Ideal situation: Patients with diffuse brain damage and epileptic seizures usually experience multiple seizure types, including generalized tonic-clonic seizures, atypical absences, myoclonic jerks, and drop attacks. The Lennox-Gastaut syndrome typifies this group of conditions. When multiple seizure types occur, valproate is often the drug of choice, but commonly polytherapy is neces sary, and often seizures cannot be completely controlled. Drop attacks are particularly refractory to pharmacotherapy, although fel-bamate, lamotrigine, topiramate, and zon-isamide may be of some benefit. Because these patients are almost always intellectually compromised, drugs that further impair cognitive function, like the barbiturates and benzodiazepines, should be avoided.
Contingency situation: As pointed out earlier, these syndromes constitute the difficult-to-treat epilepsies even under optimal situations. While treating such patients, the efforts of the clinicians in developing countries are hampered not only by the refractory nature of the seizures but also by the limited availability of AEDs. The choice of AEDs while treating such patients in developing countries will be limited to those drugs that are available, and many times, the drugs used are not necessarily the ideal ones. Rectal diazepam (if available) could prove to be a very handy drug in case of recurrent and breakthrough seizures and even managing status epilepticus before the patient can be shifted to a hospital or even at a hospital with limited facilities.
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