Management Of Seizure Disorders Research Articles

Perampanel-associated Psychiatric Problems

Perampanel is a noncompetitive α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid glutamate receptor antagonist used in the management of seizure disorder. Management of uncontrolled seizures is a challenging task. Perampanel is a recent antiepileptic which comes with a warning of causing behavioral and psychological adverse effects. Here, the authors report an interesting case where the perampanel was started to control refractory seizures and the person developed severe behavioral disturbances. The condition warranted a psychiatry referral, and the problems subsided after stopping perampanel. Clinicians need to be vigilant about perampanel-associated behavioral and psychiatric problems which can become a serious clinical concern.

Evaluation of the anticonvulsant properties of the ethanol extract of Detarium senegalense leaves in mice

Detarium senegalense, J.F. Gmelin (Fabaceae) is used in Nigerian folk medicine to treat different diseases including epilepsy, microbial infections, gastrointestinal diseases and inflammation; its efficacy is widely acclaimed among communities in South Eastern Nigeria. The leaf extract (100 mg/kg, 200 mg/kg and 400 mg/kg) was evaluated for its anticonvulsant activity in mice. Three different study models were used; pentylenetetrazole (PTZ), brucine and isoniazid (INH) convulsion methods. The acute toxicity study and the phytochemical analysis of the extract were also determined. The extract produced significant (p<0.05 and p<0.01) dose-dependent delay in onset, frequency and duration of seizures in mice in the three models of convulsion which is comparable to the standard anticonvulsant drug. The oral acute toxicity test was greater than 5000 mg/kg in mice. The phytochemical screening revealed that D. senegalense leaf extract contains bioactive principles that are relevant in the management of seizure disorders. These findings suggest that D. senegalense leaf extract possesses anticonvulsant properties and justifies its use in traditional medicine.

The epilepsy specialist nurse: A mixed-methods case study on the role and activities

PurposeTo describe the role and activities of epilepsy specialist nurses (ESNs) operating as a team in the setting of a hospital specialising in the diagnosis and management of seizure disorders. MethodsWe conducted a descriptive mixed-methods embedded single case study. We recruited 9 ESNs, 14 of their professional colleagues and 9 ‘key informants’ to analyse their perceptions of the role and activities of ESNs. We collected data through interviews, questionnaires, observations, and documentation. The study was conducted at the Filadelfia Epilepsy Hospital, Denmark. ResultsThe team of ESNs offers holistic care to patients and their caregivers regarding the clinical, social, and emotional aspects of epilepsy. The ESNs are integrated in a multidisciplinary team and promote collaboration among the team members. ESNs also contribute to organisational aspects and perform research activities. ConclusionA structured group of ESNs can operate effectively and extensively in a specialised hospital setting. Our findings contribute to clarifying the description of the ESN’s role, and provide an example of how ESNs can be incorporated into a hospital’s organisational structure.

Lobectomia temporal anterior en el tratamiento de epilepsia temporal mesial: detalles técnicos y perspectivas en el control de las convulsiones

La lobectomía temporal anterior es un valioso procedimiento en el manejo de convulsiones cuya etiología es la epilepsiamesial del lóbulo temporal. Se está describiendo modificaciones en las técnicas quirúrgicas de la epilepsia mesial del lóbulotemporal cuya finalidad es reducir las complicaciones derivadas del procedimiento mientras preserva el control de las convulsiones. Objetivos: Discutir las técnicas, modalidades quirúrgicas, riesgos, complicaciones y resultados de la lobectomía temporal anterior en pacientes afectados por epilepsia mesial del lobo temporal. Métodos: Consulta bibliográfica se realizó utilizando la base de datos MEDLINE, LILACS, SciELO, PubMed, utilizando el lenguaje como criterio de selección eligiendo preferentemente artículos recientes en portugués, español o Inglés. Resultados: Este procedimiento mejora la calidad de vida de los pacientes afectados por la epilepsia del lóbulo temporal mesial. Además, este abordaje quirúrgico ha sido descrito asociada a una menor dificultad técnica, menor tiempo quirúrgico y mejor control de convulsiones cuando comparado a la amygdalohippocampectomy selectiva. Sin embargo, los enfoques selectivos se han descrito con menores tasas de complicaciones visuales en comparación con la lobectomía anterior. Conclusiones: No hay un estudio importante comparando lobectomía temporal anterior frente a todas las técnicas de migdalohippocampectomía selectiva, lo que sería para el futuro necesario para una importante fuente de datos sobre este tema.

Hemispherectomía en el tratamiento de las convulsiones: perspectivas actuales de las indicaciones, técnicas y complicaciones - Revisión de literatura

Introducción: A hemisferectomía es un procedimiento valioso en el tratamiento de trastornos convulsivos causados por desordenes hemisféricos unilaterales. El hemisferectomía anatómica se ha utilizado para este fin desde 1938, sin embargo, se abandonó este procedimiento después de informes de complicaciones postoperatorias causadas por hemosiderosis superficial, ependimitis e hidrocefalia obstructiva. Así que, se ha mostrado en la literatura modificaciones en las indicaciones y técnicas de hemisferectomía anatómica cuya finalidad es la de reducir la incidencia de esta complicación sin dejar de lograr control de las convulsiones. Sobre la base de la literatura, la hemisferectomía mejora la calidad de vida de los pacientes que tiene la indicación para realizar este procedimiento, ya que permite reducir la frecuencia de las convulsiones, si tónica o átona, tónico-clónicas Objetivo: El objetivo de esta revisión de la literatura es discutir los detalles técnicos, modalidades, riesgos, complicaciones, resultados y de pronóstico de hemisferectomía basado en la revisión crítica de la literatura. Casuística y Métodos: Se realizó la consulta bibliográfica, utilizando la base de datos MEDLINE, LILACS, SciELO, que utiliza el lenguaje como criterios de selección, la elección de los artículos recientes preferiblemente en portugués, español o inglés. Conclusión: Según las referencias, hemisferectomía es un procedimiento con buen resultado para las personas con convulsiones derivadas cuando está indicado para casos seleccionados y la tasa de éxito no es proporcional a la extensión de la reseccióndel tejido neuronal. A mayor resección puede o no reducir la frecuencia de las crisis, sin embargo, la incidencia de la morbilidad puede ser mayor.

Photosensitive lichenoid drug eruption due to zonisamide

Zonisamide is a sulfonamide anticonvulsant now being increasingly used in the management of seizure disorders. We report possibly, the first case of a photosensitive lichenoid drug eruption due to zonisamide in a middle-aged male.

Management of Seizure Disorders in the Deployed Environment: A Treatment Guide for the Non-Neurologist in Theater

Patients with seizures can present a common and challenging problem for medical providers in the deployed environment. Unfortunately, there is a paucity of controlled clinical trial data that can be used to formulate evidence-based guidelines for management. In an attempt to aid the non-neurologist deployed provider in the care of patients presenting with seizures, the authors describe two cases illustrative of common presentations. Thereafter, the authors address many facets of the management questions commonly raised by such cases and offer suggestions regarding such issues as initial pharmacologic management, the need for admission and evacuation, seizure precautions, differentiation from syncope and nonepileptic seizures, addressing patient and command concerns regarding evaluation and duty restrictions, and obtaining online management assistance.

Seizures and Epilepsy in Adolescents and Adults

Sofia Dobrin, MD ll individuals with epilepsy experience seizures, whereas all those with seizure do not have epilepsy. An epileptic seizure is a transient ccurrence of signs and/or symptoms due to abnormal excessive or ynchronous neuronal activity in the brain. Epilepsy is a disorder of the rain characterized by an enduring predisposition to generate epileptic eizures and by the neurobiologic, cognitive, and psychosocial conseuences of this condition. The definition of epilepsy requires the ccurrence of at least 1 epileptic seizure. In practice, however, epilepsy s most commonly diagnosed after 2 or more unprovoked seizures. Seizures can be acute, symptomatic, or unprovoked. Acute symptomatic eizures occur at the time of a systemic insult, such as during alcohol ithdrawal or in the setting of severe hypoglycemia, or in close temporal ssociation with a brain insult, such as in acute head trauma. The ondition leading to the seizure is believed to disrupt normal brain euronal physiology in a transient manner. Unprovoked seizures occur in he absence of such precipitating factors. Recurrent provoked seizures do ot constitute epilepsy and therefore do not require treatment with ntiepileptic medication. Epilepsy has many causes, including structural (eg, tumors, strokes, and ascular abnormalities), metabolic, infectious, and genetic. Often, no lear cause can be determined. Several epilepsy syndromes have been ecognized with clustering of symptoms and signs in epilepsies, which aid n accurate diagnosis and management of seizure disorders.

Neurologic Complications of Critical Illness, Third Edition.

University of Maryland School of Medicine, Baltimore, Maryland. rdarwish@anes.umm.eduNeurologic Complications of Critical Illness, Third Edition. By Eelco F. M. Wijdicks, M.D., Ph.D. Series edited by Sid Gilman, M.D., and William J. Herdman, M.D. New York, Oxford University Press, 2009. Pages: 480. Price: $129.95.Diagnosis and management of neurologic disorders in the intensive care unit (ICU) are challenging. Advances in the knowledge and understanding of pathophysiology and clinical presentations of neurologic disorders, aided by the considerable effect of advanced imaging technologies, are reflected in this revised edition of a classic textbook. This third edition adds more than 100 new figures, tables, helpful management algorithms, and illustrations that are based on the understanding of pathophysiology and neurologic presentation of critical illness in the ICU.In the first of four parts, the author describes in detail general clinical neurologic problems in the ICU. Delirium and coma are common clinical states that confront intensive care physicians. With appropriate diagnosis and treatment, coma can often be treated successfully. Any delay in diagnosis and treatment can be detrimental. The author emphasizes that the clinician must determine whether the cause of impairment is structural or metabolic because diagnostic testing and treatment methods will differ accordingly.Recent technologic improvements in computed tomography, magnetic resonance imaging, and positron emission tomography have facilitated earlier intervention. The detailed description of neurologic examination of patients in coma is outstanding. The author then describes the effect of commonly used medications in clinical practice and their neurologic manifestations, with emphasis on the pharmacokinetics and pharmacodynamics of commonly used sedatives and narcotics in critical illness. The addition of ketamine and butyrophenones to this review would have made the chapter more comprehensive, however.Furthermore, the author describes in detail the differential diagnosis and management of seizure disorders in the ICU, with emphasis on early detection of structural lesions. For practicing intensivists, the reviews of drug-associated seizures as well as seizures associated with drug withdrawal and metabolic abnormalities provide an important resource in patient management. The author also evaluates the current knowledge of neuromuscular problems in the critically ill, peripheral neuropathy, critical illness polyneuropathy, acute motor neuropathy, neuromuscular junction dysfunction, and myopathy.In part two, the author reviews neurologic complications of commonly performed invasive procedures in the ICU. Then he provides a detailed review of the neurologic manifestations of acute bacterial and viral infections.In addition, the author offers practical advice on how to manage various forms of encephalopathy resulting, in the medical and surgical ICUs, from toxicity of endogenous products secondary to organ failure, with detailed reviews of liver and renal failure, endocrine dysfunction, and toxicity secondary to exogenous poisons (e.g. , sedative drugs, psychotropic drugs). He also addresses abnormalities secondary to electrolyte and acid-base disturbances. The author also provides a review of neurologic complications of hematologic disorders. The author's discussion of neurologic complications of cardiac arrest, resuscitation, and the use of therapeutic hypothermia is especially helpful.In part three, the book describes outcomes after various neurologic complications. The review of the outcomes of medical pathology was outstanding. It is extremely important that surgical pathology and stroke be well defined for timely consultation and intervention by neurosurgical and neurology services. However, I believe this section needs more detailed criteria for critical care physicians to obtain proper imaging for thorough and timely consultation. The end of the book details the challenges of consultation in the ICU, especially end-of-life decisions, brain death, and organ donation.In general, Neurologic Complications of Critical Illness provides very comprehensive coverage of neurologic diseases, including reviews on virtually all critical illness with serious neurologic complication. Certain chapters of this book are written for neurologists, however, and not for medical intensive care specialists, especially the chapter on consultations in the ICU. I believe defining the indications for neurologic service consultations should provide guidelines for the timely intervention of the neurologists in the management of critically ill patients.University of Maryland School of Medicine, Baltimore, Maryland. rdarwish@anes.umm.edu

Behavioral intervention to increase compliance with electroencephalographic procedures in children with developmental disabilities

The EEG, or electroencephalogram, is a neurophysiological technique used to detect and record electrical activity in the brain. It is critical to the diagnosis and management of seizure disorders, such as epilepsy, as well as other neurological conditions. The EEG procedure is often not well tolerated by children with developmental disabilities because of anxiety about unfamiliar equipment, difficulty inhibiting motion, and tactile defensiveness. The inability of children with developmental disabilities to tolerate an EEG procedure is especially problematic because the incidence of epilepsy is considerably higher in children with disabilities. This clinical outcome study sought to determine the efficacy of using behavioral intervention to teach children with developmental disorders to cooperate with an EEG procedure. The behavioral training employed modeling, counterconditioning, escape extinction, and differential reinforcement-based shaping procedures. Results indicated that behavioral training is successful in promoting EEG compliance without restraint, anesthesia, or sedation.

Seizures in Children

1. Philippe Major, MD* 2. Elizabeth A. Thiele, MD, PhD* 1. *Department of Neurology, Massachusetts General Hospital, Boston, Mass After completing this article, readers should be able to: 1. Classify the different seizure types. 2. Distinguish seizures from other paroxysmal phenomena. 3. List the possible causes of seizures according to age and mode of presentation. Seizures are among the most common pediatric neurologic disorders. The overall prevalence of epilepsy is approximately 1%, and as many as 5% of all children experience febrile seizures before the age of 6 years. Seizures are caused by an abnormal and excessive discharge of neurons, usually accompanied by behavioral or sensorimotor manifestations. Epilepsy is defined classically as the occurrence of two or more unprovoked seizures. A seizure can be viewed as a symptom of an underlying central nervous system disorder that requires thorough evaluation and specific treatment. In addition to the consequences of the seizures, 50% of those who have epilepsy experience learning difficulties, and 30% to 50% have mental health and behavioral issues. In this first of two articles on seizures in children, we review the diagnosis and classification of seizures as well as possible causes of seizures in childhood. The second article, to be published in the November 2007 issue of Pediatrics in Review , focuses on the laboratory diagnosis and management of seizure disorders. The diagnosis of epilepsy and classification of specific seizure types are essential to determining a prognosis and choosing an appropriate treatment. The investigation of a child experiencing seizures begins with a medical history and physical examination. Although significant technologic advances have been made in electrophysiology and neuroimaging, the diagnosis of seizures and epilepsy remains largely clinical. Table 1 lists key features of the medical history and physical examination of a child presenting with paroxysmal events. | Questionnaire | || | |

Practitioner Review: Use of antiepileptic drugs in children

The aim in treating epilepsy is to minimise or control seizures with full respect of quality-of-life issues, especially of cognitive functions. Optimal treatment first demands a correct recognition of the major type of seizures, followed by a correct diagnosis of the type of epilepsy or of the specific syndrome. Review of data from literature and personal clinical experience in treating children with epilepsy. After summarising the general aspects on the diagnosis and treatment of the main forms of childhood epilepsy, we review key issues about management of seizure disorders, including when to start treatment, how to proceed when the first treatment fails, and how to set the targets of treatment. A special section is devoted to the new concept of epileptic encephalopathy and to the influence of "interictal" EEG abnormalities on cognition, behaviour, and motor abilities in children, providing some suggestions on why and how to treat these conditions. A second section approaches the choice of treatment according to the specific syndromes including infantile spasms, focal epilepsies, syndromes with typical absence seizures, the myoclonic epilepsies and the Lennox-Gastaut syndrome. Antiepileptic drugs (AEDs) can efficiently control seizures in most children. However, the specificity of AEDs is relatively limited, although continuing research is leading to a better understanding of the relationship between pathogenesis and the mechanism(s) and site(s) of drug action.

Development of a Self-Efficacy Scale for Children and Adolescents With Epilepsy

The purpose of this study was to develop and test the psychometric properties of a Seizure Self-Efficacy Scale for Children (SSES-C). An initial pool of test items was generated using a variety of resources, including literature reviews, child self-efficacy measures from other chronic diseases, and self-efficacy measures for adult patients with epilepsy. Experts in the field of self-efficacy, chronic illness self-management, and behavioral management of seizure disorders were asked to evaluate item content and readability. The scale was administered via computer-assisted telephone interviews to 175 children ages 9 through 14 years who had had epilepsy for 6 months or more. Content validity of the SSES-C was ensured by 80% agreement on test items by experts. The final version of the scale has 15 items. Construct validity was supported by factor analysis and correlation of the SSES-C to other constructs of influence on the health behavior of children with epilepsy. Specifically, the SSES-C was significantly correlated with attitude toward illness, worry, unmet needs for psychosocial care, child depression, and child self-concept. Internal consistency reliability for the measure was also adequate (a = .93). The primary result of this study was the development of an easily administered and useful 15-item scale to measure the degree of self-efficacy experienced by children and adolescents related to the management of their seizure disorder. The SSES-C is a promising questionnaire that has potential for use as a clinical and research tool to measure self-efficacy in children with seizures.

Role of Neuroimaging in the Management of Seizure Disorders

Neuroimaging is one of the most important advances made in the past decade in the management of seizure disorders. Magnetic resonance imaging (MRI) has increased substantially the ability to detect causes of seizure disorders, to plan medical or surgical therapy, and to prognosticate the outcome of disorders and therapy. However, MRI must be performed with techniques that will maximize the detection of potentially epileptogenic lesions, especially in candidates for epilepsy surgery. Functional imaging has an established role in evaluating patients for epilepsy surgery. It is relied on when results from standard diagnostic methods, such as clinical information, electroencephalography, and MRI, are insufficient to localize the seizure focus. Also, functional imaging is a reportedly reliable alternative to invasive methods for identifying language, memory, and sensorimotor areas of the cerebral cortex. Despite the availability of multimodality imaging, the epileptogenic zone is not determined solely by a single imaging modality. Evidence and experience have shown that concordance of results from clinical, electrophysiologic, and neuroimaging studies is needed to identify the epileptogenic zone accurately. With modern techniques in image processing, multimodality imaging can integrate the location of abnormal electroencephalographic, structural, and functional imaging foci on a "map" of the patient's brain. Computer image-guided surgery allows surgically exact implantation of intracranial electrodes and resection of abnormal structural or functional imaging foci. These techniques decrease the risk of morbidity associated with epilepsy surgery and enhance the probability of postsurgical seizure control.

Anticonvulsants and breast feeding: a critical review.

Progress in the diagnosis and management of seizure disorders and the availability of effective anticonvulsive medications has enabled increasing numbers of epileptic women of child-bearing age to raise families. Breast feeding, which these women may wish to choose, provides health, nutritional, immunological, developmental, social, economic and environmental benefits. The traditional anticonvulsants, such as phenytoin, carbamazepine and valproic acid (valproate sodium), are generally considered safe for use during breast feeding; however, observation for adverse effects is recommended. The use of phenobarbital while breast feeding is controversial because of its slow elimination by the nursing infant. The newer anticonvulsants, such as clobazam, felbamate, gabapentin, lamotrigine, oxcarbazepine, tiagabine, topiramate, and vigabatrin, are used mainly as adjunctive therapy. Data on the use of these drugs in pregnancy and lactation, and regarding long term effects on cognition and behaviour, are sparse. Weighing the benefits of breast feeding against the potential risk to the nursing infant, breast feeding is considered to be safe when the mother is taking carbamazepine, valproic acid or phenytoin. Infant monitoring for potential adverse effects is advisable when the mother is taking phenobarbital, clobazam, gabapentin, lamotrigine, oxcarbazepine or vigabatrin. Monitoring of infant serum drug concentrations is advisable but not compulsory. The use of felbamate, tiagabine and topiramate during breast feeding should await further study.

Vigabatrin: A Novel Therapy for Seizure Disorders

To review the pharmacology, pharmacokinetics, efficacy, and adverse effects of vigabatrin and its role in the management of seizure disorders. A MEDLINE search of English-language literature from January 1993 through January 1999 was conducted using vigabatrin as a search term to identify pertinent studies and review articles. Additional studies were identified from the bibliographies of reviewed literature. The manufacturer provided postmarketing surveillance data. Priority was given to randomized, double-blind, placebo-controlled studies. Vigabatrin is a selective and irreversible inhibitor of gamma-aminobutyric acid transaminase. In controlled clinical trials of vigabatrin add-on therapy in patients with uncontrolled partial seizures, 24-67% of patients achieved a < or =50% reduction in seizure frequency. Data from two comparative trials with carbamazepine monotherapy indicate that vigabatrin monotherapy reduces the frequency of partial seizures in patients with newly diagnosed epilepsy. Vigabatrin also controls infantile spasms, particularly those associated with tuberous sclerosis. Vigabatrin is more effective in patients with partial seizures than in those with generalized seizures. The drug is generally well tolerated. Headache and drowsiness were the most common adverse effects observed in controlled clinical trials; visual field defects, psychiatric reactions, and hyperactivity also have been reported. There are no known clinically significant drug interactions. Vigabatrin improves seizure control as add-on therapy for refractory partial seizures and may produce therapeutic benefits in the treatment of infantile spasms. Vigabatrin is generally well tolerated, with a convenient administration schedule, a lack of known significant drug interactions, and no need for routine monitoring of plasma concentrations.

Modern electroencephalography: its role in epilepsy management

Epilepsy is the area in which electroencephalography is probably of greatest potential clinical value, and yet is most abused. In general, the sensitivity of the waking interictal EEG for detecting epilepsy and its specificity for distinguishing epilepsy from other episodic disorders are both very limited, and routine examination for diagnostic screening or follow up is of little value. However, as this review attempts to demonstrate, EEG is of crucial importance for answering specific, clearly defined questions which commonly arise in the management of seizure disorders, especially so, when non-routine and if necessary complex investigations are undertaken, to address the problems of individual patients.

Pseudoseizures and Pseudo-Toxicity Syndrome for Secondary Gain

The clinical management of seizure disorders in prisoners often is difficult. This task is more challenging when a toxicity syndrome develops secondary to anti-convulsant therapy for epilepsy. Additionally, prisoners may develop pseudoseizures (PS) or pseudo-toxicity syndrome (PTS) for secondary gain. The co-occurrence of these disorders has not been reported previously in the literature. Since the above issues can be very complex, patients (especially prisoners) with PS and/or PTS appear to be best served by a biopsychosocial multi-disciplinary team approach for both diagnosis and treatment.

Seizure disorders in children.

During the past year, a number of issues concerning the diagnosis and management of seizure disorders in children were addressed in large clinical studies and in carefully developed position papers. These issues included the syndrome of benign familial neonatal convulsions, the treatment and prognosis of infantile spasms, the prevention of febrile seizures with oral diazepam, the treatment of status epilepticus, and the identification of predictors of outcome of childhood epilepsy that may impact therapeutic decisions. Although the findings of some of these studies were controversial, each presents data that can be useful in the clinical assessment and treatment of children with these disorders.

Book Review: Diagnosis and Management of Seizure Disorders, edited by Ronald P. Lesser. Published in 1991 by Demos Publications, New York, 162 pages, $19.95 (paperback)

Book Review: Diagnosis and Management of Seizure Disorders, edited by Ronald P. Lesser. Published in 1991 by Demos Publications, New York, 162 pages, $19.95 (paperback)