SeminarEpilepsy: new advances
Introduction
With 65 million people affected worldwide, epilepsy is the most common, chronic, serious neurological disease.1 People with epilepsy suffer from discrimination, misunderstanding, social stigma,2 and the stress of living with a chronic unpredictable disease that can lead to loss of autonomy for activities of daily living. Although epilepsy can be successfully treated in most cases, the treatment gap is enormous, especially in low-income and middle-income countries,3 because antiepileptic drugs are inaccessible or too expensive.4 Nevertheless, not all patients respond to available medical treatments, with increasing evidence that surgery and other treatments (eg, neurostimulation and diet) can be beneficial. Key features of epilepsy in children5 and adults6 were discussed in two previous Seminars. Here, we focus on new advances.
Section snippets
Definitions
An epileptic seizure is defined by the International League against Epilepsy (ILAE) as “a transient occurrence of signs and/or symptoms due to abnormal excessive or synchronous neuronal activity in the brain”.7 Epilepsy is characterised conceptually as an “enduring predisposition of the brain to generate epileptic seizures, with neurobiologic, cognitive, psychological, and social consequences”.7
Because the conceptual definition can be difficult to apply in everyday practice, the ILAE has now
Incidence and prevalence
The prevalence of active epilepsy is 5–8 per 1000 population in high-income countries1, 13 and 10 per 1000 population in low-income countries, where even higher rates have been reported in rural areas.15 These regional differences probably result from differences in risk factors for epilepsy, including infections and inadequate antenatal and perinatal care.16 Similar differences exist for the incidence of epilepsy: findings from a 2011 meta-analysis17 showed that annual incidence is 45 per
Diagnosis
Diagnosis of the epileptic nature of a seizure can be based on a precise systematic description of the episode by the patient and witnesses, and might not need any specific investigation. The most important recent advance stems from the availability of smartphones, with which relatives can video-record the seizures. Unfortunately, many doctors lack knowledge of the semiology that allows differentiation between epileptic seizures and other disorders such as convulsive syncope and psychogenic
General principles
Overall, about 70% of patients achieve seizure freedom with appropriately used medical treatment (panel 2), with response rates varying in relation to epilepsy syndrome, underlying cause, and other factors.5, 6, 53, 54 Irrespective of prognostic factors, most patients who become seizure-free respond to the initially prescribed drug.54, 55, 56, 57, 58
No single antiepileptic drug is ideal for first-line treatment in all patients. As recommended by the UK National Institute for Health and Care
Challenges for the future
Epilepsy is a multifaceted disease that needs a comprehensive approach. The impediments to achievement of a productive life for people with epilepsy can be conceptualised as a series of gaps that have been identified for more than 20 years, but progress towards their resolution is slow. They include gaps in knowledge, diagnosis, treatment, advocacy, education, legislation, and research. The knowledge gap refers to poor understanding among health-care professionals of the various components of
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