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This page has moved. Click here to view. Seizure DisordersSeizure disorders are a common problem in medicine, and the internist often plays an important role in the diagnosis, initiation of therapy, and long-term management. The physician must rely on behavioral manifestations to make the diagnosis, yet it is often difficult to distinguish epileptic from nonepileptic behavior. A seizure is defined as an "episodic and paroxysmal change in behavior" usually associated with an alteration in or loss of consciousness. It can be precipitated by a variety of systemic pathophysiological processes such as fever, or by metabolic derangements such as hypoglycemia or toxic reactions seizure disorders, epilepsy, epelepsy, epileptic, epeleptic. Epilepsy is characterized by recurrent paroxysmal abnormalities in brain function associated with abnormal electrical discharges from neuronal aggregates. Epileptic seizures are usually brief and self-limited. In contrast to nonepileptic seizures, the source of an epileptic seizure is within the In terms of both its physical and psychological effects and its associated social stigma, epilepsy can be extremely disabling. For example, seizures may prevent an epileptic patient from driving a car or piloting an aircraft and also present special problems during pregnancy. Management is often challenging, because an individual patient may require different types of treatment at different times, and because inappropriate therapy may actually worsen the Classification of epileptic seizures Generalized seizures (convulsive or nonconvulsive)
Partial seizures (focal, local)
In order to classify seizure disorders, the physician should carefully question the patient about his or her state of consciousness at the time of the seizure. If the patient remains conscious at the onset of the episode, the seizure is classified as "partial;" if the patient loses consciousness with no warning the seizure is "generalized," or "secondarily generalized" if an aura precedes the loss of Once the seizure has been classified, appropriate additional tests can be selected. For strictly generalized seizures, the physician should evaluate the patient for metabolic disorders, including hyponatremia, hypokalemia, hypocalcemia, and hypoglycemia, as well as withdrawal from alcohol or other drugs. In the adult population, de novo generalized seizures nearly always have a metabolic origin. Since some apparently generalized seizures are actually secondarily generalized, all adult patients should be evaluated for The incidence of partial seizures is very high in adults. In such cases, the physician should rely on CT or MRI to detect the associated malformation, tumor, or other lesion. Although it was once believed that patients should not be examined immediately after a seizure because the findings would be meaningless, in fact the opposite is true. Patients should always be examined after a seizure to detect any evidence of asymmetry--for example, weakness or twitching that is more pronounced in on arm than the other. Such evidence would indicate a focal rather than a generalized seizure. Since patients often have preconceived notions about the type of epilepsy they have, the physician should always ask for a detailed description of the seizures rather than accepting the patient's reported "diagnosis" or accepting it at face value. Patients often mistakenly assume that "petit mal" simply means a relatively minor seizure and that "grand mal" means a major seizure. However, the Generalized Seizures Although there are seven distinct types of generalized seizures, the events are usually classified into three major groups: major motor seizures, absence seizures, and minor motor seizures. Grand Mal (Tonic-Clonic or Major Motor) Seizures Grand mal seizures are the most common type of generalized seizure; they also occur when a partial seizure becomes secondarily generalized. In a purely generalized grand mal seizure, the first event is loss of consciousness; the patient will be unaware of what has happened. The second event is the tonic stage, characterized by contraction of the skeletal muscles, extension of the axial musculature, upward deviation of the eyes, and paralysis of the respiratory muscles due to thoracoabdominal contractions. This stage is brief, ranging from only about 3 seconds to a maximum of 30 seconds, although it may seem longer because of its dramatic appearance. The most striking feature is extension of the upper and lower extremities into a semi-opisthotonic posture. Sudden spasm of the respiratory muscles results in forced exhalation, which may sound like a scream--the so-called epileptic cry. Although contraction of the respiratory muscles causes the patient to stop breathing, it is not cause for concern, since the tonic stage lasts only a few seconds. As the muscles of mastication go into spasm, the patient may bite down hard. Contrary to popular belief, the patient will not swallow Absence Seizures The second group of generalized seizures, which includes petit real, is referred to as absence seizures. Absence seizures occur mainly during childhood and are rare after puberty. They are characterized by the arrest or suspension of consciousness for 5 to 10 seconds. Although a mother might say that her son appears healthy, and may not notice the typically brief seizures, the child's teacher will report that the child stares absently for short intervals throughout the day. Without treatment, petit mal seizures occur about 70 to 100 times per day, and such frequent blackouts can Once you have seen a petit mal attack, you will never forget it. The child will seem to be looking straight through out. Other signs include rhythmic blinking (at a rate of three blinks per second) and rudimentary motor behaviors called automatisms, which also occur in adult temporal lobe epilepsy. Petit mal epilepsy is the easiest seizure disorder to diagnose because of its pathognomonic EEG--a spike-and-wave pattern that occurs Minor Motor Seizures The most common types of minor motor seizures are myoclonic and akinetic seizures. Although these seizures usually occur in childhood, adults may sometimes experience them. Myoclonic seizures are characterized by sudden, brief muscular contractions that may occur singly or repetitively. One type of myoclonic epilepsy of childhood is West Syndrome or infantile spasms, which typically appear at about 6 months of age and consist of sudden abduction of the upper extremity and flexion of the hip and knees. This disorder has a poor prognosis in terms of both intellectual development and long-term survival. Myoclonic seizures may also occur in adolescents with gray matter disease and in adults with viral infections such as encephalitis. Unfortunately, these seizures will probably become more common in the years ahead as a result of the increasing prevalence of infections due to the human immunodeficiency virus (HIV); they may also occur in association with Unlike myoclonic seizures, akinetic seizures are characterized by a loss of muscle tone. The appearance depends on the muscles affected. "Head bobbing" occurs if the neck loses muscle tone, "bending seizures" occur if the upper extremities are affected, and "drop attacks" occur if the lower extremities are involved. However, it is much more common for children to faint than to have akinetic seizures. Although not diagnostic, the EEG is often helpful in identifying akinetic seizures. A typical pattern consists of Partial Seizures As described above, partial seizures follow Jackson's focal model of epilepsy and are associated with brain lesions. These disorders are usually classified as either simple or complex, depending on whether or not consciousness is affected. Simple Partial Seizures In a simple partial seizure, consciousness is maintained. Since much of the motor cortex is devoted to controlling the face and hands, focal motor seizures most commonly affect these parts of the body. Motor movements may spread along the body, usually starting the hands and then affecting other areas, such as the face and upper half of the body. This is known as the "Jacksonian march." (There is almost never movement of the hip or trunk.) Motor seizures may also occur when the lesion (particularly a tumor) affects the Sylvian seizures are benign motor seizures that involve the tongue and may lead to aspiration. They are seen in adolescents, usually at night, and generally disappear once the child reaches adulthood. Although the seizure itself is benign, the potential for fatal aspiration makes it essential to diagnose and treat this condition appropriately. Fortunately, Sylvian seizures are easily controlled with Simple partial seizures also include a large subgroup of sensory seizures that can sometimes be difficult to diagnose. The vertiginous seizure, originating in the temporal lobe, is probably the most common type of sensory seizure; unfortunately, dizziness has a broad differential diagnosis. Somatosensory seizures are usually described as a tingling feeling (paresthesia) or a sensation of heat or water running over the affected area; this sensation may spread rapidly from one body part to another. Rarely, a patient will report pain or a burning sensation as well as various auras. Complex Partial Seizures These are the most common types of seizures seen in adult medicine. They are characterized by an alteration of consciousness as well as other complex manifestations, and are also the most difficult to diagnose and treat. Patients may experience any or all of four symptom types: psychomotor, psychosensory, cognitive, and affective. Psychomotor symptoms, or "automatisms," may take the form of simple vegetative movements or complex actions, such as disrobing. The most common automatisms are oral and buccal movements, such as lip smacking, licking, or chewing, and the picking behavior sometimes seen in patients with dementia. In some cases, these individuals may pick at their skin to the point of maceration. Walking is one of the most interesting automatisms that may occur during a complex partial seizure. The physician should not attempt to prevent such behavior during a seizure, because the patient may become violent if restrained. When questioned about their behavior, patients often say they have the urge to leave their present location, and some may drive off or go to the bus station or airport out of a desire to travel. Psychomotor symptomatology also includes staring Epilepsy and Behavior The issue of epilepsy and behavior presents two distinct complex and difficult management problems: (1) diagnosis and management of cognitive' and behavior changes in patients with different types of epilepsy, and (2) diagnosis and management of patients presenting with behavioral symptoms or symptom complexes akin to those seen in epileptic patients but without classical ictal or electroencephalographic (EEG) manifestations of seizures. The latter has been referred to as temporolimbic dysfunction, as the manifestations of these symptoms and symptom complexes are similar to those described in the literature as being associated with complex partial epilepsy and/or focal lesions in the temporal lobe, frontal lobe, the limbic system, and their connections. Although these problems have been recognized since antiquity, and have been the subject of numerous anecdotal reports and small and large prospective and retrospective studies, for a number of reasons, including the Classification of Behavioral Changes Many recent studies have utilized psychiatric classifications of disease to address these behavioral manifestations. Although the symptoms seen in patients with epilepsy or temporolimbic dysfunction do not exactly correspond to the criteria set for these diagnoses in the different versions of the Diagnostic and Statistical Manual, this classification offers a practical model for the practicing clinician. The major categories are as follows: (1) Cognitive disorders (disorders of attention, memory, and learning) (2) Psychoses (ictal, interictal, and forced normalization) (3) Affective disorders (depression, mania, and bipolar symptoms) (4) Anxiety disorders (panic attacks and phobias) (5) Personality disorders (hypergraphia, hyperreligiosity, viscosity, altered sexuality, and aggressivity) (6) Pseudoseizures (somatoform disorders and conversion) (7) Hypothalamic disorders (neuroendocrine disorders and eating disorders (anorexia) Symptoms in each one of these categories can be seen in different stages in relationship to the seizure. Cognitive Disorders Both in the pediatric as well as the adult population, major issues of management related to cognitive difficulties are raised. Complaints are primarily of attention and concentration, and memory problems. As with other symptoms, in the evaluation of cognitive disorders, multiple factors must be considered: biologic factors (cognitive function as a result of the site of the original lesion and/or as a result of clinical and subclinical seizures); psychiatric factors (as a result of affective disorders, primarily depression); iatrogenic factors (side effects of antiepileptic medication); and social factors (secondary to lack of educational opportunities and school environmental acceptability of the seizure patient). For the younger patient in school, issues surrounding learning can be evaluated by direct contact with the school or the school psychologist, although many studies have shown reduced global intelligence in patients with epilepsy. This is certainly not tree for all forms of epilepsy. Earlier age of onset of seizures and frequency of generalized seizures have been correlated with reduced intelligence quotient (IQ). Neuropsychological testing, specifically Wexler Intelligence Scale for Children and Wechsler Adult Intelligence Scale for the older patient are the two most commonly-used tests in the evaluation of these patients. Memory disorders are the most common cognitive complaint of patients. Laterality has been considered, although most patients with memory complaints show bilateral-temporal foci; as expected, problems with verbal memory is more prominent in patients with left temporal lesions. In-patients who complain of memory problems, the EEG is helpful to rule out the possibility of frequent subclinical discharges. Sedation and cognitive difficulties secondary to anticonvulsant drags should also be considered. Psychosis The oldest, and one of the most controversial, correlations of abnormal behavior in epilepsy is with psychosis. Many investigators have questioned the correlation between seizures and psychotic symptoms. A number of studies, however, have shown an unequivocal increase in the prevalence of psychosis among epileptic patients. To distinguish the behavioral abnormality of interictal psychosis from functional psychosis, the term schizophrenia-like psychosis of epilepsy has been used. Certain findings have been considered to be more common among patients with epilepsy who show psychosis. These are left-handedness or ambidexterity, left-sided or bilateral temporal foci, left-hemisphere tumors or other Anxiety Disorders Ictal fear is one of the most common symptoms of complex partial seizures. When present, it has been associated with increasing prevalence of interictal behavioral disorders and psychopathology. Prodromal anxiety is also quite common. Prolonged periods of heightened anxiety is seen in the postictal period. Interictally, patients report, anxiety as frequently as depressive episodes. Panic attacks also occur with greater frequency among patients with epilepsy, and are clinically difficult to distinguish from complex partial seizures. Many studies have tried to distinguish between the two disorders. Hyperventilation, which may occur with both disorders, may result in symptoms in patients with panic that one usually Affective Disorders As in the other behavioral manifestations, depression in epilepsy is multifactorial. Ictal depression is usually sudden in onset and resolves spontaneously. However, both prodromal and postictal depression have been reported to last over 2 or 3 days. Interictal depression is seen in association with the other interictal disorders, and the prevalence seems to be higher among patients with complex partial seizures, with a suggestions of a predominance of left temporal focus on EEG. The issue of suicide and epilepsy has received much attention in the literature. Studies claim that the rate is 5 to 25 times higher than in the general population. These patients usually overdose on anticonvulsant drugs. A number of factors should warn of increased risk of suicide, especially (1) family history of depression, (2) presence of interictal psychosis, (3) past history of repeated suicide attempts, and (4) left-sided lesions. Mania is not uncommon among patients with epilepsy. Mostly, patients exhibit hypomanic episodes, sometimes referred to in the literature as Personality Disorders The issue of interictal personality disorders has been the subject of much controversy. The diagnosis is difficult clinically, and standard neuropsychological tests for personality disorders, such as the Minnesota Multiphasic Personality Inventory, fail to measure some of the traits known to be associated with epilepsy. Some of these personality characteristics may actually constitute a positive aspect in the life of a patient, like deepened philosophical interests and hypergraphia, while others may be the causes of morbidity and social maladjustment, like altered sexuality, aggressivity, and viscosity. It is also not clear that these symptoms and symptom complexes are not present in all patients with epilepsy, and although primarily associated with complex partial seizures, they are only seen in a small percentage of patients with temporal lobe epilepsy. References to these symptoms have been present in the literature for many years. They became the focus of recent attention since the report of Waxman and Geschwind on hypergraphia in patients with temporal lobe epilepsy. Subsequently, these authors described a symptom complex of varied and interesting personality characteristics, including religiosity, deep concern with religious and philosophical issues, feelings of deepened emotionality, hyposexuality, tendency to adhere to certain Hypergraphia As opposed to disorders of spoken language, disorders of. writing are relatively less-explored in the neurologic literature. The correlation between agraphia and aphasias was made much later than the original descriptions of aphasias. However, disorders of writing in psychiatric disease has been long recognized, specifically, compulsive writing in schizophrenia. Studies comparing hypergraphia in patients with schizophrenia and temporal lobe epilepsy have shown a greater prevalence of this symptom among patients Religiosity Commonly associated with hypergraphia, an unusual and deep interest in religion has been described in patients with complex partial seizures. Ictal religious auras and more prolonged feelings of ecstasy associated with religious aspects have been reported in the prodromal phase and during ictus. Interictal symptoms have been described--during times of increased seizure frequency and also in periods of forced normalization- as sudden religious conversions, and periods of heightened interest in religion in patients Viscosity Patients with temporal lobe epilepsy have been reported to have a tendency to engage in long conversations and verbal exchanges, showing an inability to terminate and perceive messages and cues for termination of such exchanges from others. In certain cases, the speech may be without informational content, and circumstantially has been described. Viscosity has been noted to be more prevalent among patients with left temporal Altered Sexuality Hyposexuality is common among patients with epilepsy. It is of interest, however, that unless the physician inquires, patients usually exhibit a lack of concern and do not complain. Both female and male patients report not only lack of sexual activity, but also reduction in masturbation and sexual fantasy. The prevalence of interfertility is higher among epileptic patients, and in males with frequent seizures, impotence has been reported, with improvement in both drive and potency after anticonvulsant therapy and after lobectomy. Females report failure to reach orgasm; however, this may be associated with the sue of some anticonvulsant, particularly barbiturates and benzodiazepines. Hypersexuality has also been reported, particularly in temporal lobe epilepsy. Reports of exhibitionism, masochism, transvestitism, and fetishism have all Aggressivity The issue of aggression and epilepsy has received a great deal of attention, both in the early literature and in the most recent studies. In the prodromal stage, most patients and their families report increased irritability and, at times, explosive behavior, but this is quite different from the more common reports of rage and explosive behavior seen during the ictus or in the immediate postictal period usually associated with restraining the patient during motor automatisms. The latter are usually nondirected and brief, and the patient may be amnestic for these events. However, The issue of ictal aggression in epilepsy has been the subject of detailed review by the Committee on Violence and Epilepsy, which found ictal aggression to be extremely rare. Self-mutilatory behavior and suicidal attempts by violent means have been seen during ictus and postictally, particularly in temporal lobe epilepsy, but these are seen less frequently in epileptics than among patients with psychosis. EEG studies in Pseudoseizures The presence of psychogenic seizures in patients with epilepsy, especially those with onset in childhood, has been reported in both generalized as well as partial and complex partial seizures. This presents not only a diagnostic difficulty but produces problems with management specifically leading to polytherapy in patients who report continuation of seizures despite adequate control of epileptic fits. Many recent reports have tried to outline clinical means of distinguishing pseudoseizures from epileptic fits. These have been aided by the use of closed-circuit TV monitoring now available in most EEG laboratories. Behavioral seizures should be suspected when patients with frequent daily seizure episodes show persistently normal EEG findings, and when the patient reports frequent seizures but this does not correspond to the family's report of frequency of seizures. In generalized seizures, atypical movements, such as alternating Evaluation Electroencephalography EEG remains the mainstay of evaluation of patients with epilepsy, although interictal EEG, if positive, can only be supportive of the diagnosis. Presence of epileptiform abnormalities can be quite helpful. A normal EEG does not rule out correlation between behavior and seizures, as most mesial temporal loci cannot be seen on a regular surface EEG. However, caution must also be used in overinterpreting some of the atypical findings seen in EEG, which in large normal studies have been found to be present in patients with no complaints of seizures or behavioral disorders. In this regard, findings of 14 and 6 positive spikes and psychomotor variants and benign epileptiform transience of sleep, which previously were considered as signs of abnormality, have now come into question. After sleep deprivation, special EEG electrode placements such as nasopharyngeal electrodes, sphenoidal electrodes, and maxillary electrodes Neuroimaging Neuroimaging studies have been most helpful in the diagnosis of epilepsy, and also have elucidated the changes underlying behavioral aspects. MRI is clearly a preferred technique to computed tomography (CT) scan in the valuation of patients with epilepsy and behavioral disorders. The lack of bony artifact, and the availability of coronal and sagittal sections allow for better evaluation of the temporal lobes. MRI can show us the presence of mass lesions, especially small, low-grade tumors, and small vascular Medical Management of Seizure Disorders Perhaps the first description of an authentic treatment for epilepsy appears in the Book of Mark in the New Testament. Mark describes how Jesus advised a man with falling sickness (epilepsy) to pray for 3 days. For Jesus, prayer also included fasting. When the man prayed and fasted for 3 days, he naturally developed ketosis, which stopped his seizures. Physicians now accept that a "ketogenic" diet--high in saturated fats such as butter and cream--is one of the most effective ways to halt myoclonic and akinetic seizures. Thus, Jesus might be considered to be the world's first epileptologist. Despite this promising beginning nearly 2,000 years ago, the treatment of seizure disorders remained in the Dark Ages until relatively recently. The dramatic seizures and interictal behavior changes, seen particularly in patients with complex partial seizures, may account for the fear and superstitions that have impeded the scientific study of epilepsy. Initially, bromides were used by Sir Charles Lockock to treat catamenial disorders, including epilepsy. In the early 20th century, physicians first recognized the anticonvulsant effects of phenobarbital and later, other barbiturates. Today, phenobarbital is reserved for those epileptic patients who cannot take drugs orally; other than phenytoin and the benzodiazepines, phenobarbital is the only antiepileptic agent that may be given intravenously. Only one other barbiturate, primidone, is still in use because it is effective in treating complex partial seizures.A number of anticonvulsants, in general use for approximately 25-30 years, are now considered to be "standard" anticonvulsants. These include phenytoin (Dilantin), carbamazepine (Tegretol), valproate (Depakote), clonazepam (Klonopin), ethosuximide (Zarontin), phenobarbital (Luminal), and primidone (Mysoline). Since the 1990s, a number of "new" anticonvulsants have become available. These include phosphenytoin (Cerebyx), felbamate (Felbatol), gabapentin (Neurontin), lamotrigine (Lamictal), tiagabine (Gabitril), topiramate (Topamax), and vigabatrin. The following is a brief discussion of each of these anticonvulsants, which are best categorized by their mechanisms of action: Voltage dependent Na+ channel blockers (phenytoin, carbamazepine, lamotrigine, topiramate, valproate: Phenytoin. Phenytoin is indicated in the treatment of partial and generalized seizures. The recommended average dose is 300-400 mg. per day in order to achieve a therapeutic level of 10-20 ug/mL. The benefits of phenytoin include parenteral administration, low-cost per dose, one dose per day (typically), and a well-known mechanism of action. The disadvantages are that there may be undesired cosmetic side effects, non-linear pk, and high-protein binding. Signs of toxicity include drowsiness, ataxia, slurred speech, diplopia, arrhythmias (IV), anemia, secondary SLE, and osteopenia Carbamazepine. Carbamazepine is indicated in the treatment of complex partial seizures. The recommended average dose is 600-1200 mg/day in order to achieve a therapeutic level of 4-12 ug/mL. The benefits of carbamazepine include that its sedative effect and effect on cognition are both mild; it is a mood stabilizer, results in linear pk, has extended release, and its cost per dose is relatively low. The disadvantages of carbamazepine include non-parenteral administration and its potential for multiple drug interactions. Signs of toxicity include ataxia, blurred vision, dizziness, lethargy, bone marrow depression, hepatic and renal enzyme changes. Lamotrigine. Lamotrigine is indicated in the treatment of generalized and partial seizures and Lennox-Gastaut syndrome. The recommended average dose is 200-400 mg/day. The benefits of lamotrigine include linear pk, BID dosing, and the fact that it is beneficial in temporal lobe epilepsy. The disadvantages of lamotrigine include its very high cost per dose, the need for slow titration, and the need for dose modification in patients with hepatic abnormalities. Signs of toxicity include skin rash, which has been found to be benign in approximately 10% of patients and serious in approximately 1% of patients. Topiramate. Topiramate is indicated in the treatment of generalized, partial, and minor motor seizures. The recommended average dose is 400 mg/day. The benefits of topiramate include good renal clearance, minimal protein binding, and BID dosing. A disadvantage is its very high cost. Signs of toxicity include marked cognitive effects and weight loss. Valproate. Valproate is indicated in the treatment of generalized and partial seizures. The recommended average dose is 700-2100 mg/day to achieve a therapeutic level of 50-150 ug/mL. The benefits of valproate include that it is a broad-spectrum anticonvulsant and a mood stabilizer. The disadvantages include: teratogenicity, high-protein binding, multiple drug interactions, weight gain, hair loss, and high cost. Signs of toxicity include gastrointestinal upset, hepatic enzyme changes, tremor, nausea, pancreatitis, and thrombocytopenia. Ca+ channel blocker (Ethosuximide). Ethosuximide is indicated in the treatment of absence seizures. The recommended average dose is 750-2000 mg/day to achieve a therapeutic level of 50-100 ug/mL. The benefits of ethosuximide include its availability in suspension form. The disadvantages include its high cost. Signs of toxicity include gastrointestinal disturbance, drowsiness, ataxia, and bone marrow toxicity. GABA-ergic mechanisms: Enhanced GABA inhibition (benzodiazepines, barbiturates, valproate, topiramate, felbamate).
Felbamate. Felbamate is indicated in the treatment of generalized and partial seizures, infantile spasm, minor motor seizures, and Lennox-Gastaut syndrome. The recommended average dose is 2000-4000 mg/day. The benefits include that it is a broad-spectrum anticonvulsant. The disadvantages include the risk for aplastic anemia (approximately 1/2000), the risk for hepatic failure (approximately 1/5000), and its high cost. Signs of toxicity include insomnia, weight loss, and headaches. GABA-ergic mechanisms: Enhanced GABA release (gabapentin): Gabapentin in indicated in the treatment of generalized and partial seizures. The recommended average dose is 900-2400 mg/day. The benefits of gabapentin include no drug interactions, no hepatic metabolism, and low teratogenicity. The disadvantages include its high cost, dose modification needed with renal patients, and the fact that it is not effective in minor motor seizures. Signs of toxicity include behavior changes, drowsiness, dizziness, and fatigue. GABA transaminase inhibition (vigabatrin) NMDA receptor blockade (felbamate) Management of Generalized Tonic-Clonic Convulsions in Adults In adults who present with a generalized seizure, following careful examination and history-taking, the EEG is the first step in evaluation. If possible, a sleep-deprived EEG (and in cases where the seizures are of doubtful nature, long-term monitoring) is recommended. Usually, a CT scan is done as part of an emergency evaluation. However, the MRI is the preferred neuroimaging study. A lumbar puncture is indicated if infection is in the differential. Phenytoin and valproate are the drugs of choice for the treatment of generalized tonic-clonic convulsions. Both are now available in intravenous form. In oral form, if loading is needed, phenytoin is preferred Management of Absence Seizures Although extremely rare in adults, either valproate or Ethosuximide can be used. Valproate is preferred because in adults tonic-clonic convulsions are associated with these seizures. Of the new anticonvulsants, felbamate, topiramate, and lamotrigine have also been used. Management of Simple Partial and Complex Partial Seizures Carbamazepine and phenytoin are the drugs of choice. However, these patients usually require polytherapy. Of the new anticonvulsants, gabapentin, lamotrigine, and topiramate are in use. However, combinations of phenytoin and carbamazepine with valproate or, particularly, with clonazepam have been most effective in the management of these patients. Management of Epilepsy During Pregnancy All child-bearing-age women should be warned against the teratogenic effects of anticonvulsants. A number of important issues should be discussed with patients. In the presence of anticonvulsants, birth control pills have a higher risk of failure, particularly in drags that induce cytochrome P-450. We regularly advise our patients to use diaphragms in addition to birth control pills. Drugs that do not Management of Interictal Psychosis Treatment of psychosis, whether interictal or ictal and postictal, still requires the use of neuroleptic medication. However, since most neuroleptic drugs are known to induce seizures, there has been a reluctance to treat psychosis vigorously. Haloperidol (Haldol) in doses not to exceed 6 mg/day, and molindone (Moban), not to exceed 225 mg/day, have been helpful. Some reports have suggested that B12 and folate deficiency is seen more frequently among patients with psychosis, and the correction of this should be included in the therapy. Carbamazepine (Tegretol) has Management of Depression and other Affective Disorders in Epilepsy Tricyclic antidepressants have been known to reduce seizure threshold and therefore should be used with caution, although in our experience, in regular therapeutic doses an increase in seizures is not usually seen. Amitriptyline, imipramine, and doxepin have been the most frequently used. Fluoxetine (Prozac) and MAO inhibitors have also been known to produce seizures, and therefore do not necessarily offer a better alternative. Management of Personality Disorders Ictal and postictal sexual symptoms, as well as interictal complaints of decreased libido, seem to improve with anticonvulsant therapy. In patients with hyposexuality, barbiturates and benzodiazepines should be avoided. Marriage counseling, psychotherapy, and group therapy should be offered to the patients. Management of Aggressivity Carbamazepine and clonazepam (Klonopin) have been used in the treatment of interictal aggressivity. We have used propranolol successfully in these patients in addition to an anticonvulsant regimen. When aggressivity has been associated with periods of mania, lithium has also been prescribed. However, lithium levels require careful monitoring in |