CONTINUUM Lifelong Learning in Neurology最新文献

Objective: This article reviews the comorbidities of epilepsy and identifies tools to incorporate comorbidity awareness into clinical practice.

Latest developments: The comorbidities of epilepsy are broadly defined, including conditions that may cause but also be a consequence of epilepsy. These can be divided into somatic and psychiatric conditions. Many conditions occur twice as frequently in people with epilepsy compared with the general population. The comorbidities of epilepsy are a major determinant of quality of life and mortality in people with epilepsy. This article provides a concerted focus on the relationship between epilepsy and cognition, mental health disorders, and cardiovascular disease.

Essential points: There are practical means of adopting a comorbidity-aware approach to clinical care without overburdening already busy clinical practices. Screening instruments can be used to identify people with comorbid anxiety or depression. Fundamental safety precautions are relevant to all people with epilepsy. Appropriate consideration of the comorbidities of epilepsy, particularly when choosing an antiseizure medication, leads to improved patient care.

Objective: The purpose of this article is to review the fundamentals and limitations of EEG, guide the selection of EEG type to answer clinical questions, and provide instruction on the interpretation of results within the patient's clinical context.

Latest developments: EEG is the single most useful ancillary test to support the clinical diagnosis of epilepsy, but if used incorrectly it can cause great harm. Misapplication of EEG findings can lead to misdiagnosis and long-term mental and physical health sequelae. Although all neurologists may not have sufficient training for independent EEG interpretation, most should be able to review and apply the findings from the report accurately to guide patient care. Longer-term EEGs with similar recording electrodes tend to have higher diagnostic yields. Common EEG findings are described in this article, along with diagnostic limitations of some classically described patterns. There is an updated definition for an epileptiform discharge, along with a consensus on EEG patterns in the critically ill.

Essential points: EEG continues to be the most useful ancillary test to assist in the diagnosis of epilepsy. Its application requires proper understanding of its limitations and variability of testing results.

Abstract: People with epilepsy must receive up-to-date, high-quality care that aligns with current understanding of basic disease mechanisms, improved diagnostic testing, and evolving medical and surgical treatments. Varying progress has been made in identifying, measuring, and mitigating epilepsy care gaps. Epilepsy guidelines and quality measures should be developed using rigorous processes informed by systematic reviews of best evidence in conjunction with prioritization of need. Epilepsy measures help operationalize guidelines and practice parameters. Most epilepsy quality indicators are process-based metrics defined by delivering care to the patient. Systematic and reliable tracking and documentation of seizure frequency using consistent language is required as a patient-reported outcome within individuals over time and across populations. Emerging literature has demonstrated gaps in epilepsy care, perhaps highlighting limitations in the dissemination and implementation of guidelines and quality measures in clinical practice. Quality improvement methods applied to clinical data registries and learning health systems may afford new opportunities to iteratively, collaboratively, and feasibly disseminate guidelines and quality measures, measure epilepsy care quality, allow for the testing of interventions to mitigate identified care gaps, and, ultimately, improve care for patients with epilepsy.

Objective: This article is an update from the article on antiseizure medication therapy published in the three previous Continuum issues on epilepsy and is intended to cover the vast majority of agents currently available to neurologists in the management of patients with epilepsy. This article addresses antiseizure medications individually, focusing on key pharmacokinetic characteristics, indications, and modes of use.

Latest developments: Since the most recent version of this article was published, one new antiseizure medication, ganaxolone, has been approved by the US Food and Drug Administration (FDA), and the indications of some approved medications were expanded. Older antiseizure medications are effective but have tolerability and pharmacokinetic disadvantages. Several newer antiseizure medications have undergone comparative trials demonstrating efficacy equal to and tolerability at least equal to or better than older antiseizure medications as first-line therapy for focal epilepsy. These agents include lamotrigine, oxcarbazepine, levetiracetam, topiramate, zonisamide, and lacosamide. Pregabalin was found to be less effective than lamotrigine. Lacosamide, pregabalin, and eslicarbazepine have undergone successful trials of conversion to monotherapy for focal epilepsy. Other newer antiseizure medications with a variety of mechanisms of action are suitable for adjunctive therapy.

Essential points: Knowledge of antiseizure medication pharmacokinetics, efficacy, and tolerability profiles facilitates the choice of appropriate antiseizure medication therapy for patients with epilepsy. Rational antiseizure medication combinations should avoid antiseizure medications with unfavorable pharmacokinetic interactions or pharmacodynamic interactions related to mechanism of action.

Objective: This article provides readers with a foundational understanding of epilepsy, including epilepsy classification, and presents a strategic approach to the diagnosis of seizures and epilepsy.

Latest developments: Epilepsy classification systems have evolved over the years, with improved categorization of seizure types and adoption of more widely accepted and comprehensible terminologies. The International League Against Epilepsy (ILAE) Classification of the Epilepsies (2017) introduces a three-tiered framework. The levels focus on the determination of seizure type, epilepsy type, and identification of epilepsy syndrome, when applicable. The 2017 ILAE classification emphasizes the evaluation of the underlying etiology of epilepsy and the identification of associated comorbidities at all stages of classification. Epilepsy syndromes often have age-dependent symptoms.

Essential points: A systematic approach to the classification of seizures and epilepsy is essential for the selection of appropriate diagnostic tests and treatment strategies. An accurate classification not only facilitates clinical assessment but has important implications in the determination of prognosis.