Thursday, April 4, 2013

American Academy of Neurology 2013 Annual Meeting: 4 Important Epilepsy Trials

During March 16th through the 23rd, the American Academy of Neurology Meeting occurred in 2013.  Among the many presentations, Dr. Andrew Wilner reported from Medscape about four important epilepsy trials.

The first poster, by Liu and colleagues, is titled, "The New Antiepileptic Drugs (Levetiracetam and Oxcarbazepine) Compared with Traditional Antiepileptic Drugs (Carbamazepine and Valproate) in the Initial 52 Weeks of Monotherapy for Epilepsy Induced by MELAS -- An Open-Label, Prospective, Randomised Controlled Multicenter Study."[1] MELAS (mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes) is caused by mutations in mitochondrial DNA. The major findings of this study are shown in the Table.
Table. Major Findings
DrugDosageSeizure-Free at 52 WeeksAdverse Events
Carbamazepine300 mg/day57.1%57.1%
Levetiracetam2000 mg/day57.1%57.1%
Topiramate200 mg/day49.2%71.4%
Valproate1000 mg/day4.8%95.2%

Although one could take issue with the dosages used, all of the antiepileptic drugs were similar in terms of efficacy and adverse events with the exception of valproate. This study is important because it provides guidance for selecting antiepileptic drugs in the uncommon but important cases of MELAS.

Seizures in Epilepsy After Stroke

The next poster is titled, "Seizures and Epilepsy After Stroke: Resources and Costs Assessment," by Guekht and colleagues.[2] In this study, there were 298 patients with stroke, as follows:
• 30 patients (10%) had seizures;
• 24 patients (8%) had early seizures;
• 3 patients (1%) had both early and late seizures; and
• 3 patients (1%) had late seizures only.
These patients were compared with control patients who had similar National Institutes of Health stroke scale scores (10.5 in cases vs. 9.5 in controls). Cases with seizures had a mortality rate of 50%, whereas control patients had a mortality rate of only 5.7%. The group with seizures spent more days in the intensive care unit; had a higher number of CT scans and MRIs; and underwent more consultations, x-rays, and endoscopic procedures. Stroke patients who have seizures need prompt attention for their seizure treatment, but this study demonstrates that stroke is also a marker for a stormy course, and stroke patients with seizures should receive greater attention.

Sudden Unexpected Death in Epilepsy (SUDEP)

The next poster was titled, "Prone Position and SUDEP," by Liebenthal and Tao.[3] This study was a meta-analysis of 205 cases of SUDEP that have been reported in the literature. The positions in which the patients were found are as follow:
• 143 patients (69.8%) were prone
• 17 patients (8.3%) were supine
• 23 patients (11.2%) were sitting or in the lateral position
• 22 patients (10.7%) were in other positions
These associations between prone body position and SUDEP are similar to those found in sudden infant death syndrome. Body position could shed light on the mechanisms of sudden death and should be included in future reports.

Stereotactic-Guided Laser Ablation

The last poster is titled, "Stereotactic-Guided Laser Ablation of Epileptogenic Abnormalities in Intractable Focal Epilepsy: Preliminary Results," and the investigators are Chatman and colleagues.[4] This is a new technology using a laser inserted through a single burr hole without a craniotomy, marketed by a company called Visualase, Inc. (Houston, Texas). This report described 5 patients with focal epilepsy, 3 of whom had mesial temporal sclerosis. After the procedure, 2 of these latter patients were seizure-free. One had auras in the first week, which resolved thereafter. Adverse events included brachial plexitis, exacerbation of bipolar disorder, and suicidality.
The other 2 cases were patients with hypothalamic hamartoma. One patient had only 3 seizures in the 4 months after surgery, and the other patient had a 50% reduction in seizures. The median length of hospital stay was only 2 days. One patient required hospitalization postoperatively with acute hypothalamic dysfunction. The main advantage of this new procedure seems to be short length of stay and the lack of a craniotomy. The initial results seem good. However, significant adverse events were associated with the procedure. A randomized trial comparing this technique with conventional surgery is needed.
Take-Home Messages
Dr. Wilner summarized the 4 posters out of more than 200 that were presented at the meeting on epilepsy. Here are the take-home messages.
• Avoid valproate in MELAS;
• Seizures after stroke are a marker for increased mortality;
• Prone position is strongly associated with SUDEP; and
• A new laser ablation technology is an alternative to resective surgery that may reduce the length of hospital stay but needs more evaluation.

To view the article, click on the American Academy of Neurology Meeting.
To view the various posters that were presented, click here.

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