Neurology
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Review Practice Guideline Guideline
Practice parameter: antiepileptic drug prophylaxis in severe traumatic brain injury: report of the Quality Standards Subcommittee of the American Academy of Neurology.
To review the evidence regarding antiepileptic drug (AED) prophylaxis in patients with severe traumatic brain injury (TBI) in order to make practice recommendations. ⋯ For adult patients with severe TBI, prophylaxis with phenytoin is effective in decreasing the risk of early post-traumatic seizures. AED prophylaxis is probably not effective in decreasing the risk of late post-traumatic seizures. Further studies addressing milder forms of TBI, the use of newer AEDs, the utility of EEG, and the applicability of these findings to children are recommended.
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Seizures have a partial onset in approximately two-thirds of epilepsy patients. In most of these cases epilepsy is a consequence of a brain-damaging insult such as head trauma, stroke, brain infection, brain surgery, or status epilepticus. The epileptic process consists of three phases: initial insult U27AA; latency period (epileptogenesis) U27AA; recurrent seizures (symptomatic epilepsy). ⋯ Analysis of these data suggests that by using compounds currently available, beneficial effects on the outcome can be achieved by modification of the epileptogenic insult at the acute phase and by modification of circuitry reorganization that is induced/maintained by brief seizures after the diagnosis of epilepsy. Discontinuation or modification of epileptogenesis in patients who experienced an epileptogenic insult months or years before is more complicated. However, molecular screening of candidate epileptogenesis-related genes has revealed novel mechanisms underlying network reorganization and will undoubtedly provide exciting avenues for the development of true antiepileptogenic and disease-modifying agents.
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With more than 16,000 patients implanted with the vagus nerve stimulation (VNS) therapy system (Cyberonics, Inc., Houston, Texas), VNS therapy has assumed an increasingly important role in the treatment of medically refractory seizures since its approval 5 years ago by the United States FDA. This review discusses the clinical trials that provided evidence for the approval, long-term efficacy, efficacy in special populations and co-morbid conditions, and safety and tolerability. Additional studies are suggested to further explore the capabilities of VNS therapy.