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In patients with cardiovascular disease, mostly if above 60 years of age, new-onset seizures should suggest stroke, either acute or in the past months to years 34 . The reported incidence of post-stroke seizures varies between around 2.5 and 10 depending on the inclusion criteria of the subjects, the underlying type of stroke, age and length of follow up 35-41 . The majority occur within the first 24 h. Early (acute) seizures occur in 4 of strokes 41 and 32 of patients with early seizures have late-onset seizures 42 . The risk of epilepsy in patients with an unprovoked single seizure due to a prior (remote) stroke is often high enough to justify starting AEDs before a second seizure 43 . However, there is no evidence that chronic treatment should be started after acute symptomatic seizures from acute strokes. This situation is probably analogous to acute traumatic brain injury with early seizures (i.e. acute symptomatic seizures) although a risk factor for later development of...
Many cases of epilepsy can be prevented by wearing seatbelts and bicycle helmets, putting children in car seats, and other measures that prevent head injury and other trauma. Prescribing medication after first or second seizures or febrile seizures also may help prevent epilepsy in some cases. Good prenatal care, including treatment of high blood pressure and infections during pregnancy, can prevent brain damage in the developing baby that may lead to epilepsy and other neurological problems later. Treating cardiovascular disease, high blood pressure, infections, and other disorders that can affect the brain during adulthood and aging also may prevent many cases of epilepsy. Finally, identifying the genes for many neurological disorders can provide opportunities for genetic screening and prenatal diagnosis that may ultimately prevent many cases of epilepsy.
In a large hospital-based study where an estimated 80 of the patients on which calculations were based had true epilepsy, mortality was increased for most causes examined 135 , Suicide was significantly more common than expected (SMR 3.5, 95 CI 2.6-4.6). Except for heart disease mortality was also increased for all causes examined in a long-term residential care unit for patients with epilepsy 130 . A later study in the same institution found an increased mortality for neoplasm (SMR 2.0, 95 CI 1.3-2.9) where only one of the 29 tumours was a brain tumour 131 . Circulatory diseases, including ischaemic heart disease and cerebrovascular disease, did not increase mortality (SMR 0.8, 95 CI 0.5-1.1). No suicides occurred 131 .
A 16-year-old female presented with episodic right hand weakness resulting in the dropping of objects. Initially this was thought to be a transient ischemic attack (TIA). An EEG later showed concomitant midline epileptiform discharges. Strength improved with resolution of each seizure (Figure 3.1.)
Cerebrovascular disease accounts for between 30 and 50 of cases (see p. 52), but this can be occult. Epilepsy is the first manifestation of previously silent cerebrovascular disease, and imaging evidence of cerebrovascular disease is found in about 15 of those presenting with apparently idiopathic late-onset epilepsy. The onset of seizures in the elderly can be a harbinger of future stroke, and in a recent study of 4709 individuals with seizures beginning after the age of 60 years, there was a 2.89-fold (95 CI, 2.45-3.41) increased incidence of subsequent stroke. In fact, the onset of seizures was a greater risk factor for stroke than either elevated cholesterol level or hypertension. Seizures also follow stroke, with a frequency of about 5 in the acute phase after stroke and 10 in the first 5 years after ischaemic
A 9-month-old male, product of a nonconsanguineous marriage, was seen for management of intractable epilepsy The pregnancy was unremarkable except for maternal supraventricular tachycardia (previous history of similar episodes) A left facial nevus was noted at birth At the age of 6 weeks, parents noticed episodes of whole-body stiffness, arching, and upward eye rolling, followed by vomiting He would become limp and lethargic for several minutes after the spells . Gastroesophageal reflux was suspected but medical management proved unsuccessful At the age of four months, a nocturnal episode of irritability, pallor, and vomiting lasting several hours was followed by right-sided hemiplegia, for which he was hospitalized Ischemic stroke was suspected however, an acute noncontrast brain computed tomography (CT) was normal The right-sided hemiplegia gradually recovered over 4-6 weeks without residual weakness . Subsequently, parents noted new episodes of behavioral arrest, body stiffness, a...
Approximately 80 of bleeding in the GM extends into the ventricles (IVH), and may also be associated with intracerebral hemorrhage. Intraventricular hemorrhage may lead to ventricular dilatation (posthemorrhagic hydrocephalus), periventricular cerebral infarction (-10-15 ), concomitant periventricular leukomalacia, local hemorrhagic injury to the subependyma (GM) and focal ischemia and injury. Severe bleeding is associated with higher mortality and progressive ventricular dilatation with serious neurological sequels.29 Those with periventricular hemorrhagic infarction (PVHI) have particularly poor prognoses. In very premature newborn, unstable hemodynamics due to anemia, hypotension, aci-dosis and disseminated intravascular coagulation is associated with very poor prognosis. Pre or perinatal ischemic stroke, both arterial and venous, presumably related to coagulopathies is also a rare but important risk factor of neurological disorders including epilepsy.44
A wide range of percentages of persons developing seizures after stroke has been reported and is mostly due to different study populations and methodology. In a population-based study of seizure disorders after cerebral infarction, early seizures occurred in 6 of patients 54 , In patients with early seizures cerebral infarcts were more likely located in the anterior hemisphere (OR 4.0 95 CI 1.2-13.7). The standardized morbidity ratio (SMR)1 for epilepsy was 5.9 (95 CI 3.5-9.4). The SMRfor an initial late seizure was 6.4 (95 CI 4.2-9.3). About two-thirds of patients with initial late seizures developed epilepsy within 5 years. The SMR of developing initial late seizures or epilepsy was highest during the first year and tended to decrease during the ensuing 3 years. There was an inverse correlation between age and risk of seizures with a peak in patients aged less than 55 years. The corresponding risks were higher after recurrent stroke. Early seizures and recurrent strokes were the...
The patient's past medical history was significant for diabetes mellitus, mild congestive heart failure following three-vessel coronary artery bypass graft surgery 4 years previously, chronic obstructive pulmonary disease, depression, rheumatoid arthritis and colostomy for resected colon cancer. Medications included phenytoin as above, insulin (Humulin 70 30) 20 units subcutaneously in the morning and 10 units in the evening, clopidogrel 75 mg day, amitriptyline 25 mg day at bedtime and sertraline 100 mg day in two divided doses. Her only known allergy was to penicillin. She had a previous history of smoking, no history of alcohol or drug abuse and a strong family history of diabetes and coronary artery disease in middle age.
A review of the world literature on RBD identified 280 published cases, of which 149 (53 ) were closely associated with a neurological disorder (Schenck and Mahowald, 1996a). A parkinsonian disorder was the most prevalent neurological condition, affecting 43 (n 64) of neurologically disordered RBD patients (representing 23 of n 280 total cases) narcolepsy was the next most prevalent condition, affecting 25 (n 38) of neurologically disordered RBD patients (representing 14 of n 280 total cases), followed by cardiovascular disorders, dementias, and miscellaneous disorders.
Diagnostic difficulties do not usually arise with respect to endogenous cardiac syncopes other than those of the long QT syndromes. However, it is up to the clinician to obtain a sufficiently clear history to determine whether a seizure or convulsion is an epileptic seizure or is a nonepileptic convulsive syncope. Sometimes ventricular tachyarhythmias occur with normal QT intervals (41-44), and there are occasions in obvious congenital heart disease when, for example, paroxysmal pulmonary hypertension may have to be inferred by a precise description, indicating an anoxic seizure precipitated by exercise (1).
Myoclonic status epilepticus in coma is a well-recognized complication of the cerebral anoxia resulting from cardiorespiratory arrest (typically after a myocardial infarction or cardiac surgery). It is characterized by spontaneous and stimulus-sensitive myoclonus usually occurring within 24 hours of the coma. To what extent this is really an 'epileptic' state, or is simply a sign of a severely damaged brain, is arguable. The patients generally have burst suppression on
Cortical venous infarcts are particularly epileptogenic, at least in the acute phase, and may underlie a significant proportion of apparently spontaneous epileptic seizures complicating other medical conditions and pregnancy. Seizures also occur with cerebrovascular lesions secondary to rheumatic heart disease, endocarditis, mitral valve prolapse, cardiac tumours and cardiac arrhythmia, or after carotid endarterectomy. Infarction is also an important cause of seizures in neonatal epilepsy. Epilepsy is also common in eclampsia, hypertensive encephalopathy, and malignant hypertension and in the anoxic encephalopathy that follows cardiac arrest or cardiopulmonary surgery. Unruptured aneurysms occasionally present as epilepsy, especially if large and if embedded in the temporal lobe for instance a giant middle cerebral or anterior communicating aneurysm.
The past medical history was unremarkable. There was no recent history of head trauma, fever or headache. There were no risk factors for stroke except for a history of heavy cigarette smoking, and no past history of transient ischemic attack or cerebral infarction. There was no history of alcohol or drug abuse. He had never experienced a similar type of event in the past.
Seizures have been reported to occur in 8 of patients with acute stroke. Among acute stroke survivors with occlusive cerebrovascular disease, up to 20 develop epilepsy, most of them within the first 2 years following stroke, although the risk for post-stroke epilepsy remains for a much longer period. Patients with cortical infarcts are at a greater risk. As in post-traumatic epilepsy, early post-stroke seizures (in the first week following stroke) are associated with an increased risk for epilepsy compared to stroke patients who do not have seizures at the time of the infarct.
Early seizure(s) has been reported to occur with a frequency of 2.5 to 5.7 within 14 days after stroke and is a predictor of recurrent seizures.5 and status epilepticus. Lesion location and stroke subtype are strong determinants of early sei-zure.32 In one study initial stroke severity has been shown as a predictor of early seizure.33 However in The Northern Manhattan Stroke Study (NOMSS) NIH stroke scale score was not an independent predictor of early seizure in multivariate analy-sis.32 The incidence of acute symptomatic seizures with stroke increases rapidly with increasing age.2 Like in developed countries, in developing countries also, stroke is 33. Reith J, Jorgensen HS, Nakayama H et al. Seizures in acute stroke Predictors and prognostic significance. The Copenhagen Stroke Study. Stroke 1997 28 1585-9.
He had a history of stable asymptomatic coronary artery disease, combined hyperlipidemia, treated hypothyroidism and a mildly increased body mass index of 31 kg m2. He had undergone coronary artery bypass surgery at the age of 62 years but had no history of myocardial infarction. He subsequently had percutaneous coronary angioplasty three times between the ages of 67 and 68 years. He had been a non-smoker for 30 years. He rarely consumed alcoholic beverages.
Retigabine is a novel anticonvulsant, initially identified in the National Institute of Neurological Disease and Stroke (NINDS) antiepileptic (AED) drug screening program, that is effective in preventing seizures induced by electrical shock or by a broad range of chemical convul-sants (pentylenetetrazole, N-methyl-D-aspartate NMDA , 4-aminopyridine, and picrotoxin, but not bicuculline or strychnine) (45). BMS-204352 is another drug initially developed as a potential therapy for acute stroke (46). Remarkably, recent studies have revealed that both these agents are potent activators of neuronal KCNQ channels (47-50). The discover of retigabine's novel mode of action has contributed to new interest in its potential clinical usefulness, and it is currently undergoing stage III trials for adult partial epilepsy (50). Although these agents have not yet been shown to be of clinical usefulness, it is clear that the cloning of the KCNQ channels has revealed an important potential new target...
The age-specific incidence of epilepsy is U shaped, with neonates and the elderly showing the highest rates. Most (75 ) elderly-onset epilepsy is explained as being due to cerebrovascular disease17 other causes include tumors, dementia, and head trauma. The diagnosis is again entirely clinical, relying upon history and eye-witnessed accounts. However, such detailed descriptions may be less achievable in frail elderly people living alone. Furthermore, comorbidities such as ischemic heart disease and cognitive impairment and polypharmacy can make diagnosing epilepsy in an elderly person a considerable challenge. An epilepsy diagnosis carries immense medical and social implications for an elderly person, including risk of injury, confusion, depression, fear of isolation, and lack of independence. Furthermore, an underlying ischemic-related arrhythmogenic cardiac syncope (easily attributed to epilepsy) may easily prove fatal, yet the misdiagnosis of epilepsy may remain unrecognized even...
The incidence of status epilepticus (SE) in the elderly is almost twice that of the general population 19-22 . Thirty per cent of acute seizures in older adults present as status epilepticus. Concurrent medical conditions are more likely to complicate therapy and worsen prognosis. Mortality of status epilepticus in older adults is the highest of any age group and reported to be 38-50 19-22 . SE aetiologies include stroke, remote symptomatic seizures, subtherapeutic serum anti-epileptic drug concentrations, hypoxia, metabolic disorders, alcohol-related, tumour, infection, anoxia, haemorrhage, trauma, and idiopathic 19-22 . If one were to combine remote symptomatic stroke cases with acute stroke cases, stroke accounts for 40 of elderly patients with SE. Thus, cerebrovascular disease is the most common cause of SE in the elderly. Non-convulsive SE is the most common form of SE in critically ill patients. Despite its frequency, non-convulsive status is easily mistaken as delirium, which...
Such patients should be considered for pacemaker insertion 17 . S-T-segment abnormailties have also been reported in association with seizures 18 . Patients with epilepsy who have a history of ischaemic heart disease may therefore be at increased risk of cardiac ischaemic events during a seizure. Some AEDs have cardiovascular side-effects, particularly when administered by intravenous infusion this may make acute seizure management difficult in patients with cardiac conditions. Phenytoin infusion causes significant hypotension in approximately 5 of patients 20 , and may be pro-arrhythmogenic when administered rapidly. For patients with heart disease, the rate of phenytoin infusion should be 25mg min 2l . Fosphenytoin, a pro-drug of phenytoin, was initially thought to be free of cardiac adverse effects however, recent literature suggests that cardiac adverse events are not uncommon 22 .
In all of these studies, the aetiology of SE is the most important risk factor for mortality, with the majority of deaths occurring in patients with acute symptomatic SE, particularly after anoxic brain injury, stroke, CNS infection and CNS tumour. Whether this is just a reflection of the severity of the underlying aetiology or a representation of the additional physiological burden of prolonged seizures on a severely ill individual remains difficult to tease out due to the lack of comparative studies. However, Waterhouse et al. 23 reported, in a prospective study, that the mortality of patients with acute stroke and SE was three times that of acute stroke alone, both groups being similar for age and lesion size. This suggests that there is a synergistic effect of SE and the underlying aetiology in causing death, emphasizing the importance of effective treatment.
Whereas neurocardiogenic syncope is fairly benign, cardiac syncope is potentially fatal. Causes include either cardiac arrhythmias (e.g., Wolff-Parkinson-White syndrome, long QT syndromes) or structural heart disease (e.g., hypertrophic cardiomyopathy, aortic stenosis). These require an accurate history, a full neurological and cardiac examination, ECG, echocardiography, and even prolonged ECG monitoring (24-hour or embedded long-term monitoring).
Other minor side-effects include constipation, oesophageal reflux and acidosis. The effect of the diet on growth is a problem. A recent review of the diet in 237 children showed that the rate of weight gain decreased at 3 months but then remained constant for up to 3 years. There is also an effect on height. Renal stones occur in 5-8 of patients. Hypercholesterolemia is common. Rare side-effects that have been reported include cardiomyopathy, pancreatitis, bruising, vitamin deficiency, hypoproteinaemia, Fanconi's renal tubular acidosis and prolonged QT interval. In adults, for whom the diet is not normally recommended, coronary heart disease and myocardial infarction have occurred, associated with hypercholesterolaemia.
It is worth noting that in certain circumstances, it may be reasonable to administer a second-line agent even if the SE is terminated by the initial treatment with lorazepam. This usually arises in the setting of irritative structural lesion, such as a tumour or acute stroke, where the risk of recurrent seizure is high and there is a desire for rapid titration of maintenance AED.
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