Revisión sistemática: Ácido valproico vs otras drogas anticonvulsivantes o no tratamiento, para profilaxis de recurrencia de convulsiones febriles / Systematic review: Valproic acid vs. other anticonvulsants drugs or non-treatment, for prophylaxis of febrile convulsions recurrence

Introducción: Las convulsiones febriles son el trastorno convulsivo más común en niños menores de 5 años. Después de una primera convulsión febril, alrededor del 33% de los niños experimentan una o más recurrencias, y alrededor del 9% tienen 3 o más. Debido a que los riesgos asociados con las convulsiones febriles simples son poco frecuentes, excepto la recurrencia, y porque el número de niños que tienen convulsiones febriles en los primeros años de vida es muy alto, una terapia propuesta tendría que ser extremadamente baja en riesgos, efectos adversos, de bajo costo y altamente efectiva. Objetivo primario: Identificar y analizar la bibliografía relevante y disponible a la actualidad para evaluar si existe evidencia científica que indique que el uso de ácido valproico es superior a otros anticonvulsivantes para prevenir recurrencias de episodios de convulsiones febriles en niños entre 6 y 60 meses. Objetivo secundario: evaluar la seguridad de la administración de las distintas medicaciones evaluadas, así como también los efectos adversos presentados. Materiales y métodos: Se realizó una revisión sistemática utilizando bases de datos de Medline, LILACS, Cochrane y Google académico. Se analizaron mediante las guías de J.A.M.A. los ECAs y metaanálisis que evalúen la eficacia del uso del ácido valproico vs otros anticonvulsivantes o el no tratamiento hasta diciembre 2012 en idiomas inglés español. Se incluyeron pacientes de 0 a 60 meses con un primer episodio de convulsión febril simple. Resultados: De 40 artículos encontrados, 20 se descartaron por no responder a la pregunta, 6 por ser estudios de baja calidad metodológica, 7 fueron descartados por inaccesibilidad al texto original completo, 1 se descartó por no ser la población humana. Por lo que solo quedaron 4 ECAs y 3 metaanálisis que compararon la eficacia del uso de ácido valproico vs. otros anticonvulsivantes o no tratamiento. Los resultados arrojaron iscrepancias; en algunos estudios el ácido valproico disminuyó el índice de recurrencia de convulsiones febriles comparado con el no tratamiento, no se encontró mayor eficacia frente a otras drogas anticonvulsivantes, como diazepam o fenobarbital, mientras que en otros no se encontró beneficio alguno. Conclusión: Si bien en algunos estudios el ácido valproico disminuyó el índice de recurrencias, se observó en otros que las recurrencias fueron mayores. Al comparar la eficacia contra la de otras drogas anticonvulsivantes las diferencias no fueron estadísticamente significativas. Por lo tanto, no existe evidencia suficiente que permita recomendar o no recomendar el uso de ácido valproico para la prevención de las recurrencias de convulsiones febriles en niños con factores de riesgo para el desarrollo posterior de epilepsia

Introduction: Febrile seizures are the most common type of seizures in children younger than 5 years. After the first febrile seizure, around 33% of children have one or more recurrences, and around 9% have three or more. Ask the risks associated with febrile seizures are not common, except recurrences, and because the number of children that have febrile seizures in the first years of life is high, a treatment protocol should have extremely low risks, have very few adverse effects, and should be low cost and highly effective. Main aim: To identify and analyze the relevant currently available literature to evaluate if there is scientific evidence that shows that the use of valproic acid is superior to other antiepileptic drugs to prevent recurrence of febrile seizures in children between 6 and 60 months of age. Secondary aim: To assess the safety of different medications used as well as the adverse effects observed. Material and methods: A systematic review of the literature using the data bases of LILACS, Cochrane, and Google scholar. The analysis was conducted using guidelines of the J.A.M.A., RCTs, and meta-analyses evaluating the efficacy of valproic acid vs other antiepileptic drugs or no treatment up to December 2012 in English and Spanish. Patients 0 to 60 months with a first simple febrile seizure were included. Results: Of 40 articles identified, 20 were excluded as they did not answer the question, 6 because of inadequate methodology, 7 because the complete original text could not be accessed, and 1 because of a non-human study population. Therefore, only 4 RCTs and 3 meta-analysis that compared the efficacy of valproic acid vs other antiepileptic drugs or no treatment were included. The results showed discrepancies: In some studies valproic acid diminished recurrences of febrile seizures compared to no treatment, no improved efficacy compared to other antiepileptic drugs, such as diazepam or phenobarbital was found, while in other studies no benefit whatsoever was found. Conclusion: Although in some studies valproic acid decreased the recurrence rate, others found that recurrences increased. When comparing efficacy with other antiepileptic drugs, the differences were not statistically significant. Therefore, there is not enough evidence that justifies recommending or not recommending valproic acid to prevent recurrence of febrile seizures in children with risk factors to subsequently develop epilepsy.

Febrile Seizures after 5 Years of Age : Clinical and Electroencephalographic Characteristics / 대한간질학회지

PURPOSE: We aimed to investigate the electroclinical characteristics of patients having persistent seizures with fever after 5 years of age, which has not been elucidated well. METHODS: We identified 101 patients over 5 years (M : F=64 : 37, range: 5.0-11.0), visited our hospital for febrile seizure. Their medical records for clinical features and EEG findings at last seizure were retrospectively reviewed. RESULTS: The mean onset age of seizure of total patients was 3.0 years (range: 0.3-8.3). The complex features were noted in 15.8%. Family history were in 53.3%. Neurologic abnormalities were in 10.9%. Abnormal EEGs were in 36.7% (generalized spike or polyspike-waves: 10, focal epileptic discharges: 16, others: 3). When we compare the patients of 5.0-5.9 years (Group A, n=48) to the patients after 6 years (Group B, n=53), complex features (20.8% vs 37.8%, p=0.063) and AED treatments (6.3% vs 18.9%, p=0.059) were more common in Group B. Among group B, patients after 8 years were more apt to be treated by AED than youngers (6.1% vs 40.0%, p=0.002). When we compare the patients starting their first seizure before 5.0 years (Group C, n=78) to the patients after 5.0 years (Group D, n=23), Group C had more frequent seizures (6.6 vs 2.3, p= < 0.0001) and family history (58.3% vs 25.0%, p=0.039). Group D had more common abnormal neurologic findings (7.7% vs 21.7%, p=0.057). CONCLUSION: Febrile seizures in older age group are more associ-ated with complex features, EEG abnormalities and AED treatments. The patients with seizure onset before 5.0 years had more seizure frequency and family histories.

The Effects of Hippocampal Sclerosis Revealed by MRI on the Pharmacoresistance of Temporal Lobe Epilepsy / 대한간질학회지

PURPOSE: Hippocampal sclerosis is known to strongly correlate with medical intractability of temporal lobe epilepsy. However, the informations about this have been biased due to improper selection of the sampling obtained from severe cases of tertiary epilepsy center and surgical epilepsy field. We tried to investigate the influence of hippocampal sclerosis on the pharmacoresistance in temporal lobe epilepsy by group comparison study. METHODS: The fifty patients with complex partial seizures of temporal lobe origin, and temporal spike on EEG and/or hippocampal sclerosis on brain MRI were selected. Follow-up period of them were more than 2 years. The patients who had a seizure or seizures during the last 1-year period and had already been in adequate doses of two or more antiepileptic drugs were considered to be poorly controlled epileptics. RESULTS: Five of 17 patients without hippocampal sclerosis (29. 4%) and 24 of 33 patients with hippocampal sclerosis (72.7%) were poorly controlled by medication and the difference was significant (p=0.003, chi-square). Other factors, including sex, age of onset, febrile convulsion, secondary generalization, familial history of epilepsy, duration of disease, and delay of initial therapy had no significant effects on medical response (p>0.05). The only independent predictor of intractable epilepsy after multiple logistic regression analysis was also hippocampal sclerosis (p=0.005). CONCLUSION: Medical response in temporal lobe epilepsy was significantly associated with hippocampal sclerosis. Hippocampal sclerosis on brain MRI itself may be a crucial factor determining pharmacoresistance of temporal lobe epilepsy.

Seizure Disorders Mimicking Epilepsy

Distinguishing epileptic seizure from non-epileptic seizure is a common diagnostic problem. Neurogenic or cardiac syncope can appear similar to atonic and even convulsive seizures. Classic migraine and transient ischemic attacks may also resemble epileptic seizures. Sleep disorders including REM sleep behavior disorder, nocturnal paroxysmal dystonia, and narcolepsy likewise simulate an epileptic seizure. Movement disorders such as paroxysmal dyskinesia can be misinterpreted as epileptic seizures (reflex epilepsy or myoclonic seizures). Psychogenic seizures are often misdiagnosed as an intractable epilepsy. Prior to the definitive diagnosis of epilepsy, possible non-epileptic seizures should be excluded. For the correct decision, a thorough and systematic history taking is important. In addition, EEG, pseudoseizure induction test, head-up tilt test, EKG, sleep studies, and video-EEG monitoring may be necessary. Misdiagnosis of non-epileptic seizures as epilepsy may result in unnecessary anti-epileptic drug use. At the same time, we should let the patients understand what the epilepsy is and that epilepsy is a treatable disease.

Management of epilepsy in a rural setting

1,489 cases of Seizure Disorder or Epilepsy treated in almost 25 years were reviewed very thoroughly. Conventional medical treatment were used. Data collected were presented and analyzed. Some comparison with other published reports were done. Discussions were made and written after the data presentation1. Seizure disorder can be diagnosed by complete family and patients past medical history, meticulous physical examination with emphasis on the neurologic, and careful observation. Negative electroencephalograhic tracings do not rule out seizure disorder, though abnormal EEG tracings are highly suggestive of the disorder2. Grant mal or major motor seizures greatly predominate among the different kinds of attacks. Petit mal epilepsy was not found in 1,489 cases reviewed. Utmost care must be given before diagnosing a case as Petit Mal since the drug of choice for this disorder cause aggravation of Major Motor and even Psychomotor or Complex Partial Seizures. Petit Mal cases most of the time are really Psychomotor or the Complex Partial Seizures3. Seizure disorder of idiopathic etiology are 90% major motor in kind, unassociated with mental retardation, physical defects or retardation, need much prolonged treatment if not life-long medications4. The most severe cases of epilepsy in this review long to the least priviledged families living in the barrios. The health services provided by the government apparently are still inadequate in the far-flung rural areas.

Early Experience in Gamma Knife Radiosurgery in Korea

Asan Medical Center has installed the first Korean and Asian 201 Cobalt 60 sources gamma knife for stereotactic radiosurgery of intracranial tumors and arteriovenous malformations. The Unit became operational at the center on May 7, 1990. In the first 4 months of it's operation, we treated 69 patients. However the unit unfortunately became disabled from heavy flooding on September 11, 190. The new unit has been operational since May 6, 1991 and we have added 105 more patients to make a total of 174 patients(61 with arteriovenous malformations, 113 with brain tumors:23 with acoustic 174 patients(61 with arteriovenous malformations, 113 with brain tumors:23 with acoustic neurinomas, 19 with meningiomas, 15 with pituitary tumors, 13 with metastatic tumors, 9 with astrocytomas, 7 with angiographically occult vascular malformations, 6 with seizure disorders who had discrete areas of bliotic changes on neuroimaging studies and 6 with schwannomas. etc). With accumulated experience of more than 6000 patients world treated with the gamma knife unit and with our own experience obtained in a short period of time, it is accurate to say that the gamma knife radiosurgery offers innovative and effective means to treat various intracranial lesions for selected patients.