Epilepsy

Seizure & Epilepsy

Definitions

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.

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.

Momentary loss of consciousness
Fit
Faint
Fake

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

Nonepileptic causes for spells
Physiologic
Tremor
Vasovagal syncope
Cardiac arrhythmias
Migraine
Medication adverse effects
Transient ischemic attacks
Autonomic dysfunction

Nonepileptic causes for spells
Psychologic
Anxiety
Panic attacks
Mood disorder
Personality disorder
Psychosis
Somatiform illness
Psychogenic seizures

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

Precipitants of seizure
Sleep and lack of sleep
Drugs and alcohol
Intercurrent illness : infection,
electrolyte imbalance
Menstruation
Stress and worry
Other precipitants-reflex epilepsy

Classification of seizure
Partial (focal, localized) seizures
Generalized seizures (convulsive or non-convulsive)
Unclassified epileptic seizures

Partial (focal, localized)seizures
Simple partial seizures (preserved consciousness)
Complex partial seizures (impaired consciousness)
Partial seizures evolving to secondarily
generalized seizures

Simple partial seizures
(preserved consciousness)
With - motor signs
- somatosensory or special
sensory systems
- autonomic symptoms or signs
- psychic symptoms

Complex partial seizures (impaired consciousness)
- Simple partial onset followed by impairment of conscious
- With impairment of consciousness at onset

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

Generalized seizures (convulsive
or nonconvulsive)
- Absence seizures
Typical absences
Atypical absences
- Myoclonic seizures
- Clonic seizures
- Tonic seizures
- Tonic-clonic seizures
- Atonic seizures (astatic seizures)

Unclassified epileptic seizures
- Neonatal seizures
- Recurrent status epilepticus
- Rare or ‘isolated’ seizures

Epileptic seizure
All clinical and
laboratory data
neuroimaging
Seizure
description
and EEG
Etiology
Seizure
type (s)

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

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.

Electroencephalogram

What value is the EEG?
Add weight to the clinical diagnosis
Aid classification of epilepsy
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

Normal EEG

Primary generalized epilepsy—ictal EEG

Primary generalized epilepsy- interictal EEG

Burst of generalized spike and wave discharges—typical absence seizure

EEG monitoring

Video Monitoring
Helpful in determining nature of seizure disorder (epilepsy, convulsive syncope, or psychogenic seizures)

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

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

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

Neurocysticercosis

Cerebral infarction

Intracerebral hemorrhage

Brain tumor or metastasis

Lt mesial temporal sclerosis

Cortical dysplasia

52 year old woman with intractable seizure
PET scan

PET using F-18 FDG-- Decreased FDG uptake in both temporal lobes, right worse then left but otherwise relatively symmetric

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

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

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

First aids

Treatment

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Choose a drug : considering the following factors
The seizure type and prognosis
Age
The possibility of pregnancy
Toxicity
Drug interaction
Price

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.

RISK OF RECURRENT SEIZURE(cont)
If you do have two seizures, there's about
80% chance that you'll have more.

Factors predictive of a high rate of seizure recurrence after the first unprovoked seizure
Abnormal neurologic status by NE or imaging
EEG abnormalities (especially epileptiform)
Partial seizures

Counseling before treatment
1. Aims of treatment
2. Prognosis and duration of the
expected treatment
3. Importance of compliance
4. Side effects

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

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

First-line choice of AEDs according to seizure type

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

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

Managing newly diagnosed epilepsy
Newly diagnosed epilepsy
47%
Seizure free
First drug
13%
Seizure free
Second drug
Refractory
Surgical assessment
Rational duotherapy

Adverse effect of AED
Dose related
Idiosyncratic / allergic
Chronic toxicity
Teratogenicity

Older AEDs

AED interactions
CBZ : autoinduction, VPA, PHT, -PB
PHT : CBZ, VPA, PB
PB : CBZ, VPA, PHT
VPA : CBZ, PB, PHT

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

Newer AEDs
Adjunctive treatment of refractory epilepsy
Some of these AEDs: LTG, GBP, OXC, TPM have also demonstrated efficacy as monotherapy

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

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

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

Stopping antiepileptic treatment
Absolute requirement
2-3 years free of all seizures
Patient’s informed agreement

Factors in favour
Childhood epilepsy
Primary generalized epilepsy
Absence of cerebral disorder
Short duration of epilepsy
Normal EEG
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

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

Status epilepticus
A condition in which epileptic activity
persists for 30 minutes or more

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

Status epilepticus management

Epilepsy and pregnancy
Seizure control
Obstetric complication
Neonatal outcome

Neonatal outcome
Risk of seizure
(3 times > normal population)
developmental outcome
congenital anomalies 4-8%
(2-3 times > normal population)

The most common malformation
Congenital heart disease
orofacial cleft
neural tube defect
intestinal atresia
urogenital defects
Neural tube defect

Fetal antiepileptic drug syndrome (minor anomalies)
Facial dysmorphism
Distal digital hypoplasia
Developmental delay
Mental deficiency

Factors affecting neonatal outcome
AED
genetics
folic acid
socioeconomic
maternal health

Recommendations for managing Women With Epilepsy
Before Conception
Educate the family regarding risks
Review classification of epilepsy
Determine most appropriate medicine for seizure control

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

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)

Consider vitamin K predelivery
Check antiepileptic drug levels prior to delivery and increase doses if needed

After Delivery
Check levels
Examine infant

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Epilepsy

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Epilepsy

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Epilepsy Presentation Transcript

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