Neuroimaging by computed tomographic (CT) and magnetic resonance imaging (MRI) has revolutionized the physician’s ability to identify both normal and abnormal anatomy. This chapter examines anatomic imaging in epilepsy, beginning with the basic history of neuroimaging. Early radiographers faced a challenge when it came to neuroimaging: the brain is radiolucent, and of a relatively uniform density. The chapter discusses the neuroimaging recommendations for firsttime seizure and established epilepsy or medication resistant epilepsy. Many neurological emergencies can provoke seizures in the acute phase, including, though not limited to traumatic injury, hemorrhages and hematomas, infarctions, tumors, and infections. Outside of the setting of a first seizure, initial epilepsy workup, and surgical evaluation, neuroimaging should be approached with some discretion. A CT is preferable in acute and unstable conditions, and when the differential includes structural neurologic emergencies; the MRI is preferable in situations of stability, where long-term planning and prognostication are in question.

Complementary and alternative (CAM) therapy may seem new, but many of these treatments are traditional remedies in other cultures going back several thousand years. Mindfulness meditation and mindfulness-based stress reduction, which pair meditation with yoga, are popular mind-body therapies developed by Jon Kabat-Zinn, but there are no controlled studies for the treatment of epilepsy. Acceptance and commitment therapy (ACT) is a structured program that is an extension of cognitive behavior therapy, but with links to relational frame theory. The goal of the therapy is to create a psychological flexibility and to broaden the patient behavioral repertoire to be able to accomplish chosen values and life goals. Chiropractic is one of many body-based therapies and medical systems. Reiki, healing touch (HT), and therapeutic touch (TT) are energy therapies where a practitioner uses hand techniques to help mold and rebalance the patient’s energy field to promote healing of the body.

Nonepileptic events (NEEs) are episodes of altered movement, sensation, or experience resembling epileptic seizures which are not associated with ictal epileptiform discharges in the brain, but which, instead, have a psychological origin. The patient may also be subjected to complications from invasive procedures if they present to an emergency department (ED) with a continuous NEE. Early diagnosis of NEEs can lower out-of-pocket and system wide costs by reducing the need for ED visits, hospitalizations, repeated diagnostic testing, and antiepileptic medications. Patients with NEEs frequently close their eyes during a seizure compared to patients with epileptic seizures who usually do not close their eyes at all or for only a few seconds. The movements in frontal lobe seizures, the most common type of seizure confused with NEEs, often involve vocalization and quick tonic posturing.

This chapter discusses the pathophysiology of bone metabolism, an overview of osteoporosis, the relationship between epilepsy and bone loss, the effect of various antiepileptic drugs (AEDs) on bone health, and the current methods for screening and treatment of bone health in patients with epilepsy. The metabolic function of bone primarily includes the storage of minerals, fat, and growth factors. Osteoblasts and osteoclasts are the cell types that function to remodel bone with the goal of maintaining calcium homeostasis and repair of micro-damages in bone. Osteoclasts remove bone by acidification and proteolytic digestion. Parathyroid hormone (PTH) increases bone remodeling by stimulating osteoclast activity and thus resulting in loss of calcium from bone. Aside from a direct effect of AEDs on bone health, patients with epilepsy may have additional risk factors for the development of osteoporosis.

The first-generation antiepileptic drugs (AEDs), often known as traditional AEDs, marked a significant advance in epilepsy therapy. Before the introduction of phenobarbital, epilepsy was treated with bromide and various faith-based treatments. Benzodiazepines clonazepam, diazepam, and lorazepam are used most often in the treatment of epilepsy. Intravenous diazepam and lorazepam are also indicated for the acute treatment of status epilepticus. Lorazepam penetrates the blood-brain barrier freely by passive diffusion, and it is the agent of choice for status epilepticus. Ethosuximide is indicated for the treatment of absence epilepsy. Absence epilepsy is typically seen in children but might persist into adulthood. Phenobarbital is also indicated for the prevention of febrile seizures in infants and young children, and for the prophylactic management of epilepsy. Phenytoin is also indicated for the prevention of seizures occurring during or following neurosurgery and the control of generalized tonic-clonic status epilepticus.

This chapter presents an overview of the various epilepsies according to the current classification. A standardized classification and terminology for epileptic syndromes is needed for organizing and differentiating the epilepsies. Rather than classifying syndromes using the dichotomies of focal versus generalized, and idiopathic versus symptomatic, epileptic syndromes were characterized according to other features, including age of onset, cognitive and developmental antecedents and consequences, neurologic examination. An epilepsy syndrome frequently indicates the anatomic or system localization of underlying known or suspected pathogenetic factors. Benign familial neonatal seizures (BFNS) is an uncommon epileptic syndrome that involves generalized seizures in neonates and very young infants. In some patients, epilepsy surgery has been successful when the infantile spasms (IS) have been facilitated by the presence of a focal lesion. The electroencephalography (EEG) shows continuous diffuse epileptiform abnormalities.

This chapter presents a framework that permits clinicians to identify a patient with possible metabolic epilepsy, assess the associated clinical features and neurophysiology findings, and develop a diagnostic approach to such epilepsies. Given that multiple seizure types or epilepsy syndromes may be the presenting manifestations of metabolic epilepsies, an array of electroencephalography (EEG) presentations similarly exists. In general, early-onset myoclonic metabolic epilepsy often manifests with burst suppression and/or irregular polyspike wave paroxysm during myoclonus. In progressive metabolic epilepsies, serial EEGs show progression from normal background to slowing, loss of sleep architecture, and an increased burden of generalized spike-and-wave activity. In certain metabolic epilepsies, there may be evidence of brain malformations, such as corpus callosal agenesis in glycine encephalopathy and pyruvate dehydrogenase deficiency or polymicrogyria in Zellweger syndrome. More recently, folinic acid-responsive epilepsies were found to be genetically identical to pyridoxine-dependent epilepsy (PDE).

Issues include the fact that individuals with epilepsy tend to be less well educated, are under- or unemployed, have lower incomes, and are less likely to be married and have children. This chapter will explore some of social issues and how clinicians may assist their patients in addressing these problems. Stigma associated with epilepsy has a long history and has been pervasive for centuries. Studies in different countries have suggested that the public perception of epilepsy, although improving, remains problematic. Individuals with epilepsy have been viewed as less favorable than those with cerebral palsy or mental illness. Obtaining medical insurance, while a nonissue in many places around the world, has been a significant problem for individuals with epilepsy in the United States. Further, as health professionals must continue to strive to help remove stigma associated with epilepsy through educational efforts to the patients themselves, their families, and the general public.

Status epilepticus (SE) has been a known entity for much of human history but only in past century have effective treatments been developed. The development of emergency medical services and critical care has also played a significant role in effectively treating SE. Morbidity and mortality in nonconvulsive status epilepticus (NCSE) differs significantly based on the underlying etiology. Other forms of absence SE (ASE) include atypical ASE as seen in symptomatic, generalized epilepsy such as Lennox-Gastaut syndrome. Focal SE (FSE) can include a wide variety of prolonged clinical manifestations, including repetitive focal motor, sensory, and myoclonic activity as well as uncommon cases of aphasia and visual loss. Although focal sensory symptoms may not lead to further neuronal damage, focal motor SE in Rasmussen’s encephalitis is strongly correlated with outcome. Most patients who develop status epilepticus have a history of epilepsy and the most common reason to develop SE is medication nonadherence.

This chapter addresses the multiple issues that impact on the management and treatment decision in a patient with epilepsy. Patients with epilepsy commonly report that sleep deprivation results in worsening of their seizure control. Given that alcohol use is typically underreported and that seizures may be precipitated by alcohol use of any degree, neurologists should council all patients with epilepsy to avoid alcohol use. Patients with benign rolandic epilepsy often do not require antiepileptic drug (AED) therapy. There are two main causes of death specific to the epilepsy patient population: sudden unexpected death in epilepsy (SUDEP) and trauma related to seizures. Women with epilepsy taking AEDs have a twofold risk of having a baby with a major birth malformation, when compared to healthy women taking no medications. Managing patients with epilepsy and liver disease can be difficult because almost all AEDs undergo hepatic transformation, except for gabapentin and vigabatrin.