Friday, November 20, 2015

Cute seizures

I wrote: A 14 months old girl with mosaic trisomy 12p has an EEG obtained to evaluate paroxysmal behaviors. During an extended duration videoEEG, she had seizures manifest as a quick shrug of the shoulders and, perhaps, ocular supraversion associated with a brief generalized paroxysmal discharge. These created no obvious interruption. I have to say the seizures were cute. With a sigh, I initiated a trial of levetiracetam therapy. I remember a 5 1/2 year old boy whose EEG and videoEEG showed generalized bursts of paroxysmal activity of 1-4 seconds, associated with a brief pursing of the lips, which I told his mother were the cutest seizures I had seen. He was treated with valproate, which seemed to cause adverse behavior, and subsequently lamotrigine. Later, while already receiving antiseizure pharmacotherapy, he had a generalized tonic-clonic seizure at a time of intercurrent illness. Indeed, do all seizures, particularly cute ones, need to treated? If my patients' parents, like I, had found their behavior cute and resisted antiseizure pharmacotherapy, how remiss would I be to go along with them? Would non-treatment truly jeopardize their development? Certainly, these could evolve into more ugly seizures, but that happened in my second patient despite the institution of pharmacotherapy, so there is obviously no guarantee. Could treatment be deferred until seizures became ugly? Are there seizures that can be acknowledged and, perhaps, admired?

(Correspondents' replies are uncorrected)

A correspondent replied: Galen Breningstall asks a very interesting question regarding the philosophical (dare I even say spiritual) significance of fairly minor seizure activity. Are we so convinced by the animal data that all seizure activity is deleterious to the developing brain that we need to wage a pharmacological war against every behavior that is accompanied by paroxysmal EEG activity? Seizures have been demonized in so many cultures that we want to make them all go away, even when that is not necesssarily the case (as in the Hmong culture described in "The Spirit Catches You and You Fall Down" by Anne Fadiman). Are we sure of the reasons why we want to do this?
I don't know whether the idea that seizures are "cute" should be a factor (maybe that plays into our own culture-driven ideas about desirable versus undesirable appearances). But at least it may be worth talking openly to parents about the risks and benefits of treatment versus nontreatment of these sort of fairly minor epileptiform behaviors, and not being too judgmental if they choose a nontraditional approach.
It is a good question that deserves serious discussion.
Another correspndent replied: Galen Breningstall asks a very interesting question regarding the philosophical (dare I even say spiritual) significance of fairly minor seizureIndeed we need to reexamine the probably secular notion that epilepsy even if involves very few not prolonged seizures need to be treated vigorously forever. Two strong concepts motivate that point of view:seizures damage the brain (neurodegeneration another strongly established concept) and they can kill. The explosion of new knowledge on cytokines and other factors and the genetic of the two hundred synaptic proteins necessitate revision of the old ideas but will be complex and therefore not attractive to granting agencies.
At a less discouraging level one might fruitfully discuss how to balance the interests of patients, families and society.
A third correspondent replied:  There is always a risk benefit balance in using antiepileptic drugs and many believe in most cases the benefits of controlling seiures balance out the risk from AED, However the difficulty we have is often proving that statment in an individual patient. Though EEG,S and its interpretaions are improving all the time we do not have a objective indisputable parameter of improvement like say blood sugar in daibetes or measurment of blood pressure.This becomes particulary difficult in those with only ocassional seizures.WE therfore have to rely on statistics   changes that left untreated these seizures could worsen
1)What are the changes that left untreated these seizures could worsen
2)Is there any risk of the abnrormal electrical discharge itself causing damage ?
3)Is there any risk at all of status/SUDEP etc in these patients?
I remember there were quite a few in one of the AES meetings I attented who felt even bemnign epilepsy with centrotemproal spikes should be left alone
It would be an interesting issue for discussion and then there are "pleasurable seizures"oh well

No comments:

Post a Comment