Epilepsy
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Epilepsy

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Epilepsy Presentation Transcript

  • 1. Seizure & Epilepsy
  • 2. Definitions
  • 3. Seizure
    A sudden surge of electrical activity in brain that usually affects how a person feels or acts for a short time.
    Some seizures can hardly be noticed, while others are totally disabling.
  • 4. Epilepsy
    A condition that affects central nervous system (CNS)
    had at least 2 seizures
    not caused by some known medical condition like alcohol withdrawal or extremely low blood sugar.
    not indicate anything about the cause of the seizures, what type they are, or how severe they are.
  • 5. Momentary loss of consciousness
    Fit
    Faint
    Fake
  • 6. Transient loss of consciousness
    History and Physical
    Witness account
    Déjà vu
    Jamais vu
    Aphasia
    Olfactory aura
    Epigastric sensation
    Tongue biting
    Post event delirium
    Focal neurodeficit
    Light-headedness
    Sweating
    Prolonged standing
    Precipitants
    eg.micturition
    Chest pain
    Palpitation
    Slow heart rate
    Low blood pressure
    Aphasia
    Delirium
    Head turn
    Automatism
    Posturing
    Convulsion
    Postictal
    delirium
    Myoclonus
    or convulsion
    after pallor,
    sweating
    and
    collapse
    Pallor
    Sweating
    Slow pulse
    Low BP
    Convulsive
    syncope
    Seizure
    Syncope
    Syncope
    Seizure
  • 7.
  • 8.
  • 9. Nonepileptic causes for spells
    Physiologic
    Tremor
    Vasovagal syncope
    Cardiac arrhythmias
    Migraine
    Medication adverse effects
    Transient ischemic attacks
    Autonomic dysfunction
  • 10. Nonepileptic causes for spells
    Psychologic
    Anxiety
    Panic attacks
    Mood disorder
    Personality disorder
    Psychosis
    Somatiform illness
    Psychogenic seizures
  • 11. Phase of seizures
    Preictal phase or aura or warning
    Ictal phase : simple or complex partial or generalized tonic-clonic seizure
    Postictal phaseor recovery period : last from seconds to minutes to hours
  • 12. Precipitants of seizure
    Sleep and lack of sleep
    Drugs and alcohol
    Intercurrent illness : infection,
    electrolyte imbalance
    Menstruation
    Stress and worry
    Other precipitants-reflex epilepsy
  • 13. Classification of seizure
    Partial (focal, localized) seizures
    Generalized seizures (convulsive or non-convulsive)
    Unclassified epileptic seizures
  • 14. Partial (focal, localized)seizures
    Simple partial seizures (preserved consciousness)
    Complex partial seizures (impaired consciousness)
    Partial seizures evolving to secondarily
    generalized seizures
  • 15. Simple partial seizures
    (preserved consciousness)
    With - motor signs
    - somatosensory or special
    sensory systems
    - autonomic symptoms or signs
    - psychic symptoms
  • 16. Complex partial seizures (impaired consciousness)
    - Simple partial onset followed by impairment of conscious
    - With impairment of consciousness at onset
  • 17. Partial seizures evolving to secondarily generalized seizures
    - Simple partial seizures evolving to generalized seizures
    - Complex partial seizures evolving to generalized seizures
    - Simple partial seizures evolving to complex partial seizures evolving to generalized seizures
  • 18. Generalized seizures (convulsive
    or nonconvulsive)
    - Absence seizures
    Typical absences
    Atypical absences
    - Myoclonic seizures
    - Clonic seizures
    - Tonic seizures
    - Tonic-clonic seizures
    - Atonic seizures (astatic seizures)
  • 19. Unclassified epileptic seizures
    - Neonatal seizures
    - Recurrent status epilepticus
    - Rare or ‘isolated’ seizures
  • 20. Epileptic seizure
    All clinical and
    laboratory data
    neuroimaging
    Seizure
    description
    and EEG
    Etiology
    Seizure
    type (s)
  • 21. Seizure
    Idiopathic
    Generalized
    epilepsy likely
    Features
    of focal
    epilepsy
    Epilepsy
    or PNES
    Provoked
    seizures
    Treat
    cause
    +/- AED
    EEG
    EEG
    MRI/CT
    brain
    Video
    EEG
    PNES=psychogenic non-epileptic seizures
    AED=antiepileptic drug
  • 22. Laboratory investigation
    CBC
    FBS, BUN, Creatinine
    Electrolyte , Liver function test , Ca+2 Mg+2
    Electro-encephalography (EEG)
    Video EEG
    Neuroimaging : CT Scan, MRI, MR Spect, PET
    Special investigation : ammonia, lactate,
    pyruvate etc.
  • 23. Electroencephalogram
  • 24. What value is the EEG?
    • Add weight to the clinical diagnosis
    • 25. Aid classification of epilepsy
    • 26. Detection of the structural brain lesion.
  • EEG
    30 minute interictal EEG –useful when clinical suspicion of epilepsy
    Timing is important
    Within 24 hr of generalized convulsion: 50% have abnormal EEG
    First 48 hr: 21-34% have epileptiform activity
    Sleep EEG or sleep-deprived EEG might increase diagnostic yield
  • 27. Normal EEG
  • 28. Primary generalized epilepsy—ictal EEG
  • 29. Primary generalized epilepsy- interictal EEG
  • 30. Burst of generalized spike and wave discharges—typical absence seizure
  • 31. EEG monitoring
  • 32. Video Monitoring
    Helpful in determining nature of seizure disorder (epilepsy, convulsive syncope, or psychogenic seizures)
  • 33. Indication for neuroimaging in patients with seizures
    Partial seizure
    Late onset unprovoked seizure (age > 25)
    Unexplained neurological signs
    Focal slow waves EEG
    poor control or new symptoms / signs
  • 34. Neuroimaging
    In the absence of trauma: CT and MRI brain for patients presenting with suspected first unprovoked seizure or with a focal neurological deficit.
    MRI is preferable for looking for neuronal migrational disorders, major malformations, vascular anomalies, tumors
  • 35. The causes of epilepsy
    Genetic factor
    Congenital abnormalities
    Trauma and the effect of craniotomy
    CNS infection
    Cerebrovascular disease
    Cerebral tumors
    Alzheimer’s disease and other degenerative
    disease
    Others
  • 36. Neurocysticercosis
  • 37. Cerebral infarction
  • 38. Intracerebral hemorrhage
  • 39. Brain tumor or metastasis
  • 40. Lt mesial temporal sclerosis
  • 41. Cortical dysplasia
  • 42. 52 year old woman with intractable seizure
    PET scan
  • 43. PET using F-18 FDG-- Decreased FDG uptake in both temporal lobes, right worse then left but otherwise relatively symmetric
  • 44. What to do?
    Generalized seizure
    Loosening the patient’s clothing
    Lower the patient gently to the floor, turn them onto their side and cushion head
    Nothing is put into the mouth
    Remove any items that could cause injury
  • 45. What to do? ---Generalized seizure
    When the seizure is over, allow the patient to rest or sleep
    If they are able to return to their feet, help them home
    Obtain medical help if they continue to experience breathing problems once the seizure is over, or if the seizure lasts a long time(over 10 mins), or when another attack quickly follows the first
  • 46. What to do?
    Partial seizures
    Stay with the patients throughout the seizure
    Protect them from any dangerous object
    Taking care not to restrain them in anyway
  • 47. First aids
  • 48. Treatment
  • 49. จะต้องให้ยากันชักหรือไม่?
    รักษา
    ไม่รักษา
    ผลข้างเคียงของยา
    โอกาสจะชักซ้ำ
  • 50. Choose a drug : considering the following factors
    The seizure type and prognosis
    Age
    The possibility of pregnancy
    Toxicity
    Drug interaction
    Price
  • 51. RISK OF RECURRENT SEIZURE
    The recurrence risk follow a first unprovoked seizure 27%-52%
    50% recurrence occur within 6 months
    over 80% within 2 years of initial seizures
    twice as likely to have another seizure if you have a known brain injury or brain abnormality.
  • 52. RISK OF RECURRENT SEIZURE(cont)
    If you do have two seizures, there's about
    80% chance that you'll have more.
  • 53. Factors predictive of a high rate of seizure recurrence after the first unprovoked seizure
    • Abnormal neurologic status by NE or imaging
    • 54. EEG abnormalities (especially epileptiform)
    • 55. Partial seizures
  • Counseling before treatment
    1. Aims of treatment
    2. Prognosis and duration of the
    expected treatment
    3. Importance of compliance
    4. Side effects
  • 56. Starting antiepileptic treatment
    Prospective risks Usual clinical Factors that may modify
    of epilepsy practice usual practice
    Single seizure No treatment Progressive cerebral disorder
    (clinically Dx) Clearly epileptic EEG
    2 or more seizure Monotherapy Seizures widely separated
    (clinically Dx) in time (> 1 year)
    Identified precipitating,
    factors (eg, drugs, alcohol,reflex stimuli)
    Probability of poor compliance (eg, personality disorder)
    Attitude of patients/parents
  • 57. More
    Antiepileptic drugs
    20
    Pregabalin
    Levetiracetam
    Oxcarbazepine
    Tiagabine
    Fosphenytoin
    15
    Topiramate
    Gabapentin
    Felbamate
    Lamotrigine
    Zonisamide
    10
    Vigabatrin
    Sodium Valproate
    Carbamazepine
    Benzodiazepines
    Ethosuximide
    5
    Phenytoin
    Primidone
    Phenobarbital
    Bromide
    0
    1840
    1860
    1880
    1900
    1920
    1940
    1960
    1980
    2000
    Calendar year
    Antiepileptic Drug Development
  • 58. First-line choice of AEDs according to seizure type
  • 59. Advantages of Monotherapy
    Better seizure control
    Reduced side effects
    Absence of drug interactions
    Reduced teratogenic effects
    Better compliance
    Reduced cost of medication
    Improved quality of life
  • 60. Expected outcomes of AED therapy
    Well
    controlled
    65%
    Unsatisfactorily
    controlled
    35%
    Monotherapy
    Well
    controlled
    10%
    Unsatisfactorily
    controlled
    25%
    Add-on therapy
    Unsatisfactorily
    controlled
    20%
    Well
    controlled
    5%
    Multiple drug therapy
  • 61. Managing newly diagnosed epilepsy
    Newly diagnosed epilepsy
    47%
    Seizure free
    First drug
    13%
    Seizure free
    Second drug
    Refractory
    Surgical assessment
    Rational duotherapy
  • 62. Adverse effect of AED
    • Dose related
    • 63. Idiosyncratic / allergic
    • 64. Chronic toxicity
    • 65. Teratogenicity
  • Older AEDs
  • 66. AED interactions
    CBZ : autoinduction, VPA, PHT, -PB
    PHT : CBZ, VPA, PB
    PB : CBZ, VPA, PHT
    VPA : CBZ, PB, PHT
  • 67. AEDs
    Drug interaction with AED and other drugs: via effect on hepatic CYP450 enzyme system
    PB, primidone, PHT, CBZ induce CYP enz. :
    Accelerate breakdown of many prescribed lipid-soluble drugs metabolized by the same system: OCP, cytotoxic, antiarrythmic, warfarin
    VPA is a weak CYP enz. Inhibitor:
    Slow clearance of other AEDs such as PHT, LTG.
    Newer AEDs : less likely to interfere with hepatic metabolism.
    GBP, LEV,PGB,VGB do not undergo hepatic metabolism
  • 68. Newer AEDs
    Adjunctive treatment of refractory epilepsy
    Some of these AEDs: LTG, GBP, OXC, TPM have also demonstrated efficacy as monotherapy
  • 69. Effects of phenytoin levels
    Level (mg/ml) Effect
    0-10 Subtherapeutic
    10-20 Therapeutic
    20-30 Mild toxicity; nystagmus, mild ataxia30-40 Moderate toxicity ; ataxia prominent
    > 40 Severe toxicity; ataxia, conscious -
    ness, encephalopathy
  • 70. Potential Causes of Treatment Resistant Epilepsy
    Diagnostic errors:
    Non-epileptic events  
    Wrong diagnosis of seizure types/ epileptic syndrome  
    Missing of underlying causes/lesions
    Patient’s errors:
    Non-compliance  
    Inappropriate life style, inappropriate metabolism
  • 71. Potential Causes of Treatment Resistant Epilepsy
    Treatment errors:
    Wrong choice of drugs
    Less optimal doses of drugs  
    Inadequate dosing schedules
    Antiepileptic drug toxicity
    Disease itself:
    Treatment resistant epilepsy
    metabolic disorder
  • 72. Stopping antiepileptic treatment
    Absolute requirement
    2-3 years free of all seizures
    Patient’s informed agreement
  • 73. Factors in favour
    • Childhood epilepsy
    • 74. Primary generalized epilepsy
    • 75. Absence of cerebral disorder
    • 76. Short duration of epilepsy
    • 77. Normal EEG
    • 78. Non-driver
  • Adverse prognostic factors
    Symptomatic etiology, identifiable brain pathology
    Partial-onset seizures or Atonic seizures
    Late-onset or first-year epilepsy
    Specific epilepsy syndrome (particularly JME)
    Abnormal EEGs
    Multiple seizure types in the same patient
    Additional mental or motor handicap
    Long duration or severe epilepsy prior to treatment
    Poor initial response to treatment
  • 79. Features common to the surgically privileged seizure disorders
    Presence of a well-circumscribed structural lesion on the MRI (lesional epilepsy)
    Presence of well-localized interictal epileptiform discharged on the EEG
    Clinical features of habitual seizures indicating focal onset
    Absence of discordance between above feature
    Focus localized by above features is surgically accessible and involves little or no eloquent cortex
    Absence of other potentially epileptogenic abnormalities
  • 80. Status epilepticus
    A condition in which epileptic activity
    persists for 30 minutes or more
  • 81. Common etiologies for status epilepticus in children and adolescents
    Idiopathic
    Acute symptomatic
    Electrolyte disturbance
    Encephalitis
    Head trauma
    Remote symptomatic
    Past stroke
    CNS infection
    Cerebral palsy
    Progressive encephalopathy
    Tuberous sclerosis
    Other neurodegeneration
    Febrile
  • 82. Status epilepticus management
  • 83.
  • 84.
  • 85. Epilepsy and pregnancy
    Seizure control
    Obstetric complication
    Neonatal outcome
  • 86. Neonatal outcome
    Risk of seizure
    (3 times > normal population)
    developmental outcome
    congenital anomalies 4-8%
    (2-3 times > normal population)
  • 87. The most common malformation
    Congenital heart disease
    orofacial cleft
    neural tube defect
    intestinal atresia
    urogenital defects
    Neural tube defect
  • 88. Fetal antiepileptic drug syndrome (minor anomalies)
    Facial dysmorphism
    Distal digital hypoplasia
    Developmental delay
    Mental deficiency
  • 89. Factors affecting neonatal outcome
    AED
    genetics
    folic acid
    socioeconomic
    maternal health
  • 90. Recommendations for managing Women With Epilepsy
    Before Conception
    Educate the family regarding risks
    Review classification of epilepsy
    Determine most appropriate medicine for seizure control
  • 91. Determine need for continued medication
    - may discontinue if seizure-free for 2 or more years
    - do not discontinue medication if epilepsy syndrome
    suggests continued need for treatment
    Reduce medicines to monotherapy, lowest dose possible
    Start folic acid 1 mg/day
    Eliminate other risk factors – smoking, drugs, alcohol
  • 92. After conception
    Do not change antiepileptic medication
    Refer for prenatal care
    Prescribe vitamins, including folic acid
    Check ‘free’ drug levels every trimester and change doses as needed
    Evaluate for neural tube defects at 12 to 16 weeks (ultrasound, alpha-fetoprotein, amniocentesis)
  • 93. Consider vitamin K predelivery
    Check antiepileptic drug levels prior to delivery and increase doses if needed
  • 94. After Delivery
    Check levels
    Examine infant
  • 95. ควรคลอดโดยวิธีใด ?
    ถ้าไม่มีข้อห้าม สามารถคลอดทางช่องคลอด แต่อาจช่วยคลอดเมื่อมีข้อบ่งชี้