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Introduction: It is unclear which patients with non-traumatic (spontaneous) intracerebral haemorrhage (ICH) are at risk of developing acute symptomatic seizures (provoked seizures occurring within the first week after stroke onset; early seizures, ES) and whether ES predispose to the occurrence of remote symptomatic seizures (unprovoked seizures occurring more than 1 week after stroke; post-stroke epilepsy, PSE) and long-term mortality., Patients and Methods: In the setting of the Multicenter Study on Cerebral Haemorrhage in Italy (MUCH-Italy) we examined the risk of ES and whether they predict the occurrence of PSE and all-cause mortality in a cohort of patients with first-ever spontaneous ICH and no previous history of epilepsy, consecutively hospitalized in 12 Italian neurological centers from 2002 to 2014., Results: Among 2570 patients (mean age, 73.4 ± 12.5 years; males, 55.4%) 228 (8.9%) had acute ES (183 (7.1%) short seizures and 45 (1.8%) status epilepticus (SE)). Lobar location of the hematoma (OR, 1.49; 95% CI, 1.06-2.08) was independently associated with the occurrence of ES. Of the 2,037 patients who were followed-up (median follow-up time, 68.0 months (25th-75th percentile, 77.0)), 155 (7.6%) developed PSE. ES (aHR, 2.34; 95% CI, 1.42-3.85), especially when presenting as short seizures (aHR, 2.35; 95% CI, 1.38-4.00) were associated to PSE occurrence. Unlike short seizures, SE was an independent predictor of all-cause mortality (aHR, 1.50; 95% CI, 1.005-2.26)., Discussion and Conclusion: The long-term risk of PSE and death after an ICH vary according to ES subtype. This might have implications for the design of future clinical trials targeting post-ICH epileptic seizures., Competing Interests: Declaration of conflicting interestThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Dr Ciccone reports grants from Daiichi-Sankyo; grants from Italfarmaco; and grants from Alexion Pharmaceuticals.Dr Paciaroni reports compensation from SANOFI-AVENTIS U.S. LLC for other services; compensation from PFIZER CANADA INC for other services; compensation from iRhythm Technologies for other services; compensation from Daiichi Sankyo Europe GmbH for other services; and compensation from Bristol-Myers Squibb for other services.The other Authors have nothing to disclose.

Younger adults with epilepsy have an increased mortality. Some deaths are seizure-related, for example, sudden unexpected death in epilepsy (SUDEP), whereas others, for example, suicide, have multiple causes, including adverse effects of the treatment on mood. In this retrospective population-based study of all Danish persons with epilepsy aged 18 to 49 years during 2007 to 2009 we evaluated the risk of death from seizures and suicide. SUDEP comprised 82.7% of all seizure-related death. Younger adults with epilepsy had an 8.3-fold increased risk of death from seizure-related causes compared with suicide. This underpins the importance of effective seizure control in preventing premature death. ANN NEUROL 2021;90:983-987., (© 2021 American Neurological Association.)

Objective: The aim of the study is to examine the incidence and risk factors for death among neonates who developed neonatal seizures (NS) in an ethnically distinctive community with high consanguinity rate in Israel., Methods: Retrospective study was conducted at a single institution on data between January 2001 and January 2016. All neonates diagnosed with NS developed up to age 28 days were included. Mortality was defined as death within the first year of life., Results: Of all 69,460 neonates born during the study period, 118 (1.7 per 1,000 live births) developed NS; 35 (29.7%) died within the first year while 83 (70.3%) survived. The leading causes of death were developmental brain malformation (31.4%), genetic/metabolic (20%), hypoxic ischemic encephalopathy (20%), intracranial hemorrhage (11.4%) and infections (11.4%). Any consanguinity between the parents was found in 18 and 14.6% among the survivors and deceased groups, respectively ( p  = 0.24). Developmental brain malformations that lead to death were present in 3.6 and 31.4% in the survivors and deceased groups, respectively ( p  = 0.001; relative risk 8.70; 95% confidence interval 2.58-29.27). Stepwise backward logistic regression analysis revealed that developmental brain malformations ( p  < 0.0001), use of more than one antiepileptic medication ( p  = 0.006), and multiorgan failure ( p  = 0.004) were significant risk factors that predicted death., Conclusion: The results of the current study show that developmental brain malformations that cause NS were the leading risk factor for death., Competing Interests: All authors have indicated they have no potential conflicts of interest to disclose., (Thieme. All rights reserved.)

Objective: To investigate the hypothesis that patients diagnosed with psychogenic nonepileptic seizures (PNES) on video-EEG monitoring (VEM) have increased mortality by comparison to the general population., Methods: This retrospective cohort study included patients evaluated in VEM units of 3 tertiary hospitals in Melbourne, Australia, between January 1, 1995, and December 31, 2015. Diagnosis was based on consensus opinion of experienced epileptologists and neuropsychiatrists at each hospital. Mortality was determined in patients diagnosed with PNES, epilepsy, or both conditions by linkage to the Australian National Death Index. Lifetime history of psychiatric disorders in PNES was determined from formal neuropsychiatric reports., Results: A total of 5,508 patients underwent VEM. A total of 674 (12.2%) were diagnosed with PNES, 3064 (55.6%) with epilepsy, 175 (3.2%) with both conditions, and 1,595 (29.0%) received other diagnoses or had no diagnosis made. The standardized mortality ratio (SMR) of patients diagnosed with PNES was 2.5 (95% confidence interval [CI] 2.0-3.3). Those younger than 30 had an 8-fold higher risk of death (95% CI 3.4-19.8). Direct comparison revealed no significant difference in mortality rate between diagnostic groups. Among deaths in patients diagnosed with PNES (n = 55), external causes contributed 18%, with 20% of deaths in those younger than 50 years attributed to suicide, and "epilepsy" was recorded as the cause of death in 24%., Conclusions: Patients diagnosed with PNES have a SMR 2.5 times above the general population, dying at a rate comparable to those with drug-resistant epilepsy. This emphasizes the importance of prompt diagnosis, identification of risk factors, and implementation of appropriate strategies to prevent potential avoidable deaths., (© 2020 American Academy of Neurology.)

With the exponential development of mobile health technologies over the past ten years, there has been a growing interest in the potential applications in the field of epilepsy, and specifically for seizure detection. Better detection of seizures is probably one of the best ways to improve patient safety. Overall, we are observing an exponential increase in the number of non-EEG based seizure detection systems and a progressive homogenization of their evaluation procedures. Most importantly, the properties of these devices for detection of tonic-clonic seizures are now very interesting, both in terms of sensitivity and in terms of false-alarm rates. Accordingly, we might expect that these be used in clinical practice in the near future, especially in patients at high risk of seizure-related injuries or sudden unexpected death in epilepsy (SUDEP)., (Copyright © 2020 Elsevier Masson SAS. All rights reserved.)

Sudden unexpected death in epilepsy (SUDEP) is a tragic condition and, despite varied risk levels among the population with epilepsy, is the cause of significant premature mortality. In the last 20 years, though awareness of SUDEP has increased among epilepsy professionals, little has changed with regard to the death rates per se, in rates of informing people with epilepsy (PWE) of their person-centered SUDEP risks, or in the awareness levels of nonepilepsy clinicians, such as, primary care practitioners and hospital doctors. The challenges to make aware and inform PWE have been multifold, in particular, 'when', 'what', and 'how' to tell about SUDEP. Current guidance recognizes that to improve SUDEP rates, it is important to engage proactively with PWE. There is a need to bring shared responsibility between clinicians and PWE to help mitigate the risk of SUDEP. To enable this, a meaningful evidence-based person-centered conversation is essential. The SUDEP and Seizure Safety Checklist ("Checklist") was created to facilitate this. This paper showcases the background, concept, development, implementation, feasibility and validity studies undertaken, challenges, barriers, and limitations of the eight-year Checklist project, which has moved from a single clinic to an international presence. It outlines the need to further reform SUDEP risk communication recognizing the differences between a basic risk message at time of diagnosis as advocated by current good practice guidance and the need for a more person-centered discussion on a regular basis for which the Checklist can be a key catalyst. This article is part of the Special Issue "Prevent 21: SUDEP Summit - Time to Listen"., Competing Interests: Declaration of Competing Interest RS and BNMcL have received institutional and research support and personal fees from LivaNova, UCB, Eisai, Special Products, Bial, and Desitin outside the submitted work., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: To understand the association of seizure frequency with healthcare resource utilisation (HCRU) and mortality in UK children with epilepsy (CWE)., Design: Retrospective cohort study., Setting: Routinely collected data in primary care from The Health Improvement Network UK database., Patients: CWE ≥1 and<18 years of age with a record of seizure frequency were included in mortality analyses from 2005 to 2015 and HCRU analyses from 2010 to 2015., Main Outcome Measures: Frequency of HCRU contacts during the year following latest seizure frequency and mortality (descriptive and Cox proportional hazards regression) from first record of seizure frequency., Results: Higher seizure frequency was related to increased HCRU utilisation and mortality. In negative binomial regression, each category increase in seizure frequency related to 11% more visits to general practitioners, 35% more inpatient admissions, 15% more outpatient visits and increased direct HCRU costs (24%). 11 patients died during 12 490 patient-years follow-up. The unadjusted HR of mortality per higher category of seizure frequency was 2.56 (95% CI: 1.52 to 4.31). Adjustment for age and number of prescribed anti-epileptic drugs at index attenuated this estimate to 2.11 (95% CI: 1.24 to 3.60)., Conclusion: Higher seizure frequency is associated with greater HCRU and mortality in CWE in the UK. Improvement in seizure control may potentially lead to better patient outcomes and reduced healthcare use., Competing Interests: Competing interests: The authors declared the following potential conflicts of interest with respect to the research, authorship and/or publication of this article. RC has received honoraria and study participation fees from Eisai Inc. BB, MM and SP were employees of IQVIA at the time of study conduct. IQVIA received funding from Eisai Inc to conduct the study. WT was an employee of Eisai Inc at the time of study conduct. The lead author affirms that the manuscript is an honest, accurate and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Stranded California sea lions considered unable to survive in the wild are often placed in public display facilities. Exposure to the biotoxin domoic acid (DA) is a common cause of stranding, and chronic effects are observed long after initial exposure. Medical records for 171 sea lions placed in US institutions between 2000 and 2016 were reviewed, including results from clinical examinations, histopathology, behavioural testing and advanced imaging. There was a statistically significant increase in neurological disease detected in neonates (24%) compared with other age classes (11%). Sixty per cent of all neurological cases died during the study period. In the 11 neurological neonate cases, six died (55%) and five are still alive with three of five developing epilepsy during placement. Of the six neurological neonate cases that died, one was attributed to DA toxicosis, one to seizures and four to acute unexplained neurological disease. This survey suggests delayed neurological disease can develop in sea lions after stranding as neonates. These data coupled with stranding records and epidemiological data on DA-producing algal blooms suggest further research into effects of neonatal exposure to DA on risk of neurological disease in later life is warranted. California sea lions offer a natural model of DA exposure to study such effects., Competing Interests: Competing interests: None declared., (© British Veterinary Association 2019. Re-use permitted under CC BY-NC. No commercial re-use. Published by BMJ.)

Introduction: The objective of the study was to identify where epilepsy or seizures may be the underlying cause of death but not identified by the death certification process in the Australian coronial system and to better characterize such deaths., Methods: Australian National Coronial Information System (NCIS) closed cases for the Australian Capital Territory (ACT) (population average 348,000) over 13 years were searched using cause of death, and a text search of police and autopsy reports, to identify all deaths where epilepsy or seizures were mentioned. Deaths where the underlying cause of death was not seizures or epilepsy were excluded (including suicide). The remaining cases (75) were categorized by the circumstances of death. Suspected sudden unexpected death in epilepsy (SUDEP) cases were further classified using the unified definition of SUDEP of Nashef and colleagues (2012)., Results: Of the final 75 cases, only 44 were found by the cause of death search. Key word document searches found another 31. Cases were classified as Definite SUDEP (37), Definite SUDEP Plus (10), Probable SUDEP (1), Possible SUDEP (3), Near SUDEP (4), Near SUDEP Plus (1), Asphyxia (3), Treatment-related (1), Head injury (2), Drowning (2), motor vehicle accident (MVA) (1), deaths related to a single convulsive seizure (6), and status epilepticus (SE) (4). Cases were 80% male., Conclusions: Epilepsy and seizure-related deaths are underreported in the Australian Coronial system. Enhanced documentation of the causal chain of events leading to deaths would increase recognition. Using the unified SUDEP definition would expand SUDEP identification., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Acute symptomatic seizures are a common sign of neurological dysfunction and brain injury in neonates and occur in approximately one to three per 1000 live births. Seizures in neonates are usually a sign of underlying brain injury and, as such, are commonly associated with adverse outcomes. Neurological morbidities in survivors often co-occur; epilepsy, cerebral palsy, and intellectual disability often occur together in the most severely affected children. Risk factors for adverse outcome include prematurity, low Apgar scores, low pH on the first day of life, seizure onset <24 or >72 h after birth, abnormal neonatal neurological examination, abnormal neonatal electroencephalographic background, status epilepticus, and presence and pattern of brain injury (particularly deep gray or brainstem injury). Despite this list of potential indicators, accurate prediction of outcome in a given child remains challenging. There is great need for long-term, multicenter studies to examine risk factors for, and pathogenesis of, adverse outcomes following acute symptomatic seizures in neonates., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Background: There is evidence that the sudden unexpected death in epilepsy (SUDEP) risk can be reduced by good seizure control, nocturnal supervision, and by early cardiopulmonary resuscitation if cardiorespiratory arrest occurs in the aftermaths of generalized tonic-clonic seizures (GTCS). These measures, however, may critically depend on the knowledge of patients and relatives on SUDEP. Here, we assessed the basic knowledge on SUDEP of people with epilepsy at a tertiary epilepsy center in Germany., Methods: Adult patients with epilepsy and relatives or caregivers of patients with epilepsy aged 16years or older attending our outpatient clinic from January to March 2014 were given the opportunity to participate in a (assisted or unassisted) written survey. In the anonymized questionnaire, people were asked if they had already heard about SUDEP, by what means and if they wish to learn (more) about SUDEP. Furthermore, age, sex, epilepsy duration, highest degree of education, number of GTCS during the last year, and estimation of subjective impairment by their disease were assessed. Statistics were done using mixed linear or logistic regression models., Results: A total of 372 patients' questionnaires were included in this survey. More than 87% of the participants had never heard of SUDEP before. Whereas about 50% of the participants wanted to learn more about SUDEP, about 40% did not. Only the age at survey was significantly associated with both being informed and the desire of learning more about SUDEP: Younger patients had more often heard (p=0.022) and wanted to know more about SUDEP (p=0.020). Thirty-nine patients were considered at high risk for SUDEP. Of these, only 6 patients (15%) knew about SUDEP prior to this survey, but 18 patients (46%) wanted to learn more about this fatal complication., Conclusion: Our data suggest that the level of information on SUDEP among people with epilepsy is poor in Germany regardless of sex, school education, or epilepsy severity. Additionally, a considerable proportion of people with epilepsy seems to prefer not getting detailed information on SUDEP. More efforts are required to understand the potential barriers of the education of patients and relatives on sudden death with the ultimate goal of decreasing the risk of SUDEP., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: To determine the definite and potential frequency of seizures and epilepsy as a cause of death (COD) and how often this goes unrecognized., Methods: Prospective determination of seizures or epilepsy and final COD for individuals aged 18-90 years with out-of-hospital sudden cardiac deaths (SCDs) from the population-based San Francisco POST SCD Study. We compared prospective seizure or epilepsy diagnosis and final COD as adjudicated by a multidisciplinary committee (pathologists, electrophysiologists, and a vascular neurologist) vs retrospective adjudication by 2 epileptologists with expertise in seizure-related mortality., Results: Of 541 SCDs identified during the 37-month study period (mean age 62.8 years, 69% men), 525 (97%) were autopsied; 39/525 (7.4%) had seizures or epilepsy (mean age: 58 years, range: 27-92; 67% men), comprising 17% of 231 nonarrhythmic sudden deaths. The multidisciplinary team identified 15 cases of epilepsy, 6 sudden unexpected deaths in epilepsy (SUDEPs), and no deaths related to acute symptomatic seizures. The epileptologists identified 25 cases of epilepsy and 8 definite SUDEPs, 10 possible SUDEPs, and 5 potential cases of acute symptomatic seizures as a COD., Conclusions: Among the 25 patients identified with epilepsy by the epileptologists, they found definite or possible SUDEP in 72% (18/25) vs 24% (6/25) by the multidisciplinary group (6/15 cases they identified with epilepsy). The epileptologists identified acute symptomatic seizures as a potential COD in 5/14 patients with alcohol-related seizures. Epilepsy is underdiagnosed among decedents. Among patients with seizures and epilepsy who die suddenly, seizures and SUDEP often go unrecognized as a potential or definite COD., (© 2017 American Academy of Neurology.)

Purpose: To observe risk factors for recurrence after withdrawal from antiepileptic drugs., Methods: We assessed 1282 patients with a definite diagnosis of epilepsy., Results: In total, 292 patients between 14 and 80 years of age were grouped according to risk factors for recurrence. Of these individuals, 119 discontinued AED(s) and relapsed. The relapse rate was 34.4 per 100 person-years. We used a Cox regression for multivariate analysis to investigate the influence of the following on seizure recurrence: receiving more than one type of AED (HR = 2.53, 95% CI 1.24-5.16) and more than 6 months prior to initiation of AED treatment (HR 1.47, 95% CI = 1.004-2.15)., Conclusions: Although the decision to discontinue AED treatment necessitates an individual evaluation of each patient, our study suggests that there may be a high risk of recurrence in individuals who: were receiving more than one AEDs and had initiated their AED treatment more than 6 months after the initial appearance of epilepsy symptoms.

People with epilepsy have increased risk of premature death, and their life expectancy may reduce by 2-10 yr. Population- and hospital-based studies have shown that the excess mortality in epilepsy is not entirely explained by deaths directly attributable to epilepsy such as accidents and drowning during a seizure. It is also significantly contributed by deaths from other causes such as cardiac deaths, deaths due to malignancies and other causes. It had recently been recognized that sudden unexpected deaths in epilepsy (SUDEP) contributed to a small yet important proportion of mortality in epilepsy. SUDEPs are deaths (witnessed or unwitnessed) unrelated to trauma, drowning or status epilepticus and not attributable to any specific medical conditions. Several factors related to epilepsy and drug therapy have been found to be associated with higher risk of SUDEP.

Purpose: Our objective was to determine the significance of PGES as a possible EEG marker of increased risk for SUDEP and explore factors that influence PGES., Methods: We identified 17 patients who died due to definite or probable SUDEP and 52 living control patients with drug resistant focal epilepsy who underwent EEG monitoring and least one seizure recorded on EEG. We reviewed 305 seizures on EEG and when available, on video, for presence or absence of PGES, the duration of PGES immediately after seizure end, seizure type, state seizure occurred (sleep vs. wake), tonic duration and time from seizure onset to initial nursing intervention. We noted that majority (93% in SUDEP group and 83% living controls) with PGES had additional brief bursts of suppression. We measured the time from the end of seizure to end of last brief suppression to determine the time to final PGES., Results: SUDEP patients had statistically significant shorter PGES duration compared to living controls (unadjusted: -32.8s, 95%CI[-54.5, -11.2], adjusted: -39.5s, 95% CI[-59.4, -19.6]). SUDEP status was associated with longer time to final PGES compare to living controls, but this was not statistically significant. Earlier nursing intervention was associated with shorter seizure duration. PGES occurred only after GCS. Time to nursing intervention, tonic duration or state did not have a statistically significant effect on PGES., Conclusions: PGES is an equivocal marker of increased SUDEP risk. Earlier nursing intervention is associated with shorter seizure duration and may play a role in reducing risk of SUDEP., (Copyright © 2017 British Epilepsy Association. Published by Elsevier Ltd. All rights reserved.)

Introduction: The prognostic value of seizures in patients with glioblastoma is currently under discussion. The objective of this research was to study the risk factors associated with seizures occurring at the diagnosis of glioblastoma and the role of seizures as a predictive factor for survival., Material and Methods: We prospectively analyzed the clinical data over the course of the disease, baseline MR imaging, and histological characteristics (p53 overexpression, the Ki67 proliferation index, and presence of the IDH1 R132H mutation), in glioblastomas treated in a single hospital from November 2012 to July 2014. The study follow-up cutoff point was October 2015., Results: In total, 56 patients were recruited (57% men, mean age 57 years). Median baseline score on the Karnofsky performance scale was 80. Complete tumor debulking followed by radiochemotherapy was achieved in 58.9%. Mean survival was 13.6 months. Epileptic seizures were the presenting symptom in 26.6% of patients, and 44.6% experienced seizures at some point during the course of the disease. On multivariate analysis, the single factor predicting shorter survival was age older than 60 years (hazard ratio 3.565 (95%CI, 1.491-8.522), p=0.004). Seizures were associated with longer survival only in patients younger than 60 years (p=0.035). Younger age, the IDH1 R132H mutation, and p53 overexpression (>40%) were related to seizures at presentation. Baseline MRI findings, including tumor size, and the Ki67 proliferation index were not associated with the risk of epileptic seizures or with survival. Prophylactic antiepileptic drugs did not increase survival time., Conclusions: Seizures as the presenting symptom of glioblastoma predicted longer survival in adults younger than 60 years. The IDH1 R132H mutation and p53 overexpression (>40%) were associated with seizures at presentation. Seizures showed no relationship with the tumor size or proliferation parameters., (Copyright © 2016 Elsevier B.V. All rights reserved.)

Background: Decompressive hemicraniectomy (DHC) is a life-saving procedure for treatment of large malignant middle cerebral artery (MCA) strokes. Post-stroke epilepsy is an additional burden for these patients, but its incidence and the risk factors for its development have been poorly investigated., Objective: To report the prevalence and risk factors for post-stroke seizures and post-stroke epilepsy after DHC for treatment of large malignant MCA strokes in a cohort of 36 patients., Methods: In a retrospective cohort study of 36 patients we report the timing and incidence of post-stroke epilepsy. We analyzed if age, sex, vascular risk factors, side of ischemia, reperfusion therapy, stroke etiology, extension of stroke, hemorrhagic transformation, ECASS scores, National Institutes of Health Stroke Scale (NIHSS) scores, or modified Rankin scores were risk factors for seizure or epilepsy after DHC for treatment of large MCA strokes., Results: The mean patient follow-up time was 1,086 days (SD = 1,172). Out of 36 patients, 9 (25.0%) died before being discharged. After 1 year, a total of 11 patients (30.6%) had died, but 22 (61.1%) of them had a modified Rankin score ≤4. Thirteen patients (36.1%) developed seizures within the first week after stroke. Seizures occurred in 22 (61.1%) of 36 patients (95% CI = 45.17-77.03%). Out of 34 patients who survived the acute period, 19 (55.9%) developed epilepsy after MCA infarcts and DHC (95% CI = 39.21-72.59%). In this study, no significant differences were observed between the patients who developed seizures or epilepsy and those who remained free of seizures or epilepsy regarding age, sex, side of stroke, presence of the clinical risk factors studied, hemorrhagic transformation, time of craniectomy, and Rankin score after 1 year of stroke., Conclusion: The incidence of seizures and epilepsy after malignant MCA infarcts submitted to DHC might be very high. Seizure might occur precociously in patients who are not submitted to anticonvulsant prophylaxis. The large stroke volume and the large cortical ischemic area seem to be the main risk factors for seizure or epilepsy development in this subtype of stroke.
., (© 2017 The Author(s)
. Published by S. Karger AG, Basel.)

Objectives: We investigated long-term (to 25 years) seizure prognosis and survival in people with newly diagnosed epilepsy in the community. We explored whether prognosis is different in those with epilepsy (>2 unprovoked seizures) and those with a single seizure at presentation., Methods: This is a prospective observational cohort study of people with newly diagnosed seizures. We investigated seizure outcome and survival in people presenting with a single seizure and in those presenting with >2 seizures (epilepsy)., Results: 695 people (median follow-up 23.6 years) had unprovoked epileptic seizures. For seizure analysis we excluded 38 people with missing data leaving 657 (309 male, and 249 aged <18 years). Seizures recurred in 67%. The 354 people with epilepsy were only slightly more likely to have further seizure recurrence than the 302 people with a single seizure at presentation (HR 1.32, 95% CI 1.09 to 1.59). In 327 people with complete follow-up, 268 (82%, 95% CI 77% to 86%) were in terminal remission; (80%, (95% CI 73% to 85%) in those with epilepsy at presentation). Premature mortality was increased in people with epilepsy (standardised mortality ratio 1.67; 95% CI 1.40 to 1.99) and those with a single seizure at presentation (standardised mortality ratio 2.65; 95% CI 2.23 to 3.15). It is also high in those with early remission., Conclusions: People with epilepsy and with single seizures at presentation in the community generally have good prognosis for seizure control with prolonged follow-up. The risk of premature mortality is significantly increased in both groups., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Objectives: "Long-term epilepsy associated tumors (LEATs)" by definition are tumors primarily causing drug-resistant seizures for two years or more. They include low-grade glial and glioneuronal tumors with normal life expectancy. We studied a large cohort of patients with LEATs who underwent surgery through our epilepsy program., Patients & Methods: From 1998-2011, 105 patients with LEATs underwent surgery in our center. We utilized their data archived in a prospective registry to evaluate their electro-clinical-imaging characteristics affecting the long-term seizure outcome., Results: Of 105 patients (age 3-50 years), mean age at surgery was 20 years and mean pre-surgical duration of epilepsy was 10.9 years. 66 (62.8%) had secondary generalized seizures. 82 had temporal tumors, 23 had extra temporal (13 frontal, 3 parietal, 2 occipital and 5 multilobar lesions) and four had associated hippocampal sclerosis. The interictal discharges and ictal onset were concordant to the lesion in 82 (78%) and 98 (93%) patients respectively. Lesionectomy and/or adjoining corticectomy or temporal lobectomy was done. Ganglioglioma was the most dominant pathological substrate in 61 (58%). During a mean follow-up of 7.5 years (range 3-16 years), 78/105 (74.2%) were seizure-free and 45 (57.4%) were totally off drugs. Secondary generalized seizures (p-0.02), temporal location of tumor (p-0.008) and spikes in third month post-operative EEG (p-0.03) caused unfavorable seizure outcome. A pre-surgical duration of epilepsy of more than 6.6 years caused less than optimal surgical outcome, Conclusions: Early surgery should be considered a priority in LEATs. Presence of secondary generalized seizures is the single most important predictor of a poor seizure outcome., (Copyright © 2015 Elsevier B.V. All rights reserved.)

Seizures are common events in children and up to 10% of all children experience at least one seizure during their childhood. They can be triggered by many conditions such as fever, medications or injury. Febrile seizures are the most common types of seizures, affecting 3-4% of children. While epilepsy is typically recurrent and unprovoked, a single, isolated seizure is not epilepsy. Taking a detailed history of the seizure description helps establish the diagnosis. A video recording of the event can also support the diagnosis and rule out non-epileptic seizures that resemble seizures, such as pseudo-seizure. Seeing a child having a seizure, particularly if it is the first one, is usually frightening and distressing for the parents. First seizure should always be evaluated by health professionals because of a possible serious underlying cause. If the seizure occurs at home, the child should be placed in the recovery side position to prevent the swallowing of any vomit. The care of a child who does have epilepsy is best achieved by a community or hospital epilepsy specialist nurse. These nurses play a pivotal role in providing a close link between the epileptic children and their families. Such a nurse is also in an ideal position to establish a link between the doctor and affected families, offering valuable advice and support, and visiting the epileptic child at home.

Neonatal seizures are the most common manifestation of neurological disorders in the newborn period and an important determinant of outcome. Overall, for babies born at full term, mortality following seizures has improved in the last decade, typical current mortality rates being 10% (range: 7-16%), down from 33% in reports from the 1990s. By contrast, the prevalence of adverse neurodevelopmental sequelae remains relatively stable, typically 46% (range: 27-55%). The strongest predictors of outcome are the underlying cause, together with the background electroencephalographic activity. In preterm babies, for whom the outlook tends to be worse as background mortality and disability are high, seizures are frequently associated with serious underlying brain injury and therefore subsequent impairments. When attempting to define the prognosis for a baby with neonatal seizures, we propose a pathway involving history, examination, and careful consideration of all available results (ideally including brain magnetic resonance imaging) and the response to treatment before synthesizing the best estimate of risk to be conveyed to the family., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Importance: Seizures are believed to be common presenting symptoms in neonates and children with spontaneous intracerebral hemorrhage (ICH). However, few data are available on the epidemiology of acute symptomatic seizures or the risk for later epilepsy., Objective: To define the incidence of and explore risk factors for seizures and epilepsy in children with spontaneous ICH. Our a priori hypotheses were that younger age at presentation, cortical involvement of ICH, acute symptomatic seizures after presentation, ICH due to vascular malformation, and elevated intracranial pressure requiring urgent intervention would predict remote symptomatic seizures and epilepsy., Design: Prospective cohort study conducted between March 1, 2007, and January 1, 2012., Setting: Three tertiary care pediatric hospitals., Participants: Seventy-three pediatric subjects with spontaneous ICH including 20 perinatal (≥37 weeks' gestation to 28 days) and 53 childhood subjects (>28 days to <18 years at presentation)., Main Outcome Measures: Acute symptomatic seizures (clinically evident and electrographic-only seizures within 7 days), remote symptomatic seizures, and epilepsy., Results: Acute symptomatic seizures occurred in 35 subjects (48%). Acute symptomatic seizures as a presenting symptom of ICH occurred in 12 perinatal (60%) and 19 childhood (36%) subjects (P = .07). Acute symptomatic seizures after presentation occurred in 7 children. Electrographic-only seizures were present in 9 of 32 subjects (28%) with continuous electroencephalogram monitoring. One-year and 2-year remote symptomatic seizure-free survival rates were 82% (95% CI, 68-90) and 67% (95% CI, 46-82), respectively. One-year and 2-year epilepsy-free survival rates were 96% (95% CI, 83-99) and 87% (95% CI, 65-95), respectively. Elevated intracranial pressure requiring acute intervention was a risk factor for seizures after presentation (P = .01; Fisher exact test), remote symptomatic seizures, and epilepsy (P = .03, and P = .04, respectively; log-rank test)., Conclusions and Relevance: Presenting seizures are common in perinatal and childhood ICH. Continuous electroencephalography may detect electrographic seizures in some subjects. Single remote symptomatic seizures occur in many, and development of epilepsy is estimated to occur in 13% of patients at 2 years. Elevated intracranial pressure requiring acute intervention is a risk factor for acute seizures after presentation, remote symptomatic seizures, and epilepsy.

Seizures and intracranial hemorrhage are possible medical diseases that any obstetrician may encounter. This article reviews the cause, treatment, and medical management in pregnancy for seizures and intracranial hemorrhage, and how the two can overlap into preeclampsia or eclampsia. This article also highlights some challenging management issues from the obstetrician's perspective., (Copyright © 2013. Published by Elsevier Inc.)

Sudden unexpected death in epilepsy (SUDEP) is the most important direct epilepsy-related cause of death. Patients with refractory epilepsy are at especially high risk of SUDEP. SUDEP occurs predominantly at night and unwitnessed, and can best be regarded as a fatal tonic-clonic seizure. While its pathophysiology is incompletely understood, SUDEP is most probably triggered by a number of predisposing and precipitating factors, including seizure-induced respiratory depression and cardiac arrhythmia. Achieving seizure freedom is the best way to prevent SUDEP. Nocturnal supervision may be another alternative preventive strategy, but this requires further research.

Background: To explore the association of clinical seizure pattern with the long-term prognosis after epilepsy surgery is important for patient counseling and risk management., Objective: To study the long-term mortality after surgery of intractable epilepsy patients with a novel classification of clinical patterns by long-term frequency and duration of seizure compared with the Engel classification., Methods: We conducted a longitudinal cohort study by enrolling 280 patients with epilepsy who underwent anterior temporal lobectomy between 1987 and 2002. In addition to the Engel classification, we proposed a novel classification of clinical patterns pertaining to at least 1 year of follow-up of the frequency and duration of seizures after surgery (inactive, delayed, intermittent, and intensive groups). We followed the vital status of these members until 2007 to obtain a 15-year survival rate for each classification. The standardized mortality ratio and hazard ratios with proportional hazards regression model by the extent of severity were estimated., Results: The overall 15-year survival rate for patients who underwent anterior temporal lobectomy was 95.1%. The standardized mortality ratio estimates (95% confidence interval) for our classification showed a gradient relationship from 0.6 (0.1-2.3), 2.5 (0.7-6.3), 7.6 (0.8-27.3), and 8.9 (3.2-19.3) for inactive, delayed, intermittent, and intensive groups, respectively (Trend test, P = .04), whereas the corresponding estimates were 0.8 (0.2-2.2), 5.9 (1.2-17.2), 6.7 (2.5-14.7), and 7.2 (0.8-25.9) for Engel I to IV, respectively, which showed a less increasing trend (Trend test, P = .82). Similar findings were noted for hazard ratios for the 2 classifications., Conclusion: The proposed novel classification with long-term observed frequency and duration of seizures after surgery is more informative for predicting long-term mortality than the Engel classification.

Purpose: This study aims to study death records mentioning epilepsy, epileptic seizures and/or status epilepticus, in order to survey the population demographics and associated medical conditions, making it possible to outline the patient's profile., Methods: A qualitative analysis was performed on the data gathered from death certificates from the Curitiba county records ranging from 1998 to 2007 bracket, in which epilepsy, seizure and/or status epilepticus were mentioned as the basic, intermediate, immediate or associated cause of death., Results: Epilepsy was mentioned on 621 death cases in this 10-year-period. The deaths were mainly of male individuals (57.3%), Caucasian (71.6%), single (48.6%) and aged between 20 and 60 years (51.8%). Most of those who died were hospitalized patients (62.5%) and in 64.3% of the reported deaths, the patient received medical care during the event that led to his/her death. Epilepsy itself was considered to be the cause of death in 44%, followed by status epilepticus (9.7%). The most common intermediary and immediate causes were pulmonary infections (11.1%) and cardiac arrest (19.2%), respectively, Discussion: Hospitalized younger Caucasian males with epilepsy were the most common cases in this 10-year-period survey. Pulmonary infections were a common finding, but other aspects such as previous trauma, cerebrovascular disease or neoplasm were eventual associated factors. Public health and medical preventative measures can be planned based on the results of this study., (Copyright © 2011 British Epilepsy Association. Published by Elsevier Ltd. All rights reserved.)

Objective: To identify independent prognostic indicators and design a predictive scoring system for neurodevelopmental outcome for term infants who experienced clinical neonatal seizures., Study Design: Retrospective analysis of 120 term infants who experienced clinical neonatal seizures between July 1991 and June 2007 in a single academic pediatric neurology practice. Logistic regression analysis was applied to determine the independent prognostic indicators of an adverse outcome, which was defined as death, cerebral palsy, global developmental delay, and/or epilepsy. These indicators were then used to develop a scoring system., Results: A total of 53 infants had a normal outcome, 56 survived with one or more neurodevelopmental impairments (31 had cerebral palsy, 41 had global developmental delay, and 29 had epilepsy), and 11 died. Eleven variables were associated with adverse outcome on univariate analysis, but only method of delivery, time of seizure onset, seizure type, EEG background findings, and etiology were independent predictors on logistic regression analysis. A five-point scoring system was devised using these independent predictors with a sensitivity of 81.1% and a specificity of 84.0%., Conclusions: In term infants, delivery via cesarean section, experiencing a seizure during the first 24 h of life, presenting with a seizure other than focal clonic, showing a moderately or severely abnormal EEG background, and having certain specific etiologies were the apparent major determinants for an adverse outcome., (Copyright © 2010. Published by Elsevier Ltd.)

Sudden unexpected death in epilepsy (SUDEP) is a significant cause of mortality in people with epilepsy. Two postulated causes for SUDEP, cardiac and respiratory depression, can both be explained by overstimulation of adenosine receptors. We hypothesized that SUDEP is a consequence of a surge in adenosine as a result of prolonged seizures combined with deficient adenosine clearance; consequently, blockade of adenosine receptors should prevent SUDEP. Here we induced impaired adenosine clearance in adult mice by pharmacologic inhibition of the adenosine-removing enzymes, adenosine kinase and deaminase. Combination of impaired adenosine clearance with kainic acid-induced seizures triggered sudden death in all animals. Most importantly, the adenosine receptor antagonist caffeine, when given after seizure onset, increased survival from 23.75 +/- 1.35 min to 54.86 +/- 6.59 min (p < 0.01). Our data indicate that SUDEP is due to overactivation of adenosine receptors and that caffeine treatment after seizure onset might be beneficial.

Purpose: To compare mortality and subsequent unprovoked seizure risk in a population-based study of acute symptomatic seizure and first unprovoked seizure due to static brain lesions., Methods: We ascertained all first episodes of acute symptomatic seizure and unprovoked seizure due to central nervous system (CNS) infection, stroke, and traumatic brain injury (TBI). Subjects were residents of Rochester, Minnesota, identified through the Rochester Epidemiology Project's records-linkage system between 1/1/55 and 12/31/84. Information was collected on age, gender, seizure type, etiology, status epilepticus (SE), 30-day and 10-year mortality, and subsequent episodes of unprovoked seizure., Results: Two hundred sixty-two individuals experienced a first acute symptomatic seizure and 148 individuals experienced a first unprovoked seizure, all due to static brain lesions. Individuals with a first acute symptomatic seizure were 8.9 times more likely to die within 30 days compared to those with a first unprovoked seizure [95% confidence intervals (CI) = 3.5-22.5] after adjustment for age, gender, and SE. Among 30-day survivors, the risk of 10-year mortality did not differ. Over the 10-year period, individuals with a first acute symptomatic seizure were 80% less likely to experience a subsequent unprovoked seizure compared with individuals with a first unprovoked seizure [adjusted rate ratio (RR) = 0.2, 95% CI = 0.2-0.4]., Discussion: The prognosis of first acute symptomatic seizures differs from that of first unprovoked seizure when the etiology is stroke, TBI, and CNS infection. Acute symptomatic seizures have a higher early mortality and a lower risk for subsequent unprovoked seizure. These differences argue against the inclusion of acute symptomatic seizures as epilepsy.

Sudden unexplained death in epilepsy is rare in children, and few studies report risk factors. We reviewed our experience with 17 cases of sudden unexplained death in epilepsy to determine risk factors in children. The charts of all patients with onset of epilepsy at less than age 18 years who suffered sudden unexplained death in epilepsy between August 1992 and April 2004 at our epilepsy center were retrospectively reviewed. Deaths were classified as possible, probable, or definite sudden unexplained death in epilepsy. There were seven cases of definite, nine cases of probable, and one case of possible sudden unexplained death in epilepsy. Generalized tonic-clonic seizures and prone position during sleep were found to be major risk factors. Sudden unexplained death in epilepsy in children and adolescents is associated with convulsive seizures, and aggressive treatment of nocturnal generalized tonic-clonic seizures might help lower the occurrence.

It is not unusual for the primary care provider to have a child present with unusual paroxysmal events or dermatological lesions that bear further investigation. Although most children with epilepsy are treated and managed by pediatric neurologists, it is imperative that the primary care provider have a clear understanding of associated comorbidities, as well as information on the available anti-epileptic drugs, their side effects, and the need for further monitoring. Those children with epilepsy whose seizures become intractable, failing to be controlled with three or more medications used appropriately at adequate doses, should be referred to a comprehensive epilepsy center for consideration for other treatments. These may include the ketogenic diet, vagal nerve stimulation, or epilepsy surgery.

The administration of neurotoxin thiolactone homocysteine in rats with cobalt-induced epileptogenic focus in the sensomotor cortical region led to the development of secondary generalized convulsions and epileptic state. The pattern was analogous to the manifestation of convulsions in epileptic state in humans. Fenitoin (50 mg/kg) inhibited the development of convulsions, arrested the epileptic state, reduced the number and duration of the secondary generalized tonic--clonic attacks, decreased the behavioral manifestations (focal convulsions, lateral position etc.), normalized EEG, and prevented fatal outcome. An increase in the fenitoin dose to 100 mg/kg decreased the antiepileptic activity, enhanced side effects, and increased the lethality in test animals.

Mortality in pediatric epilepsy is the subject of this review. Epilepsy in both adults and children increases the risk of premature death. Conditions that are comorbid with epilepsy may carry an increased mortality risk. Patients with neurologic compromise may be at risk for aspiration and critical respiratory disease. Epilepsy per se enhances the risks of accidents, particularly drowning. Epilepsy may result in unwitnessed or, less frequently, witnessed sudden death. Witnessed sudden death frequently involves an observed seizure. Cardiac and respiratory mechanisms for epileptic sudden death have been proposed. Reducing the number of seizures should reduce the risk for sudden death. Awareness of the increased risk for premature death associated with epilepsy may enhance patients' and parents' cooperation with therapy.

Background: The historically higher incidence of seizures in children has changed, the elderly now have a higher incidence than any age-group, 2-3 times of that found in children. Classical teachings on etiologies, clinical presentation and progression of seizures are based on observations of a younger population and need to be revised in view of features unique to this age-group. The findings of two large VA cooperative studies show that even in sophisticated medical environments, up to 30% of patients 60 years and older with recurrent partial seizures go undiagnosed for more than 1 year of seizure onset., Objective: (a) To characterize the manifestations of auras, seizures and postictal states in the elderly and the relevance of various etiologies to these presentations. (b) To identify and discuss factors that contribute to the difficulties in the diagnosis of seizures in this population., Methods: A review of our experience in treating a large population of elderly patients in a university epilepsy center and a review of the literature relating to the problem., Conclusions: Seizures in the elderly are both overdiagnosed and underdiagnosed: either situation can have serious adverse consequences. Diversity of etiologies and atypical presentations make recognition of seizures difficult. Histories are frequently inadequate: complaints of multiple physical symptoms confuse the picture, unwillingness of elderly patients to admit to problems they believe are physiological in nature by the fear others may think they are 'losing their mind' and high staff turnover result in erratic identification of problems. The significant morbidity and mortality associated with poorly controlled seizures in this population are in large part preventable since excellent response to treatment can be achieved in more than 80% of individuals. The correct diagnosis of seizures is more likely if both physician and patients are familiar with the nuances of epilepsy in the elderly., (Copyright 1999 S. Karger AG, Basel)

Purpose: Few population-based studies of long-term survival in people with seizures or epilepsy have been made., Methods: Between January 1, 1960 and December 31, 1964, we identified 224 incidence cases of unprovoked seizures in Iceland and determined survivorship status and date of death for the cases as of January 1, 1996. We compared survivorship with that expected based on data from age-/sex-specific life tables from the country for 1961-1990 and calculated the standardized mortality ratio (SMR)., Results: By 30 years after diagnosis, there were 45 deaths among patients with unprovoked seizures as compared with an expected 28 deaths [standardized mortality ratio (SMR) 1.6; 95% confidence interval (CI) 1.2-2.2]. Patients with unprovoked seizures of unknown etiology did not have a significant increase in mortality overall (SMR 1.3, 95% CI 0.8-1.9) or in any time interval. For patients with remote symptomatic unprovoked seizures, mortality was increased (SMR 2.3, 95% CI 1.4-3.5). This increase was attributable to excess mortality for the first 15 years after diagnosis (SMR 4.1, 95% CI 2.4-6.6), and SMR was not different after that time., Conclusions: Survivorship was decreased for the population of patients with unprovoked seizures. The increased mortality was primarily due to excess mortality in patients with remote symptomatic seizures, occurring in the first 15 years after diagnosis. Overall mortality for idiopathic unprovoked seizures was not significantly increased.

The clinical characteristics and prognosis of first ever seizures among the elderly (aged 65 years or more) were ascertained by following up a cohort of patients for 7 years. Twenty-three patients (mean age, 69.9 +/- 4.9 years) were registered in the Neurology Service between January 1988 and March 1989. Twelve patients had partial seizures with or without generalization. Three patients had status epilepticus, whereas ten had presented for single seizure. On presentation 61.9% patients had neurological deficits and 73.9% had one or more systemic disorder. Head computerized tomography scans were abnormal in 17 cases. Seizures were attributed to acute stroke (26.1%), trauma (8.7%), subdural haematoma, degenerative diseases of the brain, cerebral metastasis, or central nervous system infections. The cause was unknown in 43.5% cases. At the end of 7 years, follow-up was complete for 15 patients (65.2%). The mean duration of follow-up was 68.6 +/- 28.7 months. Eight (53.3%) patients had died. Nine patients (60%) had attained 2-year remission of which three remained seizure free throughout. Six of the seven living patients were continuing antiepileptic drugs treatment. Forty per cent of them were dependent on others for the activities of daily life.

Sudden death, often seizure related, may occur in patients with epilepsy. Population-based incidence is probably on the order of 1:1,000/year. The incidence is much higher in selected groups, however. We wished to establish the incidence of sudden unexpected death (SUD) in a young cohort with severe epilepsy and learning difficulties. The study cohort included 310 pupils with epilepsy enrolled at a special residential school between April 1970 and April 1993. The follow-up period totaling 4,135 person-years included a period of residence at the school as well as time after leaving. Age and sex standardized overall mortality ratio was 15.9 [95% confidence interval (CI) 10.6-23.0], with 20 of 28 deaths considered epilepsy related. An incidence of sudden death cases of 1:295/year was noted. All 14 sudden deaths occurred when the pupils were not under the close supervision of the school and most were unwitnessed, which has implications for prevention.

The outcome in 165 subjects with either an unknown (n = 93) or an alcohol-related (n = 72) seizure etiology, admitted to the emergency room of a general hospital in 1977-1978, was assessed after 10 years on the basis of subsequent hospital records and death-certificate-based mortality data. Alcohol and/or drug poisoning was the most frequent cause of death in the group with alcohol-related seizures. Sixty-four percent of the deaths in this group were directly related to alcohol abuse. The crude mortality was 45.8 (expected 8.6)/100 persons/10 years in the group with alcohol-related seizures and 15.1 (expected 6.0)/100 persons/10 years in the other group, the odds ratio between the groups being 4.8. Twenty percent of those with an unknown seizure etiology were found to show alcohol-related seizures, while the seizure etiology remained unknown in 59%, and a specific etiology other than alcohol abuse was revealed in 21% during the follow-up period. We conclude that alcohol abuse is an important, though often undetected, seizure etiology carrying a poor prognosis. The difference in mortality between the groups was due more to alcoholism than to seizures. There was no difference in mortality between those with a first alcohol-related seizure and those with previous alcohol-related seizures.

The brains of 14 elderly patients who died after status epilepticus were examined pathologically. Three of the 14 patients showed unilateral brain damage which corresponded to the side of the seizures, and the lesions were thought to be caused by seizures. In these three and two other patients, no causative lesion related to the seizures was found. In these five patients, status epilepticus occurred during theophylline therapy and thus the seizures in these five patients were assumed to be induced by theophylline. In the three patients with unilateral brain damage, the damage was seen in the hippocampus, amygdala and thalamus in two patients, while in the third, the whole hemisphere was damaged, including the hippocampus, amygdala, thalamus, basal ganglia and cerebral cortex. The distribution of pathological changes within the thalamus was described. It is suggested that the thalamus was primarily affected by seizures, rather than by secondary degeneration from the cortex.

We report 12 adults with seizures associated with serum theophylline levels between 14 and 35 mg/l. The seizures were frequently prolonged, and outcome was generally poor with eight deaths. Although we did not identify comparable control groups, possible risk factors for serious outcome in theophylline-associated seizures were age, previous brain injury or disease, severe pulmonary disease, and possibly low serum albumin level. In patients with these risk factors, serum theophylline levels should be maintained below 10 to 15 mg/l.

This article concerns seizure disorders that occurred in the medical examiners' population of Metropolitan Dade County between 1978 and 1982. These accounted for 2% of the natural and accidental manners of death. The percentage of males was more frequent than females, with an equal proportion of blacks and whites. The age distribution was half under age 40 and half over age 40. Alcohol abuse was common, although alcohol was absent at time of autopsy in at least 42.5%. Brain pathology and absence of seizure medicine are also discussed.

Over 200 children from a group of 628 were followed up after 25 years. The children were identified as having had at least one seizure. Particular attention was given to the long-term prognosis in relation to medical, social, and educational problems. Although nearly two-thirds of the sample suffered minimal ill-effects, the problems of the remainder were considerable. 10-1% had died. Of the survivors 11-2% were confined to institutions, and 6-6% were invalids at home. Just under a quarter had chronic epilepsy. While overall the educational achievement of the sample was good, there was also a considerable number of educational problems. Continuing epilepsy was associated with greatly reduced educational and occupational achievement compared with the group in remission. The study reveals the considerable cost of epilepsy to the community in both human and material terms. It also reveals why epilepsy is regarded as a frightening illness.