1/7. Management of the difficult patient with complex partial seizures.Successful treatment of partial complex seizures (and the epilepsies in general) is a process of management over time and involves several factors. It starts with accurate and adequate diagnostic formulations. To this end the physician must be thoroughly familiar with the ictal manifestations of partial complex and other epilepsies as well as the clinical features of other transient but reversible episodes that might present difficulties in differential diagnosis. The diagnosis is based upon the history of a patient experiencing partial complex seizures, and the most important resource is a careful and detailed history of the ictal events and the circumstances under which they occur. Clinical observation and electrophysiologic monitoring of the patient during attacks, either spontaneous or induced, is the most powerful technique available in cases which present difficult diagnostic problems. In addition to recognition and proper classification of the seizures themselves, diagnosis and treatment of the cause of the seizures, particularly when it is an active disease, is of prime importance. Even after accurate diagnosis, the heterogenous nature of the population of patients with partial complex seizures is such that marked variation in response to treatment with antiepileptic drugs is to be anticipated. The use of these drugs must be individualized and based upon a thorough and working knowledge of their clinical pharmacology. The most frequent mistakes in our experience have been prescribing the drugs in too little doses or for too short a time. Less often the problem is overmedication. The best indicator of the effectiveness of the drugs is the clinical response of the individual patient, and in general each drug should be prescribed in increasing doses until either the seizures are controlled or unacceptable degrees of toxicity develop. The use of serum level determinations can be very helpful if not invaluable, particularly in identifying and understanding potential adverse effects of the drugs. Patient noncompliance in adhering to drug schedules is widespread, but usually can be detected by measuring serum levels. Even with the most efficient use of the drugs, however, some patients will be intractable, and elective surgical treatment should be considered. Finally, control of seizure occurrence alone is not necessarily adequate treatment, as many patients will have difficult psychosocial problems associated with their epilepsy. Treatment of such associated problems is necessary on its own merits, but occasionally can result in significant improvement in seizure control.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
2/7. Transient inability to distinguish between faces: electrophysiologic studies.It is not known with certainty at which level of face processing by the cortex the distinction between a familiar and an unfamiliar face is made. Subdural electrodes were implanted under the fusiform gyrus of the right temporal lobe in a patient who developed an unusual inability to distinguish differences between faces as part of the epileptic aura ("all faces looked the same"). A cortical region located posterior to the epileptic focus was identified that exhibited a maximum evoked response to the presentation of facial images (N165), but not to objects, scenes, or character strings. evoked potentials elicited by a variety of visual images indicated that any perturbation away from novel whole-face stimuli produced submaximal responses from this region of the right temporal lobe. Electrical stimulation of this region resulted in an impairment of face discrimination. It was found that presentation of familiar faces (grandmother, treating physician) produced a different response from that observed for novel faces. These observations demonstrate that within 165 msec of face presentation, and before the conscious precept of face familiarity has formed, this cortical region has already begun to distinguish between a familiar and an unfamiliar face.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
3/7. Dostoevsky's epilepsy: a case report and comparison.The Russian writer Dostoevsky (1821-1881) suffered from a rare form of temporal lobe epilepsy termed "ecstatic epilepsy." Dostoevsky used his epileptic experiences to create Prince Myshkin, the protagonist of The Idiot. The recent case of a patient who experienced ecstatic epilepsy as a result of a temporal lobe brain tumor is presented and compared with that of Prince Myshkin. reading Dostoevsky can give the contemporary physician an insight into the inner life of an epileptic patient--an example of how art can directly benefit medical practice.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
4/7. Psychomotor seizures.A 30-year-old woman presented to the emergency department after an episode of "dizziness" that caused her to lose control of her car. During the preceding 12-month period she had had recurrent "dizzy" spells and abdominal pains for which she was evaluated by several physicians in various emergency departments. Physical and general neurological examination on presentation was within normal limits. Outpatient CT scan was normal, and an EEG revealed a right temporal lobe spike with slow wave pattern suggestive of temporal lobe focus. Since begun on therapeutic doses (300 mg per day of phenytoin), the patient has not experienced further spells or abdominal pains. This report emphasizes the need to be cognizant of an underlying seizure disorder as a possible etiologic agent responsible for a traumatic incident.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
5/7. The patient exhibiting episodic violent behavior.This case presentation describes a 21-year-old white male patient seen for episodic violent behavior. The case is seen as relevant for primary care physicians because of the frequency of violent acting out in the general population, the importance of making an accurate diagnosis, and the many medical, psychological, and social implications involved in diagnosing such disorders. In such cases it is important that the physician keep an open mind and include within the differential diagnosis a variety of psychiatric disturbances such as paranoid schizophrenia, antisocial personality disorder, drug abuse syndromes including a variety of hallucinogens as well as prescription medication, organic diseases affecting the central nervous system, including encephalitis and temporal lobe epilepsy, and a variety of interpersonal difficulties, including spouse abuse and spousal rape. The case presentation method demonstrates how the psychiatric interview and a judicious use of biochemical and physiological testing can lead the practitioner to a correct diagnosis.- - - - - - - - - - ranking = 2keywords = physician (Clic here for more details about this article) |
6/7. Treatment approach in a child with hysterical seizures superimposed on partial complex seizures.This article reports the case of a 9 1/2 year old child with a history of psychomotor epilepsy which was uncontrolled by multiple anticonvulsant medications. When admitted to the psychiatric inpatient service, he was treated with a combination of pharmacological, behavioural and psychodynamically oriented approaches. A period of intensive family counseling was conducted to clarify the parents' concerns about causality of the seizures and methods for dealing with them. This combined approach led to a complete cessation of reported seizures and a decreased number and dosage of anticonvulsant medications. The authors discuss the reluctance of some physicians to accept the co-existence of neurogenic and psychogenic seizures in a given patient. patients with pharmacologically uncontrolled seizures must be identified and accurately diagnosed (neurogenic and/or psychogenic) to prevent complication such as over-medication and to administer appropriate treatment. Multiple disciplinary therapy including psychodynamic, pharmacological, behavioural and educational approaches should be implemented.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
7/7. The surgery for epilepsy with speech arrest.The problems confronting patients with epilepsy, their families, and the surgeons wishing to help such patients, are discussed. It is important for physicians in other specialties to realize that epilepsy surgery is not nowadays complex, difficult, painful or uncertain; furthermore such operations are based on finding and removing focal lesions rather than "epileptogenic cortex" and the result in terms of integration of the patient into society is much improved if such intervention is performed while the patient is young, with time to gain academic and social skills after the operation. The selection of patients suitable for operation is discussed as well as methods of determining which hemisphere is dominant for speech and whether or not the focal lesion involves language centres. The majority of patients with drug resistant epilepsy suitable for operation have abnormalities in one temporal lobe. The pathological lesion is described and the advantages and disadvantages of various operations for temporal lobe epilepsy discussed. Extra-temporal cortical resection in the dominant hemisphere is also considered, particularly with reference to the preservation of language function. It is important that neurosurgeons realise that MRI and CT scanning have transformed epilepsy surgery from being a rather nebulous, time consuming art, to being for the majority of patients, a clear cut, straight forward procedure firmly based on "Oslerian" pathological principles. Far too few patients are being offered an operation (which renders 60-70% seizure free); neurosurgeons should respond to this challenge.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |