Medicine: Clinical approach to epilepsy Must know things for MBBS

1. EPILEPSY

2. PAST QUESTIONS
• Investigation for seizure and guideline for anticonvulsant therapy and
choice of antiepileptic drugs.(2=3=3)
• Define seizure. Difference between syncope and seizure. Mm of
status epilepticus. (10)

3. Defn
• Seizure is the occurrence of s/s due to abnormal, excessive and
synchronous neuronal activity in brain
• Epilepsy is the tendency of recurrence of seizure

4. pathophysiology

5. ILAE 2017 classification
ABCES
A2CE
HMT
2TC 3MAE
TAME

7. Focal seizure
• Abnormal electric discharge
arise from a focal area of one
hemisphere of brain
• Later become generalized k/a
focal to b/l tonic clonic
Generalized seizure
• Abnormal electric discharge
arise from diencephalic
activating system which spread
to whole brain.

8. Common epilepsy syndromes

9. • Intercurrent infection
• Uncommon: loud noise, music, reading, hot baths
• Flickering of light (TV and computer) (generalized epilepsy syndrome only)
• Recreational drug misuse (amphetamines)
• Alcohol (withdrawal)
• Missed dose of AED drugs
• Metabolic causes
• Exhaust; physical and mental
• Sleep deprivation
Triggers of Seizures

10. Causes of focal seizure
• Idiopathic
BREC (Benign Rolando’s epilepsy of childhood)
BOEC (Benign occipital epilepsy of childhood)
• Focal structural lesion (GIT VDM)
Genetic
Tuberous sclerosis
von-Hippaul Disease
Cerebral migration disease
Neurofibromatosis
Autosomal dominant nocturnal frontal lobe
seizure
AD partial seizure with auditory features
Infective (she said TC)
Subdural empyema
HIV
Encephalitis
Tuberculoma
Toxoplasmosis
Cysticercosis
cerebral abscess

11. Inflammatory
Sarcoidosis
Vasculitis
Autoimmune disease (anti
GABA receptor ab
disease)
Trauma
Tumors(primary and
secondary)
Vascular
Intracerebral hage
Av malformation
Cavernous hemangioma
Dysembryoni
Struge weber syndrome
Cerebral dysgenesis
Mesial temporal epilepsy(asso
with febrile convulsion)

12. Causes of Generalized seizure (Giim d c2hat)
• Genetic
Inborn error of metabolism
Storage diseases
Phakomatoses (tuberous sclerosis)
Infective
Post infectious encephalitis
Meningitis
Inflammatory
Sle
Ms
•metabolic
Ca, Mg, Na, Glucose
Liver Renal failure
Drugs (A3C2P)
AB: Penicillin, metronidazole, INH
Antimalarial: Chloroquine, mefloquine
Amphetamines (withdrawal)
Ciclosporine
Cardiac arrhythmias (lidocane and
disopyramide)
Psychiatric drugs (TCA, lithium,
phenothiazine)

13. Diffuse degenerative diseases
Alzheimer disease
Cruezfeldtz jakob disease
Cerebral anoxia
Cerebral birth injury
Hydrocephalus
Alcohol withdrawal
Toxins
OP and heavy metals (tin and lead)

14. Approach
• History
Symptoms
Focal seizure/ Generalized seizure
Focal seizure
Aware
Impaired awareness
Spreading type

15. • Generalized seizure
• Tonic-clonic
Aura-Tonic(rigid log like)-clonic(jerking)-flaccid state of deep coma-regain
consciousness- post ictal state(confusion, disoriented, amnesia)
Urine incontinence and Tongue biting (severe and bleeding)
Absence
Myoclonic
Tonic
clonic

16. • Family h/o
• Drug history
• Developmental h
• Recreational drug h
• Alcohol withdrawal

17. • Physical sign:
• Rigidity
• Jerking
• Automatism
• Postictal confusions
• Todds paralysis

18. DDS
• Syncope
• Nonepileptic attacks
• Tremors dyskinesia
• Nonepileptic myoclonus following hypoxic event

21. EEG recordings
Normal
GTCS
21

22. Indications for brain imaging in epilepsy
• • Epilepsy starting after the age of 16 years
• • Seizures having focal features clinically
• • Electroencephalogram showing a focal seizure source
• • Control of seizures difficult or deteriorating

23. Management
• 1. immediate care

24. 2. Lifestyle changes
• Do not risk pt and pt related people
• Occuupation
• activiteis

25. 3. AED

27. 4. monitoring
• Aed level in blood for adherence and status epilepticus

28. 5. Withdrawal of drug
• After 2 yrs of seizure free period

29. 6. Epilepsy sx
• Sx resection of epileptogenic brain
• Vagal stimulation of brain
• Deep brain stimulation

30. Status epilepticus
• Defn. 5 min and recurrence without no recovery inbetween
• Causes- denovo:metabolic, infection, tumor
Low level of aed drug level
Diagnosis: T-C, Loss of awareness
Cyanosis, acidosis, pyrexia, sweating
Complication: cardioac arrhythmias, hypotension, liver,renal failure,
aspirn

31. mm.
initial mm
• Airway
• Rr, bp, pulse, BM stix
• IV access
• Send blood for
Metabolic causes
infectious cause
Aed level

32. • If seizure >5 min: give one of the below
Midazolam 10mg buccally/intranasally
Lorazepan 4mg iv
Diazepam 10 mg rectally/iv
• treat the cause