Epilepsy : scientific foundations of clinical practice

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Because of the long duration of action, alterations in the GABA-B receptor are thought to possibly play a major role in the transition between the interictal abnormality and a partial-onset seizure. Improving Access to Mental Health Care for Youth with Epilepsy Despite continued progress in the treatment of epilepsy, the psychosocial outcome in adults is reported as poor, even in patients who reach seizure freedom. Properties of the chloride channels associated with the GABA-A receptor are often clinically modulated by using benzodiazepines eg, diazepam, lorazepam, clonazepam , barbiturates eg, phenobarbital, pentobarbital , or the anticonvulsive drug topiramate. Be the first to add this to a list. Of these, 63 CPGs met all eligibility criteria for data abstraction.

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Epilepsy: Scientific Foundations of Clinical Practice

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Epilepsy: Scientific Foundations of Clinical Practice

Gilhus and J. These actions would translate directly into worsening quality of life compared with that without warnings , rapid battery depletion, and unforeseen, possibly deleterious, effects on neural dynamics. For the generic algorithm, a 50th percentile or median filter was chosen, but this percentile value may be changed as needed to enhance detection performance in terms of speed and sensitivity or specificity. How does a median filter work? Unlike a mean or average filter commonly used in seizure detection algorithms that takes into account all values in a distribution e.

This filtering step markedly reduces detections that do not merit issuance of warnings or treatment. There is the ability to deliver therapy in close temporal proximity to seizure onset and to objectively assess efficacy using not only one frequency or rate but three additional relevant variables intensity, duration, and extent of spread.

The results of a clinical trial 5 performed by these authors will be used to illustrate these benefits in detail. For this trial, subjects with localization-related, pharmaco-resistant epilepsies were assigned to two groups based on the results of invasive monitoring. The other group comprised four subjects whose seizures originated independently from both mesial temporal regions and were thus inoperable. This group was also treated with high-frequency currents, but these were delivered to the anterior thalamic nuclei, not to the epileptogenic tissue. Seizure quantification allows precise assessment of the effects of therapy.

Figure 4 compares the intensities and durations of seizures during the control phase blue curve with those treated with different frequencies. Currents at Hz red curve markedly decrease intensity and duration, whereas those at 50Hz green curve increase intensity and duration.

Scientific Foundations of Clinical Practice, 1st Edition

Seizure quantification also uncovers effects of therapy that otherwise are likely to be overlooked. The intensity and duration of seizures stimulated at onset are considerably decreased red curve compared with those in the control blue phase. Note that in this experimental paradigm, 5 stimulation was delivered to every other seizure, and non-stimulated seizures green curve in the experimental phase had lower intensity than those in the control phase but were more intense and longer than those receiving electrical stimulation.

Current clinical practice ignores seizure intensity, duration, and extent of spread and lacks accurate logging of the time between seizures and their frequency of occurrence , variables that are complexly inter-related. For example, electrical stimulation directly to the epileptogenic zone may decrease seizure intensity significantly p A quantitating detection algorithm also allows investigation of the role that circadian rhythms, seizure interdependencies, and different stimulation parameters have on the severity variables seizure frequency, intensity, duration, and extent of spread.

Cardiac-based EKG detection 15 is a promising avenue, especially for seizures originating from mesial temporal and insular regions. Once fully developed, extracerebral seizure detection will expand automated detection and logging, warning, and delivery of therapy possibly to non-refractory subjects. Although in humans the source of these data is likely to be restricted to subjects with pharmaco-resistant seizures, the dynamic knowledge thus accrued may provide insight into questions of central importance to epileptology, such as: Do seizures beget seizures, or is epilepsy a progressive disorder?

Are seizures predictable? If the probability of seizure occurrence and intensity is subject to circadian variations, what factors i. Valid answers to these questions will lay the basis for rational, evidence-based management of epilepsies. Modern clinical epileptology continues to rely solely on utterly inaccurate and incomplete seizure diaries 16,17 to develop and assess therapies.

Electrical current is not the only therapeutic modality amenable to automated contingent delivery. The efficacy of targeted spatially selective delivery of antiseizure compounds and of thermal energy cooling , although technically more demanding and cumbersome than electrical currents, is worth assessing. Automated warning to patients or caregivers is possible only if automated seizure is practicable and may take place at several seizure stages.

The most desirable is that which is issued before the subject loses awareness. Notification that a seizure is occurring, even though the subject may be unaware or unconscious, is useful, especially for the pediatric and geriatric populations and for subjects with nocturnal epilepsies and those who live alone.

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Automated warnings may decrease risk of injury and partly relieve patients and their care-givers from the burden of unpredictability. What about seizure prediction? This valuable aim will take time to bear fruit but should be pursued vigorously for practical and heuristic reasons. An invaluable by-product of attempts to predict seizures is much-needed knowledge about the dynamics of the epileptic brain.