Presentation on epilepsy

1. EPILEPSY
PRESENTER : NAWA LIKANDO
3RD YEAR ML STUDENT
MODERATOR : DR S. LUEDERS
[ML SITE CONSULTANT ,KDH ]
23-03-2017

2. PRESENTATION OUTLINE
 Definition
 Epidemiology
 Aetiology
 Classification
 Pathophysiology
 Precipitating factors
 Seizure types
 Signs and symptoms
 Diagnosis
 Differential diagnosis
 Management
 Status epilepticus
 Complications

3. DEFINITION(S)
 Epilepsy is a chronic brain disorder characterized by repeated attacks of
unprovoked, abnormal electrical discharge of cerebral neurons resulting in
EEG, sensory, motor, autonomic and physiologic changes.
 Epilepsy can also be defined as a tendency to unprovoked recurrent
seizures.

4. EPIDEMIOLOGY - GLOBAL
 Epilepsy affects 0.4 to 0.6% of the world`s population at any point in time.
 The global burden of epilepsy is estimated to be >50 millions of whom 80%
live in low or middle income countries.
 There are two peak age groups
 childhood and adolescence
 older adults(>65 yrs)

5. EPIDMIOLOGY CONT.....ZAMBIA
 1.5% of population
 1.5% of admissions
 16% of outpatients
(Birbeck 2000, 2004)

6. AETIOLOGY
 Primary epilepsy (Idiopathic) – 60 to 70 %.
 Secondary epilepsy (Cryptogenic) – 30 to 40 %.
 Local causes – Trauma, meningitis, brain tumors etc.
 Systemic causes – Hypoglycemia, hypocalcaemia, fevers etc.
 Drugs – Insulin, TCAs, CNS stimulants , antipsychotics etc.

7. CLASSIFICATION
The International league against epilepsy (ILAE) has revised classification of
epilepsy. – 2016.
 Focal seizures – Previously called partial seizures. These start in an area or
network of cells on one side of the brain.
 Generalized seizures – Previously called primary generalized seizures. These
involve networks on both sides of the brain at the onset characterized by ; tonic-
clonic limb movements, loss of consciousness, frothing from the mouth, tongue
biting, incontinence and post ictal confusion.
 Unknown onset seizure – The seizure type falls into unknown category if the
onset is not known.
 Focal to bilateral seizure – Previously called secondary generalized seizures. A
seizure type that starts in one side or part of the brain and spreads to both sides.

8. Classification cont….
 Focal seizures & focal
to bilateral seizures
 Generalised seizures
 Unclassified seizures

9. PATHOPHYSIOLOGY
The hyperactivity of cerebral neurons in epilepsy might be due to ;
 Change in brain transmitters.
 Increase in excitatory brain transmitters (Glutamate).
 Decrease in inhibitory brain transmitters (GABA)
 Increased membrane permeability to ions (Ca++,Na+).

10. Characteristics of a seizure
 It should be recurrent.
 It should present in a similar manner.
 It should respond to AEDs.

11. PRECIPITATING FACTORS
 Sleep deprivation
 Alcohol
 Drug abuse
 Menstruation
 Flickering lights
 Noise
 Stress

12. SEIZURE TYPES
 Tonic-clonic seizures
 Tonic seizures – sustained contraction.
 Clonic seizures – rhythmic contractions.
 Absence seizures – staring, unresponsiveness, and eye flutter - Few secs.
 Myoclonic seizures – rapid shock like contractions, usually < 50 sec.
 Atonic seizures – loss of tone, usually longer and lasts longer.
 Seizures can either be convulsive type (60%) or non- convulsive type
(40%).

13. Types of epilepsy (based on cerebral
lobes)
 Temporal lobe epilepsy –memory & learning problems
 Frontal lobe epilepsy –personality change, disordered thought process
resulting in language & speech problems
 Occipital lobe epilepsy – visual hallucinations, rapid eye blinking etc
 Parietal lobe epilepsy .

14. SIGNS AND SYMPTOMS
Clinical presentation depends on the part of the brain that is affected and
may include ;
 Change in awareness, behaviour, emotions, or senses.
 Stiffness/rigidity lasting longer than 1- 2 minutes.
 Tongue bite or self injury.
 Urine or faecal incontinence.
 Drowsiness, sleepiness, confusion, headache, muscle aches etc.

15. DIAGNOSIS
 Good history taking (Epilepsy Hx).
 Thorough physical examination.
 Investigations.
 History of at least two seizures in the last 12 months on two different days.
 History of one seizure episode with risk factors – birth asphyxia, head injury,
infection of the brain, family history of seizures etc.
 Note – Epilepsy is diagnosed clinically.

16. Blood Tests
Glucose
Electrolytes
Calcium/Magnesium
Liver function
Full blood count
Blood films
Hiv test
Syphilis test

17. Lumbar puncture

18. EEG - Electroencephalography

19. CT scanner

20. DIFFERENTIAL DIAGNOSIS
 Syncope
 Severe malaria with seizures.
 Hyperventilation.
 Migraines.
 Narcolepsy.
 Drop attack.
 Meningitis

21. MANAGEMENT
MEDICATION
Antiepileptic drugs (AEDs), choice determined by:
 Type of Seizures.
 Co-morbid conditions.
 Side Effect Profile.
 Pharmacokinetics.
 Cost.
 Compliance.
 The goal of treatment in patients with epileptic seizures is to achieve a seizure-free
status without adverse effects.
 Monotherapy is desirable because it decreases the likelihood of adverse effects,
and avoids drug interactions. In addition , Monotherapy is cost effective.

22. MANAGEMENT CONT…
Anti epileptic drugs (AEDs) used in different types of epilepsy include ;
 Focal, focal to bilateral and generalized seizures.
 Drugs of choice : - Carbamazepine, Sodium valproate, Lamotrigine,
Phenytoin .
 Second line drugs : - Phenobarbital (Sedation & tolerance limits its use).
 Absence seizures.
 Drugs of choice : - Ethosuximide(safest), valproate (Hepatotoxic).
 Second line drugs : - Clonazepam(Sedation & tolerance limits its use).
 Myoclonic seizures.
 First line : - Valproate.
 Second line : - Clonazepam.

23. MANAGEMENT CONT….
SURGERY
 Recommended in refractory seizures , e.g Patient who has tried 2 to 3
different medication in optimum doses without success.
 Lesionectomy- Most common, removes a seizure focus.

24. MANAGEMENT CONT….
 Lobectomy-Takes away large area of brain (Temporal lobectomy most
common).
 Corpus callosotomy- Cuts connection between right and left
hemisphere of brain.
 Hemispherectomy-removal of half of the cortex or outer layer of the
brain.

25. STATUS EPILEPTICUS
 Is defined as a seizure that lasts longer than 5 minutes.
 Or more than 2 seizures without a return to a normal level of consciousness
between them .
 Or a seizure not response to two doses of diazepam.
 Status epilepticus can either be convulsive or non- convulsive type.

26. Aetiology
 Antiepileptic drug noncompliance or discontinuation.
 Withdrawal syndromes-alcohol, barbiturates, benzodiazepines etc.
 Acute structural injury-brain tumor/cerebral metastasis, stroke, head trauma,
infections etc.
 Metabolic abnormalities-hypoglycemia, hepatic encephalopathy, uremia etc.
 Use of, or overdose with drugs that lower the seizure threshold- TCAs,
quinolone antibiotics, metronidazole, isoniazide etc.

27. Differentials
 Coma - usually irreversible & normal EEG.
 Delirium – difficult to differentiate .
 Psychogenic non-epileptic status epilepticus – persistent eye closure,
discontinuous motor activity, no postictal state, positive psychiatric Hx, &
normal video EEG.

28. Management
 ABC.
 Oxygen.
 Iv access-large vein.
 Dextrose- - 50 ml bolus of 50%.
 Thiamine - 100mg iv.
 Consider adding naloxone 0.2 – 2mg iv to the dextrose bag
in cases of drug intoxication.
 Diazepam (0.15/kg) or lorazepam (0.1mg/kg) iv over 5
minutes.
 Phenytoin (18-20mg/kg) at a rate not exceeding 50mg/min.
In N/saline.

29. Management cont….
 Phenytoin (10mg/kg iv) , if seizures continue after 20 min.
 Phenobarbital (15mg/kg iv), if seizures continue after 20 min .
 Consider general anaesthesia if seizures continue-propofol, midazolam,
ketamine.

30. COMPLICATIONS
 Sudden unexplained death in epilepsy (SUDEP)
 Permanent brain damage
 Intellectual disability
 Head injury
 Aspiration pneumonia
 Fractures
 Accidents
 Tongue bite
 Chronic inter-ictal psychosis(Schizophrenia like illness).

31. THANKYOU FOR LISTENING
!!!!
“EPILEPSY - ONCE A SACRED DISEASE”