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Hypocalcemia frequently complicates renal failure and acute pancreatitis (7), and may also occur along with vitamin D deficiency and renal tubular acidosis. Nutritional rickets is still reported, although rarely in the United States, occasionally with hypocalcemic seizures (18). Manifesting as spontaneous, irregular, repetitive action potentials that originate in peripheral nerves, tetany is sometimes confused with seizure activity. Latent tetany may be unmasked by hyperventilation or regional ischemia (Trousseau test). Hypomagnesemia Hypomagnesemia is associated with seizures, but usually only at levels lower than 0. Because a related hypocalcemia may be produced by a decrease in, or end-organ resistance to , circulating levels of parathyroid hormone, magnesium levels should be measured in the patient with hypocalcemia who does not respond to calcium supplementation. Convulsions are treated with intramuscular injections of 50% magnesium sulfate every 6 hours. Hypoparathyroidism Seizures occur in 30% to 70% of patients with hypoparathyroidism, usually along with tetany and hypocalcemia. Typically, thyrotoxicosis may be associated with nervousness, diaphoresis, heat intolerance, palpitations, tremor, and fatigue. Hashimoto thyroiditis often coexists with other autoimmune disorders (33), such as Hashimoto encephalopathy, a steroid-responsive relapsing condition (34) that produces seizures even in euthyroid patients (35). As many as 20% to 25% of patients with myxedemic coma have generalized convulsions. Patients with hypothyroidism may have obstructive sleep apnea (36) with hypoxic seizures (37). Adrenal Disorders Seizures are uncommon with adrenal insufficiency but may occur in patients with pheochromocytoma (38). More commonly, a pheochromocytoma-induced hypertensive crisis may trigger a hypertensive encephalopathy, characterized by altered mental status, focal neurologic signs and symptoms, and/or seizures. Other neurologic complications include stroke caused by cerebral infarction or an embolic event secondary to a mural thrombus from a dilated cardiomyopathy. Additional symptoms are tremor, nausea, anxiety, sense of impending doom, epigastric pain, flank pain, constipation or diarrhea, and weight loss. The treatment of renal failure may also lead to dialysis dysequilibrium, characterized by headache, nausea, and irritability, which may progress to seizures, coma, and death attributable to the entry of free water into the brain, with resultant edema. Renal transplant recipients may experience cerebrovascular disease, opportunistic infections, or malignant neoplasms, particularly primary lymphoma of the brain. In uremic patients with renal insufficiency, adverse reactions to antibiotics are a common cause of seizures (44). Hence, levels of a drug such as phenobarbital (40% to 60% protein bound) will decrease during dialysis more than will levels of valproic acid (80% to 95% bound). One way, albeit cumbersome, to avoid "losing" an agent is to dialyze against a dialysate containing the drug. Another option, if seizures occur near the time of dialysis, is to use a highly protein-bound drug, such as valproic acid. For special considerations in the kidney transplant patient, see "Transplantation and Seizures. Epileptic seizures occur in up to one fourth of patients with uremia, and the reasons are quite varied. In nonuremic patients, up to 10% of phenytoin is not protein bound, whereas in uremic patients, as much as 75% may not be protein bound. Thus, free phenytoin levels (between 1 and 2 g/mL) should be used instead of total phenytoin levels to assess therapeutic efficacy (40).

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These findings indirectly support another recent report that testosterone levels are perhaps a minor factor for sexual functioning in men with epilepsy, and that psychosocial factors are of greater importance (170). Change in sexuality was more likely to occur in women and in patients with right-sided resections. This lateralization of change in sexuality after surgery is consistent with a report by Herzog et al. These findings would suggest, therefore, that right temporal resection could improve sexual functioning. In a carefully performed questionnaire study of sexual functioning in men and women with either right or left temporal lobe epilepsy, Daniele et al. Ictal sexual behaviors and ictal orgasm have been specifically associated with right temporal epilepsy as well (173). There is also lateralization in the central regulation of gonadotropin secretion: experimental evidence indicates that the right hypothalamus is predominant in the control of reproductive functioning (174), although lateralized kindling has not clearly been shown to be associated with seizure differences in animal studies (175). Therefore, a body of evidence from divergent sources, both clinical- and laboratory-based, suggests that right-sided epilepsy and right temporal lobe epilepsy specifically may be associated with a risk of sexual and reproductive dysfunction. Evaluation and Treatment the difficult task of interviewing patients regarding their sexual functioning is simplified as follows, and adapted from a suggested interview developed by Bartlik et al. When you have sex or masturbate, what proportion of the time do you achieve orgasm Possible total scores range from 5 to 30, with the higher scores indicating more sexual dysfunction. Evaluation of sexual dysfunction should include consideration of the contribution of the following comedications associated with adverse sexual side effects: Antidepressants Antihypertensives Antipsychotics Chemotherapeutic agents Statins Diuretics Allergy meds Although evaluation and treatment of sexual dysfunction may be outside the realm of most neurologists, an initial laboratory evaluation would include the following serum levels: Klein et al. However, the women who had frequent seizures, occurring at least monthly, experienced earlier menopause, at age 46 to 47 years on average. Further, the survey assessed whether a history of a catamenial seizure pattern would influence this course (182). Thirty-nine perimenopausal women with epilepsy as defined by a recent change in menstrual pattern and the occurrence of "hot flushes" were evaluated (182). Nine subjects reported no change in seizures at perimenopause, five reported a decrease in seizure frequency, and the majority of women, 25, reported an increase. However, the cyclic progesterone elevation during the luteal phase of the menstrual cycle gradually becomes less frequent throughout perimenopause, resulting in increasing rates of anovulatory cycles (183). Therefore, the elevation of the estrogen-to-progesterone ratio may contribute to the increase in seizure frequency at perimenopause. Forty-two postmenopausal women with epilepsy as defined as 1 year without menses were evaluated (182). There the mainstays of treatment for sexual dysfunction, when obviously treatable causes and contributors such as thyroid disease or medication side effects have been ruled out, remain the phosphodiesterase inhibitors and testosterone replacement. These have only been proven effective for men, and phosphodiesterase inhibitors are only useful for improving erectile dysfunction but not libido or sexual desire, which is mediated largely by testosterone. While the phosphodiesterase inhibitors have been nearly miraculous for men with erectile dysfunction, they have not been reliably effective for women, but may be worth trying depending on the clinical situation. The use of aromatase inhibitors in men with epilepsy has been shown to increase testosterone levels and possibly improve seizures as well; however, this intervention remains incompletely explored (178). Testosterone is also important for libido, desire, and sexual functioning for women of both premenopausal and postmenopausal years. Testosterone replacement is often useful in women with low testosterone status and sexual dysfunction, and it is becoming more widely accepted as a treatment approach although long-term studies are lacking; the most frequent side effects for women are hirsutism and acne (179). One of the first scientific reports of early perimenopause was put forth by Chapter 44: Hormones, Catamenial Epilepsy, Sexual Function, and Reproductive Health in Epilepsy 551 was no overall directional change in seizure frequency within this group: 12 subjects reported no change in seizures at menopause, 17 reported a decrease in seizure frequency, and 13 reported an increase. A history of catamenial seizure pattern was significantly associated with a decrease in seizures at menopause (P 0. Further, these findings indicate that catamenial seizure pattern may be associated with seizure increase during perimenopause but seizure decrease after menopause, indicating that subsets of women with epilepsy are especially sensitive to endogenous hormonal changes.

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A mini-atlas of common epileptogenic lesions is displayed at the end of the chapter. The main focus of this section will be to review the anatomy relevant for the location of eloquent cortex, and temporal lobe anatomy, as temporal lobe epilepsy remains the most common surgically remediable epilepsy syndrome in most epilepsy centers. Eloquent cortex refers to areas of cerebral cortex that is indispensable for defined cortical function and whose damage leads to predictable pattern of neurologic deficits. Sylvian fissure has three major components: an anterior ascending and anterior horizontal rami, a central stem with its minor rami, and a posterior terminal ascending ramus. The central stem of the sylvian fissure is in relation to the inferior regions of motor and sensory cortex. In far lateral sagittal sections, the V or Y shaped anterior horizontal (anterior arm of V or Y) and anterior ascending rami (posterior arm of V or Y) of sylvian fissure can be identified. The sulcus that is superior and perpendicular to these anterior rami is the inferior frontal sulcus and the sulcus posterior and parallel to the anterior ascending rami of sylvian fissure denotes inferior precentral sulcus. In most cases, the anatomic location and extent of these otherwise benign lesions is more critical than the pathology itself. Anatomic location of the lesion is the chief determinant of the type of epilepsy syndrome. The extent of the lesion and its spatial relationship to eloquent areas of the brain has major implications for the surgical strategy. Inferior frontal gyrus consists of three regions, namely pars opercularis, pars triangularis, and pars orbitalis. Atypical locations of language area tend to occur when congenital or early acquired brain lesions are located in the vicinity of the presumptive language areas. These lesions may result in shift of the language areas to the perilesional regions or in extreme cases, to the contralateral homologous region of the brain. Central sulcus begins near the interhemispheric fissure and descends in a slight forward angle toward the sylvian fissure. Central sulcus is longer than other adjacent sulci and is least intersected by other sulci. Precentral sulcus is frequently discontinuous and intersected by superior and inferior frontal sulci on its course toward the sylvian fissure. The sagittally oriented superior frontal sulcus at its posterior end meets the coronally oriented precentral sulcus; the adjacent gyrus posterior to the precentral sulcus is the precentral gyrus. The right and left marginal sulci (the ascending terminal portion of the cingulate sulcus) on either side of the interhemispheric fissure produce an easily recognizable mustache-like image. Central sulcus is usually the first sulcus anterior to this marginal sulcus in most individuals. The hand motor area on precentral gyrus has an easily recognizable morphologic pattern in most individuals and can further aid in identification of precentral gyrus. The most common morphologic pattern described on axial image is the "inverted omega" or "knob" or "knuckle" like appearance, with its rounded knob abutting the central sulcus (12). Other morphologic patterns such as "horizontal epsilon" and "asymmetric horizontal epsilons" have been recognized (10,11). As described earlier, in far lateral sagittal images, at the anterior end of sylvian fissure, the anterior ascending rami of sylvian fissure can be identified. The sulcus Primary Motor Area: the Precentral Gyrus Surgery for epileptogenic lesions around the central sulcus pose special challenges due to the risk of motor deficits. A thorough knowledge of the anatomy of the central sulcus and precentral gyrus-the primary motor area, is crucial to localize the lesions around this region. Central sulcus and the precentral gyrus are best identified on the axial and sagittal images. A: T2-weighted image shows a cavernoma at the junction of right superior frontal gyrus and precentral gyrus. C, D: A cystic lesion in the precentral gyrus over the lateral convexity displayed in axial and sagittal planes. Central sulcus lies posterior and parallel to the precentral sulcus and it usually does not unite with the sylvian fissure unlike the precentral sulcus.

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Thus, changes in therapy should be made slowly with careful clinical monitoring (38). In addition to behavioral and cognitive adverse effects, drug interactions can result in cumulative toxic reactions. Complicating the reduction in polypharmacy is the belief that any change in medication will exacerbate seizure frequency. In one study of 244 mentally retarded patients with epilepsy who were followed up for 10 years, monotherapy could be increased in 36. Barbiturates and benzodiazepines have a long association with rebound or withdrawal seizures; stability may return when these drugs are replaced (37). High doses of antidepressants have been linked to increased incidences of seizures in clinical trials (52): bupropion 2. Psychostimulants and the new agent, atomoxetine, appear unlikely to exacerbate seizures, but the subject is controversial (53); use of these agents in the management of attentional disorders and hyperactivity is not contraindicated (41,53). The physician treating a patient with multiple handicaps must appreciate this potential unwanted effect. Bone health, contracture formation, weight regulation, gastrointestinal disturbances, gynecologic concerns, and drug interactions affect not only the treatment of epilepsy but also medications prescribed for other comorbidities (44,46). Increased irritability or changes in behavior may often be the only sign of significant abnormality in this group. A careful assessment of all comorbid conditions must be part of the intake evaluation, which should include the natural history of the epilepsy and previous treatment. New-onset seizures or seizures that have changed in type or intensity warrant a complete evaluation. Similarly, management of comorbidities besides epilepsy will greatly improve the total outcome and quality of life. Understanding the difficulties in diagnosis and treatment of individuals with multiple handicaps and the inter-relationship between epilepsy and comorbidities and their treatments is essential. Initiating and discontinuing antiepileptic drugs in children with neurologic handicaps and epilepsy. Practice parameter: screening and diagnosis of autism: report for the Quality Standards Subcommittee of the American Academy of Neurology and the Child Neurology Society. Risk of autistic spectrum disorders after infantile spasms: a population based study nested in a cohort with seizures in the first year of life. A decade of modern epilepsy therapy in institutionalized mentally retarded patients. Results of antiepileptic drug reduction in patients with multiple handicaps and epilepsy. Removal of sedative-hypnotic antiepileptic drugs from the regimen of patients with intractable epilepsy. Notably, the incidence (new cases) of epilepsy is significantly higher in this population than in any other (2,3). High rates of epilepsy in the elderly have also been reported from the Netherlands and Finland (5,6). Thus, due to the projected increase in the number of elderly persons, as well as their propensity to develop epilepsy, these individuals will represent an increasingly large group of patients needing expert care pertaining to this disorder. During the 9 months of follow-up in this study, epilepsy, as defined by the onset of a second seizure, occurred in 47 out of 1897 (2. Some retrospective studies have indicated that the eventual risk of experiencing seizures after suffering a stroke may be as high as 20% (10). Accordingly, the incidence of seizures after stroke may exceed 36,000 cases per year (10). Most problematic, though, is that in a large number of cases the precise cause cannot be determined and the etiology is termed cryptogenic (crypt hidden; genic cause). Until recently, it has been accepted that persons should not be diagnosed with epilepsy until an individual experienced two or more seizures.

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Its use as a herbal remedy is not recommended due to reports of hepatotoxicity and renal toxicity. The herb also contains flavonoids, which include isorhamnetin, kaempferol and quercetin, and their derivatives. There is also a volatile oil present containing calamene, eudesmol, limonene, - and -pinene, and 2-rossalene. A cytotoxic naphthoquinone derivative, larreantin, has been isolated from the roots. For information on the pharmacokinetics of individual flavonoids present in chaparral, see under flavonoids, page 186. For information on the interactions of individual flavonoids present in chaparral, see under flavonoids, page 186. Use and indications Chaparral has been used in the treatment of bowel cramps, 128 Chinese angelica Angelica sinensis (Oliv. Pharmacokinetics Evidence is limited to experimental studies, which suggest that the effects of Angelica dahurica and Angelica sinensis may not be equivalent. If all these effects are found to be clinically relevant then Chinese angelica (where Angelica dahurica is used) has the potential to raise the levels of a wide range of conventional drugs. Constituents the major constituents include natural coumarins (angelicin, archangelicin, bergapten, osthole, psoralen and xanthotoxin) and volatile oils. Angelica sinensis also contains a series of phthalides (n-butylidenephthalide, ligustilide, n-butylphthalide). Interactions overview Angelica dahurica may raise the levels of diazepam and tolbutamide, thereby increasing their effects. Case reports suggest that Chinese angelica may increase the bleeding time in response to warfarin, and may possess oestrogenic effects, which could be of benefit, but which may also, theoretically, oppose the effects of oestrogen antagonists, such as tamoxifen. Inhibitory potential of herbal medicines on human cytochrome P450-mediated oxidation: Properties of Umbelliferous or Citrus crude drugs and their relative prescriptions. Use and indications One of the most common uses of Chinese angelica root is for the treatment of menopausal symptoms and menstrual disorders. It has also been used for rheumatism, ulcers, anaemia, constipation, psoriasis, the management of hypertension and to relieve allergic conditions. The results are difficult to reliably extrapolate to the use of Chinese angelica with nifedipine in humans, but it is possible that alcoholic extracts of Angelica dahurica may decrease nifedipine metabolism, and therefore increase its levels and effects. Ishihara K, Kushida H, Yuzurihara M, Wakui Y, Yanagisawa T, Kamei H, Ohmori S, Kitada M. Interaction of drugs and chinese herbs: Pharmacokinetic changes of tolbutamide and diazepam caused by extract of Angelica dahurica. Inhibitory potential of herbal medicines on human cytochrome P450-mediated oxidation: Properties of Umbelliferous or Citrus crude drugs and their relative prescriptions. Chinese angelica + Diazepam the interaction between Angelica dahurica and diazepam is based on experimental evidence only. Experimental evidence In a study in rats,1 Angelica dahurica had little effect on the pharmacokinetics of intravenous diazepam 10 mg/kg. In a mobility study, Angelica dahurica potentiated the muscle relaxant effects of intravenous diazepam. It was also suggested by the authors that there was a considerable effect of Angelica dahurica on the first-pass metabolism of diazepam. Ishihara K, Kushida H, Yuzurihara M, Wakui Y, Yanagisawa T, Kamei H, Ohmori S, Kitada M. Interaction of drugs and chinese herbs: Pharmacokinetic changes of tolbutamide and diazepam caused by extract of Angelica dahurica. C Chinese angelica + Oestrogens or Oestrogen antagonists Chinese angelica may contain oestrogenic compounds. This may result in additive effects with oestrogens or it may oppose the effects of oestrogens.

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Increase primidone while other drug dose is decreased to appropriate combination or discontinuation of therapy with original agent over at least 2 weeks. The incidence of epilepsy is highest in children less than 5 years of age with another peak in the elderly. Seizures in the elderly often present as status epilepticus, associated with a 40% mortality rate, and are a strong predictor for stroke. Conversely, stroke (cerebrovascular disease) acts as a risk factor for epilepsy, increasing risk of epilepsy by 20%. The strong interplay between epilepsy and stroke risk defines one basis for the higher incidence of epilepsy observed in the elderly. Reports of anticonvulsant use in the elderly find 10% of patients in nursing homes and 20% in a Veterans administration setting receive more than one anticonvulsant medication with 42 -79% (respectively) receiving the medication for a non-epilepsy diagnosis. Seizures may result from hypoxia, ischemia, prenatal injury, developmental disorders. The affected neocortex produces impulses which stimulate corresponding muscle fascicles producing seizure-like activity. A seizure may manifest with a loss of consciousness, an increase or decrease in muscle tone, paresthesias, Deja-vu, or hallucinations. Epilepsy on the other hand, is a clinical disease process constituting a number of seizure types and etiologies which often requires chronic antiepileptic therapy. Although two-thirds of patients will respond to medications, the remaining 1/3 of patients do not respond, continue to have seizures, and are at increased morbidity and mortality risk. New classifications combine clinical characteristic with specific electrophysiological findings. Epilepsy has a focal origin in approximately 2/3 of patients and generalized origin in 1/3 of patients, 2) etiology, now defined as genetic. West syndrome), 4) distinctive constellations reflecting underlying pathology, some of which are known to respond to surgical intervention. Rasmussen encephalitis), 5) structural or metabolic epilepsies now described by the underlying cause, 6) finally, 30% of epilepsies fall into a heterogeneous group of epilepsies of unknown cause. Epileptic Spasm Patients having a single seizure may not require pharmacologic treatment. In this case, anticonvulsant medications are chosen on the basis of the diagnosis of epilepsy type or syndrome. Upon completion of the seizure, consciousness is regained often accompanied by post-ictal lethargy and confusion. Seizures can begin in both hemispheres of the brain (primary) or in one hemisphere that spreads to the other hemisphere (secondary). Seizures begin abruptly, are associated with a short loss of consciousness lasting a few seconds to a half minute and are not associated with a post-ictal state. They are often associated with 26 a loss of muscle tone leading to a gradual slump or myoclonic jerks. Focal seizures may progress to a larger area within the same hemisphere or progress to include both hemispheres (secondary generalization). Consciousness is maintained and additional symptoms reflect the area of the brain that is affected. If focal impulses spread, the patient may lose consciousness, experience automatisms. Juvenile myoclonic epilepsy has on onset around puberty, affects the upper body, is most commonly experienced upon awakening and persists throughout life. Manifestations may include eyelid drooping, head nodding, dropping of a limb or slumping to the ground. West Syndrome (Infantile Spasms) is a rare age-specific epileptic disorder of infancy and early childhood (incidence of 0. Other common characteristics include psychomotor retardation and impaired mental development. Although 90% of children become seizure free by age 5, up to 50% will develop another seizure disorder. It most commonly affects males between 3-5 years of age although it has been diagnosed in children up to 8 years.

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Intraventricular electrode is another technique that involves endoscopically placed temporal horn electrodes. Frameless image guidance can be used to place a 10-contact depth electrode through a rigid neuroendoscope within the atrium of the lateral ventricle. Invasiveness is less than transcortical depth electrode placement, and complications may be fewer (28). This newer semi-invasive option may be useful for lateralization of temporal lobe epilepsy (29). This is a useful technique for patients in whom further localization studies are required or who are not able to tolerate intraoperative testing (anxious patients or patients who refused awake surgery). Electrode location was identified by flow-void artifacts and coregistered on the image (dots). The lateral convexity of the frontal lobe is covered by an 8 by 8 array with 1 cm interelectrode spacing. The lesion is located beneath the first two electrodes in the third column from the anterior superior edge. The patient underwent resection of the superior and middle frontal gyri including the lesion. Subdural electrodes permit detailed definition of the epileptogenic zone in relation to eloquent cortex. Epileptiform discharges may be recorded during wakefulness, sleep, and seizures and then mapped to define the safest, most complete resection of epileptogenic zones (23,24). Sensory, negative motor, and language function cannot be assessed reliably during stimulation in infants. Special stimulation paradigms are required to elicit positive motor effects in children younger than 3 or 4 years (30,33). Evoked potential studies with subdural electrodes may help to identify the postcentral gyrus at any age. Occurring in approximately 2% of patients, subdural or epidural hemorrhage may prompt premature removal of electrodes and evacuation of hemorrhage. Concerns about intracranial pressure limit the number of subdural electrodes, so that only restricted unilateral cortical areas can be covered with grids. Strips can cover widespread areas through multiple burr holes, but mobility of the strips can be a problem and blind insertion of the strips may be impeded by subdural scarring or other structural lesions. Intravenous narcotics and nitrous oxide are continued to maintain a state of manageable general anesthesia without potential effects of inhalation agents. Interictal Disadvantages the risks of wound infection and flap osteomyelitis are the main disadvantages of chronically implanted subdural electrode grids. The incidence of 5% to 15% (21,23,24) about a decade ago has decreased in recent years, but occasional infections have occurred despite compulsive intraoperative culturing of all wound layers and vigorous prophylactic use of antibiotics. Other complications of subdural electrodes-acute meningitis, cerebral edema, and hemorrhage-are rare. Meningitis necessitates immediate electrode removal and vigorous antibiotic therapy. Brain edema can, rarely, be symptomatic, requiring early removal of electrodes, but usually it can be Chapter 81: Intracranial Electroencephalography and Localization Studies 919 epileptiform activity can be recorded for a stated period to define a zone of frequent interictal spiking. This may help the surgeon tailor the resection for maximal excision of areas with frequent interictal epileptiform activity. Surgical manipulation itself, however, may create some spike activity ("injury spikes"), and the practice of "chasing spikes" to maximize resection has not been shown convincingly to improve the outcome of resective epilepsy procedures. Preexcision spikes on three or more gyri that persist after resection, especially at a distance from the resection border, carry a poor prognosis, at least in nontumoral frontal lobe epilepsy (42). Intraoperative cortical stimulation can delineate areas of primary motor, sensory, and speech function under local anesthesia. Even under light general anesthesia (without paralytic agents), this technique can reliably identify primary motor areas by allowing direct observation of clonic or tonic movement in respective muscle groups, assisting in tailored resections close to motor regions. Only depth electrodes reliably record faster frequencies at onset (49,50), suggesting closer proximity to the generator. Although depth electrodes probably remain the gold standard for recording hippocampal onset, subdural strips are probably adequate when the issue is only lateralization of temporal lobe epilepsy (51). Epileptogenic Zone Near Eloquent Cortex Subdural electrodes are the method of choice whenever eloquent cortex must be clearly separated from the epileptogenic zone.

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Clinical manifestations include erythema, marked discomfort, swelling, and induration along the course of the infected vein. Navigational Note: Synonym: Boil Rhinitis infective Localized; local intervention indicated Definition: A disorder characterized by an infectious process involving the nasal mucosal. Navigational Note: Viremia Moderate symptoms; medical Severe or medically significant intervention indicated but not immediately lifethreatening; hospitalization or prolongation of existing hospitalization indicated Definition: A disorder characterized by the presence of a virus in the blood stream. Symptoms include marked discomfort, swelling and difficulty moving the affected leg and foot. Navigational Note: Biliary anastomotic leak Asymptomatic diagnostic Symptomatic; medical Severe symptoms; invasive Life-threatening Death finding; intervention not intervention indicated intervention indicated consequences; urgent indicated operative intervention indicated Definition: A finding of leakage of bile due to breakdown of a biliary anastomosis (surgical connection of two separate anatomic structures). Navigational Note: Bladder anastomotic leak Asymptomatic diagnostic Symptomatic; medical Severe symptoms; invasive Life-threatening Death finding; intervention not intervention indicated intervention indicated consequences; urgent indicated operative intervention indicated Definition: A finding of leakage of urine due to breakdown of a bladder anastomosis (surgical connection of two separate anatomic structures). Navigational Note: Bruising Localized or in a dependent Generalized area Definition: A finding of injury of the soft tissues or bone characterized by leakage of blood into surrounding tissues. Burns can be caused by exposure to chemicals, direct heat, electricity, flames and radiation. The extent of damage depends on the length and intensity of exposure and time until provision of treatment. Navigational Note: Dermatitis radiation Faint erythema or dry Moderate to brisk erythema; Moist desquamation in areas Life-threatening Death desquamation patchy moist desquamation, other than skin folds and consequences; skin necrosis mostly confined to skin folds creases; bleeding induced by or ulceration of full thickness and creases; moderate edema minor trauma or abrasion dermis; spontaneous bleeding from involved site; skin graft indicated Definition: A finding of cutaneous inflammatory reaction occurring as a result of exposure to biologically effective levels of ionizing radiation. Navigational Note: Fall Minor with no resultant Symptomatic; noninvasive Hospitalization indicated; injuries; intervention not intervention indicated invasive intervention indicated indicated Definition: A finding of sudden movement downward, usually resulting in injury. Navigational Note: Fallopian tube anastomotic Asymptomatic; clinical or Symptomatic; medical Severe symptoms; invasive Life-threatening Death leak diagnostic observations only; intervention indicated intervention indicated consequences; urgent intervention not indicated operative intervention indicated Definition: A finding of leakage due to breakdown of a fallopian tube anastomosis (surgical connection of two separate anatomic structures). Navigational Note: Prior to using this term consider specific fracture areas: Injury, poisoning and procedural complications: Ankle fracture, Hip fracture, Spinal fracture, or Wrist fracture Gastric anastomotic leak Asymptomatic diagnostic Symptomatic; medical Severe symptoms; invasive Life-threatening Death finding; intervention not intervention indicated intervention indicated consequences; urgent indicated operative intervention indicated Definition: A finding of leakage due to breakdown of a gastric anastomosis (surgical connection of two separate anatomic structures). Navigational Note: Gastrointestinal anastomotic Asymptomatic diagnostic Symptomatic; medical Severe symptoms; invasive Life-threatening Death leak finding; intervention not intervention indicated intervention indicated consequences; urgent indicated operative intervention indicated Definition: A finding of leakage due to breakdown of a gastrointestinal anastomosis (surgical connection of two separate anatomic structures). Navigational Note: Gastrointestinal stoma Superficial necrosis; Severe symptoms; Life-threatening Death necrosis intervention not indicated hospitalization indicated; consequences; urgent elective operative intervention indicated intervention indicated Definition: A disorder characterized by a necrotic process occurring in the gastrointestinal tract stoma. Navigational Note: Infusion related reaction Mild transient reaction; Therapy or infusion Prolonged. Navigational Note: Intestinal stoma site bleeding Minimal bleeding identified Moderate bleeding; medical Transfusion indicated; on clinical exam; intervention intervention indicated invasive intervention not indicated indicated Definition: A disorder characterized by bleeding from the intestinal stoma. Navigational Note: Intraoperative hemorrhage - Postoperative invasive intervention indicated; hospitalization Life-threatening consequences; urgent intervention indicated Death Definition: A finding of uncontrolled bleeding during a surgical procedure. Navigational Note: Large intestinal anastomotic Asymptomatic diagnostic Symptomatic; medical Severe symptoms; invasive Life-threatening leak finding; intervention not intervention indicated intervention indicated consequences; urgent indicated operative intervention indicated Definition: A finding of leakage due to breakdown of an anastomosis (surgical connection of two separate anatomic structures) in the large intestine. Navigational Note: Pharyngeal anastomotic leak Asymptomatic diagnostic Symptomatic; medical Severe symptoms; invasive finding; intervention not intervention indicated intervention indicated indicated Definition: A finding of leakage due to breakdown of a pharyngeal anastomosis (surgical connection of two separate anatomic structures). Navigational Note: Postoperative thoracic Extubated within 24 - 72 hrs Extubated >72 hrs procedure complication postoperatively postoperatively, but before tracheostomy indicated Life-threatening consequences; urgent operative intervention indicated Death Life-threatening consequences; urgent intervention indicated Death Life-threatening airway compromise; urgent intervention indicated. Navigational Note: Prolapse of urostomy Asymptomatic; clinical or Local care or maintenance; Dysfunctional stoma; elective Life-threatening diagnostic observations only; minor revision indicated operative intervention or consequences; urgent intervention not indicated major stomal revision intervention indicated indicated Definition: A finding of displacement of the urostomy. The inflammatory reaction is confined to the previously irradiated skin and the symptoms disappear after the removal of the pharmaceutical agent. Navigational Note: Rectal anastomotic leak Asymptomatic diagnostic Symptomatic; medical Severe symptoms; invasive Life-threatening Death finding; intervention not intervention indicated intervention indicated consequences; urgent indicated operative intervention indicated Definition: A finding of leakage due to breakdown of a rectal anastomosis (surgical connection of two separate anatomic structures). Navigational Note: Seroma Asymptomatic; clinical or Symptomatic; simple Symptomatic, elective diagnostic observations only; aspiration indicated invasive intervention intervention not indicated indicated Definition: A finding of tumor-like collection of serum in the tissues. Navigational Note: Small intestinal anastomotic Asymptomatic diagnostic Symptomatic; medical Severe symptoms; invasive Life-threatening Death leak finding; intervention not intervention indicated intervention indicated consequences; urgent indicated operative intervention indicated Definition: A finding of leakage due to breakdown of an anastomosis (surgical connection of two separate anatomic structures) in the small bowel. Navigational Note: Spermatic cord anastomotic Asymptomatic diagnostic Symptomatic; medical Severe symptoms; invasive Life-threatening Death leak finding; intervention not intervention indicated intervention indicated consequences; urgent indicated operative intervention indicated Definition: A finding of leakage due to breakdown of a spermatic cord anastomosis (surgical connection of two separate anatomic structures). Navigational Note: Stomal ulcer Asymptomatic; clinical or Symptomatic; medical Severe symptoms; elective diagnostic observations only; intervention indicated operative intervention intervention not indicated indicated Definition: A disorder characterized by a circumscribed, erosive lesion on the jejunal mucosal surface close to the anastomosis site following a gastroenterostomy procedure. Navigational Note: Tracheal hemorrhage Mild symptoms; intervention Moderate symptoms; Transfusion indicated; Life-threatening not indicated intervention indicated invasive intervention consequences; urgent indicated; hospitalization intervention indicated Definition: A disorder characterized by bleeding from the trachea. Navigational Note: Tracheostomy site bleeding Minimal bleeding identified Moderate bleeding; medical Transfusion indicated; Life-threatening on clinical exam; intervention intervention indicated invasive intervention consequences; urgent not indicated indicated intervention indicated Definition: A disorder characterized by bleeding from the tracheostomy site.

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Mitch, 45 years: The iodine content can be high, and kelp may be standardised to the total iodine content. Inactive ingredients in the tablets: poloxamer 407, copovidone, cornstarch, magnesium stearate, hydroxypropyl cellulose, talc, and candelilla wax Inactive ingredients in the oral solution: glycerin, xylitol, purified water, and artificial flavor. In a separate case, evaluating zonisamide concentrations in breast milk to 30 days postpartum, Shimoyama observed breast milk concentrations to range from 81% to 100% of maternal plasma concentrations (42).

Steve, 38 years: Nevertheless, it has been recommended to treat neonates with folinic acid for 24­48 h in case of intractable seizures not responding to a trial with vitamin B6 (54). Instructor in Neurology, Epilepsy Division University of Miami Miller School of Medicine Jackson Memorial Hospital, University of Miami Hospital Miami, Florida Katherine C. Notes this is a process measure, and improvement is noted as an increase in the rate.

Marus, 58 years: The seizure pattern has spread to involve more widespread frontal and central regions of the right hemisphere. Each series requires approval from a qualified health care professional before driving, and therefore specific rules should be reviewed. B: Ictal electroencephalogram at age 13 months, showing hypsarrhythmia with diffuse electrodecrement at the onset of an infantile spasm (arrow).

Chris, 62 years: Up regulation of a T-type Ca2+ channel causes a long-lasting modification of neuronal firing mode after status epilepticus. Effect of restricting the legal supply of prescription opioids on buying through online illicit marketplaces: interrupted time series analysis. However, the study does support the finding of somewhat reduced platelet responsiveness.

Benito, 33 years: However, there are some volumetric studies that suggest that the anterior half to the thalamus is larger in patients with absence epilepsy, suggesting a possible structural correlate (14). Pharmacokinetics and tolerance of fosphenytoin and phenytoin administration intravenously to healthy subjects. All lifetime costs were discounted by 3% per annum, to derive the net present value of costs in 2019-20 (Table 3.

Hanson, 29 years: The contents of the therapeutic class overviews on this website ("Content") are for informational purposes only. Significant impairment is further increased when diazepam is combined with low concentrations of alcohol (0. Testing Imaging Imaging of the brain has been extremely helpful to predict the risk of seizures after head injury.

Abbas, 26 years: Most of these seizures with automatisms last longer than 30 seconds-up to 1 to 2 minutes (sometimes as long as 10 minutes). Activation procedures (drug injection, suggestion, hyperventilation, exercise, re-enactment of precipitating events), testing of reaction times, etc. Finally, surgical or pharmacological treatment of seizures may produce adverse cognitive effects.

References

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