Ketogenic diet in epilepsy

2. 
 Ketogenic diet initially was developed in 1920 in
response to the observation that fasting had anti
seizure properties.
 Ketogenic diet can stimulate metabolic effects of
starvation.
 Ketogenc diet-High fat and low carbohydrate
Introduction

3. 
 It has beneficial effect on variety of metabolic,
Oncologic, neurodegenerative and psychatric
disorders with different mechanism of actions.
 It also has anti angiogenic effect
 Direct and Indirect effects (neurotransmission, ATP
production)

4. 
CLASS 1 CLASS 3
EPILEPSY PARKINSONS DISEASE
ALZHEIMER DISEASE AML
TRAUMATIC BRAIN INJURY
AUTISM
DEPRESSION
Indication

5. 
 Epilepsy-mutation in GLUT-1,PDH deficiency
DRAVERT SYNDROME: severe myoclonic epilepsy
febrile seizures
DOOSE SYNDROME: myoclonic astatic epilepsy
 Metabolic defects: PFK deficiency, McArdle
diease(glycogenolysis type V)
Indications

6. 
 Malignancy : Advanced astrocytoma,Gliomas
 Trauma and ischemia: fuel to injured brain and
cardio protective effects.
 Neurodegenerative diseases: PD,AD calorie
restriction itself is protective, ketogenic diet enhance
mitochondrial function, improvement in UPDRS

7. 
 Ketogenic diet protect against deposition of amyloid.
In AD high carb diet worsens the memory.
 Mitochondrial dysfunction is found to be the cause
of progression of ALS
 Autism: patients on modified Radcliffe diet shown
improvement in Childhood autism rating
scale(CARS)

8. 
 Depression: Ketogenic diet shown improvement in
Porsolt test and behavioural changes.
 Migraine , Headache and Narcolepsy

9. 
 In ketogenic diet body uses fat as primary source.
 Fat break down in liver-Ketones
 In neuronal tissue ketones are used in mitochondria
to generate ATP.
 Relation between urine ketones and seizure control
is imprecise .
Mechanism of action

10. 
 Enhancement of GABA function by ketone bodies
and increases the expression of GAD( 65 & 57)
 Saturated fatty acid and PUFA has neuro protective
effect. Arachidonic acid inhibit voltage gated sodium
channels.
 Brain metabolizes ketone better under conditions of
reduced glucose(calorie restriction)

11. 
DIRECT INDIRECT
KETONE BODIES
SUBSTRATE DELIVERY
ENHANCEMENT OF
MITOCHONDRIAL FUNCTION
ATP PRODUCTION
DECREASE ROS
NEUROTRANSMISSION
ION CHANNELS
MITOCHONDRIAL BIOGENISIS
Potential mediators

12. 
16
49
35
Protein
Carb
Fat
Standard diet

13. 
90
2
8
fat
Carb
Protein
Ketogenic Diet

14. 
646
30
Fat
Carb
Protein
Modified Atkins diet

15. 
Diet compostion Ketogenic diet Atkins Diet
Fat(% by weight) 80 60
Protein(% by weight) 15 30
Carbs 5 10
Calorie(% of DRA) 75 Not restricted

16. 
Typical ketogenic diets
Salad with walnuts Bluberry tart
Sausage and
cabbage dinner
with cream

17. 
Day prior to admission(Sunday):
Reduce carb for 24 hr on fasting from evening
Day 1(Monday)
On non carb fluids only, fasting continues till
dinner(1/3 rd of the calculated maintainance).
fluid restriction 60-75 cc/kg
BG Q6H, orange juice for glucose
John Hopkins Protocol

18. 
Day 2 (Tuesday)
Urine ketones periodically
Dinner increased to 2/3 rd. of maintenance.
Day 3 (Wednesday)
Breakfast and lunch given providing 2/3 rd of
maintainance
Dinner full Ketogenic meal

19. 
Day 4 (Thursday)
Full ketogenic diet breakfast
Education completed
Prescription for carb free diet
Child discharged

20. 
 Low level acidosis
 Lack of weight gain
 Constipation
 Diarrhoea and bloating
Side effects

21. 
 Significant dyslipidemia
 Kidney stones
 Hypoalbuminemia
 Pancreatitis
 Vitamin deficiencies
Less common

22. 
 After 2 years of seizure free or no improvement after
3- 6 months
 Dietary factors that worsen seizure:
1. Glutamate eg: MSG
2. Caffeine
3. Alcohol
4. betel nuts
5. Herbal remedies
Discontinuation

23. 

24. 
 59 year old male known case of Diabetes, CVA ,HTN
came with history of diplopia and blurring of vision.
 1 st episode of CVA on 2012 during that time he
presented with blurring of vision with pupil dilated
right eye and ptosis with left homonymous
hemianopia. With no EOM involvement.
 No limb weakness, DTR NORMAL.
Case presentation

25. 
 At that time provisional diagnosis was mid brain
stroke.
 The images MRI Brain showed

26. 

27. 

28. 

29. 
 On 2015 jan CVA with slurring of speech and right
facial palsy. At that time CT brain was took

30. 

31. 
 Patient presented with diplopia

32. 

33. 

34. 
SUMMARY

35. 
Final diagnosis:
 CVA-RIGHT OCCIPITAL ,LEFT
PARIETAL(MCA/PCA)
 RIGHT MEDIAL RECTUS PALSY
 PARTIAL 3RD NERVE PALSY (RIGHT SIDE)
 RIGHT FACIAL N UMN PALSY (RECOVERED)
 T2DM UNCONTROLLED (HBA1C :11)
 HTN