Problems in the management of epilepsy

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Problems in the management of epilepsy

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

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