Early Treatment and Prognosis of Epilepsy

Abstract

Recent community-and hospital-based studies of epilepsy from its onset suggest a much better prognosis than previously recognized, with about three-quarters of patients entering long-term remission on current medication. The first two years of medication are crucial in determining longer-term prognosis. Early effective therapy may be important in preventing the evolution of chronic epilepsy. Adverse prognostic factors include brain lesions, neuropsychiatric handicaps, and poor compliance. PROGNOSIS OF EPILEPSYThe traditional and rather gloomy view of prognosis was summarized in the detailed review by Rodin [1] which spans the period from Gowers [2], who first applied a statistical approach to prognosis in the late nineteenth century, to Rodin's own valuable studies. Rodin concluded that only approximately one-third of epileptic patients are likely to achieve a terminal remission of at least two years; that the longer patients are followed up, the more likely is relapse to occur; and that 80 percent of all patients with epilepsy are likely to have a chronic seizure disorder. Although the latter does not rule out short-term remissions, it emphasizes that epilepsy should be regarded as a chronic condition with remissions and exacerbations. Rodin recognized that his review was based almost wholly on studies of chronic patients in institutions or attending special outpatient clinics. He noted that the longer the history of epilepsy prior to hospital consultation the worse the prognosis, and he rightly drew attention to the good prognosis reported by Gowers [2] in patients with a short history of epilepsy treated with bromides. At the time of his review there had been no systematic study of epilepsy at its onset and, as Shorvon [3] has pointed out, a weakness or source of misunderstanding in the studies reviewed was a failure to appreciate certain temporal aspects of the development of epilepsy, arising from the retrospective, cross-sectional nature of the investigations, based on heterogeneous populations of patients with a very variable duration of illness. Another interesting feature of the period, approximately a century, reviewed by Rodin was the introduction and use of many major anticonvulsant drugs of undoubted efficacy, from bromides, through barbiturates, to hydantoins, succinamides, and carbamazepine, most of which are still widely prescribed today. Rodin questioned whether there had been any improvement in overall prognosis throughout this time. A factor which was and still is missing in our understanding of prognosis is any information about the prognosis of untreated epilepsy. Practice was and still is perhaps influenced by Gowers's [2] view that the spontaneous cessation of the disease was an event too rare to be reasonably anticipated in any given case.In the last decade new studies have focused attention on epilepsy as viewed and 79

Controversies in Management: Do anticonvulsants alter the natural course of epilepsy? Treatment should be started as early as possible

“…Several studies have confirmed Gower's observation2 that the longer the history of epilepsy the worse the longer term prognosis 3 4. Only Feksi et al in East Africa, based on a retrospective analysis of poorly educated patients with a mean duration of epilepsy of seven years, did not agree 5.…”

“…Epilepsy used to be thought of as a chronic disorder in most patients, but recent community and hospital based studies of newly diagnosed patients have shown that only 20–30% of patients develop intractable epilepsy 3 4. Is this intractability inevitable because we do not have powerful enough drugs to suppress more “severe” forms of epilepsy or could some of it be avoided by early treatment to prevent the escalation of the process of epilepsy into a chronic disorder?…”

“…A more recent view, which has some neglected historical roots,2 suggests that antiepileptic drugs may also influence the natural history of epilepsy, that epilepsy should be viewed as a process that has the potential to develop into an intractable disorder, and that early effective treatment may reduce this risk of chronicity 3 4…”

PCR based molecular characterization of Nepenthes khasiana Hook. f.—pitcher plant

“…Plumbagin, one kind of nepenthoquinone has been reported from Nepenthes of Nepenthaceae (Cannon et al 1980). Other possible roles of Nepenthoquinone are as allelopathic substance (Harbone 1982;Reynolds 1987;Jayaram and Prasad 2005), or as insecticidal, molluscicidal or antifeedant chemicals (Thomson 1987). The species is officially classified as a threatened species and is included in the list of (Jain and Baishya 1977;Jain and Sastri 1980).…”

Clinical course of untreated tonic-clonic seizures in childhood: prospective, hospital based study

“…In addition, a larger number of seizures before starting treatment seemed to be associated with a poorer control of seizures 2. If these observations are correct, an aggressive approach may be appropriate, as has been advocated by Reynolds et al , who advised starting treatment as soon as possible, preferably after the first seizure, to prevent the development of intractable epilepsy 3 4 5. Early treatment for all patients with newly diagnosed seizures has considerable consequences, however, as all antiepileptic drugs have side effects.…”