The contribution of tertiary centers to the quality of the diagnosis and treatment of epilepsy

Purpose: A survey was made of a network of 14 epilepsy centers in Italy to assess whether integrated diagnosis and treatment monitoring led to a more precise syndromic classification of the patients and a better response to treatment. Methods: Data on the diagnosis and treatment of epilepsy and the degree of seizure control were recorded in a register on 2 separate occasions, on June 30, 1990 (t0), before starting the integrated activities, and on June 30, 1992 (t1), on completion of a 2-year follow-up. Each patient's history was required to fit a specific category of the International Classification of the Epilepsies (ICE) (1). Response to treatment was classified as complete remission, occasional seizures, recurrent nonrefractory seizures, and drug-resistant epilepsy. A total of 3,469 patients of the ages of 4-80 years were enrolled. Results: At t0, 44% of cases had localization-related epilepsy, 31% generalized epilepsy, 9% undetermined epilepsy, 6% special syndromes, and 10% epileptic syndromes with atypical features. At t1, the percentages in each category were 51, 27, 7, 6, and 9%. The cases classified as 'other' within each syndromic category at t0 were 11-23% and remained unchanged at t1. Patients with symptomatic localization-related epilepsies were largely recoded as symptomatic or cryptogenic epilepsies. About one-third of patients with symptomatic generalized epilepsy were recoded as localization-related epilepsies. Nine percent of patients were classified as 'uncertain' epilepsies at t0, and the same proportion at t1. However many 'uncertain' diagnoses became 'definite' and vice versa. Conclusions: There was a slight increase in the proportion of patients achieving complete remission (from 13 to 28%) and untreated patients (from 10 to 17%). Nine percent of patients unresponsive to treatment at t0 had achieved remission at t1. Drug resistance was confirmed in 78% of cases and was mostly independent of the therapeutic decision. Ten percent of cases achieved remission with unchanged or simplified treatment schedules

ILAE classification of epilepsies: Its applicability and practical value of different diagnostic categories

Purpose: The study was aimed at verifying the applicability of the ILAE classification and the appropriateness of the different diagnostic categories in a large series of patients with epilepsy observed by epilepsy centers. Methods: Data concerning 10,342 patients observed by a network of 14 epilepsy centers in the Lombardy region between June 1990 and June 1994 were collected by using a simple standard form and stored in a PC database. Results: The diagnosis of epilepsy was assessed in 8,570 patients: the remaining 1,722 cases were excluded from the analysis as being affected by nonepileptic ictal events or by isolated or situation-related seizures, including febrile and neonatal convulsions. A definite syndromic diagnosis, according to the ILAE Classification criteria, was made in 7,332 (85%) of 8,570 cases. Atypical features were found in 995 (11.6%) cases, who were therefore classified as uncertain; 198 (2.3%) cases remained unclassified; and in the remaining 45 patients, the diagnosis was not properly codified. The seizure-control profile was found to be highly related to the syndromic diagnosis. The highest percentage of drug-resistant cases was found among patients with generalized symptomatic or cryptogenic syndromes (32.3%) and among cases with partial symptomatic epilepsy (19.8%), whereas virtually no drug-resistant cases were found among patients with idiopathic epilepsies. Conclusions: The ILAE classification was found satisfactory in the large majority of cases observed at tertiary centers; however, the appropriateness of its various items in identifying homogeneous subpopulations was uneven, being maximal for those syndromes defined by highly consistent electroclinical pictures. An early identification of the characteristic pictures of distinct epileptic syndromes appears to be a valuable prerequisite for diagnostic and therapeutic approaches