Epilepsy Care in Latin America and the Caribbean: Overcoming Challenges and Embracing Opportunities.

The burden of epilepsy in the Latin America and the Caribbean (LAC) region causes a profound regional impact on the health care system and significantly contributes to the global epilepsy burden. As in many other resource-limited settings worldwide, health care professionals and patients with epilepsy in LAC countries face profound challenges due to a combination of factors, including high disease prevalence, stigmatization of epilepsy, disparities in access to care, limited resources, substantial treatment gaps, insufficient training opportunities for health care providers, and a diverse patient population with varying needs. This article presents an overview of the epidemiology of epilepsy and discusses the principal obstacles to epilepsy care and key contributors to the epilepsy diagnosis and treatment gap in the LAC region. We conclude by highlighting various initiatives across different LAC countries to improve epilepsy care in marginalized communities, listing strategies to mitigate treatment gaps and facilitate better health care access for patients with epilepsy by enhancing the epilepsy workforce.

Implementing American Academy of Neurology Quality Measures in Antigua Using Quality Improvement Methodology.

Background and Objectives: The American Academy of Neurology has developed quality measures related to various neurologic disorders. A gap exists in the implementation of these measures in the different health care systems. To date, there has been no electronic health care record nor implementation of quality measures in Antigua. Therefore, we aimed to increase the percent of patients who have epilepsy quality measures documented using standardized common data elements in the outpatient neurology clinic at Sir Lester Bird Medical Center from 0% to 80% per week by June 1, 2022 and sustain for 6 months. Methods: We used the Institute for Health care Improvement Model for Improvement methodology. A data use agreement was implemented. Data were displayed using statistical process control charts and the American Society for Quality criteria to determine statistical significance and centerline shifts. Results: Current and future state process maps were developed to determine areas of opportunity for interventions. Interventions were developed following a "Plan-Do-Study-Act cycle." One intervention was the creation of a RedCap survey and database to be used by health care providers during clinical patient encounters. Because of multiple interventions, we achieved a 100% utilization of the survey for clinical care. Discussion: Quality improvement (QI) methodology can be used for implementation of quality measures in various settings to improve patient care outcomes without use of significant resources. Implementation of quality measures can increase efficiency in clinical delivery. Similar QI methodology could be implemented in other resource-limited countries of the Caribbean and globally.

Encefalopatías epilépticas y del desarrollo. ¿Que hay de nuevo? / Developmental and epileptic encephalopathy. What is new?

Resumen Este artículo no tiene como objetivo el presentar una descripción detallada de cada una de las encefalopatías epilépticas y del desarrollo, sino más bien discutir cam bios recientes en la terminología y criterios diagnósticos de ciertas encefalopatías, en base a una revisión actua lizada de los últimos 10 años. Se analizan cambios importantes en definiciones de síndromes específicos y nuevos tratamientos que han demostrado eficacia en el manejo de crisis convulsivas en estos pacientes. En conclusión: Las nuevas terapias de modulación genética, contribuirán no solo a reducir la carga de crisis epilépticas, sino también a mejorar el pronóstico cognitivo, y por lo tanto la calidad de vida.

Abstract It is not the intend of this article to present a de tailed description of each developmental and epileptic encephalopathy, but to discuss recent changes in the terminology and diagnostic criteria of specific disorders, based on an updated review of the last 10 years. Important changes in the definitions of specific syn dromes and new treatments that have shown efficacy in the management of seizures in these patients are analyzed. In conclusion: New gene modulation therapy will likely improve not only seizure frequency, but also cog nitive outcome and therefore quality of life.

[Developmental and epileptic encephalopathy. What is new?] / Encefalopatías epilépticas y del desarrollo. ¿Qué hay de nuevo?

It is not the intend of this article to present a detailed description of each developmental and epileptic encephalopathy, but to discuss recent changes in the terminology and diagnostic criteria of specific disorders, based on an updated review of the last 10 years. Important changes in the definitions of specific syndromes and new treatments that have shown efficacy in the management of seizures in these patients are analyzed. In conclusion: New gene modulation therapy will likely improve not only seizure frequency, but also cognitive outcome and therefore quality of life.

Este artículo no tiene como objetivo el presentar una descripción detallada de cada una de las encefalopatías epilépticas y del desarrollo, sino más bien discutir cambios recientes en la terminología y criterios diagnósticos de ciertas encefalopatías, en base a una revisión actualizada de los últimos 10 años. Se analizan cambios importantes en definiciones de síndromes específicos y nuevos tratamientos que han demostrado eficacia en el manejo de crisis convulsivas en estos pacientes. En conclusión: Las nuevas terapias de modulación genética, contribuirán no solo a reducir la carga de crisis epilépticas, sino también a mejorar el pronóstico cognitivo, y por lo tanto la calidad de vida.

Access to Pediatric Neurology Training and Services Worldwide: A Survey by the International Child Neurology Association.

Pediatric neurology is the medical subspecialty responsible for diagnosing and managing diseases and disorders of the nervous system in childhood and adolescence. In many, but not all, regions of the world, the discipline of pediatric neurology is recognized as a specialty or subspecialty of either neurology or pediatrics. Significant knowledge and competencies in this area are necessary to be effective in clinical practice. The need for this is driven by the high burden of disease from neurologic conditions in children and the effect on their families. As the first part of a multistaged project under the auspices of the International Child Neurology Association, in collaboration with key stakeholders, a survey was undertaken to establish which countries have practicing child neurologists. For those countries that have child neurologists, the survey established the number of practitioners and which countries have access to in-country child neurology training. Responses were obtained from 177 countries. Worldwide, there is a median of 0.07 and mean of 0.39 child neurologists per 100,000 population. The greatest deficits in child neurology specialists and access to training were evident in countries which fell under the World Bank rating of low-income country status (range of 0-0.008 child neurologists per 100,000 population). Seventy-three percent of low-income countries lack access to child neurologists: The majority are in the African and South-East Asia regions. For the population of 1.37 billion in the continent of Africa, there were 324 child neurologists, equating to a median of 0.01 per 100,000 population in comparison with a median of 0.59 child neurologists per 100,000 across high-income countries. Ninety-four countries had capacity to support in-country pediatric neurology training. Worldwide, there are inadequate numbers of child neurologists and a great need for increased training capacity.

Epilepsy care delivery during COVID-19 in resource-limited countries: A survey in collaboration with International Epilepsy Equity Group.

BACKGROUND: The impact of pandemic has had worse effects in countries with already stretched healthcare resources. study's The study aimed to explore changes in epilepsy care delivery in resource-limited countries during and since the acute phase of the COVID-19 pandemic. METHOD: A cross-sectional survey was conducted in 22 countries among healthcare providers (HCPs) caring for persons with epilepsy (PWE), in collaboration with newly formed global collaborators, the International Epilepsy Equity Group. Findings were compared based on the World Bank Ranking (WBR) and HCPs' practice type. Data were analyzed using Chi-square tests (α = 0.05) and pairwise multiple comparisons with α = 0.017 (Bonferroni adjustment). Open-ended responses were analyzed using thematic analysis. FINDINGS: A total of 241 HCPs participated in the study. Of these, 8.30%, 65.98%, and 21.99% were from high-income (HIC), upper-middle-income (UMIC), and lower-middle-income countries (LMICs), respectively. Among HCPs, 31.12% were adult specialists, and 43.98% were pediatric specialists. During the acute phase of the pandemic, HCPs reported that the major barrier for PWE was difficulty reaching physicians/healthcare providers. Except for difficulty reaching physicians/healthcare providers (WBR P = 0.01 HIC < LMIC), no other significant differences in barriers during the acute phase were observed. Since the acute phase of the pandemic, the major concern for PWE was fear of getting infected with the SARS-CoV-2 virus. Significant differences in concerns since the acute phase included lockdowns (WBR: P = 0.03 UMIC < LMIC), fiscal difficulties (WBR: P < 0.001 UMICs < LMICs, UMICs < HIC; practice type: P = 0.006 adult < others, pediatrics < others), clinic closure (WBR: P = 0.003 UMIC < HIC; practice type: P =< 0.001 adult < others, pediatric < others), and long waiting times (WBR: P = 0.005, LMIC < UMIC, LMIC < HIC; practice type: P = 0.006 pediatric < adults). Diagnostic services, including EEG, MRI, CT (practice type: P < 0.001, adult < others; pediatric < others), and lab work (WBR: P = 0.01 UMIC < HIC), were restricted. The telephone was the most reported teleconsultation method used. Except for SMS/texting (WBR P = 0.02 UMIC < LMIC), there were no significant differences in teleconsultation methods used. DISCUSSION: There is a high probability that the initial wave and consequent reduction of in-person care, restriction of health services, and fiscal difficulties affecting all involved in care delivery, led to the disruption of epilepsy care. Additional support are needed in resource-limited countries to cope with future pandemics.

Description of electroencephalographic data gathered using water-based medium-expansion foam as a depopulation method for nursery pigs.

The United States' swine industry is under constant threat of foreign animal diseases, which may emerge without warning due to the globalized transportation networks moving people, animals, and products. Therefore, having disease control and elimination protocols in place prior to pathogen introduction is paramount for business continuity and economic recovery. During extraordinary circumstances, it may become necessary to depopulate large populations of animals, including swine, as a disease containment measure. Currently approved depopulation methods for swine present significant logistical challenges when scaled to large populations or performed in field conditions. In the United States, water-based foam is currently approved for poultry depopulation, and recent field studies demonstrate water-based foam is an effective depopulation alternative for swine. While effective, the speed at which water-based foam induces loss of consciousness prior to death, a major welfare consideration, has not been adequately investigated. In this study, 12 nursery pigs were terminated using water-based medium-expansion foam to quantify the time to induce loss of consciousness and ultimately brain death. Each pig was implanted with subdermal electrodes to capture electroencephalographic data, placed in a body sling, and suspended in a plastic bulk container that was subsequently filled with water-based foam. Electroencephalographic data was recorded for 15 min, during which the pigs remained immersed in the water-based foam. Conservatively, average (± SD) time to unconsciousness and brain death was 1 min, 53 s ± 36 s and 3 min, 3 s ± 56 s, respectively. The relatively rapid loss of consciousness compared to other methods limits the amount of distress and is overall a positive finding for the welfare of the pigs that might be depopulated with water-based foam. The findings of this study add additional evidence supporting the use of water-based medium-expansion foam for an emergency depopulation of swine.

Prioritizing Hormone Therapy Over Vigabatrin as the First Treatment for Infantile Spasms: A Quality Improvement Initiative.

BACKGROUND AND OBJECTIVES: Infantile spasms (IS) are early childhood seizures with potentially devastating consequences. Standard therapies (adrenocorticotropic hormone [ACTH], high-dose prednisolone, and vigabatrin) are strongly recommended as the first treatment for IS. Although this recommendation comes without preference for one standard therapy over another, early remission rates are higher with hormone therapy (ACTH and high-dose prednisolone) when compared with vigabatrin. Using quality improvement (QI) methodology that included hormone therapy as the first treatment, we sought to increase the percentage of children with new-onset nontuberous sclerosis complex (TSC)-associated IS achieving 3-month electroclinical remission from a mean of 53.8% to ≥70%. METHODS: This was an observational consecutive sample cohort study at a single academic tertiary care hospital that compared a prospective intervention cohort (May 2019-January 2022, N = 57) with a retrospective baseline cohort (November 2015-April 2019, N = 67). Our initiative addressed key drivers such as the routine use of vigabatrin over hormone therapy as first treatment and the common initiation of a second treatment after 14 days for initial nonresponders. We included consecutive children without TSC presenting with new-onset IS diagnosed and treated between ages 2 and 24 months. We displayed our primary outcome and process measures as control charts in which the centerline is the quarterly (previous 3 months) mean based on statistical process control methodology. RESULTS: QI interventions that included the standardization of hormone therapy as the first treatment resulted in higher rates of 3-month remission, rising from 53.8% (baseline cohort) to 75.9% (intervention cohort). Process measure results included an increased rate of children receiving hormone therapy as first treatment (mean, 44.6%-100%) and a decreased number of days to both clinical follow-up after first treatment (mean, of 16.3-12.6 days) and starting a second treatment within 14 days for initial nonresponders (mean, 36.3-17.2 days). DISCUSSION: For children with IS, improved rates of 3-month electroclinical remission can be achieved with QI methodology. Implementation of similar QI initiatives at other centers may likewise improve local remission rates.

Child Neurology Care in Latin America: Challenges and Potential Solutions.

BACKGROUND: The current practice of child neurology in Latin America has been impacted by the waves of sociopolitical unrest that in the last decades have swept the region. METHODS: We searched the available literature referring to the situation of child neurology in Latin America and conditions that specifically impact the region. RESULTS: In lower-middle-income countries, the number of child neurologists is inadequate. Child neurologists working in large public hospitals can only afford to do so on a part-time basis as these institutions are chronically underfunded. Several circumstances are particularly relevant to Latin America: Spanish is the main language spoken, something that limits the opportunity to keep local child neurologists up to date. The structure of health care systems in Latin America varies significantly. Some countries have fragmented systems with inadequate capacity to offer equitable access to medical care. Latin America has been impacted by epidemics of arthropod-borne viruses: zika, chikungunya, and dengue. It stands to reason that the COVID-19 pandemic will affect the distribution of resources for chronic neurological conditions. CONCLUSIONS: The virtual platforms such as Zoom, expanded during the COVID-19 pandemic, are useful not only to improve access to care through telemedicine but also for educational purposes. Collaborative efforts to support educational courses and symposia in Spanish are ongoing. It is necessary to set short- and long-term priorities to improve child neurology care in the region. Immediate priorities should focus on improving the diagnosis of neurological conditions, making emphasis on locally available resources.

Improving time for administration of second-line antiseizure medications for children with generalized convulsive status epilepticus using quality improvement methodology.

OBJECTIVE: Status epilepticus is a life-threatening neurological emergency. However, delay in median time to administration of second-line antiseizure medication exists. The aim of this quality improvement initiative was to decrease the average delay before fosphenytoin is administered for pediatric patients with generalized convulsive status epilepticus from 30 min (baseline data collected in 2013) to 15 min (50% reduction) by December 2015 and sustain this for 1 year. METHODS: Our team conducted an analysis of baseline data for patients with continuous generalized convulsive status epilepticus who received fosphenytoin after receiving first-line benzodiazepine treatment. Using quality improvement methodology, areas for improvement were identified and specific interventions developed and implemented. A timeline of 15 min to initiate fosphenytoin administration after failure of first-line treatment was considered reasonable and achievable as a project aim. RESULTS: A total of 199 patients were included in the dataset for the project. The database included patients aged 1 month and older. Ninety-eight percent of patients were between 1 month and 19 years of age. The gender distribution was even, with 54% of patients being White or Caucasian, 30% African American or Black, and 16% classified as "other." From January 2014 through December 2019, the average time before initiating fosphenytoin administration after failure of benzodiazepine therapy, for patients with generalized convulsive status epilepticus, decreased from 30 min (SD = 45.7) to 11.4 min (SD = 8.2, p = .043), thus reducing time to administration by 62%. SIGNIFICANCE: Quality improvement methodology can be successfully applied to decrease administration time between first- and second-line antiseizure medications for status epilepticus.

A reliable interictal EEG grading scale for children with infantile spasms - The 2021 BASED score.

OBJECTIVE: To develop an improved interictal electroencephalogram (EEG) grading scale for children with infantile spasms founded on elements with adequate inter-rater reliability (IRR) to justify its further study for clinical and research purposes. METHODS: Three blinded reviewers assessed five-minute sleep epochs in 93 EEGs from 62 children (31 consecutive controls, 31 consecutive infantile spasms [pretreatment and posttreatment studies]) using a longitudinal bipolar montage. We determined the IRR of background amplitude, epileptiform discharges, >3 spike foci (including <50 % or >50 %), grouped multifocal spikes, paroxysmal voltage attenuations, and symmetry of sleep spindles. Data were used to finalize the 2021 BASED (Burden of AmplitudeS and Epileptiform Discharges) score. RESULTS: All elements included in the 2021 BASED score had moderate to near perfect IRR. Among controls, >200 µv background waves occurred commonly in the bilateral posterior temporal (T3-T5, T4-T6) and midline (Fz-Cz, Cz-Pz) regions. Excluding midline and occipital channels (which have normal high amplitude background waves), we designated abnormal high amplitude background waves as >200 µv for most channels, but >300 µv for T3-T5 and T4-T6. The IRR was moderate to near perfect for <50 % >3 spike foci, >50 % >3 spike foci, paroxysmal voltage attenuations, grouped multifocal spikes (GMFS), and symmetric sleep spindles. Paroxysmal voltage attenuations, GMFS, and >50 % >3 spike foci all significantly distinguished pretreatment from posttreatment studies whereas symmetric sleep spindles did not (as planned, the latter was not included in the 2021 BASED score). When the 2021 BASED score was applied to the 22 children with infantile spasms achieving clinical remission with treatment, 19 met criteria for electroclinical remission and three did not. SIGNIFICANCE: The 2021 BASED score includes elements with high levels of IRR and correlates well with the presence or absence of infantile spasms.

Electroencephalography Technologist Inter-rater Agreement and Interpretation of Pediatric Critical Care Electroencephalography.

OBJECTIVES: Electroencephalography (EEG) technologists commonly screen continuous EEG. Until now, the inter-rater agreement or sensitivity for important EEG findings has been unknown in this group. METHODS: Twenty-nine EEG technologists and three clinical neurophysiologists interpreted 90 five-minute samples of pediatric critical care EEG. Inter-rater agreement was examined with Cohen's kappa and Fleiss' kappa for EEG findings. A gold-standard consensus agreement was developed for examining sensitivity and specificity for seizures or discontinuity. Kruskal-Wallis tests with Benjamani-Hochberg corrections for multiple comparisons were utilized to examine associations between correct scoring and certification status and years of experience. RESULTS: Aggregate agreement was moderate for seizures and fair for EEG background continuity among EEG technologists. Individual agreement for seizures and continuity varied from slight to substantial. For individual EEG technologists, sensitivity for seizures ranged from 44 to 93% and sensitivity for continuity ranged from 81 to 100%. Raters with Certified Long Term Monitoring credentials were more likely to identify seizures correctly. SIGNIFICANCE: This is the first study to evaluate inter-rater agreement and interpretation correctness among EEG technologists interpreting pediatric critical care EEG. EEG technologists demonstrated better aggregate agreement for seizure detection than other EEG findings, yet individual results and internal consistency varied widely. These data provide important insight into the common practice of utilizing EEG technologists for screening critical care EEG.

Long-term Risks of Recurrent Febrile Seizures.

Investigators from Denmark at Aarhus University studied the long-term risk of epilepsy, psychiatric disorders, and mortality among children with recurrent febrile seizures.

Compliance With Standard Therapies and Remission Rates After Implementation of an Infantile Spasms Management Guideline.

BACKGROUND: We implemented an infantile spasms management guideline recommending standard therapies and, early start of next treatment. After six years, we determined (1) our compliance with standard therapies, (2) time to next treatment, and (3) rate of initial and three-month electroclinical remission with first, second, and third treatments. METHODS: This is a retrospective record review of newly diagnosed spasms from September 2012 to September 2018, with the onset age of two months to two years. RESULTS: Standard therapies (hormone or vigabatrin) were the first treatments in 114 of 115 consecutive patients. The second and third treatments were started within 14 days of failed treatment in only 21% and 24%, respectively. Remission with the first and second treatments was similar (41% and 40%). Remission was lower for the third treatment (15%), although higher if standard therapy was used (36%). Initial and three-month remission by the first treatment was significantly higher for adrenocorticotropic hormone (ACTH, 66% and 79%, respectively) and prednisolone (53% and 83%, respectively) than for vigabatrin (19% and 40%, respectively). There were no significant differences in patient characteristics or rates of remission between ACTH and prednisolone. CONCLUSIONS: Although we achieved excellent compliance with standard therapies as initial treatment, a next treatment often started after two weeks. Given the superiority of hormone therapies over vigabatrin and standard therapies over nonstandard therapies, as well as the potentially negative impact of delays in effective treatment, future interventions need to focus on increasing the use of hormone over vigabatrin (for patients without tuberous sclerosis complex), use of standard therapies as second and third treatments, and reducing delays to next treatment.

Seizure Characteristics, Outcome, and Risk of Epilepsy in Pediatric Anti-N-Methyl-d-Aspartate Receptor Encephalitis.

BACKGROUND: We identified seizure characteristics, long-term outcome, and predictors of persistent seizures in children with anti-N-methyl-d-aspartate receptor (anti-NMDAR) encephalitis. METHOD: Data were analyzed from patients with anti-NMDAR encephalitis who presented with seizures at our center between August 2012 and June 2018. RESULTS: Sixty-two of 86 patients with anti-NMDAR encephalitis experienced seizures. Seizures occurred within two weeks of disease onset in 58 of 62 (93.6%) patients; 36 of 62 (58.1%) had seizures as the initial symptom. Males were more likely to exhibit seizures as the initial symptom (P = 0.039). More than a quarter of patients (17 of 62, 27.4%) manifested two or more seizure types. Focal seizures were the most common (46 of 62, 74.2%). Status epilepticus occurred in 27 of 62 (43.5%) patients, and nonconvulsive status epilepticus, in two of 62 (3.2%) patients. No patient developed refractory status epilepticus. No systemic tumors were found. Electroencephalographic abnormalities included background slowing (77.4%), absence of a posterior dominant rhythm (62.9%), interictal epileptic discharges (50.0%), and extreme delta brush (6.5%). In the acute phase, 45 patients (45 of 62, 72.6%) received antiepileptic drugs. Persistent seizures occurred in only five of 62 (8%) patients. On univariate analysis, status epilepticus and combination antiepileptic drug treatment were associated with persistent seizures, but neither independently predicted persistent seizures. CONCLUSIONS: Multiple seizure types may develop at any stage of anti-N-methyl-d-aspartate receptor encephalitis. Refractory status epilepticus, systemic tumors, and extreme delta brush in electroencephalography are rare in pediatric patients. Anti-NMDAR encephalitis-associated seizures appear to have good prognosis, without the need for long-term antiepileptic drug treatment.

[New antiepileptic drugs]. / Nuevos fármacos antiepilépticos.

Antiepileptic drugs are the first treatment option in patients with epilepsy. Drugs developed after 2000 are known as third generation antiepileptic drugs. These medications offer new mechanisms of action and favorable pharmacokinetics, decreasing the occurrence of side effects and drug-drug interactions. Broad spectrum antiepileptic drugs, such as brivaracetam and clobazam are good choices for generalized tonic colonic seizures and are well tolerated.New sodium channel blockers such as lacosamide and eslicarbazepine, have a more "benign" side effect profile than the first or second generation of sodium channel blockers. These new drugs are useful therapies in patients with epilepsy of difficult control. Cannabidiol and fenfluramine are useful in the treatment of Dravet or Lennox Gastaut syndrome. Allopregnenolona and ganaxolone showed good efficacy in status epilepticus and could play an important future role in this clinical scenario.

Los fármacos antiepilépticos constituyen el tratamiento inicial en pacientes con epilepsia. Los antIepilépticos producidos después del año 2000 se conocen como fármacos de tercera generación. Estas drogas ofrecen nuevos mecanismos de acción y una farmacocinética más favorable, minimizando efectos adversos o interacciones medicamentosas. Las drogas de amplio espectro como brivaracetam y clobazam son una buena opción en casos de crisis generalizadas y poseen un grado de tolerabilidad muy aceptable. Los nuevos antiepilépticos bloqueadores de canales de sodio, como lacosamida y eslicarbazepina tienen un perfil de efectos adversos más favorable que los bloqueadores de sodio de primera o segunda generación. Estos nuevos medicamentos pueden utilizarse en pacientes con epilepsia de difícil control. Cannabidiol y fenfluramina son muy útiles en el tratamiento del síndrome de Dravet o Lennox Gastaut. La Alopregnenolona y ganaxolona demuestran buena eficacia en casos de estado epiléptico y podrían en el futuro cercano tener un papel importante en este escenario clínico.

Nuevos fármacos antiepilépticos / New antiepileptic drugs

Los fármacos antiepilépticos constituyen el tratamiento inicial en pacientes con epilepsia. Los antIepilépticos producidos después del año 2000 se conocen como fármacos de tercera generación. Estas drogas ofrecen nuevos mecanismos de acción y una farmacocinética más favorable, minimizando efectos adversos o interacciones medicamentosas. Las drogas de amplio espectro como brivaracetam y clobazam son una buena opción en casos de crisis generalizadas y poseen un grado de tolerabilidad muy aceptable. Los nuevos antiepilépticos bloqueadores de canales de sodio, como lacosamida y eslicarbazepina tienen un perfil de efectos adversos más favorable que los bloqueadores de sodio de primera o segunda generación. Estos nuevos medicamentos pueden utilizarse en pacientes con epilepsia de difícil control. Cannabidiol y fenfluramina son muy útiles en el tratamiento del síndrome de Dravet o Lennox Gastaut. La Alopregnenolona y ganaxolona demuestran buena eficacia en casos de estado epiléptico y podrían en el futuro cercano tener un papel importante en este escenario clínico.

Antiepileptic drugs are the first treatment option in patients with epilepsy. Drugs developed after 2000 are known as third generation antiepileptic drugs. These medications offer new mechanisms of action and favorable pharmacokinetics, decreasing the occurrence of side effects and drug-drug interactions. Broad spectrum antiepileptic drugs, such as brivaracetam and clobazam are good choices for generalized tonic colonic seizures and are well tolerated.New sodium channel blockers such as lacosamide and eslicarbazepine, have a more "benign" side effect profile than the first or second generation of sodium channel blockers. These new drugs are useful therapies in patients with epilepsy of difficult control. Cannabidiol and fenfluramine are useful in the treatment of Dravet or Lennox Gastaut syndrome. Allopregnenolona and ganaxolone showed good efficacy in status epilepticus and could play an important future role in this clinical scenario.