A word is added here concerning neuromuscular paralysis and continuous EEG monitoring in status epilepticus. With failure of aggressive anticonvulsant and anesthetic treatment, there may be a temptation to paralyze all muscular activity, an effect easily attained with drugs such as pancuronium, while neglecting the underlying seizures. The use of neuromuscular blocking drugs without a concomitant attempt to suppress seizure activity is inadvisable. If such measures are undertaken, continuous or frequent intermittent EEG monitoring is essential; this may also be also helpful in the early stages of status epilepticus in that it guides the dosages of anticonvulsants required to suppress the seizures.
In the related but less-serious condition of acute repetitive seizures, in which the patient awakens between convulsions, a diazepam gel, which is well absorbed if given rectally, is available and has been found useful in institutional and home care of epileptic patients, although it is quite expensive. A similar effect has been attained by the nasal or buccal (transmucosal) administration of midazolam, which is absorbed from these sites (5 mg/mL, 0.2 mg/kg nasally; 2 mL to 10 mg buccally). Midazolam may be preferred among the diazepines for transmucosal use because it produces somewhat less respiratory depression than the others in the class and has been more effective at controlling seizures according to a study by McIntyre and colleagues. Still, only half were controlled. These approaches have found their main use in children with frequent seizures who live in supervised environments, where a nurse or parent is available to administer the medication.
Absence status should be managed by intravenous lorazepam, valproic acid, or both, followed by ethosuximide. Nonconvulsive generalized status is treated along the lines of grand mal status, usually stopping short of using anesthetic agents (see Meierkord and Holtkamp). In the case of epilepsia partialis continua, typically a difficult condition to control, a balance must be found between stopping the phenomenon and the risk of overuse of medications that can produce stupor. The patient must be involved by way of determining how troubling the movements are to him.
Surgical Treatment of Epilepsy
The surgical excision of epileptic foci that have not responded to intensive and prolonged medical therapy is being used with increasing effectiveness. At these centers, it has been estimated that approximately 25 percent of all patients with epilepsy are candidates for surgical therapy and more than half of these may benefit from extirpation of the epileptic cortical focus. With increasing experience and standardized approaches, especially in patients with temporal lobe epilepsy, it has been suggested that many patients are waiting too long before the surgical option is employed. A perspective that may promote surgery in even further is the observation that approximately 60 percent of patients with focal seizures will respond to a conventional anticonvulsant, but that among the remainder, few will respond to the addition of a second or third drug.
However, considerable effort, time and technology are required to determine the site of epileptic discharge and the method of safe removal of the cortical tissue. To locate the discharging focus requires a careful analysis of clinical, imaging, and EEG findings, often including those obtained by long-term video/EEG monitoring and, sometimes, intracranial EEG recording by means of intraparenchymal depth electrodes, subdural strip electrodes, and subdural grids. Recently, functional imaging, magnetoencephalography, and specialized EEG analysis have been introduced to supplement these methods.