Predictive Power of Interictal Epileptiform Discharges in Fitness-to-Drive Evaluation.

Kreste, Heinz; Schreier, David; Sakiri, Elmaze; von Allmen, Andreas; Abukhadra, Yasmina; Nirkko, Arto; Steinlin, Maja; Rosenow, Felix; Markhus, Rune; Schneider, Gaby; Jagella, Caroline; Mathis, Johannes; Blumenfeld, Hal (2023). Predictive Power of Interictal Epileptiform Discharges in Fitness-to-Drive Evaluation. Neurology, 101(9), e866-e878. American Academy of Neurology 10.1212/WNL.0000000000207531

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BACKGROUND

This study aimed to evaluate and predict the effects of interictal epileptiform discharges (IEDs) on driving ability using simple reaction tests and a driving simulator.

METHODS

Patients with various epilepsies were evaluated with simultaneous EEGs during their response to visual stimuli in a single-flash test, a car-driving videogame, and a realistic driving simulator. Reaction times (RT) and missed reactions or crashes (miss/crash) during normal EEG and IEDs were measured. IEDs, as considered here, were a series of epileptiform potentials (>1 potential) and were classified as generalized typical, generalized atypical, or focal. RT and miss/crash in relation to IED type, duration, and test type were analyzed. RT-prolongation, miss/crash probability, and odds ratio of miss/crash due to IEDs were calculated.

RESULTS

Generalized typical IEDs prolonged RT by 164ms, compared to generalized atypical IEDs (77.0ms) and focal IEDs (48.0ms) (p<0.01). Generalized typical IEDs had a session miss/crash probability of 14.7% compared to a zero median for focal and generalized atypical IEDs (p<0.01). Long repetitive bursts of focal IEDs lasting >2s had a 2.6% miss/crash probabilityIED. Cumulated miss/crash probability could be predicted from RT-prolongation: 90.3ms yielded a 20% miss/crash probability. All tests were non-superior to each other in detecting miss/crash probabilitiesIED (zero median for all three tests) or RT-prolongations (flash test: 56.4ms, car-driving videogame: 75.5ms, simulator 86.6ms). IEDs increased the odds ratio (OR) of miss/crash in the simulator by 4.9-fold compared to normal EEG. A table of expected RT-prolongations and miss/crash probabilities for IEDs of a given type and duration was created.

CONCLUSION

IED-associated miss/crash probability and RT-prolongation were comparably well detected by all tests. Long focal IED-bursts carry a low risk, while generalized typical IEDs are the primary cause of miss/crash. We propose a cumulative 20% miss/crash risk at a RT-prolongation of 90.3ms as a clinically relevant IED effect. The IED-associated odds ratio in the simulator approximates the effects of sleepiness or low blood-alcohol level while driving on real roads. A decision aid for fitness-to-drive evaluation was created by providing the expected RT-prolongations and misses/crashes when IEDs of a certain type and duration are detected in routine EEG.

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