The neurosurgical treatment of epilepsy

Despite the new advancements in antiepileptic drug development, thousands of people with epilepsy will remain intractable to medication. For a considerable proportion of these people, epilepsy surgery is a consideration for better control of their seizures. Resective surgery is now standard practice for patients with medication-refractory epilepsy. Temporal lobectomy continues to be the most common surgery performed. Once patients fail 2 to 3 optimal trials of antiepileptic medication, further drug therapy offers a minimal number of patients freedom from seizures. In contrast, temporal lobectomy in carefully selected patients may result in seizure-free outcomes in more than 70% to 90% of patients with intractable seizures. As technology and drug availability increases in the new millennium, it is important for the primary care physician to be aware of epilepsy surgery as a means to treat patients with antiepileptic drug-refractory epilepsy. Arch Fam Med. 2000;9:1142-1147     

A Markov model of treatment of newly diagnosed epilepsy in the UK

Long-term comparative trials among newer antiepileptic drugs are lacking; therefore decision models are needed to guide treatment decisions. The goal of this study was to develop an economic model of newly diagnosed epilepsy in the UK and to provide the first assessment of topiramate. A Markov model was developed combining data from clinical trials, cost-of illness, mortality, and utility studies. Expected costs and utilities associated with treatment strategies (first- and second-line treatments) were compared to find the cost-effectiveness frontier. First- and second-line monotherapy with topiramate or carbamazepine in partial seizures was less costly and more effective than other scenarios. In generalised seizures first-line topiramate was cost-effective with valproate or lamotrigine as second-line treatments depending on the set of utilities used. Models provide a relevant framework within which costs and health gains of antiepileptic drugs treatment options can be studied. Our findings are further evidence of the promising role of topiramate for patients with newly diagnosed epilepsy.     

Pattern reversal VEP in epilepsy (a prognostical tool?).

72 adult outpatients treated for epilepsy were examined by pattern reversal VEP method. 36 had generalized tonic-clonic seizures, 23 partial epilepsy with secondary tonic-clonic seizures and 13 had partial epilepsy with simple seizures. The patients were divided into three groups according to medical successfulness. The frequency of epileptic seizures per year was the criterion for dividing the group. Statistically significant relation was recorded in the occurrence of abnormal VEP findings to the frequency of epileptic seizures. Increased number of abnormal VEP findings occurred in the group of patients with greater frequency of epileptic seizures. The possible cause of the VEP abnormality in patients with frequent epileptic seizures is discussed.     

老年癫痫65例临床分析

目的探讨老年癫痫的临床特点、病因、治疗及预后。方法回顾性分析解放军总医院癫痫门诊收治的65例老年癫痫患者的临床资料。结果65例老年癫痫患者占所有就诊癫痫患者的2．8％。70．8％为部分性发作,24．6％为全身强直阵挛发作．4．6％以癫痫持续状态起病。发病原因：40．0％为脑血管病,其余主要为脑外伤、脑肿瘤、睡眠呼吸暂停综合征、缺氧性脑病、阿尔茨海默病、低血糖等,20．0％原因不明。常规脑电图异常率44_4％,动态脑电图异常率84．2％。80．0％患者药物治疗,抗癫痫药物主要为卡马西平、丙戊酸钠、苯妥英钠及托吡酯,73．1％为单药治疗,治疗后88．5％发作减少,9．6％未再出现发作,1．9％发作加重。结论老年癫痫绝大多数为继发性癫痫,有明确的病因,部分性发作比例高。抗癫痫药物治疗效果较好。因老年患者基础疾病多且病情复杂,抗癫痫药应从小剂量开始,逐渐加量,以小剂量长期治疗。     

具有中央-颞区棘波的儿童良性癫痫临床及脑电图特点

目的 总结具有中央一颞区棘波的儿童良性癫痫(BECCT)的临床及脑电图(EEG)特点。方法 对78例BECCT患儿的临床资料和脑电图进行回顾性分析。结果 发病年龄3-14a，其中5～10a发病者62例(80％)；发作频度变异大，以短期发作数次者及偶发者为主，占67％(67／78)；72例(92．3％)发作与睡眠密切相关；部分性发作63例(80．8％)，其中继发全身性发作者24例，发现时即为全身性发作15例(19．2％)；发作间期脑电图可见一侧或双侧中央和／或中颞区有尖波或棘波发放，清醒脑电图阳性率55．4％，睡眠脑电图阳性率92％；绝大多数患儿应用抗癫痫药物(AEDs)治疗疗效满意，占93．2％(69／74)，但发作停止≥1年者复查EEG仅部分恢复正常。结论 BECCT是一种与睡眠密切有关的部分性癫痫，发作的基本类型为部分性发作，部分患儿可伴有全身泛化，脑电图为中央、颞区局灶发电，脑电图睡眠诱发试验可提高脑电图辅助诊断的阳性率。本病预后良好，早期诊断有助于对患儿的良好预后尽早做出判断，从而减轻患儿及家庭的心理负担。     

Injuries, accidents and mortality in epilepsy: a review of its prevalence risk factors and prevention

Currently, there is intense clinical research into various aspects of the medical risks relating to epilepsy, including total and cause-specific mortality, accidents and injuries in patients with epilepsy and mortality related with seizures. Submersion injuries, motor vehicle accidents, burns, and head injuries are among the most feared epilepsy-related injuries. Published risk factors for injuries include the number of antiepileptic drugs, history of generalized seizures, and seizure frequency. In general, studies focusing on populations with more severe forms of epilepsy tend to report substantially higher risks of injuries than those involving less selected populations. On the other hand, studies based in non selected populations of people with epilepsy have not shown an increase frequency of injuries in people with epilepsy compared with the general population. Some studies have shown that patients with epilepsy are more frequently admitted to the hospital following an injury. Possible explanations include are more cautious attitude of clinicians toward injuries occurring in the setting of seizures; hospitalization required because of seizures and not to the injuries themselves; and hospitalization driven by other issues, such as comorbidities, which are highly prevalent in patients with epilepsy. This article reviews information about specific type of injuries such as fractures, burns, concussions, dislocations, etc. Finally this article review in a comprehensive way information of mortality in patients with epilepsy. Aspects of mortality discussed in this review are: epidemiology, causes of mortality, sudden death in epilepsy and prevention measures.     

Management of seizures in the elderly: a survey of UK geriatricians.

The incidence and prevalence of epilepsy increase substantially with old age. Despite this, the investigation and management of this patient population remains a grey area. Four hundred and eleven (53%) consultant geriatricians responded to a questionnaire exploring their approach to seizures in the elderly in order to establish an overview of current clinical practice. Between one and five patients presenting with seizures, predominantly aged between 75-85 years, were reviewed monthly. Seventy per cent of geriatricians undertook to investigate the patients themselves with biochemical and haematological profiles performed by most. Electroencephalography and computerized tomographic scanning were routinely requested by a quarter of responders. Only 58% would themselves initiate therapy with antiepileptic drugs, with 16% of consultants starting treatment following the first seizure, 59% after a second and 5% after a third. Phenytoin was first choice for generalized tonic-clonic seizures with carbamazepine preferred for partial seizures. If good control was not obtained, 67% would substitute another first line drug, while 27% would add in a second. Less than 3% would use the new anticonvulsants lamotrigine or vigabatrin. Sixty per cent monitored anticonvulsant concentrations in patients with poor control or suspected toxicity. A wide variability was seen in the current approach to seizures in the elderly, which reflects a lack of established practice. Epilepsy clinics for the elderly would encourage structured research into the many unanswered questions affecting the care of older people with seizures.     

Adaptation and evaluation of the Liverpool Seizure Severity Scale and Liverpool Quality of Life battery for American epilepsy patients

The Liverpool Seizure Severity Scale (LSSS) and the Liverpool Quality of Life (LQOL) battery were developed in Great Britain to assess the severity of seizure symptoms and the impact of epilepsy on patients' quality of life. The scales have been validated on British patients, but have not been validated for use with American patients. The objectives of this study were to adapt the scales to the American population and to evaluate their reliability and validity. After modifications recommended by focus groups with patients and epilepsy specialists, the scales were administered to a sample of 90 epilepsy patients who had experienced seizures within the previous 4 weeks. Comparisons of patients with generalized tonic-clonic seizures (n=58) and partial seizures (n=32) revealed significant differences on 9 of the 20 items on the LSSS as well as the total score. None of the six LQOL subscales (negative drug effects, positive drug effects, affect balance, sense of mastery, life fulfilment and impact of epilepsy) distinguished patients with different seizure types but five of the six subscales were significantly correlated with seizure severity. The internal consistency and test-retest reliability were adequate for both the LSSS and LQOL. Finally, five of the six LQOL scales were significantly correlated with independent measures of mental health, physical health and role functioning.     

New antiepileptic drugs in childhood

In recent years, many new antiepileptic drugs have been available for the treatment of epilepsy in pediatric age. In this review, we describe these new antiepileptic drugs (vigabatrin, lamotrigine, felbamate, gabapentin, tiagabine, topiramate) which can be used together with "old" antiepileptic drugs (e.g. phenobarbital, valproate, etc.). We report their mechanisms of action, effectiveness, dosage and side effects; moreover, some practical advice for their use in pediatric patients is given.     

长程视频同步脑电监测在儿童癫痫诊断和分类中的价值

【目的】 评价长程视频脑电图监测(video-EEG monitoring,video-EEG)在儿童癫痫的临床诊断和分型中的应用价值。 【方法】 对98例临床拟诊为癫痫的患儿进行连续12~18 h的包括清醒及睡眠的长程video-EEG监测。 【结果】 98例患儿中,发现痫样放电比例为91.8%(90/98),44例癫痫样放电与临床发作同步出现(44.9%),长程Video EEG监测前根据临床表现诊断全面性发作占53.1%(52/98),局限性发作占43.9%(43/98)。不能分类的发作有3例,占3.0%(3/98);长程video-EEG监测后全面性发作共32例,占32.7%,局限性发作共有 60 例,占61.2%,不能分类的发作2例,占2%。监测前后发作类型一致的有58例,不一致的有40例。 【结论】 长程视频同步脑电图监测对于儿童癫痫的临床诊断和分类有重要的价值。     

Malnutrition et épilepsie : des liens complexes

A link between malnutrition and epilepsy has been suspected for many years. Several studies which have been performed on animal models or on humans highlighted the adverse effects of malnutrition in the onset of seizures. Proteinoenergetic, electrolytes, vitamine or trace-element deficiencies could be implied. The possible negative effect of epilepsy on nutritional status has also been studied, with several determinants leading to malnutrition: foods which are forbidden during epilepsy in developing countries and probably in France, social exclusion which is common for people with epilepsy, role of antiepileptic diets or treatments on appetite for example. Two different hypotheses exist as a vicious circle: malnutrition predisposing to epilepsy or conversely epilepsy predisposing to malnutrition.     

Epilepsy in adolescents: diagnosis and treatment

Although seizures are one of the most common presenting neurologic problems in adolescence, the diagnosis and management of seizures in this population can be a challenge. Seizures can be secondary to an underlying illness or to a genetically based epileptic syndrome. The first task of the clinician is proper diagnosis and evaluation. The second task is to determine whether treatment with antiepileptic drugs (AEDs) is necessary and, if so, which AED is the most appropriate for the patient's epilepsy with the least impact on the adolescent's quality of life. The newer AEDs allow the clinician more flexibility to treat not only the epilepsy, but also any coexisting medical conditions in the patient. The impact of epilepsy on the quality of life of the adolescent cannot be overestimated. Epilepsy affects the adolescent's social life, peer interactions, educational and career decisions, driving ability, and reproductive life. Communication with the adolescent regarding the effect epilepsy can have on these issues is crucial to proper management of the patient. Although treating the seizures and all of the ramifications of the diagnosis is a challenge, the majority of adolescents can achieve the primary goals of therapy: seizure freedom and the maintenance of high quality of life.     

蛛网膜下腔出血继发癫痫发作的临床分析

目的观察蛛网膜下腔出血(SAH)继发癫痫发作的临床特点。方法回顾分析近10年来167例SAH中22例继发癫痫的临床资料。结果 SAH继发癫痫的发病率为13.2%,死亡率36.4%;以癫痫发作为首发症状的18例;发作类型以全身强直—阵挛发作(GTCS)为主,占54.5%(12/22),简单部分性运动发作(SPS)占27%(6/22),复杂部分性发作(CPS)占18%(4/22)。结论 SAH易伴发癫痫发作,其发作类型与出血量及部位相关,继发脑损害发生率与死亡率高于未伴发癫痫者。     

脑卒中后癫痫47例临床研究

目的:探讨脑卒中后癫痫的临床特点,癫痫对脑卒中恢复期神经功能康复的影响。方法:回顾性分析47例脑卒中后癫痫患者的临床资料。结果:早发型癫痫27例,其中出血性脑卒中(19例),缺血血性脑卒中(8例);迟发型癫痫20例,出血性脑卒中(8例),缺血血性脑卒中(12例)。早发型癫痫患者中16例长期服用抗癫痫药,12例(75%)无发作;11例未给予抗癫痫治疗,8例(72.72%)无发作。迟发型癫痫患者中15例长期服用抗癫痫药。13例(86.67%)无发作;5例未给正规应用抗癫痫药物,2例(40%)无发作。结论:出血性卒中发生早发型癫痫的可能性大,缺血性卒中更倾向于发生迟发型癫痫。服用抗癫痫药物对早发型癫痫预后并无明显影响,但可明显改善迟发型癫痫的预后。     

Adaptation and Evaluation of the Liverpool Seizure Severity Scale and Liverpool Quality of Life Battery for American Epilepsy Patients

The Liverpool Seizure Severity Scale (LSSS) and the Liverpool Quality of Life (LQOL) battery were developed in Great Britain to assess the severity of seizure symptoms and the impact of epilepsy on patients' quality of life. The scales have been validated on British patients, but have not been validated for use with American patients. The objectives of this study were to adapt the scales to the American population and to evaluate their reliability and validity. After modifications recommended by focus groups with patients and epilepsy specialists, the scales were administered to a sample of 90 epilepsy patients who had experienced seizures within the previous 4 weeks. Comparisons of patients with generalized tonic-clonic seizures (n = 58) and partial seizures (n = 32) revealed significant differences on 12 of the 20 items on the LSSS as well as the total score. None of the six LQOL subscales (negative drug effects, positive drug effects, affect balance, sense of mastery, life fulfilment and impact of epilepsy) distinguished patients with different seizure types but five of the six subscales were significantly correlated with seizure severity. The internal consistency and test-retest reliability were adequate for both the LSSS and LQOL. Finally, five of the six LQOL scales were significantly correlated with independent measures of mental health, physical health and role functioning. This revised version was published online in June 2006 with corrections to the Cover Date.     

Antiepileptic primidone shortly to be withdrawn from sale: change medication now

The antiepileptic drug primidone is to be withdrawn from sale by January 2004. After this date, the drug will still be available for a time, but only on a limited basis. Most primidone users are elderly patients who have been prescribed this drug for many years. Changing to a new drug constitutes a health risk for them. If primidone treatment is discontinued too quickly, withdrawal seizures may appear, some of which may be severe. In patients who have not suffered an epileptic seizure for many years, discontinuing medication may be considered. Whenever continuation of anticonvulsive treatment is desirable, it may probably be a good idea to switch over to some newer antiepileptic drug. If a simple and quick substitution is essential, primidone may be replaced by its main metabolite: phenobarbital. General practitioners and neurologists are strongly advised to alter patients' medication in good time.     

Psychoeducational Programs for Patients with Epilepsy

Epilepsy is a common neurological disease, which affects people of all ages. Patients often have deficits regarding their knowledge of epilepsy. Many of them have recurrent seizures, psychosocial, and emotional problems and report restrictions in daily living as a result of their epilepsy. Meanwhile, a variety of psychoeducational programs have been developed with the intention to improve knowledge, coping with epilepsy, quality of life, compliance, and health status.This review article discusses the content and designs of formal patient educational programs for persons with epilepsy and reviews their role in improving patient outcomes. A systematic research of medical and psychological literature reveals that a sizeable amount of literature has been produced within the last decade that focuses on (psycho-) educational programs for adults, adolescents, and children with epilepsy as well as their families. These educational programs vary considerably in regard to content, didactic approach, and objectives. It is sometimes difficult to differentiate educational programs from psychological treatments or other interventions (e.g. by specialist epilepsy nurses). Information given about the theoretical frameworks guiding interventions, teaching strategies, and methodological approach of the programs is often sparse or lacking.The crucial point is that only very few educational programs have been evaluated in a randomized controlled trial. Furthermore, the methods of evaluation (e.g. questionnaires, inclusion and exclusion criteria, randomization, follow-up period) vary substantially and sometimes the number of subjects included in the study is too small for sufficient statistical evaluation.Overall, from the small number of evaluated programs it is evident that educational programs can improve epilepsy-related knowledge, improve the management of seizures, and reduce misinformation and misconceptions about epilepsy. They can support adults, adolescents, and children with epilepsy and their families and enable them to cope with the disease; they can sometimes also reduce seizure frequency and improve compliance with antiepileptic drugs. The effects on emotional disorders (e.g. depression) and quality of life are less obvious.Evaluated or standardized psychoeducational programs are available for specific target groups of patients with epilepsy. The review indicates that it is reasonable to perform or to adapt these educational programs for the benefit of the patients. Future research should focus on controlled evaluation studies of educational programs.     

Reversible memory disorders in an older patient caused by epilepsy

Memory impairment in a 63-year-old man was the most prominent expression of partial epileptic seizures from the temporal lobe, probably resulting from a head injury. Treatment with antiepileptic drugs resulted in complete recovery. This case illustrates that epilepsy should be considered in the differential diagnosis in elderly patients with an isolated memory disorder. The diagnosis is made by clinical methods and may be confirmed by electroencephalography.     

Febrile seizures and epilepsy: the contributions of epidemiology

In the past, febrile seizures were considered to be a sign of epilepsy, a disorder characterised by recurrent unprovoked seizures. Currently, febrile seizures are considered to be a benign seizure syndrome that is distinct from epilepsy. This distinction has been possible largely because of the epidemiological evidence which is presented here in the form of a two-part argument. If febrile seizures are epilepsy one might expect that: (1) following a first febrile seizure, the risk of a second febrile seizure should be similar to the risk of an unprovoked seizure (in fact, the risk of a recurrent febrile seizure is approximately 34%, whereas the risk of an unprovoked seizure after having had a febrile seizure is approximately 2% to 3%); (2) the factors that predict recurrent febrile seizures should also predict subsequent unprovoked seizures. From the available literature, young age at the time of the first febrile seizure and a family history of febrile seizures predict recurrent febrile seizures, but do not predict subsequent unprovoked seizures. By contrast, a family history of epilepsy, complex febrile seizures and neurological abnormality are associated with an increased risk of subsequent epilepsy but are not consistently associated with the risk of a recurrent febrile seizure.