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Continuum,
Epilepsy, August 2007,
Volume 13,
Issue 4
| Issue Overview |
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faculty.
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errata.
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editor's preface.
- Miller, Aaron
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classification of epileptic seizures.
- Herman, Susan
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Show/Hide Abstract
Correct classification of seizure type and epilepsy syndrome are important first steps in the management of patients with epilepsy, providing critical information for choice of diagnostic tests, selection of optimal treatment, and determination of prognosis. The two currently accepted classifications are the International Classification of Epileptic Seizures and the International Classification of Epilepsies and Epileptic Syndromes. Epileptic seizures are divided into focal seizures, which begin in a localized region of one hemisphere, and generalized seizures, which involve both hemispheres at onset. Epilepsy syndromes are constellations of features such as seizure type, age of onset, etiology, interictal deficits, and EEG and neuroimaging findings. Epilepsy syndromes are divided into syndromes with focal seizures, syndromes with generalized seizures, undetermined syndromes, and special syndromes. They are further subdivided by etiology. Idiopathic syndromes have a presumed genetic etiology, while symptomatic epilepsies have a clearly identified cause. Probably symptomatic syndromes are those in which an etiology is suspected, but the exact cause cannot be determined. Over the past 6 years, the International League Against Epilepsy (ILAE) Task Force on Classification and Terminology has proposed important modifications for these classification systems. In addition, a new diagnostic scheme for patients with epilepsy provides structure in the form of five diagnostic axes: ictal phenomenology, seizure type, epilepsy syndrome, etiology, and impairment. This chapter focuses on the current classifications and proposed diagnostic axes in adolescents and adults. Proposed modifications that reflect important changes in classification philosophy will also be discussed.(C) 2007 American Academy of Neurology
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differential diagnosis of epilepsy.
- Benbadis, Selim
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Show/Hide Abstract
Because the diagnosis of seizures relies entirely on the history, epilepsy is frequently misdiagnosed. In addition, EEGs that are overread contribute to the misdiagnosis. Psychogenic nonepileptic seizures are the most common condition misdiagnosed as epilepsy, followed by syncope. Other conditions that cause paroxysmal short-lived neurologic dysfunction are usually easier to differentiate from seizures, but should also be considered in the differential diagnosis.(C) 2007 American Academy of Neurology
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treatment with antiepileptic drugs, new and old.
- French, Jacqueline
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Show/Hide Abstract
Many effective antiepileptic drugs (AEDs) are currently available. These are generally subdivided into the first-generation AEDs (phenytoin, carbamazepine, phenobarbital, primidone, valproate, ethosuximide, and the benzodiazepines), and the second-generation AEDs (felbamate, gabapentin, lamotrigine, topiramate, tiagabine, oxcarbazepine, levetiracetam, zonisamide, and pregabalin). Selection of the ideal drug for each individual patient should be based on a number of factors, including cost, spectrum of activity, potential for dose-related and serious side effects, drug interactions, and others. Special consideration must be given to populations such as women, older adults, and newly diagnosed patients. When all factors are taken into consideration, most patients can find an effective and well-tolerated drug.(C) 2007 American Academy of Neurology
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antiepileptic drug interactions.
- Pollard, John, Delanty, Norman
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Show/Hide Abstract
Drug interactions involving antiepileptic drugs (AEDs) can cause serious morbidity and mortality if not anticipated and managed appropriately. These interactions are most easily incorporated into daily practice if the mechanisms of interaction are understood. To a large extent, these interactions occur through alterations of the pharmacokinetic parameters of one of the drugs. Both inhibition and induction of hepatic enzyme systems such as the cytochrome p450 system contribute to this problem. Some pharmacodynamic interactions are important to recognize as well, although the mechanisms are less well understood. Interactions among AEDs can lead to toxicity or to loss of antiepileptic activity. The most important interactions involve inhibition of the clearance of an AED, because this inhibition can quickly lead to toxicity. Some non-AEDs can also inhibit the clearance of AEDs, similarly leading to rapid development of toxicity. A less acute problem is the potential loss of activity of non-AEDs when the clearance rate has been increased because of enzyme induction caused by the AEDs. Understanding these principles, incorporating important interactions into daily practice, and applying appropriate therapeutic drug monitoring where appropriate will reduce morbidity and mortality from drug interactions.(C) 2007 American Academy of Neurology
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idiopathic pediatric epilepsy syndromes.
- Bergqvist, A.
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Show/Hide Abstract
Epilepsy in children has a high incidence of genetic etiology, and idiopathic pediatric epilepsy syndromes are common. Genes that cause or contribute to the development of the idiopathic epilepsy syndromes have recently been identified. This group of epilepsies therefore offers a better understanding of the age-dependent development of epilepsy and the many complicated interactions between genes and environment and allows us to choose more specific treatments and predict neuro-developmental outcomes with better accuracy. In this chapter we will review our current understanding of the demographics, presentation, types of seizures, EEG findings, genetic relationships, treatment, and prognosis of the pediatric idiopathic epilepsy syndromes.(C) 2007 American Academy of Neurology
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status epilepticus.
- Hirsch, Lawrence, Arif, Hiba
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Show/Hide Abstract
Status epilepticus (SE) is a medical emergency. It requires prompt diagnosis and treatment since delay is associated with worse outcome and a higher likelihood of poor response to treatment. Lorazepam is well established as first-line therapy. Rectal diazepam or nasal or buccal midazolam should be given if IV access is not immediately available. This is usually followed by phenytoin or fosphenytoin. SE may be either convulsive or nonconvulsive; the nonconvulsive form remains underdiagnosed. Urgent EEG is indicated in any patient with fluctuating or unexplained alteration of behavior or mental status, and after convulsive seizures or SE if the patient does not rapidly awaken. For refractory SE, continuous IV midazolam and propofol, separately or in combination, are rapidly effective.(C) 2007 American Academy of Neurology
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surgical treatments for epilepsy.
- Thadani, Vijay, Taylor, John
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Show/Hide Abstract
An estimated 250,000 patients in the United States who have medically refractory epilepsy are candidates for epilepsy surgery, but only 2000 surgeries are done each year. If a patient fails trials with two or three antiepileptic drugs, the chances of controlling his or her seizures with medical therapy are quite low, and referral to a specialized epilepsy center is desirable. Patients with focal or secondarily generalized seizures are usually the best candidates for resective surgery, and complete control of seizures can be anticipated in 50% to 70% of patients who undergo a focal resection. Temporal lobectomy has the best outcome and the best-documented improvement in quality of life. Low-grade tumors, vascular lesions, and cortical dysplasias outside the temporal lobes can also be addressed successfully. The key to successful epilepsy surgery is multimodality localization of the seizure focus. Video-EEG recording of seizures with scalp plus or minus intracranial EEG plays a vital role. Advances in imaging technology, including receptor-ligand PET scans, ictal SPECT scans, and magnetic resonance spectroscopy can be used to guide the placement of intracranial EEG electrodes and may someday replace them altogether in identifying the area to be resected. In the future, devices for electrical stimulation, including vagus nerve stimulation and intracranial stimulation, may replace destructive methods, just as they have in the realm of movement disorders.(C) 2007 American Academy of Neurology
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ethical perspectives in neurology.
- Conway, Jill
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practice issues in neurology.
- Barkley, Gregory
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appendix a: use of serum prolactin in diagnosing epileptic seizures: report of the therapeutics and technology assessment subcommittee of the american academy of neurology.
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appendix b: practice advisory: the use of felbamate in the treatment of patients with intractable epilepsy: report of the quality standards subcommittee of the american academy of neurology and the american epilepsy society.
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appendix c: efficacy and tolerability of the new antiepileptic drugs i: treatment of new onset epilepsy: report of the therapeutics and technology assessment subcommittee and quality standards subcommittee of the american academy of neurology and the american epilepsy society.
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appendix d: efficacy and tolerability of the new antiepileptic drugs ii: treatment of refractory epilepsy: report of the therapeutics and technology assessment subcommittee and quality standards subcommittee of the american academy of neurology and the american epilepsy society.
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appendix e: practice parameter: temporal lobe and localized neocortical resections for epilepsy: report of the quality standards subcommittee of the american academy of neurology, in association with the american epilepsy society and the american association of neurological surgeons.
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appendix f: practice parameter management issues for women with epilepsy (summary statement): report of the quality standards subcommittee of the american academy of neurology.
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patient management problem.
- French, Jacqueline
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index.
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