Current treatment strategies in selected situations in epilepsy.

Several special situations in the management of epilepsy require specific treatment strategies. Recurrence rates after a single seizure vary between 26 and 71%. Antiepileptic drug (AED) therapy should be initiated after a first seizure only when a definitive diagnosis of epilepsy can be made. Although several AEDs have been shown to be anti-epileptogenic in animal models, no data yet prove the efficacy of any AED in preventing the development of post-traumatic or postoperative epilepsy. Therefore, there is no rational basis for prophylactic treatment with AEDs. The incidence of epilepsy rises dramatically after the age of 50 years. Similtaneously, many physiological changes increase the potential for adverse effects and drug interactions when AEDs are used in the elderly. Careful attention to changing pharmacokinetic parameters is necessary when that group of patients is being managed. Pregnancy also brings about physiological changes that may either increase or decrease the seizure frequency. The risk of fetal malformations is approximately double in children born to mothers with epilepsy compared with children born to nonepileptic mothers. The risk is dose-dependent and increases with the number of AEDs. All AEDs may cause fetal malformations; valproate and carbamazepine increase the risk of spina bifida. Nonetheless, the best AED for a woman who wants to become pregnant is the AED that best controls her seizures, which should be given at the lowest possible effective dose. Discontinuation of AEDs can be considered after 2-4 years of complete seizure control. Most of the risk of relapse occurs within the first 6 months. Status epilepticus (SE) is a medical emergency. The most common form of SE is generalized convulsive status epilepticus, in which the patient may present with either overt or subtle convulsions. Because of the potential for neuronal damage, all electrical as well as clinical seizure activity must be completely stopped for treatment of SE to be considered successful.