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Focal or Generalized Seizures in Late Adult Life
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Hauser and Kurland have reported a marked increase in the incidence of seizures as the population ages from 119 per 100,000 in the 40- to 60-year age group to 82 per 100,000 in those 60 years of age or older A person in the latter age group who begins to have seizures of either partial or generalized type is always to be suspected of harboring a primary or secondary tumor or an infarct that had not declared itself clinically This is a matter usually settled by the neurologic examination and by CT or MRI Tumor, either primary or secondary, will be found to account for about half the cases of seizures occurring for the rst time in late adult life In our clinical material, almost 10 percent of patients with infarction involving the cerebral cortex later developed recurrent partial or generalized seizures, but most published series cite a lower proportion According to Sung and Chu, previous infarcts are by far the most common lesions underlying status epilepticus in late adult life, but our experience has been that old trauma is as common Cortical and subcortical encephalomalacia, the result of previous traumatic contusions, is a particularly important cause of seizures among alcoholics; the lesions are revealed by brain imaging and are typically located in the anterior frontal and temporal lobes Brain abscess and other in ammatory and infectious illnesses are less common except in tropical regions Seizures as a result of Alzheimer and other degenerative diseases do occur but are uncommon In the not infrequent cases of an adult with a rst seizure that
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CARDINAL MANIFESTATIONS OF NEUROLOGIC DISEASE
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Table 16-5 Common antiepileptic drugs
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EFFECTIVE GENERIC NAME TRADE NAME USUAL DOSAGE CHILDREN, MG/KG ADULTS, MG/DAY SERUM PRINCIPAL THERAPEUTIC INDICATIONS HALF-LIFE, HOURS BLOOD LEVEL,a G/ML
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Major anticonvulsants used as monotherapy Valproic acid Depakote 30 60 Phenytoin Dilantin 4 7
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1000 3000 300 400 600 1200b 90 200 3 500 400
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Generalized tonic-clonic, atypical absence, myoclonic, partial Vigabatrin 4000 Partial and secondary generalized, Lennox-Gastaut Tiagabine Gabitril 30 60 Partial and secondary generalized, Gabapentin Neurontin 30 60 900 1800b Partial and secondary generalized, Primidone Mysoline 10 25 750 1500b Generalized tonic-clonic, partial Ethosuximide Zarontin 20 40 750 1500 Absence Methsuximide Celontin 10 20 500 1000 Absence ACTH 40 60 Units daily Infantile spasms Clonazepam Klonopin 001 02 2 10 Absence, myoclonus Anticonvulsants for status epilepticus (initial loading or continuous infusion doses shown)c phenytoin and doses higher than shown above Diazepam Valium 015 2 2 20 Status epilepticus Lorazepam Ativan 003 022 2 20 Status epilepticus Midazolam Versed 01 04 mg/kg/h Status epilepticus Propofol Diprivan 25 35 2 8 mg/kg/h Status epilepticus Fosphenytoin Cerebyx 30 50 mg 1000 1500 Status epilepticus
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Carbamazepine Tegretol 20 30 Phenobarbital Luminal 3 5 (8 for infants) Lamotrigine Lamictal 05 Adjuvant and special use anticonvulsants Topiramate Topamax
Generalized tonic-clonic, partial, absence, myoclonic Generalized tonic-clonic, partial, absence, myoclonic Generalized tonic-clonic, partial Generalized tonic-clonic, partial Generalized
6 15 12 36 14 25 40 120 15 60 20 30 20 40 7 9 5 7 6 18 20 60 28 50
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Average trough values May require slow dose escalation Administered intravenously
remains unexplained after thorough evaluation, it has been our practice to administer an anticonvulsant and to re-evaluate the situation in a matter of 6 to 12 months, with the goal of eventually discontinuing medication Usually, a second MRI and EEG are performed to exclude focal abnormalities that were not appreciated during the initial evaluation, but often these studies are again unrevealing This approach has been prompted by data such as those of Hauser and colleagues, who found that about one-third of patients with a single unprovoked seizure will have another seizure within 5 years; the risk is even greater if there is a history of seizures in a sibling, a complex febrile convulsion in childhood, or a spike-and-wave abnormality in the EEG Moreover, the risk of recurrence is greatest in the rst 24 months In patients with two or three unexplained seizures, three-quarters have further seizures in the subsequent 4 years
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