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    Epilepsia.ppt Epilepsia.ppt Presentation Transcript

    • Seizures and Epilepsy Enrique De La Mora Glasker M.D.
      • Terms seizure and epilepsy are not synonymous
    • Seizure
      • A seizure is a paroxysmal event due to abnormal, excessive, hypersynchronous discharges from an aggregate of central nrvous system (CNS)neurons.
      • Have various manifestations.
    • Epilepsy
      • Epilepsy describes a condition in which a person has recurrent seizures due to a chronic, underlying process.
      • Single seizure, or recurrent seizures due to correctable or avoidable circumstances, does not necessarily have epilepsy
    • Causes
      • Seizures are a result of a shift in the normal balance of exitation and inhibition within the CNS.
      • 3 important clinical observations
    • 3 clinical observations
      • 1.- The normal brain is capable of having a seizure under the appropriate circumstances, and there are differences between individuals in the susceptibility or threshold for seizures.
      • Fever in childrens
      • Underlying endogenous factors.
      • 2.- Variety of conditions that have an extremely high likelihood of resulting in a chronic seizure disorder
      • Head trauma, stroke, infections, abnormalities of CNS development.
      • 3.- Seizure are episodic: provocative or precipitating factor
      • Psychological or physical stress, sleep deprivation, or hormonal changes, exposure to toxic substances and certain medications.
    • Drugs that can cause seizures
      • Inmunosupressants:
        • Cyclosporine
        • Monoclonal antibodies to T cells
    • Drugs that can cause seizures
      • Antimicrobials:
        • B-lactam and related compounds
        • Quinolones
        • Isoniazid
        • Ganciclovir
    • Drugs that can cause seizures
      • Anesthetic and antiarrhythmics:
        • B- adrenergic antagonists
        • Local anesthetics
        • Clase 1 B agents
    • Drugs that can cause seizures
      • Psycotropics
        • Antidepressants
        • Antipsychotics
        • Lithium
    • Drugs that can cause seizures
      • Radiographic contrast agents
      • Theophyline
      • Sedative hypnotic drug withdrawal
        • Alcohol
        • Barbiturates
        • Benzodiazepines
    • Drugs that can cause seizures
      • Drugs of abuse:
        • Amphetamine
        • Cocaine
    • Causes According to Age
      • Neonates: (<1month):
        • Perinatal hypoxemia and ischemia
        • Intracranial hemorrhage and trauma
        • Acute CNS infection (meningitis)
        • Metabolic disturbances
        • Developmental disorders
        • Genetic disorders
      • Infants and children: (> 1 month < 12 years )
        • Febril seizure
        • Genetic disorders
        • CNS infections
        • Developmental disorders
        • Trauma
        • Idiopatic
      • Adolescents: (12-18 years)
        • Trauma
        • Genetic disorders
        • Infection
        • Brain tumor
        • Illicit drug use
        • Idiopatic
      • Yung adults: (18-35 years)
        • Alcohol withdrawal
        • Illicit drug use
        • Brain tumor
        • Idiopathic
      • Older adults: (>35 years)
        • Cerebrovascular disease
        • Brain tumor
        • Alcohol withdrawal
        • Metabolic disorders (uremia, hepatic failure, electrolyte abnormalities, hypoglycemia)
        • Alzheimer`s disease
        • Idiopatic
    • Basic mechanism
      • Partial seizure activy can begin in a very discrete region of cortex and then spread to neighboring regions.
        • Seizure initiation phase
        • Seizure propagation phase.
    • Classification
    • Classification
      • Partial seizures
      • Primarily generalized seizures
      • Unclassified seizures
      • Partial seizures
        • Simple-partial seizures
        • Complex partial seizures
        • Partial seizures with secondarygeneralization
      • Primarily generalized seizures
        • Absence (petit mal)
        • Tonic clonic (grand mal)
        • Tonic
        • Atonic
        • Myoclonic
      • Unclassified seizures
        • Neonatal seizures
        • Infantile spasms
    • Partial
      • Synonymous with focal
      • Activity is restricted to discrete areas of cerebral cortex.
      • Typically associated with structural abnormalities of the brain.
    •  
    • Generalized
      • Involve difusse regions of the brain simultaneously in a bilaterally symetric fashion
      • May result from cellular, biochemical, or structural abnormalities that have a more widespread distribution.
    •  
    • Partial Seizures
    • Partial Seizures
      • Discrete regions of the brain.
      • Consciousness is fully preserved during the seizure ( Simple-partial seizure )
      • Consciousness is impaired ( Complex partial seizure )
      • Partial seizure and then spread diffusely throughout the cortex ( partial seizure with secondary generalization )
    • Simple-Partial Seizure
      • Motor, sensory, autonomic, or psychic symptoms.
      • Without an obvious alteration in consciousness.
      • Three additional features
    • Three features
      • “ Jacksonian march ” abnormal motor movements may begin in a very restricted region, and gradually progress (over seconds to minutes).
      • May experience a localized paresis ( todd`s paralysis ) minutes to many hours.
      • Seizure may continue for hours or days. ” epilepsia partials continua ”.
    • Simple partial. And Aura
      • Other forms of simple-partial seizures include those that cause changes in somatic sensation.
      • Some patients describe odd internal feelings. (fear, dejà vu)
      • When precede a complex-partial or secondarly generalized seizure, these simple partial seizures serve as a warning or aura.
    • Complex-Partial Seizures
      • Focal seizure activity
      • Patient is unable to respond to visual or verbal commands during the seizure and has impaired recollection or awareness of the ictal phase.
      • Frequently begin with an aura.
      • The start of the ictal phase is often a sudden behaivoral arrest or motionless stare.
      • Usually acompained by automatisms.
      • The patient is typically confused following the seizure.(seconds up to an hour).
    • Partial Seizures with Secondary Generalization
      • Partial seizures can spread to involve both cerebral hemispheres and produce a generalized seizur, usually of the tonic-clonic variety.
      • Is often difficult to distinguish from a primarilly generalized tonic-clonic seizure.
      • Careful hystory identifies a preceding aura.
    • Generalized Seizures
      • Arise from both cerebral hemispheres simultaneously .
      • It is currently impossible to exclude entirely the existence of a focal region of abnormal activity that initiates the seizure prior to rapid secondary generalization .
    • Generalized Seizure.
      • Practically defined as bilateral clinical and electrographic events without any detectable focal onset.
    • Generalized Seizures
      • Absence Seizure (Petit Mal)
      • Atypical Absence Seizures
      • Generalized, Tonic – Clonic Seizure (Grand Mal)
      • Atonic Seizure
      • Mioclonic Seizure
    • Absence Seizures (Petit Mal)
      • Sudden brief lapses of consciousness without loss of postural control.
      • Typically last for only seconds, consiousness returns as suddenly as it was lost.
      • No postictal confusion
      • Absence seizures are usually accompained by subtle, bilateral motor signs (rapid blinking of the eyelids, chewing movements, or small-amplitude clonic movements of the hands.
      • Can occur hundreds of times per day.
      • Always begin in childhood (ages 4 to 8) or early adolescence.
      • Hyperventilation tends to provoke.
      • Typical Absence seizure are not associated with other neurologic problems and respond well to treatment with specific anticonvulsants.
      • 60 – 70 % will have a spontaneous remission during adolescence.
      • Atypical Absence Seizures:
        • Lapse of consciousness is usually of longer duration.
        • Less abrupt in onset and cessation
        • Accompained by more obvious motor signs.
    • Generalized Tonic – Clonic Seizures (Grand Mal)
      • The most common seizure type resulting from metabolic derangements.
      • The initial phase of the seizure is usually tonic contraction of muscles throughout the body.
      • After 10 to 20 s. The tonic phase of the seizure typically evolves into the clonic phase, produced by the superimposition of periods of muscle relaxion on the tonic muscle contraction.
      • The periods of relaxation progressively increase until the end of the ictal phase.
      • Usually last no more than 1 min.
      • Postictal phase is characterized by:
        • Unresponsiveness
        • Muscular flacciditidy
        • Excessive salivation
        • Bleadder or bowel incontinence
      • Patients gradually regain consciousness over minutes to hours
      • Tipically a period of postictal confusion.
      • Headache, fatigue, and muscle ache.
    • Atonic Seizure
      • Sudden loss of postural muscle tone lasting 1 to 2 s.
      • Consciousness is briefly impaired
      • Usually no postictal confusion
      • Very brief seizure may cause only a quick head drop or nodding movement.
      • Longer seizure will cause the patient to collapse. (extremelly dangerous)
    • Myoclonic Seizure.
      • Sudden and brief muscle contraction that may involve one part of the body or the entire body.
      • Pathologic myoclonus is most commonly seen in association with metabolic disorders, degenerative CNS diseases, or anoxic brain injury.
    • Unclassified Seizures
    • Neonatal Seizure
      • Less than 1 month of age.
      • Brief episodes of apnea, eye deviation, eye blinking, or repetitive movements of the arms and legs.
    • Infantile Spasms
      • Infants under 12 months.
      • Abrupt movements of the head, trunk, or limbs.
      • The classic spasm is a sudden flexion of the neck and abdomen with extension of the limbs.
    • Evaluation of the patient
    • Laboratory studies
      • Electrolytes
      • Glucose
      • Ca
      • Mg
      • Liver and renal function test
      • Urianalysis
      • Toxicology screen
      • Lumbar puncture
      • EEG
      • CT
      • MRI
      • SPECT
    • Diferential Diagnosis
      • Syncope
      • Psychological disorders
      • Metabolic disturbances
      • Migraine
      • TIA
      • Sleep disorders
      • Movement disorders
    • Treatment Valproic Acid Ethosuximide Valproic Acid Valproic acid Lamotrigine Carbamazepine Phenitoiin Valproic acid Lamotrigine Myoclonic Atonic Absence Tonic-clonic Partial