Ammar T. Abdulaziz

Objective: This study was undertaken to assess whether periconceptional folic acid (FA) supplementation affects seizures, maternal, and fetal outcomes in Chinese women with epilepsy. Methods: We included pregnant women with epilepsy enrolled in the West China Pregnancy Registry of Epilepsy between 2012 and 2021. Detailed data on maternal health, FA intake, antiseizure medications (ASMs), pregnancy, and perinatal outcomes were obtained during regular visits to neurology clinics. Primary outcomes were seizure control status and adverse maternal and fetal outcomes. To adjust for potential confounders, subgroup and sensitivity analyses were performed. Results: We included 1638 pregnancies of 1405 women with epilepsy. A total of 1299 (79.3%) pregnancies in 1173 women used FA supplements during periconception, and 1351 (82.5%) pregnancies were exposed to ASMs. The recurrence rate of convulsive seizures was significantly higher among non‐FA users compared with FA users throughout pregnancy. Low FA dose, delayed initiation, and short use duration were associated with an increased risk of seizures during pregnancy. Most pregnancies (78.8%) in the non‐FA group were lost compared to 13% in the FA group ( p < .001). Non‐FA users had 3.5‐fold and 7.5‐fold increased risks of spontaneous and elective abortions compared with FA users. The protective effect was more prevalent among those using ASMs. Pregnancies exposed to low‐dose FA had higher rates of adverse maternal–fetal outcomes than those receiving medium‐ to high‐dose FA supplements. Significance: Periconceptional FA intake by women with epilepsy was associated with an approximately 66% decreased risk of abortion and improved seizure control during pregnancy. Low‐dose FA may be insufficient to prevent adverse maternal–fetal outcomes in this population. Further studies are warranted to confirm these findings.

Objective: New onset refractory status epilepticus (NORSE) is a neurologic emergency in people without a history of active epilepsy or other preexisting neurological disorders. There are not many studies reporting on the long‐term outcomes of NORSE. We investigate factors associated with outcomes such as mortality and sequelae in NORSE. Methods: This retrospective, single‐center study involved individuals diagnosed with NORSE in West China hospital who were consecutively admitted between January 2018 and December 2022. The primary outcome was death at follow‐up. Secondary outcomes included functional recovery and sequelae among survivors. Lasso–Cox regression was used to evaluate factors for death. A Cox proportional hazard regression model was then established, incorporating several parameters identified through Lasso–Cox regression. Results: One hundred one individuals with NORSE were identified and reviewed (median age = 30 years, 45 (45%) were female). The etiology was unknown in 37 (37%) people despite comprehensive diagnostic workups. Among the remaining 64 (64%), the most common etiology of NORSE was autoimmune encephalitis ( n = 53, 83%), followed by infectious encephalitis ( n = 9, 14%). One person died in‐hospital, and 24 (24%) died during follow‐up. Factors independently associated with death were the presence of superrefractory status epilepticus (hazard ratio [HR] = 3.99, 95% confidence interval [CI] = 1.09–14.61, p = .036) and initial response to immunotherapy (HR = .11, 95% CI = .02–.62, p = .012). The median follow‐up duration among the 76 survivors was 40 months (range = 24–82 months). Among them, functional recovery was achieved in 52 (68%) at the last follow‐up, whereas sequelae were seen in 24 people, the most common being active epilepsy ( n = 9, 12%). Significance: The primary etiology in the NORSE cohort was autoimmune, followed by unknown causes. Response to immunotherapy is highly associated with long‐term mortality, even in those with unknown etiology.

Folate deficiency is associated with increased risks of adverse maternal and offspring health outcomes. This review aimed to review the available evidence on folate deficiency among women with epilepsy, particularly potential causes and identified predictors of inadequate folic acid (FA) supplement use. We conducted this review using the PRISMA extension for scoping reviews. We searched Medline, Embase, EBM reviews and all Ovid journals for studies reporting on folate status/FA use in women with epilepsy. Of 3778 items reviewed, 105 relevant articles were identified and included. Many reports suggest that folate deficiency is common among women with epilepsy. Common triggers for folate deficiency include poor dietary intake, inadequate FA use, genetic susceptibility, poor fortification policies, antiseizure medications, increased demands, chronic inflammation, lifestyle factors and lack of counselling. The prevalence of FA use among women with epilepsy is low, with more than half not taking supplements before conception. Predictors of inadequate FA use are unplanned pregnancy, low educational achievement, low socio-economic status, being part of an ethnic minority, lack of counselling, young age, no antiseizure medication exposure and concerns about its use. Current practice needs adjustments towards establishing an adequate, rather than minimal, folate concentration in women with epilepsy to prevent adverse outcomes. One-size-fits-all seems inappropriate; folate intake should be individualized and adjusted to achieve adequate folate status based on folate levels and other metabolic biomarkers. Folate deficiency in women with epilepsy may reflect disparities in care and links to several social determinants of health. Despite the potential progress recently achieved in understanding folate deficiency in women with epilepsy, there are still significant gaps in knowledge requiring further work. Folate deficiency is common among women with epilepsy. The causes of folate deficiency are multifactorial, and awareness, early recognition, proper intervention and regular follow-ups are required to maintain adequate folate levels. Establishing an adequate, rather than minimal, folate concentration to prevent adverse outcomes is imperative. More work is needed to understand the mechanisms of folate deficiency in women with epilepsy and to develop the optimal intervention strategies.

Objective: Data on seizure and pregnancy outcomes in Asian women with epilepsy are limited. We used a Chinese pregnancy registry to assess the impact of seizures and antiseizure medications (ASMs) on pregnant women with epilepsy and their children. Methods: This is an ongoing prospective multicenter study of pregnant women with epilepsy that has been running since 2012. Eligible participants were consecutively enrolled and had multiple follow‐ups up to one year after delivery. We assessed ASM use and seizure frequency during pregnancy to establish potential effects on the mothers and infants and to identify relevant correlations. Descriptive analysis was used to estimate proportions. Logistic regression was used to identify the relevant risk factors and correlations. Results: Of 1907 potentially eligible pregnancies, we included 1763 in 1483 women with known outcomes from January 2012 to February 2022. There were 1278 completed pregnancies, resulting in 1270 live births. Tonic–clonic seizures occurred in fewer than one‐third of pregnancies in each trimester. Compared with baseline, seizure frequency remained relatively stable throughout approximately two‐thirds of the pregnancies. The majority were on ASM, with levetiracetam (39%), oxcarbazepine (19%), and lamotrigine (17.5%) being the most commonly used. In contrast, only 14.2% of pregnancies were exposed to valproate (VPA). There was a declining trend in treatment adjustments over the course of the pregnancy, with most changes occurring in the first trimester. The incidence of major congenital malformation (MCM) was 4.4%, with cardiogenic and orofacial anomalies being the most common. VPA use ( p < .001), lack of folic acid use ( p = .009), positive family history of MCM ( p = .006), and topiramate (TPM) use ( p = .04) were the most important predictors of MCM. Significance: Seizure control remained stable for the majority of women with epilepsy throughout pregnancy. Family history of MCM, VPA use, TPM use, and not taking folic acid were strong predictors of MCM in infants born to women with epilepsy.

An epilepsy diagnosis in the elderly may be challenging, as seizures are often unwitnessed, atypical, or have subtle presentations in the context of multimorbidity. So diagnosis is often delayed^4,5. The same applies to clinical management, and, not surprisingly, epilepsy in senior citizens is associated with increased admission rates and length of hospital stay. It is also the herald of bad news since having seizures in old age is a predictor of a fatal outcome, with significant mortality in the next two years⁶. This ultimately adds to the burden of epilepsy to the individual, society and the healthcare systems.