Book Review

Epilepsy: Scientific Foundations of Clinical Practice

N Engl J Med 2005; 352:738-739February 17, 2005

Article

Epilepsy: Scientific Foundations of Clinical Practice
(Neurological Disease and Therapy. Vol. 64.) Edited by Jong M. Rho, Raman Sankar, and José E. Cavazos. 510 pp., illustrated. New York, Marcel Dekker, 2004. $165. ISBN: 0-8247-5043-8

Progress in epilepsy research during the past several decades has advanced our understanding of the disease and greatly expanded our choice of treatments. Research in molecular and cellular biology has improved our understanding of the pathologic changes that ensue during a latent period, eventually giving rise to seizures. This understanding, in turn, has served as the basis for the development of effective therapies. Despite exciting scientific discoveries, however, there is a disconnect between bench research and clinical practice. For the most part, the clinical-practice aspect remains largely empirical in the general neurology community.

There is no question that the types of therapeutic options for epilepsy have increased during the past several decades. However, epilepsy is a very heterogeneous disorder; its variants share only one fundamental cellular similarity — neuronal hyperexcitability — and hypersynchrony. Thus, treatment has to be tailored to the specific epilepsy syndrome and type of seizure. For that reason, effective seizure management requires an understanding of pathogenesis and mechanisms of the various epilepsy syndromes and seizure types, and Epilepsy: Scientific Foundations of Clinical Practice is a much-needed textbook. It attempts to integrate data regarding the most relevant developments in research with those regarding clinical issues that have a direct effect on therapeutics. The book achieves this goal by reviewing current therapies and discussing new areas of research and treatment. Much of what is discussed provides a good review for not only the epilepsy community but also for general neurologists.

As is desirable in any book about treatment, this one begins with a discussion of basic anatomical and functional substrates of the genesis of seizures, mechanisms of drug resistance, and status epilepticus. From there, the book delves into various treatments and diagnostic tests. Since at least 16 antiepileptic drugs are available in the United States, choosing one is not straightforward. Not all drugs are equal for all seizure types and epilepsy syndromes. In addition, epilepsy is a chronic disease, often coexisting with other illnesses. The various cytochrome P-450 enzyme systems make it challenging to understand drug interactions. This book provides a concise, mechanistic review of the drugs, summarizing their metabolic pathways and their effects on the hepatic enzyme systems.

In addition, for patients whose epilepsy is difficult to control with drugs, surgery is now often considered, owing to advances in structural and functional neuroimaging that have improved both the selection of patients and the clinical outcomes. In the area of neuroimaging, the book provides a good update, with a particularly excellent discussion of the means of enhancing visualization by magnetic resonance imaging. The book also offers the medical community a glimpse of treatment methods on the horizon, such as nonsurgical ablation techniques and deep-brain stimulation.

Perhaps the most exciting discussion in the book concerns the future of epilepsy research and treatment. Clinicians and researchers in the field have long recognized that since current medical treatment is limited to preventing seizures from recurring, drugs for treating such conditions are more aptly called anticonvulsant or antiepileptic agents. However, such drugs do very little to prevent the development of epilepsy. An ambitious goal undertaken by epilepsy researchers in the past decade has been to pursue a cure for the disease. The final chapter, by Philip Schwartzkroin, eloquently summarizes the current status of epilepsy research and identifies challenges for the future. Although such goals may have seemed far-reaching a decade ago, the findings and ideas presented here make the concept of antiepileptogenesis appear to be an attainable goal.

Teresa Tran, M.D.
MINCEP Epilepsy Care, Minneapolis, MN 55416