All pts with unexplained new-onset seizures should have a brain imaging study (MRI or CT) to search for an underlying structural abnormality; the only exception may be children who have an unambiguous history and examination suggestive of a benign, generalized seizure disorder such as absence epilepsy. Newer MRI methods have increased the sensitivity for detection of abnormalities of cortical architecture, including hippocampal atrophy associated with mesial temporal sclerosis, as well as abnormalities of cortical neuronal migration.
Treatment: Seizures and Epilepsy - Acute management of seizures
- - Pt should be placed in semiprone position with head to the side to avoid aspiration.
- - Tongue blades or other objects should not be forced between clenched teeth.
- - Oxygen should be given via face mask.
- - Reversible metabolic disorders (e.g., hypoglycemia, hyponatremia, hypocalcemia, drug or alcohol withdrawal) should be promptly corrected.
- - Treatment of status epilepticus is discussed in Chap. 22. Status Epilepticus.
- Longer-term therapy includes treatment of underlying conditions, avoidance of precipitating factors, prophylactic therapy with antiepileptic medications or surgery, and addressing various psychological and social issues.
- Choice of antiepileptic drug therapy depends on a variety of factors including seizure type, dosing schedule, and potential side effects (Tables 181-5 and 181-6).
- Therapeutic goal is complete cessation of seizures without side effects using a single drug (monotherapy) and a dosing schedule that is easy for the pt to follow.
- - If ineffective, medication should be increased to maximal tolerated dose based primarily on clinical response rather than serum levels.
- - If still unsuccessful, a second drug should be added, and when control is obtained, the first drug can be slowly tapered. Some pts will require polytherapy with two or more drugs, although monotherapy should be the goal.
- - Pts with certain epilepsy syndromes (e.g., temporal lobe epilepsy) are often refractory to medical therapy and benefit from surgical excision of the seizure focus.
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For a more detailed discussion, see Lowenstein DH: Seizures and Epilepsy, Chap. 445, p. 2542, in HPIM-19. |