Epilepsia
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Tumors, particularly low grade glioma and glioneuronal tumors, account for 25-35% of patients who are undergoing epilepsy surgery for intractable seizures. A comprehensive epilepsy evaluation including video-electroencephalography (EEG) monitoring is useful for most of these patients, to determine the optimal extent of resection for the achievement of seizure-free outcome without causing postoperative deficits. Video-EEG monitoring for patients with brain tumor should also be considered in specific situations, such as patients with new postoperative seizures or advanced tumors with unexplained mental status change.
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Up to 40% of patients with temporal lobe epilepsy (TLE) are refractory to medication. Surgery is an effective treatment but may cause new neurologic deficits including visual field deficits (VFDs). The ability to drive after surgery is a key goal, but a postoperative VFD precludes driving in 4-50% of patients even if seizure-free. ⋯ The optic radiation can be delineated in vivo using diffusion tensor imaging tractography, which has been shown to be useful in predicting the postoperative VFDs and in surgical planning. These data are now being used for surgical guidance with the aim of reducing the severity of VFDs. Compensation for brain shift occurring during surgery can be performed using intraoperative magnetic resonance imaging (MRI), but the additional utility of this expensive technique remains unproven.
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Brain functioning is increasingly seen as a complex interplay of dynamic neural systems that rely on the integrity of structural and functional networks. Recent studies that have investigated functional and structural networks in epilepsy have revealed specific disruptions in connectivity and network topology and, consequently, have led to a shift from "focus" to "networks" in modern epilepsy research. ⋯ In this review, we aim to provide an overview that would introduce the clinical neurologist and epileptologist to this new theoretical paradigm. We focus on the application of a theory, called "network analysis," to characterize resting-state functional and structural networks and discuss current and future clinical applications of network analysis in patients with epilepsy.
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The Italian League Against Epilepsy Commission Guidelines Subcommittee on Status Epilepticus (SE) has published an article on the management of SE in adults, and now presents a report on the management of convulsive status epilepticus (CSE) in children, excluding the neonatal period. Children's greater susceptibility than adults to epileptic seizures results from many factors. Earlier maturation of excitatory than inhibitory synapses, increased susceptibility and concentration of receptors for excitatory neurotransmitters, peculiar composition of the receptor subunits resulting in slower and less effective inhibitory responses, all cause the high incidence of SE in the pediatric population. ⋯ As alternatives to phenobarbital, the following can be considered for treatment of refractory CSE: valproate, levetiracetam, and lacosamide. In cases with refractory CSE, pharmacologic options can be thiopental, midazolam, or propofol in continuous intravenous infusions to suppress electroencephalographic bursts and convulsive activity. These drugs need to be administered in intensive care units to ensure the monitoring and support of vital signs and brain electrical activity.
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The Italian League Against Epilepsy has issued evidence-based guidelines to help practicing physicians in their decision to stop or withhold antiepileptic drugs (AEDs) in patients achieving a prolonged period of seizure freedom. Six adult and two child neurologists, divided into four pairs, critically appraised 128 published reports and provided graded recommendations answering 15 key questions: length of the seizure-free period after treatment initiation, difference in seizure-free periods in children and adults, electroencephalography (EEG) pattern at the time of discontinuation, etiology of epilepsy, seizure type(s), patient's age and sex, family history of epilepsy, history of febrile seizures, epilepsy syndrome, seizure frequency before entering remission, duration of active epilepsy, tapering period, number and type of AEDs taken at time of discontinuation, combination of risk factors for recurrence, and length of patient monitoring after treatment discontinuation. Based on the available data, the following recommendations can be outlined: (1) antiepileptic treatment might be discontinued after a minimum period of 2 years of seizure freedom; shorter seizure-free periods are associated to a higher risk of relapse; (2) in children, AED discontinuation could be considered after less than two seizure-free years because of a marginally higher risk of relapse for early withdrawal; (3) factors, such as abnormal EEG (including epileptiform abnormalities) at the time of treatment discontinuation, a documented etiology of seizures (including mental retardation, perinatal insults, and abnormal neurologic examination), partial seizures, or an older age at disease onset, enhance the risk of relapse; however, patients should not be encouraged to withhold treatment unless a combination of two or more of these factors is present; (4) female sex, family history of epilepsy, history of febrile seizures, disease length/severity, and number and type of drugs taken should not influence the decision to stop treatment; (5) epilepsy syndrome should be always included in the decision process; (6) slow (at least 6 months) AED discontinuation should be encouraged; in any case the duration of the tapering period should be tailored to the patient's needs and preference; and (7) patient discontinuing treatment should be followed for no <2 years. As a general habit, the decision to stop treatment should be discussed and shared with each patient, taking into account social and personal complications of a seizure relapse and the medical complications of chronic AED treatment.