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He was initially m isdiagnosed with Marfan syndrome because of his thin body habitus discount 100 mg vantin with amex antibiotic used for urinary tract infection, Lens dislocation is probably not present at birth but the absence ot mental retardation buy 100 mg vantin visa bacteria news articles, and the presence or suDiuxated develops in the first year or two of life in this group of lenses purchase vantin australia virus infection. Isolated cases may determined that they in fact had Schwartz-fampel have been reported in the literature purchase vantin in india bacteria that causes tuberculosis. Most patients die in the rhegmatogenous retinal detachment in four, cataracts in first decades of life from spinal compression. A brother and sister had clinical and A woman and her two daughters had bilateral congenital radiologic features similar to those of the Kniest dysplasia ptosis, high myopia, and subluxated lenses. An abnormality but did not have the characteristic “Swiss cheese” appear of connective tissue was presumed to cause all three ance of the cartilage on histopathology; there were rather components of the syndrome. Fibrillin, a new 350-kD glycoprotein, is a com ponent of extracellular microfibrils. Fibrillins I and 2 perform partially overlapping functions during aortic developm ent. Latent transform ing growth factor beta-binding protein 1 interacts with fibrillin and is a microfibril associated protein. Microfibril abnor malities o f the lens capsule in patients with Marfan syndrom e and ectopia lentis. Clinical m anifestations of ectopia lentis et pupillae in in the zonule of the m ouse during development. Fibrillin-rich microfibrils: structural plus prononcce aux extrem ites, characterisee par lallongem ent dcs m odifications during ageing in norm al hum an zonule. Diagnosis and m an a rccurrcnt dc novo m issense m utation in the fibrillin gene. Probable hom ozygotic form of variability in a family segregating a missense m utation in the epider the Marfan syndrom e in a new born child. Rotary shadow ing o f elastic heterozygous M arfan patient: tw o defective fibrillin alleles result in a system microfibrils in the ocular zonule, vitreous, and ligamentum lethal phenotype. FibriUin-containing microfibrils: struc- and location on clinical outcom e in 1,013 probands with Marfan turc and function in health and disease. G cnom ics 1993; 17: involving clcft palate, cardiac anom alies, typical facies, and learning 476-84. Solution structure of a pair M arfanoid-craniosynostosis (Shprintzen-Goldberg) syndrom e. Nat of calcium -binding epiderm al growth factor-like dom ains: im plica Genet 1996;12:209-11. Glaucoma in the Marfan of mitral valve prolapse in a mouse model of Marfan syndrome. Cornca in Marfan disease: Marfan syndrome: should wc now treat surgical patients with losartan? Strabismus in the Marfan lular deposition of fibrillin and decorin in neonatal Marfan syndrom e syndrom e. Histologic study of the cham ber angel of subjects and subjects with Marfan syndrome. Im m unohistochem ical tion of haploinsufficiency in the complex pathogenesis of Marfan com parison of ocular zonules and the microfibrils o f elastic tissue. M olybdenum - co n tractu al arachnodactyly and severe m itral regurgitation in a cofactor deficiency: an easily missed cause of neonatal convulsions. Absence of hepatic m olyb natural history and long-term follow-up of cardiovascular involve denum cofactor: an inborn e rro r o f m etabolism leading to a m ent. Ocular m anifestations of fixation for the m anagem ent of dislocated lenses in a family with familial hyperlysinem ia. Possible genetic carriers in the autosom al recessive syndrom e o f ectopia lentis and distinctive sphcrophakia-brachym orphia syndrom e. Spherophakia with brachydaclyly; com parison with blebs in a patient with m icrosphcrophakia. Pupillarv-block glaucom a in the cartilage collagen resulting in im perfect fibril assembly. Spectrum of Schwartz-Jampel chrom osom c 21q 3nd to proxim al m ouse chrom osom c 17. Am J syndrom e includes m icrom elic chondrodysplasia, kyphom elic H um Genet 1988;42:550-9. The hydrogen peroxide produced can be converted to oxygen and water by catalase or by peroxidation to form water. Whereas in mitochondria separate enzymes arc used as is the case for mitochondria, the first stage of ^-oxidation for the hydration and dchydrogenation steps, these reactions in peroxisomes takes place by two acyl-СоЛ oxidases. Phytanic acid is not synthesized in the body role in the regulation of oxidation of long-chain fatty acids. Mitochondrial (3-oxidation is capable of being induced to, Plant phytol is bound to chlorophyll and cannot be absorbed at most, only a two-fold increase in activity. Peroxisomal by humans but can be broken down by ruminants such as (3-oxidation, on the other hand, is capable of increasing up cows. Thus, the human source of phytol comes primarily to 15- to 20-fold in activity in response to a fatty diet, from animal fats and dairy products. Instead, phytanic chain, no citric acid cycle, and no phosphorylation within acid is broken down exclusively by 01-oxidation to pristanic peroxisomes. Peroxisomal (3-oxidation, thus, may be of acid, followed by three subsequent steps of (3-oxidation in importance in the supply of acetyl CoA for anabolic reactions the peroxisome, the products of which are transported to during times when energy stores are high. In the fourth step, prista Phytanic acid is a fully saturated, branched-chain, 20-carbon nal is oxidized to pristanic acid by a yet-to-be-identified fatty acid that is normally present in trace amounts in blood aldehyde dehydrogenase. Blood levels of pipecolic acid are neous disease characterized by ichthyosis and macular usually elevated in disorders of peroxisomal biogenesis. However, because its elevation is age-dependent, within peroxisomes by a process of p-oxidation from the and because it is usually normal in the neonatal period, u)-cnd. Leaf humans, phytanic acid a-oxidation to pristanic acid and microbodies or peroxisomes have additional enzyme subsequent (5-oxidation of pristanic acid take place pre systems involving glycolate and glycerate. Patients with Zellweger syndrome converted by oxidative deamination to glyoxylate by and neonatal adrenoleukodystrophy have elevated urinary peroxisomal D-amino acid oxidase, whereas glycolate is concentrations of medium-chain-length dicarboxvlic acids. However, 10 of the 173 had unusually mild clinical manifestations with survival into the fifth decade or had congenital cataracts as the only abnormality. Therefore, to facilitate further protein importation, moscopic abnormalities in infancy cannot exclude significant PexSp and Pex7p must be recycled back into the cytosol or retinal dysfunction that, with time, would be associated with otherwise deposed. Mono-ubiquination various diseases, and will form the cornerstone for the early leads to receptor recycling, while poly-ubiquination targets identification of patients for treatment trials by metabolic the receptor to the proteosome. Renal cysts 93% 0 0 0 0 + 0 0 0 Rhtzomella 3% 0 0 0 0 0 9 3 % + + Choncrodysplasia 69% 0 0 0 0 0 10 0 % + + punctata 67% 4 + 4 Neuronal migration 20%?
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Monohydroxycarbazepine reaches peak con- absence seizures (strychnine order vantin without prescription infection gone septic, pentylenetetrazole and picrotoxin) centrations in 4–6 h  afer immediate release tablets cheap 200mg vantin otc treatment for dogs galis, and slightly [4 buy vantin 200 mg low price antibiotic skin infection,8] order vantin paypal antibiotic infusion. The prod- Oxcarbazepine and monohydroxycarbazepine modulate volt- uct information for the reference brand of the immediate-release age-sensitive cationic channels . The mechanism of blockade of formulation states that absorption of these tablets is unafected by sodium channels has been considered to be similar to that of pheny- food once steady-state is reached . The extended-release tablets toin and carbamazepine, although monohydroxycarbazepine has a display an earlier peak concentration in the fed state and, for that greater afﬁnity for the fast inactivated state of the channel. However, reason, it is recommended that they be taken at least 1 h before or the two enantiomeric forms of monohydroxycarbazepine may af- 2 h afer a meal . Occasional patients report spontaneously that fect these channels in diferent ways . The R-enantiomer, (R)-li- dosing of immediate-release tablets with breakfast produces more carbazepine, appears to have a greater afnity for the voltage-gated peak-time mid-morning side-efects than if they are taken fasting. This mechanism is commonly attributed to phenytoin The volume of distribution of oxcarbazepine is 0. As a lipophilic sub- but may exert a major antiepileptic action by modifying properties stance, monohydroxycarbazepine is widely distributed in the body of the slow inactivation state of these sodium channels , a mech- and easily passes the blood–brain barrier. The channels enter the slow inactivat- monohydroxycarbazepine exhibit low protein binding (33–38% ed state only afer prolonged depolarizations and this mechanism for monohydroxycarbazepine and 60–67% for oxcarbazepine), in- is thought to both raise action potential thresholds and limit their dependent of the dose [4,15]. It is not clear from these data protein-binding interactions with highly protein-bound drugs such which enantiomeric form of monohydroxycarbazepine is most re- as phenytoin and valproic acid. The following relationship between monohydroxycarbazepine channel currents, unlike carbamazepine, which has a greater efect concentration and dose of oxcarbazepine has been described, over on L-type channels . N- and P/Q-type channels are activated by the range of 300–2700 mg/day : high voltage changes and are important for linkage of membrane potentials to intracellular mechanisms of neurotransmitter release monohydroxycarbazepine concentration (mg/L = 0. The elimination Tere are reports that monohydroxycarbazepine elevates hip- half-life of monohydroxycarbazepine is 9. Neve- The metabolic pathways of carbamazepine and oxcarbazepine theless, the major efect appears to be on voltage-gated sodium difer signiﬁcantly (Figure 40. Oxcarbazepine is rapidly and 536 Chapter 40 extensively reduced by cytosolic aldoketoreductase enzymes in pharmacokinetics of oxcarbazepine has not been evaluated in se- the liver to the active metabolite monohydroxycarbazepine (96%). Monohydroxycarbazepine exists in two isomeric tion, but patients with creatinine clearances of <30 mL/min/1. At steady-state about 81% of the monohydroxycarbazepine exhibited signiﬁcant increases in elimination half-life and plasma concentration is in the form of the L-enantiomer (eslicarbazepine) concentrations of monohydroxycarbazepine . Before steady state is reached, the proportions of the two enantiomers are more similar, suggesting that the R-enantiomer is Drug interactions cleared more rapidly . The addition of oxcarbazepine can produce a small in- unchanged monohydroxycarbazepine (28%). A tive accounts for 3% of the dose excreted in the urine, with <13% of variable increase in phenytoin concentration can occur, mainly at the drug excreted as minor conjugates of oxcarbazepine and mono- higher phenytoin serum levels because at high serum levels pheny- hydroxycarbazepine . Serum monohydrox- An open-label study of oxcarbazepine as monotherapy or adjunc- ycarbazepine concentrations can decrease by 29–40% (Table 40. In 109 children, aged 3–17 years, oxcar- when oxcarbazepine is added to a stable regimen of oral contra- bazepine was found to have a low propensity to inhibit or induce ceptives, as a result of induction of the metabolism of both ethi- oxidative enzymes. Young chil- epine, oxcarbazepine does not interact signiﬁcantly with warfarin, dren can be given higher milligram per kilogram doses than older cimetidine, propoxyphene or erythromycin . This may be explained by age-related decreases in creatinine minophen (paracetamol) and amiodarone . Because of their difering efects on the drug metabolizing en- Mild to moderate hepatic dysfunction did not alter the pharma- zyme systems, substituting carbamazepine with oxcarbazepine cokinetics of oxcarbazepine or monohydroxycarbazepine, but the may result in de-induction and a consequent increase in the serum Table 40. Oxcarbazepine is not indicated for absence, myo- clonic and other types of generalized seizures other than tonic– clonic seizures, and indeed may exacerbate them . Serum level monitoring Measurement of monohydroxycarbazepine, not oxcarbazepine it- Double-blind trials in comparison with carbamazepine self, may be useful. The usual method is high-performance liquid Tree randomized double-blind controlled trials compared ox- chromatography. If a carbamazepine level is ordered in error, it will carbazepine with carbamazepine (Table 40. In a group of 214 patients treated with a clinically opti- enrolled 40 patients whose phenytoin therapy had been unsatis- mized dose, the mean serum level of monohydroxycarbazepine was factory, and randomized them to either carbamazepine or oxcar- 15. A reference (optimal) range of monohydroxycarbazepine con- with either focal or primary generalized seizures, but equivalent ef- centrations of 3–35 mg/L has been suggested, although this is not fcacy for the two drugs was noted. Routine monitoring of levels is not pine for 12 weeks each in random order, in addition to the titra- recommended, although it may be helpful to assess compliance or tion period. Oxcarbazepine signiﬁcantly reduced tonic–clonic and to gauge dosage in the presence of enzyme-inducing concomitant tonic seizures in comparison with carbamazepine, but there was no drugs. As monohydroxycarbazepine levels have been reported to diferential efect on complex partial seizures. Tese trials conception, during pregnancy and in the immediate post partum were far too small to prove non-inferiority of either drug, but the period. In a larger double-blind controlled monotherapy trial enroll- ing 235 patients with newly diagnosed epilepsy , patients with Effcacy previously untreated primary generalized tonic–clonic seizures The efﬁcacy of oxcarbazepine has been established in many rand- or focal seizures with or without secondary generalization were omized controlled clinical trials. Oxcar- mazepine with fexible dosage adjustments allowed during a 4- to bazepine was compared with carbamazepine [36,37,38], phenytoin 8-week titration period . At the end of the 48-week mainte- [39,40], valproate  and levetiracetam  in controlled trials, nance phase, carbamazepine patients were taking a mean dose of mostly as monotherapy. Other randomized trials utilized oxcar- 685 mg/day, while oxcarbazepine patients were taking 1040 mg/ bazepine monotherapy in comparison with either placebo  or day. Fify-two per cent of oxcarbazepine patients and 60% of car- lower dose oxcarbazepine [44,45]. Randomized controlled trials of bamazepine patients were seizure-free during this year-long study, adjunctive therapy for refractory patients have enrolled adults aged not a signiﬁcant diference. Oxcarbazepine therefore was sim- 15–65 , children aged 3–17 years  and infants from 1 month ilar in efﬁcacy to carbamazepine in this series of double-blind, to 4 years of age . Percentage of Number and type drop-outs for Study of patients Trial design Mean dose/day Effcacy results adverse events Houtkooper 48 adult inpatients Crossover Oxcarbazepine: 9% seizure None on either et al. In a Cochrane review, this trial was the only one deemed to ondary generalized seizures, or generalized tonic–clonic seizures meet the reviewers’ criteria for a direct comparison of monotherapy without focal onset, were seizure-free while taking oxcarbazepine efcacy between carbamazepine and oxcarbazepine for non-refrac- during a 48-month maintenance treatment period, compared with tory focal seizures . The mean daily dose at the start oxcarbazepine and carbamazepine were similarly efective, using of the maintenance period was 1028 mg for oxcarbazepine and these criteria. A similar result emerged from a study of 193 Oxcarbazepine was reported to be slightly less efective (72% children aged 5–18 years, who were randomized to oxcarbazepine seizure-free) than levetiracetam (90% seizure-free) in a rand- or phenytoin afer a new diagnosis of epilepsy with focal or gener- omized, open-label trial of 39 children with benign epilepsy with alized tonic–clonic seizures . Sixty per cent in each group was centrotemporal spikes, although the study was too small to state seizure-free during the maintenance period. However, in both these either statistical superiority or non-inferiority of either drug . A study of similar Short-term double-blind monotherapy trials in design compared oxcarbazepine with valproate among 249 patients comparison with placebo or low-dose active control with focal or generalized tonic–clonic seizures aged 15–65 years A small double-blind, placebo-controlled study enrolled patients . Seizure-free rates were 57% for oxcarbazepine and 54% for with recent-onset untreated focal seizures, who received a placebo valproate, not signiﬁcantly diferent. The median daily maintenance or 1200 mg/day oxcarbazepine for a period of up to 90 days or until dose was 900 mg for each drug.
Patients were randomized to receive appears to achieve nothing and cheap vantin 100 mg with mastercard antibiotics to treat lyme disease, in a few cases cheap 100mg vantin with visa treatment for dogs broken toe, it is appropriate to the diet immediately or afer 3 months order vantin visa virus back pain. Tirty-eight per cent on the diet had a >50% reduction Doose syndrome in seizures compared with 6% not on the diet order vantin in united states online antibiotics for dogs after spaying. Numbers were too Tere are no randomized controlled studies of any treatment for small to analyse by syndrome but there was no signifcant diference Doose syndrome and the best evidence available is from case series. Corpus callosotomy can be used for the treatment of atonic lamotrigine, sometimes combined with sodium valproate, is ofen and tonic drop attacks, seizure types that characteristically occur in used. A study from Taiwan reported that 68% of patients (children became seizure-free on lamotrigine and there are no reports of lam- and adults) had at least a 50% reduction in seizures following ante- otrigine exacerbating seizures in Doose syndrome . Indeed, it rior callosotomy and that this was not dependent on whether West was found to be efective in 6 out of 10 patients who were hitherto Management of Childhood Epilepsy Syndromes 189 pharmacoresistent . Because this is an area of eloquent cortex, 3 months and in six out of eight patients at 6 months. However, the technique of mul- particularly efective against myoclonic–astatic seizures . However, even in those children who re- syndrome, 11 of whom were treated with the ketogenic diet. At 18 spond quickly, age-appropriate language appears to be only occa- months, six remained on the diet, two were seizure-free, two had sionally achieved. Reports suggest that earlier surgery is associated a 75–99% reduction in seizures and two experienced a 50–74% with a better functional impact. Treatment of this rare syndrome is guided by information from case Treatment with no other drug (including levetiracetam, carbamaz- series. Tere is one report of myoclonic status epilepticus in Doose zure control is said to be associated with a better long-term cognitive syndrome apparently provoked by levetiracetam . Both are rare and there References are no randomized controlled trials to help guide their manage- 1. This and other drugs, such as oxcarbazepine, vigabatrin, ti- tiepileptic drugs, I: treatment of new onset epilepsy: report of the Treatment and agabine and gabapentin, are probably best avoided. It is sometimes Technology Assessment Subcommittee and the Quality Standards Subcommittee of the American Academy of Neurology and the American Epilepsy Society. Efcacy and tolerability of the new an- or two of them before trying other treatment modalities. The diagnosis and management of the ethosuximide, benzodiazepines (administered rectally) and sulth- epilepsies in adults and children in primary and secondary care. Treatment of pediatric It is usually advocated that they should be tried early on the clinical epilepsy: European expert opinion, 2007. Epilepsy and evidence-based medicine: a vote of conf- dence in expert opinion from the National Institute for Clinical Excellence? Stiripentol in severe myoclonic epilepsy Success is also claimed for the use of intravenous immunoglobulins in infancy: a randomised placebo-controlled syndrome-dedicated trial. Human herpesvirus 6 and 7 in febrile withdrawal of such treatment can usually be achieved. Intermittent oral diazepam prophylaxis in an unblinded randomised controlled trial. J Pediatr trolled trial of ibuprofen syrup administered during febrile illnesses to prevent 1961; 58: 211–218. Clobazam in treatment of refractory the recurrence of febrile seizures in children? A systematic review of randomized epilepsy: the Canadian experience – a retrospective study. Lamotrigine as frst-line drug in child- on Febrile Seizures American Academy of Pediatrics. Febrile seizures: clinical hood absence epilepsy: a clinical and neurophysiological study. Brain Dev 2004; practice guideline for the long-term management of the child with simple febrile 26: 26–29. Lack of efcacy of phenytoin in children pre- frst-line monotherapy in newly diagnosed typical absence seizures: an open-label, senting with febrile status epilepticus. Lamotrigine for patients with juvenile intravenous diazepam for treating febrile seizures in children: prospective ran- myoclonic epilepsy following prior treatment with valproate: results of an open-la- domised study. Exacerbation of juvenile myoclonic epilepsy with lam- trigine for absence seizures in children and adolescents. Ethosuximide, valproic acid, and lamotrig- lamotrigine in juvenile myoclonic epilepsy in adults: a prospective, unblinded ran- ine in childhood absence epilepsy. Topiramate monotherapy for childhood absence seizures: an open label ine in childhood absence epilepsy: initial monotherapy outcome at 12 months. Benefcial efect of antiepileptic medication pathic generalized epilepsy with myoclonic seizures. The efects on cognitive function and behavioural topiramate in Lennox–Gastaut syndrome. Neurolo- problems of topiramate compared with carbamazepine as monotherapy for chil- gy 1999; 52: 1882–1887. Felbamate in the treatment of Lennox–Gastaut syndrome: results benign childhood epilepsy with centrotemporal spikes: a clinical and cognitive of a 12-month open-label study following a randomized clinical trial. Topiramate in Lennox–Gastaut racetam monotherapy to improve language dysfunction associated with benign syndrome: open-label treatment of patients completing a randomized controlled rolandic epilepsy. Anticonvulsant-induced status epilepticus in Len- opoulos syndrome: a case report. Clobazam for the treatment of intractable childhood epilep- by carbamazepine in Panayiotopoulos syndrome. Rolandic epilepsy has little efect on adult life 30 years ment of epilepsy in children. Treatment of benign focal epilepsies in children: when and how should 1997; 38: 68–73. Ictal cardiorespiratory arrest in Panayiot- single-blind trial in children with Lennox–Gastaut syndrome. First long-term experience with the or- Treatment of refractory epilepsy with intravenous immunoglobulins: results of phan drug rufnamide in children with myoclonic-astatic epilepsy (Doose syn- the frst double-blind/dose fnding clinical study. The ketogenic diet for the treatment of myoclonic-astatic epilepsy of early childhood. A comparison of seizure outcome afer cal- status epilepticus in myoclonic-astatic epilepsy: a case report. Epileptic Disord losotomy in patients with Lennox–Gastaut syndrome and a positive or negative 2006; 8: 213–218. Sulthiame therapy for continuous spike and development subcommittee of the American Academy of Neurology. Vagus nerve stimulation and Lennox–Gastaut syndrome: a review of syndrome and continuous spike–wave discharges during sleep.
Multiple subpial transection for hypothalamic hamartomas causing refractory epilepsy: preliminary results from intractable partial epilepsy: an international meta-analysis buy vantin online pills antibiotic resistance in bacteria is the result of. Patients with re- single-center experience in 40 pediatric patients with epilepsy generic 100mg vantin with mastercard infection zombie. Epilepsia2013;54: fractory epilepsy treated using a modifed multiple subpial transection technique generic vantin 200mg online bacteria proteus mirabilis. Intraoperative and perioperative complications with a vagus nerve leptogenic periventricular nodular heterotopia order vantin discount antibiotic resistance uganda. Complications of vagal nerve stimulation for drug-re- the lef vagal nerve in children: efect on swallowing. Epilepsia 1998; 39: sistant epilepsy: a single center longitudinal study of 143 patients. Cardiac responses of vagus nerve stimulation: intraoperative thalamus for treatment of refractory epilepsy. Each patient presents a unique combi- to contribute to haemorrhagic complications . Practice varies nation of neuropathology, medical conditions, concurrent phar- among centres that perform epilepsy surgery. However, an understanding of how anaesthetic agents might modulate seizure activity, of interactions between anaesthetic Anaesthesia and antiepileptic therapy agents and drugs used in the treatment of epilepsy and of the par- Tere are interactions between drugs used in anaesthesia and med- ticular requirements of the surgical procedure to be performed puts ications used to treat epilepsy. Tese interactions are mediated by the anaesthesia team in the best position to contribute efectively to enzyme induction, enzyme inhibition and other mechanisms. In patients taking phenytoin and bazepine [3,4] are best identifed preoperatively. Precautions, including frequent such as bone marrow suppression, anaemia, thrombocytopenia and monitoring of neuromuscular blockade, are advisable to prevent liver injury, may require that the team re-evaluate the timing of sur- untoward events related to unanticipated patient movement during gery and anaesthesia. Pertinent information is available in several comprehensive receptors, may contribute . Chronic administration of carbamazepine and phenytoin has less Intravenous anaesthetic induction drugs have anticonvulsant and efect on the benzylisoquinoline-derived neuromuscular blocking proconvulsant properties. Recovery from atracurium is with predominantly anticonvulsant properties, is not currently not afected [15,16]. Propofol, the most commonly used induction agent, has magnitude of the efect is smaller than that observed when steroidal anticonvulsant properties in experimental animal models, decreases non-depolarizing agents are administered . It either diminishes, or to maintain therapeutic blood levels and to provide postoperative does not increase, epileptiform activity in epileptic foci . Parenteral a phenomenon observed at lower plasma concentrations that dis- formulations, when available, are substituted for oral medications. The barbiturate Alternative therapies must be considered to replace medications induction agent methohexital and the imidazole derivative etomi- that do not have a parenteral formulation. Hypotension is and low doses are used to activate and defne seizure foci intraop- quite common during the administration of phenytoin to patients eratively [24,34,35]. During non-emergent administration of pheny- intensivists for the treatment refractory status epilepticus. However, toin it is prudent to monitor blood pressure closely and to consider it is proconvulsant in some animal models  and may induce substantially slower infusion rates than the recommended maxi- subcortical epileptiform activity and bizarre movements [24,37]. Additive sedation, ital, etomidate and ketamine are unlikely frst-choice anaesthesia which might confound prompt return to baseline mental status af- induction drugs for epileptic patients. Sevofurane and desfurane are inhalation agents com- romuscular blockade, which might increase the risk of postopera- monly used in the clinical practice of anaesthesiology. Desfurane tive residual neuromuscular weakness, is a potential side-efect of is not epileptogenic even at high alveolar concentrations or during acute phenytoin administration to patients not taking it prior to hypocapnia [38,39]. If the diet will be maintained precipitating factors are rapidly increasing concentration and hy- during anaesthesia, considerations include limiting glucose admin- perventilation [40,43,44,45]. No sequelae of sevofurane-associated istration in drugs and fuids and monitoring serum glucose and epileptiform activity are reported. Isofurane, at present a less commonly longed administration has been reported to cause fatal metabolic used inhalation agent, also has anticonvulsant properties despite oc- derangement in a patient on the diet [22,23]. Both desfurane and isofurane have been used in the last-line treatment of super-refractory status epilepticus, although their use is controver- sial and presents a challenge in the intensive care setting . Anticonvulsant and proconvulsant effects Many narcotic analgesics used in anaesthesia care are potentially of anaesthetics proconvulsant [24,25,26,27,34]. Generally, although not uniformly, Many drugs used in anaesthesia have proconvulsant or anticonvul- this attribute is manifested at the high end or above the range used sant efects. Mechanisms postu- consistent with convulsive activity during anaesthesia’ applied in lated to mediate the proconvulsant actions of narcotic analgesics in- some reports that lack electroencephalography corroboration to de- clude interactions with opioid receptors, release of excitatory amino fne drugs that are administered during anaesthesia as epileptogen- acids and suppression of inhibitory intraneurons [46,47,48]. Another source of ambiguity is the extrapolation of observations tients with focal epilepsy, bolus doses of remifentanil and alfentanil from non-epileptic patients to patients with chronic intractable are used to trigger epileptiform activity during intraoperative map- epilepsy and vice versa. In fact, diferent responses to anaesthetic ping of epileptogenic parts of the brain [46,47,48,49]. Administra- drugs are observed even among populations of patients with dif- tion of bolus fentanyl is also epileptogenic in patient with epilepsy ferent types of epilepsy. However, in clinically relevant doses these narcotic analgesics in anaesthesia have both proconvulsant and anticonvulsant efects, are safely administered as part of anaesthesia care during epilepsy some have proconvulsant metabolites and some used to activate sei- surgery, as are intravenous morphine and hydromorphone for im- zure foci during epilepsy have also been used to treat status epilep- mediate postoperative analgesia [27,34]. The only procedure-specifc anaesthesia care issue for gener- electroencephalogram abnormalities used to map cortical epilep- al anaesthesia for subdural grid placement, as compared to general togenic foci. When brain mapping is to be performed to delineate anaesthesia for craniotomy for another indication, is to be aware of cortical seizure foci, anaesthesia technique is modifed to minimize rare instances in which grid placement may breach an aferent to this possibility. When the anaesthesia technique is sedation and brain mapping The surgical procedure for depth electrode placement is per- for seizure foci is planned, benzodiazepines are usually not admin- formed under general anaesthesia or with local anaesthesia and in- istered, even in the small doses typically used for anxiolysis. Choice of technique depends on patient factors ative infusions of propofol can be administered [29,34]. In either case, a stereotactic frame is suspending infusion 15 min prior to electroencephalography has placed before the patient comes to the operating theatre. Terefore a plan for mapping the best choice may be remifentanil or dexmedetomidine. Airway management strategies for When the anaesthesia technique is general anaesthesia and brain patients who will receive general anaesthesia afer frame placement mapping for seizure foci is planned, anaesthesia technique is also include preinduction awake fberoptic endoscopy-assisted endotra- modifed. The best technique is controversial and has not been cheal intubation, use of a laryngeal mask airway, endotracheal in- systematically evaluated. Several studies have demonstrated that tubation via an intubating laryngeal mask airway and endotracheal propofol, inhalation anaesthetics and nitrous oxide decrease inter- intubation using a glide scope. In contrast, a study of in- patient’s particular physical characteristics, airway exam, medical creasing depth of sevofurane and propofol anaesthesia, as assessed history and local expertise. Another ministration of potent inhalation agents and continue anaesthesia consideration is that brain shif, such as might be produced by ex- with a combination of nitrous oxide and narcotic analgesics in cessive hyperventilation during controlled ventilation, theoretically advance of cortical mapping. We inform adult patients of an in- could alter the position of targeted structures.