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department of veterans affairs,epilepsy manual,department of veterans affairs. epilepsy manual,aatif m husain tung t tran,Published by. Epilepsy Centers of Excellence,Department of Veterans Affairs. 4150 Clement Street 127E,San Francisco CA 94121,Phone 415 379 5599. Fax 415 379 5666,E mail ECoE va gov,www epilepsy va gov.
Project Manager Pamela R Kelly MBA HCM,Copyeditor Proofreader Caitlin Burke. Indexing Michael Ferreira,Design Production Monica Lacerda. First Printing 2014,Printed in U S A, This book is dedicated to my brother Aasim Mairaj Husain who has. always been protective supportive and inspirational I hope someday my. sons can do for each other what he has done for me aatif m husain. This book is also dedicated to the memory of my father So Van Tran. who as a Veteran and teacher himself taught his family to strive. constantly to serve others tung t tran,con t en ts. Tables and Figures vi,Preface ix,Acknowledgements x.
Contributors xi,Abbreviations xiv, 1 Classification of Seizures and Epilepsy Syndromes 1. 2 Epidemiology 20,3 Etiology 29,4 Differential Diagnosis 33. 5 Clinical Evaluation 40,6 Seizure Semiology 59,7 Electroencephalography 69. 8 Neuroimaging 88,9 Evaluation for Epilepsy Surgery 110. 10 Principles of Treatment 120,11 Antiepileptic Drugs First Generation 128.
12 Antiepileptic Drugs Second Generation 150, 13 Antiepileptic Drugs Third Generation and in Development 165. 14 Advanced Therapies 177,15 Status Epilepticus 189. 16 SUDEP and Other Risks of Seizures 205,17 Post traumatic Seizures 210. 18 Psychogenic Nonepileptic Attacks 225,19 Psychiatric Comorbidities 232. 20 Epilepsy Migraines and Cognition 239, 21 Reproduction Issues and Bone Health in Epilepsy 242.
22 Social Issues 251,23 VHA Benefits 260,About the Epilepsy Centers of Excellence 279. v Epilepsy Manual Department of Veterans Affairs,f i g ures an d tab les. Appendix 8 1 ACR Appropriateness Criteria 105, Figure 2 1 VHA FY11 Epilepsy Prevalence and Incidence Estimates 25. Figure 2 2 Percent of FY11 Prevalent Epilepsy Patients with PTSD and TBI 25. Figure 4 1 Differential Diagnosis of New Onset Spells 35. Figure 4 2 Schema of Seizure Types 36, Figure 4 3 Differential Diagnosis of Physiologic Nonepileptic Events 38. Figure 7 1 Focal Spike Discharges 72, Figure 7 2 Burst of Generalized Spike Wave Discharges 72.
Figure 7 3 Frontal Intermittent Rhythmic Delta Activity FIRDA 73. Figure 7 4 Diffuse Background Slowing 73,Figure 7 5 Focal Slowing 75. Figure 7 6 Bitemporal Slowing 75, Figure 7 7 Temporal Intermittent Rhythmic Delta Activity TIRDA 75. Figure 7 8 Background Asymmetry 76,Figure 7 9 Breach 76. Figure 7 10A B Focal Seizure 77,Figure 7 11 Mesial Temporal Seizure 77. Figure 7 12A B Parietal Seizure 78,Figure 7 13 Absence Seizure 79.
Figure 7 14 Primary Generalized Seizure 79, Figure 7 15 Benign Epileptiform Transients of Sleep BETS 80. Figure 7 16 Wicket Spike 80, Figure 7 17 Rhythmic Midtemporal Theta Bursts of Drowsiness RMTD 80. Figure 7 18A B C Subclinical Rhythmic Electrographic Discharge of Adults SREDA 82. Figure 7 19 6 Hz Spike Wave Pattern 83, Figure 7 20 Periodic Lateralized Epileptiform Discharges PLEDs 84. Figure 7 21 Generalized Periodic Epileptiform Discharges GPEDs 84. Figure 7 22 Triphasic Waves 84,Figure 8 1 Acute Stroke in Evolution 91. Figure 8 2 Hyperdense Vessel Sign 91,Figure 8 3 Vasogenic Edema on Noncontrast CT 91.
Figure 8 4 Acute Subarachnoid Hemorrhage 92, Figure 8 5 Postcontrast CT Showing Multiple Enhancing Lesions 92. Figure 8 6 Acute Stroke on CT Angiogram with Perfusion 93. Figure 8 7 Tumor on CT Angiogram with Perfusion 94. vi Epilepsy Manual Department of Veterans Affairs,Figure 8 8 Aneurysm on CT Angiogram 95. Figure 8 9 Subacute and Remote Blood on MRI 95, Figure 8 10 Encephalomalacia and Gliosis from Prior Trauma 95. Figure 8 11 Cortical Dysplasia on MRI 96,Figure 8 12 Gliosis 96. Figure 8 13 Tumor on Postcontrast MRI 97,Figure 8 14 Acute Stroke on DWI MRI 97.
Figure 8 15 Acute Water Restriction in the Splenium of the Corpus Callosum 98. Figure 8 16 Cellular Tumor on DWI 98, Figure 8 17 Restricted Diffusion in Intracranial Abscess 99. Figure 8 18 Herpes Encephalitis 99, Figure 8 19 Black Dots on Blood Sensitive Sequences 100. Figure 8 20 Hemosiderosis 100,Figure 8 21 MTS on MRI 102. Figure 8 22 Interictal and Ictal SPECT Imaging 102. Figure 8 23 Cortical Dysplasia on PET CT 103, Figure 8 24 fMRI and DTI for Preoperative Planning 104. Figure 14 1 Right Anterior Temporal Lobectomy 180,Figure 14 2A B Intracranial Monitoring 183.
Figure 14 3 Vagal Nerve Stimulator VNS 183, Figure 15 1 Brief Sample Treatment Algorithm in SE 194. Figure 15 2 Periodic Lateralized Epileptiform Discharges PLEDs 202. Figure 15 3 Right Temporal Seizure 202,Figure 15 4 Left Hemisphere Seizure 202. Figure 23 1 Form 21 0960C 11 Seizure Disorders Epilepsy Disability Benefits. Questionnaire 264, Table 1 1 1981 ILAE Classification of Epileptic Seizures 4. Table 1 2 1989 ILAE Classification of Epilepsies and Epileptic Syndromes 10. Table 1 3 2010 ILAE Classification of Epileptic Seizures 16. Table 1 4 2010 ILAE Description of Seizures According to Degree of Impairment. During Seizure 16, Table 1 5 2010 ILAE Electroclinical Syndromes and Other Epilepsies 18. Table 2 1 VHA FY11 Epilepsy Patients Frequencies 26. Table 3 1 Etiology 30, vii Epilepsy Manual Department of Veterans Affairs.
Table 4 1 Key Questions to Ask Patients and Witnesses as Part of a New Onset. Seizure Work up 35,Table 5 1 Classification of Seizures 41. Table 5 2 Classification of Electroclinical Syndrome and Other Epilepsies. Most Likely to Be Seen in Veterans Adult Patients 42. Table 5 3 Features of a Seizure History and Description 43. Table 5 4 Other Seizure Details 45,Table 5 5 Risk Factors for Seizures 45. Table 5 6 Etiology of Seizures 46,Table 5 7 Traumatic Brain Injury and Epilepsy 47. Table 5 8 VA Depression Screen 49, Table 5 9 ICD 9 Epilepsy and Spells Diagnostic Codes 53. Table 5 10 Epilepsy Patient Education 54,Table 5 11 Websites with Epilepsy Resources 56.
Table 5 12 AAN Epilepsy Quality Measures 56,Table 6 1 Seizure Classification 60. Table 6 2 Localization of Motor Features 62, Table 6 3 Features of Epileptic and Nonepileptic Seizures 66. Table 6 4 Features of Different Seizure Types 67, Table 8 1 Evolution of Blood Products on Conventional MRI Sequences 101. Table 10 1 AED Choices by Seizure Type 122, Table 11 1 Antiepileptic Drugs First Generation 144. Table 12 1 Lamotrigine Dose Titration 151, Table 12 2 Antiepileptic Drugs Second Generation 162.
Table 13 1 Antiepileptic Drugs Third Generation and in Development 172. Table 15 1 Medications for Treatment of Status Epilepticus 195. Table 17 1 Risk Factors for Late Post traumatic Seizures 216. Table 21 1 Arizona Sexual Experience Scale 245,Table 21 2 AEDs and Teratogenesis 247. Table 21 3 Enzyme Inducing AEDs 248,Table 21 4 Second Generation AEDs 248. Table 23 1 Length of Service Requirements 263, Table 23 2 General Rating Formula for Epileptic Seizures 263. viii Epilepsy Manual Department of Veterans Affairs. Epilepsy is a common and complex neurological disorder It has not only. medical but also psychosocial consequences Healthcare providers of all specialties may be called upon to care. for these patients Veterans are at particular risk for developing epilepsy due to the frequency with which they. suffer significant head injuries This is likely to become a greater problem in the near future as many Veterans. in recent years have seen combat and suffered traumatic brain injuries TBI In recognition of this reality the. United States Congress passed the Public Law S 2162 in 2008 which included a provision for the creation of. Epilepsy Centers of Excellence ECoEs with the Department of Veterans Affairs DVA healthcare system. Implementation of the Veterans Mental Health and Other Care Improvements Act by the DVA resulted in. the creation of 4 regional ECoEs Northeast Northwest Southeast and Southwest Each regional ECoE is. composed of 3 to 5 medical centers at least one of which is also a polytrauma center Over the last few years. the ECoEs have been enhancing the services they are able to provide Veterans with epilepsy This has included. improving and increasing the capability for providing intensive inpatient epilepsy care including epilepsy. surgery for appropriate patients Various innovative programs have also been implemented to facilitate care. such as video telemedicine clinics clinical note entry template for data basing educational case conferences for. referring providers and routine video seminars for patients and interested providers on various topics related to. epilepsy Along with the ECoEs a National VA Epilepsy Consortium was established to allow networking of all. epilepsy centers within the VA Health System, Veterans with epilepsy face many of the same issues faced by other patients with epilepsy They also have many. other comorbidities and psychosocial issues that make their disease state even more complex TBI and post. traumatic stress disorder PTSD are two such comorbidities that frequently complicate the management of. Veterans with seizures, The DVA Epilepsy Manual is meant to address the unique needs of the practitioner who manages Veterans with.
epilepsy All aspects of clinical epilepsy care are addressed in this manual in a practical manner The manual is. divided into four broad categories of chapters Clinical Aspects Diagnostic Evaluation Treatment and Special. Situations Non VA practitioners including trainees will find this manual useful as it condenses what can take. up a large textbook to the essential and practical topics References are provided in case one is interested in more. information Tables figures and summaries are used to further organize the information. The authors of the chapters of this manual are all involved in the care of Veterans with seizures Many of them. practice in the ECoEs and they represent different areas of expertise We are indebted for their contributions. to this manual We hope the DVA Epilepsy Manual will enhance the care of heroes who have given so much of. themselves for the sake of their country,Aatif M Husain MD. Tung T Tran MD,ix Epilepsy Manual Department of Veterans Affairs. Ac kn owled g emen ts, We are indebted to Dr Pamela Kelly Regional Administrative Director. of the Southeast ECoE for facilitating this project Without her constant encouragement we would not have. been able to complete this book We also gratefully acknowledge the support of leadership of the Epilepsy. Centers of Excellence Neurology and Veteran Affairs Central Office. x Epilepsy Manual Department of Veterans Affairs,con t ri butors. Eilis A Boudreau MD PhD Sunita Dergalust PharmD BCPS. Associate Professor Department of Neurology and Clinical Pharmacist Specialist Department of Pharmacy. Department of Medical Informatics and Clinical Epidemiology Services and Neurology. Oregon Health Science University Veterans Affairs Greater Los Angeles Healthcare System. Portland Epilepsy Center of Excellence Los Angeles California. Portland Veterans Affairs Medical Center,Portland Oregon Amanda Everhart FNP BC.
Epilepsy Nurse Practitioner Epilepsy Center of Excellence. Ali M Bozorg MD Durham Veterans Affairs Medical Center. Assistant Professor Departments of Neurology and Durham North Carolina. Neurosurgery, University of South Florida Alfred T Frontera Jr MD. Tampa Florida Director Tampa Epilepsy Center of Excellence. Tampa Veterans Affairs Medical Center, Jos E Cavazos MD PhD Assistant Professor of Neurology. Professor and Assistant Dean Departments of Neurology University of South Florida. Pharmacology and Physiology Tampa Florida, University of Texas Health Science Center at San Antonio. San Antonio Veterans Affairs Epilepsy Center of Excellence. Nina I Garga MD,South Texas Veterans Health System. Director San Francisco Epilepsy Center of Excellence. San Antonio Texas,San Francisco Veterans Affairs Medical Center.
David K Chen MD Assistant Clinical Professor of Neurology. University of California San Francisco School of Medicine. Assistant Professor Peter Kellaway Section of,San Francisco California. Neurophysiology Department of Neurology,Baylor College of Medicine. Houston Epilepsy Center of Excellence Neurology Care Line Barry E Gidal PharmD. Michael E DeBakey Veterans Affairs Medical Center Professor of Pharmacy and Neurology. Houston Texas University of Wisconsin,Clinical Pharmacist. James WY Chen MD PhD William S Middleton Memorial Veterans Hospital. Director West Los Angeles Veterans Affairs Epilepsy Center Madison Wisconsin. of Excellence, West Los Angeles Veterans Affairs Medical Center Stephen Holloway MD PhD. VAGLAHS Clinical Neurophysiology Fellowship Program Neurology Service. Department of Neurology Minneapolis Veterans Affairs Medical Center. Veterans Affairs Greater Los Angeles Health Care System Minneapolis Minnesota. Associate Professor Department of Neurology, David Geffen School of Medicine at University of California Richard A Hrachovy MD.
Los Angeles Director Houston Epilepsy Center of Excellence. Los Angeles California Michael E DeBakey Veterans Affairs Medical Center. ix EpilEpsy Manual DEpartMEnt of VEtErans affairs Epilepsy is a common and complex neurological disorder It has not only medical but also psychosocial consequences Healthcare providers of all specialties may be called upon to care for these patients Veterans are at particular risk for developing epilepsy due to the frequency with which they

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