He remembered that he always had one minute just before the epileptic fit when suddenly in the midst of sadness, spiritual darkness and oppression, there seemed at moments a flash of light in his brain, and with extraordinary impetus all his vital forces suddenly began working at their highest tension. The sense of life, the consciousness of self, were multiplied ten times at these moments which passed like a flash of lightning. His mind and heart were flooded with extraordinary light… But these moments, these flashes, were only the prelude of that final second in which the fit began.
-Fyodor Dostoevsky, The Idiot
In his novel The Idiot, Fyodor Dostoevsky gave voice, through his character Prince Mishkin, to his own experiences as an epileptic. Not only does he describe his seizures, including the aura vividly depicted in this passage, but he also movingly portrays the life of the epileptic in 19th-century society. Fortunately, much has changed in the 140 years since Dostoevsky penned his novel. In this issue of CONTINUUM, Dr Jacqueline French has assembled a talented panel of experts to update us on the current diagnosis and management of epilepsy.
Understanding epilepsy begins with understanding seizures. Dr Susan Herman provides vivid descriptions and a detailed classification of seizure types. In the following chapter, Dr Selim Benbadis provides a differential diagnosis of epilepsy, which includes an extensive discussion of the very important subject of psychogenic nonepileptic events.
Dostoevsky also serves as an example of the difficulty in distinguishing epileptic from psychogenic episodes, for the nature of his own spells has been the subject of intense debate in the literature. As it now seems likely that the novelist did, indeed, have epilepsy, no less a neurologist than Sigmund Freud appears to have gone astray, as his psychoanalytic theories led him to believe Dostoevsky experienced hysterical seizures (his term). Perhaps video monitoring, had it been available, would have resolved the question! Later in this issue, Dr A. G. Christina Bergqvist provides more detailed classification of pediatric epilepsy syndromes, many of which have unique clinical features.
Great advances have been made in the management of epilepsy, and the past decade or so has been marked by an explosion of new antiepileptic medications. This proliferation of choices may leave neurologists bewildered. No longer, after reading the chapter by Dr French, who skillfully delineates the respective roles of both old and new anticonvulsants in a variety of specific circumstances. Although this knowledge is necessary, it is not sufficient for the optimal management of epileptics today. Many of our patients are taking additional medications, which often have important interactions with the prescribed antiepileptic drugs. Drs Norman Delanty and John Pollard explain these interactions with great clarity so that we might avoid pitfalls that could have serious consequences for our patients.
In describing Prince Mishkin's seizures, Dostoevsky goes on to say, "…at the very last conscious moment before the fit began, he had time to say to himself clearly and consciously, 'Yes, for this moment one might give one's whole life!'" Perhaps the author recognized the excessive occurrence of sudden unexpected death in epilepsy. However, another potentially lethal consequence of seizures is the development of status epilepticus. In their very thorough chapter on this subject, Drs Lawrence Hirsch and Hiba Arif instruct us in the recognition of this perilous state, as well as tell us the best ways to end it. They also emphasize the critical importance of identifying and controlling the entity known as nonconvulsive status epilepticus.
Among the more dramatic advances in recent years have been the improvement in surgical treatment of epilepsy and the recognition that many more patients could benefit from this therapeutic modality than currently receive it. Drs Vijay Thadhani and John Taylor emphasize the importance of identifying potential surgical candidates much earlier in the course of this chronic condition in order to optimize patient outcome and quality of life, as they review the features that identify appropriate candidates for surgery and the options that are available.
In his chapter "The Differential Diagnosis of Epilepsy," Dr Benbadis discusses the use of placebos and suggestion during the video-monitoring of patients. In the Ethical Perspectives in Neurology section of this issue, Dr Jill Conway presents a strong dissent from this prevalent practice, arguing cogently that it is ethically inappropriate. Ethical issues are seldom black and white, however; pragmatic clinicians must often make difficult choices. The editorial staff of CONTINUUM mindfully presents this controversy for your thoughtful consideration.
This issue of CONTINUUM introduces a new feature, Practice Issues in Neurology, which will be edited by Dr Jonathan Hosey. With each issue, we will now provide a discussion of subjects related to economic or other practice-related matters associated with the particular topic. Herein, Dr Gregory Barkley offers a look at some of the important coding issues related to epilepsy, which may have significant impact on your reimbursement for these conditions.
As usual, this issue includes a patient management problem, devised by Dr French, which will challenge you to apply the knowledge you have gained. You will be further tested-but, more importantly, educated-by the multiple-choice questions, which have been artfully crafted by Drs Steven Lewis and Eduardo Benarroch. I urge you to look them over-or take them online at http://www.aan.com/go/elibrary/continuum/cme-for they will, indeed, help you cement your knowledge of epilepsy.
Finally, this issue contains yet another bonus. It features the new streamlined Quintessentials, now available entirely online (as well as on paper) with links directly to the relevant sections of CONTINUUM. Its unique case-based approach, developed for this issue by Dr Simon Glynn, will allow you to exercise your diagnostic and management skills now and then come back at a later date and repeat the process to see whether you have truly incorporated your knowledge into your practice. Not only will you get instant feedback, but 3 additional hours of CME credit.
Clearly, this issue on Epilepsy offers you numerous ways to enhance your knowledge of one of the most important problems neurologists encounter on a regular basis. We are grateful for the contributions of Dr French and her very able faculty in helping us to improve our care of patients with epilepsy. And all in much less time than it takes to read Dostoevsky's The Idiot.
Aaron E. Miller, MD