Professional Development

Every neurologist and most physicians in developing regions will at times feel overwhelmed by the burden of disease they encounter and the limited resources available for care provision. Furthermore, outside of academic centers, intellectual endeavors may be difficult to identify that will help ongoing professional development. All of these issues undoubtedly contribute to the brain drain, whereby health professionals from developing regions migrate to developed countries. It should be...

Examining the Patient after a Seizure

When possible, a physical examination should be performed immediately after an attack, aimed at identifying signs of injury, cyanosis, cardiac rhythm abnormalities, acute motor deficits, and the level of consciousness. The presence of bruises, tongue or other oral lesions, as well as of prolonged stupor or obtundation suggests that the seizure was indeed epileptic and generalized. Vital signs and cardiac rhythm should be checked. Any focal motor or sensory deficits or aphasia should be noted,...

Epileptic versus Nonepileptic Seizures

Misdiagnosis of other entities as epilepsy leads to social stigma, a failure to recognize and treat the true underlying pathology, and the unwarranted risk and expense of antiepileptic drugs. Because epilepsy is a chronic condition requiring continuous treatment for a substantial time, misdiagno-sis can result in unnecessary long-term phar-macologic treatment. Paradoxically, in underdeveloped communities where neurologic care is substandard relative to developed regions, the misdiagnosis of...

When to Treat a Single Seizure or Infrequent Seizures

Estimates of seizure recurrence after a first unprovoked seizure vary from 20 to 70 within the next two to five years, although most patients will have their second seizure within a year of the first. The lower recurrence figures apply to patients who have had a generalized (as opposed to focal) attack with no past history of febrile seizures, and who present with a normal neurologic development and examination, no family history of seizures, and normal EEG and brain imaging after the first...

Cranial Xray

Cranial X-ray is of limited value in the evaluation of epilepsy and should be performed only when CT is not available and there is a suspicion of a calcified lesion associated with the seizures, such as in areas endemic for cysticercosis. Additionally, other conditions can be associated with intracranial calcifications, including Sturge-Weber disease, tuberous sclerosis, and celiac disease. Although diagnosis of these conditions is usually apparent from general examination, when there is doubt,...

Seizures versus Epilepsy

As described in Chapter 1, not all seizures indicate the presence of epilepsy. Epilepsy is the chronic persistence of a brain dysfunction, which leads to recurrent epileptic seizures. Some individuals may have a single epileptic seizure, while others may have a few recurrent seizures during life, always related to a specific transient provoking factor. These people do not have epilepsy. Examples include generalized seizures in susceptible individuals under conditions of alcohol withdrawal or...

Distinguishing Isolated Epileptic Seizures from Epilepsy

Epilepsy is a disorder of recurrent seizures, so a single event, even if it is unequivocally epileptic, does not make a diagnosis of epilepsy. Even recurrent epileptic seizures, if they are clearly provoked, for example as a result of alcohol withdrawal or use of procon-vulsant agents, do not warrant a diagnosis of epilepsy. Treatment in these situations is not AEDs, but avoidance of the provocative insult where possible. More detailed discussions of the differential diagnosis between isolated...

What Is Epilepsy

Alteration Consciousness

The nervous system has a limited repertoire of responses to insult it can underact, causing negative signs and symptoms such as paralysis and blindness, or it can overact, causing positive signs and symptoms such as pain, hallucinations, and epileptic seizures. This, of course, is an oversimplification, because most neurologic disorders produce complex signs and symptoms with both negative and positive features for instance, paresis is often accompanied by spasticity, and epileptic seizures...

Nemos

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Neurocysticercosis

Nonepileptic spells with loss of consciousness can occur due to acute intracranial hypertension associated with intraventricular cysts. The much more common scenario, however, is misdiagnosis of epilepsy as a result of different types of nonepileptic paroxysmal spells in patients in whom computed tomography CT shows single or multiple residual calcified cysts. In endemic regions for neurocysticercosis, particularly The physician must realize that patients without epilepsy can have epileptiform...

Enzyme Induction Enzyme Inhibition and the Pharmacokinetic Counterparts of AED Mono versus Polytherapy

Most, but not all drugs are detoxified in the liver. Hepatic metabolism occurs through a concerted action of enzymatic systems, which are influenced by a variety of factors, including hepatic dysfunction and the interference of a variety of drugs including AEDs . The interaction among different AEDs at the level of hepatic enzymatic systems is the main reason why polytherapy that is, combination of two or more drugs often leads to an increased incidence of toxic side effects and may even...

Corpus Callosotomy

A section of the corpus callosum interferes with interhemispheric synchronization of epileptic activity, thus reducing the probability of occurrence of generalized seizures dependent on such synchronization. As such, the procedure aims at reducing tonic, atonic, and myoclonic drop attacks, as well as generalized tonic-clonic seizures. Partial seizures are often unaffected or even increased by the procedure. Preoperative evaluation must exclude a resectable epilep-togenic zone, but is usually...

Panic Attacks

A growing sensation of anxiety, fear of something vague, tachycardia, and effortful breathing that occurs during panic attacks may lead to loss of consciousness. In these episodes, some patients may have a parasympathetic syncope and others may hyperventilate and faint. Irrespective of the final mechanism, panic attacks are always associated with an initial sensation of anxiety. As with most neuropsychiatric conditions, panic attacks result from an interaction of genetic predisposition with...

EEG in the Diagnosis of Epilepsy

An abnormal EEG is not essential for a diagnosis of epilepsy, and it should never substitute for careful history-taking. In most instances, the diagnosis of epilepsy is clinically not challenging, and EEG has a limited role for this purpose. On the other hand, there are situations in which the physician faces a difficult differential diagnosis between epilepsy and other disorders that may mimic epilepsy see Chapter 2 , and the EEG can, at times, be helpful to confirm that recurrent spells are...

Traditional Healing

Unfortunately, modern allopathic medicine is too often in conflict with traditional practices. In such circumstances, traditional healers can interfere with timely and appropriate medical interventions, causing unnecessary disability. On the other hand, the unpredictable nature of epilepsy causes a psychological tension borne by the individual, the family, and the group, and this stress is often better managed by the traditional healers than the modern doctors. The time and quality of listening...

Breathholding Spells BHSs

The most typical scenario of BHSs involves an infant or a child up to age 6 who starts crying following a minor injury or frustration, and then stops breathing. Clinical history is usually all that is needed to make the diagnosis. The first episode is frightening to parents, because the prolonged crying episode is followed by cyanosis, limpness, and loss of consciousness. Less frequently, a pallid form of BHS may occur. Both forms can present with tonic or clonic movements toward the end of the...

Stomach Congestion

In some developing countries, episodes of loss of consciousness are often attributed to digestive tract abnormalities. Some epileptic seizures by chance occur after meals, which supports the traditional hypothesis that diversion of blood to the digestive tract leads to loss of consciousness. Similar to the discussion on parasitic disorders, these beliefs can delay diagnosis of true epileptic seizures. On the other hand, infants with epileptic spasms can have spasms during feeding, which causes...

Head Trauma Stroke and Degenerative Brain Disorders

High rates of head trauma in developing countries occur through a wide variety of mechanisms. Poor enforcement of motor vehicle safety, including roads frequented by overcrowded vehicles without seat belts, brakes, and or headlights is particularly problematic. Riding motor bikes without a helmet is a common cause of brain injury. Societal violence and war contribute substantially to traumatic brain injury in developing regions. Prolonged unconsciousness after head trauma, post-traumatic...

Case Study

Presentation A 27-year-old woman complained of difficulties maintaining jobs, being repeatedly fired due to inadequate behavior at work. She had been working as a secretary, and often became spaced out during phone calls, did not register important appointments, and failed to deliver messages to her colleagues and chiefs. In addition, her colleagues would mention strange behaviors during which she would stare fixedly ahead and purposelessly remove all objects from her table-top, or else lick...

Abnormal EEGs in Nonepileptic Children and Adolescents

There is a strong, but by no means absolute, correlation between the occurrence of inter-ictal EEG epileptiform discharges and the predisposition for epileptic seizures. Therefore, the EEG may be useful in the workup of patients presenting with paroxys- Unless the EEG is performed correctly and interpreted by someone formally trained in EEG, it can do more harm than good. There is significant variability in the rate of maturation of EEG rhythms during wakefulness and sleep. Clinically relevant...

Toxic Metabolic Insults

Electrolyte imbalance, hypo- or hyper-glycemia, and other toxic metabolic insults may lead to or facilitate the occurrence of seizures. Correction of the underlying systemic insult is the most important therapeutic measure, and AEDs are usually not indicated in those without a history of unprovoked seizures. Prolonged periods of excessively hot temperatures as well as endemic parasitic disorders in developing countries frequently lead to dehydration, vomiting, and diarrhea. In these situations,...

Frequency and Provoking Factors

As mentioned in other parts of this volume, close attention should be paid to the possible relationship between seizure occurrence and seizure-provoking factors. Developing country environments increase the likelihood of several factors that can precipitate seizures. Foremost is suboptimal compli ance with the intake of antiepileptic drugs. Such noncompliance may be driven by cultural factors such as the perception by relatives that the patient is taking too much medication, or that the...

Common Conditions Often Misdiagnosed as Epilepsy

The paroxysmal events most frequently misdiagnosed as epileptic seizures are reviewed below, and summarized in Table 2.1 and in the algorithms shown in Figures 2.1 through 2.4. Neurologists in developing countries are often under pressure to examine too many patients in a short period of time. Thus, a practical clinical approach to patients presenting with spells will narrow diagnostic possibilities and optimize the use of more Scintillating scotomas black white irregular lines, focal...

Monitoring Antiepileptic Drug Serum Levels

Facilities for monitoring serum levels are often not available in developing countries, but where they are, it is important that they not be overused. Even in the industrialized world, adjustments in AED regimens are primarily based on clinical grounds, irrespective of the serum levels. Dosage adjustments should always be made on an individual basis and dictated by the performance of a given AED regimen in terms of seizure control on the one hand and side effect profile on the other. Serum...

The Economic Impact Of Epilepsy

The direct costs associated with epilepsy include medical expenses associated with medications, hospitalization, and outpatient clinic fees. Costs not typically considered in studies of developed countries include medical services rendered for seizure-related injuries e.g., burns and the high cost of simply reaching a clinic equipped to deal with seizure disorders. Such expenses should be included when assessing the direct cost of epilepsy in developing regions. In Italy, the direct costs of...

Seizure Sequelae

Seizure sequelae can represent either neurologic deficits provoked by acute neuronal exhaustion and other neurochemical changes depressing neuronal function, or injuries sustained during the actual or previous seizures. Scars may offer evidence of previous seizure-related injuries. The presence of scars probably indicates the need to improve seizure control. Scar identification offers an opportunity to educate the patient and his or her relatives about measures to avoid further similar...

Triage Of Epileptic Conditions

Most people with epilepsy have seizures that are easy to treat, respond to relatively low doses of all appropriate AEDs, and can usually be managed by primary care physicians. The majority of patients with these types of epilepsy will experience no disability if treatment is initiated appropriately, and for some, seizures will eventually remit and medication will no longer be necessary. In reality, 40 of patients with epilepsy have epileptic seizures that are difficult to control, but for many...

Sensory Stimulation

Seizures may be precipitated by a variety of sensory stimuli, particularly in certain specific epilepsy syndromes. Most common are patients with primary idiopathic generalized epilepsies who display photosensitivity. Intermittent photic stimulation from video games, stroboscopic lights, or a variety of alternating dark light patterns may induce myoclonic jerks or generalized convulsions in these patients. Photosensitive-related seizures are at times self-induced by intellectually disabled...

Seizure and Injury Prevention

Although antiepileptic drugs AEDs comprise a critical component of epilepsy care, AEDs will not cure epilepsy. However, some lifestyle interventions can assist with seizure control and injury prevention. In addition to encouraging patient compliance with medications, healthcare providers caring for people with epilepsy should recom mend maintenance of a regular, adequate sleep schedule. People with epilepsy should also be cautioned against excessive intake of alcoholic beverages or stimulants,...