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1 Solitary seizures In patients who have had only one seizure, investigation as outlined above should exclude an underlying cause requiring specific treatment An EEG should also be performed, preferably within 24 hours after the seizure, because the findings may influence management especially when focal abnormalities are present Prophylactic anticonvulsant drug treatment is generally not required unless further attacks occur or investigations reveal some underlying pathology that itself is untreatable The risk of seizure recurrence varies in different series between about 30% and 70% Epilepsy should not be diagnosed on the basis of a solitary seizure If seizures occur in the context of transient, nonrecurrent systemic disorders such as acute cerebral anoxia, the diagnosis of epilepsy is inaccurate, and long-term prophylactic anticonvulsant drug treatment is unnecessary 2 Alcohol withdrawal seizures One or more generalized tonic-clonic seizures may occur within 48 hours or so of withdrawal from alcohol after a period of high or chronic intake Patients should be hospitalized for at least 24 hours for observation and to follow the severity of withdrawal symptoms If the seizures have consistently focal features, the possibility of an associated structural abnormality, often traumatic in origin, must be considered Head CT scan or MRI should be performed in patients with new onset of generalized seizures and whenever there are focal features associated with any seizures Treatment with anticonvulsant drugs is generally not required for alcohol withdrawal seizures, since they are self-limited Benzodiazepines (diazepam or lorazepam) are effective and safe for preventing further seizures Status epilepticus may rarely follow alcohol withdrawal and is managed along conventional lines (see below) Further attacks will not occur if the patient abstains from alcohol 3 Tonic-clonic status epilepticus Poor compliance with the anticonvulsant drug regimen is the most common cause; others include alcohol withdrawal, intracranial infection or neoplasms, metabolic disorders, and drug overdose The mortality rate may be as high as 20%, and among survivors the incidence of neurologic and mental sequelae may be high The prognosis relates to the length of time between onset of status epilepticus and the start of effective treatment Status epilepticus is a medical emergency Initial management includes maintenance of the airway and 50% dextrose (25 50 mL) intravenously in case hypoglycemia is responsible If seizures continue, an intravenous bolus of lorazepam, 4 mg, is given and repeated once after 10 minutes if necessary; alternatively, 10 mg of diazepam is given intravenously over the course of 2 minutes, and the dose is repeated after 10.

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minutes if necessary This is usually effective in halting seizures for a brief period but occasionally causes respiratory depression Regardless of the response to lorazepam or diazepam, phenytoin (18 20 mg/kg) is given intravenously at a rate of 50 mg/min; this provides initiation of long-term seizure control The drug is best injected directly but can also be given in saline; it precipitates, however, if injected into glucose-containing solutions Because arrhythmias may develop during rapid administration of phenytoin, electrocardiographic monitoring is prudent Hypotension may complicate phenytoin administration, especially if diazepam has also been given In many countries, injectable phenytoin has been replaced by fosphenytoin, which is rapidly and completely converted to phenytoin following intravenous administration No dosing adjustments are necessary because fosphenytoin is expressed in terms of phenytoin equivalents (PE); fosphenytoin is less likely to cause reactions at the infusion site, can be given with all common intravenous solutions, and may be administered at a faster rate (150 mg PE/min) It is also more expensive If seizures continue, phenobarbital is then given in a loading dose of 10 20 mg/kg intravenously by slow or intermittent injection (50 mg/min) Respiratory depression and hypotension are common complications and should be anticipated; they may occur also with diazepam alone, although less commonly If these measures fail, general anesthesia with ventilatory assistance and neuromuscular junction blockade may be required Alternatively, intravenous midazolam may provide control of refractory status epilepticus; the suggested loading dose is 02 mg/kg, followed by 005 02 mg/kg/h After status epilepticus is controlled, an oral drug program for the long-term management of seizures is started, and investigations into the cause of the disorder are pursued 4 Nonconvulsive status epilepticus Absence (petit mal) and complex partial status epilepticus are characterized by fluctuating abnormal mental status, confusion, impaired responsiveness, and automatism Electroencephalography is helpful both in establishing the diagnosis and in distinguishing the two varieties Initial treatment with intravenous diazepam or lorazepam is usually helpful regardless of the type of status epilepticus, but phenytoin, phenobarbital, carbamazepine, and other drugs may also be needed to obtain and maintain control in complex partial status epilepticus.

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