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Can Epilepsy Be Prevented

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.

Case Of Complex Partial Status Epilepticus

The patient is a 56-year-old man who was admitted to the hospital for bizarre behavior. He had a history of hypertension and hypercholesterolemia, which had been diagnosed approximately 15 years ago. Six years before admission he experienced a cerebral infarct in the distribution of the left middle cerebral artery distribution, and he had mild residual right hemiparesis. Approximately 1 year after this he was noted to have episodes of staring followed by confusion that lasted for approximately 15 minutes. A neurological evaluation at that time demonstrated left temporal spike discharges emanating maximally from the T3 electrode, with minimal temporal slowing. A diagnosis of complex partial seizures was made and the patient was started on carbamazepine and had no further seizures after attaining a dose of 1200 mg day.

Cerebrovascular disease

Epilepsy can complicate all forms of cerebrovascular disease. Stroke is the most commonly identified cause of epilepsy in the elderly, and occult stroke also explains the occurrence of many cases of apparently cryptogenic epilepsies in elderly individuals. A history of stroke has been found to be associated with an increased lifetime occurrence of epilepsy (odds ratio OR 3.3 95 CI, 1.3-8.5). Among the other vascular determinants, only a history of hypertension was associated with the occurrence of unprovoked seizures (OR 1.6 95 CI, 1.0-2.4). The risk of unprovoked seizures rises to 4.1 (95 CI, 1.5-11.0) in subjects having a history of both stroke and hypertension.

Collagen vascular diseases and other cerebral vasculitides

The epilepsy can be due to the primary disease process and also to the secondary complications such as arterial hypertension, infarction, vasculitic changes, immunological reactions, and hepatic or renal failure. Epilepsy is a common symptom of all forms of cerebral vasculitis, and particularly in systemic lupus erythematosus (SLE). In SLE, seizures can be the presenting and only symptom, and occur during the course of the illness in about 25 of cases. Seizures are particularly common in severe or chronic cases and in lupus-induced encephalopathy. Epilepsy can also occur in Behcet disease, Sjorgren syndrome, mixed connective tissue disease, Henoch-Schonlein purpura and other forms of large, medium or small vessel vasculitis, sometimes on the basis of infarction.

Left Arm And Leg Shaking In A Patient With A History Of Treated Syphilis

A 65-year-old man presented to the emergency department in April 1999 for evaluation of possible seizures.1 He had a history of treated hypertension and treated syphilis, and he was undergoing outpatient evaluation for an aortic arch aneurysm. His chief complaint was uncontrollable shaking of his left arm and leg. The first shaking episode had occurred 1 year earlier. At that time, he was walking when he suddenly developed uncontrollable shaking of the left arm and leg. This episode lasted for a few seconds and terminated spontaneously when the patient sat down. From that point onwards, the episodes occurred intermittently, about once or twice a week. The shaking would occur only when the patient was upright and always resolved when he sat or lay down.

Examination under Special Conditions

The patient's age can focus the physical examination. For instance, children presenting with seizures should have their body temperature checked and receive a thorough evaluation for infections, including examination for the presence of meningeal signs. In developing countries, particularly in regions with endemic parasitosis or malnutrition, physical signs related to chronic diarrhea, malnutrition, skin lesions, and other related abnormalities often provide a clue to the etiology of the seizures or epilepsy, without the need for costly laboratory tests. Similarly, the physical examination of elderly patients should focus on evidence of actual or impending organ failure, and on physical signs that can detect risk factors for specific diseases common in older people (e.g., hypertension, chronic obstructive pulmonary disease).

If At First You Dont Succeed

His past medical history includes hyperthyroidism and hypertension, which he treats with medications. As a result of his seizures, he has fractured both wrists and his right foot and has suffered numerous lacerations on his face and scalp. He has no allergies and does not abuse drugs nor does he drink alcohol or smoke. F is the only one in his family with epilepsy. His social life is very limited because of his seizures and limited cognitive and social skills. His mother is overprotective. His stepfather mostly ignores him. A prior evaluation included a normal EEG and a normal magnetic resonance imaging (MRI) study. He takes phenytoin (100 mg four times daily) and primidone (250 mg four times daily).

The Treatment Of Epilepsy In The Elderly

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

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Eclampsia and preeclampsia

Most new-onset seizures in the late stages of pregnancy (after 20 weeks) are caused by eclampsia. Pre-eclampsia is characterized by hypertension, proteinuria, oedema, and abnormalities of hepatic function, platelets and clotting parameters. About 5 of cases, if left untreated, progress to eclampsia. The eclamptic encephalopathy results in confusion, stupor, focal neurological signs and cerebral haemorrhage as well as seizures. The epilepsy can be severe and progress rapidly to status. The incidence of eclampsia in Western Europe is about 1 in 2000 pregnancies, but it is more common in some developing countries with rates as high as 1 in 100. It carries a maternal mortality rate ofbetween 2 and 5 and significant infantile morbidity and mortality.

Initial Assessment and Treatment

If the patient is pregnant, eclampsia should be considered. Special attention should be given to looking for other evidence of eclampsia (e.g., hypertension). Magnesium sulfate may be used as the long-acting antiseizure medication 2 g given IM, then continuous administration of 2 g per hour in 5 dextrose. Because magnesium sulfate is also a muscle relaxant, it can mask continuing status when EEG is not available thus, deep tendon reflexes should be monitored and the rate decreased if reflexes cannot be elicited. Maximum of 40 g per 24 hours. Rapid delivery of the infant should be considered.

Other vascular disorders

Frequently in systemic lupus erythematosus, and in patients with vasculitis involving the brain. In these conditions, often seizures are not due to the primary disease process, but rather are due to to secondary complications, like arterial hypertension, renal failure or atherosclerosis.

Approach To Newonset Seizures In The Hospital

- for example, diffusion-weighted imaging (DWI) is best for identifying acute ischaemia. Fluid-attenuated inversion recovery (FLAIR) sequences are used to detect inflammatory changes or oedema. In the reversible posterior leukoencephalopathy syndrome ( RPLS , a cause of seizures associated with hypertension, particularly in transplant patients on certain immunosuppressant medications) FLAIR images may show bilateral hyperintensities in the subcortical and cortical parieto-occipital regions, and DWI images will show increased diffusion, corresponding to vasogenic oedema rather than ischaemia 2, 3 .

Seizures In Transplant Patients

Immunosuppressive drug neurotoxicity is the most common aetiology cited in this population, particularly the calcineurin inhibitors cyclosporine and tacrolimus. These are associated with a wide spectrum of neurotoxic effects, mostly described in liver transplant patients, ranging from tremor and visual hallucinations to more severe symptoms if undiagnosed, including speech difficulties, cortical blindness, posterior leukoencephalopathy and seizures. Factors that may promote the development of serious complications include advanced liver failure, hypertension, hypocholesterolaemia, higher cyclosporine or tacrolimus blood levels and hypomagnesaemia.

Other Cardiac Syncopes

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).

Funding Epilepsy Care Services

Fiscal resources for funding even basic health services are frequently insufficient to meet the needs of people in the developing world. Regardless, efforts must be made to make public policy makers aware of the burden of this treatable disease. Even the poorest countries may offer lower clinic fees and medications to people with certain chronic conditions (e.g., hypertension, diabetes). Epilepsy should be included among these recognized and subsidized disorders. Incorporating epilepsy care into the primary clinics will best suit those countries or regions with the least resources available, since marginal costs will be least under this system. Optimal health policy planning for epilepsy care requires reviewing the healthcare system's resources and recognizing the population's geographic, social, and financial barriers to accessing these services.

Neurological disease in which both dementia and seizures occur

It is well recognized that symptomatic seizures occur in the context of dementia syndromes in older people (Forsgren et al., 1996). Breteler et al. (1995) found that people aged 50-75 with a diagnosis of epilepsy had an overall relative risk of 1.5 of subsequently developing a dementia, which they described as a moderately increased risk over the expected rate. People with Down's syndrome are at particular risk of developing early Alzheimer's disease, and this is frequently associated with seizures (Collacott, 1993 Lott and Lai, 1982). In people with mental retardation (learning disabilities) who do not have Down's syndrome, the incidence and prevalence of dementia is higher than expected, and is often associated with poorly controlled epilepsy (Cooper, 1997). There are also isolated case reports showing an apparent association between seizures, dementia and a pathological lesion. It may well be that there are many such very rare or even one-off disorders (Yerby et al., 1986). One...

Phase 2 phase of decompensation

The status epilepticus may then enter a second late phase in which cerebral protective measures progressively fail. The main systemic characteristics of this phase are a fall in systemic blood pressure and progressive hypoxia. Hypotension is due to seizure-related autonomic and cardio-respiratory changes and drug treatment, and in the later stages can be severe and intractable. At a critical stage cerebral autoregulation begins to fail and the control of blood flow then becomes dependent on systemic blood pressure. This is potentially hazardous, as falling blood pressure leads to a failure of cerebral perfusion. The high metabolic demands of the epileptic cerebral tissue cannot be met and this results in ischaemic or metabolic damage. The hypotension can be greatly exacerbated by intravenous anti-epileptic drug therapy, especially if infusion rates are too fast. Intracranial pressure can rise dramatically in late status, and the combined effects of systemic hypotension and...

Pharmacologic And Psychotherapeutic Treatments For Depression And Anxiety

A number of SSRIs are approved by the Food and Drug Administration (FDA) in the United States to treat anxiety disorders. Sertraline is approved to treat panic disorder, post traumatic stress disorder and obsessive compulsive disorder, and par-oxetine is approved for treatment of panic disorder, obsessive compulsive disorder, generalized anxiety disorder, and social phobia. Obsessive compulsive disorder can also be treated by fluoxetine. In the general population SSRIs are effective, tolerated and safe for the treatment of anxiety disorders. Other drugs approved to treat anxiety disorders include clonazepam for panic disorder, and alprazolam for generalized anxiety disorder and panic disorder. Benzodiazepines can cause sedation, psychomotor slowing, decreased attention, impaired memory and a risk for addiction. Venlafaxine is approved for use in generalized anxiety disorder (Davidson et al. 1999) . It inhibits serotonin and NE reuptake. Venlafaxine has side effects that include...

Status Epilepticus in a Heavy Snorer

A 50-year-old railwayman suffered from idiopathic absence seizures until the age of 16 years and had been seizure-free without antiepileptic treatment since then. Hypothyroidism and arterial hypertension were adequately treated. He was a heavy, habitual snorer. His wife witnessed nocturnal apneas and he reported excessive daytime sleepiness (e.g. falling asleep when watching television or when traveling in the train, or in the car as a passenger). One day after lunch he was tired and nervous and shortly thereafter had three generalized tonic clonic seizures in succession, corresponding to tonic clonic status epilepticus. The patient was treated with intravenous benzodi-azepines, phenytoin, and muscle relaxation, followed by intubation. He was transferred to our department.

Infantile sPAsMs AND west sYNDRoME

The common reported adverse effects associated with ACTH treatment and oral steroids are hypertension, irritability, infection and cerebral atrophy. Hypertension and cerebral atrophy were more common with higher doses of ACTH 39 . In addition, longer duration of ACTH treatment was associated with cardiomyopathy 46 . A number of retrospective studies, as well as an open-label prospective comparative study from Japan, suggest that lower doses of synthetic ACTH (doses ranging from 0.2 to 1.28 IU kg day) are better tolerated than and as effective as higher doses 44, 47 . A total of 51 out of 106 patients were seizure free at follow-up (98 patients were followed 2 years) in one retrospective series 48 . Cessation of spasms and resolution of hypsarrhythmia was reported in 17 out of 27 (55 ) patients treated with 0.2 IU kg day for 2-3 weeks 49 . Of the 27 patients that were followed up for 12 months, 13 (48 ) remained in remission, including one patient who received a second 2-week treatment...

Treatment Epileptic Apnea Infant

Threatening event previously called sudden infant death syndrome (SIDS) . Since apnea may also be an important sign of neurologic diseases such as hypoxic-ischemic encephalopathy, intraventricular hemorrhage, infections, hypoglycemia, and medication side effect, an extensive search for an underlying etiology should be undertaken. If there are other concurrent manifestations, such as eye opening, eye deviation, mouth movements, tachycardia, or hypertension, an ictal etiology should be suspected (5,6).

Basic Mechanisms

There are many more provoked seizures in neonates and infants than in adults. Their causes may involve trauma, hypoxic-ischemic encephalopathy, hypertension, metabolic abnormalities (amino acid disturbances, hypocalcemia, hypoglycemia, and electrolyte imbalance), infections, drug withdrawal, pyridoxine dependency, and toxins (4). Similarly, a genetic predisposition to epilepsy may be expressed in infancy. Genetic factors may involve congenital cerebral malformations and familial seizures such as neurocutaneous syndromes, genetic syndromes, and benign familial epilepsy (4). Additionally, several intractable seizure syndromes occur in early infancy or childhood and not later on (5). In children, focal dysfunction may often produce multifocal seizures and status epilepticus, suggesting less effective barriers for seizure spread and generalization (6).

Neurocognitive Risks

The first report regarding an association between intrauterine exposure with a specific AED and cognitive outcome was in 1995 26 on a cohort of adult men in Denmark who were exposed to phenobarbital in utero. Phenobarbital was not used for epilepsy - in fact maternal epilepsy was an exclusion criteria it was generally used for hypertension or as a sedative. The cohort was studied at approximately age 30, and verbal IQ was significantly decreased, by a mean of 7 points, in phenobarbital-exposed men compared with matched controls. Exposure that included the third trimester was a risk factor for this decreased verbal IQ, which suggests that the risk of adverse neurocognitive effects is not confined to the first trimester, as is the exposure that causes MCMs.

Imaging

There are age-related changes seen commonly on MRI. These findings include diffuse atrophy defined as cerebral volume loss manifesting as dilatation of ventricles and foci, and periventricular hyperintensities 44-50 . When any of these radiological signs are found, they are not readily attributable to the aetiology of epilepsy, but rather contribute to nonspecific findings commonly associated with longstanding hypertension or small-vessel atherosclerosis. Therefore, one must be careful in ascribing causes of seizures when obtaining imaging.

Drug Interactions

Alteration in liver function is responsible for a majority of drug interactions. Therefore, attempting to find compounds that are not metabolized through the liver can be beneficial in older patients who are on polypharmacy. Enzyme-inducing agents - phenytoin, carbamazepine, phenobarbital and primidone - are the most problematic in regard to drug interactions due to the induction of cytochrome P450 enzyme. Induction will increase clearance of many drugs metabolized through the liver, which includes a number of drugs commonly prescribed to the elderly, for hypercholesterolaemia, hypertension and depression. Higher doses of these other drugs will be necessary to produce the same therapeutic effect, which can increase the cost of concomitant therapy. Unfortunately, doses are often not increased appropriately, leading to under-treatment. Thus, avoiding these agents may be beneficial. Further information on which drugs are affected can be found in Chapter 13.

Cardiac Disease

Carbamazepine has also been associated with adverse cardiac events. With acute overdose, acute cardiac failure and tachyarrhythmias have been reported with chronic use and therapeutic drug levels, bradyarrhythmias and refractory hypertension have been reported 23-25 . It has been suggested that sudden unexpected death in epilepsy (SUDEP) may in some cases be attributable to AED-induced cardiac dysfunction 26 this remains controversial.

Potassium Channels

Potassium channels play a major role in regulating neuronal excitability. Although more than 20 types of potassium channels have been identified by biophysical studies, there are four major groups calcium-activated, voltage-gated, sodium-activated, and inwardly rectifying potassium channels. These different types of potassium channels are regulated by neuromodulators, ions, and second messenger systems. The opening of potassium channels has the effect of hyperpolarizing neurons or reversing depolarizing actions that exist during the transmission of the action potential or the neuroexcit-atory input. Following depolarization, several calcium-activated potassium channels play a major role in the after-hyperpolarization that occurs to restore the resting potential of a neuron (39). Electrographic studies on hip-pocampal neurons from patients undergoing temporal lobectomies have demonstrated alterations in potassium channels in epileptic tissue (40). In addition, compounds that can block...

Seizure Sequelae

Such examination can disclose abnormalities suggestive either of a phacomatosis (e.g., neurofibromatosis, tuberous sclerosis), a storage disorder (e.g., sialidosis, with a marked cherry red spot in the fundi), a metabolic disease (e.g., the retinitis pigmentosa associated with mito-chondrial diseases), or can show signs of intracranial hypertension, indicative of a mass lesion, that should be aggressively diagnosed and treated.

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

Tuberculoma

Tuberculomas present particularly with epilepsy, and therapy for the epilepsy follows conventional lines. Surgical resection of the tuberculoma was the usual procedure in the past, but increasingly a conservative approach is now initially taken. Surgery is still indicated in the initial stages in cases of diagnostic uncertainty and where larger, symptomatic mass lesions cause midline shift and severe intracranial hypertension. In patients presenting simply with epilepsy, it is now usual to treat with antitubercular and antiepileptic drugs (with a short course of adjunctive steroids), and to defer surgery. When medical therapy is initiated, without diagnostic confirmation from a biopsy, the patient should be carefully monitored, and if the mass does not decrease in size after 8 weeks of therapy, biopsy should be reconsidered. With early diagnosis and a balanced combination of surgical and medical management, tuberculomas are now potentially curable.

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