"Navigating Epilepsy: A Holistic Approach with Dr. Ganesh" 🌟 Hello, everyone! Dr. Ganesh here, and today, we embark on a journey to explore a topic close to my heart: the comprehensive approach to epilepsy. Whether you're a patient, a caregiver, or simply curious about understanding epilepsy, this discussion is crafted with you in mind.

1. BASICS OF EPILEPSY
Presenter: Dr Ganeshgouda
Neurologist Nanjappa Hospitals
Davanagere
ganeshgoudam4@gmail.com
9380906082

2. What are seizures?
• Seizures are
– Excessive, and synchronous electrical discharges in groups of
cortical neurons
– It is usually self-limiting
– They may be clinically in apparent (subclinical), or they may
produce various clinical phenomena

3. What are Convulsions?
• Convulsions are when a person's body shakes rapidly and uncontrollably.
• During convulsions, the person's muscles contract and relax repeatedly.
• The term "convulsion" is often used interchangeably with "seizure,"
• There are many types of seizure, some of which have subtle or mild symptoms instead of
convulsions.

4. What is Epilepsy ?
• The medical syndrome of recurrent, unprovoked seizures is termed epilepsy
• Seizures can occur in people who do not have epilepsy.
Epilepsy is a disease of the brain defined by any of the following conditions
1. At least two unprovoked (or reflex) seizures occurring >24 hours apart
2. One unprovoked (or reflex) seizure and a probability of further seizures similar to the
general recurrence risk (at least 60%) after two unprovoked seizures, occurring
over the next 10 years
3. Diagnosis of an epilepsy syndrome

5. TERMINOLOGY AND CLASSIFICATION
OLD
TERMSNOLONGERINUSE
• Complex partial
• Simple partial
• Partial
• Dyscognitive
• Secondarily generalized tonic-clonic

6. ILAE 2017 CLASSIFICATION

7. ILAE 2017 CLASSIFICATION

8. Why so much emphasis on classification ?
The first step is to separate epilepsy by how they begin in the brain. The type of seizure onset is
important because
 It helps to decide choice of seizure medication
 Helps to delineate type of lab/imaging to be ordered
 Possibilities for epilepsy surgery/intervention
 Outlook/prognosis
 Making diagnosis epilepsy syndrome

9. Defining Where Seizures Begin
• 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, these engage or involve
networks on both sides of the brain at the onset
• Unknown onset: If the onset of a seizure is not known, the seizure falls into the unknown
onset category. Later on, the seizures type can be changed if the beginning of a person’s
seizures becomes clear.
• Focal to bilateral seizure: A seizure that starts in one side or part of the brain and
spreads to both sides has been called a secondary generalized seizures.
• The new term for secondary generalized seizure would be a focal to bilateral seizure.

10. Describing Awareness
• Practically importance because it is one of the main factors affecting a person’s safety during a
seizure.
• Awareness is used instead of consciousness, because it is simpler to evaluate.
• Focal aware: If awareness remains intact, even if the person is unable to talk or respond
during a seizure, the seizure would be called a focal aware seizure. This replaces the term
simple partial.
• Focal impaired awareness: If awareness is impaired or affected at any time during a seizure,
even if a person has a vague idea of what happened, the seizure would be called focal impaired
awareness. This replaces the term complex partial seizure.

11. Motor and Other Symptoms in Focal Seizures
• It is also possible for a focal aware or impaired awareness seizure to be
sub-classified as:
Focal motor seizure : This means that some type of movement occurs
during the event.For example twitching, jerking, or stiffening
movements of a body part, or
Focal non-motor seizure:
• This type of seizure has other symptoms that occur first.
• Such as changes in sensation, emotions, thinking, or experiences.
Auras:
• Used to describe symptoms a person may feel in the beginning of a
seizure.
• These early symptoms may be the start of a seizure.
• Auras are simple partial seizures
– most common: paresthesias, jerking of an extremity, epigastric
discomfort, fear, or an unpleasant smell, psychic experience, deja vu
and jamais vu

12. JACKSONIAN MARCH
• Abnormal movement may begin in very restricted region like fingers and
gradually progressive to include larger portion of extremity over seconds to
minute.
• Todd's paralysis: Some patients may experience a localized paresis for minutes to
many hours in the involved region following a seizure.

13. GENERALISED SEIZURES
– Generalized tonic–clonic
• Main seizure type in ~ 10% of all seizures
• Most common seizure resulting from metabolic derangements.
• Initial phase is tonic contraction of all muscles of the body. Increased sympathetic activity like
increased HR, BP, pupillary size.
• Then the clonic phase, produced by superimposition of periods of muscle relaxation on tonic
muscle contraction.
• Postictal phase – unresponsivesness, muscular flacidity, excessive salivation, bladder and bowel
incontinence.

14. Seizure Semiology
Semiology Seizure type
Generalized Focal
Auras No Present
Prodrome Occasional Occasional
Start with LOC Present Present
Start with automatisms No Present
Prolonged postictal Not usual Present
confusion
True head version No Present
GTCS Present Present
Focal clonic or tonic No Present

16. TYPICAL ABSENCE SEIZURES
• Characterized by sudden brief lapse of consciousness without loss postural control, Absence of
features
• Age defined - beginning in childhood between the ages of 3 and 12.
• Typically last for only seconds.No postictal confusion.
• May be associated with motor sign like rapid blinking of eye lids chewing movements.
• Seen in childhood and early adolescences.
• EEG – generalized symmetrical 3hz spikes and wave patterns. Hyperventilation provokes these
discharge.
• Momentary lapses of consciousness
• Automatism - eye blinking, Perseverative
• No loss of tone
• Hyperventilation precipitates (Avoid Pranayam)
• Poor school performance
• Family history

17. ATYPICAL ABSENCE SEIZURES
• Loss of conciousness is for longer duration.
• Usually associated with diffuse or multifocal structural abnormality.
• EEG shows generalised slow spike wave pattern with frequency < 2.5 per second.

18. ATONIC SEIZURES
• Characterized by sudden loss of postural muscle tone lasting for 1-2 sec.
• Consciousness is briefly impaired but these is no postictal confusion.

19. MYOCLONIC SEIZURES
• Characterized by sudden and brief muscle contraction that may involve one part or entire
body.
• Common normal physiological phenomenon while falling a sleep
• Pathologically seen in metabolic disorders, degenerative , CNS diseases and anoxic brain
injury.
• Consist of sporadic jerks, usually on both sides of the Body. Photosensitive
• Patients sometimes describe the jerks as brief electrical shocks.
• When violent, these seizures may result in dropping or involuntarily throwing objects.
• Normal myoclonus include hiccups and hypnic jerk.
• Also seen in variety of conditions various types: SSPE,CJD,Hypoxia &PME

21. Clinical approach to a patient with seizure

22. Semiology
Focus
Pathology
Syndrome

23. Semiology
• Why is knowing the semiology important ?
– Is this a seizure ?
– What is the seizure type?
– What is the possible locus ?
• How to know semiology ?
– CLINICAL HISTORY
– WITNESS ACCOUNT (Insist for witness to accompany)

24. Localization in focal seizures
• Temporal or extratemporal
• Frontal Adversive or like pseudo
seizures
• Temporal limbic / mesial / neocortical
• Occipital (Visual)
• Parietal (sensory)

27. Postictal behavior / language /memory disturbance
Aura
B/L TONIC CLONIC
Automatism and behavior
arrest
nonversive movement
Vocalization or speech arrest
Dystonic posturing
Cotralateral versive
movement
Cotralateral Tonic posturing
Prodrome
Few seconds to 1-2 min
1-2 min FAS/FIAS
DESCRIBE SEMIOLOGY

28. • Name
• Age OPD no
• Sex Date
• Father’s Name
• Address
• Tel. no
• Occupation
• Handedness
• Age at seizure onset
• Age at onset of habitual seizures
EPILEPSY PROFORMA

29. SEIZURE SEMIOLOGY
• Prodrome:
Aura:
• Epigastric
• Somatosensory
• Auditory
• Vertiginous
• Olfactory
• Gustatory
• Emotional
• Psychic
• Cephalic
• Sexual
EPILEPSY PROFORMA

30. • ICTAL PHASE:
– Behavioural arrest
– Oral-alimentary automatism
– Semipuroseful movements of upper extremity
– Posturing of upper extremity
– Whole body movements
• POSTICTAL PHASE:
– Duration
– Todd’s paralysis
– Amnesia
– Dysphasia/aphasia
– Headache
– Behavioural abnormality
EPILEPSY PROFORMA

31. • INTERICTAL PHASE:
– History of secondary generalization
– Diurnal variation
– History of clusters
– H/o status epilepticus
– Present seizure frequency /Week
– Date of last Seizure
– Seizure related disability
EPILEPSY PROFORMA

32. • BIRTH HISTORY:
• Developmental milestones
• History of febrile Seizure
• Family history of Seizures
• History of Consanguinity
• ASM’S TRIED:
• Effect on Seizures Frequency / complete control
• Adverse events with ASMs
• Current ASMs
• Best Response with ASM
EPILEPSY PROFORMA

33. EXAMINATION:
GPE
Pulse
BP
Lymph nodes
Neurocutaneous markers
Chest,CVS,P/A
CNS
Higher mental functions:
MMSE
Cranial nerves
Fundi
VA, VF
MOTOR
SENSORY:
GAIT:
Cerebellar
Extra pyramidal sign (if any)
EPILEPSY PROFORMA

34. • INVESTIGATIONS:
• Hb/TLC/DLC
• ESR,Mantoux test
• B. Sugar
• B. Urea/S. creatinine
• S. Na/S.K/S. Ca
• S. Bilirubin ,SGOT / SGPT /ALP
• Total Proteins/ Albumin/Globulin
• Ammonia
• X-ray chest
• ASM level
• CT scan
• MRI
• Scalp EEG,Video EEG
• Followup and other relevant history
EPILEPSY PROFORMA

36. Pathology
• Granulomas
• Tumours
• Trauma
• Infections (HSE)
• Cortical dysplasia
• Hypoxic damage
• Gliosis
• MTS
• Autoimmune

37. SEIZURE VS SYNCOPE

38. HISTORICAL CRITERIA THAT DISTINGUISH SYNCOPE FROM SEIZURES

39. IMITATORS OF SEZURES

40. IMITATORS OF SEZURES

41. IMITATORS OF SEZURES

42. IMITATORS OF SEZURES

43. IMITATORS OF SEZURES

45. MISDIAGNOSIS OF SEZURES

47. INVESTIGATIONS

48. Hippocampal sclerosis
Normal left hippocampus
Decreased NAA/Cho ratio.
Normal range of NAA/Cho and NAA/Cr ratios
INVESTIGATIONS

49. INVESTIGATIONS

50. OTHER INVESTIGATIONS
• PET
• MEG
• INVASIVE EEG
• MRS
• fMRI
• vEEG

51. WHILE WRITING DIAGNOSIS
RIGHT FOCAL MOTOR ONSET TO
BILATERAL TONIC CLONIC,FRONTAL
LOBE EPILEPSY(LATERAL
PREFRONTAL, DOMINAT LOBE)-
STRUCTURAL ETIOLOGY,
DEPRESSION/COGNITIVE DELAY

52. Syndromes
• Specific seizure type(s)
• Typical EEG pattern
• Associated clinical features
• Natural history
• Precipitating factors
• Response to antiepileptic drugs
• Inheritance pattern

53. APPROACH

54. PATIENT EDUCATION

55. EPILEPSY PROFORMA IN BUSY OPD

56. Take home message..
• Detailed history Meticulous description of semiology
• Precipitating factors
• Associated conditions
• Possible pathology - Treatable first
• Syndrome
• Investigate accordingly
• Start drugs and modify as needed
• Comprehensive care
– Lifestyle modifications
– Social adjustment

57. Thank you
ganeshgoudam4@gmail.com
9380906082

58. Motor Signs: Lateralization or Lobar Localization
Signs Lateralizing value
Early non-forced head turn Ipsilateral to seizure origin
Late forced head turn Contralateral: temporal, frontal
Eye deviation Contralateral to seizure origin
Focal clonic Contralateral to seizure origin
Asymmetric clonic ending Ipsilateral: temporal, frontal

59. Motor Signs: Lateralization or Lobar Localization
Signs Lateralizing value
Dystonic limb posturing Contralateral: temporal, frontal
Tonic limb posturing Contralateral to seizure origin
Fencing limb posturing Contralateral: frontal (SMA)
Figure of 4 sign Contralateral to the extended
limb: temporal. frontal, SMA
Ictal paresis or immobile Contralateral to seizure origin
limb

60. Automatisms: Lateralization or Lobar Localization
Automatisms Lateralizing value
Oral automatism Non-lateralizing: temporal
Unilateral limb Ipsilateral: temporal
automatisms
Unilateral eye blinking Ipsilateral: temporal
Laughing Non-lateralizing: hypothalamic,
mesial temporal or frontal cingulate

61. Automatisms: Lateralization or Lobar Localization
Automatisms Lateralizing value
Bipedal automatisms Non-lateralizing: frontal
Automatisms with Non-dominant temporal or
preserved responsiveness extratemporal on either side
Postictal cough Non-lateralizing: temporal
Postictal nose wiping Ipsilateral: temporal

62. Autonomic Signs: Lateralization or Lobar Localization
Autonomic signs Lateralizing value
Ictal spitting Right temporal
Ictal vomiting Right temporal
Ictal urinary urge Right temporal
Ictal drinking Right temporal
Piloerection Left temporal

63. Speech: Lateralization or Lobar Localization
Peri-ictal speech Lateralizing value
Ictal speech preservation Non-dominant temporal
Ictal arrest Dominant hemisphere
Postictal dysphasia Dominant hemisphere
Ictal vocalization Frontal

64. EPILEPSY PROFORMA

65. EPILEPSY
PROFORMA

66. EPILEPSY PROFORMA

67. EPILEPSY PROFORMA

68. EPILEPSY PROFORMA