Epilepsy · Clinical pearls

Epilepsy Clinical Pearls

By Yash D. Shah, MD, MPH · Pediatric neurologist & epileptologist · Adapted from posts on X, 2020–2025

Over the years I've shared short takeaways from studies, talks and cases in epilepsy and clinical neurophysiology. Here they are in one place.

Choosing first-line medicines: SANAD II

The SANAD II study had some interesting results: lamotrigine (LTG) was effective and cost-effective as a first-line choice for focal epilepsy; the evidence did not support levetiracetam (LEV) or zonisamide (ZNS) as first-line for focal epilepsy; and valproate (VPA) did better than levetiracetam for generalized tonic-clonic seizures. [view on X]

Seizure cycles and forecasting

Epilepsy can be thought of as the cyclical recurrence of heightened seizure risk, with “pro-ictal” states lasting a few days that likely reflect slow fluctuations in cortical excitability. It's a fascinating basis for seizure forecasting (thanks to Dr. Vikram Rao for the talk). [view on X]

SUDEP risk

From a great talk: post-ictal generalized EEG suppression (PGES) is linked to increased SUDEP risk and to respiratory dysfunction. SSRI use was associated with less ictal central apnea (ICA) and post-convulsive central apnea (PCCA), suggesting a possible protective effect against SUDEP. The talk also covered the importance of TcpCO2 monitoring. [view on X]

MEG in children

Beyond the convincing data on magnetoencephalography (MEG), it was interesting to learn that it is well tolerated by pediatric patients and has good sensitivity. [view on X]

Learning from cases

I thoroughly enjoyed a beautifully written 1997 case of a newborn with stroke and seizures. The clinicians, including Dr. Paul Rosman, dissected every clinical point and backed each one with evidence. [view on X]

The Pellock epilepsy case discussion with Dr. Sarah Kelley taught me a lot about pediatric epilepsy, including amantadine, promising new SCN1A therapies and private academic practice. [view on X]

A difficult case I once brought to colleagues: a 6-year-old with refractory focal impaired-awareness seizures occurring only at night, with bifrontal onset on EEG, maxed out on phenytoin, lacosamide, CBZ and cannabidiol. [view on X]

The child had already failed valproate, levetiracetam, brivaracetam, oxcarbazepine and eslicarbazepine, with a negative epilepsy gene panel. The next steps were VNS and later RNS. [view on X]

Acute flaccid myelitis

From grand rounds on acute flaccid myelitis (AFM): cases spike every two years for reasons we don't yet understand, so it pays to be prepared with an up-to-date guideline and protocol. [view on X]

More than seizures

Neurologists and epilepsy doctors often lack formal training in recognizing the mental health challenges that come with epilepsy. Seizures are just the tip of the iceberg. [view on X]

This is general information, not medical advice. Please talk with your child's doctor about their care.