Brain, Vol. 124, No. 9, 1879-1880,
September 2001
© 2001 Oxford University Press
Book reviews |
EPILEPSY: COMPREHENSIVE REVIEW AND CASE DISCUSSION
By Hans Luders. 2000. London: Martin Dunitz. Price £65. Pp. 400. ISBN 1-85317-741-5.
Department of Neurology, Radcliffe Infirmary, Oxford, UK
The last few years have seen the appearance of an increasing number of books, of varying size and complexity, about the management of epilepsy, and it is difficult to envisage a niche for any new publication on general epilepsy issues. This book, with its combination of comprehensive coverage of almost all aspects of epilepsy management, and case studies to illustrate the problems and aid learning, will almost certainly find such a niche.
The preface of the book describes it as `an edited syllabus' of the course on comprehensive epileptology organized by the Cleveland clinic group since 1996. This conjured up the possibility of rather dry reading: the reality is very different, providing a very readable, up-to-date and well-balanced yet succinct account of the most important areas of epileptology. Diagnosis, classification, neuroimaging, neurophysiology and clinical management are some of the areas tackled, as well as the issue of `pseudoseizures'. Although the overall emphasis of the book is on the clinical aspects of epilepsy, where relevant, accounts of the underlying basic mechanisms are included, both in the illuminating chapter on pathophysiology and elsewhere, for example, in the excellent section on paediatric epilepsy syndromes.
Arguably the most important, and often difficult, area of epilepsy management is that of diagnosis. It depends largely on the clinical description of the seizure, and investigations are often unhelpful; as such, it is a skill which is difficult to teach but tends to improve with experience (and the lessons learned from previous misdiagnoses). The first chapter thoughtfully addresses this problem, pointing out the common pitfalls (particularly the fact that errors of commission are more common than those of omission in making a diagnosis), and the difficulties encountered in making the diagnosis with an inadequate history. After discussing epidemiological and aetiological risk factors which predispose to the development of epilepsy, the author moves on to discuss the use and abuse of various investigations, particularly the EEG. An account of the conditions most likely to be confused with seizures (and some of the less common differential diagnoses) rounds off the chapter.
A section on the pathophysiology of epilepsy follows. The authors have managed to simplify this difficult area into an account that is both clear and readable. Their description of the basic mechanisms underlying epileptic activity is followed by a review of the common pathologies and aetiologies and the probable means by which these produce seizures.
What differentiates this book from many others is its helpful use of case presentations to illustrate practical points in the management of epilepsy. These accompany several of the chapters, for example, those on neuroimaging, electroencephalography and the chapters discussing the medical and surgical management of seizures. For the most part, the case presentations are divided by age, with sections on both paediatric and adult epilepsy problems. Each case history, together with the results of scans, EEGs or other relevant investigations, is accompanied by implied or direct questions regarding diagnosis and management, the `answers' in the form of case discussions being given at the end of the section. By this means the reader can test his or her knowledge and identify areas for further study. In general this provides an effective and interesting aid to learning, though those questions involving specific medications often translate poorly from one country to another, where the range of drugs available, or even their place in management, may be different.
The chapter on neuroimaging provides a useful historical overview of this subject, though the emphasis is on magnetic resonance imaging and the light this has shed on our knowledge of the aetiology of epilepsy. Examples of the most important causes of epilepsy are provided, either in the body of the text or in the case presentations following. Similarly useful case studies involving both children and adults with accompanying EEGs follow the chapter on electroencephalography, which is commendable in the manner in which it condenses the most relevant areas of this vast topic into a few pages, yet remains clear, clinically relevant and immensely practical.
The classification of epilepsy is both complicated and, in many respects, unsatisfactory. An example of the difficulties encountered is that in the classification of the epilepsies and epileptic syndromes suggested by the International League Against Epilepsy, the extent of investigation may determine whether a person's epilepsy is deemed symptomatic or cryptogenic. The lack of access to EEG found in many developing countries means that the classification may be impossible to apply in large areas of the world, and developments in the field of genetics have as yet not been addressed. The section on paediatric epilepsy syndromes analyses these, and other, problems in a critical manner, and employs a stimulating and comprehensive discussion of the issues encountered in classifying absence seizures, to illustrate the problems that arise. The section on epileptic syndromes in adults is also helpful, though here the concentration, certainly with regard to the focal epilepsies, is on localization.
Neurologists specializing in the treatment of epilepsy inevitably also see a considerable number of people with non-epileptic attacks, and this is acknowledged by the presence of a chapter headed `Pseudoseizures'. This concentrates mainly on non-epileptic attacks of psychological origin, but also briefly addresses a number of `organic' causes of non-epileptic attacks and, in this respect, overlaps somewhat with the first chapter, on differential diagnosis. The chapter gives a comprehensive account of the clinical features of psychogenic pseudoseizures, their epidemiology and the investigations which may be helpful in differentiating them from epileptic attacks, but does not address the issue of management, concluding that `we do not know yet how to treat them'.
The second half of the book concentrates largely on treatment. A review of the pharmacokinetics of anticonvulsants dealing mainly with general principles is followed by case studies involving common problems encountered in the use of these drugs. Subsequent chapters deal with the medical treatment of focal epilepsies and generalized epilepsy: the management of women with epilepsy, the prevention and treatment of status epilepticus and finally, epilepsy surgery. All are liberally, and helpfully, illustrated by case studies, including sections devoted to the management of first seizures and the withdrawal of antiepileptic drugs. Unfortunately, as indicated above, these sometimes read awkwardly outside their country of origin due to a combination of factors such as different driving laws, the variety of drugs available and differences between countries in the use of those drugs which are available, for somewhat ill-defined reasons. Notable omissions from the chapter on the medical treatment of focal epilepsies are oxcarbazepine and levetiracetam, while the visual field problems which have caused a major change recently in the use of vigabatrin by many neurologists are somewhat summarily dismissed. Whether or not one is a proponent of vagal nerve stimulation, it is surprising that this too has been omitted from discussion.
Overall, however, this book provides a succinct but clear discussion of modern epilepsy management, and should be of use to practising neurologists and trainees, and others involved in the care of people with epilepsy.
CiteULike 
Connotea 
Del.icio.us What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||