Undergrad teaching

1. By
Dr Junaid Saleem
MBBS FCPS Med
Consultant Physician and Hepatologist
Hearts International Hospital
The Mall Rawalpindi

3. Conflicts of interest
 NONE

4. Do NOT Take Notes
 This slide set is free for all to copy

5. Plan
 Definitions
 Aetiology
 Classification
 Clinical Manifestations
 Investigations
 Diagnosis
 Treatment
 Who to Treat?

6. Plan
 Definitions
 Aetiology
 Classification
 Clinical Manifestations
 Investigations
 Diagnosis
 Treatment
 Who to Treat?

7. Definitions
 Seizure or Ictus:
 Is the clinical manifestation of an abnormal,
excessive excitation and synchronization of a
population of cortical neurons
○ Clinically apparent – symptoms or signs
○ Subclinical – only seen on EEG
 Epilepsy:
 recurrent seizures (two or more) which are not
provoked by systemic or acute neurologic
insults

8. Definitions
 Status Epilepticus:
 Continuous convulsion lasting >30 minutes
OR
 Occurrence of serial convulsions lasting >30 minutes
between which there is no return of consciousness

9. Famous People who had
Epilepsy
Definite Most Likely
 Alexander of Macedon
 Julius Caesar
 Aristotle
 Socrates
 Martin Luther
 Cardinal Richelieu
 Leonardo da Vinci
 Michelangelo
 Isaac Newton
 Alfred Nobel
 Richard Burton
 Leo Tolstoy
 Alfred Tennyson
 Ludwig van Beethoven
 Karen Armstrong
 Napoleon Bonaparte
 Vincent van Gogh

10. Plan
 Definitions
 Aetiology
 Classification
 Clinical Manifestations
 Investigations
 Diagnosis
 Treatment
 Who to Treat?

11. Incidence and Prevalence
 Seizure:
• Incidence: 80/100,000 per year
• Lifetime incidence: 9%
(1/3rd are febrile convulsions)
 Epilepsy:
• Incidence: 45/100,000 per year
• Point prevalence: 0.5-1%
• Cumulative lifetime incidence: 3%

12. Aetiology
 Mostly cause
unknown
 Genetic Disorders
 Metabolic
 Tumours
 Trauma
 Toxins and drugs
 Degenerative
 Demyelinating
Disorders
 Vascular
 Infections (including
Venereal)
 Infestations
 Inflammations

13. Plan
 Definitions
 Aetiology
 Classification
 Clinical Manifestations
 Investigations
 Diagnosis
 Treatment
 Who to Treat?

14. Classification
 By symptoms
 motor, sensory etc
 By Age
 Infantile, childhood adult
 Pathophysiological
 Not possible
 Treatment Response
 Controlled / uncontrolled
 Anatomical / Connections
 Thalamic, Limbic, Temporal Lobe, Motor Cortex
etc

15. Internationally Accepted
 ILAE -
 International League Against Epilepsy
 First Proposed in 1981
 Modified several Times
 Latest Modifications 2010 & 2017

16. Terms to understand
 Generalized
 Whole of brain is involved
 Partial or Focal
 Part of brain is involved
 Simple
 Consciousness not lost
 Complex
 Consciousness is lost
 Secondary Generalization
 Starts as Focal but spreads to involve the whole
brain

17. ILAE Classification of
Seizures
C-Slide 17
Seizures
Partial Generalized
Simple Partial
Complex Partial
Secondarily
Generalized
Absence
Myoclonic
Atonic
Tonic / Clonic
Tonic-Clonic
ILAE – International League Against EpilepsyAmerican Epilepsy Society 2010
Reflex Status Epilepticus

18. ILAE Classification of
Seizures
C-Slide 18
Seizures
Partial Generalized
Simple Partial
With somatosensory
or special sensory
symptoms
With motor signs
With autonomic
symptoms or signs
With psychic or
experiential symptoms
American Epilepsy Society 2010

19. Plan
 Definitions
 Aetiology
 Classification
 Clinical Manifestations
 Investigations
 Diagnosis
 Treatment
 Who to Treat?

20. GTC Seizures
Aura + Tonic Phase Clonic Phase + Postictal
 Aura +/-
 Sudden sharp tonic
contraction of body
and respiratory muscle:
stridor / moan
 Falls
 “Cry”
 Respiratory inhibition
cyanosis
 Tongue biting
 Urinary incontinence
 Synchronized jerking of the
body
 Small gusts of grunting
respiration
 Frothing of saliva
 Tongue biting
 Urinary incontinence
 Deep respiration
 Muscle relaxation
 Remains
unconscious/confused
 Awakens feeling sore,
headaches

21. Absence seizures
 Children
 Sudden onset
 Interruption of on-going activities
 Blank stare
 Brief upward rotation of eyes
 Duration: Less than 10 seconds
 No motor involvement
 May develop generalized
convulsive seizure in later age

22. Other generalized
Epilepsies
Myoclonic seizures
 ‘Jerks’ take the form of
momentary brief
contractions of a muscle
or muscle groups
 Often seen while going
to sleep or on waking up
 Sudden involuntary
twitch of a finger or
hand.
Tonic seizures
 stiffening of the body,
not followed by jerking.
Clonic Seizures
 Jerking of the body, not
preceded by stiffening
Atonic seizures
 A sudden collapse with
loss of muscle tone and
consciousness.

23. **
 During sleep a patient can have only two
abnormal movements
 GTC Seizures
 Myoclonic Jerks

24. Simple Partial Epilepsy
 focal motor seizure (Jacksonian)
 Originate within the motor cortex
 Jerking typically begins on one side of
the mouth or in one hand,
 march of a seizure : Jacksonian
 Local temporary paralysis of the limbs
affected sometimes follows – Todd’s
paralysis.

25. Complex Partial Epilepsy
 Arise from the temporal lobe (60%) or the
frontal lobe.
 Preceding aura
 Epigastric sensation and nausea with a wide
variety of possible psychic phenomena or
hallucinations
 Déjà vu, Olfactory or visual hallucinations or
misperceptions like micropsia or macropsia
 Period of complete or partial loss of
awareness of surroundings, lasting for 1–2
minutes

26. Complex Partial Epilepsy
 Speech arrest
 Automatism – semi-purposeful
stereotyped motions such as lip
smacking or dystonic limb posturing
 Complex motor behaviours such as
walking in a circle
 Short period of post-ictal confusion or
may develop into a secondary
generalized convulsive seizure.

27. Complex Partial Seizures
 Impaired consciousness
 Clinical manifestations
vary with site of origin
and degree of spread
• Presence and nature of aura
• Automatisms
• Other motor activity
 Duration typically < 2
minutes
C-Slide 27
Seizures
Partial Generalized
Complex
Partial

28. Secondarily Generalized
Seizures
 Begins focally, with or
without focal neurological
symptoms
 Variable symmetry, intensity,
and duration of tonic
(stiffening) and clonic
(jerking) phases
 Typical duration 1-3 minutes
 Postictal confusion,
somnolence, with or
without transient focal
deficit
C-Slide 28
Seizures
Partial Generalized
Secondarily
Generalized
American Epilepsy Society 2010

29. Plan
 Definitions
 Aetiology
 Classification
 Clinical Manifestations
 Investigations
 Diagnosis
 Treatment
 Who to Treat?

30. Investigations
 Blood CBC
 Urinalysis + Ketones
 LFTs + Albumen
 Na K Ca Mg
 RFTs
 Blood Sugar R
 Lipid Profile R
 ABGs
 Drug Levels
 Toxicology Screen
 Chest X Ray
 CT Scan Head
 MRI Brain
 SPECT Brain
 EEG
 With hyperventilation
 ECG
 2 D Echo
 Tumour Markers
 CSF Examination

31. Investigations
 Neuroimaging can
be:
 Static
 CT Scan
 MRI Scan
 Dynamic
 Electrphysiological
Neuroimaging ENI
 Electromagnetic
Source Imaging
(EMSI)
 EEG
 10 – 20 eelectrodes
in the head
 Records electrical
activity

34. Plan
 Definitions
 Aetiology
 Classification
 Clinical Manifestations
 Investigations
 Diagnosis
 Treatment
 Who to Treat?

35. Diagnosis
 History
 Clinical Examination
 Investigations

36. Plan
 Definitions
 Aetiology
 Classification
 Clinical Manifestations
 Investigations
 Diagnosis
 Treatment
 Who to Treat?

37. Treatment
 General Measures
 Reassurance
 Education
○ Patient, family, Parents, Teachers etc
 Precautions
 Specific Treatment
 Medical Management
 Surgery

38. Precautions while on
treatment
 Driving
 Can be allowed after 2 years FIT FREE
while on drugs, OR
 3 years with only nocturnal fits
 Heights – mountains, cliffs, roof edges
 Water – pools, lakes etc
 Fires – large fires, bonfires etc
 Moving Heavy Machinery – eg thrasher

40. Mechanism of Action
Suppress repetitive action potentials in
epileptic foci in the brain
 Sodium channel blockade
 GABA-related targets
 Calcium channel blockade
 Others: neuronal membrane
hyperpolarisation

41. Adverse Effects
 Teratogenicity
 Neural tube defects
 Fetal hydantoin syndrome
 Overdosage toxicity
 Life-threatening toxicity
 Hepatotoxicity
 Stevens-Johnson syndrome
 Abrupt withdrawal

42. Special Considerations
 Women
 Pregnancy – up to 7% teratogenecity
 Lactation – some drugs excreted in milk
 Children
 Growth, activities and psychological
development
 Drug-Drug Interactions
 Liver based metabolism and detoxification
 Can Either suppress or activate P-450
enzyme systems

43. Surgery
 Curative
 Catastrophic unilateral or secondary
generalised epilepsies of infants and young
children
○ Sturge-Weber syndrome
○ Large unilateral developmental abnormalities
 Palliative
 Vagal nerve stimulation

44. Plan
 Definitions
 Aetiology
 Classification
 Clinical Manifestations
 Investigations
 Diagnosis
 Treatment
 Who to Treat?

45. Who To Treat?
 First Seizure – no treatment needed
 Second Seizure – Treat
 Precipitating cause recognized
 Treat cause
 Once on treatment - continue for 2 years
 Check drug levels for compliance
 Taper off after 2 years – in months