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Repeated subthreshhold of a neuron generates an action potentials seizures
It has been suggested that chronic epileptic discharges may lead to secondary epileptogenesis.
Short, uncomplicated seizures cause no permanent/ progressive neorological dysfunctions in human brain BUT uncontrolled generalized tonic-clonic seizures or status epilepticus is associated with high neurological morbidity and permanent brain damage ( due to hypo perfusion, hypoxia, acidosis and other metabolic disturbance).
Complex Partial Seizures (Psychomotor Seizures/Temporal lobe Epelepsy) Always involved impairment of consciousness. Majority originate in Temporal lobe (60%); but also originate another lobe – particularly Frontal(30%). May start as simple partial seizures then progress. Aura may be present-short live (few seconds) Automatism: Oro-Alimentary, Mimicry, Gestural, Ambulatory, Verbal, Responsive and Violent.
Generalized Tonic-clonic (grand mal) Convulsive seizures No Aura but have prodormal phase- general malaise Tonic phase: stiff, crying out, tongue bite, apnea,cyanosed, increase heart rate and blood pressure, fall, labored breathing, salivation. Clonic phase: intermittent clonic movements of muscles, followed by brief relaxations, involved four limbs. Incontinence at the end of clonic phase. Duration: few minutes Post ictal period: drowsiness, confusion, headache, deep sleep
Typical Absence Seizures (Petit mal): Occur almost exclusively in childhood or early adolescent.
Sudden loss of consciousness and cease all motor activities. Suddenly appears blank and stares, fluttering of the eyelids, swallowing, flopping of the head. Attacks last only a few seconds (<10 sec) and often pass un- recognized. About 100-200 attacks may occur/day. Characteristic EEG : 3 per sec generalized spike and wave
Attacks precipitate by fatigue, drowsiness, relaxation , photic stimulation or hyperventilation.
Myoclonic seizures Abrupt , very brief, involuntery flexion movements. Involve whole body or part of the body Occur most commonly at morning, shortly after walking. May occur in healthy people (physiological)
Atonic Seizures Brief loss of muscle tone. Heavy fall , with or without loss of consciousness.
Versive seizures A frontal epileptic foci may involve the frontal eye field. Force deviation of the eyes and turning head to the opposite side.
Status Epilepticus Series of recurrent Tonic-Clonic seizures occurs without regaining consciousness over 30 min.
Waist Syndrome: Infantile spasm, hypsarrhythmic patterns of EEG, severe encepalopathy with mental retardation.
Infantile Spasm: Sudden brief seizures, typically tonic flexor spasm of waist, extremities and neck. 20% mortality, who survive 75% have mental retardation, 50% have life long seizures.
Juvenile myoclonic epilepsy : Inherited condition.Under recognized syndrome with myoclonic jerks, tonic-clonic or clonic- tonic-clonic seizures or absence seizures. EEG shows spike and wave pattern of 3.5-6 Hz.
Lennox-Gastaut syndrome : Devastating disorder in children. Mixed types of seizures and mental retardation. Usually cognitive deficit present. EEG shows slow (<2.5 Hz ) spike and wave patterns.
Catamenial epilepsy : Epileptic women experienced that their seizures worsen during menstruation; due to the imbalance between the proconvulsant estrogen and anticonvulsant progestogen.
No Change (may worsen) Suppress seizures Anti Epileptic drug usage No change Raised Serum prolactin (after attack) No Change Slowing pattern EEG after attack No Change Abnormal EEG during attack Yes No Can be precipitated by suggestion No Yes Occurs during sleep No Yes Injury Absent Present Post-Ictal Phenomena Long Short Duration No Yes Tongue bite No Yes Resemble known seizure types Pseudoseizure True Seizure Features & Lab findings
Medical treatment: Immediate care of seizures Move persons away from danger Recovery position (semi prone) Ensure clear airway Do not insert anything into mouth Urgent medical attention- (patent airway, O 2 , anticonvulsant, investigate cause) Should not be left alone after recovery Consider about regular AED
Surgical treatment: Indicated when seizures shown to be intractable to medical treatment. Removal of epileptic focus (eg: mesial temporal sclerosis)
Anterior Temporal Lobectomy Corpus callostomy Subpial transection
After complete control of seizures for 2-4 years, withdrawal of Anti Epileptic drugs may be considered. But in case of special professional group (car driver, machine man etc) withdraw the AED after keen follow-up.
AED should be tapered during the stopping of medications.
Slow reduction by increments over at least 6 months.
If the patient is taking two AEDs one drug should be slowly withdrawn before the second is tapered.
Mood variation : Nearly 1 in 3 patients of epilepsy report significant concern about their mood.
Depression: Upto 55% prevalent in patients with epilepsy.
Suicide rate: In depressed patients with epilepsy is 5 times higher than that in the general population and 25 times higher in patients with complex partial seizures of temporal lobe origin .
Anxiety : Upto 50% prevalent in patients with epilepsy.
Psychosis : Incidence of Psychosis 3.3% in patients with idiopathic generalized epilepsy, 14% in Temporal lobe epilepsy. In the concern of severity; Psychosis occurs in 0.6-0.7% patients with epilepsy in community and 19-27% of epilepsy patients who require hospitalization.
Drug treatments: Sodium valporate or Lamotrigin is chosen as first line treatments for Absence seizures and partial seizures. [BMJ vol 318 ]
SANAD ( Standard and New Anti-epileptic Drugs ) study : Valporate is significantly better than Topiramate and Lamotrigine in treatment of idiopathic generalized seizures .[Lancet vol 369 March 2007]
Surgery: In developing countries, in patients with Mesial TLE are feasible by a knowledgeable team consisting epileptologist, neurosurgeon, and technicians with using MRI and EEG. [Epilepsia 49(3):381-5.2008]
In Benign Rolandic Epilepsy: Children with BRE demonstrated specific recognition impairments due to cortical auditory dysfunction. [Epilepsia, 49(6):1018-1026.2008]
Seizure after Stroke: Overall incidence of seizures within 24 hours after stroke was 3.1%. Higher incidence seen in hemorrhagic stroke (8.4%). Seizures after stroke had higher mortality at 30 days after stroke .[ Epilepsia 49(6):974-981.2008]
Akershus Study : Seizure free epilepsy patients on AED monotherapy improve neuropsychological performance after withdrawn the AED but a relative risk of seizures relapse 2.46, compared to those continuing medications. [Epilepsia 49(3):455-463.2008 ]