Manejo de la primera crisis epiléptica y del status en urgencias

First epileptic seizure is a common reason for attending the emergency department. Its management is focused on diagnosis of the episode and on identification and treatment of the underlying cause. Occasionally, anti-epileptic treatment will be required. However, when the seizure is prolonged - a condition known as status epilepticus - it becomes a life-threatening process and requires immediate treatment. In this article, general advice and guidelines for the management of seizures and of sta

Estado epiléptico no convulsivo en el siglo XXI: clínica, diagnóstico, tratamiento y pronóstico

Non-convulsive status epilepticus is a significant issue for a neurologist because, despite its low prevalence, it mimics other pathologies, with therapeutics and prognostic outcomes. Diagnosis is based on clinical features, mainly mental status or impaired consciousness and electroencephalographic changes, so electroencephalogram is the first exploration we must perform with clinical suspicion. There are three clinical forms: generalized or absence status, with diffuse epileptiform discharges; focal, with epileptic discharges located in a specific brain area and may not affect consciousness; and subtle, with diffuse or local epileptic activity after a tonic-clonic seizure or convulsive status and limited or no motor activity. Treatment are benzodiazepines and antiepileptic drugs; anesthetic drugs are only recommended for patients with subtle status and in some with partial complex status. Prognosis is mainly determined by etiology and associated brain damage

Estimulación vagal en el tratamiento de la epilepsia

The vagal nerve stimulation is a new technique for the treatment of drug resistant epilepsies. DEVELOPMENT: In 1997, it was approved in United States by the FDA to be used in adults with refractory focal epilepsies not candidates for epilepsy surgery. Its mechanism of action is unknown. The results in the controlled studies indicated a decrease of 30 50% in the seizure frequency in around 50% of the patients. Although more experience is needed to corroborate these results, it seems reasonable as a treatment for patients with difficult epilepsies, especially when the response to the antiepileptic drugs is poor or they are producing secondary effects, and the resection of the focus is not possible

Clasificación de los trastornos del sueño

Sleep disorders are frequent processes, both as a symptom associated with other diseases and as independent disorders. However, only in the last 4 decades has Sleep medicine gained its position among the medical specialties. In fact, it was only in these years that significant advances were obtained in the study of the etiology and treatment of these disorders. Similarly, the different classifications have been evolving over the years. First, they were based upon the clinical symptom; later on, more emphasis was given to the diseases. Finally, in 2005, the new classification was once again based on the symptoms. More than 90 disorders are listed in this latest classification, and an attempt is made to include the symptoms and the diseases of sleep, as well as those in which sleep disorders are fundamental. It is essential to have a clear idea of this complete classification of sleep disorders in order to deal with these patients appropriately

Changes in the Heart Rate Variability in Patients with Obstructive Sleep Apnea and Its Response to Acute CPAP Treatment

INTRODUCTION: Obstructive Sleep Apnea (OSA) is a major risk factor for cardiovascular disease. The goal of this study was to demonstrate whether the use of CPAP produces significant changes in the heart rate or in the heart rate variability of patients with OSA in the first night of treatment and whether gender and obesity play a role in these differences. METHODS: Single-center transversal study including patients with severe OSA corrected with CPAP. Only patients with total correction after CPAP were included. Patients underwent two sleep studies on consecutive nights: the first night a basal study, and the second with CPAP. We also analyzed the heart rate changes and their relationship with CPAP treatment, sleep stages, sex and body mass index. Twenty-minute segments of the ECG were selected from the sleep periods of REM, no-REM and awake. Heart rate (HR) and heart rate variability (HRV) were studied by comparing the R-R interval in the different conditions. We also compared samples from the basal study and CPAP nights. RESULTS: 39 patients (15 females, 24 males) were studied. The mean age was 50.67 years old, the mean AHI was 48.54, and mean body mass index was 33.41 kg/m(2) (31.83 males, 35.95 females). Our results showed that HRV (SDNN) decreased after the use of CPAP during the first night of treatment, especially in non-REM sleep. Gender and obesity did not have any influence on our results. CONCLUSIONS: These findings support that cardiac variability improves as an acute effect, independently of gender or weight, in the first night of CPAP use in severe OSA patients, supporting the idea of continuous use and emphasizing that noncompliance of CPAP treatment should be avoided even if it is just once

Paresia poscrítica durante estudios de monitorización de vídeo-EEG

To know the frequency of Todd s paralysis during the video EEG monitoring studies, to investigate in its pathophysiology, and to confirm its value to localise the epileptic focus. PATIENTS AND METHODS: We reviewed 114 monitoring studies, in 102 patients. RESULTS: Sixty patients had epileptic seizures. An obvious paresis was noted in four seizures of two patients (3 and 1, respectively). Both patients had frontal epilepsy. During the paralysis, in the first patient the EEG showed ictal discharges on the contralateral centrotemporal area. In the second patient, the EEG demonstrated slow waves in the contralateral frontal region. The ictal onset was contralateral to the paresis in all cases. No patient with pseudoseizures had paralysis. CONCLUSIONS: Postconvulsive paralysis are not frequent in video EEG monitoring studies. However, if present it points out to a contralateral seizure onset. In our series it happened in patients with frontal seizures. The EEG may help to clarify if it correspond to a true postictal phenomenon or to a ictal paralysis

Changes in the heart rate variability in patients with obstructive sleep apnea and its response to acute CPAP treatment

Obstructive Sleep Apnea (OSA) is a major risk factor for cardiovascular disease. The goal of this study was to demonstrate whether the use of CPAP produces significant changes in the heart rate or in the heart rate variability of patients with OSA in the first night of treatment and whether gender and obesity play a role in these differences. METHODS: Single-center transversal study including patients with severe OSA corrected with CPAP. Only patients with total correction after CPAP were included. Patients underwent two sleep studies on consecutive nights: the first night a basal study, and the second with CPAP. We also analyzed the heart rate changes and their relationship with CPAP treatment, sleep stages, sex and body mass index. Twenty-minute segments of the ECG were selected from the sleep periods of REM, no-REM and awake. Heart rate (HR) and heart rate variability (HRV) were studied by comparing the R-R interval in the different conditions. We also compared samples from the basal study and CPAP nights. RESULTS: 39 patients (15 females, 24 males) were studied. The mean age was 50.67 years old, the mean AHI was 48.54, and mean body mass index was 33.41 kg/m(2) (31.83 males, 35.95 females). Our results showed that HRV (SDNN) decreased after the use of CPAP during the first night of treatment, especially in non-REM sleep. Gender and obesity did not have any influence on our results. CONCLUSIONS: These findings support that cardiac variability improves as an acute effect, independently of gender or weight, in the first night of CPAP use in severe OSA patients, supporting the idea of continuous use and emphasizing that noncompliance of CPAP treatment should be avoided even if it is just once

Vídeo-electroencefalografía: una necesidad

El vídeo-EEG es una herramienta diagnóstica habitual. Los avances técnicos de la última década la han simplificado de tal modo que con poco más de un ordenador y una cámara de vídeo pueden conseguirse registros de calidad. Se requiere personal preparado para su ejecución e interpretación. Es muy útil para el diagnóstico de episodios paroxísticos, para la clasificación y caracterización de crisis epilépticas y para la cuantificación de crisis o grafoelementos epileptiformes. Dada la importancia de un diagnóstico exacto, certero, ante un episodio paroxístico, no cabe duda de que esta herramienta debe ser cada vez más asequible para evitar el mal trato a muchos enfermos neurológicos. A pesar del paso de los años, un 20-30% de pacientes diagnosticados de epilepsia no son realmente epilépticos, lo cual sigue siendo excesivo e inaceptable.The video-EEG is a common diagnostic tool nowadays. The technical achievements of the last decade have brought a simplification of the equipment required to obtain good quality recordings, with little more than a computer and a video camera being necessary. However, the medical and technical staff must be well trained to execute and interpret the study. It is very useful in the diagnosis of paroxysmal events, for the classification and characterization of epileptic seizures and to quantify epileptiform discharges. Due to the importance of a correct diagnosis to avoid mistreating many neurological patients, this tool should be accessible to clinicians. In spite of the advances of recent years, 20-30% of patients diagnosed with epilepsy are not really epileptic, a fact that it is excessive and unacceptabl

Increased sympathetic and decreased parasympathetic cardiac tone in patients with sleep related alveolar hypoventilation

Patients with SRAH exhibited an abnormal cardiac tone during sleep. This fact appears to be related to the severity of nocturnal oxygen desaturation. Moreover, there were no differences between OSA and SRAH, supporting the hypothesis that autonomic changes in OSA are primarily related to a reduced nocturnal oxygen saturation, rather than a consequence of other factors such as nocturnal respiratory event