Stroke

Epilepsy

Dx. of epilepsy (start medication at dx. and EEG at 2nd seizure)

2 unprovoked seizure more than 24 hours apart (2-year-recurrence 30% then 70%, multifactorial)
(MESS trial : early treatment result in high 2-year-free seizure chance but not significance in long term recurrence) 1 unprovoked seizure with recurrence risk (>60%/10 year or 70% in abnormal EEG/imaging) = assess medium to high risk of recurrence for normal population or start medication in any recurrence risk for cautious occupations/pt. does not accept risk of recurrence
EEG shows epilepsy syndrome (sensitivity 50%, 80-90% for triple test)

Medical treatment each provides the same efficacy. Choice is based upon S/E, spectrum, and co-morbidity.

Seizure/Syndrome	Partial	Secondary generalized	Tonic-clonic	Absence	Myoclonic	Lennox-Gastaut	Infantile spasms
Carbamazepine	+	+	+	-	-	0	0
Clobazam	+	+	+	?	+	+	?+
Clonazepam	+	+	+	?	+	?+	?+
Ethosuximide	0	0	0	+	0	0	0
Phenobarbital	+	+	+	0	?+	?	?
Phenytoin	+	+	+	-	-	0	0
Primidone	+	+	+	0	?	?	?
Sodium Valproate	+	+	+	+	+	+	+
Eslicarbazepine	+	+	+	-	-	0	0
Felbamate	+	+	?+	?+	?	+	?
Gabapentin	+	+	?	-	-	?	?
Lacosamide	+	+	+	?	?	?	?
Levetiracetam	+	+	+	?+	+	?	?
Lamotrigine	+	+	+	+	+ (some -)	+	?+
Oxcarbazepine	+	+	+	-	-	0	0
Perampanel	+	+	?	?	?	?	?
Pregabalin	+	+	?	-	-	?	?
Rufinamide	+	+	+	+	?	+	?
Retigabine	+	+	?	-	-	?	?
Tiagabine	+	+	?	-	?	?	?+
Topiramate	+	+	+	?	+	+	?+
Vigabatrin	+	+	?	-	-	?	?
Zonisamide	+	+	+	?+	+	?+	?+

Pt. status

infant <2 y	close monitor with valproate
female	valproate increases PCOS, teratogenic chance, phenobarbital = teratogenic, phenytoin = gingival hyperplasia, hirsutism, acne, facial coarsening
elderly	lamotrigine / gabapentin is indicated, slow clearance for lipophilic drugs (benzodiazepine, phenobarbital), phenytoin and valproate competitively bind to protein > lower Vd = increase S/E
kidney disease	levetiracetam, gabapentin/pregabalin/vigabatrin are contraindicated
liver disease	BZD, carbamazepine, phenytoin, phenobarbital, valproate are contraindicated