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Archive for the ‘Epilepsy’ Category

Dec
15

EPILEPSY: THE FACTS-NEW DRUGS AND SURGERY

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In the past, many new drugs were tested on their ability to stop experimental seizures in animals. This is what happened with drugs such as phenobarbitone, phenytoin, carbamazepine, and sodium valproate. Because such a drug’s action is not just on stopping seizures, other effects, some adverse, are common. More recently through biochemical and neurological research, a number of chemicals, have been identified which appear to have a crucial role in epilepsy. One of these, gamma aminobutyric acid (GABA), acts by inhibiting or stopping seizures. One new drug, vigabatrin, has been developed to increase the concentration of this substance within the brain, and so prevent seizures from happening. Other neurotransmitters called glutamate and aspartate can stimulate a seizure, or make a seizure more likely to happen. Lamotrigine is a new drug designed specifically to reduce the concentration of these substances in the brain and therefore prevent seizures. There are other drugs which are being assessed in a similar way, and which may become generally available in the next few years. Examples include gabapentin, oxcarbazepine, topirimate, remacemide, and zonisamide. It is to be hoped that such drugs

‘tailor-made’ to interfere with specific chemical processes will be associated with fewer

side-effects, and will therefore be safer, and more acceptable to patients.

Surgery-It is likely that the surgical treatment of epilepsy will increase over the next decade. This is because scanning and EEG techniques will become more advanced, and more widely available, thereby enabling the identification of subtle abnormalities within the brain responsible for seizures, some of which will be capable of being removed surgically. It is likely that more specialist centres will become established to perform such surgery, and the operations will be undertaken at a younger age.

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Dec
15

THE TREATMENT OF EPILEPSY: HOW TO HELP CHILDREN AND ADULTS TAKE THEIR DRUGS REGULARLY

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If a drug is to be taken reliably and regularly, a patient must be informed fully about that drug. A plan of the proposed management and possible side-effects of the anti-epileptic drug must be discussed with the patient (or family) at diagnosis and at the outset of treatment. In the children’s seizure clinic at the Royal Liverpool Children’s Hospital (Alder Hey) and at St. Bartholomew’s Hospital, families are provided with a drug information sheet with written details about the drug. Included is information about:

• its preparation (e.g. tablet, capsule, or liquid);

• the method of administration;

• the dosage regime;

• its possible interactions with drugs bought over the counter in chemist’s shops as well as with other prescribed drugs; and

• its side-effects.

Advice is also given regarding what to do about doses which are forgotten, missed, or vomited.

Written information is in addition to, rather than a substitute for, oral advice. Patients often do not remember, or may misunderstand, much of what is said to them by doctors in a busy hospital clinic or surgery. This is particularly relevant with regard to adverse events or side-effects. Unexpected side-effects may distress or annoy patients (and their families) and thus adversely affect whether they will continue to take the drug, with its potential benefits. Patients should also be warned that different, or additional drugs may be needed depending on the specific epilepsy syndrome and their initial response to treatment. Well-informed patients and families are more likely to use their drugs with discretion and obtain the benefits which modern drugs can offer.

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Dec
15

TESTS IN EPILEPSY: HOW SENSITIVE IS THE EEG?

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The EEG is often thought to be able either to prove, or to exclude a diagnosis of epilepsy, but this is rarely possible. A single, routine EEG is likely to show any abnormal (and therefore helpful) activity in only about half of those who have had a tonic-clonic (grand mal) seizure.

If further, or longer duration EEGs are done, the yield increases. It must therefore be clearly understood that the EEG does not prove, nor disprove the diagnosis of epilepsy. There is one important exception to this, and this is with a type of epilepsy called non-convulsive status epilepticus. This may present with bizarre or confused behaviour with semi-purposeful, almost automatic movements. It may be difficult to decide whether this behaviour is epilepsy, but if it is, the EEG helps make the diagnosis

The EEG also is not a good guide to either the activity or prognosis of epilepsy. There is one type of epilepsy, however, in which the EEG is particularly useful—this is typical absence epilepsy (petit mal). In this epilepsy syndrome the frequent seizures may be so brief and subtle that some time may elapse before they are recognized. In children with typical absences, the EEG almost always shows a seizure discharge, which may be induced by hyperventilation, and even more easily after deprivation of sleep.

The EEG is usually not helpful in identifying a cause. Occasionally, however, the EEG may show marked differences between the two sides of the brain, such as a slow wave discharge arising from one particular area. This suggests the presence of a structural abnormality as the cause of the patient’s epilepsy. However, structural abnormalities are best investigated by imaging techniques (brain-scans). These are, after the EEG, the most commonly used investigation in epilepsy.

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Dec
15

THE RELATIONSHIP BETWEEN TYPES OF SEIZURE AND TYPES OF EPILEPSY

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Three interlocking circles, the area of which is roughly proportional to the frequency of occurrence of various types of seizure. The central circle incorporates tonic-clonic (grand mal) seizures. The left-hand circle contains partial seizures, many of which become secondarily generalized, as indicated by the considerable overlap between the two circles. Most partial seizures arise from some focal area of structural abnormality within the brain. These seizures can be said to be symptomatic of some underlying problem—so-called symptomatic epilepsy.

The right-hand circle indicates typical absences (petit mal seizures). About 30 per cent of children with petit mal also have grand mal seizures, as is indicated by the overlap between right hand and centre circles. Such primary generalized epilepsy is not symptomatic of underlying structural brain disease, and may be said to be constitutional or idiopathic epilepsy.

The area of the centre circle that is not overlapped by the left and right hand circles contains those subjects who only have tonic-clonic (grand mal) seizures. Such cryptogenic epilepsy (epilepsy of hidden cause), less common since the advent of sophisticated investigations, should not be called idiopathic. Two possibilities exist—either the petit mal trait was not obvious in childhood, and grand mal seizures are the only manifestation of idiopathic epilepsy, or the seizure discharge from a small lesion becomes generalized so quickly that its initial partial phase is overlooked. It is often difficult to distinguish between the two possibilities even with prolonged EEG recording, unless a seizure actually occurs during the record.

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