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Epilepsy is a potentially devastating brain disorder characterized by a predisposition to spontaneous epileptic seizures. In patients with medically refractory epilepsy, new non-pharmacological therapeutic approaches may be considered. In this scenario, palliative surgery such as vagus nerve stimulation (VNS) or deep brain stimulation (DBS) may be indicated in a subset of patients. In this paper we make recommendations for the use of VNS and DBS in patients in Brazil with refractory epilepsy.

We evaluated the efficacy of vigabatrin (VGB) as a first drug to be used as monotherapy for West syndrome (WS), its side effects and correlations with the electroencephalogram (EEG). The sample consisted of 13 infants examined between October 2001 and September 2002 at IMIP ambulatory patients office or private clinic. Administration of vigabatrin was around 118 mg/kg/day. Suppression of spasms was obtained in 4 children (31%), partial control in 3 (23%), 5 of them did not present therapeutic response (38%) and just one (8%) got worse. On the two patients with tuberous sclerosis, one was seizure-free and in another there was partial control. Side effects happened in 8 children (62%) and consisted of irritability, insomnia, somnolence and agitation, and all of them have been well tolerated. The second EEG showed disappearance of hipsarrhythmia in 6 patients (46%). Four of these were seizure-free. We conclude that VGB is effective and well tolerated as initial monotherapy for WS.

Paracoccidioidomycosis (PCM) is a systemic granulomatous disease caused by Paracoccidioides brasiliensis, prevalent in Latin America, particularly in Brazil. Central nervous system (CNS) involvement occur in about 10% of cases. Thirteen patients with PCM involving CNS were studied considering clinical manifestation, neuroradiology and treatment modalities. Age ranged from 30 to 71 years-old (M=47.1+/-11.6 Me=46). There were eleven men and two women. The most frequent symptoms were motor deficits (53.8%), cognitive disturbance (53.8%), weight loss (46.1%), headaches (46.1%) and seizures (46.1%). The diagnosis was confirmed by the demonstration of P. brasiliensis. Granulomatous forms were present in all patients. Four (30.8%) of them had also meningeal involvement (mixed form). Computerized tomography (CT) scans were obtained in all cases and magnetic resonance imaging (MRI) was used in one case. Serology for HIV was done in ten patients (76.9%), and all the tests were negatives. Amphotericin B was used in twelve patients (92.3%), one of them by intraventricular infusion. In eight patients (61.5%), trimethopim and sulfamethoxazole were used, and, in two (15.4%), sulfadiazine and pirimetamine. Fluconazole, ketoconazole and itraconazole were each one used in a different patient as well. Six patients died (46.1%) and seven (53.9%) had satisfatory outcome. The follow-up period ranged from 2 to 74 (M=30.9) months. In conclusion, the CNS involvement in paracoccidioidomycosis is more frequent and more serious than thought before. The clinical manifestations, CT scans and MRI findings are not specific of paracoccidioidomycosis.