Table Of ContentIllustration entitled Possession from the Bible
of 1720. Jesus is shown driving out an unclean
spirit from the victim of a seizure. Note the vapor
emanating from the unfortunate's mouth. When
looking at this picture one is reminded of the des
peration which gave rise to ancient beliefs, mis
conceptions, and prejudices concerning epilepsy;
of the hope born of empirical but genuine therapy
such as provided by paraldehyde, a drug excreted
through the lungs; and of the enlightenment of sci
entific understanding which now gives rise to the
rational development of progressively more specific
anticonvulsant therapy.
THE PRIMARY CARE
OF SEIZURE
DISORDERS
A Practical Guide
to the Evaluation
and Comprehensive
Management of
Seizure Disorders
Hugh B. Mclntyre, M.D., Ph.D.,
F.A.C.P.
Professor of Neurology
Chief, Division of Clinical Neurophysiology
Harbor-UCLA Medical Center
Torrance, California
with coauthors
BUTTERWORTHS
Boston · London
Copyright © 1982 Butterworth Publishers.
AU rights reserved.
No part of this publication may be reproduced, stored in
a retrieval system, or transmitted, in any form or by any
means, electronic, mechanical, photocopying, recording, or
otherwise, without the prior written permission of the pub
lisher.
Every effort has been made to ensure that the drug dosage
schedules within this text are accurate and conform to stan
dards accepted at time of publication. However, as treatment
recommendations vary in light of continuing research and
clinical experience, the reader is advised to verify drug dos
age schedules herein with information found on product
information sheets. This is especially true in cases of new
or infrequently used drugs.
Library of Congress Cataloging in Publication Data
Mclntyre, Hugh B., 1935-
The primary care of seizure disorders.
Includes index.
1. Epilepsy. 2. Epilepsy—Treatment.
1. Title [DNLM: 1. Epilepsy—Therapy.
2. Epilepsy—Diagnosis. WL 385 M478p]
RC372.M34 616.8'53 82-4157
ISBN 0-409-95022-X
Butterworth Publishers
10 Tower Office Park
Woburn, MA 01801
Printed in the United States of America
COAUTHORS
Bruce Blumberg, M.D.
Senior Fellow in Medical Genetics
Genetic Aspects of Epilepsy
Hugh M. Firemark, Ph.D., M.D.
Associate Professor of Neurology
Noncompliance and the Management of Epilepsy
Andrea Sue Goldberg, M.D.
Assistant Professor of Neurology
Medical-Legal Aspects of Epilepsy
Arnold W. Gurevitch, M.D.
Associate Professor of Medicine (Dermatology)
Medical Treatment of Seizure Disorders
Gene A. Kallenberg, M.D.
Assistant Professor of Medicine (Family Medicine)
Seizure Disorders: Some Basic Considerations
Harriet Smith Kaplan, M.D.
Assistant Professor of Psychiatry
Practical Psychiatric Aspects of Epilepsy
X The Primary Care of Seizure Disorders
Andrew Jay Kaufman, J.D.
Medical-Legal Aspects of Epilepsy
Donald L. Leake, D.M.D., M.D., F.A.C.S.
Professor of Surgery (Oral and Maxillofacial)
Medical Treatment of Seizure Disorders
Larry J. Shapiro, M.D., F.A.A.P.
Associate Professor of Pediatrics
Genetic Aspects of Epilepsy
Marvin L. Weil, M.D., F.A.A.P.
Professor of Pediatrics and Neurology
Medical Treatment of Seizure Disorders
ACKNOWLEDGMENTS
The authors, except for Mr. Kaufman, all have academic appointments
in one of the various series of the College of Medicine at the University
of California at Los Angeles and are faculty members or members of
the staff of the Los Angeles County Harbor General Hospital UCLA
Medical Center. Mr. Kaufman is a practicing attorney in Los Angeles,
California.
Dr. Gene Kallenberg did the survey described in Chapter 1, "Sei
zure Disorders: Some Basic Considerations," and was coauthor. Dr.
Marvin Weil was the primary author of the section on neonatal sei
zures and seizures in infancy which is included in Chapter 2, "The
Clinical Evaluation of Seizures." The primary authors for Chapter 3,
"Genetic Aspects of Epilepsy," were Drs. Larry Shapiro and Bruce
Blumberg. Dr. Arnold Gurevitch was the primary author for the sec
tion on cutaneous reactions to anticonvulsants in Chapter 5, "Medical
Treatment of Seizure Disorders," and Dr. Leake wrote the section on
gingival hyperplasia in the same chapter. Dr. Harriet Kaplan was
primary author for Chapter 7, "Practical Psychiatric Aspects of Epi
lepsy." Dr. Hugh Firemark was primary author for Chapter 8, "Non-
compliance in the Management of Epilepsy." Mr. Andrew Kaufman
and Dr. Andrea Goldberg, husband and wife, were the primary authors
for Chapter 9, "Medical-Legal Aspects of Epilepsy."
The photomicrographs in Figure 2.2 of Chapter 2, "The Clinical
xii The Primary Care of Seizure Disorders
Evaluation of Seizures," were provided by Hideo Itabashi, M.D., Pro
fessor of Pathology and Neurology, Los Angeles County Harbor Gen
eral Hospital UCLA Medical Center.
PREFACE
This book is designed to help physicians who in the course of clinical
practice care for patients who have epileptic seizures.
The intention is to provide a thorough but concise treatment of
the subject which may serve as a basic text as well as a handy reference
source for solving problems as they arise on a case-by-case basis. It
is hoped that the tables and glossaries and the attention to the broader
aspects of case management will be of particular value in this regard.
The organization of the book reflects the sequence which clinical man
agement often follows: differential diagnosis and genetic aspects, the
electroencephalographic evaluation, medical therapy of seizure dis
orders including first aid and the treatment of status epilepticus, psy
chiatric aspects, problems of noncompliance and finding ancillary,
community resources for patients.
The author would be pleased to hear from any reader who may
have a suggestion for any future edition and would be grateful if
notified of any error found in the text.
1
SEIZURE DISORDERS:
SOME BASIC
CONSIDERATIONS
Statisticians have called epilepsy "the hidden disease" because it is
believed that many people who suffer from this disorder are well
controlled and able to conceal their illness and therefore remain un
detected by surveys. Obtaining a random sample from the total epi
leptic population is nearly impossible. Bearing this in mind and
weighing a great deal of evidence, the Professional Advisory Board
of the Epilepsy Foundation of America has concluded that in the
United States a minimum of 4 million persons suffer from some form
of seizure disorder.
STATISTICS
The term prevalence refers to the ratio of those people affected by a
particular problem to those not affected at a given time. The preva
lence rate for seizure disorders is no less than 3 per 1,000 population
and is probably much closer to 6 to 7 per 1,000. Incidence refers to the
number of new cases within a population within a given period of
2 The Primary Care of Seizure Disorders
time. The overall incidence of epilepsy is betwen 0.3 and 0.7 percent
per year. In the United States the range of new cases is from about
23,000 to 147,000 per year. The Epilepsy Foundation of America points
out that if a prevalence rate of 2 percent is assumed as constant the
population growth alone between 1970 and 1980 should have resulted
in approximately 70,000 new cases in the United States a year. This
would reflect a 0.2 percent incidence rate. Epilepsy is a minor cause
of death. Life insurance company estimates of death ascribable to
epilepsy indicate a rate of 1.3 per 100,000 population. This is lower
than the death rate from appendectomies.
Approximately 85 percent of patients with seizure disorders
achieve enough seizure control to lead essentially normal lives. Ap
proximately half have complete to 90 percent control. The extent to
which anticonvulsant medication will be effective is usually known
within the first year of treatment.
Unemployment has always been a major problem for those with
epilepsy. Estimates of unemployment place the rate between 20 to 25
percent. When compared to other disabilities, seizure disorders have
the highest rate of exclusion in hiring by virtually all firms surveyed.
The outlook, however, is not all bad. The Epilepsy Foundation of
America has estimated that there were as many as 1.7 million people
with epilepsy in the 1972 labor force of 88 million. The three industries
with the highest percentage of employees with epilepsy are banking,
hospitals or clinics, and wholesale sales. The poorest opportunity for
employment exists in government and private utilities.
INTELLIGENCE
The presence of epilepsy per se does not affect innate intelligence, and
the majority of people with seizure disorders do not suffer intellectual
impairment as a result of having seizures. Many famous and intel
ligent historical figures have had seizure disorders. However, an epi
leptic patient's intellectual achievement is liable to the combined
effects of social and psychological pressures, side effects of medication,
and possibly unusually frequent and uncontrolled seizures. Of course
some patients will have both seizures and intellectual impairment as
a result of brain injury or progressive brain disease.
NEUROLOGICAL CONSULTATION
From the incidence and prevalence figures alone it is clear that phy
sicians engaged in the delivery of primary care will have responsibility
for both new and continuing care patients who have seizures. In many
