LACONORTE study: Efficacy and security of lacosamide as first add-on therapy for focal-onset epilepsy in real-life setting.

RATIONALE: Many patients with epilepsy need a second antiepileptic drug (AED), due either to inefficacy or side effects of the first tried one. We evaluated the efficacy and safety of lacosamide (LCM) as first add-on therapy in the real-life setting. METHODS: LACONORTE is a multicenter, retrospective, one-year study. Patients with focal epilepsy on monotherapy with another AED who were started on lacosamide as first add-on therapy were included. Clinical data was obtained at 3, 6 and 12 months and then analyzed. RESULTS: Seventy-three patients (48.6% men) with a mean age of 50.3 and a median duration of the epilepsy of 3.0 years (range 0-65) were included. At 1 year, 91.8% were responders (with at least 50% reduction in the number of seizures) and 64.4% of all patients and 75.8% of those with secondary generalization were seizure-free. Fifteen patients (20.5%) had adverse events (AE), most of them were transient and no severe AEs were reported. LCM was withdrawn in 2 patients due to intolerance and in 1 patient because of inefficacy. Neither side effects nor withdrawal seemed to be related to total dose or to escalating regimes. Seventy patients (95.9%) continued on LCM after the last visit (median dose 200 mg/day, ranging 100-400). Eighteen (24.7%) converted to monotherapy during the 12-month period, 83.3% of them remaining seizure-free. CONCLUSIONS: These results of real-life setting show LCM to be efficacious and safe when used as first add-on therapy for focal-onset epilepsy. Most adverse events were mild and/or transient.

Epilepsia muy refractaria en una muestra escasamente definida / Highly refractory epilepsy in a poorly defined sample

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Nueva clasificación de las epilepsias de la Liga Internacional contra la Epilepsia (ILAE): ¿un paso en dirección equivocada? / The new International League Against Epilepsy (ILAE) classification of epilepsies: a step in the wrong direction?

Introducción. La clasificación de las epilepsias de la Liga Internacional contra la Epilepsia (ILAE) de 1989 se ha usado en todo el mundo en numerosos estudios. En el año 2010 la ILAE propuso una nueva clasificación. Objetivo. Intentamos valorar la aportación de la clasificación de las epilepsias de 2010 comparándola con la versión previa y analizándola de acuerdo con los principios de una buena clasificación. Desarrollo. La clasificación de 2010 muestra cambios radicales, tanto en terminología como en criterios taxonómicos, respecto a la de 1989. La nueva versión carece de muchos atributos propios de una buena clasificación. El criterio mayor elegido para clasificar las epilepsias (mezcla de especificidad sindrómica y etiología) divide las epilepsias en cuatro grupos que no son mutuamente excluyentes. Por ejemplo, la epilepsia rolándica benigna sería incluida tanto entre los ‘síndromes electroclínicos’ como entre las ‘epilepsias de causa desconocida’. Además, el criterio elegido parece clínicamente menos relevante que los de la clasificación previa (localización y etiología). La ILAE propuso un ejemplo de ‘organización’ de las epilepsias, no una verdadera clasificación, y animó a crear otras clasificaciones para fines específicos. Si estas últimas no estuvieran conectadas con una clasificación principal previa, supondrían un verdadero riesgo. Varias autoridades internacionales en la materia han criticado ya las nuevas propuestas de la ILAE. Conclusiones. El lanzamiento de la nueva clasificación de las epilepsias no ha sido un éxito. Un debate internacional sobre el tema ayudaría a desarrollar una nueva clasificación con amplio respaldo universal (AU)

Introduction. The 1989 International League Against Epilepsy (ILAE) classification of epilepsies has been used in many studies world-wide. In 2010, the ILAE proposed a new classification. Aim. We evaluated the potential contribution of the 2010 classification of epilepsies compared to the previous one. We also analyzed the new version according to the principles of a good classification. Development. The 2010 classification of epilepsies shows radical changes, both in terminology and taxonomic criteria, when compared to the 1989 classification. The new version lacks many of the desirable principles of a good classification system. The main criterion selected to classify the epilepsies (a mixture of syndromic specificity and etiology) divides the epilepsies in four groups which are not mutually exclusive. For instance, benign rolandic epilepsy should be included both under ‘electroclinical syndromes’ and ‘epilepsies of unknown cause’. The division of clinical entities in ‘electroclinical syndromes’, ‘constellations’, and ‘ill-defined syndromes’ could have avoided such problem, although it appears to be clinically less relevant than 1989 classification criteria (localization and etiology). The ILAE has proposed an example of ‘organization’ of the epilepsies, instead of a true classification, and has encouraged the creation of different classifications for specific purposes. Should these ones were not linked to a previously established main classification they would represent a risk. Several international authorities have already disapproved the new proposals of the ILAE. Conclusions. The attempts to replace the 1989 ILAE classification of epilepsies have been far from successful. An international debate on the subject might help to develop a new classification supported world-wide (AU)

[The new International League Against Epilepsy (ILAE) classification of epilepsies: a step in the wrong direction?]. / Nueva clasificacion de las epilepsias de la Liga Internacional contra la Epilepsia (ILAE): un paso en direccion equivocada?

INTRODUCTION: The 1989 International League Against Epilepsy (ILAE) classification of epilepsies has been used in many studies world-wide. In 2010, the ILAE proposed a new classification. AIM: We evaluated the potential contribution of the 2010 classification of epilepsies compared to the previous one. We also analyzed the new version according to the principles of a good classification. DEVELOPMENT: The 2010 classification of epilepsies shows radical changes, both in terminology and taxonomic criteria, when compared to the 1989 classification. The new version lacks many of the desirable principles of a good classification system. The main criterion selected to classify the epilepsies (a mixture of syndromic specificity and etiology) divides the epilepsies in four groups which are not mutually exclusive. For instance, benign rolandic epilepsy should be included both under 'electroclinical syndromes' and 'epilepsies of unknown cause'. The division of clinical entities in 'electroclinical syndromes', 'constellations', and 'ill-defined syndromes' could have avoided such problem, although it appears to be clinically less relevant than 1989 classification criteria (localization and etiology). The ILAE has proposed an example of 'organization' of the epilepsies, instead of a true classification, and has encouraged the creation of different classifications for specific purposes. Should these ones were not linked to a previously established main classification they would represent a risk. Several international authorities have already disapproved the new proposals of the ILAE. CONCLUSIONS: The attempts to replace the 1989 ILAE classification of epilepsies have been far from successful. An international debate on the subject might help to develop a new classification supported world-wide.

Epilepsia focal refractaria: ¿tratamiento médico o quirúrgico? / Focal refractory epilepsy: medical or surgical treatment?

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Trastornos cognitivos y neuropsiquiátricos en la enfermedad de Parkinson / Cognitive and neuropsychiatric disorders in Parkinson’s disease

Introducción. En la enfermedad de Parkinson hay pacientes con déficit cognitivo aislado y múltiple y el rendimiento cognitivo forma un abanico que va desde la normalidad hasta un avanzado grado de demencia. La mayoría de los enfermos presenta un déficit ejecutivo, aislado o combinado con otras alteraciones cognitivas, que se considera lo mas característico de la enfermedad, y un 30-40% de afectados acabara presentando una demencia clínicamente definida. Desarrollo. La presencia de alteración cognitiva leve en los enfermos parkinsonianos significa la existencia de un riesgo elevado de aparición de demencia en el transcurso de la enfermedad. La demencia asociada con enfermedad de Parkinson esta específicamente relacionada con sintomatología neuropsiquiátrica, que puede tener tres posibles explicaciones: alteración de vías mesolímbicas, alteración cortical y límbica difusa, o fenomenología de tipo Alzheimer asociada. Los episodios psicóticos se presentan preferentemente en los pacientes con tratamiento dopaminérgico y el espectro clínico de la psicosis parkinsoniana abarca: ilusiones visuales, alucinaciones visuoaudioolfatorias, delirio y psicosis alucinatoria paranoide grave. Todos los fármacos antiparkinsonianos pueden provocar alucinaciones y psicosis, pero los agonistas dopaminérgicos detentan la mayor capacidad. Conclusiones. En el manejo de esta problemática es muy importante la prevención y el diagnóstico y tratamiento tan pronto hagan aparición. Han de disminuirse las dosis de antiparkinsonianos, aunque ello no suele ser suficiente, por lo que habrá que asociar antipsicóticos atípicos, que actúen preferentemente sobre receptores 5-HT y no produzcan bloqueo D2, la mayoría de las veces (AU)

Introduction. In Parkinson’s disease there are patients with isolated and multiple cognitive impairment, and their cognitive performance ranges from normal to an advanced degree of dementia. Most patients present an executive deficit, either in isolation or combined with other cognitive disorders, which is considered to be the most characteristic aspect of the disease, and 30-40% of those affected will end up with a clinically-defined dementia. Development. The presence of a mild cognitive disorder in patients with Parkinson means that the risk of dementia appearing at some time during the development of the disease is high. The dementia associated with Parkinson’s disease is specifically related with neuropsychiatric signs and symptoms, which may have three possible explanations: disorders affecting the mesolimbic pathways, diffuse limbic and cortical compromise, or associated Alzheimer-type phenomenology. Psychotic episodes tend to present more often in patients with dopaminergic treatment and the clinical spectrum of Parkinson-related psychosis covers visual illusions, visual-audio-olfactory hallucinations, delirium and severe paranoid hallucinatory psychosis. All the antiparkinsonian drugs can give rise to hallucinations and psychosis, but the dopamine agonists are the ones with the greatest capacity to do so. Conclusions. In managing these problems, it is crucial for prevention as well as diagnosis and treatment to be carried out as soon as they are detected. Doses of antiparkinsonian drugs must be reduced, although this is not usually enough, and so it will be necessary to associate atypical antipsychotics, which act mainly on 5-HT receptors and, in most cases, do not produce D2 blockage (AU)