Abordagem inicial e manejo das crises epilepticas na emergência / Initial approach and management of epileptic crises in emergency

Frequentemente somos confrontados com pacientes em crises convulsivas nas unidades de atendimento emergencial. Em sua grande maioria, quando chegam à emergência, geralmente as crises já cederam. Ao se deparar com recorrência de crises frequentee e seu estágio ainda mais grave, as crises que não cessam (Status Epilepticus), é essencial reconhecer esta emergência médica e abordá-la de maneira correta.

Frequently, patients with recurrent, often continuous seizures are seen at the Emergency Room. In most, the attacks have ceased before arriving at the ER, and management should contemplate diagnosis of the reason for the attack or seizure recurrence. When faced with Status Epilepticus, one of the worst outcomes a seizure can have, it is essential to recognize it as a medical emergency and approach it correctly.

An 18-year follow-up of seizure outcome after surgery for temporal lobe epilepsy and hippocampal sclerosis.

OBJECTIVES: To evaluate the very long-term clinical outcome of surgery for mesial temporal lobe epilepsy and unilateral hippocampal sclerosis (MTLE/HS) without atypical features. The impact of surgical technique and postoperative reduction of medication on this outcome was investigated. DESIGN: Prospective longitudinal cohort follow-up study for up to18 years. SETTING: Epilepsy surgery centre in a university hospital. PATIENTS: 108 patients who underwent unilateral MTLE/HS. INTERVENTION: Surgery for MTLE/HS. MAIN OUTCOME MEASURE: Engel classification (I). Clinical evaluations were based on systematic interviews in person or by phone. Kaplan-Maier survival curves estimated the probability of remaining seizure free. The impact of medication management in the postoperative outcome was analysed using Cox regression. RESULTS: The probability of remaining completely seizure-free at 12 and 18 years after MTLE/HS surgery was 65% and 62%, respectively. The risk of having any recurrence was 22% during the first 24 months and increased 1.4% per year afterwards. Type of surgical technique (selective amygdalohippocampectomy vs anterior temporal lobectomy) did not impact on outcome. Remaining on antiepileptic drugs and history of generalised clonic seizure diminished the probability of remaining seizure free. CONCLUSIONS: MTLE/HS surgery is able to keep patients seizure free for almost up to two decades. Removal of the neocortex besides the mesial portion of the temporal lobe does not lead to better chances of seizure control. These findings are applicable to the typical unilateral MTLE/HS syndrome and cannot be generalised for all types of TLE. Future longitudinal randomised controlled studies are needed to replicate these findings.

Tratamento medicamentoso da hipertensão / Pharmacological treatment of hypertension

A hipertensão arterial sistêmica (HAS) afeta cerca de 30% da população adulta mundial. Pode ser definida como a elevação persistente da pressão arterial (PA) acima de 140/90 mmHg. Em cerca de 5-10% dos hipertensos, identifica-se uma causa secundária de HAS. Contudo, a maioria dos pacientes apresenta o que chamamos de HAS essencial ou primária. As medidas não-farmacológicas para controle de HAS incluem redução de peso, redução de consumo de sal e bebidas alcoólicas, aumento do consumo de frutas e verduras e prática de atividade física regular. O tratamento medicamentoso deve ser individualizado conforme a raça, idade, clínica e risco cardiovascular.

Arterial Hypertension (AH) affects nearly 30% of the world wide population. It can be defined as persistent blood pressure elevation over 140/90 mmHg. In nearly 5-10% of the hypertensive patients, one can identify a secondary cause of HA, however, the most patients have what we define as primary or essential HA. Non-pharmacological treatment for AH control include weight loss, reduction of salt and alcohol intake, increased consumption of fruits and vegetables and regular physical activity. The pharmacological treatment must be individualized according to ethnicity, age, clinic, and cardiovascular risk.