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Semin Neurol 2008; 28(3): 364-378
DOI: 10.1055/s-2008-1079341
© Thieme Medical Publishers

Common Errors Made in the Diagnosis and Treatment of Epilepsy

Andres M. Kanner1
  • 1Department of Neurological Sciences, Rush University Medical Center, Chicago, Illinois
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Publication History

Publication Date:
24 July 2008 (online)

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ABSTRACT

Learning from one's mistakes is the best learning tool in medicine and this applies as well to epilepsy. This article is a compilation of some of the frequent mistakes that are made in the evaluation and management of patients with epilepsy. It encompasses errors in the clinical diagnosis that result in the choice of the erroneous antiepileptic drug (AED), errors in the way auxiliary tests like the electroencephalogram and magnetic resonance imaging studies are ordered, mistakes in the recognition of subclinical status epilepticus, errors in the selection of AEDs, consequences of the failure to factor in the pharmacokinetic and pharmacodynamic properties of AEDs in the choice and dosification of medication, misconceptions on the expectations of therapeutic effect of AEDs, delay in recognition of refractory epilepsy with consequent delay in a timely identification of patients whose epilepsy can be cured with surgical treatment, and mistakes in the recognition and management of comorbid psychiatric disorders. In addition to a discussion of the reasons for the errors, the article provides practical solutions.

KEYWORDS

Applied pharmacokinetics - antiepileptic drugs - intractable epilepsy - nonepileptic seizures - status epilepticus

REFERENCES

  • 1 Kanner A M. Psychogenic pseudoseizures: semiology and pathogenic mechanisms. In: Luders HO, Noachtar S The Epileptic Seizures: Pathophysiology and Clinical Semiology. New York, NY; Churchill Livingstone 2000: 766-773
    Google Scholar
  • 2 Kanner A M. Psychogenic seizures and the supplementary sensory motor area. In: HO Luders The Supplementary Sensory Motor Area. Advances in Neurology. Vol. 70. New York, NY; Raven Press 1996: 461-466
    Google Scholar
  • 3 Kanner A M, Iriarte J. Psychogenic pseudoseizures: differential diagnosis. In: Kotagal P, Luders HO Etiologies of the Epilepsies. San Diego, CA; Academic Press 1999: 509-518
    Google Scholar
  • 4 Jallon P, Latour P. Epidemiology of idiopathic generalized epilepsies.  Epilepsia. 2005;  46(suppl 9) 10-14
    PubMedGoogle Scholar
  • 5 Welty T E. Juvenile myoclonic epilepsy: epidemiology, pathophysiology, and management.  Paediatr Drugs. 2006;  8 303-310
    PubMedGoogle Scholar
  • 6 Kwan P, Brodie M J. Early identification of refractory epilepsy.  N Engl J Med. 2000;  342 314-319
    CrossrefPubMedGoogle Scholar
  • 7 DeLorenzo R J. Epidemiology and clinical presentation of status epilepticus.  Adv Neurol. 2006;  97 199-215
    PubMedGoogle Scholar
  • 8 Treiman D M, Meyers P D, Walton N Y et al.. A comparison of four treatments for generalized convulsive status epilepticus. Veterans Affairs Status Epilepticus Cooperative Study Group.  N Engl J Med. 1998;  339 792-798
    CrossrefPubMedGoogle Scholar
  • 9 DeLorenzo R J, Waterhouse E J, Towne A R et al.. Persistent nonconvulsive status epilepticus after the control of convulsive status epilepticus.  Epilepsia. 1998;  39 833-840
    CrossrefPubMedGoogle Scholar
  • 10 Brodie M J, Chadwick D W, Anhut H et al.. Gabapentin versus lamotrigine monotherapy: a double-blind comparison in newly diagnosed epilepsy.  Epilepsia. 2002;  43 993-1000
    CrossrefPubMedGoogle Scholar
  • 11 Brodie M J, Perucca E, Ryvlin P, Ben-Menachem E, Meencke H J. Levetiracetam Monotherapy Study Group . Comparison of levetiracetam and controlled-release carbamazepine in newly diagnosed epilepsy.  Neurology. 2007;  68 402-408
    CrossrefPubMedGoogle Scholar
  • 12 Mohanraj R, Brodie M J. Pharmacological outcomes in newly diagnosed epilepsy.  Epilepsy Behav. 2005;  6 382-387
    CrossrefPubMedGoogle Scholar
  • 13 Privitera M D, Brodie M J, Mattson R H et al.. Topiramate, carbamazepine and valproate monotherapy: double-blind comparison in newly diagnosed epilepsy.  Acta Neurol Scand. 2003;  107 165-175
    CrossrefPubMedGoogle Scholar
  • 14 Arroyo S, Dodson W E, Privitera M D et al.. Randomized dose-controlled study of topiramate as first-line therapy in epilepsy.  Acta Neurol Scand. 2005;  112 214-222
    CrossrefPubMedGoogle Scholar
  • 15 Trimble M R, Mula M. Antiepileptic drug interactions in patients requiring psychiatric drug treatment. In: Majkowski J, Bourgeois B, Patsalos P, Mattson R Antiepileptic Drugs: Combination Therapy and Interactions. Cambridge; Cambridge University Press 2005: 350-368
    Google Scholar
  • 16 Patsalos P N, Perucca E. Clinically important drug interactions in epilepsy: interactions between antiepileptic drugs and other drugs.  Lancet Neurol. 2003;  2 473-481
    PubMedGoogle Scholar
  • 17 Sitsen J, Maris F, Timmer C. Drug-drug interaction studies with mirtazapine and carbamazepine in healthy male subjects.  Eur J Drug Metab Pharmacokinet. 2001;  26(1–2) 109-121
    PubMedGoogle Scholar
  • 18 Pihlsgard M, Eliasson E. Significant reduction of sertraline plasma levels by carbamazepine and phenytoin.  Eur J Clin Pharmacol. 2002;  57 915-916
    CrossrefPubMedGoogle Scholar
  • 19 Majkowski J, Patsalos P N. Interaction between epileptic and non-epileptic drugs. In: Majkowski J, Bourgeois B, Patsalos P, Mattson R Antiepileptic Drugs: Combination Therapy and Interactions. Cambridge; Cambridge University Press 2005: 139-177
    Google Scholar
  • 20 Ucar M, Neuvonen M, Luurila H, Dahlqvist R, Neuvonen P J, Mjorndal T. Carbamazepine markedly reduces serum concentrations of simvastatin and simvastatin acid.  Eur J Clin Pharmacol. 2004;  59 879-882
    CrossrefPubMedGoogle Scholar
  • 21 Relling M V, Pui C H, Sandlund J T et al.. Adverse effect of anticonvulsants on efficacy of chemotherapy for acute lymphoblastic leukaemia.  Lancet. 2000;  356 285-290
    CrossrefPubMedGoogle Scholar
  • 22 Villikka K, Kivisto K T, Maenpaa H, Joensuu H, Neuvonen P J. Cytochrome P450-inducing antiepileptics increase the clearance of vincristine in patients with brain tumors.  Clin Pharmacol Ther. 1999;  66 589-593
    PubMedGoogle Scholar
  • 23 Rowan A J, Ramsay R E, Collins J F et al.. New onset geriatric epilepsy: a randomized study of gabapentin, lamotrigine, and carbamazepine.  Neurology. 2005;  64 1868-1873
    CrossrefPubMedGoogle Scholar
  • 24 Leppik I E. Epilepsy in the elderly.  Epilepsia. 2006;  47(suppl 1) 65-70
    CrossrefPubMedGoogle Scholar
  • 25 Garrard J, Harms S, Hardie N et al.. Antiepileptic drug use in nursing home admissions.  Ann Neurol. 2003;  54 75-85
    CrossrefPubMedGoogle Scholar
  • 26 Feldkamp J, Becker A, Witte O W, Scharff D, Scherbaum W A. Long-term anticonvulsant therapy leads to low bone mineral density: evidence for direct drug effects of phenytoin and carbamazepine on human osteoblast-like cells.  Exp Clin Endocrinol Diabetes. 2000;  108 37-43
    PubMedGoogle Scholar
  • 27 Vestergaard P, Tigaran S, Rejnmark L, Tigaran C, Dam M, Mosekilde L. Fracture risk is increased in epilepsy.  Acta Neurol Scand. 1999;  99 269-275
    CrossrefPubMedGoogle Scholar
  • 28 Annegers J F, Melton III L J, Sun C A, Hauser W A. Risk of age-related fractures in patients with unprovoked seizures.  Epilepsia. 1989;  30 348-355
    CrossrefPubMedGoogle Scholar
  • 29 Valmadrid C, Voorhees C, Litt B, Schneyer C R. Practice patterns of neurologists regarding bone and mineral effects of antiepileptic drug therapy.  Arch Neurol. 2001;  58 1369-1374
    CrossrefPubMedGoogle Scholar
  • 30 Pack A M, Morrell M J. Treatment of women with epilepsy.  Semin Neurol. 2002;  22 289-298
    Article in Thieme ConnectPubMedGoogle Scholar
  • 31 Engel Jr J, Wiebe S, French J. Practice parameter: temporal lobe and localized neocortical resections for epilepsy. Report of the Quality Standards Subcommittee of the American Academy of Neurology, in association with the American Epilepsy Society and the American Association of Neurological Surgeons.  Neurology. 2003;  60 538-547
    CrossrefPubMedGoogle Scholar
  • 32 Mani J, Gupta A, Mascha E et al.. Postoperative seizures after extratemporal resections and hemispherectomy in pediatric epilepsy.  Neurology. 2006;  66 1038-1043
    CrossrefPubMedGoogle Scholar
  • 33 Semah F, Picot M C, Adam C et al.. Is the underlying cause of epilepsy a major prognostic factor for recurrence?.  Neurology. 1998;  51 1256-1262
    CrossrefPubMedGoogle Scholar
  • 34 Spooner C G, Berkovic S F, Mitchell L A, Wrennall J A, Harvey A S. New-onset temporal lobe epilepsy in children: lesion on MRI predicts poor seizure outcome.  Neurology. 2006;  67 2147-2153
    CrossrefPubMedGoogle Scholar
  • 35 Dlugos D J. The early identification of candidates for epilepsy surgery.  Arch Neurol. 2001;  58 1543-1546
    CrossrefPubMedGoogle Scholar
  • 36 Gilliam F, Kuzniecky R, Faught E et al.. Patient-validated content of epilepsy-specific quality-of-life measurement.  Epilepsia. 1997;  38 233-236
    CrossrefPubMedGoogle Scholar
  • 37 Lehrner J, Kalchmayr R, Serles W et al.. Health-related quality of life (HRQOL), activity of daily living (ADL) and depressive mood disorder in temporal lobe epilepsy patients.  Seizure. 1999;  8 88-92
    CrossrefPubMedGoogle Scholar
  • 38 Perrine K, Hermann B P, Meador K J et al.. The relationship of neuropsychological functioning to quality of life in epilepsy [see comments].  Arch Neurol. 1995;  52 997-1003
    PubMedGoogle Scholar
  • 39 Boylan L S, Flint L A, Labovitz D L, Jackson S C, Starner K, Devinsky O. Depression but not seizure frequency predicts quality of life in treatment-resistant epilepsy.  Neurology. 2004;  62 258-261
    PubMedGoogle Scholar
  • 40 Kanner A M, Wuu J, Barry J, Hermann B, Meador K J, Gilliam F. Atypical depressive episodes in epilepsy: a study of their clinical characteristics and impact on quality of life.  Neurology. 2004;  62(suppl 5) A249
    PubMedGoogle Scholar
  • 41 Harris E C, Barraclough B. Suicide as an outcome for mental disorders: a meta-analysis.  Br J Psychiatry. 1997;  170 205-228
    PubMedGoogle Scholar
  • 42 Jones J E, Hermann B P, Barry J J, Gilliam F G, Kanner A M, Meador K J. Rates and risk factors for suicide, suicidal ideation, and suicide attempts in chronic epilepsy.  Epilepsy Behav. 2003;  4(suppl 3) S31-S38
    PubMedGoogle Scholar
  • 43 Kanner A M. Depression in epilepsy: prevalence, clinical semiology, pathogenic mechanisms and treatment.  Biol Psychiatry. 2003;  54 388-398
    CrossrefPubMedGoogle Scholar
  • 44 Kanner A M. Current review in clinical science. Depression in epilepsy: a neurobiologic perspective.  Epilepsy Curr. 2005;  5 21-27
    CrossrefPubMedGoogle Scholar
  • 45 Alper K, Schwartz K A, Kolts R L, Khan A. Seizure incidence in psychopharmacological clinical trials: an analysis of Food and Drug Administration (FDA) summary basis of approval reports.  Biol Psychiatry. 2007;  62 345-354
    CrossrefPubMedGoogle Scholar
  • 46 Dunn D W, Austin J K, Harezlak J, Ambrosius W T. ADHD and epilepsy in childhood.  Dev Med Child Neurol. 2003;  45 50-54
    PubMedGoogle Scholar
  • 47 Hesdorffer D C, Ludvigsson P, Olafsson E, Gudmundsson G, Kjartansson O, Hauser W A. ADHD as a risk factor for incident unprovoked seizures and epilepsy in children.  Arch Gen Psychiatry. 2004;  61 731-736
    CrossrefPubMedGoogle Scholar
  • 48 Feldman H, Crumine P, Handen B L, Alvin R, Teodori J. Methylphenidate in children with seizures and attention-deficit disorder.  Am J Dis Child. 1989;  143 1081-1086
    PubMedGoogle Scholar
  • 49 Gross-Tsur V, Manor O, van der Meere J, Joseph A, Shalev R S. Epilepsy and attention deficit hyperactivity disorder: is methylphenidate safe and effective?.  J Pediatr. 1997;  130 670-674
    CrossrefPubMedGoogle Scholar
  • 50 Ott D, Caplan R, Guthrie D et al.. Measures of psychopathology in children with complex partial seizures and primary generalized epilepsy with absence.  J Am Acad Child Adolesc Psychiatry. 2001;  40 907-914
    CrossrefPubMedGoogle Scholar

Andres M KannerM.D. 

Department of Neurological Sciences, Rush University Medical Center

1653 West Congress Parkway, Chicago, IL 60612

Email: akanner@rush.edu