Few neurologic phenomena are as striking and dramatic as generalized tonic-clonic seizures. One need only tune in to various TV series to note how often these events are depicted. Less dramatic, but no less fascinating, are patients who appear entirely oblivious to their examiners yet perform apparently purposeful, sometimes complex actions. These patients, too, are having seizures. In fact, the gamut of seizure phenomenology not only challenges the clinician's diagnostic skills but requires mastery of a host of interventions, including dietary change, medication, device implantation and programming, and surgery. In this issue of Continuum, Dr Joseph Sirven has recruited a large and talented faculty to address a wide range of issues in the field of epilepsy.
A patient with epilepsy, by definition, has seizures, but not all patients with seizures have epilepsy. Drs Leslie Rudzinski and Jerry Shih kick off this issue by emphasizing this important distinction and providing a lucid classification of both seizures and epilepsy syndromes. Then, Drs Joseph Drazkowski and Steve Chung follow by clarifying the differential diagnosis of epilepsy and helping us distinguish among epileptic seizures, psychogenic nonepileptic seizures, and physiologic nonepileptic events.
Seizures and epilepsy, of course, span the lifespan from the neonate to the centenarian. Nevertheless, certain epilepsy syndromes are unique to childhood, and Drs Elaine Wirrell and Katherine Nickels expound on these.
Seizures themselves grab the limelight in people with epilepsy. However, epilepsy comorbidities, including cognitive and psychiatric problems, may be even more disabling than the seizures, as discussed in the article by Drs Sean Hwang, Alan Ettinger, and Elson So. These authors also include a discussion of the important and tragic issue of sudden unexplained death in persons with epilepsy. Later in this issue, Drs Hamada Hamid and Ruth Nass address this matter further in their section on Ethical Perspectives in Neurology.
The opportunity to make an effective therapeutic intervention in most people with epilepsy creates much of the excitement in this field. Generally, initial treatment involves medication, and the next few chapters in this issue address aspects of this subject. Not all people with seizures must begin medication, and those who do may not need it forever. Dr Jeffrey Britton addresses this question in his article "Antiepileptic Drug Therapy: When to Start, When to Stop." In recent years, many new antiepileptic drugs (AEDs) have been added to our armamentarium, often offering considerable advantages over the old warhorses. Dr Nathan Fountain guides us through this therapeutic garden to help us choose among the AEDs. Therapeutically, there are rarely any "free rides." Thus, Dr William Tatum IV helps us recognize not only adverse effects of the respective AEDs but also important potential drug interactions. The latter may occur either between AEDs themselves or between an AED and drugs used for other purposes.
Epilepsy has no particular sexual bias. However, a number of issues uniquely affect women with epilepsy, as clearly discussed by Drs Katherine Noe and Alison Pack.
Although pharmacotherapy is the first line of defense against recurrent seizures, the important roles of epilepsy surgery and, to a lesser extent, electronic devices such as the vagus nerve stimulator, are gaining increased recognition. Drs Gregory Cascino and William Theodore discuss these subjects, emphasizing the need for clinicians to more quickly recognize when epilepsy surgery is appropriate and thereby may save the patient years of unnecessarily inadequate seizure control.
Probably the most feared consequence of epilepsy is the occurrence of status epilepticus, which carries an ominous prognosis when not aggressively and successfully managed. Dr Elizabeth Waterhouse reviews multiple aspects of this problem, including the sometimes vexing problem of nonconvulsive status epilepticus.
Finally, issues relating to quality care in neurologic practice in epilepsy are discussed by Dr Robert Gumnit. Practitioners will also benefit from the Coding Table provided by Drs Laura Powers and Jeffrey Buchhalter.
As usual, you can test your mastery of the subject of epilepsy by working through the patient management problem developed by Drs Matthew Hoerth, Drazkowski, and Sirven, and the multiple-choice questions (MCQs) prepared for this issue by Drs Eduardo Benarroch and Julie Hammack. If you haven't tried doing the MCQs on your smart phone at m.aan.com, you might find this a convenient way to pick up some knowledge on the fly, as well as to accumulate CME credits.
This is a bonanza issue of Continuum, and I am indebted to Guest Editor Sirven for his personal efforts in producing both Quintessentials and a CD illustrating various seizure types, which will undoubtedly prove to be an invaluable resource. Be sure to try Quintessentials; you will find its clinical vignettes and related questions offer an excellent way to actually assess your own clinical practice skills. With these varied and stimulating learning modalities, I'm sure you will particularly enjoy this issue of Continuum.
-Aaron E. Miller, MD