Treatment with antiepileptic medication and withdrawal in the context of NCC Antiepileptic treatment should be initiated if seizure activity is recurrent, irrespective of whether epileptic seizures occur within the setting of symptomatic cysticerci or calcifications. According to the latest guidelines of the ILAE92 treatment should Trichostatin A clinical trials already be initiated after the first epileptic seizure if an underlying lesion is present, or in the circumstances of a resource-poor setting, is suspected. Unfortunately, the choice of antiepileptic treatment is limited in subSaharan Africa with mainly phenobarbitone, phenytoin and carbamazepine available. Valproate is found rarely and often antiepileptic drugs are out of stock. Dosing and potential side effects are given in Table 1. Carbamazepine would be the drug of choice in generalised epilepsies with an obvious or assumed focal start as is the case with epileptic seizures related to NCC. Phenobarbitone and phenytoin can also be used for treatment of generalised epilepsy with a focal start, but have substantial side effects, especially the former, which are better avoided. Therefore, results on T. solium cysticercosis serology and/or neuroimaging may guide the choice towards the right antiepileptic drugs for people with epilepsy in areas endemic for T. solium taeniosis/ cysticercosis and should be sought for, if possible. As the majority of patients in sub-Saharan Africa do not have access to these diagnostics, antiepileptic treatment has to be started empirically and the response has to be monitored. If seizures still recur on sufficient doses, switching to another antiepileptic drug may be necessary. If possible the patient should be maintained on monotherapy. A recent study has shown that most patients with NCC-related epilepsy are well STI-571 web Controlled on monotherapy compared to those with epilepsy due to other reasons.53 It is selfevident that patients have to be informed about side effects of antiepileptic medication, especially the potentially ensuing tiredness, in order to increase compliance. Short follow-up visits at the epilepsy clinic are necessary. Prolonged usage of antiepileptic medication may have short- and long-term side effects. Hence, when a patient with epilepsy is in remission (free of seizures for some time) discontinuation of medication can bePathogens and Global HealthVOL .NO .WinklerNeurocysticercosis in sub-Saharan Africajustified. Controlled withdrawal of antiepileptic treatment in sub-Saharan Africa is important as the majority of patients may stop medication at once when the seizures have died down, which may lead to severe withdrawal seizures. There are no guidelines as to withdrawal of antiepileptic mediation in the context of NCC and therefore this has to be decided on a case-by-case basis. In neurological practice, discontinuation of antiepileptic treatment usually is considered in people with epilepsy who have been seizure-free for two years or longer. In the context of sub-Saharan Africa one year may be justified.25 The decision to withdraw antiepileptic mediation must weigh the risk of seizure recurrence against the benefits in terms of medical, emotional and social implication of treatment. The factors associated with a higher-than-average risk of seizure relapse include partial seizures, the presence of an underlying neurological condition or brain lesions and abnormalities on electroencephalogram at the time of withdrawal, among others.93 Predictors for remaining seizur.Treatment with antiepileptic medication and withdrawal in the context of NCC Antiepileptic treatment should be initiated if seizure activity is recurrent, irrespective of whether epileptic seizures occur within the setting of symptomatic cysticerci or calcifications. According to the latest guidelines of the ILAE92 treatment should already be initiated after the first epileptic seizure if an underlying lesion is present, or in the circumstances of a resource-poor setting, is suspected. Unfortunately, the choice of antiepileptic treatment is limited in subSaharan Africa with mainly phenobarbitone, phenytoin and carbamazepine available. Valproate is found rarely and often antiepileptic drugs are out of stock. Dosing and potential side effects are given in Table 1. Carbamazepine would be the drug of choice in generalised epilepsies with an obvious or assumed focal start as is the case with epileptic seizures related to NCC. Phenobarbitone and phenytoin can also be used for treatment of generalised epilepsy with a focal start, but have substantial side effects, especially the former, which are better avoided. Therefore, results on T. solium cysticercosis serology and/or neuroimaging may guide the choice towards the right antiepileptic drugs for people with epilepsy in areas endemic for T. solium taeniosis/ cysticercosis and should be sought for, if possible. As the majority of patients in sub-Saharan Africa do not have access to these diagnostics, antiepileptic treatment has to be started empirically and the response has to be monitored. If seizures still recur on sufficient doses, switching to another antiepileptic drug may be necessary. If possible the patient should be maintained on monotherapy. A recent study has shown that most patients with NCC-related epilepsy are well controlled on monotherapy compared to those with epilepsy due to other reasons.53 It is selfevident that patients have to be informed about side effects of antiepileptic medication, especially the potentially ensuing tiredness, in order to increase compliance. Short follow-up visits at the epilepsy clinic are necessary. Prolonged usage of antiepileptic medication may have short- and long-term side effects. Hence, when a patient with epilepsy is in remission (free of seizures for some time) discontinuation of medication can bePathogens and Global HealthVOL .NO .WinklerNeurocysticercosis in sub-Saharan Africajustified. Controlled withdrawal of antiepileptic treatment in sub-Saharan Africa is important as the majority of patients may stop medication at once when the seizures have died down, which may lead to severe withdrawal seizures. There are no guidelines as to withdrawal of antiepileptic mediation in the context of NCC and therefore this has to be decided on a case-by-case basis. In neurological practice, discontinuation of antiepileptic treatment usually is considered in people with epilepsy who have been seizure-free for two years or longer. In the context of sub-Saharan Africa one year may be justified.25 The decision to withdraw antiepileptic mediation must weigh the risk of seizure recurrence against the benefits in terms of medical, emotional and social implication of treatment. The factors associated with a higher-than-average risk of seizure relapse include partial seizures, the presence of an underlying neurological condition or brain lesions and abnormalities on electroencephalogram at the time of withdrawal, among others.93 Predictors for remaining seizur.
