Epilepsy Counseling:
(from French, NEJM, 2008):
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High risk features for recurrence:
- Epileptiform abnormality on EEG, abnormal neurologic exam, structural abnormality on neuroimaging, historical risk factors (ie. remote major head trauma)
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Recurrence risk:
After single seizure with one or more risk factor: <40% over 2 years
After single seizure w/ no risk factor: ~25%
Increased after single seizure w/ abnormal EEG (epileptiform) or abnormal imaging: ~ 60-70%
After two unprovoked seizures ~70% (Hauser, NEJM, 1998)
50% seizure free after first AED monotherapy
66% seizure free after second/third AED monotherapy
Rate of being seizure-free at 3-5 years after single seizure similar if treated or not treated So, who do you treat after first seizure? (controversial)
Consider treatment with high risk features such as EEG abnormality or abnormal neuroimaging, otherwise can observe
Treat after second unprovoked seizure in patients w/o risk factors
Counseling a patient with new seizures:
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New York Driving Rules:
Patients should not drive if they have had a seizure in the last 12 months, with exceptions made in 2 circumstances by DMV: (1) If physician writes letter stating that physician aware of patient condition and that they are safe to operate vehicle OR, (2) If the physician writes that the patient’s loss of consciousness was caused by a medication
There are no required reporting laws in NY
Consider job safety (working at heights, operating high-risk power equipment, driving)
Recommend patient not to swim alone, not to stand at edge of platform at the train station
Recommend patient take showers and not baths