Epilepsy. Classification and genetics

A common symptom of epilepsies are recurrent unprovoked epileptic seizures. These can be classified as focal or generalised. Thus, we can speak of focal or generalised epilepsies. Considering the rest of the medical history and the results of EEG and brain imaging the terms idiopathic, symptomatic and cryptogenic (i.e. probably symptomatic) are used to further characterise an epilepsy in a single patient. These classification scheme which is used since the end of the eighties allows decision making in therapy and an estimation of prognosis. Due to progress in epileptology during the last decade a more sophisticated approach is required. Thus, semiology of the single seizure becomes more important. The evolution of signs and symptoms during a seizure tells us something about the seizure onset zone and the mode of seizure propagation. The knowledge of them is a prerequisite for surgical treatment. Furthermore, semiology of seizures should determine social implications of epilepsy by far more than the fact that they are epileptic. Beside seizure semiology we have to consider the underlying neuropathological condition since it determines treatment and prognosis. Epilepsy is a consequence of acquired or genetic brain diseases. In case of the latter it becomes more and more possible to characterise and diagnose the genetic syndromes and to understand their pathophysiology. In epileptology the exact knowledge of an underlying genetic disease is not only of scientific interest. Beside being a condition sine qua non for adequate genetic counselling it influences the choice of anti-epileptic drugs and determines whether surgical treatment is indicated. Thus genetics are an important part of comprehensive care in epilepsy.     

Hemispherectomy for seizures

Hemispherectomy, or hemidecorticectomy as it is more accurately described, has been highly effective in reducing or eliminating medically intractable seizures associated with hemiplegia. Because of late onset postoperative superficial cerebral hemosiderosis and its associated neurologic deterioration, this procedure was all but abandoned for years. With improved surgical techniques and diagnostic testing, some medical centers with a special interest in epilepsy are again using hemispherectomy as a treatment for uncontrolled seizures associated with Rasmussen's encephalitis, as well as other etiologies. Specialized nursing care throughout the hospital course is essential to a positive outcome for the patient and family.     

Intractable partial epilepsy: evaluation and treatment

Partial (focal or localization--related) epilepsy is the most common seizure disorder encountered in patients with epilepsy. These seizures are focal at onset-that is, emanating from a localized region of the brain. Patients with partial epilepsy may have seizures that are refractory to antiepileptic drug medication. The financial burden for these patients includes the cost of medical care and often the loss of employment. Psychosocial deterioration may be progressive as long as the seizures are intractable. Management includes confirmation of the type (or types) of seizures, exclusion of an intracranial epileptogenic lesion, and use of appropriate antiepileptic drug therapy. Referral of affected patients to a comprehensive epilepsy center for possible surgical treatment and investigational drug studies should be considered. In the care of the patient with intractable partial epilepsy, the goals should be to render the patient free of seizures and to allow the patient to become a participating and productive member of society.     

Management of Adult Onset Seizures

Epilepsy is a common yet heterogeneous disease. As a result, management often requires complex decision making. The ultimate goal of seizure management is for the patient to have no seizures and no considerable adverse effects from the treatment. Antiepileptic drugs are the mainstay of therapy, with more than 20 medications currently approved in the United States. Antiepileptic drug selection requires an understanding of the patient's epilepsy, along with consideration of comorbidities and potential for adverse events. After a patient has failed at least 2 appropriate antiepileptic drugs, they are determined to be medically refractory. At this time, additional therapy, including dietary, device, or surgical treatments, need to be considered, typically at a certified epilepsy center. All these treatments require consideration of the potential for seizure freedom, balanced against potential adverse effects, and can have a positive effect on seizure control and quality of life. This review article discussed the treatment options available for adults with epilepsy, including medical, surgical, dietary, and device therapies.     

Management of seizures

Seizure patients represent a population that is frequently seen in medical practice. Critical care physicians will encounter chronically epileptic patients as well as patients with isolated seizures that develop in the course of treatment of surgical and other medical disorders. In such circumstances, knowledge of seizure type and common antiepileptic medications facilitates appropriate medical management. More emergently, SE may constitute a life-threatening indication for admission to an intensive care unit. Rapid treatment of SE is necessary to prevent multiple medical complications leading to morbidity and mortality.     

在新生儿惊厥观察中对家长实施健康教育的探讨

目的 :为使新生儿惊厥能被及时发现及时处置 ,以减少对其脑的影响。方法 :随机将196例存在惊厥高危因素的新生儿分成两组 ,对观察组患儿家长实施新生儿惊厥相关知识的健康教育 ,使家长在新生儿惊厥的观察中能充分发挥作用 ;对对照组患儿家长仅实施常规治疗、护理和安全育儿常识的宣传。结果 :两组新生儿被发现惊厥的总例数经统计学处理有统计学意义 (P <0 .0 5 ) ,而由护士发现的惊厥例数无统计学意义 (P >0 .0 5 )。结论 :加强健康教育可提高家长的观察意识 ,使新生儿惊厥得到严密的连续性观察。     

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.     

Epilepsy

Seizures are common and are treated in all branches of medicine. Approximately 10% of the population will have one or more seizures during their lifetime. Seizures are symptoms that occur in acute illness, ie, provoked seizures, or in epilepsy, ie, unprovoked seizures. Epilepsy is any disorder in which spontaneous recurrence of unprovoked seizures is the main symptom. It is a common chronic neurologic disorder and affects 1% to 3% of the population. Classification of seizure type is important because it enables identification of the region of the brain where the seizure originated and guides initial diagnostic testing. Classification of epilepsy syndrome, rather than only type of seizure, is more important. Epilepsy syndromes are defined by many factors, including type of seizures, age at onset of seizures, family history of seizures, and findings at physical examination, electroencephalography (EEG), and neurologic imaging studies. Identifying the epilepsy syndrome provides insight into natural history, prognosis, diagnostic testing, and therapy of the disorder and facilitates communication between health care professionals. Understanding seizure type provides useful information even when the epilepsy syndrome cannot be classified. Many sudden events are easily confused with seizures, in particular, pseudoseizures, syncope, migraine, cerebrovascular disease, movement disorders, and sleep disorders. In most cases a detailed history and physical examination concentrated on the details of the event, and results of routine EEG and magnetic resonance imaging can aid in determination of which events are seizures. Video EEG monitoring is occasionally necessary to capture events to enable definitive determination of whether they are seizures and to further characterize them. Provoked seizures are treated with relief of the provoking factor. Antiepileptic drugs (AEDs) are not indicated. However, AEDs may be required to treat unprovoked seizures of new onset in patients at high risk for seizure recurrence or when a second seizure can have devastating psychosocial effects. High risk for recurrence is present when there is a history of brain insult, an EEG demonstrates epileptiform abnormalities, and magnetic resonance images demonstrate a structural lesion. AED therapy is the standard treatment for epilepsy, ie, two or more seizures. Selection of the appropriate AED depends on type of seizure and epilepsy present, and individual drug characteristics, including pharmacokinetics, side effects, dosing interval, and cost. All available AEDs except ethosuximide are effective as adjunctive therapy, and most are effective as initial monotherapy for partial seizures. Generalized seizures preferentially respond to valproate, lamotrigine, and topiramate, among other drugs. If trials of more than two AEDs do not control seizures, additional AEDs are unlikely to be effective, and the patient should be referred to an epilepsy center, where other treatment options, in particular, epilepsy surgery, can be offered. Epilepsy surgery renders 60% to 70% of patients with temporal lobe epilepsy free of disabling seizures.     

How to evaluate the patient after a first seizure

The primary care physician who is approached by a patient or the parents of a patient who has had a first seizure must determine that a seizure has indeed occurred and then ascertain the type of seizure before any treatment is prescribed. While there is a variable recurrence risk after generalized tonic-clonic and partial seizures, certain types, such as absence seizures, have a high recurrence risk. Studies disagree on whether all patients with a first seizure require treatment, especially considering the side effects that can accompany anticonvulsant drugs. If the diagnosis is uncertain, waiting for a second seizure before starting treatment is usually a good idea. Electroencephalography should be done and, depending on results, followed by electrocardiography, a fasting glucose test, and/or computed tomography. If the diagnosis is certain, computed tomography or magnetic resonance imaging is useful in ruling out structural lesions as the cause of the seizure. The dosage of an anticonvulsant drug that is appropriate for the patient can then be determined by slowly increasing the dosage of one drug at a time until the patient becomes seizure-free without clinical toxicity.     

Treatment of Epilepsy

Epilepsy is best studied as a symptom of brain disease rather than as a disease in itself. The diagnosis of the seizure depends on witnessing an attack or obtaining an adequate history of such seizures. For proper handling of causes, social management and treatment of the patient, it is useful to classify the seizure by its clinical symptoms and to describe it as grand mal, petit mal or focal. Therapy is aimed at control of seizures, and may be achieved by psychologic, medical, dietary and surgical methods.     

Advances in pharmacotherapy: recent developments in the treatment of epilepsy

Epilepsy is a disorder of the central nervous system in which the clinical symptoms are recurrent seizures. An increased understanding of the underlying mechanism of seizures and more definitive diagnostic procedures have improved the care of the patient with epilepsy. An improved classification of various seizure types, including specific epilepsy syndromes has helped optimize use of the standard antiepileptic drugs. Research on the mechanism of seizures has led to new antiepileptic drugs. More definitive diagnostic procedures have led to more accurate identification of patients likely to benefit from epilepsy surgery. This review focuses on these areas.     

Neurocysticercosis: nursing perspectives.

Management of neurocysticercosis (NCC) is mostly by means of prevention and antihelminthic medications. We reviewed the role of medical and surgical intervention in patients with NCC lesions. We also identified two patients with isolated NCC lesions to determine whether they might be rendered seizure free through surgical removal of the lesion. The two patients, one male and one female, ages 21 and 43 years, respectively, presented with generalized seizures. Electroencephalograms showed focal slowing consistent with the site of the lesion and had failed antiepileptic drug therapy. Magnetic resonance imaging scans showed a distinct single-ring-enhanced lesion in each patient consistent with late-stage NCC. The patients underwent surgery with ultrasonagraphic guidance to remove the cysts. Surgery involved resection of the suspected calcified neurocystic lesion. Both patients have been seizure free since surgery. Patients with a single calcified neurocystic lesion may benefit from surgery for control of seizures. Prospective evaluations are needed to assess the timing of surgery in relation to the stage of the disease. Nurses play a significant role in the primary prevention of this disease and care throughout treatment.     

Alcohol-related seizures

The term alcohol-related seizures (ARS) is used to refer to all seizures in the aggregate associated with alcohol use, including the subset of alcohol withdrawal seizures (AWS). From 20% to 40% of patients with seizure who present to an emergency department have seizures related to alcohol abuse. However, it is critical to avoid prematurely labeling a seizure as being caused by alcohol withdrawal before performing a careful diagnostic evaluation. Benzodiazepines alone are sufficient to prevent AWS. The alcoholic patient with a documented history of ARS, who experiences a single seizure or a short burst of seizures should be treated with lorazepam, 2?mg intravenously.     

Scope of practice of an Advanced Practice Nurse at the Swiss Epilepsy Centre

Epilepsy is, after stroke, the second most prevalent neurological disease. The disease has a manifold etiology and symptoms and hence treatment options. From the patients who seek treatment in epilepsy centres, some suffer from psychogenic, non-epileptic seizures. Patient with epileptic seizures have to integrate a medication regimen into their lives, accept symptoms and change their life style to seizure preventing habits. Patients with non-epileptic seizures need psychotherapeutic treatment. Care has to be offered over long periods of time and needs to be tailored to very diverse patients' and family situations. Nurses in this field need broad knowledge about the diseases and treatments as well as enhanced skills in counselling and caring for these patients. Therefore the Swiss Epilepsy Centre in Zurich hired an Advanced Practice Nurse (APN) to increase patients' satisfaction with care and enhance nurses' skills and knowledge. This article analyses the work content of the advanced practice nurse and describes first experiences one year after the implementation of an APN-role. The APN worked half of her time in direct patient and family care. The rest of her work load concerned practice development in coaching and educating the nursing staff, being involved in projects and collaborating with the head nurse on specific topics. In conclusion, implementation of an advanced practice nurse has been shown to be beneficial since patients' feedback were very positive and the increase in nurses' skills and competencies has been assessed as noticeable.     

Possible gatifloxacin-induced seizure

OBJECTIVE: To report a case of seizure activity following gatifloxacin administration during treatment of urosepsis in an intensive care unit. CASE SUMMARY: An 86-year-old African American male nursing home resident with a history of hypertension and cerebrovascular accident with aphasia was initiated on gatifloxacin therapy for treatment of urosepsis. After 2 intravenous doses (400 mg followed 24 h later with 200 mg), he developed 2 generalized seizures lasting <2 minutes each. Gatifloxacin was discontinued, and the patient was switched to ceftazidime. Phenytoin was initiated, and no recurrent seizures were witnessed. DISCUSSION: Fluoroquinolones have been shown to induce seizures or decrease seizure threshold. The majority of reports include older-generation fluoroquinolones such as ofloxacin.The incidence of seizures associated with fluoroquinolones varies among the individual agents and is relatively rare. Risk factors include increased age, compromised renal function, history of seizures, and coadministration with theophylline or nonsteroidal antiinflammatory drugs. Application of an objective causality scale indicates the seizures in our patient were possibly associated with gatifloxacin. CONCLUSIONS: This case of gatifloxacin-induced seizures may reflect a class-effect phenomenon versus an effect caused by an individual fluoroquinolone. Caution is warranted when using these agents in patients at risk for drug-induced seizures.     

Dynamic Causal Modelling of epileptic seizure propagation pathways: a combined EEG-fMRI study

Simultaneous EEG-fMRI offers the possibility of non-invasively studying the spatiotemporal dynamics of epileptic activity propagation from the focus towards an extended brain network, through the identification of the haemodynamic correlates of ictal electrical discharges. In epilepsy associated with hypothalamic hamartomas (HH), seizures are known to originate in the HH but different propagation pathways have been proposed. Here, Dynamic Causal Modelling (DCM) was employed to estimate the seizure propagation pathway from fMRI data recorded in a HH patient, by testing a set of clinically plausible network connectivity models of discharge propagation. The model consistent with early propagation from the HH to the temporal-occipital lobe followed by the frontal lobe was selected as the most likely model to explain the data. Our results demonstrate the applicability of DCM to investigate patient-specific effective connectivity in epileptic networks identified with EEG-fMRI. In this way, it is possible to study the propagation pathway of seizure activity, which has potentially great impact in the decision of the surgical approach for epilepsy treatment.     

Evaluation of a single seizure: guidelines for advance practice nurses

Deciding whether or not to treat a client after a single seizure can be challenging for the clinician. The risk of seizure recurrence is greatest in the first six months after the initial episode. The decision to treat a single seizure should be based on diagnostic and clinical findings that assess the client's risk for recurrence. When making treatment decisions, the clinician must consider the benefits and risks of single-seizure therapy. Careful consideration should be given to differential diagnosis, factors that induce symptomatic seizures and risk factors for epilepsy.     

Clinical indications and diagnostic yield of video-electroencephalographic monitoring in patients with seizures and spells

Video-electroencephalographic (EEG) monitoring is an important neurodiagnostic technique that may be used for selected patients who present with recurrent and unprovoked spells. For most patients who have epilepsy, the "routine" EEG is sufficient for physicians to classify seizure types and initiate medical therapy; however, routine EEG has substantial limitations for approximately 20% of patients who do not have epilepsy but are referred to comprehensive epilepsy programs because of medically refractory "seizures." These patients may have physiological or psychological disorders that may cause diagnostic confusion with epilepsy and result in the patients being treated unnecessarily with antiepileptic drugs. Video-EEG monitoring, ie, ictal EEG monitoring, performed either on an outpatient basis or in an epilepsy monitoring unit, can help physicians identify ictal EEG patterns that may be necessary for classifying seizure types and determining surgical localization. The sensitivity and specificity of EEG recordings during clinical episodes are superior to those of the routine interictal EEG. Video-EEG monitoring may prove to be an essential procedure for helping physicians confirm diagnoses of seizure disorders, classify seizure types, and select surgical candidates who have intractable epilepsy.     

Common emergent pediatric neurologic problems

Although there are a variety of neurologic disease processes that the emergency physician should be aware of the most common of these include seizures, closed head injury, headache, and syncope. When one is evaluating a patient who has had a seizure, differentiating between febrile seizures, afebrile seizures, and SE helps to determine the extent of the work-up. Febrile seizures are typically benign, although a diagnosis of meningitis must not be missed. Educating parents regarding the likelihood of future seizures, and precautions to be taken should a subsequent seizure be witnessed, is important. The etiology of a first-time afebrile seizure varies with the patient's age at presentation, and this age-specific differential drives the diagnostic work-up. A follow-up EEG is often indicated, and imaging studies can appropriate on a nonurgent basis. Appropriate management of SE requires a paradigm of escalating pharmacologic therapy, and early consideration of transport for pediatric intensive care services if the seizure cannot be controlled with conventional three-tiered therapy. Closed head injury frequently is seen in the pediatric emergency care setting. The absence of specific clinical criteria to guide the need for imaging makes management of these children more difficult. A thorough history and physical examination is important to uncover risk factors that prompt emergent imaging. Headaches are best approached by assessing the temporal course, associated symptoms, and the presence of persistent neurologic signs. Most patients ultimately are diagnosed with either a tension or migraine headache; however, in those patients with a chronic progressive headache course, an intracranial process must be addressed and pursued with appropriate imaging. Syncope has multiple causes but can generally be categorized as autonomic, cardiac, or noncardiac. Although vasovagal syncope is the most common cause of syncope, vigilance is required to identify those patients with a potentially fatal arrhythmia or with heart disease that predisposes to hypoperfusion. As such, all patients who present with syncope should have an ECG. Additional work-up studies are guided by the results of individual history and physical examination.     

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.