Abstracts

Rationale: The interrater agreement on the diagnosis of a first seizure in childhood is just moderate (J Neurol Neurosurg Psychiatry 2004;75:241-245), but when it comes to the decision of when to start anti-epileptic drugs in children, evidence in literature and the majority opinion are well aligned: after a second unprovoked seizure (J Child Neurol 2008;23:507-515). However, in individuals with single, few or infrequent seizures, there will be more doubt and uncertainty about starting and stopping treatment. For most adults, the decision to withdraw treatment also falls into a grey area of uncertainty (Epilepsia 2006;47:58-61). This study investigates neurologists' reported decisions about treatment of adults with (suspected) epilepsy, for better understanding of the uncertainty in current practice in (suspected) epilepsy. Methods: An online survey was developed. 1100 members of the Dutch Neurological Society were invited to participate. Currently, almost 10% (n=98) has responded, among which were neurologists-in-training (29%), general neurologists (31%) and neurologists specialized as clinical neurophysiologists (27%), pediatric neurologists (9%), or epileptologists (4%). Results: None of the neurologists would start medication in an adult after a first seizure when the MRI and EEG are both normal, but 49% would start medication when 2 seizures occur on one day, 70% when the MRI is normal but the EEG contains epileptiform discharges, and 63% when the MRI is abnormal and the EEG is normal. When a recurrent seizure occurs after 6, 12 or 24 months, 87%, 54% and 14% of the neurologists would start medication respectively. Figure 1 illustrates when neurologists would prefer to stop treatment (if no seizures occurred during that time), in three different cases: when the EEG and MRI are normal (1), when there are epileptiform discharges in the EEG (2), and when there is an underlying MRI abnormality (3). After two years of seizure freedom, 44% of the neurologists would immediately discontinue medication, 25% would make an EEG, and 30% would stop medication immediately if the patient wishes so. Conclusions: There still seems to be a lack of consensus about when to start treatment in (suspected) epilepsy, mainly when two ‘first' seizures occur on one day and when a recurrent seizure occurs at 12 months after the first seizure. Also, there is no consensus on when to stop medication and whether or not to make an EEG before stopping medication. More knowledge about the influence of patient factors and the use of different diagnostic tools (EEGs in particular) on management decisions may lead to better guidelines to enhance consensus on when to start or stop treatment.