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epilepsy

A tendency towards recurrent seizures. Defined as >= 2 unprovoked seizures > 24 hours apart or 1 unprovoked seizure with a risk of further seizures of >= 60% [2] Classification: Epilepsy syndromes: 1) benign childhood epilepsy 2) juvenile myoclonic epilepsy - epilepsy prior to age 18 3) idiopathic generalized epilepsy 4) focal epilepsy, epilepsia partialis continuans 5) temporal lobe epilepsy (most common syndrome in adults) 6) post-traumatic epilepsy 7) febrile seizures * International League Against Epilepsy has updated its system for classifying epilepsies [16] - focal is now used instead of partial - focal seizures are now classified by awareness - the terms dyscognitive, simple partial, complex partial, psychic, & secondarily generalized are no longer used [16] Etiology: - inherited syndromes - congenital brain malformations - focal cortical dysplasia - infection - head trauma (most common cause in children)* [14] - brain tumors - stroke (most common in elderly) [14,22] - neurodegenerative disease, dementia [14,22] - risk factors for late-life epilepsy [22] - hypertension - diabetes mellitus - highest risk: black patients with diabetes - smoking - apoE4 allele [22] - reduced risk associated with - physical activity is a negative risk factor - moderate alcohol consumption is a negative risk factor [22] * no mention of febrile seizures [14] Epidemiology: - cumulative lifetime incidence in U.S. is 3% [2] - 44% of patients with epilepsy report seizures under control [21] Clinical manifestations: - risk of recurrent seizures is > 60% [2] Diagnostic criteria: - diagnosis of epilepsy requires 2 or more unprovoked seizures 24 hours apart [2,8], or - one unprovoked seizure plus >= 60% likelihood of additional seizure(s) within 10 years (a single seizure 1 month after a stroke), or - presence of an epilepsy syndrome * resolution of epilepsy may be considered if - a patient has outgrown an age-dependent epilepsy syndrome - 10 years without a seizure & off anticonvulsants for 5 years [8] Laboratory: - avoid routine drug levels in patients with epilepsy [23] - see ARUP consult [3] Special laboratory: - electroencephalogram (EEG) - do not routinely order EEG as initial part of syncope workup [23] - negative results do not exclude epilepsy [2] - electroencephalography is 40-50% sensitive in diagnosing epilepsy [2] - EEG not useful in assessing need for continuation of anticonvulsants in patients who respond to combination of 2 anticonvulsants [2] - video EEG monitoring should be considered - patients not responding to 2 or more anticonvulsants - seizures requiring further characterization [2] - gold standard for classifying type of epilepsy Radiology: - magnetic resonance imaging - negative results do not exclude epilepsy [2] - do not routinely obtain neuroimaging after an acute seizure in a patient with established epilepsy [23] Complications: - major depression - bipolar disorder - cognitive impairment - increased risk of bone fractures - increased risk of sudden, unexplained death [2,6,9] - 11 year mortality ~ 0.9% [9] - up to 1% with intractable seizures, multiple anticonvulsants [2] - 3-fold risk of unnatural mortality [20] - 5-fold risk of unintentional medication overdose - opioid & psychotropic major implicated drugs - anticonvulsants not implicated in overdoses [20] - increased risk of major cardiovascular events (RR=1.6) [25,26] Management: - see specific form of seizure - anticonvulsant therapy - avoid valproic acid in women of child-bearing age [23] - levetiracetam or lamotrigine* - anticonvulsants of choice in women of child-bearing age - discovery of pregnancy is not reason enough to stop anticonvulsant [2] - uncontrolled seizure can result in fetal anoxia & death [2] - no significant interactions with hormonal contraceptives [2] - dosage reduction in patients with renal failure [2] - levetiracetam, lamotrigine & gabapentin are anticonvulsants of choice in older patients [2] - do not prescribe long-term anticonvulsant therapy to patients with withdrawal seizures [23] - patients who do not respond to combination of 2 anticonvulsants are considered refractory [2] - lifelong therapy of at least 2 anticonvulsants in patients who respond to combination of 2 anticonvulsants [2] - patients with refractory epilepsy should be referred to an epilepsy center for evaluation [2] - avoid drugs the lower seizure threshold - among antibiotics Zosyn with lower risk of triggering seizures than levofloxacin, cefepime, imipenem - medical marijuana may improve seizure control & quality of life in refractory epilepsy [17] - high out-of-pocket costs & inconvenient access cited as reasons for discontinuation - behavioral interventions can reduce seizures in patients with refractory epilepsy [19] - muscle relaxation with diaphragmatic breathing (29%) - control focused-attention activity with extremity movements (25%) - neurosurgery to remove epileptic focus for patients with refractory focal seizures [2] - laser ablation when location of seizure activity can be pinpointed is FDA-approved but not approved by Aetna [18] * avoid valproic acid, phenobarbital, phenytoin, topiramate, carbamazepine in pregnant women & women of child-bearing age

Interactions

disease interactions

Related

hormonal effects on epilepsy

Specific

Amish infantile epilepsy syndrome benign familial infantile convulsions benign familial neonatal epilepsy catamenial epilepsy; menstruation-associated seizures childhood absence epilepsy epilepsy during pregnancy epilepsy female-restricted with mental retardation (convulsive disorder & mental retardation) epilepsy X-linked with variable learning disabilities & behavior disorders (XELBD) epileptic encephalopathy early infantile type 2; atypical CDKL5-related Rett syndrome focal epilepsy generalized epilepsy & paroxysmal dyskinesia generalized epilepsy with febrile seizures (GEFS) idiopathic generalized epilepsy infantile epileptic encephalopathy intractable childhood epilepsy with generalized tonic-clonic seizures (ICEGTC) myoclonic epilepsy myoclonic epilepsy with ragged-red fibers (MERRF) syndrome nocturnal epilepsy pyridoxine-dependent epilepsy; neonatal epileptic encephalopathy; pyridoxine-5'-phosphate oxidase deficiency; PNPO deficiency status epilepticus

General

chronic neurologic disease seizure; epileptic seizure

References

  1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 1034-35
  2. Medical Knowledge Self Assessment Program (MKSAP) 11, 16, 17, 18, 19. American College of Physicians, Philadelphia 1998, 2012, 2015, 2018, 2021. - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022 - Medical Knowledge Self Assessment Program (MKSAP) 20 American College of Physicians, Philadelphia 2025
  3. ARUP Consult: Seizure Disorders - Epilepsy deprecated reference
  4. French JA, Pedley TA. Clinical practice. Initial management of epilepsy. N Engl J Med. 2008 Jul 10;359(2):166-76 PMID: 18614784
  5. Kwan P, Brodie MJ. Early identification of refractory epilepsy. N Engl J Med. 2000 Feb 3;342(5):314-9. PMID: 10660394
  6. Nei M, Hays R. Sudden unexpected death in epilepsy. Curr Neurol Neurosci Rep. 2010 Jul;10(4):319-26 PMID: 20446062
  7. Arain AM, Abou-Khalil BW. Management of new-onset epilepsy in the elderly. Nat Rev Neurol. 2009 Jul;5(7):363-71 PMID: 19578343
  8. Herman AO Epilepsy Case Definition Revised Physician's First Watch, April 15, 2014 David G. Fairchild, MD, MPH, Editor-in-Chief Massachusetts Medical Society http://www.jwatch.org - Fisher RS et al A practical clinical definition of epilepsy. Epilepsia. April 14, 2014 PMID: 24730690 http://onlinelibrary.wiley.com/doi/10.1111/epi.12550/full
  9. Selassie AW et al Premature Deaths Among Children with Epilepsy - South Carolina, 2000-2011 MMWR Weekly November 7, 2014 / 63(44);989-994 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6344a2.htm
  10. Gaffield ME, Culwell KR, Lee CR. The use of hormonal contraception among women taking anticonvulsant therapy. Contraception. 2011 Jan;83(1):16-29 PMID: 21134499
  11. Glauser T, Ben-Menachem E, Bourgeois B et al Updated ILAE evidence review of antiepileptic drug efficacy and effectiveness as initial monotherapy for epileptic seizures and syndromes. Epilepsia. 2013 Mar;54(3):551-63. PMID: 23350722
  12. Jette N, Quan H, Tellez-Zenteno JF et al Development of an online tool to determine appropriateness for an epilepsy surgery evaluation. Neurology. 2012 Sep 11;79(11):1084-93. Epub 2012 Aug 15. PMID: 22895589
  13. Maschio M, Dinapoli L. Patients with brain tumor-related epilepsy. J Neurooncol. 2012 Aug;109(1):1-6 PMID: 22528794
  14. Kao A Medscape: Quiz: January 12, 2016 Test Your Knowledge of Epilepsy and Seizure-related Conditions. http://reference.medscape.com/viewarticle/856770_2
  15. Ko DY, Benbadis SR Medscape: Epilepsy and Seizures. http://emedicine.medscape.com/article/1184846-overview
  16. Scheffer IE et al ILAE classification of the epilepsies: Position paper of the ILAE Commission for Classification and Terminology. Epilepsia. March 8, 2017 PMID: 28276062 http://onlinelibrary.wiley.com/doi/10.1111/epi.13709/full - Fisher RS et al Instruction manual for the ILAE 2017 operational classification of seizure types. Epilepsia. March 8, 2017 PMID: 28276064 http://onlinelibrary.wiley.com/doi/10.1111/epi.13671/full - Fisher RS et al Operational classification of seizure types by the International League Against Epilepsy: Position Paper of the ILAE Commission for Classification and Terminology. Epilepsia. March 8, 2017 PMID: 28276060 http://onlinelibrary.wiley.com/doi/10.1111/epi.13670/full - Zuberi SM, Perucca E. A new classification is born. Epilepsia. March 8, 2017 PMID: 28276059 http://onlinelibrary.wiley.com/doi/10.1111/epi.13694/full
  17. Basen R. Epilepsy Patients Failing Regular Meds Improved with Medical Cannabis - Reported better overall health as well as seizure control in pilot study MedPage Today, Dec 05, 2017 - Papalia A, et al Has the New York Medical Marijuana Program benefited medically refractory epilepsy patients? American Epilepsy Society (AES) 2017; Abstract 2.186.
  18. Drash W Girl has words for Aetna after brain surgery was denied. CNN. Dec 11, 2017 https://www.msn.com/en-us/news/us/girl-has-words-for-aetna-after-brain-surgery-was-denied/ar-BBGzd2w
  19. George J. Stress-Reducing Techniques Lead to Fewer Seizures. Muscle relaxation, focused attention help patients with medication-resistant epilepsy. MedPage Today. Feb 15, 2018 https://www.medpagetoday.com/neurology/seizures/71192 - Haut SR, Lipton RB, Cornes S et al Behavioral interventions as a treatment for epilepsy: A multicenter randomized controlled trial. Neurology. 2018 Feb 14 PMID: 29444968
  20. Gorton HC, Webb RT, Carr MJ et al Risk of Unnatural Mortality in People With Epilepsy. JAMA Neurol. Published online April 9, 2018. PMID: 29630689 https://jamanetwork.com/journals/jamaneurology/fullarticle/2677847 - Devinsky O, Singh A, Friedman D. Deaths in Epilepsy. What We Are Missing. JAMA Neurol. Published online April 9, 2018. PMID: 29630704 https://jamanetwork.com/journals/jamaneurology/fullarticle/2677846
  21. Tian N, Boring M, Kobau R, Zack MM, Croft JB. Active Epilepsy and Seizure Control in Adults - United States, 2013 and 2015. MMWR Morb Mortal Wkly Rep 2018;67:437-442 https://www.cdc.gov/mmwr/volumes/67/wr/mm6715a1.htm
  22. Johnson EL, Krauss GL, Lee AK et al Association Between Midlife Risk Factors and Late-Onset Epilepsy. Results From the Atherosclerosis Risk in Communities Study. JAMA Neurol. Published online July 23, 2018. PMID: 30039175 https://jamanetwork.com/journals/jamaneurology/fullarticle/2688301
  23. Choogin Wisely. Five Things Physicians and Patients Should Question. American Epilepsy Society. Aug 15, 2018 http://www.choosingwisely.org/societies/american-epilepsy-society/
  24. Dobrin S. Seizures and epilepsy in adolescents and adults. Dis Mon. 2012 Dec;58(12):708-29. PMID: 23149523
  25. Greb E More Evidence Epilepsy Tied to Risk for Major Cardiovascular Events. Medscape - Jul 07, 2021. https://www.medscape.com/viewarticle/954347 - Lee-Lane E, Torabi F, Lacey A et al Epilepsy, antiepileptic drugs, and the risk of major cardiovascular events. Epilepsia 2021. May 27 PMID: 34046890 https://onlinelibrary.wiley.com/doi/10.1111/epi.16930
  26. Li J, Shlobin NA, Thijs RD et al Antiseizure Medications and Cardiovascular Events in Older People With Epilepsy. JAMA Neurol. 2024 Sep 30. PMID: 39348143 https://jamanetwork.com/journals/jamaneurology/fullarticle/2824203
  27. Perucca E, Perucca P, White HS, et al. Drug resistance in epilepsy. Lancet Neurol. 2023;22:723-734. PMID: 37352888
  28. Bui E. Women's issues in epilepsy. Continuum (Minneap Minn). 2022;28:399-427. PMID: 35393964
  29. Nieto-Salazar MA, Velasquez-Botero F, Toro-Velandia AC, et al Diagnostic implications of neuroimaging in epilepsy and other seizure disorders. Ann Med Surg (Lond). 2023;85:73-75. PMID: 36845800
  30. Deng DZ, Husari KS. Approach to patients with seizures and epilepsy: a guide for primary care physicians. Prim Care. 2024;51:211-232. PMID: 38692771
  31. Wirrell E. Evaluation of first seizure and newly diagnosed epilepsy. Continuum (Minneap Minn). 2022;28:230-260. PMID: 35393959
  32. Villanueva V, Artal J, Cabeza-Alvarez CI, et al. Proposed recommendations for the management of depression in adults with epilepsy: an expert consensus. Neurol Ther. 2023;12:479-503. PMID: 36692706
  33. The Human Epilepsy Project http://www.humanepilepsyproject.org/ - NINDS Epilepsy Information Page https://www.ninds.nih.gov/Disorders/All-Disorders/Epilepsy-Information-Page - Centers of Disease Control and Prevention (CDC) Epilepsy http://www.cdc.gov/epilepsy/index.html - Epilepsy Foundation: State Driving Laws Database http://www.epilepsy.com/driving-laws