Medical Conditions. Neurology (Seizures/Epilepsy)

Transcription

1 Medical Conditions Neurology (Seizures/Epilepsy)

2 MEDICAL CONDITIONS NEUROLOGY (SEIZURES/EPILEPSY)/2015 NEUROLOGY (SEIZURES AND EPILEPSY) SEIZURES AND EPILEPSY The well-educated and well-motivated law enforcement officer (LEO) with a history of seizure or epilepsy may be capable of safe and effective job performance. However, a seizure while on duty may result in sudden incapacitation jeopardizing the LEO s ability to safely and effectively perform essential job functions thereby creating a safety risk for the public, co-workers, or the LEO. BROAD CATEGORIES The following broad classifications and subsequent subclassifications of seizures used in this document are consistent with medical literature and international professional society classification schemes current as of mid (See Appendix A for definition and classification of seizure disorders.) Provoked Seizures Provoked seizures are ones for which a transient precipitating factor can be identified and removed. Provoked Seizures with Low Risk a of Recurrence For the following situations, once the underlying cause has resolved and/or is being appropriately treated, restriction as related solely to the seizure is not recommended. The underlying cause needs to be evaluated regarding possible effect on safe and effective essential task performance. Additionally, the nature of the underlying cause for the seizure should be assessed for possible re-occurrence while performing job functions as this may necessitate restriction of job activities. If the treating physician prescribes anti-epileptic drugs, the LEO should be evaluated according to Provoked Seizure with High Risk of Recurrence (see below). Examples of provoked seizures with a low risk of recurrence include: Medication-associated Transient toxin-exposure-associated Transient metabolic abnormality-associated Eclampsia-associated Drug or alcohol withdrawal-associated Immediately at the time of or less than seven (7) days following head trauma with no intracranial hemorrhage Provoked Seizures with High Risk of Recurrence Persons who have had a single seizure provoked by one of the following conditions have a risk of recurrent seizure equivalent to that found for persons with epilepsy. 1 Thus, they should be assessed by the same guidelines as persons with a formal diagnosis of epilepsy. Examples of provoked seizures with a high risk of recurrence include those occurring in the context of: More than seven (7) days following head trauma 2 Intracerebral or intracranial hemorrhage Brain infection encephalitis, bacterial meningitis, abscess, cysticercosis Stroke ischemic or hemorrhagic Brain surgery Structural brain lesion such as brain tumor Occurrence during an active phase of an autoimmune disease a Low risk is defined here as being no more than approximately 1% above the general population risk for having a seizure. ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers 1

3 NEUROLOGY (SEIZURES/EPILEPSY)/2015 MEDICAL CONDITIONS Single Unprovoked Seizure Unprovoked seizures are defined as having no identifiable precipitant following evaluation including lab studies, brain MRI, EEG, and evaluation by a neurologist with expertise in seizure evaluation and management. Normal EEG, Labs, and Brain MRI Persons who have been seizure-free for 5 years on or off anti-epileptic drugs approach the risk of seizure for persons who have never had a seizure. Persons with single unprovoked seizure may be able to safely and effectively perform essential LEO job functions if they having been seizure-free for the most recent consecutive 5 years. Abnormal EEG and/or Brain MRI Persons who have had an unprovoked seizure and an abnormal EEG (consistent with an eliptogenic pattern) or abnormal brain MRI should be considered as having epilepsy (see below). Epilepsy Epilepsy is defined as a disease of the brain 1 (see also Appendix A) and is characterized by any of the following: Two or more unprovoked seizures more than 24 hours apart; OR One unprovoked seizure and a probability of further seizures similar to the general recurrence risk (at least 60%) after two unprovoked seizures, occurring over the next 10 years; OR Diagnosis of an epilepsy syndrome. Controlled Epilepsy Persons with epilepsy may be able to safely and effectively perform essential LEO job functions if they: have been seizure-free for the most recent consecutive 10 years; AND take an on-going regimen of seizure medications; AND are not having any side effects from the anticonvulsant medication that would adversely affect safe and effective performance of essential LEO job functions as noted in the Medications Chapter. (Note: A neuropsychology assessment may be used to evaluate any cognitive impairment caused by the medications or associated with the seizure disorder. 3,4,5,6 ) Resolved Epilepsy 1 A person s epilepsy is considered resolved if they: are past the applicable age of an age-dependent epilepsy syndrome; OR have not had a seizure for the most recent 10 consecutive years; AND are not taking any seizure medications for at least the most recent 5 consecutive years. Seizures Associated with Withdrawal of Anti-Epileptic Drugs in Persons with a Diagnosis of Epilepsy Persons who have stopped anti-epileptic drugs (AEDs) either under medical management or on their own and have a recurrent seizure prompting recommencing medications may be able to safely and effectively perform essential LEO job functions if they either: 1) have been seizure-free for the most recent consecutive 10 years; AND are taking an on-going regimen of seizure medications; AND are not having any side effects from the anticonvulsant medication that would adversely affect safe and effective performance of essential LEO job functions as noted in the Medications Chapter; OR 2) have not had a seizure for the most recent 10 consecutive years; AND are not taking any seizure medications for at least the most recent 5 consecutive years. 7,8 2 ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers

4 MEDICAL CONDITIONS NEUROLOGY (SEIZURES/EPILEPSY)/2015 Seizures in Association with Surgical Treatment Epilepsy Although many people who have undergone surgical treatment for refractory temporal lobe epilepsy achieve high rates of seizure freedom, the risk of recurrent seizures is high with or without anticonvulsant therapy. Persons who had surgical treatment for epilepsy may be able to safely and effectively perform essential LEO job functions if they either: 1) have been seizure-free for the most recent consecutive 10 years following surgery; AND are taking an on-going regimen of seizure medications; AND are not having any side effects from the anticonvulsant medication that would adversely affect safe and effective performance of essential LEO job functions as noted in the Medications Chapter; OR 2) have not had a seizure for the most recent 10 consecutive years following surgery; AND are not taking any seizure medications for at least the most recent 5 consecutive years. 9,10 INITIAL EVALUATIONS LEOs recently diagnosed with any type of seizure should have an initial evaluation with a neurologist. LEOs with seizures should have appropriate blood work, a brain MRI, and a sleep-deprived EEG unless there is no clear reason to do so (i.e., a type of provoked seizure with low risk of recurrence). On-going Monitoring Any LEO cleared to full duty following a seizure leading to restrictions should have on-going monitoring, at least annually, for manifestations of any seizure activity or seizure triggers. LEOs who are on a medication regimen should have levels verified on a regular basis for those medications for which levels can be obtained and should be monitored for adverse effects. The LEO with a history of seizure should provide the police physician with copies of office notes and/or a medical report from his or her treating physician after each visit or change in medication (see Appendix B). The LEO with a seizure disorder should be evaluated by the police physician at least annually. The LEO must immediately notify the police physician of any seizure activity, loss of consciousness, impaired cognition, or change in medical regimen. The police physician will decide whether restrictions are indicated. The LEO must seek medical attention and undergo diagnostic evaluation including anti-epileptic drug level determination (if applicable). ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers 3

5 NEUROLOGY (SEIZURES/EPILEPSY)/2015 MEDICAL CONDITIONS APPENDIX A: BACKGROUND INFORMATION ON SEIZURES 1. Introduction Epidemiological, molecular, biological, and genomic understanding of seizures and epilepsy has been advancing rapidly over the past 50 years leading to variation in the manner in which scientific reports are focused and the basic terminology used to discuss the entities being studied. For over the past 50 years, the International League Against Epilepsy (ILAE has had the role of defining terminology. Thus, this discussion will follow definitions promulgated by ILAE. As noted, however, terminology has evolved over that time, leading to difficulty in pooling or comparing conclusions from various studies. Epilepsy is a disorder of the brain characterized by an enduring predisposition to generate epileptic seizures, and by the neurobiologic, cognitive, psychological, and social consequences of this condition. The definition of epilepsy requires the occurrence of at least one epileptic seizure. 11 In 2010, the ILAE Commission revised the terminology and concepts for definition and classification of seizures and epilepsy as follows: an epileptic seizure is a transient occurrence of signs and/or symptoms due to abnormal excessive or synchronous neuronal activity in the brain. 12 The ILAE recently updated the definition of epilepsy as a disease of the brain characterized by any of the following conditions: 1) at least two unprovoked seizures more than 24 hours apart; 2) one unprovoked seizure and a probability of further seizures similar the general recurrence risk (at least 60%) after two unprovoked seizures, occurring over the next 10 years; and 3) diagnosis of an epilepsy syndrome Classification of Epileptic Seizures In 2010, the ILAE adopted an updated schema for classification of seizures, partly as a result of advances in neuroimaging, biochemical understanding, and genomics. 12 i. Focal Seizures Focal seizures originate within a network of neurons limited to one hemisphere of the brain and the signs and resulting symptoms depend on precisely where the disruptions in brain activity occur. Focal seizures may have motor, sensory, autonomic, or other symptoms (e.g., hallucinations, déjà vu). Focal seizures are sub-categorized as with or without impairment of consciousness or awareness. ii. Generalized Seizures Generalized seizures originate within a network of neurons that distribute to both hemispheres of the brain. They may vary considerably in their clinical features, from subtle alterations in consciousness to body convulsions. Generalized seizures are categorized as the following: a) Tonic-clonic (in any combination) A type of seizure that starts with a sudden loss of consciousness and generalized stiffening of body (tonic phase) followed by contraction of the muscles (clonic phase). b) Absence Often common in childhood, absence (previously called petit mal) seizures are generally brief lapses in awareness. Some clonic motor activity may occur. 1) Typical 2) Atypical 3) Absence with special features a) Myoclonic absence b) Eyelid myoclonia c) Myoclonic Characterized by sudden and brief muscular contractions, myoclonic seizures may involve any group of muscles and can resemble tremors. 1) Myoclonic 2) Myoclonic atonic 3) Myoclonic tonic d) Clonic Consists of alternating successions of contractions and partial relaxations of a muscle. 4 ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers

6 MEDICAL CONDITIONS NEUROLOGY (SEIZURES/EPILEPSY)/2015 e) Tonic Brief seizures involving a sudden onset of increased muscle tone. f) Atonic Characterized by a sudden loss of muscle tone, atonic seizures begin suddenly and cause the individual, if standing, to fall quickly to the floor. iii) Unknown (epileptic spasms) 3. Epilepsy Syndromes A number of different syndromes of epilepsy have been differentiated with various implications in terms of evaluating persons for effect on safe and effective performance of essential law enforcement job functions: Juvenile myoclonic epilepsy a generalized seizure disorder that appears in early adolescence and is usually characterized by bilateral myoclonic jerks. Remission is uncommon. Lennox-Gastaut syndrome occurs in children and is associated with multiple seizure types. The epilepsy is usually poorly controlled. Mesial temporal lobe epilepsy syndrome usually associated with complex partial seizures and with pathology to the hippocampus. Is sometimes refractory to treatment with anticonvulsants, but tends to respond well to surgical intervention. Other syndromes associated with genetic abnormalities, most of which will have significant problems from the underlying syndrome that may also adversely affect the ability to safely and effectively perform essential law enforcement job functions. 4. Risk of Recurrence A primary issue of concern in assessing the safety of an LEO with a seizure disorder for performing essential law enforcement job functions is prediction of the risk of a recurrent seizure. Single Unprovoked Seizure Several studies have looked at the cumulative risk of recurrence of seizure following a single unprovoked seizure. 13 Data from 5 studies involving adult patients with single unprovoked seizures were reported as the cumulative risk of recurrence of seizure at specified follow-up periods 14-18: The additional risk of recurrence does not fall close to a 1% risk level until at least year 5 or beyond, 15,16,17 other than in the Hopkins s and Elwes Author Year 1 Year 2 Year 3 Year 4 Year 5 reports. 14,18 Additionally, it should be Hopkins mentioned that treatment with anticonvulsants Annegers after a single unprovoked seizure does not significantly reduce relapse. According to the First Seizure Trial Group (1997), the treatment of first tonic-clonic seizure does not improve the prognosis of epilepsy. 19 In a randomized trial of treated and untreated patients, 87% of treated patients had no seizures for a year; 68% had no seizures for 2 years; and in treated patients, 83% and 60% achieved similar endpoints. Epilepsy In one large study, after 9 years from the index seizure, the 5 year remission rate was an average of 71%. 7 Another study found the relapse rate in adults after withdrawal of AEDs was 39% to 74% at 1 year, and 35% to 57% at 2 years. 8 Hauser 16 Cleland 17 Elwes ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers 5

7 NEUROLOGY (SEIZURES/EPILEPSY)/2015 MEDICAL CONDITIONS The risk of recurrence after one or more seizures is related to etiology and other factors. There is no reliable risk of recurrence applicable to all individuals with a seizure disorder. Adapted from Seizure disorders and CMV driver safety FMCSA Seizure Recurrence in the Setting of Withdrawal of Anti-epileptic Drugs About 1/3 of patients seizure-free on anti-epileptic drugs (AEDs) will relapse AED withdrawal probably increases the risk of seizures during the withdrawal period, and may increase the risk in the 1 to 2 years after withdrawal, although there is a possibility that these patients would have relapsed nonetheless. Also, certain patients who have recurrent seizures do not achieve control when AEDs are restarted. Some risks of recurrence can be identified. According to Specchio and Beghi, The relapse rate was highest in the first 12 months (especially in the first 6 months) after withdrawal and tended to decrease thereafter. Based on a previously published meta-analysis of data published up to 1992, the pooled relapse risk was 25% (95% CI 21-30%) at 1 year and 29% (95% CI 24-34%) at 2 years after AED withdrawal. The factors associated with a higher-than-average risk of seizure relapse included adolescent-onset epilepsy, partial seizures, the presence of an underlying neurological condition and abnormal EEG findings at the time of AED withdrawal in children Sequelae of Seizures and Epilepsy At present, there is reasonable evidence of structural and functional adverse effects on the brain from epileptic electrical discharges, particularly those that involve greater parts of the brain. Thus, in performing fitness-for-duty evaluations of persons with either a relatively recent single seizure of any class outlined above (or of persons with epilepsy fitting a category above that would not be recommended for restriction), the evaluation should include a specific focus on functions such as short- and long-term memory, executive functions, and emotional control. The adverse effects of temporal lobe epilepsy and surgical treatment on memory have been known and studied for decades. 25 Frontal lobe epilepsy and surgical treatment are also associated with neuropsychological aberrancies that may have adverse effects on safe and effective performance of essential law enforcement job functions. 26 As the current diagnosis of epilepsy promulgated by the ILEA implies, psycho-social ramifications of the diagnosis of epilepsy may represent a significant burden on the person in question. While specific guidelines do not exist for correlating a seizure disorder (single unprovoked seizure not in a remote time or epilepsy) with psychological effect and possible adverse effect on safe and effective performance of essential law enforcement job functions, fitness-for-duty evaluations should take this aspect into consideration. 6 ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers

8 MEDICAL CONDITIONS NEUROLOGY (SEIZURES/EPILEPSY)/2015 APPENDIX B: PHYSICIAN EVALUATION FORM FOR PERSONS WITH SEIZURES I am a board-certified neurologist or physician (MD or DO) knowledgeable in the diagnosis and treatment of seizure disorders. My credentials as a physician knowledgeable about epilepsy are as follows (or attach CV): I have evaluated and/or provided care to the following person: Name: Date first evaluated: Date last seen: DOB: Please provide all outpatient and in-patient medical record(s) of the last 10 years or since date of diagnosis (whichever is shorter). Please provide detailed clinical information on each of the following characteristics of the person s seizures: Aura or prodrome Seizure onset: Description of event (include possible triggers) Ictal manifestation Post-ictal period Dates of all seizures Dates of any other unexplained events or loss of consciousness Report of most recent EEG is attached. Report of most recent MRI is attached. Date of first seizure: Approximate seizure frequency: Seizure etiology: Date of most recent seizure: ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers 7

9 NEUROLOGY (SEIZURES/EPILEPSY)/2015 MEDICAL CONDITIONS Has your patient had any history of suicide attempt, suicidal ideation, substance abuse, manic episode, psychosis symptoms and/or psychiatric hospitalization in the past 5 years? Yes No Has your patient had any symptom of mood disorder, depression or bipolar disease, or psychosis or substance abuse in the past 5 years? Yes No Current medications (including OTC and supplements), with dosage and frequency: Changes in medications in the past 5 years and reasons for changes: Please indicate which category below applies to the seizure disease of the applicant: provoked seizure single unprovoked seizure epilepsy Anti-epileptic Drugs Date: Drug: Serum level: Therapeutic range: Date: Drug: Serum level: Therapeutic range: Has LEO demonstrated compliance with treatment regimen? Yes No (Note: non-compliance may require frequent monitoring of drug levels until sustained compliance demonstrated.) Does the LEO have medication-related symptoms or does the treatment regimen interfere in any way with performance of essential functions of the job. If so, please specify. [Note, the LEO agency should have provided the treating physician with a list of essential LEO job functions.] Has the LEO been educated in his/her seizure disorder and has he/she been thoroughly informed of the risk of recurrence and the importance of treatment compliance? Yes No 8 ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers

10 MEDICAL CONDITIONS NEUROLOGY (SEIZURES/EPILEPSY)/2015 Please provide additional information, not included above, that may be helpful to the police physician. Signature of Physician Date Printed Name of Physician Telephone ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers 9

11 NEUROLOGY (SEIZURES/EPILEPSY)/2015 MEDICAL CONDITIONS REFERENCES 1. Fisher RS, Acevedo C, Arzimanoglou A, et al. ILAE official report: a practical clinical definition of epilepsy. Epilepsia. 2014;55(4): Available at: Accessed February 23, Annegers JF, Hauser WA, Coan SP, Rocca WA. A population-based study of seizures after traumatic brain injuries. N Engl J Med. 1998;338:20-1. Available at: Accessed February 23, Phabphal K, Kanjanasatien J. Montreal Cognitive Assessment in cryptogenic epilepsy patients with normal Mini-Mental State Examination scores. Epileptic Disord. 2011;13(4): Pérez-Mojica D. A-42Utility of the Montreal Cognitive Assessment (MoCA) Spanish version in detecting cognitive impairment in a Puerto Rican temporal lobe epilepsy (TLE) sample. Arch Clin Neuropsychol. 2014;29(6): Aarts HP, Binnie CD, Smit AM, Wilkins AJ. Selective cognitive impairment during focal and generalized epileptiform EEG activity. Brain. 1984;107(Pt 1): Dikmen SS, Temkin NR, Miller B, winn HR. Neurobehavioral effects of phenytoin prophylaxis of posttraumatic seizures. JAMA. 1991;265(10): Cockerell OC, Johnson AL, Sander JW, Hart YM, Shorvon SD. Remission of epilepsy: results from the National General Practice Study of Epilepsy. Lancet. 1995;346(8968): Specchio LM, Beghi E. Should antiepileptic drugs be withdrawn in seizure-free patients? CNS Drugs. 2004;18(4): Wiebe S, Blume WT, Girvin JP, Eliasziw M; Effectiveness and Efficiency of Surgery for Temporal Lobe Epilepsy Study Group. A randomized, controlled trial of surgery for temporal-lobe epilepsy. N Engl J Med. 2001;345(5): Available at: org/doi/full/ /nejm #t=articletop. Accessed February 23, Kim YD, Heo K, Park SC, et al. Antiepileptic drug withdrawal after successful surgery for intractable temporal lobe epilepsy. Epilepsia. 2005;46(2): Fisher RS, Boas WVE, Blume W, et al. Epileptic seizures and epilepsy: definitions proposed by the International League Against Epilepsy (ILAE) and the International Bureau for Epilepsy (IBE). Epilepsia. 2005;46(4): Available at: wiley.com/doi/ /j x/pdf. Accessed February 23, Berg AT, Berkovic SF, Brodie MJ, et al. Revised terminology and concepts for organization of seizures and epilepsies: report of the ILAE Commission on Classification and Terminology, Epilepsia. 2010;51(4): Available at: onlinelibrary.wiley.com/doi/ /j x/pdf. Accessed February 23, Berg AT, Shinnar S. The risk of seizure recurrence following a first unprovoked seizure: a quantitative review. Neurology. 1991;41(7): Hopkins A, Garman A, Clarke C. The first seizure in adult life. Value of clinical features, electroencephalography, and computerized tomographic scanning in prediction of seizure recurrence. Lancet. 1988;1(8588): Annegers JF, Shirts SB, Hauser WA, Kurland LT. Risk of recurrence after an initial unprovoked seizure. Epilepsia. 1986;27(1): Hauser WA, Rich SS, Annegers JF, Anderson VE. Seizure recurrence after a 1st unprovoked seizure: an extended follow-up. Neurology. 1990;40(8): Cleland PG, Mosquera I, Steward WP, Foster JB. Prognosis of isolated seizures in adult life. Br Med J (Clin Res Ed). 1981;283(6303):1364. Available at: Accessed February 23, Elwes RDC, Chesterman P, Reynolds EH. Prognosis after a first untreated tonic-clonic seizure. Lancet. 1985; 326(8458): First Seizure and Trial Group. Randomized clinical trial on the efficacy of antiepileptic drugs in reducing the risk of relapse after a first unprovoked tonic-clonic seizure. Neurology. 1993;43(3 Pt 1): Chadwick D, Taylor J, Johnson T. Outcomes after seizure recurrence in people with well-controlled epilepsy and the factors that influence it. The MRC Antiepileptic Drug Withdrawal Group. Epilepsia. 1996;37(11): Schmidt D, Löscher W. Uncontrolled epilepsy following discontinuation of antiepileptic drugs in seizure-free patients: a review of current clinical experience. Acta Neurol Scand. 2005;111(5): ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers

12 MEDICAL CONDITIONS NEUROLOGY (SEIZURES/EPILEPSY)/ Prognostic index for recurrence of seizures after mission of epilepsy. Medical Research Council Antiepileptic Drug Withdrawal Study Group. BMJ. 1993;306(6889): Available at Accessed February 23, Sirven JI, Sperling M, Wingerchuk DM. Early versus late antiepileptic drug withdrawal for people with epilepsy in remission. Cochrane Database Syst Rev. 2001;(3):CD Schiller Y. Seizure relapse and development of drug resistance following long-term seizure remission. Arch Neurol. 2009;66(10): Hoppe C, Elger CE, Helmstaedter C. Long-term memory impairment in patients with focal epilepsy. Epilepsia. 2007;48 Suppl 9: Patrikelis P, Angelakis E, Gatzonis S. Neurocognitive and behavioral functioning in frontal lobe epilepsy: a review. Epilepsy Behav. 2009;14(1): Additional Resources Guidance/Standards Federal Aviation Administration. Guide for Aviation Medical Examiners. Published December 6, Available at: about/office_org/headquarters_offices/avs/offices/aam/ame/guide/app_process/app_history/item18/l/. Accessed February 23, Federal Motor Carrier Safety Administration. Medical Examiner Handbook. Published March 18, Available at: fmcsa.dot.gov/documents/fmcsamedicalexaminerhandbook-2014mar18.pdf. (Update in process.) Federal Motor Carrier Safety Administration. Expert Panel Recommendations: Seizure Disorders and Commercial Motor Vehicle Driver Safety. Published October 15, Available at: MEP-Recommendations-v2-prot.pdf. Accessed February 23, Federal Motor Carrier Safety Administration. Medical Review Board Meeting Summary January 28, Available at: www. mrb.fmcsa.dot.gov/documents/fin_meet_min_jan28_2008mrb_meet_revised pdf. Accessed February 23, State of California. Neurology. Available at: Accessed February 23, National Fire Protection Association. Standard on Comprehensive Occupational Medical Program for Fire Departments. Published December 12, Available at: Accessed February 23, Journal Articles/Other Publications Annegers JF, Hauser WA, Elveback LR. Remission of seizures and relapse in patients with epilepsy. Epilepsia. 1979;20(6): Annegers JF, Shirts SB, Hauser WA, Kurland LT. Risk of recurrence after an initial unprovoked seizure. Epilepsia. 1986;27(1): Berg AT, Shinnar S. Relapse following discontinuation of antiepileptic drugs: a meta-analysis. Neurology. 1994;44(4): Berg AT, Shinnar S. The risk of seizure recurrence following a first unprovoked seizure: a quantitative review. Neurology. 1991;41(7): Beydoun A, Passaro EA. Appropriate use of medications for seizures. Guiding principles on the path of efficacy. Postgrad Med. 2002;111(1):69-70, 73-8, Britton JW. Antiepileptic drug withdrawal: literature review. Mayo Clin Proc. 2002;77(12): Callaghan N, Garrett A, Goggin T. Withdrawal of anticonvulsant drugs in patients free of seizures for two years. A prospective study. N Engl J Med. 1988;318(15): Chadwick DW. Driving restrictions and people with epilepsy. Neurology. 2001;57(10): Drazkowski JF. Management of the social consequences of seizures. Mayo Clin Proc. 2003;78(5): Eadie M. The single seizure. To treat or not to treat. Drugs. 1997: 54(5): Gastaut H, Zifkin BG. The risk of automobile accidents with seizures occurring while driving: relation to seizure type. Neurology. 1987;37(10): Gibberd FB, Bateson MC. Sleep epilepsy: its pattern and prognosis. Br Med J. 1974;2(5916): ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers 11

13 NEUROLOGY (SEIZURES/EPILEPSY)/2015 MEDICAL CONDITIONS Hansotia P. Automobile driving and epilepsy: a medical perspective. Wis Med J. 1991;90(3): Hauser WA, Chokroverty S, Dawson D, et al. Task force IV report: Episodic neurologic conditions II. In: Washington Consulting Group, ed. Conference on Neurological Disorders and Commercial Drivers. Washington DC: Office of Motor Carriers; 1988: Krauss GL, Krumholz A, Carter RC, Li G, Kaplan P. Risk factors for seizure-related motor vehicle crashes in patients with epilepsy. Neurology. 1999;52(7): Krumholz A, Fisher RS, Lesser RP, Hauser WA. Driving and epilepsy. A review and reappraisal. JAMA. 1991;265(5): Lings S. Increased driving accident frequency in Danish patients with epilepsy. Neurology. 2001;57(3): Musicco M, Beghi E, Solari A, Viani F. Treatment of first tonic-clonic seizure does not improve the prognosis of epilepsy. First Seizure Trial Group (FIRST Group). Neurology. 1997;49(4): Prego-lopez M, Devinsky O. Evaluation of a first seizure. Is it epilepsy? Postgrad Med. 2002;111(1):34-6, Prognostic index for recurrence of seizures after remission of epilepsy. Medical Research Council Antiepileptic Drug Withdrawal Study Group. BMJ. 1993;306(6889): Reynolds EH, Trimble MR. Adverse neuropsychiatric effects of anticonvulsant drugs. Drugs. 1985;29(6): Sander JW. Some aspects of prognosis in the epilepsies: a review. Epilepsia. 1993;34(6): Sanders JW, Shorvon SD. Remission periods in epilepsy and their relation to long-term prognosis. In: Wolf P, Dam M, Janz D, Freifuss FF, ed. Advances in Epileptology: XV Epilepsy International Symposium. New York, NY: Raven Press; 1987: Schiller Y, Cascino GD, So EL, Marsh WR. Discontinuation of antiepileptic drugs after successful epilepsy surgery. Neurology. 2000;54(2): Schmidt D, Gram L. A practical guide to when (and how) to withdraw antiepileptic drugs in seizure-free patients. Drugs. 1996;52(6): Shorvon SD. Epidemiology, classification, natural history, and genetics of epilepsy. Lancet. 1990:336(8787):93-6. Sirven JI. Demystifying seizures and epilepsy: introduction to the symposium on seizures. Mayo Clin Proc. 2002;77(9): Sirven JI. Antiepileptic drug therapy for adults: when to initiate and how to choose. Mayo Clin Proc. 2002;77(12): Spencer SS. Long-term outcome after epilepsy surgery. Epilepsia. 1996;37(9): Thurman DJ, Beghi E, Begley CE, et al. Standards for epidemiologic studies and surveillance of epilepsy. Epilepsia. 2011;52 Suppl 7:2-26. Verrotti A, Trotta D, Salladini C, Morgese G, Chiarelli F. Risk factors for recurrence of epilepsy and withdrawal of antiepileptic therapy: a practical approach. Ann Med. 2003;35(3): Weiss GH, Feeney DM, Caveness WF, et al. Prognostic factors for the occurrence of posttraumatic epilepsy. Arch Neurol. 1983;40(1): ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers