Prevalence of epilepsy its treatment gap and knowledge, attitude and practice of its population in sub-urban Senegal an ILAE/IBE/WHO study.

A door-to-door survey was used to determine the prevalence of epilepsy among 4500 people within the Pikine Health District (population 480,000) Senegal. Prevalence was 14.2/1000, and 23.4% of all people with epilepsy had never received appropriate treatment. Figures for the prevalence had increased since a previous survey in 1989. In parallel a study of knowledge attitude and practice was performed in the same district. Salient findings were that: two-thirds of interviewees had at some time witnessed a seizure, 51% agreed when asked if epilepsy is caused by evil spirits, 35% said epilepsy is contagious, only about 18% said that traditional therapy is best, 60% would not mind their child to play with a child with epilepsy but only 32% would agree if their child would want to marry a person with epilepsy.

Mortality of epilepsy in developed countries: a review.

Mortality in people with epilepsy has been studied in many different populations. In population-based incidence cohorts of epilepsy with 7-29 years follow-up, there was up to a threefold increase in mortality, compared to the general population (standardized mortality ratios [SMR] ranged from 1.6 to 3.0). When studies include selected epilepsy populations where patients with frequent and severe seizures are more common, the mortality is even greater. Relative survivorship (RS) following the diagnosis of epilepsy was 91%, 85%, and 83% after 5, 10, and 15 years, respectively. In a population with childhood-onset epilepsy, RS was 94% and 88% after 10 and 20 years. The level of increased mortality is affected by several factors. In idiopathic epilepsy where the causes of seizures are unknown, the results are conflicting. There was no significant increase in mortality in studies from Iceland, France, and Sweden, a barely increased risk in a study from the United Kingdom, and a significantly increased risk in a study from the United States. In contrast, all studies report a significant increased mortality in remote symptomatic epilepsy (standardized mortality ratios [SMRs] ranging from 2.2 to 6.5). The highest mortality is found in patients with epilepsy and neurodeficits present since birth, including mental retardation or cerebral palsy (SMRs ranging from 7 to 50). Mortality is also affected by age, with the highest SMRs in children, the combined effect of low mortality in the reference population, and high mortality in children with neurodeficits and epilepsy. The highest excess mortality is found in the elderly, > or =75 years. A pronounced increase in mortality is found during the first year following the onset of seizures due to underlying severe diseases. The increased mortality remains in different studies 2-14 years following diagnosis. Most of the factors responsible for the increased mortality are related to the underlying disorder causing epilepsy with pneumonia, cerebrovascular disease, and neoplastic disorders (risk remains elevated when primary brain tumors are excluded), as the most frequently recorded causes. The most common direct seizure-related cause of death in adolescents and young adults is sudden unexpected death, which is 24 times more common than in the general population.

A longitudinal study of brain morphometrics using quantitative magnetic resonance imaging and difference image analysis.

Serial quantitative magnetic resonance imaging (MRI) allows the detection of subtle volumetric changes in brain volume. We used serial volumetry and voxel-based difference image analysis to quantify and characterize longitudinal changes in the hippocampus, cerebellum, and neocortex in younger and middle-age individuals. Paired volumetric MRI brain scans 3.5 years apart were performed on 90 healthy subjects 14 to 77 years old. Quantitative assessment of registered images included hippocampal volumetry, cerebellar volumetry, and automatically determined regional brain volumes. Longitudinal volume changes in three age epochs (<35, 35-54, >54 years) were compared and neocortical changes beyond regions of interest were visualized using filtered difference images. Cross-sectional analysis revealed a significant association between age and reduction in all brain volumes except hippocampal volume. Changes in normalized hippocampal and white matter volume were significantly different among the three groups. Individual analysis revealed 5 subjects with significant longitudinal volume changes lying outside the normative range. Difference image analysis showed global involutional changes in the >54 age group. Our findings suggest that cross-sectional observations in intracranial volume, cerebellar volume, and gray matter volume are likely to reflect uniform rates of volume loss or secular changes. Accelerated brain atrophy was seen from the age of 35-54 and increased rates of hippocampal atrophy from the age of 54. Our findings emphasize the importance of controlling for age effects when studying pathological brain changes over a wide age range.

Psychiatric adverse events during levetiracetam therapy.

The prevalence and psychopathologic features of psychiatric adverse events (PAE) in 517 patients taking levetiracetam (LEV) were investigated. Fifty-three (10.1%) patients developed PAE. A significant association was found with previous psychiatric history, history of febrile convulsions, and history of status epilepticus, whereas lamotrigine co-therapy had a protective effect. PAE were not related to the titration schedule of LEV, and certain patients seem to be biologically more vulnerable.

[National demonstration project on epilepsy in Brazil]. / Projeto demonstrativo em epilepsia no Brasil.

Epilepsy is the most prevalent non-communicable serious neurological condition worldwide. Unfortunately, the majority of people with epilepsy in low-income countries do not receive appropriate treatment. Stigmatisation is the rule. In this setting, the World Health Organisation, the International League against Epilepsy and the International Bureau for Epilepsy launched the Global Campaign against Epilepsy in 1997. This entered its second phase in 2001 and as part of it has set up demonstration projects in the People's Republic of China, Zimbabwe, Senegal and, more recently, in Brazil. The objective of the demonstration projects is to show, through methodological evaluation, that it is possible to establish a model of treatment for people with epilepsy in primary health care settings. The Brazilian demonstration project has targeted regions in Campinas and S o Jose do Rio Preto, both in Sao Paulo State. A task force has been established to assess strategies to expand this project nationwide.

Projeto demonstrativo em epilepsia no Brasil / National demonstration project on epilepsy in Brazil

A epilepsia é a condiçäo neurológica grave de maior prevalência no mundo. Infelizmente, a maioria dos pacientes com epilepsia nos países em desenvolvimento näo recebem tratamento adequado e sofrem estigmatizaçäo pelo diagnóstico. Diante deste cenário, em 1997 foi lançada uma Campanha Global Contra Epilepsia liderada pela Organizaçäo Mundial da Saúde, a Internacional League Against Epilepsy, e International Bureau for Epilepsy. A Campanha entrou na sua segunda fase em 2001 com os projetos demonstrativos que estäo em curso na China, Zimbábue, Senegal e recentemente no Brasil. A finalidade do projeto demonstrativo é mostrar através de avaliaçäo metodológica que é possível estabelecer um modelo de atendimento integral aos pacientes com epilepsia. O projeto demonstrativo brasileiro tem como regiöes de atuaçäo Campinas e São José de Rio Preto. Uma Task Force foi instituída para estudar a expansäo da atuaçäo para outras áreas do país

Certification of deaths attributable to epilepsy.

OBJECTIVE: To estimate the number of sudden unexpected epilepsy deaths occurring annually in England and Wales in those 16-50 years of age. METHODS: All 1997 death entries mentioning epilepsy as a cause of death in those 16-50 years were examined and classified as sudden unexpected death in epilepsy (SUDEP), other epilepsy related deaths, or non-epilepsy deaths. RESULTS: 612 death entries were obtained with postmortem examination having been performed in 498 cases. Forty four deaths were certified as being attributable to SUDEP and a further 292 deaths were considered to be probable SUDEP cases. CONCLUSION: It is estimated that between 350 and 400 cases of SUDEP occurred in England and Wales in 1997 in those 16-50 years. SUDEP is the commonest category of epilepsy related death and accurate certification of such deaths is vital for the monitoring of trends in mortality.

Sudden unexpected death in epilepsy.

Sudden unexpected death in epilepsy is the most common category of seizure-related death for patients who develop chronic epilepsy, accounting for up to 17% of epilepsy deaths. Sudden unexpected death in epilepsy is defined as a sudden, unexpected, non-accidental death in an individual with epilepsy with or without evidence of a seizure having occurred (excluding documented status epilepticus) and where autopsy does not reveal an anatomical or toxicological cause of death. Incidence rates range between 0.35 and 2.70 per 1000 person-years in the population-based studies and between 1.50 and 9.30 per 1000 person-years in selected cohorts. Seizure frequency appears to be an important factor in sudden unexpected death in epilepsy, although the exact pathogenetic mechanisms involved are unclear.

Disease modification in partial epilepsy.

With the growth in antiepileptic drug treatment, the question arises as to what extent we are merely treating the symptom (i.e. the seizures) rather than the underlying disease process (i.e. epileptogenesis). Epileptogenicity can be considered as the process whereby structural and functional changes occur following an insult that in some cases result in epilepsy. Epileptogenicity also describes some of the changes and processes that contribute to the progression observed in some epilepsies. These processes have been modelled in animals mostly by the kindling model of epilepsy, in which repetition of subconvulsive stimuli results in a progressive epileptic state and eventually leads to spontaneous seizures. However, it is not clear that kindling has a human correlate, so models in which an initial insult (status epilepticus, hyperthermia, hypoxia, trauma) is followed by the development of lowered seizure threshold and, in some instances, spontaneous seizures have been used. These models seem to support the "second hit" hypothesis, in which there is an initial insult resulting in lowered seizure threshold, and then a later insult, the "second hit", that results in the expression of epilepsy. These models also support the concept of a latent period during which there could be targeted therapies to prevent the epileptogenic process. Although the occurrence of neuronal damage is one such target, neuronal damage is not necessary for epileptogenesis, and other mechanisms are at play. At the present time, it is not known whether targeted therapies may also affect compensatory processes, such as brain repair. Clearly, this would be a potential risk of such strategies. Epidemiological evidence and trials indicate that our present antiepileptic drugs are not effective in preventing epileptogenesis; antiepileptic drugs were, however, not designed for this purpose. Data from animal experiments suggest that treatment of non-convulsive status epilepticus following specific insults may prevent epileptogenesis. The relevance of this for the human condition remains uncertain, but non-convulsive status epilepticus is probably an under-recognized and probably under-treated condition. Perhaps one of the most salutary findings has been the observation of decreased childhood epilepsy with improved neonatal care. This highlights the importance of medical care at the time of an insult, and of prevention of the insults. This review discusses the data that support the concepts underlying epileptogenesis and the model systems that are presumed to reflect the human condition. Particular attention is paid to the potential for interrupting the processes underlying epileptogenesis.

Differences in the use of health services among people with and without epilepsy in the United Kingdom: socio-economic and disease-specific determinants.

We aim to examine the socio-economic, demographic and disease-specific determinants in the use of health services by patients with epilepsy, compared to people without epilepsy. We used data from the fourth national survey of morbidity in general practice, carried out in 1991-1992. Overall mean annual number of consultations with general practitioners, home visits and referrals to secondary care per person were calculated for people with epilepsy, stratified by age, sex and socio-economic status. The proportion of patients consulting for certain diseases or disease groups were also calculated for patients with epilepsy. Results were compared to these in people without epilepsy, and rate ratios were calculated. Patients with epilepsy consulted twice as often, required three to four times more home visits, and were referred to secondary care three times more often than people without epilepsy, irrespective of age, sex and social class. Among patients with epilepsy, consultation rates and home visits were higher in females, older people and people from the manual social classes. A higher proportion of patients with epilepsy consulted for neoplasms, haematological and mental health disorders, dementia, stroke and gastrointestinal bleeding. Older age and low social class were less strongly associated with health service utilisation than in people without epilepsy, indicating that people with epilepsy lose much of the protective effect of young age and high social class on health. Factors contributing to the higher utilisation of health services in people with epilepsy need to be studied further and their effects taken into account in the organisation of health services for people with epilepsy.

Forced normalization at the interface between epilepsy and psychiatry.

In 1953, Landolt described a group of patients with poorly controlled epilepsy who had psychotic episodes associated with remission of their seizures and disappearance of epileptiform activity on their EEGs. He called this phenomenon "forced normalization." Since then, neurologists and psychiatrists have been intrigued by this phenomenon, and although it has been also reported by others, its existence continues to be the source of much debate. In this article, we review the clinical characteristics and potential pathogenic mechanisms of forced normalization and illustrate the complexities inherent in reaching this diagnosis, as well as its differential diagnosis in two representative cases.

Allergic skin rash with lamotrigine and concomitant valproate therapy

Cutaneous rash is one of the commonest adverse events associated with lamotrigine. We assessed whether the risk is increased in patients receiving concomitant valproate therapy in a population of 103 adult patients with intractable epilepsy, who had lamotrigine added to their treatment. Of the 33 patients taking valproate, 10 (30 per cent) developed a rash, whilst of the 70 not taking valproate, only 6 (8 per cent) developed a rash. This suggests a significantly higher risk of cutaneous rash when starting lamotrigine in patients already taking valproate (p

Myoclonic epilepsy of late onset in trisomy 21

Pacientes com trissomia 21 (T21), com o passar dos anos, sao propensos a desenvolver crises epilépticas parciais concomitantes ao aparecimento de degeneraçao cerebral do tipo Alzheimer. Pacientes com T21 e demência parecem ter o risco maior de apresentarem crises epiléticas que outros pacientes com degeneraçao cerebral do tipo Alzheimer. O caso relatado é de um paciente com T21 com epilepsia de início tardio. A história clínica consiste de crises mioclônicas ao despertar. ocasionais crises generalizadas tônico-clônicas, demência e ponta onda generalizada no EEG. Demência do tipo Alzheimer familial é ligada ao cromossoma 21, bem como epilepsia mioclônica progressiva (tipo Unverricht-Lundborg) Isto sugere que este caso possa representar um tipo distinto de epilepsia mioclônica progressiva, ligado ao cromossoma 21.

Ictal ECG changes in temporal lobe epilepsy

Alteraçöes no ritmo cardíaco podem ocorrer durante crises epilépticas. Estas alteraçöes têm sido sugeridas como possível mecanismo para explicar morte súbita em pacientes com epilepsia crônica. Analisamos o eletrocardiograma (ECG) em 61 crises parciais complexas do lobo temporal de 20 pacientes. Taquicardia foi observada em 24/61 (39 por cento) e bradicardia em 3/61 (5 por cento). A média e a mediana da taquicardia foram 139 e 140 batimentos por minuto (variando de 120-180). O intervalo R-R mais longo foi 9 segundos. Näo houve diferença em relaçäo a lateralizaçäo das crises e alteraçäo do ritmo cardíaco. Um paciente com bradicardia recebeu marcapasso de demanda, com diminuiçäo importante das suas quedas durante as crises. Em conclusäo, as alteraçöes cardíacas ictais em crises do lobo temporal mais comuns säo taquicardia sinusal e menos frequentemente bradicardia. Em pacientes com queixas vagas que sugerem tanto epilepsia e arritimia cardíaca, monitorizaçäo simultânea com EEG/ECG é recomendada e se as crises forem frequentes, vídeo-EEG deve ser considerado. Estudos nesta área säo necessários para esclarecimento de possíveis mecanismos da morte súbita em pacientes com epilepsia

Nifedipina como droga coadjuvante no tratamento da epilepsia refrataria / Nifedipine as a coadjuvant drug in the treatment of refractory epilepsy

Os autores relatam os efeitos de Nifedipina, um antagonista do canal de calcio, adicionada a terapia antiepileptica de 20 paciente com com epilepsia refrataria severa. seis pacientes desenvolveram efeitos colaterais e em dois destes a administracao da droga teve que ser interrompida. Os efeitos colaterais mais comuns foram cefaleia, tontura e letargia. Dois pacientes apresentaram deterioracao da epilepsia e somente 2 pacientes demonstraram a melhora no controle das crises. Um desses pacientes desenvolveu subsequentemente tolerancia apos cinco meses de aparente beneficio. Em 16 pacientes nao foi observada nenhuma alteracao.

Sindrome de Lennox-Gastaut com inicio na vida adulta? A respeito de um caso / Lennox-Gastaut syndrome with onset in the adult life? a case report

A Sindrome de Lennox-Gastaut so foi definitivamente aceita como entidade distinta em 1966. Desde entao, o eponimo tem sido utilizado para designar uma encefalopatia severa da infancia, caracterizada fundamentalmente por crises epileticas refratarias de diversos tipos, associadas com alteracoes eletrograficas tipicas. Entretanto, varios autores consideram que o rotulo de Sindrome de Lennox-Gastaut esta abrigando quadros nosologicos distintos, que deveriam ser separados e individualizados, ilustrando esta situacao, o caso de um paciente que iniciou um quadro de Sindrome de"Lennox-Gastaut-like" aos 20 anos de idade e reportado. Adicionando mais confusao, alguns casos similares tem sido descritos nos ultimos anos sob uma variada nomenclatura. Desde que um dos principais criteruios para o diagnostico da Sindrome de Lennox-Gastaut e a idade dependencia, como deverao entao ser chamados tais quadros? Uma revisao dos criterios empregados para o diagnostico da Sindrome de Lennox-Gastaut se faz necessaria

Ketoconazole in the treatment of cryptococcosis of the central nervous system

Dois pacientes com neurocriptococose foram tratados com ketoconazole (KTZ), um derivado imidazólico de propriedades fungostáticas. Ambos foram tratados inicialmente com o esquema terapêutico tradicional (anfotericina-B + 5-flurocitosina) porém em um dos casos para-efeitos intoleráveis obrigaram a suspensäo do tratamento e, no outro caso, näo houve resposta ao esquema terapêutico. KTZ foi administrado regularmente por via oral em regime de monoterapia na dose de 800mg diárias durante 6 meses com ótimos resultados. Todavia , um mês após a suspensäo do tratamento, houve recorrência da infecçäo em um paciente. Efeitos colaterais foram mínimos durante o curso do tratamento, KTZ pode ser útil no tratamento de aluns casos de neurocriptococose

Epilepsia em um hospital psiquiatrico / Epilepsy in a psychiatric hospital

Recenseamento de pacientes com epilepsia, realizado no Hospital Colonia Sant'Ana, a maior instituicao psiquiatrica do estado de Santa Catarina,mantido pela Secretaria de Saude do Estado. Foram identificados 171 pacientes com epilepsia de um total de 1126 internos, dando a alta prevalencia de 152/1000. A utilizacao exagerada de medicacao sedante e a convivencia forcada com psicoticos poderiam ser responsabilizadas nao somente pela persistencia das crises, mas tambem pelas alteracoes cognitivas e comportamentais observadas em grande parte dos pacientes. A criacao de ambulatorios para uma abordagem multidisciplinar parece ser a unica alternativa frente a essas concepcoes equivocadas que transformam o geralmente benigno sintoma epilepsia em uma devastadora doenca mental

Síndrome de Lennox-Gastaut com início na vida adulta?: a respeito de um caso / Lennox-Gastaut syndrome of late onset? Apropos of a case

Apesar de ter sido relatada anteriormente, a síndrome de Lennox-Gastaut (SLG) só foi definitivamente aceita com entidade distinta em 1966. Desde entäo, o epônimo tem sido utilizado para designar encefalopatia severa da infância, caracterizada fundamentalmente por crises epilépticas refratárias de diversos tipos associadas com alteraçöes eletrográficas típicas. Entretanto, vários autores consideram que o rótulo de SLG está abrigando quadros nosológicos distintos, que deveriam ser separados e individualizados. Ilustrando esta situaçäo, o caso de um paciente que iniciou quadro de aos 20 anos de idade é relatado. Adicionando mais confusäo, alguns casos semelhantes têm sido descritos nos últimos anos sob variada nomenclatura. Desde que um dos principais critérios para o diagnóstico da SLG é a idade dependência, como deveräo entäo ser chamados tais quadros? Revisäo dos critérios empregados para o diagnóstico da SLG se faz necessária