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C P Panayiotopoulos
406 pp Price £60 ISBN 0-86196-577-9 (h/b)
London: John Libbey, 2000 .
In the last quarter of the twentieth century, epileptology made considerable progress thanks to new neuroimaging techniques, better antiepileptic drugs, but probably above all more accurate definition and description of the epileptic disorders. ‘Epilepsy’ is not an entity: because epilepsies encompass many and various conditions, accurate diagnosis is essential for management and prognosis. This is the view of Dr Panayiotopoulos, who declares, ‘Dramatic progress in the management of epilepsies can be expected if more time and emphasis are given on how to diagnose epilepsies rather then the current theme how to treat epilepsy’. Commissions of the International League against Epilepsy proposed categorizations, a classification of epilepsy syndromes in 1989, and an epidemiological classification in 1992. However, such proposals have a short half-life and must be updated and revised. Dr Panayiotopoulos' book is both an extensive review of established facts and also a critical view of current knowledge, based on his personal experience.
In chapter 1, under the heading The Diagnosis of Epilepsies the syndromic concept is convincingly championed. Chapter 2 demonstrates that the electroencephalogram (EEG) is not an obsolete tool but is indispensable for a correct diagnosis (magnetic resonance imaging is normal in some two-thirds of seizure patients). Chapter 3 offers a nice summary of these disorders, and also suggests that the term ‘seizures’ or ‘seizure susceptibility’ should be used instead of ‘epilepsy’. Apart from the pathophysiological arguments, an objection to this proposal is that the best way to draw epilepsy out of the shadows and abolish its stigma is to accept the term.
Some syndromes are well defined and easy to diagnose if the necessary details are ascertained—as in most cases of benign childhood epilepsy with centrotemporal spikes (chapter 4) and early-onset idiopathic childhood occipital epilepsy (chapter 8). They are astutely and thoroughly described here. The borders of benign childhood epilepsy with centrotemporal spikes and other conditions with a similar EEG pattern are detailed in chapter 5. Chapter 6 describes occipital seizures and chapter 7 shows that they occur in various epileptic disorders, symptomatic as well as idiopathic. The fact that, whereas rolandic seizures are mainly a manifestation of an idiopathic epilepsy, the same is not true in occipital seizures, is clearly shown. Correct diagnosis of late-onset benign childhood epilepsy is far more difficult (chapter 9). The pitfalls of a hasty interpretation of occipital epileptiform abnormalities are discussed at length in chapter 10.
After these updated descriptions, subsequent chapters place them in an historical frame. The obvious relationship between occipital seizures, occipital EEG foci and the role of cortex in visual functions leads to a discussion of seizures with specific modes of precipitation and mainly photosensitive epilepsies, illustrated with the author's personal studies. Differentiation of occipital epilepsies from migraines is justified because of the complex relation between migraine and epilepsy and the fact that, in 1978, cases of idiopathic occipital epilepsy were published as basilar migraine. Last, the author addresses the problem of the borders of the so-called benign partial seizure susceptibility syndrome, with other clinical phenotypes or other locations of EEG epileptiform abnormalities, and of what are called ‘related epileptic syndromes’ such as Landau—Kleffner syndrome, epilepsy with continuous spikes and waves during slow sleep and atypical benign partial epilepsy of childhood. Since the proposal of a classification of epilepsies and epileptic syndromes in 1989, epileptologists have divided themselves into splitters, admitting a host of specific syndromes, and lumpers, finding a continuum between epileptic events. Panayiotopoulos is both a splitter (read this book) and a lumper (read chapter 18). He is also a precursor, adding personal and astute views to an exhaustive review of the published work.