Epilepsy

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Epilepsy

• Dr payam Sasannejad
• Assistant Professor of MUMS

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What Is the Difference Between Epilepsy
Seizures?

• A seizure is a brief, temporary disturbance in
  the electrical activity of the brain
• Epilepsy is a disorder characterized by recurring
  seizures (also known as seizure disorder)

A seizure is a symptom of epilepsy
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Differential diagnosis of seizures

• Syncope
• Drop attacks
• Narcolepsy-Cataplexy
• Pseudoseizures
• Panic attacks
• Hypoglycemia
• Migraine

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Classifying Epilepsy and Seizures

• Classifying epilepsy involves more than just
  
• seizure type
• Seizure types
• Partial Generalized
• Simple Complex Absence Convulsive

Consciousness is maintained
Consciousness is lost or impaired
Altered awareness
Characterized by muscle contractions with or
without loss of consciousness
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Seizure Types
Single
Recurrent
Nonepileptic
Epileptic

• Syncope
• Migraine
• Psychogenic
• Toxic
• Cerebrovascular
• Metabolic

Generalized
Partial

• Absence
• Tonic-clonic
• Tonic
• Clonic
• Myoclonic
• Atonic

Simple
Complex
Secondarily Generalized
Adapted from International League Against
Epilepsy. Epilepsia. 198122489-501.
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Epilepsy - Classification

• Focal seizures account for 80 of adult
  epilepsies
• Simple partial seizures
• Complex partial seizures
• Partial seizures secondarilly generalised
• Generalised seizures
• Unclassified seizures

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Focal (partial) seizures

• Simple partial seizures
• Motor, sensory, vegetative or psychic
  symptomatology
• Typically consciousness is preserved

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Focal (partial) seizures

• Simple partial seizures
• Motor, sensory, vegetative or psychic
  symptomatology
• Typically consciousness is preserved

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Focal (partial) seizures

• Partial seizures evolving to tonic/clonic
  convulsions secondary generalised tonic/clonic
  seizures (sGTCS)

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Generalized seizures(convulsive or
non-convulsive)

• Absences
• Myoclonic seizures
• Clonic seizures
• Tonic seizures
• Atonic seizures

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Generalized seizures

• Absences
• Myoclonic seizures
• Clonic seizures
• Tonic seizures
• Atonic seizures

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Epilepsy

• is a symptom of numerous disorders, but in the
  majority of
• sufferers the cause remains unclear despite
  careful history
• taking,examination and investigation!

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An approach to Seizures
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Epilepsy Investigation

• The concern of the clinician is that epilepsy may
  be symptomatic of a treatable cerebral lesion.
• Routine investigation Haematology, biochemistry
  (electrolytes, urea and calcium), chest X-ray,
  electroencephalogram (EEG).
• Neuroimaging (CT/MRI) should be performed in all
  persons aged 25 or more presenting with first
  seizure and in those pts. with focal epilepsy
  irrespective of age.
• Specialised neurophysiological investigations
  Sleep deprived EEG, video-EEG monitoring.
• Advanced investigations (in pts. with intractable
  focal epilepsy where surgery is considered)
  Neuropsychology, Semiinvasive or invasive EEG
  recordings, MR Spectroscopy, Positron emission
  tomography (PET) and ictal Single photon emission
  computed tomography (SPECT)

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Diagnosis of epilepsy

• Clinical picture
• Clinical history
• Description of Sz
• Symptomatology
• Physical/Neurologic examination
• Therapy

• EEG
• Background activity
• Epileptiform activity
• Interictal
• Ictal
• Postictal
• Laboratory tests
• Neuroimaging

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Secondary Partial Epilepsy - MRI
Heterotopia
Mesial Temporal Sclerosis
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Considerations in Epilepsy Management
Age andGender
Underlying Pathology
Syndrome vs Seizure Type

Seizure Frequency
Comorbidities
Medication Side Effects
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Classification of Anticonvulsants

• Classical
• Phenytoin
• Phenobarbital
• Primidone
• Carbamazepine
• Ethosuximide
• Valproic Acid
• Trimethadione

• Newer
• Lamotrigine
• Felbamate
• Topiramate
• Gabapentin
• Tiagabine
• Vigabatrin
• Oxycarbazepine
• Levetiracetam
• Fosphenytoin
• Others

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Treatment of epilepsy

• AEDs selection on types of epileptic seizure

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Antiepilepsy drugs,AEDs
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Update on newer AEDs
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Status epilepticus treatment (1)

• Maintain A-B-Cs at onset and during therapy
• EKG and oximeter monitoring
• Start IV access (saline), draw CBC, lytes,
  glucose, BUN, creat, AST, ALT, ? anticonvulsant
  levels
• Rule out hypoglycemia with fingerstick, or give
  50 dextrose bolus urgently
• Send toxicology screen on urine or blood

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Status epilepticus treatment (2)

• Lorazepam 0.05-0.1 mg/kg IVP (lt2 mg/min) or
  diazepam 0.15-0.25 mg/kg IVP (lt5 mg/min)
• Load phenytoin 20 mg/kg (IV saline) (lt50 mg/min),
  or fosphenytoin 20 (PE) phenytoin equivalents/kg
  IV
• (lt150 mg/min)
• (fosphenytoin, a prodrug of phenytoin, has less
  risk of hypotension, arrhythmia and skin
  reactions than phenytoin given IV)

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Status epilepticus treatment (3)

• If seizures persist, give 1 or 2 extra boluses of
  5 mg/kg phenytoin or 5 PE/kg fosphenytoin IV
• If more seizures, load phenobarbital 20 mg/kg IV
  (lt50 mg/min)
• Intubation ventilation may be needed now
• Check that anticonvulsant levels are therapeutic
• Emergent EEG if patient doesnt wake up

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Refractory status epilepticus therapy

• Midazolam 0.2 mg/kg IV bolus, then 0.75 to 10
  microgm/kg/min infusion, or
• Propofol 1 mg/kg IV bolus (can repeat), then 1-15
  mg/kg/hr infusion, or
• Pentobarbital 5-15 mg/kg loading dose, then 0.5-5
  mg/kg/hr
• Suppress electrical seizure activity on
  continuous EEG monitoring, watch for hypotension

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Thank you
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