seminar

1. EpilepsyEpilepsy
Presented by :
Mohammad Ihmeidan

2. DEFINITIONDEFINITION
A seizure is an abnormal and excessive
discharging of the neuroglial network .
Epilepsy is a chronic neurological condition
characterized by recurrent, unprovoked
seizures.

3. Seizure EtiologySeizure Etiology
 Virtually any insult to the cerebral cortex
can cause a seizure.
Most seizures are self-limited, and once the
inciting process resolves, the seizures cease.

4. Synaptic TransmissionSynaptic Transmission
Neuron to neuron communication is
mediated by neurotransmitters (NTs) and
resultant EPSPs and IPSPs
Excitatory NTs
– Glutamate
– Aspartate
Inhibitory
– GABA
– Glycine

6. Epilepsy etiologyEpilepsy etiology
An epidemiologic study in Rochester,
Minnesota reported that :
1- the largest percentage of individuals
(children and adults) with epilepsy fell into
the idiopathic /cryptogenic category (i.e.
presumed genetic or unknown etiologies)
2- followed in order by vascular, traumatic,
developmental ,infectious, neoplastic, and
degenerative causes

7. 3-In the under-14-year age group, a
developmental etiology was most common
(i.e. conditions manifested by mental
retardation and/or cerebral palsy presumed
to be present from birth )

8. EpidemiologyEpidemiology
The age-adjusted prevalence of epilepsy in
developed countries is 5 per 1,000
population

9. Epilepsy ClassificationEpilepsy Classification
Partial (Focal) Primary Generalized
Simple Complex Absence Myoclonic Clonic Tonic Atonic Tonic-
clonic
May secondarily generalize

10. PARTIAL SEIZUREPARTIAL SEIZURE

11. Partial SeizurePartial Seizure
originate within networks limited to one
hemisphere
Partial or focal seizures constitute 40% to
60% of the classifiable epilepsies of
childhood.

12. Simple PartialSimple Partial
Simple partial seizures arise from a specific
anatomic focus.
Clinical symptoms include motor, sensory,
psychic, or autonomic abnormalities
consciousness is preserved.

13. Partial seizures that manifest only with
psychic or autonomic symptoms can be
difficult to recognize.
Uncinate seizures arising from the medial
temporal lobe manifest with an olfactory
hallucination of an extremely unpleasant
odor (burning rubber).
Limbic temporal lobe discharges result in
dreamlike states (déjà vu and bizarre
psychic abnormalities).

14. Video

15. Complex PartialComplex Partial
Complex partial seizures are similar to
simple partial , but in addition,
consciousness is impaired

16. Complex Partial SeizureComplex Partial Seizure
Video

17. GENERALIZED SEIZUREGENERALIZED SEIZURE

18. AbsenceAbsence
 Brief staring episodes with unresponsiveness
 Sudden onset with an arrest of activity
 May have associated eye flutter or simple
automatisms
 Generalized 3 per second spike and wave
 usually begin between 4 and 6 years of age
 80% will have resolution with age
 20% also have convulsive seizures.

19. absence epilepsy Vs partial complexabsence epilepsy Vs partial complex
 Differentiating absence epilepsy from partial complex
staring seizures can be difficult.
 Both seizure types are characterized by cessation of
activity, staring, and alteration of consciousness and may
include automatisms.
 Partial complex seizures are often followed by postictal
confusion; absence seizures are not.
 Absence seizures are provoked by hyperventilation and
usually last a few seconds; partial complex seizures occur
spontaneously and usually last several minutes.
 Children may have dozens of absence seizures per day;
children rarely have more than one or two partial complex
seizures in a day.
 The distinction is important because the choice of
anticonvulsant treatment is different.

20. AbsenceAbsence
Video

21. Generalized Motor (Convulsive)Generalized Motor (Convulsive)
Tonic, clonic, tonic-clonic
No warning; abrupt onset
Bowel and bladder incontinence are
common
Postictal unresponsiveness or confusion
During an attack, the EEG shows repetitive
synchronous bursts of spike activity
followed by periodic paroxysmal discharges

22. compose 10% to 15% of childhood
epilepsies.
These seizures frequently are associated
with underlying structural brain disease and
are difficult to treat and classify.
They often occur in combination with each
other and with generalized tonic-clonic
seizures.
Myoclonic, tonic, atonic, andMyoclonic, tonic, atonic, and
atypical absence seizuresatypical absence seizures

23. MyoclonicMyoclonic
Myoclonus is a sudden jerk of all or part of
the body; not all myoclonus is epileptic in
nature.
Nonepileptic myoclonus may originate in
the basal ganglia, brainstem, or spinal cord.
It may be benign, as in sleep myoclonus, or
indicate serious disease.

24. Myoclonic epilepsy usually is associated
with multiple seizure types.
Myoclonic absence refers to the body jerks
that commonly accompany absence seizures
and atypical absence seizures.

25. Myoclonic SeizureMyoclonic Seizure
Video

26. AtonicAtonic
No warning; abrupt onset
Loss of muscular tone results in sudden fall
Brief duration
Injuries common
Very difficult to treat

27. AtonicAtonic
Video

28. Evaluation of EpilepsyEvaluation of Epilepsy
EEG & Epilepsy
– Awake only (≅ 30-40% abnormal)
– Awake and asleep (≅ 60-70% abnormal)
– Photic stimulation
 may induce generalized spike and wave or occipital
spikes
– Hyperventilation
 may induce 3/sec. spike and wave (absence)

29. Evaluation of EpilepsyEvaluation of Epilepsy
 Neuroimaging
– Indicated with:
 Abnormal neurological exam
 Focal onset seizures
 Uncertain if focal or primary generalized onset
 Onset of seizures after adolescence
– MRI is the gold standard (not CT)
– CT is helpful in the acute setting
 i.e. persistent alteration of consciousness or abnormal
neurologic exam

30. General Guidelines forGeneral Guidelines for
Therapy:Therapy:
Correct classification of seizures leads to
correct AED selection
Treat when the benefit of therapy outweighs
the risk
Avoid polypharmacy
Monotherapy usually results in better
seizure control and less side effects

31. General Guidelines forGeneral Guidelines for
Therapy:Therapy:
Maximize one medication before changing
to the second
Treat the patient, not the EEG or the AED
level
Use rational polypharmacy when indicated

33. Alternative Therapy forAlternative Therapy for
EpilepsyEpilepsy
Ketogenic diet
Vagus nerve stimulator
Epilepsy surgery

34.  First described by Wilder, Mayo Clinic Bulletin,
1921
 Mark 9:29 “This kind can come forth by nothing,
but by prayer and fasting.”
 Typically reserved for children with severe,
debilitating and intractable seizures
 4:1 (Fat: Protein + Carbohydrates)
– 75-90% of caloric intake as fat
 Urinary ketosis 80- 160 millimolar
Ketogenic DietKetogenic Diet

35. Ketogenic Diet: EfficacyKetogenic Diet: Efficacy
150 children prospectively evaluated
Age range: 4 months - 16 years
Average of 410 seizures per month
Results after 1 year:
– 55% remained on the diet
– 1/2 had > 50% reduction in seizures
– 1/4 had > 90% decrease in seizures
Freeman, Vining, et.al. Pediatrics, December, 1998

36. Vagus Nerve Stimulator:Vagus Nerve Stimulator:
Rule of ThirdsRule of Thirds
 1/3 - marked improvement
 1/3 - some improvement
 1/3 – little/no improvement
 Potential benefits
– fewer seizures, less severe seizures, shorter
recovery period, decreased meds and side effects,
less fear and anxiety, more control

37. Epilepsy Surgery:Epilepsy Surgery:
Criteria for ConsiderationCriteria for Consideration
Seizures must be medically intractable
Seizures must be debilitating
There should be no chance for spontaneous
resolution

38. EpilepsyEpilepsy
SurgerySurgery
 Temporal lobectomy
– 75-90% seizure free
 Extratemporal lesional
resection
– 50-75% seizure free
 Extratemporal non-
lesional resection
– < 50% seizure free
 Functional
hemispherectomy
 Corpus callosotomy
– Especially for atonic and
brief tonic seizures

39. Children with EpilepsyChildren with Epilepsy
School IssuesSchool Issues
Children with poor seizure control are more
likely to have trouble making friends.
Taking medication at school may be
associated with a significant decrease in
social and peer relationships. Even in
children with self reported good seizure
control.

40. ‫ا‬ ‫جزاكم‬‫ا‬ ‫جزاكم‬
‫خيرا‬‫خيرا‬