Epilepsy2
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epilepsy 2022.pptx
- 1. Childhood epilepsy AREVIEW DR OMAR ALI NAFI MRCP
- 2. EPILEPSY DEFINITION Seizure Disturbance in the electrical activity of the brain Epilepsy Is recurrent (2 or more) unprovoked seizures Transient provoked seizures caused by fever electrolyte imbalance toxic expos head injury Are not classified as epilepsy
- 3. Status epilepticus Continuous seizures >5 minutes , generalized or focal , during which the patient remains unconscious or has 2 or more sequential seizures without full recovery of consciousness between seizures .
- 4. Etiology 70% Unknown cause 30% are due to the following: Head trauma Poisoning Infection Maternal injury Brain tumor and CVA
- 5. Classification of epilepsy 3 classifications 1- accordind to semiology : generalized partial :simple ,complex 2-according to cause : idiopathic sypmtomatic cryptogenic 3-according to clinical + EEG + age : syndromic classification
- 6. PARTIAL SEIZURES a. Simple partial (no impairment of consciousness) - motor/sensory/autonomic/psychic b. Complex partial (impairment of consciousness) - simple evolving to complex - complex from outset c. Partial seizures evolving to secondary GTCS
- 7. GENERALIZED SEIZURES The first clinical and EEG changes indicate involvement of both cerebral hemispheres. a. Absence b. Myoclonic c. Clonic d. Tonic e. Tonic-clonic f. Atonic
- 8. Generalized convulsive (grand mal) or generalized tonic-clonic sudden, immediate loss of consciousness without warning initial generalized tonic contraction and posture (causing fall and epileptic cry) then, generalized, bisynchronous rhythmic forceful jerking movements slowing of the frequency of the convulsive movements Typically last 1-3 minutes post-ictal exhaustion, sleep, disorientation
- 9. Childhood Absence Epilepsy Seizure type: simple absence seizures. 1/3 or less will also have at least one generalized tonic-clonic seizure. Often frequent (many per day). Etiology: unknown (idiopathic). often familial. Age: childhood (5-12years) EEG: generalized 3/sec spike and wave discharges. Treatment: ethosuximide or valproic acid. Prognosis: excellent. easy seizure control. remission in 70% or more. few with long term sequellae No aura Abrupt onset Brief duration Prompt recovery
- 10. Epileptic Syndromes West syndrome Infantile spasm Described>170 yr ago Triad of: - Infantile spasm flexor extensor mixed - Arrest psychomotor development - Hypsarrythmia Onset peak 4-7 months Alwayas before 1yr age Treatment : - ACTH - VIGABATRIN Fp1-F3 F3-C3 C3-P3 P3-O1 Fp2-F4 F4-C4 C4-P4 P4-O2 Fp1-F7 F7-T3 T3-T5 T5-O1 Fp2-F8 F8-T4 T4-T6 T6-O2 1 sec 50 µV Hypsarrhythmia Electrodecremental Seizure
- 11. Juvenile Myoclonic Epilepsy Seizure type: early morning myoclonic seizures (single or multiple myoclonic jerks). absence seizures. generalized tonic-clonic seizures. Etiology: unknown (idiopathic). often familial. presumed ion channel? Age: childhood (10-16years); female predominance. EEG: generalized fast spike and wave discharges (4 to 6 cycles/sec) often with photosensitivity. Treatment: valproic acid. Prognosis: generally excellent seizure control possible but remission is rare
- 12. Rolandic Epilepsy The most common seizure disorder of childhood. Seizure type: partial or secondarily generalized sensory-motor seizures occurring at the transitions between wakefulness and sleep. usually affect oral-motor function particularly. infrequent (weekly or less) Etiology: unknown (idiopathic). often familial. presumed ion channel?. Age: childhood (5-12years) EEG: focal, centrotemporal (Rolandic) spikes. Treatment: no treatment or carbamazepine. Prognosis: excellent. easy seizure control. remission in 95%. no long term sequellae.
- 13. EVALUATION Detailed history Physical examination EEG Labs Imaging technique
- 14. HISTORY Carefull detailed history corner stone for accurate diagnosis Video tape the event diagnostic Ask parents to mimic the event Physician may mimic different seizure type to find a match with the child event
- 15. Phisical examination Anthroprometric parameteres measured and plotted Vital signs fever---hypothermia BlP bradicardia alt concious ICP Meningeal signs neck stiffiness meningencephalities subarachnoide hemorrage cerebellar herniation
- 16. Physical exam cont Examination of skull shape fontanelle size tension sututre prem closure wide separation
- 17. Physical examination cont Ophthalmic examination lisch nodule retinitis pigmentosa cherry red spots
- 18. Physical examination cont Skin examination ash leaf spots facial angioma café au lait spot
- 19. Investigation Laboratory testing electrolytes ca po4 alp mg glucose Febrile child CBC blood and urine culture Lumbar puncture strongly 12 mo or if previous antibiotics considered 12-18 mo indication more 18
- 20. electroencephalogaphy EEG 56% abnormal in newly dx epileptics repeat additional 11% 20% of epileptics repeatedly normal EEG 5% of normal children epileptiformeactivity
- 21. Neuroimaging cont Indications partial onset seizure focal or new focal deficit neonatal persistent altered mental status HX of anticouagulation HX of cancer
- 22. Differential diagnosis cont BREATH HOLDING SPELLS cyanotic spells Always provocated Cry-apnea-cyanosis-loc-myoclonic Onset 6 mo---peak 2yr abate 5 yr EEG normal pallid spells Trauma to the back of head or startle Apnea—loc—pallor---hypotonia—tonic EEG normal
- 23. Differential diagnosis cnt SYNCOPE Decrease blood flow----hypotension Loss of conciousness—deviation of eyes Provoked by pain fear excitement Rare before 10-12 years More in females
- 24. Differential diagnosis cont Prolonged Q-T syndrome sudden LOC during exercise or emotional orstressfull experience Onset late childhood or adolescence during event recover or die
- 25. Treatment Medication Vagus Nerve stimulator Surgical Dietary
- 26. Medication
- 27. • Zonisamide - 2000 • Leveteracetam - 1999 • Tagabine - 1998 • Topiramate - 1996 • Lamotrigine - 1994 • Felbamate - 1993 • Gabapentin - 1993 • Vigabatrin - 1992 • Valproic Acid - 1973 • Carbamazepine - 1965 • Ethosuximide - 1955 • Primidone - 1950 • Phenytoin - 1938 • Phenobarbitone - 1912 DRUGS NAME YEAR
- 28. Phenobarbitone (Luminal) • Used for all types and all ages. • Nowadays also used for treatment of neonatal seizures, and status epilepticus • Side effects: •1)In children Hyperactivity, cognitive impairment. •2)In adults •Sedation
- 29. Phenytoin (Epanuten) • Broad spectrum •The drug of choice in Status epilepticus •Follows Zero-order pharmacokinetics •Side effects: •1)May reach toxic levels •2)Hirsutism •3)Coarse features •4)Hypertrophic gums
- 30. Ethusoximide (Zarontin) • Narrow spectrum •The drug of choice in Absence epilepsy •Side effects: •1) Skin rash •2)Agranulocytosis
- 31. Carbamazipine (Tegretol) • The drug of choice in Partial seizures, also used in complex seizures, and secondary generalization. • Also used in treatment of trigeminal neuralgia. • Side effects: •1) Skin rash •2) Agranulocytosis •3) Hyponatremia
- 32. Valproic acid (Depakine) • Broad spectrum • A component in all anti- epileptic regimens. • When given with Lamotrigine, the dose should be lowered to (1/10 th) of the usual dose, since Valproic acid increases the half life of Lamotrigine. •Mood stabilizer • Side effects: 1)Hepatotoxic 2)Transient hair loss 3)Weight gain
- 33. Vigabatrin (Sabril) • New generation anti- eplipletic drugs • The drug of choice in West syndrome( which results from tuberculous sclerosis) • Side effects: 1)Visual field defects
- 34. Gabapentin (Neurontin) • Broad spectrum • Has no interactions with other drugs • Safe to be used in organ failure( Liver or renal failure) • Used in treatment of neuropathic pain
- 35. Lamotrigine (Lamictal) • Broad spectrum • Side effects: •1) Measeles like rash •2) Stevens Johnson syndrome
- 36. Topiramate (Topamax) • Broad spectrum • Used for intractable partial complex seizures especially in combination with tegretol •Also used in prophylaxis of migraine •Side effects: •1)Renal stones •2)Decreases attention and ability to concentrate
- 37. Levetiracetam (Keppra) • Used for children and neonate age group •Used as a primary drug.
- 38. Treatment Primary generalized valproic acid Infantile spasm steroids vigabatrin Partial seizures carbamazepine ABSENCE EPILEPSY ethosuxamide valproic acid lamotrigine
- 39. Treatment MOST OF AEDs start small dose then increase if max dose reached no response serum level routine drug level discouraged MONOTHERAPY avoide interaction better compliance BEFORE switching to another drug reconsider DX
- 40. Treatment SIDE EFFECT Most are idiosyncratic Skin rash Steven johonson syndrome Hepatotoxicity pancreatitis
- 41. Medication Phenytoin (Dilantin) Gingival hyperplasia occuring in approximately 20% of patients.
- 42. Guidelines for discontinuation AEDs seizure free 2-5 years on AEDs mean 3.5 years single type of partial generalized seizures normal neurological and IQ examination EEG normalized with treatment
- 43. Vagus Nerve Stimulator Limited for localization related epilepsy Implanted device Stimulates the left vagus nerve for 30 seconds every five minutes 30% experiences 50% reduction in seizure activity
- 44. Surgical First surgery in 1886 Only utilized when medication cannot achieve satisfactory control INDICATIONS: intractable partial seizures intractable hemiepilepsy Mesial temporal sclerosis
- 45. Dietary Ketogenic diet (Metabolic shift-Ketosis state) High fat and oils High calorie Low in proteins Low in carbohydrates
- 46. THANK YOU
