Fam Physician 2000 Sep 1;62(5):1109-16
A practical approach to uncomplicated seizures in children.
McAbee GN, Wark JE
University of Medicine and Dentistry of New Jersey, Stratford, USA.
Uncomplicated seizures and epilepsy are common in infants and children.
Family physicians should be aware of certain epilepsy syndromes that occur
in children, such as febrile seizures, benign focal epilepsy of childhood,
complex partial epilepsy, juvenile myoclonic epilepsy and video
game-related epilepsy. Not all uncomplicated childhood seizures require
neuroimaging or treatment. Febrile seizures, rolandic seizures and video
game-related seizures are childhood epileptic syndromes that are typically
not associated with brain structural lesions on computed tomography or
magnetic resonance imaging, and are often not treated with anticonvulsant
drugs. Juvenile myoclonic epilepsy does not require neuroimaging but does
require treatment because of a high rate of recurrent seizures. Complex
partial epilepsy often requires both neuroimaging and treatment. Although
seizures are diagnosed primarily on clinical grounds, all children with a
possible seizure (except febrile seizures) should have an
electroencephalogram. Interictal EEGs may be normal. Computed tomography
has demonstrated abnormalities in 7 to 19 percent of children with
new-onset seizures. The yield of magnetic resonance imaging for specific
childhood seizure types is not known, but it is the preferred modality of
neuroimaging for many clinical presentations. Most children's seizures
treated with anticonvulsants are controlled by the first drug selected.
The value of "therapeutic' serum drug levels is questionable in the
management of uncomplicated childhood seizures.
Rev Neurol 2000 Jun;30 Suppl 1:S85-9
[Article in Spanish]
Salas-Puig J, Mateos V, Amorin M, Calleja S, Jimenez L
Servicio de Neurologia, Hospital General de Asturias, Oviedo,
INTRODUCTION: Reflex seizures are provoked by a specific sensory stimulus.
Approximately 6% of all epileptic patients have reflex seizures. For
identification of these seizures it is necessary to take a directed
history and make an EEG study whilst the patient is being exposed to the
stimulus, which will confirm the diagnosis. DEVELOPMENT: Many stimuli are
effective in provoking reflex seizures, the commonest are visual. Amongst
the various epileptic syndromes there are different types of epilepsies
with reflex seizures which generally correspond to idiopathic generalized
epilepsies. The physiopathogenic mechanisms are usually complex. The
cerebral cortex corresponding to the function which induces the epileptic
crisis is hyperexcitable, and is the cause of an identifiable lesion or
dysfunction without an underlying lesion. CONCLUSION: The diagnostic
importance of reflex seizures is that when some formerly drug-resistant
patients can control the mechanism which triggers off their seizures they
attain good control of them.
Rev Neurol 2000 Jun;30 Suppl 1:S81-4 [Texto
[Article in Spanish]
Salas-Puig J, Parra J, Fernandez-Torre JL
Servicio de Neurologia, Hospital General de Asturias, Oviedo,
INTRODUCTION: The commonest reflex seizures are those induced by visual
stimuli, and amongst these, those provoked by intermittent luminous
stimulus. DEVELOPMENT: A directed anamnesis and suitable intermittent
light stimulation are important during electroencephalographic studies for
the confirmation of the diagnosis of photosensitive epilepsy. The
photogenic epilepsies, that is those in which all the epileptic seizures
are provoked by visual stimuli, form a small group of epilepsies within
the idiopathic generalized epilepsies with their onset during adolescence.
These seizures have had great social impact, since media diffusion of the
possibility of their appearance whilst watching television or playing
video games. CONCLUSION: The correct diagnosis and preventive measures,
together with the correct anti-epileptic treatment are in favour of a good
prognosis in the great majority of patients.
Rev Neurol 2000 Jun;30 Suppl 1:S42-6 [Texto
[Clinical aspects of epileptic ion channel disorders].
[Article in Spanish]
Campos-Castello J, Canelon de Lopez M, Garcia-Fernandez M
Servicio de Neuropediatria, Hospital Clinico Universitario San Carlos,
Madrid, Espana. firstname.lastname@example.org
OBJECTIVE: One of the recent findings in the investigation of
epileptogenesis is the localization of new gene situses and mutations of
the ion channels. The pathology of these ion channel disorders is
responsible for a considerable number of disorders affecting the central
nervous and musculoskeletal systems. Their clinical expression is often
paroxystic. Mutations cause inactivation of the channel, which depending
of the degree, conditions the phenotype of the disorder. DEVELOPMENT: We
studied the main ion channel disorders related to simply inherited
idiopathic epileptic syndromes in which four genes have been codified to
date: benign familial neonatal convulsions, generalized epilepsy with
febrile seizures plus and autosomal dominant nocturnal frontal lobe
epilepsy. CONCLUSIONS: The ion channels, both voltage dependent and
receptor channels, are involved in the genesis of idiopathic epileptics
syndromes. Their importance is due to their contribution to the
understanding of epileptogenesis and its application to the investigation
of drugs which modify the initial cause of the seizure. At present, it may
be affirmed that the idiopathic epilepsies, or at least some of them, seem
to form a family of ion channel disorders.
Rev Neurol 2000 Jun;30 Suppl 1:S25-41 [Texto
[Ion channels and epilepsy].
[Article in Spanish]
Armijo JA, de las Cuevas I, Adin J
Servicio de Farmacologia Clinica, Hospital Universitario Marques de
Valdecilla, Universidad de Cantabria, Santander, Espana. email@example.com
OBJECTIVE: We review the role of ligand-gated ion channels and
voltage-gated ion channels as a substrate for the epileptogenesis and as
targets in the development of new antiepileptic drugs. DEVELOPMENT:
Voltage-gated calcium channels are involved in the release of
neurotransmitters, in the sustained depolarization-phase of paroxysmal
depolarisation shifts (PDS), and in the generation of absences; they are
also the genetic substrate of generalized tonic-clonic convulsions and
absence-like pattern seen in some mice. The voltage-gated potassium
channel has been implicated in the hyperpolarization-phase of PDS, it is
the genetic substrate of the long QT syndrome, benign neonatal epilepsy,
and episodic ataxia/myokymia syndrome, and it is the target of some
antiepileptic drugs which activate this channel. The voltage-gated sodium
channel is the target of most of the classical and newer antiepileptic
drugs; it is also the substrate for generalized epilepsy with febrile
seizures plus. The sodium channel of the nicotinic acetylcholine receptor
is the substrate for nocturnal frontal lobe epilepsy. The sodium channels
of the AMPA and KA glutamate receptors have been proposed as substrate for
juvenile absence epilepsy and are a target for new antiepileptic drugs
which inhibit it. The calcium channel of the NMDA glutamate receptor has
been implicated in the sustained depolarization-phase of PDS and in
epileptogenesis after kindling and is a main target for new antiglutamate
drugs. The chloride channel of the GABAA receptor is responsible for the
rapid hyperpolarization of PDS, it has been involved in epileptogenesis
after kindling, it may be the substrate of the Angelman syndrome, and it
is activated by many classical and new antiepileptic drugs. CONCLUSION:
The knowledge of the role of the ion channels in the epilepsies is
allowing the design of new and more specific therapeutic strategies.
BMJ 2000 Jan 8;320(7227):94-7 [Texto
Cross sectional study of reporting of epileptic seizures to general
Dalrymple J, Appleby J
Schools of Health, University of East Anglia, Norwich NR4 7TJ.
OBJECTIVE: Comparison of reporting of recent epileptic seizures by
patients to a doctor and anonymously. DESIGN: Cross sectional study of
patients with epilepsy by comparison of paired questionnaires. SETTING:
Rural and urban general practices in Norfolk. PARTICIPANTS: 122 patients
aged over 16 years and able to self complete a questionnaire who were
recruited by 31 general practitioners when attending for review of their
epilepsy. MAIN OUTCOME MEASURE: The difference in reported occurrence of
seizure to general practitioners and in a linked anonymous questionnaire.
RESULTS: 18 patients failed to report a seizure in the past year to their
general practitioner (uncontrolled epilepsy). 40% (24/60) of people with
epilepsy who anonymously reported a seizure in the past year held a
driving licence, but only six revealed this to their general practitioner.
The unemployment rate was 34%, substantially higher than the 9% in the
general population. Measures of anxiety, depression, and stigmatization
were higher in patients with uncontrolled epilepsy. CONCLUSIONS: A
significant proportion of patients with epilepsy under-report their
seizures. Recognition of underreporting is important if patients are to
benefit from adequate and appropriate treatment. General practitioners'
ability to treat epilepsy is hampered by their role in regulating the
rights of epileptic patients to hold a driving licence or access certain
Geriatrics 1999 Dec;54(12):31, 34, 39-40 passim
Strategies for successful management of older patients with seizures.
Eisenschenk S, Gilmore R
Department of Neurology, University of Florida, J Hillis Miller Health
Center, Gainesville, USA.
The incidence of seizures increases dramatically with age, making epilepsy
in the older patient a common clinical presentation in the primary care
practice. In the case of a single seizure or when the underlying cause can
be corrected, antiepileptic drug (AED) therapy may not be warranted. For
recurrent seizures, single AED therapy should be initiated at a low dose
and gradually titrated upward. Control of seizure frequency is dependent
on appropriate AED selection and compliance, drug-drug interactions, and
minimization of side effects. Monitoring of AED serum levels is imperative
for effective AED therapy. Conventional AEDs remain the standard initial
anticonvulsants for epilepsy in older patients. The newer AEDs have
demonstrated efficacy as adjunctive therapy and may offer reduced
side-effect profiles and fewer drug-drug interactions.
Comment in: Geriatrics 2000 Feb;55(2):16, 19
Postgrad Med J 1999 Jul;75(885):387-90
HIV infection and seizures.
Department of Neurology, Banaras Hindu University, Varanasi, India.
New-onset seizures are frequent manifestations of central nervous system
disorders in patients infected with human immunodeficiency virus (HIV).
Seizures are more common in advanced stages of the disease, although they
may occur early in the course of illness. In the majority of patients,
seizures are of the generalised type. Status epilepticus is also frequent.
Associated metabolic abnormalities increase the risk for status
epilepticus. Cerebral mass lesions, cryptococcal meningitis, and
HIV-encephalopathy are common causes of seizures. Phenytoin is the most
commonly prescribed anticonvulsant in this situation, although several
patients may experience hypersensitivity reactions. The prognosis of
seizure disorders in HIV-infected patients depends upon the underlying
Comment in: Postgrad Med J 2000 Aug;76(898):523-4
Rev Neurol 1999 May 1-15;28(9):846-9 [Texto
[Symptomatic epilepsy: review of 208 patients].
[Article in Spanish]
Santos S, Mauri JA, Lopez del Val J, Tejero C, Morales F
Servicio de Neurologia, Hospital Clinico Universitario Lozano Blesa,
OBJECTIVE: To determine the main etiological mechanisms of symptomatic
epilepsy and its frequency according to age. PATIENTS AND METHODS: We made
a retrospective analysis of 208 patients admitted during a period of four
and a half years, studying the variables: age, sex and type of seizures:
simple partial, secondarily generalized partial, complex partial,
tonic-clonic, generalized tonic, and also EEG and neuroimaging. RESULTS:
The main etiological mechanisms found were: vascular (31.25%), alcoholic
(12.01%), intracranial disorders (9.61%), traumatic (5.28%), degenerative
(5.28%), infectious (2.88%) and cryptogenic (33.65%). In the last group
there was an outstandingly large proportion of patients with silent
infarcts. When considering vascular epilepsy, those seizures occurring
during the acute phase of the stroke (24/65) are differentiated from those
of late onset (41/65). In the latter there was a marked predominance of
ischemic etiology (48.78% corresponded to extensive infarcts in the
territory of the middle cerebral artery; 36.58% were associated with
partial infarcts) probably because of the greater frequency of ischemic
stroke as compared with hemorrhagic stroke. After the acute phase, the
latency was of 10.68 +/- 0.43 months and the most frequent seizures were
tonic-clonic (48.78%). CONCLUSION: In persons under 30 years of age,
etiology is multifactorial; between 30 and 50 years of age alcoholic
epilepsy (39.53%) and traumatic epilepsy (11.62%) predominate; over the
age of 50 years the cause was vascular in 43.5%. In the latter age group
there was a high proportion of patients with heraldic seizures.
N Engl J Med 1999 May 20;340(20):1565-70
Patients with refractory seizures.
Department of Neurology, New York University Medical Center, New York
Rev Neurol 1999 Jan 1-15;28(1):32-5 [Texto
[Etiology of epilepsy in adolescents].
[Article in Spanish]
Prats JM, Garaizar C
Unidad de Neuropediatria, Hospital de Cruces, Barakaldo, Vizcaya, Espana.
OBJECTIVE: To review the etiology of epilepsies in adolescent patients
treated at the Child Neurology Clinic, during the years 1995-1997.
PATIENTS AND METHODS: All 13 years old patients, or older, were selected
and considered adolescents. RESULTS AND CONCLUSIONS: A total of 863
patients with epileptic seizures were reviewed. Among them, 225 were
epileptic adolescents and another 8 were adolescents with a single seizure
or with several seizures clustering into a single event. Among the former,
163 suffered from partial epilepsy and 62 from generalized epilepsy.
Partial epilepsies were distributed as: idiopathic (69), remote
symptomatic (49) and cryptogenic (45). Generalized epilepsies were:
idiopathic (22), cryptogenic (16) and cryptogenic-remote symptomatic (24).
The latter included the Lennox-Gastaut syndrome, West syndrome,
polymorphic epilepsy, etc. The etiology of these patients and related
literature are reviewed in order to study the proper nosologic location of
Emerg Med Clin North Am 1999 Feb;17(1):203-20, ix-x
Evaluation of the patient with seizures: an evidence based approach.
Bradford JC, Kyriakedes CG
Department of Emergency Medicine, Northeastern Ohio Universities College
of Medicine, Rootstown, USA.
Statistics tell us that as many as 1 in 20 members of the population will
suffer a seizure at some point in their lifetime, a figure which becomes
even more likely if one lives to the age of 80. Thus, a careful evidence
based approach to the patient with seizure is immensely useful to the
emergency physician. The authors evaluate current studies on the subject,
discuss seizures as they relate to specific patient groups, and,
ultimately, make recommendations on this important subject.
Acad Emerg Med 1998 Sep;5(9):905-11
New-onset generalized seizures in patients with AIDS presenting to an
Pesola GR, Westfal RE
Department of Emergency Medicine, Saint Vincents Hospital, New York, NY
OBJECTIVE: To determine the etiology of new-onset generalized seizures in
patients with AIDS presenting to an ED. Patients without HIV infection
with a first-time seizure were used as a comparison group. With these
data, the current American College of Emergency Physicians (ACEP)
guidelines on the workup of new-onset seizures were applied to determine
whether they could safely be used in patients with AIDS. METHODS: The
authors conducted a retrospective review of all patients with new-onset
generalized seizures who presented to an academic medical center hospital
ED in New York City over 2 years. A standard ED medical evaluation with
history, physical examination, and routine laboratory studies-including at
least a panel 7 chemistry, serum magnesium, and complete blood count-was
performed. RESULTS: The causes of new-onset seizures in 26 patients with
AIDS were idiopathic (8), HIV encephalopathy (8), CNS toxoplasmosis (5),
alcohol withdrawal (2), progressive multifocal leukoencephalopathy (2),
and CNS lymphoma (1). In 120 patients without HIV infection, idiopathic
(43) and alcohol withdrawal (29) were the most common diagnoses. Six
patients with AIDS had CNS lesions necessitating immediate admission to
the hospital (5 with toxoplasmosis and 1 with lymphoma). Only 2 of 6 had
findings on initial ED examination that would have suggested admission
under current guidelines written for patients without HIV infection. The 4
patients with no findings were 3 with CNS toxoplasmosis and 1 with CNS
lymphoma. CONCLUSION: Four of 26 AIDS patients with immediately treatable
CNS lesions could have been sent home for outpatient evaluation of their
seizures on the basis of current guidelines for non-HIV-infected patients.
However, the updated 1997 ACEP guidelines now include emergent brain
neuroimaging studies on patients who have or are suspected of having AIDS.
This study helps to strengthen this recommendation. Based on these
findings, the authors suggest a neuroimaging study with a lumbar puncture,
if indicated, in the ED or inpatient admission workup for all patients
with AIDS or suspected AIDS presenting with new-onset generalized
Lancet 1998 Aug 1;352(9125):397-9 [Texto
Aetiology of transient global amnesia.
Department of Neurological Sciences, Rush-Presbyterian-St Luke's Medical
Center, Chicago, IL 60612, USA. firstname.lastname@example.org
The pathophysiology of transient global amnesia (TGA) has been obscure
since the definition of this syndrome more than 30 years ago. Current
hypotheses include migraine, seizure, or transient cerebral arterial
ischaemia. However, none of these potential mechanisms explain both the
absence of other neurological signs or symptoms during TGA, and its
frequent precipitating activities: many of which would be expected to
result in marked increases in venous return from the arms to the superior
vena cava. Patients with TGA also commonly have a Valsalva manoeuvre at
the onset of attacks. I suggest that a Valsalva manoeuvre, blocking venous
return through the superior vena cava, may allow brief retrograde
transmission of high venous pressure from the arms to the cerebral venous
system, resulting in venous ischaemia to the diencephalon or mesial
temporal lobes and to TGA.
Comment in: Lancet 1998 Nov 7;352(9139):1557-8
Lancet 1998 Aug 1;352(9125):383-90 [Texto
Medical causes of seizures.
Delanty N, Vaughan CJ, French JA
Department of Neurology, Hospital of the University of Pennsylvania,
Philadelphia 19104-4283, USA. email@example.com
Seizures are commonly encountered in patients who do not have epilepsy.
Factors that may provoke such seizures include organ failure, electrolyte
imbalance, medication and medication withdrawal, and hypersensitive
encephalopathy. There is usually one underlying cause, which may be
reversible in some patients. A full assessment should be done to rule out
primary neurological disease. Treatment of seizures in medically ill
patients is aimed at correction of the underlying cause with appropriate
short-term anticonvulsant medication. Phenytoin is ineffective in the
management of seizures secondary to alcohol withdrawal, and in those due
to theophylline or isoniazid toxicity. Control of blood pressure is
important in patients with renal failure and seizures. Non-convulsive
status epilepticus should be considered in any patient with confusion or
coma of unclear cause, and electroencephalography should be done at the
earliest opportunity. Most ill patients with secondary seizures do not
have epilepsy, and this should be explained to patients and their
families. Only those patients with recurrent seizures and uncorrectable
predisposing factors need long-term treatment with anticonvulsant
Comment in: Lancet 1998 Oct 24;352(9137):1390
Am Fam Physician 1998 Apr 1;57(7):1589-600, 1603-4 [Texto
Management of seizures and epilepsy.
Marks WJ Jr, Garcia PA
Northern California Comprehensive Epilepsy Center, University of
California, San Francisco 94143-0138, USA.
While the evaluation and treatment of patients with seizures or epilepsy
is often challenging, modern therapy provides many patients with complete
seizure control. After a first seizure, evaluation should focus on
excluding an underlying neurologic or medical condition, assessing the
relative risk of seizure recurrence and determining whether treatment is
indicated. Successful management of patients with recurrent seizures
begins with the establishment of an accurate diagnosis of epilepsy
syndrome followed by treatment using an appropriate medication in a manner
that optimizes efficacy. The goal of therapy is to completely control
seizures without producing unacceptable medication side effects. Patients
who do not achieve complete seizure control should be referred to an
epilepsy specialist, since new medications and surgical treatments offer
patients unprecedented options in seizure control.
N Engl J Med 1998 Feb 12;338(7):429-34
Risk of recurrent seizures after two unprovoked seizures.
Hauser WA, Rich SS, Lee JR, Annegers JF, Anderson VE
G.H. Sergievsky Center, College of Physicians and Surgeons, Columbia
University, New York, NY 10032, USA.
BACKGROUND: Patients with a single unprovoked seizure have about a 35
percent risk of recurrence in the subsequent five years. We studied the
risk of recurrence after two unprovoked seizures. METHODS: We
prospectively followed 204 patients with a first unprovoked seizure from
the day of the initial seizure. Information was obtained from patients
(and verified by a review of their medical records) about the dates and
circumstances of any subsequent seizures. The risk of a second, third, and
fourth seizure was estimated by the Kaplan-Meier method. RESULTS: Of the
204 patients, 63 had a second seizure, 41 a third seizure, and 26 a fourth
seizure. The mean age of the patients was 36 years, 10 percent were less
than 16 years of age, 70 percent were male, 71 percent had epilepsy of
unknown cause, and 66 percent had generalized seizures. The risk of a
second unprovoked seizure was 33 percent. Among those with a second
seizure, the risk of a third unprovoked seizure was 73 percent; among
those with a third unprovoked seizure, the risk of a fourth was 76
percent. Most recurrences occurred within one year of the second or third
seizure. The risk of a third seizure was higher in those with a presumed
cause of epilepsy (relative risk, 1.9; 95 percent confidence interval, 1.0
to 3.4). CONCLUSIONS: Although only about one third of patients with a
first unprovoked seizure will have further seizures within five years,
about three quarters of those with two or three unprovoked seizures have
further seizures within four years.
Comment in: N Engl J Med 1998 Jul 9;339(2):128-9; discussion 129-30
Comment in: N Engl J Med 1998 Jul 9;339(2):129; discussion 129-30
Lancet 1997 Apr 5;349(9057):1009-12
First tonic-clonic seizures in childhood.
Department of Child Health, University Hospital of Wales, Cardiff, UK.