Meningiomas are benign tumors order accutane with mastercard anti-acne, histologically quality 10mg accutane acne 9 month old, slow growing purchase accutane pills in toronto skin care clinique, and cause symptoms due to cord and nerve root compression. Complete resection is achieved surgically in 95% of cases and, despite complete removal, 5% recur. Ependymoma Ependymomas are the most common spinal cord tumor of adults, with a mean age at presentation of 40 years. An important histologic variant is a myxo- tradural extramedullary in location, and causes slight compression papillary ependymoma, which accounts for less than 20% of the cord posterolaterally, ﬁndings well seen on these axial scans. They are slow growing, well- Meningioma circumscribed tumors with a tendency to compress adja- Twenty-ﬁve percent of all intraspinal tumors are menin- cent neural tissue. On imaging, a small nodular, enhancing giomas, with this lesion second in incidence only to benign intramedullary lesion limited to two to three vertebral neural tumors. Meningiomas are usually solitary, with a levels, with an accompanying cyst, favors the diagno- peak age of incidence of 45 years. Sagittal images slightly oﬀ midline demonstrate a round intradural extra- medullary, homogeneously enhancing soft tissue mass. Note the marked compression and deformity of the cord (which is displaced to the left, *) on the axial scan. Clinical symptoms are often minimal, consistent with a very slow growing benign neoplasm. Sagittal images demonstrate a ing it as intradural, as opposed to an extradural lesion, which would meningioma that lies just below the conus, which despite its size displace and compress the thecal sac. Ependymomas are usually well-delineated, and (disregarding the myxopapillary vari- ant) are most common in the cervical region. On imaging, these are seen centrally within the cord, often with promi- nent enhancement (Fig. These lesions represent 20% of all spinal ependymomas, but 80% of those involving the conus or ﬁlum terminale. An intramedullary mass lesion lary ependymomas often span multiple vertebral body segments, causing focal cord expansion is demonstrated, with its epicenter at and may ﬁll the spinal canal. The weighted scans, due to the presence of mucin, with intense en- lesion itself is relatively short in length, extending only two vertebral hancement post-contrast. Edema is seen within the cord, extending both cra- in the case illustrated, represents leptomeningeal tumor spread, nial and caudal to the lesion, with abnormal high signal intensity on which was conﬁrmed at surgery. On sagittal images of the cervical spine, there is a long segment, spanning in this instance more than four vertebral bodies, of marked, diﬀuse cord expansion, with abnormal high signal intensity on the T2-weighted scan and heterogeneous enhancement. Myxopapillary ependymomas may oc- casionally present as large lesions (scalloping the vertebral bodies), also typically display marked enhancement, and Fig. Post-contrast, two enhancing focal intramedullary cord lesions are noted, at the C5 and T2–3 levels. In this patient with von Hippel-Lindau syndrome, both Astrocytoma hemangioblastomas are located in the more posterior aspect of the cord, with lesions rarely present anteriorly. Multiple cord lesions of In children, spinal cord astrocytomas are more common varying size are common in von Hippel-Lindau syndrome; however, than ependymomas, with ependymomas more common in the extensive cord edema noted in this instance is unusual. These inﬁltrative tumors are not the spine, a hemangioblastoma will lie along the wall of amenable to surgical resection, unlike ependymomas. He- segment of involvement (multiple vertebral segments), mangioblastomas occur anywhere along the spinal cord, with near complete involvement of the width of the cord, and in patients with von Hippel-Lindau disease small poorly deﬁned margins, and cord expansion (Fig. Hemangioblastomas can be solitary or multiple, is present, the imaging appearance includes focal irregu- the latter speciﬁcally with von Hippel-Lindau disease. In a minority of cases in large and small nodules, and coating of nerve roots (which Fig. A characteristic imag- 213 ing appearance for a spinal cord hemangioblastoma is that of an intensely enhancing lesion with an associated cyst and serpentine flow voids, the latter due to lesion vascularity. These features are all illustrated (part 1), with the enhancing component small in this instance relative to the size of the cyst, also a characteristic finding. About a third of all hemangioblastomas are seen in patients with von Hippel-Lindau syndrome. In such cases, as with this patient, there may be multiple small hemangioblastomas – with a small pinpoint le- sion (arrow) involving a nerve root, and a larger nodular lesion (arrow) in the lumbar region illustrated (part 2) on axial scans. A small this patient, fat saturation can be useful for improved detection of dis- enhancing intramedullary lesion is seen on both sagittal (arrow) and ease (on the basis of abnormal contrast enhancement), even for lesions axial T1-weighted scans. The absence of high signal intensity from fat (and tasis to the cord, or extension to involve the cord from metastatic fatty marrow) in this scan improves detection of both a nodular focus disease to the pia-arachnoid. Additional, mild enhancement along of leptomeningeal disease within the subarachnoid space (white arrow), the surface of the cord is indicative of more extensive involvement as well as the coating (also termed “icing”) of the cord surface (*). If very high-reso- lution images are acquired, small nodular leptomeningeal metasta- ses may be well visualized on a T2-weighted scan, as illustrated with a midline sagittal image. However, contrast enhancement oﬀers the most sensitive approach, with axial post-contrast scans illustrating a large, irregular, enhancing nodular metastasis involving the conus and innumerable small enhancing foci adherent to nerve roots in Fig. In ambulatory patients, gravity may result in involvement primarily of the caudal thecal sac, mandating careful inspection of the low lumbar and sacral regions. In advanced disease, as illustrated, lepto- may appear “beaded” in appearance) (Fig. The meningeal metastatic disease can present as a conﬂuent mass in the entire spinal axis (cervical, thoracic, and lumbar regions) lumbar region. Due to the ef- fect of gravity, if the patient is ambulatory, the disease as depicted by imaging may be restricted to the distal thecal sac (Fig. On imaging, thick vertical stria- primary tumors) ependymoma and medulloblastoma and tions/trabeculation will be evident. Unfor- spinal cord, with associated vasogenic edema, that dem- tunately, atypical hemangiomas (in terms of imaging onstrates contrast enhancement and causes mild focal characteristics) are common. Bronchogenic carcinoma is the most com- agnosis is focal fat (within vertebral bodies), another com- mon primary. They can be solitary or multiple, though benign, is generally considered within the cat- and vary in size from small to involving the entire verte- egory of neoplastic disease and often requires treatment. Histologically, hemangiomas contain About 20% arise in the spine, with the majority of these 3 Spine 215 Fig. Within L5, on sagittal images (part 1), there is a large round lesion, which is hyperintense on T2- and T1-weighted im- ages (consistent with fat), with characteristic accentuated vertical trabeculae. Aneurysmal bone cysts have both cystic and solid components, with the lat- ter enhancing. The cystic components often contain blood degradation products, with ﬂuid–ﬂuid levels present. Focal collections of fat Osteoid Osteoma within a vertebral body are common, particularly in the elderly pa- An osteoid osteoma is a common benign bone tumor com- tient population. There is an expansile mass of the spinous process (of this cervical vertebra), with abnormal high signal intensity on the T2-weighted scan and prominent enhancement. This expansile benign neoplasm consists of blood-ﬁlled spaces, with enhancement present in solid por- tions of the lesion.
Т1-weighted images (а purchase accutane online pills acne cyst,b) and Т2-weighted image (c) reveals a large tumour within the cavity of en- larged sella turcica order generic accutane acne treatment for teens, with supra- 20mg accutane sale acne no more, latero-, and infrasellar growth. Т1-weighted images (а,b) and Т2-weighted image (c) reveals a large cystic tumour within the cavity of enlarged sella turcica, with suprasellar growth. Sedimentation efect seen as a level of fuid well demonstrated in the cystic cavity Fig. Sagittal T1-weighted image (а) and coronal T2-weighted image (b) reveals the intrasu- pralaterosellar pituitary tumour. The cyst in the tumour stroma is hypointensive on T1-weighted images and hyperintensive on T2 -weighted images. The efect of signal void of blood in arteries makes them well identifed in relation to tumour tissue and anterior cerebral arteries strictly delimits performance of the internal carotid artery is the most reliable sign of cavern- presurgical direct angiography to identify location of these ous sinus invasion. Upward growth into the suprasellar cavernous sinuses as well as the high plasma level of prolac- cistern is better seen on sagittal Т1-weighted imaging, due to tin should lead one to suspect sinus invasion. On frontal and axial T1-weighted images, to note that despite the fact that lateral invasion of cavernous the passage of optic nerves, and location of chiasm and optic sinuses is a frequent event, compression and occlusion of the tracts and their spatial relationship with a tumour are opti- cavernous segment of the internal carotid artery rarely oc- mally seen (Fig. Tis has diagnostic signifcance in the diferential diag- A frequent phenomenon is laterosellar growth of adenomas nosis between adenomas and meningiomas (Fig. The main reason for this is and mass lesions with intratumoural haemorrhages are pres- that the medial wall of the sinus is very thin and thus is not ent. On the other hand, the venography with suppression of blood fow signal in arteries lateral wall of the cavernous sinus is a reliable landmark—it is (Fig. The growth of The infrasellar growth of a tumour is easily identifed on a tumour between the lateral wall of the cavernous sinus and sagittal and coronal T1-weighted images when the adenoma’s Sellar and Parasellar Tumours 553 Fig. Т2-weighted images (а,b) and Т1-weighted images (c) reveal a large tumour on the skull base, which flls the sella turcica and both cavernous sinuses. The internal carotid artery siphons are included in the tumour structure, without their narrowing Fig. On a series of Т1-weighted images (b–d), a large tumour originating from the cavity of the sella turcica is seen. Coronal Т1-weighted imaging well defnes intra-infralaterosuprasellar growth of the tumour. Т2-weighted imaging (а) re- growth, and there is no even dislocation or narrowing of the internal veals a tumour within the cavity of enlarged sella turcica, with lat- carotid artery. Т2-weighted imaging (а,b) shaped upward displacement of the A1 segment of the anterior cere- shows a tumour within the cavity of enlarged sella turcica with bral artery, the vascular net of the tumour is absent, and there is no suprasellar growth. Direct angiogram (c) visualises a typical bow- compression of the internal carotid artery siphon Fig. Т1-weighted imaging (а,b) typical bow-shaped upward displacement of the A1 segment of the demonstrates a large infrasuprasellar tumour with hemorrhagic foci. Т2-weighted imaging (а) reveals a tumour within the cavity of enlarged sella turcica, with laterosellar lefward growth. Tu- characterised by rapid growth, frequent haemorrhages, and mour invasion into the depth of clivus is also well visualised extended invasion of the surrounding structures (Fig. Gadolinium-chelate injection is feasible in the high protein content in the cystic fuid, which shortens T1 large pituitary tumours when it is necessary to diferentiate the relaxation time. Sometimes the sedimentation phenomenon tumour and the adjacent brain structures (Figs. However, it has not been yet explained and to perform the diferential diagnosis from other tumours how the remnants of diaphragm, dura mater, diferent tumour and nontumour mass lesions of the sellar region. Treatment regions, and the adjacent dislocated structures may be cor- tactics and optimal choice of surgical accesses or their com- rectly visualised or enhanced. Tus, subacute hae- morrhage shows hyperintensive signal on Т1-weighted images and on T2-weighted images (Fig. However, in contrast to adults the percentage of ma- 21%, and 7% of all cases of brain tumours in children), 4% of lignant tumours in children is high. Malignant tumours are all supratentorial tumours, and up to 56% of all tumours of Sellar and Parasellar Tumours 557 Fig. Cysts with hyperintensive signal on T1-weighted imaging (a) and T2 -weighted imaging (b) are seen within the solid part of the pituitary tumour. Coronal (а) and sagittal (b) Т1-weighted image shows the dumbbells-like shape of the tumour. Tere are a few exophytic tu- mours of adenoma through the rupture of diaphragm of the sella turcica upwards Fig. Sagittal (a) and coronal T1-weighted imaging (b): a tumour flls the cavity of enlarged sella turcica and the lef half of the sphenoidal sinus, and has a suprasellar growth with invasion of the lef cavernous sinus. Along with the isointensive signal of the tumour a hyperintensive focus of haemorrhage is seen in the lef half of it Fig. The tumour tumour is isointensive to brain tissue; cystic components are hypoin- is revealed, which flls the cavity of the enlarged sella turcica, and tensive. The node on the upper pole of the tumour displaced the optic chiasm upwards 560 Chapter 6 Fig. Т2-weighted images (а,b) and Т1-weighted images (c) show a large and extended tumour with su- pratentorial growth and invasion of the maxillary sinus the chiasmal–sellar region. The bulk of the tumour lies within the cavity of Neuroimaging fndings depend on the type and anatomic the third ventricle; the pituitary stalk and the pituitary tis- variant of a tumour. X-ray craniography reveals typical signs sue remain intact under these circumstances. Laminar calcif- wider expansion, penetration into the ventricular system, and cations are frequent, which are usually situated in the tumour development of hydrocephalus, ofen obstructive. In some cases, arteries follow crease in size, deepening of the bottom, widening of the entry, the tumour capsule and supply it with blood, in other cases, and deformity (thinning, lifing, shortening) of the anterior arteries that are located within the tumour stroma take part in clinoid processes. Calcifcations are usually found within the the tumour and the adjacent structures blood supply, and in cavity of sella and above it. Typical features of this variant are polymorphism of sutures, and changes in the sella turcica elements. Calcifcations are usually located in the chiasmal and ad- mic fuid in the thin-walled cysts, or brownish-green, fritter- jacent regions. Teir viscous consistency includes a good deal of their sizes and location, and the condition of the ventricular cholesterol, detritus, and fats. Growing upwards, the tumour flls the region of mour invades the posterior cranial fossa, the brainstem. The chiasmal cisterns (partially or completely), with upward dis- extent of these symptoms and their sequence of their develop- placement of the bottom of the third ventricle. Calcifcation of irregular shape is located above the anterior clinoid process of the sella turcica Fig. Sometimes cystic tumours are represented located in the third ventricle cavity, they penetrate into the by a system of cysts, which are hardly diferentiated and may lateral ventricles, and ofen reach giant sizes. Cysts are hypodensive; many calcifcations of diferent size are inside their walls.
Massive cutaneous T-cell lymphoma involving both eyelids with multiple lesions on face order accutane online now acne jawline. There was no recurrence and no evidence of systemic apy and was treated with systemic chemotherapy purchase cheap accutane line acne 37 weeks pregnant. Solitary extramedullary plasmacytoma is a primary lesion that tends to be locally invasive buy accutane 30 mg with amex acneorg, but does not often metastasize. Secondary plasmacytoma, on the other hand, is a manifestation of multiple myeloma, which is a malig- nant systemic plasma cell neoplasm, affecting primarily bones. Multiple myeloma is a more aggressive neoplasm and tends to exhibit systemic metastasis. Both the primary plasmacytoma and multiple myeloma can rarely occur in the choroid, orbit, or eyelid (1–11). Clinical Features Plasmacytoma of the eyelid appears as a smooth, circum- scribed, violaceous mass involving the dermis and sometimes the epidermis. It may be indistinguishable clinically from lym- phoma or other subcutaneous tumors. Pathology Cutaneous plasmacytoma is a densely cellular nodule com- posed of a monomorphous inﬁltrate or plasma cells that can range from benign to malignant. Management Management is excisional biopsy when the lesion is localized and amenable to resection (8). The tumor is sensitive to irra- diation and chemotherapy and these modalities are used for unresectable lesions or those associated with multiple myeloma. Presumed malignant plasmacy- toma of the choroid as the ﬁrst manifestation of multiple myeloma. Chapter 9 Eyelid Lymphoid, Plasmacytic, and Metastatic Tumors 167 ■ Eyelid Plasmacytoma Figure 9. In one series of 240 malignant eyelid tumors, metastasis accounted for 3 cases (1). In a review of 30 cases of eyelid metastasis, the primary location was breast in 10 cases, cutaneous melanoma in 7 cases, lung in 5 cases, and stomach in 1 case, with indi- vidual examples from colon, thyroid, parotid and trachea (2). Rarely, other primary tumors, including renal cell carcinoma (6), esophageal leiomyosarcoma (11), neuroendocrine carci- noma (13), and prostate cancer (14) can metastasize to the eyelid. As is the case for uveal metastasis, eyelid metastasis is probably more common than believed, but many are not noted clinically because they occur in patients with extensive metastases. The subject of eyelid metastasis has been reviewed by Sassani and associates and a number of references were provided (8). Clinical Features Clinically, eyelid metastasis usually presents as a solitary sub- cutaneous nodule that simulates a chalazion. In contrast to chalazion, however, it usually has fewer inﬂammatory signs and shows more progressive enlargement and eventual ulceration. In addition, most patients have a history of prior cancer and many have known metastatic disease when they develop the eyelid mass. Metastatic breast cancer to the eyelid, in particu- lar, can often be diffuse and ill-deﬁned, suggesting an inﬂam- matory process such as blepharitis (9). We have seen patients in whom an eyelid metastasis was the ﬁrst sign of dissemination of choroidal melanoma (4). Pathology The histopathologic ﬁndings with eyelid metastasis vary with the primary tumor and the degree of differentiation of the metastatic focus. Some lesions, like melanoma (4), breast cancer (5), or renal cell carcinoma (6) have characteristic features. Breast cancer metastasis can sometimes have a his- tiocytoid appearance, thus making the diagnosis difficult (5,9,10). Primary mucinous carcinoma of sweat gland origin can have an almost identical histopathologic appearance. In some instances, the eyelid metastasis is so poorly differenti- ated that the primary neoplasm cannot be determined based on microscopic appearance alone. Management In addition to management of the primary neoplasm, the eye- lid metastasis may need speciﬁc management. Larger lesions may require a punch biopsy or shaving biopsy to conﬁrm the diagnosis. Needle biopsy can be performed, but it generally yields less tissue, making diagnosis more difﬁcult. If the patient is receiving speciﬁc chemotherapy for the pri- mary malignancy, an eyelid metastasis can be observed to assess the response to chemotherapy. Radiotherapy can be employed for cases that are not easily resectable and that are not responding to chemotherapy or other systemic treatment. Chapter 9 Eyelid Lymphoid, Plasmacytic, and Metastatic Tumors 169 Selected References 1. Leiomyosarcoma of the esophagus metastatic to the eyelid: a clinicopathologic report. Histopathology of metastatic prostate cancer from patient metastatic prostate cancer. Biopsy of the eyelid tumor led to the diagnosis and malignant cells with clear cytoplasm, characteristic of renal cell subsequent evaluation disclosed an occult renal neoplasm. Management should include evaluation of the tumorous proportions, it is called a xanthoma. Xanthelasma affected patient for various hyperlipidemias and Erdheim- tends to be bilateral and more common in the elderly. The wound can be closed with normolipemic, about 50% of them have essential hyperlipi- sutures or allowed to heal by secondary intention (16). Others have of one or more elevated nodules that are usually located in the advocated topical 100% bichloracetic acid (18). One case results have also been obtained by using a carbon dioxide of multiple bilateral eyelid tumors was initially believed to laser to vaporize the lesions (15, 21). In addition, affected patients should be treated patients who experience a rapid rise in serum triglyceride lev- medically for elevated serum lipids. In some cases, these lesions can become very large treatment alone brings about resolution of xanthelasma (26). Affected patients are believed to be at higher risk of death from cardiovascular disease (4). Xanthelasma is also seen with greater frequency in patients with the Erdheim- Chester disease, an idiopathic condition characterized by lipid deposition in bones, heart, retroperitoneum, and orbit (12–14). Clinical Features Clinically, xanthelasma appears as one or more, ﬂat or mini- mally elevated, yellow, placoid lesions that affect the loose skin of the eyelids, more commonly on the medial aspect of the eyelids. It is often bilateral and sym- metrical, and can sometimes slowly enlarge and coalesce to form large, raised, plaquelike, or nodular lesions. When a xan- thelasma becomes elevated and nodular, it is more properly called a tuberous xanthoma (7–11). Pathology Microscopically, xanthelasma and xanthoma are forms of lipoma that consist of an inﬁltration of the superﬁcial reticular dermis by foamy histiocytes.
Many drugs used in blood pressure and occasionally other cardiovascular prob- childhood psychiatric illness are not properly tested in lems discount accutane skin care 9. In children height (in general) to have safety tests in children subsequent to should also be monitored to assess growth effective accutane 10 mg skin care shiseido. Some drugs are deemed not to instant release formulations can be abused and some have have adequate risk:benefit ratios in children cheap accutane 5mg online skin care in 30s, e. It is thought to act by increasing noradrenaline/norepinephrine Summary and dopamine availability in the frontal cortex (where do- Table 20. Theyalsohave arolein treatmentresistant social anxiety disorder and some evidence supports the use of pregabalin in other anxiety disorders. They delay the onset of severe illness but cannot ultimately halt or change the course of the disease. Second-line treatment options include clonidine and the antipsychotic agents, risperidone, haloperidol and sulpiride. Second-generation versus first- based guidelines for treating statement on posttraumatic stress generation antipsychotic drugs for depressive disorders with disorder from the International schizophrenia: a meta-analysis. Lancet antidepressants: a revision of the 2000 Consensus Group on Depression 373 (9657), 31–41. Treatment of International Consensus Group on disorder: revised second edition – depression in children and Depression and Anxiety. The days) does not in itself qualify as epilepsy, since these sei- treatments of other common neurological disorders zures may have been due to a febrile illness or drug intox- are covered in other sections: namely: headaches (Pain ication that themselves later resolve. Only one-third of people other neurological disorders, including: movement having seizures develop chronic epilepsy. The other half A seizure is a clinical symptom or sign caused by abnormal of adult epilepsy is due to acquired causes, such as alcohol, electrical discharges within the cerebral cortex. Because of its unusual manifestations epilepsy intercession from Saint Valentine to relieve their condition. Wilson J V K, Reynolds E H 1990 more than one Saint Valentine and it is unclear whether he was also Medical History 34:192. Conversely, Practical guide to antiepilepsy drugs where focal brain injury has occurred, e. Following a single seizure the chance discharges occur within the brain leading to a partial sei- of a further seizure is approximately 25% over the zure – i. Importantly, partial seizures can majority of first seizures are provoked by a reversible, propagate very quickly to become a ‘secondary generalised and often recognisable, factor, e. For these reasons, following a single ilepsy is maldevelopment of the medial temporal lobes seizure6 anticonvulsants are not generally prescribed, (‘mesial temporal sclerosis’) believed to be due to injury, whereas after two or more distinct seizure episodes (i. Although the choice of anticonvulsants is • Educate the patient about the disease, duration of large (approximately 20), first-line therapy is generally treatment and need for compliance. As the number of • For most cases with recurrent seizures, an antiepileptic single anticonvulsants tried increases, the incremental drug is prescribed with subsequent monitoring and likelihood that any new one will offer a significant adjustment of dosage or drug type (see below). For example, few minutes, rectal or buccal diazepam or intranasal carbamazepine is an effective first-line therapy for partial seizures but may worsen primary generalised, 4 absence or myoclonic seizures; similarly phenytoin can So-called ‘primary’ or ‘idiopathic’ generalised epilepsies that reflect the fact that the specific cause is usually undetermined, although presumed to be developmental (e. Ethosuximide, Dosage and administration by contrast, is only effective in primary generalised, and The manner in which drug dosing is initiated depends on: not partial, seizures. Phenytoin and phenobarbital seizure types allowing for more confidence of use allow for a rapid loading (within 24 h); valproate, levetir- even when seizure type is uncertain. Thus sodium acetam and oxcarbazepine allow for escalation over days or valproate, lamotrigine and levetiracetam are active a few weeks, whilst lamotrigine and carbamazepine require against both primary and secondary generalised gradual escalations over many weeks. If seizures are infre- epilepsy, and being relatively well tolerated, account quenThat the time of presentation, e. In one head-to-head tiepileptics should generally be started at their lowest dose, study comparing popular first-line therapies for with small increments made every 1–2 weeks. In this way, generalised and partial seizures, lamotrigine was the risk of unwanted effects, especially dizziness or ‘feeling generally tolerated better than other drugs, while drunk’ are minimised. A slow introduction of lamotrigine valproate was the most efficacious; carbamazepine is also essential to reduce the risk of rash or more severe hy- and topiramate were more likely to cause unwanted 7 persensitivity reactions, Most drugs have a generally recog- effects. These range that achieves a reasonable degree of seizure control categories of patients prompt selection of particular should be established. Monitoring of blood concentrations drugs and avoidance of others (see below for more is helpful in guiding dosage of carbamazepine, phenytoin detail). Polytherapy offers mended maintenance dose range having been reached, the theoretical advantage of controlling neuronal there are numerous possible explanations: hyperexcitability by more than one mechanism, that Non-compliance, diarrhoea and vomiting, patients • can be synergistic. In reality, increasing polytherapy instructed to be ‘nil by mouth’ (revealed by measuring often adheres to the law of diminishing returns, viz. For years, it is reasonable to consider withdrawal of antiepi- example, in catamenial epilepsy, clobazam can be lepsy drug therapy. The toxicological hazard must be weighed against epilepsy, temporal or frontal lobe epilepsies often the risk of seizures which themselves can be harmful to require lifelong treatment. Discontinuing antiepilepsy medication is associated with Advance planning is preferred because: about 20% relapse during withdrawal and a further 20% • neural tube defects are related to deficiencies in folic relapse over the following 5 years; after this period re- acid stores before pregnancy, so that antiepileptic drugs lapse is unusual. In general, patients having Driving regulations and epilepsy seizures with blackouts should be on an effective dose Multiple driving regulations exist that relate epilepsy of an anticonvulsant, because of the risks of anoxia, (and neurological conditions predisposing to epilepsy, lactic acidosis and trauma. These rules are based upon statistical data relating lamotrigine before conception require a gradually in- specific diagnoses or clinically described events (e. Epileptic patients who wish to Secondly, enzyme-inducing drugs often aggravate a rela- continue driving therefore need to contact their national tive deficiency of vitamin K that occurs in final trimester driving licensing body so that each case can be judged women, predisposing to postpartum haemorrhage; vita- on its merits; while waiting for a decision, patients must min K is therefore given by mouth during the last 2 weeks not drive. Exceptions include: pa- Breast feeding tients who have had exclusively nocturnal seizures for at Antiepilepsy drugs pass into breast milk: phenobarbital, least 3 years, or patients in whom a single seizure has oc- primidone and ethosuximide in significant quantities, phe- curred more than 6 months earlier, providing they have nytoin and sodium valproate less so. Pregnancy and epilepsy Pregnancy worsens epilepsy in about a third of patients, 10Aswellasspinabifida,cleftpalates,cardiacandurogenitalanomaliesin but also improves epilepsy in another third. One of the the fetus, valproate during early pregnancy or pre-conception is main concerns in this patient group is that all anticonvul- associated with a particular dysmorphic appearance of the newborn (‘fetal valpraote syndrome’) characterised by wide, flat nasal bridge, sants increase the chance of teratogenicity slightly, with long philtrum, thin lip, widely spaced eyes (hypertelorism) and valproate, phenytoin and phenobarbital carrying most epicanthic folds. Treatment of seizures is initially with the intravenous benzodiazepine lorazepam Many antiepileptic drugs induce steroid-metabolising en- (0. Lorazepam is preferred to diazepam because it zymes and so can cause hormonal contraception to fail. The speed of action of these drugs and wishing to remain on the combined con- lorazepam and diazepam are both rapid. Subsequently a maintenance dose suboptimal level of contraception, and a non-oestrogenic of approximately 300 mg/day is given and adjusted accord- form of contraception is preferred. At this point, the level of sedation (due both to seizures and drugs) is usually sufficiently great to warrant general anaes- Epilepsy in children thesia, e. In some those used inadults,butcertain seizure types necessitate drugs cases, midazolam (nasally) may be preferred, e. Intravenous zures, or vigabatrin for refractory partial seizures (partly be- benzodiazepines should not be used if resuscitation facilities cause children may become irritable or more cognitively are unavailable as there is risk of respiratory arrest. Magnesium sulphate is the treat- will have only one attack, and in total only 2% will progress ment of choice for seizures related to eclampsia (see also to adult epilepsy. Febrile con- over 30 s, repeat if necessary, or diazepam vulsions may be prevented by treating febrile children with 10–20 mg over 2–4 min, repeat once after paracetamol and cooling with sponge soaks. It often arises in patients al- Refractory Thiopentalor propofolor midazolamwith full ready known to have epilepsy, in whom antiepileptic drug intensive care support therapy has been inappropriately withdrawn or not taken.