Evaluación y manejo de primera crisis epiléptica / Assessment and management of the first epileptic seizure

RESUMEN Las crisis epilépticas son una causa frecuente de consulta en la emergencia y en la atención ambulatoria. La evaluación de una primera crisis epiléptica reviste gran trascendencia en este contexto, ya que la ocurrencia de ésta no implica necesariamente el diagnóstico de epilepsia (dos o más crisis no provocadas separadas por más de 24 horas; una crisis única con alto riesgo de recurrencia (>60%); o la evidencia de un síndrome epiléptico - definición de la Liga Internacional para la Lucha Contra la Epilepsia, ILAE) y el tratamiento subsecuente. Por otro lado, no todo paciente con primera crisis debe ser dejado en observación sin recibir el manejo apropiado. Esta decisión está en función del riesgo de recurrencia de crisis. Para ello, la Academia Americana de Neurología (AAN de sus siglas en inglés) recomienda la clasificación de la primera crisis epiléptica en cinco grupos y dependiendo del riesgo de recurrencia de crisis establecido para cada uno de ellos, se tendrá una guía para proceder o no con el tratamiento antiepiléptico. Los grupos son: pacientes con crisis epiléptica provocadas; pacientes con crisis sintomáticas agudas; pacientes con crisis sintomática remotas; primera crisis asociada a síndromes epilépticos; primera crisis de causa desconocida. La guía publicada por AAN en el 2015 para el manejo de primera crisis, sugiere que los pacientes con crisis sintomáticas remotas (lesiones cerebrales pasadas no evolutivas), pacientes con anormalidades epileptiformes interictales; pacientes con estudios de imagen anormales (RMN y TC); y pacientes con crisis nocturnas, tienen un riesgo elevado para recurrencia de crisis (>60%) por lo que deben ser tratadas. La evidencia disponible a la fecha sugiere también que no hay diferencia significativa en el inicio precoz o diferido del tratamiento antiepiléptico para el control de las crisis a largo plazo.

SUMMARY Epileptic seizures are a common cause of medical consultation in the emergency room and in outpatient settings. The evaluation of the first epileptic seizure is of upmost importance as not all patients presenting with seizures have epilepsy (two or more unprovoked crises separated more than 24 hours; one single crisis with a high risk of recurrence (>60%); or evidence of an epileptic syndrome needing treatment based on the definition by the International League against Epilepsy). On the other hand, not every patient with a first episode should be just observed not offering proper treatment. This decision is based on the risk of recurrence. For that purpose, the American Academy of Neurology (AAN) recommends classifying the first seizures into five groups depending on the risk of recurrence, these groups are: patients with provoked seizures; patients with acute symptomatic seizures; patients with remote symptomatic seizures; first seizure associated with an epileptic syndrome, and first seizure of unknown origin. The AAN guidelines for the management of the first seizure published in 2015 suggests that patients with symptomatic remote seizures (non-evolutive and old cerebral lesions), patients with interictal epileptiform abnormalities, patients with abnormal findings on MRI or CT scan, and patients with nocturnal seizures had a high risk for recurrence (>60%) and should be treated. Current evidence suggests that there is no difference in early or delay treatment for controlling seizures at the long-term.

Effects of a brief psychotherapeutic intervention on resilience and behavior in patients with drug-resistant mesial temporal lobe epilepsy and late seizure recurrence after surgery.

Seizure recurrence (SR) after epilepsy surgery in patients with medically resistant temporal lobe epilepsy and mesial temporal sclerosis (TLE-MTS) can compromise medical treatment and quality of life (QOL). However, there is a scarcity of interventions specifically addressing this issue in the literature. We aimed to evaluate the impact of a four-week psychotherapeutic intervention on the levels of resilience, behavioral symptoms, and QOL of patients with drug-resistant TLE-MTS who underwent corticoamygdalohippocampectomy (CAH) and who presented with late SR. Fifty patients who had been diagnosed with TLE-TMS, undergone CAH, and presented with late SR were included. The study instruments included a clinical and sociodemographic questionnaire and the Brazilian versions of the Connor-Davidson Resilience Scale (CD-RISC-10), the Neurological Disorders Depression Inventory for Epilepsy (NDDI-E), the Interictal Dysphoric Disorder Inventory (IDDI), and the Quality of Life in Epilepsy Inventory (QOLIE-31). Significant reductions in the IDDI (p < 0.001) and NDDI-E (p < 0.001) scores, improvements in the CD-RISC-10 (p < 0.001) and QOLIE-31 (p < 0.001) scores, and positive correlations between resilience levels and QOL (p < 0.01), as well as a negative correlation between depressive symptoms and resilience (p < 0.01) and QOL (p < 0.01), were observed after the psychotherapeutic intervention. Improvements in the resilience levels and QOL, with concomitant reductions in depressive symptoms, were observed in patients with TLE-MTS and late SR after a brief psychotherapeutic intervention. Since there is a lack of studies that measured the impact of interventions in this patient subpopulation, these results may support the development of treatment strategies for this specific group.