Testing awareness in focal seizures: Clinical practice and interpretation of current guidelines

Ramirez, Violeta Contreras; Vaddiparti, Aparna; Blumenfeld, Hal

doi:10.1002/acn3.51552

Cited by 5 publications

(4 citation statements)

References 9 publications

(19 reference statements)

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“…Interestingly, the memory recall scores were impaired in both seizures classified as FIAS and FAS based on clinical assessment, indicating that recall of events during seizures may be less reliable than responsiveness testing during seizures for classification of FIAS versus FAS. These findings add to the growing literature suggesting that responsiveness should be formally included in the definition of FIAS versus FAS in addition to memory recall (Contreras Ramirez et al, 2022a, b).…”

Section: Discussionsupporting

confidence: 59%

Automatic Responsiveness Testing in Epilepsy with Wearable Technology: The ARTiE Watch

Wheeler,

Kremen,

Mersereau

et al. 2024

Preprint

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Objective An accurate evaluation of behavioral responsiveness during and after seizures in people with epilepsy is critical for accurate diagnosis and management. Current methods for assessing behavioral responsiveness are characterized by substantial variation, subjectivity, and limited reliability and reproducibility in ambulatory and epilepsy monitoring unit (EMU) settings. In this study, we aimed to develop and implement a novel mobile platform for deployment of automated responsiveness testing in epilepsy — the ARTiE Watch, to facilitate standardized, objective assessments of behavioral responsiveness during and after seizures. Methods We prospectively recruited patients admitted to the epilepsy monitoring units for diagnostic evaluation and long-term video-electroencephalographic monitoring at Mayo Clinic and Yale New Haven Hospital. Participants wore the ARTiE Watch, a smartwatch paired with custom smartphone software integrated with cloud infrastructure allowing for remote activation of standardized assessment on the participants' smartwatch. The assessment consisted of 18 command prompts which test behavioral responsiveness across motor, language, and memory domains. Upon visually identifying an electrographic seizure during EMU monitoring, the BrainRISE platform was used to deploy the ARTiE Watch behavioral testing sequence. Responsiveness scoring was conducted on smartwatch files. Results Eighteen of 56 participants had a total of 39 electrographic seizures assessed with the ARTiE Watch. The 18 subjects with ARTiE Watch-tested seizures had a total of 67 baseline (interictal) ARTiE Watch tests collected for analysis. The analysis showed distinct ARTiE Watch behavioral responsiveness phenotypes: (1) decreased responsiveness across all ARTiE Watch commands during seizure (ictal-postictal) periods compared (p<0.0001) to baseline, (2) decreased responsiveness in bilateral tonic-clonic seizures compared to baseline (p<0.0001) and compared (p<0.0001) to focal seizures, and (3) decreased responsiveness during focal impaired awareness seizures compared (p<0.0001) to baseline and compared (p<0.001) to focal aware seizures. Significance ARTiE Watch behavioral testing deployed utilizing a mobile cloud-based platform is feasible and can provide standardized, objective behavioral responsiveness assessments during seizures.

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Section: Discussionsupporting

confidence: 59%

Automatic Responsiveness Testing in Epilepsy with Wearable Technology: The ARTiE Watch

Wheeler,

Kremen,

Mersereau

et al. 2024

Preprint

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“…This is a fundamental gap in epileptology will be addressed in the future with assessments that are triggered on seizure detections in real time. [68][69][70]…”

Section: Discussionmentioning

confidence: 99%

“…seizure detections) in real time. [67][68][69] Participants. Seven participants with drug resistant mesial temporal lobe epilepsy were identified and provided written consent in accordance with IRB and FDA requirements.…”

Section: Discussionmentioning

confidence: 99%

A platform for brain network sensing and stimulation with quantitative behavioral tracking: Application to limbic circuit epilepsy

Kremen,

Sladky,

Mivalt

et al. 2024

Preprint

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Temporal lobe epilepsy (TLE) is a common neurological disease characterized by recurrent focal seizures. These seizures often originate from the mesial temporal limbic networks and the parahippocampal neocortex. People with TLE frequently experience comorbidities related to memory, mood, and sleep (MMS). Deep brain stimulation targeting the anterior nucleus of the thalamus (ANT-DBS) is a proven therapy for reducing TLE seizures, but the optimal stimulation parameters for improving seizures and MMS comorbidities remains unclear. We developed a neurotechnology platform for tracking seizures and MMS during ANT-DBS to address this clinical gap. The platform enables bidirectional data streaming between a brain sensing-stimulation implant, compact mobile devices, and cloud-based data storage, viewing, and computing environment. Machine learning algorithms provided accurate, unbiased catalogs of seizures, interictal epileptiform spikes (IES), and wake-sleep brain states to inform ANT-DBS. Remotely administered memory and mood assessments were used to objectively and densely sample cognitive and behavioral response to ANT-DBS. In participants with mesial TLE, we evaluated the efficacy of low-frequency versus high-frequency ANT-DBS. Low-frequency and high-frequency ANT-DBS both reduced reported seizures. But continuous low-frequency ANT-DBS showed greater reductions in electrographic seizures and IES, as well as better sleep and verbal memory compared to high-frequency ANT-DBS. These results highlight the potential of synchronized brain sensing and behavioral tracking for optimizing neuromodulation therapies.

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“…Another valuable study design would be systematic surveys of clinicians regarding their methods for evaluating awareness during seizures. A recent survey of 11 medical centers in North America with data mainly from epilepsy specialists found that most clinicians use both recall and responsiveness to assess awareness in either the inpatient or outpatient settings; and interestingly, most clinicians incorrectly believe that current ILAE guidelines recommend using both recall and responsiveness to classify awareness during focal seizures [27]. Again, further work is needed including clinicians from broader geographic regions and including non-epilepsy specialists to better understand current widespread clinical practice and to help develop future guidelines.…”

Section: Discussionmentioning

confidence: 99%

Evaluating consciousness and awareness during focal seizures: responsiveness testing versus recall testing

Ramirez¹,

Litvinov²,

Gunawardane³

et al. 2022

Epileptic Disorders

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Objective. The current International League Against Epilepsy (ILAE) guidelines classify focal seizures based on awareness, defined as successful postictal recall of ictal experiences, and exclude the use of responsiveness during seizures for classification. One reason for this exclusion is that responsiveness was thought to not be commonly tested during seizures. Our goal was to determine whether, in at least some settings, responsiveness testing during seizures is relatively common. Methods. We assessed how often responsiveness and recall were each evaluated in patients with focal epilepsy undergoing surface and intracranial EEG-video monitoring. We performed this evaluation by retrospectively reviewing video recordings from 121 seizures from 48 patients during their stay in the epilepsy monitoring unit between September 2012 and November 2019.Results. We found that responsiveness during seizures was tested more frequently than recall of ictal events after seizures. Of 121 seizures in 48 patients, responsiveness was tested in 101 seizures, whereas recall was tested in only 38. Significance. Evaluating if consciousness is impaired during seizures is of critical importance for guiding recommendations for people with epilepsy, such as whether it is safe for them to drive or operate machinery. The ILAE classification guidelines are intended to be broadly useful, but our findings demonstrate that at least in one important clinical setting, responsiveness was used more commonly than recall to evaluate patients during focal seizures. Although our preliminary findings should be replicated in a larger sample and in other patient groups, they suggest that responsiveness testing during focal seizures might be relatively common in at least some clinical practice settings. With further study, this may lead to a re-evaluation of criteria for classifying focal seizures to include both responsiveness and recall of experiences during seizures, as both may provide important information to guide clinical care.

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Testing awareness in focal seizures: Clinical practice and interpretation of current guidelines

Cited by 5 publications

References 9 publications

Automatic Responsiveness Testing in Epilepsy with Wearable Technology: The ARTiE Watch

Automatic Responsiveness Testing in Epilepsy with Wearable Technology: The ARTiE Watch

A platform for brain network sensing and stimulation with quantitative behavioral tracking: Application to limbic circuit epilepsy

Evaluating consciousness and awareness during focal seizures: responsiveness testing versus recall testing

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