Bailliere's clinical neurology最新文献

{"title":"Modern management of epilepsy: Adolescents.","authors":"F M Besag","doi":"","DOIUrl":"","url":null,"abstract":"<p><p>Epilepsy most commonly starts in the first two decades of life. Adolescence is a time of great change both in the epilepsy itself and in a number of other areas. Growth into adulthood, issues of preparation for university or employment, driving, drinking, preparation for marriage/conception and a general increase of responsibility add to the complexity of this time of life. Epilepsy affects all these areas to a significant degree. The incidence of several epilepsy syndromes peaks in adolescence. These include juvenile myoclonic epilepsy, juvenile absence epilepsy, epilepsy with grand mal on awakening, benign partial seizures of adolescence and reading epilepsy. Photosensitivity also appears to peak around puberty and needs to be managed well to avoid both unreasonable risks and unnecessary restrictions. Early diagnosis and correct management of the epilepsy and the specific epilepsy syndrome are the main factors in minimizing the difficulties. Epilepsy may change in the early adolescent years, with seizures starting and stopping or altering in form, all of which add to the uncertainty. Denial of the epilepsy may lead to risk-taking which may include be provided on the high risk of the unsupervised bath, the effect of irregular sleep, alcohol, driving, sport, employment, genetic implications, advantages/adverse effects of specific antiepileptic drugs and the role of surgery. The doctor should listen, counsel and inform. Adolescents generally do not appreciate being given advice. They should be empowered by the doctor to make informed decisions and encouraged to take control in a situation which they may view as implying devastating loss of control, unless it is managed wisely.</p>","PeriodicalId":77030,"journal":{"name":"Bailliere's clinical neurology","volume":"5 4","pages":"803-20"},"PeriodicalIF":0.0,"publicationDate":"1996-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"20023742","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Modern management of epilepsy: Vagus nerve stimulation.","authors":"E Ben-Menachem","doi":"","DOIUrl":"","url":null,"abstract":"<p><p>Vagus nerve stimulation (VNS) was first tried as a treatment for seizure patients in 1988. The idea to stimulate the vagus nerve and disrupt or prevent seizures was proposed by Jacob Zabarra. He observed a consistent finding among several animal studies which indicated that stimulation of the vagus nerve could alter the brain wave patterns of the animals under study. His hypothesis formed the basis for the development of the vagus nerve stimulator, an implantable device similar to a pacemaker, which is implanted in the left chest and attached to the left vagus nerve via a stimulating lead. Once implanted, the stimulator is programmed by a physician to deliver regular stimulation 24 hours a day regardless of seizure activity. Patients can also activate extra 'on-demand' stimulation with a handheld magnet. Clinical studies have demonstrated VNS therapy to be a safe and effective mode of treatment when added to the existing regimen of severe, refractory patients with epilepsy. Efficacy ranges from seizure free to no response with the majority of patients (> 50%) reporting at least a 50% improvement in number of seizures after 1.5 years of treatment. The side-effect profile is unique and mostly includes stimulation-related sensations in the neck and throat. The mechanism of action for VNS is not clearly understood although two theories have emerged. First, the direct connection theory hypothesizes that the anticonvulsant action of VNS is caused by a threshold raising effect of the connections to the nucleus of the solitary tract and on to other structures. The second is the concept that chronic stimulation of the vagus nerve increases the amount of inhibitory neurotransmitters and decreases the amount of excitatory neurotransmitters. Additional research into the optimal use of VNS is ongoing. Animal and clinical research have produced some interesting new data suggesting there are numerous ways to improve the clinical performance of vagus nerve stimulation as a treatment for refractory patients.</p>","PeriodicalId":77030,"journal":{"name":"Bailliere's clinical neurology","volume":"5 4","pages":"841-8"},"PeriodicalIF":0.0,"publicationDate":"1996-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"20026399","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Modern management of epilepsy: Rational polytherapy.","authors":"D Schmidt","doi":"","DOIUrl":"","url":null,"abstract":"<p><p>Although monotherapy is universally accepted for treating early epilepsy, as many as 40% of patients will continue to have seizures and develop intolerable adverse effects or most commonly, both. Once initial monotherapy has failed, the physician has the choice of either polytherapy by adding a second drug or of alternative monotherapy, that is, substitution of the first drug by another agent active for the same type(s) of seizures. No large randomized comparative trials exist although smaller studies indicate that polytherapy and alternative monotherapy may both achieve complete seizure control in up to 17% and further improvement in approximately 40% of cases. Polytherapy has the advantage of providing benefit in the small minority (15%) of patients who probably cannot be treated satisfactorily by alternative monotherapy, this often being achieved at the price of additional toxicity, undesirable drug interactions and the failure to identify the action of the individual drug. The real basis for rational choice of drugs in polytherapy are features such as efficacy, lack of interaction and low intrinsic toxicity. Theoretical and experimental considerations are of limited value until we know more about the basic mechanism(s) of specific seizures and epilepsy syndromes. At present, it is recommended that undue toxicity and inconvenient drug interactions should be avoided by lowering the dosage of the first drug as much as possible before a second drug is added. In most patients alternative monotherapy, that is, complete removal of the first drug, is a safe and effective option and polytherapy remains available when alternative monotherapy fails.</p>","PeriodicalId":77030,"journal":{"name":"Bailliere's clinical neurology","volume":"5 4","pages":"757-63"},"PeriodicalIF":0.0,"publicationDate":"1996-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"20023739","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Epilepsy surgery.","authors":"H G Wieser","doi":"","DOIUrl":"","url":null,"abstract":"<p><p>Surgical therapy of epilepsy, although still underutilized, is presently well accepted and performed world-wide with increasing frequency. In the last decade the following changes have been noticed: non-invasive pre-surgical evaluation is increasingly carried out in close collaboration with referring centres so that often no (or only a very short) hospitalization is necessary in highly specialized epilepsy centres for this purpose. Stereoelectro-encephalography (SEEG) is used less often in invasive evaluation while the subdural strip and grid electrode-techniques are used more often. There is a general trend for a more flexible and collaborative multidisciplinary and multi-method approach utilizing the whole spectrum of modern diagnostic facilities in a more patient-oriented and therefore more cost-effective way. The main objective of the pre-surgical evaluation is to determine the onset area of the patient's spontaneous habitual seizures. The primary epileptogenic zone is not necessarily synonymous with the so-called lesional zone, although in the great majority of patients they are related. In a small percentage of candidates for epilepsy surgery additional special examinations are necessary to prevent and/or predict the degree of post-operative deficits. At present selective Amytal tests are often used but these invasive procedures might be replaced in the future by functional PET and functional MR studies. Surgery in patients with epilepsy can be categorized into: (i) lesion-oriented surgery (lesionectomy sensu stricto), (ii) epilepsy-oriented lesional surgery, (iii) surgery for epilepsy sensu stricto. Surgery is performed with a 'curative (= causal)' or a 'palliative' intention. Furthermore surgery can be categorized into standardized epilepsy surgery (such as anterior temporal lobe resection, selective amygdalohippeocampectomy, anterior callosotomy); and individually tailored surgical interventions. It is obvious that also so-called standardized operations are tailored to some degree, usually based on pre-operative findings as well as on intraoperative corticography and/or other intra-operative neurophysiological tests (functional mapping). Individually tailored operations comprise smaller topectomies and larger resections. Surgery for temporal lobe epilepsy still prevails. For mesial temporal lobe epilepsy more selective operations, such as the selective amygdalohippocampectomy, are increasingly performed. Today the majority of patients suffering from this syndrome can be evaluated non-invasively (or 'semi-invasively' with the foramen ovale electrode technique) in combination with MRI (including volumetry of the hippocampus) and PET or SPECT. In general one has the impression that extratemporal resections without a lesion are performed less often. But, if a morphological abnormality is present, pre-surgical evaluation (using grids), and surgery making use of 'functional mapping' are increasingly offered from more and more centres. An","PeriodicalId":77030,"journal":{"name":"Bailliere's clinical neurology","volume":"5 4","pages":"849-75"},"PeriodicalIF":0.0,"publicationDate":"1996-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"20026400","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Rational monotherapy for epilepsy.","authors":"I E Leppik","doi":"","DOIUrl":"","url":null,"abstract":"<p><p>At the present time monotherapy is preferable to polytherapy if the epilepsy can be controlled with a single drug. However, persons with intractable epilepsy may need more than one antiepileptic drug to attain the best seizure control with the fewest side-effects. Although clinical studies have not been performed to identify the best combinations, rational polytherapy would imply combining antiepileptic drugs with different mechanisms of action.</p>","PeriodicalId":77030,"journal":{"name":"Bailliere's clinical neurology","volume":"5 4","pages":"749-55"},"PeriodicalIF":0.0,"publicationDate":"1996-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"20023738","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Seizures.","authors":"T P Bleck","doi":"","DOIUrl":"","url":null,"abstract":"<p><p>The ICU patient who develops seizures presents diagnostic and therapeutic dilemmas for the physician. The diagnostic studies required vary with the underlying disorders of the patient and with the other therapies in progress. For both individual seizures and status epilepticus, electroencephalography is essential, and a brain imaging study is usually necessary. Other diagnostic testing depends on the clinical situation and the results of these initial studies. Therapy for a single seizure or a few seizures remains controversial. Management of the patient in status epilepticus should proceed along parallel approaches to terminating status epilepticus, preventing its recurrence and treating its complications. Lorazepam appears to be the initial drug of choice; phenytoin is commonly used as a second choice. Phosphenytoin will probably replace intravenous phenytoin in this role. Although phenobarbital has long been used as a third-line agent, its utility has fallen into question. Refractory status epilepticus can usually be controlled with extraordinary doses of midazolam, propofol, or pentobarbital. Patients requiring treatment for refractory status epilepticus require excellent, multidisciplinary critical care.</p>","PeriodicalId":77030,"journal":{"name":"Bailliere's clinical neurology","volume":"5 3","pages":"565-76"},"PeriodicalIF":0.0,"publicationDate":"1996-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"20065628","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Infections.","authors":"C F Bolton","doi":"","DOIUrl":"","url":null,"abstract":"","PeriodicalId":77030,"journal":{"name":"Bailliere's clinical neurology","volume":"5 3","pages":"599-626"},"PeriodicalIF":0.0,"publicationDate":"1996-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"20065630","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Management of Guillain-Barré syndrome (GBS).","authors":"A F Hahn","doi":"","DOIUrl":"","url":null,"abstract":"<p><p>GBS is an acute immune-mediated neuropathy which, in one-third of cases, leads to total paralysis requiring ICU admission for assisted ventilation and management of autonomic cardiovascular instability. The management can be challenging and even with most expert care and modern ICU facilities the mortality remains at 5-8%. This chapter gives an outline of the natural history and pathophysiology of the condition with emphasis on newer concepts. Guidelines are given for the management of patients prior to and during the admission to an ICU by highlighting the potential complications. An up-to-date account is given on the specific immunomodulatory therapies.</p>","PeriodicalId":77030,"journal":{"name":"Bailliere's clinical neurology","volume":"5 3","pages":"627-44"},"PeriodicalIF":0.0,"publicationDate":"1996-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"20066198","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Severe stroke.","authors":"T Brandt,&nbsp;A J Grau,&nbsp;W Hacke","doi":"","DOIUrl":"","url":null,"abstract":"<p><p>Severe stroke is an emergency and requires rapid neurological assessment and diagnosis. CT scan is the first diagnostic step with the aim of finding out the extent, localization and possible pathophysiology of ischaemia in order to direct specific diagnostic and therapeutic options. An intracranial haemorrhage must be excluded. Early CT signs, including the size of the hypodensity and brain swelling, are important prognostic markers. Extracranial and transcranial Doppler sonography are valid for primary assessment of vascular pathophysiology and haemodynamics in most cases. Cerebral angiography should be performed if acute occlusion of the basilar artery or middle cerebral artery trunk is suspected and intra-arterial thrombolysis is a potential therapy. Intravenous thrombolyis has been proven to be effective in improving outcome in severe stroke; it is safe if the exclusion criteria are strictly applied. Prevention of secondary complications of stroke include general medical treatment with control of blood pressure, infections and cardiac and respiratory function, anti-coagulation. anti-oedematous treatment and surgical decompressive therapy for cerebellar and MCA space-occupying infarcts. Monitoring in the ICU is recommended. The medical therapy of intracerebral haemorrhage consists of control of ventilation and blood pressure, seizure prevention and anti-oedema treatment. Treatment of secondary ICH due to anti-coagulation or thrombolysis consists of administration of specific antidotes and the correction of the coagulopathy. Ventricular drainage should be performed when there is marked ventricular dilatation due to obstruction or blood in the ventricles. Most patients with cerebellar haemorrhage of more than 3 cm in diameter should undergo surgery to avoid brain-stem compression and hydrocephalus. In younger patients, non-dominant hemisphere putaminal and lobar haemorrhages with lateral displacement of midline structures and extensive oedema should be evacuated if the patient's level of consciousness deteriorates rapidly, or if the elevation of ICP cannot be controlled pharmacologically, and herniation is incipient. New techniques such as stereotactic and endoscopic evacuation still need to be tested prospectively. Patient selection for surgery should be cautious considering age, clinical status and possible contraindications such as cerebral amyloid angiopathy and coagulation disorders. Stroke therapy is rapidly becoming a focus of research and major changes in diagnostic and therapeutic options can therefore be expected.</p>","PeriodicalId":77030,"journal":{"name":"Bailliere's clinical neurology","volume":"5 3","pages":"515-41"},"PeriodicalIF":0.0,"publicationDate":"1996-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"20065626","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Subarachnoid haemorrhage.","authors":"C G diPierro,&nbsp;G Lanzino,&nbsp;G A Helm,&nbsp;N F Kassell","doi":"","DOIUrl":"","url":null,"abstract":"","PeriodicalId":77030,"journal":{"name":"Bailliere's clinical neurology","volume":"5 3","pages":"543-63"},"PeriodicalIF":0.0,"publicationDate":"1996-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"20065627","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}