Diagnostiquer une crise d’épilepsie chez la personne âgée peut s’avérer délicat étant donné la multiplicité des diagnostics différentiels (accident ischémique transitoire, syncopes, ictus ...amnésiques…) et la présentation parfois trompeuse des manifestations épileptiques (état confusionnel, manifestations cognitives ou comportementales, paralysie postcritique prolongée…). La difficulté diagnostique est donc réelle et impose une stratégie commune aux gériatres et neurologues impliquant tout à la fois une connaissance des pièges et spécificités de la clinique des crises chez le sujet âgé et un raisonnement épileptologique spécifique non plus basé sur la seule classification syndromique mais sur un raisonnement plus général tenant compte de la comorbidité et de la prise en charge globale du patient : raisonner en termes de crises et non plus de syndromes épileptiques. Un groupe de réflexion multidisciplinaire sur l’épilepsie du sujet âgé s’est constitué et a établi à partir d’une revue exhaustive de la littérature et d’une réflexion d’experts un score électro-radioclinique visant à aider et orienter le diagnostic de crise d’épilepsie chez le sujet âgé. Ce score électro-radioclinique, proposant quatre degrés de plausibilité diagnostique, requiert une validation clinique vérifiant la pondération de chaque élément décisionnel, pour pouvoir être diffusé et utilisé par les différents praticiens concernés. Il s’agit dans l’immédiat d’un outil de travail dont la diffusion facilitera l’expertise.
Diagnosis of epileptic seizure may be difficult in older patients because seizure manifestations are often unusual: confusion, paresis… and because there are multiple differential diagnoses (syncope, transient ischemic attack, transient global amnesia…). To promote and facilitate the diagnosis of seizures in the elderly, neurologists and gerontologists must work together and focus their strategy on two points: firstly, the knowledge of the specific presentation of seizures in elderly patients, and secondly, the adoption of a reasoning based on seizures and not epileptic syndromes. A multidisciplinary group worked on epilepsy of the elderly to elaborate an electro-clinical score which aims to help establish the diagnosis of epilepsy in elderly patients in different clinical settings. This electro-clinical score is based on a systematic review of scientific literature and the recommendations are explicitly linked to supporting evidence. Further, clinical validation of the electro-clinical score is required.
To determine prospectively the efficacy of hyperventilation (HV) to activate epileptic seizures and the contribution of antiepileptic drug tapering.
Eighty patients with proven epilepsy and referred ...for long-term video-EEG monitoring were consecutively enrolled from November 2007 to December 2008. A seizure was considered as 'activated' if it occurred during HV or within 5 min after completion. The rate of activated seizures (number of seizures/h) was compared with the rate of spontaneous seizure. The authors finally compared the effect of HV before and during antiepileptic drug (AED) tapering.
The authors analysed 247 days of monitoring. Among 52 recorded seizures, 18 were activated by HV. The rate of activated seizure was nine times higher than the rate of control seizures (p=0.001). In the subgroup of patients with no AED tapering, there was no significant activating effect of HV on seizures. In the subgroup undergoing AED tapering, the effect of HV was not significant before (p=0.257) but very significant during AED tapering (p<0.004).
The findings confirm that hyperventilation is efficient to activate epileptic seizures in epileptic patients referred for long-term video-EEG monitoring and that this activating effect is mainly related to the potentiating effect of AED tapering. Repeated HVs combined with AED tapering increase the rate of recorded seizures and the diagnostic yield of daytime video-EEG monitoring.
Diagnosis of epileptic seizure may be difficult in older patients because seizure manifestations are often unusual: confusion, paresis... and because there are multiple differential diagnoses ...(syncope, transient ischemic attack, transient global amnesia...). To promote and facilitate the diagnosis of seizures in the elderly, neurologists and gerontologists must work together and focus their strategy on two points: firstly, the knowledge of the specific presentation of seizures in elderly patients, and secondly, the adoption of a reasoning based on seizures and not epileptic syndromes. A multidisciplinary group worked on epilepsy of the elderly to elaborate an electro-clinical score which aims to help establish the diagnosis of epilepsy in elderly patients in different clinical settings. This electro-clinical score is based on a systematic review of scientific literature and the recommendations are explicitly linked to supporting evidence. Further, clinical validation of the electro-clinical score is required.
Although frequently investigated in the general population, the epidemiology of insomnia complaints and their treatment have received little attention in general practice. This study recruited ...patients ≥15 years of age, consecutively, from 127 general practitioners in France. The physicians collected data from 11,810 of their patients, of whom 55.5% were women. Insomnia complaints were reported by 26.2% (25.4% to 27%) of the sample and use of sleep-promoting medication by 10.1% (9.7% to 10.7%). About 47% of the prescribed drugs used were anxiolytics and 45% hypnotics. Most consumers took sleep-enhancing drugs on a daily and long-term basis and most reported that the medication improved their quality of sleep. However, few distinctions emerged between elderly drug-taking insomniacs and elderly nontreated insomniacs with respect to the various dimensions of sleep. Results underscore the persistent general tendency among French general practitioners to overprescribe anxiolytics for the treatment of insomnia complaints and that they do so on a long-term basis, despite the findings of numerous studies showing that benzodiazepines are ineffective in the treatment of sleep complaints over the long term.
Purpose: To assess the comparative effectiveness, efficacy, and tolerability of lamotrigine (LTG) and sustained‐release carbamazepine (CBZ) in the treatment of newly diagnosed epilepsy in the ...elderly.
Methods: Patients aged 65 years or older, who had experienced at least two unprovoked partial and/or generalized tonic–clonic seizures, were randomized to receive LTG (n = 93) or CBZ (n = 92) according to a multicenter double‐blind, parallel‐group design. Trial duration was 40 weeks and included a 4‐week dose escalation followed by a maintenance phase during which dosages could be adjusted according to response. Initial, maintenance and maximum dosages were 25 mg, 100 mg, and 500 mg per day for LTG, and 100 mg, 400 mg, and 2,000 mg per day for CBZ, respectively. The primary end point was retention in the trial.
Results: In the LTG group, 68 patients (73%) completed the 40‐week study period compared with 61 (67%) in the CBZ group, a nonsignificant difference. Time to withdrawal from any cause did not differ between groups (p = 0.34). The number of subjects who completed the 40‐week period and were seizure free in the last 20 weeks was 48 (52%) in the LTG group and 52 (57%) in the CBZ group. Adverse events leading to withdrawal occurred in 13 (14%) subjects in the LTG group and 23 (25%) subjects in the CBZ group.
Conclusion: LTG and CBZ showed comparable effectiveness, with a trend for higher seizure‐free rates for CBZ and better tolerability for LTG. Differences in outcome compared with previous trials may be related to different dosing rates and use of a sustained‐release formulation for CBZ.
Éducation thérapeutique et information Vespignani, H.; Beaussart, J.; Ducrocq, X. ...
Revue neurologique,
6/2004, Letnik:
160
Journal Article, Conference Proceeding
Recenzirano
Les auteurs montrent que l’éducation thérapeutique du malade présentant des crises épileptiques et de son entourage est nécessaire, mais non encore organisée en particulier en cas d’épilepsie ...pharmaco-résistante. Les objectifs de cette éducation thérapeutique sont détaillés à partir des constats existants et des besoins. Les auteurs précisent l’exigence d’un abord global subjectif autant qu’organique intégrant des dimensions psychosociales et le vécu du patient. La nécessité d’une formation spécifique des médecins et autres professionnels de santé est soulignée dans l’attente d’un statut de l’éducation thérapeutique. Les auteurs proposent un projet d’éducation thérapeutique d’un malade atteint d’une épilepsie pharmaco-résistante.
The authors show that therapeutic education of the epileptic patient and his proxies is necessary but not yet organized for drug-resistant epilepsy; the objectives of this education are detailed after looking at the current status and the needs. The authors insist on the necessity of a global consideration of the patient: subjective and organic as well, taking into account the psychological and social dimensions and the experiences of the patient. The need of a specific formation for the physician and other Health workers is emphasized, awaiting a status for therapeutic education. The authors propose a project of therapeutic education of the patient suffering from drug-resistant epilepsy.
We report the MR imaging findings in a 20 year old woman with status epilepticus of more than 3 months duration following an episode of lymphocytic meningitis. Repeated MR examinations showed ...progressive symmetrical cortical lesions, followed by subcortical and basal ganglia lesions which evolved to cortical laminar necrosis and hemorrhagic necrosis with eventual subcortical cerebral atrophy. This case has similarities with animal status epilepticus models. Biological investigations were all negative. This suggests that the brain lesions may be related to the prolonged status epilepticus.
Semiologic Value of Ictal Autoscopy Maillard, Louis; Vignal, Jean Pierre; Anxionnat, Rene ...
Epilepsia (Copenhagen),
April 2004, Letnik:
45, Številka:
4
Journal Article
Recenzirano
Odprti dostop
Purpose: Autoscopy is a pathologic perception of one's body or one's face image within space, either from an internal (“as in a mirror”) or from an external (“out‐of‐body experience”) point of view. ...Among various psychiatric and neurologic disorders, partial epilepsy is the main etiology. However, the significance of this rare ictal symptom remains controversial. We report this phenomenon in three epilepsy patients and discuss its semiologic value and neuropsychological significance.
Methods: Interictal EEG and/or video‐EEG monitoring was performed, as well as neuropsychological examination and cerebral magnetic resonance imaging (MRI).
Results: The three patients had a lesion involving, or limited to, the right parietal region on cerebral MRI. All three patients experienced autoscopy associated with other ictal signs supporting a right parietal lobe origin of seizures. In one patient, seizure origin was documented with video and surface EEG ictal recordings.
Conclusions: Autoscopy was shown to have an ictal mechanism and was associated with seizures arising from the nondominant parietal region. We hypothesize that ictal autoscopy may result from disruption of the normal integration of body representation.
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