Dr Lara JehiIhas brought an outstanding group of experts on board to so thoroughly inform each of us in our provision of the most up-to-date care of our patients with these disorders.
This issue of Continuum is devoted to the diagnosis and management of our patients with epilepsy and seizures across the lifespan. To accomplish this critically important goal, Dr Lara Jehi, the director of research at the Cleveland Clinic Epilepsy Center, has brought an outstanding group of experts on board to so thoroughly inform each of us in our provision of the most up-to-date care of our patients with these disorders.
Dr Lara Jehi…has brought an outstanding group of experts on board to so thoroughly inform each of us in our provision of the most up-to-date care of our patients with these disorders.
The issue begins with an article by Drs Erik K. St. Louis and Gregory D. Cascino that clearly outlines the new International League Against Epilepsy practical clinical definition of epilepsy, reviews the differential diagnosis of seizures and other paroxysmal physiologic spells, and discusses the approach to the initial diagnosis of epilepsy. Next, Dr Gregory K. Bergey discusses the management of a first seizure and clearly outlines the concepts and distinction between provoked and acute symptomatic seizures, as well as remote symptomatic seizures, and their significance in relation to seizure recurrence risk.
The next two articles are devoted to the care of our pediatric patients, starting with the article by Dr Ajay Gupta, who reviews the diagnosis and management of febrile seizures, stressing the importance of an individualized clinical assessment, risk stratification, and care plan for each patient and caregiver. Dr Elaine Wirrell then reviews the remarkable variety of (common and rarer) epilepsy syndromes that occur in infancy, childhood, and adolescence, including their clinical and electroencephalographic features, management, and prognosis.
Dr Christopher T. Skidmore discusses the typical clinical features and electroencephalographic findings in the various forms of adult focal epilepsy as defined by the anatomic localization of their onset, such as mesial temporal lobe epilepsy, lateral (neocortical) temporal lobe epilepsy, and frontal lobe epilepsy. Drs David K. Chen and W. Curt LaFrance Jr next discuss nonepileptic seizures, with particular emphasis on psychogenic nonepileptic seizures, including their diagnostic (clinical and investigational) differentiation from epileptic seizures, psychological underpinnings and prognostic features, and management.
Both antiepileptic drug (AED) therapy and AED resistance form the basis for the next two articles in the issue. First, Dr Bassel W. Abou-Khalil reviews each one of the many AEDs that are now available to neurologists to manage our patients with epilepsy, including its spectrum of efficacy, pharmacokinetic properties, safety and tolerability profile, and place in our current therapeutic armamentarium. Next, Dr Dileep R. Nair discusses the definition and evaluation of drug-resistant epilepsy and its management options, including resective epilepsy surgery, electrical stimulation therapy, and dietary therapy.
Dr Stephen Hantus discusses the diagnosis and treatment recommendations for epilepsy emergencies, including acute repetitive seizures and status epilepticus. In the next article, Dr Joseph I. Sirven reviews the management of the many common comorbid conditions that occur in patients with epilepsy, including depression, anxiety, and memory problems, as well as other important issues such as driving restrictions and sudden unexpected death in epilepsy and its risk factors. Drs Elizabeth E. Gerard and Kimford J. Meador review the many considerations in the management of women with epilepsy, including AED selection (and risk of structural and cognitive teratogenesis) for women of childbearing age, contraceptive options and recognition of drug-drug interactions, and catamenial seizures.
Dr Nicolas Gaspard discusses the recent developments in autoimmune epilepsy, including the increasingly recognized syndromes of autoimmune encephalitis and their clinical diagnosis and management, as well as the emerging concept of autoimmunity and its potential relationship to chronic epilepsy. In the final review article of the issue, Drs Chad Carlson and Christopher T. Anderson review a variety of important—and commonly encountered—issues of special concern in patients with epilepsy, including issues specific to the management of elderly or immunosuppressed patients with epilepsy, and discuss risk factors and assessment for bone disease and recommendations with regard to bone health in patients with epilepsy.
In this issue’s Ethical Perspectives article, Dr Jill Miller-Horn analyzes the ethical dilemma created when the neurologist and a parent have a disagreement over the optimal care of the child with epilepsy. In the Practice Issues article, Drs Georgia Montouris and Anna D. Hohler discuss how cultural barriers can affect adherence to medications, of particular importance in AED therapy for seizure disorders. Drs Korwyn Williams, Marc R. Nuwer, and Jeffrey R. Buchhalter review the many considerations that neurologists need to be aware of with regard to diagnostic coding for seizures and epilepsy syndromes.
Given the above, it is clear that Dr Jehi has put together a remarkably thorough and up-to-date treatise on epilepsy, and perhaps the “last word” on epilepsy for many of us for the time being. But, speaking of “last words,” the “last word” you will find in this issue is “semiology,” a term that has been ubiquitous in the epilepsy literature since the 1990s. Despite the common use of this word in the epilepsy literature, the term is ill defined, although it seems mainly used in this context to refer to the clinical manifestations of a seizure and is rarely, if ever, used to refer to the signs or symptoms of other neurologic or medical conditions. Although the Greek root of “semiology” means “sign,”1 in the broad medical context the term has classically referred (typically outside of the United States) to a course of study in medical education relating to the diagnosis of disease using the patient’s clinical history, symptoms, and signs. In keeping with my philosophy in Continuum to be as jargon free (and abbreviation free) as possible, for optimal educational purposes this issue is semiology free (with the sole exception of a single table that used the term in the original source).
As with every issue of Continuum, a number of opportunities exist for CME. By taking the Postreading Self-Assessment and CME Test, written by Drs D. Joanne Lynn and James W. M. Owens Jr, after reading the issue, you may earn up to 12 AMA PRA Category 1 Credits™ toward self-assessment and CME. The Patient Management Problem, written by Dr Daniel Friedman, describes the case of a 24-year-old woman who presents to the emergency department for evaluation of a witnessed convulsion at work. By following her case and answering multiple-choice questions corresponding to diagnostic and management decision points along the course of her disorder, you will have the opportunity to earn up to 2 AMA PRA Category 1 CME Credits.
Finally, a few important changes have been made to the Continuum Editorial Board since the previous issue. Dr Daniel Larriviere has completed his tenure as Associate Editor of Ethics, and I would like to sincerely thank him for his dedication to this important section for the last 3 years. Dr Joseph Kass of Baylor College of Medicine, a current editorial board member, will be taking over this role, which will now be called Associate Editor of Ethics and Medicolegal Issues. Recognizing that a number of important challenges are facing neurologists, some clearly in the realm of ethics but many that also have legal implications, the scope of the ethics section will expand to address important issues that have legal aspects that neurologists should know about. The plan is to alternate between more ethics-focused articles and more legal-focused ones in successive issues. I am also pleased to announce that Dr Joseph Safdieh, also a current editorial board member, will be taking on the newly created role of Associate Editor of Self-Assessment and CME, supervising and editing all of the question-writing and CME activities in Continuum.
I want to sincerely thank Dr Jehi for the painstaking work she put into the organization of this remarkable issue and her incredible responsiveness and insights with all of the critical details that occur throughout the editing process. Additional thanks to each of the expert faculty members in this issue, whose clear and thorough articles provide us with such practical information to help us provide the most up-to-date care to our patients with seizures and epilepsy.
—Steven L. Lewis, MD, FAAN