CONTINUUM Lifelong Learning in Neurology最新文献

Objective: This article provides a guide for neurologists managing nonepileptic events (NEEs), a complex intersection of neurology and psychiatry. It covers risk factors, pathophysiology, current treatment approaches, and prognosis, with specific management strategies for challenging scenarios such as patients with intellectual disabilities and comorbid epilepsy.

Latest developments: An emphasis on strong communication and coordinated care among health care specialists improves patient outcomes and reduces unnecessary medical consultations and procedures. This approach is now recognized as essential for addressing the complex presentation and comorbidities associated with NEEs.

Essential points: NEEs are prevalent and highly disabling, and multiple pathophysiologic mechanisms for these events have been proposed. Mortality is comparable with that of patients with treatment-refractory epilepsy, and prognosis is better for children than adults. Achievable treatment goals for adults include improved quality of life and reduced frequency and severity of events, even if complete remission of NEEs is not achieved. Enhanced communication and coordinated care through multidisciplinary care teams enable the efficient use of individual expertise at different treatment stages to address the presentation, risk factors, and comorbidities associated with NEEs, resulting in a better quality of life for patients.

Objective: This article provides current evidence on how and when to treat unprovoked first seizures in children and adults, guides intervention with appropriate doses and types of modern and effective therapies for acute repetitive (cluster) seizures, and reviews evidence for the diagnosis and management of established, refractory and super-refractory status epilepticus.

Latest developments: Artificial intelligence shows promise as a clinical assistant in decision making after a first seizure. For nonanoxic convulsive refractory status epilepticus third-phase treatment, equipoise exists regarding whether it is better to add a second IV nonsedating antiseizure medication given via loading dose (eg, brivaracetam, lacosamide, levetiracetam, fosphenytoin or valproic acid) or to start an anesthetizing continuous IV infusion antiseizure medication such as ketamine, midazolam, propofol or pentobarbital.

Essential points: After a first seizure, the risk of a second seizure is about 36% at 2 years and 46% after 5 years. The risk is doubled in the presence of EEG epileptiform discharges, a brain imaging abnormality, a nocturnal first seizure, or prior brain trauma. For acute repetitive seizures, providers should give a proper dose of benzodiazepines based on the patient's weight and needs. First-phase treatment for convulsive established status epilepticus is the immediate administration of full doses of benzodiazepines. Second-phase treatment for convulsive established status epilepticus is a full loading dose of IV fosphenytoin, levetiracetam, valproic acid, or if necessary, phenobarbital.

Objective: This article reviews essential concepts and terminology in epilepsy genetics, discusses current guidance on when and how to pursue genetic evaluation, provides an overview of genetic syndromes, and offers illustrative examples of the effect of genetic diagnosis in epilepsy patient care.

Latest developments: The growing availability of next-generation genetic sequencing methods for clinical use provides an opportunity to make etiologic diagnoses in a larger number of epilepsy patients, which can affect therapeutic management, prognostic counseling, surveillance for comorbid conditions, and other aspects of epilepsy care. Exome and genome sequencing may have high diagnostic yields in patients with unexplained epilepsy. The body of knowledge in epilepsy genetics is growing more complex, not only because of gene discovery but also because of an increasingly nuanced understanding of the varying pathophysiologic effects of specific types of variation within epilepsy genes.

Essential points: Genetic testing plays a key role in the evaluation of epilepsy patients. Clinicians caring for patients with epilepsy should understand patient selection, test selection, and result interpretation in genetic testing. The recommended first-line test in most patients is exome or genome sequencing.

Objective: The goal of this article is to review the use of neuroimaging in the treatment of new-onset seizures and epilepsy. The article will focus predominantly on MRI because this is the most common modality, but it will also review others that are often used in individuals being considered for epilepsy surgery. The article also reviews common causes of epilepsy and their appearance on imaging and various imaging tools that can be combined to assist in the care of people with epilepsy.

Latest developments: MRI has revolutionized the ability to diagnose the cause of many forms of epilepsy. However, to maximize the diagnostic power of MRI, it is essential to order the correct imaging sequences. In this article, the harmonized neuroimaging of epilepsy structural sequences (HARNESS) MRI protocol proposed by the International League Against Epilepsy is discussed.

Essential points: MRI is the preferred imaging modality to identify lesions associated with epilepsy. Protocols should include thin-cut, no-gap sequences to permit the identification of small epileptogenic lesions, and studies should be reviewed with an understanding of all the clinical information to help guide the identification of potential lesions.

Objective: The management of epilepsy should be patient centered, and the treating team should carefully balance eliminating seizures while minimizing adverse effects associated with antiseizure medications. This article highlights important aspects of care related to sexual and reproductive health in people with epilepsy.

Latest developments: Gender- and sex-based management in epilepsy can present unique challenges especially in people with epilepsy of childbearing potential. One of the most important considerations with the prescription of antiseizure medications to people of childbearing potential involves reproductive health. Folic acid supplementation is recommended to reduce the risk of congenital malformations, but there is no consensus on the optimal dose. The clinical management of pregnancy in the setting of epilepsy can be challenging. Significant knowledge gaps remain regarding the risks for most new antiseizure medications, neurostimulation therapy, and ketogenic diets during pregnancy. Ongoing multicenter pregnancy registries continue to inform practitioners on the medical treatment of people with epilepsy of childbearing potential. Data evaluating the effect of antiseizure medications on male patients with epilepsy, especially around conception, continue to be insufficient.

Essential points: The decision to prescribe an antiseizure medication depends on several considerations because of the potential for lifetime treatment with a daily medication. It is important to tailor management to the patient's specific circumstances. Seizures and antiseizure medications can both affect sexual and reproductive health. Furthermore, hormone fluctuations may affect seizure frequency, treatment, and contraception. All these factors should be considered when treating people with epilepsy during their reproductive years. In addition, it is important to foster a multidisciplinary approach for the treatment of people with epilepsy.

Objective: Many patients with epilepsy are unable to achieve optimal seizure control with medical therapy. This article focuses on surgical approaches, dietary therapies, and seizure detection devices.

Latest developments: For more than a century, resective epilepsy surgery has been a treatment option for some patients with drug-resistant epilepsy. Other surgical options have emerged for patients for whom resection is not possible or is associated with unacceptable risks, including minimally invasive epilepsy surgery and neurostimulation therapies. Dietary therapies, such as the ketogenic diet, can also help improve seizure control, especially in children. For patients with ongoing nocturnal convulsive seizures, seizure detection devices can alert caregivers and potentially reduce the risk of sudden unexpected death in epilepsy (SUDEP).

Essential points: Patients with drug-resistant epilepsy should be referred to comprehensive epilepsy centers to determine if they qualify for nonpharmacologic treatment options to reduce the risk of seizures and premature death and improve quality of life.

Objective: Despite advancements in epilepsy management, disparities and lack of inclusion of many people with epilepsy are associated with increased morbidity and mortality. Compounding these problems is the paucity of diversity among health care providers, research participants, and researchers. This issue as well as potential solutions are explored in this article.

Latest developments: Prompted by recent social justice incidents, patient advocacy groups, epilepsy societies, and governing bodies such as the National Institute of Neurological Disorders and Stroke, US Centers for Disease Control and Prevention, and the Intersectoral Global Action Plan on Epilepsy and Other Neurological Disorders have proposed initiatives to improve disparities in epilepsy care. Public health epilepsy research continues to expose deficiencies and disparities. Increased awareness of health care gaps and technologic advances should help foster improved epilepsy health equity and inclusivity.

Essential points: To deliver timely, effective care for people with epilepsy, we must be knowledgeable of sociodemographic obstacles to access. These include confounding factors such as historical determinants, unconscious bias, and lack of diversity. Improving awareness and promoting diversity in research participation can advance treatment for underserved populations and improve trust.