Management of Alcohol Withdrawal Syndrome and Alcohol Withdrawal Seizure

Alcohol withdrawal syndrome (AWS) is a common condition occurring after intentional or unintentional abrupt cessation of alcohol in an alcohol-dependent individual. AWS represents a major problem in our society and alcohol withdrawal seizure is the major cause of seizures encountered by neurology residents in the emergency department. Patients with AWS present with mild symptoms of tremulousness and agitation or more severe symptoms including withdrawal seizures and delirium tremens. Particularly, severe AWS can produce significant rates of the morbidity (complications) and mortality. When diagnosed and managed insufficiently, the morbidity and mortality rates increase. Nevertheless, patients with AWS may be neglected and are often marginalized and the teaching about AWS to neurology residents is usually minimal. Also, attending neurologists are often poorly informed on the topic. Although there is insufficient consensus about the optimal investigation and management, the purpose of this review is to serve as a summary of the appropriate identification and management of this important condition in a neurological setting.

Convulsões relacionadas ao alcoolismo: atualização / Seizures related to alcoholism: update

OBJETIVO: Revisão sobre crises convulsivas relacionadas ao alcoolismo,discutindo sua classificação, fisiopatologia, investigação diagnóstica e seu tratamento. MÉTODO: Revisão não sistemática de artigos utilizando-se os unitermos: "alcoholism", "alcohol", "seizures" e "withdrawal". Priorizou-se a utilização de artigos que apresentassem associação desses unitermos no título. Foram utilizadas as bases de dados do PubMed, Lilacs e Google Scholar. RESULTADOS: Foram encontrados 2.362 artigos associando os unitermos no título, tendo sido escolhidos 26 artigos em inglês, 3 em português, 1 manual e 1 tese em inglês para a elaboração desta revisão. CONCLUSÃO: As crises convulsivas relacionadas ao álcool representam uma das mais graves complicações do alcoolismo. O diagnóstico e o tratamento corretos melhoram o prognóstico desses indivíduos, diminuindo o risco de complicações, a recorrência de crises, a ocorrência de status epilepticus ou a evolução para um quadro de delirium tremens.

OBJECTIVE: Review alcoholism related seizures, discussing classification,pathophysiology, diagnosis and treatment. METHOD: A non-systematic review was performed of articles using the keywords: "alcoholism", "alcohol", "seizures", and "withdrawal". Articles with the combination of these keywords in the title were favored. The search was performed on PubMed, Lilacs database and Google Scholar. RESULTS: Using these search terms 2,362 articles were found, being selected 26 articles in English, 3 articles in Portuguese, 1 English manual, and 1 thesis in English to elaborate this review. CONCLUSION: Seizures related to alcohol are one of the most serious complications of alcoholism. The correct diagnosis and treatment improves the prognosis of these individuals, decreasing the risk of complications,seizure recurrence, status epilepticus and the progression to delirium tremens.

[Etiology of first seizure, in patients refered to neurology emergency]

Seizures are frequent and important disorders in patients admitted in emergency wards, and arise from a variety of underlying conditions. This study was done to evaluate the etiology of first seizure in Neurology Emergency Department. In this descriptive study, 170 patients reffered to Neurology Department of Ghaem Hospital in the year 2003 were studied. Obtaning medical history and performing clinical examination, a questionnaire was filled and paraclinical studies [peripheral blood examination, EEC, bran CT scan and, in some cases, MRI] were done. Data was analyzed by descriptive statistics and frequency distribution tables. Out of 170 patients 97 were male and 73 female; mostly 33- 60 years of age. Most common etiologies of seizure in this study were: idiopathic, stroke, neoplastic, trauma, withdrawal syndrome, CNS infections, congenital and degenerative diseases. In this study the most common cause of first seizures was idiopathic epilepsy; but cerebrovascular diseases, head injuries, and opioid withdrawal syndrome were among the frequent causes of first seizures, wich can be controlled to reduce the number of seizures in our socity

Sonhos e craving em alcoolistas na fase de desintoxicação / Dreams and craving in alcohol addicted patients in the detoxication stage

O objetivo desta pesquisa foi avaliar a presença da relação entre os sonhos e craving em alcoolistas nos três primeiros dias de desintoxicação em unidades de internação hospitalar. Verificou-se se aqueles que tinham o craving aumentado relatavam sonhos com o tema "álcool" e analisou-se a qualidade do sono desses sujeitos. Foi um estudo transversal, de associação entre variáveis. A amostra foi de 77 sujeitos adultos do sexo masculino, dependentes de álcool, sem comorbidades clínicas ou psiquiátricas e não-dependentes de outras substâncias psicoativas, salvo a nicotina. Os instrumentos foram: entrevista estruturada; escala de avaliação do craving; questionário de avaliação do sono e dos sonhos; Mini-Mental State Examination e questionário Short-Form Alcohol Dependence Data. Quanto à fase inicial do sono, 67,6 por cento considerou no mínimo satisfatória, 80,5 por cento emitiu a mesma opinião quanto ao seu final, porém apenas 22,1 por cento nunca apresentou interrupções durante o sono. Sonhar com álcool não foi um comportamento freqüente (27,3 por cento), e a média de pontuação do craving foi "fraca", havendo associação entre sonhar com álcool e um aumento no craving (p < 0,001). Os sonhos podem ser mais bem aproveitados pelos profissionais da dependência química, devendo ser utilizados elementos sinalizadores de uma "situação de risco" nas técnicas de prevenção à recaída.

Seizures in Chronic Alcoholics / 대한간질학회지

PURPOSE: Seizures constitute one of the most frequent medical complications in alcoholics. The purpose of this study is to elucidate clinical characteristics of seizures in chronic alcoholics. METHODS: Subjects were 50 alcoholics with seizure who were admitted to Kang-Dong Sacred Heart Hospital between Jan. 1999 to May. 2002. We classified them into alcohol withdrawal seizure (AWS) and alcohol related seizure (ARS). AWS was defined as 1) seizures occur within 72 hrs after the last alcohol intake and 2) occurring in the patients without focal abnormalities on brain CT and EEG. ARS was defined as 1) seizures occurring more than 72 hrs after the last alcohol intake, 2) occurring regardless of onset-time in the patients who had concomitant focal brain lesions or focal abnormalities on EEG, and 3) occurr in patients who had experienced seizure unrelated with alcohol. Their clinical, electrophysiologic and neuroradiologic features were analyzed. RESULTS: 45 patients (90%) were male. Mean age was 47 years. 48 patients (96%) were presented with generalized tonic-clonic seizure. 28 patients (56%) were classified into AWS and 22 (44%) into ARS. Mean age was 46 years in patients with AWS and 54.9 in ARS (p=0.04). Mean duration of alcohol intake was 17 years in AWS and 26.2 in ARS (p=0.002). Mean amount of alcohol intake (yrs x bottles/day) were 30.3 in AWS and 42.0 in ARS (p=0.061). EEG showed diffuse slowing in 5 of AWS, sharp waves in 4 of ARS, focal slowing in 3 of ARS and PLEDs in one of ARS. Among 28 patients with AWS, only one patient was treated with long term antiepileptic drugs (AED). Among 22 ARS, 14 (64%) patients were treated with long term AED. One patient of each group experienced recurrent seizure during follow up. Delirium tremens was developed in 17 patients (34%). Among them, 13 (76%) had alcoholic liver disease (p=0.036). CONCLUSIONS: Our study suggests that patients with ARS were older and drunk more for a longer period of time than patients with AWS. Long term AED administration may be required to prevent recurrent seizures in patients with ARS. On the other hand, delirium tremens may be significantly associated with alcoholic liver disease.

Management of status epilepticus.

Status epilepticus is a medical emergency, if not treated in time and effectively may cause significant mortality and morbidity. Medical therapy has been the mainstay of treatment but in refractory status surgical resection, multiple subpial transection, electroconvulsive therapy, caudate stimulation and acupuncture play important role. The present operational definition for adults and older children considers status as > or = 5 minutes of continuous seizure or two or more discrete seizures without regaining of full consciousness. Status epilepticus accounts for 1-8% of all hospital admissions for epilepsy. Physiological changes in generalised convulsive status epilepticus include transient or early (0-30 minutes) and late (after 30 minutes) changes. Temporal changes occur as tonic-clonic status epilepticus progresses. Management can be considered in two ways--out hospital management and inpatient management. Benzodiazepine is considered 1st line of treatment outside hospital. Emergency/inpatient management includes basic life support (0-10 minutes) and pharmacological management (10-60 minutes). Drugs used in pharmacological management are lorazepam, midazolam, propofol, phenobarbital, phenytoin, fosphenytoin, i.v. valproate, rectal diazepam, etc. The classical definition of refractory status epilepticus includes seizure that has not responded to sequential treatment of lorazepam, phenytoin or phenobarbitone or seizure continuing > 60-90 in spite of adequate treatment.

Síndrome de abstinência alcoólica / Alcohol abstinence syndrome

O alcoolismo é um dos problemas mais importantes de Saúde Mental no Brasil, com uma prevalência durante a vida variando de 7,6 a 9,2 por cento, sendo 10 vezes mais freqüente em homens do que em mulheres (ALMEIDA FILHO e col, 1997). Considerando-se o conceiro mais almplo de "bebedores problemas", ou seja, pessoas que ainda näo desenvolveram uma nítida dependência ao álcool, mas já apresentam alguma conseqüência do seu uso abusivo, pode-se estimar um aumento de quatro vezes destas proporçöes (JORGE, 1987)

Changes in Blood Superoxide Dismutase Activities after Alcohol Withdrawal

OBJECTIVES: The aims of this study were to evaluate changes in plasma superoxide dismutase(SOD) activities in alcohol depedence, to fine out variables to influence on the SOD activities, and finally to identify the correlation of SOD activities with the alcohol-associated cognitive disorders. METHODS: For 24 male alcoholics and 21 healthy male controls, plasma SOD activities were measured by spectrophotometry on 1-2 wks after alcohol withdrawal. Structured interviews and laboratory tests were also performed. RESULTS: 1) Upon comparing SOD activities between controls and alcoholics, the SOD activities were significantly(p<0.01) lower in alcoholics(0.308+/-0.140 units/mL) than in healthy controls(0.313+/-0.086 units/mL). 2) Upon comparing SOD activities according to the presence of alcohol-related cognitive disorders, the SOD activities were significantly(p<0.05) lower in alcoholics with cognitive disorders(0.247+/-0.049 units/mL) than in alcoholics without cognitive disorders(0.317+/-0.148 units/mL). 3) Upon comparing SOD activities according to the presence of alcoholic polyneuropathy or alcohol withdrawal seizure, the SOD activities showed no significant differences between alcoholics with polyneuropathy or epilepsy and those without. 4) Upon analyzing variables influencing on the SOD activities in alcoholics, the SOD activities had the negative correlation with hemoglobin(gamma=-0.433) and severity of alcohol withdrawal symptoms(gamma=-0.375). 5) Upon comparing variables according to the presence of alcohol-related cognitive disorders, the occurrence of alcoholic polyneuropathy(p<0.05) and blood phosphorus concentrations(p<0.01) were significantly higher in alcoholics with cognitive disorders than those without. 6) Upon analyzing an association between SOD activities and variables in alcoholics with cognitive disorders, the SOD activities were positively correlated with the onset age(gamma=0.995), and negatively correlated with the severity of alcohol withdrawal symptoms(gamma=-0.996). CONCLUSIONS: Lower SOD activities in alcohol dependence suggested alcohol-associated cognitive disorders and alcohol withdrawal symptoms might be caused by oxidative stress.

Analysis of Risk Factors Related to Delirium Tremens in Alcohol withdrawal Seizure Patients

BACKGROUD: It is generally acknowledged that a close relationship exists between chronic alcohol abuse and the occurrence of alcohol withdrawal seizure(AWS). About one third of AWS patients have been reported to be followed by delirium tremens (DT). OBJECTIVES: We assessed the factors that have influence on the development of DT in AWS patients. METHODS: We investigated clinical features and laboratory findings of 39 AWS patients who were admitted. The following factors were analyzed ; duration of alcohol intake, interval from last drinking to onset of AWS, interval from AWS to treatment, number of seizure, fever, laboratory findings (Mg, K, Na, Ca, P, respiratory alkalosis). RESULT: Fourteen patients developed DT(35.8%). There was fever in 36% of AWS patients with DT(5/14) and in 8% of AWS patients without DT(2/25). Number of seizure (p<.05) and interval from AWS to treatment(p<.01) showed statistically significant difference. But other factors were insignificant statistically. CONCLUSION: Our study suggests that number of seizure and interval from AWS to treatment seem to be significantly related to the development of DT in AWS patients.

Etiologic Analysis of Adult Onset Seizure

A clinical study was done on 161 patients (male 94, female 67) with the first onset of seizure over the age of 16 who were admitted to Keimyung University Hospital from 1979 to 1983 in order to analyze the causative factors, the age distribution at onset, the seizure pattern and E.E.G. findings. The results were summarized as follows. 1. The etiological factors of 161 seizure patients revealed metabolic encephalophaties 75 cases (46.6%), cerebrovascular disease 26 cases (16.2%), unknown cause 21 cases (13%), CNS infectious disease 17 cases (10.6%), posttraumatic seizure 12 cases (7.5%), brain tumor proved by brain biopsy 8 (5%) and hysteric seizure 2 cases in order of frequency. 2. Among the 75 cases of metabolic encephalopathies, the most common cause was drug intoxication (34 cases), followed by alcohol withdrawal seizure (21 cases), water intoxication (5 cases), uremia and hypocalcemia (4cases respectively), hepatic encephalopathies (3 cases) and then hypoglycemia and anoxia (2 cases respectively) in order of frequency. Among the 26 cases of cerebrovascular disease, spontaneous subarachnoid hemorrhage was presented in 9 cases, intracerebral hemorrhage and cerebral infarction in 7 cases respectively and arteriovenous malformation in 3 cases. Among the 17 cases of CNS infectious diseae, meningitis was presented in 9 cases, Japanese B encephalitis in 3 cases, paragonimiasis in 2 cases, and then cerebral cysticercosis, tuberculoma, and focal cerebritis in 1 case respectively. Among the 8 cases of brain tumor, meningioma was presented in 5 cases, oligodendroglioma, glioblastoma multiforme and epidermoid cyst in 1 case respectively. 3. The mean age at the onset of each causes of seizure revealed metabolic encephalopathies 38 yrs. CNS infectious disease 33 yrs, posttraumatic seizure 34 yrs, arteriovenous malformation 23 yrs, brain tumor 42 yrs, and cerebrovascular disease 54 yrs. 4. The most frequent seizure pattern of 161 patients was the generalized seizure in 126 cases (78.3%) followed by the partial elementary seizure in 29 case and the partial seizure with secondary generalization in 6 cases. The incidence of partial seizure was slightly higher than the generalized seizure in brain tumor and CNS infectious disease. 5. There were no correlation between the E.E.G. degree and causative factors of seizure.

A Study on the Seizures in Chronic Alcoholics

The authors reported and reviewed 7 cases of seizures among 53 chronic alcoholics who had been hospitalized in Kyung Hee University Hospital from Jan. 1, 1979 to Mar. 31, 1983. Case 1 was considered to be alcohol withdrawal seizure (so called "rum fit") in terms of it's clinical and laboratory findings. And other 6 cases, which had no past history of epilepsy and had been drinking alcoholic beverages for 9.6 years on the average before the appearances of seizures, were considered to belong to alcoholinduced seizures.