Monograph: Epilepsy Rajesh Shankar Iyer, Mugundhan Krishnan
INDEX
×
Chapter Notes

Save Clear


MONOGRAPH EPILEPSY
MONOGRAPH EPILEPSY
Editors Rajesh Shankar Iyer MD DM (Neuro) FRCP (Glasgow) Senior Consultant Neurophysician and Epileptologist Kovai Medical Center and Hospitals Coimbatore, Tamil Nadu, India Mugundhan Krishnan MD DM (Neuro) FRCP (Glasgow) FRCP (London) FRCP (Ireland) FACP (USA) FICP Professor and Head Department of Neurology Government Stanley Medical College Chennai, Tamil Nadu, India Foreword BA Muruganathan AV Srinivasan
Jaypee Brothers Medical Publishers (P) Ltd
Headquarters
Jaypee Brothers Medical Publishers (P) Ltd
4838/24, Ansari Road, Daryaganj
New Delhi 110 002, India
Phone: +91-11-43574357
Fax: +91-11-43574314
Overseas Offices
J.P. Medical Ltd
83 Victoria Street, London
SW1H 0HW (UK)
Phone: +44 20 3170 8910
Fax: +44 (0)20 3008 6180
© 2020 Indian College of Physicians, Academic Wing of Association of Physicians of India.
The views and opinions expressed in this book are solely those of the original contributor(s)/author(s) and do not necessarily represent those of editor(s) of the book.
All rights reserved. No part of this publication may be reproduced, stored or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission in writing of the publishers.
All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The publisher is not associated with any product or vendor mentioned in this book.
Medical knowledge and practice change constantly. This book is designed to provide accurate, authoritative information about the subject matter in question. However, readers are advised to check the most current information available on procedures included and check information from the manufacturer of each product to be administered, to verify the recommended dose, formula, method and duration of administration, adverse effects and contraindications. It is the responsibility of the practitioner to take all appropriate safety precautions. Neither the publisher nor the author(s)/editor(s) assume any liability for any injury and/or damage to persons or property arising from or related to use of material in this book.
This book is sold on the understanding that the publisher is not engaged in providing professional medical services. If such advice or services are required, the services of a competent medical professional should be sought.
Every effort has been made where necessary to contact holders of copyright to obtain permission to reproduce copyright material. If any have been inadvertently overlooked, the publisher will be pleased to make the necessary arrangements at the first opportunity. The CD/DVD-ROM (if any) provided in the sealed envelope with this book is complimentary and free of cost. Not meant for sale.
Inquiries for bulk sales may be solicited at: jaypee@jaypeebrothers.com
Monograph: Epilepsy / Rajesh Shankar Iyer, Mugundhan Krishnan
First Edition: 2020
9789386261427
Printed at
Contributors
Editors
Contributing Authors
Foreword
BA Muruganathan
MD FRCP (Glasgow, London, Ireland) FACP (USA) FPCP (Philippines) FICP
Dean, Indian College of Physicians (ICP), 2016–17
Governor Elect, American College of Physicians (ACP) India Chapter
President, Hypertension Society of India (HSI), 2015–16
President, Association of Physicians of India (API), 2013–14
Emeritus Professor, The Tamil Nadu Dr MGR Medical University
Chairman, AG Hospital
Tirupur, Tamil Nadu, India
Epilepsy is one of the most common problems encountered by the practising physician in his day to day practice. There are plenty of problems and pitfalls in the current clinical practice of epilepsy. This results in various errors in the identification, evaluation, and management of this intriguing disease. Epilepsy may be diagnosed in some when they actually do not have the disease and vice versa. The practising clinician is many a time uncertain as to when a diagnostic test is to be done and what is the ideal test for the given candidate. Anti-epileptic drugs may be inappropriately chosen and inadequately administered. Drug resistant epilepsy may not be identified sufficiently early. The benefits of epilepsy surgery are not yet sufficiently recognized and understood by the community level practitioner. Women with epilepsy may not get proper guidance and counseling to handle marriage, pregnancy, and motherhood. The myths surrounding the disease are not making life easier for the unfortunate patient with epilepsy.
The past two decades have seen plenty of developments in the diagnosis and management of epilepsy. Video electroencephalogram is now widely used and helps to separate the mimickers from epilepsy. Various refinements in magnetic resonance imaging techniques have come to precisely identify the seizure focus. The sophisticated investigatory modalities like positron emission tomography and single-photon emission computed tomography are more freely available than before. More centers have come up in India with dedicated care for epilepsy and more epilepsy surgeries are currently being performed.
This monograph edited by Dr Rajesh Shankar Iyer and Dr Mugundhan Krishnan comprehensively covers the clinically relevant and common problem of epilepsy. All the 10 chapters have been carefully chosen addressing the various pitfalls mentioned above. The authors have done a wonderful job by succinctly elucidating the topics making it highly appealing to the practitioner. I am sure this initiative by the editors will bridge the information gap of the treating physician, with regard to epilepsy and help them practice epilepsy in a more evidence based manner. I congratulate Dr Iyer and Dr Krishnan for successfully bringing out this monograph which is a must read for all practising physicians.
Foreword
AV Srinivasan
MD DM PhD (Neuro) DSc FRCP (London) FAAN FIAN
Emeritus Professor
The Tamil Nadu Dr MGR Medical University
President
Indian Academy of Neurology
I am extremely pleased and honored to write this foreword for this easy paced monograph on epilepsy.
I extend my heartfelt congratulations to Dr Rajesh Shankar Iyer, Dr Mugundhan Krishnan, and their colleagues for putting together this brilliant monograph on epilepsy. The topic selection and presentations have been very appropriate and is written in simple prose and presented succinctly touching all the relevant aspects of epilepsy. This provides an excellent introduction to epilepsy of the past, present, and future. The chapters on classification of epilepsy, epilepsy mimics, and diagnosis of epilepsy give an excellent observation sense. An approach to adult with the first unprovoked seizure and women with epilepsy explicitly express the word sense. The sheer brilliance of common sense is exquisitely seen in drug resistant epilepsy and status epilepticus in adults. The clinical sense provided in epilepsy surgery is clear and concise.
I have no doubt that this monograph on epilepsy should be in the bookshelves of every neurophysician, neurosurgeon, physician, and in medical libraries of all institutions of neurosciences.
Preface
Rajesh Shankar Iyer
MD DM (Neuro) FRCP (Glasgow)
Mugundhan Krishnan
MD DM (Neuro) FRCP (Glasgow) FRCP (London)
FRCP (Ireland) FACP (USA) FICP
Epilepsy is a chronic disorder with lot of peculiarities. It is not a joke to live with the fear of getting an attack of seizure any time. One might also get perturbed by the thought of the adverse effects of anti-epileptic drugs taken indefinitely. It is one of those disorders where the quality of life may get severely compromised. It could interfere with driving; adversely affect employment and marriage possibilities. Psychiatric comorbidities are common including disorders of mood and affect. Social stigma and ill-conceived beliefs about the disease make the treatment extremely difficult.
Learning of any disease is incomplete without proper understanding of the history and epilepsy is no exception. The introductory chapter “Epilepsy: Past, Present, and Future” touches upon the past, discusses the present state, and outlines the future prospects for the disease. When dealing with recurrent seizures, one should move from seizure to syndrome, i.e., try and make a syndromic diagnosis. This would enable to choose the appropriate treatment and more importantly prognosticate better. Hence, the various seizures and the syndromes are lucidly brought out in the second chapter, “Epilepsy Classification: Seizures and Syndromes”.
One of the major pitfalls while managing the disease is failure to recognize the nonepileptic conditions. These mimickers are well described in the third chapter “Epilepsy Mimics”. One should take all efforts to avoid this mistake considering the huge psychosocial burden associated with the diagnosis of epilepsy. Proper history and video electroencephalogram recording would help us in this regard. With the advent of technology, the treating physician is now bombarded with an array of investigatory modalities. Which one to choose in which situation is well discussed in the fourth chapter, “Epilepsy Diagnosis”. That these advanced technological initiatives are bound to fail without a proper history taking is emphasized by the author in no uncertain terms.
Dealing with the first episode of seizure is different from that of dealing with recurrent seizures. We are unsure whether it is a one-off incident or there are many more seizures to follow. The guidelines to follow while evaluating and treating the first seizure episode have been discussed in the fifth chapter, “Approach to the First Episode of Seizure”. In the good old days of practice, only phenytoin, phenobarbitone, carbamazepine, and sodium valproate were available for the treatment of epilepsy. Nowadays the market is flooded with newer anti-epileptic drugs, thereby giving the physician plenty of options. On the flip side, more caution need to be exercised in drug selection as one should ensure suitability of the drug for the syndrome. Dose titration should be carefully done as some drugs show adverse effects only with faster titration. One should be aware of the ideal anti-epileptic drug for comorbid medical conditions and the drug interactions. These issues have been well addressed in the sixth chapter, “Epilepsy Pharmacotherapy: The Anti-epileptic Drugs”.
Women suffering from epilepsy have unique issues with regard to marriage, contraception, fertility, and childbearing. You can read the seventh chapter “Epilepsy and Women” to get a good overview as to how to help them through these situations. One of the major challenges while handling epilepsy is the partial or total unresponsiveness to drugs. When seizures do not respond to drugs, the quality of life of the individual and, therefore, of the entire family gets jeopardized. An evidence based approach to drug resistant epilepsy highlighting the latest trends in its management is available in the eighth chapter, “Drug Resistant Epilepsy”.
Status epilepticus is the other major challenge faced by emergency physicians. The outcome in a status depends on the etiology and also on how fast one is able to arrest the seizures and hence it is a medical emergency. Of late, the new entity called super-refractory status has come in vogue wherein the status continues beyond 24 hours and new treatment modalities are being recommended for control of seizures in this situation. The etiology in super refractory status is mostly unknown though autoimmune epilepsy syndromes are being increasingly blamed. I am sure the ninth chapter “Status Epilepticus: The Current Status” would make a very interesting and informative reading.
Epilepsy surgery comes as a boon for those unfortunate patients who fail to respond to drugs but are fortunate to have a surgically remediable syndrome. Only a few with drug resistant epilepsy become eligible for surgery and hence are deemed surgically privileged. Unfortunately, this treatment modality has failed to permeate and reach the masses. Misconceptions persist not only among general practitioners and physicians but even among the specialist population. For all these reasons, epilepsy surgery remains the most underutilized among all the available therapeutic strategies today leaving a big surgical treatment gap in the community. This gap is the difference between the surgically eligible candidates and those who really undergo surgery. This situation is akin to what prevailed in the society three decades ago when cardiac surgery opening the chest wall was introduced as a coronary revascularization technique. It is time the society at large, and the clinician in particular, recognize epilepsy surgery for the appropriately selected candidate as a life changing treatment modality improving the quality of life by leaps and bounds. All the various surgical treatments currently available are discussed in the last chapter, “Epilepsy Surgery”.
It is thus clear that epilepsy means more than recurrent seizures. When dealing with such a chronic disorder of wider ramifications, the physician should be well equipped in handling the vagaries. We have conceived the chapters and brought out this monograph with the sole idea of facilitating the medical practitioner dealing with epilepsy on a daily basis. We profusely thank all the contributing authors who despite their busy schedule came forward and contributed immensely towards this theme. We hope our efforts will enable the physician to approach, investigate and treat epilepsy more confidently and in an evidence based manner.
Happy and enjoyable reading to one and all.
Rajesh Shankar Iyer
Mugundhan Krishnan