[Psychogenic non-epileptic seizures]. / Psykogene ikke-epileptiske anfall.

BACKGROUND: Psychogenic non-epileptic seizure is the term used for epilepsy-like seizures assumed to have psychological causes. Many patients with such seizures are misdiagnosed with epilepsy, and are consequently treated with antiepileptic drugs for many years. Assessment of a thorough medical history and ictal EEG-recordings will lead to the right diagnosis in most cases. The article provides an overview of this condition, which often represents large diagnostic and therapeutic challenges and is the most frequent differential diagnosis in epilepsy. MATERIAL AND METHODS: The article is based on literature identified through a non-systematic search in PubMed up to January 2009. RESULTS: Much literature is available in the field. 10-20 % of those referred to epilepsy centers because of therapy-resistant epilepsy, have psychogenic non-epileptic seizures. 70-80 % of these patients are women. The attacks may resemble all types of epileptic seizures, from absence-like episodes to tonic-clonic-like seizures. INTERPRETATION: Such seizures may have a wide spectre of causes, including chronic psychological conflicts and psychotraumas. Treatment should therefore be tailored to individuals.

[Epilepsia partialis continua (Kojevnikov's syndrome)]. / Epilepsia partialis continua (Kojevnikovs syndrom).

BACKGROUND: Lesions close to the central sulcus may give rise to focal motor seizures of long duration. This condition is called epilepsia partialis continua (Kojevnikov's syndrome). MATERIAL AND METHODS: Over the last two years, the National Centre for Epilepsy in Norway has treated 12 patients with epilepsia partialis continua. We discuss the occurrence, etiologies, semiology, findings from supplementary investigations, and therapeutic options on the basis of relevant literature and our own experience with these patients. RESULTS AND INTERPRETATION: Morphological lesions were found in 10 out of these 12 patients; cortical dysplasia in 3 patients, brain tumour in 2 patients, cerebral infarction in 2 patients, Rasmussen syndrome in 2 patients, and cerebral haemorrhage from an arteriovenous malformation in 1 patient. 9 patients had intermittent periods of jerking lasting from some hours to several days; the remaining 3 had permanent jerks. One of them had had this condition for 44 years. In 11 patients the jerks were localised to the face and/or the hand. The effect of antiepileptic drugs was disappointing; none became seizure-free. Five patients had undergone surgery. Surgical lesionectomy in this brain area is associated with a high risk of damage to eloquent cortex, but multiple subpial transections may have a seizure-blocking effect. One patient with Rasmussen's syndrome became seizure-free after a functional hemispherotomy.

Levetiracetam in adult patients with and without learning disability: focus on behavioral adverse effects.

Optimal antiepileptic drug treatment in patients with learning disability (LD) represents a particular challenge. These patients are often unable to report toxicity, and side effects may manifest as behavioral problems. The aim of this open study was to compare efficacy and tolerability of levetiracetam (LEV) in patients with LD and those without LD. One hundred eighty-four consecutive adult patients who received LEV were followed for an average of 8.1 months. Fifty-six patients (30%) had LD. Thirty-nine percent of patients with refractory epilepsy (37% with and 40% without LD) had > 50% seizure reduction. Significantly more behavioral side effects (23% vs 10%) and a tendency toward less reported somatic central nervous side effects were found in the LD group. We conclude that LEV is equally effective and well tolerated in both patients with LD and patients without LD. However, behavioral problems are more frequent in patients with LD, whereas the tendency toward seizure increase is not enhanced.

[Levetiracetam in the treatment of epilepsy]. / Levetiracetam i behandlingen av epilepsi.

BACKGROUND: A proportion of patients with epilepsy are still without seizure control. This open study aims to evaluate the effect and tolerability in consecutive patients treated with the new antiepileptic drug levetiracetam. MATERIALS AND METHODS: 184 adult patients were followed up for an average period of 8.1 months. 166 patients (90%) had refractory epilepsy, defined as having seizures more than once a month despite having tried at least two antiepileptic drugs. RESULTS: 64 (39%) of the patients with refractory epilepsy had at least a 50% reduction of seizure frequency. Of these, 16 (10%) became seizure free. 24 (15%) had at least a 25% increase in seizure frequency. The overall effect was not significantly different for patients with and without learning disability. Levetiracetam also had promising effects in patients with juvenile myoclonic epilepsy and Lennox-Gastaut syndrome. Side effects were reported by 88 (44%) of all patients. Only 10 (5%) discontinued levetiracetam because of side effects. Behavioural effects were more frequent in patients with learning disability. INTERPRETATION: Levetiracetam was well tolerated and effective as add-on treatment in partial and generalised seizures. Some patients experienced an increase in seizure. A possible favourable pharmacodynamic interaction between levetiracetam and carbamazepine should be further explored.

Vagal nerve stimulation--the Norwegian experience.

The purpose of this open retrospective study was to analyze the efficacy and tolerability of vagal nerve stimulation (VNS) in a Norwegian cohort of referral patients with refractory epileptic seizures. A total of 47 patients have been assessed after a mean follow-up time of 2.7 years. Mean age was 34.4 years, mean duration of epilepsy was 25.3 years. Forty-two patients (89%) had localization-related epilepsy, 36 patients (77%) had daily seizures. The patients had tried on average 9.5 antiepileptic drugs, and 12 patients (26%) had undergone epilepsy surgery. Sixteen patients (34%) had >50% reduction of seizure frequency with VNS, of which one patient became seizure free. The stimulation was generally well tolerated, but three patients requested the device removed because of troublesome side effects. We conclude that VNS is an efficacious and safe mode of treatment that should be offered to patients with medically and surgically refractory seizures.

A paradoxical effect of levetiracetam may be seen in both children and adults with refractory epilepsy.

The aim of this prospective, uncontrolled clinical study was to evaluate the tolerability and the efficacy of levetiracetam as add-on treatment in 78 adults and 44 children with intractable epilepsy. The patients' seizure frequency in the 8 weeks baseline period was compared to their seizure frequency after a mean follow-up of 8 months of treatment.A greater than 50% reduction in seizure frequency was achieved in 31 adults (40%) and 9 children (20%), of whom 7 adults (9%) and 3 children (7%) became seizure free. Most often levetiracetam was well tolerated, somnolence being the most frequently reported side effect (18% in adults and 7% in children). However, in 14 adults (18%) and 19 children (43%) levetiracetam was associated with an increase (>25%) in seizure frequency. Such a paradoxical effect, including the development of status epilepticus in three adults and four children, appeared most often in mentally retarded patients during the first 2 months of treatment, and on relatively high doses. Two children developed status epilepticus after 5 and 7 months, respectively. In conclusion, levetiracetam is usually well tolerated as add-on treatment in patients with difficult-to-treat partial onset seizures. By using a lower initial dose and a slower dose escalation than recommended by the manufacturer, a paradoxical effect may perhaps be avoided. In children, doses >20 mgkg(-1) per day should be introduced with caution.

[Epilepsy and death]. / Epilepsi og plutselig død.

BACKGROUND: The risk of premature death in the epilepsy population is estimated to be two or three times of that in the general population. Premature death is partly a consequence of the aetiology of the epilepsy (tumours, infections, cerebrovascular insults etc.), partly a direct or indirect consequence of a seizure: head trauma, drowning, traffic accident, suicide, status epilepticus, and sudden unexpected death in epilepsy (SUDEP). MATERIAL AND METHODS: On the basis of a review of the current literature on sudden unexpected death in epilepsy, we discuss incidence, risk factors and the assumed pathophysiological mechanisms. RESULTS: Most of these deaths are probably seizure-related. Among patients between 20 and 45, sudden unexpected death is the most frequently occurring epilepsy-related cause of death. In patients with refractory epilepsy, sudden unexpected death comprises about 10% of deaths; the incidence is about 1:200-300 per year. Risk factors are symptomatic epilepsy, tonic-clonic seizures, early onset of the epilepsy, polytherapy, and non-compliance. Ictal central apnoe or ictal fatal cardioarrhythmia are probably the most plausible explanations for these deaths. INTERPRETATION: Some of these deaths may be prevented by better seizure control. Patients and their families should be given balanced information about this potential outcome. Family members should learn first aid and resuscitation.