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ABSTRACT

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Epilepsy is a frequent neurological condition characterized by an enduring predisposition of the brain to develop unprovoked seizures. Epilepsy must be differentiated from acute symptomatic seizures.

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A careful history is essential for the diagnosis of seizures and epilepsy. Electroencephalography (EEG) is often the most useful diagnostic test to confirm the diagnosis and classify seizures and epilepsy. Brain magnetic resonance imaging (MRI) is indicated in the absence of a well-defined genetic etiology. Identification of a specific epilepsy syndrome, when possible, guides medical treatment and prognosis.

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Epileptic seizures are often misdiagnosed. Patients with uncertain diagnosis and/or pharmaco-resistant seizures should be referred to an epilepsy center for long-term video-EEG evaluation to confirm the diagnosis and assess patients as potential candidates for epilepsy surgery.

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Selection of antiepileptic drugs (AEDs) is mainly based on seizure-type classification. There are currently more than 20 AEDs. Focal seizures may respond to practically any AED with the exception of ethosuximide. Generalized seizures respond better to a much more restricted group of AEDs (broad-spectrum drugs) including lamotrigine, levetiracetam, topiramate, valproate, and zonisamide. Other factors influencing drug selection include efficacy, toxicity, ease of use (determined by its pharmacokinetic profile and drug–drug interaction potential), and cost. Patient-related factors include age, gender, comorbidities, co-medications, and genotype.

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Surgical therapy should be considered in patients with medication-resistant epilepsy and disabling seizures. Temporal lobectomy is the most commonly utilized surgical procedure and may result in complete seizure freedom in 60–70% of patients. Vagus nerve stimulation (VNS) is a palliative procedure, effective in a wide variety of epileptic syndromes. The ketogenic diet may be very effective, especially in pediatric patients.

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INTRODUCTION

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Epilepsy is one of the most frequent neurological disorders, affecting between 0.5 and 1% of the population in the United States. Epilepsy has a predilection for children and the elderly. Approximately 200,000 new cases are diagnosed each year, a number expected to grow at a faster rate as the population ages. It is estimated that between 3 and 10% of Americans experience some kind of seizures during their lifetime.

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A neurohospitalist or any physician providing inpatient care frequently interacts with seizure patients in five different situations: new-onset seizures; patients admitted for another illness; patients admitted via the emergency department (ED) for possible seizures; patients with known epilepsy admitted for another condition that may interfere with their seizures; and patients electively admitted for long-term video-EEG monitoring. The neurohospitalist should also familiarize themselves with their state laws regarding driving restriction after first seizures, recurrence of seizure, and major changes to medications.

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DEFINITIONS

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Epilepsy is characterized by an “enduring predisposition of the brain to generate epileptic seizures.” Epilepsy has been classically defined as at least two unprovoked seizures more than 24 hours apart. Newer practical definitions have been proposed by a task force of the International League Against Epilepsy (ILAE) in 2014 ...

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