Background and Purpose-Warfarin is the most effective stroke prevention medication for high-risk individuals with atrial fibrillation, yet it is often underused. This study examined the magnitude of this problem in a large contemporary, prospective stroke registry. Methods-We analyzed data from the Registry of the Canadian Stroke Network, a prospective database of consecutive patients with stroke admitted to 12 designated stroke centers in Ontario (2003Ontario ( to 2007. We included patients admitted with an acute ischemic stroke who (1) had a known history of atrial fibrillation; (2) were classified as high risk for systemic emboli according to published guidelines; and (3) had no known contraindications to anticoagulation. Primary end points were the use of prestroke antithrombotic medications and admission international normalized ratio. Results-Among patients admitted with a first ischemic stroke who had known atrial fibrillation (nϭ597), strokes were disabling in 60% and fatal in 20%. Preadmission medications were warfarin (40%), antiplatelet therapy (30%), and no antithrombotics (29%). Of those taking warfarin, three fourths had a subtherapeutic international normalized ratio (Ͻ2.0) at the time of stroke admission. Overall, only 10% of patients with acute stroke with known atrial fibrillation were therapeutically anticoagulated (international normalized ratio Ն2.0) at admission. In stroke patients with a history of atrial fibrillation and a previous transient ischemic attack or ischemic stroke (nϭ323), only 18% were taking warfarin with therapeutic international normalized ratio at the time of admission for stroke, 39% were taking warfarin with subtherapeutic international normalized ratio, and 15% were on no antithrombotic therapy. Conclusions-In high-risk patients with atrial fibrillation admitted with a stroke, and who were candidates for anticoagulation, most were either not taking warfarin or were subtherapeutic at the time of ischemic stroke. Many were on no antithrombotic therapy. These findings should encourage greater efforts to prescribe and monitor appropriate antithrombotic therapy to prevent stroke in individuals with atrial fibrillation.

The transition from a pediatric to adult health care system is challenging for many youths with epilepsy and their families. Recently, the Ministry of Health and Long-Term Care of the Province of Ontario, Canada, created a transition working group (TWG) to develop recommendations for the transition process for patients with epilepsy in the Province of Ontario. Herein we present an executive summary of this work. The TWG was composed of a multidisciplinary group of pediatric and adult epileptologists, psychiatrists, and family doctors from academia and from the community; neurologists from the community; nurses and social workers from pediatric and adult epilepsy programs; adolescent medicine physician specialists; a team of physicians, nurses, and social workers dedicated to patients with complex care needs; a lawyer; an occupational therapist; representatives from community epilepsy agencies; patients with epilepsy; parents of patients with epilepsy and severe intellectual disability; and project managers. Three main areas were addressed: (1) Diagnosis and Management of Seizures; 2) Mental Health and Psychosocial Needs; and 3) Financial, Community, and Legal Supports. Although there are no systematic studies on the outcomes of transition programs, the impressions of the TWG are as follows. Teenagers at risk of poor transition should be identified early. The care coordination between pediatric and adult neurologists and other specialists should begin before the actual transfer. The transition period is the ideal time to rethink the diagnosis and repeat diagnostic testing where indicated (particularly genetic testing, which now can uncover more etiologies than when patients were initially evaluated many years ago). Some screening tests should be repeated after the move to the adult system. The seven steps proposed herein may facilitate transition, thereby promoting uninterrupted and adequate care for youth with epilepsy leaving the pediatric system.

Our objective was to assess the ability of a smartphone-based electroencephalography (EEG) application, the Smartphone Brain Scanner-2 (SBS2), to detect epileptiform abnormalities compared to standard clinical EEG. The SBS2 system consists of an Android tablet wirelessly connected to a 14-electrode EasyCap headset (cost ~ 300 USD). SBS2 and standard EEG were performed in people with suspected epilepsy in Bhutan (2014–2015), and recordings were interpreted by neurologists. Among 205 participants (54% female, median age 24 years), epileptiform discharges were detected on 14% of SBS2 and 25% of standard EEGs. The SBS2 had 39.2% sensitivity (95% confidence interval (CI) 25.8%, 53.9%) and 94.8% specificity (95% CI 90.0%, 97.7%) for epileptiform discharges with positive and negative predictive values of 0.71 (95% CI 0.51, 0.87) and 0.82 (95% CI 0.76, 0.89) respectively. 31% of focal and 82% of generalized abnormalities were identified on SBS2 recordings. Cohen’s kappa (κ) for the SBS2 EEG and standard EEG for the epileptiform versus non-epileptiform outcome was κ = 0.40 (95% CI 0.25, 0.55). No safety or tolerability concerns were reported. Despite limitations in sensitivity, the SBS2 may become a viable supportive test for the capture of epileptiform abnormalities, and extend EEG access to new, especially resource-limited, populations at a reduced cost.

Objective: Epilepsy is one of the most common neurological disorders . Many individuals continue to have seizures despite medical and surgical treatments, suggesting adjunctive management strategies are required. Promising effects of daily listening to Mozart on reducing seizure frequency in individuals with epilepsy have been demonstrated over the last 20 years, but not in a rigorously controlled manner.In this study, we compared the effect on seizure frequency of daily listening to either Mozart K.448 or a spectrally similar, yet non-rhythmic control piece. We hypothesized that there would be no difference in seizure counts when participants listened to Mozart K.448 vs when they listened to the control piece. Methods: We employed a randomized crossover design, in which each participant was exposed to both three months of daily listening to the first six minutes of Sonata for two pianos in D major by Mozart (Mozart K.448; treatment period) and three months of daily listening to phase-scrambled version (control period). There was a three-month baseline and a three-month follow-up period before and after the sixmonth listening period, respectively. Change in seizure counts obtained from the seizure diaries was considered as the main study outcome. Results: Using three methodologies to investigate the existence of the treatment effect (paired t test, estimation statistics and plots, and Cohen's d), our results revealed a reduction in seizure counts during the treatment period, which was not observed for the control period (P-value < .001). Significance: Using a spectrally similar control piece, our study advances previous reports that were limited by a "no music" control condition. Daily listening to Mozart K.448 was associated with reducing seizure frequency in adult individuals with epilepsy. These results suggest that daily Mozart listening may be considered as an adjunctive therapeutic option to reduce seizure burden in individuals with epilepsy. |

Surface electroencephalogram (EEG) recording remains the gold standard for noninvasive assessment of electrical brain activity. It is the most efficient way to diagnose and classify epilepsy syndromes as well as define the localization of the epileptogenic zone. The EEG is useful for management decisions and for establishing prognosis in some types of epilepsy. Electroencephalography is an evolving field in which new methods are being introduced. The Canadian Society of Clinical Neurophysiologists convened an expert panel to develop new national minimal guidelines. A comprehensive evidence review was conducted. This document is organized into 10 sections, including indications, recommendations for trained personnel, EEG yield, paediatric and neonatal EEGs, laboratory minimal standards, requisitions, reports, storage, safety measures, and quality assurance.

Phenobarbital remains one of the most widely used antiepileptic drugs worldwide, yet there are limited data regarding side effects associated with its use in routine clinical care settings in low-income countries. Available data suggests that phenobarbital is as effective as other first-line drugs for treating tonic-clonic seizures, but side effect reports differ widely between high and low-income settings. A better understanding of phenobarbital side effect profile and severity in low-income settings is warranted given its role in efforts to decrease the epilepsy treatment gap. We used the Liverpool Adverse Events Profile (LEAP) to assess side effects in consecutive patients with epilepsy on phenobarbital seeking care in rural Zambia. Data regarding age, gender, medication dose, and medication adherence were also collected. T-tests and Spearman’s correlation coefficient were used to assess predictors of LEAP score and medication adherence. Thirty-five patients receiving a mean dose of 2.1 mg/kg/day (SD: 2.78 mg/kg/day) of phenobarbital were assessed. All participants reported at least one side effect in the previous four weeks with a median of 6 symptoms (IQR: 4–8) and a mean side effects score of 28/76 (SD: 5.38). Over half reported sleepiness and dizziness. Memory problems and depression were also common (both 46%). Total LAEP score was not associated with age (p=0.88), gender (p=0.17), or phenobarbital dose (p=0.13). Medication adherence was not associated with side effects total score (p=0.56). Rural Zambian adults taking phenobarbital at doses recommended by the WHO report a significant number of side effects. The most common side effects reported were similar to those reported in high-income countries. The significant burden of phenobarbital-associated side effects in this African cohort is in contrast to data from non-randomized clinical trials in China that reported phenobarbital to be well-tolerated with few side effects. Additional investigations regarding phenobarbital side effects in routine care in low income settings is warranted.

PURPOSE OF REVIEW: Issues pertaining to women with epilepsy have advanced with a better understanding of multidirectional influences among hormones, seizures, and antiseizure medications, as well as pregnancyrelated concerns around fertility, seizure destabilization, and antiseizure medication-associated teratogenicity. This article highlights important developments in this field and reviews best practices in the management of women with epilepsy.RECENT FINDINGS: Important external hormonal influences may impact women with epilepsy particularly in the context of gender-affirming medications, hormonal replacement therapy, and fertility therapies. Fertility for women with epilepsy is influenced by multiple variables; however, in the absence of preexisting fertility issues, epilepsy per se is not associated with significantly impaired fertility. Once women with epilepsy are pregnant, the majority have a stable course. Antiseizure medication use in pregnancy is associated with major congenital malformations 2 to 5 times that of the general population and is highest with high-dose (≥1500 mg or greater total daily) valproate. Carefully considered changes in drug choice and dose may mitigate these risks. Therapeutic drug monitoring plays an important role in pregnancy care, and under expert supervision, women with epilepsy in pregnancy have similar seizure risks as women with epilepsy who are not pregnant. As women with epilepsy age, bone health and menopause may further be impacted by seizures and antiseizure medications. SUMMARY: The care of women with epilepsy is a multifaceted discipline that recognizes the life-long impact of sex and gender influences on epilepsy care.

T he taser stun gun, manufactured by Taser International in Scottsdale, Arizona, is a weapon used increasingly among law enforcement personnel to temporarily incapacitate detainees. Questions have arisen in both the scientific literature and the lay press about the device's safety. [1][2][3] In this article, we report the occurrence of a generalized tonic-clonic seizure in a person who received a taser shot to the head. Case reportThe patient was a previously well police officer in his 30s who took part in a police chase involving a suspected robber. He and a colleague cornered the suspect, who initially appeared to surrender but then attempted an escape. The officer had begun to chase the suspect on foot when he experienced a sudden, severe pain in the back of his head. He later described the moment as feeling like he had been "hit by a bat." He recalled letting out a brief gasp before losing consciousness. He had no recollection of falling to the ground on top of the suspect. Police records indicate that the officer's colleague had fired a taser shot meant for the suspect but that the 2 copper darts had instead struck the officer in the occiput and upper back. The officer had been wearing an armoured vest. Immediately after being shot, he was found by his colleague to be unresponsive and foaming at the mouth. His eyes were rolled upward and he had generalized tonic-clonic movements with apnea lasting for about 1 minute. He did not have urinary incontinence. Postictally, he was initially confused and combative. Emergency medical services personnel were able to restrain him. They recorded a Glasgow Coma Score of 9 within 5 minutes after arrival; 5 minutes later, his score was 13.The patient's next memory was of being in the emergency department. During this period, he felt as if he were in "a bad dream." As he gradually regained orientation over the next few hours, he became aware of thoracic tightness that was aggravated by deep breaths, and a severe headache. He was monitored overnight, then discharged in stable condition.The patient had no history of febrile or unprovoked seizures, head injuries, headaches, meningitis or encephalitis. He had no family history of seizures or of other neurologic or psychiatric conditions. His developmental history was normal. He was not taking any medications.The results of a general physical and neurologic examination were normal. Results of routine blood tests were unremarkable except for an elevated leukocyte count of 12.9 (normal 3.6-11.0) × 10 9 /L 30 minutes after the event (decreasing to 11.2 × 10 9 /L 5 hours later) and an elevated serum creatine kinase level of 580 (normal < 232) U/L.The patient returned to full-time work 5 days after the incident. He experienced persistent headaches, dizziness, back pain and chest tightness. Magnetic resonance imaging scans of the head (1.5 and 3 Tesla) as well as routine and 24-hour ambulatory electroencephalography were performed 1, 2 and 12 months after the seizure. All findings were normal.A diagnosis of mild traumatic brain injur...