The Epilepsies: Seizures, Syndromes and Management

The Epilepsies, an update of A Clinical Guide to Epileptic Syndromes and their Treatment (2002) through the same publisher, continues to force the pace. I still find many of my colleagues talking (and thinking) of grand mal and petit mal: and such clinicians will have difficulty conceptualizing the epilepsies rather than epilepsy. The truth is that this is ‘state of the art’. Everyone must now say to themselves, ‘Is it epilepsy?’; ‘Which seizure type?’ and last of all, and most challenging, ‘Which epilepsy?’. In practice much has to be done in retrospect. The ‘classification pending’ file is large in my practice. Were there really localizing features? What is to be made of the varying asymmetry on the EEG? However, for most, with the passing of a few months, clarification of the history especially, and where appropriate a repeat EEG, the definition of the epilepsy becomes possible. Although one would expect much dogma in a book which defines a classification, there is very little. The emphasis is on a pragmatic approach around a classification that is expected to change. The necessarily pragmatic approach of clinical practice is compared with the structure of scientific classification. Lumpers and splitters are compared to botanists and gardeners, who in turn are compared to scientists and clinicians. Tom Panayiotopoulos writes ‘The botanists, like all scientists, need a taxonomy, other gardeners, like all practising physicians need something to use in daily work’. Hughlings Jackson (1874) is quoted in the context of this debate as indicating that the scientific classification (taxonomy) is ‘for the better organisation of existing knowledge and for discovering the relations of new facts; its principles are methodological guides to further investigation to great utilitarian value, but not directly’. This remains true today. I think all of us in paediatric neurological practice acknowledge that the definition of the phenomenon in small parts allows it better to be studied. Then as new knowledge emerges we may—or may not as the case may be—realize that many of the small parts are part of the same continuum; that a particular variety of phenotypes may represent many genotypes and indeed that a genotype may lead to many phenotypes. The Epilepsies is more than a comprehensive definition of seizure types and EEG appearances. It contains lists of practice points and pitfalls that will be useful even to the experienced. The colour coding is at times imprecise (red for the pitfalls and blue for the practice points), but then there is bound to be overlap between these two areas anyway. The yellowish headings seem not to represent any particular message and that particular colour might usefully be dropped next time round. Meanwhile we have a book not to be kept on the shelf but rather to be thumbed regularly for details of the challenging children we see, to be checked almost day by day to see to what extent their epilepsy might be defined. We should try to link this in our resource-stretched health service, to computerized databases, to audit and research and to the best approach to treatment, prognosis and so on. The advantage of multicentre input could readily be pursued—and that is not to mention a fruitful liaison with the neurogeneticists. Nine of the fourteen chapters in the book define some eighty syndromes (this exercise is not for the faint-hearted). However, probably 80% of the children have an epilepsy under the twenty commonest headings (the rest requiring a more specialist approach). An editorial point concerns children ‘suffering from’ epilepsy—an expression I dislike. They may ‘have’ an epilepsy but we can reassure ourselves that 80% will go into remission. If we all take the content of this book seriously and work together to advance knowledge and improve our approach, any ‘suffering’ will diminish as time goes by. All paediatric neurologists and paediatricians with special responsibility for epilepsy, and neurodevelopmental paediatricians, should have a copy and strive to put the examples into practice.