Epilepsy, Kinds, Treatment, Prognosis 2018. Neurology and internal medicine By Dr. Omar Ansari, Specialist, Internal medicine

1. EPILEPSY

2. General consideration
 The term “epilepsy” denotes any disorder
characterized by recurrent unprovoked seizures.
 A seizure is a transient disturbance of cerebral
function due to an abnormal paroxysmal neuronal
discharge in the brain.
 Epilepsy is common, affecting approximately 0.5%
of the population in the United States.

3. Etiology
 According to the International League Against
Epilepsy classification system, the many
etiologies of seizures can be grouped into three
categories:
1. Genetic Epilepsy
2. Structural/Metabolic Epilepsy
3. Unknown Epilepsy

4. Genetic Epilepsy
 This category encompasses a broad range of
disorders, for which the age at onset ranges from the
neonatal period to adolescence or even later in life.

5. Structural/Metabolic Epilepsy
 Pediatric age groups: Perinatal injuries
 Metabolic disorder:
1. Withdrawal from alcohol or drugs is a common
cause of recurrent seizures,
2. uremia and
3. hypoglycemia or hyperglycemia) may also be
responsible.
Since these seizures are provoked by a readily
reversible cause, this would not be considered
epilepsy.

6. Structural/Metabolic Epilepsy cont’d
 Trauma is an important cause of seizures at any
age, but especially in young adults.
 Posttraumatic epilepsy is more likely to develop if the
dura mater was penetrated
 Generally becomes manifest within 2 years
following the injury.
 However, seizures developing in the first week after
head injury do not necessarily imply that future
attacks will occur.
 There is no clear evidence that prophylactic
anticonvulsant drug treatment reduces the incidence
of posttraumatic epilepsy.

7. Structural/Metabolic Epilepsy cont’d
 Neoplasm and other space occupying lesions:
Neoplasms may lead to seizures at any age, but they
are an especially important cause of seizures in
middle and later life, when the incidence of
neoplastic disease increases. The seizures are
commonly the initial symptoms of the tumor and
often are focal in character. They are most likely to
occur with structural lesions involving the frontal,
parietal, or temporal regions.
 Tumors must be excluded by imaging studies (MRI
preferred over CT) in all patients with onset of
seizures after 30 years of age, focal seizures or
signs, or a progressive seizure disorder.

8. Structural/Metabolic Epilepsy cont’d
Vascular diseases—Stroke and other vascular
diseases become increasingly frequent causes of
seizures with advancing age and are the most
common cause of seizures with onset at age 60
years or older.
Degenerative disorders—Alzheimer disease and
other degenerative disorders are a cause of seizures
in later life.

9. Structural/Metabolic Epilepsy cont’d
 Infectious diseases—Infectious diseases must be considered
in all age groups as potentially reversible causes of
seizures.
 Seizures may occur with an acute infective or inflammatory
illness, such as bacterial meningitis or herpes
encephalitis, or in patients with more longstanding or chronic
disorders, such as neurosyphilis or cerebral cysticercosis.
 In patients with AIDS, seizures may result from central
nervous system toxoplasmosis, cryptococcal meningitis,
secondary viral encephalitis, or other infective complications.
 Seizures are a common sequela of supratentorial brain
abscess, developing most frequently in the first year after
treatment.
Cysticercosis is a tissue infection caused by the young form of
the pork tapeworm.

10. 3. Unknown Causes
 In many cases, the cause of epilepsy cannot be
determined.

11. Classification of Seizures
 According to ILAE two types:
1. Focal seizures
2. Generalized seizures

12. 1. Focal Seizures
 only a restricted part of one cerebral hemisphere
has been activated.
 Two types:
1. Without impairment of consciousness (Simple
Seizure)
2. With impairment of consciousness (Complex
seizure)

13. A. Focal Seizures without conscious impairment
 Seizures may be manifested by focal motor
symptoms (convulsive jerking) or somatosensory
symptoms (eg, paresthesias or tingling) that spread
(or “march”) to different parts of the limb or body
depending on their cortical representation; such
seizures were previously described as “simple
partial” seizures.

15. B. Focal Seizures with impaired consciousness
 Such dyscognitive seizures were previously called
“complex partial” seizures.

17. 2. Generalized Seizures
 There are several different varieties of generalized
seizures, as outlined below. In some circumstances,
seizures cannot be classified because of
incomplete information or because they do not fit into
any category.
1. Absence Seizure (Petit mal)
2. Atypical absence seizure
3. Myoclonic seizure
4. Tonic-clonic (Grandmal) Seizure

18. Definition of tonic clonic and flaccid
 Tonic phase: Sudden loss of consciousness, with
rigidity and arrest of respiration, lasting < 1 minute.
 Clonic phase: Jerking occurs, usually for < 2–3
minutes.
 Flaccid coma: Variable duration
 Atonic means a loss of muscle tone. In
an atonic seizure, a person suddenly loses muscle
tone so their head or body may go limp. Also called
drop attacks.

19. Types of Seizure

25. Grand mal Seizures
 Two other types:
Further convulsion without recovery of consciousness
between the attacks (status epilepticus), or after
recovering consciousness have a further convulsion
(serial seizures).

26. Symptoms and signs
1. Prodromal symptoms such as headache, mood
alterations, lethargy, and myoclonic jerking alert some
patients to an impending seizure hours before it occurs.
 These prodromal symptoms are distinct from the aura;
the aura that may precede a generalized seizure by a few
seconds or minutes is itself a part of the attack and it
arises locally from a restricted part of the brain.
 Occasionally, however, they occur at a particular time
(eg, during sleep) or in relation to external precipitants
such as lack of sleep, missed meals, emotional stress,
menstruation, alcohol ingestion (or alcohol withdrawal or
use of certain drugs)

27. Prodromal symptoms
 Fever and nonspecific infections may also
precipitate seizures in epileptic patients.
 In a few patients, seizures are provoked by specific
stimuli such as flashing lights or a flickering
television set (photosensitive epilepsy), music, or
reading

28. Imaging
 Some clinicians routinely order MRI for all patients
with new-onset seizure disorders, but this may be
unnecessary.
 MRI is indicated for patients with focal neurologic
symptoms or signs, focal seizures, or
electroencephalographic findings of a focal
disturbance. It should also be performed in patients
with clinical evidence of a progressive disorder and
in those with new onset of seizures after the age
of 20 years because of the possibility of an
underlying neoplasm.
 CT is generally less sensitive than MRI in detecting
small structural brain abnormalities but may be used
when MRI is contraindicated

29. EEG
 Electroencephalography may support the clinical
diagnosis of epilepsy (by demonstrating paroxysmal
abnormalities containing spikes or sharp waves),
 Classification of the disorder is important for
determining the most appropriate anticonvulsant drug
with which to start treatment.
 For example, absence and focal seizures with
impairment of consciousness may be difficult to
distinguish clinically, but the electroencephalographic
findings and treatment of choice differ in these two
conditions.
 Finally, by localizing the epileptogenic source, the
electroencephalographic findings are important in
evaluating candidates for surgical treatment.

33. Blood tests
 Glycemic level
 Electrolytes
 CBC
 KFT
 LFT
 Lumbar Puncture

34. DDX
 Focal seizure with:
1. TIA
2. Panic attack
 Generalized seizure:
 1. 1. Syncope—Syncopal episodes usually occur in relation to
postural change, emotional stress, instrumentation, pain, or
straining. They are typically preceded by pallor, sweating,
nausea, and malaise and lead to loss of consciousness
accompanied by flaccidity; recovery occurs rapidly with
recumbency, and there is no postictal headache or confusion.
In some instances, however, motor accompaniments
and urinary incontinence may simulate a seizure.

35. DDX
 Cardiac disease: Cerebral hypoperfusion due to a
disturbance of cardiac rhythm should be suspected in
patients with known cardiac or vascular disease or in
elderly patients who present with episodic loss of
consciousness. Prodromal symptoms are typically
absent.
 Psychogenic nonepileptic seizure PNES —Simulating an
epileptic seizure, a PNES may occur due to a conversion
disorder or malingering.
 Although a PNES tends to occur at times of emotional.
 The serum level of prolactin has been found to increase
dramatically between 15 and 30 minutes after a tonic-
clonic convulsion in most patients, whereas it is
unchanged after a PNES. Serum creatine kinase levels
also increase after a convulsion but not a PNES.

36. Treatment: General measures
 For patients with epilepsy, drug treatment is
prescribed
with the goal of preventing further attacks and is
usually
continued until there have been no seizures for at
least 2 years.
 driving cessation for 6 months or as legislated is
appropriate following an unprovoked seizure.

37. Treatment
 Surgical treatment—Patients with seizures refractory
to pharmacologic management may be candidates for
operative treatment.
 Surgical resection is most efficacious when there is a
single well-defined seizure focus, particularly in the
temporal lobe.
 Among well-chosen patients, up to 70% remain seizure-
free after extended follow-up.
 Bilateral deep brain stimulation of the anterior
thalamus for medically refractory focal-onset seizures
may be of benefit, and there is an evolving role for
electrical stimulation of other cortical and subcortical
targets.

38. Vagal nerve stimulation
Treatment by chronic vagal nerve stimulation for adults
and adolescents with medically refractory focal
seizures is approved in the United States and
provides an alternative approach for patients who are
not optimal candidates for surgical treatment. The
mechanism of therapeutic action is unknown.
Adverse effects consist mainly of transient hoarseness
during stimulus delivery.

39. Treatment: solitary seizures
 Solitary seizures—In patients who have had only one
seizure or a flurry of seizures over a brief period of
several hours, investigation as outlined earlier should
exclude an underlying cause requiring specific treatment.
 An electroencephalogram should be obtained,
preferably within 24 hours after the seizure, because
the findings may influence management—especially
when focal abnormalities are present.
 Prophylactic anticonvulsant drug treatment is generally
not required unless further attacks occur or investigations
reveal some underlying pathology. The risk of seizure
recurrence varies in different series between about 30%
and 70%. Epilepsy should not be diagnosed on the
basis of a solitary seizure

40. Alcohol withdrawal seizures
 Alcohol withdrawal seizures—The characteristic alcohol
withdrawal seizure pattern is one or more generalized
tonic-clonic seizures that may occur within 48 hours or so
of withdrawal from alcohol after a period of high or prolonged
intake.
 If the seizures have consistently focal features, the possibility of
an associated structural abnormality, often traumatic in origin, must
be considered.
 Head CT scan or MRI should be performed in patients with new
onset of generalized seizures and whenever there are focal features.
 Treatment with anticonvulsant drugs is generally not required for
alcohol withdrawal seizures, since they are self-limited.
Benzodiazepines (diazepam or lorazepam, dosed as needed to
reduce withdrawal symptoms and to avoid oversedation) are
effective and safe for preventing further seizures. Status epilepticus
may rarely follow alcohol withdrawal.
 Further attacks will not occur if the patient abstains from alcohol.

41. Tonic clonic status epilepticus
 Causes: Poor compliance with the anticonvulsant
drug regimen is the most common cause; other
causes include alcohol withdrawal, intracranial
infection or neoplasms, metabolic disorders, and
drug overdose.
 The mortality rate may be as high as 20%, and
among survivors the incidence of neurologic and
cognitive sequelae is high.
 The prognosis relates to the length of time
between onset of status epilepticus and the start
of effective treatment.

42. Nonconvulsive status epilepticus
 Nonconvulsive status epilepticus—In some cases,
status epilepticus presents not with convulsions,
but with a fluctuating abnormal mental status,
confusion, impaired responsiveness, and
automatism.
 Electroencephalography
is helpful in establishing the diagnosis.