Clinical Epilepsy: Adult
2005; Wiley; Volume: 46; Issue: s8 Linguagem: Romeno
10.1111/j.1528-1167.2005.460801_37.x
ISSN1528-1167
Tópico(s)Epilepsy research and treatment
ResumoEpilepsiaVolume 46, Issue s8 p. 335-360 Free Access Clinical Epilepsy: Adult First published: 19 October 2005 https://doi.org/10.1111/j.1528-1167.2005.460801_37.xAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinked InRedditWechat Abstract 1 Ahmed T. Abdelmoity, and 1 Amit Verma ( 1 Peter Kellaway Section of Neurophysiology, Department of Neurology, Baylor College of Medicine, Houston, TX ) Rationale: Benzodiazepines are rarely used as long term therapy for patients with epilepsy. However, once traditional antiepileptic drugs have failed an adjunct trial may be justified to help reduce seizure frequency. Patient's Initials Seizure Type Seizure frequency before Seizure Frequency after Date started Clorazepate dose S.A. Generalized Epilepsy 2 per week one every 2–3 months 10/12/2004 11.25 mg in am, 22.5 in pm K.C. Generalized Epilepsy 1–2 per week None 3/16/2005 11.25 at night S.M. Localization Related-Right Temporal 2–3 per week None 3/25/2005 11.25 at night M.N Localization Related-Midline Central/Right Temporal Daily None 4/15/2005 5.625 at night B.B. Localization Related - Right Frontal 5–6 per week 1–2 per week 2/09/2005 11.25 at night Patient Demographics and Seizure Frequencies Prior to and After Starting Tranxene SD. Methods: We performed a retrospective chart review of patients from the Baylor Comprehensive Epilepsy Program Outpatient Clinic. Patients who had been started on Tranxene SD (a sustained release preparation of Clorazepate) were enrolled into the study. Five patients with refractory epilepsy, met criteria for enrollment. Of these patients, two patients had a diagnosis of primary generalized epilepsy, and three had a diagnosis of localization related epilepsy. Seizure frequencies were recorded prior to and after the initiation of Tranxene SD. Baseline seizure frequencies ranged from daily seizures to two seizures a week. Duration of follow-up ranged from 20 days to seven months. The total daily dose ranged from 5.625 mg up to 33.75 mg (either in once or twice a day dosing). Results: Tranxene SD was effective in 100% of patients, with 3 of 5 patients becoming seizure free. Please see table for detailed results in each patient. Irritability and increased daytime sleepiness were the most common side effects to Clorazepate. These side effects were tolerated well by the patients. Subjective sleepiness was initially reported by patients, which then returned to baseline. Conclusions: In our small series of patients with refractory generalized and localization related epilepsy, a significant reduction in seizure frequency was seen in all patients started on Tranxene SD. The small sample size may be resonsible for the realtively dramatic results seen in our patients. Adverse reactions including increased sleepiness were manageable. The duration of follow-up was relatively short to assess whether tachyphylaxis is a problem with continued treatment. It is possible that treatment with Tranxene SD (or other benzodiazepines) may be useful in short term durations to help decrease seizure frequencies. (Supported by Peter Kellaway Foundation for Research.) 1,2 Ricardo M. Arida, 1 Tania M.G. Henriques, 1,2 Fulvio A. Scorza, 2 Carla A. Scorza, 2,4 Roberta M. Cysneiros, 1 Fernando Freua, 1 Sandro Mandaoufas, 1 Luciano Costantini, 1 Ricardo Staffa, 2 Viviane Brito, 3 Cristine Baldauf, 3 Meire Argentoni-Baudochi, 3 Cassio R. Forster, 3 Carla Baise-Zung, 3 Valeria A. Mello, 3 Claudia T.S. Ruggi, 3 Arthur Cukiert, and 1,2 Marly De Albuquerque ( 1 Engenharia Biomedica, Universidade de Mogi das Cruzes, Sao Paulo, Sao Paulo, Brazil ; 2 Neurology, Universidade Federal de Sao Paulo, Sao Paulo, Sao Paulo, Brazil ; 3 Hospital Brigadeiro, Sao Paulo, Sao Paulo, Brazil ; and 4 Departamento de Farmacologia, Universidade Sao Camilo, Sao Paulo, Sao Paulo, Brazil ) Rationale: To address the employment status of people with refractory epilepsy submitted to CR. Methods: Forty-six non-consecutive patients with refractory epilepsy submitted to CR were studied. Age ranged from 17 to 58 years (M = 37.6±8.7). Twenty-seven patients were males. All patients have been followed up at the Hospital Brigadeiro Epilepsy Surgery Program in São Paulo. The follow-up time range from 2 months to 11 years. Only one patient was unable to read and write. Twenty-four patients have been rendered seizure-free after surgery, 20 patients had partial complex seizures and 2 patients had partial with secondary generalization. Results: Twenty-six patients (56.5%) were professionally impaired by epilepsy. Twenty-seven of them (58.7%) were afraid that seizures could interfere in their professional life; twenty-six patients (56.5%) believed that epilepsy restricted their professional choices and thirty-two of them (69.5%) believed that epilepsy had already caused problems in their professional life. Six of them who were employed before surgery lost their jobs. Three patients that were not working before surgery are employed nowadays. Conclusions: Data concerning epilepsy and employment are scarce in the Brazilian population, especially after CR. Despite the fact that almost all patients could read and write, most of them had no professional skills. The high unemployment and sub-employment rate found in our patients, even in those who were cured by surgery, highlights the need for the development of rehabilitation programs directed to this selected population, as a way of improving quality of life and self-esteem. (Supported by FAEP, FAPESP, CNPq and CAPES.) 1 Ferhan Soyuer, 1 Füsun Erdogan, 1 Vesile Senol, and 1 Fehim Arman ( 1 Halil Bayraktar Health Vocational Collage, Erciyes University, Kayseri, Talas, Turkey; Neurology Departmant of Medical Faculty, Erciyes University, Kayseri, Talas, Turkey; Halil Bayraktar Health Vocational Collage, Erciyes University, Kayseri, Talas, Turkey; and Neurology Departmant of Medical Faculty, Erciyes University, Kayseri, Talas, Turkey ) Rationale: Fatigue is a common complaint in clinical practice. Although fatigue is a frequent and disabling symptom in epileptic patients, there have been only a few investigations on the subject. We examined the frequency of fatigue and depression in semptomatic and idiopatic epilepsy patients and we aimed to assess the relationship between fatigue and cognitive dysfunction in idiopatic and semptomatic epilepsy patients by using P300. Methods: We measured fatigue and depression with the Fatigue Severity Scale(FSS) and Beck Depression Scale(BDS), respectivelly in 19 patients with idiopatic epilepsy, 54 patients with semptomatic epilepsy and 31 control subjects. The oddball paradigm was used in the measurement of P300 in all groups. Results: FSS and BDS scores were significantly high and latancies of P300 were significantly long in idiopatic and semptomatic epilepsy patients. There was a poor corelation between depression and fatigue in epileptic patients. Although latencies of P300 was significantly long in idiopatic and semptomatic epilepsy patients with fatigue, there was no correlation latencies of P300 and depression. Conclusions: These findings suggest that there is an important relationship between fatigue and cognitive dysfunctions in idiopatic and semptomatic epilepsy patients. 1 Sinan A. Barazi, 1 Richard P. Selway, 1 Gautam Tawari, and 1 Charles E. Polkey ( 1 Neurosurgery, Kings College Hospital, London, United Kingdom ) Rationale: VNS is being used increasingly as treatment for intractable epilepsy. There is to date no long term study investigating the satisfaction of patients with this emerging therapy, and few data on outcome at more than five years Methods: We performed a retrospective study of 62 patients with intractable epilepsy, who were treated at King's College Hospital between 1995 and 2000, by RPS and CEP. The patients' mean age at time of implantation of VNS was 28.7 years (range 6 to 59 years); the average duration of epilepsy at implantation was 20.4 years (4 to 56); the mean age at seizure onset was 8.8 years (0 to 50); mean follow-up was 76 months (51 to 114). 3 patients died of sudden unexpected death in epilepsy. We questioned patients on overall benefit of their VNS treatment, and differences in memory, achievements, mood, verbal skills, alertness, cluster seizures and post-ictal confusion. Results: The median pre- and post-implantation monthly seizure frequency in the 35 patients who continue to use the device are 24 (3 to 1800) and 4.5 (0 to 1000) respectively (mean improvement 59.1%, median follow-up 71 months). Retention rate is 59%. Corresponding median monthly seizure frequency in all patients was 22 (1 to 1800), and 9.5 (0 to 1000). 26 patients (44.1%) had no improvement, 5 (8.5%) had less than 50% improvement, 26 (44.1%) had greater than 50% improvement in seizure frequency (including 4 seizure-free), and 2 patients (3%) were worse. 24 patients who no longer use the device have undergone explantation (median 71 months follow-up; one infection, 23 non-efficacy). 27 patients (45.8%) were dissatisfied with VNS, 26 (44.1%) were satisfied, and 6 (10.1%) were undecided. Of 28 patients who had no improvement or a deterioration in their seizure frequency, 1 was satisfied with the VNS experience, 3 were undecided, and 24 were dissatisfied. Of the 31 patients who experienced an overall improvement in seizure frequency, 3 were dissatisfied, 3 were undecided, and 25 were satisfied. Mean quality of life measures showed an improvement in all domains. Conclusions: VNS shows a long term retention rate and efficacy which is highly favourable when compared to medical treatments for intractable epilepsy. 44.1% of our patient group was satisfied with VNS, and 45.8% of patients was dissatisfied. 1 Iblissen Ben Hamouda, 1 Claude Adam, 1 Michel Baulac, and 1 Vincent Navarro ( 1 Epilepsy Unit, Pitié-Salpêtrière Hospital, Paris, France ) Rationale: Pseudo-epileptic seizures (PES) with prolonged duration and resistance to short-acting antiepileptic drug may sometimes be taken for a status epilepticus. Ours goal were to examine (i) the frequency of pseudo-epilepticus status admitted on intensive care units (ICU) among patients with pseudo-epileptic seizures, (ii) the clinical and electrophysiological presentations of these patients and (iii) their comorbidity. Methods: We researched among the population of patients with PES, followed in our Epilepsy Unit on a period of 28 months, those who were admitted in an intensive care unit. We examined clinical and EEG presentation of their manifestations, and medical history. Results: (i) We identified 13 patients for which the diagnosis of pseudo-epilepticus status was secondarly done, among 64 patients with PES. Patients were aged from 16 to 58 years, 5 males and 8 females. Diagnosis of PES was done in intensive care unit in 1/13 cases. (ii) Motor activities were present during PES (n = 12). In intensive care unit, EEG was not performed (n = 6), showed artefacts during the motor activities (n = 2) (that were considered as epileptic for 1 patient), slow waves (n = 1), fast activities due to medication (n = 1) and was normal (n = 3). Eight patients received high doses of AED when admitted on intensive care unit, and three where under respiratory assistance. (iii) Eleven had chronic psychiatric manifestations and 9 had psychogenic precipitating factors. Three patients have a history of epilepsy. Four patients had previous hospitalisations for pseudo-epilepticus status. Conclusions: Pseudo-epileptic statuses admitted in intensive care units are frequent. Clinical presentation and EEG may be misleading. ICU physicians must be aware of this condition and avoid aggressive treatment. 1 Meriem K. Bensalem Owen, and 1 Toufic A. Fakhoury ( 1 Department of Neurology, University of Kentucky, Lexington, KY ) Rationale: The objective of this study is to emphasize the importance of repeating video-EEG monitoring in patients with epilepsy when they have a change in seizure semiology and to pay special attention to concomitant ECG recordings. Methods: We describe two patients who developed a change in their semiology after initial video-EEG monitoring. The first patient is a 25 year old man with stereotypic events since childhood characterized by palpitations at times associated with a sensation of fear. His first EEG-CCTV study was unrevealing. Subsequent interviews with witnesses to his events revealed that brief periods of confusion and pressured out of context speech are at times associated with these events. The second patient is a 60 year old woman who was evaluated for a longstanding history of refractory epilepsy. EEG-CCTV monitoring showed partial seizures originating from the left temporal lobe. A few months later there was a change in the semiology of her seizures, which became more severe and associated with loss of consciousness leading to falls. Both patients had repeat EEG-CCTV studies. Results: During the first patient's repeat EEG-CTV study, stereotypical events were recorded and consisted of simple partial seizures with or without evolution to complex partial seizures. On one occasion, there was secondary generalization. The study localized the epileptogenic focus to the right temporal lobe. Concomitant ECG showed sinus tachycardia, with the heart rate increasing up to 200 beats per minute. In the second patient the repeat study again localized the epileptogenic focus to the left temporal lobe. However, with the more severe seizures associated with loss of consciousness, concomitant ECG showed bradycardia leading to asystole which lasted as long as 16 seconds. The patient subsequently had a demand pacemaker inserted. Conclusions: Repeating video-EEG monitoring is critical in the evaluation of patients with epilepsy who develop a change in seizure semiology. In addition, concomitant ECG recordings should be reviewed carefully in view of possible arrhythmogenic effects of seizures. 1 Dietrich Blumer, and 2 Bola Adamolekun ( 1 Psychiatry, University of Tennessee, Memphis, TN ; and 2 Neurology, University of Tennessee, Memphis, TN ) Rationale: A majority of studies has shown a concurrence rate of epilepsy in patients with nonepileptic seizures (NES) of about 10% to 18%; most frequently epileptic seizures (ES) and NES occur sequentially rather than simultaneously, often beginning with the former (1). This group of patients has found little attention. We have explored the alternating relationship of the two types of paroxysmal disorders and report a novel treatment for patients with the history of both ES and NES - reduction of the antiepileptic drugs (AEDs) to the minimum required to achieve optimal freedom from seizures - that proved remarkably effective in our first two patients, one with initial ES and one with initial NES. The same treatment has since been applied in five more patients with both well documented ES and NES. Methods: Presence of ES and NES were documented by Video-EEG (VEEG) whenever possible. AEDs were very gradually decreased as frequent NES predominated. Results: The first patient had experienced nocturnal ES for 30 years. After 2 years of freedom from seizures, diurnal spells occurred and, over 15 years, became more frequent upon increasing antiepileptic treatments; she became anergic, fearful and headaches became constant. After EEG monitoring showed NES only, her antiepileptic treatment was gradually decreased until she regained, after 2 years, full health without seizures. The second patient was initially diagnosed by VEEG as having NES; he was disabled, anxious and depressed. After 6 years he experienced a flurry of ES, followed by remarkable improvement of his mental state. Upon treatment with AED his former NES condition resumed. He finally recovered once the AED was reduced. Over the last 6 months, the effectiveness of reducing AEDs has been clearly confirmed in five consecutive patients with both types of seizures. Of the seven patients, five had initially presented for treatment with ES and two with NES. Six had a personal history of early trauma, and five had a family history of epilepsy. Conclusions: A lowering of the AED to the minimum required for control of the ES appears to be required to achieve optimal freedom from either seizure. NESs have a psychobiologic basis and have been recognized as posttraumatic startle seizures (2). Excessive suppression of the epileptic paroxysmal activity favors the expression of the posttraumatic paroxysmal activity in patients with both types of paroxysmal disorders. Of etiological significance is the finding that the patients commonly have both a personal history of trauma and a family history of epilepsy. REFERENCES 1. Krumholz, A, Ting, T: Coexisting epilepsy and nonepileptic seizures. In: PW Kaplan, eds: Imitators of Epilepsy, 2nd ed., New York , Demos , 2005, pp 261– 276. 2. Blumer, D: On the psychobiology of nonepileptic seizures. In: JR Gates, eds: Nonepileptic Seizures. Boston , MA : Butterworth-Heineman, 2000, pp. 305– 310.Treatment Etiology 1 Alexis Boro, 1 Fred Lado, and 1 Solomon Moshe ( 1 Neurology, Albert Einstein College of Medicine, Bronx, NY ) Rationale: Temporal lobe seizures often differentially affect sympathetic and vagal heart rate modulation. The time course of these effects has not been fully determined. Methods: The hour before through the hour after seizures in 4 patients with TL epilepsy (11 to 42 years old; 3 female, 1 male; right- sided onset seizures in 2, left-sided onset in 2) were studied. RR intervals were interpolated with a cubic spline function and highpass filtered. Wavelet coefficients were determined from the continuous wavelet transform and converted to amplitudes with the Hilbert transform. Changes in sympathetic and vagal HR modulation were inferred from changes in high frequency (HF, 0.15–0.5 Hz) and low frequency (LF, 0.04–0.15 Hz) power from the following rules: a change in vagal activity is reflected by a change in HF and LF power in that direction, a change in sympathetic activity is reflected in HF activity in that direction, and changes in the LF/HF ratio resolve ambiguous patterns arising from simultaneous changes in sympathetic and vagal HR modulation. Results: Nine complex partial seizures were recorded: 4 secondarily generalized (left onset in 3, right in 1) and 5 did not (left onset in 2, right in 3). Pre-ictal HR modulations attributable to seizures were small in relation to background fluctuations. The number of seizures showing increased sympathetic and decreased vagal HR modulation increased as the seizure approached (1, 1). 8/9 seizures demonstrated ictal tachycardia (mean pre-ictal HR + 3 SD). All were associated with a very low frequency peak (0.004–0.04 Hz), on average exceeding the pre-ictal baseline by 4.8 SD. This peak was coincident with LF and HF minima, and corresponds to sustained sympathetically mediated acceleration of the HR. In the post-ictal period, in 8/9 seizures vagal HR modulation was at least transiently lower in the post-ictal state than in any of the points in a reference state composed of a random sampling of 20% of the points on the HF and LF curves in the pre-ictal period. Secondarily generalized seizures were associated with longer periods of this degree of vagal depression than complex partial seizures (mean 26 vs. 11 min): limited data suggested that LF HRV and respiratory frequency were uncoupled in this period. Increased post-ictal sympathetic HR modulation was often evident, but was less extreme and of a shorter duration. Conclusions: These preliminary data suggest that increased sympathetic and decreased vagal HR modulation often precede the electroclinical onset and ictus of TL seizures. The post-ictal period is characterized by decreased vagal HR modulation that persists for considerably longer after secondarily generalized seizures. (Supported by Rett Syndrome Research Foundation.) (1) [Changes in sympathetic and vagal HR modulation over 15-second epochs prior to seizure onset. A plus sign (+) denotes increased HR modulation with resoect to previous epoch; ♦, decreased HR modulation with respect to previous epoch; Δ SNS and Δ PSNS, interval change in sympathetic and vagal HR modulation, respectively.] 1 Andrea O. Rossetti, 2 Giancarlo Logroscino, and 1 Edward B. Bromfield ( 1 Neurology, Brigham & Women's Hospital, Boston, MA ; and 2 Epidemiology, Harvard School of Public Health, Boston, MA ) Rationale: Despite the fact that refractory status epilepticus (RSE) represents an important cause of neurological morbidity and mortality, there have been few studies of its treatment, particularly comparisons among drugs used for coma-induction. Most studies are case series in which a specific antiepileptic drug (AED) was prescribed, and do not accurately reflect the variety of approaches used in clinical practice. Moreover, the impact on outcome of EEG suppression remains unclear. Methods: Among 127 episodes (107 patients) of status epilepticus (SE) collected from a retrospective database of two tertiary-referral hospitals in Boston, we identified cases that were refractory to first-line (benzodiazepines) and second-line (phenytoin valproate, phenobarbital, or other) AED, and needed intubation and induced coma for clinical management. Coma induction was assessed with regard to the AED used and the extent of EEG suppression achieved. Short-term mortality was analyzed in relationship to demographic and clinical variables, and the treatment strategy used. Statistical analysis was performed with Fisher exact tests for categorical variables and t-tests for continuous variables. Results: We identified 49 episodes of RSE occurring in 47 patients. RSE tended to occur more frequently in incident SE than in recurrent SE episodes (p = 0.06). Mortality was 23% for RSE and 8% for non-RSE patients (p = 0.05); patients with RSE episodes were more likely to lack a history of epilepsy (p = 0.01) or of SE (p = 0.05) prior to the study period, and had a higher prevalence of nonconvulsive SE with coma (p = 0.07). One coma-inducing AED was prescribed in 45%, whereas two ore more were used in 55% of episodes; the most used agents were barbiturates (31 episodes), propofol (27) and midazolam (19); in 20/33 (61%) monitored episodes, the medication was titrated to EEG burst-suppression. Demographics, clinical variables and outcome did not differ significantly between the different coma-inducing strategies, or between episodes with and without EEG burst-suppression. Barbiturates showed a tendency to be used preferentially in episodes related to ominous etiologies. Conclusions: RSE has a higher prevalence in incident than in recurrent SE, and shows higher mortality than non-RSE. In our series, RSE episodes were managed with a combination of coma-inducing AED markedly more often than in series published previously. In this setting, which may more accurately reflect usual clinical practice, mortality appears to be independent of the specific AED used for coma induction and the extent of EEG suppression, suggesting, in agreement with previous studies, that the underlying etiology is the main determinant of outcome. (Dr. Rossetti is supported by the Swiss National Science Foundation and the SICPA Foundation, Prilly, Switzerland.) 1 Yotin Chinvarun ( 1 Division of Neurology, Department of Medicine, Pramongkutklao Hospital, Bangkok, Thailand ) Rationale: To evaluate the efficacy and safety of topiramate used as monotherapy in adult patients with recently diagnosed partial-onset seizures. Methods: A 6-month, open-label, uncontrolled trial was undertaken in 28 patients. Eligible patients were aged ≥ 16 years and weight ≥ 30 kg with the maximum interval since epilepsy diagnosis was 3 years and had at least one partial-onset seizure during a 3-months retrospective baseline phase. The main outcome measures proportion of patients who showed 50% or greater reduction in frequency of seizures and withdraw from the study for any reason. Topiramate was initiated at 50 mg/day and titrated to a recommended dose of 200–400 mg/day Results: Topiramate treated patients demonstrated significant improvement in seizure severity based on 77.3% were seizure-free. The percentage of patients with a ≥50% seizure rate reduction from baseline was 13.6%, and 9.1% were not improved. There were no discontinuations from the study due to adverse events. The adverse events were mild intensity included paresthesia, dizziness, weight loss, anorexia, numbness, slow mentation, and hypoesthesia. Conclusions: The study suggests that topiramate in doses 50–200 mg/day was well tolerated and effective in the monotherapy treatment of patients with partial epilepsy. (Supported by Janssen-Cilag, Tahiland.) 1,2 Fulvio A. Scorza, 1,2 Ricardo M. Arida, 1,2 Marly De Albuquerque, 2 Carla A. Scorza, 2,4 Roberta M. Cysneiros, 3 Cristine Baldauf, 3 Meire Argentoni-Baldochi, 3 Cassio R. Forster, 3 Carla Baise-Zung, 3 Valeria A. Mello, 3 Claudia T.S. Ruggi, and 3 Arthur Cukiert ( 1 Engenharia Biomedica, Universidade de Mogi das Cruzes, Sao Paulo, Sao Paulo, Brazil ; 2 Neurology, Universidade Federal de Sao Paulo, Sao Paulo, Sao Paulo, Brazil ; 3 Hospital Brigadeiro, Sao Paulo, Sao Paulo, Brazil ; and 4 Departamento de Farmacologia, Universidade Sao Camilo, Sao Paulo, Sao Paulo, Brazil ) Rationale: Sudden unexpected death in epilepsy (SUDEP) is an important cause of death among epilepsy surgery patients. The aim of this study was to determine the mortality rate due to SUDEP in patients who had epilepsy surgery at the Hospital Brigadeiro Epilepsy Unit (São Paulo, Brazil). Methods: Nine hundred and fifty patients who underwent epilepsy surgery between January 1996 and January 2005 were included in the study. All subjects had been followed up until January 2005. Results: During the study period, two SUDEP episodes occurred. Both patients died during the early stage after surgical procedures. No SUDEP occurred among the rem
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