Complications
Particular anticonvulsants can worsen seizures.
Most commonly occurs when underlying syndrome is unknown or wrongly diagnosed and an inappropriate anticonvulsant is initiated.
Rarely occurs in correctly diagnosed and treated patients.
Developmental delay and intellectual disability in children with epilepsy may be due to drug toxicity, sociopsychological factors, status epilepticus, and continuous or long-lasting periods of epileptic activity detected on electroencephalogram without clinical seizures occurring in children with some syndromes (e.g., infantile epileptic spasms syndrome, Lennox-Gastaut syndrome) and epileptic encephalopathies.[3]
Neurodevelopmental conditions occur in many children with epilepsy, and attention, internalizing, and thought problems may be specific to epilepsy. ADHD is more prevalent among the pediatric epilepsy population than among children and adolescents without epilepsy. Improved early identification of children with epilepsy at risk for these conditions, evidence-based treatment, and multidisciplinary management strategies are required to optimize patient management.[178]
Mood disorders (e.g., depression, anxiety) are common among people with epilepsy and can negatively impact on seizure outcome and quality of life.[179][180]
Anticonvulsant drugs may be associated with a small increased risk of suicidal thoughts and behavior. People with epilepsy are also at higher risk of mood and anxiety disorders and suicidal ideation at the time of diagnosis, before starting anticonvulsant medications, and risk of suicide associated with these medications is much lower than the risk of harm due to stopping medications or not starting them.[48][49]
Patients should be monitored for mood disorders at each review, and referred for treatment as appropriate.[181] Evidence to inform choice of antidepressant and anticonvulsant drugs in people with epilepsy and depression is very limited.[182]
Status epilepticus is defined as either 5 minutes or more of continuous seizure activity, or two or more discrete seizures between which there is incomplete recovery of consciousness.[174]
Aim of treatment is to intervene at 5 minutes. Immediate transportation to a medical facility is essential.
Having an agreed written emergency care plan may significantly improve the outcome in case of prolonged or repeated seizures.
Benzodiazepines (buccal, rectal, intravenous, or intranasal, depending on drug used) are used first line to treat status epilepticus.[175][176] Intravenous phenytoin may also be used once the patient is hospitalized.
Sudden unexpected death (SUDEP) has been reported as the cause of death in 1 in 4500 children annually. The major risk factor for SUDEP is the occurrence of generalized tonic-clonic (GTCS) seizures, and the risk increases in association with increasing frequency of GTCS occurrence.[168]
Interventions to prevent SUDEP, such as nocturnal supervision (presence of an individual in the bedroom) or special precautions (regular checks throughout the night or the use of a listening device), have been associated with fewer deaths in people with epilepsy, but the evidence is of very low quality, and conclusions cannot be drawn.[177]
It is important to exclude long QT syndrome as a cause of seizures. There are other cardiac causes (e.g., Brugada syndrome or other genetic cardiac channelopathies) that could cause sudden death. Hence, if the clinical history is suggestive of a cardiac cause (e.g., seizures brought on by exertion, or if there is a family history of sudden death), then a cardiologist should be consulted.
Some epileptic syndromes may evolve into another syndrome regardless of the age of the patient and the type of epilepsy they initially have.[3]
For example, infantile epileptic spasms syndrome may evolve into Lennox-Gastaut syndrome, patients with myoclonic epilepsy in infancy may develop infrequent generalized tonic-clonic seizures, and childhood absence epilepsy may evolve into juvenile absence epilepsy or juvenile myoclonic epilepsy.
Certain anticonvulsants, including valproic acid, carbamazepine, phenobarbital, and phenytoin, as well as the presence of a homozygous 5-methylenetetrahydrofolate reductase polymorphism in the genotype, are potential causes of elevation in plasma homocysteine and serum lipoprotein concentrations. Persistent elevation of these biochemical markers has been shown to be associated with the development of long-term sequelae such as cardiovascular disease, prompting concerns about the long-term implications of chronic anticonvulsant use in children.[183]
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