The Spanish Neurological Society official clinical practice guidelines in epilepsy.

Previous Official Clinical Practice Guidelines (CPGs) in Epilepsy were based on expert opinions and developed by the Epilepsy Study Group of the Spanish Neurological Society (GE-SEN). The current CPG in epilepsy is based on the scientific method, which extracts recommendations from published scientific evidence. A reduction in the variability in clinical practice through standardization of medical practice has become its main function. SCOPE AND OBJECTIVES: This CPG is focused on comprehensive care for individuals affected by epilepsy as a primary and predominant symptom, regardless of the age of onset and medical policy. METHODOLOGY: 1. Creation of GE-SEN neurologists working group, in collaboration with Neuropediatricians, Neurophysiologists and Neuroradiologists. 2. Identification of clinical areas to be covered: diagnosis, prognosis and treatment. 3. Search and selection of the relevant scientific evidence. 4. Formulation of recommendations based on the classification of the available scientific evidence. RESULTS: It contains 161 recommendations of which 57% are consensus between authors and publishers, due to an important lack of awareness in many fields of this pathology. CONCLUSIONS: This Epilepsy CPG formulates recommendations based on explicit scientific evidence as a result of a formal and rigorous methodology, according to the current knowledge in the pre-selected areas. This paper includes the CPG chapter dedicated to emergency situations in seizures and epilepsy, which may present as a first seizure, an unfavorable outcome in a patient with known epilepsy, or status epilepticus as the most severe manifestation.

Validation of a short useful questionnaire in Spanish for the epidemiological screening of epilepsy in Spain. EPIBERIA Questionnaire.

INTRODUCTION: There is a major gap in knowledge about the epidemiology of epilepsy in Mediterranean countries. The EPIBERIA group was formed with the aim of promoting the conducting of epidemiological studies in this region in order to improve this situation. This paper deals with the validation of a brief questionnaire for screening patients with epilepsy in the general population. METHODS: We selected an English-language questionnaire previously validated by the Ottman group. It was translated, modified to suit the characteristics of the Spanish population, and administered to a sample of 200 patients (93 epileptics and 107 non-epileptic patient controls) sampled consecutively from 5 epilepsy units in different cities in Spain. Both groups were homogeneous in demographic variables and the control group was representative of the general population. RESULTS: We obtained a sensitivity of 100% and a specificity of 74.77% for the least rigorous correction model for the questionnaire, with a sensitivity of 94.62% and a specificity of 99.07% for the most stringent correction model. The PPV ranged from 7.48% for the first case to 69.49% in the second, assuming an epilepsy prevalence of 2%. CONCLUSIONS: The questionnaire EPIBERIA is a valid Spanish tool for epilepsy screening in the general population in Spain.

Drug-resistant epilepsy: current recommendations for diagnosis and treatment in Spain.

INTRODUCTION: Drug-resistant epilepsy (DRE) is a top-priority social health problem which requires early individual treatment due to its dramatic repercussions for the patient and society. DEVELOPMENT: The International League Against Epilepsy (ILAE) has recently defined DRE as that in which the seizures are not controlled after having correctly taken two appropriate and well tolerated anti-epileptic drugs, with lack of control being understood as the appearance of seizures within one year or in a period less than three times the inter-seizure interval before starting treatment. This International Society recommends a rapid and detailed assessment of all patients in an Epilepsy Unit. A Clinical Epilepsy Unit (CEU) is understood as a group of professionals who, acting in collaboration, have the diagnosis and treatment of the patient with epilepsy as their primary objective. CEUs in Spain may be stratified into different levels depending on the activity carried out in each of them. The specific epilepsy clinic is considered the fundamental type of CEU and includes the necessary figure of an expert in epilepsy. Prolonged video-monitoring is performed in medical CEUs. In medical-surgical CEUs epilepsy surgery with varying degrees of difficulty is also performed. CONCLUSIONS: All CEUs must cooperate with consensus protocols, and there must be a two-way flow between them. Stratification of CEUs increases efficacy and efficiency, due to there being a sufficient number of them to ensure easy access by all patients with epilepsy.

Consensus-recommended diagnostic and therapeutic guidelines for drug-resistant epilepsy in Spain (Consenso RATE-España).

OBJECTIVE: To ascertain the opinions of an Epilepsy Expert Group and prepare a consensus document on the definition of drug-resistant epilepsy (DRE) according to the International League Against Epilepsy (ILAE) and the different healthcare levels for the patient with epilepsy in Spain. MATERIAL AND METHODS: The study was conducted using the Delphi method, by means of successive rounds of questionnaires. A scientific committee prepared a preliminary document and fourteen associated questions, which were sent by e-mail to the panel of experts. They included items related to the concept of DRE, health care levels and the route between these levels for patients with DRE. RESULTS: A total of 41 experts answered the questionnaire. They agreed regarding the necessity and applicability of the DRE definition according to the ILAE, the need for an expert panel on epilepsy, specialist epilepsy clinics, and clinical epilepsy units stratified depending on the level of activities they carried out. There was moderate consensus on the resources and activity of the clinical units of reference and there was no consensus on the referral of patients who have suffered an epileptic seizure to an epilepsy clinic. CONCLUSIONS: The expert panel agreed with the definition of DRE according to the ILAE and on referring patients with DRE for a detailed study in an epilepsy clinic or epilepsy clinical unit. They highlighted the need for video-EEG monitoring in the study of patients with DRE and the need to propose other forms of treatment in selected patients.

[Characteristics and indications of gabapentin]. / Características e indicaciones de la gabapentina.

Gabapentin is a drug that shares a similar structure to that of GABA, although its mechanism of action cannot be explained solely by a direct gaba mimetic effect. It is well absorbed when administered orally and displays linear kinetics up to doses of 1,800 mg/day. It is been found to be effective both in added therapy and in mono therapy, and is particularly useful in special populations like the elderly and children, as well as patients suffering from liver diseases. Its safety profile and the absence of interactions make it a suitable drug for the treatment of recently diagnosed epilepsies, both in mono therapy and in bi therapy.

[Prognosis of epilepsy and suppression of treatment. Prognosis of epilepsy]. / Pronóstico de las epilepsias y supresión del tratamiento. Pronóstico de las epilepsias.

OBJECTIVE: On the occasion of the XXXVII Annual Meeting of the Spanish Anti-Epilepsy League we have reviewed the prognosis of epilepsy. DEVELOPMENT: The latest population studies of prognosis indicate that the long-term prognosis of epilepsy is good. Over 80% of these patients experience remission of their illness for at least three years, within nine years of diagnosis. The probability of remission is little influenced by the aetiology of the epilepsy. The mortality of epileptic patients is 2.5-3 times greater than that of the general population, adjusted for age, is markedly influenced by the aetiology and generally occurs within the first few years after diagnosis.

[Monotherapy using gabapentin in epilepsy]. / Monoterapia con gabapentina en epilepsia.

DEVELOPMENT: We report a study of 62 patients with partial seizures treated with gabapentin as monotherapy for two years. After two years 78% of the patients were still on the same treatment. In 67.7% of the patients there was more than 50% reduction in major seizures and 11.1% were free of seizures. There was little difference in efficacy and tolerance when the first and second years were compared. We reviewed the data published in the literature, both in clinical trials and open studies. CONCLUSIONS: Gabapentin is an effective, well tolerated drug used as monotherapy in newly diagnosed epilepsy.

[Preventive and therapeutic attitude in post-traumatic epileptic seizures]. / Actitud preventiva y terapéutica en las crisis epilépticas postraumáticas.

INTRODUCTION AND DEVELOPMENT: Due to the vast number of different circumstances surrounding them, the frequency with which post traumatic epileptic seizures occur varies greatly from study to study. Immediate and early epileptic seizures, within a week of the traumatism having taken place, are usually of little importance as regards the risk of post traumatic seizures. The most important factors governing the presentation of post traumatic seizures have to do with the seriousness of the injury, the extension of the brain tissue that is affected and the penetrating nature of the brain traumatism. CONCLUSION: Although antiepileptic medication significantly reduces the risk of early seizures from occurring, a review of well designed clinical trials has found no evidence that these drugs reduce the morbidity and mortality associated with head injuries, or the appearance of late seizures.

[Cerebrovascular disease in young adults. A study of its course in 167 patients]. / Enfermedad vascular cerebral en el adulto joven. Estudio evolutivo en 167 pacientes.

INTRODUCTION: Few studies have been made of the prognosis of ictus in the young adult. The objective of this paper is to study the short term evolution of 167 patients, aged between 15 and 45 years, with cerebral vascular disease. MATERIAL AND METHODS: Since 1986 a protocolized study has been made of all patients aged between 15 and 45 who were admitted to the Neurology Department of the Hospital General Universitario in Valencia for a cerebral vascular incident. The results obtained up to 1993 have been recorded in a data base. In this paper the demographic data and information as to intrahospital evolution have been used with the Canadian, modified Rankin and Barthel Scales in the various ictus groups. RESULTS: 28.7% of the patients were AIT and 71.3% were diagnosed as established ictus, of whom 38.8% were haemorrhagic and 61.2% were ischaemic. 29.8% of the HIP, 33.3% of the embolic infarcts and 18.2% of the atherothrombotic infarcts were severely disabled on discharge from hospital. Mortality was 4.2% when AIT were excluded. DISCUSSION: Most studies are basically aetiopathological and much fewer include evaluation of prognosis. In our series, the patients had a satisfactory clinical course and low short-term mortality. As in the other series, the two groups with the worst prognosis were the HIP and the cardioembolic infarcts. Patients with HSA and HIV made outstandingly good progress.

[Encephalitis caused by Rickettsia conorii without exanthema]. / Encefalitis por Rickettsia conorii sin exantema.

INTRODUCTION: Mediterranean boutonneuse fever, caused by Rickettsia conorii, is an endemic disease in the Mediterranean area. The serious forms of the disease, which include encephalitis, are infrequent but are associated with a high mortality rate. Diagnostic suspicion is backed up by the development of exanthema. We report the case of a patient who developed encephalitis caused by Rickettsia conorii without exanthema. Clinical case. A 27 year old woman who had nauseas, headache, fever, abdominal upset and generalised pain during the days before being admitted to hospital. On the day she was admitted, she noticed reduced strength in the left limbs, together with numbness and pins and needles in the left side of the body. In the casualty department she presented tonic seizures in the left extremities and later generalised tonic clonic seizures. Exploration showed facial paresis and 4/5 hemiparesis on the left side. Complementary tests carried out in casualty, including cerebrospinal fluid (CSF), did not reveal any significant findings. She was admitted after a loading dose of phenytoin. After 48 hours she presented fever and repeated complex partial seizures. A new CSF analysis was normal. She was treated with valproate, clonazepam, ceftriaxone, doxycycline and acyclovir. An electroencephalogram (EEG) showed theta activity in the left centroparietal areas and slow delta waves in the right temporal regions. Magnetic resonance imaging (MRI) of the brain showed contrast enhancement in the meninges. 24 later, due to the frequency of the seizures, phenobarbital and methylprednisolone were added, which enabled the seizures to be controlled. The posterior brain MRI revealed a right parasylvian lesion. Serological Rickettsia conorii IgM +, IgG 1/256 was administered. After eight months, she has presented no seizures or neurological deficit. CONCLUSIONS: There are cases of encephalitis from Rickettsia conorii that can present without exanthema. This means that in endemic areas early treatment with doxycycline could be advisable when faced with encephalitis of unknown aetiology, bearing in mind the high mortality rate that occurs when no early treatment is administered and the good tolerance to doxycycline.

[Bilateral peripheral facial paralysis secondary to Lyme disease]. / Parálisis facial periférica bilateral secundaria a enfermedad de Lyme.

Simultaneous bilateral facial paralisis (SBFP) occurs in 0.3-2% of all facial paralisis. We report a case of SBFP in association with Lyme disease. A review of literature about SBFP is made, studing specially the one caused by Borrelia burgdorferi. We present a diagnostic guideline of SBFP. Suspect diagnosis of Lyme disease is based on clinical and epidemiological criteria. Culture isolation of this bacteria is difficult, therefore serologic testing is required. Neuroborreliosis treatment is intravenous Ceftriaxone or Cefotaxime. Oral Doxycycline is useful in the treatment of neuritis without central nervous system involvement.

Guía oficial de la Sociedad Española de Neurología de práctica clínica en epilepsia / The Spanish Neurological Society official clinical practice guidelines in epilepsy

Las anteriores Guías oficiales de práctica clínica en epilepsia elaboradas por el Grupo de Estudio de Epilepsia de la Sociedad Española de Neurología (GE-SEN) estaban basadas en la opinión de expertos. La actual Guía de práctica clínica (GPC) en epilepsia se basa en el método científico que extrae recomendaciones a partir de evidencias científicas constatadas. Su principal función es disminuir la variabilidad de la práctica clínica a través de la homogeneización de la práctica médica. Alcance y objetivos: Esta GPC se centra en la atención integral de personas afectadas por una epilepsia, como síntoma principal y predominante, independiente de la edad de inicio y ámbito asistencial. Metodología: 1) Constitución del grupo de trabajo integrado por neurólogos del GE-SEN, con la colaboración de neuropediatras, neurofisiólogos y neurorradiólogos; 2) determinación de los aspectos clínicos a cubrir: diagnóstico, pronóstico y tratamiento; 3) búsqueda y selección de la evidencia científica relevante; 4) formulación de recomendaciones basadas en la clasificación de las evidencias científicas disponibles. Resultados: Contienen 192 recomendaciones. El 57% son de consenso entre autores y editores, como consecuencia del desconocimiento en muchos campos de esta patología. Conclusiones: Esta GPC, en epilepsia, con una metodología formal y rigurosa en la búsqueda de evidencias explícitas donde ha sido posible, formula recomendaciones extraídas de las mismas. En este artículo incluimos el capítulo de la GPC dedicado a situaciones de urgencia en crisis epilépticas y epilepsia, que pueden presentarse como una primera crisis epiléptica, una evolución desfavorable en un paciente con una epilepsia conocida o en su forma más grave como un estado epiléptico

Previous Official Clinical Practice Guidelines (CPGs) in Epilepsy were based on expert opinions and developed by the Epilepsy Study Group of the Spanish Neurological Society (GE-SEN). The current CPG in epilepsy is based on the scientific method, which extracts recommendations from published scientific evidence. A reduction in the variability in clinical practice through standardization of medical practice has become its main function. Scope and objectives: This CPG is focused on comprehensive care for individuals affected by epilepsy as a primary and predominant symptom, regardless of the age of onset and medical policy. Methodology: 1. Creation of GE-SEN neurologists working group, in collaboration with Neuropediatricians, Neurophysiologists and Neuroradiologists. 2. Identification of clinical areas to be covered: diagnosis, prognosis and treatment. 3. Search and selection of the relevant scientific evidence. 4. Formulation of recommendations based on the classification of the available scientific evidence. Results: It contains 161 recommendations of which 57% are consensus between authors and publishers, due to an important lack of awareness in many fields of this pathology. Conclusions: This Epilepsy CPG formulates recommendations based on explicit scientific evidence as a result of a formal and rigorous methodology, according to the current knowledge in the pre-selected areas. This paper includes the CPG chapter dedicated to emergency situations in seizures and epilepsy, which may present as a first seizure, an unfavorable outcome in a patient with known epilepsy, or status epilepticus as the most severe manifestation

[Drug regimens in patients with medication-resistant epilepsy in neurology and epilepsy outpatient departments in Spain]. / Pautas terapéuticas en el paciente con epilepsia farmacorresistente en consultas ambulatorias de neurología y epilepsia en España.

INTRODUCTION: About 30% of epileptic patients suffer from drug-resistant epilepsy (DRE). Quality of life is worse and costs are higher than in controlled epilepsy. One of the aims of the LINCE study was to assess the prevalence of DRE in epilepsy-specialized and general neurology clinics in Spain and the clinical management of these patients in routine clinical practice. PATIENTS AND METHODS: Cross-sectional, retrospective study to evaluate clinical prevalence and cost of DRE in Spain. Every participant neurologist assessed the percentage of DRE among the first 40 patients with diagnosed epilepsy seen. Patients of both sexes, older than 18 years were recruited. Their treatment before and after DRE diagnosis was analyzed. RESULTS: DRE prevalence in Spain is 22.7% (36% in epilepsy-specialized and 18.5% in neurology clinics; p < 0.0001), with no differences between genders. More than 50% of these patients have hardly achieved a secondary education and only 44% are employed. The most frequent drugs used after DRE diagnosis are lamotrigine (33.5%), levetiracetam (32.4%), carbamazepine (31.9%) and topiramate (25.8%) in various combinations, but the highest efficacy (equal or more than 50% seizures reduction) is obtained with pregabaline (53.1%), oxcarbazepine (50.6%) and levetiracetam (49.5%) and topiramate (48%). CONCLUSIONS: 22.7% of epileptic outpatients in Spain are diagnosed with DRE in clinics of neurology. These will require certain social interventions and greater use of health resources, including treatment with more appropriate AEDs. Pregabaline, oxcarbazepine, levetiracetam and topiramate are among the most effective AEDs in this type of patients.

[Methods for diagnosing seronegative myasthenia gravis]. / Métodos diagnósticos de la miastenia grave seronegativa.

INTRODUCTION: A peculiar feature of seronegative myasthenia gravis is that it presents negative acetylcholine-receptor antibodies; determination of muscle-specific receptor tyrosine kinase (MuSK) antibodies defines a subgroup of patients with generalised myasthenia gravis with certain clinical and neurophysiological peculiarities. DEVELOPMENT: Its diagnosis requires the presence of weakness with fatigability, determination of positive anti-MuSK antibodies and alterations in neurophysiological testing of the neuromuscular junction. It is usually more serious and has a poorer prognosis than the seropositive forms, develops in an acute or subacute manner, and the neurological deficit predominates in the facial, bulbar and respiratory muscles. CONCLUSIONS: Titration of the anti-MuSK antibodies and conducting neurophysiological tests, especially jitter assessment using single-fibre electromyography in clinically deficient muscles, are not only necessary for an early diagnosis of these clinical forms, but also so as to be able to carry out an objective evaluation of the clinical progression and response to treatment.

[Pregabalin. A new treatment for neuropathic pain]. / Pregabalina. Un nuevo tratamiento para el dolor neuropático.

Neuropathic pain is a condition affecting a significant proportion of the world's population. Many therapeutic drugs have been used. They achieve less than satisfactory results and are associated to common side effects that affect the daily life of patients. Pregabalin is a new drug that has been shown to be effective for treating partial epilepsy and peripheral neuropathic pain in clinical trials. It is a structural, but not functional, analogue of GABA. It acts as a ligand of the alpha2-delta subunit, a protein associated to the voltage-dependent calcium channels. Modulation of these channels decreases calcium entry into nerve endings, resulting in a decreased release of several excitatory neurotransmitters. Pregabalin had a linear pharmacokinetics with little variability between the different subjects. It does not bind to plasma proteins, has no liver metabolism, and is excreted trough the kidneys. Few interactions with other drugs may be expected based on these characteristics. In clinical trials, pregabalin has been shown to be effective in postherpetic neuralgia and painful diabetic neuropathy at doses ranging from 150-600 mg/day. The analgesic effects of pregabalin occur in the first few days of treatment and are sustained over time. Side effects are few; most are transient and well-tolerated by patients, and the treatment discontinuation rate is minimal.

[Reintervention in gliomas: the necessity of nuclear magnetic resonance]. / Reintervención en gliomas: necesidad de la resonancia nuclear magnética.

The reoperation of patients with recurrence of cerebral glioma is a technique offering survival with a good quality of life. The accepted criteria are a Karnofski index until reoperation greater than or equal to 70, young age, and a favourable histologic grade of tumor. NMR offers better sensitivity than other neuroimaging techniques for the detection of tumoral extension, local and at a distance, and allows a good tumoral resection. We report a patient with recurrence of a cerebral astrocytoma grade II with the criteria for reoperation, but when we performed NMR a dissemination of the tumor to the posterior fossa was seen, and reoperation was consequently counter-indicated. We discuss the mechanism of the extension of cerebral gliomas, the value of neuroimaging techniques and the role of reoperation in this context. We consider it necessary to perform NMR prior to reoperation in this special group of patients with a cerebral glioma recurrence.

Validación en castellano de un cuestionario breve útil para cribado epidemiológico de epilepsia en España: Cuestionario EPIBERIA / Validation of a short useful questionnaire in Spanish for the epidemiological screening of epilepsy in Spain. EPIBERIA Questionnaire

Introducción: Existe una importante laguna de conocimiento sobre la epidemiología de la epilepsia en los países de la cuenca mediterránea. El grupo EPIBERIA nace con el objetivo de promocionar la realización de estudios epidemiológicos en este ámbito, capaces de paliar esta situación. El presente trabajo aborda la validación de un cuestionario breve de cribado de pacientes con epilepsia en población general. Métodos: Se seleccionó un cuestionario de origen anglosajón validado en inglés por el grupo de Ottman. Fue traducido, modificado para adaptarlo a las características de la población española y administrado a una muestra de 200 pacientes (93 epilépticos y 107 controles no epilépticos), extraídos de manera consecutiva de 5 unidades de epilepsia dispersas por España. Ambos grupos fueron homogéneos en variables demográficas y el grupo de control fue representativo de la población general. Se realizó una estimación de la sensibilidad (S), la especificidad (E), los valores predictivos positivos (VPP) y los valores predictivos negativos (VPN) para cuatro diferentes criterios de corrección del cuestionario. Resultados: Se obtuvieron una sensibilidad del 100% y una especificidad del 74,77% para el criterio menos riguroso y una sensibilidad del 94,62% y una especificidad del 99,07% para el criterio más estricto de corrección del cuestionario. Los VPP variaron entre el 7,48% en el primer supuesto y el 69,49% en el segundo, asumiendo una prevalencia pretest para la epilepsia del 2%. Conclusiones: El cuestionario EPIBERIA es un instrumento válido como cuestionario de cribado de epilepsia en la población general en castellano en España(AU)

Introduction: There is a major gap in knowledge about the epidemiology of epilepsy in Mediterranean countries. The EPIBERIA group was formed with the aim of promoting the conducting of epidemiological studies in this area in order to improve this situation. This paper deals with the validation of a brief questionnaire for screening of patients with epilepsy in general population. Methods: We selected an English language questionnaire previously validated by the Ottman group. It was translated, modified to suit the characteristics of the Spanish population, and administered to a sample of 200 patients (93 epileptics and 107 non-epileptic patient controls) sampled consecutively from 5 Epilepsy Units scattered throughout Spain. Both groups were homogeneous in demographic variables, and the control group was representative of the general population. Results: We obtained a sensitivity of 100% and a specificity of 74.77% for the less rigorous correction criteria of the questionnaire, with a sensitivity of 94.62% and a specificity of 99.07% for the most stringent ones. The positive predictive values (PPVs) ranged from 7.48% for the first case to 69.49% in the second, assuming a prevalence for epilepsy of 2%. Conclusions: The questionnaire EPIBERIA is a valid Spanish tool for epilepsy screening of epilepsy in the general population in Spain(AU)

Consenso de las Recomendaciones de Actuación diagnóstica y Terapéutica sobre Epilepsia resistente a fármacos antiepilépticos en España (Consenso RATE-España) / Consensus-recommended diagnostic and therapeutic guidelines for drug-resistant epilepsy in Spain (Consenso RATE-España)

Objetivo: Conocer la opinión de un colectivo de expertos en epilepsia y elaborar un consenso sobre la definición de epilepsia resistente a fármacos (ERF) según la Liga Internacional Contra la Epilepsia (ILAE) y los distintos niveles asistenciales al paciente con ERF en España. Material y métodos: El estudio fue realizado utilizando el método Delphi, mediante dos rondas sucesivas de cuestionarios. Un comité científico confeccionó un documento preliminar y catorce preguntas relacionadas y fueron remitidos por correo electrónico al panel de expertos. Se incluían ítems relacionados con el concepto de ERF, niveles asistenciales e itinerario entre dichos niveles de los pacientes con ERF. Resultados:Contestaron el cuestionario 41 expertos. Se alcanzó acuerdo sobre la necesidad y aplicabilidad de la definición de ERF según la ILAE, necesidad de la existencia del experto en epilepsia, consulta específica de epilepsia y unidades clínicas de epilepsia con diversa estratificación, según la graduación de actividades que se realicen. Existió moderado consenso con la dotación y actividad de las unidades clínicas de referencia y no hubo consenso sobre la remisión de pacientes que han presentado una crisis epiléptica a una consulta de epilepsia. Conclusiones: El panel de expertos estuvo de acuerdo con la definición de ERF según la ILAE y en remitir a todo paciente con ERF a un estudio pormenorizado a una consulta de epilepsia o unidad clínica de epilepsia. Se resalta la necesidad de la monitorización vídeo-EEG en el estudio del paciente con ERF y el proponer otras formas terapéuticas en pacientes seleccionados (AU)

Objective: To ascertain the opinions of an Epilepsy Expert Group and prepare a consensus document on the definition of drug-resistant epilepsy (DRE) according to the International League Against Epilepsy (ILAE) and the different healthcare levels for the patient with epilepsy in Spain. Material y methods: The study was conducted using the Delphi method, by means of successive rounds of questionnaires. A scientific committee prepared a preliminary document and fourteen associated questions, which were sent by e-mail to the panel of experts. They included items related to the concept of DRE, health care levels and the route between these levels for patients with DRE. Results: A total of 41 experts answered the questionnaire. They agreed regarding the necessity and applicability of the DRE definition according to the ILAE, the need for an expert panel on epilepsy, specialist epilepsy clinics, and clinical epilepsy units stratified depending on the level of activities they carried out. There was moderate consensus on the resources and activity of the clinical units of reference and there was no consensus on the referral of patients who have suffered an epileptic seizure to an epilepsy clinic. Conclusions: The expert panel agreed with the definition of DRE according to the ILAE and on referring patients with DRE for a detailed study in an epilepsy clinic or epilepsy clinical unit. They highlighted the need for video-EEG monitoring in the study of patients with DRE and the need to propose other forms of treatment in selected patients (AU)