Emergency management of epileptic seizures: a consensus statement. / Documento de consenso para el tratamiento del paciente con crisis epiléptica urgente.

This consensus statement was developed to optimize the emergency management of epileptic seizures in prehospital and hospital settings. A list of clinical questions was drafted and the literature on the emergency treatment of epileptic seizures was reviewed by a multidisciplinary team of emergency physicians, neurologists, and pediatric neurologists from 3 associations: the Spanish Epilepsy Society (SEEP), the Spanish Society of Emergency Medicine (SEMES), and the Spanish Neurology Society (SEN). The team members first answered the questions individually and then discussed them during a meeting of experts from the 3 associations, to reach consensus on the content of the present statement. The recommendations and protocols proposed attempt to standardize the emergency management epileptic seizures. Earlier concepts and definitions are reviewed, a new definition of an epileptic seizure emergency is proposed, treatment options are described for different clinical scenarios, and a crisis code for seizures is also set out.

El presente documento de consenso se ha desarrollado con el objetivo de optimizar el tratamiento de pacientes con crisis epilépticas (CE) en los ámbitos de urgencias prehospitalario y hospitalario. Un equipo multidisciplinar formado por urgenciólogos, neurólogos y neuropediatras de tres sociedades científicas, la Sociedad Española de Epilepsia (SEEP), la Sociedad Española de Urgencias y Emergencias (SEMES) y la Sociedad Española de Neurología (SEN), elaboró un listado de preguntas clínicas y revisó la literatura científica sobre el tratamiento urgente del paciente con CE. Después de un periodo de trabajo individual dando respuesta a las preguntas planteadas, se discutieron y consensuaron en una reunión con expertos de las tres sociedades los contenidos del presente documento. Las recomendaciones y los protocolos que se proponen tratan de unificar el tratamiento urgente de los pacientes con CE. Se han revisado conceptos y definiciones previas y se ha propuesto una nueva definición de CE urgente, planteando diferentes recomendaciones terapéuticas según los escenarios clínicos, incluyendo una propuesta de código crisis.

Documento de consenso para el tratamiento del paciente con crisis epiléptica urgente / Emergency management of epileptic seizures: a consensus statement

El presente documento de consenso se ha desarrollado con el objetivo de optimizar el tratamiento de pacientes con crisis epilépticas (CE) en los ámbitos de urgencias prehospitalario y hospitalario. Un equipo multidisciplinar formado por urgenciólogos, neurólogos y neuropediatras de tres sociedades científicas, la Sociedad Española de Epilepsia (SEEP), la Sociedad Española de Urgencias y Emergencias (SEMES) y la Sociedad Española de Neurología (SEN), elaboró un listado de preguntas clínicas y revisó la literatura científica sobre el tratamiento urgente del paciente con CE. Después de un periodo de trabajo individual dando respuesta a las preguntas planteadas, se discutieron y consensuaron en una reunión con expertos de las tres sociedades los contenidos del presente documento. Las recomendaciones y los protocolos que se proponen tratan de unificar el tratamiento urgente de los pacientes con CE. Se han revisado conceptos y definiciones previas y se ha propuesto una nueva definición de CE urgente, planteando diferentes recomendaciones terapéuticas según los escenarios clínicos, incluyendo una propuesta de código crisis

This consensus statement was developed to optimize the emergency management of epileptic seizures in prehospital and hospital settings. A list of clinical questions was drafted and the literature on the emergency treatment of epileptic seizures was reviewed by a multidisciplinary team of emergency physicians, neurologists, and pediatric neurologists from 3 associations: the Spanish Epilepsy Society (SEEP), the Spanish Society of Emergency Medicine (SEMES), and the Spanish Neurology Society (SEN). The team members first answered the questions individually and then discussed them during a meeting of experts from the 3 associations, to reach consensus on the content of the present statement. The recommendations and protocols proposed attempt to standardize the emergency management epileptic seizures. Earlier concepts and definitions are reviewed, a new definition of an epileptic seizure emergency is proposed, treatment options are described for different clinical scenarios, and a crisis code for seizures is also set out

Detecting Atrial Fibrillation in Patients With an Embolic Stroke of Undetermined Source (from the DAF-ESUS registry).

Atrial fibrillation (AF) causes a substantial proportion of embolic strokes of undeterminded source (ESUS). Effective detection of subclinical AF (SCAF) has important therapeutic implications. We conducted a prospective study to determine the prevalence of SCAF in patients with ESUS through of a 21-day Holter monitoring. In an early-monitoring group, Holter was initiated immediately after hospital discharge. The results were compared with a previous cohort of patients in whom the Holter was initiated at least 1 week after hospital discharge (late-monitoring group). We included 100 patients (50 each group; 69 ± 13 years, 56% male). Mean time from ESUS to Holter was 1.2 ± 1 day in the early-monitoring group and 30 ± 15 days in the late-monitoring group. SCAF was detected in 22% of patients in the early-monitoring and 6% in the late-monitoring group (p <0.05). Patients with SCAF were older (77 ± 9 vs 67 ± 11 years, p <0.05), with a higher rate of left atrial enlargement (50% vs 20%, p<0.05), renal impairment (28% vs 5%; p<0.01), and a slower mean heart rate (55 ± 6 vs 70 ± 6 beats/min; p<0.001). On multivariate analysis, the presence of persistent bradycardia (≤60 beats/min) in the 21-day Holter was a powerful and significant risk factor for SCAF. In conclusion, the sooner 21-day Holter electrocardiogram monitoring is initiated after ESUS, the more likely SCAF can be detected. Sinus bradycardia is a powerful predictor of SCAF in patients with ESUS.

Clinical implications of mechanisms of resistance to antiepileptic drugs.

BACKGROUND: Despite the currently available armamentarium of antiepileptic drugs, seizures are not adequately controlled in about one-third of epileptic patients. The mechanisms of antiepileptic drug resistance are multiple and not fully clarified. METHODS: We conducted a literature search in PubMed and the Cochrane Library databases with the terms: "Drug Resistance" [MeSH] and "Epilepsy" [MeSH], LIMITS: added to PubMed in the last 5 years, only items with abstracts, English, Spanish, Humans. REVIEW SUMMARY: It is currently known that membrane transporter proteins are increased in brain tissue of refractory epileptic patients and in animal models of epilepsy and that overexpression of these transporters and their inhibition are correlated with a reduction and an increase, respectively, of epileptic drugs in epileptic tissue (pharmacokinetic hypothesis). It has also been shown that alterations in voltage-gated sodium channels and GABAA receptors are responsible for resistance to some epileptic drugs. These changes may be constitutional (genetically determined) or acquired (as a consequence of the seizures themselves or disease progression) and may seem alone or combined with each other (pharmacodynamic hypothesis). Associations have been shown between certain genetic polymorphisms and resistance to epileptic drugs, and although they have not been replicated by all authors, they constitute a very attractive line of research. More detailed knowledge of these molecular mechanisms will probably lead to the development of new strategies for pharmacological treatment of epilepsy.

Genetic causes of epilepsy.

BACKGROUND: The contribution of genetic factors to the origin of different epilepsies is a fact established by epidemiological, clinical, and molecular studies. These studies have made it possible to identify numerous mutations in different genes that cause or predispose to the development of certain types of epilepsy. REVIEW SUMMARY: The study of single-gene epilepsies has contributed relevant data regarding the pathophysiology of epilepsy. Most of these genes encode voltage- or ligand-gated ion channels. Other single-gene epilepsies are related to mutations that provoke alterations in neuronal maturation and migration during embryonic development. Nevertheless, the most common forms of epilepsy are not caused by single mutations but by a combination of polymorphisms, most of which are unknown, that generate an alteration in neuronal excitability. In some syndromes, genetic alterations and their consequences have made it possible to explain the therapeutic response to different drugs. Therefore, the progress being made in genetics is changing the classification and diagnosis of epilepsy; moreover, it can sometimes influence the choice of treatment. CONCLUSION: The advances made in genetic knowledge of epilepsy have led to the description of new epilepsy syndromes and to a better characterization of known ones. However, the genes responsible for the most common forms of idiopathic epilepsy remain mostly unknown. This means that for the time being, in clinical practice, genetic diagnosis is limited to uncommon syndromes and to cases in which treatment decisions or genetic counseling can be derived from the diagnosis.