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Epilepsy (3)


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Epilepsy (3)

  1. 1. WELCOME
  2. 2. EPILEPSYthe “sacred disease’’ByBasil
  3. 3. IntroductionThe brain normally contain millions ofneurons interacting through electricaldischarges .If these interactions misfire it can causeseries of problem in the brain.It can cause changes in the way personfeels, think, and moves. Those changesare called seizure
  4. 4. History of epilepsyReferences to epilepsy date back to ancienttimes and mystical explanation continueduntil 18th century.Hippocrates wrote the first book on epilepsyin 400 BC.He believed that epilepsy is a curse or signfrom the GOD.In 1494 it was believed that seizure is acharacteristics of witches. The prosecutionthat followed resulted in 2 lack deaths.
  5. 5. In 1890 one of the neurologist JohnHughlings Jackson defined seizure as anoccasional excessive and disorderlydischarge of nerve tissue on the muscletissue.In 1912 first seizure medicationPhenobarbitone was created as a sedativebut soon it was found useful for seizure andit is still using today.1929 the German Psychiatrist Horns Burgerinvented the Electro Encephalo Gram(EEG) provided the first recording ofepileptic discharge from brain.
  6. 6. • In 1930 Gibbs co-related the clinicalevidence of epilepsy EEG findings.• Even in 20th century some state has the lowthat ―Those With Epilepsy Shall Not Wed‖ .But luckily this practice was ended.• 1997 FDA approved a device ― The VagusNerve Stimulator‖ to treat partial epilepsy inadults.• Napoleon, Julius Caesar, and Jonty Rhodesare some prominent personalities whosuffered due to epilepsy.
  7. 7. Seizure• Seizure the word came from a Latin wordsacire means -to take possession of• Seizure is a paroxysmal uncontrolledelectrical discharge of neurons in the brainthat interrupts normal functioning, leading to asudden, violent involuntary series ofcontractions of a group of muscle.
  8. 8. DEFINITION• Seizure is a clinical syndrome caused by anelectrical event that is characterized byhyper excitability and hyper synchronizationof large group of neurons in the brain.• Seizure is a medical disorder in which toomany brain cell become excited at the sametime.• This can cause unexpected changes in thebehavior, motor activity, sensation, orconsciousness.
  9. 9. • Seizure is like an electrical storm in thebrain.• The end of the seizure is the transitionback to the individuals normal stage.• Seizure may occur spontaneouslywithout any cause.• A seizure typically goes on for a fewseconds to a few minutes.
  10. 10. In adults metabolic disturbances thatcause seizure include Acidosis Electrolyte imbalance Hypoglycemia Hypoxia Alcohol and barbiturate withdrawal Dehydration.
  11. 11. Extracranial disorders that cause seizureare• Heart, lung, liver, or kidney diseases• Systemic lupus erythematosus.• Diabetes mellitus• Hypertension• Septicemia
  12. 12. What is Epilepsy?[Epilepsia- (Greek)- seizure]Epilepsy is a chronic disorder of abnormal,recurrent, excessive, and self terminatingelectrical discharge from neurons.Spontaneously recurrent seizure more thanone time is called as epilepsy.The periods between seizures can varywidely and can be measured in minutes,hours, days, weeks, months, or evenyears.
  13. 13. • However there is repetitive seizure activity atsome time in the future regardless of theinterval.• Clinically epilepsy is recurring seizure inwhich there is disturbance in some type ofbehavior ( motor, sensory, autonomic, orconsciousness.)• To count it as epilepsy seizure should haveto appear spontaneously without animmediate precipitating factor.• Seizure resulting from systemic or metabolicdisturbance are not considered as epilepsy.
  14. 14. Epidemiology• About 1% of the world population hasepilepsy.• Around 60 million people in the worldare affected by epilepsy.• Every individual have 1% life time riskto develop epilepsy.• Incidence of epilepsy is 1 in 100 peoplein India.
  15. 15. • Every year one lack more cases getadded.• 30% of the epilepsy cases are ofuncontrollable or persistent.• The greatest number of people withnewly diagnosed epilepsy will be amongchildren under the age of two years andthe elderly over the age of 60 years.• The children who have Parents withepilepsy are having 5- 20% chance todevelop epilepsy.
  16. 16. more common in
  17. 17. Etiology and risk factorsSeizure is a symptom of numerousdisorders, but in 70% of sufferersthe cause remains unclear(idiopathic) despite careful historytaking,clinical examination andinvestigation!
  18. 18. Common causes• The risk factors for developing seizurecan be broadly classified under threeheadings.• 1- Metabolic or Chemical Imbalance.• 2- Structural defects• 3- Infections or Inflammatory reactions.
  19. 19. Metabolic or Chemical Imbalance• Hypoglycemia.• Hyperglycemia• Hypocalcaemia• Hyponatremia• Hypoxia• Uremia• Toxins• Drugs intoxication or withdrawal.• Alcohol consumptions• Hyperthermia
  20. 20. Structural defects• Gliotic scars• Post traumatic• Post infraction• Post infections• Congenital malformation• Vascular malformations• Brain tumors ( primary or metastatic)
  21. 21. Infections or Inflammatory reactions.• Meningitis• Encephalitis• Brain abscess• Syphilis• Systemic lupus erythematosus .• Neurocysticercosis ( parasitic infectionof the CNS)
  22. 22. OTHER CAUSES• Genetic factors(hereditary)/mutations• Other diseases like• Alzheimers disease• Dementia• Kidney Failure• Liver Failure• Heart Failure
  23. 23. The risk factors classifiedaccording to age group• In young adults-• Trauma• Alcohol withdrawal• Illicit drug use• Brain tumor
  24. 24. • Above 35 yr and older-• Cerebrovascular disease• Alzheimer’s disease• Neurodegenerative disease• Metabolic disorder• Brain tumor• Alcohol withdrawal
  25. 25. Common triggers• Stress• Sleep deprivation• Boredom• Alcohol• Missing tablets• Menstruation• Photosensitivity (TV/flicker)• Missed meals/hypoglycaemia• Sudden loud noise• Street drugs• Particular odour
  26. 26. PATHOPHYSIOLOGY• Ropper and Brown explains that there is threesets of disturbances present before a seizureactivity.• 1-A population of pathologically excitableneurons.• 2- A reduction in the activity of normalinhibitory gamma- aminobutyaric acid(GABA).• 3-An increase in excitatory glutaminergicactivity through recurrent connections tospread the discharge(hyper synchronization ofneurons).
  27. 27. PATOPHYSIOLOGYDue to etiological factorsAlteration in normal chemical and structuralenvironment of brain neuronsScarring of brain tissue (gliosis)A group of abnormal neurons forms in the brain(seizure focus)
  28. 28. The neurons present in the seizure focus arehypersensitive neurons and their cytoplasmicmembrane are highly permeable(hyper excitable).This increased permeability renders themsusceptible to activation by triggering factorsAny stimulus that causes depolarization of the cellmembrane of these neurons induce spontaneousfiring of electrical impulse
  29. 29. Once the intensity of seizure discharge exceeds acertain point or seizure threshold, it spreads byphysiologic pathways to involve adjacent ordistant areas of the brainIt spreads to the adjacent, cortical, and thalamicbrain stem nuclei.This activity spread to involve the whole brainthen a generalized seizure occurs causing musclecontraction and loss of consciousness.
  30. 30. There are some inhibitory centers in the brain whichact as counter regulatory mechanismThese inhibitory neurons of the cortex, anteriorthalamus, and basal ganglion nuclei becomes activeand slows the neuronal electrical discharge(diencephalo cortical inhibition)This interrupting the seizure and produceintermittent contraction and relaxation phase(clonic phase)
  31. 31. As epileptogenic neurons are exhausted and theinhibitory process builds up the seizure stops andparalysis of neurons of epileptogenic focus occurs.This leads to Todd’s post epileptic paralysis.Todd’s paralysis is a temporary focal weakness orparalysis following a partial or generalized seizurethat can last for up to 24 hours.
  32. 32. • Several ligand-gated ion channels have beenlinked to some types of frontal andgeneralized epilepsies.• Epilepsy is linked to mutations of the geneswhich code for sodium channel proteins;these defective sodium channels stay openfor too long thus making the neuron hyper-excitable.
  33. 33. • Glutamate, an excitatory neurotransmitter,may thereby be released from theseneurons in large amounts which — bybinding with nearby glutaminergic neurons— triggers excessive calcium (Ca2+)release in these post-synaptic cells.• Such excessive calcium release can beneurotoxic to the affected cell
  34. 34. • The hippocampus, which contains a largevolume of just such glutaminergic neurons isespecially vulnerable to epileptic seizure,subsequent spread of excitation, andpossible neuronal death.• Another possible mechanism involvesmutations leading to ineffective GABA (thebrains most common inhibitoryneurotransmitter) action.
  35. 35. During seizure there is drastic increase incellular respiration and glycolysis. Thismarkedly increased demand for ATP, (themajor direct source energy in the brain) thebrain depends mainly on the metabolism ofglucose for the production of phosphatebonds necessary for ATP. Cerebral blood flow to the brain alsoincreased to meet the increased oxygendemand.
  36. 36. Increased metabolic activity in contractingskeletal muscle often can result inhypoxemia and hypoglycemia particularlyduring status epilepticus.A rapid decrease in ATP and glucose withincreased level of lactate following seizure.This produce energy deficit, hypoxia,cellular exhaustion, and selected cellulardestruction.
  37. 37. Phases of seizure1- The prodromal phase This refers to symptoms, such as aheadache or feeling of depression, thatprecede a seizure by hours Some people have vague feeling oneor two days prior to the seizure thatsomething is going to happen.
  38. 38. 2- The aural phaseBreeze (Greek word)It is a premonitory sensation or warning experiencedat the beginning of a seizure, which the patientremembers.An aura may be gustatory, visual, auditory, orvisceral experiences. unusual sounds unusual taste(metallic taste) disturbed vision(flashing lights) rising thoughts unusual smell(burning rubber)
  39. 39. • In complex partial seizure the person mayfeel• déjà vu—new experiences appear familiar,jamais vu—familiar things appear foreign• Forced thinking may occur in seizureinvolving temporal lobe.• Some may feel rising of body• Some person may feel fear and panic.• There are some other strange feeling whichis difficult to explain.
  40. 40. Physical symptoms of aura are dizziness headache lightheadedness numbness upset stomach tingling sensation• Aura usually occur seconds to minutesbefore a seizure• If a patient has an aura it usually the sameexperience each time.
  41. 41. 3- The ictal phase ― Ictus ― is a Latin word means seizure. It proceeds with full seizure activity. In this phase there is abnormal electricaldischarge from the brain cause alteration insensation, movement, behavior andconsciousness.
  42. 42. 4- The postictal phase It is the period immediately after aseizure has occurred The end of the seizure is thetransaction back to the individualnormal stage.This can last to seconds to hours.The person may have headache,muscle soreness, sore tongue or cheek.The person may be tired and sleep forlong hours
  44. 44. PARTIAL SEIZURES (FOCALSEIZURES)• It begins with an electrical discharge in onelimited area of the brain.• Partial seizure begin in a specific region of thecortex as indicated by the EEG changes and byclinical manifestations.• Partial seizure may be confined to one area ofthe brain and remain partial or focal in nature.• The impact of partial seizure depends on wherein the brain it originates and how it spread
  45. 45. Partial seizures are again dividedin to,Simple partial seizures.Complex partial seizures.Partial seizures evolving tosecondary generalized seizure.
  46. 46. Simple partial seizures.The awareness is preservedThe memory is preserved.The consciousness is preserved.If all these are preserved then we call thepartial seizure as simple partial seizure.In simple partial seizures, only a finger orhand may shake or the mouth may jerkuncontrollably
  47. 47. • The person may talk unintelligibly, maybe dizzy, and may experience unusualor unpleasant sights, sounds, odors, ortastes, but without loss ofconsciousness.• They may involve motor, sensory,autonomic, or psychic phenomena or acombination of these.
  48. 48. Focal motor seizure• Symptoms depend on the motor regionactivated.• May remain focal or may spared toother areas on the motor strip, aprocess called march, this type ofseizure called jacksonian seizure.
  49. 49. • If a seizure spread along the motor strip theswitching can watch along with the differentparts of the body. It is called as jacksonianmarch.• For example the seizure may begins in thefingers of one side and march to the hand,wrist, forearm, and arm of the same side ofthe body.• Focal motor attack may cause head to turnto one side opposite epileptic foci.
  50. 50. • Todd’s paralysis may result and may lastsfor minutes to hours.• Continuous focal motor seizure is calledEpilepsia Paralysis ContinuaFOCAL SENSORY SEIZUREArise from cortical sensory stripUsually feel like numbness, tinglingsensation, spatial disorientation etc.Auditory seizures with various sounds,gustatory sensation like metallic taste orprimary tastes(salty, sweet, sour, or bitter).
  51. 51. • Occipital lobe contains brain cell responsiblefor vision . Seizure in the occipital lobe canproduce flashing lights and visualhallucination.• Some patients have the feelings of floatingsensation or vertigo.• Autonomic seizures• Autonomic seizures are common, evokingchanges in autonomic activity (e.g., alteredheart or breathing rate, sweating) or visceralsensations (e.g., in abdomen or chest).
  52. 52. Psychic seizures• Psychic seizures affect how we feel, think,and experience things.• Patients may report a "dreamy state,"transitional between waking andunconsciousness.• Psychic seizures can alter language function,perception or memory.
  53. 53. • They can also evoke spontaneousemotions (e.g., fear, anxiety, ordepression), altered perceptions of time(time slowing down or speeding up)• Altered perceptions of familiarity;(déjàvu—new experiences appear familiar,jamais vu—familiar things appearforeign), depersonalization (feeling oneis not oneself), derealisation (the worldseems unreal, dream-like), or autoscopy(viewing ones body from outside).
  54. 54. Complex partial seizuresThe consciousnessThe awarenessThe memoryIf any of the above factors are absent wecall the partial seizure as complexpartial seizure.These are often called as psychomotorseizures.
  55. 55. • The person either remains motionless ormoves automatically but in appropriative fortime and place.• This will leads to a moment to momentworld. During this time the person mayrepeat the same phrase or action over andover in an automatic way not recognizingthe repetition. This automatic activity iscalled as automatisms.
  56. 56. • Automatic movements (automatisms) arecommon and involve the mouth (e.g., lipsmacking, chewing, swallowing), upperextremities (e.g. fumbling, picking),vocalization/verbalization (e.g., grunts,repeating a phrase), or complex acts (e.g.,shuffling cards).• More dramatic automatisms occasionallyoccur (e.g., screaming, running, pelvicthrusting).
  57. 57. • Others just freeze and steer blanklywithout any movement.• Some time the person may experienceexcessive emotions of anger, fear,elation, or irritability.• Complex partial seizures usually lastfrom 15 seconds to 3 minutes.• After the seizure, postictal confusion iscommon, usually lasting less than 15minutes, although other symptoms,such as fatigue, may persist for hours.
  58. 58. • Whatever the manifestation the persondoes not remember the episode when itis over and what they did.• Later the memory start working againexcept for a gap during the seizure.• The location of the discharging focus isusually in the temporal lobe, hence it isknown as temporal lobe seizure.
  59. 59. • If the temporal lobe seizure spreads to bothtemporal region then the manifestationinclude• Pause in activity• Confusion• Temporary memory loss and• Fragmentary automatic robot likeactivity
  60. 60. Partial seizures evolving tosecondary generalized seizure• It begins as a Partial seizure may spread to involvethe entire brain, culminating in a generalized tonic-clonic seizure• The abnormal electrical activity may spread toinvolve other areas of the brain, to cause a tonicclonic seizure.• This may result in a transient residual neurologicdeficit postictally.• This is called as Todd’s paralysis (focal weakness)
  61. 61. GENERALIZED SEIZURES• It is characterized by hypersynchronized electrical activity of theneuron throughout the brain.• Generalized seizure occur when themisfiring of the nerve cell occur over theentire brain at the same time.• Because the entire brain is affected atthe onset of the seizure there may beno warning or aura.
  62. 62. Generalized tonic-clonic seizureAbsence seizureMyoclonic seizureTonic seizureClonic seizureAtonic seizureGeneralized seizures is classifiedagain in to
  63. 63. Tonic – Clonic seizure (grand mal)A prodromal period of irritability and tension mayprecede the seizure activity.Tonic-clonic seizures usually last 30–120 seconds.The tonic clonic seizure begins with a sudden lossof consciousness .The tonic phase there is a major contraction(increased tones) of the voluntary muscle.The body stiffens with legs and arms extended.If the person is standing he will fall in to the ground.The jaw snaps shut and the tongue may be bitten.
  64. 64. • A shrill cry may be heard because of theforcible exhalation of the air through theclosed vocal cord as the thoracic muscleinitially contract.• The pupil may dilate and unresponsive tolight.• During the tonic phase the person mayapnic and may appear pale and dusty.• This tonic phase may last for 10- 20seconds.
  65. 65. • The clonic phase begins with gradual transitionfrom the tonicity of the tonic phase.• The clonic phase is characterized by violentrhythmic muscular contractions accompanied bystrenuous hyperventilation.• The eyes roll, and there is excessive salivationwhich frothing from the mouth.• Profuse sweating and rapid pulse are common.• The clonic jerking gradually subsides in frequencyand amplitude over a period of about 30-40seconds• The bladder or bowel control may loose as themuscle relaxes.
  66. 66. • The patient have no consciousness and willnot remember what was happened.• The person slowly awakes, confusion anddisorientation are common.• Headache, muscle ache, and fatigue arecommon. Sometime the person may sleep forlong hours.• Tonic-clonic seizure occur at anytime of theday or night, whether the patient is awake orasleep.• The frequency of occurrence can vary fromhours to weeks, months, or years
  67. 67. Emergency management of tonic-clonicseizure.• Ensure patent airway• Assist ventilations if patient does notbreathe spontaneously after seizure.Anticipate need for intubation if gag reflexabsent.• Suction as needed• Establish IV access• Anticipate administration of AED’s tocontrol seizure.
  68. 68. • Monitor vital signs, level of consciousness,oxygen saturations, pupil reactivity andGlasgow coma scale.• Never force an airway between a patient’sclenched teeth.• Give IV dextrose for hypoglycemia.
  69. 69. Absence seizure (Petit mal )• It is characterized by 3-20 seconds of absence ofconsciousness during which the child may blink rapidlyor roll the eyes or snaffle the lips .• In absence seizure they disconnect from the world fora few seconds and came back exactly where they leftout.• But the child doesnt know what was happened duringthose 3-20 seconds.• It can be mistaken for day dreaming.• This can happen about 100 times per day and it mayinterfere with learning.
  70. 70. • Seizures begin and end suddenly.• There is no warning before the seizure, andimmediately afterward the person is alert andattentive.• This lack of a postictal period is a key featurethat allows one to distinguish betweenabsence and partial complex seizures.• Absence seizures are often provoked byhyperventilation• The EEG signature of absence epilepsy isthe generalized 3 Hz spike-wave discharge
  71. 71. • This is more common in childrenbetween the age group of 4 - 14 year ofage, it may disappear during adolescentperiod.• After the seizure the child may anxiousabout what was happened and the childmay need reassurance.• This condition usually not require anyfirst aide.
  72. 72. Myoclonic seizure• Myoclonic seizures involve a brief, shock-likejerk of a muscle or group of muscles.• These are usually so brief, last only for asecond or two.• Epileptic myoclonus usually causes bilateral,synchronous jerks most often affecting theneck, shoulders, upper arms, body, andupper legs. Brief loss of consciousness, may cause falland often occur on waking.
  73. 73. Tonic seizure A sudden onset of maintained increasedtone or stiffness of the extensor muscle They often occur during sleep. They are characterized by flexion at thewaist and neck, abduction and flexion orextension of the upper extremities, andflexion or extension of the lower extremities. Typical duration is 5–20 seconds. It involves bilateral musculature in asymmetric or nearly symmetric manner.
  74. 74. Clonic seizure• It is characterized by repetitive rhythmicclonic movements that are bilateral andsymmetric.• The EEG characteristics is symmetricspike wave complexes.
  75. 75. Atonic seizure (“drop attack”)• This type of seizure is also called as akineticseizure or epileptic drop attack.• Atonic seizures consist of a sudden loss ofpostural tone, often resulting in falls, or,when milder, head nods or jaw drops.• Consciousness is usually impaired andsignificant injury may occur.• Duration is usually several seconds, rarelymore than 1 minute.
  76. 76. Diagnostic evaluation• History collection- Birth and developmental history.- Significant illness and injuries- Family history- Febrile seizures• Seizure history.- Precipitating factor- Seizure description(including onset,duration, frequency, postictal stage)
  77. 77. • Physical Examination- Comprehensive neurologicalassessment• Other diagnostic studies includesCBCUrinalysisElectrolytesS. creatinineFasting blood glucose
  78. 78. Lumbar punctureCT scanMRIPET scan , (Positron emissiontomography)EEG ( video-EEG monitoring)
  79. 79. First Aid For Seizure• During seizure Stay calm Keep the surrounding safe Support the victims head by placing a pillow Keep the person lie on their side Record the time period of seizure Make the person as safe and comfortable aspossible Loose tightened clothing
  80. 80. Do not shift the person unless the place isharmful to him.Do not put or give anything in their mouthKeep their head inclined, so that theydon’t chokeAssess the course and nature of seizureactivity, the body parts involved in theseizure activity and the presence ofautonomic signs.
  81. 81. • After the seizureDo not restrain him after the seizure is over.Keep the person in a safe place.Be calm and reassuring.Ask the person some simple questions.Check for injuries.Be supportive and use a calm andreassuring voice.Check the vital signs, and assess thegeneral condition
  82. 82. NEVER DO IT
  84. 84. COLLABORATIVE CARE• Antiepileptic drugs(AED’s)• Surgery• Vagal nerve stimulation• Psychosocial counseling
  85. 85. Antiepileptic drugs
  86. 86. Principles for AED therapy.1- Do we need to treat the seizure with AEDtherapy ?2- Choosing the best medication for thepatient.The factors need to consider are Efficacy Side effects Risk of a serious reaction Convenience of administration Cost
  87. 87. 3- Decide best AED regimen.• The regimen of one drug is called asMonotherapy (―Start low, increase slow―).• Advantage of Monotherapy:• Fewer side effects, decreased drug-druginteractions, better compliance, and lowercosts• Addition of a second drug is likely toresult in significant improvement in onlyapproximately 10 % of patients.
  88. 88. 4- Side effects need to be considered.5- AED can be tapered.Withdrawal may be considered if thepatient meet the below mentioned criteria Normal neurological examination Normal IQ Normal EEG prior to withdrawal Seizure- free for 2-5 yrs or longer The person not have had problems withprior attempts to stop medication.
  89. 89. PHENYTOIN (Dilantin)• Route -Well absorbed when given orally, however,it is also available as iv. (for emergency)• Dose -300-400 mg/day• Indication- Used for partial Seizures & generalizedtonic-clonic seizures. But not effective for absenceSeizuresMechanism of Action:Membrane stabilization by blocking Na & Ca influxinto the neuronal axon or inhibits the release ofexcitatory amino acids via inhibition of Ca influx..
  90. 90. Side effects• Gingival hyperplasia• Hirsutism• Megaloblastic anemia• Hypersensitivity reactions (mainly skin rashes and lesions,mouth ulcer)• Hepatitis –rare• Fetal malformations- especially cleft plate• Bleeding disorders (infants)• Osteomalacia due to abnormalities in vitamin D metabolism• Hyperglycemia• GI Disturbances
  91. 91. CARBAMAZEPINE(Tegretol)• Route-available as an oral form only• Dose -200-800 mg/day (given BD assustained release form)• Indication -First line drug for partialseizures and tonic – clonic seizures.• Action –decrease sodium and calcium ioninflux in to neuronal membranes.
  92. 92. Side Effects of Carbamazepine:• G.I upset• Drowsiness, ataxia and headache; diplopia• Hepatotoxicity- rare• Congenital malformation (craniofacialanomalies & neural tube defects).• Hyponatremia & water intoxication.• Late hypersensitivity reaction (erythematousskin rashes, mouth ulceration andlymphadenopathy).
  93. 93. PHENOBARBITAL(PHENOBARBITONE)• Route- oral and IV• Dose- 50- 150 mg/day (1-3 mg/ kg/ day).• Indication- status epilepticus, and ingeneralized seizures except absence andpartial seizures.Mechanism of Action:• Increases the inhibitory neurotransmitters(eg: GABA ) and decreasing the excitatorytransmission(CNS depressant).
  94. 94. Side effects: Somnolence Confusion Hypersensitivity reaction Renal impairment Sedation Drowsiness Fatigue Depression of cognitive functioning.
  95. 95. SODIUM VALPROATE orVALPROIC ACID• Route – oral (available as capsule, Syrup),and I.V• Dose-1000- 3000 mg/ day.• Indication -Very effective against absenceseizure. Also, effective in generalizedtonic-clonic, tonic, atonic and Myoclonicseizures.
  96. 96. ACTION- Increase the concentration of inhibitoryneurotransmitter GABA.Side effects• Drowsiness• Difficulty in thinking• Psychotic reactions• Nausea, vomiting and GIT disturbances• Increased appetite & weight gain• Transient hair loss.• Hepatotoxicity• Thrombocytopenia
  97. 97. TOPIRAMATE (topamax)• Route – Oral• Dose- 25-50 mg/ day(max-1600mg/day) atweekly interval.• Indication- Recently, this drug becomeone of the safest antiepileptic which canbe used alone for partial and generalizedtonic-clonic, and absence seizures.Action- Blocks sodium channels (membranestabilization) and also enhances theinhibitory effect of GABA.
  98. 98. Side effects:• Ataxia• Nystagmus• Diplopia• Weight loss• Sedation• Dizziness• Fatigue• Nausea• Paresthesias (abnormal sensation )• Nervousness
  99. 99. Surgery
  100. 100. SURGICAL MANAGEMENT• A proportion of the patients with intractableepilepsy will benefit from surgery.• The aim of the surgery is to carefully removethe brain tissue that is sparkling the seizurewhile leaving intact areas that control otherfunctions.• Epilepsy surgery procedures:• Curative (removal of epileptic focus) and• palliative (seizure-related risk decrease andimprovement of the QOL)
  101. 101. Curative (resective) procedures: Temporal lobectomyLesionectomy,Cortical resection,Hemispherectomy.Palliative procedures:• Corpus callosotomy• Vagal nerve stimulation (VNS).
  102. 102. TEMPORAL LOBECTOMY Seizure most commonly arising from the one orboth temporal lobe. Temporal lobectomy is a resective surgery(resection= removal) in which the area of thetemporal lobe which is responsible for seizure issurgically removed. In the deep front part of the temporal lobe arelocated the most seizure prone structures. These areas are hippocampus and the amygdalawhich is removed by cutting and suction. The CSF surrounding the brain fill the area
  103. 103. • Nausea and headache are common during postoperative period.• The clean surgical scar will not produce seizuremost of the time.• Temporal lobectomy is the most common andsuccessful type resective surgery.• Following temporal lobectomy memory and wordfinding may be affected.• There is improvement in anxiety and depressionafter temporal lobectomy.• Some patients may experience visual problems ofright upper visual field
  104. 104. • There is 1-2% chance of stroke aftersurgery• 0.1% chance of death• After temporal lobectomy 55- 75% are freeof seizure that impair consciousness.• 10-30% have significant reduction ofseizure after surgery.• However 15% of patients have noimprovement after surgery.
  105. 105. LESIONECTOMY• Is the removal of the scar tissue or brainlesion which is responsible for seizure.• Lesionectomy have a stroke risk of 1-2% .• Depending up on the position of seizurefocus there is risk of causing impairment inlanguage, movement , or sensation.
  106. 106. CORPUS CALLOSOTOMY• The cerebral hemispheres are connectedinternally by the corpus callosum.• These are a broad band of white mattercontaining axons that extended between thehemispheres.• After a partial corpus callosotomy the seizurereduction is around 60-80% for certain seizuretypes including tonic-clonic, Atonic, and tonicseizures.• This surgery have a slightly higher risk of strokeor problems with attention and behavior.
  107. 107. HEMISPHERECTOMY• Removal of half of the brain• In the patients some of the brain functionis already impaired and the remaining willbe lost after surgery.• This procedure will provide completeseizure relief in 75% of patients.
  108. 108. Vagal nerve stimulation• Is effective in treatment of partial seizures inpatients who are: Refractory to multiple drugs Sensitive to the adverse effects of antiepileptic Having difficulty to follow medication schedule• In this method an electrode is surgically placedaround the left Vagus nerve in the neck.• It is connected to a battery placed beneath the skinin the upper chest and the battery is surgicallyreplaced about every 5 years.
  109. 109. • The device is programmed to deliver intermittentelectrical stimulation to the brain to reduce thefrequency and intensity of seizures.• Intermittent stimulation is delivered every 0.3–10minutes for 7–30 seconds, but patients whoexperience a seizure warning can trigger thedevice manually.• The stimulation may interrupt synchronization ofepileptic brain wave activity.• 30% of patients have 50% reduction of seizure byimplanting this device.
  110. 110. The adverse effects are• Coughing• Hoarseness• Dyspnoea• Tingling in the neck
  111. 111. Non PharmacologicalMethods Of Treatments.• Lifestyle modifications,• particularly avoidance of alcohol and sleepdeprivation, can be very important in certainsyndromes and individuals.• Relaxation, biofeedback, and otherbehavioural techniques can help a subset ofpatients, especially those with a reliable aurapreceding complex partial or secondarilygeneralized seizures.
  112. 112. KETOGENIC DIET• The ketogenic diet has been used for morethan 80 years in children with severe seizuredisorders.• It is based on the observation that ketosisand acidosis have anti-seizure effects.• Strict protein, calorie, and especiallycarbohydrate restriction in the setting of ahigh fat diet is needed for ketosis, and maybe difficult to maintain.
  113. 113. • In a minority of patients with intractableepilepsy, staying on this diet for monthsor years can result in a sustainedimprovement in seizure control, rarelyeven allowing withdrawal of AEDs.
  114. 114. Complication1-STATUS EPILEPTICUSStatus epilepticus is defined as more than 30minutes continues seizure activity or two or moresequential seizure without full recovery ofconsciousness between seizure .The most common cause is an abruptdiscontinuation of antiepileptic drugs.Other causes are fever, withdrawal from alcohol, orsedative.Status epilepticus may occur with frontal lobelesions (strokes), following head injury, drugintoxication, metabolic disturbances or pregnancy.
  115. 115. Clinically status epilepticus present withobvious tonic, clonic, or tonic-clonicmovements with subtle twitching of thehand or face; or with absence ofmovement.It can occur in both convulsive and nonconvulsive seizure.Convulsive seizures can be easilyobserved clinically, but partial seizures areless obvious and very difficult to identify.
  116. 116. The most common type of status epilepticusis tonic-clonic status epilepticus.Higher rates among the very young andvery old.Status epilepticus is a medical emergencyassociated with significant mortality ormorbidity (20%), if not treated aggressively.It can cause cardiopulmonary dysfunction,hyperthermia, and metabolic imbalance canoccur , leading to cerebral ischemia andneural death.
  117. 117. Management of statusepilepticus• 1- ABCs of life support.• Position the patient to avoid aspiration orinadequate oxygenation.• A soft plastic airway is inserted if it is possibleto do so without forcing the teeth apart.• The airway will need to be suctioned.• Oxygen is administered 100% through nasalcannula.
  118. 118. • Monitor respiratory function with pulseoximetry.• IV access should be secured and vital signsand neurological signs should be monitoredfrequently.• Monitor arterial blood gases as the patientwill have profound metabolic acidosis.• Hypoglycemia should be treated byadministering 50 ml of 50% glucose.• Hyperthermia should be corrected bypassive cooling.
  119. 119. • 2-Administrating antiepileptic drugs.Time lineinminutesDrug (progression along this algorithm ifthe pervious drug is not effective)0-3 1-Lorazepam ;0.1 mg/kg IV at 2mg/minutes4-23 2-Phenytoin 20 mg/kg in normal saline at rateof 50mg/minutes.22-33 3- Phenytoin (additional) 5- 10 mg/kg37-58 4- Phenobarbital 20mg/kg IV at a 50-75mg/min58-68 5- Phenobarbital additional 5-10mg/kg6- anesthesia with midazolam or protocol
  120. 120. • 3-Treating The Underlying Cause.• Find out the underlying cause and treat theprimary problem.• 4- Preventing Or Treating MedicalComplications.• The patient must be moved to well equippedICU .• Hypoxia, hyperthermia, hypoglycemia,hypotension, cardiac arrhythmias, aspirationpneumonia and myocardial infraction canoccur.
  121. 121. • Other complications of epilepsy include• 2- Severe Injury Due To Accidents• 3- Depression• 4- Sudden Unexpected Death InEpilepsy.(SUDEIP)• This is the syndrome attached where aperson with epilepsy dies suddenly and noother cause of death is revealed.
  122. 122. Patient educationAdhere to treatment regimen.Regular review and health check upAvoid alcoholProper dietProper rest and sleepAvoid stress by practicing yoga,meditation etc..Never suddenly stop medication
  123. 123. Non-epileptic attackdisorder• These are attacks which arise forreasons other than those which causeepilepsy. They suggest an underlyingpsychological or emotional problem.• The incidence of NEAD is higher inwomen• NEAD often begins in adolescence orearly twenties
  124. 124. • A history of previous trauma or abuse isquite common• Antiepileptic drugs are unhelpful• Stress AttacksThe person is unable to cope withcertain situations. This may be specificlife events, or more general changessuch as adolescence.
  125. 125. • Distress AttacksFeeling of slipping in and out ofconsciousness. Inner distress. Attacksoccur as a way of avoiding feelings.Often difficult and painful recovery.Treatment:“support without fuss”Psychotherapy
  126. 126. Nursing diagnosis• Ineffective breathing pattern related toneuromuscular impairment secondary toprolonged tonic phase as evidenced byabnormal respiratory rate and rhythm.• Risk for injury related to seizure activity..
  127. 127. • Ineffective coping related to perceivedloss of control and denial of diagnosisas evidenced by verbalizations aboutnot having epilepsy.• Ineffective therapeutic regimenmanagement related to lack ofknowledge about management ofseizure disorder as evidenced byverbalization of misconception.
  128. 128. Questions?????????
  129. 129. Thank you