Epilepsy research
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Treatment of elderly patients with epilepsy may present unique challenges to physicians. Co-morbid conditions and drugs to treat such conditions are common in elderly patients, possibly complicating epilepsy therapies that are dependent on drugs alone. For this reason, surgical intervention may be an attractive option for elderly patients with epilepsy, particularly for medically intractable patients with key disease features, such as lateralization and precisely localized epileptic foci. ⋯ When a curative surgical procedure is not an option, palliative procedures, including vagus nerve stimulation and deep brain stimulation, may be viable options. Vagus nerve stimulation has been reported to reduce seizure rates and improve quality of life in elderly patients with epilepsy. Currently, widespread therapeutic application of deep brain stimulation is limited by risks, costs, and pending studies.
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Status epilepticus (SE), defined as recurrent epileptic seizures without complete recovery between seizures, is one of the most serious manifestations of epilepsy. Generalized convulsive status epilepticus (GCSE) is the most common and most life-threatening form of SE, and aging increases the mortality risk. In a recent study of treatment of GCSE, 226 of 518 evaluable patients (43.6%) were of age 65 or older. ⋯ The diagnosis can be challenging, particularly in the elderly, as overlapping clinical features and electroencephalogram patterns can be seen in SE and in a variety of encephalopathic conditions. There is a suggestion that aggressive treatment of elderly patients with nonconvulsive SE may worsen prognosis. Clearly, there is a need for more data to better understand management of elderly patients with both convulsive and nonconvulsive SE.
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Sudden unexplained/unexpected death in epilepsy (SUDEP), with an incidence of 0.35-9.3/1000 patient-years depending on the severity of epilepsy, remains a diagnostic and therapeutic challenge. Potential pathomechanisms comprise cardiac arrhythmia, due to myocardial ischemia, electrolyte disturbances, arrhythmogenic drugs, or transmission of the epileptic activity via the autonomic nervous system to the heart, and central or obstructive apnea. ⋯ Whereas cardiac dysfunction during seizures has been documented by electrocardiography, and cardiac abnormalities are found in up to 33% of SUDEP cases autoptically, investigations between seizures found only little cardiac abnormalities. More knowledge about the cardiovascular and pulmonary status of epileptic patients during, immediately after and between seizures is needed, which may contribute to better understand and possibly prevent SUDEP by measures like "cardioprotective" drugs, respiratory therapy or implantation of a cardioverter/defibrillator.
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This article reviews types and prognostic significance of seizures that occur after epilepsy surgery, so-called postsurgical seizures.
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Review
Why does surgery fail to cure limbic epilepsy? Seizure functional anatomy may hold the answer.
Surgery for the mesial temporal lobe epilepsy syndrome is highly effective in controlling seizures in as many as 80% of the patients who undergo this procedure. However, the majority of the patients with successful operations still require medications to control their seizures. ⋯ In this paper we will discuss two hypotheses for the functional anatomy of limbic epilepsy in light of what is known about the pathology and physiology of limbic epilepsy. Combining the clinical and scientific observations with these constructs for seizure initiation may lead us to a better understanding of this particular epilepsy syndrome as well as to more effective surgical approaches.