1 Adult Epilepsy Update J. Layne Moore, MD, MPH Associate Professor Department of Neurology and Pharmacy Director, Division of Epilepsy The Ohio State University Epilepsy • Affects 1 to 2% of US Population • Chronic Condition • Multiple Drug Therapies • Issues Patients • Compliance • Drug Interactions • Education • Social and Behavioral Used by permission Health Press Oxford Annual Incidence “the spontaneous cessation of the disease is an event too rare to be reasonably anticipated in any give case.” Gowers 1881
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Epilepsy - OSU Center for Continuing Medical Education - PDF of Slides.pdfBenign Rolandic Epilepsy (BRE) • One of the most frequent syndromes, occurring in up to 24% of all epileptic
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Adult Epilepsy Update
J. Layne Moore, MD, MPHAssociate Professor
Department of Neurology and PharmacyDirector, Division of Epilepsy
The Ohio State University
Epilepsy• Affects 1 to 2% of US Population• Chronic Condition• Multiple Drug Therapies• Issues
Patients• Compliance• Drug Interactions• Education• Social and Behavioral
Used by permission Health Press Oxford
Annual Incidence
“the spontaneous cessation of the disease
is an event too rare to be reasonably
anticipated in any give case.”
Gowers 1881
2
Refractory Epilepsy• What is refractory epilepsy?
Uncontrolled with multiple medicationsIntolerable side-effects to achieve control• How to fight back?
Newly Diagnosed (n=470)
Seizure-free 47%(n=222)
Uncontrolled 53%(n=248)
Seizure-free 13%(n=61)
Uncontrolled 40%(n=187)
Seizure-free 4%(n=18)
Uncontrolled 36%(n=169)
Kwan & Brodie NEJM 2000
1st drug
2nd drug
3rd drug
Which patients respond?
• Early response in key • Response to the 1st drug
11% response to 2nd drug if 1st was ineffective41% for SE55% idiosyncratic reaction
Kwan and Brodie
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Seeking a Cause• For most persons with epilepsy or
seizures no cause is found
• People without a clear cause have the best prognosis.
Risk Ratios for Selected Causes
1
29
4
1.5
20
7.3
2
16
10
0 5 10 15 20 25 30 35
Baseline
Severe HI
Moderate HI
Mild HI
Stroke
HTN LVH
Aseptic Meningitis
Encephalitis
Alzheimers
Risk Ratio
4
Diagnostic Pitfalls• Is the diagnosis correct?
• Does the patient have epilepsy?
• SyncopeOften prominent autonomic symptoms
• Seizure• An “aura” is a seizure
symptoms may be positive, negative, or mixed• pSychogenic spell
Almost anything goes• other Stuff
cataplexymigraineTIA
Our Differential Diagnoses
Seizure or Spell Evaluation
• Careful history hopefully with collateral history
Past Medical History• Risk factors
• Neurological examination• EEG• Neuroimaging
Seizure Evaluation• EEG
Awake and asleep increase sensitivityLooking for evidence of epilepsy*Less than 2% of normal people have
epileptiform discharges• Evidence of focal-onset vs.
generalized-onset seizure• This will dictate our choice of AEDs
• NeuroimagingMRI with thin coronal cuts through hippocampusCT scan is only indicated if:• Patient has contraindications to MRI• It is emergent to look for a bleed or