Adult Epilepsy E-Book

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 493

Veröffentlichungsjahr: 2011

Beschreibung

Designed to provide a comprehensive but accessible introduction to epilepsy and seizure disorders, Adult Epilepsy provides state-of-the-art information in a concise format useful to a wide audience, from neurology residents to epilepsy fellows and practitioners. This illustrated guide to the assessment, diagnosis, and treatment of epilepsy is a valuable resource enabling clinicians to stay on top of the latest recommendations for best practice.

Leseprobe

Table of Contents

Title Page

Copyright

Dedication

List of contributors

Preface

Chapter 1: Introduction: Epilepsy

1.1 Epilepsy Care: Beginnings of Observation and Recognition

1.2 Epilepsy Care: Initial Understanding and Treatment

1.3 Epilepsy Care: The Mayo Clinic

Section 1: Pathophysiology and Epidemiology of Seizures and Epilepsy

Chapter 2: Seizure and Epilepsy Syndromes Classification

2.1 Introduction

2.2 The Classification of Epileptic Seizures

2.3 Conclusion

Chapter 3: Epidemiology of Seizure Disorders

3.1 Incidence and Prevalence of Epilepsy

3.2 Incidence and Prevalence of Acute Symptomatic Seizures

3.3 Looking Beyond Epidemiology: The State of Epilepsy Care in the United States

3.4 Risk Factors for Epilepsy

3.5 Conclusion

Section 2: Diagnostic Evaluation

Chapter 4: The Role of Routine Scalp Electroencephalography

4.1 Introduction

4.2 Clinical Application of EEG

4.3 Scalp EEG Recording Methods

4.4 Activation Procedures

4.5 Interictal Discharges Correlated with Epilepsy

4.6 Epileptic Syndromes and the Role of EEG

4.7 Conclusions

Chapter 5: Neuroimaging in Epilepsy

5.1 Introduction

5.2 Magnetic Resonance Imaging

5.3 Functional Neuroimaging

Chapter 6: Video-EEG Monitoring Data

6.1 Introduction

6.2 Pre-monitoring Evaluation and Preparation

6.3 Management During Monitoring

6.4 Discharge Management

Acknowledgments

Chapter 7: Etiologies of Seizures

7.1 Introduction

7.2 Acute Symptomatic Seizures

7.3 Febrile Seizures

7.4 Unprovoked Seizures

Chapter 8: The Evaluation of Nonepileptic Paroxysmal Events

8.1 Introduction

8.2 Syncope

8.3 Transient Ischemic Events (TIAs)

8.4 Transient Global Amnesia (TGA)

8.5 Movement Disorders

8.6 Sleep Disorders

8.7 Psychogenic Nonepileptic Seizures (PNESs)

8.8 Summary

Section 3: Principles of Medical Management

Chapter 9: Mechanisms of Action of Antiepileptic Drugs

9.1 Introduction

9.2 Treatment of Epilepsy

9.3 Excitatory Mechanisms Targeted by AEDs

9.4 Inhibitory Mechanisms Targeted by AEDs

9.5 Mechanism of Action-Specific Drugs

9.6 Conclusions

Chapter 10: Antiepileptic Drugs: Pharmacology, Epilepsy Indications, and Selection

10.1 Introduction

10.2 AED Selection

10.3 Generic AED Therapy

10.4 The AEDs: Summary of Clinical Use, Pharmacokinetics, and Efficacy

Section 4: Generalized Epilepsies

Chapter 11: Idiopathic Generalized Epilepsies

11.1 Overview of the Generalized Epilepsies

11.2 Introduction

11.3 Differentiating Generalized Seizures from Partial Seizures

11.4 Clinical and EEG Characteristics of Generalized Seizures

11.5 Generalized Epilepsy Syndromes

11.6 Treating Generalized Seizures

11.7 Treatment Algorithm

11.8 Prognosis/Outcomes

Chapter 12: Symptomatic Generalized Epilepsies

12.1 Introduction

12.2 Infantile Onset Syndromes

12.3 Childhood Onset Syndromes

12.4 Symptomatic Generalized Epilepsy Syndromes of Known Cause

Section 5: Partial Epilepsies

Chapter 13: Overview of Diagnosis and Medical Treatment of Partial Epilepsies

13.1 Diagnosis and Evaluation

13.2 Electroencephalography (EEG)

13.3 Imaging

13.4 Treatment and Management

13.5 Which Patient should be Treated with Antiseizure Drugs?

13.6 Evidence-Based Guidelines

13.7 How Well do Seizure Medications Work?

13.8 Conclusion and Summary

Chapter 14: Medial Temporal Lobe Epilepsy

14.1 Introduction

14.2 Functional Neuroanatomy of the Temporal Lobe

14.3 Pathology

14.4 Differential Diagnosis

14.5 Diagnosis

14.6 Concluding Statements

Chapter 15: Substrate-Directed Epilepsy

15.1 Intractable Partial Epilepsy

15.2 Epilepsy Surgery

15.3 Localization of the Epileptogenic Zone

15.4 Lesional MRI (or Substrate-Directed Epilepsy Syndromes)

15.5 Functional Neuroimaging and Intracranial EEG

15.6 Symptomatic Partial Epilepsy

15.7 Non-Lesional MRI (Non-Substrate-Directed Partial Epilepsy)

15.8 Non-Lesional Temporal Lobe Epilepsy (Surgically Remediable Syndrome?)

15.9 Surgical Advances

Chapter 16: Non-Substrate-Directed Partial Epilepsy

16.1 Introduction

16.2 Genetic or IPE Syndromes

16.3 Medically Refractory Non-Substrate-Directed Partial Epilepsy

16.4 Conclusions

Chapter 17: Surgical Treatment

17.1 Introduction

17.2 The Process of Presurgical Evaluation

17.3 Intracranial Monitoring

17.4 Surgical Procedures

17.5 Conclusion

Index

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Library of Congress Cataloging-in-Publication Data

Adult epilepsy / edited by Gregory Cascino and Joseph Sirven.

p. ; cm.

Includes bibliographical references.

ISBN 978-0-470-74122-1 (cloth)

1. Epilepsy. 2. Adult. I. Cascino, Gregory. II. Sirven, Joseph I.

[DNLM: 1. Epilepsy. 2. Adult. WL 385]

RC372.A44 2010

616.8′53-dc22

2010037013

A catalogue record for this book is available from the British Library.

This book is published in the following electronic formats: ePDF: 978-0-470-97502-2; Wiley Online Library: 978-0-470-97503-9; ePub: 978-0-470-97619-7

Set in 10.5/13pt Times Roman by Laserwords Private Limited, Chennai, India

First Impression 2011

This book is dedicated to our spouses Teresa Griffin Cascino and Joan Sirven who have been so gracious of their efforts and remarkable talents to support our personal and professional careers.

List of contributors

Eduardo Benarroch, MD

Department of Neurology

Division of Autonomic Disorders

Mayo Clinic

200 First Street SW

Rochester, MN 55905

USA

Jeffrey W. Britton, MD

Department of Neurology

Divisions of Clinical Neurophysiology-EEG and Epilepsy

Mayo Clinic

200 First Street SW

Rochester, MN 55905

USA

Gregory D. Cascino, MD, FAAN

Professor of Neurology, Mayo Clinic College of Medicine, and

Chair, Division of Epilepsy,

Mayo Clinic and Mayo Foundation

200 First Street SW

Rochester, MN 55905

USA

Julie Cunningham, Pharm D

Department of Pharmacy

Mayo Clinic

200 First Street SW

Rochester, MN 55905

USA

Joseph F. Drazkowski, MD

Division of Epilepsy

Mayo Clinic Arizona

5777 East Mayo Boulevard

Phoenix, AZ 85054

USA

Matthew Hoerth, MD

Division of Epilepsy

Mayo Clinic Arizona

5777 East Mayo Boulevard

Phoenix, AZ 85054

USA

Terrence D. Lagerlund, MD

Consultant, Department of Neurology,

Division of Clinical Neurophysiology

Mayo Clinic, and

Associate Professor of Neurology,

Mayo Clinic College of Medicine,

200 First Street SW

Rochester, MN 55905

USA

Katherine C. Nickels, MD

Child and Adolescent Neurology and Epilepsy

Mayo Clinic

200 First Street SW

Rochester, MN 55905

USA

Katherine H. Noe, MD, PHD

Assistant Professor of Neurology

Mayo Clinic College of Medicine, and

Consultant, Department of Neurology

Division of Epilepsy

Mayo Clinic Arizona

5777 East Mayo Boulevard

Phoenix, AZ 85054

USA

Raj D. Sheth, MD

Professor of Neurology

Mayo Medical School, and

Department of Neurology

Division of Epilepsy

Mayo Clinic

4500 San Pablo Road

Jacksonville, FL 32224;

Chief of Neurology

Division of Pediatric Neurology

Nemours Children's Clinic

807 Children's Way

Jacksonville, FL 32207

USA

Jerry J. Shih, MD

Department of Neurology

Division of Epilepsy

Mayo Clinic

4500 San Pablo Road

Jacksonville, FL 32224

USA

Cheolsu Shin

Department of Neurology

Division of Epilepsy

Mayo Clinic

200 First Street SW

Rochester, MN 55905

USA

Joseph I. Sirven, MD

Professor of Neurology, Mayo Clinic College of Medicine,

Chairman of Education, Mayo Clinic Arizona, and

Department of Neurology, Division of Epilepsy

Mayo Clinic Hospital, 5 East

5777 East Mayo Boulevard

Phoenix, AZ 85054

USA

Elson L. So, MD

Professor of Neurology

Director, Section of Electroencephalography

Mayo Clinic College of Medicine

200 First Street SW

Rochester, MN 55905

USA

Korwyn Williams

Department of Pediatrics University of Arizona College of Medicine

Phoenix, AZ 85004;

Division of Neurology Children's Neuroscience Institute

Phoenix Children's Hospital

Phoenix, AZ 85004

USA

Elaine Wirrell

Professor of Neurology

Divisions of Epilepsy and

Child and Adolescent Neurology

Mayo Clinic

200 First Street SW

Rochester, MN 55905

USA

Gregory A. Worrell, MD, PHD

Department of Neurology

Divisions of Epilepsy and Clinical Neurophysiology

Mayo Systems Electrophysiology Laboratory

Mayo Clinic

Rochester, MN 55905

USA

William O. Tatum IV, DO

Professor Department of Neurology

Division of Epilepsy

Mayo College of Medicine

Mayo Clinic

4500 San Pablo Road

Jacksonville, FL 32224

USA

Tarek M. Zakaria, MD

Director, Epilepsy Monitoring Unit

Co Director Epilepsy surgery program

Norton Neuroscience Institute

Louisville, KY 40241

USA

Preface

The idea for this book came from a Mayo Clinic Clinical Neurophysiology course that is held annually in January or February. Colleagues from the Division of Epilepsy participate as course faculty in the EEG and Epilepsy didactic sections and workshops for the attendees. We are fortunate to have three Mayo Clinic comprehensive epilepsy programs in Jacksonville, FL, Scottsdale/Phoenix, AZ, and Rochester, MN. All authors of this monograph are actively involved in patient care and clinical research, are members of the Mayo Clinic Division of Epilepsy, and have academic appointments at the Mayo Clinic College of Medicine. Similar to our Mayo Clinic educational program, the target audiences for this textbook are health care professionals involved in the diagnostic evaluation or management, or both, of patients with seizure disorders. Our goal is provide a contemporary and concise review of information pertinent to the management of individuals with epilepsy.

Greg Cascino

Rochester, MN

Joe Sirven

Phoenix, AZ

July 2010

Chapter 1

Introduction: Epilepsy

Gregory D. Cascino

Department of Neurology, Division of Epilepsy, Mayo Clinic, Rochester, MN, USA

1.1 Epilepsy Care: Beginnings of Observation and Recognition

Epilepsy historically has been one of the most commonly recognized and distinct neurological disorders [1, 2]. In fifth-century BC Greece, Hippocrates, the father of medicine, made several profound observations regarding epilepsy that have survived many centuries [1]. He was a follower of the Greek god of medicine Asclepius whose symbol of a serpent-entwined staff has been representative of medical practice to the present. On the island of Cos in the Aegean Sea, Hippocrates observed patients with a malady referred to as the “sacred disease.” He indicated that seizures appeared no more divine or spiritual than any other illness. Hippocrates also implicated the brain as the site of seizure onset and recognized the genetic predisposition in selected patients. Galen was another outstanding physician of Greek origin who was born in 129 AD and was influenced by the teachings of Hippocrates. Upon traveling to Rome he made several seminal observations in medicine and introduced the term “aura” to describe the patients' symptoms that recognized the onset of a seizure. Initially Galen recognized the abdominal complaints that may occur in patients prior to the impairment in consciousness. The aura was compared to a “breeze” that may indicate an oncoming weather storm.

Epilepsy in the Middle Ages was considered to be emblematic of the absence of a spiritual or divine presence [1, 2]. The paroxysmal behavior was thought to be related to an external evil force that was possessing the soul of the unfortunate individual. The removal of “demons” was necessary to control the “convulsions” that gripped the patient. Later, patients were often isolated from the general population and placed in institutions or epilepsy colonies. The segregation of people with epilepsy had a profoundly negative impact on the ability of these individuals to successfully integrate and live in “normal” society.

1.2 Epilepsy Care: Initial Understanding and Treatment

The contemporary care of patients with seizure disorders began with the pivotal observations and writings of John Hughlings Jackson (1835–1911), the father of epilepsy, at the National Hospital for Diseases of the Nervous System including Paralysis and Epilepsy in Queen Square, London [1-4]. Jackson influenced the Scottish neurologist Sir David Ferrier working in London to confirm the relationship between nervous system physiology and structure to better elucidate the pathophysiology associated with seizures [4]. Ferrier performed electrical stimulation of the motor cortex in the dog providing evidence that focal motor seizures were associated with excitation of the precentral gyrus [1-4]. Prior to the works of Jackson in the mid nineteenth century, there was considered to be only one prominent seizure type, the generalized tonic-clonic seizure. There was a broad consensus that the “grand mal seizure” involved the lower brainstem or upper cervical cord, or both structures. Jackson postulated that the cerebral cortex was the site of seizure onset and that the ictal behavior correlated with the region of functional anatomy. A focal or lateralized neurological abnormality may indicate the region of hemisphere of seizure onset. Further, he introduced the concept of partial epilepsy indicating that “part” of the cerebral cortex was involved in seizure onset [3]. This area of cerebral cortex was considered to be abnormal resulting in a focal neurological deficit and seizure activity. The potential therapeutic importance of Jackson's brilliant conclusions was that surgical treatment may be effective as an underlying pathology or structural lesion was presumed to be associated with the site of epileptogenesis [4]. Resection of the lesional pathology was entertained as an effective means of rendering the patient seizure-free [4]. These seminal observations occurred prior to the development of electroencephalography (EEG), neuroimaging, or use of antiepileptic drug therapy. Subsequently, beginning in 1886 Dr. Victor Horsley, a young surgical colleague of Hughlings Jackson, performed neurosurgical procedures for epilepsy in patients at the National Hospital [4]. The localization of the epileptogenic brain tissue was based on the ictal semiology, the neurological examination, and knowledge of functional neuroanatomy. The efforts of Jackson and colleagues began the rewarding and productive relationship between neurology and neurosurgery in the management of patients with intractable epilepsy [4].

1.3 Epilepsy Care: The Mayo Clinic

Dr. Willam J. Mayo and Dr. Charles H. Mayo, the brothers who founded the group practice in Rochester, Minnesota, were close colleagues of the “fathers” of contemporary neurosurgery, Dr. Harvey Cushing of Johns Hopkins University and later Harvard University, and Dr. Charles H. Frazier of the University of Pennsylvania [5, 6]. The strong relationship between Dr. Cushing and the Mayos lasted until the time of the brothers' deaths in 1939 [6, 7]. Dr. C. Mayo published his initial experience with neurosurgery in 1891 [8]. The importance of seizures as a diagnostic symptom of neurological disease and the effect of neurosurgery on seizure tendency were recognized. Ultimately, in 1917, Dr. Alfred W. Adson became the first full-time neurosurgeon at the Mayo Clinic [5]. The growth of neurology and neurosurgery at this institution were forever intertwined during this period as Dr. Walter D. Shelden had come to the Mayo Clinic in 1913 and founded the neurology section. Perhaps most importantly, Dr. Adson had insisted that neurosurgery should be a separate department from surgery and a unique subspecialty at the Mayo Clinic. Advances in diagnostic technology would be necessary to expand the care of patients with epilepsy.

The first EEG study at the Mayo Clinic was performed by Dr. E.J. Baldes, a biophysicist, on Dr. Charles LeVant Yeager who was a Mayo neurology fellow in 1936 [9]. Dr. Yeager was an amateur radio operator who became interested in the works of Hans Berger when the first publication of EEG appeared in 1929. He personally translated the 10 works of Berger on EEG into English. Dr. Frederick Moersch, one of the pioneers in neurology at the Mayo Clinic, had visited Nobel Laureate Lord Edgar Douglas Adrian's laboratory working on EEG at the University of Cambridge in 1935, and encouraged development of this innovation in Rochester, MN [9]. The initial EEG recordings were performed at the Rochester State Hospital and the laboratory was subsequently moved to Saint Marys Hospital. The development of EEG at the Mayo Clinic was selected by Dr. Henry Woltman, the section head of neurology, as Dr. Yeager's “research project.” Working closely with Dr. Adson the diagnostic utility of EEG was analyzed in patients with known intracranial lesions. Dr. Adson had insisted that only the ages of the patients and not the clinical information be made available to the EEG readers. The results of EEG studies in a series of patients demonstrated the favorable diagnostic importance of the “new” technique for structural localization compared to other studies, for example, ventriculography and pneumoencephalography. EEG was also demonstrated to assess the seizure tendency in these individuals and indicate the likely site of seizure onset.

After World War II the clinical and basic research activities of the EEG laboratory were expanded. The recruitment in 1948 of Dr. Reginald G. Bickford from the University of Cambridge increased the research interests of EEG to include the evaluation of patients with seizure disorders [9]. Dr. Bickford had worked with E.D. Adrian and EEG pioneer Dr. W. Grey Walter during the war and had had the opportunity to perform intracranial EEG recordings in patients with penetrating head injuries undergoing neurosurgical treatment [9, 10]. He brought to the Mayo Clinic his interest in reflex epilepsy and intracranial EEG recordings. Therefore, Rochester, MN was one of the earliest centers in North America performing these depth electrode recordings in patients with seizure disorders. A symposium on “intracerebral electrography” was held in 1953 summarizing the outcome of these studies in patients with epilepsy [10]. Beginning in 1948, Dr. Bickford and colleagues also performed motion picture recordings for diagnostic classification of seizures and nonepileptic events. Dr. Donald W. Klass started as neurology resident at the Mayo Clinic in 1953 and went on to become head of the EEG section in 1967 [11]. Dr. Klass had described the epileptogenic potential of several paroxysmal EEG patterns and recognized the benign nature of selected discharges. Importantly, he also educated a generation of neurologists in EEG interpretation [9].

In 1968, Dr. Frank W. Sharbrough joined the staff at the Mayo Clinic after completing his training at the University of Michigan and serving in the military. His interests included routine EEG, intraoperative EEG monitoring during cerebrovascular surgery and epilepsy surgery, evoked potentials, and use of computer applications to monitor neurophysiological techniques. Focal cortical resections for patients with epilepsy and excisions of potentially epileptogenic lesions were performed by several neurosurgeons including Dr. Ross H. Miller who served as chair of the department of neurosurgery (1975–1980) and performed over 4000 operations for intracranial tumors [5]. Surgical treatment for intractable partial epilepsy achieved a significant advance with the arrival of Dr. Edward P. Laws, Jr. at the Mayo Clinic in 1972 [5]. Dr. Laws was trained in neurosurgery at the Johns Hopkins University by the renowned neurosurgeon Dr. A. Earl Walker and collaborated with famed electroencephalographer, Dr. Ernst Niedermeyer. At the Mayo Clinic he was a prominent academic neurosurgeon and educator actively involved in epilepsy surgery as well as resection of pituitary tumors and craniopharyngiomas [12, 13].

In 1973 the Mayo Clinic was the first institution in the United States to have an x-ray computed tomography (CT) scanner installed [14]. The use of CT and the subsequent development of magnetic resonance imaging (MRI) had a profound effect on the evaluation of patients with epilepsy. The pivotal importance of MRI in identifying structural abnormalities and the potential for performance of intraoperative imaging to guide surgical procedures and implantation of intracranial electrodes had an enormous impact on the care and management of epilepsy. In 1984, Dr. Patrick J. Kelly joined the staff in neurosurgery [5]. After his neurosurgery residency he completed training at the Hospital Sainte Anne in Paris with the founder of stereotactic neurosurgery, Dr. Jean Talairach. The emergence of the new imaging technology and Dr. Kelly's experience combined for the use of stereotactic neurosurgical procedures to resect epileptogenic lesions and for computer-assisted placement of intracranial depth electrodes [15, 16]. Stereotactic “lesionectomy” was particularly useful for intra-axial lesions involving functional cerebral cortex [15].

The last decade of the twentieth century was remarkable for major advances in neuroimaging at the Mayo Clinic that significantly improved the ability to care for patients with intractable seizure disorders. Colleagues in neuroradiology, neurology, neurosurgery, and nuclear medicine were critical for the development of MRI hippocampal formation volumetry and subtraction ictal single photon emission computed tomography (SISCOM) [17, 18]. The former structural neuroimaging study has proven beneficial in correlating quantitative hippocampal atrophy with neuronal cell loss, neuropsychometric studies, and seizure outcome in patients undergoing temporal lobe surgery for intractable epilepsy [17]. The latter functional neuroimaging procedure has been adapted to the evaluation of patients with nonlesional partial epilepsy or if the preoperative evaluation has conflicting findings regarding the localization of the epileptogenic zone [18].

The practice of epileptology at the Mayo Clinic is predicated on the motto for medical care since the pioneer practice of Dr. William W. Mayo in the nineteenth century: “The needs of the patient always come first.” At the three Mayo Clinic sites in Arizona, Florida, and Minnesota the goals of epilepsy treatment are to reduce seizure tendency and improve the quality of life enabling the individual to become a participating and productive member of our society.

References

1. Temkin, O. (1994) The Falling Sickness: A History of Epilepsy from the Greeks to the Beginnings of Modern Neurology, 2nd edn, Johns Hopkins University Press, Baltimore.

2. Eadie, M.J.and Bladin, P.F. (2001) A Disease Once Sacred: A History of the Medical Understanding of Epilepsy, John Libbey, Eastleigh.

3. Jackson, J.H. (1931) On epilepsy and epileptiform convulsions, in Selected Writings of John Hughlings Jackson, vol. 1 (ed. J. Taylor), Hodder and Stoughton, London.

4. Taylor, D.C. (1987) One hundred years of epilepsy surgery: Sir Victor Horsley's contribution, in Surgical Treatment of the Epilepsies, (ed. J. Engel Jr.), Raven Press, New York, pp. 7–11.

5. Spinner, R.J., Al-Rodhan, N.R., and Piepgras, D.G. (2001) 100 years of neurological surgery at the Mayo Clinic. Neurosurgery, 49, 438–446.

6. Cohen-Gadol, A.A., Homan, J.M., Laws, E.R. et al. (2005) Historical vignette. The Mayo brothers and Harvey Cushing: a review of their 39-year friendship through their personal letters. J Neurosurg, 102, 391–396.

7. Cushing, H. (1939) The Mayo brothers and their clinic. (Obituary) Science, 90, 225–226.

8. Mayo, C.H. (1891) A contribution to cerebral surgery: Part I—Cerebral abscess; operation; recovery. Part II—Arteriovenous aneurism in cavernous sinus; operation; recovery. Northwest Lancet, 11, 59–60.

9. Klass, D.W.and Bickford, R.G. (1992) Reflections on the birth and early development of EEG at the Mayo Clinic. J Clin Neurophysiol, 9, 2–20.

10. (1953) Symposium on intracerebral electrography. Proc Staff Meet Mayo Clinic, 28, 145–192.

11. Thomas, J.E., Reagan, T.J., and Klass, D.W. (1977) Epilepsia partialis continua. A review of 32 cases. Arch Neurol, 34, 266–275.

12. Niedermeyer, E., Laws, E.R. Jr., and Walker, E.A. (1969) Depth EEG findings in epileptics with generalized spike-wave complexes. Arch Neurol, 21, 51–58.

13. Meyer, F.B., Marsh, W.R., Laws, E.R. Jr., and Sharbrough, F.W. (1986) Temporal lobectomy in children with epilepsy. J Neurosurg, 64, 371–376.

14. Baker, H.I. Jr. and Houser, O.W. (1976) Computed tomography in the diagnosis of posterior fossa lesions. Radiol Clin North Am, 14, 129–147.

15. Cascino, G.D., Kelly, P.J., Hirschorn, K.A. et al. (1990) Stereotactic resection of intra-axial cerebral lesions in partial epilepsy. Mayo Clin Proc, 65, 1053–1060.

16. Cascino, G.D., Kelly, P.J., Sharbrough, F.W. et al. (1992) Long-term follow-up of stereotactic lesionectomy in partial epilepsy: predictive factors and electroencephalographic results. Epilepsia, 33, 639–644.

17. Jack, C.R. Jr., Sharbrough, F.W., Twomey, C.K. et al. (1990) Temporal lobe seizures: lateralization with MR volume measurements of the hippocampal formation. Radiology, 17, 423–429.

18. O'Brien, T.J., So, E.L., Mullan, B.P. et al. (1998) Subtraction ictal SPECT co-registered to MRI improves clinical usefulness of SPECT in localizing the surgical seizure focus. Neurology, 50, 445–454.

Section 1

PATHOPHYSIOLOGY AND EPIDEMIOLOGY OF SEIZURES AND EPILEPSY

Chapter 2

Seizure and Epilepsy Syndromes Classification

Jerry J. Shih

Department of Neurology, Division of Epilepsy Mayo Clinic, Jacksonville, FL USA

2.1 Introduction

Understanding the classification of epileptic seizures is the first step towards the correct diagnosis, treatment, and prognostication of the condition. The initial management of a patient with seizures begins with an understanding of the patient's seizure type and, if pertinent, epilepsy syndrome. The classification of epileptic seizures is still largely based on clinical observation and expert opinions. The International League Against Epilepsy (ILAE) first published a classification system in 1960. The last official update for seizures was published in 1981 [1], and the last official update for the epilepsies was in 1989 [2]. These updates form the officially accepted classification system, although there is a new proposal to amend the current system [3].

2.2 The Classification of Epileptic Seizures

By definition, epilepsy is diagnosed after a patient has two or more unprovoked seizures.

Partial Seizures

Partial or focal seizures comprise one of the two main classes of epileptic seizures, with generalized seizures being the other. Partial seizures are subdivided between simple and complex partial seizures, which are distinguished by the presence or absence of impairment of consciousness. Simple partial seizures are defined as seizures without impairment of consciousness while complex partial seizures are defined as seizures with impairment of consciousness. Partial seizures manifest themselves in many different forms, depending on which area of the cortex is involved in the onset and spread of the ictal discharge. Partial seizures originate from a focal area of cerebral cortex and may spread to other cortical regions either unilaterally or bilaterally. A partial seizure may manifest with motor signs, autonomic symptoms, somatosensory or special sensory symptoms, or psychic symptoms. The term aura is synonymous with a simple partial sensory or psychic seizure. An aura often reflects the location of the seizure onset zone.