Gabapentin in late-onset poststroke seizures

Stroke is a frequent cause of epileptic seizures (ES) in adults. The authors evaluated the long-term efficacy and tolerability of gabapentin (900 to 1,800 mg/day) in 71 patients with a first poststroke late ES during a mean follow-up time of 30 months. ES recurred in 18.3% of the patients and side effects were noted in 27 cases (38%), but only two (2.8%) required discontinuation or early withdrawal. Gabapentin monotherapy was useful and safe for late poststroke ES.

[Advances in the treatment of epilepsy: status epilepticus]

OBJECTIVE

The complexity of the treatment of status epilepticus (SE) is due to the wide variety of forms of clinical presentation. In this review we wish to emphasize that satisfactory management of SE requires a system which takes account of the successive phases of the gravity of the electroclinical course of SE and the different types of SE according to the electroclinical semiology of the seizure.

DEVELOPMENT

The concepts and classifications which, in current epileptology, are used in SE are mainly based on criteria developed at three international symposia: in Marseilles in 1962 and Santa Monica, California, in 1979 and 1997. Current knowledge permits distinction of different therapeutic periods depending on the chronology of each SE and to classify the SE according to the type of seizures, age of the patient and underlying pathology.

CONCLUSIONS

The classifications described permit the standardization of treatment: preventive measure in high-risk patients; immediate and in situ treatment during the prodromal phase; three parallel lines of action--differential diagnosis, general measures and antiepileptic treatment--during the initial phase; measures in hospital emergencies and in the Intensive Care Unit when the SE is at a fully established phase; special measures, including induction of anaesthesia in the refractory phase; transition to long-term treatment, recovery of autonomy by the patient and long-term management in the phases following remission of the SE. The standardization proposed may perhaps serve as a basis for the future development of guidelines.

[Withdrawal of antiepileptic treatment in adults]

INTRODUCTION

The withdrawal of antiepileptic treatment is a major challenge for the epileptologist who has to make a decision involving two risks, namely long term maintenance of drug treatment and recurrence of the seizures.

OBJECTIVE

In our review we wish to systematize the process of decision-making and calculation of the possibilities of recurrence.

DEVELOPMENT

First we review the factors to be considered when making a decision. This is complex since epileptics are a very heterogeneous group of patients. We emphasize the respect due to the patient who, in the end, is the one who assumes the risk involved. Then we consider the factors to be taken into account when calculating the individual's possibilities of having a recurrence and describe a theoretical outline of non-recurrence. Finally, we give details of the practical aspects of withdrawal of treatment.

CONCLUSIONS

We emphasize that the current challenge in this field is to design a method of measuring risks to permit the prediction of probabilities of recurrence in individual patients. We quote examples of the classification and measurement of risks, and suggest that only by institutional measures--perhaps by organizations such as LECE--can further essential epidemiological studies, of great scientific interest in the long term, be carried out.

[The treatment of epilepsy. A therapeutic guide of the Catalan Society of Neurology]

INTRODUCTION

There have been major advances in the treatment of epilepsy over the past ten years, leading to marked changes in the way this illness is treated. However, the introduction of new drugs and new non-drug treatments have led to uncertainty in the medical profession with regard to their exact indications. For this reason, a group of neurologists of the Catalan Society of Neurology have drawn up guide-lines for the treatment of epilepsy.

DEVELOPMENT

A panel of eight neurologists with a special interest in the diagnosis and treatment of epilepsy reviewed the literature to assess the data available regarding the treatment of epilepsy. A joint document was drawn up describing the basic rules for the use of antiepileptic drugs and the indications for other non-drug treatments.

CONCLUSION

This document is an approved therapeutic guide to the treatment of epilepsy.

[Monotherapy with gabapentin ++]

INTRODUCTION AND OBJECTIVE

Gabapentin is an anti-epileptic drug approved in the USA in December 1993 as an additional treatment for patients with crises of partial onset. Recently it has been approved for use as monotherapy. We review the characteristics of this molecule as an anti-epileptic drug and the clinical trials which have permitted approval of the current indications.

DEVELOPMENT

We review the particular difficulties of designing trials using monotherapy, both for ethical reasons (problems with the use of a placebo) and for technical reasons and those of interpretation (problems comparing two drugs with equivalent results) and analyze the trials in which attempts were made to overcome these difficulties. A trial designed to replace polytherapy in drug-resistant patients by monotherapy did not show conclusive results, although they were suggestive. A trial of patients admitted for pre-surgical studies permitted verification of the efficacy and safety of higher doses (3,600 mg/day) than those previously used (800-2,400 mg/day). Another trial, this time of newly diagnosed patients, permitted verification of the efficacy and safety of gabapentin used in different dosages.

CONCLUSIONS

Gabapentin is effective when used as monotherapy. The dose recommended for the initial treatment of newly-diagnosed patients is 900 mg/day. It has a better safety profile than carbamazepine and is indicated in simple and complex partial crises with or without secondary generalization.

Lipoid proteinosis. A biochemical and ultrastructural investigation of two new cases

Lipoid proteinosis is a rare autosomal recessive disease characterized by cutaneous and visceral lesions, in which large amounts of amorphous material are constantly found in stroma. Morphological and biochemical studies indicate abnormal collagen production, but little attention has been paid to the lipid component of lesions. Microscopic and ultrastructural studies of skin, with special emphasis on fibroblasts, vessels, nerve endings and eccrine sweat glands, were conducted in two patients with lipoid proteinosis. Biochemical studies were undertaken in cultured fibroblasts. Evidence of lysosomal storage in epithelial cells of eccrine sweat glands and in dermal histiocytes, very similar to that found in some metabolic disorders, particularly Farber disease, was found in both cases. Our findings suggest that two alterations might coexist in lipoid proteinosis, one characterized by impaired normal collagen production and the other related to a metabolic defect which may lead to accumulation of ceramide or more complex lipids.

[Usefulness of the EEG recording in the diagnosis of cyclosporin A-induced encephalopathy]

INTRODUCTION

Cyclosporine A is one of the immunosuppressors most frequently used to prevent transplant rejection. Neurotoxicity is one of the complications often associated with it. These complications include acute encephalopathy, lethargy, confusion state, tremor, headache, motor disorders, visual changes and epileptic crises amongst others, even when blood levels are at what are considered to be 'therapeutic' levels.

CLINICAL CASES

We present the EEG anomalies found in 3 transplant patients (two liver transplants and on double lung transplant) to whom cyclosporin A had been given and who presented with status epilepticus. The EEG recordings showed paroxystic discharges of focal onset in the temporo-occipital areas. They were mainly correlated with the clinical findings of oculomotor and eyelid disorders.

CONCLUSION

The topography of the neurophysiological findings supports--as do the other clinico-radiological findings--localization preferably to the posterior areas of cerebral dysfunction associated with cyclosporin A. Although the physiopathological origin of the encephalopathy of patients treated with cyclosporin A seems to correspond to multiple factors, we wish to point out the diagnostic usefulness of the identification of EEG changes localized to the temporo-occipital areas in the recognition of the neurotoxic syndrome in these patients.

[Diagnosis of seizures originating in the amygdala and the hippocampus]

INTRODUCTION

Lesions in the hippocampus of some epileptic patients were first described one hundred and seventy years ago. Since then our knowledge of the relationship between epileptic seizures and temporal lobe lesions has greatly improved.

DEVELOPMENT

The aim of this paper is to systematize the symptomatology of the hippocampus and amygdala seizures. These seizures may have a great number of different clinical features: special 'loss' or 'impairment of consciousness', epileptic automatisms and autonomic changes. Moreover, at the beginning of seizures some patients have reported experiences having subjective qualities similar to those experienced in everyday life. P Gloor named them 'experiential phenomena' and subdivided them into affective (eg: fear), perceptual (eg: visual hallucinations) and mnemonic (eg: 'déjà vu' illusion).

CONCLUSION

It is very important to know the contribution of the hippocampus and the amygdala to the symptomatology of temporal lobe seizures due to the progress of MRI diagnostic possibilities that are improving the surgical outcome.

[Treatment of status epilepticus]

The management of status epilepticus (SE) is very complex due to the variability of its clinical features. This paper aims to achieve an schematic basis for a consensus in the treatment of these patients. Thus we need the clinical forms of SE grouped according to the differences in treatment. We also need to divided the development of every type of SE into stages in order to adjust the correct application of general measures and antiepileptic drugs. In patients prone to suffering recurrent seizures it is important to prevent risk factors. We can sometimes identify a premonitory phase during which the clinical deterioration presages SE; in these cases immediate treatment at home can prevent the evolution into true SE. Once SE has developed up to stage of early SE or stablished SE, the treatment must be carried out in emergency department. If seizures have not responded, the stage of refractory SE is reached and Intensive Care Unit facilities are mandatory. We devote special attention to conic-clonic SE but the other clinical forms of SE are categorized according to the differences in treatment.

Validation of different techniques for the diagnosis of ventilator-associated pneumonia. Comparison with immediate postmortem pulmonary biopsy

To assess the accuracy of clinical parameters for the diagnosis of ventilator-associated (VA) pneumonia, as well as the diagnostic value of several invasive techniques, such as protected specimen brush (PSB), bronchoalveolar lavage (BAL), fiberoptic bronchial aspirates (FBAS), and percutaneous lung needle aspiration (PLNA), we compared the results of these techniques with the histopathology of immediate postmortem pulmonary biopsies, considered the "gold standard" reference test. We studied 30 mechanically ventilated patients (age 52 +/- 21 yr; mechanical ventilation period 9 +/- 7 days) who died in an intensive care unit. All patients received prior antibiotic treatment. The following procedures were performed immediately after death: bilateral PSB, BAL, FBAS, and PLNA, as well as bilateral minithoracotomies to obtain pulmonary biopsies as close as possible to the area sampled with the other techniques. According to the histopathology 18 patients had pneumonia and 12 did not. The presence of fever (sensitivity 55%, specificity 58%), purulent secretions (sensitivity 83%, specificity 33%), and chest radiograph infiltrates (sensitivity 78%, specificity 42%) could not differentiate in all instances presence from absence of pneumonia. Quantitative bacterial cultures of lung biopsies using 10(3) cfu/g as a cutoff point had low sensitivity (40%) and low specificity (45%) and could not differentiate the histologic absence or presence of pneumonia. Considering the histopathology of pulmonary biopsies as a gold standard, we found the following sensitivities for PSB, BAL, FBAS, and PLNA: 36, 50, 44, and 25%. The specificities were 50, 45, 48, and 79%, respectively. The sensitivities and specificities of different invasive techniques are much lower than those reported in clinical studies.(ABSTRACT TRUNCATED AT 250 WORDS)

Value of fiberoptic bronchoscopy and angiography for diagnosis of the bleeding site in hemoptysis

We evaluated 36 patients during active hemoptysis and compared the diagnostic yield of different procedures. Twenty-seven patients (75%) had one or more previous episodes of hemoptysis, most of which were not massive. Fiberoptic bronchoscopy was performed in 25 patients, and the bleeding site was identified in 17 (68%). The likelihood of localizing the bleeding site was significantly higher with early versus delayed fiberoptic bronchoscopy (91% versus 50%). Bronchial arteriography was performed in all 36 patients; positive arteriographies were observed in 20 cases (55.5%). Arteriography was positive in only 2 of the 8 cases in which fiberoptic bronchoscopy did not localize the site of bleeding. Bronchial artery embolization was successfully performed in 10 patients. However, the bleeding recurred within the first week after embolization in 2 patients, and 1 of them died.

Spontaneous dissection of intracranial vertebral artery: clinical recovery with conservative treatment

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