Evolución de la epilepsia en gestaciones sucesivas / Evolution of epilepsy in successive pregnancies

Introducción. Se ha sugerido que factores hormonales y metabólicos propios de la gestación pueden aumentar la susceptibilidad a las crisis durante el embarazo. Si así fuese cabría esperar una evolución similar de la epilepsia en las distintas gestaciones de una misma mujer. En este trabajo analizamos el comportamiento de la epilepsia no gestacional en embarazos sucesivos. Métodos. Es un estudio prospectivo, en el que se analiza la frecuencia de crisis epilépticas en dos embarazos sucesivos de más de 36 semanas de duración en 12 pacientes. En el protocolo de estudio se define como empeoramiento o mejoría un cambio en el número de crisis de ñ 50 por ciento respecto al número de crisis padecidas en los 11 meses previos a la concepción. Resultados. Ocho de las pacientes recibían el mismo tratamiento antiepiléptico en los dos embarazos estudiados y una no tomó medicación en ninguno de ellos. Tres pacientes sufrieron empeoramiento respecto a la frecuencia previa en la primera gestación y dos en la segunda. Siete pacientes tuvieron la misma frecuencia de crisis en ambas gestaciones. Los niveles plasmáticos totales de antiepilépticos tienden a descender en proporción similar en ambas gestaciones si se mantiene la misma dosis. No hemos observado diferencias en las concentraciones hormonales medias en los tres trimestres en ambos embarazos, tengan las pacientes crisis o permanezcan asintomáticas. Conclusiones. En esta serie, con excepción de un caso de epilepsia farmacorresistente, la causa de la discrepancia en la frecuencia de crisis entre dos gestaciones sucesivas de una misma paciente es una modificación brusca o rápida del régimen terapéutico. En mujeres con epilepsia bien controlada puede esperarse una evolución concordante en gestaciones sucesivas si se mantiene el tratamiento adecuado (AU)

[Evolution of epilepsy in successive pregnancies]. / Evolución de la epilepsia en gestaciones sucesivas.

INTRODUCTION: Hormonal and metabolic factors related to pregnancy itself are considered to increase the likelihood of seizure recurrence. If so, we should expect a similar evolution of epilepsy in a subsequent pregnancy. We investigated differences in evolution of non-gestational epilepsy in each pregnancy of women suffering from epilepsy. METHODS: A prospective study was conducted in order to compare seizure frequency in two successive pregnancies of more than 36 weeks duration in 12 patients. Improvement/worsening is defined as a change of +/- 50 % in the number of seizures regarding that which occurred within the previous eleven months. RESULTS: Twelve epileptic women were studied during two subsequent pregnancies. Eight of them took the same antiepileptic treatment for both pregnancies and one took no antiepileptic drug. Three worsened in the first pregnancy and two in the second. Seven patients had the same seizure frequency during both pregnancies. The total plasma antiepileptic concentrations tended to decline with the same proportion in both pregnancies if the dose remained unchanged. We observed no differences in mean hormone plasma concentrations for each quarter, within subsequent pregnancies. CONCLUSION: Except for one case with drug-resistant epilepsy, we found that the reason for the discrepancy in the frequency of the seizure between two successive pregnancies in the same patient was a sharp or rapid change in antiepileptic drug dose or non-compliance. In well controlled epileptic women a consistent evolution of epilepsy should be expected in a subsequent pregnancy, if adequate treatment is maintained.

Manifestaciones neurológicas en la esclerosis sistémica / Neurological involvement in systemic sclerosis

Introducción. La esclerosis sistémica (ES) se considera la enfermedad del tejido conjuntivo que con menor frecuencia presenta complicaciones neurológicas; sin embargo, estudios recientes demuestran que dichas complicaciones son más frecuentes de lo que se había estimado. Pacientes y métodos. Veintiséis pacientes con ES definida fueron sometidos a un examen clínico neurológico y en 23 casos se practicó un electroneurograma con el fin de determinar la prevalencia de patología neurológica central y de neuropatía periférica, definir sus características e investigar posibles asociaciones con parámetros clínicos y de autoinmunidad. Resultados. Veintitrés casos (88 por ciento) fueron mujeres y 3 (12 por ciento) hombres, con una edad media de 57,5 ñ 12,0 desviación estándar (DE), una edad media al diagnóstico de 51,3 ñ 12,3 DE y un tiempo medio de evolución de la enfermedad de 6,2 ñ 3,1 años. Siete pacientes (26,9 por ciento) presentaron afectación del sistema nervioso central (SNC), siendo la cefalea y las manifestaciones neuropsiquiátricas las patologías más comunes (11,5 por ciento). La prevalencia de neuropatía periférica fue del 39,1 por ciento (9 casos); atendiendo a la extensión de la lesión, predominó la polineuropatía en un 30,4 por ciento de casos; con respecto a la selectividad funcional, las formas sensitivomotoras fueron las más frecuentes (55,6 por ciento), y según la estructura principalmente afectada, la neuropatía axonal fue la más común (44,4 por ciento).Discusión. Se discuten los posibles mecanismos patogénicos de la patología neurológica en esta enfermedad. (AU)

[Neurological involvement in systemic sclerosis]. / Manifestaciones neurológicas en la esclerosis sistémica.

INTRODUCTION: Systemic sclerosis (SS) is recognized as the connective tissue disease which less frequently presents neurological complications; in recent studies it is demonstrated, however, that neurological involvement in SS is more frequent of what it had been assumed. PATIENTS AND METHODS: Clinical neurological exploration was done in 26 patients with definitive SS; an electroneurogram was carried out in 23 cases in order to determine the prevalence of central neurological pathology and of peripheral neuropathy, to define its characteristics, and to investigate possible associations with clinical parameters and with autoimmunity. RESULTS: 23 cases (88%) were females and 3 cases (12%) males; the median age was 57.5 12.0 (SD) years, while the median age to the diagnosis was 51.3 12.3 (SD) years and the median period of natural history of disease was 6.2 3.1 years. Seven patients (26.9%) showed involvement of the CNS, being the headache and the neuropsychiatric manifestations the most common conditions (11.5%). Peripheral neuropathy prevalence was 39.1% (9 cases); according to the distribution of the injury, the polyneuropathy prevailed in 30.4% of cases. With regard to the functional selectivity, the sensitive-motor forms were most frequent (55.6%); according to the most involved structure, the axonal neuropathy was most common (44.4%).Discussion. The possible pathogenic mechanisms of the neurological pathology in this disease are discussed.

[Preventive prophylactic treatment in posttraumatic epilepsy]. / Tratamiento preventivo-profiláctico de la epilepsia postraumática.

Posttraumatic epilepsy (PTE) represents about 2 3% of all the etiologies of epilepsy. The so called early seizures , which appear in the first week after the traumatic brain injury (TBI), are related to the severity of the injury; they do not have an strictly epileptic mechanism, but they become a risk factor to the development of PTE. PTE appears in 5% of all the patients suffering from all TBI, and in 15 20% of the patients suffering from a severe TBI. However, the endpoint uses to be to use antiepileptic drugs (AEDs) as prophylactic treatment in all well established PTE. The efficacy of classic antiepileptic drugs (Phenobarbital, Phenytoin, Carbamazepine, Valproate acid) to control the kindling effect has not been confirmed yet as a prophylactic treatment for PTE. Prophylactic efficacy of other drugs, like lipid peroxidation inhibitors, neuroprotectors (especially antioxidants), glutamic receptor blockers, NMDA receptor blockers, and drugs that modulate apoptosis via caspasas inhibition; however, they constitute new ways of therapeutic investigation with a strong experimental basis. Our recommended therapeutic strategy is not to administrate AEDs indiscriminately, but analyzing risk factors, designing a careful prevention for late seizures using AEDs with proven efficacy in partial seizures and with the best achievable tolerability; being also attentive to the possible use of new drugs in the future, like lipid peroxidation inhibitors, and drugs designed to inhibit other excitotoxic, ionic or oxidative processes.

Tratamiento preventivo-profiláctico de la epilepsia postraumática / Preventive-prophylactic treatment in posttraumatic epilepsy

La epilepsia postraumática (EPT) representa un 2-3 por ciento de las causas de todas las epilepsias. Las llamadas `crisis cerebrales tempranas o precoces' aparecidas en la primera semana posterior al TCE, son proporcionales a la gravedad del mismo, no tienen mecanismo estrictamente epiléptico, pero son factor de riesgo para la formación de EPT. Ésta aparece en el 5 por ciento de todos los TCE, y en el 15-20 por ciento de los graves. Por ello no se aconseja el tratamiento profiláctico con fármacos antiepilépticos (FAE) en todos los TCE. En cambio, se concluye que deben administrarse FAE como tratamiento de la EPT bien definida. La eficacia de los FAE clásicos (Fb, fenitoína, carbamacepina, valproato) para controlar el efecto kindling no se ha confirmado en su administración profiláctica de la EPT. Todavía no está suficientemente probada la eficacia profiláctica de inhibidores de la peroxidación lipídica, diversos neuroprotectores, especialmente antioxidantes, bloqueantes del receptor glutamato y de los NMDA, y moduladores de la apoptosis por inhibición de las caspasas, aunque constituyan nuevas vías de investigación terapéutica de fuerte base experimental. Como estrategia terapéutica se recomienda no administrar FAE indiscriminadamente, sino analizando factores de riesgo, hacer una cuidadosa prevención de las crisis sintomáticas agudas, hasta ahora con fenitoína, y programar la profilaxis tardía con fármacos eficaces en crisis focales y de la máxima tolerabilidad posible, contemplando la posible incorporación en un próximo futuro de inhibidores de la peroxidación lipídica y de otros procesos excitotóxicos, iónicos y oxidativos (AU)

[Leukocytes and primary intracerebral hemorrhage]. / Leucocitos y hemorragia intracerebral primaria.

INTRODUCTION AND OBJECTIVE: The association between the leucocyte count and prognosis observed in ischemic cerebrovascular disease and subarachnoid hemorrhage has rarely been reported in primary intracerebral hemorrhage. The objective of our study is to assess the importance of the number of leukocytes in the peripheral blood during the first 24 hours for prognosis of mortality. PATIENTS AND METHODS: We made a prospective analysis of supratentorial primary intracerebral hemorrhages seen during the first 24 hours during the period 1987-1994. We evaluated the relationship between age, sex, size of hematoma, blood found in the ventricles, level of consciousness on admission, survival and prognosis after 30 days, level of glucaemia, arterial hypertension and leucocyte count. RESULTS: We considered 186 primary intracerebral hemorrhages (64% men and 36% women); the average age was 64 years (Standard Deviation: 10 years). There were 63% deep and 37% lobar hemorrhages. Thirty five percent of the patients died. Leucocytosis was associated with survival (p = 0.003), prognosis (p = 0.0005) and intraventricular bleeding (p = 0.03). We found a significant relationship between the size of the hematoma (r = 0.256; df = 186; p < 0.0001), level of glycaemia on admission (r = 0.282; df = 186; p < 0.0001), level of consciousness (r = -0.263; df = 186, p < 0.0001) and leukocyte count. CONCLUSIONS: The peripheral blood leucocyte count was significantly associated with prognosis and increased mortality. It may therefore be considered to be another parameter of bad prognosis in primary intracerebral hemorrhage.

[Therapeutic benefits of monotherapy with lamotrigine]. / Beneficio terapéutico de la monoterapia con lamotrigina.

OBJECTIVE: To analyze the overall therapeutic benefit (effect on seizures and quality of life) in 100 patients, aged 14-89 years, treated with lamotrigine (LTG) as primary (25) or secondary (75) monotherapy, followed up for between one and six years. PATIENTS AND METHODS: The patients were selected for treatment, under open observation, and not randomized at all. Thirty patients suffered from generalized seizures and 70 from partial crises, with progression to generalized tonic-clonic crises in 36 cases. The usual LTG serum level when bi-therapy was used was 2 to 4 mg and was similar with monotherapy. The predominant dosage of LTG (100 to 200 mg) was similar for monotherapy and for bi-therapy in those treated with valproate, as compared with 200-400 mg in most of those in whom the associated drug was carbamazepine (24), phenobarbital (14), phenytoin (6) or other drug, with a considerable reduction in dose (of 100 mg to 250 mg) when they were treated by monotherapy instead. RESULTS: Overall therapeutic benefit was obtained in 79 cases, partly due to suppression or reduction of the seisures, or maintenance free of them, but mainly due to correction of the side-effects, especially somnolence, attention disorders, obesity, tremor, ataxia, reduced global productivity, hyperlipidaemia and liver enzyme changes. CONCLUSION: Lamotrigine was more effective and better tolerated in smaller doses as monotherapy, and better than other drugs in reference to quality of life, especially by the supression of side-effects, demonstrating that it is valuable in obtaining overall improvement of the disease and its consequences.

[Prognosis in status epilepticus]. / Pronóstico de los estados epilépticos.

Status epilepticus (SE), an special epileptic syndrome, is a frequent neurological emergency (50/100,000) and a critical condition (mean mortality 22%, in 3% of pediatric patients and 38% in the elderly). Accepting its widest concept, it appears without history of epilepsy in 58%. Neuronal damage, mainly hypocampal, has been experimentally demonstrated in convulsive and nonconvulsive SE. We attempt to demonstrate that the most important prognostic factors are: age, more related to morbidity in children and in mortality in the elderly; etiology, determining the evolution in most cases, but not always: in the same etiological group, the coincidence of SE can increase threefold the mortality; the seizure type, especially the convulsive SE; patients with previous epilepsy have a better outcome; the epileptic syndrome, rather determinant of incidence and outcome of the SE in the childhood; the length of SE, but in the cases of outcome directly depending on the etiology; the evolutive phase in which treatment is started; the complications, mainly respiratory; the global therapeutical strategy and the adequate use of drugs, related to order, dosage and timing, are determinant of morbidity and mortality.

[Quality of life in epilepsy]. / La calidad de vida en epilepsia.

Quality of life scales present scoring and response quantification problems when applied to epileptics patients. Moreover, to date they have been based on subjective concepts. Factors related to disease, on the other hand, can give rise to inconsistencies in the objective quality of life. We propose a new scale called the Global Assessment Sheet for Epilepsy in the Adult developed by the Epilepsy Study Group of the Spanish Neurological Society. On a single sheet, whether scored by computer or on paper, the scale attempts to give a clear reflection of clinical picture and course of disease. The data come from multiple sources, homogeneous scores are given for a variety of items and the components are modular such that scores can be used together or separately. The scale represents an effort to provide an objective, concrete scoring system, associating definitions to each score and avoiding responses such as "a lot/normal/little/very little". The scale is physician-assessed so that the questionnaire can be superimposed on well-recorded follow-up medical histories within a reasonable amount of time. New concepts are introduced, such as a crisis index, divided into four main notions: severity of crises, negative impact of side effects, quality of life indicators and self-evaluation of quality of life.

[The development of epilepsy during fetal gestation: a prospective study of 45 women]. / Evolución de la epilepsia durante el período gestacional: estudio prospectivo en 45 gestantes.

We observed a clinical deterioration of epilepsy observed during pregnancy in 29% of 45 consecutive epileptic women. Increase in frequency of attacks is not related to type of attack, previous frequency, type of epilepsy, age at first appearance, family history or presence of anomalies by computed tomography imaging. No association has been found between recurrence of attacks and maintenance of sub-therapeutic plasma levels of anti-epileptic drugs (AED). In 60% of the patients who deteriorate, there is a temporal relation between increase in attacks and the suspension of or reduction of AED doses. Changes observed during one pregnancy cannot always predict what will happen during subsequent pregnancies.