Intractable epilepsy

A 26-year-old female had her first partial seizure at the age of five years. Further seizures occurred and later became generalised in nature. Control of the seizures became difficult despite the use of nine different anticonvulsants over a period of 20 years. She was not suitable for neurosurgical intervention because of the diffuse nature of her seizures. Cerebellar stimulation had only a marginal effect on seizure frequency. With time she became mentally retarded and was unable to benefit from formal education. Her illness demonstrates many of the long-term clinical features and management problems of intractable epilepsy.     

Handle with care

Approximately 4% of children experience febrile seizures, making it one of the most common childhood neurologic disorders. Most incidences occur between six months and three years of age, and 30%-40% of these children will experience a recurrence. The priorities in emergent management of pediatric seizures are airway maintenance, seizure termination and correction of reversible causes. When a child experiences a febrile seizure, gradual passive cooling will assist the child in terminating it. The exact cause of febrile seizures is still uncertain, but studies seem to suggest that the height of the fever is less of a factor than the rapidity of its rise. In other words, a child is more likely to seize if his or her temperature rises rapidly, even if it reaches a lower maximum temperature. The same child may slowly increase his/her temperature to a higher maximum without suffering a seizure. In this case, the patient obviously had a respiratory infection that was the source of the fever. It is important to reassure the parents in such a case of the benign nature of febrile seizures and that less than 5% of children experiencing them will develop a seizure disorder. The seizure in this case was terminated with i.v. Atvan, a drug that has been shown to work well as an anticonvulsant in children. But in most circumstances, a febrile seizure will end spontaneously or with gentle cooling. Either acetaminophen or ibuprofen can be given to treat the fever, and rectal forms of these medicines are preferred in the early treatment phase. Oral forms of the medicine can be administered after the child has stopped seizing and is not vomiting. The child should be exposed to a cooler, but not cold, environment, and the airway supported. Tepid baths can help to bring down a fever, but alcohol rubdowns or any fast cooling measures should be avoided because they may induce shivering and further elevate the fever.     

New-Onset Seizure in Patient Medicated With Bupropion for Smoking Cessation: A Case Report

BackgroundBupropion is a pharmacologic agent approved by the U.S. Food and Drug Administration as an antidepressant and to support smoking cessation. Because reduction of seizure threshold is a rare but serious side effect of bupropion, its use in patients with a known history of seizures is contraindicated. We report a patient without seizure risk factors who presented to the emergency department (ED) with new-onset seizures secondary to bupropion use.Case ReportA 66-year-old female presented to the ED by emergency medical services with altered mental status. She was determined to be postictal after a witnessed new-onset seizure 4 days after starting bupropion for smoking cessation. She had no personal or family history of seizure disorders, although her medication list raised suspicion that recent discontinuation of alprazolam may have contributed to a reduced seizure threshold.Why Should an Emergency Physician Be Aware of This?New-onset seizures secondary to bupropion use are less likely in patients with no personal or family history of seizure disorders. Emergency medicine clinicians should be aware, however, of the seizure risk associated with bupropion regardless of personal risk factors. Discontinuation of bupropion should be considered if determined to be a contributor to seizures.     

中风后痫性发作及癫痫的再发因素

目的　进一步研究中风 ,以试图揭示中风后痫性发作的再发因素。方法　对 415 2例住院的中风病人的所有曾经有过第 1次痫性发作的病人的资料进行回顾性分析研究 .结果　 176例有痫性发作 (4.2 4% )。其中缺血性中风后痫性发作为 78例 ,出血性中风发作者为 98例。皮质病变 137例 ,占 77.84%。早期发作者 12 9例 ,晚期发作者为 47例。 136例 (77.2 7% )观察了 2年以上的病史 ,其中 5 6例发生了第 2次痫性发作。对于晚发者有 39例复发 ,早发者为 17例 ,(P<0 .0 1)。 5 6例复发者中 15例为单纯发作 ,41例为复杂发作。结论　出血性中风 ,枕叶、颞叶病变 ,大面积 (两叶以上 )脑梗塞 ,大量脑出血 (>40ml)及晚期发作者易发生痫性发作的复发。中风后癫痫应分为早期发作和晚期发作 ;早期发作复发者少 ,1月后如不再发作可暂不予抗痫治疗 ,如出现第 2次发作应正规抗痫治疗。枕叶病变与复杂部分性发作有关。     

Seizure possibly associated with fluvoxamine

OBJECTIVE: To inform clinicians of the possibility that seizures due to therapeutic doses of fluvoxamine may not be as rare as previously considered. CASE SUMMARY: A 49-year-old white man with schizoaffective disorder and a past history of seizures secondary to head trauma had been seizure-free for approximately 10 years. Fluvoxamine therapy was begun due to increasing obsessive-compulsive behavior. Despite receiving anticonvulsants for his mood disorder, the patient had a breakthrough seizure. There were no underlying medical conditions that might have induced this seizure. No further seizures occurred after he was placed on a higher dosage of the anticonvulsants. The obsessive-compulsive behavior improved considerably as a result of fluvoxamine treatment. DISCUSSION: The patient presented here developed a seizure with a therapeutic dosage of fluvoxamine; seizures associated with this agent have occurred more often with overdose. Multiple factors such as a prior history of seizures, head trauma, and concurrent treatment with other psychotropic agents are considered in this case report. CONCLUSIONS: Despite the relatively safe and benign adverse effect profile of the selective serotonin-reuptake inhibitors such as fluvoxamine, clinicians should be cautious about seizures as an adverse effect, especially when the patient has even a remote history of seizure or head trauma.     

Prosthetic management of an epileptic patient

This case report illustrates the problems of tooth loss in an epileptic patient. The patient presented with a broken denture following a seizure. She gave a history of breaking and swallowing her dentures during seizures. Before presentation she had worn five upper removable partial dentures. An upper removable partial denture with increased thickness of the acrylic palatal was fabricated and fitted satisfactorily. The patient was taught how to insert and remove the prosthesis as quickly as possible. Epileptic patients can use dentures but run the risk of frequently breaking and swallowing them during seizures. The risk can be reduced if patients and relatives are taught how to remove the dentures prior to or during seizures.     

Juvenile myoclonic epilepsy presenting as a new daily persistent-like headache

New daily persistent headache (NDPH) is a recognized subtype of chronic daily headache with a unique presentation of a daily headache from onset typically in individuals with minimal or no prior headache history. Various secondary mimics of NDPH have now been documented but at present there has been no association made between primary epilepsy syndromes and new daily persistent-like headaches. A case patient is presented who developed a daily continuous headache from onset who 3 months after headache initiation had her first generalized tonic-clonic seizure. Further investigation into her history and her specific EEG pattern suggested a diagnosis of juvenile myoclonic epilepsy (JME). Her NDPH and seizures ceased with epilepsy treatment. Clinically relevant was that the headache was the primary persistent clinical symptom of her JME before the onset of generalized tonic-clonic seizures. The current case report adds another possible secondary cause of new daily persistent-like headaches to the medical literature and suggests another association between primary epilepsy syndromes and distinct headache syndromes.     

Ertapenem-associated seizures in a peritoneal dialysis patient

OBJECTIVE: To report a case of a patient undergoing peritoneal dialysis who developed refractory seizures after 2 doses of ertapenem. CASE SUMMARY: A 56-year-old white man with end-stage renal disease requiring continuous ambulatory peritoneal dialysis experienced 5 seizures following 2 doses of ertapenem 500 mg given intravenously. The first generalized tonic-clonic seizure occurred 16 hours after the second ertapenem dose and lasted 3 minutes. Three hours after his first seizure, the patient experienced 2 more seizures 15 minutes apart, lasting 3 minutes each. After suffering a fifth seizure, the patient became apneic and pulseless and was not resuscitated, as he had previously requested a "do not resuscitate" status. DISCUSSION: Carbapenem treatment has been associated with simple partial, complex partial, and generalized tonic-clonic seizures, with generalized seizures representing the most frequently occurring type. Safety data from 7 published clinical trials of ertapenem revealed a seizure incidence of 0.18%. To our knowledge, there are no previously published reports of ertapenem neurotoxicity in patients undergoing peritoneal dialysis. Moreover, little information is available regarding the pharmacokinetics of carbapenems in end-stage renal disease. Ertapenem pharmacokinetics were not tested in any patients receiving peritoneal dialysis during published clinical trials. CONCLUSIONS: Our patient experienced 5 seizures, possibly induced by ertapenem, as validated by the Naranjo probability scale. Clinicians administering ertapenem to patients undergoing peritoneal dialysis should use caution, as clinical experience with the agent is limited and pharmacokinetic data are lacking.     

Retrospective study of febrile seizures: subsequent electroencephalogram findings,unprovoked seizures and epilepsy in adolescents

A retrospective questionnaire to determine the prevalence of febrile seizures was given to adolescents (16- and 17-year-olds) in the final 2 years of secondary school at the five schools in Alexandroupolis, Greece. Parents were interviewed, and clinical and electroencephalographic examinations were performed in all adolescents with a history of febrile seizures. Of 1708 adolescents, 56 (3.3%) had experienced at least one febrile seizure. Of these, 44 (78.6%) were simple and 12 (21.4%) were complex febrile seizures. Recurrent seizures occurred in 22 cases (39.3%), and the mean age at onset was 25.1 months. There was a positive first-degree family history in eight cases (14.3%) and this increased to 27.3% in cases with recurrent seizures. Two of the adolescents (3.6%) had had one unprovoked seizure before the age of 3 years, and another two children developed epilepsy. Epileptiform electroencephalogram discharges were observed in only one case (1.8%) with generalized tonic-clonic epilepsy.     

Seizures associated with fluoroquinolones.

OBJECTIVE: To report two cases of seizures following administration of levofoxacin and ciprofloxacin. CASE SUMMARY: A 75-year-old white woman admitted to the hospital was prescribed levofloxacin for ischemic toes. After receiving three doses of oral levofloxacin, the patient experienced a seizure. One month later, the patient was rechallenged with ciprofloxacin and again experienced a seizure. The patient was hypomagnesemic and had elevated serum creatinine at the time of both seizures, and was hyponatremic during the second seizure. A 74-year-old white woman admitted to the hospital was prescribed levofloxacin for bacterial pneumonia. After five doses, the patient experienced a seizure. The woman had no electrolyte imbalances at the time of the seizure and no history of a seizure disorder. DISCUSSION: Quinolone antibiotics vary in their ability to induce seizures, with trovafloxacin having the greatest potential and levofloxacin possibly having the least potential. Neither patient had a history of a previous seizure disorder. Electrolyte imbalances are common with previous reports of fluoroquinolone-induced seizures. CONCLUSIONS: Although levofloxacin monotherapy has not been implicated in inducing seizures, it appears to be the causative agent in the second case. In the first case, the quinolones may have been a necessary, but not sufficient, cause in a patient with electrolyte abnormalities. Risk factors for fluoroquinolone-induced seizures may Include seizure history, electrolyte imbalances,dose unadjusted for renal insufficiency, and concomitant treatment with agents that lower the seizure threshold.     

Controlled-release oxycodone-induced seizures

BACKGROUND: The use of the opioid oxycodone hydrochloride in the management of chronic pain is gaining popularity principally because of its tolerability. However, opioid-related seizure in patients with epilepsy or other conditions that may decrease seizure threshold has been described in the literature; in particular, oxycodone has been associated with seizure in a patient with acute renal failure. OBJECTIVE: The aim of this article was to report a patient with a history of seizures but normal renal and hepatic function who developed seizure on 2 occasions after oxycodone ingestion. METHODS: A 54-year-old male patient presented with a history of tonic-clonic seizures that developed immediately after intracranial surgery. Long-term treatment with carbamazepine 400 mg QD was started, and the patient was free of convulsions for approximately 7 years. The patient presented to us with severe headache that was nonresponsive to an NSAID and the opiate agonist tramadol. Treatment with controlled-release (CR) oxycodone and tramadol drops (50 mg QID if necessary) was started, and tonic-clonic seizures developed 3 days later. RESULTS: Based on laboratory analysis, the patient had normal renal and hepatic function. On discontinuation of oxycodone treatment, the seizures resolved. However, due to effective pain relief with oxycodone, the patient decided to continue treatment, and seizures recurred. Carbamazepine was then administered 4 hours before oxycodone dosing, which allowed continuation of treatment without seizure. CONCLUSIONS: A patient with a history of seizures controlled with long-term carbamazepine therapy developed seizures when he started treatment with oxycodone CR at recommended doses. Oxycodone CR should be used with extreme caution in patients with epilepsy or other conditions that may decrease seizure threshold.     

Evaluation and treatment of the child with febrile seizure

Up to 5 percent of children in North America and western Europe experience at least one episode of febrile seizure before six years of age. Most of these seizures are self-limited and patients do not require treatment. Continuous therapy after the seizure is not effective in reducing the development of afebrile seizures. Antipyretics are effective in reducing the risk of febrile seizures if given early in the illness. Immediate care for the patient who has had a febrile seizure includes stopping the seizure, if prolonged, and evaluating the patient for the cause of the fever. Bacterial infections are treatable sources of fever but are not usually the cause of the fever that triggers a seizure. The patient must be assessed for these treatable sources. Long-term consequences of febrile seizure are rare in children who are otherwise healthy. Current recommendations do not support the use of continuing or intermittent neuroleptic or benzodiazepine suppressive therapies after a simple febrile seizure.     

Emergency management of seizures in the school setting.

Effective seizure management in the school setting is a critical issue for students with seizures, as well as their parents, classmates, and school personnel. The unpredictable nature of seizures and the potential outcomes of experiencing a seizure in school are sources of anxiety for students with seizures. The ability to respond appropriately to a seizure is of concern to parents and school personnel. Implementation of a seizure emergency treatment plan empowers school personnel to quickly treat the child. Diazepam rectal gel is commonly used in seizure emergency treatment plans. It is safe and effective in terminating seizures and reduces the time to treatment and the need for emergency department visits when used in the school setting, and can be administered by medical and delegated to trained nonmedical personnel. School nurses should be aware of the laws and professional recommendations that pertain to rectal medication administration in schools for optimal emergency seizure management.     

Incidence and onset of delayed seizures after overdoses of extended-release bupropion

Background

Delayed seizures have been reported with overdoses of bupropion extended-release (XL). This study systematically evaluates the frequency and timing of seizures and an association between other toxic effects (ie, agitation, tremors, and hallucinations) and seizures.

Methods

A 3-year multi–poison center observational study of hospitalized patients with ingestion of bupropion XL ≥600 mg in adults and ≥4 mg/kg in children was performed. Patients with coingestants or a medical history that could affect seizure occurrence were excluded. Data collection forms captured onset time of seizure(s), other symptoms, and treatment.

Results

One hundred seventeen patients met inclusion criteria: median age of 22 years (range, 1.3-65 years) with 16 children ≤ 3 years. Seizures occurred in 37 (31.6%) patients, with initial seizure at 0.5 to 24 hours after ingestion; 12 (32%) patients had initial seizure at > 8 hours. Subsequent seizures occurred in 49%. Children ages 1.3, 3, and 7 years, developed seizures. In patients ≥ 13 years of age, median dose with seizures was 4350 mg (range, 600-54?000) compared to 2400 mg (range, 600-9000) in patients without seizures. Agitation, tremors, and hallucinations occurred in 29.7%, 40.5%, and 18.9% of patients with seizures, respectively, compared with 12.5 %, 17.5%, and 10% in patients without seizures. The neurologic effects agitation (P = .045) and tremors (P = .005) occurred more frequently.

Conclusion

Delayed seizure onset suggests a minimum observation period of 24 hours after bupropion XL overdose. Although patients experiencing agitation or tremors may be at greater risk, seizures can occur without preceding central nervous system toxicity.     

Early Recurrence of First Unprovoked Seizures in Children

Objectives

The risk of early seizure recurrences after first unprovoked seizures in children is largely unknown. We aimed to determine the rate of seizure recurrence within 14 days of first unprovoked seizures in children and identify associated risk factors. Secondarily, we aimed to determine the risk of recurrence at 48 hours and 4 months.

Methods

We conducted a secondary analysis of a multicenter cohort study of children 29 days to 18 years with first unprovoked seizures. Emergency department (ED) clinicians completed standardized histories and physical examinations. The primary outcome, recurrent seizure at 14 days, and the secondary outcomes, recurrence at 48 hours and 4 months, were assessed by telephone follow‐up and medical record review. For each recurrence time point, we excluded those patients for whom no seizure had recurred but chronic antiepileptic drugs had been initiated.

Results

A total of 475 patients were enrolled in the parent study. Of evaluable patients for this secondary analysis, 26 of 392 (6.6%, 95% confidence interval [CI] = 4.4%–9.6%) had recurrences within 48 hours of the incident seizures, 58 of 366 (15.8%, 95% CI = 12.3%–20.0%) had recurrences within 14 days, and 107 of 340 (31.5%, 95% CI = 26.6%–36.7%) had recurrences within 4 months. On logistic regression analysis, age younger than 3 years was independently associated with a higher risk of 14‐day recurrence (adjusted odds ratio [OR] = 2.1, 95% CI = 1.2–3.7; p = 0.01). Having had more than one seizure within the 24 hours prior to ED presentation was independently associated with a higher risk of seizure recurrence at 48 hours (adjusted OR = 4.3, 95% CI = 1.9–9.8; p < 0.001).

Conclusions

Risk of seizure recurrence 14 days after first unprovoked seizures in children is substantial, with younger children at higher risk. Prompt completion of an electroencephalogram and evaluation by a neurologist is appropriate for these children.     

Afebrile pediatric seizures

Most well-appearing children who have had an afebrile seizure can be managed as outpatients with instructions for an outpatient electroencephalogram and primary care physician follow-up. Laboratory studies are needed only in children younger than 6 months, in patients with prolonged seizures or altered level of consciousness, or in those with history of a metabolic disorder or dehydration. Emergent neuroimaging is not recommended in children with a first unprovoked afebrile seizure, although studies should be considered in children with a predisposing condition or focal seizures if younger than 3 years.     

42例缺血性卒中后癫痫发作危险因素探讨

目的：研究缺血性卒中患者继发早期癫痫发作和晚期癫痫发作的发病率、发作类型及缺血性卒中继发癫痫发作的临床危险因素。方法：分析山西省人民医院近3年来首发缺血性卒中的408例患者的年龄、性别、入院时意识、糖尿病、高血压、心源性疾病和卒中部位等的临床特征,随访6~12个月,其中缺血性卒中后继发癫痫发作患者42例,未继发癫痫发作患者366例。缺血性卒中后癫痫发作的患者依据癫痫发作的发生时间分为早期癫痫发作组（18例）和晚期癫痫发作组（24例）。分析缺血性卒中后早期癫痫发作和晚期癫痫发作的发病率、发作类型以及缺血性卒中后发生继发癫痫发作的临床危险因素。结果：缺血性卒中后癫痫发作的发病率为10.3%（42/408）,其中早期癫痫发作的发病率为4.4%（18/408）;晚期癫痫发作的发病率为5.9%（24/408）。早期癫痫发作的50.0%（9/18）为全面性强直-阵挛发作,晚期癫痫发作的58.3%（14/24）为单纯部分性发作。缺血性卒中后癫痫发作组与非癫痫发作组的临床特征经统计学比较,两组间心源性脑栓塞病例的发生率和累及皮质梗死的发生率比较差异有显著性（P〈0.05）。结论：缺血性卒中后早期癫痫发作以全面性发作为主,晚期癫痫发作以单纯部分性发作为主;心源性脑栓塞和累及皮质梗死是缺血性卒中后癫痫发生的危险因素。     

Hormones and seizures

The opposing effects of estrogen (proconvulsant) and progesterone (anticonvulsant) on seizure threshold have been noted in animal and human studies. Levels of these hormones fluctuate throughout the menstrual cycle, and, in some women with epilepsy, these fluctuations may be related to the occurrence of seizures around the time of menses or an increase in seizures in relation to the menstrual cycle, also known as catamenial epilepsy. Variations in concentrations of antiepileptic drugs across the menstrual cycle may also contribute to increased seizure susceptibility. Diagnosis of catamenial epilepsy requires careful assessment of menstrual and seizure diaries and characterization of cycle duration and type. While there are several approaches to the treatment of catamenial epilepsy, each is based on small, unblinded studies or anecdotal reports. It is important for the physician to work closely with the patient to determine whether her seizures are indeed catamenial and to design an appropriate treatment plan.     

Effect of stimulus intensity on the profile of anticonvulsant activity of phenytoin, ethosuximide and valproate

The relative ability of phenytoin, ethosuximide and valproate to prevent minimal (clonic) threshold, maximal (tonic extension of the hindlimbs) threshold and supramaximal (tonic extension of the hindlimbs) seizures elicited by electrical and chemical (Metrazol, bicuculline, and picrotoxin) stimulation was determined. Ethosuximide and valproate were effective against minimal (clonic) threshold seizures, whereas phenytoin was ineffective and even activated them. All three anticonvulsants were effective against maximal (tonic extension of the hindlimbs) threshold seizures. Phenytoin and valproate, but not ethosuximide, were effective against supramaximal (tonic extension of the hindlimbs) seizures. The results suggest that the specificity of experimental models of epilepsy used in the evaluation of potential antiepileptic drugs is primarily due to the intensity rather than the nature of the stimulus used or the kind of seizure component evoked. Models based only on maximal (tonic extension of the hindlimbs) threshold seizures may identify anticonvulsant activity, but do not differentiate between substances that prevent seizure spread and those that increase seizure threshold.