Epilepsy, the "falling sickness," recognized since ancient times, continues to terrify and mystify the lay public. Seizures remain a leading condition for referral to neurologists, as few other physicians are willing to undertake diagnosis and treatment on their own. As neurologists, we must continue to improve our understanding of seizures themselves and the epilepsy syndromes of which they are components in order to achieve more effective therapy and improved quality of life for our patients.
The past decade has brought new treatments, both pharmacologic and nonpharmacologic. Equally important have been advances in our understanding of prognosis, which helps us determine how and when to apply particular therapeutic approaches. Increased recognition of the psychosocial aspects of epilepsy has also contributed substantially to our ability to help our patients deal with the difficulties of living a life with epilepsy. For this issue of Continuum, Dr Solomon Moshé has assembled a talented cadre of experts to update our knowledge of these and other issues in epilepsy.
In their introductory chapter, Drs Galanopoulou and Lado help us distinguish seizures from other paroxysmal events and describe recent proposals for better classification of seizure types and epilepsy syndromes. Dr Buchalter, in his chapter on epidemiology and genetics, enables us to apply the information learned in these areas to better understand prognosis as well as to help guide treatment decisions. Dr Theodore addresses the important issue of surrogate markers in epilepsy, providing a thorough discussion of the advantages and disadvantages of a panoply of physiologic and imaging techniques.
After a relatively stagnant therapeutic period in the 1980s, the 1990s brought a plethora of new antiepileptic drugs to market. In fact, few other areas of neurology have seen such a dramatic increase of available therapeutic agents over such a short period of time. At least in part because these new drugs were tested as add-on agents and, therefore, were not approved by the US Food and Drug Administration as monotherapy, neurologists have been appropriately cautious in embracing their use. However, in many circumstances these newer agents offer distinct advantages over long-utilized medications. Drs Ballaban-Gil and French provide a thorough discussion of antiepileptic medications that will enable clinicians to make better choices about drugs used both as monotherapy and in combinations.
Despite our best efforts, many individuals with epilepsy will fail to achieve adequate seizure control with medication. Epilepsy surgery has been available for many years but continues to be underutilized. Recent understanding that failure of as few as two antiepileptic drugs, given proper therapeutic trials, portends a poor prognosis for medical treatment alone may help to increase the use of surgical treatment. Recent important clinical studies have demonstrated an advantage of surgery over continued medical therapy in poorly responding patients with temporal lobe epilepsy resulting from mesial temporal sclerosis. In their chapter on surgical treatment of epilepsy, Drs Patwardhan and Mathern provide a comprehensive review of this subject, with attention to the indications for surgery, the importance of diagnostic investigations leading to proper patient selection, and the variety of surgical techniques available.
Even under the care of expert neurologists, many patients will not achieve satisfactory seizure control with conventional medications and may not be appropriate candidates for epilepsy surgery. In their chapter on emerging treatments for epilepsy, Drs Haut and Boro emphasize two other established modalities to improve seizure control. They provide extensive discussion of the use of the vagus nerve stimulator and also of the resurgent interest and use of the ketogenic diet. They also discuss a variety of other alternative and complementary therapies, ranging from herbal remedies to biofeedback to seizure alert dogs. While such treatments may not be "mainstream," they are subjects about which patients often hear and subsequently query their physician.
Although placed last in this issue of Continuum, the chapter on life issues by Patricia Osborne Shafer and Colleen DiIorio, two nurses who have contributed greatly to the care of patients with epilepsy, is of paramount importance. In the final analysis, for most individuals with epilepsy who do not have a progressive disease, it is the quality of life that matters. The authors highlight the recent emphasis on this subject by the emerging mantra, "no seizures, no side effects." They also focus on the importance of "self-management," through which the patient partners with the health care team to maximize seizure control while minimizing adverse experiences. This philosophy helps patients achieve a sense of control that further optimizes their life experience.
As you read and master the contents of this issue of Continuum, I believe that you, too, will begin to feel a sense of control that comes from the realization that you have the knowledge and skills necessary to provide modern comprehensive care to your patients with epilepsy. That expertise encompasses not only knowing how to diagnose and how to treat, but also when to refer to others with more specialized techniques and capabilities. We are grateful to Dr Moshé and his contributors for helping us to reach this state.
One final word: After enhancing your knowledge of epilepsy with this issue of Continuum, you have the opportunity to assess and improve your own patient management skills by taking advantage of the recently published Quintessentials Epilepsy module. Although, beginning in June 2004 we have added Quintessentials as a benefit to your Continuum subscription 2 times a year, the Quintessentials Epilepsy module was produced prior to that policy in March 2004. As a Continuum subscriber, you may take advantage of a special discount for that valuable publication. Please see the offer at the back of this issue for details.
Aaron E. Miller, MD