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Problems in the management of epilepsy

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  • 1. EPILEPSY Medical and surgical management
  • 2. Basic Classification
    • Primary
      • focal
        • simple
        • complex partial
      • generalized
    • Secondary
      • focal
      • generalized
    • Mis: febrile, alcoholic etc
  • 3. Is it epilepsy?
    • Features suggestive of epilepsy
      • Suddenness of attack
      • Symptoms of recognized seizure type
      • An attack during sleep
      • Stereotyped attack
      • Injury, incontinence, headache and vomiting
  • 4. History
    • Onset and detail description
    • Associated features and modifying factors
    • Medical and psychiatric history
    • Neurological disorders
    • Family history
    • Occupation
  • 5. Clinical Examination
    • Skin and vital signs
    • Focal neurological deficit
    • Features of raised intracranial pressure
    • Systemic examination
  • 6. What blood test in epilepsy?
    • Complete blood count
    • Blood sugar fasting and post pandrial
    • Serum creatinin
    • S. Calcium and sodium
    • SGPT, bilirubin
  • 7. EEG in Epilepsy
    • To confirm the diagnosis
    • To classify the type of seizure
    • To locate the focus of discharge
    • To find out triggering factors
    • To find out associated brain disease
    • To monitor anticonvulsant
  • 8. When to do Neuroimaging?
    • Above 25 years of age
    • Focal onset or focal neurological sign
    • Features of raised intracranial pressure
    • Uncontrolled seizure
    • Features of focal lesion in EEG
  • 9. CT or MRI
    • CT
      • Calcification
      • Acute hemorrhage
      • Emergency
    • MRI
      • Tumor
      • Old hematoma
      • AVM
      • Temporal atrophy
      • Granuloma
  • 10. When to start medication
    • Following two seizure within one years
    • Following first seizure with underlying cause
    • Employed in dangerous profession
  • 11. How to start drug treatment?
    • Confirm the diagnosis
    • Use single anticonvulsant
    • Use proper doses
    • Loading dose of certain drug in emergency
    • Build up dose of others
    • Use minimal effective dose
  • 12. What drug to choose?
  • 13. Drug level monitoring
    • To maintain minimum dose
    • Uncontrolled epilepsy
    • Noncompliance
    • Polytherapy
    • Drug interaction
    • Toxicity
    • Hepatic diseases
    • Pregnancy
  • 14. What is the chance of remission?
    • 50% Remission off treatment for 20 years
    • 20% Remission on treatment
    • 30% Seizure on treatment
  • 15. Catamenial epilepsy
    • 10-70% of epilepsy in women
    • Estrogen induces seizure
    • Progesterone falling levels
    • Adjust antiepileptic dose
    • Estrogen inhibitors (clomifen)
    • Progesterone
  • 16. Contraceptive in epileptic
    • PHY, PHB, CBZ, induces hepatic P450 enzyme and cause contraceptive failure in 6-10%
    • Topiramate is weak enzyme induce
    • BNZ, LMT, VIG, GPT do no induces P-450
    • Estrogen induces seizure
  • 17. Pregnancy and Epilepsy
    • Choice of drug:
      • All antiepileptics are teratogenic
      • Use single drug in low dose
      • Control GTCS
      • Use Folic acid 1mg 4-6 week before pregnancy
      • Use Vit K before delivery to prevent bleeding
  • 18. Followup in Pregnancy
    • Weeks Examination
    • 6-10 AED levels (free and total), serum folate level
    • 15-16 Maternal serum AFP, amniocentesis,* AED levels
    • 18-19 Ultrasound for neural-tube defects
    • 22-24 Ultrasound for oral clefts and heart anomalies
    • 28 AED levels
    • 34-36 AED levels, maternal vitamin K
  • 19. Antiepileptic in breast milk
    • Carbamazepine 40%
    • Ethosuximide 90%
    • Phenobarbital 36%
    • Phenytoin 18%
    • Primidone 70%
    • Valproic acid 5%
    • Topiramate,Gabapentin, ?? Lamotrigine
  • 20. What drug in systemic disease
    • Liver disease
    • Gabapantine
    • Phynobarbitone
    • Phenytoin
    • Benzodiazepine
    • Renal disease
    • Phenytoin
    • Phynobarbione
    • Benzodiazepine
  • 21. Febrile seizure
    • No seizure for single febrile seizure
    • Diazepam orally for recurrent febrile seizure
    • Valproate or phenobarb for recurrent febrile seizure
  • 22. Good prognostic signs
    • Granuloma
    • Early posttraumatic epilepsy
    • Mild infrequent seizure
    • Secondary systemic or toxic seizure
    • Benign rolandic epilepsy
    • Primary generalized epilepsy
    • Absence seizure
    • Early treatment
  • 23. Bad prognostic signs
    • Diffuse cerebral disease
    • Late posttraumatic epilepsy
    • Multiple seizure types
    • Complex partial seizure
    • Long untreated seizure
    • History of Status in the past
  • 24. When to stop treatment
    • Primary generalized seizure with normal EEG for 2-3 seizure free years
    • Taper slowly
    • Severe brain damaged needs life long treatment
    • Short course following medical disorder
  • 25. Intractable seizures
    • 20-30% of epilepsy
    • Poor compliance
    • Inadequate drug doses
    • Improper choice of drug
    • Inappropriate combination of drugs
    • Misdiagnosis of seizure or seizure type
  • 26. New antiepileptic drugs
    • 1. Clobazam
    • 2. Gabapantin
    • 3. Lamotrigine
    • 4. Topiramate
    • 5. Vigabatrin
    • 6. Falbamate
  • 27. Clobazam
    • Benzodiazepine, anxiolytic
    • Weak antiepileptic
    • For add on therapy
    • Less side effect
    • Can be used in children with primay and febrile seizure
    • Dose: 0.1-0.5mg/Kg/dayBD
  • 28. Gabapantine
    • First pass metabolism
    • No interaction
    • Drug level monitoring not required
    • Can be use in high doses
    • Renal and hepatic failure and transplant patient
  • 29. Lamotrigine
    • Broad spectrum antiepileptic
    • Skin rash common, no other significant toxicity
    • Can be used in all age as primary and secondary drug
    • Dose: 0.5-10mg/kg in two divided dose
  • 30. Topiramate
    • GABArgic
    • Efficacy: Partial seizure
    • Side effects: fatigue, nervousness, difficulty with concentration, tremor, weight loss , renal stone
    • Dose: 50-400mg in two divided doses
  • 31. Status epilepticus causes
    • Drug withdrawal 25
    • Alcohol withdraw 25
    • Cerebrovascular: 22
    • Metabolic: 10
    • Systemic infection 12
    • Trauma 15
    • Drug toxicity 15
    • CNS infection 12
    • Tumor 8
    • Congenital lesion 8
    • Prior Epilepsy 33
    • Idiopathic 30
  • 32. Status epilepticus management
    • ABCD
    • Blood: Electrolytes, CBC, Calcium, Magnesium, BUN, Liver function Anticonvulsant level, Alcohol, Toxicology screen
    • If hypoglycemia suspected, give 50% glucose
    • Give Thiamine 100 mg iv
    • Lorazepam 0.1 mg/kg iv
    • Phenytoin 20 mg/kg iv, 50 mg/min
  • 33. Status management cont.
    • If seizure persists:
    • Phenobarbital 20 mg/kg iv at 50 to 100 mg/min
    • Review lab result and correct any abnormality
    • CT/MRI: bleed, infection, AV malformations, neoplasm
    • Lumbar puncture: if CNS infection suspected
    • Blood cultures: Sepsis
    • For refractory seizure :
    • Intubation, EEG monitoring and Pentobarbital 5-15 mg/kg loading over 3 minutes, 0.5 to 5 mg/kg/hr drip or
    • Midazolam (Versed) 0.15-0.20 mg/kg loading, then 0.06-1.1 mg/kg/hr drip
    • Propofol 1-2 mg/kg loading, then 3-10 mg/kg/h
  • 34. Surgical Procedures
    • Resection of epileptic focus
      • cortical resection
      • temporal lobectomy
      • Amygdylohippocampectomy
    • Corpus callosotomy
    • Hemispherictomy
  • 35. Resection of epileptic focus
    • Partial seizures
      • Temporal origin
      • extratemporal origin
    • Generalized seizure with identifiable resectable focus
  • 36. Corpus callosotomy
    • Atonic seizures
      • frequent episodes
      • frequent falls and injury
      • 70% reduction with callosotomy
    • Infantile hemiplegic syndrome
    • some patients with generalized seizures with epsilateral focus
  • 37. Evaluation:
    • MRI
      • hippocampal asymmetry
      • temporal lobe abnormality
    • CT
      • interictal CT: may show enhancement with contrast, slow uptake
    • PET
      • hypometabolism lateralized to side of temoral lobe focus in 70% of patients
    • WADA test
      • localizes dominant hemisphere
      • Amytal
    • Video EEG monitoring
    • Invasive EEG monitoring
  • 38. Corpus callosotomy
    • leave Ant commissur
    • usuallt anterior 2/3
    • may produce post op decresed verbalization
    • usually resolves in few days
  • 39. Temporal lobectomy
    • 80% pt have focus in anterior temporal lobe
    • most of the pathology in mesial temporal lobe
    • Limit of resection:
      • dominant 4.5 cms
      • non dominant 6-7 cms
  • 40. Epilepsy surgery :Outcome
    • 2 years post op
      • 50% seizure free
      • 80% more than 50% reduction in frequency
    • Dominant temporal lobectomy without intraoperative monitoring
      • 6% mild dysphasia
      • major deficit; < 2%

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