In his editorial, Dr. Panayiotopoulos expressed much concern about the proposed classification of focal seizures according to their manifestations. "Such a proposition defies the essence and the principal of any classification that requires an organization and a common language for communication."
Neglecting to rely upon expert opinion is a large error, he said. "The ILAE Commission could benefit by asking experts in basic and clinical science to provide a concise statement in their field of expertise as, for example, what are focal, myoclonic, or absence seizures, and their subtypes, their manifestations, and their possible pathophysiology."
Areas of disagreement should be "identified and stated clearly, with documentation of the reasons for it."
But this approach could throw the debate back into the turbulent waters of the last decades, Dr. Buchhalter said. The new proposal is just one in a long line of criteria adjustments – some of them accepted into use and many of them not.
"Before 1981, seizure classifications were based on semiology. Beginning then, though, things changed and we started to base classifications on EEG type. Then, as we gained knowledge about genetics and family history, we incorporated that information as well."
This led to an ILAE uproar – members said the system was too bulky and complicated, Dr. Buchhalter said. "A task force met and said this was just getting too confusing and that everything but indicators of focality or generalization should be stripped out. All the data on what the seizures looked like, family history, and genetics were all thrown out."
It wasn’t long before the complaints started. "Within 8 years, ILAE took a lot of heat," because of this oversimplified system. In 1986, there was a "paradigm shift," with the addition of information, such as developmental status, family history, and imaging findings. "We established measurable, objective criteria that recognized seizure types and syndromes as unique entities," Dr. Buchhalter said.
In another failed effort to simplify classification, Dr. Luders proposed a five-faceted semiology-based scheme. Seizures could be classified, he proposed, by localizing the epileptogenic zone and by seizure semiology, etiology, frequency, and medical comorbidities.
"All cases can be classified according to this five-dimensional system, even at an initial encounter when no detailed test results are available," he wrote in the German journal Der Nervenarzt. "Information from clinical tests such as MRI and EEG are translated into the best possible working hypothesis at the time of classification, allowing increased precision of the classification as additional information becomes available" (Nervenarzt 2006;77:961-9).
"I say forget all of these names and syndromes – you don’t have to use them," he said in an interview. "If you’re a general neurologist or psychiatrist who occasionally sees an epilepsy patient, these labels are very confusing. It’s much easier to handle [with the semiologic system], and this is the way we do it [at Case Medical Center]. It’s the same way that we classify any of the neurological diseases."
Dr. Luders’s suggestion was likewise unpopular, said both Dr. Buchhalter and Dr. Berg. And all three agreed on one thing: Change of any kind is difficult in a large group.
"When things like this are proposed, you have to factor in the emotional part," Dr. Buchhalter said. "People get used to concepts and don’t want to let them go."
Dr. Luders, Dr. Berg, Dr. Buchhalter, and Dr. Panayiotopoulos reported having no financial disclosures.