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Epilepsy
Definition
• A group of disorder of unprovoked recurrent seizure (idiopathic
epilepsy)
Pathophysiology
1. Hypersynchronous discharge
2. Large group of neuron activated repetitively
3. Imbalance between excitatory and inhibitory transmitter
4. Abnormal voltage-controlled membrane channel
Etiology
1. Idiopathic
2. Secondary
• Genetic : family history
• Congenital malformation of the brain : hydrocephalus with large head or headache
• Perinatal complications : birth asphyxia or trauma
• Neurocutaneous syndrome : neurofibromatosis with skin lesion
• Intracranial haemorrhage : bleeding disorder,NAI
• CNS infection : meningitis,encephalitis,brain abscess
• Trauma : history of MVA or NAI
• CVA : vasculitis
• Neoplasm : solid CNS tumor
Classifications
• Partial seizures
• Simple partial seizures
• Begin in a specific area of the brain
• Consciousness not impaired
• Motor:originate in the motor cortex cause recurrent contraction of the muscle of one part of the
body
• Sensory:originate from sensory centrer (postcentral gyrus)
• Visual
• somatic
• Psychic : originate from temporal lobe
• Emotional disturbances
• Autonomic disurbances
• Complex partial seizures
• Aura > may be generalized > may be altered consciousness + post ictal confusion and
drowsiness + amnesia
• Partial seizures evolving to secondary generalized seizures
Classification
• Generalized seizures
• Tonic clonic
• Tonic : generalized contraction of muscle and extension of the limb and trunk + cyanosis
• Clonic : bilateral symmetrical and intense jerking then slowly diminish + urine and fecal incontinence +
buccal oral trauma
• For few seconds - minutes
• Post ictal drowsiness or deep sleep for several hours
• Awakening : confused,tired,headache,muscle pain
• Absence seizures
• Frequent brief impairment of consciounsness
• Stop > stares blankly or blink repeatedly not less than 30s
• Consciousness recovered immediately
• No incontinence or falling
• Myoclonic : Sudden brief shock like contractions of one extremity or entire body
• Clonic
• Tonic atonic : Common in retarded children with mixed children disorder
• Atonic > fall abruptly
Classification
• Unclassified epileptic seizure
• Primary childhood seizure
• West syndrome (infantile spasm)
• Juvenile myoclonic epilepsy
• Neonatal seizure
• Febrile convusion
• Status epilepticus
History
• Chief complaint : fitting and duration
• Seizures description by witness
• What is he doing at that time
• Description :
sudden LOC,posture,jerking movement,up rolling eyeball,drooling of saliva,cyanosis,
urine/incontinence
• Post ictal : drowsiness,lethargy,amnesia,insoluble crying,irritability,diarrhea,trauma
• Precipitated factor : flash light,extreme exhaustion,tired,emotionally
unstable,sleep deprivation
• Etiology : fever,vomiting,photophobia,neck stiffness,insoluble
crying,irritability,diarrhea,trauma
Differential diagnosis of seizures
• Neonates and infants
• Jitteriness
• Benign myoclonus
• Apnea
• GERD
• Shuddering attacks
• Benign paroxysmal torticollis
• Hyperekplexia
• Young children
• Breath holding spells
• Reflex anoxic seizures
• Parasomnia
• Benign paroxysmal vertigo
• Paroxysmal choreoathetosis
• Rage attack
• Childhood and adolescent
• Vasovagal syncope
• Migraine
• Narcolepsy
• Panic attacks
• Pseudoseizures
• Others
• Drugs induced dystonia
• Cardiac dysrythmias
Complications of seizures
• Muscle ache
• Head trauma
• Oral or buccal trauma
• Impact on life
Examination
• Normal
• Rule out secondary causes
• Dysmorphism
• Neurocutaneous sign
• Hydrocephalus
• Head trauma
• NF manifestation
Investigation
• Recommended when 2nd afebrile seizures occur
• FBC
• Blood C&S
• RBS
• Serum Ca,PO4,Mg and BUSE
• Skull Xray
• ECG
• EEG
• MRI/CT scan
Principles of anticonvulsant therapy for
epilepsy
1. Treatment initiated after 2 episodes (recurrence risk is 80%)
2. Classify seizure type and epileptic syndrome
3. Monotherapy,most appropriate drug,increase dose gradually (until max
dose or side effects occur)
4. 1st drug fail > optimize 2nd drug then withdraw the 1st drug
5. If combine,use different MOA
6. Monitor drugs level : compliance,well controlled,drug interaction
(polypharmacy)
7. Withdraw drug when seizure free for 2 years (taper within 3-6months)
8. Seizure recur:last dose reduction is reversed and refer
Selecting anticonvulsant
• Partial seizure
• 1st line : Carbamazepine,Sodium Valproate
• 2nd line : Lamotrigine,Topiramate,Levetiracetam,Phenytoin,Phenobarbitone,
Clonazepam
• Generalized seizure
• 1st line : Sodium Valproate,Adrenocorticotrophin,Prednisolone,Vigabatrin
• 2nd line : Lamotrigine,Topiramate,Nitrazepam,Clonazepam,Valproate
Side effect and toxicity of anticonvulsant
• Carbamazepine
• Side effects:drowsiness,dizziness,ataxia,diplopia,rash
• Toxicity:agranulocytosis,Steven-Johnson syndrome
• Sodium Valproate
• Side effects:nausea,epigastric pain,tremor,alopecia,weight gain,hair loss, thrombocytopenia
• Serious toxicity:hepatotoxicity (2years of age),hepatitis,pancreatitis, encephalopathy
• Lamotrigine
• Side effects:Dizziness,somnolence,insomnia,rash
• Serious toxicity:Steven-Johnson syndrome
• Topiramate
• Side effects:Weight loss,somnolence,mental slowing,word finding difficulty,hypohidrosis
• Renal calculi
Advice
• Educate and counsel on epilepsy
• Compliance!
• Don't stop medication by yourself > breakthrough seizure
• Watch TV in bright light room and avoid sleep deprivation
• No cycling,swimming or climbing alone
• Emergency treatment for seizure
• Inform teacher and school about the condition

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Epilepsy

  • 2. Definition • A group of disorder of unprovoked recurrent seizure (idiopathic epilepsy)
  • 3. Pathophysiology 1. Hypersynchronous discharge 2. Large group of neuron activated repetitively 3. Imbalance between excitatory and inhibitory transmitter 4. Abnormal voltage-controlled membrane channel
  • 4. Etiology 1. Idiopathic 2. Secondary • Genetic : family history • Congenital malformation of the brain : hydrocephalus with large head or headache • Perinatal complications : birth asphyxia or trauma • Neurocutaneous syndrome : neurofibromatosis with skin lesion • Intracranial haemorrhage : bleeding disorder,NAI • CNS infection : meningitis,encephalitis,brain abscess • Trauma : history of MVA or NAI • CVA : vasculitis • Neoplasm : solid CNS tumor
  • 5. Classifications • Partial seizures • Simple partial seizures • Begin in a specific area of the brain • Consciousness not impaired • Motor:originate in the motor cortex cause recurrent contraction of the muscle of one part of the body • Sensory:originate from sensory centrer (postcentral gyrus) • Visual • somatic • Psychic : originate from temporal lobe • Emotional disturbances • Autonomic disurbances • Complex partial seizures • Aura > may be generalized > may be altered consciousness + post ictal confusion and drowsiness + amnesia • Partial seizures evolving to secondary generalized seizures
  • 6.
  • 7. Classification • Generalized seizures • Tonic clonic • Tonic : generalized contraction of muscle and extension of the limb and trunk + cyanosis • Clonic : bilateral symmetrical and intense jerking then slowly diminish + urine and fecal incontinence + buccal oral trauma • For few seconds - minutes • Post ictal drowsiness or deep sleep for several hours • Awakening : confused,tired,headache,muscle pain • Absence seizures • Frequent brief impairment of consciounsness • Stop > stares blankly or blink repeatedly not less than 30s • Consciousness recovered immediately • No incontinence or falling • Myoclonic : Sudden brief shock like contractions of one extremity or entire body • Clonic • Tonic atonic : Common in retarded children with mixed children disorder • Atonic > fall abruptly
  • 8. Classification • Unclassified epileptic seizure • Primary childhood seizure • West syndrome (infantile spasm) • Juvenile myoclonic epilepsy • Neonatal seizure • Febrile convusion • Status epilepticus
  • 9. History • Chief complaint : fitting and duration • Seizures description by witness • What is he doing at that time • Description : sudden LOC,posture,jerking movement,up rolling eyeball,drooling of saliva,cyanosis, urine/incontinence • Post ictal : drowsiness,lethargy,amnesia,insoluble crying,irritability,diarrhea,trauma • Precipitated factor : flash light,extreme exhaustion,tired,emotionally unstable,sleep deprivation • Etiology : fever,vomiting,photophobia,neck stiffness,insoluble crying,irritability,diarrhea,trauma
  • 10. Differential diagnosis of seizures • Neonates and infants • Jitteriness • Benign myoclonus • Apnea • GERD • Shuddering attacks • Benign paroxysmal torticollis • Hyperekplexia • Young children • Breath holding spells • Reflex anoxic seizures • Parasomnia • Benign paroxysmal vertigo • Paroxysmal choreoathetosis • Rage attack • Childhood and adolescent • Vasovagal syncope • Migraine • Narcolepsy • Panic attacks • Pseudoseizures • Others • Drugs induced dystonia • Cardiac dysrythmias
  • 11. Complications of seizures • Muscle ache • Head trauma • Oral or buccal trauma • Impact on life
  • 12. Examination • Normal • Rule out secondary causes • Dysmorphism • Neurocutaneous sign • Hydrocephalus • Head trauma • NF manifestation
  • 13. Investigation • Recommended when 2nd afebrile seizures occur • FBC • Blood C&S • RBS • Serum Ca,PO4,Mg and BUSE • Skull Xray • ECG • EEG • MRI/CT scan
  • 14. Principles of anticonvulsant therapy for epilepsy 1. Treatment initiated after 2 episodes (recurrence risk is 80%) 2. Classify seizure type and epileptic syndrome 3. Monotherapy,most appropriate drug,increase dose gradually (until max dose or side effects occur) 4. 1st drug fail > optimize 2nd drug then withdraw the 1st drug 5. If combine,use different MOA 6. Monitor drugs level : compliance,well controlled,drug interaction (polypharmacy) 7. Withdraw drug when seizure free for 2 years (taper within 3-6months) 8. Seizure recur:last dose reduction is reversed and refer
  • 15. Selecting anticonvulsant • Partial seizure • 1st line : Carbamazepine,Sodium Valproate • 2nd line : Lamotrigine,Topiramate,Levetiracetam,Phenytoin,Phenobarbitone, Clonazepam • Generalized seizure • 1st line : Sodium Valproate,Adrenocorticotrophin,Prednisolone,Vigabatrin • 2nd line : Lamotrigine,Topiramate,Nitrazepam,Clonazepam,Valproate
  • 16. Side effect and toxicity of anticonvulsant • Carbamazepine • Side effects:drowsiness,dizziness,ataxia,diplopia,rash • Toxicity:agranulocytosis,Steven-Johnson syndrome • Sodium Valproate • Side effects:nausea,epigastric pain,tremor,alopecia,weight gain,hair loss, thrombocytopenia • Serious toxicity:hepatotoxicity (2years of age),hepatitis,pancreatitis, encephalopathy • Lamotrigine • Side effects:Dizziness,somnolence,insomnia,rash • Serious toxicity:Steven-Johnson syndrome • Topiramate • Side effects:Weight loss,somnolence,mental slowing,word finding difficulty,hypohidrosis • Renal calculi
  • 17. Advice • Educate and counsel on epilepsy • Compliance! • Don't stop medication by yourself > breakthrough seizure • Watch TV in bright light room and avoid sleep deprivation • No cycling,swimming or climbing alone • Emergency treatment for seizure • Inform teacher and school about the condition