Epilepsy

Patients with epilpesy pose many clinical challenges. Even experienced clinicians occasionally arrive at the point where diagnostic, work-up, treatment, or prognostic thinking becomes blocked. Epilepsy is the fifth volume in the "What Do I Do Now?" series and provides the clinician with the necessary tools to evaluate and treat an epilepsy patient. Applying a case-based approach of curbside consultation, the authors present 31 actual cases, providing key points to remember and recommendations for further reading at the end of each case and including EEGs and imaging where applicable. Concise and readable, Epilepsy is the perfect quick-reference guide for anyone working with epilepsy patients.

Auteur

Carl W. Bazil, MD, PhD, Caitlin Tynan Doyle Professor of Clinical Neurology, Director, Division of Epilepsy and Sleep, Department of Neurology, Columbia University, New York, NY. Derek Chong, MD, Assistant Professor of Clinical Neurology, Director, Clinical Anticonvulsant Drug Trials, Department of Neurology, Columbia University, New York, NY. Daniel Friedman, MD, Assistant Professor of Neurology, Department of Neurology, New York University, New York, NY.

Contenu

Section 1: Diagnostic Questions 1. Febrile seizures and first seizures in infants, Daniel Friedman Febrile seizures are common and are often benign with little risk of subsequent epilepsy. However, febrile seizures with complex features may increase the risk of epilepsy later in life or may be the heralding seizure of a severe infantile epilepsy syndrome. 2. Idiopathic Partial Epilepsies (IPE) of childhood, Derek J. Chong Benign rolandic epilepsy, or BECTS, and the benign occipital epilepsies have specific clinical features and electrographic findings that set them apart from other types of epilepsy. The diagnosis of these conditions is important as they impart a high chance of spontaneous and complete remission. 3. Nonconvulsive status epilepticus in hospitalized patients, Daniel Friedman Seizures without overt convulsive activity are common in critically ill and acute brain injury patients. Often the only manifestation is altered mental status and EEG monitoring is required for the diagnosis. Treatment is aimed at controlling seizures to limit secondary neuronal injury while minimizing the adverse effects of therapy. 4. Psychogenic nonepileptic seizures, Carl W. Bazil About 25% of patients with refractory epilepsy who are referred to epilepsy centers actually are found to have psychogenic nonepileptic seizures. These can be very confusing to treating clinicians, as by history they may sound exactly like epileptic seizures. Correct diagnosis usually requires video-EEG monitoring, and diagnosis is critical in redirecting appropriate care for the patient. 5. Frontal lobe seizures, Daniel Friedman Seizures of frontal lobe origin often have little EEG correlate and can have bizarre semiologies that can be mistaken for nonepileptic seizures. Nocturnal onsets and stereotyped features are clues to the diagnosis. 6. Seizure versus parasomnias, Carl W. Bazil Paroxysmal episodes that occur during sleep can be a diagnostic dilemma. History may be imperfect or even nonexistent, as patients may not recall the actual episode, and witnesses may not be present. Careful history may be able to distinguish whether the event is a seizure or a parasomnia, however diagnostic testing with polysomnography and/or video-EEG may be required to confirm the diagnosis. 7. Seizure versus syncope, Carl W. Bazil Sudden loss of awareness could represent syncope or seizure. History is usually helpful in making the diagnosis, as characteristics such as tongue biting, incontinence, and postictal confusion are more suggestive of seizure. Section 2: Treatment Considerations: AEDs 8. First unprovoked seizure, Derek J. Chong Up to 10% of the population will have a seizure in their lifetime, yet only 1% of the population will have recurrent, unprovoked seizures. The first recognized seizure is a frightening occurrence for patients. Standard of care includes an EEG and MRI of the head for prognostication of recurrence, and to rule out symptomatic causes. 9. Initial treatment of idiopathic generalized epilepsy (IGE), Derek J. Chong Patients with idiopathic (or primary) generalized epilepsies are presumed to have a low threshold for seizures that may be of genetic origin. These syndromes comprise 20% of all epilepsy. Treatment consists of broad-spectrum agents with some specific medications used for specific seizure types seen in IGE. 10. Initial treatment of localization related epilepsy (LRE), Derek J. Chong There are over a dozen medications available to reduce the risk of partial onset seizures. The current motto of 'no seizures, no side-effects' requires tailoring the choice of medication based on their characteristics and side-effect profile with the patient's own priorities. Mood and weight change are among the issues that are often important to patients. 11. Treatment of status epilepticus, Daniel Friedman Generalized status epilepticus is a neurological emergency associated with significant morbidity and mortality. Prompt diagnosis and treatment, often guided by EEG monitoring, is necessary. 12. Idiosyncratic reactions - Rash, Daniel Friedman Skin eruptions are common reactions to AEDs and can rarely be serious and life threatening with systemic manifestations. The key to treatment is usually discontinuing the offending drug without placing the patient at risk for seizures. 13. Other idiosyncratic reactions and adverse drug effects, Daniel Friedman AEDs can have rare but serious effects that cannot be predicted by their mechanisms of action or metabolic pathways. These reactions can hepatic dysfunction, hematologic abnormalities, pancreatitis and CNS dysfunction. 14. Generic AED substitutions, Carl W. Bazil Patients and insurers often inquire about lower cost generic alternatives. While these may be appropriate for many patients, in epilepsy the additional variability introduced when using a generic equivalent requires more vigilance than in most other conditions. 15. Withdrawal of AEDs, Carl W. Bazil When a patient has been controlled for many years, it is often appropriate to ask whether anticonvulsant treatment may safely been withdrawn. There are many considerations here, and individual patietn concern and preferences, including risk aversion, must be taken into account before a recommendation can be made. 16. Approach to the patient who fails the first drug, Derek J. Chong Seizures may continue to occur with medical treatment or the treatment may cause intolerable side-effects. Both are considered failures. The main choice to consider is substitution with another agent in monotherapy versus dual therapy. 17. Drug-drug interactions: AEDs, Derek J. Chong Many AEDs have effects on the each other due to changes in liver enzymes and protein binding particularly of the older generation. Pharmacodynamic effects, including interactions at the level of the receptor, can be important in neurotoxic side-effects, and may play a role in polytherapy efficacy as well. 18. Drug-drug interactions: others, Derek J. Chong Enzyme-inducing medications include phenytoin, carabamazepine and phenobarb, and to a lessor extent oxcarbazepine and topiramte. Significant interactions occur with frequently concomitantly used medications such as oral contraceptives, coumadin. 19. Treating epilepsy in pregnant or lactating women, Daniel Friedman AEDs pose particular difficulties in pregnant women including teratogenicity and altered metabolism. Many drugs are also excreted in breast milk though most women with epilepsy are able to successfully breast feed. 20. Treating seizures in the elderly, Derek J. Chong Single and recurrent seizures are common in the elderly population. Acute symptomatic seizures are less likely to turn into epilepsy, and longterm treatment is often not indicated. In other situations…