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Placebo-controlled pilot study of randomized to sham stimulation and 96 patients received centromedian thalamic stimulation in treatment of intractable seizures fungus king twom buy grifulvin v 250 mg with visa. Unadjusted median declines at the end of the blinded neurostimulation stop seizures Electric field suppression of epilepti- caudatus on epileptic electrical activity of brain in patients with intractable form activity in hippocampal slices antifungal young living essential oils buy grifulvin v visa. Electrical stimulation of the mammillary nuclei hippocampal epileptiform activity with radial electric fields fungus gnats on indoor plants order grifulvin v 250mg visa. Effect of chronic electrical stimula- electric fields in chronically implanted animals fungus gnat damage purchase generic grifulvin v. Hippocampal electrical therapy for partial-onset seizures: a randomized active-control trial. Long-term safety study of vagus nerve stimulation for the treatment of refractory seizures. Even temporal lobe seizures of relatively modest frequency As a group, individuals with epilepsy have impaired cognitive over several decades can increase the severity of hippocam- performance in comparison to healthy subjects matched for pal atrophy and reduce cognitive abilities (13,14). Memory age and education (1); however, considerable intersubject vari- problems are common in patients with epilepsy. Most persons with epilepsy have intelligence in many factors contribute to these problems, it is interesting the normal range, and some have superior cognitive abilities. Psychosocial fac- structural cerebral damage as a consequence of repetitive or tors may adversely affect cognition through such mechanisms prolonged seizures; (ix) hereditary factors; (x) psychosocial as depression or restriction of environmental influences (17). Patients with new onset epilepsy have been shown to have impaired cognition (1,4). Patients with seizures attributable to progressive cere- bral degeneration usually exhibit dementia, those with men- Epilepsy surgery usually does not cause a general cognitive tal retardation have an increased incidence of epilepsy, and decline because dysfunctional tissue is primarily removed those with seizures caused by a focal brain lesion may (18). Surgery may even result in improved cognition because exhibit a specific neuropsychological pattern of deficits. However, clinically contrast, patients with idiopathic epilepsy are more likely to significant postoperative cognitive deficits may occur (19). Seizure type may be strongly For example, left temporal lobectomy may lead to declines associated with cognition (6). However, the risks are myoclonic epilepsy usually have normal intelligence, but largely predictable (19–22). In gen- epilepsy onset is later or if hippocampal gliosis/atrophy is eral, the earlier the age of seizure onset, the more likely it is not present. Verbal memory is at greater risk following left that a patient will have cognitive impairment. Additionally, temporal lobectomy if baseline verbal memory is high in a patients with mental retardation are more likely to have patient with left cerebral language dominance or if func- refractory epilepsy (6,7). Thus, a patient interictally when consciousness is altered during generalized undergoing left temporal lobectomy is at particular risk if or complex partial seizures. Epileptiform discharges and the patient has high baseline verbal memory with left cere- postictal suppression may impair cognition interictally bral language dominance and lack of evidence of left tempo- (9,10). Rarely, unilateral temporal lobec- temporal cortex in patients with epilepsy caused by mesial tomy has resulted in a severe global anterograde memory temporal lobe sclerosis (12). Fortunately, modern advances in preoperative 1028 Chapter 92: Cognitive Effects of Epilepsy and Antiepileptic Medications 1029 evaluation techniques have minimized this risk. In 1850, Huette (41) noted that bro- selective approaches may be affected by collateral white mide produces general sedation, mental slowing, and depres- matter damage (23,24). Somerfeld-Ziskind and Ziskind (43) Vagus Nerve Stimulation randomized 100 patients with epilepsy to phenobarbital or ketogenic diet. Numerous studies (31,32,44) have subsequently exam- (27,28), but this may be the result of reduced seizures. Selection bias is a problem when subjects sider the risk-to-benefit ratio of any treatment. Nonequivalence of depen- patients on monotherapy in whom anticonvulsant blood lev- dent measures may occur when there is no assurance that els are within standard therapeutic ranges (31). Furthermore, treatment groups performed similarly on dependent measures the cognitive effects may be partially offset by the reduction prior to treatment. Even when statistically an individual patient is the one that best controls seizures significant findings are apparent, the magnitude and impact of with the fewest side effects, and for some patients this regi- the findings have to be interpreted in terms of clinical signifi- men may involve polytherapy. Meador and associ- effects of carbamazepine, phenytoin, and valproate have been ates (48) also found no cognitive differences between carba- demonstrated (31,32). The investiga- healthy volunteers comparing treatment with carbamazepine tors found no overall difference between carbamazepine and and gabapentin. In another study (49), mazepine in adults (58), and better overall tolerability was 32% of the variables were significantly worse with phenobar- seen with gabapentin in healthy elderly adults (59). In con- bital than with phenytoin or valproate, with the latter two trast, gabapentin can produce irritability, hyperactivity, and agents being similar to each other, and about half of all vari- agitation in children (60,61). Other studies with healthy adults demonstrated comparing carbamazepine and phenytoin have described fewer cognitive side effects with lamotrigine compared with car- modest negative effects on cognition with both agents, but few bamazepine, diazepam, phenytoin, placebo, and valproate differential effects (52–54). In clinical trials, lamotrigine was better tolerated A possible criticism of some of the crossover studies than carbamazepine and phenytoin (66–69). See section described above might be the relatively short duration of Topiramate for additional studies. Significantly more improvements in mood ences in cognitive performance were observed over the 5-year occurred with lamotrigine compared to levetiracetam in a dou- follow-up. Although both agents produced some effects, signifi- A double-blind, randomized, parallel, placebo-controlled, cantly fewer untoward cognitive effects were seen with multidose study found no statistically significant cognitive gabapentin compared with carbamazepine. The increased susceptibility of the elderly difficulty with word-finding and fluency). Factors affecting to the cognitive effects of a variety of agents is attributable to these adverse effects include titration rate, maintenance time, both pharmacokinetic and pharmacodynamic factors. In a single- example, it is well established that the elderly are at increased blind, randomized, parallel-group study in healthy volunteers risk for untoward cognitive effects from benzodiazepines (85), topiramate was associated with more adverse cognitive (100). Similar to studies in younger adults, one study (101) effects than gabapentin and lamotrigine at 1 month, but the reported comparable cognitive effects of phenytoin and val- topiramate titration rate was faster than recommended. Unfortunately, investigations in chil- therapy reported more adverse neuropsychological effects for dren are inadequate (105). Adverse cognitive effects of phenobarbital In four double-blind, randomized, add-on studies of patients have also been found in placebo-controlled, parallel-group with epilepsy (91–95), vigabatrin had few adverse effects on studies of children with febrile convulsions (107,108). A single-dose study in healthy volun- mazepine, phenytoin, and valproate in children have yielded teers showed less impairment than lorazepam (95), and viga- few differences (109–112). Abnormal behaviors, including parallel-group study in children and adolescents with newly depression and psychosis, have been reported in 3. The agent was reported to impair cognition velopmental deficits in children of mothers with epilepsy, (e. Further, the effects of in utero phenobarbital exposure on intelligence cognitive/behavioral deficits. Phenytoin and valproate alter neu- exposed to valproate monotherapy, compared with 3% to 6% ronal membranes in the hippocampus (135,136). Valproates effect in this and other studies was prospective studies, follow-up began postnatally rather than dose-dependent. In many studies, the influences of possible have also reported an increased risk for autistic spectrum confounding factors have not been addressed in an empirical disorder or behavioral abnormalities in children exposed to fashion (e. The incidence of mental retardation is increased in Possible Mechanisms of Antiepileptic children of mothers with epilepsy versus children of mothers Drug Effects on Neurodevelopment without epilepsy, but not in children of fathers with epilepsy versus controls (148,156). Gaily and mediates by means of embryonic prostaglandin H synthetase coworkers (143) related risk for cognitive dysfunction to or lipoxygenases (176–178). Carbamazepine, lamotrigine, During pregnancy, folate demand is increased because of its and valproate have positive psychotropic effects. Phenobarbital, treatment goal in each patient is to achieve the best control of phenytoin, and primidone, but not carbamazepine, deplete seizures while producing the fewest side effects. For an indi- folate (180–183), and valproate affects folate-dependent one- vidual patient, the best risk-to-benefit ratio may be obtained carbon metabolism (184). Blood folate concentrations are sig- with judicious use of polypharmacy or with anticonvulsant nificantly lower in women with epilepsy who have abnormal blood level above standard therapeutic ranges.
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The amplitude of the activity more localizing information (34) fungus gnats human skin buy generic grifulvin v, and employing the lower- is measured between the zero and the maximum peak antifungal mechanism of action discount 125mg grifulvin v visa. Sometimes sharp activity Mapping the Electrical Field can be separated from a slower background fungus or bacteria purchase grifulvin v in india, if the frequency of the epileptic activity is clearly different xylitol fungus purchase grifulvin v 250mg online, by using filtering. The two-dimensional display of the scalp regions involved in Practically, the amplitude is measured as peak-to-peak or epileptiform or other activity is called mapping. Identification of the baseline and peak may lines are drawn on a representation of the scalp to specify the be particularly troublesome in the case of polyphasic dis- topography of equivalent electrical potentials, similar to the iso- charges, in which each phase is brief and difficult to line up contour lines drawn by a surveyor on a land map. During visual analysis of a waveform, the montage convenient isopotential contours. But as shown in Multiple peaks or phase reversals with small time shifts reflect Figure 7. As the initial step, a longitudinal or transverse chain of sensitive to the selection of the appropriate time frame. Errors the electrodes is used to map the one-dimensional relationship in identifying the peaks that are to be mapped can cause extra- of voltage level to electrode position, as illustrated in Figure 7. To create an isopotential contour map, a 100% value is generally has the highest amplitude at the electrode closest to assigned to the maximum and a 0% value is assigned to the the involved cortical epileptogenic neurons (7). However, as discussed later, the polarity of the component of an epileptic discharge may be preceded by a maximum depends on an assumption about the generator. The vertical marker reveals that the discharge actually consists of three phases, with each peak at a slightly different time. Note that the specific choice of reference electrode does not affect the shape of the isocontours of this left temporal discharge. Similarly, the minimum may be neg- show the largest pen deflection, and the amplitude of the ative or positive, or may have a mid-curve value when two deflection in all the other channels will be directly proportional maxima of opposite polarity are assumed, for example, a hor- to the magnitude of the activity recorded from each of those izontal dipole generator. This situation makes it especially easy to find the maximum, that is the point given a 100% value, at least two maximum and to assess the extent of the field distribution different isocontour maps can be obtained, as shown in (see Fig. To make the correct choice, some assumptions will recognize a contaminated reference and construct a dis- must be introduced, as described later. In this situation, those channels showing the bipolar measurements first must be converted to voltages some activity will deflect in one direction only, as illustrated in relative to a selected reference electrode. Two voltage/electrode maps for the spike indicated by the arrow are recon- structed manually from the two montages, respectively. In the bipolar montage, the dif- ference of the potential level (amplitude) and relative polarity (deflection) between neigh- boring electrodes is sequentially tracked along the chain of the montage. Here, the potential mapping was started from a com- mon electrode O1 with a value of 0 V assumed. Employing the algebraic relation- ships between the electrode derivations, the calculated amplitudes at each individual elec- trode are graphed. The resulting voltage level at Fp1 differed slightly between the two bipo- lar chains, owing to minor differences in manual measurement of the amplitudes. For the referential montage, the measured ampli- tudes are written down directly, as no calcula- tions are necessary. If all the deflections are in the same direction and the referential elec- trode (input 2) is located at the minimum, as seen in this example, then the amplitude of the deflection simply reflects the voltage level of the electrode. No matter which montage is used, the field determination should be same in terms of location of the maximum. The voltage/electrode maps may differ in detail, however, reflecting a varying degree of visibil- ity of the spike between montages. A 100% value is assigned to the maximum and a 0% value is assigned to the minimum. Depending on the polarity of the maximum, at least two different maps can be obtained, illustrated on the bottom row. In the map on the left side the maximum is assumed to be negative, and the falloff of potential with distance is physiologi- cal. On the right, the opposite assump- tion was made, that is, the maximum is a positive potential, resulting in a very unphysiological distribution. Thus, it was deduced that this spike has maxi- mum negativity from the left temporal area. For instance, one can determine the relative amplitude at any electrode to in the double-banana longitudinal montage, the frontal the reference electrode. Of course, the exact amplitude (in polar and occipital electrodes occur in both ipsilateral chains. However, these common electrodes provide an electrical connection electrodes relatively distant from the site of maximum activity between chains and allow an algebraic determination of the see a negligible potential, hence the assumption that the potential gradient of the electrical field over the entire area potential of the particular transient under study at these unin- covered by the two chains. The same time period is shown on the right, and the distribution montage to an uninvolved con- tralateral electrode confirms the left posterior maximum of this surface-negative discharge. Although it is possible to localize a spike or sharp wave Bipolar Montage from a single montage if electrical connections between the Derivations in a bipolar montage are customarily arranged in chains (or appropriate assumptions) exist, recording from mul- chains (6,76,77); that is, the electrode connected to input 2 of tiple montages, especially crisscrossing montages, will help one channel is also connected to input 1 of the next channel. When the amplitudes of sagittal axes, and contain no single electrode common to all the potential distribution do not match exactly between chains channels. Generally, referential montages with uninvolved refer- immediate clues to localize maxima and minima. Measure the amplitude of the component of interest in the deflections point toward each other), and positive phase each channel. Assume If there is a phase reversal, the electrode where it occurs is a value of zero for that electrode. Calculate the amplitude of all the electrodes relative to (The term maximum denotes absolute value, not necessarily the selected electrode, based on the algebraic relationship maximum negativity. Follow this procedure for all the chains connected by involving surface-negative activity generate a negative phase common electrodes. Assume another zero electrode to calculate the distribu- However, the same picture theoretically could result from a tion in chains not connected by a common electrode. If the resulting distribution has potentials both above and reversal and larger at the ends of the chain. Draw isopotential contours around the resulting bipolar chain will cause the deflections to point away from distribution. If the topographic distribution is unphysiologic, assume If there is no phase reversal, then the electrical field maxi- the opposite polarity for the waveform. The potential field minimum trode montages are simple and systematic, as recommended must then be at the opposite end of the chain. Inexperienced electroencephalographers will often (erroneously) localize by Montage type Phase reversal Conclusion a cursory impression of the maximum field. Bipolar Yes Maximum or minimum is located at the Referential Montage electrode of the All derivations in a referential montage connect the same elec- phase reversal trode (or electrode combination) to input 2. If some deriva- Referential No Referential electrode is tions within a given montage use one reference electrode (e. Electroencephalo- graphers are used to looking for phase reversals in a bipolar montage. In this tracing there is no phase reversal; there- fore, the discharge must be coming from either the beginning or the end of the chain. If the sharp wave is negative, implying that the activity is at the begin- ning of the chain (F7), the distribution has a much more realistic falloff. If the sharp wave is assumed to be positive, then the maximum would have to be at the end of the chain (F8) with an oddly flat distribution on the right and a rapid falloff on the left. The amplitudes of the differences between the voltages at input 1 and input 2 do not indicate the maximum of the electrical field. In this circumstance, the amplitude of the sharp wave is actually maximum at F7 and T7, but approximately equal in those two adjacent eletrodes, so the dis- charge is localized to both electrodes. This montage, which employs a contralateral reference chosen because it appeared to be unin- volved in the discharge, helps to clarify the location of a spike widely distibuted across the left temporal region. Since there is a phase reversal between channels 2 and 3, the reference is neither minimum nor maxi- mum, that is, it must be involved. If the ref- average reference (85–87) and is the principle of computer- erence electrode is the minimum of the electrical field, the aided montage reformatting. The amplifiers in a reference montage perform their this situation is the easiest to analyze, because the amplitude differential function exactly as in a bipolar montage. Specifically, however, they measure largest-amplitude channel is at the minimum of the electrical the difference between each electrode and a chosen common field. Instead of chains of electrodes, with each succeed- deflection, the electrodes connected to input 1 of those chan- ing amplifier sharing one input from the previous amplifier, nels are also maximum. What the amplifier If there is a phase reversal, then the reference electrode is sees depends on the electrical relationship between the ref- neither the minimum nor the maximum of the electrical field erence and the field of the waveform.
Food allergens are investigated by performing detailed history (5) Neurological symptoms: Paresthesia may occur in the distal taking antifungal used in cell culture order cheap grifulvin v on-line, allergen tests and then by combining elimination tests and extremities with aggravation of dermatitis symptoms and provocation tests (not performed for cases accompanied by 236 I fungus gnats aloe vera buy grifulvin v online from canada. A case-series study in high-risk children was conducted to determine whether moisturizer application during the newborn 5 fungus covered chest nagrand buy cheapest grifulvin v and grifulvin v. Sweating period prevents the development of atopic dermatitis fungus gnats aloe vera buy 250 mg grifulvin v mastercard, in light of Sweating is an important cause and exacerbating factor for the importance of cutaneous barrier functions in atopic dermatitis. Bathing and was applied during the newborn period, had a low incidence rate of showering are important not only for washing away the compo- 15%. Physical irritation newborn period needs to be demonstrated in a randomized Causes and exacerbating factors other than the above- comparative study in future. The pathology of atopic dermatitis is a chronic inammation of the skin that is aggravated by the deterioration of compliance. Environmental factors necessary to educate patients repeatedly so they may understand Allergens such as mites and house dust, pollen allergens in the pathology and realize that a long-term antiinammatory specic seasons, and organic solvents such as formaldehyde and therapy is required. Being sensitized to mites in in- fancy is reportedly a marker for the development of asthma. Summary of the basic therapy of atopic dermatitis Periocular pathological changes are often observed during air- 6. These are If no infectious symptoms are seen in the affected part, a topical investigation and countermeasures of causes and exacerbating steroid can be applied to encourage the improvement of the cuta- factors; second, correction of skin dysfunctions (skin care); and neous symptom, even if the site is densely populated with Staph- third, pharmacotherapy. These are based on the concept that this ylococcus aureus (with bacterial counts of 1000 cfu/10 cm2 or more disease is an inammatory cutaneous disease that forms an as detected by the stamp method). These 3 points are equally (2) Care should be taken against microbial substitution with important and thus need to be appropriately combined in accor- methicillin-resistant S. Contact antigen skin barrier functions of patients with atopic dermatitis are Contact dermatitis is divided into allergic contact dermatitis, deteriorated due to abnormality in function such as deteri- which is developed by a sensitized patient, and primary irritant orated water retentivity, lowered threshold of itch, and contact dermatitis, which can be developed by anyone depending susceptibility to infection. Stress (3) Basics of pharmacotherapy: If countermeasures against the Aggravation by mental stress is often experienced in daily causes and exacerbating factors and the skin care have not medical practice. The high rate of aggravation of atopic dermatitis resulted in improvement of dermatitis, pharmacotherapy reported in areas affected by the Great Hanshin-Awaji Earthquake will be needed. Scratching will not only damage the cutaneous barrier functions b) Assessment of severity and activity level: Attempts have by injuring the skin, but also worsen the symptoms by causing the been made to assess the severity and activity level by release of various phlogogenic agents. If no improvement is observed or if an abnormal medication, such oral administration may be used for a change in symptoms is observed after approximately 1 short period of time. If remission cannot be main- If an abnormal change is observed in symptoms during treat- tained after approximately 6 months, the patient should ment or if no improvement is observed after treatment based on a be referred to a specialized medical institution to dene basic therapy for approximately one month, referral to a more the condition as severe, most severe, or intractable, in specialized medical institution should be considered. Skin care against atopic dermatitis execute): If remission cannot be maintained, external Skin care is highly important, as is shown by consideration of application of a higher ranked steroid, oral administration the fact that the skin tends to become more prone to drying due to of immunosuppressive agents (cyclosporine), oral aging, and given the adverse effects of settlement of S. In such conditions, with facilitation of transcutaneous invasion of Oral administration of steroids should not be executed in allergens and irritants, likely resulting in allergic reactions and ir- principle. However, if the patient develops extremely ritability, patients may come to suffer from itch due to the lowered 238 I. Abnormality in the water barrier function and the water retention capability of the horny cell layer are considered as causing/exacerbating factors of atopic dermatitis. Accordingly, the incidence rate of atopic dermatitis could be decreased by mois- turizer application during the newborn period. If the bacterial count is larger, it is important to take a skin care regimen with consideration of the bacterial ora on the skin surface. Given that a moisturizer is known to exert a higher moisturizing effect when externally applied twice a day than when applied once a day, consid- eration should be given to the number of external applications. Therefore, physicians should instruct patients not to forget the external application of 8. In the sweaty summer season, mild cases with the aim of moistening and protecting the skin, washing away sweat by showering improves rashes. For the treatment of weeping lesions in the such regions as the hairline, the side of the nose, and jaws, acute phase, a surface dressing with a zinc ointment may be etc. Urea preparations should be used with caution, as they can stimulate an eroded surface or strongly inammatory skin. Pharmacotherapies for atopic dermatitis turizer is useful to prevent relapse of atopic dermatitis; however, 8. External medicine studies have shown that the continuous use of a moisturizer since 8. Topical therapy the newborn period may reduce the incidence rate or delay the Topical therapy refers to skin care chiey with moisturizers, and development of atopic dermatitis. There ointment or topical steroids intermittently in combination with a they activate steroid-responsive genes to exert their pharmaco- moisturizer is useful in the remission maintenance period. This logical actions that include antiinammatory action in a narrow therapy is referred to as proactive therapy (Fig. Administration method of topical steroids not only control the relapse of cutaneous symptoms, but also to be (1) Selection of topical steroid: Topical steroids are classied into cost-effective. A steroid of an appropriate Health Care, Nara, Japan) with an externally applied medicine is rank should be used in accordance with the severity of effective for the prevention of scratching. A dose for children is also in consideration of progressive reduction, intermittent proposed. Acne-like rash, including folliculitis and rosacea steroid to identify any side effects and the need for 2. Epidermal-dermal atrophy, dermal vulnerability (most likely to occur on the stepping down or stepping up the dose. The absorption geriatric or sunlight damaged skin, intertriginous zone, or facial surface) ratio of steroids varies signicantly among skin sites. Hidden or exacerbated dermatophyte infection limus ointment while gradually stepping down the dose. Contact dermatitis c) Monitoring of the dose of topical steroid: Monitoring (i) May be caused by an ingredient of the preservative or other base material. Improvement in symptoms should be react with a corticosteroid molecule of similar structure. Topical immunosuppressant (tacrolimus ointment class or higher shows no difference in efcacy after 3 [Protopic ]) weeks or more between twice-a-day external applica- (1) Pharmaceutical form and mechanism of action of tacrolimus tion and once-a-day external application. It is recom- ointments: Tacrolimus ointments will be used when existing mended that a strong topical steroid be initially applied therapies are not effective enough or not indicated because twice a day and then changed to once-a-day application of side effects. It should be used in consideration of pre- after remission of an acute or intractable lesion is cautions and after obtaining informed consent from the observed, for the purpose of enhancing the compliance patients. The action mechanism of advised against discontinuing the use of the drug on his tacrolimus is the inhibition of the function of T lymphocytes, own judgment. In addition, sufcient explanation should which play a central role in the development of allergic be provided to the patient about the side effects likely to inammation, and improvement in the barrier function. This property is considered an advantage tion) was reported mostly on the face and genital area because they are more absorptive and effective for the (99. Excessive exposure to ultraviolet light should be a topical steroid should be administered at a necessary avoided when the ointment is applied externally. If systemic aggravation is observed, tacrolimus ointment for adults should be administered at a the patient should be hospitalized for a short period and a dose of 5 g or less. The tacrolimus ointment should be administered at a methods for children are divided intothe age groups of <2 maximum of twice per day. When applied twice per day, an years of age, 2e12 years of age, and >13 years of age. Care interval of approximately 12 h between applications is rec- should be taken so that insufcient administration for ommended. Occlusive dressing therapy should not be used fear of side effects likely generated in the treatment of because it may cause an increase in the blood level. It is reported that twice-a-day external adverse events were observed in a study of post-marketing application of a moisturizer (preparation containing hep- prolonged administration; therefore, tacrolimus ointments arinoid) signicantly inhibits the relapse of inammation of are considered safe. Precautions for the use of tacrolimus atopic dermatitis compared with the untreated group (no ointment include the possibility of skin effects such as a application group). This problem can be managed by using a mois- (3) Side effects turizer before the application of the ointment or by using a a) Central nervous system effect: the drug generally gener- tacrolimus ointment in combinationwith a topical steroid for ates side effects in the form of sleepiness, loss of con- a short period of time. Combinations with other external centration, or malaise, and it may cause excitement if medicines should be avoided because of potential effects on administered in a large quantity. Precaution is necessary the stability and absorptive properties of the tacrolimus in use of antihistaminics in children, particularly against ointment.
These goals may sometimes be reached even in the absence of complete freedom from the goals of epilepsy surgery may vary according to age fungus gnats mushrooms grifulvin v 250 mg sale. For infants and young children with many daily adolescents and adults fungus ease purchase 250mg grifulvin v with visa, the main goals are usually related to seizures and developmental stagnation or regression fungus gnats garlic buy line grifulvin v, a post- driving fungus festival buy generic grifulvin v 250mg on line, independence, and employment, and their achieve- operative outcome with rare or infrequent seizures and ment requires complete postoperative freedom from seizures. Chapter 89: Special Considerations in Children 1003 Even in the less-favorable-outcome group with malformation of cortical development, 68% of patients in the Cleveland Clinic series had few or no seizures after surgery (3). Developmental delay is common in pedi- atric epilepsy surgery candidates, especially infants. Duchowny and associates noted normal preoperative develop- ment in only 20% of infant candidates for epilepsy surgery, whereas the remainder had moderate (52%) or severe (28%) delay (1). Postoperatively, the developmentally normal infants remained normal after surgery, whereas the severely delayed infants remained severely delayed. Parents reported cognitive and social gains in children with seizure-free outcome, although these were difficult to appreciate on examination (1). In a series of infants who had epilepsy surgery at the Cleveland Clinic (49), the developmental quotient indi- cated modest postoperative improvement in mental age. Developmental status before surgery predicted developmental function after surgery, and patients who were operated on at younger age and with epileptic spasms showed the largest increase in developmental quotient after surgery (49). These results suggest that early surgery for refractory epilepsy may offer an opportunity for improved developmental outcome. Seizures that begin in the first few years of life, regardless of etiology, constitute a risk factor for mental retardation (50–52). Early surgical intervention may reduce this risk, but quantitative and prospectively collected data are scant. Midline shift with bulging of anterior falx to the left and compression focal cortical resection or hemispherectomy at a mean age of of the right lateral ventricle suggest a mass effect as a result of 21 months (53). Raw scores 2 years after surgery increased increased volume of the brain parenchyma. Dysplastic changes are significantly compared with preoperative levels, although only diffuse, with thick and disorganized cortex, poor gray-white matter four children had a normal rate of development. Presurgical Assessment of the Epilepsies 0 With Clinical Neurophysiology and Functional Imaging. During long-term follow-up, late death occurred in Surgery within the first year of life may therefore maximize 2% of the Cleveland Clinic series (3) and in 11% of a series developmental outcome by allowing resumption of develop- from Guldvog and associates involving patients with persis- mental progression during critical stages of brain maturation tent seizures (14). A more recent study (54) on cognitive outcome of hemi- Other risks of epilepsy surgery, including new postoperative spherectomy in 53 children who underwent presurgical and neurologic deficits (e. Language may transfer to the right hemisphere dictor of cognitive skills after surgery was etiology, with dys- during the course of destructive processes such as Rasmussen plasia patients scoring lowest in intelligence and language but chronic focal encephalitis or may develop in an unusual region not in visual-motor skills (54). Other studies have also of the left hemisphere in a congenital left frontal or pos- reported similar improvements in the cognitive and behavior terotemporal tumor (65,66). At the advent of epilepsy surgery, Falconer urged that outside a damaged or malformed rolandic region, so that resec- adolescents be considered for operative treatment before the tion of a perirolandic lesion results in little or no additional end of secondary school so that they could pass more nor- postoperative motor deficit (see Fig. Factors favoring mally through the maturational stages of early adulthood developmental plasticity include early onset of the lesion (e. In patients who had temporal resection for childhood- perinatal infarction or congenital malformation) and surgery onset epilepsy and were studied after a mean interval of 15 performed within the first few years of life. It is Age-Related Risks of Epilepsy Surgery not known whether the intracarotid amobarbital procedure can accurately predict this complication in children. Low mem- the extensive multilobar and hemispheric surgeries performed ory retention scores may occur during this testing in a signifi- in children and adolescents may carry some risk. In the cant proportion of children (70), and withholding mesial tem- Cleveland Clinic series (3), 2 of 149 patients (1. Mortality may be slightly higher for infants, in part because of their Seizure Outcome after Epilepsy Surgery small blood volumes. These to compare owing to the inclusion of patients with diverse results emphasize the need to reserve surgery for infants with pathologic conditions, use of different evaluation and surgical severe epilepsy. Risk may be reduced by a dedicated team of techniques, and variable definitions of postoperative outcome pediatric anesthesiologists, intensivists, and surgeons. Good postoperative outcomes with rare or no At any age, the mortality from epilepsy surgery must be seizures occur with similar frequencies at all ages, according weighed against the mortality from uncontrolled seizures to recent series in infants, children, adolescents, and adults, treated medically. Nashef and associates (61) found this risk despite age-related differences in causes and surgery types to be 1:295 per year in children and adolescents with severe (1,3,11,28,71,72). In a population-based come postoperatively does not diminish significantly, even in cohort study in children (62) (1 to 16 years of age) who devel- infancy. These results compare favorably with those achieved oped epilepsy between 1977 and 1985, 26 (3. The majority (13/26) who died the rate of responders (at least 50% improvement in seizure had secondarily generalized seizures. Neurologic deficit was frequency) was 20% to 40% and seizure freedom was fairly the only independent factor that determined mortality. More recent studies show only modest chances of study, mortality in children with comorbid neurologic deficits seizure freedom ( 5%) after failure of two antiepileptic med- (15/1000 person-years) was higher than in those without any ications and report no difference between established and deficits (0. Mortality in the children newer antiepileptic drugs used as initial monotherapy (74). These epidemiologic data (3), this outcome was significantly more common in patients reinforce consideration for early surgical intervention, as chil- who had temporal resection (78%) than in those who had dren with catastrophic partial epilepsy who are candidates for extratemporal or multilobar resection (54%). However, this surgery often have neurologic deficits and secondarily general- difference based on surgery type disappeared when results ized seizures. The increased long-term mortality from epilepsy were analyzed by etiologic factors. Significantly more patients in children can also be seen in outcome studies of epilepsy with low-grade tumor (82%) than patients with malformation Chapter 89: Special Considerations in Children 1005 of cortical development (52%) were seizure free, regardless of 6. Temporal and extended tem- poral resections for the treatment of intractable seizures in early childhood. Duchowny and colleagues (1) noted that it infantile spasms: neuroimaging perspectives. Predictors of outcome in pediatric seizure outcome appears similar to that in adults. Significance of surgery for temporal lobe epilepsy in child- for intractable temporal lobe epilepsy, 78% of patients were hood and adolescence. Selection of patients with intractable epilepsy for resective up of 3 months to 22 years. Defining the spectrum of international the procedure for acquired diseases like Rasmussen encephali- practice in pediatric epilepsy surgery patients. Seizure symptomatology in infants 55% to 80% of those with acquired causes were seizure free with localization-related epilepsy. Symptomatology of epileptic tions of cortical development showed higher rates (68% to seizures in the first three years of life. Proposal for revised clinical and electroencephalographic classification of 80%) of seizure freedom in partial (sparing anterior or poste- epileptic seizures. Localization of focal cortical lesions influences age of presurgical evaluation, but it also provides a great opportunity onset of infantile spasms. Even in some older children, it is nuclei and brain stem activation on positron emission tomography. Pediatric epilepsy surgery in focal extensive experience in pediatric epilepsy surgery. Surgical treatment of children with medically intractable frontal or temporal lobe epilepsy: results and high- References lights of 40 years experience. Epilepsy surgery in the first three poral epilepsy: clinical, radiologic, and histopathologic findings in 60 years of life. Seizure outcome after epilepsy of cortical lesions in medically refractory epilepsy: a prospective study. Presurgical Assessment of the children with tuberous sclerosis complex using alpha-[11C]methyl-L-tryp- Epilepsies with Clinical Neurophysiology and Functional Imaging. A randomized, controlled trial of children with tuberous sclerosis complex and refractory partial epilepsy. The postoperative course and man- come following surgery for intractable epilepsy in children with normal or agement of 106 hemidecortications. Atypical language in lesional and dren with epilepsy: the Dutch study of epilepsy in childhood.
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