Treatment for epilepsy in later life

Old age is now the commonest time to develop epilepsy, often as a consequence of underlying cerebrovascular or neurodegenerative disease. Age-related physiological changes can affect the pharmacokinetics and pharmacodynamics of antiepileptic drugs. Only three double-blind, head-to-head, randomised, controlled trials have been undertaken in this patient population and so pharmacological treatment tends to be empirical, often based on what antiepileptic drug not to chose for an individual patient. The available evidence has tended to favour lamotrigine, and perhaps gabapentin, over carbamazepine, based on better tolerability rather than superior efficacy for newly diagnosed epilepsy in this population. Preliminary data with levetiracetam suggest that this drug will also be useful in older people as a consequence of its favourable side effect profile and lack of idiosyncratic reactions and drug interactions. Despite the dearth of high quality trial evidence, published outcome data hint at a good prognosis with a single antiepileptic drug for the majority of elderly people with epilepsy. A few patients will require low dose combination therapy. Epilepsy surgery is also an occasional option in this population. As life expectancy rises, so will the likelihood of presenting with seizures in later life placing an increasing burden on healthcare resources. <<< leia mais >>>

The electroencephalogram of idiopathic generalized epilepsy (critical review)

Idiopathic generalized epilepsy (IGE) is classified into several subsyndromes based on clinical and electroencephalography (EEG) features. The EEG signature of IGE is bisynchronous, symmetric, and generalized spike-wave complex; although focal, irregular, and so called “fragments” of discharges are not uncommon. Other characteristic EEG features include polyspikes, polyspike-wave discharges, occipital intermittent rhythmic delta activity, and photoparoxysmal response. Both human and animal data suggest involvement of the thalamus and the cortex in the generation of spike-wave discharges in IGE. Circadian variations of generalized epileptiform discharges are well described, and these can be useful in diagnostic confirmation. Those discharges tend to occur more often after awakening and during cyclic alternating pattern phase-A of non–rapid eye movement sleep. Activation procedures such as hyperventilation, intermittent photic stimulation, eye closure, and fixation-off are useful techniques to increase the yield of both interictal and ictal EEG abnormalities. Although not in routine use, specific triggers such as pattern stimulation and cognitive tasks may also be of value in eliciting rare reflex seizure-related EEG abnormalities. Variations of EEG abnormalities are evident between different electroclinical syndromes. EEG is also affected by certain external as well as internal factors, which should be borne in mind when interpreting EEG studies in IGE. (Epilepsia, 53(2):234–248, February 2012). <<< leia o artigo >>>

The Treatment of Super-Refractory Status Epilepticus

Super-refractory status epilepticus is defined as status epilepticus that continues or recurs 24 h or more after the onset of anaesthetic therapy, including those cases where status epilepticus recurs on the reduction or withdrawal of anaesthesia. It is an uncommon but important clinical problem with high mortality and morbidity rates. This article reviews the treatment approaches. There are no controlled or randomized studies, and so therapy has to be based on clinical reports and opinion. The published world literature on the following treatments was critically evaluated: anaesthetic agents, anti-epileptic drugs, magnesium infusion, pyridoxine, steroids and immunotherapy, ketogenic diet, hypothermia, emergency resective neurosurgery and multiple subpial transection, transcranial magnetic stimulation, vagal nerve stimulation, deep brain stimulation, electroconvulsive therapy, drainage of the cerebrospinal fluid and other older drug therapies. The importance of treating the identifying cause is stressed. A protocol and flowchart for managing super-refractory status epilepticus is suggested. In view of the small number of published reports, there is an urgent need for the establishment of a database of outcomes of individual therapies.

Seizure versus syncope

One of the most common but difficult management problems in medicine is that of patients who present with a paroxysmal loss of consciousness. All too often the underlying diagnosis remains elusive. This has a cost both in terms of mortality and ongoing morbidity and in terms of the financial burden associated with hospitalisation and repeated investigations. We describe a practical approach to this clinical dilemma, which is rooted in adherence to basic principles of history talcing and examination, formulation of a reasonable differential diagnosis, followed by an intelligent use of specific investigations and selection of an appropriate treatment. We also discuss the effect of sudden unexpected deadi in epilepsy and sudden cardiac dead». Despite a careful and thorough approach to the patient with a “seizure versus syncope” problem, many will require repeated assessment before a diagnosis is made. >>> leia o artigo >>>