Common Pitfalls in Epilepsy: Case-Based Learning

✍ Scribed by Dieter Schmidt

• Publisher: Cambridge University Press
• Year: 2018
• Tongue: English
• Leaves: 263
• Edition: 1
• Category: Library

✦ Synopsis

Epilepsy is amongst the most frequently encountered of neurological disorders, yet its diagnosis and management is fraught with pitfalls. Issues surrounding differential diagnosis, seizure type, underlying causes, EEG interpretations, treatment options and prognoses can often trip-up clinicians. Common Epilepsy Pitfalls: Case-Based Learning, is a comprehensive guide to anticipating and managing the pitfalls in the diagnosis and management of epilepsy. Real-life cases are presented along with pragmatic recommendations for courses of action that guide the reader through accurate and effective epilepsy diagnosis and treatment. Cases have been chosen to answer key questions such as: the first seizure – is it epilepsy? Which drug? When should stopping treatment be considered? What to do in an epileptic emergency? Containing detailed coverage of psychiatric, social and family issues – and authored by world experts in epilepsy management – this text is invaluable for neurologists, internists, family practitioners and advanced medical students.

✦ Table of Contents

Cover
Half Title
Title page
Imprints page
Dedication
Contents
Preface
Acknowledgments
1 Mistaking Nonepileptic Events for Epilepsy
What are the Pitfalls Involved in This Case for the Clinician?
Differential Diagnosis
Psychogenic Nonepileptic Attacks
Historical Features
Clinical Features of PNEAs
Bizarre Seizures
EEG
Video-EEG Monitoring
Rule of Two: 2 Normal EEGs + 2 Seizures/Week + 2 AED Failures = 85% Positive Predictive Value for PNEA
Treatment
References
2 Mistaking EEG Changes for Epilepsy
Misinterpreted Spells
Does She Have Epilepsy?
Misinterpreted EEG
Does She Have Epilepsy?
What about Her Abnormal EEG?
Diagnosis: Neurocardiogenic Syncope
Specific EEG Changes Mistaken for Epilepsy
Variations of Normal Waveforms
Benign Variants of Uncertain Significance
Artifact
Traps and Pitfalls in Epilepsy
Why the Clinical-EEG Disconnect?
References
3 Radiographic Errors in Epilepsy
MRI
Recommendation
References
4 The First Seizure: Is It Epilepsy?
Seizure Misdiagnosis
What are the Pitfalls Involved in this Case?
Final Diagnosis: Convulsive Syncope
Accurate Seizure Diagnosis
Types of First Seizures
Question: Does He Have Epilepsy?
Classifying First Seizures
Diagnosis: Focal Epilepsy
Evaluating a First Seizure
Neuroimaging
EEG
Treatment of a First Unprovoked Seizure
References
5 Errors in the Diagnosis of Seizure Types and Epilepsy Syndromes
Diagnostic Assessment of the First Seizure
Classification of Epileptic Seizures
The 2010 Classification of Epileptic Seizures
The 2017 ILAE Classification of Epileptic Seizures
Pitfalls in the Diagnostic Assessment of Unequivocally Epileptic Seizures
Pitfall: Underestimating the Difficulty to Accurately Count Seizures in Clinical Practice
Pitfall: Estimating the Duration of Seizures
Pitfall: Mistaking an Absence or a Myoclonic Seizure for a Focal Seizure
Pitfall: Ictal (Seizure) or Postictal Symptoms?
Pitfall: Elementary Ictal Hallucinatory States: Ictal or Postictal or Both?
Pitfall: Prolonged “Postictal” Confusion
Pitfall: Recognize “Postictal” Psychosis
Pitfall: Ictal versus Postictal Behavior in Childhood Epileptic Encephalopathies and Other Encephalopathies
Pitfall: Coma with or without NCSE. Ictal or Postictal?
Take Home Message
Pitfalls: Misdiagnosis of Nonepileptic Seizures as Epilepsy
Mistaking Psychogenic Seizures for Epilepsy
Psychogenic Nonepileptic Seizures
Pitfall: How to Avoid Missing Red Flags for PNES
Pitfall: How to Confirm the Diagnosis of PNES
Management of PNES
Take Home Message
Mistaking Psychiatric Disorders (Other Than PNES) for Epilepsy
Mistaking Non-psychogenic Attacks for Epilepsy
Syncope Mistaken for Epilepsy
Pitfalls in the Diagnosis of Syncope
Non-Psychogenic Attacks Other than Syncope Mistaken for Epilepsy
Take Home Message
Misdiagnosis of Epilepsy in Children
Pitfalls: Misdiagnosis of Epilepsy in the Elderly
How to Prevent Misdiagnosis of Nonepileptic Events as Epilepsy: No Fast and Hard Rules
Classification of Epilepsies
The ILAE Classification Update of 2010
Pragmatic Classification to Avoid Major Pitfalls
Clinically Relevant Pitfalls in the Diagnosis of Epilepsies
Pitfall: Missing the Diagnosis of Autoimmune Epilepsy
References
6 When to Start Treatment?
What a Physician Should Know before Deciding to Start Treatment
Scenario 1: The Decision Not to Start AEDs
Pitfall: Failure to Mention the Limitations of Current Treatment
Pitfall: Failure to Recognize that Not All Patients Need AEDs
Scenario 2: The Decision to Start AEDs in Patients Presenting with a Single Seizure
Are You Aware How Often Seizures Recur after a Single Seizure?
Is Failure to Start Early Treatment Associated with Poorer Long-Term Epilepsy Outcome?
Recommendation
Scenario 3: The Decision to Start AEDs in Patients Presenting after Two or More Seizures
Recommendation When to Start Treatment
References
7 Which Drug is Best?
Integrative Choice of Antiepileptic Drug
The Pitfalls in Finding the Best AED
The Most Common Sources of Pitfalls
Pitfall 2: Are Modern Drugs Generally Preferable over Older Drugs?
What is the Evidence Base for Preferring New over Older Drugs for New-Onset Focal Epilepsy?
Should Old or New Drugs Be Preferred for New-Onset Idiopathic Generalized Epilepsy?
Are Old or New AEDs Preferred for New-Onset West Syndrome?
The Choice of AEDs When Prior Drugs have Failed
Pitfall 1: Failure to Recognize the Risk-Benefit Profile of the Drug for Refractory Epilepsy
Pitfall 2: No Adequate Guidance of Head-to-Head Comparison from Controlled Trials
Pitfall 3: Avoid Less-Often-Used Drugs Unless You are Seeing Many Patients with Uncontrolled Seizures
Pitfall 4: Delayed Referral to a Comprehensive Epilepsy Center if Two Appropriately Selected and Dosed Drugs have not Achie ...
Pitfall 5: Refractory Generalized Epilepsy does Exist!
Pitfall 6: Failure to be Aware of the Best Drug for Lennox–Gastaut and Related Syndromes
Pitfalls in the Choice of Drugs for Children
Pitfall: Is Gene Testing Ready for Prime Time in the Choice of Drugs?
Pitfall: Relying on the Molecular Action of AEDs as a Guide for the Choice of Drugs
Pitfall: Failure to Adapt the Drug Choice to the Individual Patient Profile
Pitfall: Is the Pharmacokinetic Profile Ready for Prime Time in the Choice of an AED?
Take Home Messages
Pitfall: Base Your Choice on the Belief that New AEDs are Better Tolerated or Safer than Older Drugs
Pitfall: Are You Aware of the Limitations of Current Treatment?
Pitfalls in the Development of New AEDs
Summary of Pitfalls in the Choice of Drugs
References
8 How to Optimize Treatment and What can Go Wrong?
Finding the Optimal Dose of AEDs for New-Onset Epilepsy
Pitfall: What to Do If the Lowest Dose Does not Achieve Seizure-Freedom
Pitfall: What to Do If Seizures Persist despite Average Doses of AEDs?
Pitfall: What to Do in a Patient Who is not Seizure-Free and Reports Intolerable Side Effects
Pitfall: How to Avoid Overtreatment
Pitfall: Undertreatment
Pitfall: Is Add-On Therapy Advisable after Failure to Control Seizures with the First AED?
Pitfall: Do I Need to Monitor Treatment with AEDs?
Take Home Messages
Pitfall: Failure to Inform the Referring Physician about Diagnostic or Therapeutic Changes
Pitfall: Failure to Address Special Patient Needs
Pitfalls in the Management of Epilepsy in the Elderly
Pitfall: Diagnostic Errors in Geriatric Epilepsy
Pitfall: Management of Epilepsy in the Elderly
Pitfall: Failure to Recognize Treatment Options for Epilepsy in the Elderly
Pitfall: Failure to Address Issues in Treatment for Epilepsy in Adolescents
Pitfall: Failure to Address Issues in Treatment for Male Epilepsy Patients
Pitfall: Failure to Recognize the Usefulness of Complementary Medicine
References
9 What to Do If Drugs Don’t Work?
Pitfalls: Drug-Resistant Epilepsy: Elusive Definitions and Unclear Mechanisms
Elusive Mechanism(s) of Drug-Resistant Epilepsy
How Many Newly Diagnosed Patients have Drug-Resistant Epilepsy?
Pitfall: Are You Aware of the Most Common Reasons for Drug-Resistance?
Pitfalls in Assessing Drug Response
Pitfall: Recognize Seizure Aggravation as Cause for Drug Failure
Recommendation
Pitfall: Recognize Non-Pharmacological Seizure Precipitation as Cause for Why Drugs Fail
Pitfall: Failure to Recognize the Clinical Importance of Epilepsy Surgery
Resective Surgery
The Evidence
Pitfall: Failure to Recognize the Clinical Potential of Epilepsy Surgery for the Elderly
Recommendation
Pitfall: Failure to Recognize the Clinical Importance of Neurostimulation
Pitfall: Failure to Recognize the Clinical Importance of the Ketogenic Diet
Pitfalls in the Management of Ketogenic Diets for Epilepsy
Pitfall: Know Who Will Likely Benefit from the KD and Who Will Not
Pitfall: Be Aware of Acute Issues during Initiation of the Ketogenic Diet
Pitfall: Be Aware of Chronic Issues with the Ketogenic Diet
References
10 How to Avoid Management Errors
Inadequate Patient Communication
Common Treatment Errors
How to Avoid Medical-Legal Issues
Reference
11 When to Stop Treatment?
Pitfall: The Patient Wants to Continue Treatment Despite the Physician’s Urge to Stop AEDs
Pitfall: Under-Communicating the Risks of Stopping AEDs
Pitfall: Failure to Appreciate that the Individual Outcome of Stopping AEDs cannot be Predicted with Certainty
Pitfall: Failure to Relate the Seizure-Free Period Prior to Stopping with the Seizure Frequency of the Last 12 months
Pitfall: Overstating the Benefits of Remaining on AEDs
Pitfall: Overstating the Benefits of Stopping AEDs
Pitfall: Rapid versus Slow Withdrawal of AEDs of Patients in Seizure Remission
Pitfall: Early versus Late Antiepileptic Drug Withdrawal for Epilepsy in Remission
Pitfall: Stopping AEDs is not Necessarily the End of Treatment
Pitfall: Should Physicians Encourage Seizure-Free Patients to Discontinue AEDs?
Individualize AED Withdrawal in Remission
Pitfall: Failure to Appreciate the Risk of Poor Seizure Control after Relapse
Pitfall: Underestimate the Risk of Relapse after AED Discontinuation in Patients Seizure-Free after Surgery
Background: Why is Stopping AEDs after Entering Remission Fraught with So Many Pitfalls?
Common Scenarios of Stopping AEDs and Their Pitfalls
Pitfall: Stopping One of Two AEDs in Uncontrolled Epilepsy
Pitfall: Stopping AEDs Completely in Uncontrolled Epilepsy
Pitfalls: Stopping AEDs after Misdiagnosis of Epilepsy
References
12 Women with Epilepsy
AEDs and Fertility
Hormonal Influence on Epilepsy
Pitfall: Assuming WWE are 100% Reliable at Planning Pregnancy
Post-Partum Care
References
13 Management of Psychiatric Issues in Epilepsy
Failure to Diagnose
Failure to Treat Depression and Anxiety
Further Reading
14 Management of Emergencies in Epilepsy
Single Seizure
Pitfalls in the Management of a Single Seizure
Medial or Lateral Tongue Bite?
Lower Back Pain Following a Seizure: Vertebral Fracture?
Status Epilepticus
The Evidence
Pitfalls in the Definition
European Federation of Neurological Societies Guideline on the Management of Status Epilepticus
Treatment of Status Epilepticus in Adults: Guidelines of the Italian League against Epilepsy
Treatment of GCSE in Childhood
Observational Evidence for the Use of Drugs not Evaluated in the VA Study
Refractory Generalized Convulsive Status Epilepticus: A Guide to Treatment from Finland
Treatment of Refractory Status Epilepticus in Adults: Guidelines of the Italian League against Epilepsy
Pitfalls in the Management of Status Epilepticus (Box 14.7)
Where Current Status Epilepticus Treatment Fails: Timing is Everything
References
15 Management of Social Issues
Failure to Discuss Driving
Clinical Scenario: Inappropriate Driving
Not Paying Attention to Quality of Life
Clinical Scenario: Impaired Quality of Life due to Poor Knowledge about Epilepsy
Overlooking the Importance of Employment to Patients
Clinical Scenario: Inappropriate Loss of Employment Resulting in Emotional Distress
Further Reading
Index