Andrew N. Wilner, MD

Disclosures

January 14, 2016

Introduction

The American Epilepsy Society (AES) annual meeting is the world's most important forum for all that is new in the world of epilepsy research, from bench to bedside. While there were literally hundreds of scientific presentations at this year's AES meeting, here are brief summaries of five presentations that caught my eye because they directly affect patient care.

  1. Three bioequivalence trials, the BEEP (Bioequivalence in Epilepsy Patients)[1] and Equigen Chronic and Single Dose studies support the interchangeability of generic lamotrigine with brand Lamictal®. Read more about these surprising trial results in my blog, Wilner on Neurology.

  2. Christian Bien, MD, professor of neurology, Epilepsy Centre Bethel, Bielefeld, Germany, provided an update[2] on autoimmune epilepsy, increasingly recognized as an occult and treatable epilepsy etiology. Autoimmune encephalitis with seizures secondary to malignancy is a well-recognized entity, but cases without malignancy have also been well documented. In addition, both intracellular and extracellular antibodies have been recognized, and it is anticipated that many more antibody types await discovery. Patients at highest risk for autoimmune epilepsy appear to be women between the ages of 15 and 45 years, particularly those with a history of autoimmune disease such as lupus or rheumatoid arthritis. Although any type of seizure may occur, the classic semiologies are facial brachial dystonic or pilomotor seizures. Electroencephalogram (EEG) may demonstrate "extreme delta brushes," cerebrospinal fluid has increased cellularity and oligoclonal bands, and the MRI may show changes consistent with encephalitis. Recognition of this syndrome is particularly important because it offers a treatable etiology to some of the many patients with cryptogenic epilepsy; immunotherapy may successfully control seizures when antiepileptic drugs fail.

  3. The vagus nerve stimulator (VNS) received US Food and Drug Administration approval in 1997 and has become a standard adjunctive therapy for intractable epilepsy. Cyberonics (Houston, Texas) has recently refined the VNS device, marketed as the AspireSR®. This latest VNS iteration can detect an increased heart rate, which may be associated with the onset of an epileptic seizure. When the VNS detects an appropriate accelerated heart rhythm, it automatically sends an electrical stimulation to the vagus nerve, potentially aborting the seizure.

  4. Localization of the seizure focus in some people with intractable epilepsy can be challenging and may require multiple depth electrodes. Accurate placement of depth electrodes is essential but time consuming. In the exhibit hall, Medtech (Newark, New Jersey) company representatives demonstrated ROSA™ (robotized surgical assistant). This high-tech robot arm facilitates more precise and faster insertion of depth electrodes for EEG recording. ROSA can also assist in brain biopsy and tumor surgeries. (ROSA's robotic arm looks quite similar to the one that drilled a couple of holes in James Bond's cranium in the most recent Bond film, Spectre).

  5. Kelly Knupp, MD, associate professor of neurology at Children's Hospital Colorado, Aurora, Colorado, presented[3] a retrospective review of the Colorado experience with medical marijuana in 100 patients. Overall, a third of patients had a 50% decrease in seizures. Dr Knupp also observed that children of families that moved to Colorado to access medical marijuana had twice the improvement in seizure control than local children, raising the possibility of observer bias. Lennox-Gastaut patients tended to do better than those with Dravet syndrome. Two children became seizure free, but that observation was colored by the fact that one had only one febrile seizure, while the other had experienced only one focal seizure. Increased alertness was reported in 33%, improved language in 11%, and improved motor skills in 11%. However, 44% experienced adverse events. Dr Knupp cautioned that the endocannabinoid system was complex, and the true value of medical marijuana would need to await results of ongoing randomized clinical trials.

Conclusions

This year's AES meeting did not disappoint with respect to advances in understanding of epilepsy pathophysiology and progress towards improved treatments. Generic lamotrigine appears to be bioequivalent to brand Lamictal. The mysterious entity of autoimmune epilepsy is gradually yielding to intensive research and may turn out to be responsible for a surprisingly large number of difficult epilepsy cases, many of which will respond to immunotherapy. Cyberonics' VNS has become more sophisticated and now features "responsive stimulation." Medtech's futuristic robot arm, ROSA, facilitates increasingly accurate and less invasive intracranial procedures. The value of medical marijuana remains cloaked in more smoke than evidence. Perhaps by next year's meeting, randomized, controlled clinical data will clear the air regarding benefits and risks of this popular, although unproven, epilepsy therapy. I can't wait to find out.

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