and 4 (2.6%) non-convulsive status epilepticus criteria. Five (22.7%) acute symptomatic seizures were exclusively electrographic. At least one remote symptomatic seizure occurred in 23 (16%) patients. In the first 7 days after stroke, more than one-fifth of patients with seizures had exclusively electrographic seizures. Without a systematic neurophysiological evaluation the frequency of post-stroke seizures are clinically underestimated.

Objective: Short‐term outcomes of deep brain stimulation of the anterior nucleus of the thalamus (ANT‐DBS) were reported for people with drug‐resistant focal epilepsy (PwE). Because long‐term data are still scarce, the Medtronic Registry for Epilepsy (MORE) evaluated clinical routine application of ANT‐DBS. Methods: In this multicenter registry, PwE with ANT‐DBS were followed up for safety, efficacy, and battery longevity. Follow‐up ended after 5 years or upon study closure. Clinical characteristics and stimulation settings were compared between PwE with no benefit, improvers, and responders, that is, PwE with average monthly seizure frequency reduction rates of ≥50%. Results: Of 170 eligible PwE, 104, 62, and 49 completed the 3‐, 4‐, and 5‐year follow‐up, respectively. Most discontinuations (68%) were due to planned study closure as follow‐up beyond 2 years was optional. The 5‐year follow‐up cohort had a median seizure frequency reduction from 16 per month at baseline to 7.9 per month at 5‐year follow‐up (p <.001), with most‐pronounced effects on focal‐to‐bilateral tonic–clonic seizures (n = 15, 77% reduction, p =.008). At last follow‐up (median 3.5 years), 41% (69/170) of PwE were responders. Unifocal epilepsy (p =.035) and a negative history of epilepsy surgery (p =.002) were associated with larger average monthly seizure frequency reductions. Stimulation settings did not differ between response groups. In 179 implanted PwE, DBS‐related adverse events (AEs, n = 225) and serious AEs (n = 75) included deterioration in epilepsy or seizure frequency/severity/type (33; 14 serious), memory/cognitive impairment (29; 3 serious), and depression (13; 4 serious). Five deaths occurred (none were ANT‐DBS related). Most AEs (76.3%) manifested within the first 2 years after implantation. Activa PC depletion (n = 37) occurred on average after 45 months. Significance: MORE provides further evidence for the long‐term application of ANT‐DBS in clinical routine practice. Although clinical benefits increased over time, side effects occurred mainly during the first 2 years. Identified outcome modifiers can help inform PwE selection and management. [ABSTRACT FROM AUTHOR]

The PreEpiSeizures project was created to better understand epilepsy and seizures through wearable technologies. The motivation was to capture physiological information related to epileptic seizures, besides Electroencephalography (EEG) during video-EEG monitorings. If other physiological signals have reliable information of epileptic seizures, unobtrusive wearable technology could be used to monitor epilepsy in daily life. The development of wearable solutions for epilepsy is limited by the nonexistence of datasets which could validate these solutions. Three different form factors were developed and deployed, and the signal quality was assessed for all acquired biosignals. The wearable data acquisition was performed during the video-EEG of patients with epilepsy. The results achieved so far include 59 patients from 2 hospitals totaling 2,721 h of wearable data and 348 seizures. Besides the wearable data, the Electrocardiogram of the hospital is also useable, totalling 5,838 h of hospital data. The quality ECG signals collected with the proposed wearable is equated with the hospital system, and all other biosignals also achieved stateof-the-art quality. During the data acquisition, 18 challenges were identified, and are presented alongside their possible solutions. Though this is an ongoing work, there were many lessons learned which could help to predict possible problems in wearable data collections and also contribute to the epilepsy community with new physiological information. This work contributes with original wearable data and results relevant to epilepsy research, and discusses relevant challenges that impact wearable health monitoring. [ABSTRACT FROM AUTHOR]

There is currently no evidence to support the use of antiseizure medications to prevent unprovoked seizures following stroke. Experimental animal models suggested a potential antiepileptogenic effect for eslicarbazepine acetate (ESL), and a Phase II, multicenter, randomized, double‐blind, placebo‐controlled study was designed to test this hypothesis and assess whether ESL treatment for 1 month can prevent unprovoked seizures following stroke. We outline the design and status of this antiepileptogenesis study, and discuss the challenges encountered in its execution to date. Patients at high risk of developing unprovoked seizures after acute intracerebral hemorrhage or acute ischemic stroke were randomized to receive ESL 800 mg/d or placebo, initiated within 120 hours after primary stroke occurrence. Treatment continued until Day 30, then tapered off. Patients could receive all necessary therapies for stroke treatment according to clinical practice guidelines and standard of care, and are being followed up for 18 months. The primary efficacy endpoint is the occurrence of a first unprovoked seizure within 6 months after randomization ("failure rate"). Secondary efficacy assessments include the occurrence of a first unprovoked seizure during 12 months after randomization and during the entire study; functional outcomes (Barthel Index original 10‐item version; National Institutes of Health Stroke Scale); post‐stroke depression (Patient Health Questionnaire‐9; PHQ‐9); and overall survival. Safety assessments include the evaluation of treatment‐emergent adverse events; laboratory parameters; vital signs; electrocardiogram; suicidal ideation and behavior (PHQ‐9 question 9). The protocol aimed to randomize approximately 200 patients (1:1), recruited from 21 sites in seven European countries and Israel. Despite the challenges encountered, particularly during the COVID‐19 pandemic, the study progressed and included a remarkable number of patients, with 129 screened and 125 randomized. Recruitment was stopped after 30 months, the first patient entered in May 2019, and the study is ongoing and following up on patients according to the Clinical Trial Protocol. [ABSTRACT FROM AUTHOR]

Background: The goal of the present study is the evaluation of the long-term clinical outcome of epilepsy in patients with mesial temporal lobe sclerosis (MTLS) submitted to amygdalohippocampotomy (AHCo). AHCo consists of the lateral ablation of the amygdala and the peri-hippocampal disconnection instead of amygdalohippocampectomy (AHC), which involves the removal of both structures. We previously reported the short-term results of AHCo, so we here present the long-term results (> 5 years of follow-up) of the patients operated on with AHCo. Method: Since 2007, 35 patients (22 females) aged 20-61 years (mean: 42 years) were operated on with the AHCo technique, 17 patients on the left side and 18 on the right. Of these patients, 21 (14 females) have been followed up > 5 years (5 to 7.5 years, mean 6.5 years). We compare the present results with those observed shortly after surgery and with the patients operated on with AHC. Findings: In all 21 cases, the diagnosis was mesial temporal lobe sclerosis (histology confirmed in 20), 11 on the left side and 10 on the right. Epilepsy results after 5 years were good/very good in 18 patients (85.7%), with Engel class IA-B in 15 (71.4%) and II in 3 (14.3%), and bad in 3 patients, with Engel Class III in 2 (9.5%) and class IV in 1 (4.8%). Concerning morbidity, one patient had hemiparesis (hypertensive capsular hemorrhage 24 h after surgery), two verbal memory worsening, two quadrantanopia and three late depression that was reversed with medication. Comparatively, the AHC long-term results were 87% Engel class I, 8% Engel class II and 5% Engel class III-IV. The morbidity was equally small. Conclusions: The good/very good results of AHCo 5 years after surgery are 86%, which is not distinct from the AHC results. So AHCo seems to be effective and potentially safer than AHC in long-term follow-up. [ABSTRACT FROM AUTHOR]

Summary: Objective: Seizures and electroencephalographic (EEG) abnormalities have been associated with unfavorable stroke functional outcome. However, this association may depend on clinical and imaging stroke severity. We set out to analyze whether epileptic seizures and early EEG abnormalities are predictors of stroke outcome after adjustment for age and clinical/imaging infarct severity. Methods: A prospective study was made on consecutive and previously independent acute stroke patients with a National Institutes of Health Stroke Scale (NIHSS) score ≥ 4 on admission and an acute anterior circulation ischemic lesion on brain imaging. All patients underwent standardized clinical and diagnostic assessment during admission and after discharge, and were followed for 12 months. Video‐EEG (<60 min) was performed in the first 72 h. The Alberta Stroke Program Early CT Score quantified middle cerebral artery infarct size. The outcomes in this study were an unfavorable functional outcome (modified Rankin Scale [mRS] ≥ 3) and death (mRS = 6) at discharge and 12 months after stroke. Results: Unfavorable outcome at discharge was independently associated with NIHSS score (p = 0.001), EEG background activity slowing (p < 0.001), and asymmetry (p < 0.001). Unfavorable outcome 1 year after stroke was independently associated with age (p = 0.001), NIHSS score (p < 0.001), remote symptomatic seizures (p = 0.046), EEG background activity slowing (p < 0.001), and asymmetry (p < 0.001). Death in the first year after stroke was independently associated with age (p = 0.028), NIHSS score (p = 0.001), acute symptomatic seizures (p = 0.015), and EEG suppression (p = 0.019). Significance: Acute symptomatic seizures were independent predictors of vital outcome and remote symptomatic seizures of functional outcome in the first year after stroke. Therefore, their recognition and prevention strategies may be clinically relevant. Early EEG abnormalities were independent predictors and comparable to age and early clinical/imaging infarct severity in stroke functional outcome discrimination, reflecting the concept that EEG is a sensitive and robust method in the functional assessment of the brain. [ABSTRACT FROM AUTHOR]

Mesial temporal lobe seizures can be misdiagnosed as panic attacks. There is a spectrum of symptoms that are common to both, like fear sensation. We report a case of a young woman, initially diagnosed as having panic attacks of short duration. The symptoms persisted for two years despite treatment with SSRIs. Epileptic seizures were suggested when the patient started reporting involuntary limb movements during some of the episodes. Further investigations showed mesial temporal sclerosis on MRI and epileptic activity in EEG, and she began antiepileptic treatment. In some patients with panic attacks, particularly if associated with atypical features, the possibility of epilepsy should be considered. [ABSTRACT FROM AUTHOR]

Seizures are not only a frequent complication of stroke but have been associated with an unfavorable functional and vital outcome of patients who have had stroke. Facing a new paradigm of acute standard stroke care, acute symptomatic seizures in this clinical setting deserve to be rethought. Reperfusion therapies, the gold standard treatment for acute ischemic stroke, improve long-term survival and outcome of patients who have had stroke and have been associated both with clinical seizures and the occurrence of epileptiform activity in the electroencephalogram (EEG). This narrative review describes the different physiopathological mechanisms underlying the possible association between reperfusion therapies and seizures, both acute symptomatic seizures and unprovoked seizures, and the current evidence regarding the risk of poststroke seizures in treated patients. It also identifies the gaps in our knowledge to foster future studies in this field. By different mechanisms, reperfusions therapies may have opposing effects on the risk of poststroke seizures. There is a need for a better definition of the specific physiopathology of seizures in clinical practice, as many factors can be recognized. Additionally, most of the current clinical evidence refers to acute symptomatic seizures and not to unprovoked seizures or poststroke epilepsy, and our analysis does not support the existence of a strong association between thrombolysis and poststroke seizures. So far, the impact of reperfusion therapies on the frequency of poststroke seizures is unclear. To study this effect, many clinical challenges must be overcome, including a better and clear operational definition of seizures and stroke characteristics, the standard of stroke and epilepsy care and EEG monitoring, and the degree of reperfusion success. Prospective, high quality, larger, and longer follow-up multicentric studies are urgently needed. Additionally, stroke registries can also prove useful in better elucidate whether there is an association between reperfusion therapies and seizures. This article is part of the Special Issue "Seizures & Stroke". • In animal models, thrombolysis seems to affect the risk of poststroke seizures. • Different mechanisms have opposing effects on the risk of poststroke seizures. • Clinical evidence does not support an association between reperfusion therapies and seizures. [ABSTRACT FROM AUTHOR]

Introduction: Patients with a neuronal migration disordered characterized by subcortical band heterotopia are prone to develop refractory epilepsy. Some attempts have been made to treat this condition surgically with Stereo-EEG and focal resections with discouraging results. In our series of deep brain stimulation of anterior nuclei of the thalamus (DBS-ANT), from 12 patients, 2 were due to this development disorder. Case Study: Seizure outcome was reviewed now at 12 and 18 months en patient 1 and 2. Both patients showed a greater than 50% decrease in seizure frequency and an increase in seizure free time. After surgery they both had a transient depressive syndrome that responded to anti-depressive medication. Discussion: Deep brain stimulation of ANT has shown a good seizure outcome in these two cases. We propose that this procedure could be considered in the treatment of patients with subcortical band heterotopia with refractory epilepsy. The etiology of depression is probably multifactorial but might be a transient adverse event of DBS-ANT. [ABSTRACT FROM AUTHOR]

Introduction: Deep Brain Stimulation (DBS) of the Anterior Nuclei of Thalami (ANT) has a growing interest as a palliative surgery for refractory epilepsy. The bilateral ANT-DBS may have a place in focal epilepsies when no focal resection is indicated or when patients refuse resective surgery. Material and Methods: The Epilepsy Surgery Group of the Hospital de Santa Maria (CHLN) started this approach in January 2011, and we have operated 12 patients (7 females) so far. Median time of epilepsy before implantation was 26 years (7-46) and median number of seizures per month 15 seizures/month (3-39). All patients have already tried 3 or more antiepileptic drugs. Three patients had previous epilepsy surgeries, one a VNS and other two resective surgeries. Electrodes were implanted with Leksell® stereotactic frame with targets and trajectories obtained from FrameLink® Medtronic's software. Both 3387 and 3389 electrodes were used through a trans-ventricular cannulated approach in the majority of the patients (9/12). Post-operative control of electrode contacts was done with CT fused with pre-operative MRI and compared to published stereotactic atlases. Results: All 12 patients have at least one contact in one ANT and 11 in both anterior nuclei. Two patients required additional surgeries due to slippage of electrode(s) to the III ventricle during a trans-ventricular approach. No intraventricular bleeding was seen in post-operative CT of all patients and no major complications related to surgery were recorded. Seizure frequency reduction was seen in more than half of the patients but almost all reported a decrease in severity of their seizures. Approximately one third of the patients developed a newly or aggravated depression early after stimulation initiation that required medication. No suicidal ideation was found in any of them. Discussion and Conclusions: The ideal candidates for ANT-DBS is yet to be found but the low incidence of major complications from this surgery and the reversibility of those related to stimulation makes this neuromodulation technique an option to treat otherwise difficult refractory epilepsy cases. Multicenter studies allow us to collect more cases faster but single center series with their more standardized approach may also add some important information. [ABSTRACT FROM AUTHOR]

The occurrence of seizures in specific types of epilepsies can follow a 24-hour nonuniform or nonrandom pattern. We described the 24-hour pattern of clinical seizures in patients with focal refractory epilepsy who underwent video-electroencephalography monitoring. Only patients who were candidates for epilepsy surgery with an unequivocal seizure focus were included in the study. A total of 544 seizures from 123 consecutive patients were analyzed. Specific time of seizures were distributed along 3- or 4-hour time blocks or bins throughout the 24-hour period. The mean age of the subjects was 37.7 years, with standard deviation of 11.5 years, median of 37. The majority were females (70/56%). The majority of patients had a seizure focus located in the mesial temporal lobe (102/83%) and in the neocortical temporal lobe (13/11%). The remaining patients had a seizure focus located in the extratemporal lobe (8/6%). The most common etiology was mesial temporal sclerosis (86/69.9%). Nonuniform seizure distribution was observed in seizures arising from the temporal lobe (mesial temporal lobe and neocortical temporal lobe), with two peaks found in both 3- and 4-hour bins: 10:00–13:00/16:00–19:00 and 08:00–12:00/16:00–20:00 respectively (p = 0.004). No specific 24-hour pattern was identified in seizures from extratemporal location. The 24-hour rhythmicity of seizure distribution is recognized in certain types of epilepsy, but studies on the topic are scarce. Their replication and validation is therefore needed. Our study confirms the bimodal pattern of temporal lobe epilepsy independently of the nature of the lesion. However, peak times differ between different studies, suggesting that the ambient, rhythmic exogenous factors or environmental/social zeitgebers, may modulate the 24-hour rhythmicity of seizures. Characterization of these 24-hour patterns of seizure occurrence can influence diagnosis and treatment in selected types of epilepsy, such as the case of temporal lobe epilepsy, the most common drug-resistant epilepsy. [ABSTRACT FROM AUTHOR]