An Unusual Cause of Neck Pain and Headache in Pregnancy.

A previously healthy 21-year-old Caucasian female G1P0 at 32 weeks gestation presented to the ED for an episode of syncope. She also complained of headaches, neck pain, and blurry vision. Physical examination revealed a healthy pregnant female. Neurological examination demonstrated Grade III papilledema but was otherwise unremarkable. CT brain revealed hydrocephalus and intraventricular hemorrhage of unclear etiology MRI of the head was negative for a mass lesion. MRA/MRV of the head was negative, ruling out cavernous sinus thrombosis. Lumbar puncture was bloody but negative for infection. Infectious workup, including HSV, toxoplasmosis, and neurocysticercosis, was negative. An intraventricular drain was placed for hydrocephalus. While in the hospital, she developed sudden left-sided weakness, prompting an emergency C-section. Further workup with CT angio of the brain and neck revealed an arteriovenous malformation (AVM) involving the anterior spinal artery and adjacent venous plexus. Digital subtraction angiography showed a C2-3 pial AVM with a partially thrombosed nidal aneurysm. She was transferred to an outside hospital for embolization. Embolization obliterated the aneurysm, but residual flow remained in the AVM. Blood products are visible on sagittal MRI after embolization. At hospital discharge, her left-sided weakness had resolved, and her neurological examination was normal. The hydrocephalus had resolved.

Health plan paid cost of epilepsy in 2009 in the U.S.

Our objectives were to estimate the health plan paid cost of epilepsy and to show major cost driver(s) of these costs. The health insurance claims and membership data from six U.S. health plans were analyzed. To prepare two comparison groups, individuals with epilepsy (n=5810) were match-paired with individuals without epilepsy (n=5810) using propensity scores derived from logistic regression using gender, age group, health plan product, and length of enrollment in the health plans. Total health plan paid cost per member per year (PMPY) was $11,232 for the epilepsy group and $3026 for the controls (p<0.001). The estimated cost PMPY for treatment of epilepsy was $8206. Relative distribution (%) of health plan paid costs ($) by cost driver category based on place of service (POS) indicated that the treatment of epilepsy places a larger cost burden in inpatient POS than in outpatient hospital or MD office POS compared to controls.

Management issues for women with epilepsy-Focus on pregnancy (an evidence-based review): I. Obstetrical complications and change in seizure frequency: Report of the Quality Standards Subcommittee and Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology and the American Epilepsy Society.

A committee assembled by the American Academy of Neurology (AAN) reassessed the evidence related to the care of women with epilepsy (WWE) during pregnancy, including the risk of pregnancy complications or other medical problems during pregnancy, change in seizure frequency, the risk of status epilepticus, and the rate of remaining seizure-free during pregnancy. The committee evaluated the available evidence according to a structured literature review and classification of relevant articles. For WWE who are taking antiepileptic drugs (AEDs), there is probably no substantially increased risk (>2 times expected) of cesarean delivery or late pregnancy bleeding, and probably no moderately increased risk (>1.5 times expected) of premature contractions or premature labor and delivery. There is possibly a substantially increased risk of premature contractions and premature labor and delivery during pregnancy for WWE who smoke. WWE should be counseled that seizure freedom for at least 9 months prior to pregnancy is probably associated with a high likelihood (84-92%) of remaining seizure-free during pregnancy. WWE who smoke should be counseled that they possibly have a substantially increased risk of premature contractions and premature labor and delivery.

Management issues for women with epilepsy-Focus on pregnancy (an evidence-based review): II. Teratogenesis and perinatal outcomes: Report of the Quality Standards Subcommittee and Therapeutics and Technology Subcommittee of the American Academy of Neurology and the American Epilepsy Society.

A committee assembled by the American Academy of Neurology (AAN) reassessed the evidence related to the care of women with epilepsy (WWE) during pregnancy, including antiepileptic drug (AED) teratogenicity and adverse perinatal outcomes. It is highly probable that intrauterine first-trimester valproate (VPA) exposure has higher risk of major congenital malformations (MCMs) compared to carbamazepine (CBZ), and possibly compared to phenytoin (PHT) or lamotrigine (LTG). It is probable that VPA as part of polytherapy and possible that VPA as monotherapy contribute to the development of MCMs. AED polytherapy probably contributes to the development of MCMs and reduced cognitive outcomes compared to monotherapy. Intrauterine exposure to VPA monotherapy probably reduces cognitive outcomes and monotherapy exposure to PHT or phenobarbital (PB) possibly reduces cognitive outcomes. Neonates of WWE taking AEDs probably have an increased risk of being small for gestational age and possibly have an increased risk of a 1-minute Apgar score of <7. If possible, avoidance of VPA and AED polytherapy during the first trimester of pregnancy should be considered to decrease the risk of MCMs. If possible, avoidance of VPA and AED polytherapy throughout pregnancy should be considered and avoidance of PHT and PB throughout pregnancy may be considered to prevent reduced cognitive outcomes.

Management issues for women with epilepsy--focus on pregnancy (an evidence-based review): III. Vitamin K, folic acid, blood levels, and breast-feeding: Report of the Quality Standards Subcommittee and Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology and the American Epilepsy Society.

A committee assembled by the American Academy of Neurology (AAN) reassessed the evidence related to the care of women with epilepsy (WWE) during pregnancy, including preconceptional folic acid and prenatal vitamin K use and the clinical implications of placental and breast-milk transfer of antiepileptic drugs (AEDs). The committee evaluated the available evidence based on a structured literature review and classification of relevant articles. Preconceptional folic acid supplementation is possibly effective in preventing major congenital malformations in the newborns of WWE taking AEDs. There is inadequate evidence to determine if the newborns of WWE taking AEDs have a substantially increased risk of hemorrhagic complications. Primidone and levetiracetam probably transfer into breast milk in clinically important amounts. Valproate, phenobarbital, phenytoin, and carbamazepine probably are not transferred into breast milk in clinically important amounts. Pregnancy probably causes an increase in the clearance and a decrease in the concentrations of lamotrigine, phenytoin, and, to a lesser extent carbamazepine, and possibly decreases the level of levetiracetam and the active oxcarbazepine metabolite, the monohydroxy derivative (MHD). Supplementing WWE with at least 0.4 mg of folic acid before pregnancy may be considered. Monitoring of lamotrigine, carbamazepine, and phenytoin levels during pregnancy should be considered, and monitoring of levetiracetam and oxcarbazepine (as MHD) levels may be considered. A paucity of evidence limited the strength of many recommendations.

The use of levetiracetam in refractory status epilepticus.

Six patients with status epilepticus (SE) of various etiologies refractory to at least two antiepileptic drugs (AEDs) had complete cessation of their seizures following administration of oral levetiracetam (LEV). Seizure types included convulsive, focal, and nonconvulsive status epilepticus. Effective doses of levetiracetam ranged from 500 to 3000 mg/day, achieving seizure control within 12-96 h. No significant adverse events were noted. Adjunctive levetiracetam should be considered for patients with status epilepticus unresponsive to initial therapy.

Therapeutic equivalency of generic antiepileptic drugs: results of a survey.

Controversy persists whether generic antiepileptic drugs (AEDs) are interchangeable with brand name drugs with respect to efficacy and adverse events. Three hundred and one neurologists responded to a survey regarding generic AEDs mailed to 6420 neurologists, for an overall response rate of 4.7%. One hundred and ninety-six (67.8%) neurologists reported breakthrough seizures after a switch from a brand name to generic AED; 93 (32.2%) did not. One hundred and sixty-three neurologists (56%) reported increased side effects in their patients after a switch from a brand name to generic AED; 128 (44%) did not. Fifty-two (18.4%) neurologists agreed that the Food and Drug Administration standards for AED bioavailability are sufficiently narrow; 231 (81.6%) did not.

Efficacy and tolerability of the new antiepileptic drugs, I: Treatment of new-onset epilepsy: report of the TTA and QSS Subcommittees of the American Academy of Neurology and the American Epilepsy Society.

PURPOSE: To assess the evidence demonstrating efficacy, tolerability, and safety of seven new antiepileptic drugs [AEDs; gabapentin (GBP), lamotrigine (LTG), topiramate (TPM), tiagabine (TGB), oxcarbazepine (OXC), levetiracetam (LEV), and zonisamide (ZNS), reviewed in the order in which these agents received approval by the U.S. Food and Drug Administration] in the treatment of children and adults with newly diagnosed partial and generalized epilepsies. METHODS: A 23-member committee, including general neurologists, pediatric neurologists, epileptologists, and doctors in pharmacy, evaluated the available evidence based on a structured literature review including MEDLINE, Current Contents, and Cochrane Library for relevant articles from 1987 until September 2002, with selected manual searches up to 2003. RESULTS: Evidence exists, either from comparative or dose-controlled trials, that GBP, LTG, TPM, and OXC have efficacy as monotherapy in newly diagnosed adolescents and adults with either partial or mixed seizure disorders. Evidence also shows that LTG is effective for newly diagnosed absence seizures in children. Evidence for effectiveness of the new AEDs in newly diagnosed patients with other generalized epilepsy syndromes is lacking. CONCLUSIONS: The results of this evidence-based assessment provide guidelines for the prescription of AEDs for patients with newly diagnosed epilepsy and identify those seizure types and syndromes for which more evidence is necessary.

Efficacy and tolerability of the new antiepileptic drugs, II: Treatment of refractory epilepsy: report of the TTA and QSS Subcommittees of the American Academy of Neurology and the American Epilepsy Society.

PURPOSE: To assess the evidence demonstrating efficacy, tolerability, and safety of seven new antiepileptic drugs (AEDs) [gabapentin (GBP), lamotrigine (LTG), topiramate (TPM), tiagabine (TGB), oxcarbazepine (OXC), levetiracetam (LEV), and zonisamide (ZNS)] in the treatment of children and adults with refractory partial and generalized epilepsies. METHODS: A 23-member committee, including general neurologists, pediatric neurologists, epileptologists, and doctors in pharmacy, evaluated the available evidence based on a structured literature review including MEDLINE, Current Contents, and Cochrane Library for relevant articles from 1987 to March 2003. RESULTS: All of the new AEDs were found to be appropriate for adjunctive treatment of refractory partial seizures in adults. GBP can be effective for the treatment of mixed seizure disorders, and GBP, LTG, OXC, and TPM for the treatment of refractory partial seizures in children. Limited evidence suggests that LTG and TPM also are effective for adjunctive treatment of idiopathic generalized epilepsy in adults and children, as well as treatment of the Lennox-Gastaut syndrome. CONCLUSIONS: The choice of AED depends on seizure and/or syndrome type, patient age, concomitant medications, and AED tolerability, safety, and efficacy. The results of this evidence-based assessment provide guidelines for the prescription of AEDs for patients with refractory epilepsy and identify those seizure types and syndromes for which more evidence is necessary.

Physicians underestimate the frequency of generic carbamazepine substitution: results of a survey and review of the problem.

Antiepileptic drugs (AEDs) possess a narrow therapeutic range, and generic substitution may lead to breakthrough seizures and adverse events. Prescribers of AEDs may be unaware how frequently generic substitution actually occurs. Surveys were administered to 845 physicians at the 2001 American Epilepsy Society (AES) meeting and the 2001 American Academy of Neurology (AAN) meeting. Two hundred fifty-eight physicians responded to the AES survey and 587 physicians to the AAN survey. Questions were multiple choice and displayed on a computer screen. Among other questions, physicians were asked: (1) What percentage of patients are substituted with a generic short-acting carbamazepine in the US annually? (2) Are you comfortable with patients receiving multiple formulations of generic carbamazepine? Responses to the first question were compared to the actual rate of generic substitution determined by an independent audit of 1,036,000 Tegretol prescriptions. In the AES survey, 10.9% of respondents estimated that 10% of patients had carbamazepine generic substitutions, 41.9% estimated a 30% substitution rate, 30.2% estimated a 50% rate, and 17.1% estimated a 70% rate. The AAN respondents had similar estimates: 17.5% guessed a 10% rate, 40.0% a 30% rate, 30.2% a 50% rate, and 12.3% a 70% rate. In the AES survey, 86.4% of respondents were not "comfortable with patients receiving multiple formulations of generic carbamazepine." Similarly, in the AAN survey, 80.3% of respondents did not endorse generic substitution of carbamazepine. An independent audit of generic substitutions revealed that of 766,000 prescriptions for 200mg of Tegretol, pharmacists substituted 551,000 (72%) with generic carbamazepine. Of 199,000 prescriptions for 100mg of Tegretol, 140,000 (70%) were filled with a generic. Of 71,000 prescriptions for Tegretol 100mg/5ml suspension, 10,000 (14%) were filled with a generic. The overall substitution rate was 701,000/1,036,000 (68%), much higher than estimated by the majority of surveyed attendees. In conclusion, most surveyed physicians at the 2001 AES and AAN meetings significantly underestimated the number of generic substitutions that occur for brand name short-acting carbamazepine. Given the potential for breakthrough seizures and adverse events related to generic substitution, physicians need to be more vigilant in their prescription-writing practices to prevent unwarranted generic substitution.