Book Review

The Epilepsies: Etiologies and prevention

N Engl J Med 1999; 340:1932June 17, 1999

Article

The Epilepsies: Etiologies and prevention
Edited by Prakash Kotagal and Hans O. Lüders. 587 pp., illustrated. San Diego, Calif., Academic Press, 1999. $159.95. ISBN: 0-12-422150-5

Up to 5 percent of the general population will have seizures during their lifetimes, and in half of those epilepsy will develop. About 1 of every 200 people has medically uncontrolled epilepsy.

Epilepsy substantially disrupts the lives of those it affects, far beyond the time lost to the seizures. Patients with uncontrolled epilepsy lose their driving privileges — a grave imposition in today's wheel-bound society. They are often underemployed, working in occupations in which their seizures can be hidden from an alarmed public. Persons with epilepsy have gradually overcome historical prohibitions against marriage or child rearing, yet many prejudices remain in the community. Even patients themselves can become housebound out of fear of the always threatening possibility of unexpected seizures. Epilepsy and seizures arise from a wide variety of underlying disorders. The many varied causes are reviewed in The Epilepsies, along with the most recent insights into the mechanisms by which seizures are generated.

New surgical and medical treatments are also discussed in the book. Modern advances have brought to the marketplace a host of new adjunctive agents with which practitioners should become familiar. In addition, surgical therapy for epilepsy has now become a standard treatment option for patients in whom medical treatment has failed. Surgical therapy can be extraordinarily successful, even allowing patients with medically refractory epilepsy to throw away their medicine bottles, once and for all cured. In another new development, stimulation of the vagus nerve at the neck can substantially improve seizure control in certain patients, a phenomenon that remains poorly understood. In fact, vagal pacemakers are now implanted in some patients.

Research in epilepsy remains a fascinating adventure in understanding the mechanisms of brain function through the study of ties to hallucinations, amnesia, and other traditionally recognized manifestations of disrupted functions of the mind. Epilepsy can provide a window for understanding some cognitive processes in new ways. The chapters in The Epilepsies that describe research into the causes of this disorder help to elucidate specific pathologic mechanisms in which the mind, the brain, and epilepsy intersect through nature's misadventures. The study of surgery for epilepsy likewise provides opportunities for monitoring, measuring, and understanding brain function. Chapters in The Epilepsies define and set forth many such examples.

Seizures may be due to defects in cellular migration during brain development, neuronal death in limbic structures due to excitotoxins, or more common conditions such as infection, trauma, tumors, ischemia, and metabolic derangements. The mechanisms by which these various disorders produce seizures and epilepsy are described in this book for the curious practitioner.

It is disturbing that a substantial portion of patients with “epilepsy” do not actually have that disorder but, rather, have psychogenic pseudoseizures. Somatoform disorders mimic many epilepsies so closely that practitioners may misdiagnose the condition on the basis of confusing or misleading elements of a patient's presentation. In some centers, as many as 30 percent of referred patients actually have pseudoseizures rather than epilepsy. Assisting in the diagnosis, however, are several new monitoring techniques that can capture electrical brain discharges and videotape behavior. In addition, physicians at epilepsy specialty centers may use positron-emission tomography and magnetic resonance spectroscopy for detecting focal neuronal loss, which localizes an epileptogenic area in preoperative evaluations.

Members of special teams at such centers include not only neurologists but also psychiatrists, neuropsychologists, clinical nurse specialists, occupational therapists, social workers, and research scientists. These teams hope to bring the treatment of epilepsy out of the era of intractability, community prejudice, disability, and underemployment and into the era of more deliberate diagnosis, focused intervention, medical and surgical treatment, and improved lifestyle. The Epilepsies shows how far this field has come. Practitioners interested in the journey should take heart from this book and its many superb chapters, illustrations, and examples.

Marc R. Nuwer, M.D., Ph.D.
UCLA School of Medicine, Los Angeles, CA 90095-8353